Clinician Perceptions of Somali-American Patients in Specialized Maternal-Fetal Care

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Methods: We conducted an electronic survey during a 17-month period (January 2023 – May 2024) and performed a qualitative analysis to report thematic findings. Results: Forty-two respondents in a variety of clinical roles from 9 unique institutions throughout the Twin Cities and Rochester, MN, completed the survey. The majority of respondents were white (91%) with greater than 10 years of clinical experience (57%). Five themes were identified to describe the clinician respondents’ perceptions of providing maternal fetal care for Somali-American patients: 1) concerns surrounding language barriers and translation accuracy, 2) perceived importance of Islamic faith in the patient’s decision-making, 3) the reality of incorporating multiple social influences in decision-making, 4) recognition of mistrust in care and skepticism regarding prenatal diagnoses, and 5) a desire to provide equitable care to this patient population. Conclusion: The clinician respondents recognized that Islamic faith and community input are fundamental to a Somali-American patient’s decision-making process for their pregnancy, and stressed concerns surrounding language barriers, translation accuracy, and medical mistrust. This work emphasizes the desire and need to develop cultural education and clinician training resources to support informed patient-centered care for Somali-American families in a maternal-fetal care setting. maternal-fetal healthcare Somali-Americans clinician perspectives culturally competent care medical decision-making Introduction Somalia has faced significant humanitarian crises over the last 30 years due to civil war, climate emergencies, and disease outbreaks. Healthcare challenges in Somalia include poor medical infrastructure, shortages of medical professionals, and limited access for rural impoverished communities [ 1 , 2 ]. These factors have led to Somali resettlement of approximately half a million individuals in North America and Europe, with the majority residing in the United States, United Kingdom, and Scandinavia [ 3 , 4 ]. Despite migration to low-mortality/high-resource settings, healthcare disparities in pregnancy continue to impact the Somali diaspora [ 5 , 6 ]. Previous research has reported that Somali immigrants are skeptical of preventative care models and mistrust Western prenatal care. In Somalia, informal care models (e.g., in-home doulas/midwives) and delaying medical care until symptomatic are the cultural norm, and Somali immigrants may not be accustomed to preventative healthcare [ 7 ]. When receiving Western prenatal care, Somali-American women have reported feeling anxious, suspicious, pressured, and victimized by discrimination [ 8 – 10 ]. In addition, language barriers, limited medical literacy, and misunderstandings surrounding traditional cultural values and their Islamic faith amplify the mistrust [ 11 – 15 ]. Western medical providers’ lack of training and experience with female circumcision adds further complexity [ 6 , 16 , 17 ]. Unwelcoming and stressful experiences may leave patients unwilling to participate in future pregnancy care [ 9 , 11 ]. Somali patients undergoing specialized maternal-fetal care may experience additional hurdles [ 11 , 18 ]. Early prenatal diagnosis often involves patient monitoring/imaging appointments throughout the pregnancy, and in some cases, the option of fetal intervention. Comprehensive care plans for fetal diagnoses typically include recurring interactions with staff across several medical specialties [ 19 , 20 ]. Previous research on specialized fetal care highlights the importance of trust and effective communication between the patient and clinical team, which affects the family's perception and ability to cope with the diagnosis [ 19 – 21 ]. Building trust through positive experiences during prenatal care is especially important for these families, as a fetus diagnosed with an anomaly will likely require ongoing medical care throughout the child’s lifetime. Minnesota is home to the largest Somali population outside of Somalia, and our specialized maternal-fetal centers routinely see Somali-American patients. Our center previously described a group of Somali-American women’s experiences with specialized maternal-fetal care [ 11 ]. In the present report, we consider the caregiver. We describe the perspectives, experiences, and perceived barriers/facilitators to care shared by maternal-fetal care professionals caring for our Somali-American community using qualitative data from an electronic survey. Materials and Methods Study Design This was a qualitative data collection study using an electronic survey. This study was approved by the [ Blinded IRB info ]. Survey respondents provided electronic informed consent at the beginning of the survey. Study data were collected and managed using a Research Electronic Data Capture (REDCap) questionnaire hosted at [ Blinded Institution ], Minneapolis, MN [ 22 , 23 ]. The survey questionnaire was developed collaboratively by the authors during a series of preparatory meetings. The questionnaire queried participants' demographics, background understanding of the Somali-American community, experiences caring for these patients, and barriers, facilitators, or concerns about caring for Somali-American patients. We partnered with local institutions to distribute the survey electronically to maternal-fetal healthcare professionals at their centers. The survey was open for 17 months (January 2023-May 2024). Data Synthesis Respondent demographics were reported using descriptive statistics. Data from individual qualitative responses were coded by three trained authors using thematic analysis techniques with qualitative analysis software (Dedoose Version 9.0.107, Los Angeles, CA: SocioCultural Research Consultants, LLC) [ 24 , 25 ]. The primary coders used inductive coding methods to analyze the data, creating codes based on the data, not a predetermined list. First, each coder assigned codes to specific words or phrases in the text. These codes were reviewed for consensus between the three coders. Next, the individual codes were grouped into broader themes, which are presented below alongside supporting direct quotations from the respondents. Results Forty-two healthcare professionals completed the survey; Table 1 summarizes the demographics and professional experience of the respondents. Various clinical roles and specialties are represented from nine institutions throughout the Twin Cities and Rochester, MN. Most respondents were white (91%) with greater than 10 years of clinical experience (57%) in their field. Five themes were identified in the qualitative analysis. An expanded selection of respondent quotations is provided in the Supplemental Material. Language Barriers Respondents identified language barriers as a significant hindrance when managing complex pregnancies in Somali-American patients. Their concerns included translation accuracy, the quality and availability of in-person interpretation, lack of interpreter training in maternal-fetal diagnosis, appointment time constraints, the need to simplify medical language, and interpreter gender discordance. All respondents reported needing a medical interpreter to communicate with Somali-American patients (always=16, frequently=18, sometimes=8). Many respondents reported difficulty conducting appointments in another language, and 25 (61%) respondents identified the language barrier as significantly impacting their care of Somali-American patients. There were 26 mentions of a lack of quality in-person interpreters, while several respondents mentioned that in-person interpretation facilitated care. “I do not feel like I provide equivalent care to Somali-American patients - there is a cultural barrier, a language barrier, and what feels like a chasm between the patient and provider. I feel like due to these limitations; they receive limited counseling and I am unable to confirm their understanding of the fetal findings and care plan.” “[W]hen we have an in-person interpreter it makes the visit go more smoothly, along with information that we relay to patients. The patients feel more comfortable when there is an interpreter present.” Respondents expressed concerns about translation accuracy and about trusting the communication of complicated medical diagnoses through an interpreter. Numerous respondents stressed the need for interpreters to be trained in specialized obstetric and fetal topics. “I do not always trust that the interpreter is either accurate or unbiased. This has become evident when I have had returning Somali-American patients return and they seem to have a different understanding of what was previously discussed.” “[W]hen we have a very knowledgeable Somali interpreter that the patient is comfortable with and that understands the medical terminology and can explain it well to the patient, they are more willing to participate.” Many respondents experienced time constraints in appointments with Somali-speaking patients due to the time needed for translation. Additionally, many respondents felt the need to simplify their language during counseling to better communicate through an interpreter. Longer appointment times was suggested as a solution. “I often find that I am simplifying the information I am presenting, and sometimes not able to present the same depth of information as I would to an English-speaking patient.” “Our leadership recognizes that some women do take longer in their visit, especially if an interpreter is utilized, and we are given more time in the schedule to care for these families.” Several respondents stated that using male interpreters may pose difficulties