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Women's Reproductive Health
ISSN: 2329-3691 (Print) 2329-3713 (Online) Journal homepage: http://www.tandfonline.com/loi/uwrh20
“If You Don’t Have a Baby, You Can’t Be in
Our Culture”: Migrant and Refugee Women’s
Experiences and Constructions of Fertility and
Fertility Control
Alexandra J. Hawkey, Jane M. Ussher & Janette Perz
To cite this article: Alexandra J. Hawkey, Jane M. Ussher & Janette Perz (2018) “If You Don’t
Have a Baby, You Can’t Be in Our Culture”: Migrant and Refugee Women’s Experiences and
Constructions of Fertility and Fertility Control, Women's Reproductive Health, 5:2, 75-98, DOI:
10.1080/23293691.2018.1463728
To link to this article: https://doi.org/10.1080/23293691.2018.1463728
Published online: 02 Aug 2018.
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“If You Don’t Have a Baby, You Can’t Be in Our Culture”:
Migrant and Refugee Women’s Experiences and
Constructions of Fertility and Fertility Control
Alexandra J. Hawkey , Jane M. Ussher and Janette Perz
Translational Research Institute, School of Medicine, Western Sydney University, Sydney, NSW, Australia
ABSTRACT
The present study was designed to explore experiences and con-
structions of fertility and fertility control among new migrant and
refugee women in Sydney, Australia and Vancouver, Canada.
Seventy-eight individual interviews and 15 focus groups (n¼82)
were conducted with women who had migrated from Afghanistan,
Iraq, Somalia, South Sudan, Sudan, Sri Lanka, and South America.
Participants positioned having children as a cultural and religious
mandate and as central to a woman’s identity. Many women had
limited knowledge about contraception, positioned contraception as
forbidden or dangerous, and described negative experiences with its
use. These findings are interpreted in relation to the provision of cul-
turally safe medical practice and sexual and reproductive
health education.
ARTICLE HISTORY
Received 11 November 2017
Revised 9 February 2018
Accepted 28 March 2018
KEYWORDS
Australia; Canada;
contraception; fertility;
migrant and refugee
women; qualita-
tive methods
The ability of a woman to choose whether and when to have children is an essential
human right endorsed by international health governing bodies (UNFPA, 2013; WHO,
2014a). Women’s access to reliable information and to a preferred method of contracep-
tion, free from coercion, discrimination, or violence, is fundamental to gender equality
and makes possible women’s full participation in society (Iba~
nez, Phillips, Fine, &
Shoranick, 2010). Contraception facilitates women’s ability to space or limit the number
of children they have, reduces associated morbidity and mortality, and enables women
to complete their education, thereby improving the economic security of women and
their families (WHO, 2017).
In industrialized Western countries, such as Australia, Canada, and the UK, a range
of hormonal contraceptive methods are available at a low cost through government sub-
sidy programs. Despite this, inequalities in contraceptive use exist among women from
disadvantaged ethnic or racial groups, including women from migrant and refugee
1
communities (Sangi-Haghpeykar, Ali, Posner, & Poindexter, 2006; Aptekman, Rashid,
Wright, & Dunn, 2014). Research conducted in Canada, Australia, and Nordic countries
has shown that, in comparison to native-born women, migrant and refugee women are
less likely to use contraception (Family Planning NSW, 2013; Omland, Ruths, & Diaz,
2014); are more likely to use less effective methods of contraception, such as condoms,
CONTACT Alexandra J. Hawkey a.hawkey@westernsydney.edu.au Translational Health Research Institute (THRI),
School of Medicine, Western Sydney University, Campbelltown Campus, Locked Bag 1797, Penrith, NSW, 2751, Australia.
Copyright ßThe Society for Menstrual Cycle Research
WOMEN'S REPRODUCTIVE HEALTH
2018, VOL. 5, NO. 2, 75–98
https://doi.org/10.1080/23293691.2018.1463728
withdrawal, and rhythm methods (Family Planning NSW, 2013; Richters et al., 2016);
and have higher rates of abortion following an unintended pregnancy (Helstr€
om,
Z€
atterstr€
om, & Odlind, 2006; Vangen, Eskild, & Forsen, 2008).
Migrant and refugee women also have fewer consultations with general practitioners
to discuss contraception management than native-born women do, and contraception is
less often prescribed to them (Mazza et al., 2012; Raben & van den Muijsenbergh,
2018). Further, in an Australian survey, Sri Lankan migrants were less likely than
Australian-born participants to have heard of more effective means of contraception,
such as contraceptive implants and IUDs (intrauterine device), and they were more
likely to report that they had difficulty in accessing helpful contraception advice
(Ellawela et al., 2017). Understanding the factors that impede migrant and refugee wom-
en’s access to and use of contraception is essential to their reproductive rights, but also
important because the ability to plan pregnancy is key to a woman’s quality of life, as
unintended pregnancies have substantial social, health, and financial costs for women
and their families (Cheng, Schwarz, Douglas, & Horon, 2009; WHO, 2009).
Qualitative studies have shown that migrant and refugee women often arrive in their
host countries with limited knowledge, or even misinformation, about the range of
contraceptive methods available to them (Watts, Liamputtong, & Carolan, 2014).
Religious objections to family planning (Degni, Koivusilta, & Ojanlatva, 2006), myths
and misconceptions about contraception use (Rogers & Earnest, 2014; Watts et al.,
2014), and sociocultural attitudes that prohibit premarital sex continue to shape wom-
en’s access to fertility control (Wray, Ussher, & Perz, 2014). The influence of patriarchal
discourse and practice is evident in migrant and refugee communities, where the use of
contraception is often not supported by husbands (Degni, Mazengo, Vaskilampi, &
Ess
en, 2008; Sargent, 2006; Ussher et al., 2012), which suggests that, despite having tran-
sitioned to countries where a reproductive rights discourse is more widely accepted, gen-
der inequalities may persist following resettlement (Khawaja & Milner, 2012).
Socially acceptable family sizes and timing of childbearing differ across cultures, reli-
gions, and history (Hampshire, Blell, & Simpson, 2012; Srikanthan & Reid, 2008). Some
migrant and refugee communities, particularly those from Africa and the Middle East,
are expected to have large families following resettlement (Allotey, Manderson, Baho, &
Demian, 2004), a cultural norm that may impact the acceptability of contraception use.
In contrast, over the past decades in developed countries there has been significant
transformation in fertility patterns and family size (Bongaarts, 2002), facilitated by a
shared cultural acceptance of modern forms of contraception. For example, the majority
of sexually active heterosexual women of reproductive age in Australia use some form
of contraception (Freilich et al., 2017; Richters et al., 2016). This has resulted in delayed
childbearing, declining fertility rates, and an increasing number of women who choose
not to have children at all (Carmichael & Whittaker, 2007; Rowland, 2007), which
stands in contrast to discourses and practices associated with women’s fertility and fer-
tility control within some migrant and refugee communities (Ussher et al., 2012; Watts,
McMichael, & Liamputtong, 2015).
