Barriers to reproductive health care for migrant women in Geneva: a qualitative study

Migrant mothers in developed countries often experience more complicated pregnancy outcomes and fewer migrant women access preventive gynecology services. The objective of this paper was to explore barriers to services for reproductive health (RH) in Geneva described by migrant women from a qualitative perspective. The study used a qualitative approach and thirteen focus groups, involving 78 women aged 18 to 66 years, conducted in seven languages. The data was analyzed, and common themes were identified.

The five main barriers that emerged were financial accessibility, language barriers, real or perceived discrimination, lack of information and embarrassment.

In conclusion, the study suggested the following four interventions to reduce barriers for migrant women to reproductive health care services:

Migration is increasing worldwide. Migrants move to high-income countries for a variety of reasons. On the one hand, individuals migrate to improve their employment opportunities (so-called labor migration), while on the other hand, individuals are forced to migrate due to conflict, human rights violations or persecution. The International Office of Migration reported in 2015 that more than one billion people in the world are migrants, among which 48% are women [1]. In Switzerland, the foreign-born population has greatly increased, and the canton of Geneva is among those with the highest migrant population. In 2016, 41% of the residents in the canton of Geneva had a nationality other than Swiss [2].

While a diverse population bears important chances for economic development, inequalities in pregnancy and childbirth outcomes and disparities in access to gynecology services between migrants and non-migrants have been reported internationally [3‐5]. This finding is in accordance with studies conducted in Switzerland, which described a higher maternal and infant mortality among women with a non-Swiss nationality in comparison to their Swiss peers [6‐8]. Furthermore, newborns of mothers, especially those from Africa or South East Asia, have been reported to have lower birth weights and to be more frequently transferred to the neonatal unit [6, 9]. In the field of gynecology, studies in Switzerland described more voluntary abortions among women with a non-Swiss nationality, higher numbers of unwanted pregnancies among undocumented migrants compared with women with a legal resident permit or Swiss women, as well as lower screening rates for cervical or breast cancer in some ethnic groups [10‐12].

Reasons for health disparities among migrants and the population of the receiving country are multi-factorial and often difficult to disentangle. Published literature has stated, among other factors, challenges in accessing the health care system (such as language barriers, lower health literacy, and low trans-cultural proficiency of health care providers) but also socio-economic difficulties or cultural beliefs [4, 13, 14].

Engaging communities in health care interventions to reduce barriers or stigma can present a unique mode to deliver care with the potential advantage of improving individual’s health. Community health programs, either in ethnic communities or in faith-based organizations, have been implemented with notable success, among others, in the United States of America [15‐17].

In Switzerland, little is known about whether communities for migrant women support their members in terms of understanding and accessing the reproductive health care system. Therefore, the aim of our study was to identify barriers to access reproductive health services by migrant women in Geneva and to understand if the community played a role in addressing those barriers.

Between April 2014 and June 2015, thirteen FGs in six communities were conducted (Table 1). A typical FG lasted between 90 and 150 min. The average age of the participating women was 41 years (range: 18 to 66 years), and the majority (57.7%) of the women were married. Participants were from 23 countries, and on average, the women had lived in Switzerland for nine years (range: 3 months to 25 years). Their education level was good, with 84.6% having at least a college degree. In addition, every sixth participant reported having no health insurance (15.4%). The socio-demographic characteristics are shown in Table 2.

The study had the overarching objective of exploring barriers to reproductive health services and understanding if the community played a supportive role. The results from the data analysis revealed five broad themes that had a major impact on migrant women’s access to reproductive health services. The identified findings were classified according to Higginbottom and colleagues’ recent paper into either factors influencing the accessibility of reproductive health services vs. factors influencing client satisfaction, and categorized as either structural or personal barriers [23].

The current study is, to our knowledge, the first with the aim of understanding barriers to reproductive health services among migrants from a qualitative perspective. Five main themes were identified and categorized either in terms of structural or personal barriers: financial accessibility, language barriers, real or perceived discrimination, lack of information and embarrassment (Table 3). In general, our results are fairly consistent with previous national and international literature [3, 15].

