WORKING PAPER:
MIGRATION AND REPRODUCTIVE HEALTH: A REVIEW OF THE
LITERATURE
Katerina Georgiadis
Introduction
According to the United Nations, there were an estimated 191 million international
migrants worldwide in 2005. Of those, 115 million were within more developed
regions, including 64 million within Europe and 44 million within North America.
Refugees comprised 7.1 per cent of the world’s stock of international migrants, while
they made up 2.3, 3.1 and 1.2 per cent of the total within more developed regions,
Europe and North America respectively. Despite the presence of so many
international migrants globally, few reproductive health and family planning
programs and services are in place to deal with their specific needs. Yet migrant
health, including reproductive health, is important for a number of reasons. Firstly, as
the WHO (2003) states, health is a basic human right that is currently being denied to
many migrant populations simply due to ignorance of their circumstances and
requirements. Secondly, healthy migrants are essential to the process of integration
because ‘illness exacerbates marginalisation and marginalisation exacerbates illness,
creating a downward spiral’ (Ingleby et al. 2005, p.1). In the absence of efforts to
understand migrants’ experiences of health their capacity to contribute to host
societies will be inhibited (WHO 2003). Finally, migrant health is worthy of attention
from a public health perspective. According to Carballo, Divino and Zeric (1998,
p.938) reproductive health in particular ‘presents one of the most important, and still
unmet, public health challenges,’ especially now that migrants are more numerous
than ever before, move further and with greater speed than in the past, and have a
relatively young age profile. Given the rise in the number of female migrants,
problems relating to pregnancy, birth and gynaecological health have also increased
(Carballo 2007), making reproductive health an ever more pressing public health
issue.
Although studies have shown that migrants are sometimes healthier than nonmigrants due to the ‘healthy migrant’ effect1, others suggest that the physical and
mental wellbeing of ethnic minorities, refugees, asylum seekers, first and secondgeneration immigrants, and undocumented or illegal migrants is often worse than that
of host populations. Research has focused on a range of health issues believed to
affect people who move, including those related to mental, sexual and reproductive
health, communicable and non-communicable diseases, such as TB and
cardiovascular diseases, and nutrition. It is clear that the source of health disparities
between minority groups and dominant populations cannot be reduced to a simple set
of causes. Refugees, asylum seekers, first- and second-generation immigrants,
undocumented migrants and members of ethnic minorities often encounter different
1
The ‘healthy migrant’ effect suggests that immigrants are generally healthier than their hosts because
those who are not as healthy tend not to migrate. Persons who leave their countries of origin to settle
elsewhere are usually the youngest and fittest from the sending population. The ‘healthy migrant’
theory is not accepted by everyone and may not apply to some specific migrant streams.
1
types of health problems on account of their past experiences, as well as their moving
and settling experiences. The severity with which certain diseases affect them also
varies and there are differences in health outcomes within groups due to the diverse
origins of each. As Carballo (2007, p.1) notes:
Migrants, like all people, carry with them personal health “prints” that are
made up of any ethnic or family disease susceptibilities they may have inherited, the
personal health experiences they may have had, including their access or lack of
access to healthcare … the ways in which cultures have adapted to their health
environments and the beliefs they have developed to deal with life, illness and death.
Investigations into the relationship between migration and health therefore tend to
focus on particular health problems among groups from specific ethnic backgrounds,
countries or regions.
Indeed, attempting to find similarities relating to the experiences and
perceptions of the health of ethnic minorities, refugees, asylum seekers, first- and
second-generation immigrants, and undocumented migrants would be futile because
the circumstances under which they move and the conditions they face upon having
moved are far too diverse. However, comparing studies that deal with each group’s
experiences of particular health problems is both achievable and informative. While
extensive research on the reproductive health of ethnic minorities, refugees, asylum
seekers, immigrants (first and second generation) and undocumented migrants has
been carried out, few systematic reviews of the literature exist that are specific to each
group (for exceptions see Gagnon et al. 2002; Driscoll et al. 2001). Constructing such
a review helps identify patterns in the major obstacles faced by each group either
upon reaching their destination or post-settlement. In turn, this raises awareness
regarding the adverse or beneficial circumstances that individuals making the same or
a similar journey in the future may encounter. In addition, it identifies the issues with
which researchers are familiar, and the research gaps concerning the relationship
between migration and reproductive health. A systematic review also points to areas
of controversy in the literature and assists in the formulation of questions that need
further investigation.
The main obstacle to the successful completion of such a comprehensive
review relates to the issue of classification. As Mladovsky (2007a, p.9) argues ‘one
difficulty in studying migrant health is defining the subject.’ Junghanss (1998, p.933)
agrees and points out that,
throwing light on the interconnectedness of migration and health is an
ambitious aim. Both the features we attribute to migrants and our definitions of
health are socially constructed and highly variable across time and space. To get a
grip on these terms continues to be a struggle and all that has been suggested so far
has been highly controversial. We have to be aware of this fundamental problem of
vague and questionable classification systems when interpreting studies on migration
and health.
The characteristics that distinguish one group of migrants from another are subject to
debate not only within but also between countries. The boundaries between ethnic
minorities and immigrants, for example, are often blurred and the former may contain
a large proportion of the latter. Variable definitions, both within and between national
2
borders, also apply to the same category of migrants. For instance, while some
countries refer to immigrants as those who were born elsewhere, others also include
persons whose parents or grandparents were born abroad (Mladovsky 2007a). This
review concentrates on research findings relating to the reproductive health of
‘documented’ or ‘legal’2 migrants who have moved voluntarily rather than by force,
across rather than within national boundaries, who have transferred to the receiving
country in their own lifetimes and, possibly, also on a temporary basis, and whose
destination has been Europe, Australia or the U.S. and Canada.
Despite such a narrow focus, reaching a verdict on the overall state of this
particular group of immigrants’ reproductive health remains difficult. This is due to a
further lack of consensus on what constitutes health, specifically reproductive health,
and disagreement over whether such concepts can be evaluated as ‘good’ or ‘bad’.
Although the reproductive health of a population can sometimes be described as
‘better’ or ‘worse’ than that of another, if, for instance, suffering from a higher
prevalence of disease or higher mortality is deemed to be ‘less good’ than having a
low incidence of both, more often than not such comparative expressions of welfare
are inappropriate. This is because particular aspects of reproductive health cannot be
graded, they are simply different. For example, whether an immigrant group has high
or low fertility, or uses condoms or the pill, is neither ‘good’ nor ‘bad’. Looking at
the long-term health impact of certain types of reproductive behaviour makes a
ranking system even less constructive. There is widespread consensus, for example,
that exclusive breastfeeding for a minimum of six months is beneficial to the health of
infants because it provides all the nutrients necessary for healthy growth and
development (www.who.int) and advantageous to mothers because it reduces the risk
of postpartum haemorrhage, iron-deficiency anaemia, osteoporosis and various
cancers (www.lalecheleague.org). However, bottle-feeding may be better for the
health and economic wellbeing of mother and baby if it enables a woman to balance
her work and family life much more efficiently than if she were breastfeeding, and
thus provide her with the financial security needed to build a healthier environment in
which to raise her child. Formula milk might also enable the father to take a more
active role in feeding and bonding with his child, whilst allowing the mother to rest
more frequently. Such trade-offs have to be taken into account when considering the
issue of migrant reproductive health.
This review does not seek to determine whether the reproductive health of
international migrants in Europe, Australia and North America is worse or better postmigration or in comparison to their hosts, but to provide an overview of their
reproductive health. In doing so, it aims to identify the key issues that affect their
experiences. This is not an attempt to oversimplify the factors that shape international
immigrants’ reproductive health or to generate a list of variables that can be used to
predict how they will feel and act upon arriving and settling in a new country. As
Ingleby et al. (2005, p.5) remind us, ‘it is misguided to try to produce generalisations
about the health needs of migrants in general,’ because they vary both spatially and
temporally, and depending on such background factors as country of birth, level of
2
There are two main reasons for focusing on ‘legal’ or ‘documented’ migrants rather than ‘illegal’ or
‘undocumented’ ones. The first is that the former are more easily identifiable and therefore also more
easily accessible to researchers. This further increases the chances that they will be willing to
participate in a research study. The second reason is that illegality itself affects a migrant’s access to
health services, and so shapes his or her experiences of wellbeing in different ways to those of the
‘legal’ migrant.
