Background
The maternity care is of great importance in normal growth and development of baby in prenatal period. A successful fetal life and safe delivery not only ensure the health of newborns but also has a grave impact on their adult life. Therefore, antenatal care is an inextricable part of maternal and child health [
1,
2]. Perinatal health depends on a variety of factors and could differ to a great extent in different populations [
3]. Most of the child problems such as congenital abnormalities, prematurity, and abnormalities in fetal growth could be prevented by early diagnosis in antenatal period. Therefore, adequate antenatal care (ANC) is essential to ensure the child and maternal health [
4]. Studies have shown that the perinatal mortality and morbidity could be three times higher in some underprivileged areas and populations whose access to ANC is inadequate [
5].
The latest statistics indicate 97% of pregnant Iranian women attend the WHO recommended ANC during their pregnancy [
6]. Furthermore, the youth literacy rate for females (98%), institutional birth rate (95%), total fertility rate (1.9%), and MMR (25/100,000 live births) are all indicative of Iran’s achievements in improving women’s health [
7]. Iran is one of the successful countries in MENA region that achieved the MDGs. By year 2015, Iran reduced the MMR by 75%, reaching to the highest reduction compared to neighboring countries [
8]. However, the population specific data especially among immigrants and refugees are missing in national statistics. This creates a huge gap in understanding and addressing the current health situation and issues of this vulnerable population.
Immigrants and refugees are among the most vulnerable populations in host country; the violence, discrimination, and deprivation of civil rights in host country could endanger their health, particularly the vulnerable groups such as pregnant mothers and children [
9]. Inadequate access to appropriate antenatal care contributes to a substantial amount of adverse birth outcomes [
5]. Iran has been a popular destination for Afghan refugees and immigrants since the Soviet war in 1979, with an estimated 3 million Afghans refugees and immigrants currently living in the country. About half of them are not registered and considered as illegal immigrants [
10,
11]. The majority of them are young and almost a third are young women at the child bearing age [
12].
Since 2016, all legal Afghans in Iran became eligible to apply for Public Health Insurance (PHI) [
9]. The insured person could benefit from the low-cost and affordable primary health care services such as primary health check-up, routine screening, vaccination, antenatal care, and basic laboratory tests provided at government facilities. However, PHI does not cover the cost for some services such as diagnostic or screening sonography at the secondary or tertiary levels especially in private facilities. This contributes to the low uptake of this insurance by Afghans. In a preliminary qualitative study, we found that it is either due to the unawareness or dissatisfaction of PHI coverage [
13]. Unfortunately, there is lack of further knowledge in this regard and further studies are required. The important fact is that the lack of health insurance could reduce the access to health system for Afghans in Iran. It is more critical for the women of childbearing ages whose health, especially during the pregnancy, is critical to prevent the adverse birth outcomes [
14]. Therefore, building capacity to facilitate the access to health system for this vulnerable group and addressing their maternity and reproductive needs are necessary.
Beside the lack of health insurance, several obstacles could reduce the access to quality and adequate maternity care among Afghan women in Iran. In previous studies, navigating ANC services, mothers’ perception of quality of care, socioeconomic status, language, cultural, religious concern were some the most frequent reported reasons hindering the adequate access to ANC among immigrants and refugees [
15]. However, the diversity in context and population-specific factors could contribute to variety in issues and concerns in accessing health system in different host countries. Therefore, a comprehensive understanding of Afghan women’s demographic and socio-cultural characteristics, their current health situation as well as the knowledge of potential barriers toward adequate ANC are essential to formulate appropriate interventions to improve the access and utilization of ANC among Afghan women in Iran. Thus, in present study, we aimed to fulfil these objectives by conducting a community-based survey among pregnant Afghan women.
In a preliminary qualitative research in 2019, we explored the potential barriers and concerns of Afghan women toward adequate antenatal care (ANC) in Iran [
13]. We interviewed 30 Afghan women living in Tehran and the results have been used to create the platform and develop and questionnaire and conduct the present survey in order to estimate the prevalence of associated factors and potential barriers toward adequate maternity care among Afghan women in Iran. In present study, we conducted a survey including 424 Afghan women of both legal and illegal backgrounds to estimate the prevalence of identified barriers and examine the association of sociodemographic factors and perceived barriers with the adequate utilization of ANC.