for female patients, who they felt would be more comfortable with a female interpreter. “If the in-person interpreter is a male then it may hinder conversation based on the traditional Somali value of women's privacy.” Islamic Faith Most respondents perceived faith identity as very important to Somali-Americans, with the Islamic belief of predetermination (“God’s will”) creating hesitance about intervention (e.g., fetal surgery). Respondents reported that Somali-American families want to do what is best for their baby, but their view of how intervention intersects with divine will affects their medical decision-making. This presented a challenge for some respondents, as non-Judeo-Christian faith values are typically not integrated into Western medicine. “Their faith in God surpasses belief in Western Medicine. When discussing fetal concerns with Somali-American patients they may not either believe the information discussed, or choose to believe that it is God's will and that everything will be okay.” “Some are resistant to learning about the diagnosis and have full belief in God's will. Others are open to medical recommendations.” Multiple Opinions in Medical Decision-Making Respondents reported other influences on medical decision-making in Somali-American patients, including family, elders, faith leaders, the greater community, and patriarchal cultural values. Respondents noted that Somali-American patients were family-oriented and aspired to have large families. Twenty-one respondents mentioned observing strong family ties. Most respondents felt these patients had a strong sense of community, potentially including elder input, and that this can be an asset or a challenge when consolidating multiple viewpoints. “Since they do often have a large community of support, there is also a large community of opinions. I do feel they get "caught in the middle" of community opinion and medical opinion.” “I presume extended family is included if they aren't present, but are referenced - and spiritual or community leaders. This is not always the case and there is variation within the Somali-American families I have worked with.” Many respondents shared that families displayed patriarchal values, with nine mentioning that male family members lead medical decision-making. “Male partners/family members are the main decision-makers in the household/community” “Paternal driven, although it seems that the patient does have input - seems cultural to defer a decision until spoken with husband, but tends to follow what the woman wants eventually.” Some respondents expressed hope that the pregnant person has autonomy in their medical decisions, and some mentioned that patriarchal values have become less prevalent over time. “Historically, most of my experience with the Somali-American families have involved medical decisions being made by the patient's husband, elders, and/or community leaders. This has been difficult to accept by some of us care providers as ultimately we feel the decisions should be made by the patient we are directly caring for… I also feel more Somali women are becoming more "independent" so some of them are making decisions on their own now.” Mistrust in Care Respondents felt Somali-American patients mistrusted Western medicine, were skeptical of prenatal diagnoses, and that trust between patient and provider must be built through effective communication and culturally competent care. Respondents acknowledged that failure to secure their patients’ trust could result in reluctance to engage in care. Respondents found that some families were reluctant to believe a prenatal diagnosis, and may wait until after delivery before developing a care plan for their child. “They are frequently mistrustful of Western medicine due to personal experiences or stories they've heard from trusted family members/friends.” “[T]here is a lot of hesitation to accept these interventions and it often takes days or weeks of discussing it and building trust.” “[M]any families are very willing to come in for ultrasounds, however do not believe diagnosis during pregnancy or make plans for what may happen for baby after birth.” Desire to Provide Equitable Care Respondents consistently stressed a desire to provide more equitable care for Somali-American families. Some acknowledged that clinicians should endeavor to understand Somali patients’ cultural viewpoints, that more Somali-American clinicians are needed, that engagement with the community is needed to facilitate peer-to-peer support, and that additional assistance should be provided to under-resourced families. Many respondents expressed concern about cultural miscommunications, especially regarding perceived risk or proposed care plans. Multiple respondents requested cultural competency training and learning opportunities in partnership with the Somali-American community. “I worry about being sensitive to their needs and ensuring I am not saying something that may be perceived incorrectly (ex. trying to explain/plan for a suboptimal outcome with frustration from the patient because only Allah knows what will happen).” “More training on how to approach decision-making, how to review bad news or recommendations in a way that is more respectful and supportive of the patients and their families.” Many respondents advocated that hiring Somali-American clinicians is critical to addressing inequitable care. Several respondents requested clinic-employed cultural liaisons for peer-to-peer support. Partnership with a hospital-appointed faith leader (Imams) was reported as a useful resource. “We need to have a Somali representative that currently works with perinatal patients, who understands the lingo.” The low socioeconomic status of some Somali-American families was identified as a challenge in managing complex pregnancies, with transportation cited as a barrier to attending appointments. Several respondents noted that Somali-American families are large, and it can be difficult to attend prenatal appointments when children are not permitted. Twelve participants mentioned childcare as a barrier to women attending appointments. “I have also noticed that childcare and transportation appear to be common problems listed by patients for getting to appointments.” Discussion This study surveyed maternal-fetal healthcare professionals about their experiences treating Somali-American patients. Common themes were that Islamic faith and community input are fundamental to patients’ decision-making processes, that language barriers, translation accuracy, and medical mistrust are significant concerns, and that clinicians desire to provide equitable care to this patient population. Our findings can guide future initiatives to improve the quality of care for Somali-American patients and create targeted educational resources to equip clinicians to provide this care. The difficulty of delivering medical advice and care across a language barrier is widely noted. In a systematic review investigating language barriers in healthcare across many countries, Shamsi et al. found that language barriers cause miscommunications between provider and patient that affect patient satisfaction and decrease the safety and quality of care [ 26 ]. Many studies demonstrate the negative effects of language barriers on the care of Somali-American patients, primarily the risk of miscommunication compounded by poor health literacy [ 10 , 27 , 28 ]. Furthermore, the specialized concepts and terminology in obstetrics present additional challenges. For example, discussions surrounding genetics and fetal development/anatomy are extremely uncommon in the Somali language [ 18 ]. For our respondents, conducting appointments in another language was extremely frustrating, and the lack of quality, in-person interpreters and appointment time constraints added to the difficulty. In a similar finding by Lazar et al. , obstetric clinicians expressed concerns about the quality of interpretation for their Somali-American patients [ 16 ]. Similarly, in our previous study, Somali-American community members shared that effective communication across a language barrier is critical, and that they prefer having healthcare providers who share their cultural background when making medical decisions [ 11 ]. In the present study, several respondents also mentioned that interpreter gender discordance, particularly the use of a male interpreter for a female pregnant person, may be uncomfortable for Somali-American patients. This agrees with previous reports that Somali-American women prefer female providers and interpreters, particularly when physical exams are conducted [ 11 , 29 ]. As a possible solution, our respondents proposed longer appointment times with a consistent, in-person, female interpreter with training in specialty obstetrics and fetal diagnoses. Alternatively, involving a female Somali-American patient advocate (i.e., hospital-provided community peer) may help patients navigate specialty maternal-fetal care. Providing culturally sensitive patient-centered care can build trust with Somali-American families and encourage future health-seeking behaviors. Multiple respondents reported that male family members lead decision-making, in contrast to our previous work, where female Somali-American community members said the pregnant person makes the final medical decisions [ 11 ]. It is possible that the pregnant person maintains autonomy in the treatment choice after discussion with her support system and then may communicate the decision through a male partner. This discordance highlights the need for clinician education regarding Somali family dynamics. Of note, our respondents have noticed that Somali-American women have recently become more vocal in medical decision-making, which could be attributed to