3
education, generation, gender, age and type of migration. Putting together a review,
however, assists in identifying the themes that appear most consistently in the
literature. Consequently, it helps to establish the extent to which the reproductive
health and medical experiences of immigrants are a consequence of moving, the new
environment in which migrants find themselves, the specific characteristics of those
who move – such as their culture and environment of origin - or a combination of all
three factors. It also makes it possible to ascertain whether international immigrants
are especially vulnerable to certain reproductive health problems and if so why and
how? Is it due to their inability or unwillingness to access appropriate health
services? Is it related to such conditions as social isolation and a lack of support from
kin and friendship networks? What other forces appear to be responsible for
migrants’ reproductive health practices in the receiving country according to the
literature, and are there some that are not examined?
The issue of reproduction is particularly salient for migrants from less
developed countries who move to Europe, North America and Australia, given that
most are in the early stages of their reproductive careers and therefore probably in the
midst of formulating ideas surrounding family size and the family-formation process.
The experience of moving is likely to affect both individual reasons for having
children and social expectations of childbearing within an immigrant community. It
is also expected to influence the timing and spacing of births, as well as events
associated with fertility, such as sexual and contraceptive behaviour and marriage.
Reproductive health encompasses abortion, contraception, pregnancy, fertility,
adolescent and male reproduction, safe motherhood, reproductive rights, family
planning, as well as sexual health, HIV/AIDS and sexually transmitted infections.
We explore the relationships between migrants and six broad aspects of reproductive
health: 1) fertility, 2) abortion, 3) contraception, 4) infertility3, 5) breastfeeding, and
6) reproductive health services. All of these are associated with the broader issue of
maternal and child health and each is potentially dependent on the other. While
fertility provides the context within which the management of abortion, contraception,
infertility and breastfeeding takes place, reproductive health services play a part in
controlling access to the information and facilities associated with them. Looking at
these issues in tandem, therefore, provides a more complete picture of migrants’
reproductive attitudes and behaviour, and offers a more comprehensive view of their
reproductive health needs.
The anthropology of reproduction
Most available evidence on the state of migrants’ reproductive health, particularly in
Europe, derives from demographic and epidemiological research. A basic search for
studies on the subject in anthropological databases (JSTOR Anthropology,
Anthropological Index Online, and AnthroSource) produces few results. However,
anthropology is well suited to the study of reproductive health and migration because
of its relatively long-standing preoccupation with reproduction. The issues raised by
those working in the field of the anthropology of reproduction point to numerous gaps
in current work on migrants’ reproductive health and offer additional perspectives
3
Although connected, the discussion relating to the topic of infertility will not touch on new
reproductive technologies or IVF treatments but exclusively on migrants’ attitudes towards and
experiences of infertility.
4
from which to interpret their experiences and here we summarise some of the key
themes which anthropologists have explored in connection with reproduction.
For anthropologists,4 human reproduction is a social, political and gendered
event that is, to a certain extent, shaped by a combination of spatially, temporally and
culturally specific forces. It is social because it is the product of a series of decisions
and actions involving a number of people often, though not always, in direct
relationship with each other. According to Petchesky (1984), although the central
figure in this web of connections is the woman with the potential to carry or carrying
a child, others may include her sexual partner(s), her children, her in-laws,
neighbours, employers, reproductive health care providers, birth control
manufacturers, as well as religious and state authorities. As a result, every woman’s
reproductive trajectory and experience is, to a degree, different from that of another.
As Ginsburg and Rapp (1991, p.330) argue, ‘no aspect of women’s reproduction is a
universal or unified experience, nor can such phenomena be understood apart from
the larger social context that frames them.’ Moreover, reproduction is social because
it not only reflects already existing relationships between people but because it can
also generate new ties and sever old ones.
Given this potential, reproductive decisions and behaviours are invariably the
outcome of relations of power and are, therefore, always political (Greenhalgh 1995).
‘Power is the ability to influence or control the behaviour and beliefs of others even
without their consent. You know who has power over you – anyone or any
organisation that influences your ability to get access to the resources that you need to
live.’ (Handwerker 1990, p.2-3). Differential access to resources (including education
and employment opportunities, as well as health care) is therefore a key determinant
of reproduction. Both local and more distant power relations can affect the number of
children a woman has, as well as the spacing and timing of her childbearing.
Kligman’s ethnography of Romania’s reproductive policies under Nicolae Ceausescu,
among which the banning of abortion was central, is a prime example of the state’s
influence in controlling births (Kligman 1998). Yet power is also exercised by other
more global types of institutions, such as those in charge of implementing family
planning programmes, or social movements, including religious ones. On a local
level, reproduction is shaped by the power dynamics operating within families or
communities. At both the local and the global level, power can also be implemented
via the control of knowledge (Ginsburg and Rapp 1995). A lack of awareness
regarding methods that can enable (assisted reproductive technologies) or hinder
childbearing (contraception or abortion) is crucial to determining who reproduces and
who does not, how often and when. Control over resources and knowledge leads to
the phenomenon of ‘stratified reproduction’ (Colen 1995), which refers to ‘the power
relations by which some categories of people are empowered to nurture and
reproduce, while others are disempowered’ (Ginsburg and Rapp 1995, p.3).
Anthropology’s objective is to trace the complex ways in which global and local
power relations, and the interplay between them, impact upon the reproductive
practices of individuals or groups.
Yet a future objective is to account for the manner in which those individuals
or groups find ways to contest local or global beliefs about who should and should not
4
In this paper, the term ‘anthropologist’ refers to social or cultural anthropologists rather than
biological anthropologists, whose perspectives on reproduction are very different.
5
have children and when. Reproduction is a product of ‘negotiated conduct’, which
refers to acting following ‘a process of using one’s own power and knowledge to
modify or create meanings for oneself and to influence the meanings that significant
others hold’ (Angin and Shorter 1998, p.557). Individuals are neither fully
subservient to rules and regulations nor completely free to impose their own will at all
times (Carter 1995). Yet they are able to manage their own reproductive lives to a
degree within the limits set by socio-structural, political, cultural and economic
conditions. The options available to each individual, however, are further defined by
their age, class, ‘race’ and, importantly, gender. Men and women face different
reproductive constraints and do not always share the same experiences of the process
of childbearing. In addition, their views concerning family size, contraceptive
methods, as well as approaches to childcare and childrearing often diverge.
Numerous anthropological studies have shown how men and women govern their
reproductive lives under various circumstances and prevailing gender ideologies
(Browner 2001; Halkias 2003; Obermeyer 1994; Renne 1993; Sargent and Cordell
2003; Sargent 2006). Sargent (2006) describes the ways in which Malian women
living in France justify the use of contraception, despite the opposition of their
husbands, by constructing their own interpretations of Islam and drawing on the
prevailing French gender ideology, which promotes gender equality and the idea of
birth control as a woman’s right. Consequently, over 40 per cent of women in her
sample whose partners were against contraception had used the pill.
