Determinants and barriers of adequate antenatal care among Afghan women in Iran; findings from a community-based survey in Iran


 Background: Almost a third of Afghan women living in Iran are at childbearing age. Antenatal care (ANC) is an inextricable part of healthy pregnancy and could prevent the adverse birth outcomes. There are several factors that affect the access and utilization of such services among Afghan women. Therefore, in the present study, we aimed to explore the sociodemographic determinates and potential barriers of adequate ANC among Afghan women in Iran.Methods: A cross sectional study was conducted between June 2019 and August 2019. Using time location sampling (TLS), we recruited 424 Afghan women aged 18-45 years old at three health centers in south Tehran. A questionnaire was developed based on a preceding qualitative study and literature review. The data were collected on sociodemographic characteristics and the reported reasons for inadequate ANC and analyzed applying bivariate, and multivariate analyses. Factor analysis was performed to reduce the number of potential reasons for inadequate ANC in order to improve the precision of regression analysis. The STATA software version 14 was used for data analysis.Results: Almost a third of Afghan women in this study had adequate ANC (≥ 8 visits). The respondent’s age, education, employment, family income, length of stay, and legal status were the most important determinates of adequate ANC among Afghan women. In multivariate analysis, after adjustment for other variables, only the poor knowledge and attitude toward ANC; poor quality of services; and to some extent, the difficulties in access were the main obstacles in having adequate ANC among the study population. Conclusion: Our study emphasized the important role of specific sociocultural and demographic characteristics on access to ANC among Afghan women in Iran. In fact, these factors need to be considered in future policies and interventions in order to improve the maternal and child health and reduce the birth complications among Afghan population. The collaboration between central government with international agencies should be directed toward enhancing the social support, promoting the awareness and knowledge, and expanding the safety net services for Afghan women in Iran.

The maternity care is of great importance in normal growth and development of baby in prenatal period. A successful fetal life and safe delivery not only ensure the health of newborns but also has a grave impact on their adult life. Therefore, antenatal care is an inextricable part of maternal and child health (1). Perinatal health depends on a variety of factors and could differ to a great extent in different populations (2). Most of the child problems such as congenital abnormalities, prematurity, and abnormalities in fetal growth could be prevented by early diagnosis in antenatal period.
Therefore, adequate and scheduled antenatal care is essential to ensure the child and maternal health (3). Studies have shown that the perinatal mortality and morbidity could be three times higher in some underprivileged areas and populations whose access to antenatal care (ANC) is inadequate (4).
Immigrants and refugees are among the most vulnerable populations in host country; the violence, discrimination, and deprivation of civil rights in host country could endanger their health, particularly the most vulnerable groups such as pregnant mothers and children (5). Inadequate access to appropriate antenatal care contributes to a substantial amount of adverse birth outcomes (4). Iran has been a popular destination for Afghan refugees and immigrants since the Soviet war in 1979, with an estimated 3 million Afghans refugees and immigrants currently living in the country. About half of them are not registered and considered as illegal immigrants (6,7). The majority of them are young and almost a third are young women at the child bearing age (8).
Since 2016, all legal Afghans in Iran became eligible to apply for public health insurance (5). However, for some unknown reasons, it appeared that many Afghans did not apply for and do not own it. In a preliminary qualitative study, we found that it is either due to the unawareness or dissatisfaction of insurance coverage (unpublished observation). Unfortunately, there is lack of further knowledge in this regard. However, the important fact is that lack of health insurance could reduce the access to health system for Afghans in Iran. It is more critical for the women of childbearing ages whose health, especially during the pregnancy, is critical to prevent the adverse birth outcomes (9). Therefore, building capacity to facilitate the access to health system for this vulnerable group and addressing their maternity and reproductive needs are necessary. Beside the health insurance, several obstacles could reduce the access to quality and adequate maternity care among young Afghan women in Iran.
These need to be considered in future policies and interventions. However, this requires deep understanding of current situation and identification of potential barriers toward adequate ANC among Afghan women.
Thus, in a preliminary qualitative research in 2019, we explored the potential barriers and concerns of Afghan women toward adequate antenatal care (ANC) in Iran (unpublished observation). We interviewed 30 Afghan women living in Tehran and the results have been used to create the platform and develop and questionnaire and conduct the present survey in order to estimate the prevalence of potential barriers and determinants of access to maternity care in Afghan women in Iran. In present study, we conducted a survey including 424 Afghan women of both legal and illegal backgrounds to estimate the prevalence of identified barriers and examine the association of sociodemographic factors and perceived barriers with the adequate utilization of ANC.

Study setting
A cross sectional study was conducted among Afghan women from June 2019 to August 2019. Based on the consultation with the experts at Tehran University of Medical Science and Iran Ministry of Health, the south region of Tehran where the highest number of Afghan nationals are living in Tehran province, was selected as the study setting.

Sample size
Based on the literature review (10), with the conservative assumption of access to antenatal care not to be less than 50%, confidence level of 95%, a relative precision of 5% points on each side, and a response rate of 90%, the sample size was estimated at 427. However, we could conduct 424 face to face interviews with 100% response rate. There was no drop out or withdrawal during the study.

Sampling method
Afghan population, particularly the illegal ones, are hard to reach in Iran; therefore, we employed a time -location sampling (TLS) approach to recruit the participants in the present study. First, we identified the common places and times that Afghan females visit to receive maternity care. It appeared that community health centers are the most popular places for maternity care among Afghan women in morning time. All the community health centers in south Tehran were identified and three centers with the highest number of Afghan visitors were selected as the study sites. We visited these centers in the morning time during the working days of four consecutive weeks in July. A random sample of 424 Afghan women, who met the eligibility criteria and consent to participate, were recruited proportionately to the size of Afghan population visiting the corresponding community health center.

Inclusion and exclusion criteria
The eligibility criteria were; being an Afghan national, aged 18-49 years, and given birth or being pregnant during the year before interview, lived in Iran at least a year and during the time of pregnancy. We excluded the women with any mental or physical disabilities that affect their access to maternity care, those who visited or stayed in Afghanistan during their pregnancy, those who suffer from infertility, and those who did not consent to participate.

Instrument and variables
The questionnaire was developed based on the findings from a preliminary qualitative research, a comprehensive literature review, and consulting the experts at Kyoto University and Tehran University of Medical Science. The questionnaire collected the data on participants' sociodemographic characteristics including the age, education, employment, family income (< 4 million vs ≥ 4 million-Iranian Toman), legal stratus (legal vs illegal), length of stay (< 5 years vs ≥ 5 years), parity, husband employment, and education. It also contained 17 questions asking about the barriers to ANC identified in the preliminary qualitative study. The answers were marked as yes/no. In addition, data on the number of ANC (< 4, 4-8, ≥ 8), usual place of visit for ANC (community health center, government hospital, private sector) were also collected. The cut-off for adequate ANC visits (≥ 8 visits during pregnancy) was selected based on the WHO recommendation (2016) for the optimal number of antenatal visits during pregnancy (11).

Data collection
A pilot study, including 12 participants was performed to test whether the questionnaire was comprehensible and appropriate, and that the questions were well defined, clearly understood and presented in a consistent manner. Patient information statements and consent forms were also tested for comprehension. The main interview took place after the pilot study. The interviewers were Afghan graduate midwifery students in Tehran University of Medical Science. The participants were randomly approached by the interviewer during the visit of community health center. A brief introduction of study and its objectives were explained for each participant prior to the interview. Given a verbal consent, the woman was entered the study and a written consent was also obtained. Data were collected in the questionnaire through face to face interviews with Afghan women. Interviews were conducted in Persian and each lasted approximately 15 minutes. At the end of interview, the women's concern regarding healthy pregnancy, child health and nutrition were addressed by the interviewers.

Data analysis
The descriptive statistics were employed to describe the distribution of sociodemographic characteristics, the number of ANC (Table 1), and the prevalence of potential barriers and the reasons for inadequate ANC (Table 3) among Afghan women. To examine the relationship between sociodemographic factors (Table 2) and reported reasons (Table 3) with inadequate ANC (< 8 visits), chi-square test was employed and the crude odds ratios (OR) and 95% confidence intervals (95%CI) were reported (Tables 2 and 3). The explanatory factor analysis was employed to explore the potential correlation between reported reasons for inadequate ANC and extract the underlying component factors grouping the correlated variables (eigenvalues > 1). This helped us to reduce the number of variables and thus to increase the power of regression analysis. Four component factors were emerged after varimax rotation; including poor knowledge/attitude toward ANC, difficulties in access, poor quality of services, and sociocultural/legal issues ( Table 4). The association between these component factors and adequate ANC was also examined (Table 4). Eventually, multivariate logistic regression analysis was performed, including the sociodemographic variables and component factors in equation, to explore the relationship between the component factors with inadequate ANC after adjusting for sociodemographic variables ( Table 5). The variables with P-value < 0.25 in bivariate analysis, were included in regression equation following the instructions of Hosmer and Lemeshow (12). In a step-wise manner, retaining the significant factors in equation, the best regression model was constructed using the likelihood-ratio test for goodness of fit. The STATA software version 14 was used for data analysis. P-value less than 0.05 was determined as significant statistical level.

