https://orcid.org/0000-0001-9388-2556
Figures
Abstract
Background
Refugee and asylum-seeking women are known to experience a myriad of intersecting sociocultural, institutional, and systemic barriers when accessing healthcare services after resettlement in high-income countries. Barriers can negatively affect service uptake and engagement, contributing to health inequities and forgone care. Access to sexual and reproductive healthcare (e.g., family planning, cervical cancer prevention) has largely been understudied. This scoping review sought to: i) examine the use of sexual and reproductive health services among refugee and asylum-seeking women in high-income countries; and ii) identify barriers and facilitators influencing access to sexual and reproductive healthcare for refugee and asylum-seeking women in high-income countries.
Methods
This review was conducted in accordance with Joanna Briggs Institute Methodology for Scoping Reviews. Ten databases (e.g., CINAHL, MEDLINE, Embase) were searched for qualitative, quantitative, mixed method studies, and gray literature published anytime before February 2024 across high-income countries (defined by the World Bank). The Health Behaviour Model was used to examine and understand factors influencing service use and access.
Results
3,997 titles and abstracts were screened, with 66 empirical studies included. Most were conducted in the United States (44%), Australia (25%), Europe (18%) and elsewhere and were qualitative (68%). Papers largely addressed contraception, abortion, cervical cancer screening, gender-based violence, and sexual health education. Included studies indicated that refugee and asylum-seeking women in high-income countries face a greater unmet need for contraception, higher use of abortion care, and lower engagement with cervical cancer screening, all when compared to women born in the resettlement country. Frequently reported barriers included differences in health literacy, shame and stigma around sexual health, language and communication challenges, racial or xenophobic interactions with healthcare providers, and healthcare/medication costs.
Conclusions
Studies across the globe identified consistent empirical evidence demonstrating health inequities facing refugee and asylum-seeking and myriad intersecting barriers contributing to underuse of essential sexual and reproductive health services. Facilitators included multilingual healthcare provider, use of interpreters and interpretation services, community health promotion work shops, and financial aid/Medicare.
Citation: Stirling-Cameron E, Almukhaini S, Dol J, DuPlessis BJ, Stone K, Aston M, et al. (2024) Access and use of sexual and reproductive health services among asylum-seeking and refugee women in high-income countries: A scoping review. PLoS ONE 19(11): e0312746. https://doi.org/10.1371/journal.pone.0312746
Editor: Rogis Baker, Universiti Pertahanan Nasional Malaysia, MALAYSIA
Received: May 22, 2024; Accepted: October 12, 2024; Published: November 7, 2024
Copyright: © 2024 Stirling-Cameron et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: This original research paper is a scoping review. All analyses completed in the submitted manuscript are based on qualitative, mixed-methods, and quantitative data available publically in existing papers that were included for extraction in this review. All articles are listed in the reference list with a DOI/link.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Sexual and reproductive health (SRH) is a fundamental component of all persons’ well-being and quality of life [1]. Sexual and reproductive health is defined as “a state of physical, emotional, mental, and social wellbeing in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction, or infirmity.” [1] (p.2646) Access to SRH reduces the incidence of gender-based violence, and helps to prevent unplanned pregnancy, reproductive cancers, unsafe abortion, and sexually transmitted and blood borne illnesses (STBBIs), ultimately contributing to gender equality, social justice, and economic development [1]. The 2018 Lancet-Guttmacher Institute report on SRH identified refugee populations as at-risk for worsened SRH outcomes, and suggested that this population is in need of special attention [1]. For the purposes of this review, SRH does not include perinatal healthcare, as this has been reviewed extensively elsewhere [2].
The world is currently amid the largest forced migration crisis ever recorded [3]. Increasing effects of the climate crisis, civil conflict, war, chronic poverty, and political instability are forcibly displacing thousands of people per day. The United Nations High Commissioner for Refugees estimated that 117.3 million people were currently displaced across the globe at the end of 2023, including 43.4 million refugees and 6.9 million asylum-seekers [4]. Approximately 1.7% of the world’s refugee population is housed in high-income countries, including the United States, Canada, Australia, and Germany [4]. Two-thirds of those forcibly displaced are fleeing five countries: Syria, Venezuela, Afghanistan, South Sudan, and Myanmar; the vast majority are racialized, and have been exposed to violence, conflict, and other traumas [4].
Half of all refugees and asylum-seekers are women (4). In situations of armed conflict, instability, and forced displacement, the breakdown of social infrastructures, disintegration of families and community, and high rates of poverty create a context in which women are particularly vulnerable [5, 6]. Women are exposed to extremely high rates of gender-based violence and human rights violations, including sexual abuse and exploitation, human trafficking, intimate partner violence, and child marriage [7, 8]. Single mothers, unaccompanied minors, and transgender women often face abuse and exploitation at the hands of intimate partners, people smugglers, humanitarian workers, and law enforcement agents [5–7, 9]. High rates of violence, coupled with limited access to SRH in refugee camps and temporary settlements, has contributed to disparities in SRH among refugee and asylum-seeking women globally. This includes the transmission of STBBIs, including HIV/AIDS, risks of unwanted pregnancies, unsafe abortions, and the forgone detection and treatment of reproductive cancers [10]. Refugee and asylum-seeking women may be in particular need of accessible, affordable, safe, and trauma-informed SRH services upon arrival in resettlement/host countries [1].
While high-income nations boast quality, comprehensive healthcare systems, SRH disparities persist among refugee and asylum-seeking populations globally [11–14]. Individual or interpersonal socio-cultural and religious beliefs endorsing traditional and patriarchal gender roles and stigma around SRH may limit women’s autonomy and decision to engage in SRH services. Often defaulted as caregivers in times of crisis [5] women report giving priority to fulfilling basic needs, such as finding affordable housing and employment—putting the needs of their families above their own [15–17]. Direct access to healthcare services is limited by women’s ability to obtain childcare and find transportation to appointments, in addition to navigating the healthcare system in their host country [17, 18].
Health and social systems in majority-White countries are often plagued by systemic racism, fostering inequities and mistrust among racialized people, including many refugees and asylum-seekers [19, 20]. Moreover, language and communication differences and a lack of interpretation services or culturally and linguistically diverse staff can complicate service use and limit the uptake of treatment and educational resources [19, 20]. Lack of, or poor-quality insurance restricts access to all healthcare, but particularly to non-acute, preventative care services, such as cervical cancer screening and prevention, and STBBI screening. The high cost of prescriptions, including hormonal and long-acting contraceptives, has been reported as a deterrent to use [21].
The reduced accessibility of SRH services and supports has resulted in inequitable negative SRH outcomes among resettled refugee women in high-income countries, including unwanted pregnancy and abortion [11, 12, 14], lower than recommended rates of cervical cancer screenings [22] and HPV vaccinations [12], high rates of STBBIs [11], reduced uptake of contraception [23], and non-consensual or painful sex [12, 24, 25]. Previous systematic reviews have largely focused on perinatal and infant healthcare access and service use for refugee and asylum-seeking women in high-income countries [2, 26, 27], neglecting other major components of sexual and reproductive health (e.g., family planning, cervical cancer screening, abortion care). Others have focused on refugee camp settings; spaces which face unique challenges and resource constrains, which differ from health access in high-income countries [10, 28]. As refugee resettlement in high-income countries is only expected to rise, a comprehensive, global review of the existing literature is warranted to understand access to and use of SRH services among refugee and asylum-seeking women across these nations.
Objectives
The objectives of this scoping review were to: i) examine the use of sexual and reproductive health services among refugee and asylum-seeking women in high-income countries; and ii) identify barriers and facilitators influencing access to sexual and reproductive healthcare for refugee and asylum-seeking women in high-income countries.
Methods
The scoping review was conducted in accordance with Joanna Briggs Institute methodology for scoping reviews [29]. A scoping review protocol for this paper was published elsewhere [30]. A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, Open Science Frameworks, and the JBI Database of Systematic Reviews and Implementation Reports was conducted and no current or in-progress scoping reviews or systematic reviews on the topic were identified.
Conceptual framework
We utilized Kaufmann et al. (2014)’s health behavior model [31] for sexual and reproductive healthcare, which has been adapted from Bronfenbrenner’s socio-ecological model [32]. The purpose of employing this conceptual framework was to organize and categorize review findings related to objective 2, which sought to identify barriers and facilitators influencing access to sexual and reproductive healthcare for refugee and asylum-seeking women in high-income countries. The health behaviour model has four nested categories which are used to describe factors influencing health care service access and use. These include individual (e.g., knowledge and information, stigma/shame), community (e.g., socio-cultural and religious norms, peer pressure, relationship equity, social support), institutional and health system (e.g., provider biases, health system operations), and structural level factors (e.g., poverty, transportation and infrastructure, service cost). Similar frameworks have been used in other scoping reviews related to refugee health [10, 33].
Eligibility criteria
Participants.