Although previous research has documented rates of contraception use with women
from migrant and refugee communities (Family Planning NSW, 2013; Omland et al.,
2014), we lack an in-depth understanding of how such women experience and construct
fertility and fertility control. Exploring women’s subjective experiences in this sphere is
76 A. J. HAWKEY ET AL.
important to understand factors that shape migrant and refugee women’s fertility practi-
ces, information that is crucial to inform culturally safe sexual and reproductive health
care, sex education, and health promotion (Allotey et al., 2004). Past researchers have
focused on knowledge and experiences of contraception or fertility among migrant
women who have experienced unintended teen pregnancy (McMichael, 2013; Watts
et al., 2014; Watts et al., 2015). Qualitative research on contraceptive beliefs and practi-
ces has focused on specific populations, such as women from African countries (Degni
et al., 2006; Rogers & Earnest, 2014; Sargent, 2006) or young unmarried women
(Meldrum, Liamputtong, & Wollersheim, 2016; Wray et al., 2014). Migrant and refugee
women are not a homogenous group but come from a wide variety of sociocultural con-
texts that shape beliefs and practices concerning sexual and reproductive health (Ussher
et al., 2012). This suggests that an understanding of the nuanced ways in which inter-
secting identities, such as gender, religion, and culture, shape adult migrant and refugee
women’s experience of fertility and reproductive agency is paramount. That was the aim
of the current study.
To explore this issue, we formulated the following research questions: How do
migrant and refugee women experience and construct fertility and fertility control? How
may understanding of these experiences and constructions be used to shape and deliver
appropriate sexual and reproductive health information and promotion, education, and
clinical practice?
Method
Participants and recruitment
Seventy-eight individual interviews and 15 focus groups (n¼82) were conducted
between July 2014 and November 2015 in Sydney, Australia and Vancouver, Canada.
Our study sample was made up of migrant and refugee women who were between the
ages of 18 and 70 years old, with a mean age of 35 years. To allow for analysis within
and across diverse cultural communities of migrant and refugee women, we recruited
participants who had migrated from Afghanistan, Iraq, Somalia, and Sudan in both loca-
tions. Women from Sri Lanka (Tamil) and South Sudan were included in the Australian
sample, and women from South America (Latinas) were included in the Canadian sam-
ple. The women practiced a range of religions including Islam, Christianity, and
Hinduism. With the exception of one Latina who reported that she was in a same-sex
relationship, all participants identified as heterosexual. Most participants had arrived in
Australia and Canada on humanitarian visas; the average time since migration was 7
years (see Table 1 for more detailed demographics of the sample).
We recruited migrant and refugee women 18 years and older who had settled in
Australia or Canada within the previous 10 years. Specific cultural backgrounds were
chosen in consultation with our community partners, organizations who provide repro-
ductive health services and resettlement support to migrant and refugee populations.
The cultural groups selected were identified as poorly served within existing sexual and
reproductive health services, despite the fact that they make up a significant proportion
of newly arrived migrant and refugee women; they were also identified as underrepre-
sented in prior sexual and reproductive health research. Australia and Canada were
WOMEN'S REPRODUCTIVE HEALTH 77
selected as the study locations due to their geographic, political, economic, and sociocul-
tural similarity; they also have comparable migrant and refugee populations.
Participants were recruited for the study through the distribution of flyers, by staff
members employed by migrant resource centers, by the community interviewers them-
selves, and through snowball methodology. In addition, women were invited to partici-
pate through pre-existing cultural community groups and through flyers displayed in
sexual and reproductive health clinics that service migrant women. We continued
recruitment within each cultural group until there was evidence of data saturation.
Procedure
This research was approved by Western Sydney University Human Research Ethics
Committee, Simon Fraser University Human Research Ethics, and by the ethics commit-
tee of one of our community stakeholder organizations. To gain cultural insights and to
refine the study aims and methods, we consulted key informants and stakeholder organ-
izations. Following this, two members of the research team, in a 1-day workshop,
trained community interviewers in qualitative research methods. Training included how
to conduct interviews and focus groups and how to transcribe data. Community inter-
viewers were migrant or former refugee women, who were engaged specifically for the
study through our stakeholder partnerships. This methodology has been successfully
adopted in prior sexual and reproductive health research with non–English speaking
Table 1. Sample sociodemographic characteristics.
Afghan Iraqi Latina Somali South Sudanese Sudanese Tamil
Variable/Group (n ¼35) (n ¼27) (n ¼17) (n ¼38) (n ¼11) (n ¼20) (n ¼12)
M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)
Age 31.4 (9.1) 38.7 (12.5) 37.1 (5.6) 31.9 (10.4) 36.6 (6.2) 38.7 (7.5) 36.8 (7.3)
Years since migration 5.1 (4.1) 4.3 (2.1) 8.3 (4.9) 5.4 (3.1) 10.8 (2.1) 8.9 (3.4) 5.1 (2.5)
Number of children 3.3 (1.3) 2.7 (1.2) 1.5 (0.7) 3.7 (2.0) 4.5 (2.2) 2.9 (1.1) 2.1 (0.5)
n(%) n(%) n(%) n(%) n(%) n(%) n(%)
Have children
Yes/pregnant 20 (57.1) 20 (74.1) 11 (73.3) 23 (60.5) 11 (100.0) 19 (95.0) 11 (91.7)
No 15 (42.9) 7 (25.9) 4 (26.7) 15 (39.5) –1 (5.0) 1 (8.3)
Religion
Islamic 35 (100.0) 23 (85.2) –38 (100.0) –16 (80.0) –
Christian –3 (11.1) 10 (58.8) –11 (100.0) 4 (20.0) 5 (41.7)
Buddhist ––1 (5.9) ––––
Hindu –––– – –7 (58.3)
Non-practicing –1 (3.7) 6 (35.3) ––––
Education
Primary 7 (20.0) 6 (22.2) –8 (21.1) 3 (27.3) 4 (20.0) –
Secondary 15 (42.9) 3 (11.1) 2 (11.8) 3 (7.9) 2 (18.2) 5 (25.0) 7 (58.3)
Tertiary 6 (17.1) 18 (66.7) 10 (58.8) 3 (7.9) 2 (18.2) 10 (50.0) 5 (41.7)
Nil 2 (5.7) ––1 (2.6) 2 (18.2) 1 (5.0) –
Other 1 (2.9) ––2 (5.3) 2 (18.2) ––
No response 4 (11.4) –5 (29.4) 21 (55.3) –––
Relationship status
Married/de facto 17 (48.6) 14 (51.9) 13 (76.5) 13 (34.2) 6 (54.5) 13 (65.0) 12 (100.0)
Single 12 (34.3) 7 (25.9) 2 (11.8) 14 (36.8) 1 (9.1) 1 (5.0) –
Divorced/separated 2 (5.7) 5 (18.5) 2 (11.8) 8 (21.1) 4 (36.4) 6 (30.0) –
Widowed 4 (11.4) 1 (3.7) –3 (7.9) ––
78 A. J. HAWKEY ET AL.
women (Morrow, Smith, Lai, & Jaswal, 2008). The majority of participants (n¼115)
were interviewed in their first languages by trained community interviewers, who were
women of the same ethnic background (n¼9) or who spoke the same languages as the
participants (n¼3). Participants who preferred to speak English or preferred not to be
interviewed by a community interviewer undertook interviews with a non-migrant
member of the research team; this occurred with 29 interviews and five focus
groups (n¼16).