Ethical consideration
The protocol of present study was reviewed and approved by the Institutional Review Board (IRB) of both Graduate School of Medicine, Kyoto University (Ethic code: R1836) and Tehran University of Medical Science (Ethic code: 1397.945). The objectives of study, potential harms and benefits were explained for all participants and an informed written consent was obtained thereafter. Table 1 The distribution of sociodemographic characteristics of participants

Sociodemographic Characteristics
A total number of 424 Afghan women aged 18-45 years old enrolled in this study. The majority of them (44.3%) were in 25-34 age group and had no education (37.7%). Almost half of them had a job.
More than half of them (56.6%) had 2-4 pregnancy experiences. In term of the husband education and employment, 27.8% of them had high school or higher education and almost all of them (98.1%) were employed. The family income was more than 4 million Toman (11500 Iranian Toman = 1 USD) in about half of the households. More than 60% of participants were legal immigrants. Only 120 participants (45.5%) of legal immigrants had health insurance (Table 1).  Table 2 The association between the sociodemographic factors and adequate ANC (≥ 8 visits) in Afghan women   Total 272 152 1 composed of: "I was healthy", "I think it is unnecessary". 2 composed of: "Expenses were unaffordable", "Clinic was too far", "Poor transportation" 3 composed of: "The services were not good", "Long waiting time" 4 composed of: "Scare of / being discriminated or poorly treated", "Religious and cultural reasons", "Fear of arrest/deportation", "No one to accompany me" c) Poor quality of services Poor quality of services appeared to be a significant obstacle in having adequate ANC in both bivariate (crude OR = 0.38; 95% CI [0.24-0.60]) and multivariate analyses (adjusted OR = 0.17 95% CI [0.07-0.41]). d) Sociocultural/legal issues The sociocultural and legal issues such the fear of being discriminated or poorly treated, religious and cultural concerns, and fear of deportation or arrest were respectively reported among 61.8%, 52.9%, and 44.1% of those with inadequate ANC. Accordingly, these issues were negatively associated with adequate ANC in bivariate analysis (crude OR = 0.50; 95% CI [0.33-0.75]). However, adjusting for other variables in multivariate analysis, reduced the cumulative impact of these issues on adequate ANC among Afghan women (adjusted OR = 0.46; 95% CI [0.19-1.10]).

Determinants Of Access
The education and socioeconomic status are some the most important determinants of access to healthcare (14). A number of surveys, in both developing and developed countries, have shown that the population with higher education and socioeconomic classes are more likely to have access to quality and adequate healthcare (7,15). Similar findings have been reported among immigrants and refugees (16)(17)(18). In our study, we found that Afghan women with higher education and family income are more likely to have adequate ANC, regardless of their legal status. Higher education has been linked to higher chance of finding a job, higher income, and better living condition (14). Furthermore, it has been shown that the educated mother are more willing to engage in their child health and better recognize the importance of ANC (19). Clearly, the husband education has the similar impact on the utilization of reproductive and maternity cares. Evidence indicate that men with higher education are more likely to contribute to the reproductive needs of their partner (17,20).
Another important determinant of maternal and child health is mother's employment (21,22).
Previous studies indicated that the employed mothers are more likely to have adequate access to ANC (22). In our study, however, we observed that unemployed mother are more likely to have adequate ANC. This could be, in part, due to the fact that employed mothers are less flexible in scheduling their ANC visits. In addition, the fact that they have lower chance in securing a decent job, due to their refugee status, often push them toward jobs with long working hours and no maternity leave. Moreover, in most instances, due to family financial struggles, they cannot afford quitting their job, especially illegal immigrants (23). This substantially reduce their access to ANC. Therefore, developing and implementing appropriate labor market laws by host country that could support maternity leave for refugees and immigrants is necessary.
It has been shown that the recent refugees and immigrants (less than 5 years of arrival) have less access to ANC compared to settled ones (more than 5 years of arrival) (17). Our results similarly indicated that the Afghan women arrived within the 5 years prior to the time of interview, are less likely to have adequate access to ANC compared to those with more than 5 years stay in Iran. This has been attributed to the higher access to health system achieved through familiarization, acculturation, and accustomization of settled population with the host country's health system, culture, and environment (24).
We observed higher rate of adequate ANC (≥ 8 visits) among legal Afghan women, even after adjustment for other variables. The legal status has been recognized as an important determinant of access to the health system in host country (9,25); Several studies have shown that the illegal status of undocumented immigrant could reduce their access to ANC and increase the adverse birth outcomes (13,26,27). One issue is their ineligibility for health insurance. Although in Iran all registered Afghan refugees and immigrants could benefit from public health insurance since 2016, the situation for illegal Afghans in unclear. In addition, this insurance scheme only reimburses for some of ANC services at the primary healthcare level; and the secondary and tertiary prenatal services which are usually expensive are not included in the scheme. Moreover, the ineligibility of illegal immigrants (5). We found that owning the health insurance could increase the likelihood of receiving adequate ANC among legal immigrants. Therefore, first, measures to improve the coverage of health insurance for ANC service and second, laws for universal health coverage of all Afghan refugees and immigrants, at least for the expectant mothers, should be pursued by national government to ensure the maternal and child health in Afghan refugees and immigrants in Iran.