the community’s cultural assimilation and/or a change in clinicians' perceptions. Religious beliefs impact medical decision-making in the Somali-American community [ 11 , 18 , 30 ]. For example, the Islamic belief in predetermination, or divine will, may affect whether a Somali-American patient chooses to undergo a Cesarean delivery or prenatal surgery [ 11 , 30 ]. Our respondents recognized the importance of faith identity, but felt discouraged that it created hesitancy toward recommended care. This hesitancy may be explained by the health behavior theory, which postulates that perceived benefits and risks in preventative care are impacted by individuals' circumstances and community [ 31 , 32 ]. The prominence of divine will and community anecdotes in medical decision-making may feel incongruent with evidence-based practice for Western clinicians. However, healthcare institutions must provide the necessary resources and training so providers maintain a culturally sensitive approach and empower patients to feel confident in their decisions. Our respondents felt accountable to their patients, and desired to increase their cross-cultural knowledge to provide more equitable care to Somali-American families. Previous reports have found that many Somali-American patients request reproductive education resources that accommodate their cultural practices, religious beliefs, and literacy levels [ 9 , 11 , 33 ], and others highlight the importance of training practitioners to provide culturally sensitive care [ 11 , 34 ]. Despite the reported benefits of training in culturally competent care [ 35 , 36 ], many medical students in the United States reported “insufficient class time dedicated to culturally sensitive care,” as well as “insufficient clinical exposure in caring for immigrants/refugees” [ 37 ]. As the United States immigrant population grows, incorporating culturally sensitive care into medical education should become a priority. The health professionals surveyed in our study reported that trust has grown within the Somali-American community, specifically regarding prenatal procedures. Becoming active in the community by hosting forums or attending community fairs may further increase patients’ trust of providers. We hope this study will prompt outreach and education initiatives based on our thematic findings, and that such initiatives would foster trust in maternal-fetal care and healthcare transculturation. The primary limitation of this study was non-responder bias [ 38 , 39 ]. Although we had 42 respondents, non-respondents may have differing viewpoints. However, as many of our respondents referenced similar concepts in open-ended questions, saturation was likely achieved. The present results reflect the viewpoints of clinicians in Minnesota, and the views of clinicians outside of Minnesota, particularly in non-US healthcare systems, may differ. In conclusion, surveyed clinicians stressed the importance of building trust with patients through means such as accurate and effective interpretation, providing culturally sensitive care through clinician training, and incorporating Somali clinicians and in-person interpreters whenever possible. Our findings suggest that when caring for Somali-American families, clinicians should be prepared to navigate their unique medical decision-making process, which prioritizes faith identity as Muslims and includes input from families and the wider community. Lastly, our respondents shared that they do not successfully provide equitable care to Somali-American patients at present, but they strongly desire to do so. Developing resources for practitioners in partnership with the community would empower clinicians to provide culturally sensitive patient-centered care for Somali-American families. Declarations Competing Interests The authors declare no financial or non-financial conflicts of interest. Funding Statement This work was supported by the [ Blinded Funding Information ]. Statement of Ethics The study protocol was approved by the [ Blinded IRB information ]. Each respondent completed an electronic consent to participate at the beginning of the survey. References Gele, A.A., et al., Beneficiaries of conflict: a qualitative study of people's trust in the private health care system in Mogadishu, Somalia. Risk Manag Healthc Policy, 2017. 10 : p. 127-135. Borders, D.W. Somalia: The deadly consequences of obstacles to health care . 2024 11/13/2024]; Available from: https://www.doctorswithoutborders.org/latest/somalia-deadly-consequences-obstacles-health-care#:~:text=The%20health%20care%20infrastructure%20in,conflict%2Daffected%20and%20inaccessible%20areas. Trends in International Migrant Stock: Migrants by Destination and Origin . 2015, United Nations, Department of Economic and Social Affairs Bureau, U.S.C., Census Bureau Releases 2020 Census Data for Nearly 1,500 Detailed Race and Ethnicity Groups, Tribes and Villages , S.G. Vidal, Editor. 2023. Johnson, E.B., et al., Increased risk of adverse pregnancy outcome among Somali immigrants in Washington state. American Journal of Obstetrics and Gynecology, 2005. 193 (2): p. 475-482. Vangen, S., et al., Perinatal complications among ethnic Somalis in Norway. Acta obstetricia et gynecologica Scandinavica, 2002. 81 (4): p. 317-322. Binder, P., S. Johnsdotter, and B. Essén, Conceptualising the prevention of adverse obstetric outcomes among immigrants using the ‘three delays’ framework in a high-income context. Social Science & Medicine, 2012. 75 (11): p. 2028-2036. Deyo, N.S., Cultural Traditions and the Reproductive Health of Somali Refugees and Immigrants , in International Studies . 2012, University of San Francisco. Lawler Turnbull, C.M., Maternal Health is a Human Right: Identifying Gaps and Directions for Policy Improvement in Perinatal Care for Somali-Americans in Minnesota , in The Hubert H. Humphrey School of Public Affairs . 2020, The University of Minnesota. Jacoby, S.D., et al., A mixed‐methods study of immigrant Somali women's health literacy and perinatal experiences in Maine. Journal of midwifery and women's health, 2015. 60 (5): p. 593-603. Eyerly‐Webb, S.A., et al., Considerations for specialized maternal–fetal care in the Somali‐American community. Prenatal Diagnosis. Hill, N., E. Hunt, and K. Hyrkäs, Somali Immigrant Women’s Health Care Experiences and Beliefs Regarding Pregnancy and Birth in the United States. Journal of Transcultural Nursing, 2012. 23 (1): p. 72-81. Salem, W., et al., Fertility after cesarean delivery among Somali-born women resident in the USA. Journal of Immigrant and Minority Health, 2011. 13 (3): p. 494-499. Agunwamba, A.A., et al., Higher Rates of Cesarean Sections Found in Somali Immigrant Women in Minnesota. Journal of Racial and Ethnic Health Disparities, 2021. Herrel, N., et al., Somali refugee women speak out about their needs for care during pregnancy and delivery. Journal of midwifery and women's health, 2004. 49 (4): p. 345-349. Lazar, J.N., et al., Providers' Perceptions of Challenges in Obstetrical Care for Somali Women. Obstetrics and Gynecology International, 2013. 2013 : p. 149640. Straus, L., A. McEwen, and F.M. Hussein, Somali women's experience of childbirth in the UK: Perspectives from Somali health workers. Midwifery, 2009. 25 (2): p. 181-186. Cheung, F.Y., et al., Developing culturally informed genetic services for the Somali immigrants in Minnesota. 2019. 28 (4): p. 887-896. Eyerly-Webb, S., et al., Understanding the care journey and needs of advanced fetal care center patients. The Permanente Journal, 2022. 26 (2): p. 11. Wilpers, A., et al., The parental journey of fetal care: a systematic review and metasynthesis. American Journal of Obstetrics & Gynecology MFM, 2021. 3 (3): p. 100320. Hodgson, J. and B.J. McClaren, Parental experiences after prenatal diagnosis of fetal abnormality. Seminars in Fetal and Neonatal Medicine, 2018. 23 (2): p. 150-154. Harris, P.A., et al., The REDCap consortium: building an international community of software platform partners. Journal of biomedical informatics, 2019. 95 : p. 103208. Harris, P.A., et al., Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 2009. 42 (2): p. 377-381. Graneheim, U.H. and B. Lundman, Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse education today, 2004. 24 (2): p. 105-112. Miles, M.B. and A.M. Huberman, Chapter 4, Fundementals of Qualitative Data Analysis. Qualitative data analysis: An expanded sourcebook . 3rd ed. 1994: sage. Al Shamsi, H., et al., Implications of Language Barriers for Healthcare: A Systematic Review. Oman Med J, 2020. 35 (2): p. e122. Maow, K., Somali refugees in Buffalo: The impact of language barrier on the health care access. 2018. Scuglik, D.L., et al., When the poetry no longer rhymes: Mental health issues among Somali immigrants in the USA. 2007. 44 (4): p. 581-595. Odunukan, O.W., et al., Provider and interpreter preferences among Somali women in a primary care setting. 2015. 6 (2): p. 105-110. Njenga, A., Somali Refugee Women’s Experiences and Perceptions of Western Health Care. 2023. 34 (1): p. 8-13. Joseph, G., et al., Perceived Susceptibility to Illness and Perceived Benefits of Preventive Care: An Exploration of Behavioral Theory Constructs in a Transcultural Context. Health Education & Behavior, 2009. 36 (5_suppl): p. 71S-90S. Kristiansen, M., et al., Migration from low‐to high‐risk countries: a qualitative study of perceived risk of breast cancer and the influence on participation in mammography screening among migrant women in D enmark. European Journal of Cancer Care, 2014. 23 (2): p. 206-213. Lightfoot, E., et al., Cultural health assets of Somali and Oromo refugees and immigrants in Minnesota: Findings from a community-based participatory research project. Journal of health care for the poor and underserved, 2016. 