Access to Reproductive Health Care Services among African Women Living in Beijing: Understanding the Challenges

Access to Reproductive Health Care Services among African Women Living in Beijing: Understanding the Challenges | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Access to Reproductive Health Care Services among African Women Living in Beijing: Understanding the Challenges Mavis Adu Asuamah, Raymond Boateng This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1018369/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Dec, 2021 Read the published version in Journal of Racial and Ethnic Health Disparities → Version 1 posted You are reading this latest preprint version Abstract A growing body of research has explored the health care experiences of African migrants in China. However, within this body of research, there is a lacuna on access to reproductive health care among African women within this population. The study adopted semi-structured interviews in exploring the challenges to reproductive health care services among African women in Beijing. Results indicate that African women face multiple barriers to accessing reproductive health care. In particular, the absence of reproductive health education and awareness, discriminatory immigration policy, discontentment with health care services, and language barrier were the key challenging factors identified. The study recommends the implementation of secure and equitable policies that cater for the need of minority groups in a multicultural context. Obstetrics & Gynecology Sexual & Reproductive Medicine African women reproductive health barriers China Introduction Within the context of migration, access to health care services is often precarious for a population at the margins of society. Several studies have explored barriers that affect access to health care among minority groups [1, 2, 3, 4]. Structural factors such as language, culture, gender, financial, ethnicity, social-economic status, and a host of others have clarified the complexity of health care access among a vulnerable population [5, 6, 7]. African migrants fall within this vulnerable group, and as women, they are marginalised and experience multiple barriers to health care services. As previously reported [8] discrimination prevents Africans in South China from accessing health care. Research on African migrants is concentrated in the city of Guangzhou that has attracted many African traders and dwellers [9]. Despite public health, a key element of ''China-Africa cooperation'', African migrants continue to experience various barriers to health care access in China [10, 9]. Previous research has explored the health care experiences among African migrants in China, particularly in Guangzhou [11, 9]. Within this body of research, evidence suggests that African migrants experience critical barriers to health care due to personal and socio-cultural factors [10, 11, 9]. However, there is limited research devoted to the reproductive health care experiences of this population. Despite the nascent research on this topic, no single research has explored the reproductive health care experiences among women within this population. Reproductive health is an integral part of the modern human rights system [12, 13]. Research has identified several factors hindering women from quality reproductive health care services in different samples [14, 15, 16]. Yet, much of the research has failed to provide the necessary distinction and consideration of demographic characteristics that compound the experiences of women in a given context. Furthermore, concerning research that has been invested in addressing access to health care services for migrants, comparatively, less is aimed at African migrant women. Furthermore, migrant health research in Asian countries is sparse [17]. Considering this gap, this study focused on reproductive health care experiences and factors that hinder African migrant women from accessing quality reproductive health care services in Beijing, China Theoretical/conceptual framework Women’s health status is affected by complex biological, social, and cultural factors which are interrelated. Thus they can be addressed through an intersectional analysis [14]. Reproductive health is not determined by the quality and availability of health care alone but also by socio-structural factors. Accordingly, to justify and explain the rationale of our research, we drew on the intersectionality approach [18] to develop a framework to understand African health care experiences in Beijing, China. Intersectionality [18] offers the analytical framework to understanding how multiple factors generate different modes of advantage and discrimination. Thus, African women being a vulnerable population within a minority; a look at intersectionality analysis enhances our understanding of the complexity of their experiences with reproductive health care. Collectively, incorporating this perspective into our framework enables the study to tease out other factors that might affect the health care experiences of African migrant women in China. Methods This study was conducted in Beijing. As already mentioned above, research on African migrants in China is saturated within Guangdong province and mainly in Guangzhou city. No single study has been conducted in Beijing [19]. Moreover, Beijing being the capital of China, serves as an interesting case for our exploration. We conducted 15 semi-structured interviews. We recruited African women in Beijing through different communal societies and organisations. The eligibility criteria were women with fluency in English, living in Beijing for a minimum of two years. This criterion allowed the interviews to be conducted in English. Considering the nature and limited research on reproductive health care, we employed a qualitative study design in our exploration. All the interviews were conducted by the first author. Specifically, the interviews explored; participants’ knowledge of reproductive health, reproductive health care participation, and the challenges associated with reproductive health care access in Beijing. The interviews were conducted in English and lasted for about sixty to a hundred and twenty minutes maximum. All the interviews were tape-recorded and later transcribed for the analysis. We first transcribed all the tape-recorded interviews and read them individually without initial coding. Upon reading the transcripts on the second round, we developed open coding with a specific focus on the challenges and barriers pointed out by participants. We