Understanding barriers to healthcare services utilization among women in Mauritania: a socio-anthropological analysis.

The findings are thematically organized into three interconnected categories of sociocultural barriers that hinder women’s utilization of healthcare services. These barriers emerged consistently across experiential workshops discussions and individual interviews and were frequently interwoven in participants’ narratives. First, GBV-specific barriers included fear of disclosure due to the risk of further harm and negative social repercussions. This fear is compounded by the internalization of sociocultural norms that reinforce silence and discourage reporting or help-seeking behavior. Second, SRH-related barriers stemmed from limited sexual health literacy, often resulting in feelings of shame and delayed recognition of medical needs. These limitations were further shaped by women’s lifelong exposure to sociocultural norms that restrict their access to information. Finally, structural and sociocultural barriers encompassed distrust of healthcare institutions, dissatisfaction with services, and reports of mistreatment and discriminatory practices by healthcare providers, all of which contributed to the avoidance or discontinuation of formal healthcare. Remaining silent about experiences of GBV emerges as a significant obstacle to seeking assistance. This silence is not unique to the Mauritanian context; participants described how shock, trauma, and the psychological consequences of violence –particularly sexual assault– impair a survivor’s capacity to seek medical assistance. Women’s silence, or, in some cases, denial, regarding GBV is rooted in deep-seated fear shaped by sociocultural expectations. Healthcare-seeking following GBV appears strongly influenced by context-specific factors embedded in sociocultural and religious norms, as well as patriarchal structures that dictate silence, normalize suffering, and restrict women’s autonomy. This dynamic created an ambivalent form of communication: women expressed a desire to speak out but they felt unable to do so, except perhaps in anonymous or protected spaces where they were not exposed to social or legal repercussions. Silence was not attributable to a single factor but emerged from intersecting conditions in which shame, fear and mistrust of institutions were recurrent barriers to disclosing GBV. Violence is frequently normalized within patriarchal and sexist systems, in which the silence of the victim is not only expected but sometimes valorized as a form of protection against greater social risk. These normative frameworks are closely linked to traditional gender roles and family honor. The normalization of violence thus contributes to the social and institutional denial of women’s rights. It is a problem of customs and shame. […]. Here we talk about castes and all that. When we talk about a family , it’s the whole family , there are tribes. Here in Mauritania we are Bedouins. It is part of our culture and our civilization. […] You are from this or that tribe , from this or that family. Even if you are raped by your elder brother or your father , you don’t dare to speak. We are going to keep this , and it eats you away , but you dare not open your mouth. Do we agree? And that’s part of our civilization and our customs. And we are not going to find a solution to it. It is a problem of customs and shame. […]. Here we talk about castes and all that. When we talk about a family , it’s the whole family , there are tribes. Here in Mauritania we are Bedouins. It is part of our culture and our civilization. […] You are from this or that tribe , from this or that family. Even if you are raped by your elder brother or your father , you don’t dare to speak. We are going to keep this , and it eats you away , but you dare not open your mouth. Do we agree? And that’s part of our civilization and our customs. And we are not going to find a solution to it. Although participants initially described physical violence against women as unacceptable, many later admitted that it was tolerated in certain cases, for example, when a woman refused to have sex with her husband or engaged in sexual relations outside of marriage. Some participants considered that, in such cases, the victim was at fault and therefore not entitled to medical assistance. These moral and cultural interpretations help to explain why GBV victims may avoid disclosing their experiences, even to healthcare professionals. Maybe if your husband has hit you and someone asks you , you say no , I fell down. You are ashamed to say that you have been beaten , so you make up a story. […] Recently there was a woman who was going to lose her arm , her husband stabbed her twice , but her husband is Malian , not Mauritanian. Maybe if your husband has hit you and someone asks you , you say no , I fell down. You are ashamed to say that you have been beaten , so you make up a story. […] Recently there was a woman who was going to lose her arm , her husband stabbed her twice , but her husband is Malian , not Mauritanian. A girl beaten by her husband , who doesn’t know her rights , who doesn’t know if she should report , will be ashamed to go to the hospital , because in the hospital they force you to tell the doctor what happened to you , and it’s that fear that makes her not want to talk about it. A girl beaten by her husband , who doesn’t know her rights , who doesn’t know if she should report , will be ashamed to go to the hospital , because in the hospital they force you to tell the doctor what happened to you , and it’s that fear that makes her not want to talk about it. Participants from the Democratic Republic of Congo and Côte d’Ivoire further explained that, in their cultures, domestic violence is sometimes interpreted as a demonstration of affection or love. Violence is thus normalized, justified, or even romanticized under the belief that “ if there is no violence , there is no passion ”. Nevertheless, most participants acknowledged that domestic violence is not just a widespread phenomenon but a serious social and health issue. One key informant, originally from Senegal, shared her personal experience of domestic violence, which forced her to flee her country. She did not seek help for two reasons: first, because from a young age “ we are told we have to endure it ”; and second, because she feared the consequences of speaking out. The idea that “one has to endure” appeared repeatedly in the discussion as a cultural expectation explaining the persistence of domestic violence and women’s reluctance to report it. That is the most recurrent thing , I think , in Mauritania. Domestic violence. And going back to society , for example , when a woman gets married , the first thing we tell her is to put up with it. When your husband hits you , you put up with it. When your husband insults you , you put up with it. Everything that happens at home , stays at home. This message comes from your own family , from society , it’s cultural. And others refer to religion , that a woman has to put up with it. That is the most recurrent thing , I think , in Mauritania. Domestic violence. And going back to society , for example , when a woman gets married , the first thing we tell her is to put up with it. When your husband hits you , you put up with it. When your husband insults you , you put up with it. Everything that happens at home , stays at home. This message comes from your own family , from society , it’s cultural. And others refer to religion , that a woman has to put up with it. Silence and shame are further reinforced by pervasive victim-blaming norms within patriarchal systems, which hold women responsible for the violence they endure. In this context, moral and social expectations conflate victimhood with guilt, creating powerful disincentives to disclosure or help-seeking. We never say she was accidentally raped. But if she’s been raped , gets pregnant , brings her baby into the world , you’re ruined forever. You’ve brought a bastard into the world. They’re always going to point the finger at you and at the child you’ve brought into the world. And that child will give birth to children who will be singled out. We never say she was accidentally raped. But if she’s been raped , gets pregnant , brings her baby into the world , you’re ruined forever. You’ve brought a bastard into the world. They’re always going to point the finger at you and at the child you’ve brought into the world. And that child will give birth to children who will be singled out. When you’re embarrassed to even undress in front of someone , you can’t tell yourself that you’ve been raped. And the lady , if she’s married , she’s screwed , plus she’ll always have the finger [pointed] on her. We’re not going to say she was accidentally raped. No , they’re going to build a whole image around it , that she was in a relationship , or that she did it on purpose. The problem is the complex and the shame. When you’re embarrassed to even undress in front of someone , you can’t tell yourself that you’ve been raped. And the lady , if she’s