Factors influencing access of women migrant domestic workers to sexual and reproductive health (SRH) services at Khartoum State: the case of Ethiopian migrant domestic workers.

Bedri, Nafisa ; Abdelmoneim, Sara Ibrahim ; Tambal, Nuha 等

Introduction

Many African women migrate to neighbouring countries to take up paid work as domestics. In Sudan, there is a decreasing, but steady influx of migrants from Ethiopia and Eritrea. The International Organization for Migration (IOM) estimated that as of 1st January 2010 615,340 refugees were in Sudan (IOM 2011, p. 42, 110). They were located mostly in Khartoum, Darfur, Equatoria and the eastern states; about 96% of the refugees were from Eritrea, Chad and Ethiopia (IOM 2011, p. 42, 85, 110). When aggregating data on refugees living in camps by sex, females accounted for 40% of the Eritreans and 60% of the Ethiopians (IOM 2011, p. 42). While only 2,000 work permits have been issued between April and December 2009, IOM also noted the existence of irregular immigration entering, most of all, the low-skill labour market, for which there are no reliable numbers (IOM 2011, p. 44, 47).

Currently, there are thousands of Ethiopians and Eritreans from varied backgrounds who have come to Sudan searching for better life, protection or other aspirations. Reasons that pushed them to leave their countries could be economic and/or political reasons with the aim of being registered with the UNHCR and hopefully resettled in Europe, Canada or Australia, i.e. they considered Sudan as a transit point. Migrants occupy different jobs such as workers in restaurants, domestic household activities as house maids, tea sellers and service providers in hair salons.

For these migrants, paying for their stay permits in Sudan is a very costly process, particularly to a domestic worker who earns 100 or 150 USD per month. Therefore even refugees with a legal status find it hard to extend their visas, and being illegal migrants with no registration, they may become afraid to seek health information, treatment or any other service that requires a valid ID or authorised document. On the same line, trafficking has increased the number of illegal and vulnerable female migrant domestic workers in Sudan. The United States Department of State's (USDS) 2011 report on trafficking stated that,

Sudan is a transit and destination country for Ethiopian and Eritrean women subjected to domestic servitude in Sudan and Middle Eastern countries. [...] Agents recruit young women from Ethiopia's Oroma region with promises of high-paying employment as domestic workers in Sudan, only to collect their salaries or force them into prostitution in brothels in Khartoum or near Sudan's oil fields and mining camps (USDS 2011a, p. 335).

Factors influencing access of women migrant domestic workers to sexual and reproductive health (SRH) services and information

Only limited studies are available on factors influencing the health-seeking behaviour of Ethiopian migrant domestic workers in Sudan at local or national level. The existing studies demonstrated that many female migrant domestic workers encounter institutional, legal, economic, social and cultural hurdles in accessing sexual and reproductive health (SRH) information and services, which distress their living conditions. These services include access to information on, treatment and care of sexual and reproductive health problems, such as reproductive tract infections, sexually transmitted infections, pregnancy, delivery and post-delivery care. Some of the cited barriers to accessing these services are linked to socio-cultural factors, such as cultural capital, which remains a serious constraint for migrants who are belonging to minority groups. For instance, if women migrant domestic workers do not speak the language of Sudanese health service providers fluently and clearly, language barriers pose a significant factor obstructing access to pertinent and appropriate health information and services (USDS 2011b).

In Sudan, issues related to women sexual and reproductive health are dealt with sparingly, and quality and access of women to these services is very poor. Premarital sex is unacceptable and punishable by law among Sudanese and foreign women, and adolescent migrant women are especially vulnerable to health risks because of their fear of being punished if it being found out that they were sexually active before marriage, or were forced into sex by their employers.

These are phenomena well-documented in the literature (IOM 2010; UNFPA 2011; Truong et al. 2014). Studies showed that health service providers may have damaging views of migrant women as not "respectable" and, in several situations, linked with prostitution. Thus, migrants preferred to seek the traditional practitioners, confidential, or more than one traditionally prescribed medication, instead of looking for treatment from SRH services. Combined with many unwanted pregnancies, mostly due to forced sex, considerable numbers of unsafe abortions are usually reported.

Migrants do not necessarily change their beliefs as a result of their migration; on the contrary, evidence shows that they tend to hold on them more. Part of these are beliefs in traditional explanations regarding health that sometimes serve as barriers to understanding the seriousness of medical conditions and the necessity to seek immediate treatment. The preservation of face', for instance being regarded as an individual who deviates from Sudanese shared customs, can have a significant impact on SRH-seeking behaviour. This is tightly connected with gender roles accredited to women, namely that they should conform to certain prescribed behaviours such as controlled mobility, dress codes and preserving their virginity.

