Access of Chin and Rohingya women refugees and asylum seekers from Burma to maternal health services in the Klang Valley, Malaysia

Barriers to accessing maternal health care are linked to adverse maternal health outcomes. Malaysia’s success in terms of maternal health outcomes is attributed to accessibility to an integrated package of maternal and child health services that especially reached poor and rural residents. Yet urban refugees in Malaysia face many barriers in accessing health care because of insecure legal status and several protection challenges. This study aimed to assess the access of Chin and Rohingya refugees and asylum seekers from Burma to maternal health services in the Klang Valley, Malaysia, by: (i) examining the relationship between documentation status (being refugee/asylum seeker) and ethnicity (being Chin/Rohingya) to the dimensions of accessibility and utilization of care; and (ii) evaluating the differences in the patterns and levels of utilization of care between Chin and Rohingya refugees and asylum seekers. The accessibility dimensions include: nondiscrimination, physical, economic, and information accessibility. The research questions were explored within the dualism of the urban refuge environment, of vulnerability contexts and opportunities to exercise agency. The right to health definition of accessibility guided the study’s conceptual and theoretical framework. This framework was used to demonstrate (i) its theoretical applicability for empirically examining accessibility to health care of a disadvantaged population; and (ii) the application of methodological tools not conventionally used to monitor the right to health. A mixed methods research design including a cross sectional survey with 343 respondents and ten qualitative in-depth interviews was implemented. Additionally, the survey respondents’ maternal health records were analyzed. Results were triangulated using these different methods and data sources. Quantitative and qualitative data were assessed separately with statistical and thematic analysis respectively, and outcomes were compared and discussed. Overall, the study population as a whole experienced many barriers in accessing maternal health care. Multiple regression analysis revealed that after controlling for documentation status, ethnicity was significantly related to physical accessibility, information accessibility, and non-discrimination. Ethnicity offered some advantages/disadvantages to navigate the health system with Rohingyas faring better than Chins. With regard to physical accessibility, a higher proportion of Rohingyas took lesser travel time. However, the experience of fear was quite pervasive with about 86.0% of the study population reporting feelings of fear while traveling to obtain maternal health care. Ethnicity was also related to feelings of fear. Among those who felt fearful, Chins had a significantly greater travel time for antenatal care, delivery care and postpartum care. This could be explained by the results which showed that a higher proportion of Rohingyas than Chins who felt fearful traveled by taxis, used their own/their friend’s car and/or motorbike. A higher proportion of Chins than Rohingyas who walked lived below the poverty line income of RM 763 per month, reflecting the overlapping dimensions of physical and economic access in the study population. In comparison to the Chins, a higher proportion of Rohingyas received more maternal health information (based on the World Health Organization’s [WHO] standards related to maternal health information to be given/received during pregnancy). Yet, only a little over half the Rohingya study population reported that the maternal health information they had obtained was adequate. Overall, the majority of the study population (68%) reported at least one form of perceived discrimination in health care. A higher proportion of Chins perceived greater discrimination in health care than the Rohingyas. Yet, a higher proportion of Chins in comparison to the Rohingyas coped actively in dealing with the perceived discrimination. Documentation status was moot to economic accessibility, measured by the maternal health expenditure ratio (ratio of out-of-pocket payments for maternal healthcare to annual family expenditure). After controlling for ethnicity, documentation status was significantly related to economic accessibility. Refugees had a higher median maternal health expenditure ratio. Documentation status (not ethnicity) was also significantly related to actual utilization of maternal health care, measured via number of antenatal care (ANC) visits. A higher proportion of refugees than asylum seekers obtained “adequate ANC visits” (assessed on the basis of the WHO recommended minimum of four visits for a normal pregnancy which adjusted for length of gestation). However, adequate utilization of maternal health care by refugees also contributed to their increased impoverishment. Tangentially, the mean and median timing of initiation of ANC visits of all the population sub-groups in this study exceeded the WHO recommended initiation of ANC by the first trimester, thereby conceivably qualifying as “delayed care”. The qualitative research revealed the influence of complex contextual factors which mediated the women’s access to maternal health care. Notwithstanding the limitations of this study, which includes non-probability survey sampling, it has contributed: (i) to studies on accessibility by demonstrating the viability of the right to health framework as a sound conceptual and theoretical framework to examine the accessibility to health care of disadvantaged populations; (ii) to the under-developed body of knowledge on urban refugees, especially urban refugee health; and (iii) to the literature on maternal health by substantiating the importance of context, specifically legal status and ethnicity, in mediating women’s accessibility to maternal healthcare.