Reach Us +44-1522-440391
All submissions of the EM system will be redirected to Online Manuscript Submission System. Authors are requested to submit articles directly to Online Manuscript Submission System of respective journal.

Refugee women in greece: – a qualitative study of their attitudes and experience in antenatal care

Iliadi P*

RN, MSc Laboratory instructor - Department of Midwifery, A.T.E.I.of Athens

*Corresponding Author:
Panagiota Iliadi
5, El. Venizelou Str. 15341
Ag. Paraskevi,Athens - Greece.
Tel : 210-6527434.
E-mail : iliadip@otenet.gr
 
Visit for more related articles at Health Science Journal

Abstract

In the last decades Greece has been an asylum country for thousands of refugees, among them women in childbearing age. Purpose of the study: The aim of the present study was to examine whether refugee women, resettled in Greece, receive antenatal care and to explore possible factors that may influence their attitude towards maternal care. Method and material : Twenty-six refugee women from five non-governmental organizations for refugees, one refugee network, three refugee communities and one reception centre took part in the study. It was a qualitative study. As method of data collection was used semi-structured interviews and as method of data analysis was used the latent content analysis. Results: Analysis showed that refugee women enter antenatal care in the first trimester of their pregnancies, but they may miss from one to many appointments due to the language and financial barrier, the unfamiliarity with the national health system, and the women’s view of pregnancy as a natural event. Conclusions: In order to improve antenatal practice for refugee women, interpreters and bilingual health workers is suggested to be employed, staffs to be trained on refugee issues, while information material in other languages needs to be published. Social services and refugee networks have to co-operate closer. Finally, continuity of antenatal care and availability of female doctors in public hospitals is also suggested to facilitate the access to antenatal care for refugee women.

Keywords

refugees, antenatal care, access, experience, maternity services

Introduction

Greece has been an intermediate post to asylum countries, and the last decades itself an asylum country for thousands of refugees. But who is a refugee? Under the 1951 United Nations Convention to the Refugee Status – the Geneva Convention – amended by the 1967 New York Protocol, a refugee is defined as: “…a person who has fled their home country or cannot go back to it, because of a well founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinion” [1].

The refugee population in Greece is estimated at 7000 persons. 2 The majority of the asylum seekers have been originated from Asian countries as Iraq, Iran, Turkey, Afghanistan, Palestine, Pakistan, and Bangladesh, less come from African countries as Sudan, Somalia, Nigeria, Congo, Sierra Leone, Ethiopia and Eritrea, while the last years a great number of asylum seekers come from countries of the former Soviet Union, Serbia and Montenegro [2,3,4,5]. According to the Greek department of the United Nations High Commission for Refugees (UNHCR) 6 it is estimated that the 23% of the population are women.

This means that there are many women in childbearing age among the refugee population. Their education varies from a 7-to-9 year education to university education [7,8]. Their socio-economic status in their country also varies from the lower to the higher classes [7,8].However, in Greece, they live on a low income, usually in deprived areas, at cheap and of poor general standard apartments and houses, or in bed and breakfast hostels [8,9,10]. A smaller number of refugees are housed in asylum seekers reception centers, [8] but there are also homeless refugees living in parks, streets, squares, under bridges, in abandoned factories and houses [4]. All the above, is mentioned because a number of studies have shown that the attitudes of women towards antenatal care varies according to the population characteristics [11,12,3,14].

Refugee women in Greece are entitled to free medical, pharmaceutical and hospital services, on the condition that they are not covered by any insurance and are in need of financial assistance [5]. Free health care includes health examinations in state hospitals, health centers and state regional medical centers, para-clinical examinations, provision of medication prescribed by a doctor in medical centers, hospitals and in-hospital care in state-run hospitals. Also, people with any disability or suffering from AIDS are entitled to the same support allowances as Greek natives.

