Annemiek Richters

Ethnic disparity in severe acute maternal morbidity: a nationwide cohort study in the Netherlands

BACKGROUND There are concerns about ethnic disparity in outcome of obstetric health care in high-income countries. Our aim was to assess these differences in a large cohort of women having experienced severe acute maternal morbidity (SAMM) during pregnancy, delivery and puerperium. METHODS All women experiencing SAMM were prospectively collected in a nationwide population-based design from August 2004 to August 2006. Women delivering in the same period served as reference cohort. Population-based risks were calculated by ethnicity and by type of morbidity. Additionally, non-Western and Western women having experienced SAMM were compared in multivariable logistic regression analysis. RESULTS All 98 Dutch maternity units participated. There were 371 021 deliveries during the study period. A total of 2506 women with SAMM were included, 21.1% of whom were non-Western immigrants. Non-Western immigrants showed a 1.3-fold [95% confidence interval (CI) 1.2-1.5] increased risk to develop SAMM. Large differences were observed among different ethnic minority groups, ranging from a non-increased risk for Moroccan and Turkish women to a 3.5-fold (95% CI 2.8-4.3) increased risk for sub-Saharan African women. Low socio-economic status, unemployment, single household, high parity and prior caesarean were independent explanatory factors for SAMM, although they did not fully explain the differences. Immigration-related characteristics differed by ethnic background. CONCLUSIONS Non-Western immigrants have an increased risk of developing SAMM as compared to Western women. Risks varied largely by ethnic origin. Immigration-related characteristics might partly explain the increased risk. The results suggest that there are opportunities for quality improvement by targeting specific disadvantaged groups.

Reintegration of former child soldiers in northern Uganda: coming to terms with children's agency and accountability

Reintegration processes of formerly abducted children have yielded limited success in northern Uganda. The article seeks answers to the question why reintegration processes in the area have failed. The approach of one Christian non-governmental organization towards reintegration is compared with the ideas and strategies of formerly abducted child soldiers and people in their communities on how best to deal with their violent past.

The epidemiology of spirit possession in the aftermath of mass political violence in Mozambique

In this article we assess the prevalence rates of harmful spirit possession, different features of the spirits and of their hosts, the correlates of the spirit possession experience, health patterns and the sources of health care consulted by possessed individuals in a population sample of 941 adults (255 men, 686 women) in post-civil war Mozambique in 2003-2004. A combined quantitative-qualitative research design was used for data collection. A major study outcome is that the prevalence rates vary according to the severity of the possession as measured by the number of harmful spirits involved in the affliction. The prevalence rate of participants suffering from at least one spirit was 18.6 percent; among those individuals, 5.6 percent were suffering from possession by two or more spirits. A comparison between possessed and non-possessed individuals shows that certain types of spirit possession are a major cause of health impairment. We propose that knowledge of both local understandings of harmful spirit possession and the community prevalence of this kind of possession is a precondition for designing public health interventions that sensitively respond to the health needs of people afflicted by spirits.

Community based sociotherapy in Byumba, Rwanda

A community based sociotherapy programme was implemented in the North of Rwanda in 2005. This article describes the background of sociotherapy, explains its principles and application in therapy for refugees in the Netherlands, and gives a justification for the introduction of the approach in a particular setting in post war and post genocide Rwanda. It then focuses on the development of the programme in this setting and addresses recruitment criteria for facilitators. It includes the qualities these facilitators and programme staff should have, the training process, the programme implementation, as well as the sociotherapy methods applied in the field with some examples from practice, the reception by the various stakeholders and the expansion to other areas. The article ends with a selection of the many challenges the programme faces.

Silencing distressed children in the context of war in northern Uganda: An analysis of its dynamics and its health consequences.

Children in northern Uganda who are the focus of this article were born and raised in the context of war. The research presented here is based on a one-year ethnographic study (2004-2005) with children aged 9-16 years. Various qualitative and quantitative methods used in this study were geared to this age group. A grounded theory approach was followed to trace the reasons for the silencing of their distress. Throughout the study a child actor perspective was implemented: children were approached as social actors capable of processing social experience and devising ways of coping with life. We found that their lives were characterized by high rates of exposure to extreme events, such as deaths, child abductions, disease epidemics, gender-based violence and poverty. As a consequence, their level of emotional distress was high. However, they did not readily speak about their distress. The article identifies and analyses a complex set of reasons for childrens distress and its silencing by the children themselves and other members of society. A distinction is made between the processes of victim blaming, self blaming, mimetic resilience and mirroring resilience. In addition, the consequences of the silencing children are presented. Children expressed their emotional suffering primarily in physical aches and pains and used pharmaceuticals and herbal medicines to minimize their distress. The result was a medicalization of psychological distress. In conclusion, we reflect on the necessity of a multi-pronged approach to address childrens distress.