This review considered studies that focused on refugee or asylum-seeking women (also sometimes referred to as refugee-claimant or undocumented women) who have been resettled in or have fled to high-income countries. A refugee is defined as someone who has been forced to flee their country of origin due to conflict, persecution, or violence, and who cannot return to their home country [34]. An asylum-seeker is someone who has fled their home country in search of protection but may not fulfil the strict criteria outlined in Convention Relating to the Status of Refugees [35]. They have applied for refugee status and are awaiting a decision [36]. Immigrant and migrant women and undocumented persons were not included. Though there are potential similarities across groups, economic im/migrants often have additional legal protections not afforded to asylum seekers or refugees (depending on the country); whereas undocumented people often have even fewer protections and privileges, owing to their lack of status. As such, we believed there would be differences among these groups, and restricted our search to just asylum-seekers and refugees. However, many findings may apply to these groups as well. No restrictions were placed on country of origin, women’s age, length of time in their host country, religion, sexual orientation, whether they had children, or their marital status. Studies that elicited health care providers perceptions on access to SRH services for refugee women were also included. This included nurses, family physicians, obstetrician gynecologists, midwives, doulas, social workers, refugee resettlement workers, and other relevant key informants.
Concept.
The main concept under study is access and use of SRH services for women. SRH services have been previously defined to include the provision of accurate information and counseling on SRH, including comprehensive, evidence-based sexuality education; information, counseling, and care related to sexual function and satisfaction; prevention, detection, and management of sexual- and gender-based violence and coercion; a choice of safe and effective contraceptive methods; safe and effective abortion services and care; prevention, management, and treatment of infertility; prevention, detection, and treatment of sexually transmitted infections, including HIV, and of reproductive tract infections; and prevention, detection, and treatment of reproductive cancers [1]. Access to health care was defined as “the opportunity to reach and obtain appropriate healthcare services in situations of perceived need for care.” (33, p.4). Access to health care has five key features, including the ability of the user to i) identify their health care needs, ii) seek out health care services, iii) reach necessary health care resources, iv) obtain or use health care services, and v) be offered services appropriate to the needs of care [37].
Context
This review considered studies that describe the access and use of SRH of refugee and refugee-claimant women that have been resettled or are seeking asylum in high-income countries, defined based on the 2020 World Bank income classifications [38]. Studies which collected data in any of the listed countries were included in the review. Access to services in refugee camps, asylum-processing or detention centers, or other temporary settlements were not included as they are liable to differ from community resettlement settings.
Types of sources
This scoping review considered all study designs: quantitative, qualitative, and mixed-methods. Systematic reviews were screened for potentially relevant papers. Any papers included in the review that appeared to fit study inclusion criteria were added to the study, but systematic review papers themselves were excluded. Due to resource constraints, studies were only included if they were available in English, French, or Arabic. There were no date restrictions.
Search strategy
A JBI three-step search strategy was implemented in this review [29]. The search strategy, developed in cooperation with a librarian scientist, aimed to locate published and unpublished studies (see S1 Appendix for CINAHL search details). The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for CINAHL. The search strategy, including all identified keywords and index terms, was adapted for each included information source. The reference lists of articles selected for full-text review were screened for additional studies.
Information sources.
Databases searched included CINAHL (EBSCO), MEDLINE (Ovid), Embase (Elsevier), Studies on Women and Gender Abstracts (Taylor and Francis), Academic Search Premier (EBSCO), Sociological Abstracts (ProQuest), Social Services Abstracts (ProQuest), PAIS Index (ProQuest), Public Affairs Index (EBSCO), and PsycINFO (American Psychological Association). The original search was conducted in February 2020 from database inception and updated in February of 2024. Sources of unpublished studies and gray literature included, The United Nations, the United Nations High Commissioner on Refugees, the International Organization for Migration, Centers for Disease Control, United Nations Population Fund, the World Health Organization, Google Scholar, ProQuest Dissertations and Theses Databases, Migration Policy Institute, Refugee Council, Canadian Council for Refugees, Gray Literature Report (via New York Academy of Medicine website), and Grey Source—a Selection of Web-based Resources in Grey Literature.
Study selection.
Following the search, all identified records were collated and uploaded into Covidence (Veritas Health Innovation, Melbourne, Australia) and duplicates were removed through the built-in automation process. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria for the review. A document was developed by the primary author (ESC) detailing the PCC framework to be used to screen relevant articles. This was adapted based on feedback from all members of the review team during early phases of full-text screening and uploaded to the inclusion/exclusions section of Covidence. The full text of selected citations was assessed in detail against the inclusion criteria by two independent reviewers. Any disagreements that arose between the reviewers at each stage of the selection process were resolved through discussion or with a third reviewer. The results of the search have been presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews (PRISMA-ScR) flow diagram [39].
Data extraction and charting.
We conducted a data charting process using the online extraction tools available through Covidence (Veritas Health Innovation, Melbourne, Australia) to sort the data and organize our findings. Our extraction tool collected evidence on study participants country of origin, ethnicity, migration status (e.g., refugee, asylum-seeker), country of resettlement, study method, main area of SRH under consideration, use of any SRH services, barriers to accessing care, facilitators to accessing care. This extraction tool was piloted by the study team, after which it was refined and finalized. Data from each full text article were extracted independently by two different reviewers (inclusive of authors ESC, SA, JD, BD, and MA). Data were then divided by objective and are reported below in two sections, each addressing an objective. Due to the large number of studies retrieved, the Health Behaviour Model was implemented to guide data analysis and reporting, which was not included in the original, published study protocol.
Results
Study inclusion
Details of included and excluded studies are reported in Fig 1. The initial search of 10 databases and hand-searching revealed a total of 6222 articles. 2227 duplicates were removed, and 3995 articles underwent title and abstract screening. 215 articles progressed to full-text review, of which 66 articles fit study inclusion criteria and were included in data extraction.
Characteristics of included studies
A total of 66 studies were included in this review. Full study characteristics can be seen in Table 1. Most studies were qualitative (n = 45), followed by quantitative (n = 17) and mixed method designs (n = 4). Most studies were published in the United States (n = 29) [40–68] followed by Australia (n = 17) [13, 69–84] Canada (n = 4) [85–88] Switzerland (n = 3) [89–91], Canada and Australia together (n = 2) [12, 92] Sweden (n = 2) [93, 94] the Netherlands (n = 2) [95, 96] United Kingdom (n = 2) [97, 98] Finland (n = 1) [99] Israel (n = 1) [100] Norway (n = 1) [101], Germany (n = 1) [23], and South Korea (n = 1) [102]. Most studies focused on understanding the experiences of resettled refugee women (n = 41), followed by asylum-seeking women (n = 6), healthcare or service providers (n = 12), refugees and healthcare providers (n = 5), and refugees and asylum-seekers (n = 2).
Our findings are reported in two sections, the first detailing use of SRH services (objective 1) and the second to identify barriers and facilitators influencing access to SRH care (objective 2) among refugee and asylum-seeking women in high-income countries. Each of these two sections have been presented within four overarching categories: gender-based violence, family planning, cervical cancer screening and prevention, and SRH education, to offer a more detailed understanding of factors shaping access to different types of services. These services and supports were most frequently discussed across all included studies. The majority of papers focused on contraception and family planning (n = 23; [13, 23, 40, 48, 54, 59, 66, 72–74, 78–80, 85, 86, 89, 91, 95, 96, 99–101, 103] followed by cervical cancer screening (n = 20; [41, 42, 47, 49, 52, 53, 56, 58, 59, 65, 69, 70, 72, 73, 75, 76, 86–88, 102] gender-based violence (n = 17; [43, 44, 46, 51, 61–64, 67, 68, 77, 81–84, 90, 93] and SRH education (n = 12; [12, 13, 33, 45, 50, 55, 71, 73, 79, 92, 94, 98]. Given the large volume of data reported in objective 2, the Health Behaviour Model [31] was utilized to further organize the data.
Use of sexual health services
The first objective of this study was to understand the use of sexual health services among refugee and asylum-seeking women in high-income countries. The results of this section are stratified by most discussed service type (i.e., GBV; family planning, contraception, and abortion; cervical cancer screening; sexual health education). The majority of studies documenting use of SRH services were quantitative. Quantitative summary statistics are reported in Table 2.
Use of family planning services.
Nine studies reported on use of contraception or engagement in family planning (25,40,82,89,97–99). The use of family planning methods (inclusive of natural, hormonal, long-acting, and permanent methods) among refugee and asylum-seeking women varied widely across studies, ranging from 13.2% to 69.2%. In North America (Canada, USA) rates of engagement ranged from 13.2% to 69.2%. In Europe, it ranged from 27% to 69%. Condoms remained the most often used method, followed by intrauterine devices, natural methods, and oral contraceptives. Two studies reported on the unmet need for contraception among asylum-seeking and refugee women. This was calculated by measuring the proportion of women who were not trying to conceive and who were not engaging in an effective method of family planning/pregnancy prevention. Unmet need for contraception was high, ranging from 26.8% (Canada; 85) to 47% (Germany; 21), both of which were significantly higher than the host population.
Eight studies reported on the use of abortion services among refugee and asylum-seeking women [23, 54, 71, 86, 91, 95, 96, 101]. All studies reported a significantly higher rate of abortion use across refugee and asylum-seeking women, when compared to women born in the host country, ranging from 1.5 to. Goosen et al. (2009) reported that the abortion rate among refugee women was 1.5 times higher than women born in the Netherlands [95]. Similarly, Raben et al. (2018) reported a significantly higher rate of abortion service use among refugee women (11.5%) compared to Dutch women (3.7%, p < 0.001). Kurth et al. (2010) reported that induced abortions were the most performed procedure among asylum-seeking women surveyed; 22.5% of participants had received an abortion since arriving in Basel, Switzerland. In Oslo, Norway, refugee women had significantly higher rates of abortion when compared to Norwegian-born women (AOR 1.94, 95% CI 1.79–2.11) [101].
