- Email: [email protected]
Preferences for Labor and Delivery Practices Between Pregnant Immigrants and US-Born Patients: A Comparative Prospective Antenatal Survey Study
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Preferences for Labor and Delivery Practices Between Pregnant Immigrants and US-Born Patients: A Comparative Prospective Antenatal Survey Study Oluseyi Ogunleye, MD; James A. Shelton; Anna Ireland; Myron Glick, MD; John Yeh, MD
Objective: To compare preferences in pregnant Somali and Sudanese immigrants with US-born women for different labor and delivery procedures and practices. Study Design: Pregnant women who received prenatal care services at the Jericho Road Family Practice were surveyed. Ninety-three consecutive patients agreed to participate. A translator-facilitated questionnaire was administered to Somali-, Sudanese-, and US-born women during antenatal visits. Results: For pain relief in labor, 66.7% of US-born, 64.0% of Somali, and 12.5% of Sudanese women preferred epidural analgesia (p = .002). More US-born women preferred for the umbilical cord to be cut by their partners (76.2%) vs Somali (6.7%) and Sudanese (0%) (p < .001). For infant feeding, more US-born women (47%) preferred only formula feeding (Somali, 3.4%; Sudanese, 0%; p < .001). Responses were not statistically different for other preference questions, such as mobility/position in labor, attendants in labor, and duration of hospital stay. Conclusions: This prospective survey quantifies the differences in preferences for labor and delivery practices from two foreign populations and from US-born women. This information is useful for all physicians who wish to better meet the needs of individual patients, especially those who are from different cultures and backgrounds. Keywords: obstetrics/gynecology n immigrants n survey J Natl Med Assoc. 2010;102:481-484 Author Affiliations: Departments of Gynecology-Obstetrics (Dr Ogunleye and Mr Shelton) and Family Medicine (Dr Glick), University at Buffalo, the State University of New York, Buffalo, New York; Jericho Road Family Practice, Buffalo, New York (Ms Ireland); Department of GynecologyObstetrics, Beth Israel Deaconess Center, Boston, Massachusetts (Dr Yeh). Correspondence: John Yeh, MD, Department of Gynecology-Obstetrics, Beth Israel Deaconess Center, 330 Brookline Ave, KS 306, Boston, MA 02215 ([email protected]).
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Introduction
T
he immigration of people from their original homes to other parts of the globe continues to occur. The reasons for immigration vary among individuals. They include desires for educational opportunities, safety from ethnopolitical conflicts, and economic improvement. Obstetrician-gynecologists can be faced with multiple medicosociological problems in rendering care to immigrant patients. An important challenge is how to provide prenatal care services to a culturally diverse population while improving utilization of antenatal care and without jeopardizing fundamental beliefs of individuals.1 There are few studies carried out in the United States on immigrants from Somalia and Sudan.1-4 The care of immigrants could improve if additional information were known about individual’s labor and delivery preferences. The objective of this study is to survey antenatal patients from Somali and Sudan and to quantify their preferences regarding common labor and delivery practices and compare those findings to US-born women.
Materials and Methods
Pregnant Somali, Sudanese, and US-born women who received prenatal care services at the Jericho Road Family Practice, in Buffalo, New York, and the University at Buffalo, The State University of New York, were studied between September 2007 and March 2008. Ninety-three consecutive pregnant patients of all age groups agreed to participate in this survey. Thirty-three were excluded due to their nationality or an incomplete survey. A total of 60 completed questionnaires were analyzed in this study. Thirty were by Somali respondents and 21 questionnaires were by the US-born women—11 of which were white and the remaining 10, blacks. The Sudanese women completed 9 questionnaires. Immigrants from other countries were fewer in this practice and were therefore excluded. A single translator was used for each of the Somali and Sudanese translations, respectively, to obtain informed consent and to administer the questionnaires. This was VOL. 102, NO. 6, JUNE 2010 481
labor and delivery practices
necessary to reduce errors related to translation. The 28-question survey was administered once during an antenatal visit for each patient in the exam room during the visit. All consent and survey forms were in English and translated into the appropriate language or dialect, and the questionnaire responses were recorded in English. Unfortunately, actual outcomes during labor and delivery were not included as part of the study. The Health Sciences Institutional Review Board of the University at Buffalo, The State University of New York granted approval for the study (#GYN0250507E). The results are presented as mean ± standard deviation or as percentages, and comparisons between ethnic groups were made using Kruskal-Wallis, Mann-Whitney U, or c2 tests, where appropriate. Due to the small sample size, exact p values were calculated using SPSS’s EXACT TESTS (SPSS version 16, SPSS Inc, Chicago, Illinois).