married , she’s screwed , plus she’ll always have the finger [pointed] on her. We’re not going to say she was accidentally raped. No , they’re going to build a whole image around it , that she was in a relationship , or that she did it on purpose. The problem is the complex and the shame. Breaking the silence exposes to judgment and social exclusion: in the case of rape, remaining silent becomes imperative to avoid stigmatization and rejection. Me , my son has to marry someone else’s daughter , she has already been raped , what are you doing with her , she has already been raped […] You must not go near her. Me , my son has to marry someone else’s daughter , she has already been raped , what are you doing with her , she has already been raped […] You must not go near her. For a married woman it would be very hard. Because she has other problems. I don’t think they would disclose. She may have a problem with her husband. Most people won’t accept it. […] They will see her as an accomplice. They will doubt her , they will ask her a lot of questions , as if she did it on purpose , so it’s a very complicated thing. It can also lead to divorce. She will prefer to hide. Because she’s already been raped , she’s divorced , people ask why she’s divorced , if there’s another man , so the situation is a bit… delicate. For a married woman it would be very hard. Because she has other problems. I don’t think they would disclose. She may have a problem with her husband. Most people won’t accept it. […] They will see her as an accomplice. They will doubt her , they will ask her a lot of questions , as if she did it on purpose , so it’s a very complicated thing. It can also lead to divorce. She will prefer to hide. Because she’s already been raped , she’s divorced , people ask why she’s divorced , if there’s another man , so the situation is a bit… delicate. Silence also extends to domestic violence, where, beyond victim-blaming and presumed culpability, speaking out is viewed not merely as personal disclosure but as a transgression that threatens social norms and exposes women to further shame. The lack of communication in the family is what causes problems for the girls. For adults it is the worst because she is already used to staying quiet , she won’t talk. Even when she has problems with her husband , we don’t talk about it. Because they will blame you. They will tell you that you have to wear the veil , see how you dress , how you have to keep the house clean. Or when your husband brings you a second wife or goes off to find girlfriends , they will tell you that you don’t run the house well , that your husband is lacking something , it’s always the wife’s fault. You are the one who doesn’t do her duty , you are the one who doesn’t look good , it’s you , it’s you. The lack of communication in the family is what causes problems for the girls. For adults it is the worst because she is already used to staying quiet , she won’t talk. Even when she has problems with her husband , we don’t talk about it. Because they will blame you. They will tell you that you have to wear the veil , see how you dress , how you have to keep the house clean. Or when your husband brings you a second wife or goes off to find girlfriends , they will tell you that you don’t run the house well , that your husband is lacking something , it’s always the wife’s fault. You are the one who doesn’t do her duty , you are the one who doesn’t look good , it’s you , it’s you. They run away from the judgment of society. Because when you suffer injustice in your family or in your marriage , and you talk about it around you , they say you have no privacy in your home , and you are judged by others. So , there is a certain reluctance that pushes people to shut up. It’s suffocating. They run away from the judgment of society. Because when you suffer injustice in your family or in your marriage , and you talk about it around you , they say you have no privacy in your home , and you are judged by others. So , there is a certain reluctance that pushes people to shut up. It’s suffocating. Participants expressed profound mistrust toward legal and institutional systems, particularly the police and judicial authorities, which were described as failing to protect victims and, in many cases, siding with perpetrators. This institutional inaction or complicity was identified as a major deterrent to reporting violence or seeking healthcare. There are rights they should have and , unfortunately , even if you go to the police or the hospital to say you’ve been raped , your rights you’re not going to have them. It’s shame you’re going to have. The police will side with the rapist. She will be made guilty. That’s why women don’t want to report. Because before you go to the hospital , you have to go to the police , to get a requisition. There are rights they should have and , unfortunately , even if you go to the police or the hospital to say you’ve been raped , your rights you’re not going to have them. It’s shame you’re going to have. The police will side with the rapist. She will be made guilty. That’s why women don’t want to report. Because before you go to the hospital , you have to go to the police , to get a requisition. The legal requirement to obtain a police requisition before receiving emergency care for sexual violence was perceived as both burdensome and dangerous. For many women, especially those assaulted by acquaintances or family members, this procedural step poses insurmountable psychological and legal barriers. If it’s a stranger , it’s easier than if it’s someone in the family. […] I think younger girls are supported , but older girls , maybe when they are over 20 , they will be embarrassed to say they have been subjected to things like that. But at a young age she may not be aware of what she’s going to report , maybe it was her mother who brought her in , or her aunt , so she doesn’t know. But at a certain age you’re going to be embarrassed to come forward and say you’ve been raped. Maybe they will ask you what you were doing , who it was , if it was a stranger , so the social pressure is greater , because you are an older person , you have to be responsible , you shouldn’t be the object of all this. If it’s a stranger , it’s easier than if it’s someone in the family. […] I think younger girls are supported , but older girls , maybe when they are over 20 , they will be embarrassed to say they have been subjected to things like that. But at a young age she may not be aware of what she’s going to report , maybe it was her mother who brought her in , or her aunt , so she doesn’t know. But at a certain age you’re going to be embarrassed to come forward and say you’ve been raped. Maybe they will ask you what you were doing , who it was , if it was a stranger , so the social pressure is greater , because you are an older person , you have to be responsible , you shouldn’t be the object of all this. In some cases, participants feared criminal prosecution if they pressed charges, particularly under accusations of zina (sexual relations outside marriage), which in Mauritania can be misapplied to victims of rape. This fear often resulted in complete inaction, even in extreme cases. I had this case in a very close family. The girl she had been raped and threatened with a knife. I went to see her and told her to go to the police. They told me no , she can’t , because they will say she is guilty and put her in jail. They prefer to keep quiet. I had this case in a very close family. The girl she had been raped and threatened with a knife. I went to see her and told her to go to the police. They told me no , she can’t , because they will say she is guilty and put her in jail. They prefer to keep quiet. Fear of retaliation and of exposure to further harm also decreased the likelihood of disclosing GBV. Immigrant women reported risks of sexual abuse by police officers or military personnel under threat of fines or deportation, and by employers in the case of domestic workers. A participant described a midwife who sheltered several mixed-race children born to women in servitude who, after being abused by their employers, could not return to work with their babies for fear of repercussions for themselves and their children. Overall, participants emphasized how the “condemnation to silence” experienced by victims is particularly pervasive in Mauritania because it has been internalized by women themselves, even those suffering from domestic violence or rape. Many participants perceived that “knowing how to put up with it” is viewed as an obligation of women in their roles as daughters and wives. As the next section illustrates, this internalized endurance extends beyond violence to shape women’s responses to illness and healthcare-seeking behavior. Participants described a culture of silence surrounding illness and the expression of bodily needs. Almost all participants agreed that this enforced silence constituted the primary obstacle to seeking medical assistance, even for basic sexual and reproductive health concerns. Sustained across the life course, this silence originates