Despite these often anticipated difficulties, many are heartened, as bread winners, to look for occupation abroad, frequently distant from the safety of usual customs and environment. But the UNFPA study also noted:

Nonetheless, community, and in particular the role of social networks, was found to be a critical factor influencing women migrants in general, including their sexual and reproductive health behaviour and, possibly, their health care choices. (UNFPA 2011, ix).

In an era of HIV/AIDS, increased poverty and ongoing conflict in the region migrant female domestic workers will remain to be at risk. Due to the gaps found in previous literature and issues emerging from the few studies on the region, it is essential to investigate in depth these women's access to healthcare and factors influencing their seeking SRH information and services. This study looks in depth at this issue from a human rights perspective, and analyses relevant policies and strategies to come out with clear evidence to set strategies to help women in this situation.

Methods

A qualitative approach was used in the study, as the researchers positioned themselves within the interpretivist-phenomenological traditions. An interpretive approach respects the difference between people and objects of the natural sciences. Hence, interpretivism comes in collaboration with a phenomenological tradition, which is a philosophy that deals with the question of how individuals make sense of the world around them, and how in particular philosophers should keep away his/her preconception of that world (Bryman 2012, p. 28, 30).

The method used was a thick description, which does more than record what a person is doing and hence, subsequently, different techniques/tools have been used in order to get rich findings. Mainly, this encompassed in-depth interviews, focus group discussions, and key informant interviews, as well as direct observation, where consideration was not only given to subjective stories, but also to the body language, i.e. gestures and visibly expressed emotions. In addition to this, a desk study of existing studies, laws and policies that pertain to domestic workers and migrants' access to health care was conducted.

The study was conducted in a purposively sampled area in Khartoum State, where access to domestic workers and their agents was possible for the researchers. The sample was purposively selected in two phases; the first phase included the selection of 30 Ethiopian female migrant domestic workers, in addition to 10 key informants. The 30 Ethiopian female migrant workers were selected using the snowball method to find employers of Ethiopian female migrants and accepted to allow the researchers to interview them. In case the domestic workers accepted, they were interviewed and asked about relatives or friends in the area who can be approached as well. The selection was repeated when a domestic worker refused to be interviewed, which happened among few of them; then another employer was approached. The 10 key informants included UNHCR staff, officials of the Ethiopian Embassy and the Ministry of Labour, a healthcare provider, an agent and 5 employers of the domestic workers.

The second phase concerned in-depth analyses of existing laws and policies in Sudan that pertain to labour and health-related policies for migrant workers, including the National Health Policy, labour and migration policies, Domestic Workers Laws and international laws pertaining to migrants. Policy documents and laws were analysed using content analysis to identify parts that refer to migrants, refugees or domestic workers, as a category in the work force.

Researchers have used an interview guide and memory aids as a summary of questions to deal with a range of topics, including time spent in Sudan, number of employments in different households, level of Arabic and Sudanese Arabic language, pathways to care when experiencing both any general illness and symptoms related to the reproductive tract. General questions were administered at the beginning to build rapport with the informants. Due to the sensitivity of the issue, respondents and key informants declined to allow researchers to tape interview sessions, hence all interviews were written down, and these transcripts were used for the content and cross-case analysis. Data was analysed using content analysis by identifying major categories of answers to the study questions. Although writing down hindered the direct observation to some extent, the researchers managed to observe the body language, i.e. facial expressions and body gestures, of the interviewee.

Because of the sensitivity of some interview issues, e.g. sexuality, special considerations were given to the ethical aspects of the research. Questions were asked in a non-embarrassing manner, e.g. by explaining the question in a way avoiding provocation of the informants by any means and helping the informants to grasp the question implicitly. Concerning confidentiality, the researchers have explained to the informants that only the researchers conducting the interview would see the data during transcription, after which the results will be anonymised and public. The informants were thereby informed very clearly who will have access to the data, and what will happen to the data when the research is complete. The process of anonymisation by removing names and other identifying information was also explained.

