BackgroundViolence against women is associated with serious health problems, including adverse maternal and child health. Antenatal care (ANC) midwives are increasingly expected to implement the routine of identifying exposure to violence. An increase of Somali born refugee women in Sweden, their reported adverse childbearing health and possible links to violence pose a challenge to the Swedish maternity health care system. Thus, the aim was to explore ways ANC midwives in Sweden work with Somali born women and the questions of exposure to violence.MethodsQualitative individual interviews with 17 midwives working with Somali-born women in nine ANC clinics in Sweden were analyzed using thematic analysis.ResultsThe midwives strived to focus on the individual woman beyond ethnicity and cultural differences. In relation to the Somali born women, they navigated between different definitions of violence, ways of handling adversities in life and social contexts, guided by experience based knowledge and collegial support. Seldom was ongoing violence encountered. The Somali-born women’s’ strengths and contentment were highlighted, however, language skills were considered central for a Somali-born woman’s access to rights and support in the Swedish society. Shared language, trustful relationships, patience, and networking were important aspects in the work with violence among Somali-born women.ConclusionFocus on the individual woman and skills in inter-cultural communication increases possibilities of overcoming social distances. This enhances midwives’ ability to identify Somali born woman’s resources and needs regarding violence disclosure and support. Although routine use of professional interpretation is implemented, it might not fully provide nuances and social safety needed for violence disclosure. Thus, patience and trusting relationships are fundamental in work with violence among Somali born women. In collaboration with social networks and other health care and social work professions, the midwife can be a bridge and contribute to increased awareness of rights and support for Somali-born women in a new society.

Muscle biopsy samples were obtained from healthy subjects in order to evaluate quantitative differences in single fibres of substrate (glycogen and triglyceride) and ion concentrations (Na+ and K+) as well as enzyme activity levels (succinate-dehydrogenase, SDH; phosphofructokinase, PFK; 3-hydroxyacyl-CoA-dehydrogenase, HAD; myosin ATPase) between human skeletal muscle fibre types. After freeze drying of the muscle specimen fragments of single fibres were dissected out and stained for myofibrillar-ATPase with preincubations at pH's of 10.3, 4.6, 4.35. Type I ("red") and II A,B, and C ("white") fibres could then be identified. Glycogen content was the same in different fibres, whereas triglyceride content was highest in Type I fibres (2-3 X Type II). No significant differences were observed for Na+ and K+ between fibre types. The activity for the enzymes studied were quite different in the fibre types (SDH and HAD, Type I is approximately 1.5 X Type II; PFK Type I is approximately 0.5 X Type II, Myosin ATPase Type I is approxiamtely 0.4 X Type II). The subgroups of Type II fibres were distinguished by differences in both SDH and PFK activities (SDH, Type II C is greater than A is greater than B; PFK, Type II B is greater than A is approximately C). It is concluded that contractile and metabolic characteristics of human skeletal fibres are very similar to many other species. One difference, however, appears to be than no Type II fibres have an oxidative potential higher than Type I fibres.

13 male subjects were studied and placed in 3 groups. Each group exercised one leg with sprint (S), or endurance (E) training and the other leg oppositely or not at all (NT). Oxygen uptake (Vo2), heart rate and blood lactate were measured for each leg separately and for both legs together during submaximal and maximal bicycle work before and after 4 weeks of training with 4-5 sessions per week. Muscle samples were obtained from the quadriceps muscle and assayed for succinate dehydrogenase (SDH) activity, and stained for myofibrillar ATPase. In addition, eight of the subjects performed after the training two-legged exercise at 70% Vo2 max for one hour. The measurements included muscle glycogen and lactate concentrations of the two legs as well as the blood flow and the a-v difference for O2, glucose and lactate.

Objective To explore the attitudes, strategies and habits of Somalian immigrant women related to pregnancy and childbirth, in order to gain an understanding as to how cultural factors might affect perinatal outcome.Interpreter assisted qualitative in depth interviews around topics such as attitudes and strategies regarding childbirth.Fifteen women from the Somalian community in a city in Sweden, between the ages of 20 and 55 years with delivery experience in Somalia and Sweden.The interviews describe how the women themselves perceived their experiences of childbirth in the migrant situation. Many voluntarily decreased food intake in order to have a smaller fetus, an easier delivery and to avoid caesarean section. The participants considered a safe delivery to be the same as a normal vaginal delivery They reduced food intake in order to diminish the growth of the fetus, thereby avoiding caesarean section and mortality. The practice of food intake reduction, while rational for the participants when in Somalia, was found less rational in Sweden and may lead to suboptimal obstetric surveillance.Somalian women have childbirth strategies that differ from those of Swedish women. These strategies should be seen as 'survival behaviours' related to their background in an environment with high maternal mortality. The hypothesis generated is that there is a relationship between the strategies during pregnancy and adverse perinatal outcome among Somalian immigrants. Considering the strong association of the habits to safe birth, it seems doubtful whether the women will change their habits as long as health care providers are unaware of their motives. We suggest a more culturally sensitive perinatal surveillance. Methods Participants Results Conclusions