Reproduction and gender are further connected due to the role that
reproductive functions play in the construction of male and female identities. As
Tremayne (2001, p.12) points out, ‘reproduction is fundamentally linked with
identity.’ This is most apparent in cases of ‘disrupted reproduction’ or ‘reproduction
gone awry’ (Culley and Hudson 2005/6), when a woman’s ability to conceive, carry a
child to term, or give birth is upset by either pregnancy loss or infertility. Yet it is
also evident among those physiologically able to have a child. In contemporary
Greece, for example, motherhood continues to be widely regarded as critical to the
‘completion’ of being a woman (Paxson 2004; Georgiadis 2006) and is also essential
to being a ‘good Greek woman’ (Halkias 2003, p.223); in other words, a responsible
citizen of the Greek nation-state. Reproduction can, therefore, shape gender and
national identities in tandem, by making one indispensable to the other. As Gal and
Kligman (2000, p.25) point out, ‘biological reproduction and biological continuity
over time are the centrepieces of creating and imagining community. Although
populations are often enlarged and diminished by migration and assimilation,
nationalist ideology commonly ignores or erases these processes, instead highlighting
and constructing ties of blood.’ As a result, women become central to narratives of
nationhood and to the making and remaking of nations and their boundaries
(Kanaaneh 2002; Paxson 2004). The consequence is that serious threats to the
integrity of the nation or state can end up being perceived as threatening to women
and their identities. As Feldman-Savelsberg (1999) illustrates in her study among the
people of the Bangangté kingdom in Cameroon, political insecurity is often expressed
in reproductive terms, particularly by women. Despite having one of the highest birth
rates in the county, Bangangté women speak at length about their fear of infertility
which is ‘a barometer of anxiety about personal fate, the future of the kingdom and of
one’s cultural heritage, and a barometer of ambivalent response to modernity and
cultural imports’ (Feldman-Savelsberg 1999, p5-6).
6
From an anthropological perspective, therefore, reproduction can act as an
expression of wider societal problems and public anxieties. Tober, Taghdisi and Jalali
(2006) describe how Pashtun Afghan refugees living in rural Iran are reluctant to
make use of the country’s renowned family planning services, and to follow the
advice of Iranian medical professionals to employ modern contraceptive methods in
order to limit their family size, partly because they perceive such suggestions as an
attempt by the host government to reduce their numbers. Reproduction, in other
words, can also be a means of acquiring legitimacy in a novel socio-political context.
As Bledsoe (2004, p.88) argues, ‘children may offer new pathways for their families’
mobility and the security it can bring. Hence, the most compelling starting point for
studying immigrant views of reproduction is less the number of children immigrants
produce than the social legitimacy that children may offer them.’ This argument
points to a final key anthropological perspective on reproduction, which is that the
value of children is temporally, spatially and culturally variable and, thus, that the
rationale behind reproductive practices is not universal or uniform. While in the
United States, for example, the motive for childbearing is mainly affective and
parenthood is a pathway to adult status and proof of maturity (Leone 1990), in other
contexts children are significant primarily as sources of social and economic security
to their parents (Price 1996), although this should not be seen to undermine the
affective dimension.
Methods
Reviewed papers were identified through the PubMed and POPLINE databases using
the terms ‘migration’, ‘migrants’, ‘immigration’ or ‘immigrant’ and each of the
following: ‘contraception’ (or ‘contraceptive use’ or ‘birth control’ or ‘family
planning’), ‘abortion’ (or ‘termination of pregnancy’ or ‘unwanted pregnancy’),
‘breastfeeding’ (or ‘infant feeding’), ‘infertility’ (or ‘childlessness’), ‘fertility’, and
‘reproductive health services’ (or ‘family planning services’, or ‘abortion clinics’ or
‘breastfeeding counsellors’ or ‘maternal and child health services’). The PubMed and
POPLINE searches were limited to those in English, while in the latter the above
terms were entered as both keywords and title. Articles were reviewed if: 1) they
focused on ‘legal’ or ‘documented’ migrants arriving in Europe, Australia or North
America from countries outside these regions or on people moving from one
European country to another; 2) they were not about internal migrants; 3) they were
exclusively about first generation migrants rather than refugees, asylum seekers or
ethnic minorities; 4) their main focus was not sexual health or sexually transmitted
diseases such as HIV/AIDS; 5) they were not about adolescents; 6) they were about
the migration of humans rather than foreign-bodies within humans; 7) the study was
designed to consider the behaviour, attitudes and/or perceptions of migrants in
relation to contraception, abortion, breastfeeding, infertility, fertility and reproductive
health services, and 8) the work was published in an academic journal.
Once duplicates were identified and removed from POPLINE, a total of 302
articles remained (Table 1). PubMed returned 189 articles and POPLINE 113 further
articles.
Abortion
Breastfeeding
PubMed
16
27
POPLINE
10
9
7
Contraception
37
23
Fertility
33
51
Infertility
5
1
Reproductive health
71
19
services
TOTAL
189
113
Table 1. Summary of initial results from database searches
After reviewing the results, another 121 articles were excluded from analysis from
PubMed and 91 articles from POPLINE either because they did not fit one or more of
the above criteria or due to the fact that they were inaccessible. This left a total of 89
articles for full review. Out of the final collection, 6 were on abortion, 17 on
breastfeeding, 12 on contraception, 20 on fertility, 3 on infertility and 31 on
reproductive health services5.
The majority of research papers, published from 1970-2007 were on reproductive
health services, followed by fertility, breastfeeding, contraception, abortion and
infertility. While many different immigrant groups are discussed in relation to each
topic, some are mentioned with more frequency than others depending on the article’s
focus. Studies exploring breastfeeding tend to concentrate on those of Hispanic, Latin
American or Mexican descent, which relates to the fact that much of the research was
based in the United States. Moreover, certain reproductive health topics are more
popular research targets in specific regions. The majority of studies examining the
relationship between immigrants and reproductive health services are based outside
Europe. The reasons behind these imbalances are not clear but they might be due to a
combination of factors, including an uneven distribution of data available for different
immigrant groups in different countries, evidence of specific reproductive health
problems or trends pertaining to particular populations, and a desire to focus on the
most numerous and accessible immigrants in the country or region in question.
Fertility
The majority of studies on the relationship between fertility and migration investigate
destinations outside Europe and many focus on internal rather than international
migrants. Although there are a few exceptions (Andersson 2004), European-based
research tends to concentrate on mapping the childbearing patterns of different
immigrant groups within their host population (Gissler, Pakkanen and Olausson 2003;
Iliffe, 1978; Penn and Lambert 2002; Raleigh, Almond and Kiri 1997;
Schoenmaeckers, Lodewijckx and Gadeyne 1999; Tribalat 1991) rather than
examining the motives behind such differentials. Irrespective of geographical focus,
most articles investigating the interplay between migration and fertility attempt to
relate their findings to at least one of four hypotheses: socialisation or assimilation,
adaptation, selection and disruption (Kulu 2005). The assimilation or socialisation
hypothesis refers to the idea that people’s values and beliefs concerning reproduction
are formed at an early age and become deeply ingrained in them. As a result, when
migrants move to a foreign environment they do not immediately adopt the norms and
Details of migrant populations covered and principal countries of destination are
available from authors
5
8
attitudes of the host population. Instead, the process of developing new approaches to
family-formation is gradual and may take several generations before it is
accomplished. Proponents of this hypothesis deem it unlikely that the first generation
will show signs of assimilation. Unlike supporters of the adaptation theory, they
believe that habits and values are hard to change and that cultural influences from
early childhood are powerful enough to minimise the effects of other conditions that
migrants might encounter when they settle in their new surroundings.
Supporters of the adaptation hypothesis take the opposite view. They assume
that reproductive preferences and behaviour do not remain unchanged from country or
place of origin to destination setting since novel circumstances, particularly economic
ones, force migrants to adjust their views and practices to suit their latest needs. The
adaptation theory states that changes in fertility are evident even among first
generation migrants.
The selection theory, on the other hand, suggests that
immigrants are a non-random group of people who already possess various
characteristics – related to their education, age at marriage, and occupation - that
make them prone to display either high or low fertility. They also have certain
unobserved qualities such as a desire for upward social mobility. Consequently, their
fertility is more similar to the population at destination rather than at origin not
because they undergo any transformations in attitude or behaviour but because they
have pre-existing principles or attributes in common with the host society. In this
sense, the selection theory is similar to the assimilation hypothesis in that it is equally
dismissive of the idea that norms and values are subject to change upon contact with
different social contexts. This supposition is contrary to the final of the four
hypotheses, disruption. It assumes that the migration process itself has an impact
upon the fertility of people who move due to such disruptive events as spousal
separation or reduced fecundity developed as a result of the stress associated with
change. The theory of disruption implies that post-migration fertility is reduced to a
level below that of non-migrants, albeit temporarily. In time, fertility increases again,
though frequent disruptions may be sufficient to lower a couple’s completed family
size.
