Background
Sexual and Reproductive Health (SRH) refers to access to information, treatment and prevention services regarding contraceptives, sexually transmitted illnesses, abortion, pregnancy, safe and low risk deliveries and post-partum services [
1]. The government should ensure the fair practice of SRH services for its citizens, and this is also an essential requirement for compliance with the Millennium Development Goals, recognized by major international organizations [
2‐
4].
At the same time, in today’s societies having large immigrant populations, the need for specialized health services for immigrants in host countries has been introduced in corresponding healthcare legislation [
5,
6]. Spain is one of the top ten countries in terms of immigration population, and with approximately 6.5 million immigrants, it is the third largest host of foreigners in absolute terms, only preceded by the United States and the United Arab Emirates [
7]. Approximately 48 % of the foreign population residing in Spain is female [
8], with the majority of these women being of reproductive age and requiring specific healthcare needs, related mainly to SRH.
However, there is a discrepancy between the proclaimed rights-based approach to healthcare and current obstacles to immigrant receipt of SRH services [
9]. Therefore, some studies have suggested that sexual and reproductive behavior in female immigrants (including the use and need for the healthcare system) is conditioned in equal parts by cultural aspects and healthcare conditions of their countries of origin, as well as by those of the host country [
10‐
12]. After migrating, females exhibit a series of sexual and reproductive risk factors that, according to some studies, are predictive. Therefore, generation, language and country of origin may be considered predictors of sexual and reproductive risk [
13‐
15].
A recent systematic review revealed that female immigrants are at greater risk of receiving inadequate healthcare services during their pregnancy and delivery as compared to native females [
16]. Additionally, some researchers have demonstrated that the contraceptive method used by female immigrants differs based on nationality [
17,
18]. Generally, the women continue to follow the same preventive and reproductive patterns as found in their countries of origin, that is, they attend health exams with less frequency, are less likely to access family planning services, have more undesired pregnancies and pregnancies at an early age, and have different obstetric clinical histories [
9,
15]. Studies have also shown that there are differences in perinatal outcomes between immigrant and native women [
15,
19‐
24].
Therefore, SRH in female immigrants is currently found to be in a vulnerable state and this population has specific needs that should be considered from a public health perspective. Organic Law 4/2000 of 11 January regarding the rights and liberties of foreign citizens in Spain and their social integration [
25], establishes that officially registered foreigners have the same rights to healthcare services as the Spanish population. However, there have been modifications in legislation regarding immigration and residency in Spain in the wake of the current economic crisis. Therefore, to access the public health system, foreigners who are not EU citizens are required to have valid residence authorization, leaving a large number of female immigrants without SRH coverage [
26].
The majority of the regions in Spain offer specific family planning programs and protocols, although all heath care centers function based on the will and interests of their healthcare professionals and based on the available resources [
27]. Furthermore, immigrants face certain problems regarding healthcare services in their host country—problems associated with the system itself, communication barriers and issues relating to the immigrant-patient. According to Lobato and Oliver, four types of barriers exist: linguistic and communication barriers, cultural and religious barriers, administrative and legal barriers and passive rejection by the healthcare system or its professionals [
28].
Ultimately, despite some established measures, healthcare services in Spain are organized and created for a culturally, linguistically and socially uniform population. Cultural diversity, and the labor and social conditions of these users are not anticipated by the system. These situations produce inequality in access and use of healthcare services [
29].
All of these assumptions suggest that healthcare practices are based on ideas, values and social rules that may be conditioned by structural characteristics such as access, economics, culture, legislation, etc. [
30]. Therefore, when researching SRH, it is necessary to consider social, cultural and psychological aspects, as well as the role of gender, since these factors may be influential in affective-social relationships, access to healthcare services, illness type, etc.
This study aims to explore one portion of this need. This paper examines the beliefs and experiences of the female immigrants regarding SRH. Partial findings from semi-structured, qualitative interviews with female immigrants in Andalusia (Spain) are presented.
Methods
Study design
A phenomenological qualitative study was designed, in order to understand and explain the experiences of female immigrants regarding sexual and reproductive health. Field work was conducted between May 2013 and September 2013 in four provinces of Andalusia (southern Spain).