Results
The basic demographic characteristics of the 3 groups are presented in Table 1. The average age of the US-born women (20 years for US-born white and 21 years for US-born blacks) was statistically less than the Somali (27 years) and Sudanese (31 years) women (p < .001). The average number of previous pregnancies reported by the US-born patients (1.6 for whites and 3.6 for blacks) was less than the Somali (4.1) and Sudanese patients (4.3) (p = .006). This may be of interest since age differences or experiences with prior deliveries might influence preferences. The responses to the questionnaire are presented in Table 2. Epidural analgesia was preferred by 66.7% of US-born, 64% of Somali, compared to 12.5% of Sudanese women (p = .002). Cutting of the umbilical cord by partner was preferred by 76.2% of US-born, 6.7% of Somali, and 0% of Sudanese women (p < .001). Exclusive formula feeding of their babies was preferred by 47.6% of US-born, 3.4% of Somali, and 0% of Sudanese women (p < .001). There were no statistical differences between the groups in regards to the
responses to the other items in the questionnaire. All of our Somali women responders were circumcised, while no Sudanese responders were circumcised. Approximately one-third (31.8%) of circumcised Somali women would like to be deinfibulated, which means having the ring, clasp, or stitches in the labia majora removed, at delivery. Eighty-four percent (84%) of these women would like to be reinfibulated, replacing the ring, clasp, or stitches in the labia majora, after delivery.
Comment
This is the first prospective antenatal survey, to our knowledge, which quantifies labor and delivery preferences of the Somali and Sudanese populations receiving pregnancy care in the United States. Both the US-born and the Somali respondents preferred epidural analgesia for pain relief in labor, but not the Sudanese women. The preferences for epidural analgesia among the Somali and the US-born responders were similar. The average length of time in the United States for our Sudanese responders (5.8 years) is not statistically different to that of our Somali responders (3.6 years) (p = .109). The preference for epidural analgesia among the Somali compared to their Sudanese counterparts is likely cultural. Differences existed among the 3 groups regarding the person who will cut the umbilical cord after birth. The usual birthing environment for the Somali and Sudanese women, typified by a preferred support person, is not often available in a foreign country, mostly because of the practicality of such an approach.5 Many of these women are often by themselves with no other members of the family at the time of labor. Additionally, their immigrant partners may be in an unfamiliar medical environment, which may, in part, explain why these men are not as involved in cutting the umbilical cord or taking any more active role in the labor process. The other reason may be cultural. Female genital mutilation (FGM) is prevalent in some parts of Africa, with nearly 100% of Somali women6 and 90% of women from Northern Sudan circumcised.7 A
Table 1. Distribution by Basic Demographic Characteristics for Ethnic Nationalities US-Born (n = 21)
Somali (n = 30)
Sudanese P (n = 9) Value
White Black (n = 11) (n = 10) Age, mean ± SD, y 20 (± 5.3) 21 (± 4.3) 27 (± 6) 31.1 (± 4.6) Average No. of previous pregnancies, mean ± SD 1.6 (± 1.2)3.0 (± 2.9) 4.1 (± 2.5) 4.3 (± 1.6) NA 3.6 (± 1.9) 5.8 (± 3.1) Average time in United States, mean ± SD, y Women reporting previous deliveries outside of United States NA 70.0% (21) 66.7% (6) Women reporting previous deliveries within United States 70% (14) 83.3 % (25) 88.9% (8) Women reporting previous cesarean sections within United States 13.3% (2) 24% (6) 25% (2)
<.001 .006 .109 1.000 .327 .709
Abbreviation: NA, not applicable.