Use of cervical cancer screening and preventative care.
Twelve studies reported on cervical cancer screening (pap smears) and HPV vaccination [41, 42, 49, 52, 53, 56, 58, 59, 76, 86, 88, 97]. Limited information was available on rates of HPV uptake, with only two studies reporting on this outcome. Kenney et al. (2021) reported that 49.2% initiated and 30.8% of Burmese refugee women completed their HPV schedule in Omaha, Nebraska [52]. Allen et al. (2019) reported that 23% of Somali refugee women had an HPV vaccine and 58% had their children vaccinated in Minneapolis. The rate of cervical cancer screening varied widely (see Table 2). Across the US, rates of engagement with cervical cancer screening ranged from 18% to 74.1%, predominantly among Burmese and Bhutanese refugee women [41, 42, 49, 52, 53, 56, 58, 59]. Among Canada, the United Kingdom, and Australia rates ranged from 25.9% to 80% among a range of multiple ethnicities and countries of origin. [76, 86, 88, 97]
Gender-based violence service use.
Ten studies discussed use of services related to gender-based violence (seven quantitative; one qualitative; [43, 44, 51, 61, 63, 67, 77, 81, 83, 93]. Women utilized a variety of services/supports for gender-based violence, including social services [61, 83], legal supports [61], economic assistance [61], law enforcement [44, 61, 83], shelters [61, 63, 67], and psychological or emotional counselling [63, 67, 83, 97].
Sociocultural and structural factors influencing access to sexual health services.
This section addresses review objective 2: to understand the barriers and facilitators influencing access to sexual healthcare for refugee and asylum seeking women in high-income countries. The results of this section are stratified by most discussed service type (i.e., GBV; family planning, contraception, and abortion; cervical cancer screening; sexual health education). Each section is then divided into the four facets of the Health Behaviour Model [31]. Fig 2 details prominent factors influencing access to sexual health services stratified across the four levels of the Health Behaviour Model. Table 3 details important, relevant quotations across strata. Tables 4 and 5 provide a summary or barriers and facilitators described across included studies.
Gender-based violence.
Individual. Four studies reported refugee and asylum-seeking women often have a limited knowledge of their host countries legal system or were unclear about their personal rights and protections [44, 51, 61, 63]. This left women unaware of where to seek help or what services were available to them. Four studies described women holding mixed perceptions around what constitutes intimate partner violence [44, 61, 62, 93]. For example, Byrskog et al. (2015) described Somali-born women as unfamiliar with certain forms of abuse, particularly psychological and financial abuse, and did not consider non-consensual sex to be a form of violence. Two studies indicated a need for linguistically/culturally appropriate programs to educate women on their personal rights, what constitutes domestic violence, and how to navigate the legal system [44, 61].
Community. Six studies reported that refugee and asylum-seeking women often did not have the appropriate amount of social and emotional support to seek help, as they had been isolated from friends and family through forced displacement and international resettlement [44, 51, 61, 62, 77, 84]. This limited women’s ability to leave abusive situations and identify and navigate services [44, 51, 61, 62, 77]. Other women were deterred from seeking support or taking legal action owing to a fear of being stigmatized within their community, particularly if they pursued separation or divorce, or had concerns around encountering victim-blaming [44, 46, 61–63, 81, 83, 90]. Other studies of Ethiopian and Somali refugee women reported acceptance and normalization of domestic violence among some members of their community [61, 93]. This normalization pressured women to remain silent, fearing a lack of support from community services, family, or friends. Refugee women felt pressured by their community and/or extended family to avoid seeking help, feeling concern around how it may impact their perception [44, 61, 77, 81]. Three studies indicated that women wanted intervention and education supports for their partners and/or other men in their communities [63, 81, 92]. For those who did have the support of community, family, or friends, this was a facilitaror for accessing and navigating GBV-related services [68]
Institutional. Eight studies detailed concerns related to interpretation [44, 51, 67, 82–84, 90, 93], including a lack of interpretation services and discomfort with the use of male interpreters when disclosing GBV [51, 93]. Fineran et al. (2020) noted that male partners may be more proficient in English and may use that to gate-keep women from English-only services. Women who had used shelter services reported encountering racism and xenophobia from other service users and employees [44, 62, 93]. Likewise, Wachter et al (2022) reported that GBV services were not equipped to care for refugee populations, with staff no reflecting the demograpics of their clients. Moreover, service providers felt ill-equipped to respond to the mental healthcare needs of refugee clients who had experienced multiuple traumas. This only perpetuates additional violence and may force women back to their abuser. Other studies described how challenging it can for refugees to naviagate services, especially regarding the reporting of violence, which is compounded by linguistic differences [82–84]. Byrskog et al. (2015) noted that perinatal healthcare appointments were critical opportunities for GBV screening, as there is often continuity of care, the opportunity to build safe, trusting relationships.
Systemic. Seven studies reported women—especially asylum-seekers—feeling fearful about reaching out to law-enforcement following an assault or incident of domestic violence, owing to their non-permanent status [44, 51, 61, 62, 81, 83, 90]. Women’s fear was multi-faceted. Four studies indicated that women did not trust police and were concerned that they may contact immigration authorities, which could impact their case to stay [44, 81, 90, 104]. Others reported that women were concerned that child protective services would remove their children if it was reported that there had been domestic violence in the home [44, 46, 62]. In some studies, women had gone to police seeking support and were not believed, not taken seriously or encountered racial or xenophobic discrimination [44, 62, 77]. Four studies also indicated that women were not financially independent and did not have the means to leave their partners [44, 46, 62, 63]. Other studies detailed the impact of partner criminalization, where women were apprehensive of reporting incidents of intimate partner violence, as it could have implications on their family income and financial stability [46, 81]. Wachter et al. (2019) and others outlined a critical need for financial assistance to give women the support to live alone, and outside of shelters [67, 83].
Family planning, contraception, and abortion.
Individual. Four publications detailed misinformation around the mechanisms of hormonal contraception among women originating from a variety of African nations, including, Ethiopia, Sudan, Liberia, Burundi, DR Congo, Kenya, and Bhutan [13, 45, 66, 74]. The prevailing myth across studies was that the effects of hormonal contraceptives were non-reversable, and long-term use would result in permanent infertility, fetal abnormalities in future pregnancies, higher risk of miscarriage, or cause maternal diseases [13, 45, 74, 99]. 16.9% of participants in Agbemenu et al. (2020) reported fear of side effects influencing use of contraceptives [40]. Persistence of these misconceptions influenced use of contraceptives [13, 45, 66, 74, 99]. Ngum Chi Watts et al. (2014) noted that contraception was often not widely available or affordable in women’s countries of origin, and was often seen as a luxury for wealthier families, which contributed to a limited understanding of effective family planning upon arrival in resettlement countries.
Community.
Sociocultural and religious norms influenced the uptake and use of modern contraceptives [13, 45, 66, 74, 78, 79]. Six studies reported that particular religious and ethnic groups valued and promoted abstinence before marriage [55, 78, 79, 92, 94, 98] This created stigma for sexually active, unmarried women who were seeking information around pregnancy prevention, limiting intergenerational and peer-to-peer knowledge sharing [13, 45, 60, 66]. Even for married women, cultural expectations and value placed around having large families—particularly among Somali women [66, 99]—restricted the acceptability and use of modern contraceptives [60]. This created additional shame and secrecy around accessing and using hormonal contraception for both married and unmarried women [13, 45, 66, 74, 78, 79]. Though several studies stated these ideals changed for many families upon arrival in high-income countries, as parents faced less social support, greater economic instability, and women had more educational and occupational opportunities outside the home [60, 66, 80, 99]. The persistence of patriarchal ideologies and power differences within relationships contributed to challenges negotiating the use of condoms [74, 80] and women’s husband not permitting or restricting the use of contraceptives [73, 80, 86, 99]. For example, four studies stated that women felt their religion did not condone the use of contraception or abortion—yet also stigmatized pregnancy in unmarried women [45, 55, 80, 99]. Supportive and open relationships with partners and families contributed to improved access to contraceptives and more open conversations around family planning [55, 78–80].
Institutional. Lack of interpretation provision was a critical barrier described across seven studies [48, 54, 73, 78, 86, 91, 100]. Three studies found that healthcare providers possessed stereotypes about Muslim women, assuming they would not be interested in hormonal contraceptives. As a result, some healthcare providers did not ask about it, due to this false assumption [48, 73, 96]. Indeed, Raben et al. (2018) found that physicians in the Netherlands discussed contraceptives significantly less often with refugees (51%) than with native Dutch women (84%; P < 0.001). Rodella Sapia et al. (2020) notes that a high proportion of asylum-seeking women who transitioned through Egypt had an intrauterine device inserted as part of a mandatory gynecological assessment and that many had this implanted without their knowledge or consent. Lor reported that some Bhutanese women had been assaulted by male healthcare providers in refugee camps and, as a result, were apprehensive about accepting care from Western, male healthcare providers [56]. These and other examples of forced or unsafe gynecologic care has resulted in feelings of mistrust among many resettled refugees and asylum-seekers [66, 90]. Culturally and linguistically congruent care providers are a key facilitator, removing the need for interpreters [72, 78, 79].
Systemic. Across a number of high-income countries including Switzerland, the United States, Israel, and Australia, women were required to pay in-part or in-full for any modern contraception, with higher up-front costs for long-acting contraceptives (e.g., intrauterine devices, sub-dermal implants; [48, 72, 73, 86, 91, 100]). Lack of coverage for contraception was linked to an increase in abortions in Switzerland [91].
Access to cervical cancer screening and prevention
Individual. Six studies cited differences in health literacy as a barrier to cervical cancer screening and uptake of HPV vaccinations, owing to a lack of access to services and education in their country of origin, transit, or resettlement [41, 47, 49, 56, 69, 75]. Awareness and knowledge around cancer more broadly was high, but limited around ovarian and cervical cancers. For example, Haworth (2014) noted that only 22.2% of respondents had ever heard of a pap smear. Refugee and asylum-seeking women were often unfamiliar with the etiology of cervical cancer and contractability of HPV or had been misinformed about the development of the disease [41, 49, 56, 69]. Allen et al. (2019) found that Somali refugees surveyed had learned that cervical cancer was linked to a genetic predisposition and use of birth control.
A number of studies reported a general unfamiliarity with the concept and prioritization of preventative healthcare [47, 49, 53, 56, 65, 69, 73, 75, 102]. This was inexplicably linked to resource limitations and service costs in countries of origin and refugee camps, with many families forced to seek care only when disease or infection was clearly present [69]. Upon resettlement, many women may be unaware of the need for regular cervical swabs. Schuster et al. (2019) reported that 80–100% of Somali Bantu and Karen participants wanted more information about preventative cancer screening. Other studies reported that women who had experienced sexual or reproductive traumas may feel reluctant to have a pap smear, due to the invasiveness of the procedure [49, 56, 69]. Ghebre et al. (2015) further noted that women who had undergone female genital mutilation may have difficulties with the insertion of a testing swab.
Community. Three studies reported participants noting that cervical cancer screening would be inappropriate for unmarried women, due to the assertion that testing may imply the woman is sexually active [47, 57, 87]. Unmarried women were concerned that receiving a pap smear or HPV vaccination may indicate that they are sexually active and could be stigmatized by their family, peers, or community [47, 49, 57, 87]. For example, 57.1% of Bhutanese-Nepali women in the US indicated that ‘shyness’ prevents them from getting a pap smear. Some parents were concerned that having their children vaccinated against HPV may contribute to or promote pre-marital sex, which was deemed as inappropriate within their cultural beliefs/norms [47, 49, 57, 87]. Support and recommendations from peers and family members contributed to an increased uptake in cervical cancer screening [53, 73, 76].
Institutional. Poor or no interpretation contributed to lack of informed consent, inability to obtain consent, and poor procedural explanations, which left many women feeling confused, uncomfortable or even traumatized [59, 75, 87, 105]. Wiedmeyer et al. (2012) found that English-proficiency significantly predicted the likelihood of getting a pap smear after registration with a community health clinic (AOR 0.625, 95% CI 0.462–0.854). Healthcare providers have been reported to assume a lower level of health literacy among refugee women and have not properly explained the purpose of their procedures, violating principles of informed consent [59]. These and other experiences of discrimination or maltreatment led to reported feelings of mistrust among participants in two studies [47, 59]. However, women across other studies indicated that they had learned about cervical cancer, pap smears, and HPV and the need for vaccination from their healthcare providers and trusted and valued the recommendations they received [41, 59, 75, 76, 87]. Providers who supported women and fostered a safe clinical environment positively contributed to the use of screening services [41, 53, 56, 59, 65, 75, 76, 87]. Other key facilitators included the use of interpreters or interpretation services, [59, 65, 73, 75, 76] appointment reminders, [65, 75] and to have screening conducted by female care providers [56, 59, 65].
Systemic. Six studies indicated that a lack of health insurance and/or cost of services were key barriers to screening and vaccination, particularly in the USA and Australia [56, 59, 69, 70, 72, 87]. For example, 75% of Bhutanese-Nepali refugee women reported that their primary insurance was Medicaid/Medicare [53]. Rubens-Auguston et al., (2019) stated that HPV vaccinations should be publicly funded. Lack of or cumbersome transportation to services was reported as a barrier to testing sites [56, 59].
Access to sexual health education and information.
Individual. Differences in sexual health education and literacy was the most commonly reported barrier influencing access to and use of SRH services [12, 13, 23, 41, 44, 45, 47, 49–51, 56, 57, 69, 70, 72–76, 92, 98, 102, 106]. For example, Ngum Chi Watts et al. (2015) reported that many young African-Australian mothers in their study sample were unaware that penile-vaginal intercourse could result in pregnancy—which contributed to unplanned pregnancies for some participants. Bolstering health literacy and empowering women with knowledge was seen as a key intervention [41, 49, 55, 59, 61, 63, 65, 70, 73, 78, 80, 87, 94, 98, 107]. Online [59, 80, 92, 94, 98], mobile [41], and social media platforms (e.g., YouTube, Facebook, Instagram; [41, 55, 59, 61, 94, 98] were suggested as modes of delivery for information, particularly around prevention, screening, and symptoms [41, 70]. Women in Hawkey at al. (2021), were particularly interested in less-often-discussed sexual health topics, and were interested in more information on sex, sexual desire and libido, vaginal pain, and consent and personal rights.
Community. Cultural and community stigma and shame surrounding SRH was one of the most prevalent barriers reported across studies, which limited knowledge sharing and access to education and services. Studies which sampled youth and/or parents reported a disconnect, with some parents feeling as though it was culturally inappropriate to educate their children on SRH, and youth felling like they couldn’t ask [12, 13, 45, 55, 74, 103]. Judgement and disapproval from family and peers contributes to feelings of fear and embarrassment around sexual health which contributes to lack of knowledge, unprotected sex, unplanned pregnancy, and the spread of STIs [13, 55, 71, 74]. While some parents still wanted to remove their children from sex education in schools, others were keen to reduce the shame and have open conversations with their children. Young women in four studies were keen to reduce the stigma around sexual health and exchange more intergenerational knowledge [13, 55, 74, 92]. A key barrier to this was that parents themselves may not have been educated in sexual health, so need support before they can educate their own children [92]. Gendered, culturally-appropriate workshops delivered in community on key SRH topics was recommended by 13 studies [41, 44, 55, 59, 61, 64, 65, 78, 92, 94, 98, 105, 107].
Institutional. Healthcare providers were viewed as valuable, trusted sources of information. Nine studies reported that women wanted SRH education from their clinicians [41, 59, 75, 76, 80, 87, 92, 98, 108]. However, two studies stated that appointment times are typically not long enough to accommodate the provision of clinical care and education, particularly if back and forth interpretation is also required [65, 87]. Additionally, a high proportion of studies reported that women did not receive any information on how to seek out and navigate SRH services in their host country and as such had difficulty locating and accessing care [47–49, 51, 56, 61, 64, 65, 70, 72, 73, 87, 94, 98]. Many studies noted that SRH education resources and materials must be made available in women’s preferred languages, which was often not the case [49, 55, 59, 61, 73, 78, 80, 87, 94, 98].
Systemic. 15 studies reported that the demands of the resettlement process often precede women’s own health concerns, especially SRH needs [44, 47, 50, 53, 56, 65, 69, 73–75, 78, 87, 92, 100, 102]. Women are often faced with more immediate demands, such as seeking affordable housing, enrolling their children in school, finding employment, and are more likely to be burdened with the additional needs of their children and family—often prioritizing their needs above their own. Additional structural barriers such as lack of childcare [47, 49, 61], limited access to transportation [49, 56, 57, 59, 61, 70, 86, 100], and their proximity to services [59, 70, 86, 100] hindered access and use.
Discussion
To our knowledge, this is the first scoping review to comprehensively document the sexual and reproductive health inequities facing refugee and asylum-seeking women and the corresponding barriers to service use. Studies across the globe identified consistent evidence demonstrating inequitable access and use of sexual health services among refugee and asylum-seeking women across high-income countries. Refugee and asylum-seeking women are experiencing greater rates of unplanned pregnancy [89], significantly higher rates of abortion use [91, 95, 101] unmet contraceptive need [23, 85], low engagement with modern contraceptives [40, 86, 96, 99], and reduced rates of cervical cancer screening [49, 52, 53, 56, 58, 59]. These inequities are borne out of a myriad of interconnected individual, interpersonal/community, institutional, and structural barriers restricting access to services, supports, and education. This includes restricted pre-migration sexual health education, shame around women’s sexual functioning and family planning [44, 50, 92], sociocultural acceptance or normalization of GBV [44, 46, 63, 81], lack of interpretation services or interpreters in healthcare facilities [56, 75], socioeconomic constraints limiting access to care [70, 73], and systemic and interpersonal racism and xenophobia [53, 90, 100]. While refugees and asylum seekers are a diverse and heterogenous population with different countries of origin, languages, races, ethnicities, religions, and journeys through forced displacement, findings were similar enough across studies and populations to allow for theme development and comparison.
