Abstract
Women and motherhood are important aspects of the immigration issue. Different behaviour related to reproduction and maternity among foreign women, when compared with that of Italian women, is a key factor that has led to a slowing down of the population decline in Italy. Difficulties connected to migration often have impacts on motherhood, in some cases posing problems and conflicts with being a mother. This can result in frequent recourse to abortion, difficulty in managing sexuality and reproductive capacity, and the decision to postpone the realization of children indefinitely – situations that may provoke deep lacerations in the fabric of women's identity. One of the main problems for immigrant women in relation to pregnancy, childbirth and childcare is a profound sense of isolation: having been uprooted from their families, friends, and their own cultural references and traditions related to motherhood, and in some cases giving birth in aseptic hospitals with doctors and nurses who do not even speak their language, either alone or in the presence of a husband or a friend from the same country. Those who work in obstetrics and gynaecology departments are well aware that the number of foreign patients has increased significantly in recent years. From a practical point of view, this means that health professionals increasingly face new and often complex situations, and are forced to rely more on common sense than protocol. In a world afflicted by political and economic crises and an unequal distribution of wealth, in order to meet the health care needs of immigrants, we need to promote an appreciation of all of the different cultures, a bioethical approach, encouraging medical staff to convey feelings of hospitality and solidarity.
When women are feeling well, the whole world is better. (Amartya Sen)
The global economic crisis has certainly caused a reduction in migration flows but less than one might have expected, taking into account the extent and the length of the recession. The European Union (EU) continues to attract international immigrants, despite the poor economic situation that continues to plague many countries in the area. The different economic performances of the various member states have definitely influenced the number of immigrants: after a general setback in 2009, some countries, in fact, experienced a good level of economic recovery in 2010–11 and in the past two years have continued to have positive rates of recovery, even though they were limited. The EU country with the highest number of foreigners living in it is Germany (7.2 million), then Spain (5.6 million), Italy (4.6 million), UK (4.5 million) and France (3.8 million). All foreigners living in these five member states account for 77.3% of the total number of foreigners in the EU.
On 1 January 2013, in Italy there were 4,387,721 foreign residents, 334,000 more than the previous year (+8.2%). The distribution of foreign residents throughout the Italian territory is not uniform. A total of 86% of foreigners live in the North and Centre of the country, the remaining 14% live in the South. The largest increases during 2012, however, occurred in the South (+12%) and on the Islands (10.9%) (Caritas Migrants and Immigration XXIII Report, Citation2013).
Regarding their origins, the impression one had at the beginning of 2013 was similar to that of recent years, the Romanians were the largest immigrant community in Italy with a number close to 1 million residents or 21% of the total. The other EU citizens present in this country, however, had significantly lower rates.
However, on 1 January 2013, in Italy there were 3,764,236 citizens not from the EU, of which 49.3% were women and 24.1% were children. Albanians accounted for over 450,000, followed closely by the Moroccans. Then there were other historic communities such as the Chinese, Ukrainian, Philippine and Moldavian. The top five nationalities accounted for over 50% of the total number of foreign citizens in Italy.
Regarding gender, the Italian national statistics institute, ISTAT (Citation2008), has registered a steady growth in the total number of female non-Italian citizens. Expulsion factors (push factors), leading to an exodus from certain countries, combined with factors of attraction (pull factors), drawing immigrants to certain destinations, and factors of choice (choice factors) have led to an increase in female immigration. Today, women represent about 53% of the more than 4,300,000 foreigners living in Italy, thanks to regulations which favour the assumption/employment of domestic workers. According to ISTAT (Citation2008), the increase in birth rates over the years is mainly due to the contribution of foreign women. In fact, keeping pace with the increase in the number of immigrants living in Italy, the incidence of foreign births has led to a remarkable growth in the number of total births. This increase was recorded only in the Centre and in the North, while the South and the Islands experienced falling birth rates. However, in the Central and Northern regions, there have been increases ranging from 11% in Trentino-Alto Adige to 30% in Lombardy. A special case is that of Emilia-Romagna; in the mid-1990s this region had the lowest level of fertility, yet in 2008 an increase was recorded in births of over 50%. By contrast, in the South, between 1995 and 2008 the reduction in births continued with values of −5% in Sardinia and −21% in Basilicata. In 2012, on average female Italian residents had 1.42 children, in line with the decrease observed in Italy in recent years. The increase in fertility recorded in Italy in the second half of the 1990s had therefore suffered a setback, after reaching the highest level of 1.46 children per woman in 2010. This reduction in fertility affected Italian women, whose birth rates fell from 1.34 children per woman in 2008 to 1.29 children per woman in 2012, and foreign women, whose birth rates fell from 2.65 to 2.37 children per woman, respectively (ISTAT Report, Citation2008, Citation2013).
