Challenges facing refugee women while accessing antenatal care in public health institutions in Durban, South Africa.

Abstract

Background Findings from international studies claim that pregnant refugee women are at increased risk of obstetric complications due to preexisting health conditions, nutritional deficiencies and increased vulnerability to infectious diseases. All these factors are related to their poor socio-economic status, poor living conditions, limited access to essential reproductive health services and substandard antenatal care. A recent report estimated a total number of recognized refugees in South Africa reaching approximately 1 per 1000 and there are no formal published studies but newspaper reports of healthcare services in South Africa not being responsive to refugees’ needs, particularly when pregnant. This study will provide a South African perspective to the current status of the antenatal care services received by pregnant refugee women in an urban District. The quality of antenatal service rendered to refugees will be compared to that received by the local South African women to establish if refugees are indeed vulnerable to substandard care. Methods: Through administering a questionnaire to women who delivered in the past 6 months, we estimated the percentage of refugees who sought antenatal care at 4 primary health care clinics (Lancers Road, Overport, Sydenham and Clare Estate) in Durban and explored the quality of antenatal care received. The questionnaire included demographic characteristics, medical history, obstetric history and experiences with accessing antenatal care at the clinic. Using a maternity chart audit, we further conducted a quantitative comparative assessment of antenatal care received by refugees and South African women as prescribed by the National Maternity Guidelines. Health care workers who provided antenatal services at the selected clinics were also invited to participate in in-depth interviews. These health care workers were asked to share their experiences with providing antenatal care to refugees. Results: Among 200 women sequentially enrolled 39% (78/200) were refugees and 61% (122/200) South Africans. The majority among the refugees were from Zimbabwe (24.4%) and Malawi (11.5%). The remaining refugees primarily came from the Democratic Republic of the Congo (29.5%), Rwanda (5.1%), Burundi (14.1%) and Somalia (1.5%) following war and political conflict in their countries. Refugee antenatal attendees tended to be older than their South African counterparts and significantly more likely to be married. While the majority (81%) of the South African antenatal attendees understood IsiZulu, a language spoken by all health workers at the 4 clinics, only 27% of refugee antenatal attendees understood IsiZulu (p<0.0001). A review of the medical records of 68 participants (45.6% refugees and 54.4 % SA citizens), an average of 70% of women had a complete history taken, and a lower but not statistically significant proportion of refugees had a complete history taken (62.5% vs 77.4% p=0.18) when compared to their SA counterparts. Generally, antenatal services rendered were similar in both groups of participants and overall provision of health information, planning and advising pregnant women were substandard for all antenatal attendees. In comparison to South African women, refugees were not advised on maintaining their general health (p=0.018), purpose of laboratory investigations (p=0.025) and indications for treatment with accompanying dosing instructions (p=0.014). In addition, refugees were uninformed of the expected labour process or identifying labour signs (p=0.03); and were not advised on infant feeding options (p=0.003) and contraception (p<0.0001). Health care workers also expressed that the most significant challenge while providing antenatal care to refugees was the language barrier. All health care workers interviewed mentioned that they were frustrated when obtaining history of a refugee. Refugees elaborated on the language-barrier, expressed client dissatisfaction and perceived intimidation when accessing antenatal care. Conclusion: Disparities in antenatal care were noted when procedures involved verbal communication between pregnant refugees and the Health Care Worker. It has been clearly demonstrated that while there were no disparities in the antenatal management of refugees when compared to their SA counterparts, inadequate history taking and relevant health information and education not being provided because of the language barrier, would need to be addressed to prevent adverse pregnancy outcomes among refugees.