Barriers to access to the Norwegian healthcare system among sub-Saharan African immigrant women exposed to female genital cutting

Examining the key features of specialist health service provision for women with Female Genital Mutilation/Cutting (FGM/C) in the Global North: a scoping review

Background

Health care for women with Female Genital Mutilation/Cutting (FGM/C) in the Global North is often described as sub-optimal and focused on maternity care. Specialist FGM/C services have emerged with little empirical evidence informing service provision. The objective of this scoping review is to identify the key features of FGM/C specialist care.

Methods

The review was conducted in accordance with JBI methodology. Participants: organisations that provide specialist FGM/C care. Concept: components of specialist services. Context: high-income OECD countries. Eligibility criteria included primary research studies of any design from 2012 to 2022, providing a comprehensive description of specialist services. Seven bibliographic databases were searched (MEDLINE, EMBASE, CINAHL, Web of Science, SCOPUS, Cochrane Library and MIC). The components of "specialist" (as opposed to "generalist") services were defined and then applied to an analysis of FGM/C specialist care. FGM/C specialist provision was categorised into primary (essential) and secondary features. Data were extracted and analysed descriptively through charting in tables and narrative summary.

Results

Twenty-five papers described 20 unique specialist services across eleven high income countries. Primary features used to identify FGM/C specialist care were:-(i) Named as a Specialist service/clinic: 11/20 (55%); (ii) Identified expert lead: 13/20, (65%), either Midwives, Gynaecologists, Urologist, or Plastic Surgeons; (iii) Offering Specialist Interventions: surgical (i.e., reconstruction and/or deinfibulation) and/or psychological (i.e., trauma and/or sexual counselling); and (iv) Providing multidisciplinary care: 14/20 (70%). Eleven services (in Spain, Sweden, Switzerland, Germany, Italy, Netherlands, France, Belgium, and USA) provided reconstruction surgery, often integrated with psychosexual support. No services in UK, Norway, and Australia offered this. Six services (30%) provided trauma therapy only; 25% sexual and trauma therapy; 15% sexual therapy only; 30% did not provide counselling. Secondary features of specialist care were subdivided into (a) context of care and (b) the content of care. The context related to concepts such as provision of interpreters, cost of care, community engagement and whether theoretical underpinnings were described. Content referred to the model of care, whether safeguarding assessments were undertaken, and health education/information is provided.

Conclusion

Overall, the features and composition of FGM/C specialist services varied considerably between, and sometimes within, countries. Global guidelines advocate that specialist care should include access to deinfibulation, mental health support, sexual counselling, and education and information. The review found that these were rarely all available. In some high-income countries women cannot access reconstruction surgery and notably, few services for non-pregnant women mentioned safeguarding. Furthermore, services for pregnant women rarely integrated trauma therapy or psychosexual support. The review highlights a need for counselling (both trauma and psychosexual) and culturally-appropriate sensitive safeguarding assessments to be embedded into care provision for non-pregnant as well as pregnant women. Further research is needed to extract the features of specialist services into a comprehensive framework which can be used to examine, compare, and evaluate FGM/C clinical specialist care to determine which clinical features deliver the best outcomes. Currently a geographical lottery appears to exist, not only within the UK, but also across the Global North.

Structural and intermediary determinants in sexual health care access in migrant populations: a scoping review

OBJECTIVES

Addressing migrant population's sexual health needs is essential, given the high vulnerability of this population, especially during migratory trajectories and when accessing health care in destination countries. The aim of this scoping review is to identify and describe the structural and intermediary determinants and their dimensions, which negatively influence sexual healthcare access in migrant population in the world in the last 20 years.

STUDY DESIGN

Scoping review.

METHODS

The search strategy was carried out in the databases PubMed/MEDLINE, Web of Science, EMBASE, and CINAHL. The inclusion criteria were primary studies published in English or Spanish from 2000 to 2022, describing determinants or barriers to access to sexual health for international migrants, refugees, and asylum seekers. The construction of the results was based on the social determinants of health framework.

RESULTS

A total of 44 studies were included. Thirteen categories that negatively affect access to sexual health in migrants were identified-structural determinants: language and communication barriers, religious and cultural values, VIH stigma and discrimination, irregular migration status, financial constraints, racism and discrimination, gender inequalities, and lack of knowledge and awareness about sexuality and sexual health; and intermediary determinants: financial health coverage, privacy and confidentiality, health system navigation; health system and facilities, and psychosocial factors.

CONCLUSION

The most relevant dimensions identified as barriers to access to health services were "culture and societal values" and "health system". Identifying the determinants that affect migrants' access to sexual health is relevant for the formulation of public policies with sociocultural relevance and an intersectional and human rights approach.

Reproductive health care appointments: How the institutional organization of obstetric/gynecological work shapes the experiences of women with female genital cutting in Toronto, Canada

We investigated the social relations shaping the reproductive health care experiences of women with female genital cutting (FGC) in Toronto, Canada. Using Institutional Ethnography, we interviewed eight women with FGC and seven obstetrician/gynecologists (OB/GYN). We found a disjuncture between women's needs during appointments that extended beyond the reproductive body and range of care that doctors were able to provide. Women engaged in emotional healthwork during appointments by explaining FGC to doctors, reading doctors' body language, and getting through vulvar/vaginal examinations. Women reported that if they had emotional reactions during appointments, they were often referred to a mental health specialist, a referral on which they did not act. OB/GYNs described their specialty as "surgical"-training centered around treating reproductive abnormalities and not mental health issues. Therefore, the disjuncture between women's needs and OB/GYNs' institutional training highlights the difficulties inherent when bodies of "difference" encounter the reproductive health care system.

Female genital mutilation and skilled birth attendance among women in sub-Saharan Africa

Background

There is evidence that women who have had their genitals cut suffer substantial difficulties during and/or after childbirth, including the need for a caesarean section, an episiotomy, an extended hospital stay, post-partum bleeding, and maternal fatalities. Whether or not women in sub-Saharan Africa who have undergone female genital mutilation utilize the services of skilled birth attendants during childbirth is unknown. Hence, we examined the association between female genital mutilation and skilled birth attendance in sub-Saharan Africa.

Methods

The data for this study were compiled from 10 sub-Saharan African countries’ most recent Demographic and Health Surveys. In the end, we looked at 57,994 women between the ages of 15 and 49. The association between female genital mutilation and skilled birth attendance was investigated using both fixed and random effects models.

Results

Female genital mutilation and skilled birth attendance were found to be prevalent in 68.8% and 58.5% of women in sub-Saharan Africa, respectively. Women with a history of female genital mutilation had reduced odds of using skilled birth attendance (aOR = 0.91, 95% CI = 0.86–0.96) than those who had not been circumcised. In Ethiopia, Guinea, Liberia, Kenya, Nigeria, Senegal, and Togo, women with female genital mutilation had reduced odds of having a trained delivery attendant compared to women in Burkina Faso.

Conclusion

This study shed light on the link between female genital mutilation and skilled birth attendance among sub-Saharan African women. The study's findings provide relevant information to government agencies dealing with gender, children, and social protection, allowing them to design specific interventions to prevent female genital mutilation, which is linked to non-use of skilled birth attendance. Also, health education which focuses on childbearing women and their partners are necessary in enhancing awareness about the significance of skilled birth attendance and the health consequences of female genital mutilation.

Models of Maternal Healthcare for African refugee women in High-Income Countries: A Systematic Review

OBJECTIVE

To explore models of maternal healthcare for African refugee women and their acceptability, cost and associated outcomes.

DESIGN

A systematic review and content analysis SETTING: High-income countries PARTICIPANTS: African refugee women REVIEW METHODS: Seven databases were searched to identify peer-reviewed literature using defined keywords and inclusion criteria. Two authors independently screened the search findings and the full texts of eligible studies. The quality of the included studies was appraised, and the findings were analysed using a template.

RESULTS

Nine studies met the criteria. Four studies were qualitative, two quantitative and three studies used mixed methods. Four models of care were identified: midwifery-led care, hospital-based integrated care, primary care physician-led integrated care and a holistic refugee-specific primary healthcare model (one-stop shop). Issues affecting care delivery were identified as communication barriers, low health literacy, high transport costs and low engagement of refugee women in their care.

KEY CONCLUSIONS

The lack of evidence regarding the impact of care models on the maternal healthcare outcomes of African refugees highlights the need to improve care evaluations. These results reinforce the importance of education and interventions to build refugee women's health literacy and strength-based communication approaches supported by multidisciplinary, multilingual and highly trained teams of health professionals. There is also a need to involve African refugee women in shared decision making.

IMPLICATIONS FOR PRACTICE

The findings suggest the need for universal access to a woman-centred whole-of-system care approach for African refugees that emphasises culturally competent, safe, respectful and compassionate multi-professional care and greater economic security to cover costs.

Barriers and facilitators to the access to specialized female genital cutting healthcare services: Experiences of Somali and Sudanese women in Norway

BACKGROUND

Girls and women subjected to female genital cutting (FGC) risk experiencing obstetrical, gynecological, sexual, and psychological health problems. Therefore, Norway has established low-threshold specialized healthcare services where girls and women with FGC-related health problems can directly seek medical attention. Nevertheless, we lack data about access to these services, especially for non-maternity-related purposes. In this article, we explore experiences of seeking medical attention for health problems that are potentially FGC-related, aiming to identify factors that hinder or facilitate access to FGC-specialized services.

METHODS

We conducted a qualitative study in three Norwegian cities employing semi-structured repeat interviews with 26 girls and women subjected to FGC, participant observation, and three validation focus group discussions with 17 additional participants. We thematically analyzed the data and approached access as a dynamic process of interactions between individuals and the healthcare system that lasts from an initial perception of need until reception of healthcare appropriate to that need.

FINDINGS

We identified several barriers to healthcare, including 1) uncertainty about FGC as a cause of experienced health problems, 2) unfamiliarity with FGC-specialized services, 3) lack of assessment by general practitioners of FGC as a potential cause of health problems, and 4) negative interactions with healthcare providers. In contrast, factors facilitating healthcare included: 1) receiving information on FGC-related health problems and FGC-specialized services from a non-profit immigrant organization, 2) referral to gynecologists with good knowledge of FGC, and 3) positive interactions with healthcare providers.

CONCLUSION

Assessing whether FGC is the cause for experienced health problems requires diagnostic competency and should not be left entirely to the patients. We recommend that Norwegian policymakers acknowledge the central role of GPs in the clinical management of patients with FGC-related health problems and provide them with comprehensive training on FGC.