coded the barriers and challenges into categories and themes. The initial coding was; cost, affordability, stressful birth registration, immigration issues, language issues, and discontentment with local health care services. Consequently, the themes were double coded and compared by the two authors to ensure consistency. In the end, we settled on four themes, namely: the lack of reproductive health education and awareness, discriminatory immigration policies, financial constraints, discontentment with health services, and language barrier. Ethical Consideration The study protocol was reviewed and approved by the institutional review board of Beijing Normal University. (Ref: SP012/18/19) In the beginning of the interviews, participants were presented an information sheet explaining the research. Afterwards, consent was obtained by asking each participant to indicate their consent to participate by signing a consent document. Participation was voluntary and confidentiality was ensured. No personal details were collected except nationality and age. Results Results from the semi-structured interviews are classified into four themes. To wit: The lack of reproductive health education and awareness, discriminatory immigration policy, discontentment with health services, and language barrier. Lack of Reproductive Health Education and Awareness One of the major issues found was the lack of reproductive health education and awareness among African women that were interviewed. We attributed this to the cultural and societal norms that African women had been previously exposed to. Nine participants outlined that reproductive health care is about obstetrics. “This is mostly for women…it is all about taking care of yourself very well as a woman by frequently seeing a doctor for body assessment, during, and after pregnancy”. (Participant 6) Participants also expressed that the aged woman does not need to access reproductive health care as they had passed pregnancy bearing age. For example, Participants 3 and 9 had this to say: “Coming from a Muslim community, it is regarded as a crime or a taboo for teachers to discuss reproductive health with students even at the tertiary level. I remember vividly some parents had to withdraw their Children from my School while I was in Senior High School because our class teacher taught us how to take care of ourselves as adolescents”. (Participant 3) “I am old now, and even when I was young I was not going to the hospital specifically for my reproductive health care unless when I get pregnant and so even now that I won’t give birth again I don’t see the essence of seeing a doctor because of that”. (Participant 9) Discriminatory Immigration Policies Other issues stemming from the institutional level emerged from the interviews. Participants expressed the difficulty associated with getting visas for new-born babies. All of the respondents admitted Chinese immigration system itself poses barriers to accessing reproductive health. Participants 7 & 4 reported: "Chinese immigration laws are biased towards foreign women including me because when I gave birth in China, it was really difficult to secure a visa and birth certificate for my son. I had to travel to my country to prepare a passport and other documents before coming back. After that incident, I have decided never to give birth in China…Even all my friends too. I will travel home, deliver, and come back.” (Participant, 5) Another respondent 7 reported: “Chinese laws are not advanced enough to separate foreign women from being treated separately as their local counterparts; I am saying this because when I was pregnant, the doctor refused to reveal the sex of my baby because it is forbidden. This is not reasonable because if our children cannot be given Chinese citizenship, then we should be treated differently…. this phenomenon scares me from accessing reproductive health in China.” (Participant 7) Responses took a different twist yet stemming from the immigration challenge system. Issues relating to cost and financial constraints were reported to hinder participants’ access to quality reproductive health care. Six participants expressed discriminatory immigration policies precluding African nationals from securing good-paying jobs to be able to afford reproductive health care. Participant 10 added: "I am educated but cannot secure a good-paying job in China because, some of the skill sets are reserved for some nationals from western countries. A discriminatory practise but because there are no mechanisms in place to correct it, some of us are left out of good jobs. I don't earn enough to spend on reproductive health which is usually expensive.” (Participant 10) The following excerpts clearly show that financial constraints mostly stemming from immigration policy on employment prevented participants from accessing reproductive health care services. Some of the participants expressed the willingness to attend international hospitals in Beijing but then again cited issues of cost and affordability as the major deterrents. Discontentment with Health Services Another challenge reported was dissatisfaction with the local health services. The majority of the women expressed that the health care system in Beijing was not foreigner-friendly. For example, participants cited issues with childbirth, poor communication at the hospital, and difficulty getting a visa for newborn babies. We also deduced from the interviews that participants equally expressed their preference for international hospitals over local Chinese hospitals for reproductive health partly because of dissatisfaction with local Chinese hospitals. Participants reported: “My friends complain that as foreigners, the doctors treat them as Chinese and apply Chinese regulations on them. It happens to me… Imagine doctors not willing to reveal the sex of your baby until it is born. Also, if there are any serious complications, you have to force the doctor before they disclose such information…. I found that a bit strange honestly”. (Respondent 12) “I don’t know if the doctors in Beijing are afraid to give proper treatments or what…When my friend travelled to Guangzhou, she had some problems with her womb and went for surgery there. When she returned, she needed to go back again because the hospital she was referred to here in Beijing could not treat her well. So she went back to Guangzhou and had to spend extra money for the treatment”. (Participant 4) Language Barrier Language barrier was most mentioned among all participants. “Language is an obstacle in China… Participants told. “The