However, barriers to health services might vary depending on the kind of services from country to country, but also among different migrant groups. Therefore, it is essential to study structural and personal barriers that are related to organizational behaviors.

In the following discussion, we will specifically address the nuanced findings of the structural barriers that influenced accessibility to or satisfaction with reproductive health services for migrant women because we assume that it might be relatively feasible to target those by health care organizations. Therefore, we will not address barriers such as physical discomfort, which have also been previously for women of the host country or structural barriers at the organizational level such as long waiting times for appointments and during visits. Because even these factors may act as a barrier to the use of such services, they can hinder migrant and Swiss patients equally [3, 24].

First, our study confirmed the recent findings by Higginbottom and colleagues who revealed that although maternity services were equally availably for all members of society, in practice the services were often not accessible to migrant women due to a lack of awareness about their existence [23]. Even if the lack of information could be interpreted as a personal barrier, it should rather be considered, in our opinion, as a structural barrier. Indeed, a health organization that is aware of this situation can provide information to their clients. The lack of information is therefore directly linked to health literacy, which has been defined by the World Health Organization as « the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health » [25]. As reported previously in two separate studies in Canada and the United Kingdom, the institutional culture of maternity services has been mainly designed for those who understand and can negotiate the system. These studies demonstrated that people who recently arrived and were not familiar with the system faced a range of barriers [26, 27]. These findings are comparable to our study in which migrant women who were either undocumented or in the process of applying for asylum appreciated the system because they were guided by specifically trained nurses or social assistants. Migrants who did not benefit from those services often felt a lack of information to navigate the system and experienced the health professionals as less helpful. Legal migrant women even stated that they would also profit from those services. These positive attitudes towards social workers or migrant health nurses support the merit of including them in the system.

Furthermore, professionals who do not work specifically with asylum seekers were not provided with accurate information concerning how to help migrants and received little assistance to develop a better understanding of the constraints and barriers experienced by this specific social group.

It is also important that information material requires sufficient language proficiency among recipients. In our study, inadequate language proficiency emerged as one of the main barriers to either accession or the on-going use of services. This finding is supported by previous studies that have reported, among others, the preference of immigrants to have same-language physicians [4, 26, 27].

However, even if at the University Hospital of Geneva more than 100 different nationalities are working in the medical and nursing sector, it is an impossible task to provide a same-language physician for every participant. In all FGs, participants indicated that language barriers increased their insecurity about seeking care. Most participants sought out ad hoc interpreters to navigate the system, and our findings revealed that few participants were aware of the provision of free-of-charge skilled interpreters for clients. The few participants who used interpreter services rated the experience positively to influence its future use. Efforts should be undertaken to raise awareness of those services and to provide information about their gratuity as well as the possibility of avoiding certain translators either due to sex or cultural background.

The second structural barrier encountered in nearly all FG and which has been previously described in the literature was the financial accessibility of the system [26]. However, in contrast to other studies, the lack of insurance did not lead to a reported delay in seeking care [4]. This might be because, in 1996, the University Hospital created a health care unit that offers free or low cost medical care to undocumented migrants in Geneva. Even if uninsured migrants are referred to the general services of the University Hospital for gynecological or obstetric care, the health care unit has generated trust among the uninsured migrants over the two decades and reaches the majority of pregnant, undocumented and uninsured women [12].

One important personal barrier influencing access to health services that has been outlined by previous studies is social isolation [4, 23]. Interestingly, this barrier was not encountered frequently in our study, which might be due to two reasons. First, FGs were mainly conducted in ethnic, religious or social groups in which the women had started to create a social network. Second, most of the participants had followed either family members or friends who had already lived for several years in Switzerland. Therefore, those residing longer in the country facilitated the arrival of the new immigrants. This phenomenon also explains why the sub-theme of isolation was mentioned mainly in women who migrated as refugees due to unstable conditions in their home country and arrived in an unfamiliar country.