In an increasingly multi-ethnic society, health care for foreigners has become one of the most important challenges. In 60% of all cases, foreign woman first come into contact with the Italian health service when they are pregnant. The presence of immigrants requires an evolution in the organization of the traditional health services. At the beginning these services for immigrants were necessarily structured as “dedicated services”, even though now, more and more, they have been incorporated within services aimed at all citizens, and this is a step in the right direction towards integration and equality in citizenship. In this sense, health services can represent not only a place of exchange between different cultures, but also an opportunity for reducing differences and promoting non-discrimination and total integration (Andreozzi, Citation2003).
Madeleine Leininger, founder and leading exponent of trans-cultural nursing, stated that to work effectively with people from different cultures, we should first be aware of our own cultural heritage, so that it can serve as a tool for understanding other cultures. Through understanding we are able to respect people's differences while recognizing their similarities, thus enabling us to respond appropriately to their needs. Every person who migrates from one country to another must process changes, accompanied by opposing feelings related to departure and the impact of the host society (Geraci, Citation2001; Geraci, Boncioni, & Martinelli, Citation2010; Mazzetti, Citation2003).
In order to effectively meet health care needs, health care professionals should seek to acquire a thorough knowledge of the patient and his/her cultural background, thereby getting a feel also for their expectations. The trans-cultural approach allows the cancellation of the being a foreigner aspect, and deals with the problems of cultural otherness, either at the moment of diagnosis, when trying to establish what the person is suffering from, or at the prescriptive moment, when wondering how best to help him/her. On 16 January 1998, the National Committee for Bioethics, when discussing bioethical issues in a multi-ethnic society, broadly stated that the coexistence of a plurality of ethnic groups in the same territory raises many problems that impact on several levels, from the sociological to the psychological, the cultural anthropological to the ethnological and from the legal to the political. The first principle that must guide bioethical reflections and biomedical practices is respect for all human beings, regardless of cultural or ethnic background. The second guiding principle is the basic equality of all men, ratified in the Declaration of Human Rights – something that should be acknowledged by all cultures. The identity of a person's native culture has a value that must be known and understood. These two principles require continuous effort, practical comparisons, intermediation and a constant search for solutions, not only political but also cultural and educational ones. A major bioethical concern is the provision of conceptual tools and effective proposals to ensure that there is no discrimination regarding access to health care facilities for the prevention, diagnosis and treatment of illnesses, and that there is tolerance of all culturally diverse people and that no one is marginalized (Sgreccia, Citation2007; “Parere del Comitato Nazionale per la Bioetica su problemi bioetici in una società multietnica”, 16 gennaio 1998).
The formulation of ethical standards for the regulation of health policy and biomedical practices requires a pluralistic and interdisciplinary approach. The interdisciplinary feature allows accurate access to information regarding emerging problems, and the identification of any common and relevant elements, areas of similarity or compatibility, in order to enhance integration and a meeting point between the two cultures. Constant comparisons and the need to find common and convergent solutions are increasingly important since cultural diversity is becoming a common part of national identities and most bioethical issues cannot be dealt with and resolved by operating within limited spheres, but require a supranational dimension (think of environmental issues).