Chinese language is one language that is difficult for me to learn and speak… (Participant 11) Another participant narrated: “Communication becomes a nightmare whenever I attend a Chinese hospital… I have been to the hospital where the doctor did not know what to do than to ask me to go home because we could not communicate”. (Participant 2) Those who could speak and understand the language or had translators on their visits expressed satisfaction. However, a participant reported that there were instances where she observed miscommunication between the doctor and the translator. She explained: "If you can speak the language you won't have an issue visiting the local hospitals. My friend recommended I went with a translator on my visit to the local hospitals…I tried that one time but at a point, I felt the doctor and the translator had some miscommunication due to their demeanour and body language". (Participant 8) Discussion While there is a small but expanding body of research on the health care experiences of Africans in China, there is still a gap in the literature on African migrant women's reproductive health care experiences in China. As a consequence, we adopted an intersectional analysis to explore factors affecting African women’s access to quality reproductive health care in Beijing. To our knowledge, this is one of the few studies that investigate reproductive health care experiences among African migrant women in Beijing China. Results from the interviews indicate that lack of reproductive health education and awareness, discriminatory immigration policy, discontentment with local health services, and language barrier were the key factors preventing African women from accessing quality reproductive health care services. Concerning intersectionality theory [18] findings imply that access to reproductive health care is influenced by not a single factor but rather a combination of socio-cultural, institutional and personal factors. The lack of reproductive health education and awareness identified is attributed to the little importance attached to reproductive health participation among African women. The few that demonstrated knowledge of reproductive health was limited to obstetric (Pregnancy, childbirth and postpartum). Generally, it is believed that women who understand the importance of reproductive health care do prioritize access [14]. Thus, it is not surprising that the majority of the women interviewed had little participation in reproductive health care. This is problematic, as per the definition of reproductive health by WHO, reproductive health exists at all stages of life [20] as opposed to the ideological points of view that restrict reproductive health to childbearing as evidenced by our results. Discriminatory immigration policy reported concerning access to reproductive health care was related to difficulty in securing visas and birth certificates for new-born babies. Issues with discrimination against Africans is not new both in academic and non-academic discussion [8, 9]. However, our results concerning discrimination were not related to race or ethnicity as previous research has it. In our study, participants reported discrimination in immigration policies against new-born babies and work permits. This issue is ascribed to biased immigration laws in China that restrict jobs to nationals from western countries. Following this revelation, it is vital to understand that immigration policy does not allow African women to work and earn income to afford reproductive health care. On the other hand, immigration policy denies China-born African babies legal status and documentation regardless of the legal status of mothers. Collectively these issues barred African women from accessing reproductive health care services in Beijing. Results indicate discontentment with reproductive health care services among African women in Beijing. Chinese laws prohibit sex screening of Festus. Consequently, revealing an unborn babies’ gender is against the law and tantamount to arrest [21]. African women expressed discontentment with this law and were reluctant to access gestation services (the most familiarised aspect of reproductive health among participants). Findings indicate that African women and Chinese health care providers lack the ability to communicate. The language barrier identified in our findings aligns with previous studies [22, 1, 9]. Previous research has found that language barrier is associated with less satisfaction with health services [23]. Ideally, the use of health services demands communication between a patient and health service provider. New Contribution to the Literature This study provides additional evidence to the expanding body of research on the challenges to health care access among Africans in China. Our study did so by adding a nuanced understanding of the barriers to accessing reproductive health care among African women in Beijing, China. To this end, African women do face multiple challenges in accessing general health care in China partly because of their biological make-up. These challenges stem from institutional, structural, cultural, and personal factors which predispose African women to from accessing quality reproductive health care. As women, they are marginalised and experience multiple barriers to health care access. To ameliorate these challenges, there is the need for the implementation of integrated, secure, and equitable policies, and health care services that cater for the need of minority groups in a multicultural context. Despite this contribution, the study has some limitations. First, findings from this study are limited to African migrant women in Beijing owing to the study’s convenience sampling approach. Second, the methodological approach that requires a smaller sample size prevents the findings from generalizing to all African women in China. Hence, future research should adopt a robust methodology to investigate such conventions. References 1. Shibli H, Aharonson-Daniel L, Feder-Bubis P: Perceptions about the accessibility of healthcare services among ethnic minority women: a qualitative study among Arab Bedouins in Israel. International Journal for Equity in Health 2021; 20 (1), 1-9. 2. Wang TF, Shi L, Nie X, Zhu J: Race/ethnicity, insurance, income and access to care: the influence of health status. International Journal for Equity in Health 2013; 12 (1), 1-7 3. Garcia-Subirats I, Vargas I, Mogollón-Pérez AS, De Paepe P, da Silva MRF, Unger JP, Vázquez ML: Barriers in access to healthcare in countries with different health systems. A cross-sectional study in municipalities of central Colombia and north-eastern Brazil. Social Science & Medicine 2014; 106 , 204-213. 