With a rising influx of refugees resettling in the United States, it is imperative for health providers to feel comfortable discussing reproductive health issues with this population — a task even I struggled with as a family physician.
Three years ago, while I was training to become a family doctor in Philadelphia, I had a routine office visit with my 42-year-old Bhutanese patient of one year, Mrs. Z. Toward the end of our visit, Mrs. Z mentioned to me that she had missed her last period. While the thought of her being pregnant was far from the top of my diagnostic list, I ordered a pregnancy test, as per protocol. To our surprise, she was pregnant. I could see the panic develop on her face as she heard this news — she had stopped her contraceptive method because she thought she could not get pregnant anymore. Mrs. Z eventually ended up having a miscarriage.
My encounter with Mrs. Z and other refugee patients in the clinic made me realize the discomfort that I and many other providers feel regarding contraceptive counseling with refugee women who come from a different cultural, religious and socio-economic background.
As providers, we tend to focus on infectious diseases, post-traumatic stress disorder and their current assimilation in the United States. With these more urgent matters at the forefront of our minds, a conversation regarding a refugee woman’s sexual and reproductive health often does not occur until a later appointment — sometimes after that woman is already pregnant.
From 2012 to 2014, the number of refugees that resettled in the U.S. rose from 58,000 to 70,000 per year. Often fleeing persecution or conflict zones, refugees have hopes for increased educational and socio-economic opportunities along with new personal rights and freedoms. For women, this extends to choices regarding their sexual and reproductive health. With increased stability and opportunities, many women want to delay pregnancy while others look at this period as the right time to establish their family.
Recently, the U.S. has seen increasing exposure and discussions regarding SRH in school and in the media, so the topic tends to be easier to discuss with the general population. However, with refugee women who are resettling from areas of the world such as in Bhutan, Nepal, Myanmar and the Middle East, the topic of sexual health can be daunting to bring up for both the patient and provider. Many women feel uncomfortable discussing these private, sensitive matters. Being a family doctor that primarily serves immigrant and refugee women, I have learned that while many of these women have concerns about their sexual health, they are unlikely to bring it up due to embarrassment. It is imperative for the provider to start this discussion early in the resettlement period to both limit unintended pregnancies, as well as promote healthy pregnancies.
A study done with refugee women by the Office of the United Nations High Commissioner for Refugees during displacement demonstrated that women had varying levels of knowledge regarding family planning methods, with many having misconceptions and a fear of side effects about modern methods. As a result, refugee women often turn to nonhormonal methods such as withdrawal, condoms and the calendar method.
Health providers tend to overlook these methods, since they are not as effective. We must re-train ourselves as providers to discuss nonhormonal methods because many women from different parts of the world prefer natural methods. Counseling on appropriate use can increase effectiveness as well as start the conversation on family planning, which often leads to increased use of modern methods in the future.
Ultimately, to provide effective counseling and to increase utilization of services, providers need to feel comfortable approaching sensitive topics such as sexual and reproductive health with women coming from different backgrounds. We as providers need to make an effort to learn about their background and the challenges our patients have faced as a population.
Additionally, we need to work as a team, learning from our peers, community health workers and our patients. Institutions can promote this through discussions and talks focused on refugee care, which includes culturally competent care.
Establishing women’s groups that are led by community health workers can also offer a more relaxed environment for women to learn about family planning options and have discussions with their peers and providers, leading to improved access and increased utilization of services.
If we are able to create an environment that promotes culturally attuned care, we as providers will feel comfortable talking to our patients about sensitive topics such as their sexual and reproductive health. In turn, we can hopefully prevent unintended pregnancies and foster healthier sexual and reproductive lives for all our patients.
Komal Soin is a practicing family physician with a special interest in the sexual and reproductive health of migrants and refugees. She recently completed her master's in public health from Johns Hopkins University and worked with International Medical Corps in the above sector. She currently lives and practices family medicine in Honolulu, Hawaii.
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