Legislative factors were shown to potentially operate as both facilitators and barriers to refugee women’s access to PPH in Australia, and were evident in 31.5% of studies. At times, policies put in place with the intention of helping refugees, instead created barriers to their access of PPH. For instance, the requirement for all healthcare appointments with non-English speaking patients to be attended by an accredited interpreter, created challenges for PPH strategies involving bilingual workers who did not have this accreditation (Riggs et al., 2012). Similarly where policies exist to prioritise the care of pregnant refugee women, (such as with dental services), both refugee women and midwives, were not aware of these entitlements (Riggs et al., 2012). Another barrier identified by Mangesha et al. (2017) was the lack of government funding for all levels of women’s health.
While each of these barriers and facilitators experienced by refugee women in accessing PPH have been siloed for data extraction, considerable evidence exists that they do not operate in isolation. For instance, English language proficiency impacts refugee women’s access to PPH (Wiley et al., 2018). So too does the availability of culturally appropriate PPH services (Hawkey et al., 2017), and the access of refugee women to transport and infrastructure to utilise such services (Stapleton et al., 2013). Similarly, the fulfillment of other settlement priorities, such as the need for housing and employment was identified as a prerequisite to refugee women seeking PPH (Ngum Chi Watts et al. 2014). Consequently, analysis of these findings would be remiss to ignore the inter-connectedness of these barriers and facilitators, and the compounding impact they have on refugee women’s access to PPH in Australia.
Links to Extant Literature
The findings of this study are both substantiated and novel. Aligned with the findings of Taylor and Lamaro Haintz (2018), Mangesha et al. (2017) and Wohler and Dantas (2016), this study also found English proficiency, cultural factors and environmental factors to operate as barriers and facilitators to refugee’s access to healthcare. Likewise, supporting the findings of Taylor and Lamaro Haintz (2018), this study found organisational, legislative factors and education to play a role in refugee’s access to health services. A novel finding of the present review was the impact of settlement priorities on refugee women’s utilisation of PPH. Research findings suggest that when more immediate settlement needs, such as housing and employment are not met, refugee women tend not to pursue PPH (Riggs et al., 2012). Thus, the satisfaction of settlement priorities was shown to be a pre-requisite for refugee women’s efforts to engage with PPH. Examination of the results within the conceptual framework of the SEM reveals the complex interplay of the barriers and facilitators experienced by refugee women in Australia in accessing PPH. These factors do not only operate in isolation, they interrelate. Likewise, they are not merely experienced at the individual level for refugee women, but a compounded effect can be seen, as they function on multiple levels of the SEM. This is aligned with Taylor and Lamaro-Haintz’ (2018) findings on the impact of the social determinants on refugee’s access to health services. Here they state, “all levels of the SEM were shown to exist independently and in interactive ways” (p.26).
Interrelationships between culture, education and language were apparent across the literature and over varied levels of the SEM. At the interpersonal level, in cultures where it was considered shameful to talk about sex, a significant impact on the SRH education of refugee women at the individual level, was clear. One Sudanese woman explained “I wanted to know more [about contraception] but at that time there was no internet… I never asked anybody” (Metusela et al., 2017, p. 845). The cultural discourse of shame, silence, secrecy and taboo surrounding SRH meant that women turned to less reliable sources for SRH information, such as films and peers, resultantly forming misconceptions about their SRH (Metusela et al., 2017).
Further, refugee women reported cultural constraints on their education, as it was considered the role of the female to carry out domestic duties. Watkins et al. (2012) explained the complexity of this inter-relationship at both the individual and interpersonal levels, stating “…women required English language to interact effectively with services and be successful in their activities…, but these responsibilities meant they were unable to devote time to education” (p. 132).
Language challenges also interacted with education and culture, at the individual, interpersonal, organisational and environmental levels. At the individual level, refugee women exhibited low rates of literacy in their native language, and even lower levels in English. This affected their ability to understand and interpret PPH messages. At the interpersonal level, limited English proficiency impacted their ability to make social connections, and to interact with health professionals, with simply booking an appointment being considered a monumental task (Riggs et al., 2012). At the organisational level, language barriers created the need for interpreters to attend appointments to promote understanding between the refugee women and health professionals, however, these were not always available. At the environmental level, women experienced challenges in accessing suitable transport to attend PPH appointments, at times resulting in failure to attend scheduled appointments. In turn, this impacted refugee women’s knowledge and understanding of PPH, as it robbed them of the opportunity to engage with the education available through these services.
While refugee women are afforded many rights and entitlements for PPH at the legislative level, Riggs et al. (2016) reported a lack of knowledge of these entitlements at the individual level for both refugees and several midwives. This had a direct impact on refugee women’s access of these services. Further, many PPH providers expressed their need for professional development in refugee care, reflecting a gap at the organisational level in training employees for their care of this demographic (studies 1, 9, 11, 17-18).