Assimilation or socialisation, adaptation, selection and disruption are not
mutually exclusive hypotheses, although one is always regarded as the driving force
behind migrants and non-migrants’ fertility differentials. Nevertheless, there appears
to be no consensus in the literature as to which of the four theories best captures
immigrants’ experiences in general. For example, Dinkel and Lebok (1997) find that
the fertility of ethnic Germans migrating back to Germany from the Soviet Union in
the early 1990s fell to below that of the host population as a result of the disruption
effect. Stephen and Bean (1992) show that despite some evidence of disruption
among the two youngest cohorts of Mexican immigrants to the U.S., women of
Mexican-origin with longer residence in the receiving country display fertility
behaviour similar to that of their hosts. Even though complete convergence between
migrant and native fertility has not yet occurred, the evidence in favour of the
assimilation hypothesis is clear, according to Stephen and Bean. Lindstrom and
Saucedo (2002), on the other hand, argue that the long-term marital fertility of male
Mexicans who move to the U.S. for the short term is not reduced by their migratory
experience and thus proves that temporary male migrants from Mexico are selected
for higher fertility. A study in support of the adaptation theory is provided by Hwang
and Saenz (1997) who look at the fertility behaviour of Chinese migrants to the U.S.
9
They find that once Chinese women from China (as opposed to Hong Kong, Taiwan
or Vietnam) escape the one-child policy, enforced in their country since 1975, and
move to the U.S. where no restrictions upon their fertility exist, an increase in the
number of births becomes apparent almost immediately.
A further, related, theme is immigrants’ contribution to the host population’s
growth and fertility rate (Feichtinger and Steinmann 1992; Jonsson and Rendall 2004;
Keely and Kraly 1978; Mitra 1990). In general, the childbearing patterns of
immigrants and the degree to which they converge or diverge from those of nonimmigrants in both receiving and sending countries appear to vary a great deal. All of
the studies suggest a host of reasons for migrants’ reproductive behaviour upon
settlement in their new surroundings. A group’s willingness to shed some of its
traditional ways of thinking about childbearing and to adopt new ones is one such
factor (Lindstrom and Saucedo 2002). The likelihood of this happening depends on a
sub-group of factors, such as the strength and character of migrants’ religious beliefs
in relation to those of their hosts (Penn and Lambert 2002), their educational status
(Ng and Nault 1997), and the reasons for migrating in the first place, along with the
amount of contact they sustain with their home country (Schoenmaeckers,
Lodewijckx and Gadeyne 1999). Another potential determinant of the probability that
a migrant group will integrate with the host society and assume its fertility practices is
its ability to do so. Again, this depends on a number of factors, including linguistic
skills (Lindstrom and Saucedo 2002), the amount of contact with local institutions
(Sargent and Cordell 2003), the extent to which immigration policies encourage their
integration (Bledsoe, Houle and Sow 2007; Sargent and Cordell 2003), and whether
they intend to stay or eventually return to their country of origin (Lindstrom and
Saucedo 2002). Yet regardless of the above reasons, whether and how a particular
migrant group will change its fertility practices cannot be predicted.
Contraception
The differences between migrants and non-migrants’ contraceptive attitudes and
practices are mainly explored within the framework of family planning and the need
to improve the delivery of family planning services to migrant men and women.
Although there is much variation in the contraceptive method mix used both by
different immigrant groups in diverse settings and by their hosts, the general message
is that the majority of migrants use less reliable means of birth control than nonimmigrants and do not take full advantage of family planning methods widely
available in the receiving country. A U.S.-based study found that although the
fertility attitudes and reproductive behaviour of Filipino migrants came close to those
of their Caucasian counterparts the longer they lived away from the Philippines, their
contraceptive practices remained relatively unchanged (Card 1978). Despite growing
awareness of a range of birth control methods Filipino migrants continued to practise
rhythm and withdrawal. Wilson and McQuiston (2006) suggest that Mexican
immigrant women in North Carolina are also disinclined to use birth control methods
with a lower failure rate in spite of a growing preference for smaller families and a
heightened sense of the need to plan the timing of births. More than half of their
pregnancies are accidental. In their study of family planning among former Soviet
new immigrants in Israel, Remennick et al. (1995) discover that although foreign-born
10
women exhibit some change in their contraceptive behaviour, their contraceptive use
remains low and, in fact, decreases.
The reasons behind immigrants’ unwillingness to adopt contraceptive methods
popular in the receiving country vary. Some argue that foreign-born individuals lack
knowledge about certain forms of birth control and remain suspicious of their sideeffects even once they learn of their existence. For instance, David, Borde and
Kentenich (2000) show that fewer Turkish women living in Germany than indigenous
Germans (3% as opposed to 22%) are well informed about specifically female bodily
functions, contraception, preventative medical examinations and the menopause.
Ethnic Korean women living in Canada (Wiebe et al. 2006) express widespread
mistrust of the health consequences of hormonal contraceptives and a strong
preference for condoms, rhythm and withdrawal. This may possibly be a reflection of
prevailing contraceptive preferences in Korea, although the authors suggest it may be
a consequence of Asian women’s general intolerance of hormonal contraceptives due
to their physiological make-up. For Soviet immigrants living in Israel family
planning is also a relatively novel concept since in the USSR there were limited
family planning clinics few available birth control methods (Remennick et al. 1995).
Others claim that cultural and religious beliefs surrounding reproduction and
fertility regulation prevent immigrants from appreciating the value of unfamiliar
methods of contraception. Comerasamy et al. (2003) contend that Somalian women
attending the African Well Women Clinic at the Central Middlesex Hospital in the
United Kingdom, are opposed to using the contraceptive services and methods
provided because for them using contraception is the same as choosing to remain
childless. According to their religious teachings, having children is a blessing and
refusing to have them sinful, while the status of both men and women largely depends
on their ability to reproduce. Young Filipinas in Australia were at risk of unintended
pregnancies and sexually transmitted infections due to low or sporadic use of
contraception (Manderson et al. 2002). While this is equally characteristic of their
Australian-born counterparts, they are less likely to receive sound contraceptive
advice because, unlike the latter, they are not accustomed to discussing birth control
openly with parents or other adults.
Although the gendered nature of contraceptive practices is often mentioned,
most publications focus on the attitudes and behaviour of either men or women
(Weston, Schlipalius and Vollenhoven 2002; Sable et al. 2006), and only refer to the
views, conduct and influence of those of the opposite gender in passing. Wiebe et al.
(2006) report that ethnic Korean women openly discuss the issue of contraception
with their husbands and are content to leave decisions regarding frequency and use of
contraceptive methods to them, which might explain why they are mainly male based
methods. Yet the implications of such an arrangement are hardly discussed by Wiebe
et al., neither are the reasons behind immigrant women’s willingness to comply with
their husbands’ wishes.
Abortion
Studies on abortion and immigrants are scarce. This is partly because in many
parts of the world abortion data are not available by ethnicity or migrant status
(Raleigh, Almond and Kiri 1997). The broad consensus in the literature on abortion is
11
that international immigrants tend to have higher abortion rates than their hosts yet
lower than their counterparts back home. However, the dominance of Soviet-Israeli
studies on the subject makes it difficult to generalise. Sabatello (1992), for example,
estimates that requests for abortion among Soviet immigrants who moved to Israel in
1990 may have risen by up to 14 per cent from 1988-89. In 1991, two years postemigration from the U.S.S.R., these Soviet immigrants were reported to have the
country’s highest applications-for-a-legal-abortion rate (Sabatello 1995). While this
abortion rate was considerably lower than had they remained in the Soviet Union, it
was double that of all Israeli women and higher than that of Soviet immigrants who
moved to Israel in the 1970s. Similarly, Addor, Narring and Michaud (2003) show
that the rate of abortion among foreign women living in a Swiss canton between 1990
and 1999 was higher than among Swiss women. Between 1997 and 1999, 51 per cent
of all abortion requests were made by foreigners, with women from Africa, the former
Yugoslavia, South and Central America, and Turkey most at risk of having a
termination. Rasch et al. (2007) found that foreign-born women have an increased
odds-ratio of requesting an abortion than Danish nationals because they know less
about contraception, are less well informed about its side-effects, and experience
more problems using it.