482 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
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labor and delivery practices
retrospective cohort US study carried out in Washington state suggests that Somali women experience an increased risk of perineal lacerations due to the consequences of female circumcision.4 Of the circumcised Somali women
in this survey, only one-third of them would like to be deinfibulated at delivery (Table 2). It thus highlights the need to ascertain from the patients what they want done with their circumcised genitalia.
Table 2. Distribution by Questions on Practices Related to Labor, Delivery and Puerperium, for the Ethnic Nationalities Preferred Birth Options Vaginal Cesarean section Don’t mind Pain relief of choice Epidural None Others Preference of mobility in labor Restricted Unrestricted Preferred position in labor Lying on back Sitting Lying on side Other Preferred birthing place Home Hospital Preferred to cut baby’s cord Don’t mind Doctor Partner Preferred method of feeding Both Breast Formula Preferred duration of hospital stay after vaginal delivery, d 1-2 ≥3 Preferred duration of hospital stay after cesarean section, d 3-4 ≥5 Preferred location of baby Nursery Room Preferred examiner during labor Don’t mind Female provider Male provider Preferred time to hold baby after delivery As soon as possible Immediately Woman circumcised Would like circumcision incised during labor and delivery No Yes Would like circumcision corrected during labor and delivery No Yes
Sudanese (n = 9)
P Value
76.2% (16) 4.8% (1) 19% (4)
96.4% (27) 3.6% (1) 0
75.0 (6) 12.5% (1) 12.5% (1)
.135
66.7% (14) 33.3% (7) 0
64.0% (16) 28% (7) 8% (2)
12.5% (1) 37.5% (3) 50% (4)
10% (2) 90% (18)
24% (6) 76% (19)
25% (2) 75% (6)
(16) (2) (2) (1)
55.6% (15) 22.2% (6) 3.7% (1) 18.5 (5)
62.5% (5) 25.0% (2) 12.5% (1) 0
9.5% (2) 90.5% (19)
3.3% (1) 96.7% (29)
0 100% (9)
14.3% (3) 9.5% (2) 76.2% (16)
3.3% (1) 90.0% (27) 6.7% (2)
28.6% (2) 71.4% (5) 0
19% (4) 33.3% (7) 47.6% (10)
79.3% (23) 17.2% (5) 3.4% (1)
77.8% (7) 22.2% (2) 0
76.2% (16) 23.8% (5)
79.3% (23) 20.7% (6)
100% (7) 0
64.7% (11) 35.3% (6)
45.5% (10) 54.5% (12)
100% (7) 0
38.1% (8) 61.9% (13)
48.3% (14) 51.7% (15)
55.6% (5) 44.4% (4)
57.1% (12) 42.9% (9) 0
37.9% (11) 55.1% (15) 10.3% (3)
85.7% (6) 14.3% (1) 0
47.6% (10) 52.4% (11) 0
75.0% (21) 25.0% (7) 30
55.6% (5) 44.4% (4) 0
US-Born (n = 21) Somali (n = 30)
76.2% 9.5% 9.5% 4.8%
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
.002
.505
.421
.567 <.001
<.001
.465
.102
.684 .087
.134
68.2% (15) 31.8% (7) 84% (21) 16% (4)
VOL. 102, NO. 6, JUNE 2010 483
labor and delivery practices
The value of culturally sensitive prenatal care services is high, especially if we are to improve on the patient satisfaction in this immigrant group of patients. As an example, programs that involve doulas in the care of the Somali parturient have shown a significantly improved patient satisfaction and a substantial decline in their cesarean section rates.8 One strength of this study was the number of Somali pregnant patients who were surveyed. An additional strength was the use of a single translator for each of the Somali and Sudanese languages who physically administered the questionnaires, ensuring good and uniform understanding of the questions by the responders and confidence in the findings. A study weakness was in the differences in the basic demographic characteristics of the average ages and of the number of prior pregnancies. This makes the comparison among the 3 study groups less equivalent. However, the contemporaneous survey of the 3 study groups in a short time period lessens this as a concern. Also, the relatively small size of the Sudanese group does not allow the authors to substantially determine more differences in the labor and delivery preferences of these different ethnicities. Further study weaknesses include the fact that background knowledge of the respective individuals, of various perinatal practices such as epidural and the respective degrees of acculturation, was not determined. Perhaps this might give an insight into the basis for some of the choices made by the respondents. It might have been helpful to have the partners’ perceptions on some of the questions raised in the questionnaire, especially the issue of partner presence during labor and the cutting of the umbilical cord, among other things. The study was also not designed to find out what actually transpired during the actual birthing experiences of these women and how much of those desires were actually expressed at birth. There is little information published regarding