Prior to participation, the women received information about the purpose of the
research and what the study involved. Participants provided informed consent before
the interview or focus group. With the exception of one participant who declined, all
participants consented to having their interviews audio-recorded. The interviews and
focus groups were semi-structured and lasted, on average, 90 minutes.
The broader study covered questions about menarche and menstruation, sexuality,
and health service provision (Ussher et al., 2017). The questions related to contraception
were: “Tell me about the use of contraception in your culture”;“Have you used some-
thing to help you not have babies, and how do you find these method(s)?”; and “Tell
me about the importance of having babies in your culture.”The use of focus groups
was intended to facilitate the collection of data that highlighted cultural or community
norms and practices concerning fertility and fertility control, whereas interviews were
used to gain more nuanced in-depth and personal accounts of women’s constructions
and experiences (Creswell, 2013). However, following data analysis, there were no obvi-
ous patterns of disclosure identified across these two methods. As recommended
(Krueger & Casey, 2014), focus groups were homogenous; the women were of the same
cultural group, but separate groups were conducted for single and married women
where possible. Interviews and focus groups took place at locations nominated by partic-
ipants, such as their homes, community centers, and libraries.
Analysis
We adopted a material-discursive-intrapsychic theoretical approach (Ussher, 2000) situ-
ated within a critical realist epistemology (Bhaskar, 2011). Critical realism recognizes the
materiality of the body or experience but conceptualizes such materiality as mediated by
culture and language (Bhaskar, 2011; Ussher, 2000). A material-discursive-intrapsychic
analysis allows researchers to acknowledge the “real”aspects of the body or experience
but conceptualizes these events as discursively constructed or shaped within a specific
sociocultural and historical context (Williams, 2003). Within a critical-realist epistemol-
ogy, none of these material, discursive, or intrapsychic levels of analysis is privileged
above the other but are seen as irrevocably interconnected (Ussher, 2010).
We also drew on the concept of intersectionality (Crenshaw, 1991) to consider how
categories of difference (e.g., gender, culture, religion) intersect to shape individual lives,
social practices, and cultural discourses (Davis, 2008). An elemental principle of inter-
sectionality is the view that social categories are not independent or unidimensional but
multiple, interdependent, and mutually constitutive (Crenshaw, 1991). Thus, in order to
understand or address health disparities, intersectionality moves away from an additive
approach of single variables (e.g., gender or race) to consider experience in the light of
multiple influential factors that are continuously interacting (Bowleg, 2008).
WOMEN'S REPRODUCTIVE HEALTH 79
Data were analyzed using a process of thematic decomposition, a form of discourse
analysis that identifies participants’subjectivity and positionality across themes within
data (Stenner, 1993). Data analysis was inductive, whereby the development of the
themes was driven by the data, not by pre-existing theory, concepts, or research.
Interviews and focus groups that were not carried out in spoken English were translated
and transcribed by the bilingual community interviewers. English spoken interviews
were professionally transcribed verbatim and integrity checked to ensure accuracy.
Participants’names were replaced with pseudonyms. A subset of transcripts of inter-
views and focus groups was read and reread by members of the research team. During
this process, first-order concepts, such as “learning about contraception”and
“experiences of contraception use,”were noted. Through discussion and modification,
these first-order concepts formed the basis of the coding framework. Two members of
the research team then concurrently discussed, crosschecked, and coded the entire data
set using NVivo, a software program that facilitates the organization of coded data. A
third member of the research team monitored this process for accuracy.
Codes were then grouped into fewer distinct categories and summarized in detail;
notes were made of participants’cultural background and geographical location to high-
light commonalities and unique experiences across the data set. The research team met
several times to discuss central themes identified through the coding process. Three core
ideas were recognized: the mandate that all women have children, men’s role in wom-
en’s fertility choices, and the impact of discursive meanings on the acceptability of
contraceptive use. These core concepts formed the three discursive themes described
and discussed below: “The motherhood imperative,”“Patriarchy, power, and parity:
Motherhood and male control,”and “Negotiating fertility control: Balancing the
unknown, forbidden, and dangerous.”Quotes are marked with the participant’s pseudo-
nym or “FG”in the case of a focus group, age, and ethnic background. As no substan-
tive differences were identified between accounts by women in Australia and Canada,
country of origin is not noted.
The researchers for this study were of a non-migrant or refugee background, as
defined by the project. We were aware of our positioning and engaged in a process of
reflexivity during the design, data collection, and analysis stages of the research.
Reflexivity requires a process of critical self-reflection into the ways in which a
researcher’s social background, assumptions, positioning, and behavior may shape the
research process (Finlay & Gough, 2003). As a part of our reflexive model, and central
to an intersectional approach (Hankivsky et al., 2010), we consulted with stakeholders
and community members who work with migrant and refugee women at each point of
the project. We also had lengthy discussions as a research team to examine and reflect
on the ways in which our own subjectivities and identities might have shaped
our analysis.
Results and Discussion
The motherhood imperative
The discursive theme “The motherhood imperative,”which encapsulates the cultural
and familial requirement for women to have children, was discussed by the majority of
80 A. J. HAWKEY ET AL.
participants interviewed. Womanhood was strongly linked to ideals of motherhood, and
thus played a central role in the women’s identity. Not only were the women expected
to be mothers, but they faced additional pressure to reproduce immediately after mar-
riage and to provide a boy child. This is reflected in the subthemes: “Motherhood as
central to identity,”“Immediate motherhood as a social requirement,”and “Preference
for a boy child.”
Motherhood as central to identity
Across cultural groups, motherhood was positioned by all participants as synonymous
with womanhood. As Akoi (40, South Sudanese) told us, “You are a woman, you are
considered to have kids,”and an Iraqi focus-group member stated, “Everybody wants
children, it’s nature.”Participants drew on religious and cultural discourses to emphasize
the importance of motherhood for women: “If you don’t have a baby, you can’tbein
our culture”(FG, Tamil); “We always respect our religion …you can’t say ‘I don’t want
marriage’and ‘I don’t want children’” (Arliyo, 26, Somali). The prerequisite of mother-
hood to achieve womanhood has previously been reported among migrant women, with
childbearing positioned as synonymous with being a “proper,”happy, and fulfilled
woman (Yebei, 2000, p. 136; van Rooij, van Balen, & Hermanns, 2009). Motherhood is
also privileged in Western societies, as evident in discourses that denigrate women who
choose to be voluntarily childless (Gillespie, 2000) or in women’s reported feelings of
inadequacy when faced with infertility (Dryden, Ussher, & Perz, 2014). However, in the
West, many women have alternative identity positions or social roles available to them
(Batool & de Visser, 2016), and voluntarily child-free women increasingly report positive
feminine identities that are separate from that of motherhood (Gillespie, 2003).