from socially constructed ignorance and shame surrounding the female body. Discussions of sexuality and reproductive health are constrained by social norms that define women primarily through their reproductive roles, limiting conversation to pregnancy, childbirth, and motherhood within narrowly prescribed reproductive years. Unmarried women are expected to refrain from discussing any health condition that might imply sexual activity, as doing so risks suspicion that they have lost their virginity or are engaged in a legally prohibited adulterous/non-married relationship. One participant stated that she saw no point in consulting a gynecologist before marriage. Women who are not yet married cannot talk about [cysts] because they are afraid to be told , why do you have this , it’s not normal for you to have diseases like that , like cysts and fibroids and things like that because you’re not married. Her sister had a cyst and never talked about it until she got married , then she got pregnant and had to terminate the pregnancy because the cyst outgrew the fetus. Women who are not yet married cannot talk about [cysts] because they are afraid to be told , why do you have this , it’s not normal for you to have diseases like that , like cysts and fibroids and things like that because you’re not married. Her sister had a cyst and never talked about it until she got married , then she got pregnant and had to terminate the pregnancy because the cyst outgrew the fetus. The importance attached to virginity was a subject of much debate among the group of young athletes for whom playing sports, using menstrual hygiene products or being examined by a doctor or gynecologist were perceived by relatives as potential threats to their virginity and, consequently, to their marriage prospects. In another group, participants explained that the growing number of unmarried minors seeking healthcare at specialized GBV units, often accompanied by their families, was not only motivated by treatment needs but also by the families’ desire to verify the girls’ virginity in order to protect their family honor. Furthermore, “married life”, understood as sexual life, is not addressed during girlhood, leaving women unprepared for their sexual and reproductive health needs as adults. One participant recounted that after becoming pregnant following a rape at age 14, she learned only during childbirth “ where the baby was supposed to come out from ”. For several participants, the lack of sex education or preparation for marriage is a deeply rooted taboo that reinforces silence around “marital issues”, including domestic violence, a theme raised in all experiential workshops. Sex education is considered taboo in some societies. We don’t talk about it. When you give your daughter in marriage you have to talk about the sexual aspect , the physical and the mental. I think other cultures have a generational conflict. They think that the girl is not ready or that it is shameful to talk about marriage. […] They give her in marriage and that’s it , it’s over. And the girl has no experience of marriage. But we prepare her for marriage. For example , we have what in Pulaar is called “mougndee” which means “to endure.” Sex education is considered taboo in some societies. We don’t talk about it. When you give your daughter in marriage you have to talk about the sexual aspect , the physical and the mental. I think other cultures have a generational conflict. They think that the girl is not ready or that it is shameful to talk about marriage. […] They give her in marriage and that’s it , it’s over. And the girl has no experience of marriage. But we prepare her for marriage. For example , we have what in Pulaar is called “mougndee” which means “to endure.” It’s a problem of education. I think there are many girls who are given in marriage when they don’t know what is at stake. In our culture , the Pulaar culture , the value of marriage is worshipped from childhood. You are told here , marriage is this , marriage is that , but there are other cultures that think it is a taboo subject that should not be talked about with girls. But even at an early age , girls have to be prepared for marriage. It’s a problem of education. I think there are many girls who are given in marriage when they don’t know what is at stake. In our culture , the Pulaar culture , the value of marriage is worshipped from childhood. You are told here , marriage is this , marriage is that , but there are other cultures that think it is a taboo subject that should not be talked about with girls. But even at an early age , girls have to be prepared for marriage. The lack of sexual education was highlighted during the drawing exercise using female silhouettes (Supplementary Material 2 . Results - participants drawings). Participants were invited to choose either clothed or nude outlines. Except for the group of young athletes, all participants chose the clothed version, explaining that they had rarely, if ever, seen depictions of naked women, except in limited educational settings. During the exercise, participants were asked to color the silhouettes while answering three open-ended questions designed to stimulate reflection on embodiment and health: What parts of your body do you use the most on a daily basis?; What parts of your body do you enjoy the most?; In what parts of your body do you feel, or have you felt pain, blockage, or illness?. Several participants expressed discomfort or hesitation when talking about their bodies. In response to the third question, many colored the stomach area. Dialogue between researchers and participants revealed that what they referred to as the “stomach” or “lower abdomen” actually denoted the genital area, and that the pain they described was caused by infections, cysts, or similar conditions. However, they were unable or unwilling to name these parts explicitly, reflecting how sociocultural taboos and limited sexual literacy constrain women’s ability to articulate their health concerns –even in safe and supportive settings. Within this sociocultural framework, healthcare utilization was often perceived as legitimate only when related to marital sexual relations or childbearing. Several participants noted that women’s access to care was justified primarily by their reproductive roles. One participant recounted that she had developed a large and painful cyst near the vaginal opening, which she only had treated by a non-healthcare professional when it began to interfere with sexual intercourse with her husband. What motivated her to seek a solution was not the recognition of a health problem but the perceived obligation to fulfill her marital duties. At the same time, the social value placed on female fertility may discourage women from seeking medical advice for fear of being diagnosed with infertility, a condition that could jeopardize their marriage or prospects for marriage. In most cases, infertility is attributed solely to the woman. One participant shared the case of a woman who, after having two children from her first marriage, experienced difficulty conceiving during her second marriage. Her mother-in-law insisted that she saw a doctor. The diagnosis (cysts and endometriosis, which made further pregnancies impossible), was disclosed to the mother-in-law in violation of medical confidentiality, leading to the annulment of the marriage and severe socioeconomic consequences for the woman and her children. Beyond infertility, this social vulnerability extends to other reproductive health issues, including HIV and sexually transmitted infections (STIs), where stigma and gendered blame further restrict women’s willingness to seek care. If the woman has no children , it will always be her fault. The husband will never go to the hospital. He will even look for another wife. […] For other things , like STIs , it’s the same thing. If the woman has no children , it will always be her fault. The husband will never go to the hospital. He will even look for another wife. […] For other things , like STIs , it’s the same thing. We can shamelessly talk about migraines , stomachaches , small operations , fibroids…. There are things we hide and others that we don’t. Because they are really scary. […] HIV is even worse , people don’t disclose it. Sometimes it is complicated to go for testing […] people are afraid , because the term HIV-AIDS… is scary. We can shamelessly talk about migraines , stomachaches , small operations , fibroids…. There are things we hide and others that we don’t. Because they are really scary. […] HIV is even worse , people don’t disclose it. Sometimes it is complicated to go for testing […] people are afraid , because the term HIV-AIDS… is scary. Many participants explained that they lack safe spaces to learn about their bodies and health. Although some occasionally turn to relatives such as mothers, sisters or friends, only one reported using the Internet, taboos and shame surrounding women’s bodies and genitalia make it difficult to discuss certain diseases, even within the family. You see little girls with a minor genital problem , and