Background
Social determinants of health, defined as “conditions in which people are born, grow, live, work and age” [
1], continuously influence both a person’s and a group’s health status at macro, meso and micro levels and are largely responsible for health inequities. After arrival at the receiving country Germany, health and wellbeing of asylum seeking women, namely those who have sought international protection and whose claim for refugee status has not yet been determined [
2], are equally subjected to health inequalities based on social determinants of health, especially during pregnancy and early motherhood. The
Conceptual Framework for Action on the Social Determinants of Health by the World Health Organization (WHO) [
3] schematically depicts how social determinants affect people’s health. At the macro level, the national policies have an indirect impact on the health of individuals, for example through social policies in the housing sector. At the meso level, socioeconomic status indirectly affects one’s health via the purchasing power (or lack of) to access health services. At the micro level, material and psychosocial factors affect a person’s health, for example through poor housing conditions and unsecure neighbourhoods. Social determinants of health, intertwining at macro, meso and micro levels, are factors associated with economic and social conditions and may dispose of a strengthening or deteriorating effect on an individual’s health status. Taking such social determinants of health into account when addressing the health and wellbeing of asylum seeking women is of great importance, particularly during pregnancy and early motherhood.
Focusing on the heterogeneous group of asylum seekers, pregnant women and those in postnatal period (up to the first six weeks after childbirth) are highly vulnerable [
4‐
6]. Female asylum seekers are especially vulnerable with regards to pregnancy-related outcomes [
5]. Results from a systematic review on maternal health outcomes in migrants, including those who have crossed an international border or left their habitual place of residence within a state [
7], showed that compared to the host population, migrant women had a significant disadvantage for the risk of low birth weight, premature birth and perinatal mortality [
8]. Furthermore, migrant women were at an increased risk of serious complications during pregnancy [
9] and had an augmented risk for poor maternal health outcomes [
10]. Studies on asylum seekers’ maternal health revealed an elevated risk of severe maternal morbidity and of maternal and perinatal mortality [
11] and conclude that maternal health needs of asylum seekers are complex [
5]. A systematic review of systematic reviews found that asylum seeking women have poorer perinatal health outcomes compared to women from other migrant groups, including mental health, perinatal mortality, and premature birth [
12]. Asylum seeking women who are pregnant or new mothers are highly vulnerable and at an increased risk for adverse maternal and perinatal health outcomes.
Based on their increased vulnerability, pregnant women and new mothers seeking asylum have special needs. Even though the
Universal Declaration of Human Rights highlights that everyone has the right to a living standard “adequate for the health and wellbeing of himself and of his family”, comprising housing, food, clothing and medical care [
13], poor social determinants of health during the post-migration arrival and integration phase jeopardize asylum seekers’ health. Often, asylum seekers’ living conditions in reception countries are marked by material and psychosocial deprivation [
14,
15]. Asylum seekers face very basic and limited socioeconomic conditions whilst living in state-provided direct provision accommodation [
15], so-called reception centres [
16]. In the course of the asylum application, a transfer to a shared accommodation centre, also mostly state-owned, is organised. In general, accommodation centres are equipped with kitchens and allow for self-catering. Transfers are realised at any time after the official hearing, a personal interview with each asylum seeker about the individual reasons for flight [
17]. The interview takes place within two days after the formal application for asylum [
18]. Most European Union (EU) member states acknowledge vulnerable persons, including pregnant women and single parents, yet only very few offer separate accommodation, additional intermediate meals, sports or activities outside the centre or cooking facilities [
19]. In some EU countries, such as Ireland, it is vividly discussed if this institutional living and institutional food offer an acceptable standard of living, in particular with regard to the right to adequate housing and rights to food and health [
15]. As applied in other EU countries, Germany executes policies of direct provision accommodation [
20,
21]. This concept of accommodation offers shelter, catering and a minimal monthly allowance in cash, also referred to as “pocket money”, and in kind to cover personal needs [
22,
23]. Direct provision accommodation represents an institutional type of living with basic living conditions and catering (inhabitants are prohibited from cooking themselves) [
16]. Direct provision accommodation, which is mandatory for asylum seekers [
24,
25], offers strongly limited benefits such as basic housing, meals and a minimal monthly allowance in cash to cover personal needs [
22,
26]. In Germany, asylum seekers are initially accommodated at a reception centre and subsequently distributed to an accommodation centre. As a consequence of restrictive policies, asylum seekers have no say in the geographic placement during the process of distribution [
16]. The duration of the asylum seeking process may take up to six months or longer [
18,
27]. In reception centers in Germany, often a high number of people live in confined spaces and certain rules and standards have to be respected [
28]. Public policies between federal states, social determinants at the macro level, vary greatly in Germany and lack nationwide attention of the special needs of vulnerable groups [
29]. State-provided accommodations cover basic needs of asylum seekers yet special needs of pregnant women and young mothers are not addressed on a national level [
29]. Policies addressing the special needs of pregnant women and new mothers seeking asylum and living in state-provided reception centres vary considerably both within Europe and Germany.