484 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
perinatal preferences between the various ethnic groups studied here. For future studies, it may be helpful to try and determine the educational levels and the exact tribes or the geographical locations within the respective countries these women might have come from, as this may explain, at least in part, the diverse views held by patients even within the same country. As mentioned, earlier it would be interesting to find out the partners’ perspectives of the questions raised here to ascertain any uniformity of desires or if the partners have any disparate views on any of the questions addressed. Similarly, future studies involving a survey of the preferences of immigrants from other countries or those of specific religious beliefs may further help obstetricians-gynecologists in having a number of reference points to use in caring for a wide variety of immigrants in the United States.
References
1. Beine K, Fullerton J, Palinkas L, Anders B. Conceptions of prenatal care among Somali women in San Diego. J Nurse Midwifery. 1995;40:376-381. 2. Arbesman M, Kahler L, Buck GM. Assessment of the impact of female circumcision on the gynecological, genitourinary and obstetrical health problems of women from Somalia: literature review and case series. Womens Health. 1993;20:27-42. 3. Herrel N, Olevitch L, DuBois DK, et al. Somali refugee women speak out about their needs for care during pregnancy and delivery. J Midwifery Womens Health. 2004;49:345-349. 4. Johnson EB, Reed SD, Hitti J, Batra M. Increased risk of adverse pregnancy outcome among Somali immigrants in Washington state. Am J Obstet Gynecol. 2005;193:475-482. 5. Essén B, Johnsdotter S, Hovelius B, et al. Qualitative study of pregnancy and childbirth experiences in Somalian women resident in Sweden. BJOG. 2000;107:1507-1512. 6. Vangen S, Johansen REB, Sundby J, Træen B, Stray-Pedersen B. Qualitative study of perinatal care experiences among Somali women and local health care professionals in Norway. Eur J Obstet Gynecol Reprod Biol. 2004;112:29-35. 7. Berggren V, Abdel Salam G, Bergström S, Johansson E, Edberg A-K. An explorative study of Sudanese midwives’ motives, perceptions and experiences of re-infibulation after birth. Midwifery. 2004;20:299-311. 8. Dundek LH. Establishment of a Somali doula program at a large metropolitan hospital. J Perinat Neonatal Nurs. 2006;20:128-137. n
VOL. 102, NO. 6, JUNE 2010
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Preferences for Labor and Delivery Practices Between Pregnant Immigrants and US-Born Patients: A Comparative Prospective Antenatal Survey Study Oluseyi Ogunleye, MD; James A. Shelton; Anna Ireland; Myron Glick, MD; John Yeh, MD
Objective: To compare preferences in pregnant Somali and Sudanese immigrants with US-born women for different labor and delivery procedures and practices. Study Design: Pregnant women who received prenatal care services at the Jericho Road Family Practice were surveyed. Ninety-three consecutive patients agreed to participate. A translator-facilitated questionnaire was administered to Somali-, Sudanese-, and US-born women during antenatal visits. Results: For pain relief in labor, 66.7% of US-born, 64.0% of Somali, and 12.5% of Sudanese women preferred epidural analgesia (p = .002). More US-born women preferred for the umbilical cord to be cut by their partners (76.2%) vs Somali (6.7%) and Sudanese (0%) (p < .001). For infant feeding, more US-born women (47%) preferred only formula feeding (Somali, 3.4%; Sudanese, 0%; p < .001). Responses were not statistically different for other preference questions, such as mobility/position in labor, attendants in labor, and duration of hospital stay. Conclusions: This prospective survey quantifies the differences in preferences for labor and delivery practices from two foreign populations and from US-born women. This information is useful for all physicians who wish to better meet the needs of individual patients, especially those who are from different cultures and backgrounds. Keywords: obstetrics/gynecology n immigrants n survey J Natl Med Assoc. 2010;102:481-484 Author Affiliations: Departments of Gynecology-Obstetrics (Dr Ogunleye and Mr Shelton) and Family Medicine (Dr Glick), University at Buffalo, the State University of New York, Buffalo, New York; Jericho Road Family Practice, Buffalo, New York (Ms Ireland); Department of GynecologyObstetrics, Beth Israel Deaconess Center, Boston, Massachusetts (Dr Yeh). Correspondence: John Yeh, MD, Department of Gynecology-Obstetrics, Beth Israel Deaconess Center, 330 Brookline Ave, KS 306, Boston, MA 02215 ([email protected]).
