Characteristics, Interventions, and Results of Studies To Improve Reproductive Health for Undocumented Female Migrants and Refugees

Study and Assessed QualityStudy Characteristics

Study Intention

Outcomes Related to Reproductive HealthIntervention Impact Resultsa
Fuentes-Afflickb (2006)20Design: Cross-sectional surveyTo compare effect of state of residence and immigration status on the use of PNC among Hispanic women in CA, NY, and FL compared to U.S. born citizens in NY after 1996 PRWORA was imposed, which prohibited using federal Medicaid funds for undocumented immigrants for publicly funded services. CA and NY continued to provide services with nonfederal resources; FL fully adopted PRWORA measures

Use of prenatal care services

  • Adequate: initiated during the first trimester and 6 ANC visits or more

  • Inadequate: initiated after first trimester and fewer than 6 ANC visits

  • 75% of UMW in CA and NY received prenatal care in the first trimester vs. 57% of UMW in FL

  • 35% of UMW in FL had fewer than 6 prenatal visits vs. CA (13%) and NY (12%)

  • UMW in CA and FL entered ANC approximately 2 weeks later than those in NY

  • UMWs had higher likelihood of inadequate use of ANC than U.S.-born citizens in CA, NY, FL but odds ratio was greater in FL (3.5) compared to CA (1.9) and NY (1.6)

Population: Postpartum Hispanic women (aged 17 years and older) (64% undocumented)
Location: USA (CA, NY, and FL)
Raheelb (2012)21Design: Cross-sectional survey

To measure effect of health subsidy on uptake of contraception among refugees, who were assigned to 2 NGOs:

  • One NGO provided 90% subsidies for health care (subsidized care)

  • One NGO only encouraged refugees to use public and private health care resources (nonsubsidized care)

  • Knowledge, attitudes, and practices regarding FP

  • Approval of FP by women, friends, and spouses

  • Has ever heard of FP (nonsubsidized vs. subsidized): 44.9% vs. 88.9%

  • Currently using any contraceptive method (nonsubsidized vs. subsidized): 24.9% vs. 54.5%

  • Approval of FP (nonsubsidized vs. subsidized):

    • Women: 49.5% vs. 85.8%

    • Friends: 47.7% vs. 85.5%

    • Spouses: 44.6% vs. 88.6%

Population: Currently married Afghan female refugees (aged 15–49 years) and their families
Location: Karachi, Pakistan
Purdinc (2008)22Design: Secondary analysis

To reduce maternal mortality among Afghan refugees in the Hangu district of Pakistan

  • Established EmOCs staffed with female Pakistani doctors, nurse-midwives, and dayas from among the refugee population. EmOC staff are available or on-call 24/7

  • Educated on danger signs during pregnancy and the importance of skilled attendance

  • Facilitation of referral forms to EmOC

  • Decreased maternal mortality ratio and maternal deaths during birth

  • Increased utilization of services (EmOC): births, complications, referrals, cesarean deliveries

  • Case fatality rate

  • Coverage

  • Knowledge of danger signs among the target population

  • Maternal mortality ratio per 100,000 (before vs. after): 291 vs. 102

  • Percentage of refugee births in an EmOC facility (1996 vs. 2007): 4.8% vs. 67.2%

  • Cesarean delivery fatality among refugees: 0.2% vs. United Nations target of less than 1%

  • Prenatal coverage (3+ PNC visits) from 2000 to 2006: 49% vs. 90%

Population: Afghan female refugees (N=96,300 distributed in 11 refugee camps)
Location: Refugee camps in Hangu district, Pakistan
Truppab (2019)23Design: Mixed-method, 2 cross-sectional post-intervention surveys (HS vs. CS)To determine if program was enabling access to essential primary health care services for the most vulnerable populations residing in catchment areas heavily affected by the Syrian crisis and determined through various indicators obtained through HS or CSUse of FP, ANC, and delivery care services
  • HS: (Lebanese women vs. Syrian refugees)

    • Percentage of women who sought but did not obtain contraception (54.11% vs. 43.6%)

    • Percentage of women that attended ANC visits (63.18% vs. 70.26%)

    • Median number of ANC visits (7 vs. 4)

  • CS (Lebanese vs. Syrian refugees):

    • Percentage of women that attended ANC visits (87.5% vs. 98.6%)

    • Median of ANC visits (4 vs. 4)

Population: Lebanese and Syrian refugee women (aged 18–50 years) and caretakers of minors (both genders)
Location: Lebanon
Tousawb (2017)24Design: Qualitative interviews post-intervention (n=22); secondary data analysis of SARP records (N=81)

To document experiences of women who accessed SARP:

  • Trained counselors in Thailand and Burma in pregnancy options counseling, skill-building exercises, and logistics of SARP

  • SARP offered referrals for care and financial coverage

  • Successful referrals

  • Denial of services to referred women

  • Experiences and satisfaction of women with the SARP

  • 52/81 successful referrals (64%)

  • 17/81 referrals that were denied service (21%)

  • Satisfactory experience with SARP services:

    • Comprehensive RH services

    • Women described SARP counselors as understanding, open, friendly and nonjudgmental

