Introduction

Conflict and crisis have dire consequences on women and girls’ sexual and reproductive health (SRH) and rights. Women and girls affected by conflict often have limited access to SRH care and are particularly vulnerable to unintended pregnancies, which may lead to high rates of unsafe abortion, maternal mortality, stillbirth, and perinatal mortality [1–3]. While migration to the United States may offer enhanced opportunities for access to SRH services, little is known about the extent of information and clinical services available for women through refugee resettlement agencies (RRAs). A study from 2004 showed that 25% of newly resettled refugee women were pregnant or had a reproductive health problem, and many had missed routine preventive care including breast and cervical cancer screenings [4]. Another study, published in Canada, calculated that 26% of newly resettled refugee women had unmet contraceptive need, meaning they were sexually active and not wanting to become pregnant but not using a contraceptive method [5]. These studies underscore that newly resettled refugee women have significant SRH needs. However, to the best of our knowledge, the role that RRAs play in supporting refugee women’s SRH needs has not been investigated.

Refugee resettlement is undertaken by a public–private partnership between the US government and nonprofit organizations. There are currently 9 organizations with a network of local affiliates across the country that have cooperative agreements with the government to provide resettlement services. The initial services—those provided in the first 3 months after arrival—include housing, food, job placement, and medical care, and are funded by the Department of State’s Reception and Placement Program [6]. At the time of this study, the researchers identified 236 individual resettlement offices throughout the US. These offices assist newly arrived refugees with housing, obtaining education and employment, accessing public services, and acclimating to life in the US.

To better understand how these agencies support the SRH needs of their clients, Advocates for Youth (AFY), a nonprofit organization that supports efforts to improve the SRH of adolescents and young adults, jointly conducted a survey with the International Rescue Committee (IRC), a nonprofit organization that responds to the world’s most severe humanitarian crises, helps people to survive and rebuild their lives, and is one of the 9 refugee resettlement agencies in the US. This effort is part of a broader AFY project to increase awareness of, access to, and use of contraception among refugee young adults. The findings from this survey may help lay the groundwork for strengthening the capacity of refugee resettlement agencies to integrate SRH services into programming and support refugees’ ability to plan for their futures by planning their pregnancies and families.

Methods

This project was designed and conducted by AFY, with the assistance of students from Harvard’s T.H. Chan School of Public Health and staff from the United States’ national office and the Atlanta, Georgia, office of the IRC. The survey instrument addressed 4 key areas: (1) available SRH resources and workshops; (2) referrals to and assistance with making appointments for SRH and primary care appointments; (3) barriers to addressing SRH needs of clients; and (4) interest in building the capacity of office staff to address SRH issues. The survey consisted of 29 yes/no or multiple-choice questions; all survey data were qualitative. The survey was created expressly for this study and was not previously used or validated. The survey included an introduction to the study, explaining how the data were intended to be used. The survey may be reviewed in supplemental information, under the document title S1 Survey. The survey data were intended to undergo descriptive analysis, which was conducted by AFY. The data analysis plan was created prior to administration of the survey, and no changes to the plan were made during data analysis.

The survey was conducted in 2 stages, first with non-IRC resettlement offices and later with IRC offices. The survey was conducted in this manner due to a concurrent collaboration between AFY and the IRC; IRC management requested to reach out to their own affiliates themselves, rather than having AFY contact them via phone or email, as was the protocol for other resettlement agency offices. Using the website of the United Nations High Committee on Refugees (available at http://www.unhcr.org/en-us/us-resettlement-agencies.html), the research team identified 210 unduplicated non-IRC refugee resettlement offices. Survey participants from each of those offices were recruited through direct phone or email outreach, with the goal that the survey be completed by one staff member familiar with the full range of services available at each office. In May and June of 2018, all 210 non-IRC offices were contacted by email or phone, a maximum of 3 times. Once an office was known to have responded to the survey, no further contacts were attempted for that office. The survey was conducted using SurveyMonkey, an online platform.

For the second stage of survey implementation with IRC offices, AFY staff worked with IRC national and Atlanta staff to make minor adaptations to survey questions to ensure alignment with IRC terminology. IRC national leadership directly invited, by email, each of the 26 IRC offices to participate in the survey. The survey was again conducted using SurveyMonkey, across a 3-week period in July and August 2018, with a request that the survey be completed by one person familiar with the range of SRH resources available at each office.

For both non-IRC and IRC surveys, data analysis was conducted on the SurveyMonkey platform. The results presented in this manuscript represent aggregated responses from both non-IRC and IRC offices.

As this survey gathered information exclusively about the practices and resources available in the respondents’ places of employment, the study protocol did not meet the criteria of human participants’ research. Per the guidelines and decision-making tool available at https://grants.nih.gov/policy/humansubjects/hs-decision.htm, the study did not require institutional review, thus it was not submitted to any institutional review board. The survey included a consent statement explaining the purposes of the survey and the risks and benefits of participating so that each respondent could choose whether or not to participate; the organizations as a whole were not approached to request consent for participation.

This study was reported per the guidelines published in “Standards for Reporting Qualitative Research,” as published in the journal Academic Medicine in September of 2014 [7]. The checklist is included in the supplemental materials, titled S1 Checklist.

Results

Across all of the 236 non-IRC and IRC offices invited to participate, the survey collected 100 responses, for a response rate of 42%. The response rate among the 210 non-IRC offices was 38%, while the response rate from the 26 IRC offices was 77%. Some respondents answered some but not all of the questions on the survey; for any given question, the response rate was between 80% and 96%. All 9 of the resettlement agencies were represented among respondents, with IRC and the US Conference of Catholic Bishops affiliates accounting for the largest percentage of respondents (Table 1). Survey respondents included resettlement managers, coordinators and directors, executive directors, deputy directors or vice presidents, program managers, and case managers. Seventy-one percent of respondents provided the name of their office and contact information. Among those that did provide contact information, there were no known instances in which 2 people from the same office responded to the survey.