The discursive construction of motherhood as central to a woman’s identity, and as a
cultural or religious duty, had material implications for migrant and refugee women.
Our findings suggest that compulsory motherhood may mean that there is little room
for women to explore other identities, life achievements, or life pathways. As Janni (32,
Tamil) told us: “In our culture, we don’t have that sort of choice, lots of women they
have the baby, we don’t have a choice.”As a consequence, women may feel devalued
and distressed when they cannot fulfill the motherhood imperative (Remennick, 2000;
Riessman, 2000). This was reflected in accounts where women were described by partici-
pants as “very broken”(Saadia, 30, Iraqi); “Our culture is like poor her, if you don’t
have a baby”(Raana, 43, Iraqi).
Among Tamil participants, women without children were described as at risk of stig-
matization and exclusion. Sumi (37, Tamil), a participant who described having had
trouble conceiving said, “Life was going okay until about 2 years after marriage. Since
we didn’t have any babies, my relations and friend’s parents started calling me names.”
Tamil focus-group participants stated that women who could not have children were
labeled “the unluckies.”Janni (32, Tamil) told us:
When you have a wedding, or …you have your first period, they have a
ceremony …women who don’t have children they don’t really take these women to this
function …they think maybe the couple won’t have babies because of this woman.
WOMEN'S REPRODUCTIVE HEALTH 81
Severe social repercussions of infertility, including ostracism, exclusion, and abuse
have similarly been reported among women from other non-Western contexts
(Fledderjohann, 2012; Riessman, 2000). However, a cross-cultural study (Batool & de
Visser, 2016) showed that, although Western women do experience infertility-related
stigma, there was no public scrutiny, rather an internalized “felt stigma”(Scambler,
1984). This is in contrast to the overt social discrimination or “enacted stigma”experi-
enced by infertile women in non-Western contexts.
Immediate motherhood as a social requirement: “When you get married you have to
get pregnant straightaway”
With the exception of Latinas, participants across all cultural groups described having
been expected to have children immediately after they got married. As Eira (26,
Sudanese) said, “When you get married in our culture, they’re going to count the first
month …[by] the third [month], you are going to get in big trouble.”The ability to get
pregnant straight after marriage was positioned as “like a test for the woman, if she can
give birth or not”(Nasira, 52, Iraqi) and was seen to be important in getting the
“reproduction system going”(FG, Afghan). Western women may be located by others
within a deficit identity position if they are not partnered with children by a certain age
(Addie & Brownlow, 2014); however, they are unlikely to experience such overt expecta-
tions and pressures to have children immediately after marriage.
The cultural expectation to reproduce immediately after marriage caused a number of
participants to become worried about their fertility. Mahta (39, Afghan) told us: “I
didn’t get pregnant for the first 5 years, everyone was talking about this …[later] I got
pregnant until we reached five [children]. I wanted his family to see we could have
children.”In instances where conception did not happen immediately, the woman’s
body was always considered at fault; as Hido (68, Somali) said, “If a man and a woman
are married and they cannot have babies, most of the time they will normally check the
woman, even the traditional medicine will only treat the woman.”In the present study,
cross-culturally, much of the reproductive pressure was said to come from mothers-in-
law and extended family, as has been found in other studies with migrant women
(Hampshire et al., 2012). An Afghan focus group member said:
My mother-in-law and all the in-law family were getting louder and more boisterous about
what’s going on, ‘why isn’t she having a child’… ‘it’s been 6 months how come she is not
pregnant’…I thought they were going to think I am barren or something so …I tried to
make it as quick as possible.
The expectation to reproduce immediately after marriage had a number of material
consequences for women’s sexual and reproductive agency, including the autonomy to
choose whether and when to use contraception and to determine the timing of child-
bearing. For example, a Sudanese focus-group participant said: “I didn’t want to get
pregnant for 2 years after marriage but …my aunt stopped me, she told me ‘you don’t
know if you can get pregnant or not, so no contraceptive pills for now.’” Even where
women were able to negotiate the timing of childbearing with their husbands following
migration, they then faced questioning by wider family and community members, as the
thought of delaying childbearing was unthinkable to others. For instance, Janni (32,
82 A. J. HAWKEY ET AL.
married, Tamil) described an aunt questioning her choice to use contraception by stat-
ing that is was “not really right”and that she would “end up having an IVF baby.”In
the West, women’s contraception decisions generally follow a “my body, my choice”dis-
course (Wigginton, Moran, Harris, Loxton, & Lucke, 2016, p. 734), but our participants’
stories reflect a collective governance over women’s reproductive bodies, which had
implications for their reproductive agency.
Preference for a boy child: “It’s a problem when you only have girls”
One of the major differences found between the participants and native-born
Australians and Canadians is the expectation for women to provide a boy child. As a
consequence of this requirement, many women reported that they felt pressured to con-
tinue to get pregnant until they had a boy: “If you don’t have a boy, they will try until
they get the boy”(FG, Tamil); “People encourage you, you have to have a boy, you have
to have a boy”(Nasira, 52, Iraqi). Across cultural groups, having a boy child was
described as important because boys are responsible for “carrying the surname,”“the
inheritance,”and supporting parents in later life. Male offspring are also responsible for
ensuring the appropriate burial of parents in the case of Hindu Tamil women. Some
women described the pressure to have a boy child as having decreased since migration,
but others said such pressure continued: “Here and back home as well, it’s the same …-
they prefer a boy to carry the name”(FG, Iraqi). The pressure to have a boy child con-
firms previous research with women from migrant backgrounds (Morrow et al., 2008;
Puri, Adams, Ivey, & Nachtigall, 2011). This is partly a reflection of gender inequalities
and patriarchal cultural beliefs that men provide greater economic security for parents
in old age (Puri et al., 2011). It is also likely to be linked to patrilineal social systems
that marginalize and devalue women (Das Gupta et al., 2003).
The expectation to have a boy impacted the acceptability of contraception use follow-
ing the birth of a child: “If you got a boy, you will be on the safe side, if you got a girl
then no, she has to try [again], they will keep pushing”(FG, Iraqi). Such expectations
were reported to have made some participants anxious, particularly due to their
husband’s disappointment about having girls. Azita (37, Afghan) told us: “I was worried
because my husband wanted a boy and we only had girls.”For some women, this
resulted in multiple pregnancies in close succession to achieve the reproductive wishes
of their partners and extended family. As Kamila (34, Sudanese) said, “I have two girls
first, everyone say you have to get pregnant quick to bring a boy.”The sociocultural
expectation to give birth to a boy is problematic, as it may increase the likelihood that
migrant women experience post-partum depression, reproductive anxiety, and/or verbal
or physical abuse from husbands and family if they do not give birth to a son (Morrow
et al., 2008; Puri et al., 2011).