4. Harris B, Goudge J, Ataguba JE, McIntyre D, Nxumalo N, Jikwana S, Chersich M: Inequities in access to health care in South Africa. Journal of Public Health Policy 2011; 32 (1), S102-S123. 5. Tang K, Zhao Y, Li, B, Zhang S, Lee SH: Health inequity on access to services in the ethnic minority regions of Northeastern Myanmar: a cross-sectional study. BMJ Open 2017; 7 (12), e017770. 6. Wang S, Kirillova K, Lehto X: Travelers’ food experience sharing on social network sites. Journal of Travel & Tourism Marketing 2017; 34 (5), 680-693. 7. Memon A, Taylor K, Mohebati LM, Sundin J, Cooper M, Scanlon T, de Visser R: Perceived barriers to accessing mental health services among black and minority ethnic (BME) communities: a qualitative study in Southeast England. BMJ open 2016; 6 (11), e012337. 8. Hall BJ, Chen W, Latkin C, Ling L, Tucker JD: Africans in south China face social and health barriers. The Lancet 2014; 383 (9925), 1291-1292. 9. Lin L, Brown KB, Yu F, Yang J, Wang J, Schrock JM, Wong FY: Health care experiences and perceived barriers to health care access: a qualitative study among African migrants in Guangzhou, Guangdong Province, China. Journal of Immigrant and Minority Health 2015; 17 (5), 1509-1517. 10. Bodomo A, Liem A, Lin L, Hall BJ: How African migrants in China cope with barriers to health care. The Lancet Public Health 2020; 5 (4), e192. 11. Lin L, Brown KB, Hall BJ, Yu F, Yang J, Wang J, Wong FY: Overcoming barriers to health-care access: a qualitative study among African migrants in Guangzhou, China. Global public health 2016; 11 (9), 1135-1147. 12. Freeman, EW, Sammel MD, Grisso JA, Battistini M, Garcia-Espagna B, Hollander L: Hot flashes in the late reproductive years: risk factors for African American and Caucasian women. Journal of women's health & gender-based medicine 2001; 10 (1), 67-76. 13. Kumar, A, Taunk A: To Study Reproductive Health Rights Affected by Socio-Cultural Factors in Tarikhet Block District Almora, Uttarakhand. International Journal of Scientific Footprints 2013; 1(1): 26–32 14. Kronfol, NM: Access and barriers to health care delivery in Arab countries: a review. EMHJ-Eastern Mediterranean Health Journal 2012; 18 (12), 1239-1246, 2012. 15. Say L, Raine R: A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bulletin of the World Health Organization 2007; 85 , 812-819. 16. Webber G, Spitzer D, Somrongthong R, Dat TC, Kounnavongsa S: Facilitators and barriers to accessing reproductive health care for migrant beer promoters in Cambodia, Laos, Thailand and Vietnam: a mixed-methods study. Globalization and Health 2012; 8 (1), 1-18. 17. Yeoh BS: Migration and health in Asia. Routledge; 2006 18. Crenshaw K: Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics 1989; U. Chi. Legal f. , 139. 19. Bodomo A: Historical and contemporary perspectives on inequalities and well-being of Africans in China. Asian Ethnicity 2020; 1-16. 20. World Health Organization. (n.d). Reproductive health in the western pacific. https://www.who.int/westernpacific/health-topics/reproductive-health. 21. Reuters: New Chinese Law Prohibits Sex-Screening of Fetuses https://www.nytimes.com/1994/11/15/world/new-chinese-law-prohibits-sex-screening-of-fetuses.html. 1994 23. Chen J, Vargas-Bustamante A, Mortensen K, Ortega AN: Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Medical care 2016., 54 (2), 140. 24. Yeo S: Language barriers and access to care. Annual review of nursing research 2004; 22, 59-76. Tables Table 1 Demographic Characteristics of participants (N = 15) Participants Country of Origin Age Occupation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Gabon Congo Togo Ghana Liberia South Africa Ivory Coast Ghana Tanzanian Cameroon Botswana Zambian Liberia Cameroon Togo 36 45 29 27 30 39 37 46 36 28 20 30 24 27 38 Student Diplomat Hairdresser Student Student Business Woman Trader Diplomat Diplomat Businesswoman Student Hair Dresser Student Trader Diplomat Cite Share Download PDF Status: Published Journal Publication published 26 Dec, 2021 Read the published version in Journal of Racial and Ethnic Health Disparities → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1018369","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":63220458,"identity":"cce8f9bf-39f0-4619-8b6c-ef6feb18d460","order_by":0,"name":"Mavis Adu Asuamah","email":"","orcid":"","institution":"Beijing Normal University","correspondingAuthor":false,"prefix":"","firstName":"Mavis","middleName":"Adu","lastName":"Asuamah","suffix":""},{"id":63220459,"identity":"64398102-b168-42a3-82d6-41536e1d976a","order_by":1,"name":"Raymond Boateng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABA0lEQVRIiWNgGAWjYPACZiSSgYHxwQMGhgQJYrWAFDIbJJCqhU0Cnxbz9jOmGz7usJYzuJH+TLqgwq6OX7r9WkXiDoY8yQbsWmTO5JjdnHkm3djgRo6Z9IwzyRKSc86U3Ug8w1AsjcMWCYYcs9u8bYcTt93IYZPmbWOWAOpNu5HYxpA4D5cW/jcwLUCH8bbVS9gDtRTg1SIBtyXBDKjlsISBRPoxBpCW2Ti1PCu7ObMt3dj+zBtj6xlnjkvOuJHDLJHYJpE4E4f3JfiTt9342GYtJ9me/vB2QUU1P/+M9IcfPrbZJM44gMMaBg4DdBEeAwZI/OAC7A8Ii4yCUTAKRsHIBgC1k1z6dEkKfAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-0091-9706","institution":"Lingnan University","correspondingAuthor":true,"prefix":"","firstName":"Raymond","middleName":"","lastName":"Boateng","suffix":""}],"badges":[],"createdAt":"2021-10-26 02:59:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1018369/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1018369/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s40615-021-01225-y","type":"published","date":"2021-12-27T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":17114555,"identity":"a7ed0210-a4f0-408b-b6d7-b19dc78d7a54","added_by":"auto","created_at":"2022-01-07 20:08:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":185019,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1018369/v1/a6727694-5148-49be-ac8d-a6f43ccec81f.