27 (1): p. 252-260. Clarkson Freeman, P.A., et al., The intersection of health beliefs and religion among Somali refugees: A qualitative study. Journal of Religion & Spirituality in Social Work: Social Thought, 2013. 32 (1): p. 1-13. Majumdar, B., et al., Effects of cultural sensitivity training on health care provider attitudes and patient outcomes. 2004. 36 (2): p. 161-166. Stone, J. and G.B.J.M.e. Moskowitz, Non‐conscious bias in medical decision making: what can be done to reduce it? 2011. 45 (8): p. 768-776. Stryker, S.D., et al., Underprepared: influences of US medical students’ self-assessed confidence in immigrant and refugee health care. 2023. 28 (1): p. 2161117. Kadam, D.J.I.J.o.P.S., The Essentials of Survey Study and Reporting. 2023. 56 (03): p. 195-196. Chung, K.C., K.A. Huynh, and R.J. Rohrich, Common Fallacies in Designing a Research Project: Guidance Principles. 2019. 144 (5): p. 1247-1253. Table 1 Table 1. Survey respondent characteristics Participants*, n = 42 Race White 38 (90.5) Asian 3 (7.1) Multiracial 1 (2.4) Ethnicity Not Hispanic/Latino 40 (95.2) Hispanic/Latino 2 (4.8) Gender, female 37 (88.1) Clinical Role Maternal-Fetal Medicine Physician 13 (31.0) Fetal/pediatric Cardiology Physician 5 (11.9) Nurse Care Coordinator 5 (11.9) Social Worker 4 (9.5) Sonography 4 (9.5) Genetic Counseling 3 (7.1) Nursing 2 (4.8) Neonatology Physician 1 (2.4) Pediatric Surgery Physician 1 (2.4) Other† 4 (9.5) Experience, years 1-5 12 (28.6) 6-10 6 (14.3) 11-20 13 (31.0) >20 11 (26.2) Format: n (%) *Respondents from 9 different institutions throughout the Twin Cities and Rochester, MN †Other respondents included 2 schedulers, 1 nurse practitioner, and 1 advanced practice registered nurse Additional Declarations No competing interests reported. Supplementary Files BarthelSupplementalTable.docx SupplementalMaterialREDCapSurvey.pdf Cite Share Download PDF Status: Published Journal Publication published 07 Apr, 2026 Read the published version in Journal of Immigrant and Minority Health → Version 1 posted Editorial decision: Revision requested 25 Jan, 2026 Reviews received at journal 16 Jan, 2026 Reviewers agreed at journal 28 Dec, 2025 Reviews received at journal 20 Oct, 2025 Reviewers agreed at journal 20 Oct, 2025 Reviewers invited by journal 28 Aug, 2025 Editor assigned by journal 20 Aug, 2025 Submission checks completed at journal 20 Aug, 2025 First submitted to journal 19 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Minnesota","correspondingAuthor":false,"prefix":"","firstName":"Jill","middleName":"","lastName":"Palmer","suffix":""},{"id":507113855,"identity":"e069d40a-1fe1-4bc0-90ab-6f4018e6aaab","order_by":8,"name":"Theresa Goodsell","email":"","orcid":"","institution":"Allina Health","correspondingAuthor":false,"prefix":"","firstName":"Theresa","middleName":"","lastName":"Goodsell","suffix":""},{"id":507113856,"identity":"7d7cdbd3-ad6b-4e35-b2f9-d40d9dedfdcd","order_by":9,"name":"Clifton Brock","email":"","orcid":"","institution":"Allina Health","correspondingAuthor":false,"prefix":"","firstName":"Clifton","middleName":"","lastName":"Brock","suffix":""},{"id":507113857,"identity":"cdde3cff-6602-48a6-9d48-64272b381b47","order_by":10,"name":"Saul Snowise","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYHACxgNgihmIPzBYyLARoweuhXEGgwQPCVpAuniAWggql28/Y3CA4c8dOYPj7A8f29RI8PBJNz9g+FGxDacWgzM5BgcY254ZGxzmMTbOOQZ0mMwxA8aeM7dxa2EAaWk4nLjtMA+bdA4bUItEggEzYxtuLfL9b0AOA2lhf/7b4h9IS/oHvFoYbgBtYWADaWEwA6oEacnBb4vBjWcFBxLbDhvbA/0i2dsH1lJwEJ9f5PuTNz748OewnGT/8YcffnyzkZOfkb7xwY8KPA4DgQR0gQP41Y+CUTAKRsEoIAQA0NFSXCEN3TYAAAAASUVORK5CYII=","orcid":"","institution":"Allina Health","correspondingAuthor":true,"prefix":"","firstName":"Saul","middleName":"","lastName":"Snowise","suffix":""}],"badges":[],"createdAt":"2025-08-19 14:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7409787/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7409787/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10903-026-01895-y","type":"published","date":"2026-04-07T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":106809178,"identity":"46ca3e59-cdc3-4d88-9f07-a75c46c46f09","added_by":"auto","created_at":"2026-04-13 16:07:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":590722,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7409787/v1/45812082-cbdb-4d68-a5b9-3b4c33769be4.pdf"},{"id":90585463,"identity":"4b60525c-ecff-4775-9db3-05ed1df31699","added_by":"auto","created_at":"2025-09-04 11:20:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":45644,"visible":true,"origin":"","legend":"","description":"","filename":"BarthelSupplementalTable.docx","url":"https://assets-eu.researchsquare.com/files/rs-7409787/v1/b78a130c6cf485c33040eda6.docx"},{"id":90585465,"identity":"8494a8f0-a982-4f0c-8d57-986bd09c16f4","added_by":"auto","created_at":"2025-09-04 11:20:47","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":37193,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementalMaterialREDCapSurvey.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7409787/v1/791d747dfe187745c35cb82b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinician Perceptions of Somali-American Patients in Specialized Maternal-Fetal Care","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSomalia has faced significant humanitarian crises over the last 30 years due to civil war, climate emergencies, and disease outbreaks. Healthcare challenges in Somalia include poor medical infrastructure, shortages of medical professionals, and limited access for rural impoverished communities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These factors have led to Somali resettlement of approximately half a million individuals in North America and Europe, with the majority residing in the United States, United Kingdom, and Scandinavia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite migration to low-mortality/high-resource settings, healthcare disparities in pregnancy continue to impact the Somali diaspora [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Previous research has reported that Somali immigrants are skeptical of preventative care models and mistrust Western prenatal care. In Somalia, informal care models (e.g., in-home doulas/midwives) and delaying medical care until symptomatic are the cultural norm, and Somali immigrants may not be accustomed to preventative healthcare [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. When receiving Western prenatal care, Somali-American women have reported feeling anxious, suspicious, pressured, and victimized by discrimination [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In addition, language barriers, limited medical literacy, and misunderstandings surrounding traditional cultural values and their Islamic faith amplify the mistrust [\u003cspan additionalcitationids=\"CR12 CR13 CR14\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Western medical providers\u0026rsquo; lack of training and experience with female circumcision adds further complexity [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Unwelcoming and stressful experiences may leave patients unwilling to participate in future pregnancy care [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSomali patients undergoing specialized maternal-fetal care may experience additional hurdles [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Early prenatal diagnosis often involves patient monitoring/imaging appointments throughout the pregnancy, and in some cases, the option of fetal intervention. Comprehensive care plans for fetal diagnoses typically include recurring interactions with staff across several medical specialties [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Previous research on specialized fetal care highlights the importance of trust and effective communication between the patient and clinical team, which affects the family's perception and ability to cope with the diagnosis [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Building trust through positive experiences during prenatal care is especially important for these families, as a fetus diagnosed with an anomaly will likely require ongoing medical care throughout the child\u0026rsquo;s lifetime.\u003c/p\u003e\u003cp\u003eMinnesota is home to the largest Somali population outside of Somalia, and our specialized maternal-fetal centers routinely see Somali-American patients. Our center previously described a group of Somali-American women\u0026rsquo;s experiences with specialized maternal-fetal care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In the present report, we consider the caregiver. We describe the perspectives, experiences, and perceived barriers/facilitators to care shared by maternal-fetal care professionals caring for our Somali-American community using qualitative data from an electronic survey.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis was a qualitative data collection study using an electronic survey. This study was approved by the [\u003cem\u003eBlinded IRB info\u003c/em\u003e]. Survey respondents provided electronic informed consent at the beginning of the survey. Study data were collected and managed using a Research Electronic Data Capture (REDCap) questionnaire hosted at [\u003cem\u003eBlinded Institution\u003c/em\u003e], Minneapolis, MN [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The survey questionnaire was developed collaboratively by the authors during a series of preparatory meetings. The questionnaire queried participants' demographics, background understanding of the Somali-American community, experiences caring for these patients, and barriers, facilitators, or concerns about caring for Somali-American patients.\u003c/p\u003e\u003cp\u003e We partnered with local institutions to distribute the survey electronically to maternal-fetal healthcare professionals at their centers. The survey was open for 17 months (January 2023-May 2024).