According to our results, individual and community/inter-personal factors were frequently discussed across studies, with an emphasis on the role stigma plays in sexual health. Stigma and shame surrounding sexual healthcare, particularly around birth control and abortion care, are not unique to refugee and asylum-seeking women; many individual and interpersonal factors discussed in this paper are not dissimilar to that affecting non-refugee women globally [109, 110]. This includes the global, gendered shame surrounding women’s sexual health and sexuality, which restricts women’s access to knowledge about their bodies and reproductive systems—all of which may have detrimental impacts on help-seeking, access to treatment, and effective family planning. Similarly, the persistence and sociocultural acceptance of gender-based violence remains a global concern, particularly for low-income, racialized, and/or queer women [111]. The dismantlement of systems of power that limit women’s autonomy and safety is critical and must be supplemented with personal and community-level education around sexuality, sexual health, and the rights of women [112, 113].
Reviewed studies revealed numerable institutional barriers to sexual health services for asylum seeking and refugee women. Results demonstrated a clear lack of accessible interpretation services in high-income countries, contributing to inaccessible care, failures to obtain informed consent, and poor procedural explanations [20, 90]. This subsequently resulted in maltreatment and mistrust for women accessing SRH care. Feelings of mistrust were reported throughout studies as a result of a lack of cultural competency and a history of forced or unsafe gynecological care [90]. Other studies recognized mistrust borne out of maltreatment and abuse women encountered by humanitarian aid workers, law enforcement and healthcare providers in transit [5, 6]. Exposure to trauma and sexual violence/exploitation in-transit necessitates culturally-safe and trauma-informed care to reduce further mistrust and violence [5, 6, 114]. While interpreters and interpretation services must be made available, culturally and linguistically congruent care providers are the gold-standard, removing the need for an intermediary entirely.
Results have demonstrated that despite living in wealthy, affluent nations with robust, comprehensive healthcare systems and services, refugee and asylum-seeking women face inequitable sexual healthcare. From a systems lens, anti-immigrant policies that restrict the livelihood and economic success of refugee and asylum-seeking families perpetuates poverty. For example, the failure to recognize internationally obtained education and employment credentials, costly re-certification programs, and low income-assistance rates force many families to live in poverty for an extended period. For example, in 2020, the poverty rate among refugees who had arrived after 2016 was nearly two-and-a-half times the rate of those born in Canada [115]. Income remains one of the most significant social dimensions of health, known to determine an individual or family’s health [116].
In countries without universal healthcare or public health insurance (e.g., USA), some families are left un- or under-insured, paying for many services out-of-pocket. Even in countries with universal care models (e.g., Canada, UK), non-citizens may receive differential health insurance with poorer coverage (see Canada’s Interim Federal Health Plan) [117, 118]. Those without extended health benefits may have to pay for additional services not covered by publilc insurance, such as prescription drugs (e.g., contraceptives, anti-viral or anti-biotic medication for STIs or STBBIs), physiotherapy for sexual dysfunction, or counselling and therapy for gender-based violence. Failure to provide comprehensive coverage for contraception is detrimental in nations where legal access to abortion is restricted or criminalized (e.g., USA, Poland) [119].
It is critical to recognize that most displaced persons have fled violence, instability, and persecution in the Global South (Venezuela, Syria, Sudan, Afghanistan)—thus most asylum-seekers and refugees are racialized [4, 120]. Most studies included in this review came from the USA, Australia, Canada, and Europe, all of which are majority-White states with long, problematic histories of colonization, slavery, and segregation, the legacies of which have created systemic inequities for racialized people which persist today [120–122]. Systems within these countries including criminal-legal systems, law enforcement, border services, healthcare, and social work, are intimately connected to, if not built on the exclusion of racialized people, and migrants [120, 123]. Systemic racism and xenophobia embedded within these systems perpetuates violence and trauma among racialized migrant communities, fostering many of the inequities reported in this review [124]. Healthcare providers, researchers, advocates, resettlement staff, and policy makers must work to recognize and advocate for the dismantling of systems of oppression.
Strengths and limitations
This review identified studies examining access and use of sexual and reproductive health services among asylum-seeking and refugee women. The most significant challenge for this review was the inconsistent terminology used globally to describe refugee and asylum-seeking populations. For example, many studies lumped refugees under more general titles of ‘migrants’ or ‘immigrants;’ others labelled asylum-seekers as ‘undocumented people.’ When screening articles, it was difficult to discern whether some articles fit the inclusion criteria or not. As such, some articles may have been missed due to these differences or other inappropriately included in this review. Our team worked to thoroughly read through all articles included at the abstract and full-text screening to review the population understudy and determine if it fit with our inclusion criteria. Additionally, the quantitative and epidemiological research documenting differences in SRH service use between refugees/asylum-seekers and host-born women was lacking. The little evidence that was available was largely descriptive. As such, inferences made using quantitative research should be made with caution, given small sample sizes across included studies and differential uses of statistics across included studies.
Directions for future research
The majority of research yielded by this systematic review was qualitative or mixed-methods with only descriptive statistics included for the quantitative portion. The limited quantitative data presented in this review should be interpreted with caution, given small sample sizes and differential statistics used across studies. To more concretely demonstrate the inequities described in this review, future epidemiological studies are needed to compare SRH outcomes between refugee women and women born in the resettlement country. This evidence may be essential when advocating for health system and policy change. Moreover, limited work was available on the experiences of asylum-seekers. Given their more precarious status, this population is at a greater risk for negative health outcomes. While this population has been historically difficult to reach, further research is essential to build health services and community programming that meets the unique needs of this highly marginalized group. Last, few, if any studies, examined the experiences of potentially more vulnerable women, such as those living with HIV/AIDS, LGBTQIA+ people, and sex workers. Refugee/asylum-seeking women with intersecting identities may face greater risks of experiencing negative SRH outcomes.
Conclusions & implications for policy/practice
This systematic review has documented significant SRH inequities for refugee and asylum-seeking women. These results are paramount as the world continues to see unprecedented annual increases in the number forcibly displaced people worldwide. We posit a number of recommendations for policy, service delivery, intervention, and programming, based on facilitators acknowledged across included studies. At the individual and community level, we recommended education on SRH for refugees after arrival in their host country, in addition to know your rights workshops related to consent and gendered violence. This programming should be developed alongside essential community partners and/or leaders and be led by culturally and linguistically congruent healthcare or service providers. Interventions and programming embedded within and driven by community will be essential in addressing stigma and shame surrounding sexuality and SRH. At the institutional level, health systems must provide quickly accessible, free interpretation services where culturally and linguistically congruent care providers are not available. In-person interpreters were preferred, however, when this cannot be achieved, video interpretation services should be on stand-by. Policy-makers and educational institutions must employ specific policies (e.g., affirmative action) to ensure a diverse healthcare workforce that appropriately represents changing community populations. At the systems level, affordable childcare and comprehensive public transit will not only drastically improve women’s ability to attend essential health appointments, but more holistically support their social and economic independence. We also recommend the full coverage of contraceptives for all people, regardless of status, and the complete decriminalization of abortion.
Supporting information
S1 Appendix. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.
https://doi.org/10.1371/journal.pone.0312746.s001
(DOCX)
S2 Appendix. Search strategy [CINAHL, EBSCO].
https://doi.org/10.1371/journal.pone.0312746.s002
(DOCX)
Acknowledgments
The authors would like to thank librarian scientist, Shelley McKibbon, at Dalhousie University for supporting the development and implementation of the search strategy.
References
- 1. Starrs AM, Ezeh AC, Barker G, Basu A, Bertrand JT, Blum R, et al. Accelerate progress—sexual and reproductive health and rights for all: Report of the Guttmacher–Lancet Commission. The Lancet. 2018;391: 2642–2692. pmid:29753597
- 2. Heslehurst N, Brown H, Pemu A, Coleman H, Rankin J. Perinatal health outcomes and care among asylum seekers and refugees: A systematic review of systematic reviews. BMC Med. 2018;16: 1–25. pmid:29890984
- 3. UNHCR. Global Trends: Forced Displacement in 2020. 2021 pp. 1–74. Available: https://www.unhcr.org/globaltrends2018/
- 4. UNHCR. Figures at a glance. 2024. Available: https://www.unhcr.org/figures-at-a-glance.html
- 5. Hourani J, Block K, Phillimore J, Bradby H, Ozcurumez S, Goodson L, et al. Structural and Symbolic Violence Exacerbates the Risks and Consequences of Sexual and Gender-Based Violence for Forced Migrant Women. Front Hum Dyn. 2021;3: 1–13.