However, researches, mainly carried out in the United States of America, the United Kingdom and Australia, have showed that refugee women do not receive adequate antenatal care during pregnancy. This may be due to various cultural practices and beliefs about pregnancy and childbirth, barriers to access the maternity services of the asylum countries, or due to the quality of the provided care [3,11,16]. Unfortunately, there is very little relevant literature on the antenatal experience of refugee women resettled in Greece. We do know that the Institution of Social Work and the Greek Council for Refugees provide information about the existing maternity services, such as telephone numbers, addresses, transport and appointment processes [17,18,19] and also offer psychological and social support during the perinatal period [1,8] Refugee women are usually sent to outpatient clinics of public maternity hospitals for their antenatal visits and medical examinations [17]. Unfortunately, there is no continuity of antenatal care in these clinics, as women are examined by different doctors and midwives at each visit [19]. Primary antenatal care is also provided by two non-governmental organisations, Doctors without Borders (DWB) and Doctors of the World (DW) [18].

Both organizations have an open polyclinic in the centre of Athens which pregnant women may visit to see an obstetrician. There is continuity of care in these clinics, as there is only one obstertician in the DWB and two in the DW [18]. However, women must visit public hospitals for medical tests and ultrasounds due to lack of technology in these clinics [18].

Finally, primary antenatal care is also provided by the clinic of Greek Red Cross to women who live in the refugee reception centre of Lavrio, but they need to visit a maternity hospital for any medical examinations, in case of emergency or pregnancy complications [3,9].

Method and Material

The purpose of the present study was to investigate whether refugee women, settled in Greece, receive antenatal care, which elements of antenatal visits are significant to them, which factors influence their attitude towards antenatal care and highlight any barriers that refugees may cope with to access maternity services, a study was decided to occur. It was a qualitative research based on focused ethnography. It took place in Athens, from December 2002 to May 2003. A purposeful sample of 30 refugee women were selected through five non-governmental organisations, a refugee centre, a refugee network, 3 refugee communities and a public hospital. The criteria of sampling were the participants to be refugee women already settled in Greece during their pregnancy, to be presently pregnant more than 12 weeks of gestation or to have been pregnant during the last five years.

Τhe population of the study consisted of twenty-six refugee women. Their characteristics appear to table 1. As method of data collection was selected to be used semi-structured interviews. The interviews were face-to-face, one-time, tape-recorded ones. They were conducted in Greek and/or in English and in 15 out of 26 interviews were used interpreters, professionals and family members or friends. The method of data analysis was selected to be used latent content analysis.

Results

From the data analysis emerged the following themes: Language barrier, financial factor, familiarity with the health system, continuity of care, support, well-being of mother and child, the man’s role in pregnancy and the vaginal examination.

Language Barrier: The language barrier affects significantly the attitude of refugee women towards antenatal care and their access to the maternity services, as Greek maternity services lack interpreting service and the information material is written in Greek. Refugee women prefer doctors who speak their language. If there are no available doctors speaking a common language with the women, women entry late to antenatal care and miss many appointments. They usually visit antenatal clinics without an appointment and wait many hours to get examined. They are escorted by family members or friends who speak Greek. Women who do not speak Greek have no access to perinatal information. For many of them these issues are taboo and they are embarrassed to ask questions in front of family members.

Financial Factor: The financial and refugee status of women seems to play a major role to the type of antenatal care that women select to receive. Women with social security are visiting the antenatal clinic of the local branch of their insurance organization for their antenatal visits and the necessary medical tests. These women visit the antenatal clinic regularly, take any prescribed medication and have all the necessary tests done. Women with refugee or asylum seeker’s status visit public hospitals for their medical tests. Depending on the family’s finances, the woman may select a private doctor, who also works in a public hospital to attend her during pregnancy and deliver the baby there. In other cases, she may visit the duty doctor of a public hospital from the beginning of her pregnancy until labour. These women visit the antenatal clinic regularly, take any prescribed medication and also have all the medical tests done. Women with no social security, nor refugee or asylum seeker’s status, visit antenatal care rarely and have few to none medical tests done. For their antenatal visits they go either to public hospitals, where the cost is low, or to non-governmental organisations, where the visits are free of charge. For any medical tests they visit a public hospital where the cost is lower than elsewhere. On the other hand, they take any prescribed medication. Furthermore, they argue that if they were in their countries and were working, they would visit the doctor regularly and would have any recommended tests done.

