Inequity in contraceptive care between refugees and other migrant women?: a retrospective study in Dutch general practice

Family Practice, 2018, Vol. 35, No. 4, 468–474 doi:10.1093/fampra/cmx133 Advance Access publication 17 January 2018 Health Service Research Inequity in contraceptive care between refugees and other migrant women?: a retrospective study in Dutch general practice Liselotte A D Rabena, and Maria E T C van den Muijsenbergha,b,* a b Department of Primary and Community Care, Radboud University Medical Centren, Nijmegen, the Netherlands and Pharos, Centre of Expertise on Health Disparities, Utrecht, the Netherlands. *Correspondence to Maria E.T.C. van den Muijsenbergh, Department of Primary and Community Care, Radboud University Medical Centre, Geert Grooteplein 21, Nijmegen, 6500 HB, the Netherlands; E-mail: Abstract Background. Female refugees are at high risk of reproductive health problems including unmet contraceptive needs. In the Netherlands, the general practitioner (GP) is the main entrance to the healthcare system and plays a vital role in the prescription of contraceptives. Little is known about contraceptive care in female refugees in primary care. Objective. To get insight into GP care related to contraception in refugees and other migrants compared with native Dutch women. Methods. A retrospective descriptive study of patient records of refugees, other migrants and native Dutch women was carried out in five general practices in the Netherlands. The prevalence of discussions about contraception and prescriptions of contraceptives over the past 6 years was compared in women of reproductive age (15–49 years). Results. In total, 104 refugees, 58 other migrants and 162 native Dutch women were included. GPs in our study (2 male, 3 female) discussed contraceptives significantly less often with refugees (51%) and other migrants (66%) than with native Dutch women (84%; P < 0.001 and P = 0.004, respectively). Contraceptives were less often prescribed to refugees (34%) and other migrants (55%) than to native Dutch women (79%; P < 0.001 and P = 0.001). Among refugees from SubSaharan Africa, contraception was significantly less often discussed (28.9%) compared with refugees from other regions (67.8%; P < 0.001). More refugees and other migrants had experienced unwanted pregnancies (14% respectively 9%) and induced abortions (12% respectively 7%) than native Dutch women (4% respectively 4%). Conclusion. Contraceptives were significantly less often discussed with and prescribed to refugees and other migrant women compared with native Dutch women. More research is needed to elicit the reproductive health needs and preferences of migrant women regarding GP’s care and experiences in discussing these issues. Such insights are vital in order to provide equitable reproductive healthcare to every woman regardless of her background. Key words: Contraception, contraceptive needs, general practitioner’s care, immigrant, migrant, primary care, refugee, sexual and reproductive health. Introduction the Netherlands with at least one parent who is also born outside Today a growing number of refugees are settling in high-income countries such as the Netherlands, and migrants constitute an essential part of the European population (1). Migrants are all persons born outside the Netherlands. Refugees are a specific type of migrants who came © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: . involuntarily to the Netherlands because of conflict or fear for persecution in the country of origin. They are protected by international 468 Inequity in contraceptive care 469 law and should not be expelled or returned to situations where their life and freedom would be under threat (2). According to the United Nations High Commissioner for Refugees (UNHCR), at the end of 2015, the number of refugees in The Netherlands were estimated to be 88 536 (0.5% of the total population). Another 28 051 people were waiting for a decision on their asylum claims (3). Most refugees in the Netherlands are of Iraqi, Afghan and Somali origin, but the vast majority of the asylum requests in 2015 were from Syrian and Eritrean refugees (3,4). The three largest first-generation ethnic minority groups in the Netherlands are the Turkish, Surinamese and Moroccan (respectively, 1.12%, 1.05% and 0.99% of the total population in 2016) (5). Several studies have documented that sexual and reproductive health (SRH) is at risk in refugees and (undocumented) female migrants (6–9). According to the World Health Organization (WHO), definition reproductive health implies that people are able to have a responsible, satisfying and safe sex life and the freedom to decide if, when and how often to reproduce (10). Since their arrival in Europe, 69.3% of the female migrants have been subjected to sexual violence compared with 30.6% of the European population (11). In a study from 2009 among all asylum seekers in the Netherlands, the overall abortion rate for asylum seekers is about one and a half times higher and the teenage birth rate more than eight times higher than average for the Netherlands. Especially, recently arrived women are at increased risk (8). SRH may be influenced by various factors such as cultural and religious norms from the country of origin and experiences during the flight. Women often originate from countries where they have a disadvantaged position in society, which makes them vulnerable, particularly in their SRH (12). Moreover, women might be confronted by war and armed conflict and come from areas with a poorly functioning healthcare system. Besides factors related to a women’s background of forced migration, SRH may also be influenced by the situation in the host country for instance by uncertainty of the asylum procedure, frequent transfers, absence of social structure and language barriers (8). In addition, many refugees and other migrants have little knowledge about risk factors for unwanted pregnancies and about contraception due to limited health literacy (13). Moreover, young migrant adults often receive too little education on sexual health, and unmet contraceptive needs are common (9,14–17). In the Netherlands, the general practitioner (GP) is the main entrance to the healthcare system and an important provider of information on and prescription of contraceptives. GPs could play an important role in informing refugee women and also help reduce the number of unwanted pregnancies among them. However, it is unknown if and to what extent they discuss reproductive health needs with refugee women or prescribe contraceptives. Better insight into these aspects can provide key information to improve the quality of healthcare and well-being of female refugees with regard to their SRH needs. Although their background and reasons to immigrate differ from refugees, SRH issues are also documented among other migrant women. Therefore, this study aimed to include not only refugee women but also other migrant women. Our research question is as fo (...truncated)