Kvinnohälsa i perspektiv : studier med barnmorskor och läkare samt med kvinnor som vårdbrukare : exempel från cervixcancerscreening och obstetrisk vård av omskurna kvinnor

In this thesis two areas of women's health are examined from different stakeholder perspectives. The areas are cervical cancer screening (CCS; articles I, III, V) and obstetrical care of circumcised/infibulated women (articles II, IV). The perspectives are those of midwives (articles I, II), gynaecologistslobstetricians (articles III, IV) and lay women (article V). The overall aim of the thesis is to investigate how different stakeholders describe and reason about these areas of women's health.

Study I: Midwives in antenatal clinics (ANCs) perform Pap smears in women attending the populationbased CCS program. The aim of study I was to investigate midwives' experiences of working with CCS. Semi-structured interviews were conducted with 21 midwives at seven ANCs. Results indicate discrepancies between ideals guiding the midwives and their practice in CCS. Positive aspects related to an ideology of care, whereas perceived negative aspects include a lack of congruence between midwives' ideology and the screening organisation, and a lack of professional familiarity with cancer and secondary cancer prevention.

In Study II, we aimed to investigate midwives' experiences of caring for circumcised women as well as perceptions and attitudes regarding female circumcision. Individual interviews and focus group discussions (FGDs) were conducted with 26 midwives in three labour wards and two ANCs. The findings are described in relation to the strong and contradictory emotions entailed in the care of circumcised women, midwives' reliance on the Swedish law when dealing with dilemmas in interactions with the women and their families, and the specific knowledge and skills needed when caring for circumcised women, which were often described as lacking.

Study III: The dynamics between individual health and health on a population level was examined in study III. The aim was to investigate how gynaecologists who practised in both public and private settings reasoned about CCS. Semistructured interviews were held with 17 gynaecologists. Results indicate ambiguity in the gynaecologists' descriptions of the purpose of both population-based CCS and smear testing in general. There were also differences in how they discussed women in regard to Pap smears, dependant on if they were seen as 'my patients' (in both public and private practices) or part of 'the population' (i.e. women unknown to the gynaecologist), with moral distinctions found in language usage related to attend an ce/no n-atte nd ance in screening.

Study IV: To complement the midwives' views on and experiences of caring for circumcised women in study II, study V was conducted to explore doctors' views and experiences of caring for circumcised women. Nineteen interviews with junior and senior physicians working in both ANC and hospital obstetric departments were analysed inductively. The findings indicate little consensus among the interviewed doctors on what constitutes good obstetrical care for circumcised women or how care should be provided, Major problems included inconsistent praxis & policy use, uncoordinated care trajectories, diffuse professional role responsibilities, difficulty monitoring labour & foetal status and inhibited communication due to language barriers, cultural differences and time constraints.

Study V: The aim of study V was to contextualise how women reason about health, ill health, health maintenance and disease prevention, to better understand their perspectives on cancer and cancer screening. Twelve FGDs were held with 48 women between 21-75 years. Results indicate that women's reasoning can be related to their ambivalent relationship to different aspects of control, noted in part by the 'high price' they ascribe to health maintenance. Whereas some women motivate their screening attendance as a means of maintaining control, others seem to abstain from screening which appears to threaten their sense of control. Women reasoned differently about mammography and CCS, contrary to assumptions guiding research in this area.

Discussion: Despite situation-specific differences between CCS and obstetrical care of circumcised women, a number of similiarities were found in these qualitative studies in the manner professionals, both midwives and doctors, reasoned about their experiences. Two notable commonalities were a relatively passive approach to obtaining new knowledge, although limits in existing knowledge were voiced, and the conceptualisation of the normal and the pathological as salient in professional role delineation. Women described health maintenance as complex, with information from professionals not matching their needs. In relation to screening, this may be related to the tension between population health and individual needs, also described by professionals.

List of scientific papers

I. Widmark C, Tishelman C, Lundgren EL, Forss A, Sachs L, Tornberg S (1998). "Opportunities and burdens for nurse-midwives working in primary health care. An example from population-based cervical cancer screening in urban Sweden. " J Nurse Midwifery 43(6): 530-40
https://pubmed.ncbi.nlm.nih.gov/9871385

II. Widmark C, Tishelman C, Ahlberg BM (2002). "A study of Swedish midwives encounters with infibulated African women in Sweden. " Midwifery 18(2): 113-25
https://pubmed.ncbi.nlm.nih.gov/12139909

III. Sarkadi A, Widmark C, Tornberg S, Tishelman C (2004). "The hows, whos, and whens of screening: gynaecologists perspectives on cervical cancer screening in urban Sweden." Soc Sci Med 58(6): 1097-108
https://pubmed.ncbi.nlm.nih.gov/14723905

IV. Widmark C, Leval A, Tishelman C, Maina Ahlberg B (2005). "Obstetrical care at the intersection of science and culture: a qualitative study of doctors perspectives on obstetrical care circumcised women in Sweden." (Submitted)

V. Widmark C, Lagerlund M, Maina Ahlberg B, Tishelman C (2005). "Cancer screening in the context of womens health: perceptions of body and self among women of different ages in urban Sweden." (Submitted)