Assessment of reproductive health and its promotion in women can reduce physical and psychological injuries, mortality and, in a wider scope, promote the level of health in a society. Given the importance of reproductive health, the present study compared this variable in the vulnerable and non-vulnerable women in Isfahan. Comparing the demographic characteristics, the results of the study showed that the economic level of vulnerable women was lower. Poverty can expose one to social harms. On the other hand, social harms are themselves the cause of poverty. Combined together, these two factors will exacerbate the negative effects of each other. Results of a study suggested that low-income women are more exposed to addiction and prostitution24. A study on women heads of households showed that in women with low economic status, 0.3% had high tendency, 24.6% had moderate tendency and 45.39% had low tendency to drug use25.
Furthermore, economic level can be a factor associated with receiving health services so that people with low economic levels are less likely to receive these services that is due to the high costs of health services.
A study found that participants in pre-pregnancy care had higher levels of income and education26. The results of a study on 30 women with unsafe sexual intercourse showed that some of them had unsafe sexual intercourse during pregnancy, which was caused by financial problems22. The results of the present study with regard to economic problems are in line with the above mentioned studies. According to these studies, as economic problems can be a factor related to social harms and lack of access to health services, a special attention should be paid to economically vulnerable groups in terms of vulnerability and access to health services. Providing low-cost or free services through allocating special governmental funding for this group or attracting public participation can be considered.
The results of the present study showed that smoking and alcohol consumption were significantly different between the two groups. Using these two substances by women can endanger their reproductive health, especially during the pregnancy. While a lot of attention is currently paid to smoking during pregnancy, the use of alcohol and drugs is not sufficiently considered27. Not only does smoking reduce the health of those at risk, it also leads to adverse consequences for women of childbearing age, including infertility, abortion, preterm birth, and so on28.
A study on female Chinese immigrants in using secondhand smoke found that smoking was more prevalent in lower-educated women, women who were cohabiting with a man, and women who used alcohol once or twice a week. Cigarettes and alcohol are often consumed concomitantly, and women who drink alcohol often cannot refuse to smoke. The results of the present study on the concomitant use of cigarettes and alcohol in women are almost consistent with the above study. Consumption of these two substances in vulnerable women exacerbates the complications of their vulnerability. As such, the inclusion of a program for curbing and reducing the use of these substances in counseling programs of vulnerable women seems to be essential. On the other hand, it can be said that alcohol and cigarette users are more likely to be vulnerable. Consumers of these two substances should, therefore, be given special attention in terms of vulnerability. Overall, various underlying factors can affect the reproductive health of individuals that need further research and attention.
According to the results of the present study, there is a concurrence of social harms in some subjects of the vulnerable group. Each of these harms or injuries can be the cause or effect of other harms. In a study, 16% of women with unsafe sex were drug users29. The results of the present study, in terms of the concurrence of social harms in some women, are in line with the above research. This concurrence can exacerbate the complications of vulnerability. In fact, groups with more than one vulnerability factor need more attention and services. In the present study, the mean total score of reproductive health was significantly different between the vulnerable and non-vulnerable groups. Studies have shown that social harms affect women's reproductive health. For instance, addiction of women or their spouses can make them do risky behaviors such as unsafe sex, thereby endangering their sexual and reproductive health30. The results of the present study, in terms of the impact of these factors on the reproductive health of women, are in line with the above study. Being in vulnerable groups, because of its nature and effects, can decrease the attention of women to the importance of pregnancy and childbirth issues, and this can be an extra risk factor for their health. Therefore, effective planning and counseling can reduce the irreparable consequences of these harms on women's reproductive health. No similar study was found comparing this variable in the two groups.
According to the results of this study on the components of reproductive health, only the mean score of access to and receipt of health services and healthy reproductive counseling was not significantly different between the two groups. This result suggests both vulnerable and non-vulnerable women have received equal services in the research setting. However, their access to health services was 70%, showing that 30% of the women of both groups have been deprived of the required health services.
Positive developments in reproductive health have been reported in several studies around the world; these developments, however, have not been comprehensive. Poor or limited reproductive health services can be improved through humanitarian interventions before the crisis31. A study conducted on 136 men and women with unsafe sexual relations found that the access of the participants to health services had been insufficient. Deprivation of treatment and hostility of the caregivers was prevalent32. However, the percent of accessibility to health services was not reported in this qualitative study. Overall, in terms of poor access to health services, the results of the present study were similar to the results of the above research. Given the importance of health services provision, especially for vulnerable groups, the health system needs to pay special attention to the provision of health services to all women.
The results of the present study showed that the mean score of other components of reproductive health was significantly different between the two groups so that it was lower in the vulnerable group, and some components obtained very low scores. The results of a study showed that drug users are more susceptible to high-risk sexual behaviors, non-use of condoms, sharing syringe for injection, and smoking. In fact, reproductive health components are at risk in this group of people20. The results of another study in this area showed that the female participants of the study had at least one pre-pregnancy risk factor such as an unhealthy lifestyle (smoking, alcohol, substance abuse) that could place them in a vulnerable group33.
Another study on the pregnancy experiences of the women with unsafe sexual relations revealed that they had at least one abortion. In fact, they also were faced with the complications of pregnancy and childbirth22. The results of the present study on the perturbation of reproductive health and its components in vulnerable women are in line with the above research. Pregnancy and childbirth issues in vulnerable women, because of the sexually transmitted diseases in this group of women, should be considered more specifically. Therefore, research on all aspects of reproductive health and emphasis on pregnancy and childbirth issues and its consequences in all vulnerable groups is necessary.
In another part of this study, we examined the relationship between some baseline characteristics and the mean scores of the reproductive health components. According to the results of the study in the vulnerable group, age was only inversely correlated with the score of reproductive health related to the features of healthy reproduction (including a history of menstrual disorders and other gynecological problems, unintended pregnancy, and illegal abortion). In other words, older women had more disorder in these areas. This may be because older people have longer fertility and are more likely to have complications and, thus, they should be considered more specifically.
According to another result of the study, the number of pregnancies was inversely correlated with the total score of reproductive health. This means that increase in the number of pregnancies will lead to more disorder in the reproductive health of women. This issue emphasizes the need of preventing multiple pregnancies in this group of women and providing them with appropriate health services. According to the results of a study, the number of pregnancies and unwanted pregnancies were among the barriers to receiving prenatal care34. The results also showed that economic level was directly correlated with the total score of reproductive health and some of its components. In fact, women with higher levels of economic were better able to provide their reproductive health because many of the reproductive health-related services are not free of charge and strongly economic-related. On the other hand, economic level, as a social determinant, has indirectly affected the health of these people. The results of a study on pre-pregnancy cares showed that women who received such cares had a higher level of income26. The results of our study are in line with this study. As such, the health care system needs to pay special attention to vulnerable women with a lower economic level. Offering free or low cost services together with engaging insurance services can be effective in this regard. No other study was found which can be compared with these results.
Overall, no other study was found with the subject of comparing reproductive health between vulnerable and non-vulnerable women. Most studies have examined a component such as drug use or unsafe sex in one of the vulnerable groups, and other components of reproductive health and other groups as well as the co-occurrence of harms in these women have been overlooked.
The lack of access to all groups of vulnerable women because of socio-cultural reasons was one of the limitations of the study. During the process of sampling, some subjects might refuse to answer some questions. In order to solve this problem, the trust of the subjects was attracted and then they were interviewed. Considering all vulnerable groups and all components of reproductive health are among the strengths of the present study. According to the results, the design and implementation of a specific reproductive and sexual health program for vulnerable women and reducing the cost of health services for this group of women can be considered.