Furthermore, housing and neighbourhood quality are relevant social determinants of asylum seekers’ health as they usually live in state-provided housing within the first weeks and months after their arrival in receiving countries. Poor material circumstances are characterized by a low housing and neighbourhood quality, including a lack of privacy and safety of the living environment [
30]. A recent mixed-methods systematic review found consistent correlations between the physical aspects of living conditions and the physical and mental health of asylum seekers [
31]. A safe living environment and neighbourhood is especially relevant for single women travelling alone or with children and pregnant and lactating women as they are in need of organised and operational safeguard measures [
32]. In receiving countries, many asylum seekers experienced depriving housing conditions and insecurity [
33,
34]. Due to the policy of sharing the accommodation with unknown persons, privacy is almost lost [
16]. Poor housing was identified as negatively affecting asylum seekers’ health and wellbeing through a range of pathways while improving quality and security of the housing could ameliorate their health outcomes [
35]. A study on female refugees in Germany showed that women considered institutional living with overcrowded space and limited privacy without any opportunities for retreat to be burdensome [
36]. In Germany, only some federal states accommodate vulnerable groups including pregnant women in separate facilities [
29]. A study on asylum seekers in the Netherlands found that poor housing conditions, including privacy, housing and safety had a high influence on their physical health and quality of life [
37]. Poor housing and neighbourhood quality, representing important social determinants of health at the micro level, can adversely affect the health of asylum seekers, especially of pregnant women and new mothers.
Furthermore, limited consumption potential displays an added social determinant of health. A large study conducted with humanitarian migrants in Australia found that almost two-thirds suffered from economic problems [
38]. They considered financial constraints as a key post-migration stress factor with negative consequences for their health [
38]. In Sweden, stressors linked with social and economic burdens have been attributed to adverse health outcomes in asylum seekers [
39]. The stress-related effects of socioeconomic worries on the health of refugees are significant [
40]. The United Kingdom National Health Service has attempted to tackle this problem by providing additional assistance to pregnant women or those with children under the age of three [
41]. Small monthly financial allowances and limited influences on socioeconomic conditions and autonomy, such as the prohibition of self-catering, jeopardize asylum seekers’ health during pregnancy and early motherhood.
In Germany, there is limited evidence of health and health-related experiences and needs of the particular group of asylum seekers who are pregnant or new mothers and live in state-provided accommodation [
42]. Therefore, we aimed at gaining in-depth in-sights into asylum seeking women’s experiences and perceived needs during pregnancy and early motherhood, paying special attention to material circumstances in one federal state in Southern Germany.
Discussion
This exploratory case study offers in-depth insights into the experiences and perceived needs of the vulnerable group of pregnant women and new mothers seeking asylum whilst living in state-provided accommodation in one federal state in Southern Germany. Focusing specifically on material circumstances and behavioural factors as social determinants of health, the main findings of this study showed that these factors exerted a perceived negative impact on the health and wellbeing of the women.
Study participants were transferred up to four times between state-provided reception centers and expressed a high level of dissatisfaction with their overall living conditions whilst being accommodated at reception centres. Their frustration was linked to the housing and neighbourhood quality which, according to interviewees, lacked privacy and security. They reported that sharing a room with unknown and sometimes intrusive persons negatively impacted on their feeling of security and privacy and resulted in poor sleep quality. Women also stated that due to prevailing regulations they had no influence over the occupancy of their room. Additionally, pregnant women described the exacerbation of their pregnancy-related nausea and their fear of catching an infection due to the poor hygienic conditions at their accommodation. The pregnant women and new mothers perceived a poor standard of housing and neighbourhood quality, a social determinant of health at the micro level, whilst being accommodated at state-provided reception centres as detrimental to their health.
Another aspect that added to the asylum seeking women’s discontent with the state-provided accommodation, which they considered as highly challenging, was the perceived dearth of consumption potential as a result of the restricted financial living allowance. They reported hardship when left without any money if their monthly allowance in cash was late or omitted, e.g. in case of a relocation. Moreover, limited financial resources meant the women could not afford to buy much of their own food and were reliant on the basic catering services. The prohibition to cook in reception centres was considered as adversely affecting their nutrition and wellbeing. According to them, the catering’s bland food with little choice was considered to be insufficient in terms of quality, especially concerning the particular needs during pregnancy and early motherhood. Asylum seeking women in our study also criticized that catering neglected individual dietary needs and cultural and religious practices. In addition, the women had limited information and availability of physical exercises recommended for pregnant women at the direct provision accommodation. Most interviewed women expressed their frustration related to these conditions stating that they had no other possibility than to accept and endure the conditions in the so called “camps” in order to “survive”. Only one participant asked for a change of the system. In our study, pregnant women and new mothers experienced restrictive regulations that negatively impacted on their material circumstances and perceived health in state accommodation.