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Introduction
T
he immigration of people from their original homes to other parts of the globe continues to occur. The reasons for immigration vary among individuals. They include desires for educational opportunities, safety from ethnopolitical conflicts, and economic improvement. Obstetrician-gynecologists can be faced with multiple medicosociological problems in rendering care to immigrant patients. An important challenge is how to provide prenatal care services to a culturally diverse population while improving utilization of antenatal care and without jeopardizing fundamental beliefs of individuals.1 There are few studies carried out in the United States on immigrants from Somalia and Sudan.1-4 The care of immigrants could improve if additional information were known about individual’s labor and delivery preferences. The objective of this study is to survey antenatal patients from Somali and Sudan and to quantify their preferences regarding common labor and delivery practices and compare those findings to US-born women.
Materials and Methods
Pregnant Somali, Sudanese, and US-born women who received prenatal care services at the Jericho Road Family Practice, in Buffalo, New York, and the University at Buffalo, The State University of New York, were studied between September 2007 and March 2008. Ninety-three consecutive pregnant patients of all age groups agreed to participate in this survey. Thirty-three were excluded due to their nationality or an incomplete survey. A total of 60 completed questionnaires were analyzed in this study. Thirty were by Somali respondents and 21 questionnaires were by the US-born women—11 of which were white and the remaining 10, blacks. The Sudanese women completed 9 questionnaires. Immigrants from other countries were fewer in this practice and were therefore excluded. A single translator was used for each of the Somali and Sudanese translations, respectively, to obtain informed consent and to administer the questionnaires. This was VOL. 102, NO. 6, JUNE 2010 481
labor and delivery practices
necessary to reduce errors related to translation. The 28-question survey was administered once during an antenatal visit for each patient in the exam room during the visit. All consent and survey forms were in English and translated into the appropriate language or dialect, and the questionnaire responses were recorded in English. Unfortunately, actual outcomes during labor and delivery were not included as part of the study. The Health Sciences Institutional Review Board of the University at Buffalo, The State University of New York granted approval for the study (#GYN0250507E). The results are presented as mean ± standard deviation or as percentages, and comparisons between ethnic groups were made using Kruskal-Wallis, Mann-Whitney U, or c2 tests, where appropriate. Due to the small sample size, exact p values were calculated using SPSS’s EXACT TESTS (SPSS version 16, SPSS Inc, Chicago, Illinois).
Results
The basic demographic characteristics of the 3 groups are presented in Table 1. The average age of the US-born women (20 years for US-born white and 21 years for US-born blacks) was statistically less than the Somali (27 years) and Sudanese (31 years) women (p < .001). The average number of previous pregnancies reported by the US-born patients (1.6 for whites and 3.6 for blacks) was less than the Somali (4.1) and Sudanese patients (4.3) (p = .006). This may be of interest since age differences or experiences with prior deliveries might influence preferences. The responses to the questionnaire are presented in Table 2. Epidural analgesia was preferred by 66.7% of US-born, 64% of Somali, compared to 12.5% of Sudanese women (p = .002). Cutting of the umbilical cord by partner was preferred by 76.2% of US-born, 6.7% of Somali, and 0% of Sudanese women (p < .001). Exclusive formula feeding of their babies was preferred by 47.6% of US-born, 3.4% of Somali, and 0% of Sudanese women (p < .001). There were no statistical differences between the groups in regards to the
responses to the other items in the questionnaire. All of our Somali women responders were circumcised, while no Sudanese responders were circumcised. Approximately one-third (31.8%) of circumcised Somali women would like to be deinfibulated, which means having the ring, clasp, or stitches in the labia majora removed, at delivery. Eighty-four percent (84%) of these women would like to be reinfibulated, replacing the ring, clasp, or stitches in the labia majora, after delivery.