When the war was over, little changed: women's posttraumatic suffering after the war in Mozambique

This article explores the psychosocial effects of womens prolonged exposure to civil war in the center of Mozambique. Using a combination of quantitative and qualitative methods, 91 women were assessed for posttraumatic stress symptoms and psychosocial indicators of ill health. The results indicate that for the majority of the women in this study, traumatic experiences are sequential processes. Their ill health ranges from symptoms of posttraumatic stress to episodes of spirit possession (gamba), affecting womens capacities to conceive and raise children, and marginalizing their social position. A careful analysis of the specific problems and needs of women in postwar contexts is recommended, along with a systematic examination of the effectiveness of the available resources that may play a role in boosting trauma recovery in this group of women.

Suffering of childless women in Bangladesh: the intersection of social identities of gender and class

Research has documented that, around the world, women who are childless against their will suffer from an array of social, economic and emotional difficulties. The causes of this suffering are primarily related to their gender position in society and their gender identity. This paper addresses the impact of class differences on the gender-related suffering of childless women in the socially very hierarchically structured society of Bangladesh. The main method was gathering life histories of illiterate rural poor childless women and educated urban middle-class childless women. The rural childless women experience strong stigma in society, as their identity is devalued due to their inability to produce children. As a result, they suffer from feelings of guilt, role failure, loss of self-esteem, abandonment by the family, social isolation, and impoverishment. In contrast, because of their relatively high socio-economic status and good educational background, urban childless women have more opportunities to avail themselves of alternative social identities and thus avoid social isolation. Despite these differences, both groups of women lead frustrated lives, burdened with a deep sense of guilt for not being able to produce children.

Agricultural cycle and the prevalence of posttraumatic stress disorder: A longitudinal community study in postwar Mozambique

The influence of physical activity on the prevalence and remission of war-related mental disturbances has never been systematically evaluated. This study examined the influence of participation in the agricultural cycle on the posttraumatic stress disorder (PTSD) prevalence and correlated symptoms longitudinally in post civil war Mozambique. Prevalence rates were examined in the end and the outset of the agricultural cycle in a community population (N = 240). The agricultural cycle, which is characterized by fluctuations in physical activities, social connectedness, and the sense of purpose in life influences the PTSD prevalence and correlated symptoms. By studying the influence of the agricultural cycle on PTSD prevalence, severe PTSD cases that fail to respond to the agricultural cycle can be identified, and subsequently evaluated regarding the need for specialized care.

It's in my blood : the military habitus of former Zimbabwean soldiers in exile in South Africa

This article examines the habitus of soldiers who either deserted or resigned from the Zimbabwe National Army in the post–2000 crisis in Zimbabwe and now live in exile in Johannesburg, South Africa. It is based on the information provided by forty-four former soldiers who related their life histories and participated in informal conversations and group discussions. A main finding is that these men, even though they have left the army, hold on in the extreme to their being as soldiers. This is shaped by at least four, interlinked dimensions of change in their lives: leaving the army without honorable discharge, leaving Zimbabwe itself, being exiles in an often unwelcoming South Africa, loss of family life and military status. The post-deployment dominance of military dispositions in the identity of the former soldiers is quite unique. Most former combatants worldwide have succeeded in different degrees to unmake their habituated forms of military identity or live with multiple identities.

Sexual transgression and social disconnection: healing through community-based sociotherapy in Rwanda

A distinguishing feature of the 1994 genocide against the Tutsi and the preceding 1990–1994 war in Rwanda was the social intimacy of the crimes committed. The legacy of this kind of violence includes distrust in social relations within communities and families, an increase of violence in everyday social interaction, transgressive sexual engagements, and a range of psychological problems. Many people feel nostalgia for their past social life, but are unable to change their current situation. In 2005, a community-based sociotherapy programme was introduced into this context of mental and social distress. The goal was to help people regain feelings of dignity and safety and to reduce distress. This paper is based on qualitative research, in particular, case studies. It explores how sociotherapy, as a specific form of peer group counselling, may facilitate the healing of suffering related to issues of sexuality, violence within the family and the breakdown of social connections on a community level.