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R E V I E W Open Access
Discrimination against childbearing Romani
women in maternity care in Europe:
a mixed-methods systematic review
Helen L. Watson
1*
and Soo Downe
2
Abstract
Background: Freedom from discrimination is one of the key principles in a human rights-based approach to
maternal and newborn health.
Objective: To review the published evidence on discrimination against Romani women in maternity care in
Europe, and on interventions to address this.
Search strategy: A systematic search of eight electronic databases was undertaken in 2015 using the terms “Roma”
and “maternity care”. A broad search for grey literature included the websites of relevant agencies.
Data extraction and synthesis: Standardised data extraction tables were utilised, quality was formally assessed
and a line of argument synthesis was developed and tested against the data from the grey literature.
Results: Nine hundred papers were identified; three qualitative studies and seven sources of grey literature met the
review criteria. These revealed that many Romani women encounter barriers to accessing maternity care. Even
when they are able to access care, they can experience discriminatory mistreatment on the basis of their ethnicity,
economic status, place of residence or language. The grey literature revealed some health professionals held
underlying negative beliefs about Romani women. There were no published research studies examining the
effectiveness of interventions to address discrimination against Romani women and their infants in Europe. The
Roma Health Mediation Programme is a promising intervention identified in the grey literature.
Conclusions: There is evidence of discrimination against Romani women in maternity care in Europe. Interventions
to address discrimination against childbearing Romani women and underlying health provider prejudice are
urgently needed, alongside analysis of factors predicting the success or failure of such initiatives.
Keywords: Discrimination, Human rights, Maternity care, Mistreatment, Roma, Prejudice, Health mediation
Plain english summary
All childbearing women in Europe are entitled to be free
from experiencing discrimination in maternity health
care. The Roma are the largest and most marginalised
ethnic minority group in Europe and experience dis-
crimination in many areas of life. This review aimed to
investigate published evidence about Romani women’sex-
periences of discrimination in maternity care in Europe
and any interventions to address this. The review
identified 900 papers, and after eligibility and quality as-
sessment, three published qualitative studies and seven
sources of non-research literature were taken forward for
analysis. These revealed that many Romani women en-
counter barriers to accessing maternity care. Even when
they are able to access care, they can experience mistreat-
ment that is discriminatory on the basis of their ethnicity,
economic status, place of residence or language. The non-
research literature revealed some health professionals held
underlying negative beliefs about Romani women. There
were no published research studies examining the effect-
iveness of interventions to address discrimination against
Romani women and their infants in Europe. The Roma
Health Mediation Programme is a promising intervention
* Correspondence: Helen.Watson@sth.nhs.uk;Watsonh2@outlook.com
1
Sheffield Teaching Hospitals NHS Foundation Trust, Jessop Wing, Tree Root
Walk, Sheffield S10 2SF, UK
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Watson and Downe Reproductive Health (2017) 14:1
DOI 10.1186/s12978-016-0263-4
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
identified in the non-research literature. The development
of further interventions to address discrimination against
childbearing Romani women and underlying health pro-
vider prejudice are urgently needed, alongside analysis of
factors predicting the success or failure of such initiatives.
Introduction
There is now wide acceptance of the relationship be-
tween human rights and maternal and infant health and
wellbeing [1]. A human rights-based approach to health
is a key feature of emerging global health policy within
the post-2015 agenda, including the Global Strategy for
Women’s and Children’s Health and the Sustainable
Development Goals [2, 3]. International efforts to improve
access to and quality of maternal and newborn care are
often hindered by the failure to eradicate discrimination in
both policy development and the provision of services [4].
There is a scarcity of studies within the academic litera-
ture that examine the implementation or impact of a hu-
man rights-based approach to maternal and infant health
care [5]. This paper presents the findings of a systematic
review of existing literature in this area, focused on the ex-
periences of Romani women.
Background
Human rights are basic values that are essential to human
dignity [6], and concern the empowerment and entitle-
ment of people with respect to certain aspects of their
lives, including their sexual and reproductive health [7].
Discrimination is prohibited in the Universal Declaration
of Human Rights and in other treaties in relation to the
exercise and enjoyment of covenant rights. Within human
rights law discrimination is defined as;
Any distinction, exclusion, restriction or preference or
other differential treatment that is directly or indirectly
based on the prohibited grounds of discrimination and
which has the intention or effect of nullifying or
impairing the recognition, enjoyment or exercise, on an
equal footing, of Covenant rights ([8], p. 3).
Discrimination may be against an individual belonging
to, perceived to belong to or associated with a group
with characteristics defined within the prohibited
grounds of discrimination (See Table 1). It is motivated
by socially derived beliefs and ideologies about specific
groups in society that justify patterns of behaviour to en-
act dominance or oppression and to obtain power or
privilege [9–11].
Discrimination in maternity care
The human rights of childbearing women incorporate
the right to freedom from discrimination and the
principle of non-discrimination in the exercise and
enjoyment of numerous other covenant rights, not least
the right to the highest attainable standard of health. Dis-
crimination against women on the basis of gender or
other grounds is implicated in preventable maternal mor-
tality and morbidity [12, 13], and particularly affects
women living in low income countries, rural areas, in pov-
erty or belonging to ethnic minority groups [14]. A human
rights-based approach to address maternal mortality and
morbidity identifies that targeted measures are required to
ensure the rights of marginalised groups [15].
In order to ensure women’s sexual and reproductive
health rights, health facilities, goods and services should
meet standards of; availability, accessibility, acceptability
and quality [7]. Non-discrimination is a vital dimension of
accessibility and States are required to ensure that mea-
sures are taken to eliminate barriers that women face in
gaining access to healthcare [7, 16]. Non-discrimination is
also a component of respectful maternity care, which is a
critical dimension of quality and acceptability standards
[7], and States should ensure that health services respect
women’s dignity and are sensitive to their needs and per-
spectives [16].
There is a growing body of global research that dem-
onstrates many childbearing women experience discrim-
ination in maternity care on the basis of their ethnicity,
race, religion, socioeconomic status, age, marital status,
medical conditions or sexual orientation [17, 18]. This
discrimination results in differential treatment that influ-
ences the quality of care the women receive, breaches of
confidentiality, humiliation, women feeling alienated
from their caregivers and women choosing to avoid the
health facility for their next birth [17]. Data from wider
studies in other areas of healthcare provision confirm
Table 1 Prohibited grounds of discrimination
Race and colour
Sex
Language
Religion
Political or other opinion
National or social origin
Property
Birth
Disability
Age
Nationality
Martial and family status
Sexual orientation and gender identity
Health status
Place of residence
Economic and social situation [8]
Watson and Downe Reproductive Health (2017) 14:1 Page 2 of 16
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that discrimination in the healthcare setting results in
delays in seeking care, reluctance to follow the advice of
medical practitioners and lower use of preventative ser-
vices [19–21]. All of these, in the context of maternity
care, may result in reduced access or uptake of services
and poor maternal and infant outcomes.
The Roma
The Roma are considered to be the largest and most mar-
ginalised ethnic minority in Europe [22, 23], and although
precise figures are unknown, are estimated to number be-
tween ten and twelve million people [24, 25]. Roma are
found in most European countries with the majority resid-
ing in Central and Eastern European countries [22] and
less than 20% reporting to be nomadic [26].
The United Nations have recently clarified:
The term “Roma”refers to heterogeneous groups, the
members of which live in various countries under
different social, economic, cultural and other
conditions. The term Roma thus does not denote a
specific group but rather refers to the multifaceted
Roma universe, which is comprised of groups and
subgroups that overlap but are united by common
historical roots, linguistic communalities and a shared
experience of discrimination in relation to majority
groups. “Roma”is therefore a multidimensional term
that corresponds to the multiple and fluid nature of
Roma identity. ([27], p. 3)
Throughout their history the Roma have been consist-
ently subjected to harassment and persecution. The repres-
sion of Roma in Europe reached its peak in what is termed,
inthelanguageoftheRoma,“porrajmos”translated as “the
devouring”; the extermination of between 220,000 and
1,500,000 Roma that began in 1940 and continued during
World War II as part of the holocaust [28, 29].
Several United Nations bodies have identified that on-
going discrimination against the Roma results in racial
violence and impacts on their rights to; education, health,
housing, employment, political participation, access to
citizenship and justice, and on the minority rights of exist-
ence, protection and promotion of collective identity and
participation in public life [1, 27, 30, 31].
There are limited data and few studies that consider
the health of Romani women within Europe [26]. The
data that are available indicate that Romani women are
more disadvantaged and suffer worse health than Roma
men and the non-Roma [26, 32]. They have less access
to family planning supplies, higher birth rates, higher
numbers of teenage pregnancies, higher rates of illegal
or unsafe abortions, and lower uptake of cervical screen-
ing [33, 34]. They have higher rates of poor infant out-
comes including low birthweight and preterm birth, and
face multiple barriers to accessing healthcare services [26].