In general, health profiles show that the state of health of the immigrant population in Italy is worse with the risk of preterm birth at 24%, perinatal mortality at 50% and congenital malformations at 61% (Bollini, Pampallona, Wanner, & Kupelnick, Citation2009). In the course of this study, it was interesting to analyse differences in health between Italian and foreign women, in relation to the different policies for welcoming and integrating immigrants into the social fabric of host countries. To this end, the rate of citizenship was used as a synthetic indicator of integration, and these were obtained from the publications of the Organization for Economic Cooperation and Development (OECD). Countries with strong political integration (Belgium, Denmark, Norway, Netherlands and Sweden) were then compared to countries with weaker integration policies (Austria, France, Germany, Italy, UK, Spain and Switzerland). The results showed that in the former group, there were similar health conditions between indigenous and immigrant mothers; while in the latter group, the health conditions of immigrant women were significantly worse (Geraci, Citation2001; Geraci et al., Citation2010). In Italy, there have been several studies on pregnancy among foreign women, with results not dissimilar to those reported above. In particular, the National Institute of Health conducted two surveys on assistance during pregnancy, the first in 1995–96 and the second in 2000–2001, which showed a higher risk of reduced prenatal surveillance for immigrant women when compared with that received by Italian women, with early follow-up delayed by one month and considerably less frequent controls. A multi-purpose survey conducted by ISTAT in 2005, confirmed the persistence of these differences, even though in progressive attenuation: for example, the percentage of immigrant women who attended the first visit after the first term of pregnancy had decreased by 12% (compared with a 5% reduction in Italians); similarly, only 69% of foreign women had an ultrasound scan within the third month of pregnancy, compared with 88% of Italian women (Istituto Nazionale di Statistica, Citation2008). The following examples serve to illustrate different behaviour and ideas related to pregnancy observed in different nationalities: Chinese women, for example, generally continue to work at a very fast pace. They have a high tolerance of pain during labour and rarely show their emotions. Arabic women believe that medical examinations and early ultrasounds can be harmful to the fetus and rarely go to the gynaecologist before the end of the first term of pregnancy. They also tend to reduce physical activity, increase their intake of food rich in carbohydrates and put on more weight. South American and Philippine women seem to become more familiar with Western management; they are diligent in arranging and attending medical examinations. Hyperemesis gravidarum affects far more foreign women than Italians and lasts for a longer period, and is possibly psychosomatic. In addition, among foreign women the frequency of spontaneous abortion is higher in the first term and the threat of premature delivery in the third term. Differences in behaviour are even more evident in the delivery room where woman tend to react differently according to their ethnic origins, culture and traditions. African women, for example, alternate songs and prayers with appeals for help in their native tongue, demonstrating both moments of sheer excitement and hyperactivity, and situations of complete abandonment, almost as though in a trance.
As pointed out by the World Health Organization (WHO, Citation2009), indicators of maternal and child health, including birth outcomes, are important tools for assessing the health status of a population. Furthermore, it is now internationally recognized that the health status of a population is determined largely by health care during pregnancy and at birth, and it is therefore essential to ensure that all women and their children receive equal access to medical services, regardless of race and social status, and that they are guaranteed safety and dignity.
Conclusions
Health must be regarded as a universal right of primary importance: it is an inalienable right recognized by declarations, conventions, international agreements and the Italian Constitution. Access to basic state assistance must be guaranteed to all. The health of every individual must be protected, regardless of race, thus protecting the health of the community as a whole. The protection of health today in Italy has now been extended in principle to protect legal immigrants also in cases of emergency.
Multiculturalism raises many problems and poses a challenge for general legal and ethical considerations since it highlights differences in our ideas of the world and of life that continually test principles of equality and difference.
A trans-cultural approach to treating immigrant women is necessary, one that takes into account the different ways that certain diseases and pregnancy are regarded by different cultures. This is particularly important when selecting appropriate therapeutic interventions, the effectiveness of which is largely determined by the relationship of trust between the health professional and the patient. Lack of assistance for pregnant immigrant women in Italy is one of the many problems of the health care system. And there is little doubt that giving birth in a foreign country, far from family and friends, often in precarious conditions, with little or no emotional or psychological support, where the climate and the food are different, and where little of what is being said around you is understood, provokes a condition of disadvantage and unease. Then, of course, there are the difficult working conditions, small inadequate living spaces, often shared with other families or immigrants, limited access to health and social services, all of which impact on the health and the reproductive success of women, as recorded by various surveys conducted in Italy (Lombardi, Citation2004). Therefore, migration often poses problems and conflicts with being a mother, which leads to frequent recourse to abortion, and difficulty in managing sexuality and reproductive capacity, with many women deciding to postpone the realization of children indefinitely – thereby creating lacerations in their very identity.
