There are several factors that influence the utilization and access to ANC among refugees and immigrants(13). Therefore, in present study, we evaluated the prevalence and the impact of sociodemographic factors and potential obstacles on adequate utilization of ANC among Afghan women in Iran. Following a preliminary qualitative research and comprehensive literature review the potential obstacles and concerns of Afghan women in seeking maternity care in Iran were conceptualized to develop the questionnaire of present study. The results indicated that almost a third of Afghan women in this study, had adequate access to ANC (8 or more ANC visits). The respondent’s age, education, employment, family income, length of stay, and legal status were the most important determinates of adequate ANC among Afghan women. Furthermore, owning health insurance proved to be an important determinant of having adequate ANC among legal immigrants. In final analysis, only the poor knowledge and attitude toward ANC; poor quality of services; and to some extent, the difficulties in access were the main obstacles in having adequate ANC among the study population.
Determinants Of Access
The education and socioeconomic status are some the most important determinants of access to healthcare (14). A number of surveys, in both developing and developed countries, have shown that the population with higher education and socioeconomic classes are more likely to have access to quality and adequate healthcare (7, 15). Similar findings have been reported among immigrants and refugees (16–18). In our study, we found that Afghan women with higher education and family income are more likely to have adequate ANC, regardless of their legal status. Higher education has been linked to higher chance of finding a job, higher income, and better living condition (14). Furthermore, it has been shown that the educated mother are more willing to engage in their child health and better recognize the importance of ANC (19). Clearly, the husband education has the similar impact on the utilization of reproductive and maternity cares. Evidence indicate that men with higher education are more likely to contribute to the reproductive needs of their partner (17, 20).
Another important determinant of maternal and child health is mother’s employment (21, 22). Previous studies indicated that the employed mothers are more likely to have adequate access to ANC (22). In our study, however, we observed that unemployed mother are more likely to have adequate ANC. This could be, in part, due to the fact that employed mothers are less flexible in scheduling their ANC visits. In addition, the fact that they have lower chance in securing a decent job, due to their refugee status, often push them toward jobs with long working hours and no maternity leave. Moreover, in most instances, due to family financial struggles, they cannot afford quitting their job, especially illegal immigrants (23). This substantially reduce their access to ANC. Therefore, developing and implementing appropriate labor market laws by host country that could support maternity leave for refugees and immigrants is necessary.
It has been shown that the recent refugees and immigrants (less than 5 years of arrival) have less access to ANC compared to settled ones (more than 5 years of arrival) (17). Our results similarly indicated that the Afghan women arrived within the 5 years prior to the time of interview, are less likely to have adequate access to ANC compared to those with more than 5 years stay in Iran. This has been attributed to the higher access to health system achieved through familiarization, acculturation, and accustomization of settled population with the host country’s health system, culture, and environment (24).
We observed higher rate of adequate ANC (≥ 8 visits) among legal Afghan women, even after adjustment for other variables. The legal status has been recognized as an important determinant of access to the health system in host country (9, 25); Several studies have shown that the illegal status of undocumented immigrant could reduce their access to ANC and increase the adverse birth outcomes (13, 26, 27). One issue is their ineligibility for health insurance. Although in Iran all registered Afghan refugees and immigrants could benefit from public health insurance since 2016, the situation for illegal Afghans in unclear. In addition, this insurance scheme only reimburses for some of ANC services at the primary healthcare level; and the secondary and tertiary prenatal services which are usually expensive are not included in the scheme. Moreover, the ineligibility of illegal immigrants (5). We found that owning the health insurance could increase the likelihood of receiving adequate ANC among legal immigrants. Therefore, first, measures to improve the coverage of health insurance for ANC service and second, laws for universal health coverage of all Afghan refugees and immigrants, at least for the expectant mothers, should be pursued by national government to ensure the maternal and child health in Afghan refugees and immigrants in Iran.