Explanations regarding differences in abortion trends between immigrants and
women native to the countries under consideration vary in both depth and direction.
A widely reported cause, discussed by three out of the five articles reviewed, relates
to methods of contraception. According to Remennick and Segal (2001), although
most of the unplanned pregnancies among Russian immigrants in Israel and Israeli
Jews are a consequence of non-use of modern contraceptives or flawed use of
efficient methods, non-use or withdrawal are more likely among the former than the
latter. This, Remennick and Segal suggest, is unsurprising given that in the former
Soviet Union contraceptives were either mistrusted or in short supply, while abortion
was ‘easily available, utterly medicalized, and never viewed as an ethical, religious or
political issue’ (2001, p.51). However, Sabatello (1995) argues, recent Soviet
immigrants in Israel are less inclined to resort to abortion than they would have been
at home because of their partial uptake of modern contraceptives, easily accessible in
the receiving country. Failure to use contraception, and a preference for coitus
interruptus rather than condoms, was also the reason that Swiss immigrants were
more likely both to have experienced previous abortions and to request further
terminations compared to Swiss natives (Addor, Narring and Michaud 2003).
While the argument that immigrants’ choices regarding contraception affect
the extent to which they resort to abortion is important, it does not offer an account of
the wider context in which decisions regarding fertility regulation are made, nor does
it reveal the experiences that women having abortions undergo. Moreover, the
assumption that immigrants act as they do because they only partially adopt the
practices prevalent in the host population while still holding on to ideas and patterns
of behaviour customary in their countries of origin, fails to provide a detailed picture
of how the process of immigration itself and their status as immigrants influence their
behaviour. It also disregards the possibility that practices long-established in one
setting can take on new meaning in novel contexts. Finally, it misses the link between
immigrant women’s attitudes towards family size and their views on abortion. The
numerous factors that contribute to decisions about whether or not to have children,
and thus about whether or not to bring to an end an unforeseen pregnancy, are
intensified when a woman is confronted by potentially conflicting ideas stemming
12
from her origins and the host society. Studies that provide such holistic accounts of
the issues that lead immigrants to have relatively high numbers of terminations are
absent from the literature.
An attempt to give a more comprehensive report of immigrants’ experiences
of abortion is made by Remennick and Segal (2001) and Liamputtong (2003). The
former argue that both macro- and micro-level factors are responsible for Soviet
women’s perceptions and experiences of abortion. While Israeli women describe an
unwanted pregnancy and abortion in personal terms, blaming themselves for acting
irresponsibly and for not being ‘modern’ or ‘in control of their lives’, Russian women
speak of abortion as an accident and of themselves as ‘victims’. Although only a
small proportion of women from either group experience serious emotional anguish
following a termination, the factors that Russians attribute to post-abortion distress are
to some extent a product of their status as immigrants - in particular, problems
stemming from their resettlement, such as unemployment, low income, poor housing
and cultural isolation from the host population. Yet Remennick and Segal (2001) fall
short of addressing the motives behind immigrants’ recourse to abortion. When they
do report on the reasons for termination they reiterate the causes given in abortion
clinics’ official documentation (for example, ‘non-marital pregnancy’, ‘mental
distress’, and ‘maternal age’). Liamputtong (2003) gives a more thorough account of
Australian immigrants’ inclination to terminate unwanted or unexpected pregnancies
by suggesting that among the Hmong abortion is seen as the ‘right’ of older women to
regulate their fertility once they have completed the process of family-formation
(usually after 4-6 children). However, she neither reveals whether Hmong women
attend abortion clinics in Australia and if they do so, the age groups to which they
belong, nor does she discuss the motivations of and consequences for younger Hmong
immigrants seeking a termination. Liamputtong’s study is significant nevertheless
because it highlights the need to take into consideration the factors that lead to
differences in why and how immigrants belonging to the same ethnic group perceive
and experience abortion.
Breastfeeding
Most research concludes that shortly upon arrival in the receiving country
immigrants’ prevalence and duration of breastfeeding declines sharply. A reduction
in the incidence of breastfeeding was observed among Asian, Chinese and African
immigrants to Scotland in the mid-1970s by Goel, House and Shanks (1978).
Although not as many immigrant children were bottle-fed as Scottish children,
immigrant parents, particularly of Asian and Chinese origins, appeared to be strongly
influenced by the infant-feeding practices of their hosts. Similarly although 97 per
cent of Indochinese immigrant mothers living in Northern California claimed to have
breastfed their last infants before emigration (Romero-Gwynn 1989), only 22 per cent
breastfed their last infant born in the U.S., and only 3.8 per cent of the 26 pregnant
women interviewed intended to breastfeed.
Furthermore, the duration of
breastfeeding fell from around 20 months for the last child born in Indochina to 8.7
months for the last infant born post-emigration. Similar changes in the prevalence
and duration of breastfeeding are reported by Evans et al. (1975) among Asian
immigrants in Wolverhampton, Rossiter (1998) among Vietnamese mothers in
13
Sydney, and Koctürk and Zetterström (1986) among Turkish female immigrants
living in the suburbs of Stockholm.
Although support for such findings is widespread, some authors contend that,
upon closer inspection, patterns vary depending on immigration status. If a woman is
born outside her host country then she is more likely to breastfeed, and to do so for
longer, than if she is second generation although all this research is from the US (e.g.
Celi et al. 2005; Bonuck et al, 2005). Using data from a longitudinal birth cohort
study, Gibson-Davis and Brooks-Gunn (2006) argue that Hispanic Americans have an
85 per cent reduction in the odds of breastfeeding in comparison to foreign-born
Hispanic mothers and a 65 per cent decrease in the odds of breastfeeding at six
months, despite the latter’s lower socio-economic status. Moreover having a U.S.born partner leads to an 83 per cent fall in the odds of breastfeeding initiation and a
reduction in breastfeeding at six months. Finally, for every additional year either
parent has lived in the U.S. there is a 4 per cent lower chance that an infant will be
breastfed. Singh, Kogan and Dee (2003) claim that the degree of acculturation
experienced by Hispanics affects breastfeeding initiation and duration in the United
States. They find that U.S.-born Hispanic children with either both U.S.-born
Hispanic parents or only one foreign-born parent are the two groups most adapted to
American life and therefore less likely to initiate and sustain breastfeeding than the
least acculturated and most recent immigrant group, foreign-born Hispanic children
and their immigrant Hispanic parents. A similar conclusion with regards to
acculturation is reached by Harley, Stamm and Eskenazi researching low income
mothers of Mexican descent in the US.
Factors other than acculturation are listed as driving immigrants’ attitudes and
conduct in relation to breastfeeding. Some claim that easy access to and the
widespread availability of formula milk in host countries lead immigrant mothers to
adopt bottle-feeding (Evans 1978; Jivani 1978; Nguyen et al. 2004; Romero-Gwynn
1987). A closely related argument is that immigrants are likely to want to emulate the
habits of the dominant population (Golin, Marzari and Zanardo 2003; Groleau,
Soulière and Kirmayer 2006; Jivani 1978), especially given the lack of support that
many migrants experience, which leave them unable to uphold the postnatal customs
and traditions practiced in their countries of origin (Romero-Gwynn 1987; Rossiter
1998). De la Torre and Rush (1987) explain that Mexican agricultural migrants in the
U.S. are more likely to breastfeed if they have the chance to observe La Cuarentena
(40 days of rest after giving birth), a finding confirmed by Hernandez (2006). The
gap between host populations and immigrants’ cultural beliefs surrounding
breastfeeding and the postnatal period is (Groleau, Soulière and Kirmayer 2006) is
evident from a qualitative study of Vietnamese women living in Canada. The
inability of mothers to practice the postnatal rituals typical in Vietnam reduce their
odds of breastfeeding not only by shortening their rest period after giving birth but
also by shaping their perceptions of their health as lactating women. Despite
recognizing the superior value of breast over formula milk, Vietnamese mothers in
Canada, like their counterparts in Sydney, Australia (Rossiter 1998), believe that
because of their ‘weak’ state of health, their milk lacks the essential nutrients
normally generated by lactating women and is, therefore, of inferior quality to the
commercially available varieties.