- 6. Freedman J. Sexual and gender-based violence against refugee women: A hidden aspect of the refugee “crisis.” Reprod Health Matters. 2016;24: 18–26. pmid:27578335
- 7. UNHCR. Women on the run: First-hand accounts of refugees fleeing El-Salvador, Guatemala, Honduras, and Mexico. 2015 pp. 1–57. Available: https://www.unhcr.org/publications/operations/5630f24c6/women-run.html
- 8. Stark L, Ager A. A systematic review of prevalence studies of gender-based violence in complex emergencies. Trauma Violence Abuse. 2011;12: 127–134. pmid:21511685
- 9. Keygnaert I, Vettenburg N, Temmerman M. Hidden violence is silent rape: Sexual and gender-based violence in refugees, asylum seekers and undocumented migrants in Belgium and the Netherlands. Cult Health Sex. 2012;14: 505–520. pmid:22468763
- 10. Tirado V, Chu J, Hanson C, Ekström AM, Kågesten A. Barriers and facilitators for the sexual and reproductive health and rights of young people in refugee contexts globally: A scoping review. PLoS ONE. 2020;15: 1–25. pmid:32687519
- 11. Sebo P, Jackson Y, Haller DM, Gaspoz JM, Wolff H. Sexual and reproductive health behaviors of undocumented migrants in Geneva: A cross sectional study. J Immigr Minor Health. 2011;13: 510–517. pmid:20623192
- 12. Metusela C, Ussher J, Perz J, Hawkey A, Morrow M, Narchal R, et al. “In my culture, we don’t know anything about that”: Sexual and reproductive health of migrant and refugee women. Int J Behav Med. 2017;24: 836–845. pmid:28620774
- 13. Ngum Chi Watts MC, Liamputtong P, Carolan M. Contraception knowledge and attitudes: Truths and myths among African Australian teenage mothers in Greater Melbourne, Australia. J Clin Nurs. 2014;23: 2131–2141. pmid:24028778
- 14. McMichael C. Unplanned but not unwanted? Teen pregnancy and parenthood among young people with refugee backgrounds. J Youth Stud. 2013;16: 663–678.
- 15. McMichael C, Gifford S. “It is good to know now…Before it’s too late”: Promoting sexual health literacy amongst resettled young people with refugee backgrounds. Sex Cult. 2009;13: 218–236.
- 16. Newbold KB, Willinsky J. Providing family planning and reproductive healthcare to Canadian immigrants: Perceptions of healthcare providers. Cult Health Sex. 2009;11: 369–382. pmid:19242836
- 17. Chan M, Johnston C, Bever A. Exploring health service underutilization: A process evaluation of the newcomer women’s health clinic. J Immigr Minor Health. 2018;20: 920–925. pmid:28660392
- 18. Cignacco E, Zu Sayn-Wittgenstein F, Sénac C, Hurni A, Wyssmüller D, Grand-Guillaume-Perrenoud JA, et al. Sexual and reproductive healthcare for women asylum seekers in Switzerland: A multi-method evaluation. BMC Health Serv Res. 2018;18: 1–13. pmid:30217153
- 19.
Machado S, Wiedmeyer M ling, Watt S, Servin AE, Goldenberg S. Determinants and Inequities in Sexual and Reproductive Health (SRH) Care Access Among Im/Migrant Women in Canada: Findings of a Comprehensive Review (2008–2018). Journal of Immigrant and Minority Health. Springer US; 2021. https://doi.org/10.1007/s10903-021-01184-w pmid:33811583
- 20. Stirling Cameron E, Aston M, Ramos H, Kuri M, Jackson L. The postnatal experiences of resettled Syrian refugee women: Access to healthcare and social support in Nova Scotia, Canada ✩. Midwifery. 2022;104: 1–7. pmid:34736018
- 21. Ivanova O, Rai M, Kemigisha E. A systematic review of sexual and reproductive health knowledge, experiences and access to services among refugee, migrant and displaced girls and young women in Africa. Int J Environ Res Public Health. 2018;15: 1–12. pmid:30049940
- 22. Aminisani N, Armstrong BK, Canfell K. Cervical cancer screening in Middle Eastern and Asian migrants to Australia: A record linkage study. Cancer Epidemiol. 2012;36: 394–400. pmid:23017217
- 23. Inci MG, Kutschke N, Nasser S, Alavi S, Abels I, Kurmeyer C, et al. Unmet family planning needs among female refugees and asylum seekers in Germany—is free access to family planning services enough? Results of a cross-sectional study. Reprod Health. 2020;17: 1–9. pmid:32727500
- 24. McMichael C, Gifford S. Narratives of sexual health risk and protection amongst young people from refugee backgrounds in Melbourne, Australia. Cult Health Sex. 2010;12: 263–277. pmid:19904650
- 25. Ussher JM, Rhyder-Obid M, Perz J, Rae M, Wong TWK, Newman P. Purity, privacy and procreation: Constructions and experiences of sexual and reproductive health in Assyrian and Karen women living in Australia. Sex Cult. 2012;16: 467–485.
- 26. Khanlou N, Haque N, Skinner A, Mantini A, Kurtz Landy C. Scoping review on maternal health among immigrant and refugee women in Canada: Prenatal, intrapartum, and postnatal care. J Pregnancy. 2017;2017: 1–14. pmid:28210508
- 27. Anderson FM, Hatch SL, Comacchio C, Howard LM. Prevalence and risk of mental disorders in the perinatal period among migrant women: A systematic review and meta-analysis. Arch Womens Ment Health. 2017;20: 449–462. pmid:28389934
- 28. Sawadogo PM, Sia D, Onadja Y, Beogo I, Sangli G, Sawadogo N, et al. Barriers and facilitators of access to sexual and reproductive health services among migrant, internally displaced, asylum seeking and refugee women: A scoping review. Wasti SP, editor. PLOS ONE. 2023;18: e0291486. pmid:37708137
- 29.
Peters MDJ, Godfrey C, McInerney P, Baldini Soares C, Khalil H, Parker D. Chapter 11: Scoping Reviews. In: Aromataris E, Munn Z, editors. Joanna Briggs Institute Reviewer’s Manual. 2017.
- 30. Stirling Cameron E, Almukhaini S, Dol J, Aston M. Access and use of sexual and reproductive health services among resettled refugee and refugee-claimant women in high-income countries: A scoping review protocol. JBI Evid Synth. 2021;19: 604–613. pmid:32833790
- 31. Kaufman MR, Cornish F, Zimmerman RS, Johnson BT. Health Behavior Change Models for HIV Prevention and AIDS Care: Practical Recommendations for a Multi-Level Approach. J Acquir Immune Defic Syndr. 2014;66. pmid:25007194
- 32. Brofenbrenner U. Ecology of the family as a context for human development: Research perspectives. Dev Psychol. 1986;22: 723–742.
- 33. Mengesha ZB, Dune T, Perz J. Culturally and linguistically diverse women’s views and experiences of accessing sexual and reproductive health care in Australia: A systematic review. Sex Health. 2016;13: 299–310. pmid:27209062
- 34. United Nations. Refugees. 2019. Available: https://www.un.org/en/sections/issues-depth/refugees/
- 35. United Nations General Assembly. Convention relating to the Status of Refugees. 1951.
- 36. UNESCO. Asylum seeker. 2017. Available: http://www.unesco.org/new/en/social-and-human-sciences/themes/international-migration/glossary/asylum-seeker/
- 37. Levesque J-F, Harris MF, Russell G. Patient-centred access to health care: conceptualising access at the interface of health systems and populations. Int J Equity Health. 2013;12: 1–9. pmid:23496984
- 38. The World Bank. World Bank country and lending groups. 2019. Available: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups
- 39. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann Intern Med. 2018;169: 467–473. pmid:30178033
- 40. Agbemenu K, Auerbach S, Ely GE, Aduloji-Ajijola N, Wang H. Family planning trends among community-dwelling African refugee women. Public Health Nurs. 2020;37: 478–486. pmid:32249486
- 41. Allen EM, Lee HY, Pratt R, Vang H, Desai JR, Dube A, et al. Facilitators and Barriers of Cervical Cancer Screening and Human Papilloma Virus Vaccination Among Somali Refugee Women in the United States: A Qualitative Analysis. J Transcult Nurs Off J Transcult Nurs Soc. 2019;30: 55–63. pmid:30170512
- 42. Barnes DM, Harrison CL. Refugee women’s reproductive health in early resettlement. J Obstet Gynecol Neonatal Nurs JOGNN. 2004;33: 723–728. pmid:15561660
- 43. Connor JJ, Hunt S, Finsaas M, Ciesinski A, Ahmed A, Robinson BQE. Sexual health care, sexual behaviors and functioning, and female genital cutting: Perspectives from Somali women living in the United States. J Sex Res. 2016;53: 346–359. pmid:26168010
- 44. Critelli F, Yalim AC. Improving access to domestic violence services for women of immigrant and refugee status: A trauma-informed perspective. J Ethn Cult Divers Soc Work Innov Theory Res Pract. 2019;29: 95–113.
- 45. Dhar CP, Kaflay D, Dowshen N, Miller VA, Ginsburg KR, Barg FK, et al. Attitudes and Beliefs Pertaining to Sexual and Reproductive Health Among Unmarried, Female Bhutanese Refugee Youth in Philadelphia. J Adolesc Health Off Publ Soc Adolesc Med. 2017;61: 791–794. pmid:28935387
- 46. Fineran S, Kohli HK. Muslim refugee women’s perspectives on intimate partner violence. J Fam Soc Work. 2020;23: 199–213.