Reasons For Inadequate Anc
Poor knowledge and attitude toward ANC was an important reason for inadequate ANC among Afghan women in this study. The statement “I was healthy” reflected the Afghan women’s lack of knowledge in term of the ANC importance for a healthy pregnancy. It was reported by almost half of the participates with inadequate ANC. Furthermore, the poor attitude toward ANC (I think it is unnecessary) which stated by almost two thirds of participants. Previous studies emphasize the importance of education for better reproductive and maternal health for immigrant and refugees in host country (28, 29). Likewise, we advocate policies and interventions to enhance the knowledge regarding the reproductive health and maternity care among Afghan refugees and immigrants in Iran.
The poor quality of health care such as long waiting time and poor quality of antenatal services, was one the most important associated factor with inadequate ANC in present study. This finding was in line with the evidence from other developing countries. The weak infrastructure of health system and inadequate number of health professionals in some remote areas; particularly in government sector, reported to be the main reasons for such issues in most developing countries (30, 31). Likewise; in Iran, these issues still exists in some remote areas; however, it appears, in big cities such as Tehran, they are not problematic anymore (32). However, our study indicate that these issues still exist in some marginalized population like Afghan immigrants and refugees even big cities like Tehran. They are more evident in government sector such as community health centers and government hospitals (32); where not only receive the highest number of Afghan visitors but also many Iranian citizen who are more vulnerable due to their low socioeconomic status. Therefore, future policies should be directed toward building capacity in order to promote the health services quality in government sector.
Religious and cultural concerns have been reported to be a potential obstacles in receiving adequate ANC and quality delivery services in some strict Islamic states such as Afghanistan (33, 34). The gender-sensitive issues such as the restriction of contact between male provider and female patient, are some of the most important religious and cultural barriers toward adequate ANC among Afghans. This reduces women access to maternity care; specially in countries of west culture in which these issues are often ignored by health providers (34–36). However, in our study, due to the dominant Islamic culture of Iranian society in which the contact of a female patient and a male provider is also restricted, these issues appeared not to be problematic. In addition, none of the participants complained about unavailability of a female provider. Fear of deportation or arrest was also an important barrier to visit health facilities especially among illegal Afghan refugees and immigrants in present study. We observed this issue in 44% of those with inadequate ANC. Therefore, we suggest expanding the safety net services by collaboration between international and national agencies for refugees support to ensure the adequate access to ANC in this vulnerable group. The fear of being poorly treated or discriminated was also a reason among approximately 60% of those with inadequate ANC. Evidence has shown that the perceived discrimination; feeling of abandonment, and isolation among immigrants and refugees could impact the individual’s perceived quality of life and satisfaction in host society (37, 38). Similar experiences were reported among Afghan people living in Iran (39). The intercultural incompetency of health personnel has been reported to be the main reason for such issues. The language barrier could also cause such bitter experience (40); however, in Iran, almost all Afghans could fluently speak and communicate in Persian. Thus, we emphasized the necessity of interventions to enhance the intercultural-competency of health personnel delivering health services at Afghan-concentrated communities in Iran. All in all, although the sociocultural and legal issues such as fear of deportation, being discriminated or poorly treated, and religious and cultural concerns; were significantly associated with the inadequate ANC in Afghan women in bivariate analysis, the cumulative effect of these issues turned to be insignificant once we adjusted for other variables in multivariate analysis.
Despite the resourceful findings of present study, there were some shortcomings that reduce the representativeness of results across different Afghan population in Iran. First, we conducted our study in urban areas where usually is the home for those refugees and immigrants with higher socioeconomic status and may not represent the underprivileged rural refugees and immigrants who may be of different sociocultural backgrounds and reproductive needs. However, engaging a random sampling, ensured recruiting participants of different sociodemographic backgrounds to represent the urban population. Therefore, further studies among rural Afghan population is recommended. Second, we recruited the Afghan women at community health centers; therefore, a group of Afghan women whose access to such facilities is limited may have been missed. There were also some participants whose residential status appeared to be illegal and refuse to participate due to the fear of disclosure and potential arrest. Although, we tried to overcome this issue by engaging interviewers of Afghan origin and explaining the objective of this study for them; however, we might loss some valuable information on those who refused to participate.