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eAccess to Reproductive Health Care Services among African Women Living in Beijing: Understanding the Challenges\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWithin the context of migration, access to health care services is often precarious for a population at the margins of society. Several studies have explored barriers that affect access to health care among minority groups [1, 2, 3, 4]. Structural factors such as language, culture, gender, financial, ethnicity, social-economic status, and a host of others have clarified the complexity of health care access among a vulnerable population [5, 6, 7]. African migrants fall within this vulnerable group, and as women, they are marginalised and experience multiple barriers to health care services. As previously reported [8] discrimination prevents Africans in South China from accessing health care. Research on African migrants is concentrated in the city of Guangzhou that has attracted many African traders and dwellers [9]. Despite public health, a key element of ''China-Africa cooperation'', African migrants continue to experience various barriers to health care access in China [10, 9]. Previous research has explored the health care experiences among African migrants in China, particularly in Guangzhou [11, 9]. Within this body of research, evidence suggests that African migrants experience critical barriers to health care due to personal and socio-cultural factors [10, 11, 9]. However, there is limited research devoted to the reproductive health care experiences of this population. Despite the nascent research on this topic, no single research has explored the reproductive health care experiences among women within this population. Reproductive health is an integral part of the modern human rights system [12, 13]. Research has identified several factors hindering women from quality reproductive health care services in different samples [14, 15, 16]. Yet, much of the research has failed to provide the necessary distinction and consideration of demographic characteristics that compound the experiences of women in a given context. Furthermore, concerning research that has been invested in addressing access to health care services for migrants, comparatively, less is aimed at African migrant women. Furthermore, migrant health research in Asian countries is sparse [17]. Considering this gap, this study focused on reproductive health care experiences and factors that hinder African migrant women from accessing quality reproductive health care services in Beijing, China\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eTheoretical/conceptual framework\u003c/h2\u003e \u003cp\u003eWomen\u0026rsquo;s health status is affected by complex biological, social, and cultural factors which are interrelated. Thus they can be addressed through an intersectional analysis [14]. Reproductive health is not determined by the quality and availability of health care alone but also by socio-structural factors. Accordingly, to justify and explain the rationale of our research, we drew on the intersectionality approach [18] to develop a framework to understand African health care experiences in Beijing, China. Intersectionality [18] offers the analytical framework to understanding how multiple factors generate different modes of advantage and discrimination. Thus, African women being a vulnerable population within a minority; a look at intersectionality analysis enhances our understanding of the complexity of their experiences with reproductive health care. Collectively, incorporating this perspective into our framework enables the study to tease out other factors that might affect the health care experiences of African migrant women in China.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study was conducted in Beijing. As already mentioned above, research on African migrants in China is saturated within Guangdong province and mainly in Guangzhou city. No single study has been conducted in Beijing [19]. Moreover, Beijing being the capital of China, serves as an interesting case for our exploration.\u003c/p\u003e \u003cp\u003eWe conducted 15 semi-structured interviews. We recruited African women in Beijing through different communal societies and organisations. The eligibility criteria were women with fluency in English, living in Beijing for a minimum of two years. This criterion allowed the interviews to be conducted in English.\u003c/p\u003e \u003cp\u003eConsidering the nature and limited research on reproductive health care, we employed a qualitative study design in our exploration. All the interviews were conducted by the first author. Specifically, the interviews explored; participants\u0026rsquo; knowledge of reproductive health, reproductive health care participation, and the challenges associated with reproductive health care access in Beijing. The interviews were conducted in English and lasted for about sixty to a hundred and twenty minutes maximum. All the interviews were tape-recorded and later transcribed for the analysis.\u003c/p\u003e \u003cp\u003eWe first transcribed all the tape-recorded interviews and read them individually without initial coding. Upon reading the transcripts on the second round, we developed open coding with a specific focus on the challenges and barriers pointed out by participants. We coded the barriers and challenges into categories and themes. The initial coding was; cost, affordability, stressful birth registration, immigration issues, language issues, and discontentment with local health care services. Consequently, the themes were double coded and compared by the two authors to ensure consistency. In the end, we settled on four themes, namely: the lack of reproductive health education and awareness, discriminatory immigration policies, financial constraints, discontentment with health services, and language barrier.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEthical Consideration\u003c/b\u003e \u003c/p\u003e \u003cp\u003e The study protocol was reviewed and approved by the institutional review board of Beijing Normal University. (Ref: SP012/18/19) In the beginning of the interviews, participants were presented an information sheet explaining the research. Afterwards, consent was obtained by asking each participant to indicate their consent to participate by signing a consent document. Participation was voluntary and confidentiality was ensured. No personal details were collected except nationality and age.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eResults from the semi-structured interviews are classified into four themes. To wit: The lack of reproductive health education and awareness, discriminatory immigration policy, discontentment with health services, and language barrier.