Comment
This is the first prospective antenatal survey, to our knowledge, which quantifies labor and delivery preferences of the Somali and Sudanese populations receiving pregnancy care in the United States. Both the US-born and the Somali respondents preferred epidural analgesia for pain relief in labor, but not the Sudanese women. The preferences for epidural analgesia among the Somali and the US-born responders were similar. The average length of time in the United States for our Sudanese responders (5.8 years) is not statistically different to that of our Somali responders (3.6 years) (p = .109). The preference for epidural analgesia among the Somali compared to their Sudanese counterparts is likely cultural. Differences existed among the 3 groups regarding the person who will cut the umbilical cord after birth. The usual birthing environment for the Somali and Sudanese women, typified by a preferred support person, is not often available in a foreign country, mostly because of the practicality of such an approach.5 Many of these women are often by themselves with no other members of the family at the time of labor. Additionally, their immigrant partners may be in an unfamiliar medical environment, which may, in part, explain why these men are not as involved in cutting the umbilical cord or taking any more active role in the labor process. The other reason may be cultural. Female genital mutilation (FGM) is prevalent in some parts of Africa, with nearly 100% of Somali women6 and 90% of women from Northern Sudan circumcised.7 A
Table 1. Distribution by Basic Demographic Characteristics for Ethnic Nationalities US-Born (n = 21)
Somali (n = 30)
Sudanese P (n = 9) Value
White Black (n = 11) (n = 10) Age, mean ± SD, y 20 (± 5.3) 21 (± 4.3) 27 (± 6) 31.1 (± 4.6) Average No. of previous pregnancies, mean ± SD 1.6 (± 1.2)3.0 (± 2.9) 4.1 (± 2.5) 4.3 (± 1.6) NA 3.6 (± 1.9) 5.8 (± 3.1) Average time in United States, mean ± SD, y Women reporting previous deliveries outside of United States NA 70.0% (21) 66.7% (6) Women reporting previous deliveries within United States 70% (14) 83.3 % (25) 88.9% (8) Women reporting previous cesarean sections within United States 13.3% (2) 24% (6) 25% (2)
<.001 .006 .109 1.000 .327 .709
Abbreviation: NA, not applicable.
482 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
VOL. 102, NO. 6, JUNE 2010
labor and delivery practices
retrospective cohort US study carried out in Washington state suggests that Somali women experience an increased risk of perineal lacerations due to the consequences of female circumcision.4 Of the circumcised Somali women
in this survey, only one-third of them would like to be deinfibulated at delivery (Table 2). It thus highlights the need to ascertain from the patients what they want done with their circumcised genitalia.