    • Women reported a sense of empowerment and commitment to advocating for SARP

Population: Migrant and refugee women from Burmese communities

Location: Northern Thailand

Tousawb (2018)25

Design: In-depth qualitative interviews (n=16)

Secondary analysis of program records (N=918)

To provide early MA in low-resource and legally restricted setting

Trained social workers and counselors (network providers) on counseling and provision of early MA

  • Provided access to a free supply of misoprostol for early MA

  • Made network providers available for questions, concerns, and follow-up within 4 weeks of initial dose

  • Percentage of successful complete MA

  • Experiences of self-managed abortions

  • 96% of women had successful complete MA

  • Qualitative results:

    • Positive experiences regarding safety, tolerable side effects, and the absence of complications

    • Satisfaction with the counseling services provided

    • Women’s concerns about the legal risks for themselves and the network providers for involvement in MA

Population: Female refugees and migrants from Burma with self-reported pregnancy of 9 weeks or less
Location: Thailand-Burma border
McGinnd (2006)26Design: Cross-sectional post-intervention survey with RHG-exposed and nonexposed refugees

To increase literacy skills, knowledge of RH, and use of RHS available in the camps

  • Literacy sessions with reproductive health content: safe motherhood, FP, STI, HIV/AIDS, and GBV

  • Literacy sessions were conducted by previously trained teachers. Sessions had a medium duration of 2 hours, twice a week for a duration of between 6 months and 5 months

  • Increased knowledge and use of contraception, as well as discussion about contraception use with partners

  • Increased knowledge of STIs

  • Antenatal care, including immunization

  • Knowledge of PNC

Difference between before vs. after of having ever spoken to their partners or family members about (before vs. after)e:

  • RH: 18% (69% vs. 87%)

  • Condoms: 20% (65% vs. 85%)

  • STIs: 31% (54% vs. 85%)

  • HIV: 18% (66% vs. 84%)

Population: Female refugees from Liberia and Sierra Leone, either illiterate or with up to 2 years of formal education (N=2,325)
Location: Guinea
Rosenbergd (2017)27Design: Qualitative study with focus groups

To train refugees engaged in sex work to become peer educators to meet the RH needs of refugees performing sex work

  • Trained 2 cohorts of peer educators on human rights, sex work, SRH, life skills, community outreach and advocacy

  • Peer educators designed and implemented community outreach activities (distributing condoms, capacity-building sessions, peer counseling and support sessions)

  • Self-reported increased knowledge on SRH, legal topics related to sex work and GBV

  • Increased willingness to share the knowledge with their peers

  • Peer educators reported an increase in knowledge (e.g., safe sex and FP)

  • Peer educators reported perceiving themselves as ambassadors for female refugees engaged in sex work

Population: Female refugees engaged in sex work (N=50 peer educators)
Location: Kampala, Uganda
Howardb (2011)28Design: Cross-sectional post-intervention survey

To improve RH of refugee women, refugee providers created RHG, which was integrated into local health system

  • Trained health care facilitators to conduct outreach/education activities with women, men, and youtha and provide information and advice on RH, and distribute condoms and spermicidesa

  • Created drama groups and youth-oriented activities to engage larger audiences and spread RH messagesa

  • Attitudes on PNC

  • Knowledge regarding:

    • Reason to attend PNC

    • Danger signs in pregnancy

    • Actions if danger signs present

  • Utilization of services by parous women

Nonsignificant differences reported in outcomes between women in intervention group vs. those who were not

Population: Female refugees (aged 15–49 years) from Sierra Leone and Liberia living in 48 refugee camps

Location: Guinea Forest Region
Stevensb (2018)29Design: Mixed-method study with surveys and focus groups

To increase FA uptake and decrease NTD incidence among migrant and refugee women

  • Workshops with health workers on NTDs and dosing of FA

  • Community outreach through posters, pamphlets, and workshops with different stakeholders (e.g., local HCWs, men, NGOs, and field managers)

  • Uptake of FA among migrant and refugee women

  • Increased knowledge about FA among HCWs

  • Negative difference in FA uptake before and after the intervention (1.3% vs. 0.65%; P=.465)

  • Percentage of HCWs that knew that NTDs could be prevented by taking FA before conception (16% before vs. 72% after; P<.001)

Population: Pregnant female migrant and refugees seeking care (N=371) and HCWs (N=100)
Location: Thailand-Myanmar border
  • Abbreviations: ANC, antenatal care; CA, California; CHW, community health workers; CS, clinic survey; EMOC, emergency obstetric care center; FA, folic acid; FHW, female health workers; FL, Florida; FP, family planning; GBV, gender-based violence; HS, household survey; HCW, health care worker; MA, medical abortion; NGO, nongovernmental organization; NTD, neural tube defects; NY, New York; PNC, postnatal care; PRWORA, Personal Responsibility and Work Opportunity Reconciliation Act; RH, reproductive health; RHG, reproductive health group; SARP, Safe Abortion Referral Program; SRH, sexual and reproductive health; STI, sexually transmitted infection; UMW, undocumented migrant women.

  • a Information obtained from an additional article cited in Howard et al.28

  • b Study rated high quality according to measures used.

  • c Study rated low quality according to measures used.

  • d Study rated medium quality according to measures used.

  • e It is not clear in the study results if women at baseline and follow-up were the same women.