\u003c/p\u003e \u003cp\u003e \u003cem\u003eLack of Reproductive Health Education and Awareness\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOne of the major issues found was the lack of reproductive health education and awareness among African women that were interviewed. We attributed this to the cultural and societal norms that African women had been previously exposed to. Nine participants outlined that reproductive health care is about obstetrics. \u0026ldquo;This is mostly for women\u0026hellip;it is all about taking care of yourself very well as a woman by frequently seeing a doctor for body assessment, during, and after pregnancy\u0026rdquo;. (Participant 6) Participants also expressed that the aged woman does not need to access reproductive health care as they had passed pregnancy bearing age. For example, Participants 3 and 9 had this to say:\u003c/p\u003e \u003cp\u003e\u0026ldquo;Coming from a Muslim community, it is regarded as a crime or a taboo for teachers to discuss reproductive health with students even at the tertiary level. I remember vividly some parents had to withdraw their Children from my School while I was in Senior High School because our class teacher taught us how to take care of ourselves as adolescents\u0026rdquo;. (Participant 3)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I am old now, and even when I was young I was not going to the hospital specifically for my reproductive health care unless when I get pregnant and so even now that I won\u0026rsquo;t give birth again I don\u0026rsquo;t see the essence of seeing a doctor because of that\u0026rdquo;. (Participant 9)\u003c/p\u003e \u003cp\u003e \u003cem\u003eDiscriminatory Immigration Policies\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOther issues stemming from the institutional level emerged from the interviews. Participants expressed the difficulty associated with getting visas for new-born babies. All of the respondents admitted Chinese immigration system itself poses barriers to accessing reproductive health. Participants 7 \u0026amp; 4 reported:\u003c/p\u003e \u003cp\u003e\"Chinese immigration laws are biased towards foreign women including me because when I gave birth in China, it was really difficult to secure a visa and birth certificate for my son. I had to travel to my country to prepare a passport and other documents before coming back. After that incident, I have decided never to give birth in China\u0026hellip;Even all my friends too. I will travel home, deliver, and come back.\u0026rdquo; (Participant, 5)\u003c/p\u003e \u003cp\u003eAnother respondent 7 reported:\u003c/p\u003e \u003cp\u003e\u0026ldquo;Chinese laws are not advanced enough to separate foreign women from being treated separately as their local counterparts; I am saying this because when I was pregnant, the doctor refused to reveal the sex of my baby because it is forbidden. This is not reasonable because if our children cannot be given Chinese citizenship, then we should be treated differently\u0026hellip;. this phenomenon scares me from accessing reproductive health in China.\u0026rdquo; (Participant 7)\u003c/p\u003e \u003cp\u003eResponses took a different twist yet stemming from the immigration challenge system. Issues relating to cost and financial constraints were reported to hinder participants\u0026rsquo; access to quality reproductive health care. Six participants expressed discriminatory immigration policies precluding African nationals from securing good-paying jobs to be able to afford reproductive health care. Participant 10 added:\u003c/p\u003e \u003cp\u003e\"I am educated but cannot secure a good-paying job in China because, some of the skill sets are reserved for some nationals from western countries. A discriminatory practise but because there are no mechanisms in place to correct it, some of us are left out of good jobs. I don't earn enough to spend on reproductive health which is usually expensive.\u0026rdquo; (Participant 10)\u003c/p\u003e \u003cp\u003eThe following excerpts clearly show that financial constraints mostly stemming from immigration policy on employment prevented participants from accessing reproductive health care services. Some of the participants expressed the willingness to attend international hospitals in Beijing but then again cited issues of cost and affordability as the major deterrents.\u003c/p\u003e \u003cp\u003e \u003cem\u003eDiscontentment with Health Services\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAnother challenge reported was dissatisfaction with the local health services. The majority of the women expressed that the health care system in Beijing was not foreigner-friendly. For example, participants cited issues with childbirth, poor communication at the hospital, and difficulty getting a visa for newborn babies. We also deduced from the interviews that participants equally expressed their preference for international hospitals over local Chinese hospitals for reproductive health partly because of dissatisfaction with local Chinese hospitals. Participants reported:\u003c/p\u003e \u003cp\u003e\u0026ldquo;My friends complain that as foreigners, the doctors treat them as Chinese and apply Chinese regulations on them. It happens to me\u0026hellip; Imagine doctors not willing to reveal the sex of your baby until it is born. Also, if there are any serious complications, you have to force the doctor before they disclose such information\u0026hellip;. I found that a bit strange honestly\u0026rdquo;. (Respondent 12)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I don\u0026rsquo;t know if the doctors in Beijing are afraid to give proper treatments or what\u0026hellip;When my friend travelled to Guangzhou, she had some problems with her womb and went for surgery there. When she returned, she needed to go back again because the hospital she was referred to here in Beijing could not treat her well. So she went back to Guangzhou and had to spend extra money for the treatment\u0026rdquo;. (Participant 4)\u003c/p\u003e \u003cp\u003e \u003cem\u003eLanguage Barrier\u003c/em\u003e \u003c/p\u003e \u003cp\u003eLanguage barrier was most mentioned among all participants. \u0026ldquo;Language is an obstacle in China\u0026hellip; Participants told. \u0026ldquo;The Chinese language is one language that is difficult for me to learn and speak\u0026hellip; (Participant 11) Another participant narrated: \u0026ldquo;Communication becomes a nightmare whenever I attend a Chinese hospital\u0026hellip; I have been to the hospital where the doctor did not know what to do than to ask me to go home because we could not communicate\u0026rdquo;. (Participant 2) Those who could speak and understand the language or had translators on their visits expressed satisfaction. However, a participant reported that there were instances where she observed miscommunication between the doctor and the translator. She explained:\u003c/p\u003e \u003cp\u003e\"If you can speak the language you won't have an issue visiting the local hospitals. My