The last two structural barriers influenced mainly client satisfaction. Challenges in delivery services such as the provision of appointments, waiting times or turnover of health care providers can hinder women’s access to services due to less satisfaction with the services and have been addressed previously [4, 23]. These barriers could be addressed at the organizational level.

One of the most important barriers influencing women’s satisfaction was “real or perceived discrimination”. Crush and colleagues described xenophobia, racism and discrimination as increasingly prevalent in countries that receive a large number of migrants [28]. As Geneva, is one of the cantons with the highest percentage of migrants in Switzerland, this risk might also be present. Xenophobia towards migrants might manifest itself as hostility towards migrants by authorities, neighbors, employers or service providers belonging to the host population [28]. Sometimes perceived discrimination is due to a feeling of inferiority emerging from the restricted rights and entitlements of migrants, which might be especially the case for vulnerable migrants. Furthermore, it has been reported that especially migrants who have migrated due to traumatic circumstances may be more inclined to perceive xenophobia against them [29]. However, this observation could not be confirmed in our study population because migrants with a non-refugee background also frequently expressed real or perceived discrimination. It is important for health care providers and administrative staff to be aware of real or perceived discrimination because it can influence the necessary trusts within the patient-provider relationship and can have negative effects on future health seeking behaviors [29, 30]. In the present study, it was not possible to verify if the staff intended to discriminate. However, efforts should be undertaken to include cultural competence training not only in medical education, as it is already part of the curriculum in Geneva, but also in professional practices for health care professionals as well as administrative staff. Intercultural competence training is a method that aims to enable professionals to communicate effectively and empathically while concomitantly reflecting their own culture and implicit assumptions [31]. Furthermore, it might effectively support patient-professional communications irrespective of the migration background. The inclusion of administrative staff in such training is important to lower the anxiety of participants because they are the first contact with the health system for participants. Even if some authors mentioned that training designed to supply specific cultural knowledge about ethnic groups might risk stereotyping and obscure attention to the needs of women, other studies have also reported that such training improves the abilities of professionals in the health care sector to meet the needs of their patients [31]. In a setting such as Geneva, patient-sensitive competence training might improve patient-provider communication. Furthermore, it might strengthen understanding among health care providers for requests (such as same-sex physicians) that might cause embarrassment among women as they have to explain themselves or their practices, or have to ask for what may be regarded as special treatment.

Research examining the reduction of barriers to healthcare services is not only beneficial at the personal and institutional level, but it can also inform health policies and strategies. Especially in times during which a constant influx of new immigrants into Geneva changes the population, efforts of health care providers and public health actors must be continuously renewed and oriented to reach new arrivals. This study identified several structural and personal barriers to reproductive health services in Geneva. Even if the data from qualitative research cannot be generalized to the broader context of Switzerland, many of the findings could potentially be applicable to other countries.

Structural improvements, which might meet the needs of the heterogeneous emergent population, are as follows: (1) the provision of information material that is easy to understand and available in multiple languages, possibly using new mHealth technologies; (2) the mandatory provision of sensitive cultural training for health professionals to inform professionals about the availability of interpreter services and social services to offer appropriate care; (3) the evaluation and adaptation of the skills of nurses or social assistance to guide migrants who are not asylum seekers or who are undocumented through the Swiss health system; and, finally, (4) the inclusion of monitoring and evaluation programs for the prevention of personal and systemic discrimination.

Our study showed that migrant communities are interested in topics about health but provide few activities to support their members. Efforts should be undertaken to involve migrant communities, for example, in the distribution of information and knowledge among newcomers to ensure that they know where to find and how to use the services to which they are entitled.

Such combined efforts could, in our opinion, reduce some of the perceived or experienced barriers on the side of the user.

However, future research exploring community-based health interventions may also be beneficial.