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Synthesis\u003c/h3\u003e\n\u003cp\u003eRespondent demographics were reported using descriptive statistics. Data from individual qualitative responses were coded by three trained authors using thematic analysis techniques with qualitative analysis software (Dedoose Version 9.0.107, Los Angeles, CA: SocioCultural Research Consultants, LLC) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The primary coders used inductive coding methods to analyze the data, creating codes based on the data, not a predetermined list. First, each coder assigned codes to specific words or phrases in the text. These codes were reviewed for consensus between the three coders. Next, the individual codes were grouped into broader themes, which are presented below alongside supporting direct quotations from the respondents.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eForty-two healthcare professionals completed the survey; Table 1 summarizes the demographics and professional experience of the respondents. Various clinical roles and specialties are represented from nine institutions throughout the Twin Cities and Rochester, MN. Most respondents were white (91%) with greater than 10 years of clinical experience (57%) in their field.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFive themes were identified in the qualitative analysis. An expanded selection of respondent quotations is provided in the Supplemental Material.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eLanguage Barriers\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents identified language barriers as a significant hindrance when managing complex pregnancies in Somali-American patients. Their concerns included translation accuracy, the quality and availability of in-person interpretation, lack of interpreter training in maternal-fetal diagnosis, appointment time constraints, the need to simplify medical language, and interpreter gender discordance.\u003c/p\u003e\n\u003cp\u003eAll respondents reported needing a medical interpreter to communicate with Somali-American patients (always=16, frequently=18, sometimes=8). Many respondents reported difficulty conducting appointments in another language, and 25 (61%) respondents identified the language barrier as significantly impacting their care of Somali-American patients. There were 26 mentions of a lack of quality in-person interpreters, while several respondents mentioned that in-person interpretation facilitated care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I do not feel like I provide equivalent care to Somali-American patients - there is a cultural barrier, a language barrier, and what feels like a chasm between the patient and provider. I feel like due to these limitations; they receive limited counseling and I am unable to confirm their understanding of the fetal findings and care plan.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“[W]hen we have an in-person interpreter it makes the visit go more smoothly, along with information that we relay to patients. The patients feel more comfortable when there is an interpreter present.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRespondents expressed concerns about translation accuracy and about trusting the communication of complicated medical diagnoses through an interpreter. Numerous respondents stressed the need for interpreters to be trained in specialized obstetric and fetal topics.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I do not always trust that the interpreter is either accurate or unbiased. This has become evident when I have had returning Somali-American patients return and they seem to have a different understanding of what was previously discussed.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“[W]hen we have a very knowledgeable Somali interpreter that the patient is comfortable with and that understands the medical terminology and can explain it well to the patient, they are more willing to participate.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany respondents experienced time constraints in appointments with Somali-speaking patients due to the time needed for translation. Additionally, many respondents felt the need to simplify their language during counseling to better communicate through an interpreter. Longer appointment times was suggested as a solution.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I often find that I am simplifying the information I am presenting, and sometimes not able to present the same depth of information as I would to an English-speaking patient.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Our leadership recognizes that some women do take longer in their visit, especially if an interpreter is utilized, and we are given more time in the schedule to care for these families.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral respondents stated that using male interpreters may pose difficulties for female patients, who they felt would be more comfortable with a female interpreter.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“If the in-person interpreter is a male then it may hinder conversation based on the traditional Somali value of women's privacy.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eIslamic Faith\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents perceived faith identity as very important to Somali-Americans, with the Islamic belief of predetermination (“God’s will”) creating hesitance about intervention (e.g., fetal surgery). Respondents reported that Somali-American families want to do what is best for their baby, but their view of how intervention intersects with divine will affects their medical decision-making. This presented a challenge for some respondents, as non-Judeo-Christian faith values are typically not integrated into Western medicine.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Their faith in God surpasses belief in Western Medicine. When discussing fetal concerns with Somali-American patients they may not either believe the information discussed, or choose to believe that it is God's will and that everything will be okay.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Some are resistant to learning about the diagnosis and have full belief in God's will. Others are open to medical recommendations.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eMultiple Opinions in Medical Decision-Making\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents reported other influences on medical decision-making in Somali-American patients, including family, elders, faith leaders, the greater community, and patriarchal cultural values.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRespondents noted that Somali-American patients were family-oriented and aspired to have large families. Twenty-one respondents mentioned observing strong family ties. Most respondents felt these patients had a strong sense of community, potentially including elder input, and that this can be an asset or a challenge when consolidating multiple viewpoints.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Since they do often have a large community of support, there is also a large community of opinions. I do feel they get \"caught in the middle\" of community opinion and medical opinion.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I presume extended family is included if they aren't present, but are referenced - and spiritual or community leaders. This is not always the case and there is variation within the Somali-American families I have worked with.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany respondents shared that families displayed patriarchal values, with nine mentioning that male family members lead medical decision-making.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Male partners/family members are the main decision-makers in the household/community”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Paternal driven, although it seems that the patient does have input - seems cultural to defer a decision until spoken with husband, but tends to follow what the woman wants eventually.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSome respondents expressed hope that the pregnant person has autonomy in their medical decisions, and some mentioned that patriarchal values have become less prevalent over time.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Historically, most of my experience with the Somali-American families have involved medical decisions being made by the patient's husband, elders, and/or community leaders. This has been difficult to accept by some of us care providers as ultimately we feel the decisions should be made by the patient we are directly caring for… I also feel more Somali women are becoming more \"independent\" so some of them are making decisions on their own now.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eMistrust in Care\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents felt Somali-American patients mistrusted Western medicine, were skeptical of prenatal diagnoses, and that trust between patient and provider must be built through effective communication and culturally competent care. Respondents acknowledged that failure to secure their patients’ trust could result in reluctance to engage in care. Respondents found that some families were reluctant to believe a prenatal diagnosis, and may wait until after delivery before developing a care plan for their child.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“They are frequently mistrustful of Western medicine due to personal experiences or stories they've heard from trusted family members/friends.