friend recommended I went with a translator on my visit to the local hospitals\u0026hellip;I tried that one time but at a point, I felt the doctor and the translator had some miscommunication due to their demeanour and body language\". (Participant 8)\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhile there is a small but expanding body of research on the health care experiences of Africans in China, there is still a gap in the literature on African migrant women's reproductive health care experiences in China. As a consequence, we adopted an intersectional analysis to explore factors affecting African women\u0026rsquo;s access to quality reproductive health care in Beijing. To our knowledge, this is one of the few studies that investigate reproductive health care experiences among African migrant women in Beijing China. Results from the interviews indicate that lack of reproductive health education and awareness, discriminatory immigration policy, discontentment with local health services, and language barrier were the key factors preventing African women from accessing quality reproductive health care services. Concerning intersectionality theory [18] findings imply that access to reproductive health care is influenced by not a single factor but rather a combination of socio-cultural, institutional and personal factors.\u003c/p\u003e \u003cp\u003eThe lack of reproductive health education and awareness identified is attributed to the little importance attached to reproductive health participation among African women. The few that demonstrated knowledge of reproductive health was limited to obstetric (Pregnancy, childbirth and postpartum). Generally, it is believed that women who understand the importance of reproductive health care do prioritize access [14]. Thus, it is not surprising that the majority of the women interviewed had little participation in reproductive health care. This is problematic, as per the definition of reproductive health by WHO, reproductive health exists at all stages of life [20] as opposed to the ideological points of view that restrict reproductive health to childbearing as evidenced by our results.\u003c/p\u003e \u003cp\u003eDiscriminatory immigration policy reported concerning access to reproductive health care was related to difficulty in securing visas and birth certificates for new-born babies. Issues with discrimination against Africans is not new both in academic and non-academic discussion [8, 9]. However, our results concerning discrimination were not related to race or ethnicity as previous research has it. In our study, participants reported discrimination in immigration policies against new-born babies and work permits. This issue is ascribed to biased immigration laws in China that restrict jobs to nationals from western countries. Following this revelation, it is vital to understand that immigration policy does not allow African women to work and earn income to afford reproductive health care. On the other hand, immigration policy denies China-born African babies legal status and documentation regardless of the legal status of mothers. Collectively these issues barred African women from accessing reproductive health care services in Beijing.\u003c/p\u003e \u003cp\u003e Results indicate discontentment with reproductive health care services among African women in Beijing. Chinese laws prohibit sex screening of Festus. Consequently, revealing an unborn babies\u0026rsquo; gender is against the law and tantamount to arrest [21]. African women expressed discontentment with this law and were reluctant to access gestation services (the most familiarised aspect of reproductive health among participants).\u003c/p\u003e \u003cp\u003eFindings indicate that African women and Chinese health care providers lack the ability to communicate. The language barrier identified in our findings aligns with previous studies [22, 1, 9]. Previous research has found that language barrier is associated with less satisfaction with health services [23]. Ideally, the use of health services demands communication between a patient and health service provider.\u003c/p\u003e \u003cp\u003e \u003cb\u003eNew Contribution to the Literature\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study provides additional evidence to the expanding body of research on the challenges to health care access among Africans in China. Our study did so by adding a nuanced understanding of the barriers to accessing reproductive health care among African women in Beijing, China. To this end, African women do face multiple challenges in accessing general health care in China partly because of their biological make-up. These challenges stem from institutional, structural, cultural, and personal factors which predispose African women to from accessing quality reproductive health care. As women, they are marginalised and experience multiple barriers to health care access. To ameliorate these challenges, there is the need for the implementation of integrated, secure, and equitable policies, and health care services that cater for the need of minority groups in a multicultural context.\u003c/p\u003e \u003cp\u003eDespite this contribution, the study has some limitations. First, findings from this study are limited to African migrant women in Beijing owing to the study\u0026rsquo;s convenience sampling approach. Second, the methodological approach that requires a smaller sample size prevents the findings from generalizing to all African women in China. Hence, future research should adopt a robust methodology to investigate such conventions.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e1. Shibli H, Aharonson-Daniel L, Feder-Bubis P: Perceptions about the accessibility of healthcare services among ethnic minority women: a qualitative study among Arab Bedouins in Israel. International Journal for Equity in Health 2021; \u003cem\u003e20\u003c/em\u003e(1), 1-9.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e2. Wang TF, Shi L, Nie X, Zhu J: Race/ethnicity, insurance, income and access to care: the influence of health status. International Journal for Equity in Health 2013; \u003cem\u003e12\u003c/em\u003e(1), \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;1-7\u003c/p\u003e\n\u003cp\u003e3. Garcia-Subirats I, Vargas I, Mogoll\u0026oacute;n-P\u0026eacute;rez AS, De Paepe P, da Silva MRF, Unger JP, V\u0026aacute;zquez ML: Barriers in access to healthcare in countries with different health systems. A cross-sectional study in municipalities of central Colombia and north-eastern Brazil. Social Science \u0026amp; Medicine 2014; \u003cem\u003e106\u003c/em\u003e, 204-213.