A crisis for minority women rooted in midwife education at university and beyond
By Owen Carpenter-Zehe, Nigar Hasanova, Louise Ekberg, and Merel Gelders
“A Swedish baby would never look like that.” This phrase Nina Snäll (42) – a cultural doula – heard repeatedly from Swedish nurses while helping immigrant women give birth. “This baby will have a Swedish personal number and passport… what do you mean this is not a Swedish baby?”
“These midwives probably don’t mean anything evil,” says Snäll. “They may just want to connect to the mother or were a little nervous, but these kinds of comments are very ignorant.” Cultural ignorance is not a new phenomenon in Swedish medicine. Multiple studies indicate women of colour or of foreign origin have poorer experience in the healthcare system. This ignorance, however, has come to the forefront in recent years, especially in women’s health.
Sweden is rapidly becoming a more diverse nation, with foreign born women having 30% of the births in the country in 2022, according to Statistics Sweden. Some of these women gave birth at Östra Maternity Ward in Gothenburg. According to Elin Madvall (41), the residing medical officer, she has never received any reports of discrimination during the two years she worked there. “The reports that we receive, cannot be linked to ethnic discrimination.”
However, Snäll observed several cases of discrimination when working at Östra. “One Latin American woman I helped, had unnecessary things done to her against her wishes,” she says. She has seen midwives refuse to speak English, at times even do a vaginal exam or break the mother’s water without asking.
Unfortunately, this is a trend across the country. In Malmö there were a lot of incidents where medical staff were not hurrying themselves when people with foreign sounding names would be hitting the alarm, says Agmall Sarwari (42), doctor and author. “This discriminatory treatment can cause neglect, which can lead to potentially dangerous situations.” According to Sarwari, the racism is being actively ignored. “Only when there’s a danger of these situations becoming public, that’s when hospitals will actually do something about it.”
A culture of silence currently prevails. Women can report discrimination, but it is not clear where, confirms Snäll. “It can take many years to realise that they were discriminated or did not give consent for something. Sometimes they do not even know it should be different.” According to Sarwari there is no way of structurally catching these cases of discrimination, expressing the need for a structural reform.
A midwife at Östra and guest lecturer, Linda Asp (36), thinks this problem can be linked to an educational gap. “We do not talk about our preconceptions enough; it is not fully integrated into the courses.” According to Asp, more training is needed. “The biggest problem is perhaps that the midwifery program is very short and compressed,” adds Herborg Holter (64), program coordinator at Sahlgrenska University. “We can’t spend enough time on certain important elements.”
“There’s a lack of structure and awareness.” Nandi Zulu (41), midwife in Malmö thinks intercultural education or sensitivity training could make a difference. “You need a level of understanding to recognize and identify the racism. This is especially important in health care, where you meet all kinds of people. We need to see the individuals instead of the differences, that’s not talked about enough in our training.”
The U.S. is investigating how to adjust the training in maternity care to a multicultural society. Researchers at Emory University have been looking into the viability of Diversity Equity and Inclusion (D.E.I.) training, in medical education. They found participating students “reported reevaluating their prior beliefs regarding the role of race in health inequity,” after finishing their seminar. These methods can be implemented in Sweden.
A few universities are changing. “We have learned and improved our education over the years to better treat the individual,” says Hanna Ulfsdottir (50), director of the midwife program at the Karolinska Institute in Stockholm. She explained they have added new trainings, and that they now have a collaboration with the University of Uganda, where they send future midwives to obtain a better understanding of midwifery in diverse cultures. However, this is not a trend that can be seen across the country.
There are no guidelines for how hospitals should handle discrimination or how schools should teach D.E.I., and mothers are facing the consequences. Snäll summarizes, some women are treated worse, because of bad communication and prejudices. “The Swedish population has changed quite a lot in a few years, and I don’t think universities have kept up,” adds Asp. “There is a huge area for improvement here, both in midwifery and in university.”