they are embarrassed to tell their mother. You see an adult woman with genital complications , and she can’t tell her husband. You see little girls with a minor genital problem , and they are embarrassed to tell their mother. You see an adult woman with genital complications , and she can’t tell her husband. However, the atmosphere of trust during the workshops enabled participants to express curiosity about how the female body functions and to ask questions for clarification. The sessions became opportunities to share personal practices and beliefs, for example, that uterine pain can be cured by marriage; that sitting in hot water relieves internal tears resulting from sexual intercourse; or that applying ginger to the vagina increases sexual pleasure. Participants’ limited access to formal information did not imply a complete lack of knowledge, nor did it prevent them from recognizing certain forms of violence and their consequences. Do you remember the story of *? The woman , she was pregnant , was raped and killed. She was married. […] Sometimes after rape they kill them. Do you remember the story of *? The woman , she was pregnant , was raped and killed. She was married. […] Sometimes after rape they kill them. Most girls don’t realize that when you’ve been circumcised you have defects. There are a lot of things, like infertility. Most girls don’t realize that when you’ve been circumcised you have defects. There are a lot of things, like infertility. I don’t think people know much about the health problems [associated with rape]. There is a lack of awareness , especially about STIs. […] they don’t think it’s a health problem , they think it’s rape , it’s over , it can’t cause them problems in the future. I don’t think people know much about the health problems [associated with rape]. There is a lack of awareness , especially about STIs. […] they don’t think it’s a health problem , they think it’s rape , it’s over , it can’t cause them problems in the future. The lack of precise terms to describe bodily ailments contributes to delayed or foregone healthcare utilization and the reliance on alternative explanations or practices. Women’s sexual and reproductive health issues, such as infertility or difficulty carrying a pregnancy to term, are rarely conceptualized as medical problems. Instead, alternative explanations are invoked – being the victim of the evil eye or a djinn . These cultural interpretations shape not only how women understand their symptoms but also how, when, and from whom they seek care. Despite the obstacles imposed by the culture of silence surrounding women’s bodies and suffering, almost all participants had at some point sought medical attention and received hospital care for childbirth, injuries, infectious diseases and complications. However, their experiences with the formal healthcare system were deeply shaped by external sociocultural constraints and internalized norms, as well as by recurrent experience of stigma, discrimination and even violence within health institutions. These factors not only undermined trust in the system but also reinforced broader patterns of exclusion from essential healthcare services. Most participants agreed that they reserved the use of formal health services for severe or life-threatening conditions, relying instead on alternative forms of care such as self-medication or traditional practices. Me , the stomach , the teeth , the neck , the feet , the back… personally , I take care of everything at home. I take some monkey bread , I take “autorelax” , I take “doliprane” [paracetamol] , I take care of myself a bit at home. It is rare for a family not to have a pharmacy at home. Me , the stomach , the teeth , the neck , the feet , the back… personally , I take care of everything at home. I take some monkey bread , I take “autorelax” , I take “doliprane” [paracetamol] , I take care of myself a bit at home. It is rare for a family not to have a pharmacy at home. And it’s when things start to get serious that you go to see the doctor , and then it’s too late. […] We’re not used to going to the doctor. And it’s when things start to get serious that you go to see the doctor , and then it’s too late. […] We’re not used to going to the doctor. Purchasing medication from pharmacies or on the informal market was described as a common and less costly practice. The cost associated with healthcare access, including transport, medication, accommodation in the city when hospitalization was required, was emphasized by nearly all participants, most of whom came from modest or poor households. One participant recounted how a colleague had died in the hospital after hours of waiting because her companion did not have enough money to pay for the oxygen. Financial hardship also affected access to family planning and maternal care. You come to the hospital , and you can’t even pay the taxi. You come , and you can’t even afford an injection. They ask you to pay for the paperwork. You come to the hospital , and you can’t even pay the taxi. You come , and you can’t even afford an injection. They ask you to pay for the paperwork. It’s too expensive. People would rather die at home than go for treatment. It’s too expensive. People would rather die at home than go for treatment. Lower cost was one of several reasons participants preferred traditional medicine. More than half reported having consulted a marabout (traditional healer) either before or after using medical services. Many valued traditional medicine because marabouts are more accessible than health centers in rural regions, are often trusted members of the community, and offer care perceived as more personal, responsive, and respectful than hospital-based services. It’s the lack of means , it’s what pushes people to go for the traditional. It’s the lack of means , it’s what pushes people to go for the traditional. First of all , it’s not expensive. Besides , it’s cultural. Also , you prefer to go to the marabout , he gives you a string that you tie and that’s it. First of all , it’s not expensive. Besides , it’s cultural. Also , you prefer to go to the marabout , he gives you a string that you tie and that’s it. There are also people who prefer traditional remedies. Here , almost everything in modern medicine is also traditional , and people prefer to go there because it is faster , especially in the case of a fracture , people prefer to go traditional , so that , it will be faster. […] Yes , it is cheaper. […] Hospitals take time , you go for tests , ultrasounds , and sometimes you can go two or three weeks without a prescription because you are still doing tests. There are also people who prefer traditional remedies. Here , almost everything in modern medicine is also traditional , and people prefer to go there because it is faster , especially in the case of a fracture , people prefer to go traditional , so that , it will be faster. […] Yes , it is cheaper. […] Hospitals take time , you go for tests , ultrasounds , and sometimes you can go two or three weeks without a prescription because you are still doing tests. While some participants preferred to go directly to the traditional healers, others did so only after receiving unsatisfactory or incomplete treatment care in hospitals. Across all discussions, participants expressed negative perception of the healthcare system, citing cost, inaccessibility, long delays, and impersonal or disrespectful treatment as major deterrents to seek formal care. Socioeconomic factors emerged as critical in shaping decisions to use formal healthcare services. Beyond affordability, participants cited education and place of residence as relevant factors for healthcare access and confidence in seeking medical attention. Women who have done the ban [primary education] are much more confident about going to the doctor. Education has a big influence. Also , if it’s in the bush or in the city. Women who have done the ban [primary education] are much more confident about going to the doctor. Education has a big influence. Also , if it’s in the bush or in the city. Yes , women don’t know their rights , of course. In the outskirts , in remote villages , in the interior of the country. Here in Nouakchott , it’s in the slums. But the people of Tevragh Zeina [the richest neighborhood in Nouakchott] they are awake. Except the watchmen (laugh). Yes , women don’t know their rights , of course. In the outskirts , in remote villages , in the interior of the country. Here in Nouakchott , it’s in the slums. But the people of Tevragh Zeina [the richest neighborhood in Nouakchott] they are awake. Except the watchmen (laugh). Discrimination based on poverty, administrative status, language and skin color, combined with gender bias, also affected the quality of care received. One participant described visiting a doctor for a rash on her buttock; the physician refused to examine her, instead issuing a diagnosis based solely on her verbal description, despite a language barrier (she spoke French while the doctor spoke Hassanya). In cases involving vaginal discomfort or infections, participants reported