The number of foreign residents in South Korea (Korea) has increased: approximately 1.9 million foreigners (3.7% of the Korean population) were living in Korea during 2015¹⁾. Most of these people are laborers, marriage-based immigrants, or students; however, the number of refugees and asylum seekers is rising steadily. Specifically, following the enactment of the Refugee Act in 2013, the annual number of asylum seekers increased from 1,143 in 2012 to 5,711 in 2015. In Korea, over the last two decades, 15,250 people have applied for refugee status—16% of these are female and 94.1% are aged 18–59 years. Among 8,001 applicants whose status was determined, only 576 (7.2%) received the status of refugee²⁾.

The Korean government has worked to improve the immigrant support system; however, that system retains numerous limitations compared with those implemented in other developed countries; accordingly, asylum seekers' quality of life and right to health are poor^3,4). Refugees typically experience malnutrition, difficulty obtaining clean water, trauma, and exposure to infectious diseases in their home countries and during the migration process due to limited or nonexistent healthcare; additionally, they often experience modification of family roles and the separation of family members. After migration, refugees may face barriers to healthcare access and often hold a low socioeconomic position in their new countries^5,6,7,8,9). Refugees experience more physical and mental health problems than the native population due to these pre- and postmigration social determinants^10,11). Specifically, refugee women of childbearing age may face problems in perinatal health and child-rearing practices⁵⁾.

Several studies have examined maternal and child health among nonrefugee immigrants in Korea; most of the examined immigrants were marriage-based and had arrived from China or southeast Asia¹²⁾. Regarding maternal health, this population received less perinatal care, typically held poor nutritional status, and experienced language challenges during using health services¹³⁾. Additionally, this population faces higher risks of adverse birth outcomes compared to native women (e.g., preterm birth, low birth weight, small for gestational age)¹⁴⁾. However, few studies have examined African refugee women and children's health needs in the perinatal and infant period.

In this context, the present study aimed to identify the health needs and barriers to health services facing African refugee families regarding pregnancy, childbirth, and infant care. Additionally, we aimed to describe the strategies these women used to cope with these obstacles. To achieve these aims, we conducted six qualitative interviews with African refugee mothers of young children living in Korea.

Participants were 6 African refugee mothers aged 25–39 years who had delivered at least one of their children in Korea within 5 years of recruitment (Table 1). The participants collectively had 12 children, 10 of whom were born in Korea at full-term. Two women came from the Republic of Liberia, 2 from the Republic of Cote d'Ivoire, one from the Republic of Mali, and one from Ethiopia. Four participants had been denied official refugee status by the Korean Government but were approved as humanitarian status holders (G-1-6 visa). Two women were legally approved as refugees (F-2-4 visa) but one of them was undocumented at the time of childbirth (Table 2). Four were married and two were single. Participants' education ranged from no schooling completed to high school graduation. Four participants reported a household monthly income under US $1,000 and mentioned that their income varied widely depending on their husband's employment circumstances. Three participants described themselves as Christian and two as Muslim. All but one reported their Korean language proficiency as “not good.”

Previous research has examined health-related challenges facing Asian immigrants, but has not examined the healthcare experiences and unmet needs of African immigrants in Korea^14,15). This study therefore examined African refugee women's unmet needs regarding pregnancy, birth, and childrearing and these women's coping strategies. Interviews with this study's participants suggest the presence of the following key barriers to equitable access to maternal child healthcare:

Unstable social identity, poor economic status, and difficulty obtaining health insurance

Poverty affects immigrants' ability to access necessary healthcare services¹⁶⁾. Socioeconomic deprivation is related to adverse health outcomes^16,17). Similarly, our participants described receiving inadequate healthcare because they did not have national health insurance or were experiencing financial hardship or due to healthcare providers' reluctance. In Korea, 98.2% of the domestic population has national health insurance, enabling those people to access most essential healthcare services with little financial stress. This coverage has been progressively expanded¹⁸⁾; however, asylum seekers in Korea still have limited access to national health insurance coverage. If asylum seekers are not granted official refugee status (i.e., the F-2-4 visa), they have few opportunities to subscribe to national health insurance, despite their status as humanitarian immigrants (i.e., the G-1-6 visa). Rarely, G1 visa holders may obtain insurance if they are regularly employed by a merciful company¹⁹⁾. In addition, the Korean government provides a subrogation payment system for assistance in the event of a medical emergency; this is also available to asylum seekers and undocumented immigrants. However, neither hospitals nor refugees are well-informed regarding this support system and hospitals tend to be reluctant to use it due to its administrative complexity. In consequence, one participant in this study was not able to obtain proper care in an emergency situation and another who had no foreign registration number was rejected by a hospital administrator. Health insurance critically determines this vulnerable population's ability to meet their need for healthcare; this point's importance cannot be overemphasized. Asylum seekers should have the right to take up national health insurance, regardless of their legal status. Further, considering the relatively low rate of health literacy among immigrants, healthcare facilities and immigration officers should provide adequate information about insurance and emergency support systems. Simplification of hospital administration is also necessary to facilitate healthcare access for asylum seekers.