Table 2. Distribution by Questions on Practices Related to Labor, Delivery and Puerperium, for the Ethnic Nationalities Preferred Birth Options Vaginal Cesarean section Don’t mind Pain relief of choice Epidural None Others Preference of mobility in labor Restricted Unrestricted Preferred position in labor Lying on back Sitting Lying on side Other Preferred birthing place Home Hospital Preferred to cut baby’s cord Don’t mind Doctor Partner Preferred method of feeding Both Breast Formula Preferred duration of hospital stay after vaginal delivery, d 1-2 ≥3 Preferred duration of hospital stay after cesarean section, d 3-4 ≥5 Preferred location of baby Nursery Room Preferred examiner during labor Don’t mind Female provider Male provider Preferred time to hold baby after delivery As soon as possible Immediately Woman circumcised Would like circumcision incised during labor and delivery No Yes Would like circumcision corrected during labor and delivery No Yes
Sudanese (n = 9)
P Value
76.2% (16) 4.8% (1) 19% (4)
96.4% (27) 3.6% (1) 0
75.0 (6) 12.5% (1) 12.5% (1)
.135
66.7% (14) 33.3% (7) 0
64.0% (16) 28% (7) 8% (2)
12.5% (1) 37.5% (3) 50% (4)
10% (2) 90% (18)
24% (6) 76% (19)
25% (2) 75% (6)
(16) (2) (2) (1)
55.6% (15) 22.2% (6) 3.7% (1) 18.5 (5)
62.5% (5) 25.0% (2) 12.5% (1) 0
9.5% (2) 90.5% (19)
3.3% (1) 96.7% (29)
0 100% (9)
14.3% (3) 9.5% (2) 76.2% (16)
3.3% (1) 90.0% (27) 6.7% (2)
28.6% (2) 71.4% (5) 0
19% (4) 33.3% (7) 47.6% (10)
79.3% (23) 17.2% (5) 3.4% (1)
77.8% (7) 22.2% (2) 0
76.2% (16) 23.8% (5)
79.3% (23) 20.7% (6)
100% (7) 0
64.7% (11) 35.3% (6)
45.5% (10) 54.5% (12)
100% (7) 0
38.1% (8) 61.9% (13)
48.3% (14) 51.7% (15)
55.6% (5) 44.4% (4)
57.1% (12) 42.9% (9) 0
37.9% (11) 55.1% (15) 10.3% (3)
85.7% (6) 14.3% (1) 0
47.6% (10) 52.4% (11) 0
75.0% (21) 25.0% (7) 30
55.6% (5) 44.4% (4) 0
US-Born (n = 21) Somali (n = 30)
76.2% 9.5% 9.5% 4.8%
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
.002
.505
.421
.567 <.001
<.001
.465
.102
.684 .087
.134
68.2% (15) 31.8% (7) 84% (21) 16% (4)
VOL. 102, NO. 6, JUNE 2010 483
labor and delivery practices
The value of culturally sensitive prenatal care services is high, especially if we are to improve on the patient satisfaction in this immigrant group of patients. As an example, programs that involve doulas in the care of the Somali parturient have shown a significantly improved patient satisfaction and a substantial decline in their cesarean section rates.8 One strength of this study was the number of Somali pregnant patients who were surveyed. An additional strength was the use of a single translator for each of the Somali and Sudanese languages who physically administered the questionnaires, ensuring good and uniform understanding of the questions by the responders and confidence in the findings. A study weakness was in the differences in the basic demographic characteristics of the average ages and of the number of prior pregnancies. This makes the comparison among the 3 study groups less equivalent. However, the contemporaneous survey of the 3 study groups in a short time period lessens this as a concern. Also, the relatively small size of the Sudanese group does not allow the authors to substantially determine more differences in the labor and delivery preferences of these different ethnicities. Further study weaknesses include the fact that background knowledge of the respective individuals, of various perinatal practices such as epidural and the respective degrees of acculturation, was not determined. Perhaps this might give an insight into the basis for some of the choices made by the respondents. It might have been helpful to have the partners’ perceptions on some of the questions raised in the questionnaire, especially the issue of partner presence during labor and the cutting of the umbilical cord, among other things. The study was also not designed to find out what actually transpired during the actual birthing experiences of these women and how much of those desires were actually expressed at birth. There is little information published regarding
484 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
perinatal preferences between the various ethnic groups studied here. For future studies, it may be helpful to try and determine the educational levels and the exact tribes or the geographical locations within the respective countries these women might have come from, as this may explain, at least in part, the diverse views held by patients even within the same country. As mentioned, earlier it would be interesting to find out the partners’ perspectives of the questions raised here to ascertain any uniformity of desires or if the partners have any disparate views on any of the questions addressed. Similarly, future studies involving a survey of the preferences of immigrants from other countries or those of specific religious beliefs may further help obstetricians-gynecologists in having a number of reference points to use in caring for a wide variety of immigrants in the United States.
References
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VOL. 102, NO. 6, JUNE 2010