The discussion about changing the system of state-provided reception centres with restrictive and even repressive regulations limiting asylum seekers’ autonomy is subject to a lively debate in reports and studies. A study on asylum seekers in an eastern state in Germany emphasized on the perceived negative consequences of repressive regulations and various socio-environmental challenges during the asylum seeking process [
59]. Based on a study of accommodation centres in the Czech Republic, a report by the International Organization for Migration labelled these centres as long-term “confinement” and “tools of migration control”, stating that in reception centers, control and assistance go hand in hand, creating a repressive environment for asylum seekers [
60]. In the United Kingdom, which also applies policies of direct provision accommodation, asylum seekers are often accommodated in areas that are coined by deprivation, with the consequence of social determinants of ill-health [
61]. The necessity of remaining at a particular allocated accommodation during the asylum application exacerbates the adverse consequences [
61]. Research on reception conditions for asylum seekers in the Republic of Cyprus labeled the circumstances as inadequate and problematic [
62]. Addressing the restrictive regulations at state-provided reception centres, a social determinant of health at the macro level, might be beneficial for asylum seekers’ health, especially during periods of increased need including pregnancy and early motherhood.
The lack of autonomy in state-provided direct provision accommodation is further exacerbated by asylum seekers’ experiences of a limited consumption potential. Women in our study highlighted the harmful consequences of financial deprivation for their health and wellbeing. Poverty and insufficient financial means impact adversely on an individual’s health [
63]. In the Republic of Cyprus, asylum seekers are excluded from the national guaranteed minimum income; they receive instead allowances in kind and/or vouchers and a small amount of cash that can be used for utilities and other expenses [
62]. Yet, the voucher system is considered as problematic, causing more problems than solutions [
62]. Asylum seekers’ experience of financial hardship was also reported in the United Kingdom where the majority of asylum seekers are needy upon arrival [
61]. A recent qualitative study on asylum seekers’ experiences with living conditions in Eastern Germany also highlights women’s perceived lack of resources and multitude of socio-environmental challenges during the asylum seeking process [
59]. Disposing of limited financial means is burdening for asylum seekers and results in limited consumption potential, a social determinant of health at the meso level, with perceived negative consequences during pregnancy and early motherhood.
In addition, housing and neighbourhood quality have been shown to be a crucial determinant of health [
31,
63]. Housing was found to be important to both physical and mental health for asylum seekers [
31,
35]. Accommodation affects health and wellbeing via physical characteristics e.g. the housing condition and social characteristics such as safety and security [
35]. As stated by the WHO’s
Health Principles of Housing [
64], adequate housing should minimize adverse factors and protect vulnerable populations such as pregnant women. The operational standards of reception centres in Europe, published by the European Asylum Support Office, declare to “ensure respect for the privacy of the applicants in collective housing” [
23]. Yet, the detailed statement states a maximum of six single applicants in one bedroom [
23], raising doubt on the level of privacy for each individual. Even though host countries should strive for creating a safe environment for asylum seekers [
65], e.g. in the United Kingdom, asylum seekers face depriving and insecure housing [
33]. As a consequence of the policy of sharing accommodation, often with unknown people, privacy is largely lost [
16]. Pregnant women experienced living in a shared room with a stranger as challenging, especially during pregnancy [
34]. A study of female refugees in Germany showed that women considered state-provided accommodation with overcrowded space and limited privacy as difficult to endure [
36]. Asylum seeking women who were exposed to violence should be availed a protected living environment in order to begin to process their trauma [
66]. Yet, reception centres with insufficient privacy, lighting and a lack of separate accommodation for women who are single, may even facilitate exposure to adverse events including aggressions [
30]. Therefore, it is important to make sure that reception centres offer well-lit accommodation for women who are single, which they can lock [
30]. As poor housing has been identified as having a negative impact on the health and well-being of asylum seekers in a variety of ways, improved quality and safety of housing may lead to better health outcomes [
35]. Additionally, hygiene plays a decisive role in housing quality as poor hygiene may have negative effects on health, especially if water and sanitation are not easily accessible [
32]. Social determinants of health, decent standards in housing, including hygiene and safe food preparation for occupants’ nutritional status and immunity were already highlighted by the WHO’s
Health Principles of Housing [
64] three decades ago. Housing and neighbourhood quality, as social determinants of health at the micro level, play a substantial role in physical and mental health of asylum seekers and are of even greater importance for those who are pregnant and new mothers.