14
The reduction in the prevalence and duration of breastfeeding among
immigrants has also been attributed to a lack of support by health professionals in
receiving countries, and has led to calls for culturally-sensitive and language-specific
education programmes that encourage breastfeeding (Denman-Vitale and Murillo
1999). The absence of professional guidance along with a lack of public display of
breastfeeding in countries such as the U.S. (Romero-Gwynn 1987) creates the
impression among immigrants that formula milk is an advantageous alternative to
maternal milk. While several studies report that immigrant women frequently give
physical reasons (such as lack of breast milk, sore nipples, infant’s refusal to suckle)
for either not breastfeeding exclusively or weaning their children early (Goel, House
and Shanks 1978; Koctürk and Zetterström 1986; Rossiter 1998), such considerations
are often not perceived as acceptable explanations for the extensive uptake of bottle
feeding following emigration. Alternative suggestions include the pressure to return
to work, considered to be great among certain groups of immigrants (de la Torre and
Rush 1987; Harley, Stamm and Eskenazi 2007; Koctürk and Zetterström 1986;
Romero-Gwynn 1987; Rossiter 1998), the lack of familial and community support
available in the host country (Celi et al. 2005; de la Torre and Rush 1987; DenmanVitale and Murillo 1999; Groleau, Soulière and Kirmayer 2006; Rossiter 1998; Singh,
Kogan and Dee 2007), especially for those born there, as well as the possibility that in
their countries of origin breastfeeding is widely prevalent and long-lasting not
because it is seen as the best form of infant feeding but because commercial formula
milk is unavailable, inaccessible and/or expensive (Romero-Gwynn 1987).
Infertility
Studies on migrants’ attitudes towards and ways of coping with involuntary
childlessness are rare in the reproductive health literature. Among Turkish
immigrants social parenthood motives are more important than for Dutch natives
(Van Rooij, Balen and Hermanns 2006). This means that Turkish immigrants view
children as a means of achieving adulthood and strengthening identity, as a way of
ensuring continuity beyond an individual’s life, and as the outcome of social pressures
to procreate. However, with a greater degree of acculturation, Turkish and Dutch
intentions begin to merge and individual motives for reproducing (such as happiness
and well-being) start to dominate. The reasons behind such disparities are only
considered cursorily, and definitions of both individual and social parenthood motives
are very narrow.
A more concerted effort to understand immigrants’ experiences of infertility is
made by Schmid et al. (2004) in their study of involuntary childlessness among
Austrian and Muslim immigrant women living in Austria. They find that Muslim
women suffering from polycystic ovary syndrome (PCOS), a side-effect of which is
often infertility, are significantly much more distressed than Austrian-born women
due to a number of reasons: the greater pressures they experience as Muslims to have
children, their difficulties in communicating with doctors because they lack
knowledge of the local language, and the embarrassment they feel they have to
undergo during infertility treatment as a result of having to reveal their medical
histories in front of relatives or husbands who act as their interpreters. Given that
stress has a negative impact upon infertility treatment, Schmid et al. suggest it is
likely that Muslim immigrants in Austria end up having even more difficulties
15
conceiving. A more in-depth look at foreign-born women’s encounters with infertility
is provided by Yebei (2000) in her study of Ghanaian immigrants living in The
Netherlands. She calls for health providers to be more sympathetic to those affected
by problems conceiving in a foreign country. While Ghanaian women always
approach Dutch infertility clinics first upon realising that they are experiencing
difficulties having a baby, their frustration at doctors’ attitudes and their inability to
communicate their concerns, often push them to seek non-biomedical treatment, such
as herbal remedies or spiritual healing.
All three studies are important in identifying some of the issues that
immigrants experiencing involuntary childlessness are forced to deal with. Yet they
also show that different immigrant groups have distinct solutions for the problems
they undergo, influenced by the experiences and values of their cultures of origin.
Moreover, they have their own perceptions of what has caused their infertility, which
they have to learn to reconcile with the biomedical explanations encountered when
seeking treatment.
Reproductive health services
The majority of the articles covering reproductive health services examine
immigrants’ perinatal health via issues surrounding labour, modes of delivery and
birth outcomes; a further eight focus on experiences of and access to antenatal care,
and four on postpartum or postnatal health. Differences between immigrants’ and
non-immigrants’ encounters with reproductive health services are communicated by
all of the reviewed studies. Although the majority establish that the migrants receive
poorer quality care than non-migrants not all find enough evidence to suggest that the
maternal and child health outcomes of immigrants are significantly worse than those
of their hosts (Reichman and Kenney 1998; Sherraden and Barrera 1996). Moreover,
immigrants often simultaneously express positive and negative views concerning
reproductive health services, with the latter not always outweighing the former.
Finally, though immigrants’ experiences of locating and accessing services concern
many of the studies under review, the provision of care received once entry has been
achieved, and perceptions of it, are equally at the core of research efforts.
The timing of migrants’ entry to prenatal care is a common theme. Reichman
and Kenney (1998) find that white women born in Mexico and Puerto Rico begin
prenatal care later than their U.S.-born counterparts, although only the latter have a
significantly higher risk than non-Hispanic whites and other Hispanic whites of
having a low-birth-weight baby. Bamford (1971) observed that most immigrant
Asian women living in Bradford, UK, delayed booking antenatal care until the second
trimester, and a greater proportion of foreign-born Asians compared to the host
population did not attend prenatal services until the third trimester. Sherraden and
Barrera (1996) reveal similar findings with regard to Mexican immigrants in the US,
and in their own small study of Mexican immigrants in Chicago, the majority of
women (68%) begin care in the first three months of becoming pregnant, 15 per cent
in their second trimester, and 17 per cent in the third, even though most do not have
difficulties locating prenatal care. More surprising, is Mexican immigrants’
disinclination to attend their antenatal appointments and to sustain enrolment in
16
prenatal care, an observation also made by Bhagat et al. (2002) among immigrant
Punjabi women in Canada.
The factors that determine immigrants’ timely entry into antenatal care and
whether or not they follow through a prenatal programme are numerous. Fullerton et
al. (2004) claim that the absence of social support networks and low levels of
acculturation are key barriers to early entry into and strict adherence to prenatal care
among Hispanic women living on the El Paso Texas/Juarez Mexico border.
Difficulties with language and communication between immigrants and antenatal
staff, long waiting times, concerns about the cost of care and lack of health insurance,
depression, a lack of energy and a fear of medical procedures all contributed to the
low and irregular use of prenatal care among Mexican immigrant women (Sherraden
and Barrera 2002). However, Stengel et al. (1986) show that the number of antenatal
visits is significantly higher among employed than non-employed immigrant women
residing in France, even controlling for duration of stay, knowledge of French and
educational level. These findings are consistent with Comino and Harris’ (2003)
conclusion that women who are socio-economically advantaged are more likely to
attend Maternal and Infant Services, irrespective of whether they are migrant women
from non-English speaking backgrounds living in south-western Sydney or
Australian-born women.
The need to improve services for foreign-born women is expressed by all the
studies reviewed. Tsianakas and Liamputtong (2002), make several suggestions
based on in-depth interviews with 15 Muslim women living in Melbourne, Australia.