Reasons For Inadequate Anc
Poor knowledge and attitude toward ANC was an important reason for inadequate ANC among Afghan women in this study. The statement "I was healthy" reflected the Afghan women's lack of knowledge in term of the ANC importance for a healthy pregnancy. It was reported by almost half of the participates with inadequate ANC. Furthermore, the poor attitude toward ANC (I think it is unnecessary) which stated by almost two thirds of participants. Previous studies emphasize the importance of education for better reproductive and maternal health for immigrant and refugees in host country (28,29). Likewise, we advocate policies and interventions to enhance the knowledge regarding the reproductive health and maternity care among Afghan refugees and immigrants in Iran.
The poor quality of health care such as long waiting time and poor quality of antenatal services, was one the most important associated factor with inadequate ANC in present study. This finding was in line with the evidence from other developing countries. The weak infrastructure of health system and inadequate number of health professionals in some remote areas; particularly in government sector, reported to be the main reasons for such issues in most developing countries (30,31). Likewise; in Iran, these issues still exists in some remote areas; however, it appears, in big cities such as Tehran, they are not problematic anymore (32). However, our study indicate that these issues still exist in some marginalized population like Afghan immigrants and refugees even big cities like Tehran. They are more evident in government sector such as community health centers and government hospitals (32); where not only receive the highest number of Afghan visitors but also many Iranian citizen who are more vulnerable due to their low socioeconomic status. Therefore, future policies should be directed toward building capacity in order to promote the health services quality in government sector.
Religious and cultural concerns have been reported to be a potential obstacles in receiving adequate ANC and quality delivery services in some strict Islamic states such as Afghanistan (33,34). The gender-sensitive issues such as the restriction of contact between male provider and female patient, are some of the most important religious and cultural barriers toward adequate ANC among Afghans.
This reduces women access to maternity care; specially in countries of west culture in which these issues are often ignored by health providers (34)(35)(36). However, in our study, due to the dominant Islamic culture of Iranian society in which the contact of a female patient and a male provider is also restricted, these issues appeared not to be problematic. In addition, none of the participants complained about unavailability of a female provider. Fear of deportation or arrest was also an important barrier to visit health facilities especially among illegal Afghan refugees and immigrants in present study. We observed this issue in 44% of those with inadequate ANC. Therefore, we suggest expanding the safety net services by collaboration between international and national agencies for refugees support to ensure the adequate access to ANC in this vulnerable group. The fear of being poorly treated or discriminated was also a reason among approximately 60% of those with inadequate ANC. Evidence has shown that the perceived discrimination; feeling of abandonment, and isolation among immigrants and refugees could impact the individual's perceived quality of life and satisfaction in host society (37,38). Similar experiences were reported among Afghan people living in Iran (39). The intercultural incompetency of health personnel has been reported to be the main reason for such issues. The language barrier could also cause such bitter experience (40); however, in Iran, almost all Afghans could fluently speak and communicate in Persian. Thus, we emphasized the necessity of interventions to enhance the intercultural-competency of health personnel delivering health services at Afghan-concentrated communities in Iran. All in all, although the sociocultural and legal issues such as fear of deportation, being discriminated or poorly treated, and religious and cultural concerns; were significantly associated with the inadequate ANC in Afghan women in bivariate analysis, the cumulative effect of these issues turned to be insignificant once we adjusted for other variables in multivariate analysis.
Despite the resourceful findings of present study, there were some shortcomings that reduce the representativeness of results across different Afghan population in Iran. First, we conducted our study in urban areas where usually is the home for those refugees and immigrants with higher socioeconomic status and may not represent the underprivileged rural refugees and immigrants who may be of different sociocultural backgrounds and reproductive needs. However, engaging a random sampling, ensured recruiting participants of different sociodemographic backgrounds to represent the urban population. Therefore, further studies among rural Afghan population is recommended. Second, we recruited the Afghan women at community health centers; therefore, a group of Afghan women whose access to such facilities is limited may have been missed. There were also some participants whose residential status appeared to be illegal and refuse to participate due to the fear of disclosure and potential arrest. Although, we tried to overcome this issue by engaging interviewers of Afghan origin and explaining the objective of this study for them; however, we might loss some valuable information on those who refused to participate.

Conclusion
To the best of our knowledge, this study is the first study exploring the determinants and barriers

Consent for publication
The participants consented for the study to be published but assured of anonymity before interview.
The participants were also given the opportunity to ask questions about the study at any stage, and to withdraw from the study at any time.

Availability of data and material
Data could be available upon a reasonable request and with the permission of Tehran University of Medical Science ethical committee.

Competing interests
The authors declare no conflict of interests.

Funding
There was no source of funding for present study.