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“[T]here is a lot of hesitation to accept these interventions and it often takes days or weeks of discussing it and building trust.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“[M]any families are very willing to come in for ultrasounds, however do not believe diagnosis during pregnancy or make plans for what may happen for baby after birth.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eDesire to Provide Equitable Care\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRespondents consistently stressed a desire to provide more equitable care for Somali-American families. Some acknowledged that clinicians should endeavor to understand Somali patients’ cultural viewpoints, that more Somali-American clinicians are needed, that engagement with the community is needed to facilitate peer-to-peer support, and that additional assistance should be provided to under-resourced families.\u003c/p\u003e\n\u003cp\u003eMany respondents expressed concern about cultural miscommunications, especially regarding perceived risk or proposed care plans. Multiple respondents requested cultural competency training and learning opportunities in partnership with the Somali-American community.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I worry about being sensitive to their needs and ensuring I am not saying something that may be perceived incorrectly (ex. trying to explain/plan for a suboptimal outcome with frustration from the patient because only Allah knows what will happen).”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“More training on how to approach decision-making, how to review bad news or recommendations in a way that is more respectful and supportive of the patients and their families.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMany respondents advocated that hiring Somali-American clinicians is critical to addressing inequitable care. Several respondents requested clinic-employed cultural liaisons for peer-to-peer support. Partnership with a hospital-appointed faith leader (Imams) was reported as a useful resource.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“We need to have a Somali representative that currently works with perinatal patients, who understands the lingo.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe low socioeconomic status of some Somali-American families was identified as a challenge in managing complex pregnancies, with transportation cited as a barrier to attending appointments. Several respondents noted that Somali-American families are large, and it can be difficult to attend prenatal appointments when children are not permitted. Twelve participants mentioned childcare as a barrier to women attending appointments.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I have also noticed that childcare and transportation appear to be common problems listed by patients for getting to appointments.”\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study surveyed maternal-fetal healthcare professionals about their experiences treating Somali-American patients. Common themes were that Islamic faith and community input are fundamental to patients\u0026rsquo; decision-making processes, that language barriers, translation accuracy, and medical mistrust are significant concerns, and that clinicians desire to provide equitable care to this patient population. Our findings can guide future initiatives to improve the quality of care for Somali-American patients and create targeted educational resources to equip clinicians to provide this care.\u003c/p\u003e\u003cp\u003eThe difficulty of delivering medical advice and care across a language barrier is widely noted. In a systematic review investigating language barriers in healthcare across many countries, Shamsi \u003cem\u003eet al.\u003c/em\u003e found that language barriers cause miscommunications between provider and patient that affect patient satisfaction and decrease the safety and quality of care [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Many studies demonstrate the negative effects of language barriers on the care of Somali-American patients, primarily the risk of miscommunication compounded by poor health literacy [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Furthermore, the specialized concepts and terminology in obstetrics present additional challenges. For example, discussions surrounding genetics and fetal development/anatomy are extremely uncommon in the Somali language [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. For our respondents, conducting appointments in another language was extremely frustrating, and the lack of quality, in-person interpreters and appointment time constraints added to the difficulty. In a similar finding by Lazar \u003cem\u003eet al.\u003c/em\u003e, obstetric clinicians expressed concerns about the quality of interpretation for their Somali-American patients [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, in our previous study, Somali-American community members shared that effective communication across a language barrier is critical, and that they prefer having healthcare providers who share their cultural background when making medical decisions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In the present study, several respondents also mentioned that interpreter gender discordance, particularly the use of a male interpreter for a female pregnant person, may be uncomfortable for Somali-American patients. This agrees with previous reports that Somali-American women prefer female providers and interpreters, particularly when physical exams are conducted [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. As a possible solution, our respondents proposed longer appointment times with a consistent, in-person, female interpreter with training in specialty obstetrics and fetal diagnoses. Alternatively, involving a female Somali-American patient advocate (i.e., hospital-provided community peer) may help patients navigate specialty maternal-fetal care. Providing culturally sensitive patient-centered care can build trust with Somali-American families and encourage future health-seeking behaviors.\u003c/p\u003e\u003cp\u003eMultiple respondents reported that male family members lead decision-making, in contrast to our previous work, where female Somali-American community members said the pregnant person makes the final medical decisions [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It is possible that the pregnant person maintains autonomy in the treatment choice after discussion with her support system and then may communicate the decision through a male partner. This discordance highlights the need for clinician education regarding Somali family dynamics. Of note, our respondents have noticed that Somali-American women have recently become more vocal in medical decision-making, which could be attributed to the community\u0026rsquo;s cultural assimilation and/or a change in clinicians' perceptions.\u003c/p\u003e\u003cp\u003eReligious beliefs impact medical decision-making in the Somali-American community [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. For example, the Islamic belief in predetermination, or divine will, may affect whether a Somali-American patient chooses to undergo a Cesarean delivery or prenatal surgery [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Our respondents recognized the importance of faith identity, but felt discouraged that it created hesitancy toward recommended care. This hesitancy may be explained by the health behavior theory, which postulates that perceived benefits and risks in preventative care are impacted by individuals' circumstances and community [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The prominence of divine will and community anecdotes in medical decision-making may feel incongruent with evidence-based practice for Western clinicians. However, healthcare institutions must provide the necessary resources and training so providers maintain a culturally sensitive approach and empower patients to feel confident in their decisions.\u003c/p\u003e\u003cp\u003eOur respondents felt accountable to their patients, and desired to increase their cross-cultural knowledge to provide more equitable care to Somali-American families. Previous reports have found that many Somali-American patients request reproductive education resources that accommodate their cultural practices, religious beliefs, and literacy levels [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], and others highlight the importance of training practitioners to provide culturally sensitive care [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Despite the reported benefits of training in culturally competent care [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], many medical students in the United States reported \u0026ldquo;insufficient class time dedicated to culturally sensitive care,\u0026rdquo; as well as \u0026ldquo;insufficient clinical exposure in caring for immigrants/refugees\u0026rdquo; [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. As the United States immigrant population grows, incorporating culturally sensitive care into medical education should become a priority.\u003c/p\u003e\u003cp\u003eThe health professionals surveyed in our study reported that trust has grown within the Somali-American community, specifically regarding prenatal procedures. Becoming active in the community by hosting forums or attending community fairs may further increase patients\u0026rsquo; trust of providers. We hope this study will prompt outreach and education initiatives based on our thematic findings, and that such initiatives would foster trust in maternal-fetal care and healthcare transculturation.