BackgroundRising caesarean section (CS) rates have been observed worldwide in recent decades. This study sought to analyse trends in CS rates and outcomes among a variety of obstetric groups at a university hospital in a low-income country.MethodsWe conducted a hospital-based panel study at Muhimbili National Hospital, Dar es Salaam, Tanzania. All deliveries between 2000 and 2011 with gestational age ≥ 28 weeks were included in the study. The 12 years were divided into four periods: 2000 to 2002, 2003 to 2005, 2006 to 2008, and 2009 to 2011. Main outcome measures included CS rate, relative size of obstetric groups, contribution to overall CS rate, perinatal mortality ratio, neonatal distress, and maternal mortality ratio. Time trends were analysed within the ten Robson groups, based on maternal and obstetric characteristics. We applied the χ2 test for trend to determine whether changes were statistically significant. Odds ratios of CS were evaluated using multivariate logistic regression, accounting for maternal age, referral status, and private healthcare insurance.ResultsWe included 137,094 deliveries. The total CS rate rose from 19% to 49%, involving nine out of ten groups. Multipara without previous CS with single, cephalic pregnancies in spontaneous labour had a CS rate of 33% in 2009 to 2011. Adjusted analysis explained some of the increase. Perinatal mortality and neonatal distress decreased in multiple pregnancies (p < 0.001 and p = 0.003) and nullipara with breech pregnancies (p < 0.001 and p = 0.024). Although not statistically significant, there was an increase in perinatal mortality (p = 0.381) and neonatal distress (p = 0.171) among multipara with single cephalic pregnancies in spontaneous labour. The maternal mortality ratio increased from 463/100, 000 live births in 2000 to 2002 to 650/100, 000 live births in 2009 to 2011 (p = 0.031).ConclusionThe high CS rate among low-risk groups suggests that many CSs might have been performed on questionable indications. Such a trend may result in even higher CS rates in the future. While CS can improve perinatal outcomes, it does not necessarily do so if performed routinely in low-risk groups.

This study focuses on communication and conceptions of obstetric care to address the postulates that immigrant women experience sensitive care through the use of an ethnically congruent interpreter and that such women prefer to meet health providers of the same ethnic and gender profile when in a multiethnic obstetrics care setting. During 2005-2006, we conducted in-depth interviews in Greater London with immigrant women of Somali and Ghanaian descent and with White British women, as well as with obstetric care providers representing a variety of ethnic profiles. Questions focused on communication and conceptions of maternity care, and they were analyzed using qualitative techniques inspired by naturalistic inquiry. Women and providers across all informant groups encountered difficulties in health communication. The women found professionalism and competence far more important than meeting providers from one's own ethnic group, while language congruence was considered a comfort. Despite length of time in the study setting, Somali women experienced miscommunication as a result of language barriers more than did other informants. An importance of the interpreter's role in health communication was acknowledged by all groups; however, interpreter use was limited by issues of quality, trust, and accessibility. The interpreter service seems to operate in a suboptimal way and has potential for improvement.

SUMMARY1. Substrate utilization in the legs during bicycle exercise was studied in five subjects when performing intermittent intense exercise (15 sec work -15 sec rest) as well as continuous exercise during 60 min, with an almost identical average power output and oxygen uptake in both situations.2. Muscle biopsies were obtained from vastus lateralis at rest, during, and after exercise in order to determine intramuscular lipid and carbohydrate utilization. The contribution from blood-borne substrates to total oxidative metabolism was determined by arterial-femoral venous (a-fv) differences for oxygen, FFA, glucose, and lactate and leg blood flow.3. Intermittent and continuous exercise revealed a similar glycogen depletion and the intramuscular lactate accumulation was rather small. A similar uptake of blood-borne substrate (FFA, glucose) was found in both situations whereas a release of lactate only was observed in intermittent exercise.4. ATP and CP levels oscillated between work and rest periods in intermittent exercise but were not resynthesized to resting levels at the end of the rest periods. The mainly aerobic energy release during each work period in intermittent exercise is partly caused by myoglobin functioning as an oxygen store; this factor was calculated to be more important than ATP and CP or lactate level oscillations.5. The metabolic response to intermittent exercise was found to be similar to that found in continuous exercise with approximately the same average power output and oxygen uptake. This indicates that some factor in the intermediary metabolism, for instance citrate, functions as a regulator retarding glycolysis and favouring lipid utilization and an aerobic energy release in intermittent exercise. 40 B. ESSflN, L. HAGENFELDT AND L. KAIJSER

BackgroundPolitical violence and war are push factors for migration and social determinants of health among migrants. Somali migration to Sweden has increased threefold since 2004, and now comprises refugees with more than 20 years of war experiences. Health is influenced by earlier life experiences with adverse sexual and reproductive health, violence, and mental distress being linked. Adverse pregnancy outcomes are reported among Somali born refugees in high-income countries. The aim of this study was to explore experiences and perceptions on war, violence, and reproductive health before migration among Somali born women in Sweden.MethodQualitative semi-structured individual interviews were conducted with 17 Somali born refugee women of fertile age living in Sweden. Thematic analysis was applied.ResultsBefore migration, widespread war-related violence in the community had created fear, separation, and interruption in daily life in Somalia, and power based restrictions limited access to reproductive health services. The lack of justice and support for women exposed to non-partner sexual violence or intimate partner violence reinforced the risk of shame, stigmatization, and silence. Social networks, stoicism, and faith constituted survival strategies in the context of war.ConclusionsSeveral factors reinforced non-disclosure of violence exposure among the Somali born women before migration. Therefore, violence-related illness might be overlooked in the health care system. Survival strategies shaped by war contain resources for resilience and enhancement of well-being and sexual and reproductive health and rights in receiving countries after migration.