Eligibility criteria

Inclusion criteria were based on the population to be included, the risk factors to be considered, the design of the studies, the geographic scope, and the timeframe. For inclusion, selected articles must:

1. Be published in French or English, the working languages of the research team;
2. Be published between January 1^st, 2000 and October 15^th, 2021. The year 2000 was the deadline to ensure universal access to healthcare [12], including for migrants, internally displaced persons, asylum seekers or refugees. We thus considered this year as the starting point of our study period;
3. Include data on females who were 12 years old or older. We considered this age group because an earlier study showed that some girls are sexually active by the age of 12 [13];
4. Describe migrant, internally displaced, asylum seeking or refugee women;
5. Focus on access to SRH, including prenatal consultations, childbirth, postnatal care, immunization, healthy infant care, family planning, and management of sexually transmitted infections;
6. Focus on barriers and facilitators;
7. Editorials, commentaries, methodological guides, manuals, and review articles (including systematic reviews) were excluded.

Data sources and search strategy

We developed a search strategy using keywords based on the eligibility criteria. The keywords used included both free and controlled vocabulary. These keywords refer to the study population (refugee or "asylum seeker" or displaced or migrant), the type of services (“healthcare accessibility”) and the focus of the study (barriers or obstacles or “facilitating factors”). Spelling variants and synonyms of the keywords were also considered in the construction of the search syntax. We queried eight databases: Embase, Medline, Cinahl, Scopus, Science Direct, Web of Science, Hinari, and Cochrane Library. We also searched grey literature on Open Grey database, on the United Nations Office for the Coordination of Humanitarian Affairs (OCHA) website and on the UNCHR website. The complete search syntax applied in each database is presented in S1 Appendix.

Selection of articles

The selection of articles was done in several steps. In the first step, the search strategies were applied to the databases to retrieve the references of the articles whose title, abstract or keywords contained the words composing the search equations. Subsequently, the records retrieved were imported into an EndNote library where duplicates were detected and removed. Articles were then imported into Rayyan for the selection of articles according to eligibility criteria. Authors PMS, SD and ETN reviewed the titles and abstracts according to the process described in Fig 1. In the case of disagreement, authors YO and SG independently reviewed titles and abstracts and their decision was used to resolve the conflict. The full texts of the selected articles were then uploaded into Rayyan and read by four co-investigators (SPM, SG, NS and AG) to eliminate those that did not meet eligibility criteria. In the event of a discrepancy, a co-investigator (IB or SR) reviewed the given article to settle the conflict.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Prisma flow-chart of identified and screened records.

https://doi.org/10.1371/journal.pone.0291486.g001

Data extraction

Articles were organized according to the geographical area where the study was conducted. Then, using a seven-item data extraction grid, we extracted the data. The seven items included: references, country of study, study population, type of study, type of service, facilitating factors and barriers. To ensure that the extraction grid was understood and used in a uniform manner, data extracted from the first five articles was done as a team during two working meetings. During this group extraction phase, no amendments were made to the form. Subsequently, the data from the remaining articles were extracted by authors PMS SD, MG and ETN.

Data analysis

The extracted factors were organized according to Peters et al. framework and adapted for an analysis of access to healthcare in the context of instability [14]. The framework centers on four main factors of access, notably: availability, geographical accessibility, financial accessibility, and acceptability. In addition, our review identified six other relevant factors, including: patient-provider communication, client knowledge, decision-making autonomy, stigma/discrimination, and administrative factors. Each factor was considered in the model and categorized as a facilitator or barrier. Finally, the frequency of the identified factors is reported.

Characteristics of the retained articles

The characteristics of the 42 selected articles are presented in Table 1. The studies spanned 30 countries. The Asian continent was the most represented with 16 articles describing studies in 12 countries, followed by the African continent (13 studies) which were mainly about Uganda (n = 5), Kenya (n = 3) and Ghana (n = 3). Methodologically, 29 studies were qualitative, ten studies used a mixed methods approach, and three were quantitative. In addition, 15 of the 42 studies focused on SRH in general and described "reproductive healthcare services" or "maternity services”. The remaining 27 studies focused on one or more specific services, including primarily prenatal healthcare, contraceptive/family planning, and childbirth services.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Characteristics of retained articles.

https://doi.org/10.1371/journal.pone.0291486.t001

Women receiving healthcare services were interviewed in all 42 studies. In addition, healthcare providers were interviewed in seven of the 42 studies. Two studies included key informants [15, 16]. With respect to the profile of the study population, 24 of 42 studies focused exclusively on immigrant women, ten on refugee women, and four on internally displaced persons. Two studies included both refugees and immigrants [17, 18], one study included asylum seekers [19], and one study included refugees and internally displaced persons [20].

Barriers and facilitators of access to sexual and reproductive health services

Fig 2 presents all the factors identified as facilitating or constraining the use of SRH by migrant, internally displaced, asylum seeking and refugee women. Factors were grouped into ten groups: geographic accessibility of services, availability of services, quality of services, communication, financial accessibility of services, knowledge of services by beneficiaries, cultural accessibility of services, stigma/discrimination, women’s decision-making autonomy and administrative factors.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 2. Conceptual framework of facilitating factors and barriers to access to reproductive health services by migrant, internally displaced, asylum seeking and refugee women.

https://doi.org/10.1371/journal.pone.0291486.g002

Geographic accessibility of services

Six of the 42 studies described geographic accessibility to healthcare services that impede access to SRH services for migrant, internally displaced, asylum seeking and refugee women. These include the distance from healthcare centers [22, 27, 48, 56] and lack of transportation [27, 45, 54]. On the other hand, two studies reported that the use of mobile healthcare teams in migrant welcome sites as a factor that improved the use of SRH services [45, 47].

Availability of services

Nine of the 42 studies reported barriers related to the availability of SRH services that handicapped their use. These included lack of supply of medications [24], long wait times for care [16, 22, 41, 43, 54, 56] and unavailability of services at certain hours of the day or days of the week [16, 45, 48, 54].

Quality of services

Eleven of 42 studies described barriers inherent in the quality of SRH services that were barriers to their use by migrant, internally displaced, asylum seeking and refugee women. Five articles noted a lack of confidentiality when receiving care [30, 31, 36, 41, 47], which was sometimes related to inadequate facilities or the use of a patient’s relatives as interpreters [36]. Feeling unwelcome was cited in five studies [16, 23, 28, 31, 56]. Two studies cited the patient’s inability to choose which gender of providers they could see as a barrier to using services [39, 43]. The high workload of healthcare providers was identified as a barrier in three articles [16, 27, 31].

Healthcare provider- patient communication

Seventeen studies reported language barriers in using SRH services [16, 20, 21, 27, 31–34, 36, 38, 40, 46, 47, 49, 53–55]. The language barrier was exacerbated by the lack of multicultural training in healthcare providers [19].

Five studies showed that communicating in many diverse languages promotes access to SRH services for migrant, internally displaced, asylum seeking and refugee women [20, 33, 38, 39, 47]. Similarly, three studies described how using a mobile app on smartphones to disseminate information about SRH services supports their use [37, 49, 50]. As well, providing a professional translator [27, 40, 47], using a family member as an interpreter [53, 57], and diversifying information sources [9] can break down communication barriers and thus promote the use of services.

Financial accessibility

Seventeen studies reported financial factors as barriers to SRH services. These were primarily women’s low purchasing power [16, 22, 26, 29, 30, 43–45, 51], and the high cost of services [22–24, 33, 38, 40–42, 44, 48, 56, 57]. Financial barriers are particularly important in some settings where the cost of services is higher for migrant women than for native women [21]. This is also the issue when migrant women, unlike local women, do not have access to social security services [51].

Knowledge of services

Twenty studies reported that inadequate knowledge limits women’s access to SRH services [15, 16, 18, 24, 25, 27–29, 33, 38, 40–42, 45–48, 53, 55, 56]. This lack of knowledge may relate to the availability or organization of services [25, 27, 28, 38, 45, 48, 55] or the presumed side effects of contraceptives [26, 27, 56]. In two studies, some women equated the use of contraceptives with abortion, revealing an obstacle to compliance with care [18, 45].