Patriarchy, power, and parity: Motherhood and male control
Across all cultural groups, a number of women described their husbands as having the
authority to decide when, and how many, children to have. Minoo (32, Afghan) told us:
“[If] their husband says he would like to have more children …the woman does not
have much say and needs to obey her husband.”In addition to the expectation to have
WOMEN'S REPRODUCTIVE HEALTH 83
children, women in the Sudanese and Somali communities positioned husbands as pres-
suring wives to conceive a large number of children: “The man will say, we should have
kids every year, he will just say that it’s the religion which suggests so”(FG, Somali).
Faaiso (32, Somali) said: “It’s really crazy, it’s the pressure from the husband, it’s a cul-
ture, men like to have more kids.”
When women did not fulfill their husbands’demands for children, divorce was a
potential consequence. Participants said things such as: “If you don’t want any more
[babies], they are going to find another wife”(Kamila, 34, Sudanese). This was further
epitomized in Nosheen’s (37, Afghan) account:
I was with him [husband] for 10 years, after that we separated because I didn’t get
pregnant …he was happy, but only because I couldn’t give him a child, he got married
again. It is our culture to have children.
This practice continued after migration, as Ranna (43, Iraqi) said, “Even here
[Australia] …they have the same mentality, she should have a baby because maybe the
husband will marry another lady.”The fear of being left by their husband had material
and psychological consequences for women’s health. As Hasina (25, Somali) told us,
“Sometimes they get sick [women], the doctor says don’t get pregnant again, and she is
thinking ‘the man will leave,’that’s why she risks herself.”The expectation to have
many children was also difficult for women to manage, particularly following migration
where women lost traditional familial support networks that help them to raise children.
As Akoi (40, South Sudanese) said, “Raising a kid is extremely difficult, we are not in
Sudan where we get support, here it’s just you and your baby.”
A further consequence of men’s preference for large families was that, in some instan-
ces, husbands prohibited their wives from using contraception. As Joyce (45, South
Sudanese) said, “Some of the men are not accepting it [contraception] …they want to
have a big family.”Other women reported that contraception use may be allowed; how-
ever, they would need to gain consent from their husbands: “We would talk to our hus-
bands, we will not do anything before talking to them”(FG, Somali). Similar accounts
have been reported by other migrant and refugee women (Rogers & Earnest, 2014) and
acknowledged by health care professionals who work within these communities (Kolak,
Jensen, & Johansson, 2017; Mengesha, Perz, Dune, & Ussher, 2017). Consequently,
addressing patriarchal control over women’s reproductive bodies needs to be made a
priority in future programs that address contraception use in migrant and refugee
communities.
Resistance to patriarchy: Negotiating fertility control with partners
In a number of accounts, women described having resisted attempts to control their fer-
tility. Some women reported taking hormonal contraceptives in secret: “I used to do it
[use contraception], but still men don’t like it you know …I used to hide them from
him”(Faaiso, 32, Somali); “I used the tablet for 2 or 3 months …he didn’t know”
(Nyandeng, 34, South Sudanese). Other women resisted their husband’s control over
their fertility by stating that contraception use was up to the woman, as she was the one
carrying the pregnancy, or by asserting their own wishes: “it’suptome…they’re not
the one carrying for 9 months”(Faaiso, 32, Somali); “I just tell my husband to back off”
84 A. J. HAWKEY ET AL.
(FG, Somali). Participants described migration as having provided women with the abil-
ity to challenge patriarchal control, which resulted in greater reproductive freedom than
they had had in their home countries: “In Afghanistan the males are dominant …in
Australia, the woman has to be happy to get pregnant, the husband cannot force her”
(Safia, 28, Afghan).
Not all husbands were described as controlling their wife’s fertility, which suggests
that not all migrant and refugee women are denied reproductive agency. A number of
women positioned contraception use as a joint decision and felt supported in their deci-
sions: “He would happily support me on whatever I wanted to use”(Akeck, 31, South
Sudanese); “I made a decision …so I talk to my husband and he was like really keen”
(Janni, 32, Tamil). Other women described normalization of family planning within the
marital relationship as having been facilitated by health care professionals after migra-
tion; as Eira (26, Sudanese) said:
When you give birth to the baby at the hospital, the nurse comes and talks to you, even
your husband …to tell you after 6 weeks, you have to go and get it [contraception], its
normal, not like Sudan, if you do it your husband can hit you.
Such accounts suggest that including women’s husbands when health care professio-
nals are providing contraceptive counseling to women may support the acceptability of
its use. This recommendation stands in contrast to practices of health care professionals
in the West, who believe that the presence of men may inhibit women’s reproductive
choices (Mengesha et al., 2017; Newbold & Willinsky, 2009).
Across Somali, Sudanese, and South Sudanese participants’accounts, women posi-
tioned large families as a choice that reflects culture, migration, and their own personal
desires. For example, Elmera (34, Sudanese) said that, having come from a “big family
background”herself, she would prefer a large family. The importance of large families
was enhanced in the context of migration for some women, particularly when they had
migrated alone or had few family members in their new host countries: “I came by
myself …I don’t have any family here. What can I do better [than] to make my own
family”(Lokoya, 42, South Sudanese). Large families were also constructed as providing
more status within the community: “Big families, nobody can bother you”(Suz, 42,
South Sudanese). Large families were also seen as necessary, in case children should die
of illness or not fulfill their duty to look after parents in old age. These accounts reveal
that large family sizes were celebrated and wanted by some women, who adopted posi-
tions of agency in relation to their reproductive choices. This suggests caution in posi-
tioning migrant and refugee women as passive victims of patriarchal cultural norms or
expectations if they fail to conform to Western norms of small family size (Hampshire
et al., 2012).
Negotiating fertility control: Balancing the unknown, forbidden, and dangerous
Participants who had considered fertility control described themselves as navigating a
myriad of discourses and regulatory practices associated with contraception use. The
three subthemes that fall beneath this central theme are: “Fertility control: An unknown
territory,”“Contraception as forbidden,”and “Dangerous liaisons: Adverse contraceptive
experiences, fears, and misconceptions.”
WOMEN'S REPRODUCTIVE HEALTH 85
Fertility control: An unknown territory
Across and within cultural groups, women reported various levels of knowledge and
uncertainty about contraception methods, which had implications for their decision
making in relation to fertility control. In some instances, women reported that they
“don’t know anything”and have “zero awareness”(FG, Tamil) or “have no idea”(Suz,
42, South Sudanese) about contraception. Other women had some knowledge and could
describe a small number of contraception options: “All I know is the IUD or taking
pills”(Mahta, 39, Afghan). Modern forms of fertility control most commonly mentioned
by women were the pill, IUD (without differentiation between hormonal and non-hor-
monal devices), injectable contraception, implants, and condoms. However, the women
did not discuss, or demonstrate awareness of, the range of contraceptive pills available,
vaginal rings, tubal ligation, or the use of emergency contraception.