Although respondents praised the standard of Australian prenatal care compared to
that available in their countries of origin, they were disheartened by the ignorance and
disrespect by hospital staff towards some of their beliefs (such as their aversion to
prenatal testing and preference for seeing a female doctor) and practices (such as
wearing the hijab and remaining covered up during medical examinations). Tsianakas
and Liamputtong argue that in order to shed Muslim women’s negative attitudes
toward antenatal care and services, and improve their experiences, Australian staff
need to communicate with and educate their patients about the procedures to be
undertaken but also to respect some of their wishes. According to Bhagat et al.
(2002) involving immigrant communities in the development of prenatal care
programmes to address their particular needs is a good way of encouraging them to
access services and maintain links with them throughout their pregnancies. This
might be particularly effective in promoting care among women who have low levels
of social support and poor health behaviours during pregnancy (Harley and Eskenazi
2006).
Although postponing antenatal care does not always lead to adverse maternal
or child health outcomes, it can do so. Robertson, Malmström and Johansson (2005)
discover that a 50 per cent higher risk of ‘non-normal’ birth (that is, with diagnosed
complications intrapartum) is associated with fewer antenatal care visits among
women from Sub-Saharan Africa, Iran, Asia and Latin America living in Sweden than
Swedish-born ones. Treacy et al. (2007) present evidence which shows that in Ireland
a considerable number of immigrant women are ‘late bookers’ or ‘unbooked’ for
prenatal care but a growing number of immigrants to Ireland arrive just before they
17
are due to give birth6. While the ‘unbooked’ have a higher rate of spontaneous vertex
delivery, the ‘late bookers’ are more likely to have a caesarean section and for their
infants to be preterm, have low birth weight or to have a higher rate of neonatal ICU
admissions. David, Pachaly and Vetter (2006) find that Turkish immigrants in Berlin,
Germany, go late for their first antenatal appointment and also display high rates of
pre- and post-partum anaemia and possibly a higher rate of congenital deformities
than German-born women. Despite evidence of a negative correlation between the
frequency and duration of antenatal care and birth outcomes, however, none of the
above studies explore the reasons behind immigrants’ propensity to delay entry into
prenatal care and to regularly skip antenatal check-ups or classes.
The quality of care foreign-born women are given during the labour process is
different from that offered to native-born women, resulting in worse birth outcomes.
Women in Sweden from Sub-Saharan Africa, Iran, Asia and Latin America have a
higher age-adjusted risk of ‘non-normal’ childbirth than Swedish-born women that
persists even after adjusting for parity, education, number of antenatal care visits and
complications in pregnancy (Robertson, et al 2005). Moreover, among women who
experience complications in pregnancy, those from Turkey, Iran, Asia and Latin
America have over 50 per cent higher risk of ‘non-normal’ childbirth than Swedishborn women. In The Netherlands, van Roosmalen et al. (2002) report that a higher
frequency of substandard care is responsible for immigrant versus indigenous
maternal deaths. Two studies discuss the relationship between quality of care and the
incidence of caesarean sections among immigrant populations but take opposing
views as to whether a caesarean delivery is a sign of high or poor quality care. Diani
et al. (2003) claim that between 1992 and 2001 non-EU women in Italy were more
likely than Italians to have very low birth weight babies and to deliver by caesarean
section, which in their view represents inadequate care. David, Pachaly and Vetter
(2006, on the other hand, show that Turkish immigrants residing in Germany are
given epidural anaesthesia less often and have less frequent operative deliveries,
which to them is indicative of inferior quality care. This contradiction in the literature
illustrates the unsuitability of words that describe reproductive health in terms of
‘good’ or ‘bad’.
Foreign-born women do occasionally have better birth outcomes than their
native-born counterparts. U.S.-born Korean women are significantly more likely to
give birth to premature infants than foreign-born mothers (Cho et al. 2005), despite
fewer social resources and greater social isolation of the foreign born. This may be
due to immigrant Koreans’ more favourable maternal age, education and prenatal care
visit status compared to U.S.-born Koreans. Foreign-born Mexican women have
better perinatal outcomes than their U.S.-born counterparts, even though they are less
well educated and initiate antenatal care later possibly due to Mexican Americans’
greater use of tobacco and alcohol, less familial and social support, and increased
incidence of unwanted pregnancies (Madan et al. 2006). Wingate and Alexander
(2006) support Madan et al.’s conclusion by showing that infants born to mothers of
Mexican migrants living in the U.S. have the lowest rates and lower risks of adverse
birth outcomes compared to U.S.-born mothers of Mexican descent.
6
This is likely due to Ireland’s nationality law, which states that a person may become an Irish citizen
through birth, irrespective of whether his or her parent(s) is an Irish citizen.
18
Irrespective of outcomes, immigrants’ experiences of perinatal health are not
always positive and efforts to understand why continue to be vital. Small et al.
(2002), for instance, find that 27 percent of Vietnamese, 48 per cent of Turkish and 39
per cent of Filipino women residing in Victoria, Australia, were happy with the care
they received during labour, compared to 61 per cent of women who completed a
state-wide survey. Immigrant women were particularly dissatisfied when their
caregivers were viewed as hostile, unaccommodating or upsetting, when they felt a
lack of control over the labour process, when particular procedures were not
explained to them, when they were left on their own and when they were unable to
communicate their concerns with midwives or doctors. Another Australian-based
study (Rice and Naksook 1998) reaches similar conclusions after investigating Thai
immigrant women’s experiences of pregnancy and childbirth. Although most
respondents were generally satisfied with the care provided during their antenatal care
and hospital stay, language problems often caused them to feel anxious, as did the
behaviour and attitudes of the midwifery-staff.
The grievances expressed by immigrants in relation to perinatal care have also
been articulated in connection with postnatal care. Sword, Watt and Krueger (2006)
compare postpartum health of immigrant women living in Canada four weeks after
leaving hospital, with that of Canadian-born women. The former are more likely to
report having poorer overall health with a greater chance of developing postpartum
depression. In addition, they are more frequently in need of financial and domestic
assistance, social support, as well as information about where to go in order to receive
help. Yelland et al. (1998) communicate equally negative views among Filipino,
Turkish and Vietnamese women with respect to their postnatal care in Australia. One
in three foreign-born women, they claim, leave Australian postnatal wards feeling
dissatisfied with the information, advice and care they have received for themselves
and their babies. A particular source of discontent revolves around the issue of
breastfeeding. Although 81.1 per cent of women intend to breastfeed, following birth
only 63.2 per cent do so exclusively, and 21.1 per cent use a combination of bottle
and breast milk, while over seventy per cent feel that they require more support with
feeding methods. Finally, only a quarter of low-income Hispanic women return for
their one-year family planning visit because they are not made sufficiently aware of
its significance to their overall health (Jones et al. 2002).
Although communication difficulties between immigrants and hospital staff
have been described as a major source of discontent about antenatal, perinatal and
postnatal health among the former (Davies and Bath 2001; Jayaweera et al. 2005;
Minkler 1983), cultural barriers are also frequently mentioned in the literature.
Somali immigrants in Norway suffer considerable distress during labour and delivery,
and thus surplus complications, as a result of Norwegian doctors and midwives’ lack
of familiarity in dealing with women who have been circumcised (Vangen et al.
2004). Hmong immigrants living in the U.S. have equally disagreeable experiences
of labour and delivery because local health providers fail to appreciate the fact that
invasive procedures, particularly incisions, contravene some of their cultural mores
(Faller 1985). Likewise, U.S. health providers’ ignorance regarding South Asian
Indian sexual education, sexual behaviour and childbirth experiences contribute to
immigrants’ dissatisfaction with perinatal care (Fisher, Bowman and Thomas 2003).
In their study of Thai mothers in Australia, Rice, Naksook and Watson (1999) show
that despite most women being happy with their postpartum care in hospital, a few
19
believe that they are unable to carry out their traditional Thai confinement practices
following birth, which mostly involve resting and receiving a hot rather than a cold
drink.