that no examination, smear or diagnostic test was performed under the pretext of modesty. Many participants believed that receiving respectful treatment in hospitals depended on having financial means or personal connections with medical staff. Others spoke of verbal abuse, discrimination, and neglect, describing the healthcare environment as dehumanizing. Moors are treated better than blacks. Let’s not beat around the bush , that’s the reality. And when you’re a migrant , you’re dead. […] The way they ignore her , they barely see her. And there’s also the question of languages , as soon as they come , they’re going to talk to you in hassanya. And they don’t take the time to understand. […] They have to at least try to understand me. I don’t think that’s human at all. And me personally , it’s happened to me several times. And why? Because I don’t speak hassanya. It’s as if you , what you are saying , is of no importance. It’s a way of putting people down. Moors are treated better than blacks. Let’s not beat around the bush , that’s the reality. And when you’re a migrant , you’re dead. […] The way they ignore her , they barely see her. And there’s also the question of languages , as soon as they come , they’re going to talk to you in hassanya. And they don’t take the time to understand. […] They have to at least try to understand me. I don’t think that’s human at all. And me personally , it’s happened to me several times. And why? Because I don’t speak hassanya. It’s as if you , what you are saying , is of no importance. It’s a way of putting people down. Several participants explained that they preferred to seek care in private hospitals or clinics when they could afford it, or even abroad, particularly in Senegal, Spain, or France. Cost and quality of care were cited as major reasons for this preference. Among those who avoided public facilities, common complaints included poor hygiene, lack of attention from staff, inadequate diagnosis or treatment, and excessive waiting times. Many women recounted spending entire days or even consecutive days in the hospital without being examined. There is a hygiene problem in hospitals. They don’t smell good. There are germs , odors and so on. There are unqualified personnel , anyone can be a doctor. The Ministry does not take the people who work in the hospitals seriously. There is a hygiene problem in hospitals. They don’t smell good. There are germs , odors and so on. There are unqualified personnel , anyone can be a doctor. The Ministry does not take the people who work in the hospitals seriously. I also think that nurses and doctors should feel something for patients. […] A woman is on the operating table and there are nurses chatting around her. Instead of being aware of this woman who is suffering and helping her , they leave her in pain and say , she will shut up when she gets tired. There is a lack of feelings. Some nurses have no feelings. They are not humanistic. For example , if there is a child who is afraid of injections , instead of calming the child down they are there screaming. It is not good for the person mentally. I also think that nurses and doctors should feel something for patients. […] A woman is on the operating table and there are nurses chatting around her. Instead of being aware of this woman who is suffering and helping her , they leave her in pain and say , she will shut up when she gets tired. There is a lack of feelings. Some nurses have no feelings. They are not humanistic. For example , if there is a child who is afraid of injections , instead of calming the child down they are there screaming. It is not good for the person mentally. Fear of mistreatment also led some women to forgo care. One participant described canceling a scheduled operation to remove a breast cyst after being frightened by the surgeon’s aggressive manner. Another recounted being sent home while in labor; she gave birth shortly afterward, without medical assistance, placing both her life and her baby’s life in danger. Women’s autonomy to seek healthcare was often restricted by both procedural and sociocultural norms. Obtaining a husband’s authorization, financial support, or physical presence was frequently cited as a prerequisite for treatment. Here when you go to the hospital , your whole family will come with you. If you go to the hospital alone , even the doctor will look at you , don’t you have a family? […] Directly they ask you where your husband is. They think that a woman has to have her husband’s permission to go to the hospital. Here when you go to the hospital , your whole family will come with you. If you go to the hospital alone , even the doctor will look at you , don’t you have a family? […] Directly they ask you where your husband is. They think that a woman has to have her husband’s permission to go to the hospital. Because it is true that we are in an Islamic country and you have to follow the rules as Islam says. For example , if you have a vaginal problem , like an infection , if you have to be seen by a man , your husband has to be there. If your husband is not there , it has to be a female gynecologist. […] They won’t give you contraceptives if your husband is not there because he has to agree. Your husband has to be there to do the [family] planning. […] Even if the woman says she is married , they don’t believe her , her husband has to be there. Because it is true that we are in an Islamic country and you have to follow the rules as Islam says. For example , if you have a vaginal problem , like an infection , if you have to be seen by a man , your husband has to be there. If your husband is not there , it has to be a female gynecologist. […] They won’t give you contraceptives if your husband is not there because he has to agree. Your husband has to be there to do the [family] planning. […] Even if the woman says she is married , they don’t believe her , her husband has to be there. Fear and prejudice toward women also extend to healthcare professionals. As noted earlier, providers may refuse to treat victims of GBV without a police requisition, fearing accusations of violating Islamic norms. This procedural requirement was cited by one key informant as a major barrier preventing adult women from accessing the health system after sexual assault, due to fear of zina accusations and other legal or social consequences. Sometimes it is the husband himself who files a complaint against the midwives. Most of the time the midwife also wants to protect herself. Sometimes it is the husband himself who files a complaint against the midwives. Most of the time the midwife also wants to protect herself. Healthcare providers themselves face threats and retaliation for assisting victims of GBV. We run a lot of risks. There are many associations that run risks in entering this rape thing and others , but they end up having a lot of problems. I come , I get a call about this neighbor , she has been raped. I come; I go to the police. The gentleman comes with his friends , he breaks into my house , or he burns my car or else he rapes my daughter. As president of an association , I am afraid. There are things I don’t do. Because I risk my life and my children’s lives. We run a lot of risks. There are many associations that run risks in entering this rape thing and others , but they end up having a lot of problems. I come , I get a call about this neighbor , she has been raped. I come; I go to the police. The gentleman comes with his friends , he breaks into my house , or he burns my car or else he rapes my daughter. As president of an association , I am afraid. There are things I don’t do. Because I risk my life and my children’s lives.

Violence against women is deeply rooted in structural, social and cultural factors. Patriarchal beliefs and cultural practices sustain the normalization of GBV and systematically limit women’s access to healthcare. This exclusion is reinforced by discriminatory stereotypes and behaviors within the health system itself, manifesting in unequal treatment, humiliation, denial of care, and moral judgement. Addressing these inequities requires a comprehensive approach that targets both the social foundations of patriarchy and the institutional dynamics that reproduce it. Healthcare professionals play a vital role in ensuring respectful, rights-based, and gender-sensitive care that acknowledges women’s specific vulnerabilities and guarantees safe, confidential, and equitable access to services. Legal and law enforcement reforms are equally urgent. Survivors face dual risks when filing complaints: disbelief or criminalization under zina laws. The requirement of police requisitions for GBV-related healthcare remains a major structural barrier, delaying treatment and deterring reporting. Transforming this situation demands coordinated evaluation and reform of current policies and service delivery frameworks to reduce health inequities and ensure inclusion. Ultimately, women’s health must be recognized as a fundamental human right, not a conditional privilege determined by marital status, socioeconomic position, or cultural norms.