\u003c/p\u003e\n\u003cp\u003e4. Harris B, Goudge J, Ataguba JE, McIntyre D, Nxumalo N, Jikwana S, Chersich M: Inequities in access to health care in South Africa. Journal of Public Health Policy 2011; \u003cem\u003e32\u003c/em\u003e(1), S102-S123.\u003c/p\u003e\n\u003cp\u003e5. Tang K, Zhao Y, Li, B, Zhang S, Lee SH: Health inequity on access to services in the ethnic minority regions of Northeastern Myanmar: a cross-sectional study. BMJ Open 2017; \u003cem\u003e7\u003c/em\u003e(12), e017770.\u003c/p\u003e\n\u003cp\u003e6. 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Globalization and Health 2012; \u003cem\u003e8\u003c/em\u003e(1), 1-18.\u003c/p\u003e\n\u003cp\u003e17. Yeoh BS: Migration and health in Asia. Routledge; 2006\u003c/p\u003e\n\u003cp\u003e18. Crenshaw K: Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics 1989; U. Chi. \u003cem\u003eLegal f.\u003c/em\u003e, 139.\u003c/p\u003e\n\u003cp\u003e19. Bodomo A: Historical and contemporary perspectives on inequalities and well-being of Africans in China. Asian Ethnicity 2020; 1-16.\u003c/p\u003e\n\u003cp\u003e20. World Health Organization. (n.d).\u0026nbsp;Reproductive health in the western pacific.\u0026nbsp;https://www.who.int/westernpacific/health-topics/reproductive-health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e21. Reuters:\u0026nbsp;New Chinese Law Prohibits Sex-Screening of Fetuses\u0026nbsp;https://www.nytimes.com/1994/11/15/world/new-chinese-law-prohibits-sex-screening-of-fetuses.html. 1994\u003c/p\u003e\n\u003cp\u003e23. Chen J, Vargas-Bustamante A, Mortensen K, Ortega AN: Racial and ethnic disparities in health care access and utilization under the Affordable Care Act. Medical care 2016., \u003cem\u003e54\u003c/em\u003e(2), 140.\u003c/p\u003e\n\u003cp\u003e24. Yeo S: Language barriers and access to care. Annual review of nursing research 2004; 22, 59-76.\u003c/p\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDemographic Characteristics of participants (N = 15)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellpadding=\"0\" cellspacing=\"0\" width=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.027027027027028%\"\u003e\n \u003cp\u003eParticipants\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.844594594594593%\"\u003e\n \u003cp\u003eCountry of Origin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.324324324324323%\"\u003e\n \u003cp\u003eAge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.804054054054053%\"\u003e\n \u003cp\u003eOccupation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" width=\"27.027027027027028%\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"25.844594594594593%\"\u003e\n \u003cp\u003eGabon\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCongo\u003c/p\u003e\n \u003cp\u003eTogo\u003c/p\u003e\n \u003cp\u003eGhana\u003c/p\u003e\n \u003cp\u003eLiberia\u003c/p\u003e\n \u003cp\u003eSouth Africa\u003c/p\u003e\n \u003cp\u003eIvory Coast\u003c/p\u003e\n \u003cp\u003eGhana\u003c/p\u003e\n \u003cp\u003eTanzanian\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCameroon\u003c/p\u003e\n \u003cp\u003eBotswana\u003c/p\u003e\n \u003cp\u003eZambian\u003c/p\u003e\n \u003cp\u003eLiberia\u003c/p\u003e\n \u003cp\u003eCameroon\u003c/p\u003e\n \u003cp\u003eTogo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"24.324324324324323%\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003cp\u003e27\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003cp\u003e28\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" width=\"22.804054054054053%\"\u003e\n \u003cp\u003eStudent\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDiplomat\u003c/p\u003e\n \u003cp\u003eHairdresser\u003c/p\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003cp\u003eStudent\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBusiness Woman\u003c/p\u003e\n \u003cp\u003eTrader\u003c/p\u003e\n \u003cp\u003eDiplomat\u003c/p\u003e\n \u003cp\u003eDiplomat\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBusinesswoman\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003cp\u003eHair Dresser\u003c/p\u003e\n \u003cp\u003eStudent\u003c/p\u003e\n \u003cp\u003eTrader\u003c/p\u003e\n \u003cp\u003eDiplomat\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"African women, reproductive health, barriers, China","lastPublishedDoi":"10.21203/rs.3.rs-1018369/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1018369/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eA growing body of research has explored the health care experiences of African migrants in China. However, within this body of research, there is a lacuna on access to reproductive health care among African women within this population. The study adopted semi-structured interviews in exploring the challenges to reproductive health care services among African women in Beijing. Results indicate that African women face multiple barriers to accessing reproductive health care. In particular, the absence of reproductive health education and awareness, discriminatory immigration policy, discontentment with health care services, and language barrier were the key challenging factors identified. The study recommends the implementation of secure and equitable policies that cater for the need of minority groups in a multicultural context.\u003c/p\u003e","manuscriptTitle":"Access to Reproductive Health Care Services among African Women Living in Beijing: Understanding the Challenges","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-11-15 16:47:53","doi":"10.21203/rs.3.rs-1018369/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e5d557fd-1146-407b-a06d-3178a8ad68c5","owner":[],"postedDate":"November 15th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":8512316,"name":"Obstetrics \u0026 Gynecology"},{"id":8512317,"name":"Sexual \u0026 Reproductive Medicine"}],"tags":[],"updatedAt":"2022-01-07T20:07:59+00:00","versionOfRecord":{"articleIdentity":"rs-1018369","link":"https://doi.org/10.1007/s40615-021-01225-y","journal":{"identity":"journal-of-racial-and-ethnic-health-disparities","isVorOnly":true,"title":"Journal of Racial and Ethnic Health Disparities"},"publishedOn":"2021-12-27 00:00:00","publishedOnDateReadable":"December 27th, 2021"},"versionCreatedAt":"2021-11-15 16:47:53","video":"","vorDoi":"10.1007/s40615-021-01225-y","vorDoiUrl":"https://doi.org/10.1007/s40615-021-01225-y","workflowStages":[]},"version":"v1","identity":"rs-1018369","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1018369","identity":"rs-1018369","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}