\u003c/p\u003e\u003cp\u003eThe primary limitation of this study was non-responder bias [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Although we had 42 respondents, non-respondents may have differing viewpoints. However, as many of our respondents referenced similar concepts in open-ended questions, saturation was likely achieved. The present results reflect the viewpoints of clinicians in Minnesota, and the views of clinicians outside of Minnesota, particularly in non-US healthcare systems, may differ.\u003c/p\u003e\u003cp\u003eIn conclusion, surveyed clinicians stressed the importance of building trust with patients through means such as accurate and effective interpretation, providing culturally sensitive care through clinician training, and incorporating Somali clinicians and in-person interpreters whenever possible. Our findings suggest that when caring for Somali-American families, clinicians should be prepared to navigate their unique medical decision-making process, which prioritizes faith identity as Muslims and includes input from families and the wider community. Lastly, our respondents shared that they do not successfully provide equitable care to Somali-American patients at present, but they strongly desire to do so. Developing resources for practitioners in partnership with the community would empower clinicians to provide culturally sensitive patient-centered care for Somali-American families.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no financial or non-financial conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the [\u003cem\u003eBlinded Funding Information\u003c/em\u003e].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the\u0026nbsp;[\u003cem\u003eBlinded IRB information\u003c/em\u003e]. Each respondent completed an electronic consent to participate at the beginning of the survey.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGele, A.A., et al., \u003cem\u003eBeneficiaries of conflict: a qualitative study of people\u0026apos;s trust in the private health care system in Mogadishu, Somalia.\u003c/em\u003e Risk Manag Healthc Policy, 2017. \u003cstrong\u003e10\u003c/strong\u003e: p. 127-135.\u003c/li\u003e\n\u003cli\u003eBorders, D.W. \u003cem\u003eSomalia: The deadly consequences of obstacles to health care\u003c/em\u003e. 2024 11/13/2024]; Available from: https://www.doctorswithoutborders.org/latest/somalia-deadly-consequences-obstacles-health-care#:~:text=The%20health%20care%20infrastructure%20in,conflict%2Daffected%20and%20inaccessible%20areas.\u003c/li\u003e\n\u003cli\u003e\u003cem\u003eTrends in International Migrant Stock: Migrants by Destination and Origin\u003c/em\u003e. 2015, United Nations, Department of Economic and Social Affairs\u003c/li\u003e\n\u003cli\u003eBureau, U.S.C., \u003cem\u003eCensus Bureau Releases 2020 Census Data for Nearly 1,500 Detailed Race and Ethnicity Groups, Tribes and Villages\u003c/em\u003e, S.G. Vidal, Editor. 2023.\u003c/li\u003e\n\u003cli\u003eJohnson, E.B., et al., \u003cem\u003eIncreased risk of adverse pregnancy outcome among Somali immigrants in Washington state.\u003c/em\u003e American Journal of Obstetrics and Gynecology, 2005. \u003cstrong\u003e193\u003c/strong\u003e(2): p. 475-482.\u003c/li\u003e\n\u003cli\u003eVangen, S., et al., \u003cem\u003ePerinatal complications among ethnic Somalis in Norway.\u003c/em\u003e Acta obstetricia et gynecologica Scandinavica, 2002. \u003cstrong\u003e81\u003c/strong\u003e(4): p. 317-322.\u003c/li\u003e\n\u003cli\u003eBinder, P., S. Johnsdotter, and B. Ess\u0026eacute;n, \u003cem\u003eConceptualising the prevention of adverse obstetric outcomes among immigrants using the \u0026lsquo;three delays\u0026rsquo; framework in a high-income context.\u003c/em\u003e Social Science \u0026amp; Medicine, 2012. \u003cstrong\u003e75\u003c/strong\u003e(11): p. 2028-2036.\u003c/li\u003e\n\u003cli\u003eDeyo, N.S., \u003cem\u003eCultural Traditions and the Reproductive Health of Somali Refugees and Immigrants\u003c/em\u003e, in \u003cem\u003eInternational Studies\u003c/em\u003e. 2012, University of San Francisco.\u003c/li\u003e\n\u003cli\u003eLawler Turnbull, C.M., \u003cem\u003eMaternal Health is a Human Right: Identifying Gaps and Directions for Policy Improvement in Perinatal Care for Somali-Americans in Minnesota\u003c/em\u003e, in \u003cem\u003eThe Hubert H. Humphrey School of Public Affairs\u003c/em\u003e. 2020, The University of Minnesota.\u003c/li\u003e\n\u003cli\u003eJacoby, S.D., et al., \u003cem\u003eA mixed‐methods study of immigrant Somali women\u0026apos;s health literacy and perinatal experiences in Maine.\u003c/em\u003e Journal of midwifery and women\u0026apos;s health, 2015. \u003cstrong\u003e60\u003c/strong\u003e(5): p. 593-603.\u003c/li\u003e\n\u003cli\u003eEyerly‐Webb, S.A., et al., \u003cem\u003eConsiderations for specialized maternal\u0026ndash;fetal care in the Somali‐American community.\u003c/em\u003e Prenatal Diagnosis.\u003c/li\u003e\n\u003cli\u003eHill, N., E. Hunt, and K. Hyrk\u0026auml;s, \u003cem\u003eSomali Immigrant Women\u0026rsquo;s Health Care Experiences and Beliefs Regarding Pregnancy and Birth in the United States.\u003c/em\u003e Journal of Transcultural Nursing, 2012. \u003cstrong\u003e23\u003c/strong\u003e(1): p. 72-81.\u003c/li\u003e\n\u003cli\u003eSalem, W., et al., \u003cem\u003eFertility after cesarean delivery among Somali-born women resident in the USA.\u003c/em\u003e Journal of Immigrant and Minority Health, 2011. \u003cstrong\u003e13\u003c/strong\u003e(3): p. 494-499.\u003c/li\u003e\n\u003cli\u003eAgunwamba, A.A., et al., \u003cem\u003eHigher Rates of Cesarean Sections Found in Somali Immigrant Women in Minnesota.\u003c/em\u003e Journal of Racial and Ethnic Health Disparities, 2021.\u003c/li\u003e\n\u003cli\u003eHerrel, N., et al., \u003cem\u003eSomali refugee women speak out about their needs for care during pregnancy and delivery.\u003c/em\u003e Journal of midwifery and women\u0026apos;s health, 2004. \u003cstrong\u003e49\u003c/strong\u003e(4): p. 345-349.\u003c/li\u003e\n\u003cli\u003eLazar, J.N., et al., \u003cem\u003eProviders\u0026apos; Perceptions of Challenges in Obstetrical Care for Somali Women.\u003c/em\u003e Obstetrics and Gynecology International, 2013. \u003cstrong\u003e2013\u003c/strong\u003e: p. 149640.\u003c/li\u003e\n\u003cli\u003eStraus, L., A. McEwen, and F.M. Hussein, \u003cem\u003eSomali women\u0026apos;s experience of childbirth in the UK: Perspectives from Somali health workers.\u003c/em\u003e Midwifery, 2009. \u003cstrong\u003e25\u003c/strong\u003e(2): p. 181-186.\u003c/li\u003e\n\u003cli\u003eCheung, F.Y., et al., \u003cem\u003eDeveloping culturally informed genetic services for the Somali immigrants in Minnesota.\u003c/em\u003e 2019. \u003cstrong\u003e28\u003c/strong\u003e(4): p. 887-896.\u003c/li\u003e\n\u003cli\u003eEyerly-Webb, S., et al., \u003cem\u003eUnderstanding the care journey and needs of advanced fetal care center patients.\u003c/em\u003e The Permanente Journal, 2022. \u003cstrong\u003e26\u003c/strong\u003e(2): p. 11.\u003c/li\u003e\n\u003cli\u003eWilpers, A., et al., \u003cem\u003eThe parental journey of fetal care: a systematic review and metasynthesis.\u003c/em\u003e American Journal of Obstetrics \u0026amp; Gynecology MFM, 2021. \u003cstrong\u003e3\u003c/strong\u003e(3): p. 100320.\u003c/li\u003e\n\u003cli\u003eHodgson, J. and B.J. McClaren, \u003cem\u003eParental experiences after prenatal diagnosis of fetal abnormality.\u003c/em\u003e Seminars in Fetal and Neonatal Medicine, 2018. \u003cstrong\u003e23\u003c/strong\u003e(2): p. 150-154.\u003c/li\u003e\n\u003cli\u003eHarris, P.A., et al., \u003cem\u003eThe REDCap consortium: building an international community of software platform partners.\u003c/em\u003e Journal of biomedical informatics, 2019. \u003cstrong\u003e95\u003c/strong\u003e: p. 103208.\u003c/li\u003e\n\u003cli\u003eHarris, P.A., et al., \u003cem\u003eResearch electronic data capture (REDCap)\u0026mdash;A metadata-driven methodology and workflow process for providing translational research informatics support.\u003c/em\u003e Journal of Biomedical Informatics, 2009. \u003cstrong\u003e42\u003c/strong\u003e(2): p. 377-381.\u003c/li\u003e\n\u003cli\u003eGraneheim, U.H. and B. Lundman, \u003cem\u003eQualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness.\u003c/em\u003e Nurse education today, 2004. \u003cstrong\u003e24\u003c/strong\u003e(2): p. 105-112.\u003c/li\u003e\n\u003cli\u003eMiles, M.B. and A.M. Huberman, \u003cem\u003eChapter 4, Fundementals of Qualitative Data Analysis. Qualitative data analysis: An expanded sourcebook\u003c/em\u003e. 3rd ed. 1994: sage.\u003c/li\u003e\n\u003cli\u003eAl Shamsi, H., et al., \u003cem\u003eImplications of Language Barriers for Healthcare: A Systematic Review.\u003c/em\u003e Oman Med J, 2020. \u003cstrong\u003e35\u003c/strong\u003e(2): p. e122.\u003c/li\u003e\n\u003cli\u003eMaow, K., \u003cem\u003eSomali refugees in Buffalo: The impact of language barrier on the health care access.\u003c/em\u003e 2018.\u003c/li\u003e\n\u003cli\u003eScuglik, D.L., et al., \u003cem\u003eWhen the poetry no longer rhymes: Mental health issues among Somali immigrants in the USA.\u003c/em\u003e 2007. \u003cstrong\u003e44\u003c/strong\u003e(4): p. 581-595.\u003c/li\u003e\n\u003cli\u003eOdunukan, O.W., et al., \u003cem\u003eProvider and interpreter preferences among Somali women in a primary care setting.\u003c/em\u003e 2015. \u003cstrong\u003e6\u003c/strong\u003e(2): p. 105-110.\u003c/li\u003e\n\u003cli\u003eNjenga, A., \u003cem\u003eSomali Refugee Women\u0026rsquo;s Experiences and Perceptions of Western Health Care.\u003c/em\u003e 2023. \u003cstrong\u003e34\u003c/strong\u003e(1): p. 8-13.\u003c/li\u003e\n\u003cli\u003eJoseph, G., et al., \u003cem\u003ePerceived Susceptibility to Illness and Perceived Benefits of Preventive Care: An Exploration of Behavioral Theory Constructs in a Transcultural Context.