Familiarity with the Health System: The majority of refugee women are familiar with the Greek health system. They are aware of the antenatal clinics that provide free antenatal care for the documented refugees and/or less expensive medical care for the undocumented ones. They are also aware of the appointment procedure, the opening and the waiting hours, the mentality of the medical and the nursing staff. The main sources of information are relatives and friends who have been to Greece for long time, refugee communities, health professionals who attend these women, and governmental and non-governmental organisations. There are few women unfamiliar with the health system, as in cases where they are already pregnant or get pregnant as soon as they come to Greece. So, it takes them time to gain access to the health system, resulting in late entrance to antenatal care.

Continuity of Care: Continuity of care for refugee women exists when women have social security and visit the local clinic of the insurance organizations, the antenatal clinics of non-governmental organisations or private doctors. In contrary, there is no continuity of care for the women who visit the antenatal clinics of public hospitals, as they get examined by different doctor each time. All refugee women wish for continuity of antenatal care. They believe that care is better when there is continuity. Doctors and paramedical staff spend more time with them discussing perinatal issues, answering to their questions, giving advice, explaining the test results, listening to their feelings and fears, and supporting them in stressful situations.

Support: Refugee women are in need of psychological support, especially during the perinatal period. Many of them have no one to discuss with, except their husbands. But, most of them feel uncomfortable to discuss female matters with men. Refugee women miss their mothers who would visit them to chat, settle their fears, help them with the household work and visit the doctor together. They admit that they feel loneliness and sometimes hopelessness, especially the women who had not been long to Greece. Women who visited the same doctor during pregnancy got information and support from him. In contrary, women who visited different doctor at each visit, complained about the unwillingness of the caregivers to give them any information and support. Social services appear to malfunction. No psychological support is offered during the perinatal period, as the social workers in public hospitals make their appearance only when they have to arrange any financial or bureaucratic refugee issues, while the local social services are unaware of women’s existence. Refugee women would like sessions with social workers and psychologists during the perinatal period in order to discuss and find solutions to their problems.

Well-being of Mother and Child: It is a matter of great significance for refugee women. The majority of women visit antenatal clinics regularly and the rest of them, who cannot due to the language and financial barriers, wish they did. The main reasons for antenatal visits are the clinical examination of mother and child, the prescription of medications, the receipt of medical advice. Refugee women have at least one ultrasound screening test done during their pregnancy. For those women who do not visit antenatal clinics regularly, the particular test can be the only test done during their pregnancy. All the other medical examinations, blood and urine tests, are of less importance to them, because there is no visual indication of the baby’s health. Thus, women with financial difficulties neglect to have these tests done regularly. Refugee women take any prescribed medication and they are complaining if the doctor does not prescribe them any. Also, they may take a taxi instead of using the public transportation, when they believe that this ensures the well being of her child and herself. Finally, refugee women would accept a vaginal examination from a male doctor, even though it is a taboo issue for the majority of them.

The man’s role in pregnancy: Men play a significant role in pregnancy. Firstly, they act as interpreters and “guardian angels”, who protect women, make them feel secure and help them communicate with the care providers. Secondly, men give women instructions of how to get to the antenatal clinic or even take them there if they are not working. Finally, men are the voice of women, as they are the ones who ask questions and make complaints when the health professionals ignore women. On the other hand, refugee women avoid discussing issues related to the female body in the presence of men, even with male doctors. They discuss such issues only if the doctors bring them up, or when women are very concerned with their situation. Finally, refugee women report that they would feel more comfortable with female doctors.