Results
Sociodemographic characteristics
A total number of 424 Afghan women aged 18–45 years old enrolled in this study. The majority of them (44.3%) were in 25–34 age group and had no education (37.7%). Almost half of them had a job. More than half of them (56.6%) had 2–4 pregnancy experiences. In term of the husband education and employment, 62.5% of them were literate and almost all of them (98.1%) were employed. The family income was more than 4 million Toman (11,500 Iranian Toman = 1 USD) in about half of the households. More than 60% of participants were legal immigrants. Only 120 participants (45.5%) of legal immigrants had health insurance (Table
1).
Access to the ANC
According to the new WHO recommendation (2016) for adequate ANC, almost 36% of Afghan women received adequate ANC (≥ 8) during their pregnancy. However, based on previous WHO recommendation (2002) for adequate ANC (4 or more visits), about 85% of participants had adequate ANC.
The sociodemographic determinants of adequate ANC
Tables
2 and
5 illustrate the results of bivariate and multivariate analyses for the association of sociodemographic factors with adequate ANC. It appeared that the oldest age group (35–45 years) are less likely to have adequate ANC (at least 8 visits) (26.3%) compared to the younger age groups; however, in multivariate analysis, after adjusting for other sociodemographic variables and component factors, the odds of having adequate ANC in this group became almost 11 times the youngest age group (18–24 years). The higher education level was significantly associated with adequate ANC in bivariate analysis. Likewise, in multivariate analysis, the literate women were more likely to have adequate ANC (AOR = 8.65; 95% CI [2.48–30.11]). It appeared that having a job reduce the likelihood of having adequate ANC in Afghan women (COR = 0.65; 95% CI [0.43–0.96]). However, it became insignificant after adjusting for other variables in regression analysis (AOR = 0.54; 95% CI [0.18–1.59]). There was no significant association between the number of pregnancies and having adequate ANC in bivariate analysis (
p = 0.399). Therefore, we did not include it in final regression equation. The higher education of husband was significantly associated with adequate ANC in both bivariate and multivariate analyses (AOR = 4.67; 95% CI [1.91–11.40]). There was no significant association between the husband employment and having adequate ANC in bivariate analysis (
p = 0.518). Having more than 4 million Toman family income was significantly associated with adequate ANC (AOR = 5.85; 95% CI [3.77–9.10]), even after adjustment for other variables in multivariate analysis, the odds of having more than 8 ANC visits was almost 8.59 times higher in women of 4 million or higher family income. It appeared that the access to adequate ANC in settled Afghan refugees and immigrants (with more than 5 years in Iran) is significantly higher than that of the recent ones (5 years or less in Iran) in both bivariate (COR = 3.55; 95% CI [2.30–5.47]) and multivariate analysis (AOR = 3.29; 95% CI [1.43–7.61]). In both bivariate and multivariate analysis, the legal immigrants were more likely to have adequate ANC (AOR = 7.07; 95% CI [2.28–21.96]).
In Iran, only legal immigrants are eligible for having health insurance; thus, this variable was only examined among legal immigrants (Tables
1,
2). The results showed that the odds of having adequate ANC is 14 times higher in insured Afghan women (COR = 14.00; 95% CI [7.71–25.39]).
The reasons for inadequate ANC
The component factor “poor personal knowledge and attitude toward ANC” was negatively associated with the adequate ANC among Afghan women (COR = 0.37; 95% CI [0.25–0.57]). Likewise, in multivariate analysis, after adjustment for other variables in equation, this relation remained significant (AOR = 0.06; 95% CI [0.03–0.15]).
The hardships in seeking ANC such as unaffordable expenses, far distance, and poor transportation were more prevalent among those with inadequate ANC (70.6, 67.7, and 79.4% respectively). Although in bivariate analysis; the component factor “difficulties in access” was associated with inadequate ANC (COR = 0.29; 95% CI [0.17–0.48]), adjustment for other variables in multivariate analysis, diluted this association (AOR = 0.33; 95% CI [0.11–1.00]).
Poor quality of services appeared to be a significant obstacle in having adequate ANC in both bivariate (COR = 0.38; 95% CI [0.24–0.60]) and multivariate analyses (AOR = 0.17 95% CI [0.07–0.41]).
The sociocultural and legal issues such the fear of being discriminated or poorly treated, religious and cultural concerns, and fear of deportation or arrest were respectively reported among 61.8, 52.9, and 44.1% of those with inadequate ANC. Accordingly, these issues were negatively associated with adequate ANC in bivariate analysis (COR = 0.50; 95% CI [0.33–0.75]). However, adjusting for other variables in multivariate analysis, reduced the cumulative impact of these issues on adequate ANC among Afghan women (AOR = 0.46; 95% CI [0.19–1.10]).
Discussion
The factors influenced the utilization and access to ANC among refugees and immigrants could be diverse in different host countries [
20]. In present study, we evaluated the prevalence and the impact of sociodemographic factors and potential obstacles on the adequate utilization of ANC among Afghan women in Iran. Following a preliminary qualitative research and comprehensive literature review the potential obstacles and concerns of Afghan women in seeking maternity care in Iran were conceptualized to develop the questionnaire of present study. The results indicated that almost a third of Afghan women in this study, had adequate access to ANC (8 or more ANC visits). The Afghan women from the older age group, those with higher education and family income, women with longer length of stay, and those of legal status were more likely to have adequate ANC. The husband education has also a positive association with adequate ANC. Furthermore, owning health insurance proved to be an important determinant of adequate ANC among legal immigrants. In final analysis, only the poor knowledge and attitude toward ANC; poor quality of services; and to some extent, the difficulties in access were the main obstacles in having adequate ANC among the study population.
The education and socioeconomic status are some the most important determinants of access to healthcare [
21]. A number of surveys, in both developing and developed countries, have shown that the educated individuals from higher socioeconomic classes are more likely to have access to quality and adequate healthcare [
11,
22]. Similar findings have been reported among immigrants and refugees [
23‐
25]. In our study, we found that Afghan women with higher education and family income, regardless of their legal status, are more likely to have adequate ANC. Higher education has been linked to higher chance of finding a job, higher income, and better living condition [
21]. Furthermore, it has been shown that the educated mother are more willing to engage in their child health and better recognize the importance of ANC [
26]. Clearly, the husband education has the similar impact on the utilization of reproductive and maternity cares. Evidence indicate that men with higher education are more likely to contribute to the reproductive needs of their partner [
24,
27].
Another important determinant of maternal and child health is mother’s employment [
28,
29]. Previous studies indicated that the employed mothers are more likely to have adequate ANC [
29]. In our study, however, we observed that unemployed mothers are more likely to have adequate ANC. The less flexible schedule and autonomy of employed mother could contribute to the inadequate ANC during the pregnancy among Afghan women. Furthermore, the lower chance in securing a decent job, due to the refugee status, often push the Afghan women toward laborious jobs with long working hours and no maternity leave. Moreover, often due to the financial struggles, they cannot afford to quit their job, especially illegal immigrants [
30] and this could substantially reduce their autonomy and access to adequate ANC. Therefore, developing and implementing appropriate labor market laws should be the priority of Iranian government to support the maternity leave for refugees and immigrants is the country.
It has been shown that the recent refugees and immigrants (less than 5 years of arrival) have less access to ANC compared to settled ones (more than 5 years of arrival) [
24]. Our results similarly indicated that the Afghan women living in Iran more than 5 years are more likely to have adequate ANC. This has been attributed to the higher access to health system achieved through the familiarization, acculturation, and accustomization of settled population with the host country’s health system, culture, and environment [
31].
The legal status has been recognized as an important determinant of access to the health system in host country [
14,
32]; Several studies have shown that the illegal status of undocumented immigrant could reduce their access to ANC and increase the adverse birth outcomes [
20,
33,
34]. Similarly, we observed lower ANC among illegal Afghan women, even after adjustment for other variables. One issue is their ineligibility for health insurance. Currently, all the registered Afghan refugees and immigrants could benefit from public health insurance (PHI) in Iran; however, the situation for illegal Afghans in unclear. In addition, PHI only reimburses for some of ANC services at the primary healthcare level; and the secondary and tertiary prenatal services which are usually expensive are not covered [
9]. We found that the insured Afghan women are more likely to have adequate ANC among legal immigrants. Therefore, first, measures to improve the coverage of current insurance scheme and second, laws for universal health coverage of all Afghan refugees and immigrants, at least for the expectant mothers, should be passes by the national government to ensure the maternal and child health in Afghan refugees and immigrants in Iran.
Poor knowledge and attitude toward ANC were important reasons for inadequate ANC among Afghan women in this study. The statement “I was healthy” reflected the Afghan women’s lack of knowledge in term of the ANC importance for a healthy pregnancy. It was reported by almost half of the participates with inadequate ANC. Furthermore, the poor attitude toward ANC (I think it is unnecessary) was observed by almost two thirds of the participants. Previous studies emphasized the importance of well-oriented education programs for enhancing the reproductive and maternal health among immigrants and refugees in host country [
35,
36]. Future policies and interventions should be directed toward enhancing the knowledge related to the reproductive health and maternity care among Afghan women in Iran.
The poor quality of health care such as long waiting time and poor quality of antenatal services, was one the most important associated factor with inadequate ANC in present study. This finding was in line with the evidence from other developing countries. The weak infrastructure of health system and inadequate number of health professionals in some remote areas; particularly in government sector, reported to be the main reasons for such issues in most developing countries [
37,
38]. Likewise; in Iran, these issues still exists in some remote areas. Although in big cities such as Tehran, these issues are shown not to be problematic anymore [
39], our study indicated that these issues still exist in some marginalized communities like Afghans even in big cities like Tehran. They are even more evident in government sector such as community health centers and government hospitals [
39]; where not only receive the highest number of Afghan visitors but also many Iranian citizen who are more vulnerable due to their low socioeconomic status. Therefore, the government should direct adequate resources toward building capacity in these underprivileged areas in order to promote the quality services.
Religious and cultural concerns have been reported to be potential obstacles in utilization of ANC and accessing quality ANC services in some strict Islamic states such as Afghanistan [
40,
41]. The gender-sensitive issues such as contact restriction between male provider and female patient are some of the reported religious and cultural barriers toward adequate ANC among Afghans. This reduces women access to maternity care; specially in countries of west culture in which these issues are often ignored by health providers [
41‐
43]. However, in our study, due to the dominant Islamic culture of Iranian society in which the contact of a female patient and a male provider is also restricted, these issues appeared not to be problematic. In addition, none of the participants complained about unavailability of a female provider.
Fear of deportation or arrest also appeared to be an important barrier to visit health facilities among illegal Afghan women in our study. We observed this issue in 44% of those with inadequate ANC. Therefore, we suggest expanding the safety net services by collaboration between international and national agencies for refugees support to ensure the adequate access to ANC in this vulnerable group. The fear of being poorly treated or discriminated was also a reason among approximately 60% of those with inadequate ANC in this study. Evidence has shown that the perceived discrimination; feeling of abandonment, and isolation among immigrants and refugees could affect the individual’s perceived quality of life and satisfaction in host society [
44,
45]. Similar experiences were reported among Afghan people living in Iran [
46]. The intercultural incompetency of health personnel has been reported to be the main reason for such issues. The language barrier could also cause such bitter experiences [
47,
48]; however, in Iran, almost all Afghans could fluently speak and communicate in Persian. We emphasized the necessity of interventions to enhance the intercultural-competency of health personnel delivering health services at Afghan-concentrated communities in Iran.
Limitations
Despite the resourceful findings of present study, there were some shortcomings that reduce the representativeness of results across different Afghan population in Iran. First, we conducted our study in urban areas where usually is the home for those refugees and immigrants with higher socioeconomic status and may not represent the underprivileged rural refugees and immigrants who may be of different sociocultural backgrounds and reproductive needs. Therefore, further studies among rural Afghan population is recommended. Second, we recruited the Afghan women at community health centers; therefore, a group of Afghan women whose access to such facilities is limited may have been missed. There were also some participants whose residential status appeared to be illegal and refuse to participate due to the fear of disclosure and potential arrest. Although, we tried to overcome this issue by engaging interviewers of Afghan origin and explaining the objective of this study for them; however, we might loss some valuable information on those who refused to participate. We also failed to collect the exact data on the gestational age at the first ANC.
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