Sample
The study subjects were female immigrants of reproductive age (between 16 and 46 years of age) residing in Andalusia. From strategies employed previously by other authors [
31], we conducted a quantitative description of immigrant women in Andalusia. We analyzed the distribution of immigrant women from different provinces of Andalusia, as from the statistics provided by the National Statistics Institute (NSI), the Institute of Statistics and Cartography of Andalusia (ISC) and the Observatory Andalusian Migration (OAM). At this time some decisions were made with respect to the sample of participants. We decided to include women immigrants from countries with low or medium Human Development Index, who emigrate for economic and /or politicians reasons and who have specific difficulties arising from the situation. The criteria that would guide the selection of informants would be the geopolitical nationality group, considering five different groups: sub-Saharan Africa, North Africa, Latin America, Eastern Europe and Asia. Whereas the motivations of women in European Community countries to take up residence in Andalusia are different from those of women from other areas, we decided to dispense with the profile of women in the study. Then we select the data of women of childbearing age (16 to 49 years), according to nationality group; first the distribution of women in each geopolitical zone of origin was observed in each province. We decided to conduct at least two interviews for each area of origin and conduct interviews in different provinces of Andalusia. Two provinces in the east and two in the western region, based primarily on accessibility criteria were chosen to reporting. Therefore sampling was conducted based upon convenience, searching for participants via letters sent to professionals working in immigration-related organizations in each province of Andalusia.
Procedure
Semi-structured, in-depth interviews were used to collect information, so as to introduce new topics and focus the attention on specific relevant dimensions. Interviews were structured around four sections: first, the story of the migration process. Secondly, sexuality. Thirdly, the reproduction. And finally, experience with the Andalusian Health System. For the purposes of this paper, we will focus on the first three topics The interview script was based on the previous literature review. The interview script is available in Table
1. Given the content of the study topic (sexual and reproductive health), the communication dynamic between interviewer and participant was much more effective when conducted in a private and comfortable environment [
32]. Participants chose the settings in which they were to be interviewed. In total, thirteen interviews were conducted by the same interviewer. They lasted from 22 to 62 min (median: 39 min). The interviews were conducted from May until September 2013. The informants received explanations of how confidentiality would be maintained, and they signed informed consent forms.
Table 1
Topics of interview
1. | What are your expectations regarding your stay here and return to your country? |
2. | Have you had experiences of discrimination as a foreigner? |
3. | Tell me about your working life in Spain |
4. | How many members of your family are in Spain with you and how long? |
5. | Have you had any health problems since arriving in Spain? |
Now, I'm going to ask some questions about your sex life, how you live the experience of sexuality |
6. | Do you often talk about issues of sexuality with someone? with who? |
7. | Tell me about your sexuality, your satisfaction with your sex life |
8. | Tell me what is typical as to the sex of women in their country of origin. Who decides whether to have sex and why? |
9. | Tell me your experience with health services in relation to their sexuality, complaint, treatments, etc |
10. | What should be improved in the attention given by the Spanish health services? |
The following questions are addressed to know what their experience with family planning |
11. | Tell me about the methods of family planning in the country |
12. | How you access them? |
13. | What has been used in your country and why? |
14. | If you use contraceptive methods in Spain, tell me their experience with health services and access methods |
15. | What does your partner think about contraception? |
16. | Tell me what is your opinion on who should use contraception in the couple and why |
17. | What is your opinion on voluntary interruptions of pregnancy? |
18. | Have you had any experience of abortion? |
19. | Who performs abortions in your country? |
Upon completion of each interview, notes were taken regarding the general progress, degree of participant collaboration, any problems encountered, interruptions, etc.
Data analysis
Data was analyzed using qualitative content analysis [
33]. First, all of the material generated (transcripts, field notes and observations) was carefully read. Initial analysis proceeded in tandem with data collection, with discussion of emerging themes between authors. This facilitated development of the topic guide for analysis. Then, a second reading was conducted, this time, an “intentional” one, to confirm or reject the initial hypotheses.
Two independent researchers coded interview transcripts based on the topic guide for initial analysis. Disagreements were discussed between the research team. Finally, one other researcher codified texts. Finally, the previously coded texts were used, as well as field notes and a reference bibliography, in order to conduct an analysis of the obtained results. The different categories were analyzed individually, and they were supported by text citations, looking for complementary data and examining similar concepts in other contexts. Content analysis was conducted using Nudist software (©NVIVO v. 10) to construct the definitive matrices and explore key connections for the final data analysis.
Different strategies were utilized to maximize the methodological rigor of the study [
34,
35]. First, throughout the research process, a thoughtful and flexible approach was used, adapting the method components to the discoveries made in each stage. This allowed for decision making regarding participant recruitment, sampling and inclusion of new analysis categories. The study aimed to gain the largest possible range of perspectives and viewpoints during the data collection process; for example, during the preliminary reading of the first interviews, it was felt that education level was a very important factor in the understanding of the discourse of the females from each area. The analysis was carried out by two of the authors and, during the process, discussed with the third author which strengthened its credibility. Finally, upon completion of the content analysis, contact was re-established with two participants in order to verify the coherence of the results.
Ethical consideration
The Research Ethics Committee of the province of Jaén (Spain) approved the study protocol. Participants voluntarily signed an informed consent and received written information on the study. Researchers ensured the confidentiality of the data collected. After analysis, all recordings were destroyed and the anonymity of the data collected was guaranteed.