- 47. Ghebre RG, Sewali B, Osman S, Adawe A, Nguyen HT, Okuyemi KS, et al. Cervical Cancer: Barriers to Screening in the Somali Community in Minnesota. J Immigr Minor Health. 2015;17: 722–728. pmid:25073605
- 48. Gurnah K, Khoshnood K, Bradley E, Yuan C. Lost in translation: reproductive health care experiences of Somali Bantu women in Hartford, Connecticut. J Midwifery Womens Health. 2011;56: 340–346. pmid:21733104
- 49. Haworth R, Margalit R, Ross C, Nepal T, Soliman A. Knowledge, Attitudes, and Practices for Cervical Cancer Screening Among the Bhutanese Refugee Community in Omaha, Nebraska. J Community Health. 2014;39: 872–878. pmid:25060231
- 50. Katcher T, Thimmesch R, Spitz A, Kulkarni L, Panth N, Weiner A, et al. Sexual and reproductive health information and referrals for resettled refugee women: A survey of d resettlement agencies in the United States. PLoS Med. 2021;18. pmid:33939705
- 51. Keller EM, Brennan PK. Cultural considerations and challenges to service delivery for sudanese victims of domestic violence: Insights from service providers and actors in the criminal justice system. Int Rev Vict. 2007;14: 115–141.
- 52. Kenny DX, Hsueh K, Walters RW, Coté JJ. Human Papillomavirus Vaccination and Pap Smear Rates Among Burmese Refugee Girls in a Healthcare System in Omaha, Nebraska. J Community Health. 2021;46: 1170–1176. pmid:34021437
- 53. Kue J, Hanegan H, Tan A. Perceptions of Cervical Cancer Screening, Screening Behavior, and Post-Migration Living Difficulties Among Bhutanese-Nepali Refugee Women in the United States. J Community Health. 2017;42: 1079–1089. pmid:28455671
- 54. Kulig JC. Cambodian refugees’ family planning knowledge and use. J Adv Nurs. 1995;22: 150–157. pmid:7560523
- 55. Kumar JL, Chan WY, Spitz A. Pathways to Sexual Health Among Refugee Young Women: A Contextual Approach. Sex Cult. 2021;25: 1789–1807.
- 56. Lor B, Ornelas IJ, Magarati M, Do HH, Zhang Y, Jackson JC, et al. We Should Know Ourselves: Burmese and Bhutanese Refugee Women’s Perspectives on Cervical Cancer Screening. J Health Care Poor Underserved. 2018;29: 881–897. pmid:30122670
- 57. Mehta PK, Saia K, Mody D, Crosby SS, Raj A, Maru S, et al. Learning from UJAMBO: Perspectives on Gynecologic Care in African Immigrant and Refugee Women in Boston, Massachusetts. J Immigr Minor Health. 2018;20: 380–387. pmid:29032521
- 58. Raines Milenkov A, Felini M, Baker E, Acharya R, Longanga Diese E, Onsa S, et al. Uptake of cancer screenings among a multiethnic refugee population in North Texas, 2014–2018. PLoS ONE. 2020;15: 1–15. pmid:32226017
- 59. Schuster RC, Rodriguez EM, Blosser M, Mongo A, Delvecchio-Hitchcock N, Kahn L, et al. “They were just waiting to die”: Somali Bantu and Karen experiences with cancer screening pre- and post-resettlement in Buffalo, NY. J Natl Med Assoc. 2019;111: 234–245. pmid:30420078
- 60. Soin KS, Beldowski K, Bates E, Garcia KP, Naik S, Plumb E, et al. Attitudes Towards Family Planning among Bhutanese, Burmese, and Iraqi Refugee Women: A Qualitative Study. Hawaii J Health Soc Welf. 2020;79: 70–77. pmid:32596682
- 61. Sullivan M, Senturia K, Negash T, Shiu-Thornton S, Giday B. “For us it is like living in the dark”: Ethiopian women’s experiences with domestic violence. J Interpers Violence. 2005;20: 922–940. pmid:15983131
- 62. Valdovinos MG, Nightingale SD, Vasquez Reyes M. Intimate Partner Violence Help-Seeking for Latina Undocumented Immigrant Survivors: Feminist Intersectional Experiences Narrated Through Testimonio. Affil—J Women Soc Work. 2021;36: 533–551.
- 63. Wachter K, Dalpe J, Heffron LC. Conceptualizations of domestic violence-related needs among women who resettled to the United States as refugees. Soc Work Res. 2019;43: 207–219.
- 64. Wachter K, Cook Heffron L, Dalpe J, Spitz A. “Where Is the Women’s Center Here?”: The Role of Information in Refugee Women’s Help Seeking for Intimate Partner Violence in a Resettlement Context. Violence Women. 2021;27: 2355–2376. pmid:33232213
- 65. Zhang Y, Ornelas IJ, Do HH, Magarati M, Jackson JC, Taylor VM. Provider Perspectives on Promoting Cervical Cancer Screening Among Refugee Women. J Community Health. 2017;42: 583–590. pmid:27838808
- 66. Zhang Y, McCoy EE, Scego R, Phillips W, Godfrey E. A Qualitative Exploration of Somali Refugee Women’s Experiences with Family Planning in the U.S. J Immigr Minor Health. 2020;22: 66–73. pmid:30941615
- 67. Wachter K, Cook Heffron L, Dalpe J. “We Weren’t Ready”: Provider Perspectives on Addressing Intimate Partner Violence Among Refugees and Immigrants in The United States. J Fam Violence. 2022;37: 235–246.
- 68. Njie-Carr VPS, Sabri B, Messing JT, Suarez C, Ward-Lasher A, Wachter K, et al. Understanding Intimate Partner Violence among Immigrant and Refugee Women: A Grounded Theory Analysis. J Aggress Maltreatment Trauma. 2021;30: 792–810. pmid:34483645
- 69. Babatunde-Sowole OO, Power T, Davidson PM, DiGiacomo M, Jackson D. Health screening and preventative health care in refugee women: A qualitative analysis. Contemp Nurse. 2020;56: 62–79. pmid:32141400
- 70. Bartlett R, Robinson T, Anand J, Negussie F, Simons Smith J, Boyle JA. Empathy and journey mapping the healthcare experience: a community-based participatory approach to exploring women’s access to primary health services within Melbourne’s Arabic-speaking refugee communities. Ethn Health. 2022;27: 584–600. pmid:32116007
- 71. Dean J, Mitchell M, Stewart D, Debattista J. Sexual health knowledge and behaviour of young Sudanese Queenslanders: a cross-sectional study. Sex Health. 2017;14: 254–260. pmid:28104040
- 72. Mengesha ZB, Perz J, Dune T, Ussher J, Dune T. Challenges in the Provision of Sexual and Reproductive Health Care to Refugee and Migrant Women: A Q Methodological Study of Health Professional Perspectives. J Immigr Minor Health. 2018;20: 307–316. pmid:28620712
- 73. Mengesha ZB, Perz J, Dune T, Ussher J. Refugee and migrant women’s engagement with sexual and reproductive health care in Australia: A socio-ecological analysis of health care professional perspectives. PloS One. 2017;12: e0181421. pmid:28727833
- 74. Ngum Chi Watts MC, Mcmichael C, Liamputtong P, Mimmie Claudine Ngum Chi W, Mcmichael C, Liamputtong P. Factors Influencing Contraception Awareness and Use: The Experiences of Young African Australian mothers. J Refug Stud. 2015;28: 368–387.
- 75. Parajuli J, Horey D, Avgoulas M-I. Perceived barriers to cervical cancer screening among refugee women after resettlement: A qualitative study. Contemp Nurse J Aust Nurs Prof. 2020;56: 363–375. pmid:32794428
- 76. Parajuli J, Horey D, Avgoulas MI. Best practice models recommended by Bhutanese refugee women for cervical and breast cancer screening in Australia: A qualitative study. Health Promot J Aust Off J Aust Assoc Health Promot Prof. 2019;31: 381–390. https://dx.doi.org/10.1002/hpja.315
- 77. Rees S, Pease B. Domestic violence in refugee families in Australia: Rethinking settlement policy and practice. J Immigr Refug Stud. 2007;5: 1–19.
- 78. Rogers C, Earnest J. A cross-generational study of contraception and reproductive health among Sudanese and Eritrean women in Brisbane, Australia. Health Care Women Int. 2014;35: 334–356. pmid:24351033
- 79. Rogers C, Earnest J. Sexual and reproductive health communication among Sudanese and Eritrean women: an exploratory study from Brisbane, Australia. Cult Health Sex. 2015;17: 223–236. pmid:25346993
- 80. Russo A, Lewis B, Ali R, Abed A, Russell G, Luchters S. Family planning and Afghan refugee women and men living in Melbourne, Australia: new opportunities and transcultural tensions. Cult Health Sex. 2020;22: 937–953. pmid:31354105
- 81. Zannettino L. “…There is No War Here; It is Only the Relationship That Makes Us Scared”: Factors Having an Impact on Domestic Violence in Liberian Refugee Communities in South Australia. Violence Women. 2012;18: 807–828. pmid:22886374
- 82. Sheeran N, Tarzia L, Douglas H. Communicating Reproductive Coercion in the Context of Domestic and Family Violence: Perspectives of Service Providers Supporting Migrant and Refugee Women. J Fam Violence. 2023;38: 51–61.
- 83. de Anstiss H. Who are you going to talk to? Help-seeking for partner violence among refugee-background young women in Australia. Aust Psychol. 2023;58: 6–17.