Another aspect of great importance for women in our study was nutrition. This is backed by latest results from a systematic review and meta-analysis that clearly state the importance of maternal diet quality during pregnancy on outcomes in children [
67]. Standards published by the European Asylum Support Office also highlight the relevance of ensuring asylum seekers’ access to adequate food in sufficient quantity in reception centres [
23]. Yet, our study participants experienced the prohibition to cook in reception centres and catering services that lacked healthy food and were not sensitive to cultural and religious practices. Similar findings are reported in a study on accommodation centres in the Czech Republic, where asylum seekers considered reception centers’ catering services as particularly oppressive and considered it demeaning, to be unable to control their lives in such an intimate matter as dietary intake [
60]. Similar to our findings, poor quality, limited variety and tastelessness of meals offered by catering services were criticised [
60]. These findings clash with women’s need of a balanced diet with a sufficient amount of vitamins as this is considered a modifiable risk factor to prevent adverse birth outcomes [
68]. As a social determinant of health at the micro level, availing a healthy diet for pregnant women and new mothers living at state-provided reception centres is a basic requirement for health of both mother and unborn child.
Furthermore, pregnant women and new mothers perceived a lack of information and offers of healthy physical activities in reception centres which was considered as troublesome for their health and wellbeing. This stands in contrast to the right to prevention which includes prevention and education programs for behaviour-related health problems and the promotion of social determinants of good health [
69]. Implementing policies in all European Union member states that avail separate accommodation, supplementary intermediate meals, healthy sports or activities outside the centre or cooking possibilities for vulnerable persons [
19], including pregnant women and single parents, might lead to a higher level of health and wellbeing of these women. Implementing policies and educational programs on health promotion, including healthy sports activities during pregnancy, may enhance women’s health via adjusting the social determinants of health on a macro level.
As health is a basic human right and its realisation may be pursued via the formulation of appropriate health policies, a main objective in promoting women’s right to health should be to reduce women’s health risks, in particular to decrease maternal mortality and to protect women from domestic violence [
69]. Yet, there is still a considerable heterogeneity in both EU member states and the German federal states in taking the specific situation and needs of vulnerable persons, including pregnant women and new mothers into account. As declared in a directive by the EU parliament, public policies of member states shall consider the particular situation of vulnerable persons [
70]. This includes to consistently provide separate accommodation, offer the possibility to cook or to receive additional intermediate meals and to avail sports possibilities or activities outside the centre, special terms that some EU Member States have already implemented [
19]. Therefore, implications for policy makers are that immigration policies should consider material circumstances and behavioural factors as social determinants of health to address the health needs of asylum seekers, including pregnant women and new mothers. Implications for the research community are that further data is needed to provide both quantitative and qualitative evidence in order to meet the health needs of these women including access to, provision of and equity of care. In addition, future studies that include a perspective on human rights and gender issues could further improve the health and wellbeing of this vulnerable group. Such future research would contribute to a sound evidence base for decision makers and help raise awareness of the special risks and health needs of these women.
One strength of this exploratory case study is its in-depth focus on the effects of social determinants of health on pregnant women and new mothers seeking asylum in Germany to illuminate the gained experiences and perceived needs with the accompanying consequences for women’s health and wellbeing whilst being accommodated at a state-provided reception center or an accommodation center. Acknowledging that this is a qualitative study on asylum seeking women in one federal state in Southern Germany and results are therefore not generalisable to a broader population, there may be common aspects for asylum seeking women during pregnancy and early motherhood, which are to health care providers and researchers in other areas. Additionally, the consolidated criteria for reporting qualitative studies and the standards for reporting qualitative research were used whilst preparing results for publication to maximize trustworthiness and to ensure the quality of our findings. Therefore, the findings of this study must be considered under the specific quality criteria applying to qualitative research that were applied in this study. A further strength of our study can be found in the conceptual framework of the WHO [
3] which supported our data analysis, as this can facilitate international comparisons and research endeavours in the related field for other researchers.
Nevertheless, some limitations must be considered when interpreting these results. A limitation of this study could have been the 20 Euro compensation for study participation during each interview. As financial hardship was reported by many participants, the compensation might have been an incentive to participate in the study. In addition, professional interpreting services have enabled us to overcome language barriers, but there is a risk of losing information caused by interpretations and it is not known how these interpreting services influenced the statements of the participants that formed the basis of the analysis. Based on the fact that there were nine study participants, the results must be interpreted with caution. Since the results are from a specific context, it should be taken into account that the results of a similar study carried out elsewhere may be very different. However, this small sample size allowed us to collect detailed data. Despite these limitations, the unique findings of our study contribute to the evidence base available for generating health-related policies and inform healthcare providers about this vulnerable group. Further studies examining the health-related consequences of state-provided accommodation and influencing social health determinants are needed, using both qualitative and quantitative approaches. These aspects must be considered when interpreting these results of this study.