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Our findings can serve to guide nurses and other healthcare providers' clinical approach to a subset of the population whose cultural beliefs and practices regarding reproductive health may be unfamiliar. Incorporating the perspective of the Somali Bantu women will facilitate the provision of person-centred care and ensure women receive appropriate, efficient and quality care that meets their needs, which may potentially reduce financial costs to the healthcare system.

Yet unknown is how they avoid obstetrical 17 interventions. This study sought to identify perceived protective mechanisms used to avoid obstetric 18 interventions as well as the underpinning factors that influence aversion to obstetrical interventions by 19 Somali refugee women. 20 Design: A descriptive, exploratory qualitative study purposively sampled Somali refugee women recruited 21 via snowball technique in Franklin County, Ohio, United States. Data was collected through audio-22 recordings of individual interviews and focus groups conducted in English and Somali languages. The 23 collected data were transcribed and analyzed using thematic analyses. 24 Results: Forty Somali refugee women aged 18 to 42 years were recruited. Participants reported engaging 25 in four perceived protective mechanisms to avoid obstetrical interventions during pregnancy and childbirth: 26 1) intentionally not seeking or misleading prenatal care, 2) changing hospitals and/or providers, 3) delayed 27 hospital arrival during labor, and 4) refusal of care. Underpinning all four avoidance mechanisms were their 28 significant fear of obstetrical interventions, and perceived lack of choice in their care processes as 29 influenced by: cultural and/or religious beliefs, feeling judged or undervalued by service providers, and a 30 lack of privacy provided to them while receiving care. 31 Conclusion: Like every woman, Somali women also have a right to choose or refuse care. If the intention 32 is to improve access to and experiences with care for this population, building trust, addressing their fears 33 and concerns, and respecting their culture is a critical first step. This should be well established prior to the 34 need for critical decisions surrounding pregnancy and childbirth wherein Somali women may feel 35 compelled to refuse necessary obstetrical care. Bridging gaps between Somali women and their providers 36 is key to advancing health equity for this vulnerable population.

This study examined maternal and reproductive health (MRH) access of Somali refugees in the U.S. across four access dimensions (willingness to seek care, gaining entry to the health system, seeing a primary provider and seeing a specialist). We conducted a cross-sectional survey of 427 Somali refugee reproductive-age women in Franklin County, Ohio. Following descriptive statistics of demographics, we conducted multivariate analyses to test associations between demographics and the four access dimensions. Most Somali refugee women were married (68%), attained primary education (92%), employed (64%) and were circumcised (82%). Young (OR 2.61, 95% CI 1.25-5.60), single (OR 1.78, 95% CI 1.15-2.78), and minors upon arrival (OR 2.36, 95% CI 1.44-3.90) were more willing to seek care. Lack of insurance, limited language fluency and being circumcised limited access to care across all dimensions. Barriers to access need to be systematically addressed. Deconstructing beliefs regarding health systems may improve access, especially among older Somali women.