Healthcare Access and Health Conditions among Somali Refugees Prior to Arrival in U.S.

Overview

Nonprofit organizations often provide health services to Somali refugees living in refugee camps and urban areas. Programs include water, sanitation, and hygiene (WASH) initiatives, primary and secondary health services, maternal and newborn services, tuberculosis (TB) treatment, and initiatives to address and reduce sexual and gender-based violence [27]. In some settings, such as Dadaab Refugee Complex, various outpatient services include consultation clinics, specialized and tertiary care, emergency medicine, as well as laboratory and pharmacy services [27]. Limited mental health services are available [27]. Refugees living outside refugee camps, particularly those not registered by UNHCR, may not have access to services in countries of asylum because they lack legal status, inability to obtain a residency permit, or inability to pay.

Immunizations

Some Somalis may have been vaccinated prior to displacement through national immunization campaigns. In Kenya, nongovernmental organizations (NGOs), often supported by the Ministry of Health, may provide immunizations. Additionally, US-bound Somali refugees may receive select vaccines as part of the voluntary Vaccination Program for US-bound Refugees depending on the country of processing (see Vaccination Program for US-bound Refugees for additional information). However, Somali refugees generally have not completed the full Advisory Committee on Immunization Practices (ACIP)-recommended vaccination schedule before departing for the United States.

Women’s Health Issues

In Somalia, maternal and infant mortality rates are among the highest in the world. The maternal mortality ratio for Somali women is 732 deaths per 100,000 live births, while the infant mortality rate is estimated at 96.6 neonatal deaths per 1,000 live births [2, 28]. The fertility rate among Somali women is also high, with the average woman giving birth to 6.4 children during her life [29]. The prevalence of contraception use is unknown.

Reproductive health data are extremely limited among Somali refugees. Generally, fertility rates among Somali refugees are high, and high rates of maternal mortality are exacerbated by a lack of awareness of the dangers of frequent childbirth and pregnancy at an early age. Even when reproductive health, family planning, and gender-based violence education and clinical services are available, utilization is often low [30].

Healthcare providers in Dadaab and Kakuma report that many camp residents lack a basic understanding of reproductive health practices, family planning methods, preventative health services, and antenatal care [31]. Although UNHCR-registered refugees in Yemen are allowed to use healthcare services, refugees often have difficulty accessing necessary care, the quality of care is largely insufficient, and public services are overburdened [30].

Female Genital Mutilation/Cutting

Female genital mutilation/cutting (FGM/C) is defined as the partial or total removal of female genitalia or other intentional injury to female genital organs [32]. Despite many countries having passed or drafted legislation banning FGM/C, global advocacy to end the practice, and lack of validation in Islam, FGM/C remains ingrained in Somali culture [32, 33].

In Somalia, FGM/C prevalence is estimated to be as high as 98%  [34]. Infibulation (Type III), the most severe form of the procedure, is most common in northeastern Africa, including Somalia [35]. FGM/C is also well documented in neighboring countries where Somali refugees have sought asylum. The prevalence of FGM/C among girls and women aged 15–49 years is estimated at 19% in Yemen, 21% in Kenya, 74% in Ethiopia, 83% in Eritrea, and 93% in Djibouti [34]. Ethnicity is the most significant predictor for FGM/C. Ethnic groups often adhere to traditional cultural norms, including FGM/C, regardless of where they live. For example, among ethnic Somalis residing in Kenya, 98% of women and girls are believed to have undergone the procedure. This prevalence mirrors estimates in Somalia, yet far exceeds the reported national prevalence in Kenya [36].

There is a large body of scientific literature on FGM/C, as well as best practices in gynecological care for FGM/C survivors. These publications may be helpful to clinicians and others working with Somali women:

  • Johnson-Agbakwu CE, Flynn P, Asiedu GB, Hedberg E, Breitkopf CR. Adaptation of an acculturation scale for African refugee women. J Immigr Minor Health 2016 Feb;18(1):252–62.
  • Johnson-Agbakwu CE, Allen J, Nizigiyimana JF, Ramirez G, Hollifield M. Mental health screening among newly arrived refugees seeking routine obstetric and gynecologic care. Psychol Serv 2014 Nov;11(4):470–6.
  • Johnson-Agbakwu CE, Helm T, Killawi A, Padela AI. Perceptions of obstetrical interventions and female genital cutting: insights of men in a Somali refugee community. Ethn Health 2014 Aug;19(4):440–57.
  • Lazar JN, Johnson-Agbakwu CE, Davis OI, Shipp MP. Providers’ perceptions of challenges in obstetrical care for Somali women. Obstet Gynecol Int 2013;2013:149640.
  • Public Policy Advisory Network on Female Genital Surgeries in Africa. Seven things to know about female genital surgeries in Africa. Hastings Cent Rep. 2012 Nov-Dec;42(6):19–27.

Sexual and Gender-based Violence

Sexual and gender-based violence (SGBV) is ongoing and has been used as a weapon of war in Somalia. In Somali society, rape victims are highly stigmatized and sexual assaults often go unreported. After an assault, survivors may isolate themselves, largely withdrawing from social life. Additionally, the health complications resulting from SGBV can be severe. Sexual assault can lead to pregnancy complications, as well as mental health issues including anxiety disorders, depression, post-traumatic stress disorder (PTSD), and somatic symptoms [37].

While refugee camps in countries of asylum provide some security and basic services, camp settings can increase the risk of SGBV. Lack of livelihood opportunities often forces women into poverty and situations where exploitation and abuse are increasingly common. Additionally, women are often responsible for obtaining food and firewood, drawing them away from secured areas. Lastly, insufficient police presence and high staff turnover negatively impact support services available to refugees [38].

References

  1. International Federation of Red Cross and Red Crescent Societies. Health, nutrition, water, sanitation and hygiene in Dadaab refugee camp. 2016 May 25.
  2. World Health Organization. Somalia Statistics Summary. 2015.
  3. World Bank. World Development Indicators, Somalia. 2015.
  4. Jaffer FH, Guy S, Niewczasinski J. Reproductive health care for Somali refugees in Yemen. Forced Migration Review 19; 2004 January.
  5. Extending Service Delivery Project and USAID. Somali refugee attitudes, perceptions, and knowledge of reproductive health, family planning, and gender-based violence. 2008.
  6. Eradication of Female Genital Mutilation in Somalia. 2004. Available from: https://www.unicef.org/somalia/SOM_FGM_Advocacy_Paper.pdfExternal.
  7. Al-Dhayi B. Towards abandoning female genital mutilation/cutting in Somalia for once, and for all. UNICEF. 2013.
  8. FGM/C prevalence among girls and women ages 15 to 49 years. February 2016.
  9. World Health Organization. Female genital mutilation (FGM). [cited 2016 September]; Available from: http://www.who.int/reproductivehealth/topics/fgm/prevalence/en/External.
  10. United Nations Population Fund. Female genital mutilation (FGM) frequently asked questions. 2015; Available from: http://www.unfpa.org/resources/female-genital-mutilation-fgm-frequently-asked-questionsExternal.
  11. Narruhn RA. Perinatal Profile for Patients from Somalia. EthnoMed. 2008.
  12. United Nations High Commissioner for Refugees. Dadaab SGBV Update. Sexual and Gender Based Violence Dashboard. 2015.