One of the main problems for immigrant women in relation to pregnancy, childbirth and childcare, is a profound sense of isolation: having been uprooted from their families, friends, and their own cultural references and traditions related to motherhood, in some cases giving birth in aseptic hospitals with doctors and nurses who do not even speak their language, either alone or in the presence of a husband or a friend from the same country. In their countries of origin, mothers, sisters and other female relatives would have supported them during pregnancy, transmitting knowledge, providing care, reassurances and practical assistance in preparing food etc. – generally assisting with problems as they arise. The pregnant woman is shielded from worries and, in some countries, is taken to holy places to meet healers or people who know how to prescribe rituals for protection. In other cultures, it is not considered fortunate to talk about either the birth or the baby beforehand. Conception, pregnancy, birth and breastfeeding are all deeply linked with culture. If culture includes everything that human beings learn from the moment of birth, then mothers are the first transmitters of culture; birth is full of symbolic gestures designed to transmit cultural messages. This is so even in Western countries, where the medicalization of birth has made it increasingly difficult to recognize the meaning of ritual gestures because they have been veiled by scientific and technical procedures (Davies-Floyd & Sargente, Citation1997).
From birth, mothers introduce babies into the world by the way they hold them in their arms, touch them, talk to them, feed them, teaching them how to relate to people, thereby conveying their vision of the world, so that the child internalizes its mother's perception of the world and shapes its own “skin culture” or cultural package (Nathan, Citation1996). The child's internal culture corresponds to that of the family and the community. The group strengthens and affirms the child's behaviour; the community supports the mother in her role as carrier of the culture. In her community, she is supported by the women of the family, her mother, sisters, sisters-in-law, godmothers, etc., and learns how to become a mother according to the model provided by society. The way the mother nurtures her baby, how she feeds it, washes it and lulls it to sleep, is determined by culture. In most cultures, rites of protection are performed for the child and the mother; in all cultures, birth is an important moment of initiation, because it marks the transition from one generation to the next, and is a period of particular vulnerability, which requires the support of the group. Children will grow up with a stronger sense of identity within a solid cultural group, because the internalized culture of the child is the culture of the group, each consolidating one another (Moro, de la Noe, Mouchenik, & Baubet, Citation2009). Migration produces complex situations for all migrants and particularly for mothers. When there is no correspondence between one's internal and external culture, this can lead to trauma, since there is no longer certainty and familiar references. This uncertainty and insecurity is defined by Moro et al. (Citation2009) as “processing loneliness” and causes young mothers great distress and deep uncertainty about what to convey to the child. The outside world is unknown and is often experienced as hostile; the child will grow up in another country and consequently the mother does not know which language to adopt and the whole process of transmission is marked by great insecurity. According to Moro et al.'s research, the fragility of the mother can also be transmitted to the child. With foreign women, their original culture should be reinforced. Some families often adopt practices that are part of their traditions, to maintain the ties with their country of origin, and it is only by recognizing the value of these behaviours that one is able to establish relationships of trust, which are of great importance when seeking to support these women (Parolai & Sacchetti, Citation2001). The lack of cultural and psychological belonging experienced by most immigrant woman should never be overlooked by the health professionals and others involved in their care. Nevertheless, women who do not belong to our culture face pregnancy and childbirth with greater confidence. Some immigrant women neglect to have periodical check-ups during pregnancy, not perceiving them to be essential: pregnancy is considered a natural event which does not require any particular clinical surveillance. To a great extent in Italy, these women receive state health care during pregnancy: a large proportion were assisted in state facilities (38.3% compared to 13.7% of Italians). There is some additional information on the possibility of foreign women having tests for prenatal diagnoses. African immigrants of medium–low education are more likely to have regular ultrasound scans than regular check-ups: ultrasonography holds great fascination for women all over the world. For African and Middle Eastern women, motherhood represents a fundamental aspect of their life and is essential for the social recognition of their role. In these cultures, the role of motherhood carries a greater weight than in Western society, where women are not made to feel inadequate or excluded if they do not form a family (Donati, Grandolfo, Patriarca, & Spinelli, Citation2001; Spinelli et al., Citation2003). There are also different expectations: in Western women, because there are numerous examinations during pregnancy, they tend to expect the “perfect child” and since diagnostic tools get more and more sophisticated, they are considered infallible, whereas the expectations of most foreign women are undoubtedly lower. Given that there are stark contrasts between the original culture and that of the host country, it is advisable to build a network to reduce the sense of loneliness that many of these women experience. In Italy, the percentage of foreign women who gave birth via caesarean section was lower (24.9% vs. 35.9%), although this was higher than the 15% maximum level indicated by WHO (Citation2009). Many consider this to be a medical intervention that can endanger life and it goes against their idea of a natural birth. These women prefer it to happen in a natural way, to endure the pain and to gain the respect of the entire community, thus elevating their own position.