Results and discussion

Policies and laws pertaining to domestic work

Seven policy documents and laws were reviewed. These were the National Health Policy (NHP) of 2006; the National Reproductive Health Policy (NRHP) of 2010; the Women Empowerment Policy (WEP) of 2006; the National Domestic Workers Law issued in 1955; the Labour Act of 1997; the National Law for Organizing Non-Sudanese Workers of 2001, and the Khartoum State Domestic Workers Law of 2009. The content analysis of these policies and laws showed that both NHP and NRHP do neither recognise special needs of migrant women, nor do they mention domestic workers' access to care. However, the WEP mentions in chapter 2 (Peace Component) the special needs of refugee, displaced and migrant women and indicates the need to address their limited access to care, as part of a whole range of vulnerable women.

The two Domestic Workers Laws (National and Khartoum State), the Labour Act, and the Law for Non-Sudanese Workers all restrict hiring workers without valid work and police permits, which is the case for most of the foreign domestic workers in the country. The Domestic Workers Law of 1955 also specifically recognises domestic workers' right to have up to 30 days paid sick leave as long as the worker has completed two years in the house and the illness was not caused by act of negligence from her part and is recognised by an authenticated medical personnel (Chapter 3 'Conditions of Service', Section 20). In the 2009 Khartoum State Law, the required duration of service before the worker is entitled to paid sick leave of 30 days is reduced to six months (Section 4 'Leaves', Article 11.1). One of the new additions in the 2009 Khartoum State Law is the restriction of domestic work of females in all-male households, or males in all-female households, as well as the restriction of domestic work for children under the age of 14 years (Chapter 2 'General Provisions', Article 8.B and 8.C). According to the key informant from the Ministry of Labour, these stipulations apply to both national and foreign domestic workers.

It is important to mention here that the general public is not accustomed to use these laws upon employing domestic workers, and there is no mechanism to ensure that employers, or domestic workers have read these laws as it used to be in the past when all domestic workers, even foreign ones, were more likely to have valid work permits. The results of this study found that there are gaps in policies and laws pertaining to the protection of the rights of domestic workers, particularly those from outside Sudan. Sudan as a country with many migrants, and as a transit country for many young women seeking to improve their lives, needs to have strong legislation and policies that organise the provision of livelihood opportunities for these migrants, so they can live easily within the boundaries of the Sudanese laws.

Entry into domestic work--the agent's role

One of our key informants was an Ethiopian man who works as an agent for recruitment of domestic workers to families in Khartoum State. In general, there are three known ways for domestic worker recruitment: either via relatives' or friends' domestic workers, via an agent, or via a legal recruitment agency, which costs more money for both the employer and the domestic worker. Therefore, most families prefer to use the agent or dealer, who is in most of the cases an Ethiopian man.

Our informant explained their policy of recruitment, and how they manage to find girls and women for work. At first, as expected, he hesitated to provide information for the study, but we encouraged him by ensuring him that his name is not included in the interview. He, eventually, started to describe how they get girls into Sudan, although he clarified that he does not have direct experiences with bringing them from abroad, but has good connections with the ones who do so. He explained that most of the girls and women come to Sudan illegally, with the help of their friends, relatives and sometimes agents as well. He usually, like others, gets a call from these agents to be notified of new girls and women coming to Khartoum. Once they arrive to Khartoum, he facilitates shelter for them with other female workers who are already in the state, and then he finds a job for them by getting calls and orders from his customers.

We enquired about the services he provides for the workers, and he stated that he facilitates a house for rent, paid by the workers according to the period they stay there, week-by-week or vacation-by-vacation, thus called the "vacation house". He also is responsible of providing medical care, if needed, and sometimes covers the cost of care for those who may not be able to afford it at the time of illness, but gets it back from them once they get a job. According to him, none of the girls he took to care had a reproductive health problem, as he explained:

   The illnesses they got were ordinary ones like malaria and
   diarrhoea and chest infections. But of course I am not the only one
   who helps them to get medical care for the sick ones, some of them
   have relatives and others get helped from the houses they work in.

It is customary that employers pay him a fee of 100 SDGs (around US$18) for bringing the domestic worker. Then, the domestic worker herself would pay for him a certain percentage of her salary for the first three months, which varies among different dealers. The role of the agent ends upon bringing the domestic worker, as he usually is not held responsible to provide another domestic worker if the one he brought decides to leave the job. Sometimes, though, if the domestic workers or the employers decide to terminate the recruitment agreement within few days, he may bring another domestic worker with no additional fees. In this case, the domestic worker sometimes has to stay until a replacement, or she will have to pay the rent in the vacation house until she finds another job.

Employers' attitudes towards Ethiopian female migrant domestic workers' use and access to sexual and reproductive health services The interviewed employers were all women, aged between 30 and 50 years, and had an average of 6-10 family members in their households. They all employed one domestic worker who does all the cleaning, washing and some help in the kitchen. All of them had several migrant domestic workers before.

Employers of the domestic workers, all females, were asked about their views on the workers' use of and access to reproductive health services. The employers indicated that they prefer to give sick days off, but in severe cases they would take the domestic worker to healthcare themselves. They explained that most of the domestic workers they have are usually assisted to use health services when they need it, and families will usually accompany them to the health facility. One, however, indicated that they need the support of one from her own family, due to the barrier in language, explaining why in some instances the domestic workers are asked to go back to her family when she falls ill.

Almost all of the employers agreed that they do provide support, money and time off when a domestic worker is ill, but few of them tell their employers about any RH problems they may experience. One of the employers said:

   When she falls ill I take her to the nearest health centre. But
   sometimes she may need a doctor and then I will take her but she
   pays a share in the cost of the doctor. I noticed that the domestic
   workers who are Muslims complain more from RH problems like pain in
   menstruation, more than the Christian ones. When I asked one she
   told me because of the 'pharaonic' circumcision.

Overall, the interviewed employers agreed that the workers rarely talk to them about RH problems, and only complain when they have a general illness, such as headache or common cold. In these cases, the nearest health facility is sought and the employer pays for the service, but in cases of a more sensitive illness that may require a specialised doctor, such as RH problems, domestic workers are sometimes required to share in the payment for the services.

Health-seeking behaviour of domestic workers

Our respondents among domestic workers were Ethiopians (n=26) and Eritreans (n=4). Most of them were single and only five of them married with children. The majority of them could speak some Arabic, while a small minority could not. As expected, almost all of them came to Sudan to get better income, but 3 of them came fleeing from their families. They came mostly via bus or car, and 10 of them said they walked from the borders till Khartoum, as they had no money to pay for car, while six of them were escorted by agents who helped them pay for the trip in return for a monthly payment from their salaries. A good majority of them had friends and relatives in Sudan, and thus a good social network, which also helped them in getting their jobs, as half said they got the job via their friends and family; the remaining half were employed through an agent. When they were interviewed, most of them said this was their second to third house to work in since arriving in Sudan. The rest worked in around 8 houses during their stay.

Regarding the domestic workers' experience with RH problems, half of them said they experienced a health problem related to their reproductive tract since they came to Sudan, but almost all could not specify what the problem was they had. Many decided to keep quiet about it until their weekly day off arrived, so they can talk to sisters, family or friends. One of them explained:

   When I get a problem like this ... a woman one ... I take some mint
   or "harjal' that Mama [i.e. the employer] gives to me to drink
   until I am alright.

One was comparing the way her different employers dealt with her illness, especially when it is related to reproductive health:

   In one of the houses I worked for, they would take me to the
   hospital and pay for me ... but the other one refused so I asked my
   aunt to come and take me. Twice she came to take me and once she
   asked me to take mint tea. This time Mama [the employer] took me to
   the nearby health centre and paid for me.

The results also showed that there are certain health institutions that these domestic workers prefer to use when they have any illness, but particularly when they have reproductive health issues. The interviewed health provider indicated that there is no difference between the way these domestic workers are treated and the other Sudanese females:

   Non-Sudanese patients are treated like Sudanese, the only
   difference is in the death certificates, if one died it has to be
   with Form 8. Of course if there is one with illegal pregnancy or
   abortion, they are reported in reference to article 146 of the
   penal code, the same as Sudanese patients, but we see that some of
   these workers when they come they prefer the Ethiopian nurses.

In comparison, the respondents indicated that they would prefer to seek healthcare by an Ethiopian doctor, due to the language barrier and because of their perception of the treatment they receive from Sudanese health providers. One of the respondents said:

   I prefer to go to my house and go with friends or family to the
   closest health centre and sometimes we go to the pharmacy or the
   Ethiopian doctor we know as he understands us and because sometimes
   there are issues that may lead to suspicion, especially if we are
   doing a laboratory test, and when we go back sometimes Mama [the
   employer] does not allow us to get rest.

Some of the providers explained that their role is only to provide medical care and not to judge other people's behaviour. However, one of them stated that,

   Some hospitals impose higher fees to non-Sudanese patients, yet,
   one of these hospitals, Ibrahim Malik Hospital [the only one
   mentioned in name by respondents], receives a high number of them,
   due to the presence of Ethiopian doctors and nurses in it.

Since Sudan has a large number of Ethiopian migrants, they have established a very strong social network, which was found to have a very significant role in enhancing their access to care in reproductive health issues, particularly in situations when the employers do not provide the required assistance, as stated by the Domestic Labour Law of 2009, or when they have no money to pay for fees. This social network also includes the Ethiopian health providers, who are highly sought after by the domestic workers.

Reasons related to language barriers and fear of discrimination was among the obstacles to healthcare found by other studies. Previous studies indicated that domestic workers and foreign workers usually do not receive similar care and treatment as the citizens of the country they live in. Socio-cultural barriers influencing these workers' access to care also include language and fees (UNFPA 2011). In our study, the Ethiopian female migrant domestic workers were indicated to receive a similar quality of healthcare as Sudanese citizens, but some reported receiving negative treatment in relation to certain illnesses that may be associated with adultery or suspicion of a sexually transmitted infection.

Conclusion

This study analysed the impact of policies, regulations and other factors on Ethiopian female migrant domestic workers' access to healthcare services in Khartoum State. Amidst significant gaps in policies and laws, social integration and support are essential for these domestic workers, and it is recommended to offer more Ethiopian trained health providers to fill gaps in care provision.

No differences in treatment or exceptions for non-Sudanese women were confirmed by Sudanese healthcare providers, except for the issuance of death certificates. Domestic workers reported, however, differences in treatment, higher fees, language barriers and discrimination when they seek care. They hence used different coping mechanisms to deal with their sexual and reproductive health problems, including using traditional tea, seeking support in the social network and visiting health facilities with Ethiopian healthcare providers. Some female employers were also found to be effective in providing care and support when the domestic workers are suffering from reproductive health problems. Rather than public services, this indicates that social networks are the essential resource to assure appropriate access to healthcare.

The study hence recommends the integration of protection and special needs for female migrants in laws and policies. Further studies are needed to examine the role of the social network and agents in protection of these migrant women's health and human rights. An examination of the possibility of a stronger inclusion of Ethiopian trained healthcare providers in the Sudanese health system may also be required to identify means for filling gaps in healthcare provision, particularly in places where there is a high population of migrants from Ethiopia. These future studies will also support migrants' organisation and development of more targeted comprehensive care and information in their own languages, as well as strengthening the role of support groups from social networks, which can be effective for the dissemination of health information.

Note on contributors

Nafisa M. Bedri is Associate Professor of Women and Community Health at Ahfad University for Women.

Sara Ibrahim Abdelmoneim is lecturer and researcher at the Institute of Endemic Diseases in Medical Laboratory.

Nuha K. Tambal is lecturer and researcher in International Education and Development at the School of Health Sciences, Ahfad University for Women.

Suzan Adam is lecturer in International Social Welfare and Health Policy at Ahfad University for Women.

References

Bryman, A. 2012. Social research methods. 4th ed. Oxford et al.: Oxford University Press.

IOM (International Organization for Migration) Regional Office for Southern Africa. 2010. Regional assessment on HIV-prevention needs of migrants and mobile populations in Southern Africa. Pretoria.

IOM (International Organization for Migration). 2011. Migration in Sudan: A country profile 2011. Geneva.

Truong, T.-D., Marin, S. & Quesada-Bondad, A. 2014. 'Intersectionality, structural vulnerability, and access to sexual and reproductive health services: Filipino domestic workers in Hong Kong, Singapore, and Qatar'. In Truong, T.-D., Gasper, D., Handmaker, J. and Bergh, S. I. (eds.). Migraton, gender and social justice. Berlin & Heidelberg: Springer. Pp. 227-239.

UNFPA (United Nations Population Fund) Asia and the Pacific Regional Office. 2011. Socio-cultural influences on reproductive health of migrant women. A review of literature in Cambodia, Lao PDR, Thailand and Viet Nam. Bangkok.

USDS (United States Department of State). 2011a. 'Sudan'. In USDS (ed.). Trafficking in persons report. June 2011, pp. 335-338. Washington. Available at: http://www.unhcr.org/refworld/docid/4e12ee4637.html. Accessed: 18/07/2015.

USDS (United States Department of State). 2011b. 'Ethiopia'. In USDS (ed.). Trafficking in persons report. June 2011, pp. 157-160. Washington. Available at: http://www.unhcr.org/refworld/docid. Accessed: 18/07/2015.