Discussion
This paper explores three themes: 1) the migratory process, 2) beliefs and behaviors regarding sexuality, and 3) beliefs and customs during the reproductive process of female immigrants living in Andalusia.
It has been verified that female immigrant brings along all of her beliefs, opinions, attitudes and behaviors regarding sexuality, contraceptives, what is “correct” and what is not, etc. All of this is influenced by manifest and latent social rules of their country of origin. So, once established in the host country, female immigrants should adjust the beliefs of their societies of origin with those of their new host society. Social and reproductive behavior may be influenced during this readjustment period, among other reasons, because the healthcare system of each country is unique. For example, access to the contraceptive pill in Morocco may be distinct from the procedure followed in Spain. In Morocco, family planning programs have considerably increased the use of oral contraceptives. The public sector and mainly, healthcare centers offer women oral contraceptives at over half the cost. Therefore, their arrival to Andalusia may require a period of adaptation; most commonly, these women give up the contraceptive method used in their country of origin and adapt to the most accessible method in Spain, which are not necessarily the same. Thus, they should first receive information, making a physician’s appointment, undertaking a process that may be unknown even to native women. During this process, undesired pregnancies may occur. Many of these women arrive in Spain without intending to have children. The reasons for their emigration were economic; their main
leitmotiv is to earn the necessary money for their families back home. A pregnancy under these circumstances may be considered to be a failure of their migratory project, and there is also the fear of losing their employment or having to reduce their working schedule, having to take on the economic expenses of raising a child, etc. Therefore, despite social and personal pressures that may exist regarding abortion, it is a resource that is used by some female immigrants [
15,
36‐
38].
Since information on SRH tends to be transmitted informally in the countries of origin, through conversations between women, healthcare service strategies should consider this special characteristic. The effectiveness of any initiative or measure increases when cultural factors are included in the healthcare messages, therefore it is necessary to work with the immigrant communities, getting to know their experiences and suggestions. And for this, it is necessary to train healthcare personnel in cultural competencies. Being culturally competent means being capable of relating to patients from other cultures, taking into account their age, gender, ethnicity, religion, socio-economic status, degree of education, etc. It means considering these variables in an ethical manner when treating patients [
39‐
42].
The use of qualitative research methodologies when studying SRH, offers rich information that may be difficult to acquire from other methodologies. This form of “scientific dialogue” via in-depth interviews allows for the understanding of some latent problems which manifest themselves in the everyday lives of the female immigrants.
But these results should be considered in light of certain limitations. We recruited a multi-ethnic sample typical of the study setting and consistent with Andalusia multicultural composition. This strategy produced a heterogeneous sample with multiple regional representations, which in turn impaired our ability to generalize all results. Despite the quality of our sample, some social groups were not included; for example, it was not possible to contact Asian women or women under the age of 20, who would most likely offer quite distinct information. Also, all of the women who were interviewed in our study spoke relatively good Spanish; therefore, the language barrier with respect to healthcare services, as documented in previous works, was not very strong. In addition, women with irregular immigration statuses did not participate in this study.
It should be noted that the methodological strategy was the same for all groups of women participating in the study. It is possible that independent studies, with their own methodological procedures and objectives for each group of origin, may offer more profound results.
Conclusions
A thorough understanding of the female immigrant experience regarding SRH services may be of great use to institutions and individuals designing healthcare plans, programs and measures. Based on some of the results, it appears that certain steps should be taken, possibly implying a social change, as opposed to an institutional change.
On the other hand, an intense effort is necessary. First, research is needed with larger samples of study that contribute to replicate these results. In second place, up until now, strategies directed at improving SRH have focused on women. Very little attention has been given to practices, beliefs and expectations of men. Studying different immigrant strategies (men and women) when once again considering gender relations in the host society may be quite useful. It is recommended that further research include a wide range of participants from different ages, geographic locations and backgrounds.
Competing interests
The authors have declared that no potential conflicts of interest exist with respect to the research, authorship, and/or publication of this article.
Authors’ contributions
CAN conceptualized and designed the study. GPM was responsible for all aspects of data collection, coding, analysis and writing of the initial manuscript draft. CAN, MLGG and MLA assisted in the interpretation of findings, provided important scientific content and wrote and revised several sections of the manuscript. All authors have read and approved the final version of the manuscript.
CAN, PhD, is a professor in the Faculty of Health Studies (University of Jaén, Spain). GPM, Sociology, MD, is a doctoral student. MLGG, PhD, is a professor in the Faculty of Health Studies (University of Jaén, Spain). MLA, PhD is a professor in the Faculty of Health Studies (University of Jaén, Spain).