In 2011 the European Council adopted the European
Union (EU) Framework for National Roma Integration
Strategies, which links social and economic inclusion with
the elimination of discrimination [35]. All EU Member
States have since adopted National Roma Integration
Strategies, or integrated national policies based on this
framework [35]. In the area of health, the strategy specifies
that States should ensure Romani women have access to
quality healthcare in line with the principle of non-
discrimination [36].
The review
Based on the background above a mixed-methods system-
atic review of existing literature was designed to fulfil the
following aims;
1. To establish the current evidence base in terms of
discrimination against Romani women in maternity
care in Europe.
2. To assess the nature, effectiveness of, and underlying
mechanisms of interventions designed to address
discrimination against Romani women and their
infants within the design and/or provision of
maternity care in Europe.
Design
A mixed-methods systematic review was undertaken, in-
formed by philosophical pragmatism with a complemen-
tary axiological framework informed by the transformative
paradigm [37, 38]. This paradigm is concerned with social
justice, societal power differences and their ethical impli-
cations including discrimination and oppression, and aims
to increase the visibility of members of communities who
have been marginalised within society [39].
An “a priori”protocol was developed using guidance
from Hayvaet et al. [40], The Centre for Reviews and
Dissemination [41], The Cochrane Handbook for
Systematic Reviews of Interventions [42], The Joanna
Briggs Institute [43], and the segregated model of data
synthesis proposed by Sandelowski et al. [44]. The terms
within the research questions were defined, and inclu-
sion and exclusion criteria developed using the PICOS
acronym; population, intervention, comparators, out-
comes and study design [41, 42].
It was intended that both types of secondary data, quali-
tative and quantitative, would be given equal weighting in
the analysis, would be collected simultaneously and inte-
grated at the synthesis phase.
Definition of terms
Romani women - women identified or self-identifying
as Romani
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Maternity care - maternal and infant health goods,
services and facilities provided during pregnancy,
birth, the postnatal period, and through to the early
weeks of life
Europe –countries belonging to the Council of
Europe (Table 2)
Discrimination in maternity care:
Any differential treatment that is directly or
indirectly based on the prohibited grounds of
discrimination and which has the intention or
effect of nullifying or impairing the exercise, on an
equal footing, of childbearing women’srightto
maternal and infant health facilities, goods and
services that are accessible, acceptable, available
and of good quality. This includes when the design
or provision of maternity care appears neutral at
face value, but has a disproportionately negative
impact on women and their infants on the basis of
prohibited grounds.
Inclusion and exclusion criteria
These are given in Table 3.
Search strategy
A broad search strategy was used which included terms
for “maternity care”and “Roma”. The search strategy
used keywords rather than MeSH terms so that it was
easily transferable between databases, and covered syno-
nyms, related terms, and spelling variations, and used
wildcard and truncation functions to ensure it was as
comprehensive as possible [42]. The development of the
search terms was an iterative process, and the final combination of terms using Boolean operators is de-
tailed in Additional file 1. This search was undertaken in
May 2015 in Medline, EMBASE, Maternal and Infant
Care via Ovid SP, AMED, CINAHL, Academic Search
Complete, PsychINFO and Wilson Social Science Ab-
stracts via EBSCOhost EJS and PROSPERO.
The search for grey literature was undertaken separ-
ately by reference tracking from relevant articles in the
initial search, searching the websites of relevant agencies
including World Health Organisation, Council of Europe,
United Nations Population Fund (UNFPA), Open Society
Foundation, Amnesty International, and broad internet
searching using Google search engine.
Data extraction and quality appraisal
Data were extracted using a standardised electronic form
that was refined iteratively. The Critical Appraisal Skills
Programme (CASP) checklists were selected for the ap-
praisal of cohort studies, case–control studies and ran-
domised control studies [45] Greenhalgh et al’s [46] tool
was chosen for mixed-method studies appraisal, the
Assessing the Methodological Quality of Systematic
Table 2 Countries belonging to the Council of Europe
Albania
Andorra
Armenia
Austria
Azerbaijan
Belgium
Bosnia and
Herzegovina
Bulgaria,
Croatia, Cyprus,
Czech Republic,
Denmark
Estonia Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Latvia
Liechtenstein
Lithuania
Luxemborg
Malta
Moldova
Monaco
Montenegro
Netherland
Norway
Poland
Portugal
Romania
Russian Federation
San Marino
Serbia
Slovak Republic
Slovenia
Spain
Sweden
Switzerland
“The former
Yusgoslav Republic
of Macedonia”
Turkey
Ukraine
United Kingdom
Table 3 Inclusion and exclusion criteria
Population Romani women or their infants living in countries
that are members of the Council of Europe
Maternity healthcare staff working with Romani
women in countries that are members of the
Council of Europe
Intervention
(Question 2 only)
Aims to address discrimination in maternity care
Occurs during pregnancy or the postnatal period
up to 42 days after birth
Addresses the design or provision of maternal
and newborn care
Not interventions with the newborn in the
absence of involving the mother
Not interventions limited to reproductive
technologies or termination services
Control
(Question 2 only)
Study includes a control group who did not
receive the intervention or program
Outcomes The accessibility or availability or acceptability or
quality of maternal or infant health goods,
facilities or services
Data from health care workers about their
experience of caring for childbearing Romani
women or their attitudes/beliefs about
childbearing Romani women and their infants
Study Type Any peer reviewed quantitative, quantitative or
mixed-methods primary research studies or
systematic reviews of these studies.
Only studies with full text
Grey literature
Language Available in English
Date No date limits
Watson and Downe Reproductive Health (2017) 14:1 Page 4 of 16
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Reviews (AMSTAR) tool for the appraisal of systematic
reviews [47], and the tool developed by Walsh and
Downe [48] for appraising qualitative studies.
The quality of the studies was grading by adopting
the system first published by Downe, Simpson and
Trafford [49], and as used by Shaw, Downe and
Kingdon [50]. This grading system uses a four cat-
egory coding, from A+ (highest quality) to D- (very
poor quality). Quantitative papers were to be graded
against the criteria of internal validity, reliability, rep-
licability and generalisability [51], and qualitative pa-
pers against criteria identified by Lincoln and Guba
[52]; credibility, transferability, dependability and con-
firmability (See Table 4). Papers graded C+ or below
were excluded.
Data synthesis
It was intended that the data would be synthesised
using the segregated method [44], in which quantita-
tive and qualitative data are synthesised separately,
meta-analytically and through meta-synthesis respect-
ively, and then integrated together in a line of argu-
ment synthesis
The intention was to synthesise the quantitative data
meta-analytically unless too heterogeneous, in which case a
narrative method would be undertaken. The chosen meta-
synthesis method was based on the methods of Finlayson
and Downe [53] and Walsh and Downe [54], both of which
were developed from meta-ethnography [55]. The grey
literature was synthesised separately using a simple narra-
tive method. It was intended that comparison with the
grey literature would allow the line of argument to be
tested and refined. The intention was to ensure the
integrity of the original research within the synthesis
and to incorporate quotes from the original respon-
dents in the primary sources to provide some internal
validity to the synthesis [56].
Confidence of the review qualitative findings were
assessed using the Confidence in the Evidence from
Reviews of Qualitative Research (CERQual) approach
[57]. This method involved an assessment of confidence
in the second order themes using the four CERQual do-
mains; methodological limitations, relevance, adequacy
of data and coherence [57]. Each finding was scored on
each domain (very low to high) and then an overall score
determined.
Results
Search outcome
Figure 1 gives the results of the search. Nine hundred
articles were identified, and after the removal of dupli-
cates, and screening of the titles and abstracts against
the inclusion criteria, four peer reviewed papers met the
inclusion criteria and were taken forward and read in
full. After final screening, one further paper was ex-
cluded on the basis of language (See Additional file 2).
The characteristics of the included studies can be seen
in Table 5.
No quantitative or mixed-methods studies met the re-
view criteria. Three qualitative studies were included
[58–60]. The studies incorporated data from Serbia,
Macedonia, Albania, Bulgaria and England. They ranged
in publication date from 2011–2014 and scored accept-
able quality ratings of B or B-.
Seven relevant sources of grey literature were identi-
fied [36, 61–66]. Their characteristics can be seen in
Table 6. Six of these sources included qualitative data
from study reports pertaining to Romani women’s expe-
riences of maternity care or access to maternity care in
Europe [36, 61–65]. One source was a section of a PhD
thesis that analysed the impact of an intervention with
childbearing Romani women [66]. The sources ranged in
publication date from 2001 to 2014 and incorporated
data from 25 European countries, although the majority
of the data were from Central and Eastern European
regions.