Vaginal examination: It is a taboo issue for refugee women, either because it is culturally unacceptable, or because they feel very uncomfortable to be with open legs in front of a stranger, regardless of culture or religion. Things are easier when the examiner is female and women are convinced that it is necessary for the well being of themselves and their children. In a few cases, the consent of the escort – relative was needed to be taken.

Discussions of the results

From the data analysis has arisen that refugee women resettled in Greece usually enter antenatal care in the first trimester of their pregnancies, but they may miss from one to many appointments. They consider routine antenatal visits essential for the well being of their babies and themselves. They take any prescribed medicine, but they may miss to have some medical tests done, except at least one ultrasound screening test. Refugee women usually visit the outpatient antenatal clinics of state hospitals, non-governmental organisations and social security organisations. Some women may also visit private doctors. The factors – barriers that seem to influence women’s attitude towards antenatal care and prevent them from utilising the maternity services are the language barrier, the financial barrier, the unfamiliarity with the national health system and the time factor. Other issues that have emerged but do not seem to affect the women’s behaviour so much as to drop out or never enter antenatal care are the improper behaviour of the staff and the short consultation time in the state clinics, the lack of psychological support and the issue of the vaginal examination by male doctors. Finally, the main information sources on perinatal issues and maternity services are relatives and friends, refugee communities, non-governmental organisations and the women’s care providers.

By reflecting on the research findings, useful recommendations come up for the improvement of antenatal practice for refugee women in Greece. In order to confront the language / communication barrier, there are a number of suggestions. Firstly, it is necessary that interpreting service function in all maternity services. The interpreters are mainly required to be female. Still, the word to word interpretation can be insufficient and care providers may continue to sound incomprehensible due to cultural differences with their clients [16,20]. Therefore, it would be ideal the recruitment of bilingual health workers – medical, nurse and auxiliary staff – who would be aware of the language and the culture of the refugee women and would meet better with their needs.21 Another suggestion is the staff training on transcultural care. This kind of training would raise the staff awareness on cultural and religious issues, help to eliminate the stereotypes for refugees and teach the staff how to deal with the health needs of a multiracial community [13,16,22,23].

Furthermore, it is required that the various signs in the maternity services must be written not only in Greek, but also in other languages. The production of understandable information material in other languages are also important for the better informing of refugee women on various perinatal issues and utilization of maternity services; taking into account that women may be illiterate and many languages are not written [19,20,24].

Eventually, it should be considered the organization of parenthood classes on the basis of culturally appropriate health education programmes, as many women have expressed their need for more information, discussion with other women experienced in motherhood and support during the perinatal period [22].

Co-operation between the social services and the refugee communities and networks must be boosted, so that refugee women will be approached and supported faster and more effectively. The social services must organize better their activities, increase and improve the provided material, social and psychological support [20].

More female health professionals in the maternity services will provide women access to more comfortable and qualitative antenatal care. The establishment of continuity of care in state hospitals is also vital to the improvement of antenatal practice. In addition, more staff must be hired in the outpatient clinics of the state hospitals. This would result in increase of the consultation time; shorter queues and possible improvement of the staff behavior, as irritating behaviors are often due to great bulk of work [20]. Another solution is to fund the various organisations for refugees to acquire the technology for the basic medical tests so as the work will be divided between the state hospitals and the particular organisations and undocumented refugees will receive a partly free antenatal care. On the other hand, the establishment of childcare facilities in the maternity services will promote the utilization of the services by women with children.

Finally, this research must be the beginning of a series of Greek researches on refugee health issues in order to understand better the needs of the growing refugee population. The recommendations that derived from such researches need to be studied and applied according to the circumstances, while liaison committees of local maternity services must be set up to monitor the effectiveness of the applied measures and suggest any necessary changes and /or adjustments [16,24].

References

Select your language of interest to view the total content in your interested language

Viewing options

Post your comment

Share This Article

Flyer image
journal indexing image
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh