Inequity in contraceptive care between refugees and other migrant women?: a retrospective study in Dutch general practice

Inequity in contraceptive care between refugees and other migrant women?: a retrospective study... Abstract Background Female refugees are at high risk of reproductive health problems including unmet contraceptive needs. In the Netherlands, the general practitioner (GP) is the main entrance to the healthcare system and plays a vital role in the prescription of contraceptives. Little is known about contraceptive care in female refugees in primary care. Objective To get insight into GP care related to contraception in refugees and other migrants compared with native Dutch women. Methods A retrospective descriptive study of patient records of refugees, other migrants and native Dutch women was carried out in five general practices in the Netherlands. The prevalence of discussions about contraception and prescriptions of contraceptives over the past 6 years was compared in women of reproductive age (15–49 years). Results In total, 104 refugees, 58 other migrants and 162 native Dutch women were included. GPs in our study (2 male, 3 female) discussed contraceptives significantly less often with refugees (51%) and other migrants (66%) than with native Dutch women (84%; P < 0.001 and P = 0.004, respectively). Contraceptives were less often prescribed to refugees (34%) and other migrants (55%) than to native Dutch women (79%; P < 0.001 and P = 0.001). Among refugees from Sub-Saharan Africa, contraception was significantly less often discussed (28.9%) compared with refugees from other regions (67.8%; P < 0.001). More refugees and other migrants had experienced unwanted pregnancies (14% respectively 9%) and induced abortions (12% respectively 7%) than native Dutch women (4% respectively 4%). Conclusion Contraceptives were significantly less often discussed with and prescribed to refugees and other migrant women compared with native Dutch women. More research is needed to elicit the reproductive health needs and preferences of migrant women regarding GP’s care and experiences in discussing these issues. Such insights are vital in order to provide equitable reproductive healthcare to every woman regardless of her background. Contraception, contraceptive needs, general practitioner’s care, immigrant, migrant, primary care, refugee, sexual and reproductive health Introduction Today a growing number of refugees are settling in high-income countries such as the Netherlands, and migrants constitute an essential part of the European population (1). Migrants are all persons born outside the Netherlands with at least one parent who is also born outside the Netherlands. Refugees are a specific type of migrants who came involuntarily to the Netherlands because of conflict or fear for persecution in the country of origin. They are protected by international law and should not be expelled or returned to situations where their life and freedom would be under threat (2). According to the United Nations High Commissioner for Refugees (UNHCR), at the end of 2015, the number of refugees in The Netherlands were estimated to be 88 536 (0.5% of the total population). Another 28 051 people were waiting for a decision on their asylum claims (3). Most refugees in the Netherlands are of Iraqi, Afghan and Somali origin, but the vast majority of the asylum requests in 2015 were from Syrian and Eritrean refugees (3,4). The three largest first-generation ethnic minority groups in the Netherlands are the Turkish, Surinamese and Moroccan (respectively, 1.12%, 1.05% and 0.99% of the total population in 2016) (5). Several studies have documented that sexual and reproductive health (SRH) is at risk in refugees and (undocumented) female migrants (6–9). According to the World Health Organization (WHO), definition reproductive health implies that people are able to have a responsible, satisfying and safe sex life and the freedom to decide if, when and how often to reproduce (10). Since their arrival in Europe, 69.3% of the female migrants have been subjected to sexual violence compared with 30.6% of the European population (11). In a study from 2009 among all asylum seekers in the Netherlands, the overall abortion rate for asylum seekers is about one and a half times higher and the teenage birth rate more than eight times higher than average for the Netherlands. Especially, recently arrived women are at increased risk (8). SRH may be influenced by various factors such as cultural and religious norms from the country of origin and experiences during the flight. Women often originate from countries where they have a disadvantaged position in society, which makes them vulnerable, particularly in their SRH (12). Moreover, women might be confronted by war and armed conflict and come from areas with a poorly functioning healthcare system. Besides factors related to a women’s background of forced migration, SRH may also be influenced by the situation in the host country for instance by uncertainty of the asylum procedure, frequent transfers, absence of social structure and language barriers (8). In addition, many refugees and other migrants have little knowledge about risk factors for unwanted pregnancies and about contraception due to limited health literacy (13). Moreover, young migrant adults often receive too little education on sexual health, and unmet contraceptive needs are common (9,14–17). In the Netherlands, the general practitioner (GP) is the main entrance to the healthcare system and an important provider of information on and prescription of contraceptives. GPs could play an important role in informing refugee women and also help reduce the number of unwanted pregnancies among them. However, it is unknown if and to what extent they discuss reproductive health needs with refugee women or prescribe contraceptives. Better insight into these aspects can provide key information to improve the quality of healthcare and well-being of female refugees with regard to their SRH needs. Although their background and reasons to immigrate differ from refugees, SRH issues are also documented among other migrant women. Therefore, this study aimed to include not only refugee women but also other migrant women. Our research question is as follows: to what extent do GPs in the Netherlands discuss and prescribe contraceptives to female refugees compared with other female migrants and native Dutch women of the same age? Method Study design For this descriptive quantitative study, we examined anonymized electronic patient records of different general practices in the Netherlands. Recruitment We contacted GPs in different parts of the Netherlands and provided them with information about the research project. GPs with at least 10 female refugees on their practice list were included until the desired total number of 100 patient records of female refugees was reached. Both the recruitment and inclusion of study participants and the data collection took place in August and early September 2016. Study population In this study, people were categorized in three groups: refugees, other (first-generation) migrants and native Dutch women. Probable refugees were identified by first creating a list of female patients of reproductive age (15 to 49 years) with a foreign surname. This list was made through the use of the electronic medical system and was done in each general practice. Identifying migrants by means of their surname has proved to be a reliable method (18). Patients were included if they had consulted the GP at least twice between January 2010 and March 2016 (representing a minimum of contacts enabling the discussion of contraceptives) and if the patient was born outside of the European Union. As not all female refugees are acknowledged as such and granted asylum, we used country of origin as proxy for the likelihood the woman concerned was a refugee and not a different type of migrant (19). Patients were excluded if their country of origin was unknown, if they moved away during the time window or if their patient record revealed they did not have need for contraception: those with infertility (including sterilization and hysterectomy), those who had female partners, were postmenopausal, pregnant or were trying to conceive. Every electronic record was searched for information about the reason of migration to the Netherlands, i.e. if somebody was a refugee or not. If reason for migration was not documented, the country of origin was checked against a list of countries that were prone to produce refugees in the time of migration of that person. We used UNHCR databases and reports, country profiles and the Dutch list of safe countries to determine if the country of origin was known for war, conflicts or persecution of its inhabitants and—as a result—of having refugees, using the UNHCR definition of a refugee. This was checked for the moment of arrival in the Netherlands or, if this was unknown, for the moment of registration in the general practice. Eventually, this resulted in the decision to list women as ‘other migrant’ (not refugee) if coming from Brazil, Bulgaria, China, Ecuador, Egypt, Ghana, India, Indonesia, Kenya, Mongolia, Morocco, Peru, Philippines, Russia, Serbia, South Africa, Suriname, Tanzania, Tunisia and Turkey. Native Dutch women were identified by creating a list of female patients aged 15 to 49 years without a foreign surname. We used similar inclusion and exclusion criteria, but, in this case, the Netherlands had to be their country of origin. Because there were more native Dutch women than refugees and migrants in each practice, we selected them randomly using systematic sampling. We matched native Dutch women with the previously included female refugees and migrants by age, collecting the same amount of women for each age group. If a refugee or migrant was younger than 17 years, we used their exact age for matching with a non-refugee. Data collection We extracted data from anonymized electronic medical records on several patient characteristics such as length of stay in the Netherlands, relational status, educational level, gravidity, unwanted pregnancies, induced abortion and when and what kind of contraceptive method was discussed or prescribed (condom, oral contraceptive, injection, intrauterine device, implant, vaginal ring, sterilization or other). Date of first registration in the general practice was also recorded in order to measure the length of registration in the practice. This was defined as the time from registration in the practice to the census date. Through this method, we were able to explore differences between women in this period of observation. Women were characterized with an unwanted pregnancy or induced abortion if this had occurred at some moment during their life. We chose to divide relational status into ‘no steady partner’ and ‘steady partner’ because these definitions were most often used in the medical record. In order to not miss discussions about contraceptives that were not coded with the specific ICPC (International Classification of Primary Care) code, we also looked into consultations where one of the following codes were used: D (gastrointestinal tract), W (pregnancy/delivery/contraceptives) or X (female genitals/breasts). Data analysis Data were processed and analysed using SPSS Statistics (version 23). Two-tailed Pearson chi-squared test was used to compare the patient characteristics of the three study groups. The variable ‘length of stay in the Netherlands’ was compared using an independent samples t-test. One-way ANOVA was used for the variables age and the amount of years registered in general practice. To compare refugees, other migrants and native Dutch women, a chi-square test and binary logistic regression analysis was used. Chi-square test was also used to determine possible significant differences between general practices. Results Five general practices participated in our study, located in Nijmegen, Amsterdam and Rotterdam. Two practices (GP3, GP5) were solo practices, and the other three were group practices (GP1, GP2, GP4). The GPs of GP3 and GP4 were male and those of GP1, GP2 and GP5 were female. One practice (GP3) exclusively delivered care to undocumented migrants and refugees; we matched them with native Dutch women from a practice (GP4) that was located in the same city representing an average population distribution. A total of 104 female refugees were included: 54 in a semi-rural area (Nijmegen) and 50 in a large city (Amsterdam, Rotterdam). Fifty-eight other migrant women were included, bringing the total of female refugees and other migrants up to 162. We matched them with 162 native Dutch women of the same age group. Demographic characteristics are summarized in Table 1. Among the women, there were seven teenagers. Two girls became 15 close before March 2016. Because we extracted data about all contacts between 2010 and March 2016, data from the period before their 15th birthday was also included. The women originated from 52 different countries. Of the refugees, the three main countries of origin were Somalia (11.5%), Iraq (8.7%) and Nigeria (8.7%). Of the other migrants, the three main countries of origin were Morocco (22.4%), Turkey (21.1%) and Bulgaria (6.9%). There were no teenage pregnancies found among any of the women. According to the registration, more refugees and other migrants had experienced unwanted pregnancies compared with native Dutch women (13.5% and 8.6% versus 3.7%, P < 0.001). Induced abortions were also more often listed among refugees and other migrants compared with native Dutch women (11.5% and 6.9% versus 3.7%, P < 0.001). Table 1. Demographics of female refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Characteristic Migrant status Refugees Other migrants Native Dutch women Sig.a Age (y), n(%) 0.502  15–19 4 (3.8) 1 (1.7) 5 (3.1)  20–24 6 (5.8) 4 (6.9) 10 (6.2)  25–29 22 (21.2) 7 (12.1) 28 (17.3)  30–34 19 (18.3) 5 (8.6) 29 (17.9)  35–39 21 (20.2) 15 (25.9) 36 (22.2)  40–44 23 (22.1) 13 (22.4) 35 (21.6)  45–49 9 (22.4) 13 (22.4) 19 (11.7) Region of origin, n(%) <0.001  Eastern Europe/Former USSR/Yugoslavia 17 (16.3) 11 (19.0) –  Sub-Saharan Africa 45 (43.3) 6 (10.3) –  Turkey/Middle East/Northern Africa 14 (13.5) 26 (44.8) –  Asia 11 (10.6) 7 (12.1) –  Afghanistan/Iran/Iraq 13 (12.5) 0 (0.0) –  Middle and South America 4 (3.8) 8 (13.8) – Length of stay in the Netherlands (y)  Mean (range) 10.3 (<1–30) 11.7 (5–35) – 0.474  Unknown 58 (55.8) 39 (67.2) Duration of registration in general practice, (y)  Mean (range) 6.5 (<1–34) 8.5 (<1–24) 10.6 <0.001  Median 4.0 6.0 8.0  Unknown 0 (0) 0 (0) 5 (3.1) Relational status, n(%) <0.001  No steady partner 12 (11.5) 8 (13.8) 30 (18.5)  Steady partner/married 50 (48.0) 36 (62.1) 94 (58.0)  Unknown 42 (40.4) 14 (24.1) 38 (23.5) Educational level, n(%) <0.001  Higher education 26 (25.0) 13 (22.4) 72 (44.4)  Secondary education 2 (1.9) 4 (6.9) 29 (17.9)  Primary education 2 (1.9) 0 (0.0) 0 (0.0)  Unknown 74 (71.2) 41 (70.7) 61 (37.7) Gravidity, n(%) <0.001  G0 23 (22.1) 15 (25.9) 70 (43.2)  G1≥ 52 (50.0) 33 (56.9) 85 (52.5)  Unknown 29 (27.9) 10 (17.2) 7 (4.3) Teenage pregnancy in history, n(%)  Registered 0 (0.0) 0 (0.0) 0 (0.0)  Unknown 56 (53.8) 15 (25.9) 10 (6.2) Unwanted pregnancy in history, n(%) <0.001  Registered 14 (13.5) 5 (8.6) 6 (3.7)  Unknown 47 (45.2) 13 (22.4) 9 (5.6) Induced abortion in history, n(%) <0.001  Registered 14 (11.5) 4 (6.9) 6 (3.7)  Unknown 46 (44.2) 12 (20.7) 9 (5.6) Characteristic Migrant status Refugees Other migrants Native Dutch women Sig.a Age (y), n(%) 0.502  15–19 4 (3.8) 1 (1.7) 5 (3.1)  20–24 6 (5.8) 4 (6.9) 10 (6.2)  25–29 22 (21.2) 7 (12.1) 28 (17.3)  30–34 19 (18.3) 5 (8.6) 29 (17.9)  35–39 21 (20.2) 15 (25.9) 36 (22.2)  40–44 23 (22.1) 13 (22.4) 35 (21.6)  45–49 9 (22.4) 13 (22.4) 19 (11.7) Region of origin, n(%) <0.001  Eastern Europe/Former USSR/Yugoslavia 17 (16.3) 11 (19.0) –  Sub-Saharan Africa 45 (43.3) 6 (10.3) –  Turkey/Middle East/Northern Africa 14 (13.5) 26 (44.8) –  Asia 11 (10.6) 7 (12.1) –  Afghanistan/Iran/Iraq 13 (12.5) 0 (0.0) –  Middle and South America 4 (3.8) 8 (13.8) – Length of stay in the Netherlands (y)  Mean (range) 10.3 (<1–30) 11.7 (5–35) – 0.474  Unknown 58 (55.8) 39 (67.2) Duration of registration in general practice, (y)  Mean (range) 6.5 (<1–34) 8.5 (<1–24) 10.6 <0.001  Median 4.0 6.0 8.0  Unknown 0 (0) 0 (0) 5 (3.1) Relational status, n(%) <0.001  No steady partner 12 (11.5) 8 (13.8) 30 (18.5)  Steady partner/married 50 (48.0) 36 (62.1) 94 (58.0)  Unknown 42 (40.4) 14 (24.1) 38 (23.5) Educational level, n(%) <0.001  Higher education 26 (25.0) 13 (22.4) 72 (44.4)  Secondary education 2 (1.9) 4 (6.9) 29 (17.9)  Primary education 2 (1.9) 0 (0.0) 0 (0.0)  Unknown 74 (71.2) 41 (70.7) 61 (37.7) Gravidity, n(%) <0.001  G0 23 (22.1) 15 (25.9) 70 (43.2)  G1≥ 52 (50.0) 33 (56.9) 85 (52.5)  Unknown 29 (27.9) 10 (17.2) 7 (4.3) Teenage pregnancy in history, n(%)  Registered 0 (0.0) 0 (0.0) 0 (0.0)  Unknown 56 (53.8) 15 (25.9) 10 (6.2) Unwanted pregnancy in history, n(%) <0.001  Registered 14 (13.5) 5 (8.6) 6 (3.7)  Unknown 47 (45.2) 13 (22.4) 9 (5.6) Induced abortion in history, n(%) <0.001  Registered 14 (11.5) 4 (6.9) 6 (3.7)  Unknown 46 (44.2) 12 (20.7) 9 (5.6) a Significance calculated with chi-square test. View Large Table 1. Demographics of female refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Characteristic Migrant status Refugees Other migrants Native Dutch women Sig.a Age (y), n(%) 0.502  15–19 4 (3.8) 1 (1.7) 5 (3.1)  20–24 6 (5.8) 4 (6.9) 10 (6.2)  25–29 22 (21.2) 7 (12.1) 28 (17.3)  30–34 19 (18.3) 5 (8.6) 29 (17.9)  35–39 21 (20.2) 15 (25.9) 36 (22.2)  40–44 23 (22.1) 13 (22.4) 35 (21.6)  45–49 9 (22.4) 13 (22.4) 19 (11.7) Region of origin, n(%) <0.001  Eastern Europe/Former USSR/Yugoslavia 17 (16.3) 11 (19.0) –  Sub-Saharan Africa 45 (43.3) 6 (10.3) –  Turkey/Middle East/Northern Africa 14 (13.5) 26 (44.8) –  Asia 11 (10.6) 7 (12.1) –  Afghanistan/Iran/Iraq 13 (12.5) 0 (0.0) –  Middle and South America 4 (3.8) 8 (13.8) – Length of stay in the Netherlands (y)  Mean (range) 10.3 (<1–30) 11.7 (5–35) – 0.474  Unknown 58 (55.8) 39 (67.2) Duration of registration in general practice, (y)  Mean (range) 6.5 (<1–34) 8.5 (<1–24) 10.6 <0.001  Median 4.0 6.0 8.0  Unknown 0 (0) 0 (0) 5 (3.1) Relational status, n(%) <0.001  No steady partner 12 (11.5) 8 (13.8) 30 (18.5)  Steady partner/married 50 (48.0) 36 (62.1) 94 (58.0)  Unknown 42 (40.4) 14 (24.1) 38 (23.5) Educational level, n(%) <0.001  Higher education 26 (25.0) 13 (22.4) 72 (44.4)  Secondary education 2 (1.9) 4 (6.9) 29 (17.9)  Primary education 2 (1.9) 0 (0.0) 0 (0.0)  Unknown 74 (71.2) 41 (70.7) 61 (37.7) Gravidity, n(%) <0.001  G0 23 (22.1) 15 (25.9) 70 (43.2)  G1≥ 52 (50.0) 33 (56.9) 85 (52.5)  Unknown 29 (27.9) 10 (17.2) 7 (4.3) Teenage pregnancy in history, n(%)  Registered 0 (0.0) 0 (0.0) 0 (0.0)  Unknown 56 (53.8) 15 (25.9) 10 (6.2) Unwanted pregnancy in history, n(%) <0.001  Registered 14 (13.5) 5 (8.6) 6 (3.7)  Unknown 47 (45.2) 13 (22.4) 9 (5.6) Induced abortion in history, n(%) <0.001  Registered 14 (11.5) 4 (6.9) 6 (3.7)  Unknown 46 (44.2) 12 (20.7) 9 (5.6) Characteristic Migrant status Refugees Other migrants Native Dutch women Sig.a Age (y), n(%) 0.502  15–19 4 (3.8) 1 (1.7) 5 (3.1)  20–24 6 (5.8) 4 (6.9) 10 (6.2)  25–29 22 (21.2) 7 (12.1) 28 (17.3)  30–34 19 (18.3) 5 (8.6) 29 (17.9)  35–39 21 (20.2) 15 (25.9) 36 (22.2)  40–44 23 (22.1) 13 (22.4) 35 (21.6)  45–49 9 (22.4) 13 (22.4) 19 (11.7) Region of origin, n(%) <0.001  Eastern Europe/Former USSR/Yugoslavia 17 (16.3) 11 (19.0) –  Sub-Saharan Africa 45 (43.3) 6 (10.3) –  Turkey/Middle East/Northern Africa 14 (13.5) 26 (44.8) –  Asia 11 (10.6) 7 (12.1) –  Afghanistan/Iran/Iraq 13 (12.5) 0 (0.0) –  Middle and South America 4 (3.8) 8 (13.8) – Length of stay in the Netherlands (y)  Mean (range) 10.3 (<1–30) 11.7 (5–35) – 0.474  Unknown 58 (55.8) 39 (67.2) Duration of registration in general practice, (y)  Mean (range) 6.5 (<1–34) 8.5 (<1–24) 10.6 <0.001  Median 4.0 6.0 8.0  Unknown 0 (0) 0 (0) 5 (3.1) Relational status, n(%) <0.001  No steady partner 12 (11.5) 8 (13.8) 30 (18.5)  Steady partner/married 50 (48.0) 36 (62.1) 94 (58.0)  Unknown 42 (40.4) 14 (24.1) 38 (23.5) Educational level, n(%) <0.001  Higher education 26 (25.0) 13 (22.4) 72 (44.4)  Secondary education 2 (1.9) 4 (6.9) 29 (17.9)  Primary education 2 (1.9) 0 (0.0) 0 (0.0)  Unknown 74 (71.2) 41 (70.7) 61 (37.7) Gravidity, n(%) <0.001  G0 23 (22.1) 15 (25.9) 70 (43.2)  G1≥ 52 (50.0) 33 (56.9) 85 (52.5)  Unknown 29 (27.9) 10 (17.2) 7 (4.3) Teenage pregnancy in history, n(%)  Registered 0 (0.0) 0 (0.0) 0 (0.0)  Unknown 56 (53.8) 15 (25.9) 10 (6.2) Unwanted pregnancy in history, n(%) <0.001  Registered 14 (13.5) 5 (8.6) 6 (3.7)  Unknown 47 (45.2) 13 (22.4) 9 (5.6) Induced abortion in history, n(%) <0.001  Registered 14 (11.5) 4 (6.9) 6 (3.7)  Unknown 46 (44.2) 12 (20.7) 9 (5.6) a Significance calculated with chi-square test. View Large Contraception discussed and prescribed Contraception was discussed significantly less often with refugees and other migrants than with native Dutch women: respectively, 51.0% and 65.5% versus 84.0% (Table 2). Although not significant, data suggest a similar trend of contraception being discussed less often with refugees than with other migrants (P = 0.075, OR 0.547, 95% CI 0.282–1.063). If we look exclusively at women who consulted the GP with a problem that could be related to reproductive health (abdominal or genital problems, ICPC-code W, D or X), a substantial difference was still found: in this group, contraception was discussed with 63.4% of the refugees and 76.0% of the other migrants versus 86.9% of the native Dutch women (P < 0.001). Table 2. The discussion of contraceptives among refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Contraception discussed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 53 (51.0) 38 (65.5) 136 (84.0) No 51 (49.0) 20 (34.5) 26 (16.0) OR 0.199 0.363 (ref.) 95% CI 0.112–0.351 0.183–0.721 – Sig.a <0.001 0.004 – Contraception discussed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 53 (51.0) 38 (65.5) 136 (84.0) No 51 (49.0) 20 (34.5) 26 (16.0) OR 0.199 0.363 (ref.) 95% CI 0.112–0.351 0.183–0.721 – Sig.a <0.001 0.004 – a Significance calculated with chi-square test and binary logistic regression analysis. View Large Table 2. The discussion of contraceptives among refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Contraception discussed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 53 (51.0) 38 (65.5) 136 (84.0) No 51 (49.0) 20 (34.5) 26 (16.0) OR 0.199 0.363 (ref.) 95% CI 0.112–0.351 0.183–0.721 – Sig.a <0.001 0.004 – Contraception discussed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 53 (51.0) 38 (65.5) 136 (84.0) No 51 (49.0) 20 (34.5) 26 (16.0) OR 0.199 0.363 (ref.) 95% CI 0.112–0.351 0.183–0.721 – Sig.a <0.001 0.004 – a Significance calculated with chi-square test and binary logistic regression analysis. View Large Regarding the refugee group, other significant differences were found related to the women’s region of origin. The proportion of refugees with whom contraception was discussed ranged from 28.9% (Sub-Saharan Africa) to 90.9% (Asia). We compared the proportion of women with whom contraception was discussed between women with a Sub-Saharan African background and women with other backgrounds. In consultations with refugee women from Sub-Saharan Africa, contraception was significantly less often discussed (28.9%) compared with refugee women who come from other regions (67.8%; P < 0.001). When looking at refugees with an unwanted pregnancy or induced abortion in history, contraception was discussed with the majority of them, but contraception was only prescribed in a minority. Contraceptives were prescribed significantly less often to refugees and other migrants than to native Dutch women (33.7% and 55.2% versus 79.0%; Table 3). The difference between refugees and other migrants was also significant (P = 0.008, OR 0.412, 95% CI 0.213–0.796). In women with whom contraceptives were discussed, the prevalence of prescribing contraceptives was higher in each group but still the lowest among refugees (64.2%) compared with other migrants (84.2%) and native Dutch women (89.7%). The difference between refugees and native Dutch women was significant (P < 0.001, OR 0.135, 95% CI 0.077–0.235). Table 3. The prescription of contraceptives among refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Contraception prescribed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 35 (33.7) 32 (55.2) 128 (79.0) No 69 (66.3) 26 (44.8) 34 (21.0) OR 0.135 0.327 (ref.) 95% CI 0.077–0.235 0.172–0.621 – Sig.a <0.001 0.001 – Contraception prescribed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 35 (33.7) 32 (55.2) 128 (79.0) No 69 (66.3) 26 (44.8) 34 (21.0) OR 0.135 0.327 (ref.) 95% CI 0.077–0.235 0.172–0.621 – Sig.a <0.001 0.001 – a Significance calculated with chi-square test and binary logistic regression analysis. View Large Table 3. The prescription of contraceptives among refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Contraception prescribed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 35 (33.7) 32 (55.2) 128 (79.0) No 69 (66.3) 26 (44.8) 34 (21.0) OR 0.135 0.327 (ref.) 95% CI 0.077–0.235 0.172–0.621 – Sig.a <0.001 0.001 – Contraception prescribed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 35 (33.7) 32 (55.2) 128 (79.0) No 69 (66.3) 26 (44.8) 34 (21.0) OR 0.135 0.327 (ref.) 95% CI 0.077–0.235 0.172–0.621 – Sig.a <0.001 0.001 – a Significance calculated with chi-square test and binary logistic regression analysis. View Large Types of contraception Several differences were found with regard to types of contraceptives prescribed by the GPs. Among the refugee group, the oral contraceptive pill was the most commonly prescribed form of contraception (62.9%), followed by intrauterine devices (20.0%) and implants (11.4%). When looking at other migrants, oral contraceptives were also most frequently prescribed (71.9%), followed by injections (12.5%) and intrauterine devices (12.5%). Among the group of native Dutch women, oral contraceptives were prescribed most often (66.4%), followed by intrauterine devices (25.0%) and the vaginal ring (3.9%). Differences between general practices The prevalence of both discussed and prescribed contraception was significantly higher at GP2 and GP5 compared with GP1, GP3 and GP4 and the overall prevalence mentioned above (Table 4). Especially, in case of discussing contraceptives, the difference between refugees and native Dutch women was much smaller in these practices. Table 4. Differences between GPs in the discussion and prescription of contraceptives among refugees, migrants and native Dutch women, 2010–March 2016 (n = 324) GP Migrant status Refugees Other migrants Native Dutch women Contraception n(%) Contraception n(%) Contraception n(%) discussed prescribed discussed prescribed discussed Prescribed GP1 8 (34.8) 4 (17.4) 4 (57.1) 3 (42.9) 22 (73.3) 23 (76.7) GP2 8 (80.0) 6 (60.0) 17 (73.9) 14 (60.9) 28 (84.8) 28 (87.9) GP3 9 (24.3) 6 (15.8) 1 (11.1) 0 (0.0) 38 (82.6) 33 (71.7) GP4 2 (66.7) 1 (33.3) – – 2 (66.7) 2 (66.7) GP5 27 (87.1) 18 (60.0) 15 (78.9) 15 (75.0) 46 (92.0) 41 (82.0) Sig.a <0.001 <0.001 0.003 0.003 0.226 0.452 GP Migrant status Refugees Other migrants Native Dutch women Contraception n(%) Contraception n(%) Contraception n(%) discussed prescribed discussed prescribed discussed Prescribed GP1 8 (34.8) 4 (17.4) 4 (57.1) 3 (42.9) 22 (73.3) 23 (76.7) GP2 8 (80.0) 6 (60.0) 17 (73.9) 14 (60.9) 28 (84.8) 28 (87.9) GP3 9 (24.3) 6 (15.8) 1 (11.1) 0 (0.0) 38 (82.6) 33 (71.7) GP4 2 (66.7) 1 (33.3) – – 2 (66.7) 2 (66.7) GP5 27 (87.1) 18 (60.0) 15 (78.9) 15 (75.0) 46 (92.0) 41 (82.0) Sig.a <0.001 <0.001 0.003 0.003 0.226 0.452 a Significance calculated with chi-square test. View Large Table 4. Differences between GPs in the discussion and prescription of contraceptives among refugees, migrants and native Dutch women, 2010–March 2016 (n = 324) GP Migrant status Refugees Other migrants Native Dutch women Contraception n(%) Contraception n(%) Contraception n(%) discussed prescribed discussed prescribed discussed Prescribed GP1 8 (34.8) 4 (17.4) 4 (57.1) 3 (42.9) 22 (73.3) 23 (76.7) GP2 8 (80.0) 6 (60.0) 17 (73.9) 14 (60.9) 28 (84.8) 28 (87.9) GP3 9 (24.3) 6 (15.8) 1 (11.1) 0 (0.0) 38 (82.6) 33 (71.7) GP4 2 (66.7) 1 (33.3) – – 2 (66.7) 2 (66.7) GP5 27 (87.1) 18 (60.0) 15 (78.9) 15 (75.0) 46 (92.0) 41 (82.0) Sig.a <0.001 <0.001 0.003 0.003 0.226 0.452 GP Migrant status Refugees Other migrants Native Dutch women Contraception n(%) Contraception n(%) Contraception n(%) discussed prescribed discussed prescribed discussed Prescribed GP1 8 (34.8) 4 (17.4) 4 (57.1) 3 (42.9) 22 (73.3) 23 (76.7) GP2 8 (80.0) 6 (60.0) 17 (73.9) 14 (60.9) 28 (84.8) 28 (87.9) GP3 9 (24.3) 6 (15.8) 1 (11.1) 0 (0.0) 38 (82.6) 33 (71.7) GP4 2 (66.7) 1 (33.3) – – 2 (66.7) 2 (66.7) GP5 27 (87.1) 18 (60.0) 15 (78.9) 15 (75.0) 46 (92.0) 41 (82.0) Sig.a <0.001 <0.001 0.003 0.003 0.226 0.452 a Significance calculated with chi-square test. View Large Discussion Summary of main findings GPs in our study significantly less often discussed contraceptives with refugees (51%) than with other migrants (65.5%) and Dutch patients (84%). Contraceptives were prescribed to 33.7% of the refugees compared with 55.2% among other female migrants and 79.0% among native Dutch women. In consultations with refugee women from Sub-Saharan Africa, contraception was significantly less often discussed (28.9%) compared with refugee women who come from other regions (67.8%; P < 0.001). More unwanted pregnancies and induced abortions were recorded in refugees and other migrants than in native Dutch women. Comparison with existing literature These findings are in line with those of previous studies that concluded reproductive health needs might be ill addressed in healthcare and could lead to more unwanted pregnancies (8,9,16). Contraceptive health needs of refugees could differ from other migrant women (for example, because their ethnic background is different) and from those of native Dutch women. However, there are several other explanations possible why contraceptives were less often discussed and prescribed among migrants, despite existing needs, resulting in inequities in care. First, SRH issues like the need for contraception are probably mentioned less frequently by refugees themselves. Sociocultural and religious beliefs, like different expectations about the doctor–patient relationship or opinions about virginity, may lead to a less active role for the patient in starting the discussion of contraception. In addition, women may not raise the issue because of concerns about stigma, taboo on sexuality and traditional health beliefs. Another important factor might be the lack of knowledge about SRH including contraception due to low health literacy (9,17,20). Besides, other studies revealed that solving social issues such as finding a home or finances often are prioritized by refugees over their SRH needs (14,21). Communication barriers are known to hamper access to healthcare in refugees and other migrants (22). It is crucial to involve interpreters with refugees and other migrants with low proficiency of the language of the GP (23,24). Therefore, GPs must be aware that informal interpreters might hinder the discussion of personal or sensitive issues like sexual health. Unfortunately, the use of professional interpreters is not commonly mentioned in patient records, so we do not have any insight into the extent to which the participating GPs made use of interpreter services. On the other hand, GPs can also experience certain barriers to discuss contraception caused by for instance prejudices and cultural stereotyping. To achieve mutual understanding between migrants and GPs, a person-centred culturally sensitive approach of the GP is needed (22,25). Differences in cultural competences, awareness and skills to discuss reproductive health could possibly explain the differences between the GPs participating in this study. Gender differences could also play a role. This could indicate room for improvement in GP care by training in cultural competences and reproductive healthcare. Limitations of the study Several limitations should be considered inherent to the retrospective nature of this study that relied on the information registered in the patient records. First, patient records of the GPs did not always mention whether a woman was a refugee or not. The method we used (defining someone as refugee depending on the country of origin), although done very carefully, cannot guarantee that every woman is placed in the right group. Besides, we know that women more often than men have their application for asylum rejected as their reasons for flight are thought to be personal and not political (19). Second, there was a lack of information about several patient characteristics and potential confounding variables that will influence the doctor–patient communication such as language used in the consultation, involvement of an interpreter and length of consultation. We excluded women whose patient record revealed they were pregnant or trying to receive, but it is possible that this information was not always known to the GP or recorded. Furthermore, the mean duration of registration in the general practice differs between refugees, migrants and native Dutch women. This might induce biases in the data if we assume that it is more likely that contraception is being discussed and prescribed if the period of observation is longer. Unfortunately, this study has no additional data about the number of consultations and when discussion of contraceptives took place during the observation period. Together with the relatively small sample size of our study groups, conclusions should be interpreted with caution. As this study was done in five general practices experienced in caring for migrants, our results might not be representative for refugees and other migrants in the average Dutch general practice. However, the fact that we found large differences in these practices makes it very likely that these differences will be even bigger in other practices. A prospective follow-up study could provide insight into this. Implications for practice and for future research Today and in the near future, the number of refugees and other migrants settling in high-income countries such as the Netherlands will increase, and culturally competent GP care is mandatory as every woman, regardless of her background or origin, has the right to adequate SRH care. Although the results of this small-scale retrospective study should be interpreted with caution, our results seem to indicate there exist differences in GP contraceptive care between refugees, other migrants and native Dutch women that could be worrisome. Our findings suggest a need for further research to identify and address any inequity in reproductive healthcare. A prospective study among a representative sample of women with clear description of their immigration status could produce this information. Qualitative research could provide insight into the experiences of GPs in discussing contraception with migrant women and into the needs and preferences regarding GP care for reproductive health issues of refugees themselves. Conclusion This study has shown that contraceptives were discussed and prescribed significantly less often among migrant women compared with native Dutch women. An even bigger disparity was seen between refugees and native Dutch women. More research is needed to elicit the reproductive health needs of migrant women and their preferences regarding GP care and on the experiences of GPs in discussing these issues. Such insights are vital in order to provide equitable reproductive healthcare to every woman regardless of her background. Declaration Funding: This study was done as part of a research internship at the Department of Primary and Community care at the Radboudumc. Ethical approval: Agreement of all GPs was received after information was given about the study to have insight in the patient records. The information collected from patient records was anonymized and stored safely. Agreement of all the patients was considered implicit due to the fact that getting explicit agreement was very difficult, if not impossible. According to the Dutch law and regulations, this project was exempted from the need for approval through the Ethical committee of the Radboudumc because this study involved anonymized patient records. Conflict of interest: There are no conflicts of interest in connection with the paper. Acknowledgements We wish to thank all GPs who participated in our research: D van Wijngaarden, H de Weerd, R Spanninga, M Slockers and M Dees. We also want to thank R Akkermans, Department of Primary and Community Care, Radboudumc, for his valued assistance in data analysis. References 1. UNHCR . Global Trends: Forced Displacement in 2015 . http://www.refworld.org/docid/57678f3d4.html ( accessed on 5 June 2017 ). 2. UNHCR . Convention and Protocol Relating to the Status of Refugees . December 2010 . http://www.unhcr.org/3b66c2aa10.html ( accessed on 6 February 2015 ). 3. VluchtelingenWerk Nederland . Vluchtelingen in Getallen 2016 . https://www.vluchtelingenwerk.nl/actueel/nieuws/publicatie-vluchtelingen-getallen-2016. 4. Immigratie- en Naturalisatiedienst . Ministerie van Veiligheid en Justitie. De IND in 2015–Jaarverslag . https://ind.nl/Documents/Jaarresultaten_2015.pdf. 5. CBS Statline (statistics Netherlands) . The Hague 2017 . http://statline.cbs.nl ( accessed on 1 September 2017 ). 6. Hynes M , Sheik M , Wilson HG , et al. . Reproductive health indicators and outcomes among refugee and internally displaced persons in postemergency phase camps . JAMA 2002 ; 288 : 595 – 603 . Google Scholar CrossRef Search ADS PubMed 7. Samari G . Syrian Refugee Women’s Health in Lebanon, Turkey, and Jordan and Recommendations for Improved Practice . World Medical & Health Policy . 2017 ; 9 : 255 – 274 . Google Scholar CrossRef Search ADS 8. Goosen S , Uitenbroek D , Wijsen C , et al. . Induced abortions and teenage births among asylum seekers in The Netherlands: analysis of national surveillance data . J Epidemiol Community Health 2009 ; 63 : 528 – 33 . Google Scholar CrossRef Search ADS PubMed 9. Schoevers MA , van den Muijsenbergh ME , Lagro-Janssen AL . Illegal female immigrants in The Netherlands have unmet needs in sexual and reproductive health . J Psychosom Obstet Gynaecol 2010 ; 31 : 256 – 64 . Google Scholar CrossRef Search ADS PubMed 10. World Health Organization . Sexual and Reproductive Health WHO 2010 . http://www.who.int/topics/reproductive_health/en/. 11. Keygnaert I , Guieu A . What the eye does not see: a critical interpretive synthesis of European Union policies addressing sexual violence in vulnerable migrants . Reprod Health Matters 2015 ; 23 : 45 – 55 . Google Scholar CrossRef Search ADS PubMed 12. Janssens K , Bosmans M , Temmerman M. Sexual and Reproductive Health and Rights of Refugee Women in Europe: Rights, Policies, Status and Needs . Ghent : International Centre for Reproductive Health (ICRH) , 2005 . 13. Wångdahl J , Lytsy P , Mårtensson L , et al. . Health literacy among refugees in Sweden–a cross-sectional study . BMC Public Health 2014 ; 14 : 1030 . Google Scholar CrossRef Search ADS PubMed 14. Aptekman M , Rashid M , Wright V , et al. . Unmet contraceptive needs among refugees . Can Fam Physician 2014 ; 60 : e613 – 9 . Google Scholar PubMed 15. Kurth E , Jaeger FN , Zemp E , et al. . Reproductive health care for asylum-seeking women–a challenge for health professionals . BMC Public Health 2010 ; 10 : 659 . Google Scholar CrossRef Search ADS PubMed 16. Keygnaert I , Vettenburg N , Roelens K , et al. . Sexual health is dead in my body: participatory assessment of sexual health determinants by refugees, asylum seekers and undocumented migrants in Belgium and The Netherlands . BMC Public Health 2014 ; 14 : 416 . Google Scholar CrossRef Search ADS PubMed 17. Rogers C , Earnest J . A cross-generational study of contraception and reproductive health among Sudanese and Eritrean women in Brisbane, Australia . Health Care Women Int 2014 ; 35 : 334 – 56 . Google Scholar CrossRef Search ADS PubMed 18. Razum O , Zeeb H , Akgün S . How useful is a name-based algorithm in health research among Turkish migrants in Germany ? Trop Med Int Health 2001 ; 6 : 654 – 61 . Google Scholar CrossRef Search ADS PubMed 19. Asylum Aid . Unsustainable: The Quality of Initial Decision-making in Women’s Asylum Claims . January 2011 . http://www.asylumaid.org.uk/wp-content/uploads/2013/02/unsustainableweb.pdf. 20. Okanlawon K , Reeves M , Agbaje OF . Contraceptive use: knowledge, perceptions and attitudes of refugee youths in oru refugee camp, Nigeria . Afr J Reprod Health 2010 ; 14 : 16 – 25 . Google Scholar PubMed 21. Benson DJ , Maldari DT , Williams MJ , et al. . The impact of culture and ethnicity on women’s perceived role in society and their attendant health beliefs . InnovAiT . 2010 ; 3 : 358 – 365 . Google Scholar CrossRef Search ADS 22. van den Muijsenbergh M , van Weel-Baumgarten E , Burns N , et al. . Communication in cross-cultural consultations in primary care in Europe: the case for improvement. The rationale for the RESTORE FP 7 project . Prim Health Care Res Dev 2014 ; 15 : 122 – 33 . Google Scholar CrossRef Search ADS PubMed 23. De Maesschalck S. Linguistic and Cultural Diversity in the Consultation Room. A Tango Between Physicians and Their Ethnic Minority Patients . Ghent, Belgium : Ghent University. Faculty of Medicine and Health Sciences ; 2012 . 24. Bischoff A . Do language barriers increase inequalities? Do interpreters decrease inequalities? Cost series on health and diversity . In: Ingleby D , Chiarenza A , Deville W , Kotsioni I (eds). Inequalities in Health Care for Migrants and Ethnic Minorities . Vol. 2 Antwerpen : Garant Publishers , 2012 , pp. 128 – 43 . 25. van den Muijsenbergh ME , Oosterberg EH . [Patient-centred and culturally competent: good health care for immigrant patients requires specific competencies] . Ned Tijdschr Geneeskd 2013 ; 157 : A5612 . Google Scholar PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

Inequity in contraceptive care between refugees and other migrant women?: a retrospective study in Dutch general practice

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Abstract

Abstract Background Female refugees are at high risk of reproductive health problems including unmet contraceptive needs. In the Netherlands, the general practitioner (GP) is the main entrance to the healthcare system and plays a vital role in the prescription of contraceptives. Little is known about contraceptive care in female refugees in primary care. Objective To get insight into GP care related to contraception in refugees and other migrants compared with native Dutch women. Methods A retrospective descriptive study of patient records of refugees, other migrants and native Dutch women was carried out in five general practices in the Netherlands. The prevalence of discussions about contraception and prescriptions of contraceptives over the past 6 years was compared in women of reproductive age (15–49 years). Results In total, 104 refugees, 58 other migrants and 162 native Dutch women were included. GPs in our study (2 male, 3 female) discussed contraceptives significantly less often with refugees (51%) and other migrants (66%) than with native Dutch women (84%; P < 0.001 and P = 0.004, respectively). Contraceptives were less often prescribed to refugees (34%) and other migrants (55%) than to native Dutch women (79%; P < 0.001 and P = 0.001). Among refugees from Sub-Saharan Africa, contraception was significantly less often discussed (28.9%) compared with refugees from other regions (67.8%; P < 0.001). More refugees and other migrants had experienced unwanted pregnancies (14% respectively 9%) and induced abortions (12% respectively 7%) than native Dutch women (4% respectively 4%). Conclusion Contraceptives were significantly less often discussed with and prescribed to refugees and other migrant women compared with native Dutch women. More research is needed to elicit the reproductive health needs and preferences of migrant women regarding GP’s care and experiences in discussing these issues. Such insights are vital in order to provide equitable reproductive healthcare to every woman regardless of her background. Contraception, contraceptive needs, general practitioner’s care, immigrant, migrant, primary care, refugee, sexual and reproductive health Introduction Today a growing number of refugees are settling in high-income countries such as the Netherlands, and migrants constitute an essential part of the European population (1). Migrants are all persons born outside the Netherlands with at least one parent who is also born outside the Netherlands. Refugees are a specific type of migrants who came involuntarily to the Netherlands because of conflict or fear for persecution in the country of origin. They are protected by international law and should not be expelled or returned to situations where their life and freedom would be under threat (2). According to the United Nations High Commissioner for Refugees (UNHCR), at the end of 2015, the number of refugees in The Netherlands were estimated to be 88 536 (0.5% of the total population). Another 28 051 people were waiting for a decision on their asylum claims (3). Most refugees in the Netherlands are of Iraqi, Afghan and Somali origin, but the vast majority of the asylum requests in 2015 were from Syrian and Eritrean refugees (3,4). The three largest first-generation ethnic minority groups in the Netherlands are the Turkish, Surinamese and Moroccan (respectively, 1.12%, 1.05% and 0.99% of the total population in 2016) (5). Several studies have documented that sexual and reproductive health (SRH) is at risk in refugees and (undocumented) female migrants (6–9). According to the World Health Organization (WHO), definition reproductive health implies that people are able to have a responsible, satisfying and safe sex life and the freedom to decide if, when and how often to reproduce (10). Since their arrival in Europe, 69.3% of the female migrants have been subjected to sexual violence compared with 30.6% of the European population (11). In a study from 2009 among all asylum seekers in the Netherlands, the overall abortion rate for asylum seekers is about one and a half times higher and the teenage birth rate more than eight times higher than average for the Netherlands. Especially, recently arrived women are at increased risk (8). SRH may be influenced by various factors such as cultural and religious norms from the country of origin and experiences during the flight. Women often originate from countries where they have a disadvantaged position in society, which makes them vulnerable, particularly in their SRH (12). Moreover, women might be confronted by war and armed conflict and come from areas with a poorly functioning healthcare system. Besides factors related to a women’s background of forced migration, SRH may also be influenced by the situation in the host country for instance by uncertainty of the asylum procedure, frequent transfers, absence of social structure and language barriers (8). In addition, many refugees and other migrants have little knowledge about risk factors for unwanted pregnancies and about contraception due to limited health literacy (13). Moreover, young migrant adults often receive too little education on sexual health, and unmet contraceptive needs are common (9,14–17). In the Netherlands, the general practitioner (GP) is the main entrance to the healthcare system and an important provider of information on and prescription of contraceptives. GPs could play an important role in informing refugee women and also help reduce the number of unwanted pregnancies among them. However, it is unknown if and to what extent they discuss reproductive health needs with refugee women or prescribe contraceptives. Better insight into these aspects can provide key information to improve the quality of healthcare and well-being of female refugees with regard to their SRH needs. Although their background and reasons to immigrate differ from refugees, SRH issues are also documented among other migrant women. Therefore, this study aimed to include not only refugee women but also other migrant women. Our research question is as follows: to what extent do GPs in the Netherlands discuss and prescribe contraceptives to female refugees compared with other female migrants and native Dutch women of the same age? Method Study design For this descriptive quantitative study, we examined anonymized electronic patient records of different general practices in the Netherlands. Recruitment We contacted GPs in different parts of the Netherlands and provided them with information about the research project. GPs with at least 10 female refugees on their practice list were included until the desired total number of 100 patient records of female refugees was reached. Both the recruitment and inclusion of study participants and the data collection took place in August and early September 2016. Study population In this study, people were categorized in three groups: refugees, other (first-generation) migrants and native Dutch women. Probable refugees were identified by first creating a list of female patients of reproductive age (15 to 49 years) with a foreign surname. This list was made through the use of the electronic medical system and was done in each general practice. Identifying migrants by means of their surname has proved to be a reliable method (18). Patients were included if they had consulted the GP at least twice between January 2010 and March 2016 (representing a minimum of contacts enabling the discussion of contraceptives) and if the patient was born outside of the European Union. As not all female refugees are acknowledged as such and granted asylum, we used country of origin as proxy for the likelihood the woman concerned was a refugee and not a different type of migrant (19). Patients were excluded if their country of origin was unknown, if they moved away during the time window or if their patient record revealed they did not have need for contraception: those with infertility (including sterilization and hysterectomy), those who had female partners, were postmenopausal, pregnant or were trying to conceive. Every electronic record was searched for information about the reason of migration to the Netherlands, i.e. if somebody was a refugee or not. If reason for migration was not documented, the country of origin was checked against a list of countries that were prone to produce refugees in the time of migration of that person. We used UNHCR databases and reports, country profiles and the Dutch list of safe countries to determine if the country of origin was known for war, conflicts or persecution of its inhabitants and—as a result—of having refugees, using the UNHCR definition of a refugee. This was checked for the moment of arrival in the Netherlands or, if this was unknown, for the moment of registration in the general practice. Eventually, this resulted in the decision to list women as ‘other migrant’ (not refugee) if coming from Brazil, Bulgaria, China, Ecuador, Egypt, Ghana, India, Indonesia, Kenya, Mongolia, Morocco, Peru, Philippines, Russia, Serbia, South Africa, Suriname, Tanzania, Tunisia and Turkey. Native Dutch women were identified by creating a list of female patients aged 15 to 49 years without a foreign surname. We used similar inclusion and exclusion criteria, but, in this case, the Netherlands had to be their country of origin. Because there were more native Dutch women than refugees and migrants in each practice, we selected them randomly using systematic sampling. We matched native Dutch women with the previously included female refugees and migrants by age, collecting the same amount of women for each age group. If a refugee or migrant was younger than 17 years, we used their exact age for matching with a non-refugee. Data collection We extracted data from anonymized electronic medical records on several patient characteristics such as length of stay in the Netherlands, relational status, educational level, gravidity, unwanted pregnancies, induced abortion and when and what kind of contraceptive method was discussed or prescribed (condom, oral contraceptive, injection, intrauterine device, implant, vaginal ring, sterilization or other). Date of first registration in the general practice was also recorded in order to measure the length of registration in the practice. This was defined as the time from registration in the practice to the census date. Through this method, we were able to explore differences between women in this period of observation. Women were characterized with an unwanted pregnancy or induced abortion if this had occurred at some moment during their life. We chose to divide relational status into ‘no steady partner’ and ‘steady partner’ because these definitions were most often used in the medical record. In order to not miss discussions about contraceptives that were not coded with the specific ICPC (International Classification of Primary Care) code, we also looked into consultations where one of the following codes were used: D (gastrointestinal tract), W (pregnancy/delivery/contraceptives) or X (female genitals/breasts). Data analysis Data were processed and analysed using SPSS Statistics (version 23). Two-tailed Pearson chi-squared test was used to compare the patient characteristics of the three study groups. The variable ‘length of stay in the Netherlands’ was compared using an independent samples t-test. One-way ANOVA was used for the variables age and the amount of years registered in general practice. To compare refugees, other migrants and native Dutch women, a chi-square test and binary logistic regression analysis was used. Chi-square test was also used to determine possible significant differences between general practices. Results Five general practices participated in our study, located in Nijmegen, Amsterdam and Rotterdam. Two practices (GP3, GP5) were solo practices, and the other three were group practices (GP1, GP2, GP4). The GPs of GP3 and GP4 were male and those of GP1, GP2 and GP5 were female. One practice (GP3) exclusively delivered care to undocumented migrants and refugees; we matched them with native Dutch women from a practice (GP4) that was located in the same city representing an average population distribution. A total of 104 female refugees were included: 54 in a semi-rural area (Nijmegen) and 50 in a large city (Amsterdam, Rotterdam). Fifty-eight other migrant women were included, bringing the total of female refugees and other migrants up to 162. We matched them with 162 native Dutch women of the same age group. Demographic characteristics are summarized in Table 1. Among the women, there were seven teenagers. Two girls became 15 close before March 2016. Because we extracted data about all contacts between 2010 and March 2016, data from the period before their 15th birthday was also included. The women originated from 52 different countries. Of the refugees, the three main countries of origin were Somalia (11.5%), Iraq (8.7%) and Nigeria (8.7%). Of the other migrants, the three main countries of origin were Morocco (22.4%), Turkey (21.1%) and Bulgaria (6.9%). There were no teenage pregnancies found among any of the women. According to the registration, more refugees and other migrants had experienced unwanted pregnancies compared with native Dutch women (13.5% and 8.6% versus 3.7%, P < 0.001). Induced abortions were also more often listed among refugees and other migrants compared with native Dutch women (11.5% and 6.9% versus 3.7%, P < 0.001). Table 1. Demographics of female refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Characteristic Migrant status Refugees Other migrants Native Dutch women Sig.a Age (y), n(%) 0.502  15–19 4 (3.8) 1 (1.7) 5 (3.1)  20–24 6 (5.8) 4 (6.9) 10 (6.2)  25–29 22 (21.2) 7 (12.1) 28 (17.3)  30–34 19 (18.3) 5 (8.6) 29 (17.9)  35–39 21 (20.2) 15 (25.9) 36 (22.2)  40–44 23 (22.1) 13 (22.4) 35 (21.6)  45–49 9 (22.4) 13 (22.4) 19 (11.7) Region of origin, n(%) <0.001  Eastern Europe/Former USSR/Yugoslavia 17 (16.3) 11 (19.0) –  Sub-Saharan Africa 45 (43.3) 6 (10.3) –  Turkey/Middle East/Northern Africa 14 (13.5) 26 (44.8) –  Asia 11 (10.6) 7 (12.1) –  Afghanistan/Iran/Iraq 13 (12.5) 0 (0.0) –  Middle and South America 4 (3.8) 8 (13.8) – Length of stay in the Netherlands (y)  Mean (range) 10.3 (<1–30) 11.7 (5–35) – 0.474  Unknown 58 (55.8) 39 (67.2) Duration of registration in general practice, (y)  Mean (range) 6.5 (<1–34) 8.5 (<1–24) 10.6 <0.001  Median 4.0 6.0 8.0  Unknown 0 (0) 0 (0) 5 (3.1) Relational status, n(%) <0.001  No steady partner 12 (11.5) 8 (13.8) 30 (18.5)  Steady partner/married 50 (48.0) 36 (62.1) 94 (58.0)  Unknown 42 (40.4) 14 (24.1) 38 (23.5) Educational level, n(%) <0.001  Higher education 26 (25.0) 13 (22.4) 72 (44.4)  Secondary education 2 (1.9) 4 (6.9) 29 (17.9)  Primary education 2 (1.9) 0 (0.0) 0 (0.0)  Unknown 74 (71.2) 41 (70.7) 61 (37.7) Gravidity, n(%) <0.001  G0 23 (22.1) 15 (25.9) 70 (43.2)  G1≥ 52 (50.0) 33 (56.9) 85 (52.5)  Unknown 29 (27.9) 10 (17.2) 7 (4.3) Teenage pregnancy in history, n(%)  Registered 0 (0.0) 0 (0.0) 0 (0.0)  Unknown 56 (53.8) 15 (25.9) 10 (6.2) Unwanted pregnancy in history, n(%) <0.001  Registered 14 (13.5) 5 (8.6) 6 (3.7)  Unknown 47 (45.2) 13 (22.4) 9 (5.6) Induced abortion in history, n(%) <0.001  Registered 14 (11.5) 4 (6.9) 6 (3.7)  Unknown 46 (44.2) 12 (20.7) 9 (5.6) Characteristic Migrant status Refugees Other migrants Native Dutch women Sig.a Age (y), n(%) 0.502  15–19 4 (3.8) 1 (1.7) 5 (3.1)  20–24 6 (5.8) 4 (6.9) 10 (6.2)  25–29 22 (21.2) 7 (12.1) 28 (17.3)  30–34 19 (18.3) 5 (8.6) 29 (17.9)  35–39 21 (20.2) 15 (25.9) 36 (22.2)  40–44 23 (22.1) 13 (22.4) 35 (21.6)  45–49 9 (22.4) 13 (22.4) 19 (11.7) Region of origin, n(%) <0.001  Eastern Europe/Former USSR/Yugoslavia 17 (16.3) 11 (19.0) –  Sub-Saharan Africa 45 (43.3) 6 (10.3) –  Turkey/Middle East/Northern Africa 14 (13.5) 26 (44.8) –  Asia 11 (10.6) 7 (12.1) –  Afghanistan/Iran/Iraq 13 (12.5) 0 (0.0) –  Middle and South America 4 (3.8) 8 (13.8) – Length of stay in the Netherlands (y)  Mean (range) 10.3 (<1–30) 11.7 (5–35) – 0.474  Unknown 58 (55.8) 39 (67.2) Duration of registration in general practice, (y)  Mean (range) 6.5 (<1–34) 8.5 (<1–24) 10.6 <0.001  Median 4.0 6.0 8.0  Unknown 0 (0) 0 (0) 5 (3.1) Relational status, n(%) <0.001  No steady partner 12 (11.5) 8 (13.8) 30 (18.5)  Steady partner/married 50 (48.0) 36 (62.1) 94 (58.0)  Unknown 42 (40.4) 14 (24.1) 38 (23.5) Educational level, n(%) <0.001  Higher education 26 (25.0) 13 (22.4) 72 (44.4)  Secondary education 2 (1.9) 4 (6.9) 29 (17.9)  Primary education 2 (1.9) 0 (0.0) 0 (0.0)  Unknown 74 (71.2) 41 (70.7) 61 (37.7) Gravidity, n(%) <0.001  G0 23 (22.1) 15 (25.9) 70 (43.2)  G1≥ 52 (50.0) 33 (56.9) 85 (52.5)  Unknown 29 (27.9) 10 (17.2) 7 (4.3) Teenage pregnancy in history, n(%)  Registered 0 (0.0) 0 (0.0) 0 (0.0)  Unknown 56 (53.8) 15 (25.9) 10 (6.2) Unwanted pregnancy in history, n(%) <0.001  Registered 14 (13.5) 5 (8.6) 6 (3.7)  Unknown 47 (45.2) 13 (22.4) 9 (5.6) Induced abortion in history, n(%) <0.001  Registered 14 (11.5) 4 (6.9) 6 (3.7)  Unknown 46 (44.2) 12 (20.7) 9 (5.6) a Significance calculated with chi-square test. View Large Table 1. Demographics of female refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Characteristic Migrant status Refugees Other migrants Native Dutch women Sig.a Age (y), n(%) 0.502  15–19 4 (3.8) 1 (1.7) 5 (3.1)  20–24 6 (5.8) 4 (6.9) 10 (6.2)  25–29 22 (21.2) 7 (12.1) 28 (17.3)  30–34 19 (18.3) 5 (8.6) 29 (17.9)  35–39 21 (20.2) 15 (25.9) 36 (22.2)  40–44 23 (22.1) 13 (22.4) 35 (21.6)  45–49 9 (22.4) 13 (22.4) 19 (11.7) Region of origin, n(%) <0.001  Eastern Europe/Former USSR/Yugoslavia 17 (16.3) 11 (19.0) –  Sub-Saharan Africa 45 (43.3) 6 (10.3) –  Turkey/Middle East/Northern Africa 14 (13.5) 26 (44.8) –  Asia 11 (10.6) 7 (12.1) –  Afghanistan/Iran/Iraq 13 (12.5) 0 (0.0) –  Middle and South America 4 (3.8) 8 (13.8) – Length of stay in the Netherlands (y)  Mean (range) 10.3 (<1–30) 11.7 (5–35) – 0.474  Unknown 58 (55.8) 39 (67.2) Duration of registration in general practice, (y)  Mean (range) 6.5 (<1–34) 8.5 (<1–24) 10.6 <0.001  Median 4.0 6.0 8.0  Unknown 0 (0) 0 (0) 5 (3.1) Relational status, n(%) <0.001  No steady partner 12 (11.5) 8 (13.8) 30 (18.5)  Steady partner/married 50 (48.0) 36 (62.1) 94 (58.0)  Unknown 42 (40.4) 14 (24.1) 38 (23.5) Educational level, n(%) <0.001  Higher education 26 (25.0) 13 (22.4) 72 (44.4)  Secondary education 2 (1.9) 4 (6.9) 29 (17.9)  Primary education 2 (1.9) 0 (0.0) 0 (0.0)  Unknown 74 (71.2) 41 (70.7) 61 (37.7) Gravidity, n(%) <0.001  G0 23 (22.1) 15 (25.9) 70 (43.2)  G1≥ 52 (50.0) 33 (56.9) 85 (52.5)  Unknown 29 (27.9) 10 (17.2) 7 (4.3) Teenage pregnancy in history, n(%)  Registered 0 (0.0) 0 (0.0) 0 (0.0)  Unknown 56 (53.8) 15 (25.9) 10 (6.2) Unwanted pregnancy in history, n(%) <0.001  Registered 14 (13.5) 5 (8.6) 6 (3.7)  Unknown 47 (45.2) 13 (22.4) 9 (5.6) Induced abortion in history, n(%) <0.001  Registered 14 (11.5) 4 (6.9) 6 (3.7)  Unknown 46 (44.2) 12 (20.7) 9 (5.6) Characteristic Migrant status Refugees Other migrants Native Dutch women Sig.a Age (y), n(%) 0.502  15–19 4 (3.8) 1 (1.7) 5 (3.1)  20–24 6 (5.8) 4 (6.9) 10 (6.2)  25–29 22 (21.2) 7 (12.1) 28 (17.3)  30–34 19 (18.3) 5 (8.6) 29 (17.9)  35–39 21 (20.2) 15 (25.9) 36 (22.2)  40–44 23 (22.1) 13 (22.4) 35 (21.6)  45–49 9 (22.4) 13 (22.4) 19 (11.7) Region of origin, n(%) <0.001  Eastern Europe/Former USSR/Yugoslavia 17 (16.3) 11 (19.0) –  Sub-Saharan Africa 45 (43.3) 6 (10.3) –  Turkey/Middle East/Northern Africa 14 (13.5) 26 (44.8) –  Asia 11 (10.6) 7 (12.1) –  Afghanistan/Iran/Iraq 13 (12.5) 0 (0.0) –  Middle and South America 4 (3.8) 8 (13.8) – Length of stay in the Netherlands (y)  Mean (range) 10.3 (<1–30) 11.7 (5–35) – 0.474  Unknown 58 (55.8) 39 (67.2) Duration of registration in general practice, (y)  Mean (range) 6.5 (<1–34) 8.5 (<1–24) 10.6 <0.001  Median 4.0 6.0 8.0  Unknown 0 (0) 0 (0) 5 (3.1) Relational status, n(%) <0.001  No steady partner 12 (11.5) 8 (13.8) 30 (18.5)  Steady partner/married 50 (48.0) 36 (62.1) 94 (58.0)  Unknown 42 (40.4) 14 (24.1) 38 (23.5) Educational level, n(%) <0.001  Higher education 26 (25.0) 13 (22.4) 72 (44.4)  Secondary education 2 (1.9) 4 (6.9) 29 (17.9)  Primary education 2 (1.9) 0 (0.0) 0 (0.0)  Unknown 74 (71.2) 41 (70.7) 61 (37.7) Gravidity, n(%) <0.001  G0 23 (22.1) 15 (25.9) 70 (43.2)  G1≥ 52 (50.0) 33 (56.9) 85 (52.5)  Unknown 29 (27.9) 10 (17.2) 7 (4.3) Teenage pregnancy in history, n(%)  Registered 0 (0.0) 0 (0.0) 0 (0.0)  Unknown 56 (53.8) 15 (25.9) 10 (6.2) Unwanted pregnancy in history, n(%) <0.001  Registered 14 (13.5) 5 (8.6) 6 (3.7)  Unknown 47 (45.2) 13 (22.4) 9 (5.6) Induced abortion in history, n(%) <0.001  Registered 14 (11.5) 4 (6.9) 6 (3.7)  Unknown 46 (44.2) 12 (20.7) 9 (5.6) a Significance calculated with chi-square test. View Large Contraception discussed and prescribed Contraception was discussed significantly less often with refugees and other migrants than with native Dutch women: respectively, 51.0% and 65.5% versus 84.0% (Table 2). Although not significant, data suggest a similar trend of contraception being discussed less often with refugees than with other migrants (P = 0.075, OR 0.547, 95% CI 0.282–1.063). If we look exclusively at women who consulted the GP with a problem that could be related to reproductive health (abdominal or genital problems, ICPC-code W, D or X), a substantial difference was still found: in this group, contraception was discussed with 63.4% of the refugees and 76.0% of the other migrants versus 86.9% of the native Dutch women (P < 0.001). Table 2. The discussion of contraceptives among refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Contraception discussed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 53 (51.0) 38 (65.5) 136 (84.0) No 51 (49.0) 20 (34.5) 26 (16.0) OR 0.199 0.363 (ref.) 95% CI 0.112–0.351 0.183–0.721 – Sig.a <0.001 0.004 – Contraception discussed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 53 (51.0) 38 (65.5) 136 (84.0) No 51 (49.0) 20 (34.5) 26 (16.0) OR 0.199 0.363 (ref.) 95% CI 0.112–0.351 0.183–0.721 – Sig.a <0.001 0.004 – a Significance calculated with chi-square test and binary logistic regression analysis. View Large Table 2. The discussion of contraceptives among refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Contraception discussed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 53 (51.0) 38 (65.5) 136 (84.0) No 51 (49.0) 20 (34.5) 26 (16.0) OR 0.199 0.363 (ref.) 95% CI 0.112–0.351 0.183–0.721 – Sig.a <0.001 0.004 – Contraception discussed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 53 (51.0) 38 (65.5) 136 (84.0) No 51 (49.0) 20 (34.5) 26 (16.0) OR 0.199 0.363 (ref.) 95% CI 0.112–0.351 0.183–0.721 – Sig.a <0.001 0.004 – a Significance calculated with chi-square test and binary logistic regression analysis. View Large Regarding the refugee group, other significant differences were found related to the women’s region of origin. The proportion of refugees with whom contraception was discussed ranged from 28.9% (Sub-Saharan Africa) to 90.9% (Asia). We compared the proportion of women with whom contraception was discussed between women with a Sub-Saharan African background and women with other backgrounds. In consultations with refugee women from Sub-Saharan Africa, contraception was significantly less often discussed (28.9%) compared with refugee women who come from other regions (67.8%; P < 0.001). When looking at refugees with an unwanted pregnancy or induced abortion in history, contraception was discussed with the majority of them, but contraception was only prescribed in a minority. Contraceptives were prescribed significantly less often to refugees and other migrants than to native Dutch women (33.7% and 55.2% versus 79.0%; Table 3). The difference between refugees and other migrants was also significant (P = 0.008, OR 0.412, 95% CI 0.213–0.796). In women with whom contraceptives were discussed, the prevalence of prescribing contraceptives was higher in each group but still the lowest among refugees (64.2%) compared with other migrants (84.2%) and native Dutch women (89.7%). The difference between refugees and native Dutch women was significant (P < 0.001, OR 0.135, 95% CI 0.077–0.235). Table 3. The prescription of contraceptives among refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Contraception prescribed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 35 (33.7) 32 (55.2) 128 (79.0) No 69 (66.3) 26 (44.8) 34 (21.0) OR 0.135 0.327 (ref.) 95% CI 0.077–0.235 0.172–0.621 – Sig.a <0.001 0.001 – Contraception prescribed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 35 (33.7) 32 (55.2) 128 (79.0) No 69 (66.3) 26 (44.8) 34 (21.0) OR 0.135 0.327 (ref.) 95% CI 0.077–0.235 0.172–0.621 – Sig.a <0.001 0.001 – a Significance calculated with chi-square test and binary logistic regression analysis. View Large Table 3. The prescription of contraceptives among refugees, other migrants and native Dutch women in five Dutch general practices, 2010–March 2016 (n = 324) Contraception prescribed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 35 (33.7) 32 (55.2) 128 (79.0) No 69 (66.3) 26 (44.8) 34 (21.0) OR 0.135 0.327 (ref.) 95% CI 0.077–0.235 0.172–0.621 – Sig.a <0.001 0.001 – Contraception prescribed n(%) Migrant status Refugees Other migrants Native Dutch women Yes 35 (33.7) 32 (55.2) 128 (79.0) No 69 (66.3) 26 (44.8) 34 (21.0) OR 0.135 0.327 (ref.) 95% CI 0.077–0.235 0.172–0.621 – Sig.a <0.001 0.001 – a Significance calculated with chi-square test and binary logistic regression analysis. View Large Types of contraception Several differences were found with regard to types of contraceptives prescribed by the GPs. Among the refugee group, the oral contraceptive pill was the most commonly prescribed form of contraception (62.9%), followed by intrauterine devices (20.0%) and implants (11.4%). When looking at other migrants, oral contraceptives were also most frequently prescribed (71.9%), followed by injections (12.5%) and intrauterine devices (12.5%). Among the group of native Dutch women, oral contraceptives were prescribed most often (66.4%), followed by intrauterine devices (25.0%) and the vaginal ring (3.9%). Differences between general practices The prevalence of both discussed and prescribed contraception was significantly higher at GP2 and GP5 compared with GP1, GP3 and GP4 and the overall prevalence mentioned above (Table 4). Especially, in case of discussing contraceptives, the difference between refugees and native Dutch women was much smaller in these practices. Table 4. Differences between GPs in the discussion and prescription of contraceptives among refugees, migrants and native Dutch women, 2010–March 2016 (n = 324) GP Migrant status Refugees Other migrants Native Dutch women Contraception n(%) Contraception n(%) Contraception n(%) discussed prescribed discussed prescribed discussed Prescribed GP1 8 (34.8) 4 (17.4) 4 (57.1) 3 (42.9) 22 (73.3) 23 (76.7) GP2 8 (80.0) 6 (60.0) 17 (73.9) 14 (60.9) 28 (84.8) 28 (87.9) GP3 9 (24.3) 6 (15.8) 1 (11.1) 0 (0.0) 38 (82.6) 33 (71.7) GP4 2 (66.7) 1 (33.3) – – 2 (66.7) 2 (66.7) GP5 27 (87.1) 18 (60.0) 15 (78.9) 15 (75.0) 46 (92.0) 41 (82.0) Sig.a <0.001 <0.001 0.003 0.003 0.226 0.452 GP Migrant status Refugees Other migrants Native Dutch women Contraception n(%) Contraception n(%) Contraception n(%) discussed prescribed discussed prescribed discussed Prescribed GP1 8 (34.8) 4 (17.4) 4 (57.1) 3 (42.9) 22 (73.3) 23 (76.7) GP2 8 (80.0) 6 (60.0) 17 (73.9) 14 (60.9) 28 (84.8) 28 (87.9) GP3 9 (24.3) 6 (15.8) 1 (11.1) 0 (0.0) 38 (82.6) 33 (71.7) GP4 2 (66.7) 1 (33.3) – – 2 (66.7) 2 (66.7) GP5 27 (87.1) 18 (60.0) 15 (78.9) 15 (75.0) 46 (92.0) 41 (82.0) Sig.a <0.001 <0.001 0.003 0.003 0.226 0.452 a Significance calculated with chi-square test. View Large Table 4. Differences between GPs in the discussion and prescription of contraceptives among refugees, migrants and native Dutch women, 2010–March 2016 (n = 324) GP Migrant status Refugees Other migrants Native Dutch women Contraception n(%) Contraception n(%) Contraception n(%) discussed prescribed discussed prescribed discussed Prescribed GP1 8 (34.8) 4 (17.4) 4 (57.1) 3 (42.9) 22 (73.3) 23 (76.7) GP2 8 (80.0) 6 (60.0) 17 (73.9) 14 (60.9) 28 (84.8) 28 (87.9) GP3 9 (24.3) 6 (15.8) 1 (11.1) 0 (0.0) 38 (82.6) 33 (71.7) GP4 2 (66.7) 1 (33.3) – – 2 (66.7) 2 (66.7) GP5 27 (87.1) 18 (60.0) 15 (78.9) 15 (75.0) 46 (92.0) 41 (82.0) Sig.a <0.001 <0.001 0.003 0.003 0.226 0.452 GP Migrant status Refugees Other migrants Native Dutch women Contraception n(%) Contraception n(%) Contraception n(%) discussed prescribed discussed prescribed discussed Prescribed GP1 8 (34.8) 4 (17.4) 4 (57.1) 3 (42.9) 22 (73.3) 23 (76.7) GP2 8 (80.0) 6 (60.0) 17 (73.9) 14 (60.9) 28 (84.8) 28 (87.9) GP3 9 (24.3) 6 (15.8) 1 (11.1) 0 (0.0) 38 (82.6) 33 (71.7) GP4 2 (66.7) 1 (33.3) – – 2 (66.7) 2 (66.7) GP5 27 (87.1) 18 (60.0) 15 (78.9) 15 (75.0) 46 (92.0) 41 (82.0) Sig.a <0.001 <0.001 0.003 0.003 0.226 0.452 a Significance calculated with chi-square test. View Large Discussion Summary of main findings GPs in our study significantly less often discussed contraceptives with refugees (51%) than with other migrants (65.5%) and Dutch patients (84%). Contraceptives were prescribed to 33.7% of the refugees compared with 55.2% among other female migrants and 79.0% among native Dutch women. In consultations with refugee women from Sub-Saharan Africa, contraception was significantly less often discussed (28.9%) compared with refugee women who come from other regions (67.8%; P < 0.001). More unwanted pregnancies and induced abortions were recorded in refugees and other migrants than in native Dutch women. Comparison with existing literature These findings are in line with those of previous studies that concluded reproductive health needs might be ill addressed in healthcare and could lead to more unwanted pregnancies (8,9,16). Contraceptive health needs of refugees could differ from other migrant women (for example, because their ethnic background is different) and from those of native Dutch women. However, there are several other explanations possible why contraceptives were less often discussed and prescribed among migrants, despite existing needs, resulting in inequities in care. First, SRH issues like the need for contraception are probably mentioned less frequently by refugees themselves. Sociocultural and religious beliefs, like different expectations about the doctor–patient relationship or opinions about virginity, may lead to a less active role for the patient in starting the discussion of contraception. In addition, women may not raise the issue because of concerns about stigma, taboo on sexuality and traditional health beliefs. Another important factor might be the lack of knowledge about SRH including contraception due to low health literacy (9,17,20). Besides, other studies revealed that solving social issues such as finding a home or finances often are prioritized by refugees over their SRH needs (14,21). Communication barriers are known to hamper access to healthcare in refugees and other migrants (22). It is crucial to involve interpreters with refugees and other migrants with low proficiency of the language of the GP (23,24). Therefore, GPs must be aware that informal interpreters might hinder the discussion of personal or sensitive issues like sexual health. Unfortunately, the use of professional interpreters is not commonly mentioned in patient records, so we do not have any insight into the extent to which the participating GPs made use of interpreter services. On the other hand, GPs can also experience certain barriers to discuss contraception caused by for instance prejudices and cultural stereotyping. To achieve mutual understanding between migrants and GPs, a person-centred culturally sensitive approach of the GP is needed (22,25). Differences in cultural competences, awareness and skills to discuss reproductive health could possibly explain the differences between the GPs participating in this study. Gender differences could also play a role. This could indicate room for improvement in GP care by training in cultural competences and reproductive healthcare. Limitations of the study Several limitations should be considered inherent to the retrospective nature of this study that relied on the information registered in the patient records. First, patient records of the GPs did not always mention whether a woman was a refugee or not. The method we used (defining someone as refugee depending on the country of origin), although done very carefully, cannot guarantee that every woman is placed in the right group. Besides, we know that women more often than men have their application for asylum rejected as their reasons for flight are thought to be personal and not political (19). Second, there was a lack of information about several patient characteristics and potential confounding variables that will influence the doctor–patient communication such as language used in the consultation, involvement of an interpreter and length of consultation. We excluded women whose patient record revealed they were pregnant or trying to receive, but it is possible that this information was not always known to the GP or recorded. Furthermore, the mean duration of registration in the general practice differs between refugees, migrants and native Dutch women. This might induce biases in the data if we assume that it is more likely that contraception is being discussed and prescribed if the period of observation is longer. Unfortunately, this study has no additional data about the number of consultations and when discussion of contraceptives took place during the observation period. Together with the relatively small sample size of our study groups, conclusions should be interpreted with caution. As this study was done in five general practices experienced in caring for migrants, our results might not be representative for refugees and other migrants in the average Dutch general practice. However, the fact that we found large differences in these practices makes it very likely that these differences will be even bigger in other practices. A prospective follow-up study could provide insight into this. Implications for practice and for future research Today and in the near future, the number of refugees and other migrants settling in high-income countries such as the Netherlands will increase, and culturally competent GP care is mandatory as every woman, regardless of her background or origin, has the right to adequate SRH care. Although the results of this small-scale retrospective study should be interpreted with caution, our results seem to indicate there exist differences in GP contraceptive care between refugees, other migrants and native Dutch women that could be worrisome. Our findings suggest a need for further research to identify and address any inequity in reproductive healthcare. A prospective study among a representative sample of women with clear description of their immigration status could produce this information. Qualitative research could provide insight into the experiences of GPs in discussing contraception with migrant women and into the needs and preferences regarding GP care for reproductive health issues of refugees themselves. Conclusion This study has shown that contraceptives were discussed and prescribed significantly less often among migrant women compared with native Dutch women. An even bigger disparity was seen between refugees and native Dutch women. More research is needed to elicit the reproductive health needs of migrant women and their preferences regarding GP care and on the experiences of GPs in discussing these issues. Such insights are vital in order to provide equitable reproductive healthcare to every woman regardless of her background. Declaration Funding: This study was done as part of a research internship at the Department of Primary and Community care at the Radboudumc. Ethical approval: Agreement of all GPs was received after information was given about the study to have insight in the patient records. The information collected from patient records was anonymized and stored safely. Agreement of all the patients was considered implicit due to the fact that getting explicit agreement was very difficult, if not impossible. According to the Dutch law and regulations, this project was exempted from the need for approval through the Ethical committee of the Radboudumc because this study involved anonymized patient records. Conflict of interest: There are no conflicts of interest in connection with the paper. Acknowledgements We wish to thank all GPs who participated in our research: D van Wijngaarden, H de Weerd, R Spanninga, M Slockers and M Dees. We also want to thank R Akkermans, Department of Primary and Community Care, Radboudumc, for his valued assistance in data analysis. References 1. UNHCR . 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Do language barriers increase inequalities? Do interpreters decrease inequalities? Cost series on health and diversity . In: Ingleby D , Chiarenza A , Deville W , Kotsioni I (eds). Inequalities in Health Care for Migrants and Ethnic Minorities . Vol. 2 Antwerpen : Garant Publishers , 2012 , pp. 128 – 43 . 25. van den Muijsenbergh ME , Oosterberg EH . [Patient-centred and culturally competent: good health care for immigrant patients requires specific competencies] . Ned Tijdschr Geneeskd 2013 ; 157 : A5612 . Google Scholar PubMed © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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Family PracticeOxford University Press

Published: Jan 17, 2018

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