Welcoming migrant mothers and creating a relationship of trust and mutual understanding can also be the way to resolving another important issue, that of female genital mutilation (FGM). Today in Italy, it is estimated that 8000 girls are at risk and are likely to undergo mutilation during a trip to the country of origin of their parents or secretly in Italy (this is an illegal practice). FGM, in any form, is internationally recognized as a serious violation of human rights.
Any type of FGM has serious adverse effects that require medical care and attention. FGM denies girls and women the right to:
physical and mental integrity
freedom from violence
the best possible state of health
freedom from sexual discrimination
freedom from torture and cruel, inhuman degrading treatments.
We need to promote a conscious bioethical approach to understanding different cultures and preparing medical staff for their arrival, with hospitality and solidarity, in a context of trans-cultural medicine, which respects professional ethics and the law.
References
- Andreozzi, S. (2003). Immigrati e zingari: salute e disuguaglianze. Roma: Istituto Superiore di Sanità (Rapporti ISTISAN 03/4).
- Bollini, P., Pampallona, S., Wanner, P., & Kupelnick, B. (2009). Pregnancy outcome of migrant women and integration policy: A systematic review of the international literature. Social Science & Medicine, 68, 452–461. doi: 10.1016/j.socscimed.2008.10.018
- Caritas e Migrantes. (2013). XXIII Rapporto Immigrazione.
- Davies-Floyd, R. E., & Sargente, C. (1997). Childbirth and authoritative knowledge: Cross-cultural perspectives. Berkeley: University of California Press.
- Donati, S., Grandolfo, M. E., Patriarca, V., & Spinelli, A. (2001). Analisi epidemiologica dell'evento nascita e valutazione dell'assistenza a gravidanza, parto e puerperio. Nascere nel 2000. Bologna: Il Mulino.
- Geraci, S. (2001). Approcci transculturali per la promozione della salute. Argomenti di medicina delle migrazioni Caritas di Roma. Roma: Anterem.
- Geraci, S., Boncioni, M., & Martinelli, B. (2010). La tutela della salute degli immigranti nelle politiche locali. Roma: Inprinting srl [PDF:1,2 Mb].
- Immigrazione Dossier Statistico. (2008, 2009). Caritas/Migrantes. Idos, rapporti.
- Istituto Nazionale di Statistica. (2008). Salute e ricorso ai servizi sanitari della popolazione straniera residente in Italia. Anno 2005. Statistiche in breve. ISTAT [PDF: 234 Kb].
- ISTAT- Rapporto annuale. (2008). Immigrazione tra nuovi flussi e stabilizzazioni.
- Lombardi, L. (2004). Donne immigrate e salute riproduttiva tra modelli culturali e condizioni sociali. Working Papers del Dipartimento di studi sociali e politici 15/12/2004 Università degli studi di Milano http://www.sociol.unimi.it/papers/lombardi.pdf
- Mazzetti, M. (2003). Il dialogo transculturale. Manuale per operatori sanitari e altre professioni di aiuto. Roma: Carocci.
- Moro, M. R., de la Noe, Q., Mouchenik, Y., & Baubet, T. (2009). Manuale di psichiatria transculturale. Dalla clinica alla società. Milano: Franco Angeli Edizioni.
- Nathan, T. (1996). Principi di etnopsicanalisi. Torino: Bollati Boringhieri.
- Parere del Comitato Nazionale per la Bioetica su problemi bioetici in una società multietnica.16 gennaio 1998.
- Parolai, L., & Sacchetti, G. (2001). Donne immigrate: gravidanza e maternità. Roma: Carocci.
- Rapporto ISTAT. (2013). La popolazione residente in Italia – Bilancio demografico. www.istat.it
- Sgreccia, E. (2007). Manuale di Bioetica. Milano Vita e pensiero.
- Spinelli, A., Grandolfo, M., Donati, S., Andreozzi, S., Longhi, C., Bucciarelli, M., & Baglio, G. (2003). Assistenza alla nascita tra le donne immigrate. Roma: Istituto Superiore di Sanità. (Rapporti ISTISAN 03/04).
- World Health Organization. (2009). World health statistics. Geneva: WHO.