- 84. Henry N, Vasil S, Flynn A, Kellard K, Mortreux C. Technology-Facilitated Domestic Violence Against Immigrant and Refugee Women: A Qualitative Study. J Interpers Violence. 2022;37: NP12634–NP12660. pmid:33719681
- 85. Aptekman M, Rashid M, Wright V, Dunn S. Unmet contraceptive needs among refugees. Can Fam Physician Med Fam Can. 2014;60: e613–9. pmid:25642489
- 86. Redwood-Campbell L, Thind H, Howard M, Koteles J, Fowler N, Kaczorowski J. Understanding the health of refugee women in host countries: lessons from the Kosovar re-settlement in Canada. Prehospital Disaster Med. 2008;23: 322–327. pmid:18935946
- 87. Rubens-Augustson T, Wilson LA, Murphy MS, Jardine C, Pottie K, Hui C, et al. Healthcare provider perspectives on the uptake of the human papillomavirus vaccine among newcomers to Canada: a qualitative study. Hum Vaccines Immunother. 2019;15: 1697–1707. pmid:30352005
- 88. Wiedmeyer ML, Lofters A, Rashid M. Cervical cancer screening among vulnerable women: factors affecting guideline adherence at a community health centre in Toronto, Ont. Can Fam Physician Med Fam Can. 2012;58: e521–526.
- 89. Casillas A, Bodenmann P, Epiney M, Gétaz L, Irion O, Gaspoz JM, et al. The Border of Reproductive Control: Undocumented Immigration as a Risk Factor for Unintended Pregnancy in Switzerland. J Immigr Minor Health. 2015;17: 527–534. pmid:24186358
- 90. Rodella Sapia MD, Wangmo T, Dagron S, Elger BS. Understanding access to professional healthcare among asylum seekers facing gender-based violence: A qualitative study from a stakeholder perspective. BMC Int Health Hum Rights. 2020;20: 1–11. pmid:32957996
- 91. Kurth E, Jaeger FN, Zemp E, Tschudin S, Bischoff A. Reproductive health care for asylum-seeking women—a challenge for health professionals. BMC Public Health. 2010;10: 659. pmid:21040588
- 92. Hawkey AJ, Ussher JM, Perz J. What do women want? Migrant and refugee women’s preferences for the delivery of sexual and reproductive healthcare and information. Ethn Health. 2021;0: 1–19. pmid:34569377
- 93. Byrskog U, Olsson P, Essen B, Allvin MK. Being a bridge: Swedish antenatal care midwives’ encounters with Somali-born women and questions of violence; a qualitative study. BMC Pregnancy Childbirth. 2015;15: 1. pmid:25591791
- 94. Svensson P, Carlzen K, Agardh A, Carlzén K, Agardh A. Exposure to culturally sensitive sexual health information and impact on health literacy: a qualitative study among newly arrived refugee women in Sweden. Cult Health Sex. 2017;19: 752–766. pmid:27894219
- 95. Goosen S, Uitenbroek D, Wijsen C, Stronks K. Induced abortions and teenage births among asylum seekers in The Netherlands: Analysis of national surveillance data. J Epidemiol Community Health. 2009;63: 528–533. pmid:19190010
- 96. Raben LAD, van den Muijsenbergh METC. Inequity in contraceptive care between refugees and other migrant women?: a retrospective study in Dutch general practice. Fam Pract. 2018;35: 468–474. pmid:29351609
- 97. Rogstad KE, Dale H. What are the needs of asylum seekers attending an STI clinic and are they significantly different from those of British patients? Int J STD AIDS. 2004;15: 515–518. pmid:15307960
- 98. Kaneoka M, Spence W. The cultural context of sexual and reproductive health support: an exploration of sexual and reproductive health literacy among female Asylum Seekers and Refugees in Glasgow. Int J Migr Health Soc Care. 2020;16: 46–64.
- 99. Degni F, Koivusilta L, Ojanlatva A. Attitudes towards and perceptions about contraceptive use among married refugee women of Somali descent living in Finland. Eur J Contracept Reprod Health Care Off J Eur Soc Contracept. 2006;11: 190–196. pmid:17056449
- 100. Gebreyesus T, Gottlieb N, Sultan Z, Ghebrezghiabher HM, Tol W, Winch PJ, et al. Barriers to contraceptive careseeking: the experience of Eritrean asylum-seeking women in Israel. Ethn Health. 2020;25: 255–272. pmid:29284285
- 101. Vangen S, Eskild A, Forsen L. Termination of pregnancy according to immigration status: A population-based registry linkage study. BJOG Int J Obstet Gynaecol. 2008;115: 1309–1315. pmid:18715418
- 102. Kim K, Kim S, Chung Y. A qualitative study exploring factors associated with Pap test use among North Korean refugees. Health Care Women Int. 2017;38: 1115–1129. pmid:28799850
- 103. Dean J, Mitchell M, Debattistia J, Stewart D, Wollin J. Young queensland sudanese’s sexual health knowledge and behaviours may place them at risk-culturally informed sexuality education is needed. Sex Transm Infect. 2015;91: A81.
- 104. Anagnostou E, Jones N, Huerta M, Halladay AK, Wang P, Scahill L, et al. Measuring social communication behaviors as a treatment endpoint in individuals with autism spectrum disorder. Autism. 2015;19: 622–636. pmid:25096930
- 105. Soin KS, Beldowski K, Garcia K. Contraception choices of refugee women in Philadelphia: A retrospective and observational study examining barriers, beliefs, and practices. Ann Glob Health. 2015;81: 172–173.
- 106. Agbemenu K, Aidoo-Frimpong G, Auerbach S, Jaffri A. Hiv attitudes and beliefs in uS-based african refugee women. Ethn Health. 2020. pmid:32228028
- 107. Zannettino L, Grant J, Hutton A. Meeting the sexual health care needs of young refugee women. Aust Nurs J July 1993. 2013;20: 49. pmid:23862342
- 108. Goldenberg SM, Krü Si A, Zhang E, Chettiar J, Shannon K. Structural Determinants of Health among Im/Migrants in the Indoor Sex Industry: Experiences of Workers and Managers/ Owners in Metropolitan Vancouver. 2017. pmid:28141835
- 109. Sorhaindo AM, Lavelanet AF. Why does abortion stigma matter? A scoping review and hybrid analysis of qualitative evidence illustrating the role of stigma in the quality of abortion care. Soc Sci Med. 2022;311: 115271. pmid:36152401
- 110. Duby Z, Katz A, Musara P, Nabukeera J, Zimba CC, Woeber K, et al. “The state of mind tells me it’s dirty”: menstrual shame amongst women using a vaginal ring in Sub Saharan Africa. Women Health. 2020;60: 72–86. pmid:31043134
- 111. UNFPA. Sexual and reproductive health and rights: An essential element of universal health coverage. 2019 pp. 1–44.
- 112. Stone K, Blinn N, Spencer R. Mental Health Impacts of Climate Change on Women: a Scoping Review. Curr Environ Health Rep. 2022;9: 228–243. pmid:35267174
- 113. Javed S, Kumar Chattu V, School of Public Health, The University of Hong Kong, Hong Kong, Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, ON M5G 2C4, Canada, Global Institute of Public Health, Thiruvananthapuram, Kerala, India. Patriarchy at the helm of gender-based violence during COVID-19. AIMS Public Health. 2021;8: 32–35. pmid:33575405
- 114. Ramage K, Stirling-Cameron E, Ramos NE, Martinez SanRoman I, Bojorquez I, Spata A, et al. “When you leave your country, this is what you’re in for”: experiences of structural, legal, and gender-based violence among asylum-seeking women at the Mexico-U.S. border. BMC Public Health. 2023;23: 1699. pmid:37659997
- 115.
Statistics Canada. Census in brief: Disaggregated trends in poverty from the 2021 census of population. Ottawa: Statistics Canada = Statistique Canada; 2022. Available: https://www12.statcan.gc.ca/census-recensement/alternative_alternatif.cfm?t=98-200-X2021009&k=750&l=eng&loc=/census-recensement/2021/as-sa/98-200-x/2021009/98-200-x2021009-eng.pdf
- 116. Braveman P, Gottlieb L. The Social Determinants of Health: It’s Time to Consider the Causes of the Causes. Public Health Rep. 2014;129: 19–31. pmid:24385661
- 117. Chen YYB, Gruben V, Liew JCY. “A Legacy of Confusion”: An Exploratory Study of Service Provision under the Reinstated Interim Federal Health Program. Refuge. 2018;34: 94–102.
- 118. Government of Canada. What is the Interim Federal Health Program? 2023. Available: https://www.cic.gc.ca/english/helpcentre/answer.asp?qnum=1272&top=33
- 119. Frost JJ, Frohwirth L, Zolna MR. Contraceptive Needs and Services, 2014 Update.
- 120. Walia H. Border and Rule: Global Migration, Capitalism, and the Rise of Racist Nationalism. Fernwood; 2021.
- 121.
National Inquiry into Missing and Murdered Indigenous Women and Girls. Reclaiming power and place: the final report of the National Inquiry into Missing and Murdered Indigenous Women and Girls. Ottawa: Privy Council Office; 2019.
- 122.
Maynard R. Policing Black Lives: State Violence in Canada from Slavery to the Present. Fernwood Publishing; 2017.
- 123. Walia H. There is no “migrant crisis.” The Boston Review. 2022. Available: https://www.bostonreview.net/articles/there-is-no-migrant-crisis/
- 124. Tuyisenge G, Goldenberg SM. COVID-19, structural racism, and migrant health in Canada. The Lancet. 2021;397: 650–652. pmid:33539727