Women’s unawareness of contraception, or specific contraceptive methods, may be a
reflection of limited knowledge of fertility control. In line with previous research with
migrant and refugee women (Quelopana & Alcalde, 2014; Watts et al., 2014), this sug-
gests that some women may arrive in host countries with limited or inaccurate know-
ledge of contraception and the reproductive functions of the body. However, women’s
self-positioning as having “no idea”may also be a reflection of a cultural reluctance to
discuss such a topic in an interview context. For example, some participants described a
lack of contraceptive knowledge as being a consequence of a “culture”in which sexuality
and reproductive talk is discouraged: “We can’t talk like that, we are very shy”(FG,
Tamil); “In general it is really hard to speak about it”(Azita, 37, Afghan).
One of the consequences of this silence is that a few women reported reluctance to
speak to one another about contraception or to seek medical advice about its use. Akeck
(31, South Sudanese) said: “No one would talk to another person regarding that [contra-
ception] …I never seek any …like health advice in that regard. I just make my own
analysis.”A reluctance to discuss contraception has similarly been reported in prior
research with migrant and refugee women (Rogers & Earnest, 2014); it may, in part,
explain why migrant women are less likely than other women to discuss contraception
management with their general practitioner (Mazza et al., 2012). It may also mean that
women could find it difficult to discuss contraception with their husbands, which is
problematic as spousal communication is associated with greater contraception use
(Kamal & Islam, 2012).
Across the cultural groups interviewed, many women described having received
extremely limited education about contraception prior to migration; thus they arrived in
their new countries of residence with little or no sexual and reproductive health know-
ledge: “Education is very low, that part of education is nil”(FG, Tamil); “In
Afghanistan, it is very hard to find information about stuff like this”(Azita, 37,
Afghan). The majority of women interviewed said they had learned about contraception
following migration: “It wasn’t until I came here [Canada] that I got information and
knowledge about the big variety of different contraceptive methods”(FG, Latina); “I got
to know about it [contraception] here”(Nita, 27, Tamil). Other reasons for poor contra-
ceptive knowledge included not having had the time to look into it and ambivalence
about contraception information, particularly if women had no intention of using it:
“It’s a very busy life …I have no time to think about that [contraception] now”
86 A. J. HAWKEY ET AL.
(Andrea, 26, Tamil); “No, I don’t know anything about it …honestly I don’t want to
take it”(Amaal, 42, Somali). These accounts highlight the importance of recognizing the
structural factors that may impede women’s ability to prioritize their sexual and repro-
ductive health. Migrant and refugee women face multiple challenges during the resettle-
ment period, such as finding employment and securing housing, which may result in
their sexual and reproductive health needs being given a low priority (Benson, Maldari,
Williams, & Hanifi, 2010).
In a few accounts, women did report good knowledge about contraception, gained
through seminars while in refugee camps, the Internet, family doctors, and community
health programs. Participants also described seeking information from mothers, aunts,
sisters, and married friends, whom they positioned as well-trusted and frequently
accessed resources: “I also knew about it [contraception] from my aunts …we have a
strong connection, they are like our sisters”(FG, Sudanese); “[I learned] from my sister,
she is older than me and is married”(FG, Iraqi). However, across cultural groups, even
where women could describe contraceptive methods and options, this did not guarantee
that they used them. Bashira (44, Iraqi) said, “I know some information about it, but
actually I didn’t use it”; and Banoo (28, Afghan) said, “Yes, I have heard of them, but I
haven’t used any.”This disjuncture between contraception knowledge and behavior has
similarly been reflected in previous literature with migrant and refugee women (Watts
et al., 2015). Women need accurate contraceptive information for informed decision-
making, and it is equally important that women’s wider sociocultural contexts are recog-
nized, as knowledge alone does not always lead to changes in fertility-related behavior
(Marston, Renedo, & Nyaaba, 2018; Watts et al., 2015).
Many women, across all cultural groups, constructed contraception as untrustworthy.
This was reflected in accounts where women described getting pregnant despite having
used contraception: “In spite of taking pills …I got pregnant”(FG, Latina); “We used
condoms, but then, that’s how I got pregnant with my second child, so I didn’t trust it
anymore”(Homa, 40, Afghan). Contraceptive failure is a commonly endorsed reason
why many non-migrant women experience unintended pregnancies (Rowe et al., 2016).
However, women or their partners may also be unaware of the ways in which specific
forms of contraception prevent pregnancy, or they may not use contraception regularly.
For example, Sharifa (43, Iraqi) told us, “The two sides of the IUD close the two pas-
sages to tubes that take you to the eggs …sperm can’t get through and they have to
return back”and Faaiso (32, Somali) said, “I got pregnant while using the tablet, maybe
I forgot sometimes.”
A large number of women across all cultural groups gave accounts that suggested that
they did not have adequate knowledge about their reproductive bodies, particularly in
relation to menstrual cycles, breastfeeding, and pregnancy. A Tamil focus group member
said, “When I got the first child, after 6 months I’m pregnant with the second one …we
never expected that”; and Erina (39, Somali) said, “I was breastfeeding only, I was think-
ing if someone is breastfeeding they can’t get pregnant …I got pregnant so quick.”
Similar findings of low knowledge in relation to fertile days of the menstrual cycle
(Rowe et al., 2016) and the use of breastfeeding as a form of contraception (Richters
et al., 2016) have also been reported among women in population-based surveys
within Australia.
WOMEN'S REPRODUCTIVE HEALTH 87
Limited knowledge about fertility was also evident when women no longer took pre-
cautions to prevent pregnancy in midlife, as they believed they were no longer fertile in
their early 40s. Ariana (40, married, Latina) said: “I’m currently not using any method
[of contraception] …fortunately now I am 40, so it is difficult for me to get
pregnant …I can finally enjoy sex without being worried that I am going to get preg-
nant.”Inadequate knowledge about the reproductive body and contraception methods
may leave women vulnerable to unintended pregnancy (Watts et al., 2014).
Consequently, migrant and refugee women may benefit from access to comprehensive
sexual and reproductive health information that details contraception options, specifics
about the way in which they function, and broader knowledge of the reproductive body.
Contraception as forbidden: “My religion doesn’t allow us to stop having children”
Although religious beliefs are important in some Western women’s fertility choices,
migrants are even more likely to report being influenced by the teachings of their affili-
ated religions (Ellawela et al., 2017). In a number of participants’accounts, contracep-
tion was discursively positioned as culturally or religiously forbidden. Such beliefs were
described as having strongly shaped women’s reluctance to use hormonal contraceptive
methods: “Whatever number of kids God will give me, I will keep on having …my reli-
gion doesn’t allow us to stop having children”(Hani, 32, Somali); “My religion doesn’t
allow it …it’s like killing”(Maano, 19, Somali). The cultural and religious prohibition of
hormonal methods of contraception resulted in many women using “natural”methods
of contraception, such as withdrawal or the rhythm method. This was particularly evi-
dent in interviews with Muslim women and in some Christian women’s accounts.