Communication problems are among the most important factors affecting immigrants and refugees' health²⁰⁾. Our participants described difficulties obtaining information, particularly during the perinatal period and their child's infancy. They experienced separation from family members and lacked the social support that would have facilitated their access to health information. Pregnancy may be refugee mothers' first opportunity to contact healthcare systems. This opportunity is highly valuable and this period may affect the lifelong health of children of immigrant mothers; therefore, it is critical that accurate health information is provided to immigrant mothers. Multilingual booklets about vaccination exist; however, only a few healthcare institutions in Korea possess these, resulting in a negligible benefit to refugees. More multilingual materials providing health and childcare information should be produced; additionally, it is important to find means of facilitating refugees' access to these materials. Some local governments run public translation services in several languages²¹⁾. This study's participants experienced communication problems during treatment and were unaware of these services. Connecting refugees with these systems and hospitals may importantly diminish language-related barriers impeding refugees' access to adequate healthcare.

Cultural differences are among the most important barriers to adequate healthcare for pregnant or childbearing Muslim women^22,23,24). Previous studies have recommended that healthcare professionals should offer considerate concern during physical examination and offer information about the location of worship areas, food choices, circumcision, and other medical information necessary to religious requirements²²⁾. Similarly, our participants reported experiencing the effects of cultural differences regarding symptom management during pregnancy and delivery. Development of a healthcare system that is able to respond to a diverse range of patients is important to managing the health of minority populations. Care providers who are more likely to encounter patients from minority groups should be informed regarding particular cultural, religious or ethnic requirements in order to help them provide culturally competent care^22,25).

In this study, weak social support also impeded participants' access to healthcare in the early stages of migration. Participants encountered a wider range of problems with language, cultural, and health system differences soon after their arrival than at later stages of their settlement. Additionally, the lack of psychosocial resources negatively affects birth outcomes^26,27). This study's participants reported gradually developing social links following settlement; this emerged as a key coping strategy. Therefore, policies or interventions should aim to provide support in the early stages following arrival. The Korean government presently administers 217 multicultural family support centers; these typically focus on marriage-based immigrants from Asian countries²⁸⁾. However, with additional governmental support, these centers might also focus on supporting African mothers. Further, the government might approach refugee mothers through churches and Non-Governmental Organizations, which importantly facilitate the development of social support networks for refugee mothers. This public-private partnership would be likely to enrich the psychosocial resources available to refugees.

This study has the following limitations. First, the sample was small and did not include currently undocumented refugees. All the undocumented refugees we approached declined to participate in the study due to concerns of identification exposure, although one undocumented refugee participated in the preinterview without providing demographic information. Additionally, one participant was of undocumented status when she gave birth; her experiences of that period were discussed in her interview. Second, interviews were conducted in participants' second language because we were unable to find proper translators for African local languages; this may have limited the range of participants' expression.

This is the first research to examine the healthcare experiences of African refugee women and children in Korea. Critically, the participants described difficulties accessing necessary maternal childcare due to socioeconomic deprivation and unavailable national health insurance. Participants who were able to access healthcare described a lack of linguistically appropriate information and experiences of severe and detrimental cultural isolation. Regarding refugee mothers, reducing negative health determinants in the perinatal and early childhood period is vital to securing children's continued health into adulthood and improving and protecting mothers' health. As refugees continue to come to Korea, the government should address these challenges by expanding national health insurance coverage to refugees, providing additional education to healthcare facilities, and disseminating proper information to both healthcare providers and refugees.