Our finding that 61% of women asylum seekers and girls in the asylum centres under investigation were of reproductive age suggests SRHC as a vital element to be considered in the healthcare provision of this population. While we found adequate accommodation in most centres, some centres lacked gender-separate sanitary facilities. The special healthcare needs of this vulnerable group are addressed inadequately in the standard healthcare model, which does not include certain essential services, such as interpreter services.
Accommodation and gender-appropriate support in asylum centres
Our finding that rooms and facilities are with few exceptions generally available in asylum centres in order to allow women to be separate from men indicates that accommodations for asylum seekers in Switzerland are in line with the recommendations of the European Parliament to take gender into account in order to improve security and safety for women and girl refugees [
40]. The European Union Agency for Fundamental Rights [
41] recommends separate accommodation and sanitary facilities to prevent gender-based violence. The gender separation within the centre may serve to prevent exposure to potential violent behaviour from men [
42] and subsequent re-traumatisation.
However, gender-separate sanitary facilities and sleeping quarters are not available in all reception and transit centres in the European Union [
40]. Our finding from Switzerland that seven out of eight centres investigated had gender-separate toilets and showers and that six out of eight centres had gender-separate sleeping quarters is encouraging. Ideally, gender-separate sanitary facilities and sleeping quarters should be available in all centres.
The employment of women staff members in all centres indicates that gender-appropriate support in terms of same-gender caretakers is ensured. The UNHCR [
43] regards the availability of female staff in refugee camps as a precondition for the effective protection of women and girls. Lack of female staff is a significant barrier to ensuring sexual and reproductive health, as women refugees may forgo seeking medical care [
44]. Similarly, women and girl refugees are less likely to report gender-based violence to men [
44]. Having female staff members for women asylum seekers to confide in may make it easier to speak about potential rape experiences and other SRHC-related issues. This is particularly significant given the high risk of female refugees of being exposed to gender-based violence during flight [
11,
33]. Our finding that female staff members are employed in all centres investigated is reassuring, as it increases the likelihood that SRHC-related matters are discussed and dealt with.
Meeting SRHC needs of women asylum seekers: Standard versus specialised healthcare provision
The healthcare model with standard care as established in the German-speaking part of Switzerland profoundly impacted the provision of health services due to a) the unavailability of pertinent patient information, b) inadequate coordination between the asylum centre and external healthcare providers, and c) marginal use of midwifery and community-based child health services. These services are known for providing more individualized woman- and family-centred care [
45]. The neglect of woman-centred care among women asylum seekers might be due to the phenomenon in industrialized countries that pregnant women of low socio-economic status are not comprehensively informed by their healthcare providers about having a choice in maternity care services, such as midwifery services or antenatal classes [
45]. They therefore tend to comply with the prevailing medical or public clinical care model, which does not meet their special needs and can lead to worse perinatal outcomes [
27,
45].
In the standard healthcare model physician-patient confidentiality was the main reason for external healthcare providers’ reticence to pass on patient information to asylum centres. Ensuring information exchange is essential to patient safety [
46].
When healthcare is handled by multiple healthcare providers, models of managed care are required to ensure appropriate and timely treatment [
47] and the availability of patient information [
48]. In regard to the availability of patient information and managed care we found favourable conditions to be present when healthcare was specialised for the needs of asylum seekers, as we encountered in the model of the French- and Italian-speaking part of Switzerland, in which information was freely exchanged among professionals within the healthcare network. The coordination of treatment also facilitated a frictionless handoff of patients between healthcare providers. This ensures patient well-being and serves to give patients peace of mind and reassurance [
48].
The study presented raised concerns that some professionals may not show appropriate sensitivity to the cultural, social, and psychological needs of women asylum seekers, as the informant seemed to suggest that in childbirth there are only medical needs that need to be attended to. This might be an indicator for a lack of cultural sensitivity. Cultural sensitivity among healthcare professionals is a concern frequently raised in regard to the healthcare of refugees [
49‐
52]. It includes responsiveness to language barriers as well as to differential beliefs, perceptions and values in regard to health and illness which female asylum seekers may hold. A lack of cultural sensitivity among professionals has been linked to differences in health outcomes among minority groups [
50].
Ensuring the availability and accessibility of essential healthcare-related services is crucial to continuity of healthcare. We noted the unavailability of certain essential services, of which we highlight three areas: a) interpreter services, b) female contraceptives and family planning, c) access to alternative healthcare professionals during pregnancy, such as midwifery services or antenatal classes.