This study is, to our knowledge, the first to examine sociocultural barriers to healthcare in Mauritania, focusing on women’s access to GBV- and SRH- related services. Drawing on participants’ narratives, shared lived experiences and collective reflection, it provides insights into the social dynamics shaping women’s healthcare-seeking behaviors beyond the structural obstacles commonly cited in the literature such as accessibility, availability and affordability of services. Our findings reveal that the non-use or discontinuation of healthcare is a widespread phenomenon. While participants frequently underscored the role of their specific cultural context—whether in terms of ethnicity or nationality—in shaping their experiences, their accounts revealed many shared life experiences. This study recognizes that cultures are complex, changing, and non-homogeneous. However, specialized GBV- and SRH-services appeared overall less likely to be utilized than emergency and maternal services, and their utilization largely affected by prevailing social norms and cultural representations of gender and health. Non-utilization was linked to fear of social exclusion and isolation, social control and pressure within the community, the family and household. This finding aligns with Mtaita et al. [ 34 ], who found that Tanzanian women and adolescent girls avoided STI screening services due to social stigmatization, insecurity, and lack of family support. Beyond the African continent, in India, Yadav et al. [ 35 ] identified embarrassment, taboos, and lack of information as barriers to contraceptive use. Consistent with global evidence, participants noted that accessing SRH- services is associated with social risks such as discrimination and social rejection, particularly for adolescent girls and unmarried women [ 6 , 36 ]. They further described how social constraints persist beyond adolescence, echoing Ndayizigiye et al. [ 37 ], who showed that religious and community pressures shaped adult women’s SRH choices in Burundi, and Sagna and Sparks [ 38 ], who found that limited women’s autonomy hindered institutional childbirths in Uganda. In Mauritania, where a weak social protection system sustains reliance on high fertility as a form of economic security in old age, women face an increased risk of seeing their fertility being appropriated. Childbearing becomes less of a personal or couple’s decision, but rather a social obligation. Reproduction becomes culturally institutionalized and part of a community sentiment, once again generating fear of stigma and social exclusion when dealing with the risk of infertility. Feelings of shock, shame, and fear have been widely documented as reasons for not seeking help after sexual assault [ 39 – 41 ], highlighting how internalized guilt and victim-blaming embedded in patriarchal gender norms appear to operate across cultural contexts. In Mauritania, however, this is further reinforced by the threat of zina accusations, a distinctive legal and moral constraint that discourages survivors from seeking medical or judicial support. Women avoid GBV specialized services precisely because their reasons for seeking care—rape, domestic violence, or complications of female genital mutilation—must be concealed for fear of social repercussions, including retaliation from perpetrators and secondary victimization by the police or the community. While research on gender norms affecting access to healthcare highlights the notion that men are more likely to be expected to endure pain and sickness [ 6 ], here, participants revealed that women are equally, if not more, expected to “endure” and bear suffering silently, a behavior socially encouraged and culturally valorized as fortitude. Participants’ testimonies also reveal that the roots of silence extend beyond legal barriers: taboos surrounding the female body, illness, sexuality, and violence create a sociocultural environment in which women “suffocate” in silence, unable to name or externalize their suffering. This culture of silence, both imposed and internalized, reflects the deep entrenchment of patriarchal norms in Mauritanian society, where women remain in positions of subordination. This manifests through the multiple forms of control and instrumentalization of women’s bodies: female genital mutilation in childhood; the absence of sexual education; the social obsession with virginity; and the reduction of women’s health to fertility and the fulfillment of marital duties. In this context, healthcare utilization becomes primarily tied to the fulfillment of social roles—particularly procreation—rather than to the intrinsic right to health or the need for care in illness or pain. This injunction to silence and endurance is compounded by widespread distrust in the healthcare system. Participants expressed pervasive dissatisfaction with the quality of care received in the public health system and their preference for traditional practitioners. They explained this with the costs, long waiting times, unhygienic conditions in public health facilities, health professionals’ poor attitude and failure to perform a physical examination – relying instead on a seemingly endless prescription of diagnostic tests. These findings reaffirm that health services must be designed around and informed by the experience of care users, aligning with current trends emphasizing patient experience as a cornerstone for improving healthcare quality [ 42 ]. Cultural barriers are not accessibility barriers per se, but rather an obstacle to the acceptability dimension of healthcare: when the health system is not culturally respectful and fair to the social determinants of health – gender, language, education level, etc. – it creates a deterrent effect that limits access. Even when women overcome social taboos and procedural barriers—such as the requirement of male authorization, costs and bureaucracy—their encounters with the health system are often marked by humiliation, racism, or neglect. Mtaita et al. [ 34 ] identified lack of confidentiality and distrust of providers as key deterrents for access to SRH services in Tanzania, and Mehrtash et al. [ 42 ] found that poor patient–provider relationships and substandard care were among the most frequently reported determinants of negative patient experiences in antenatal care. Achieving health equity requires that health services be available, accessible, acceptable, equitable and of high quality [ 43 , 44 ]. Yet overt racism, discrimination, and gender bias constitute intersecting forms of exclusion that undermine these principles. They not only affect diagnosis and treatment but also undermine women’s trust in institutions [ 45 ]. However, providers’ perspective also emerged from our study: both directly, through a professional’s testimony about personal safety risks when providing help to GBV survivors, and indirectly, when participants reported that health workers demanded a police requisition for victims to access services after sexual assault. As documented elsewhere [ 17 ], this requirement does not stem from a legal imperative, but from health workers’ fear of being perceived as endorsing unlawful conduct ( zina ) by administering emergency contraceptives or pregnancy-related care to women who would have engaged in consensual intercourse. This aligns with Schaaf et al. [ 46 ] who highlight that, worldwide, SRH professionals often operate amid contradictory legal, religious, and ethical expectations, compounded by chronic resource scarcity. Boydell et al. [ 47 ] likewise showed that frontline health workers in SRH frequently face hostility, harassment, and threats, both professionally and personally. Hence, while institutional mistrust is a key factor driving non-utilization, focusing solely on individual provider behavior risks obscuring the systemic nature of these challenges. Particularly within GBV and SRH health services, deconstructing the patriarchal nature of clinical practices and health structures remains essential to improve both patient care and working conditions of health workers—often women themselves and subject to similar forms of social risks [ 48 ]. Lori Heise’s [ 49 ] ecological model of GBV emphasizes the interconnectedness of individual, relational, and structural forms of violence, and offers insights into how gendered power dynamics drive women’s disengagement from formal healthcare systems through mechanisms such as lack of autonomy, fear, stigma and systemic exclusion. These conditions amount to gender-based systemic violence and threaten women’s constitutional right to a health-enabling environment, as guaranteed under Mauritanian law. Addressing the systemic injustices voiced in this study requires structural transformation both within health systems and the broader sociopolitical context that sustains them. This includes the economic barriers and the persistence of legal frameworks that hinder gender equality and women’s rights. Furthermore, control and power mechanisms that impede women’s emancipation fuel an epistemic injustice, i.e. the systemic discredit of their narratives and lived experiences that reinforces women’s silencing [ 22 ]. In the lineage of Awa Thiam’s La parole aux négresses [ 20 ], this study was conducted to allow women’s voices to resonate. It aimed at recognizing their roles as producers of knowledge, political subjects, and active agents in the reconfiguration of health systems that too often treat them as passive recipients or distant targets—particularly when examined from the perspective of the Global North. The prescriptive orientation of international SRH policy profoundly shapes the nature of healthcare available, allocating greater attention and resources in Mauritania to family planning and maternal health than to other aspects of women’s health [ 9 ]. When given the freedom to express their concerns, participants chose to emphasize women’s health conditions often rendered invisible in global health literature—such as cysts, fibroids, infertility, endometriosis, pain, and vaginal discomfort—rather than the commonly highlighted issue of unmet need for contraception. This finding also reveals that, while acknowledging gaps in their own knowledge, participants demonstrated a high level of health literacy in areas frequently overlooked. They likewise displayed significant agency in prioritizing quality of care over accessibility, whether geographic or financial. Whereas national SRH policy tends to privilege accessibility, the notion that women should be instructed to accept substandard care, or care focused on reproductive functions, is as ethically untenable and analytically flawed as the social norms that command them to avoid healthcare during adolescence or to restrict their use of it to fulfilling marital duties. Women, as their testimonies show, have always known better. Given the sensitivity of the topic and the trust required to explore it, this study relied on a convenience sample, which limits the generalizability of its findings. Nonetheless, the participatory approach fostered a climate of mutual trust that enabled rich exchanges and meaningful discussions on otherwise silenced experiences. For practical and financial reasons, the study was limited to Nouakchott. As Mauritania’s capital, it may not fully reflect the realities of women in provincial rural areas, where social norms and access barriers are likely to differ. Mauritania’s linguistic diversity also posed challenges. Although French and Hassanya are commonly spoken, many participants’ first languages were Halpulaar, Soninké, or Wolof. Translation across these languages, and subsequently into English, may have constrained the nuance of participants’ expressions, despite rigorous efforts to ensure linguistic fidelity. Conducting research in complex contexts is a challenge and involves tensions between scientific rigor, feasibility, and ethical responsibility. This study could be subject to ethical limitations, including the absence of a national ethics committee at the time of its initiation, reliance on internal NGO ethical review processes, and the need to prioritize participant safety and confidentiality over full methodological transparency in a sensitive and potentially identifiable population. Despite these limitations, the study’s grounding in locally led participation and its integration of diverse voices represent a significant strength, ensuring that the analysis remains deeply contextualized and grounded in participants’ lived lives, especially in the under-documented context of Mauritania.