Several refugee women expressed their desire to make social connections within their community at the interpersonal level. Language barriers, as well as a lack of understanding of Australian cultural norms and behaviours at the individual level, operated as a barrier to the establishment of such connections at the interpersonal level (Walker et al., 2015). Social support was also shown to have the potential to operate as a facilitator to refugee women’s access of PPH. In cases where PPH had been experienced and validated by peers, refugee women were more likely to engage with these services. Thus, social support had the potential to operate as both a barrier and facilitator to refugee women’s access of PPH (Mangesha et al., 2017).
These language, cultural and knowledge factors also operated at the organisational level, as refugee women had limited understanding of how the health system works in Australia, many having no prior experiences with PPH (Riggs et al., 2012). At times, this meant women’s attempts to access health services were in vain, with one mother reporting she had walked to a MCH centre with her children, only to be given a phone number to book an appointment (Riggs et al., 2012). Walker et al. (2015) reported that the fostering of social connections through peer support groups both promoted learning of host cultural norms, and enhanced personal support networks. This impacted refugee women’s integration in their new host country, and illustrates the interrelationships between culture, language and social support, and their compounding impact on access to PPH.
The findings of the present review convincingly demonstrate the inter-woven nature of the barriers and facilitators experienced by refugee women in Australia in accessing PPH. Not only did the barriers and facilitators operate in a bi-directional fashion, one barrier was shown to have the potential to exacerbate or even create another (ie. low English language proficiency reduced access to knowledge). Similarly, the barriers and facilitators functioned at all levels of the SEM, suggesting that it is essential for PPH strategies to adopt a multi-level approach in order to improve PPH access for refugee women.The findings of this review strongly support the need for future PPH initiatives targeted towards refugee women to adopt a multi-level and multi-faceted approach. A multi-level approach would be one where various levels of the SEM are addressed, while a multi-faceted approach would be one that addresses the many factors that impact refugee women’s access to PPH.
While the SEM is a powerful tool for analysing the impact of a determinant of health across multiple levels, it does not visually represent the inter-relationships of factors across these levels. Therefore, a theoretical implication of this review’s findings is to propose the re-development of the SEM so that it visually depicts the complexities of the functions of its use.
The review of qualitative data was aligned with the social-constructivist approach taken by this review. It enabled rich examination of the lived experiences of the barriers and facilitators experienced by refugee women in accessing PPH in Australia. Despite this, a methodological implication for future examination of this area would be to adopt a mixed-methods approach. Including quantitative data alongside qualitative would enable larger research samples and increase the generality of findings, without subtracting the rich and insightful data obtained through qualitative methods.
Given the paucity of Australian-based research on refugee women’s access to PPH, more studies need to be conducted. The findings from this review may be utilised by researchers to direct their investigation and build on existing understandings of the factors impacting refugee women’s access to PPH services. While the present review provides a comprehensive overview of the barriers and facilitators experienced by refugee women in accessing PPH, further exploration into the preferences of refugee women in terms of modes of delivery of PPH needs to be conducted.
Strengths and Limitations
The utilisation of the SEM to analyse the findings of the data included in this review provided a solid theoretical framework from which to evaluate the complex interactions of the factors impacting refugee women’s experiences in accessing PPH, on multiple levels.
The findings of this review align with the conclusions drawn by other researchers in similar fields (Taylor and Lamaro Haintz, 2018; Wohler and Dantas, 2016; and Mangesha et al. 2017). They are also novel, as this is the first systematic literature review to focus on the experiences of refugee women in Australia in accessing PPH. Thus, a notable contribution made by this review is the potential for its findings to be used by policy makers and health authorities to inform the development of future PPH initiatives.
A limitation of this study is the lack of research that focuses solely on refugee women and their access to PPH services. Thus, to collect a reasonable sample of studies, the eligibility criteria was expanded to allow for studies to be included with a refugee women focus group. This means that the data may be somewhat skewed, as some data also included CALD women, who weren’t refugees. Further, PPH services are often implemented by treatment and care providers, resulting in some studies including access to these types of services in their findings.
Another challenge encountered in this review was that maternal and child health are often researched and discussed concurrently. This meant that some PPH measures examined did not just involve PPH for refugee women, but also discussed that of their children.
The factors impacting refugee women’s access to PPH are complex, interactive, and operate at multiple levels of the SEM. As such, PPH initiatives attempting to address the barriers in isolation and at only one level of the SEM are likely to be futile. Research findings strongly support the need for PPH initiatives to be both multi-level and multi-faceted to effect change and improve the experiences of refugee women accessing PPH in Australia. More action needs to be taken to address the barriers and promote the facilitators experienced by this marginalised group within Australia. The development of effective PPH strategies will serve to bolster refugee women’s health outcomes and reduce the current health disparities between them and the general Australian population.