\u003c/em\u003e Health Education \u0026amp; Behavior, 2009. \u003cstrong\u003e36\u003c/strong\u003e(5_suppl): p. 71S-90S.\u003c/li\u003e\n\u003cli\u003eKristiansen, M., et al., \u003cem\u003eMigration from low‐to high‐risk countries: a qualitative study of perceived risk of breast cancer and the influence on participation in mammography screening among migrant women in D enmark.\u003c/em\u003e European Journal of Cancer Care, 2014. \u003cstrong\u003e23\u003c/strong\u003e(2): p. 206-213.\u003c/li\u003e\n\u003cli\u003eLightfoot, E., et al., \u003cem\u003eCultural health assets of Somali and Oromo refugees and immigrants in Minnesota: Findings from a community-based participatory research project.\u003c/em\u003e Journal of health care for the poor and underserved, 2016. \u003cstrong\u003e27\u003c/strong\u003e(1): p. 252-260.\u003c/li\u003e\n\u003cli\u003eClarkson Freeman, P.A., et al., \u003cem\u003eThe intersection of health beliefs and religion among Somali refugees: A qualitative study.\u003c/em\u003e Journal of Religion \u0026amp; Spirituality in Social Work: Social Thought, 2013. \u003cstrong\u003e32\u003c/strong\u003e(1): p. 1-13.\u003c/li\u003e\n\u003cli\u003eMajumdar, B., et al., \u003cem\u003eEffects of cultural sensitivity training on health care provider attitudes and patient outcomes.\u003c/em\u003e 2004. \u003cstrong\u003e36\u003c/strong\u003e(2): p. 161-166.\u003c/li\u003e\n\u003cli\u003eStone, J. and G.B.J.M.e. Moskowitz, \u003cem\u003eNon‐conscious bias in medical decision making: what can be done to reduce it?\u003c/em\u003e 2011. \u003cstrong\u003e45\u003c/strong\u003e(8): p. 768-776.\u003c/li\u003e\n\u003cli\u003eStryker, S.D., et al., \u003cem\u003eUnderprepared: influences of US medical students\u0026rsquo; self-assessed confidence in immigrant and refugee health care.\u003c/em\u003e 2023. \u003cstrong\u003e28\u003c/strong\u003e(1): p. 2161117.\u003c/li\u003e\n\u003cli\u003eKadam, D.J.I.J.o.P.S., \u003cem\u003eThe Essentials of Survey Study and Reporting.\u003c/em\u003e 2023. \u003cstrong\u003e56\u003c/strong\u003e(03): p. 195-196.\u003c/li\u003e\n\u003cli\u003eChung, K.C., K.A. Huynh, and R.J. Rohrich, \u003cem\u003eCommon Fallacies in Designing a Research Project: Guidance Principles.\u003c/em\u003e 2019. \u003cstrong\u003e144\u003c/strong\u003e(5): p. 1247-1253.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 1","content":"\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 492px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Survey respondent characteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003eParticipants*, n = 42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eRace\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eWhite\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e38 (90.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e3 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003eMultiracial\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eEthnicity\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Not Hispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e40 (95.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Hispanic/Latino\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eGender, female\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e37 (88.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eClinical Role\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Maternal-Fetal Medicine Physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e13 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Fetal/pediatric Cardiology Physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e5 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Nurse Care Coordinator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e5 (11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Social Worker\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sonography\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Genetic Counseling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e3 (7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Nursing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e2 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Neonatology Physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Pediatric Surgery Physician\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e1 (2.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Other\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e4 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u003cem\u003eExperience, years\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 1-5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e12 (28.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; 6-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e6 (14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;11-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e13 (31.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 312px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026gt;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 180px;\"\u003e\n \u003cp\u003e11 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 492px;\"\u003e\n \u003cp\u003eFormat: n (%)\u003c/p\u003e\n \u003cp\u003e*Respondents from 9 different institutions throughout the Twin Cities and Rochester, MN\u003c/p\u003e\n \u003cp\u003e\u0026dagger;Other respondents included 2 schedulers, 1 nurse practitioner, and 1 advanced practice registered nurse\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"maternal-fetal healthcare, Somali-Americans, clinician perspectives, culturally competent care, medical decision-making","lastPublishedDoi":"10.21203/rs.3.rs-7409787/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7409787/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e This study describes healthcare professionals’ perspectives on the barriers, facilitators, and considerations when delivering care to the Somali-American community in a maternal-fetal healthcare setting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003eWe conducted an electronic survey during a 17-month period (January 2023 – May 2024) and performed a qualitative analysis to report thematic findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Forty-two respondents in a variety of clinical roles from 9 unique institutions throughout the Twin Cities and Rochester, MN, completed the survey. The majority of respondents were white (91%) with greater than 10 years of clinical experience (57%). Five themes were identified to describe the clinician respondents’ perceptions of providing maternal fetal care for Somali-American patients: 1) concerns surrounding language barriers and translation accuracy, 2) perceived importance of Islamic faith in the patient’s decision-making, 3) the reality of incorporating multiple social influences in decision-making, 4) recognition of mistrust in care and skepticism regarding prenatal diagnoses, and 5) a desire to provide equitable care to this patient population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e \u0026nbsp;The clinician respondents recognized that Islamic faith and community input are fundamental to a Somali-American patient’s decision-making process for their pregnancy, and stressed concerns surrounding language barriers, translation accuracy, and medical mistrust. This work emphasizes the desire and need to develop cultural education and clinician training resources to support informed patient-centered care for Somali-American families in a maternal-fetal care setting.\u003c/p\u003e","manuscriptTitle":"Clinician Perceptions of Somali-American Patients in Specialized Maternal-Fetal Care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-04 11:20:42","doi":"10.21203/rs.3.rs-7409787/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-25T20:14:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-16T21:22:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"188926209128737306769124062414215430297","date":"2025-12-28T18:33:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T16:59:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"293515049015102019555932539429326223911","date":"2025-10-20T14:57:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-28T14:31:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-20T05:44:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-20T05:42:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Immigrant and Minority Health","date":"2025-08-19T14:41:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-immigrant-and-minority-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"joih","sideBox":"Learn more about [Journal of Immigrant and Minority Health](http://link.springer.com/journal/10903)","snPcode":"10903","submissionUrl":"https://submission.springernature.com/new-submission/10903/3","title":"Journal of Immigrant and Minority Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"5e807f9f-baa4-4206-88c4-1e38cb3d1c00","owner":[],"postedDate":"September 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:04:09+00:00","versionOfRecord":{"articleIdentity":"rs-7409787","link":"https://doi.org/10.1007/s10903-026-01895-y","journal":{"identity":"journal-of-immigrant-and-minority-health","isVorOnly":false,"title":"Journal of Immigrant and Minority Health"},"publishedOn":"2026-04-07 15:57:11","publishedOnDateReadable":"April 7th, 2026"},"versionCreatedAt":"2025-09-04 11:20:42","video":"","vorDoi":"10.1007/s10903-026-01895-y","vorDoiUrl":"https://doi.org/10.1007/s10903-026-01895-y","workflowStages":[]},"version":"v1","identity":"rs-7409787","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7409787","identity":"rs-7409787","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}