Antenatal, perinatal and postnatal health programmes that seek to narrow the
cultural distance between immigrant patients and their carers are called upon by a
number of authors (Hutchins and Walch 1989; Minkler 1983), while others
(Jayaweera, D’Souza and Garcia 2005; Small 2002; Yelland et al. 1998) suggest the
need for schemes that go beyond overcoming cultural barriers. Yelland et al. (1998),
for example, note that although 45 per cent of Filipino, Turkish and Vietnamese
immigrants living in Australia believe that caregivers are ignorant of their cultural
beliefs and practices regarding the postnatal period, 74.4 per cent feel that this is not a
concern. Small et al. (2002) argue that efforts to improve local health providers’
cultural awareness may lead to the development of cultural stereotyping. Instead, it is
best to concentrate on improving relations between staff and patients by ensuring the
former are better equipped to deal with non-English speaking women with dissimilar
attitudes to perinatal care than their own. Simply making immigrants aware of the
procedures to be undertaken throughout their pregnancies and labour, and making
sure that they are understood is, according to Small et al., likely to ameliorate foreignborn women’s experiences of perinatal care. Understanding the effects of welfare
policies on access to services is also important (Joyce et al. 2001). As Jayaweera et
al. (2005) contend making certain that immigrant women have access to information,
through community-based support organisations, about health care benefits is an
essential step in building relations of trust between them and local health providers.
Conclusions
This literature review has provided an overall picture of what is known about
international, first-generation, legal immigrants’ experiences of reproductive health in
Europe, Australia and North America by focusing on six closely related topics:
fertility, abortion, contraception, infertility, breastfeeding and reproductive health
services. Its aim has been to highlight the strengths and weaknesses of individual
studies concerning each aspect of reproductive health, to draw attention to the overall
themes that the literature covers and to expose the gaps in research carried out so far.
The first point to emerge out of this review is that generalisations regarding
migration and reproductive health are misleading. The experiences of migrants vary
depending on where they come from and where they settle, the conditions they face in
the receiving country upon settlement, as well as their personal background, including
age, gender, education, cultural beliefs and values, aspirations, and migratory and
medical history. The second is that migrants do not always suffer from worse
reproductive health than their hosts; their outcomes may be better or just different.
Thirdly, while it is impossible to predict migrants’ approaches to reproduction and
reproductive health, it is useful to test them against the four hypotheses developed in
the literature on fertility and migration - socialisation or assimilation, adaptation,
selection and disruption. For example, studies on contraception, suggest that
immigrants are usually reluctant or slow to adopt the host society’s prevalent birth
control methods and therefore mainly show signs of assimilation or socialisation. The
breastfeeding literature, on the other hand, clearly provides evidence of adaptation.
20
This is not always due to immigrants’ overwhelming desire to bottle-feed. It is also a
product of the difficulties they experience in being able to hold on to traditional infant
feeding methods7. Although immigrants’ approaches to infertility and abortion reveal
a degree of socialisation, there are not enough examples available to reach any general
conclusions, whereas research on reproductive health services presents clearer
evidence of assimilation and some signs of disruption due to difficulties in
communication between immigrants and local health providers.
The fourth point that the review brings to light is that cultural and linguistic
miscommunication between migrants and their hosts frequently have a negative
impact upon the reproductive experiences and health of the former. This is
particularly evident in the literature on breastfeeding, infertility and reproductive
health services. Consequently, culturally-sensitive and language-specific programmes
that bridge the gap between migrants and non-migrants’ understandings of
reproduction and reproductive health are in need of development. Migrants’
perceptions of health and illness do not always match the biomedical models on
which health professionals in the selected destination countries rely in order to come
up with a diagnosis and provide treatment. Finally, the studies reviewed show that the
level of familial, community and professional support has a major influence upon
migrants’ approaches to family-formation, contraception, abortion, infertility and
breastfeeding, and therefore also upon their reproductive health and use of related
services.
Despite the spread of issues covered by the literature, several topics remain underresearched and a number of questions remain unanswered. To begin with there is a
lack of data on the reproductive health of different immigrant groups both within and
between countries, whilst existing data are often incomparable due to an absence of
consensus on what constitutes health, including reproductive health, and on who is a
migrant as opposed to a member of an ethnic minority or a non-migrant. This issue
has been raised in other reports on migrant health (Carballo and Mboup 2005; Ingleby
et al. 2005; Mladovsky 2007a). A dearth of studies into migrants’ experiences of and
attitudes towards abortion and infertility, as well as a narrowness of focus, is further
apparent from the review. More attention ought to be paid to the connection between
abortion, contraception and fertility. Aspirations regarding family-formation and
family size often determine how individuals use and perceive contraception, which in
turn may influence the number of unwanted pregnancies and, consequently, the
number of abortions. Likewise, ways of dealing with infertility ought to be looked at
together with attitudes towards the family, parenthood and reproduction in general.
Yet the biggest gap identified relates to the relationship between migration,
culture and reproductive health. The majority of studies reviewed fail to provide indepth accounts of how cultural factors shape ‘the particular ways in which
reproductive events are associated with health outcomes’ (Obermeyer 2001). This is
related to the limited number of anthropological and ethnographic studies with a focus
on migrant reproductive health (for exceptions see: Sargent 2003, 2006; Bledsoe,
Houle and Sow 2007) and, as a result, inattention to broader definitions of
It is also questionable whether the prevalence and duration of breastfeeding among
immigrants would fall to the extent that the studies reviewed demonstrate if similar
investigations were undertaken in destination countries where breastfeeding is more
popular such as Scandinavia.
7
21
reproduction discussed in the ‘Anthropology of reproduction’ section (p.4). As
Petchesky (1984, p.6) reminds us a ‘woman’s reproductive situation is never the result
of biology alone, but of biology mediated by social and cultural organization.’ Paying
closer attention to the social and cultural origins of reproductive behaviour and
attitudes would provide insight into migrants’ decision-making processes regarding
their reproductive health, and help explain why migrants may act in, what appear to
health professionals to be irrational ways when it comes to making such decisions.
Incorporating this perspective would also involve looking at the global and local
power relations that shape migrants’ reproductive health ‘choices’ and the gender
relations and ideologies that underpin them. Consequently, migrants’ resistance
strategies to dominant ideologies about how they should manage their reproductive
lives and health would be made apparent. Understanding migrants’ motives for
wanting or not wanting to reproduce post-migration by exploring such issues as
legitimacy, identity and the value of children would add another helpful dimension to
the study of reproductive health approaches among foreign-born populations.
The non-comparative nature of existing research on the subject of migrant
reproductive health is a reflection of the absence of work in the above vein and also
needs to be addressed. As Mladovsky (2007a, p.28) points out in reference to migrant
health in general, few studies compare countries of origin and destination in order to
understand the ‘health norms, culturally relevant methods of research and treatment,
and the expectations and health beliefs of migrants.’ Those wishing to explore
migrants’ access to and use of reproductive health services will also find that,
although there are important differences in how health care systems are organised in
sending and receiving countries, none of the studies reviewed look at the impact that
this may have on different immigrant groups’ ability and willingness to approach
reproductive health services. A final gap in the literature reviewed concerns
immigrant groups with distinct migratory histories rather than just diverse origins.
The impact of moving upon individuals can differ considerably depending on, for
example, whether they are foreign- or native-born, first-generation migrants who
moved to the host society as infants, children or adults, or second-generation migrants
conceived, born and raised in the host society by foreign- or native-born parents or
even grandparents (Núñez-de la Mora et al. 2007). Conducting reviews of immigrants
with similar status and ethnicity yet of different migratory intentions is also useful.
For example, temporary or return migrants are unlikely to have the same reproductive
health attitudes and practices as those who are intending to stay in the receiving
country for the long-term.
The above challenges will only be overcome if more studies are conducted with
an inter-disciplinary focus on migrant reproductive health. These should be both
quantitative, such as epidemiological surveys with an appropriate disaggregation of
different migrant populations, and qualitative, or ethnographic, in character. While
the former would enable the collection of new data on migrant populations and thus
improve our understanding of the reproductive health issues that confront them, the
latter would deepen our knowledge of the socio-economic, political and cultural
forces that contribute to reproductive health inequities between specific migrant
groups and their hosts.
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