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Table 1. Respondent characteristics.

https://doi.org/10.1371/journal.pmed.1003579.t001

Available SRH resources or workshops

All survey respondents were asked whether their offices offered written materials (such as pamphlets or handouts) on SRH for clients (Table 2). Of the 95 offices who responded to this question, 15% (14) stated that their offices do have written materials, such as pamphlets or flyers. Of those offices that do have written SRH materials for clients, 92% (11) reported providing materials in at least one language other than English. Only 5% (5) of offices display any posters or signs that provide SRH information. Pamphlets and signs contained information on family planning/birth control and how to access clinical reproductive health services.

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Table 2. Availability of SRH resources and education.

https://doi.org/10.1371/journal.pmed.1003579.t002

Forty-one percent (37) of offices offer workshops that cover SRH topics. Among those offices, 51% (18) offer workshops in a single session, and 11% (4) offer a multi-workshop SRH series. Forty-nine percent (17) also include SRH content in cultural orientation courses. Forty percent (14) of offices reported conducting classes at least 4 to 6 times per year. The most common topics covered include: family planning/birth control; the reproductive health system and how pregnancy occurs; and how to access clinical reproductive health services. Sixty-nine percent (24) of workshops are always or usually separated by gender, and 82% (28) are voluntary for clients.

Only 17% (15) of 86 responding offices have a health educator on staff. Only 12% (10) of agencies surveyed always or usually screen female clients upon intake for whether they want to become pregnant in the next year.

Among the offices that responded, 52% (44) reported developing partnerships with other organizations to provide SRH workshops. These other organizations included medical clinics and providers and local departments of health.

Interest in building office capacity

Seventy-three percent (60) of respondents reported either “yes” or “maybe” when asked if they thought their office would be interested in increasing its capacity to provide SRH information and referrals to clients (Table 3). Those who responded positively were asked to select which listed trainings would be of potential interest to them; respondents could choose all that applied. Thirty-six percent (27) selected general staff training about SRH, 19% (14) selected training specifically about birth control, and 64% (47) selected training about how to talk to clients about SRH. Additionally, 87% (64) of respondents stated offices needed written SRH materials (handouts, pamphlets) for clients.

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Table 3. Interest in expanding agency capacity.

https://doi.org/10.1371/journal.pmed.1003579.t003

Discussion

Refugee resettlement offices are typically refugees’ first points of contact with the social services and supports that are available to them upon arrival in the US. They assist newly arrived refugees with a number of primary needs, including housing, food assistance, cultural orientation, healthcare, and employment—needs which are clearly important to refugees’ ability to establish a new life in this country and to become self-supporting. This study examines the extent to which resettlement offices are addressing the SRH needs of newly arrived refugees, which could be accomplished by a nonmedically trained staff person who asks about clients’ desire to become pregnant, use of contraception, and whether or not she has any questions or concerns about her sexual or reproductive health.

The findings from this survey document that only a minority of resettlement offices are directly helping refugee women and couples plan for their futures by planning their pregnancies and families, or linking them to SRH services. For example, only 15% of responding agencies provide written SRH information to clients, and only 5% had posters or signs providing this information. Only 41% of offices provide SRH content in classes or workshops, and just slightly more than 25% provide information specifically about family planning and contraceptive methods. While the majority of agencies refer clients for primary care and intend that refugees seek reproductive healthcare through that resource, only a small percentage of agencies refer clients to clinical resources specifically for reproductive healthcare. These findings highlight an oversight in the provision of care for refugee women, often times leaving the burden of seeking to understand, request, and access SRH services solely to women themselves. These findings point to a gap in services for refugee women, a gap that may have a detrimental effect on those women’s ability to set and reach their goals in a new community, such as educational, career, and well-being goals.

Refugee resettlement agencies cited a number of barriers to providing SRH information and referrals to clients, including the presence of multiple competing priorities, a lack of culturally appropriate sexual health materials to give to clients, and clients’ own attitudes and cultural beliefs about reproductive health. Some agencies felt that addressing reproductive health was outside the scope of resettlement services, while other agencies reported lack of time and resources as the key barrier to providing this service. However, having an unintended or mistimed pregnancy would be detrimental to a family’s ability to achieve economic self-sufficiency, so attending to clients’ SRH needs is a necessary part of supporting their resettlement.

The majority of respondents reported that their agency would or might be interested in improving their capacity to provide SRH information and referrals. The most commonly cited needs for offices to expand this capacity were written materials in multiple languages developed specifically for refugee clients and staff training on how to talk to clients about SRH. These findings point to the lack of on-site technical capacity at resettlement agencies to accurately and effectively formulate and share this information with women.

Recommendations

Recognizing that resettlement agencies may lack the capacity to meet the SRH needs of their clients due to limited resources, the following recommendations may be helpful for integrating SRH services into existing resettlement service delivery.

Conclusions

Findings from this survey may assist with laying the groundwork for strengthening the capacity of US RRAs to integrate SRH services into programming and to support refugees’ ability to plan for their futures and to have intended pregnancies and families. The current landscape of capacity, established in part through this survey, will inform the cross-organizational effort by IRC and AFY to pilot programs aimed at increasing access to SRH education and services for refugee clients. Further, additional research into the experiences of refugee women themselves would contribute greatly to an understanding of their needs for service provision.

Supporting information

Acknowledgments

The authors wish to gratefully acknowledge Jessica Dalpe and Beth Farmer from the International Rescue Committee for their valuable contributions to this work.