Elmera (34, Sudanese) told us: “In my religion, I can’t go to the doctor to make the
medicine [contraception], I use natural rhythm.”Fears about hormonal contraception
use were a further reason why some women used natural methods. Anju (44, Tamil)
said she “never used anything …we avoided the conceiving time”; and Kamelah (36,
Sudanese) told us, “I think the ‘days system’is safer for me and it works.”A high use of
withdrawal for contraception has similarly been reported in population-based studies in
Australia and Canada (Black et al., 2009; Rowe et al., 2016). This may reflect broader
concerns that women and couples have about side effects of hormonal contraception, as
well as the view that withdrawal offers a safe, convenient, and free alternative (Jones,
Fennell, Higgins, & Blanchard, 2009).
However, practices such as withdrawal and the rhythm method are problematic
because they are less effective methods of pregnancy prevention (Trussell, 2004), which
was confirmed by Zarina (32, Tamil), “[I didn’t] use any pills or condoms I made a mis-
take on the day’s calculation and fell pregnant with my second child,”and a Tamil focus
group participant, “two time[s], it was an accident, then I got a termination.”Natural
methods also had intrapsychic implications for women; participants described feeling
anxious about unwanted pregnancy, as it was always “on your mind”(Tamil, FG).
Religious edicts also prohibited contraception for unmarried women, because they are
often forbidden to be sexually active prior to marriage: “I don’t use it you know, we are
not married”(FG, Somali); “I’ve never been in that sort of [sexual] relationship …I
haven’t had the need to think about it …I don’t find any interest to ask people either”
(Samira, 21, Afghan). However, a lack of contraception knowledge prior to marriage
88 A. J. HAWKEY ET AL.
may leave married women vulnerable to unintended pregnancy, as evident in Nasira’s
(52, Iraqi) account: “I didn’t know how to use it …the contraception pills, so I didn’t
use them.”It could also mean that when young women choose to have premarital sex,
they may avoid contraception use or health care services, in fear that their parents or
community would discover they are sexually active (Rogers & Earnest, 2014; Shoveller,
Chabot, Soon, & Levine, 2007).
In a few accounts however, women drew on religion to justify family planning and
fertility control. Amran (47, Somali) told us, “Even the religion itself talks about spacing
the children”; and Arliyo (26, Somali) said, “I don’t know why they think you can’t use
it [contraception] …the religion allows that.”These contrasting findings highlight how
diverse religious interpretations account for different reproductive practices (Degni
et al., 2006; Srikanthan & Reid, 2008) and how religion may be employed to both criti-
cize and legitimize sexual and reproductive health practices (Sargent, 2006).
Dangerous liaisons: Adverse contraceptive experiences, fears, and misconceptions
Negative experiences with hormonal contraception and fear of its side effects are con-
sistently cited across global contexts and sociocultural settings in both Western and
developing countries (Chebet et al., 2015; Dixon, Herbert, Loxton, & Lucke, 2014). In
line with previous research, women in our study, across all cultural groups, described
concerns about side effects and constructed contraception as dangerous. For example,
women reported that, in their communities, “There’s a lot of concerns”(FG, Sudanese)
and “There were a lot of horror stories”because contraception “creates a whole range of
damages to other parts of the body”(FG, Afghan). Feared concerns and embodied expe-
riences included weight gain, hair loss, growths in the uterus, fibroids, cancer, changes
in libido, headaches, infertility, fluctuations in mood, and changes to the menstrual
cycle. As Sumi (37, Tamil) said, “We didn’t want to use contraceptives because through
my friends I knew it can mess up conceiving.”A Latina focus group participant told us:
“The pills had a very negative effect on my body and my overall emotional life.”
A“disturbance to the menstrual cycle”(Setara, 23, Afghan) as a consequence of
contraception was culturally constructed as “very unhealthy”or “harmful”because men-
struation is thought to play a cleansing role in the body. For example, Habibah (43,
Iraqi) said: “In our culture, we say that if there is no bleeding, the blood will harm the
body.”Anosha (30, Afghan) had questions about the long-term ramifications of no
monthly bleeding: “I wonder …will it create complications? So, all those periods just
stay in and gather up, right? I don’t know, but these are the kind of problems.”The
value of regular monthly menstruation has also been reported in other non-Western
contexts in relation to its “cleaning”function and as a signifier of fertility (Marston
et al., 2018). Although some women in Western contexts view regular menstruation as
important, many other women see the absence of menses as a positive non-contracep-
tive benefit of methods such as subdermal implants (Flore et al., 2016; Kelly et al.,
2017). This highlights how different cultural constructions of menstruation influence the
acceptability of certain contraceptive methods.
Similar to previous research (Kelly et al., 2017; Weisberg, Bateson, McGeechan, &
Mohapatra, 2014), many of our participants described experiences of heavy bleeding
after having used the IUD, “the implant,”or “the injection.”Madina (45, Iraqi) said: “I
WOMEN'S REPRODUCTIVE HEALTH 89
had bleeding for 4 months …so I went to the physician and told him ‘I can’t stand it, I
want to pray, I want to fast …I don’t want it. Please remove it.’” Cultural constructions
that position a woman’s menstrual blood as dirty and polluting prohibit some women
from diverse cultural and religious backgrounds from engaging in specific activities dur-
ing menses, including praying and sexual intercourse (Dunnavant & Roberts, 2013;
Hawkey, Ussher, Perz, & Metusela, 2017). It is therefore likely that these restrictions
render some forms of contraception, which may cause unpredictable or prolonged
bleeding, unacceptable (Hawkey et al., 2017). Consequently, possible changes in bleeding
patterns following initiation of contraception, such as long-acting reversible methods,
must be sufficiently acknowledged with women during pre-contraception counseling
(Weisberg et al., 2014).
These negative embodied and psychological experiences led women to use a range of
contraceptive methods in an attempt to find an appropriate fit or to stop using contra-
ception altogether. As one participant said, “I tried the IUD, it was not suitable for me
because of the continuous bleeding …then I used contraception pills, it caused nervous-
ness and headaches …I have no other options”(FG, Iraqi); another said, “Once I used
the IUD and it made me bleed and I stopped it. I didn’t do anything else”(FG,
Sudanese). Feelings of dissatisfaction with available contraceptive methods that led to
discontinuation have similarly been reported by Western women (Dixon et al., 2014;
Mills & Barclay, 2006). This highlights not only women’s experimentation with contra-
ceptive methods to avoid pregnancy and find an appropriate fit, but also the need for
clinicians to adopt a model of shared responsibility, such as encouraging the use of male
condoms (Wigginton, Harris, Loxton, Herbert, & Lucke, 2015).
In contrast to the positioning of contraception as dangerous, a few women described
being “very happy,”feeling “safe,”and feeling “worry free”with their choice of contra-
ception and reported no negative effects on their health and well-being. For example,
one woman said that she liked having no periods following the insertion of her IUD: “I
didn’t get any period …I think it’s a good thing because I had over-bleeding”(FG,
Tamil). Similarly, Nafisa (36, Sudanese) told us: “I’m very happy …I would not try
something else, it’s [IUD] very convenient for me right now.”These examples show that
some women were able to overcome negative past experiences and community myths or
misconceptions to find an appropriate contraceptive fit.
