Education and knowledge are the best tools to serve refugees and identify their health care needs. Refugees themselves can often be the best teachers of their own culture. Individualized attention should be paid to each refugee woman as each woman’s concerns may vary. Special attention and focus to the following areas will enhance the quality of care and experience for both the woman and her health care providers.
- Language – Culturally and linguistically appropriate, gender-matched language interpretation should be made available at all times to avoid miscommunication and misunderstanding by both the woman and her health care providers. Interpretation by family members, minors, and the lay community should be avoided. Live, in-person interpretation by trained personnel allows direct hands-on education and counseling, which can be enhanced by the use of audio-visual or pictorial aids and is preferred whenever feasible.
- Access to Care – Avoid lapses in insurance coverage, particularly for women with low literacy for whom letters in the mail may be difficult to comprehend; address transportation needs; promote awareness of available health and social services; be aware of prevailing social/cultural taboos and stigma that may limit women’s self-efficacy in seeking help; and ensure continuity of care with the same provider whenever possible.
- Issues of Gender – Whenever possible health care staff and interpreters should be gender-matched with the patient. However, circumstances may arise in which the only staff available or the most skilled personnel in performing a designated procedure is a male. Counseling should take place in advance with the woman and her partner/spouse to determine whether or not this would be acceptable, and if not, secure an alternative strategy that ensures the safety and quality of care while respecting the couple’s wishes.
- Respect of Modesty – Touching private parts of the body may be deemed disrespectful or insulting for a woman patient, especially if by a male health care provider. There should always be a chaperone in the examination room, regardless of the provider’s gender. If a male interpreter is present, interpretation should be provided from behind a curtain during the examination process. Efforts should be made to keep the woman as fully clothed or draped as is feasible during examinations to minimize skin exposure and patient embarrassment.
- Understand Cultural/Traditional Practices and Religious Observances – Be cognizant of relevant religious and/or traditional cultural practices (i.e. female genital cutting, coining, Ramadan, etc.) that may influence pregnancy, delivery, and prenatal care utilization as well as the woman and her spouse’s health care decision-making. Due to the sensitive nature of certain practices, patients may be reticent to readily discuss certain issues, but as trust is built and continuity of care occurs over time, there may be opportunities for more sensitive discussion and disclosure. Be aware of a woman’s autonomy in decision-making and the role that a woman’s spouse and/or matriarchal familial support may play in decision-making.
- Fasting for Ramadan During Pregnancy – While the holy month of Ramadan is a period of spiritual renewal and strength in the Islamic faith, it may pose a challenge for pregnant women. Muslim women who plan to fast should meet with their health care provider before Ramadan to discuss any pertinent advantages and/or disadvantages of fasting. Medical and pregnancy-related conditions that may prevent safe fasting should be assessed and information provided on maintaining adequate nutrition and hydration during this time.
- Anticipatory Guidance – Special care and surgical interventions may become necessary during pregnancy or childbirth. Anticipatory guidance, counseling, and education should be provided and referrals made for technical expertise and assistance, if deemed necessary.
- Coordination of Care and Case Management – Involving a multidisciplinary team to support refugee women’s health improves the consistency of follow-up and quality of care as women’s self-efficacy in navigating the health care system increases. Given the low health literacy and unfamiliarity with the U.S. health care system, particularly among new refugee arrivals, efforts should be made to extend the traditional provider network to include social workers, case managers, interpreters, and community health workers along with refugee resettlement agencies to facilitate seamless coordination of care.
Contributed by Crista Johnson-Agbakwu, M.D., M.Sc., F.A.C.O.G.
 Redwood-Campbell L, Thind H, Howard M, Koteles J, Fowler N, Kaczorowski J. Understanding the Health of Refugee Women in Host Countries: Lessons from the Kosovar Re-Settlement in Canada. Prehospital and Disaster Medicine. 2008;23(4): 322-327.
 Bruce, H. Women’s Health Issues. Immigrant Medicine. Editors: Walker PF, Barnett ED, Saunders Elsevier, 2007.