This qualitative study employed a feminist, socio-anthropological approach to examine women’s lived experiences of accessing and discontinuing GBV and SRH services in Nouakchott, Mauritania. The qualitative design was chosen for its capacity to generate in-depth, contextualized insights and foster dynamic interaction. Given the sensitivity of the research topic, focused on violence, structural exclusion, deprivation, and gendered power asymmetries, the study employed a feminist and non-extractivist methodology for data collection [ 18 – 20 ]. Feminist methodology challenges the notion that research is neutral, arguing instead that knowledge is the sum of lived experiences, grounded in situated and responsible knowledge [ 21 , 22 ]. Non-extractivism refers to a critique of the extractive model of the economy and epistemology, proposing instead that testimonial information and the use of narratives be employed for common interest and the benefit of the community [ 23 ]. Combined, these two approaches incorporate care and relational ethics in the co-creation of knowledge. Finally, an anthropological approach guided the analysis [ 20 , 24 ], focusing on lived realities through the lens of culture, society, and community. Given that women and girls constitute the vast majority of individuals affected by GBV, the study focused on the needs, experiences, and voices of women. To minimize the risk of re-victimization, only participants aged 18 years or older were included. A total of 33 women participated in experiential workshops and individual interviews in October 2023. Of these, 28 were recruited between August and September 2023 through a stratified purposive sampling strategy designed to maximize diversity in age (under 30 / over 30), cultural backgrounds, and socioeconomic status. These criteria guided recruitment but were not treated as analytical variables. All workshop participants resided in Nouakchott or its surrounding suburbs, reflecting the social and geographic diversity of urban and peri-urban neighborhoods (Table  1 ). Additionally, five key informants were purposively selected in September 2023 for their professional or social roles, ensuring representation of underrepresented perspectives. These informants participated in semi-structured, in-depth interviews that provided space for personal reflection and exploration of institutional or community-level dynamics. Informants included a youth counselor from a local municipality, a midwife specialized in family planning, a sex worker, the president of a civil society organization and traditional healer, and an artist. Table 1 The demographic characteristics of participants in the experiential workshops Location Designation Composition Participants ( n  = 28) Toujounine (popular Nouakchott neighbourhood) Adult women, 30+ Women of Pulaar, Soninké and Beidan culture 3 Adult women, 18–30 4 Nouakchott-South (popular outskirts) Adult women, 30+ Women of Pulaar, Soninké and Beidan culture 5 Adult women, 18–30 6 Associative setting Adult women 18 + of foreign nationality/in precarious administrative situation Natives from Mali, the Democratic Republic of Congo and Ivory Coast 3 Sports federation Adult women, 18–25 Young athletes 8 The demographic characteristics of participants in the experiential workshops Toujounine (popular Nouakchott neighbourhood) Nouakchott-South (popular outskirts) Participation was voluntary. Women were invited only if they expressed clear interest and felt comfortable engaging in a group setting. To ensure the inclusion of voices often marginalized or excluded from formal healthcare and GBV protection systems, the study also included women experiencing marginalization, including those with irregular administrative or residency status, women engaged in sex work, and women whose sexual orientation is criminalized under Mauritanian law. For ethical and safety reasons, specific details about their recruitment are not disclosed. These participants were reached through a trusted network facilitated by the Mauritanian consultant, whose identity is protected given the legal risks involved. Rather than relying on conventional semi-structured interviews, the study used non-directive, experiential workshops that enabled deeper engagement through facilitated dialogue, critical reflection, and creative expression [ 25 ]. This approach aimed to minimize power imbalances between researchers and participants and to contribute to participants’ well-being, while also allowing the sessions to be adapted in response to participants’ contributions through an inductive process of knowledge generation. It is worth noting that, although power imbalance cannot be fully eliminated, they were mitigated through specific practices such as: limiting consultants’ interventions; prioritizing the emotional and relational well-being of the group, as well as the dialogue flow among participants; jointly defining ethical and relational guidelines for the workshops in advance – including allowing participants to redirect topics –; incorporating all voices and not letting the same people always speak. Participant validation was also carried out during a subsequent meeting with participants in April 2024. Each four-hour workshop followed a guideline (see Supplementary Material 1 . Session guideline and material) and comprising an introduction setting common agreements, followed by a body exploration session through drawing and mapping (Supplementary Material 1 , Drawings models). The interactive activity supported an open discussion about personal relationship with one’s body, cultural taboos surrounding sexuality, and the gradual introduction of violence to foster a collective understanding of domestic and sexual violence and FGM, based on spontaneous disclosure, hypothetical scenarios, and USPEC data. Participants then discussed personal experience and interactions with healthcare services, both positive and negative, in healthcare-seeking, not seeking, discontinuing, or avoiding in the context of GBV and SRH. A decision-theoretic algorithm based on Warin & Chauveaud [ 26 ] was used as a heuristic device (Supplementary Material 1 , Decision tree: pathway to healthcare), distinguishing three trajectories: 1) Non-utilization : The individual perceives a need for care but does not engage with formal healthcare services; 2) Alternative care utilization : The individual seeks care outside the formal healthcare system, either exclusively or following unsatisfactory initial contact; and 3) Forgoing care : The individual intends to seek formal care but either does not follow through or discontinues after the first visit. The algorithm was applied to two illustrative scenarios: i) routine SRH or maternal health service use (e.g., prenatal consultations); and ii) responses to GBV (e.g., domestic violence, sexual assault, or FGM). To avoid pressuring participants into personal disclosures or re-victimization, they were invited to discuss these situations from their own, others’, or hypothetical perspectives. Participants were then invited to discuss on how intersecting factors such as poverty, education, administrative situation, and ethnicity shape healthcare access and utilization. They were also provided with medical information and referral contacts. Data from experiential workshops were completed by in-depth individual interviews with key informants, used to capture experiences and representations among particularly marginalized or underrepresented groups. As detailed in Supplementary Material 1 , the workshop guideline was adapted for these interviews, excluding experiential activities and instead focusing on participants’ analyses of barriers and alternative care pathways, including interpretation of USPEC data patterns. Both experiential workshops and interviews were conducted in French. However, participants were free to communicate in their preferred language, with one consultant facilitating multidirectional translation when needed. All sessions were audio-recorded with prior written informed consent, except for two participants who were not, at their request. Audio recordings and notes were transcribed by the consultants. When participants spoke in languages other than French, the relevant segments were translated into French during transcription. All transcripts were anonymized prior to analysis. Identifying information was removed, and consent forms were stored separately from the research material. To further ensure confidentiality, verbatim extracts were classified by topic rather than by individual participant. The transcripts were reviewed, translated into English and coded thematically by authors CB and MJG. A thematic analysis was conducted on the transcripts to identify recurrent patterns and meanings across participants’ narratives, paying attention to both the explicit content and the implicit nuances in their experiences. The analysis followed an iterative, primarily inductive but theoretically informed process, in which textual segments were systematically coded and progressively organized into interpretive themes capturing women’s healthcare experiences, perceived barriers, and decision-making processes [ 27 ]. This process made it possible to construct a solid analytical framework, reflecting the complexity of participants’ experiences. The analysis was further grounded in a critical reading of cultural norms and relational dynamics shaping decision-making. Analytic rigor was strengthened through detailed transcription, iterative coding, team discussion of emerging themes, and strict confidentiality procedures. In the context of women’s health, this approach facilitated the identification of structural inequalities and forms of violence embedded in sociocultural systems [ 28 ]. Conceptions of social disparities and health inequities were understood as culturally mediated and historically situated, intersecting with gender, age, cultural background or “ethnicity”, and social class [ 29 – 31 ]. Gender was treated not merely as an analytical variable but as a foundational lens guiding the research process. Sociodemographic factors such as education, income, or cultural background were not positioned as explanatory determinants but as exploratory elements to contextualize shared and divergent experiences. Special attention was given to the cultural and symbolic dimensions of women’s health narratives, with participant-generated accounts serving as the primary interpretive material. This non-interventional study was initially conducted by MdM with the operational aim of improving understanding of the utilization of USPEC services. No national-level ethics committee existed yet at the time of study’s inception; for participants’ protection, we made the choice not to engage with the scientific authorities consulted for the first MdM’s publication [ 17 ]. For this reason, as well as the operational purpose that originally drove the study, we opted for the best available alternative to introduce a practical ethical mechanism while respecting participants’ confidentiality and safety, i.e. existing internal mechanisms through Médicos del Mundo’s ethics committee. As a medical NGO, MdM has its own protocols and procedures, such as informed consent forms adapted to the context; strict confidentiality and anonymization measures; specialized training for the team on GBV in humanitarian and sensitive contexts; as well as a commitment to using participatory methods and attending to the emotional well-being of the participants. MdM ensures the protection of patients and study participants in accordance with the principles of the Declaration of Helsinki and through internally established ethical and data-protection protocols. The study received ethical approval from MdM Ethics Committee in January 2023, comprising members from scientific and academic backgrounds (Ref. n° 01-2023). Upon approval, the referent for transversal approaches at MdM headquarters provided technical guidance throughout the study period. MdM Medical Coordinator in Mauritania was responsible for the implementation of ethical and procedural safeguards with the consultants involved in data collection. Retrospective ethical approval was subsequently sought to assess the adequacy of both the process and the final results, ensuring that protection, care, and harm minimization practices adhered to national standards. Following completion of the study and restitution of its findings to the Ministry of Health in Mauritania, formal ethical approval was obtained for publication purpose from an ad hoc committee in bioethics and scientific ethics at the University of Nouakchott, in December 2025 (Ref. n° 334-27.12.25). Conducting research in GBV in Mauritania entails ethical complexities. For their safety and their network’s, the two consultants who conducted the interviews – one of them Mauritanian –, are not listed as authors. At the individual level, discussions of GBV may retraumatize participants [ 32 ]; at the collective level, there is a risk of homogenizing women’s experiences and reinforcing stereotypes about the Mauritanian society [ 18 , 33 ]. Special attention was given to ensuring informed, ongoing consent during the workshop and interviews. All participants provided initial written consent after receiving detailed information about the study and having the opportunity to ask questions, and were informed of their right to stop the interaction at any stage. Anonymity was guaranteed, in accordance with participants’ explicit requests, and those willing signed an agreement to share drawn and video material. Verbatims are presented in quotation marks in the study, and participants’ drawings, for which specific consent for publication was obtained, are included in supplementary material Supplementary Material 2 .

Significant progress has been made since the early 2000s in defining and measuring gender-based violence (GBV). Affecting nearly one in three women worldwide [ 1 , 2 ], GBV is now recognized as a public health issue, causing mortality and morbidity through femicide, suicide, injuries, sexually-transmitted diseases, complications from pregnancy, as well as long-term physical harm and psychological trauma, further exacerbated by delayed access to care [ 3 – 5 ]. Moreover, embedded within systemic inequalities and gender discrimination, GBV violates fundamental rights, including equality, health, and access to care [ 1 , 6 , 7 ]. Mauritania ranks among the countries with the highest Gender Inequality Index and occupies the lowest position on the Social Institutions and Gender Index [ 8 ]. The 2019–2021 Mauritanian Demographic and Health Survey reflects the pervasiveness of GBV and women’s limited utilization of health services. Overall, 10% of women aged 15 to 49 reported experiencing physical partner violence, 6% sexual violence, and 64% female genital mutilation (FGM). Among victims of GBV, 65% had neither sought help nor disclosed the abuse, while an additional 13% disclosed it without seeking support from health, protection or justice services. Only 55% of married women reported participating in key household decisions, including those concerning healthcare utilization. Over 10% of adolescent girls were pregnant or had given birth by age 17, while 39% of married women reported an unmet need for contraception [ 9 ]. Several studies have documented the structural and sociocultural drivers for unmet reproductive care needs [ 10 ], early pregnancy [ 11 ] and FGM [ 12 – 14 ] in Mauritania. However, all but one – focused on FGM and gavage (the practice of force-feeding girls) – implied 10 to 30 African countries, obscuring how context-specific structural injustices, including racial hierarchies and cultural marginalization, intersect with gender-based discrimination to compound barriers to healthcare. Mauritania’s colonial legacy and history of slavery and racial conflict has perpetuated deep inequalities between Arab-Berber Beidan (or “white” Moors, Hassanya-speaking) and sub-Saharan African populations (estimated to represent 30% of the population, referred to as “blacks”, speaking Halpulaar, Soninké, Wolof and/or French) [ 15 ]. Besides, as documented by the 2018 Human Rights Watch report “ They told me to remain silent ” [ 16 ], the country’s legal and institutional context generates specific obstacles. The Islamic legal notion of zina , referring to consensual sexual relationships outside of marriage, is at times misapplied to rape survivors, thereby criminalizing victims and discouraging reporting [ 16 ]. Although limited, specialized services for GBV victims exist in Mauritania. Médicos del Mundo (MdM), an international medical nongovernmental organization, has established since 2017 six GBV-specialized units, the Unités Spécialisées de Prise en Charge (USPEC). In 2023, a retrospective review of their caseload showed that nearly 80% of 3,550 cases received involved adolescent girls subjected to sexual violence; in contrast, domestic violence and FGM accounted for only 7% and less than 1%, respectively [ 17 ]. These findings pointed to an under-representation of adult, married women, and of non-sexual forms of GBV despite their national prevalence. Besides, 80% presented with a police requisition, suggesting that legal rather than medical motives often drove access to USPECs. This led MdM to commission the present study to understand the influence of context-specific social norms on health-seeking behaviors, beyond the essentializing characterization of “Sub-Saharan African Women”. Accordingly, this study aims to understand how social norms and representations influence healthcare utilization among Mauritanian women. Specifically, it explores the sociocultural barriers to accessing formal GBV and SRH services, the reliance on alternative (informal) care pathways, and the discontinuation of care following initial contact with the healthcare system. Although this study was commissioned with an operational aim of improving access to the USPECs, it also sought to generate emancipatory knowledge by centering the voices and lived experiences of Mauritanian women in the design of more inclusive, responsive, and rights-based healthcare services.

Below is the link to the electronic supplementary material. Supplementary Material 1 Supplementary Material 1 Supplementary Material 2 Supplementary Material 2