Implications and Suggestions for Future Research
The results indicate that migrant and refugee women’s fertility and fertility control were
shaped by the interplay of cultural and religious discourse and the materiality of wom-
en’s relational context and influenced by women’s negotiation of both. Although cultural
or religious discourse acted to regulate some women’s fertility and fertility control, other
women actively resisted restrictive discourses and practices to enact their own repro-
ductive agency. This finding illustrates how women have the potential to “rewrite”or
resist traditional constructs and practices associated with their reproductive bodies by
mobilizing counter-stories that position their fertility choices in more agentic ways
(McKenzie-Mohr & Lafrance, 2014). These nuanced differences highlight the heterogen-
eity that exists both within and across cultural and religious groups of migrant women,
and they show that religion and culture are often exaggerated categories of difference
90 A. J. HAWKEY ET AL.
that are drawn on to describe the cultural “other”as devoid of agency or autonomy
(Bilge, 2010). It is important that health care professionals recognize migrant and refu-
gee women’s different constructions and experiences by providing individualized sexual
and reproductive care that avoids stereotypes often attached to specific cultural or reli-
gious groups (Srikanthan & Reid, 2008).
At the same time, however, health care professionals working with migrant and refu-
gee women need to be aware of the range of sociocultural factors that shape women’s
ability or willingness to use contraception (Newbold & Willinsky, 2009). To address
these factors, it is important that health care professionals ask women whether there are
any cultural or religious beliefs that they should be aware of when discussing contracep-
tive methods. To facilitate such conversation in practice, future researchers could work
with migrant and refugee women and health care professionals to develop a contracep-
tion decision-making tool to be used during contraceptive counseling. This could pro-
vide clear information of the contraception options available and how they work, their
efficacy, and their potential side effects.
It is also important that, where possible, health care professionals employ a whole-of-
family approach to education and decision making about contraception and family plan-
ning (Rogers & Earnest, 2014; Watts et al., 2015). It is equally important that women
are aware of their own sexual and reproductive rights following migration to Australia,
Canada, or elsewhere. For women who wish to enact control over their fertility and who
do not have support from their husband or family, it is important that health care pro-
fessionals encourage women to make their own contraceptive decisions by drawing on a
human rights–based approach (WHO, 2014b). Furthermore, given the reported effect of
husbands on some women’s reproductive agency, future researchers need to include in
their studies migrant and refugee men’s perspectives on fertility and fertility control.
This could include possible changes in gender roles in the context of migration, how
men themselves construct hormonal methods of contraception, strategies that best foster
husbands’support of contraception, and the most appropriate ways to increase men’s
access to sexual and reproductive health education.
High-quality communication between patient and health care providers about contra-
ception has been associated with patients’continued use of highly effective contraceptive
methods (RamaRao, Lacuesta, Costello, Pangolibay, & Jones, 2003). However, migrant
and refugee women often report a lack of cultural competency and ineffective communi-
cation with health care professionals (Degni et al., 2006; Rogers & Earnest, 2014). This
suggests the need for cultural competency training for health care professionals and
health educators who work with migrant and refugee communities (Mengesha, Perz,
Dune, & Ussher, 2018; Rogers & Earnest, 2014). Such training could cover ways to initi-
ate and discuss sexual and reproductive health effectively, as well as provide insight into
health issues specific to migrant and refugee women (Mengesha et al., 2018). To support
women in finding the most appropriate contraceptive fit, health care professionals must
go beyond simply prescribing contraception and must enter into a process of shared
decision-making and information sharing, and they must appropriately respond to con-
cerns and manage side effects (Carvajal, Gioia, Mudafort, Brown, & Barnet, 2017;
Chebet et al., 2015).
It is critical to address misconceptions about and negative experiences with hormonal
contraception methods in order to support migrant and refugee women to achieve
WOMEN'S REPRODUCTIVE HEALTH 91
reproductive goals and counter secondhand knowledge that may be present within their
communities (Chebet et al., 2015). Following arrival and during resettlement, migrant
and refugee women need access to transparent information about culturally constructed
contraceptive misconceptions, the ways in which contraceptive methods work, and com-
prehensive education about the reproductive body (Rogers & Earnest, 2014). Women
may also need reassurances that, although some women do experience mild side effects,
such as headaches or weight gain, severe complications are rare (Kiley & Hammond,
2007). Given women’s reluctance to communicate about contraception, providing sexual
and reproductive health information in the women’s native languages that accommo-
dates different literacy levels may also facilitate increased reproductive health knowledge
and awareness of available health care services (Rogers & Earnest, 2014). To ensure cul-
tural sensitivity, education sessions focused on sexual and reproductive health topics
could be developed and disseminated by same-sex community educators or community
leaders and could take place at migrant resource centers or as outreach activities
attached to community events (Kolak et al., 2017).
Strengths and Limitations
The strengths of the current study include the use of a qualitative research methodology,
which captured women’s voices, subjective experiences, and constructions of fertility
control. Including women from multiple different cultural backgrounds facilitated exam-
ination of differences and commonalities across cultural groups. Interviewing women in
their first language allowed women to explore their experiences without the limits of
their spoken English and meant that newly arrived migrant women could participate in
the study. Providing English-speaking participants with the option of being interviewed
in English with a non-migrant interviewer meant that we could provide women with
choices in relation to how they were interviewed, as some might have felt more comfort-
able talking with another member of their community, whereas others might have felt
more comfortable with an outsider. Limitations include the fact that some participants’
accounts were retrospective (i.e., they may not be representative of women’s experiences
in their home countries today). Furthermore, we could not back-check translated tran-
scripts for accuracy or complete member checking of our findings. Member checking,
particularly where researchers do not share the same cultural background as partici-
pants, could be a useful strategy in future research with migrant and refugee women to
help ensure that the realities of women’s lived experiences are represented appropriately.
Conclusion
It is important that migrant and refugee women have access to appropriate contracep-
tive information and methods, but education about methods of fertility control alone is
unlikely to result in changes to fertility behaviors. Greater recognition of the complex
cultural, religious, and gendered discourses and practices that restrict women’s repro-
ductive agency must be reflected in sexual and reproductive health care provision, edu-
cation, and health promotion programs.
92 A. J. HAWKEY ET AL.
Note
1. The term culturally and linguistically diverse (CALD) is used in Australia to describe people
who have a cultural heritage different from the dominant Anglo Australian culture
(Australian Government Department of Health, 2016); it replaced the previously used term
of people from a “non-English-speaking background”(NESB). As this term is not used in
Canada, where many of our participants reside, we define our sample as “migrant and
refugee women.”
Disclosure statement
No potential conflicts of interest were disclosed.
Funding
This study was funded by an Australian Research Council Linkage Grant LP130100087, in con-
junction with Family Planning New South Wales (FPNSW), the Community Migrant Resource
Centre (CMRC) and Centre for the Study of Gender, Social Inequities and Mental Health, Simon
Fraser University, Vancouver, Canada.
ORCID
Alexandra J. Hawkey http://orcid.org/0000-0003-0851-9117
Jane M. Ussher http://orcid.org/0000-0002-2128-0019
Janette Perz http://orcid.org/0000-0003-2065-8662
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