Practices that have been developed to increase migrant women’s knowledge and thus promote the use of reproductive health services were highlighted in two studies. This included the provision of health promotion representatives to improve migrant women’s knowledge about the availability of SRH services and thus encourage their use [38, 40].

Cultural acceptability of services

Fifteen studies identified sociocultural considerations that conflict with the requirement for reproductive health services. Four studies found that some migrant, internally displaced, asylum seeking and refugee women have pro-natalist beliefs, which is conflicts with inherent need for contraceptive services [18, 20, 33, 51]. Nine articles describe the cultural imperative of sexual abstinence for unmarried women and for those whose husbands are away from home. This prevents women from using family planning or receiving STI or prenatal care [15, 17, 18, 20, 27, 28, 30, 42, 57]. In the same vein, one study found that the social imperative of virginity inhibited unmarried girls from obtaining cervical cancer screening, HPV vaccination, or family planning services [18]. In addition, three articles showed that the use of traditional medicine or other alternatives (e.g. self-medication) in the place of modern reproductive healthcare reduced the use of SRH services [22, 25, 36].

In one study, the fact that healthcare services did not allow an attendant for women in labor limited the use of labor and delivery services [54]. Similarly, the presence of religious symbols that are incompatible with migrant women’s beliefs hinder the use of healthcare centers [47]. Finally, women reported not accessing services due to experiencing feelings of shame when they were required to be examined naked during gynecological examinations, a necessity for prenatal consultations, STI management and family planning services [17].

In addition to sociocultural barriers, similar facilitating factors were reported. For example, six studies reported that programming of services by community groups [32], developing a partnership with community leaders [33, 47], and having home healthcare visits [27, 45] made it possible to remove cultural barriers to the use of SRH services. Similarly, a positive effect was seen in two studies when healthcare providers received training on person-centered care [31, 32]. Finally, four studies reported positive effects from the training of healthcare providers on cultural sensitivity and cultural communication [33, 38, 39, 47].

Stigma/Discrimination

Five studies describe that the stigma of being a migrant, internally displaced person (IDP), asylum seeker or refugee was a barrier to the use of SRH services [17, 27, 32, 43, 49]. Feelings of discrimination were also reported in seven studies [21, 27, 28, 31, 38, 43, 54]. Finally, women were not motivated to seek preventive care as they considered it relatively less important in comparison to the multitude of other problems they faced [46].

Autonomy in decision-making

Insufficient autonomy in decision-making was identified as a barrier to the use of SRH services. This reflects the low decision-making power of women, the effect of which was identified in nine studies [15, 16, 23, 25, 33, 35, 43, 55, 57]. Barriers related to decision-making autonomy are exacerbated by spouses’ low level of education [51] and lack of involvement in reproductive healthcare issues [57].

Administrative factors

Four studies reported that the lack of documents required for healthcare access limits access to reproductive health services for migrant, internally displaced, asylum seeking and refugee women [21, 43, 44, 48].

Strengths and weaknesses

A major strength of this review is that it has allowed for the development of a framework for analyzing the drivers and barriers to access to sexual and reproductive health services. This framework, an adaptation of Peters et al. [14], considers the lived experiences of the issues faced by migrant, internally displaced, asylum seeking and refugee women regarding sexual and reproductive healthcare access. It can be used as a framework for analyzing factors influencing the use of reproductive health services for these populations in future studies.

Another strength of this review is that we consulted a large number of databases (n = 8), which allowed for the retrieval and review of many articles. Similarly, the broad geographic scope allowed for the investigation of this issue in parts of the world that deserve further study. This synthesis provides an almost complete picture of the facilitating factors and barriers to the use of reproductive health services by migrant, internally displaced, asylum seeking and refugee women.

The main limitation of this study is the heterogeneity of the study population. Indeed, our study population includes people who were forced into displacement (IDPs, asylum seekers and refugees) and ordinary migrants whose displacement was planned. Thus, the challenges in accessing reproductive healthcare services may be different for each. Pooling these two subpopulations complicates the interpretation of the results. Future synthesis studies should focus on a more homogeneous population.