Interpreters provide essential services to physicians, which, e.g., aids in obtaining patient histories [
27,
53]. In our study we found that the unavailability of interpreter services in the standard healthcare model severely impacted the ability to conduct a clinical assessment. It also strongly curtailed the ability of healthcare professionals to explain medical treatments to asylum seekers and to ensure medical compliance. Not surprisingly, interpreter services are strongly recommended as part of refugee healthcare by numerous studies [
54].
In regard to family planning we found that the main issue in the centres lies in the limited access to female contraceptives due to the costs involved in obtaining them. Asylum seekers were required to pay for female contraceptives partially or in full out of their allowance. Only condoms were available for free and easily accessible. Contraception that is mainly based on condom use is problematic, as it is contingent on the male partner’s approval and use. Given that the abortion rate among women asylum seekers in Switzerland is 2.5 times that of the Swiss population [
15], the policy of not funding female contraceptives may need to be reviewed. Since funding for contraceptives was shown to increase the use of contraceptives among refugees in camps [
55], it is probable that increased availability of female contraceptives will reduce the frequency of abortions. The reallocation of funding from free abortions toward free female contraceptives is likely to contribute to protecting asylum seekers’ health and to reducing abortions.
Non-physician healthcare professionals were not included as part of standard care in the asylum centres. The likelihood of various negative outcomes, such as foetal loss and episiotomy, is significantly reduced with midwife-led healthcare, while the likelihood of desirable outcomes, such as spontaneous vaginal birth, maternal breastfeeding, and maternal feelings of control are increased [
56]. With its holistic view of healthcare and focus on health promotion [
57], midwife care may be able to affect positive outcomes not only in the ante- and perinatal period, but also in child development after birth [
58]. Similarly, midwife-led antenatal education can have a positive effect on psychological outcomes, such as a reduction in fear of childbirth and an increase in maternal self-efficacy [
59], as well as physical outcomes, such as a reduction in caesarean sections and other interventions [
60].
Strengths and limitations
The present study is the first to investigate sexual and reproductive healthcare provision for female asylum seekers in asylum centres in Switzerland and, to our knowledge, in Europe.
We provide new insights on a subject that is of growing importance to nations around the world, which are receiving a growing number of refugees. Based on our investigation into the conditions of healthcare provision of a vulnerable population, we provide specific recommendations for the improvement of SRHC for female asylum seekers in asylum centres.
The study is limited by the approach to gathering data on women asylum seekers indirectly through interviewing centre staff members in asylum centres. A further limitation lies in the fact that qualitative inquiries are more strongly influenced by contextual factors and the subjective experiences of the informant than are quantitative studies. However, its exploratory nature allows for topics to be discussed that go beyond the initial interview questions. This facilitates the discovery of issues that are related to the phenomenon under study. Finally, data were collected from a purposive sample of asylum centres, which limits our ability to generalise the findings beyond asylum centres that feature the selected characteristics.
Recommendations for healthcare practise for women asylum seekers
Based on our findings and discussion we suggest adaptations in the most important domains of asylum seekers’ healthcare: a) healthcare organisation, b) availability of services, c) continuing professional education. Our findings strongly suggest that specialised healthcare models are likely to be more effective in addressing the special health needs of a highly vulnerable patient population. They entail benefits to the free exchange of information, frictionless collaboration among healthcare providers and give asylum seekers the chance to make informed choices in treatment.
The integration of low-barrier access to specific support services may reduce the possibility of fragmented healthcare. Specifically, and most importantly, we recommend that funding should be provided for interpreter services to facilitate communication between healthcare providers and asylum seekers on complex healthcare topics. This will allow valuable patient information to be gained and ensure that patients understand and can adhere to their treatments. Finally, continuing professional postgraduate education that includes courses on culture and gender-sensitive care may aid in raising awareness of the circumstances and issues that women asylum seekers face.
While our recommendations seek to address the healthcare shortcomings we encountered in our research, their scope is limited to the healthcare context in Switzerland. It is evident that certain issues can only be addressed on a larger, EU-wide scale. Patient information exchange between Italy and Switzerland, for instance, was one of the problems that we discovered which requires cooperation across national borders. Several European directives and conventions concerning sexual and reproductive health have been proposed [
61]. We recommend a closer collaboration and coordination of efforts between nations, as they are essential in ensuring that the policies, resources, and procedures are in place to support effective healthcare delivery for migrants.