Qualitative findings
The findings from the peer-reviewed papers were com-
pared and grouped into first and second order themes as
shown in Table 7. A search was made for any discon-
firming or unexplained data and an assessment of each
second order theme was undertaken to determine the
Table 4 Grading criteria for quality of qualitative studies
Qualitative papers
Graded against the criteria of internal validity, reliability, replicability
and generalisability [51].
A No, or few flaws. The study’s internal validity, reliability, replicability
and generalisability are high.
B Some flaws, unlikely to affect the internal validity, reliability,
replicability and generalisability of the study.
C Some flaws that may affect internal validity, reliability, replicability
and generalisability of the study.
D Significant flaws that are very likely to affect the internal validity,
reliability, replicability and generalisability of the study.
Quantitative papers
Graded against criteria identified by Lincoln and Guba [52]; credibility,
transferability, dependability and confirmability.
A No, or few flaws. The study’s credibility, transferability, dependability
and/or confirmability are high.
B Some flaws, unlikely to affect the credibility, transferability,
dependability and/or confirmability of the study.
C Some flaws that may affect the credibility, transferability,
dependability and/or confirmability of the study.
D Significant flaws that are very likely to affect the credibility,
transferability, dependability and/or confirmability of the study.
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Fig. 1 Flow diagram of study selection
Table 5 Characteristics of the included published research studies
Author and
countries
Focus Design and methods Sampling
strategy
Sample
characteristics
Analytic strategy Quality
score
Funding
Janevic et al., [58]
Serbia and
Macedonia
Discrimination and
access to prenatal
and maternity care
amongst Romani
women
Community-based
participatory research.
8 focus groups
In-depth structured
interviews
Purposive sampling
of Romani women.
Snowball sampling
of gynaecologists
71 Romani
women who
had given birth
in past year,
age 14–44.
8 Gynaecologists
Constant
comparison
method
B Not specified
Columbini et al. [59]
Albania, Bulgaria,
Macedonia
To explore access
of Roma in
South-Eastern
Europe to sexual
and reproductive
health services
Focus group
discussions
Purposive sampling 58 male and
female Romani
participants
Thematic analysis
using AtlasTi
B- UNFPA, and European
Observatory on
Health Systems and
Policies
Condon and
Salmon [60]
South-west
England
To explore mothers
and grandmothers’
views on feeding in
the first year of life,
including the
support provided by
health professionals.
1-1 interviews Not specified 22 women, of
whom 11 were
Romani. 2 were
grandmothers
and 9 mothers.
Coding using
NVivo 9 and
development
of themes
B- University of the West
of England as part of
the SPUR Early Career
Researcher funding
stream.
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Table 6 Characteristics of included grey literature
Author Aim Source type Setting Study method Participants Funding
Pohjolainen [36] To outline barriers and issues
experienced by Romani women
in relation to maternal health,
and issues raised by practitioners
in relation to the provision of
inclusive maternal health services
for Roma.
Parvee Point Report Ireland Findings from the Roma
maternal and child health
seminar, including speakers,
focus group discussions
among seminar participants,
and interviews with
practitioners and members
of Roma communities.
Romani women
Health professionals
Roma Health Seminar
participants
Health Service
Executive, Ireland.
European Roma
Rights Centre [61]
To document discriminatory
practices and other forms of
human rights abuse against
Roma in the provision of health
care as well as exclusion from
access to health care.
Report for European
Roma Rights Centre
Bosnia and Herzegovina,
Czech Republic, Croatia,
Greece, France, Italy, Kosovo,
Romania, Serbia, Slovakia,
Slovenia, Bulgaria, Hungary
and Spain.
Interviews in Bulgaria
Hungary and Spain,
research with partner
organisations and
information from ERRC
legal databases
Romani men and women
aged 18–70
Physicians treating Roma
patients. Number not
specified.
Open Society Institute
Iszak [62] To document practices of
discrimination against Romani
women within the health care
sector in Hungary.
Report published by
European Roma Rights
Centre
Szabolcs-Szatmár Bereg,
Hajdú-Bihar and
Borsod-Abaúj-Zemplén
counties in Hungary
Interviews 131 Romani women
Physicians, number not
specified.
Not specified
Centre for Reproductive
Rights [63]
To document suspected cases of
coerced sterilizations against
Romani women who accessed
reproductive health services in
Slovakia.
Report by Center for
Reproductive Rights
and Poradna
40 Romani settlements
in Eastern Slovakia
Individual interviews and
group interviews
230 Romani women
25 doctors, 7 hospital
administrators, 6 nurses
Not specified
European Monitoring
Centre on Racism
and Xenophobia [64]
To investigate the situation of
Romani women accessing
healthcare.
Report to Council of
Europe
Bulgaria, Finland, France, UK.
Greece, Hungary, Ireland,
Lithuania, Moldova, The
Netherlands, Poland,
Romania, Serbia and
Montenegro, Slovakia
and Spain.
Country visits and individual
interviews and questionnaires.
Romani women,
representatives of
governments and NGOs
and health workers.
Numbers not specified.
UK Government
and European Union’s
European Monitoring
Centre on Racism and
Xenophobia
Zoon [65] To document the ways in
which the Romanian, Bulgarian,
and Macedonian governments
and their representatives
discriminate against the Roma
in the provision of social
protection benefits, health care,
and housing.
Open Society
Foundation report
Romania, Bulgaria and
Macedonia
Interviews Government officials,
legislators, social workers,
Romani activists, health
workers and Romani
residents. Numbers not
specified.
Open Society Institute
Benjenariu, &
Mitrut [66]
To analyse a large-scale public
health program targeting Roma
minority, the Roma Health
Mediation programme, and its
impact on prenatal care and
child health
Section of PhD thesis
published by University
of Gothenburg
Romania Quantitative analysis of the
2000–2008 Vital Statistics
Natality (VSN), Vital Statistics
Mortality (VSM) files, and
data from the Roma Health
Mediator registry and the
Roma Inclusion Barometer
2006.
Romani women and
their infants born
between 2000–2008
(10,885 –13,685
observations)
Not specified
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CERQual score as shown in Table 8. Two second order
themes achieved an overall medium CERQual score, as
although the findings were well grounded in the data,
there were only a very small number of primary studies
which represented a limited number of geographical
contexts across Europe and the quality score of the stud-
ies were medium. A third second order theme achieved
an overall low CERQual score as there were very few
primary studies containing thin data from a small num-
ber of participants and no convincing explanation for
contrasting data.
Mistreatment within maternity care
The Romani women reported a variety of poor experi-
ences that constituted mistreatment within maternity
care, including poor communication [58–60], being
abandoned [58], physical and verbal abuse [58, 59], being
refused care [59] and being made to wait until the non-
Roma women had been attended to [59].
The Romani women reported that health care workers,
particularly doctors, communicated with them poorly
and rarely explained anything about procedures or
problems;
“They are not interested and always tell us that
everything is fine, even when it isn’t, and all that just
because we are Roma.”([59], p.530)
Some women described being abandoned by the
medical staff when they were inpatients at the mater-
nity facilities;
“After the delivery…they placed me in a separate
room alone and nobody came to ask me how I feel, the
entire night I bleed till 7 am. I could die.”([58], p.4)
The women reported they experienced rough treat-
ment particularly during the delivery of their baby [58]
and verbal abuse and racial slurs [58, 59];
“My doctor…she only yells and shouts. They say that
she hates Roma”([58], p.4)
“When I gave birth to my sixth child, the midwife
told me: ‘Gypsy job! Only Gypsies have so many
children!’It was offensive, I was not happy with
this. ([59], p.530)
Table 7 Qualitative data themes
Second order themes First order themes
Mistreatment within
maternity care
Poor communication
Being abandoned
Physical and verbal abuse
Refused care
Made to wait until other non-Roma
patients seen to
Negative attitudes of doctors
Barriers to accessing
maternity care
Lack of perceived need for care
Lack of awareness of right to care
Geographical barriers and transport barriers
Denial of treatment
Language barriers
Financial barriers
Patriarchal culture
Making things better Connection with the health centre
improving experience
Knowledge of rights to overcome barriers
Presence of Romani health workers
improving quality of care
Table 8 CERQual scores
Themes Evidence
(Study Code)
CERQual score and comments
Methodological
limitations
Relevance Adequacy of data Cohrerence Overall score
Mistreatment within
maternity care
58, 59, 60 Medium Medium Low High Medium
Studies with quality
scores of B to B-
Studies represented
limited number of
geographical contexts
across Europe
Small number of primary
studies (3), although thick
data available.
Well grounded
in the data
Barriers to accessing
maternity care
58, 59, 60 Medium Medium Low High Medium
Studies with quality
scores of B to B-
Studies represented
limited number of
geographical contexts
across Europe
Small number of primary
studies (3) although thick
data available.
Well grounded
in the data
Making things better 58, 59 Medium Medium Very low Low Low
Studies with quality
scores of B to B-
Studies represented
limited number of
geographical contexts
across Europe
Only 2 primary studies
and very thin data from
small number of
participants
No convincing
explanation for
contrasting data
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Some Romani women reported that medical pro-
fessionals were unwilling to treat them in medical
facilities [58, 59];
“There are cases in which doctors do not want to
examine us. Maybe because we are ‘black’,‘dark’”
([59], p.530)
The women reported that the medical staff prioritised
non-Roma women above them and made them wait
unfairly;
“No matter if we are first in line, we are always
checked-up last. The Macedonians and Albanians,
they always have priority…all that just because we are
Roma.”([59], p.530)
Barriers to accessing care
The Romani women described barriers to accessing care
that included; a lack of awareness of their right to care [58],
a lack of perceived need for care [58], geographical and
transport barriers [58, 59], being denied treatment [58, 59],
language barriers [60], and financial barriers [58, 59].
Many women were unaware of their right to mater-
nity care. In one study they questioned the focus
group moderators about their rights to social assist-
ance during the research process [58]. Other Romani
women did not perceive any need to visit a doctor
during pregnancy;
“I didn’t go to the gynecologist during my pregnancy.
Why should I go to the doctor? I knew that I was
pregnant. I went to the doctor when I felt my
contractions.”([58], p.7)
The women reported a lack of local maternal health
service provision within their settlements [58] and trans-
port barriers to accessing services including lack of dir-
ect bus services [58], the costs of transport [58, 59], and
particular difficulties for those living further from the
cities [59].
“It would be much easier, if we have a doctor here, so
that we wouldn’t have to roam the road.”([59], p.530)
The women identified that they were denied access to
healthcare by doctors refusing to register them for pri-
mary care services [58], by medical professionals unwill-
ing to treat them in medical facilities [58, 59] or by
emergency services who were unwilling to attend when
required in Roma settlements [58];
“But if you call an ambulance here you might die”
([58], p.6)
Some women reported that health professionals did
not provide health information in a language they could
understand;
“We received leaflets in English, about how to
breast feed and what to expect when you’re a
Mum, but we don’tactuallyknowhowtoreadin
English.”([60], p.789)
The women described that their lack of finances, in-
ability to give informal payments or bribes and their lack
of health insurance or access to private healthcare im-
pacted on their access to care and to the quality of care
they received [58, 59]. Their inability to give informal
payments or bribes resulted in poorer care and neglect
by the health professionals [58, 59] and resulted in
health professionals refusing to allow them to have the
support of a family member present with them in the
maternity unit [58];
“They asked me to pay 11,000 MKD [equivalent to
USD 252]; I didn’t have that kind of money, but they
weren’t interested, so I had to give birth to my child at
home. The childbirth lasted for two days and I fell
unconscious several times.”([59], p.528)
“They looked for money from me, they didn’twantto
deliver my baby until my mother-in-law gave them
money and then everything was different.”([58], p.7)
“Next to me was an Albanian woman giving birth, she
called the nurse over and gave her a gold bracelet,
then the nurse and doctor were the whole time next to
her, but they hardly looked at me.”([58], p.7)
Making things better
Three Romani women described how they overcame poor
experiences or barriers to accessing care; having a connec-
tion with the health centre [58], knowledge of rights [59],
and the presence of Romani health workers [58].
One woman described that having a family member who
was a health worker improved the doctors’behavior, the
quality of treatment received and the waiting time [58];
“But then he saw that my mother is a health worker,
his behavior changed and he apologized.”([58], p.6)
Another woman explained that her knowledge of her
entitlement to care enabled her to overcome an unfair
request for additional payment [59];
“I started to go for regular check-ups with a
[gynaecologist] who at first sought money from me,
but, after telling him that I know that if a woman
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is pregnant, she shouldn’t pay for the checkups and that
Icouldsue,Ididn’tpayforanything[…] I didn’tpay
the 200 Macedonian denar [equivalent to 4 US dollars]
because I knew I don’thaveto…” ([59], p.529)
Another woman described that the quality of care she re-
ceived was improved as a Romani obstetrician intervened
in her treatment to prevent an unnecessary Caesarean
Section [58]. By contrast another woman reported that the
verbal abuse she experienced was perpetrated by all the
staff caring for her including a Romani nurse [59].
Line of argument synthesis
Romani women in Europe report that they experience
various forms of mistreatment within maternity care and
barriers to accessing maternity care. Some of these experi-
ences are discriminatory on the basis of multiple grounds
including Roma ethnicity, economic situation, place of resi-
dence, and language. Awareness of rights to care and a rela-
tional connection with health service staff they encounter
may reduce ‘othering’, and increase Roma women’sagencyto
improve the care they receive.
Given the few studies included, the medium and low
CERQual scores for these findings and the lack of quantita-
tive data for comparison, this line of argument synthesis is
tentative. When describing their experiences, the Romani
women did not always make a comparison with the
experience of other women, or propose a reason for the
mistreatment or barriers they experienced. Only one of the
included studies considered Romani women’s understand-
ing of the concept of discrimination [58]. The researchers
reported that there was often little understanding of this
concept particularly amongst the women with little educa-
tion. Despite this, nearly all the respondents believed that
the treatment of Romani women was better in Western
Europe, and there was implicit evidence in the data that
some Romani women felt the mistreatment they experi-
enced was on the grounds of their ethnicity.
Data from health workers were limited and were only
presented in one included study [58], which included eight
gynaecologists in Serbia and Macedonia. The respondents
described the Romani women as being mostly unedu-
cated, having lower literacy levels and health knowledge,
being non-compliant, not listening, having large numbers
of children and having an inherent “gypsy fear”.Negative
attitudes were mostly directed towards the most unedu-
cated Romani women.
In order to test and refine the tentative line of argument,
a comparison was undertaken with the grey literature.
Findings from the grey literature
The grey literature included qualitative accounts from
women; qualitative accounts from staff; and one report
of an intervention. In this section, the first set of data
are compared with the synthesis above, to see how well
the line of argument explains the broader data from
women’s own experiences.
Given the paucity of data on staff views from the
qualitative research data, the staff views in the grey lit-
erature are presented in more depth, as a basis for future
more detailed research. The single intervention is de-
scribed in some detail, again, as the basis for future
intervention studies in this area.
Testing the line of argument: women’s views and
experiences
Six sources of grey literature contained qualitative data
about Romani women’s experiences of maternity care
[36, 61–66]. These revealed that childbearing Romani
women experienced poorer care than non-Roma women
on the basis of their ethnicity, poverty, and place of resi-
dence and confirms the line or argument synthesis. No
reports highlighted any positive experiences of maternity
care in Europe.
The Romani women reported they were not treated
with respect [36], were abandoned by maternity care
health professionals [61, 62], denied treatment [61, 63],
attended by underqualified staff [61, 62], and subjected
to verbal or physical abuse [61–64] and degrading or hu-
miliating treatment [63].
“Doctors speak to you like you would speak to a dog.”
([62], p.9)
“When I was in the delivery room…The doctor started
to call me names (Gypsies) and hit me really hard on
my face. The nurse who was attending me hit me on
my legs. It hurt, it gave me bruises.”([63], p.83)
Women reported that they were obliged to wait until
all the non-Roma patients had been seen before being
attended to by maternity healthcare professionals [63, 64],
they were not allowed to have family members present
with them during labour and delivery [63], their newborns
were sometimes detained in the medical facilities until
they had paid for their treatment [62, 64, 65], medical
treatment was undertaken without consent [61] and in the
most extreme cases women had been subjected to forced
or coerced sterilisation [61, 63].
“They took me to the operation theatre the next day…
Before I was released, they gave me something to sign,
but I did not know what it was and they did not explain
it to me. Later I was given a medical release report
where it was written that I was sterilized.”([63], p.64)
There was widespread evidence of racial segregation of
maternity wards in Central and Eastern European regions,
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with Romani women reporting that the “Gypsy rooms”are
of poorer quality, not cleaned by the hospital staff, not
heated and contain fewer facilities including toilets [61–65].
“Gypsy room…It is like in a concentration camp there.”
([63], p.75)
Five of the sources of grey literature revealed reports
from Romani women about barriers to accessing care
which clearly resonate with the findings in the published
literature and confirm the line of argument synthesis
[36, 61, 62, 64, 65]. Barriers included lack of information
about the healthcare system [36], language barriers and
lack of provision of translation services [36], and finan-
cial barriers including the requirement of informal pay-
ments or lack of access to documentation or insurance
services that were prerequisites for care [36, 61, 62, 65].
“If you have money –you will have a baby, if you don’t
have money –you won’t have a baby.”([62], p.10)
The women also had to overcome poor local infrastruc-
ture, lack of public transport services and lack of willing-
ness of emergency services to attend the Roma settlements
in order to access care [61, 64]. Some women reported that
they did not access care as they were fearful of the poor
treatment they would experience, others avoided care as
they were fearful of the possible involvement of social care
services and the removal of their children [36].
Attitudes of health professionals caring for Romani women
The line of argument appears to be robust in terms
of women’s views and experiences. However, it does
not have sufficient explanatory power as the basis for
a potential future solution in the absence of substan-
tial data from the staff who are accused of discrimin-
atory behaviours. This section provides insight on this
aspect from the grey literature.
Six studies included interviews with health professionals
working with pregnant Romani women [36, 61–65]. Two
of these included data concerning the attitudes of health
professionals towards childbearing Romani women in
Spain, Hungary, Bulgaria and Slovakia, which consisted of
only negative and discriminatory views and no positive at-
titudes [61, 63].
These health professionals expressed racist remarks
concerning excessive birth rates amongst the Roma,
their abuse of the social welfare system, their unwilling-
ness to find decent work and irresponsibility about their
lives and the lives of their children [61, 63].
“They start having babies at the age of 12. It is
worthless to instruct them. They all know about
contraceptives but they have babies on purpose.
They know that they will have family allowance if
they have children.”([61], p.64)
“Gypsies make their living on irregular work, robbery
and the usage of the elders’pensions. Only 10% of
them have a decent job. They expect a lot but do very
little.”([61], p.65)
“Roma are poor…parents encourage children to steal,
and they teach them to hate white people.”([63], p.88)
One report found that medical professionals stated
that they believed that Romani women to be promiscu-
ous, that they leave the hospital early after delivery to re-
turn to their husbands to have sexual intercourse [63],
“Romani women…have intercourse all the time, even
while pregnant…have several partners, are
promiscuous, travel a lot, and bring diseases with
them from other countries.”([63], p.54)
“Mothers frequently leave the hospital without their
babies…because they have to go home to be available
for their husbands…for sex.”([63], p.88)
The health professionals also described Romani women
as irresponsible, neglectful of their health [63], less intelli-
gent than non-Roma women [61, 63], trouble-makers, de-
generate, less civilized and less human [63].
“Roma are dull-witted. There is no point to explain
to them anything because they will not understand
anyway, and it is intellectually exhausting to deal
with Romani patients.”([61], p.65)
“Romani women give birth quite easily. More
intelligent women give birth with more difficulty, it
is something in the brain.”([63], p.87)
“They neglect their health and health problems.”
([63], p.74)
Some health professionals considered the women to
be lacking maternal instincts, and that they intermarried
to purposely conceive disabled children to increase their
benefit allowance [61, 63].
“Roma leave [the hospital] early because of insufficient
maternal instincts. Even an animal doesn’t leave its
baby.”([63], p.88)
Health care staff in five reports confirmed the practice
of segregation of the maternity wards [60–64]. Within
these reports staff denied it was discriminatory, and
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justified this practice on the basis that it was done for
hygienic reasons [61], to spare the Romani women from
the discriminatory attitudes of the other non-Roma
women and their families [61, 62], that it was at the
request of the Romani women who wanted to be other
Romani women [61, 64, 65], was on account of the
Romani women being smokers [60] and was necessary
to respect the rights of the white non-Roma women
[61–63]. Some said that they were powerless to transfer
a Roma patient to a non-Roma ward as it was decided
by higher authority in the institutions [64].
“I’m very careful so Roma won’t feel discriminated
against, but Romani women want to be separated.”
([63], p.78)
They [Roma women] all want to be together in one
room, even if they had to share one bed in the Gypsy
room.”([63], p.78)
“White women do not want to be with primitive,
uneducated Romani women.”([63], p.78)
Some health professionals also justified denial of emer-
gency services to respond to calls from Romani women
on the basis that they were misusing the services be-
cause they were free or because it was more comfortable
and they didn’t have to wait for their appointment with
doctors [61, 63].
“Most Romani women are abusing ambulances by
saying they don’t have a car when they do…They lie to
bring the ambulance because then they are treated
immediately in the hospital.”([63], p.81)
Amending the line of argument synthesis
On the basis of these data, the line of argument synthe-
sis could be reframed as follows:
Romani women in Europe report that they experience
various forms of mistreatment within maternity care and
barriers to accessing maternity care. Some of these expe-
riences are discriminatory on the basis of multiple
grounds including Roma ethnicity, economic situation,
place of residence, and language. Maternity health care
staff accounts indicate that they are believe the Roma to
be criminal, unintelligent, abusers of the welfare and
health system, and bad mothers. In these accounts,
health professionals deny discriminatory treatment and
provide justification for segregation of maternity wards
and denial of emergency services. This underlying preju-
dice contributes to maternity health care for Romani
women that fails to meet standards of availability, ac-
ceptability, accessibility and quality. Awareness of rights
to care and a relational connection with health service
staff encounter may reduce ‘othering’for Romani women,
and increase their agency to improve the care they
receive.
Intervention to address maternity service provision to
Romani women
Given the data on poor reproductive outcomes amongst
Roma women, and the evidence of widespread discrim-
inatory attitudes it is surprising that there have been no
formal intervention studies designed to address these is-
sues. The single report located by the search strategy of
an intervention study in the grey literature is described
in this section, and compared with the emerging line of
argument synthesis above, to see how the underlying
programme theory for the intervention might fit with
the findings of this review, and how this could, poten-
tially, trigger improved outcomes.
The study is the Roma Health Mediation (RHM)
Programme in Romania [66]. This programme aimed
to improve the health status of pregnant and postpar-
tum Romani women, infants and children by imple-
menting health mediators from the local community.
The evaluation report does not include an analysis of
the philosophy of the RHM programme, attitudes of
staff or experiences of the women or mediators, or
the underlying mechanisms that were hypothesised to
result in an increase in access to services. However,
several features can be identified which would suggest
that the programme was designed to overcome dis-
crimination in the system. This included explicit in-
tentions for the Roma health mediators to provide
basic health education, raise awareness of the right to
free health insurance and assist Roma women to ob-
tain it, promote improved communication between
the Roma and healthcare practitioners, and to raise
awareness of the need for antenatal care and right to
access care.
The evaluation was a retrospective analysis of outcomes
before and after implementation of the programme. The
time period for the evaluation was 2002–2008, and the
number of localities included during this time increased
from 42 to 281. Post-implementation outcomes were sep-
arated into “up to 2 years after implementation”and
“more than 2 years after implementation”.Datasources
included the 2000–2008 Vital Statistics Natality (VSN)
files and the Vital Statistics Mortality (VSM) files, as well
as data from The Roma Health Mediators’registry and
the Roma Inclusion Barometer 2006.
The report found that the RHM programme resulted
in improved uptake of antenatal care by Romani women,
an increase in length of time breastfeeding, and a reduc-
tion in the local stillbirth rate and infant mortality rate.
There was no apparent effect on other infant outcomes
including low birthweight and preterm birth. Survey
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data generated alongside the intervention demonstrated
that Roma in the localities where the RHM programme
had been implemented for more than two years felt sig-
nificantly less discrimination in general and even less
discrimination in hospitals and medical facilities when
compared to Roma in localities where the programme
had not yet been implemented or had been implemented
very recently.
Discussion
Limitations
Considering only studies published in English may have
introduced language bias and excluded relevant studies
published in other languages [41]. This is particularly
relevant as the Romani community is located widely
across Europe, where studies and reports may be pub-
lished in local languages only. There were no published
intervention studies or quantitative surveys identified.
There were only a very small number of included pub-
lished qualitative studies, focussed on a few settings.
None of the included studies made any comparisons
with non-Roma women, so the findings may be common
to a wide range of groups that are discriminated against,
and not just to Roma women in particular. There were
limited data that considered the perspectives of health
providers, and the CERQual assessment of the review
findings resulted in medium and low confidence results
for all the findings
The authors of the grey literature often did not specify
the methodology that had been adopted, and quality as-
sessment could not be undertaken. Many of the sources
had been funded or commissioned by organisations keen
to promote Romani women’s rights and expose experi-
ences of poor care, and hence publication bias cannot be
excluded. There may be further sources of grey literature
that this search did not identify. An additional source of
relevant grey literature [67] was highlighted to us by an
expert in the field after we had completed the analysis.
This report, however, served as a further confirmatory
check on the findings from the review about Romani
women’s’experiences of maternity care in Europe.
The experiences of Romani women in a global context
The experiences of childbearing Romani women can be
contextualised by a wider body of global evidence concern-
ing disrespect, abuse and mistreatment of childbearing
women in healthcare facilities and poor maternity health-
care professional behaviours, which include; physical, sexual
and verbal abuse, stigma and discrimination, lack of com-
munication or information, neglect or abandonment of pa-
tients, refusal to deliver services, lack of informed consent,
lack of willingness to accommodate traditional practices,
breaches of confidentiality or privacy and detention in facil-
ities [17, 18, 68]. The experience of mistreatment in
maternity care is occurring across the world in low-middle-
and high-income settings, and disadvantaged or margina-
lised women are particularly affected [18].
The recent Lancet Series on Maternal Health identifies
that a global approach to equitable and quality maternal
health is needed, through the implementation of respect-
ful, evidence-based care for all childbearing women [69].
There has been growing international interest in the im-
plementation of a model of maternity health care that
addresses the mistreatment of childbearing women
across the world, by promoting positive staff attitudes
and behaviours [68]. To achieve this, it is crucial to em-
ploy context-specific solutions that address the under-
lying macro, meso and micro-level contributing factors.
Globally these include; lack of regulation or legal frame-
work for health rights, poor working conditions, heavy
workloads, long working hours, shortages of equipment,
cultural norms and provider beliefs [18, 68, 70]. Inter-
ventions have included the implementation of mecha-
nisms to ensure accountability to professional standards
and ethics at all levels of the health system and increas-
ing patient knowledge of their rights to an acceptable
standard of treatment by healthcare providers [68]. Strat-
egies have also included advocacy measures, addressing
laws, policies and local protocols, investment in health
facilities and salaries of health workers and education
and training of health workers, particularly related to
interpersonal and communication skills [70].
Anti-Gypsyism
Anti-Gypsyism, is a specific form of racism that is fo-
cussed on groups that are encompassed by the stigmatis-
ing term “Gypsy”, which includes Roma, Sinti, and
Travellers [71]. In common with other forms of racism, it
is undergirded by the construction of the “otherness”of
the “othered”group, in this case “Gypsies”, who are con-
sidered to share certain negative characteristics, that make
them inferior, and not worthy of equal treatment [71]. The
dehumanisation of those considered to be in the outgroup
involves the denial of uniquely human characteristics such
as intellectual ability, agency and emotional responsive-
ness, and results in the justification of discrimination [72].
The “othering”and dehumanisation of childbearing
Romani women was clearly demonstrated in this review
by comments made by health professionals about their na-
ture and intelligence, and the subsequent justification of
discriminatory behaviours including the segregation of
wards and denial of emergency services.
Strength of the line of argument synthesis as the basis for
afutureinterventionstudy
On the basis of the line of argument synthesis, it is
hypothesised that addressing maternity health profes-
sionals underlying prejudice and “othering”of the Roma
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in Europe is crucial to reduce discriminatory mistreat-
ment within maternity care and to improve Romani
women’s experience of care and access to care. This hy-
pothesis is in line with the European Commission
against Racism and Intolerance recommendations to
Council of Europe member states to combat anti-
Gypsyism in healthcare, which includes to provide train-
ing to health workers aimed at combating stereotypes,
prejudice and discrimination [73]. Whilst the Council of
Europe does not specify the types of training health
workers should receive to combat antigypsyism, there is
a need for the development of interventions that go be-
yond traditional healthcare diversity training or cultural
competency or cultural awareness training. These have
been widely criticised for increasing stereotyping and re-
inforcing essentialist racial identities [74, 75], thus ac-
centuating the “otherness”of cultural groups and failing
to address personal bias or prejudice [76].
When considering the RHM programme, further ana-
lysis in other areas of health have suggested that it im-
proves doctors’cultural competency and understanding of
the Roma community [77, 78] and that this then leads to
doctors being less likely to engage in discriminatory be-
haviour including the use of abusive language [77]. In the
context of the RHM programme as presented in this re-
view, it is not clear whether incorporating a cultural com-
petency component has impacted on its success positively
or negatively, nor is it clear if cultural competency was a
specific aim or a by-product of the programme. Further
analysis of the impact of the other elements of the
programme on the doctors’views of the “otherness”of the
Roma is warranted, including how the doctors’contact
with the Roma mediators impacts on their underlying
prejudice.
The line of argument synthesis findings indicate that
re-categorisation of Romani women by individual health
professionals, for example as “intelligent”or “relative of
a co-worker”, positively impacted on their experience in
different maternity care settings. This is in line with so-
cial psychology theory of multiple categorisation to over-
come dehumanisation, which suggests the simple
categorisation of in-group and out-group that leads in to
intergroup discrimination [79] can be overcome by the
use of multiple criteria for social categorisation [72].
Here, the availability of multiple criteria means that
judgements based on criteria are no longer meaningful
[72] and results in de-categorisation, the cognitive re-
construction of the target as an individual rather than a
member of an oppositional group [80], hence inhibiting
pre-existing stereotypes [81]. Although there are not yet
examples within healthcare settings, models that incorp-
orate multiple categorisation techniques, whereby partic-
ipants are instructed to think about the multiple
affiliations that characterise a target “outgroup”, rather
than single affiliations, have been demonstrated to re-
duce intergroup bias, stereotypes, prejudice, dehuman-
isation and linguistic discrimination [72, 81–86].
The development of interventions utilising multiple
categorisation techniques could enable health profes-
sionals working with Romani women in Europe to over-
come dehumanising stereotypes that were demonstrated
in the line of argument synthesis, and hence improve
the quality, availability, acceptability and accessibility of
maternity services to these women. The development of
such interventions to address underlying health profes-
sional beliefs and prejudice could be transferable both
geographically and contextually, and may benefit child-
bearing women who are experiencing discrimination and
poor experiences of maternity care on the basis of other
prohibited grounds.
Conclusion
This review has demonstrated that Romani women in
Europe experience various forms of discriminatory mis-
treatment within maternity care and barriers to accessing
maternity care. The testing of the line of argument synthe-
sis against grey literature findings confirmed the key ele-
ments of the synthesis, but also suggested that where
particular Romani women had characteristics that led
health care providers to see them as individuals rather than
as ‘other’, underlying prejudice and discrimination could be
overcome. Multiple categorisation techniques could be a vi-
able basis for future interventions in this group, and for
other marginalised population groups.
Additional files
Additional file 1: Search Strategy. (DOCX 13 kb)
Additional file 2: Excluded Research Studies. (DOCX 14 kb)
Abbreviations
AMSTAR: Assessing the methodological quality of systematic reviews;
CASP: Critical appraisal skills programme; CERQual: Confidence in the
evidence from reviews of qualitative research; EU: European Union;
UNFPA: United Nations Population Fund
Acknowledgements
Not applicable.
Funding
This research received no funding from any agency in the public,
commercial, or not-for-profit sectors.
Availability of data and materials
The data for this review is available as referenced in the text.
Authors’contributions
HW and SD both participated in the conception and design of this review,
data extraction and analysis, draft writing, and final approval of the
manuscript. HW was responsible for implementing the search strategy.
Competing interests
The authors declare that they have no competing interests.
Watson and Downe Reproductive Health (2017) 14:1 Page 14 of 16
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not required for this review.
Author details
1
Sheffield Teaching Hospitals NHS Foundation Trust, Jessop Wing, Tree Root
Walk, Sheffield S10 2SF, UK.
2
Research in Childbirth and Health (ReaCH)
group, University of Central Lancashire, Preston PR3 2LE, UK.
Received: 26 September 2016 Accepted: 7 December 2016
References
1. Human Rights Council. Report of the Special Rapporteur on adequate
housing as a component of the right to an adequate standard of living.
2010. http://www2.ohchr.org/english/bodies/hrcouncil/docs/16session/A-
HRC-16-42-Add2.pdf. Accessed 20 Aug 2016.
2. United Nations. Global Strategy 2.0. 2015. http://www.
everywomaneverychild.org/global-strategy-2. Accessed 18 Aug 2015.
3. United Nations General Assembly. Transforming our world: the 2030
Agenda for Sustainable Development A/70/L.1. 2015. http://www.un.org/ga/
search/view_doc.asp?symbol=A/70/L.1&Lang=E. Accessed 12 Jan 2016.
4. PMNCH. Operationalizing human rights in efforts to improve health. 2015.
http://www.who.int/pmnch/knowledge/publications/summaries/ks34/en/.
Accessed 25 Sept 2015.
5. Bustreo F, Hunt P. Women’s and Children’s Health: Evidence of Impact of
Human Rights. Geneva: World Health Organisation; 2013.
6. United Nations Population Fund. A Human Rights-Based Approach to
Programming. 2010. http://www.unfpa.org/resources/human-rights-based-
approach-programming. Accessed 13 Dec 2016.
7. Human Rights Council. Technical guidance on the application of a human-
rights based approach to the implementation of policies and programmes
to reduce preventable maternal morbidity and mortality. United Nations;
2012. http://www2.ohchr.org/english/issues/women/docs/A.HRC.21.22_en.
pdf. Accessed 21 Sept 2015.
8. Economic and Social Council. General Comment 20. 2009. http://www2.ohchr.
org/english/bodies/cescr/docs/E.C.12.GC.20.doc. Accessed 21 Sept 2015.
9. Altman A. Discrimination. The Stanford Encyclopedia of Philosophy. 2011
http://plato.stanford.edu/archives/spr2011/entries/discrimination/. Accessed
24 July 2015.
10. Jary D, Jary J. Collins Dictionary of Sociology. Glasgow: Harper Collins; 1995.
11. Krieger N. Discrimination and health inequities. Int J Health Serv. 2014;44(4):
643–710.
12. Gruskin S, Cottingham J, Martin Hilber A, Kismodi E, Lincetto O, Roseman
MJ. Using human rights to improve maternal and neonatal health: history,
connections and a proposed practical approach. Bull World Health Organ.
2008; doi:10.2471%2FBLT.07.050500.
13. Thompson JB. A human rights framework for midwifery care. J Midwifery
Women’s Health. 2004; doi:10.1016/j.jmwh.2003.12.011.
14. UN General Assembly. The right of everyone to the enjoyment of the
highest attainable standard of physical and mental health Sixty-first session
A/61/338. 2006. http://www.who.int/medicines/areas/human_rights/A61_
338.pdf. Accessed 17 July 2015.
15. Center for Reproductive Rights. From Risks to Rights. Realizing states ’
obligations to prevent and address maternal mortality. New York: Center
for Reproductive Righ ts; 2014.
16. Committee on the Elimination of Discrimination against Women. General
Comment No. 24. 1999. http://www.refworld.org/docid/453882a73.html.
Accessed 17 July 2015.
17. Bohren MA, Vogel JP, Hunter EC, Lutsiv O, Makh SK, Souza JP, et al. The
mistreatment of women during childbirth in health facilities globally: a
mixed-methods systematic review. PLoS Med. 2015; doi:10.1371/journal.
pmed.1001847.
18. Bowser D, Hill K. Exploring evidence for disrespect adn abuse in facility
based childbirth. Report of a landscape analysis. Washington: USAID
Traction Project; 2010.
19. Bird ST, Bogart LM, Delahanty DL. Health-related correlates of perceived
discrimination in HIV care. AIDS Patient Care STDS. 2004; doi:10.1089/
108729104322740884.
20. Blanchard J, Lurie N. R-E-S-P-E-C-T: Patient reports of disrespect in the
health care setting and its impact on care. J Fam Pract. 2004;53:721–30.
21. Trived i AN, Ayanian JZ. Perceived discrimination and the use of
preventative health services. J Gen Intern Med. 2006; doi:10.1111%2Fj.
1525-1497.2006.00413.x.
22. Kostadinova G. Minority rights as a normative framework for addressing
the situation of Roma in Europe. Oxford Dev Stud. 2011; doi:10.1080/
13600818.2011.570864.
23. Ravnbol CI. The human rigts of minority women: Romani women’s rights
from a Perspective on International Human Rights Law and Politics. Int J
Minor Group Rights. 2010; doi:10.1163/157181110X12595859744123.
24. European Union Agency for Fundamental Rights. The Fundamental Rights
Position of Roma and Travellers in the European Union. 2010. http://fra.
europa.eu/sites/default/files/fra_uploads/1012-roma-travellers-factsheet_en.
pdf. Accessed 26 June 2015.
25. Walsh C, Krieg B. Roma identity: contrasting constructions. Can Ethnic Stud.
2007; doi:10.1353/ces.0.0007.
26. European Commission. Roma Health Report. 2014. http://ec.europa.eu/
health/social_determinants/docs/2014_roma_health_report_en.pdf.
Accessed 25 June 2015.
27. Human Rights Council. Report of the Special Rapporteur on Minority Issues.
2015. http://www.ohchr.org/EN/Issues/Minorities/SRMinorities/Pages/
GlobalStudyonRomaworldwide.aspx. Accessed 30 Sept 2015.
28. Hancock I. The pariah syndrome. An account of gypsy slavery and
persecution. Ann Arbour: Karoma; 1987.
29. Martinez Guillem S. European identity: across which lines? Defining Europe
through public discourses on the Roma. J Int Intercult Commun. 2011; doi:
10.1080/17513057.2010.533788.
30. Human Rights Council. Report of the Special Rapporteur on contemporary
forms of racism, racial discrimination, xenophobia and related intolerance.
2011. www2.ohchr.org/english/bodies/hrcouncil/docs/17session/A-HRC-17-
40.pdf. Accessed 30 Sept 2015.
31. Human Rights Council. Report of the Special Rapporteur on the human
right to safe drinking water and sanitation. 2012. http://www.ohchr.org/
Documents/HRBodies/HRCouncil/RegularSession/Session21/A-HRC-21-42_
en.pdf. Accessed 30 Sept 2015.
32. FRA. Analysis of FRA Roma survey results by gender. 2013. http://fra.
europa.eu/sites/default/files/ep-request-roma-women.pdf. Accessed
1 Oct 2015.
33. Colombini M, Mayhew S. Rechel B. Sexual and reproductive health needs
and access to services for vulnerable groups in Eastern Europe and Central
Asia. UNFPA; 2011. http://eeca.unfpa.org/sites/default/files/pub-pdf/
vulnerable%20groups%20book_0.pdf. Accessed 25 Sept 2015.
34. Mihailov D. The Health Situation of Roma CommunitiesAnalysis of the data from
the UNDP/World Bank/EC Regional Roma Survey 2011. Bratislava: UNDP; 2012.
35. European Commission. Progress made by EU member states in Roma
Integration. European Commssion; 2015. http://ec.europa.eu/justice/
discrimination/files/roma_factsheet2015_en.pdf. Accessed 13 Dec 2016.
36. Pohjolainen L. Challenging Barries and Misconceptions. Roma Maternal
Health in Ireland. Pavee Point Traveller and Roma Centre. 2014. http://
www.paveepoint.ie/wp-content/uploads/2013/11/Roma-Maternal-Health-
in-Ireland.pdf. Accessed 15 May 2015.
37. Biddle C, Schafft KA. Axiology and anomaly in the practice of mixed
methods work: pragmatism, valuation, and the transformative paradigm.
J Mixed Methods Res. 2014; doi:10.1177/1558689814533157.
38. Mertens DM. Mixed methods and the politics of human research: the
transformative participatory perspective. In: Tashakkori A, Teddlie C, editors.
Handbook of Mixed Methods in social and behavioural research. Thousand
Oaks: Sage; 2003. p. 135–64.
39. Mertens DM, Bledsoe KL, Sullivan M, Wilson A. Utilization of Mixed Methods
for Transformative Purposes. In: Tashakkori A, Teddlie C, editors. SAGE
Handbook of Mixed Methods in Social and Behavioural Research. 2nd ed.
Thousand Oaks: Sage; 2010. p. 193–214.
40. Heyvaert M, Maes B, Onghena P. Mixed methods research synthesis: definition,
fraework and potential. Qual Quant. 2011; doi: 10.1007/s11135-011-9538-6.
41. CRD. Systematic Reviews. CRD’s guidance for undertaking reviews in
healthcare. York: CRD University of York; 2008.
42. Higgins J, Green S. Cochrane Handbook for systematic reviews of
interventions. 2015. http://handbook.cochrane.org/. Accessed 13 Dec 2016.
43. Joanna Briggs Institute. Methodology for JBI Mixed Methods Systematic
Reviews. Adelaide: Joanna Briggs Institute; 2014.
Watson and Downe Reproductive Health (2017) 14:1 Page 15 of 16
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
44. Sandelowski M, Voils CI, Barroso J. Defining and designing mixed research
synthesis studies. Res Sch. 2006;13:29–40.
45. CASP. CASP checklists. 2015. http://www.casp-uk.net/#!checklists/cb36.
Accessed 5 May 2015.
46. Greenhalgh T, Robert G, Bate P, Macfarlane F, Kyriakidou O. Diffusion of
Innovations in Helath Service Organisations: A Systematic Literature Review.
Oxford: Blackwell Publishing Ltd; 2005.
47. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, et al.
Development of AMSTAR: a measurement tool to assess the
methodological quality of systematic reviews. BMC Med Res Methodol.
2007;doi:10.1186/1471-2288-7-10.
48. Walsh D, Downe S. Apprasing the quality of qualitative research. Midwifery.
2006; doi:10.1016/j.midw.2005.05.004.
49. Downe S, Simpson L, Trafford K. Expert intrapartum maternity care: a meta
synthesis. J Adv Nurs. 2007; doi:10.1111/j.1365-2648.2006.04079.x.
50. Shaw J, Downe S, Kingdon C. Systematic mixed-methods review of
interventions, outcomes and experiences for imprisoned pregnant women.
J Adv Nurs. 2015; doi:10.1111/jan.12605.
51. Bryman A, Becker S, Sempik J. Quality criteria for quantitative, qualitative
and mixed methods research: a view from social policy. Int J Soc Res
Methodol. 2008; doi:10.1080/13645570701401644.
52. Lincoln YS, Guba EG. Naturalistic Inquiry. Newbury Park: Sage Publications; 1985.
53. Finlayson K, Downe S. Why do women not use antenatal services in low or
middle-income countries? A meta-synthesis of qualitative studies. PLoS
Med. 2013; doi:10.1371/journal.pmed.1001373.
54. Walsh D, Downe S. Meta-syntheis method for qualiative research: a
literature review. J Adv Nurs. 2005;50:204–11.
55. Noblit GW, Hare RD. Meta-ethnography: synthesizing qualitative studies.
Newbury Park: Sage; 1988.
56. Jensen L, Allen M. A synthesis of qualitative research on wellness-illness.
Qual Health Res. 1994; doi:10.1177/104973239400400402.
57. CERQual. CERQual - Confidence in the Evidence from Reviews of Qualitative
Research. 2015. http://www.cerqual.org/what-is-the-grade-cerqual-
approach2/. Accessed 13 Dec 2016.
58. Janevic T, Sripad P, Bradley E, Dim itrievska V. “There’snokindof
respect here”A qualitative study of racism and access to maternal
health care among Romani women in the Balkans. Int J Equity Health.
2011; doi:10.1186/1475-9276-10-53.
59. Colombini M, Rechel B, Mayhew SH. Access of Roma to sexual and
reproductive health services: qualitative findings from Albania, Bulgaria
and Macedonia. Global Public Health. 2012; doi:10.1080/17441692.2011.
641990.
60. Condon L, Salmon D. “You likes your way, we got our own way”: Gypsies
and traveller’s views on infant feeding and health professional support.
Health Expect. 2014; doi:10.1111/hex.12214.
61. European Roma Rights Centre. Ambulance not on the way: the disgrace of
health care for Roma in Europe.Budapest: ERRC. 2006. http://www.errc.org/
cms/upload/media/01/E6/m000001E6.pdf. Accessed 20 May 2015.
62. Iszak R. “Gypsy Rooms”and Other Discriminatory Treatment Against Romani
Women in Hungarian Hospitals. Roma Rights Quarterly. 2004;3-4:7–11.
63. Centre for Reproductive Rights. Forced Sterilisation and Other Assaults on
Roma Reproductive Freedom in Slovakia. Cent Reprod Rights. 2003. https://
www.reproductiverights.org/document/body-and-soul-forced-sterilization-
and-other-assaults-on-roma-reproductive-freedom. Accessed 20 May 2015.
64. European Monitoring Centre on Racism and Xenophobia. Breaking the
Barriers - Romani women and access to public health care.Office Official
Publ Eur Commun. 2003. http://fra.europa.eu/sites/default/files/fra_uploads/
180-ROMA-HC-EN.pdf. Accessed 20 May 2015.
65. Zoon I. On the Margins: Roma and Public Services in Romania,
Bulgaria and Macedonia. Open Society Institute; 2001. https://www.
opensocietyfoundations.org/sites/default/files/romania_bulgaria_
macedonia.pdf. Accessed 20 May 2015.
66. Benjenariu S, Mitrut A. Bridging the Gap for Roma Women: The Effects of a
Health Mediation Program on Roma Prenatal Care and Child Health.
University of Gothenburg, School of Business, Economics and Law; 2014.
http://economics.handels.gu.se/digitalAssets/1508/1508395_roma_health_
mediators_dec_2014.pdf. Accessed 5 Sept 2015.
67. Ravnbol CI, Grover D. Women Motherhood Early Childhood Development.
Exploring the question of how poor Roma women’s status and situation
influences children’s survival, growth and development. 2011. https://www.
unicef.org/ceecis/Women_Motherhood-07-21-2011-final-WEB.pdf. Accessed
28 Nov 2016.
68. Mannava P, Durrant K, Fisher J, Chersich M, Luchters S. Attitudes and
behaviours of maternal health care providers in interactions with clients: a
systematic review. Globalisation Health. 2015; doi:10.1186/s12992-015-0117-9.
69. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comandé D, et al.
Beyond too little, too late and too much, too soon: a pathway towards
evidence-based, respectful maternity care worldwide. Lancet. 2016; doi:10.
1016/S0140-6736(16)31472-6.
70. Reis V, Deller B, Carr C, Smith J. Respectful maternity care - country
experiences.USAID. 2012. https://www.k4health.org/sites/default/files/
RMC%20Survey%20Report_0.pdf. Accessed 12 May 2015.
71. Alliance agains Antigypsyism. Antigypsyism - a reference paper. 2016. www.
antigypsyism.eu. Accessed 5 Sept 2016.
72. Prati F, Crisp R, Meleady R, Rubini M. Humanizing outgroups through
multiple categorization: the roles of individuation and threat. Pers Soc
Psychol Bull. 2016; doi:10.1177/0146167216636624.
73. European Commission Against Racism and Intolerance. ECRI General Policy
Recommendation No.13 on combating anti-gypsyism and discrimination
against Roma. Eur Commission Racism Intolerance. 2011. https://www.coe.
int/t/dghl/monitoring/ecri/activities/GPR/EN/Recommendation_N13/e-
RPG%2013%20-%20A4.pdf . Accessed 12 May 2015.
74. Downing R, Kowal E. A postcolonial analysis of Indigenous cultural training for
health workers. Health Sociol Rev. 2011; http://dx.doi.org/10.5172/hesr.2011.20.1.5.
75. Truong M, Paradies Y, Priest N. Interventions to improve cultural
competency in healthcare: a sytematic review of reviews. BMC Health Serv
Res. 2014; doi:10.1186%2F1472-6963-14-99.
76. Kowal E, Franklin H, Paradies Y. Reflexive antiracism: a novel approach to
diversity training. Ethnicities. 2013; doi:10.1177/1468796812472885.
77. Open Society Foundation. Roma Health Mediators: Successes and
Challenges. Open Society Foundation; 2011. https://www.
opensocietyfoundations.org/sites/default/files/roma-health-mediators-
20111022.pdf. Accessed 20 Sept 2015.
78. Roman G, Gramma R, Enache A, Parvu A, Moisa SM, Dumitras S, Loan B.
The health mediators-qualified interpreters contributing to health care
quality among Romanian Roma patients. Med Health Care Philos. 2013;
doi:10.1007/s11019-013-9467-3.
79. Tajfel H, Billig MG, Bundy RP, Flament C. Social categorization and
intergroup behaviour. Eur J Soc Psychol. 1971;1:149–78.
80. Crisp RJ, Hewstone M, Rubin M. Does multiple categorization reduce
intergroup bias? Pers Soc Psychol Bull. 2001; doi: 10.1177/0146167201271007.
81. Prati F, Crisp R, Pratto F, Rubini M. Encouraging majority support for
immigrant access to health services: Mutiple categorization and social
identity complexity as antecedants of health equality. Group Processes
Intergroup Relat. 2016; doi:10.1177/1368430216629814.
82. Hall NR, Crisp RJ. Considering multiple criteria for social categorization can
reduce intergroup bias. Pers Soc Psychol Bull. 2005; doi:10.1177/
0146167205276084.
83. Albarello F, Rubini M. Reducing dehumanization outcomes towards Blacks:
the role of multiple categorization and of human identity. Eur J Soc Psychol.
2012; doi:10.1002/ejsp.1902.
84. Prati F, Vasiljevic M, Crisp JR, Rubini M. Some extended psychological
benefits of challenging social stereotypes: Decreased dehumanization and a
reduced reliance on heuristic thinking. Group Processes Intergroup Relat.
2015; doi:10.1177/1368430214567762.
85. Prati F, Menegatti M, Rubini M. Reducing linguistic outgroup
derogation: A matter of multiple categorization and intergroup contact.
J Lang Soc Psychol. 2015; doi:10.1177/0261927X14567777.
86. Rubini M, Moscatelli S, Palmonari A. Increasing group entitativity linguistic
intergroup discrimination in the minimal group paradigm. Group Processes
Intergroup Relat. 2007; doi:10.1177/1368430207075156.
Watson and Downe Reproductive Health (2017) 14:1 Page 16 of 16
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