1 INTRODUCTION

The health of the Roma is worse and life expectancy is shorter compared to the majority population in European union, while Roma women have even poorer health than Roma men (1). Roma women are exposed to double discrimination – ethnic and gender – which significantly affects their position in the primary Roma community as well as in society at large, perpetuating disadvantage and lack of empowerment (2, 3). In addition to unfavourable socioeconomic determinants, the health of Roma women is largely influenced by cultural and social values in the Roma community as well as by the unhealthy lifestyle. Some conservative Roma families still see the role of women strictly as home keepers and mothers, which preserves behavioural patterns from the past, such as underage marriages as well as underage birth and dropping out of regular education. The consequence is the interruption of girls' personal development and the setting in advance the long-term path to social marginalization and multifaceted disadvantage of women (2, 3, 4, 5). Thus, the sexual and reproductive behaviour and health of Roma women represents a crossroads of influences of various factors, which on the one hand are a result of inequality and insufficient empowerment of women, and on the other hand reflects the status of their health.

Research from other European countries showed that Roma women have a significantly lower age at first pregnancy, a higher number of pregnancies and abortions, and less frequent use of prenatal services. The presence of risky behaviours, such as smoking and illicit substance use, were more present than in non-Roma women (7, 8, 9). The health of their new-borns is closely related to the reproductive health of Roma women. Roma women are more likely to give birth prematurely and their new-borns are more likely to have a low birth weight (10, 11).

The accumulation of socioeconomic disadvantages in connection with low health literacy and general literacy as well as unhealthy lifestyles may contribute to the explanation of the poorer health and higher infant mortality in Roma children (12). The exposure to discrimination within the health sector, as well as financial and geographical barriers in access to health services are identified as factors that lead to lower use of preventive services (13, 14). Roma in Slovenia live mainly in the two regions – in Pomurje region and JugovzhoSouth-eastern region. In addition to these, in the last three decades there has been a large influx of Roma immigrants to larger urban centres, especially to Maribor, Ljubljana, Velenje, Celje and Jesenice. The previous research showed, that the demographic pyramid of the age structure of the Roma population, made based on the Geodetic Institute of Slovenia (GIS) data, showed that the Roma in Slovenia, as in other European countries, were a distinctly young population. The approximate average age of a member of the Roma community in Slovenia was 27.9 years, while Statistical Office of Slovenia indicates 42.7 years for the general population (Figure 1). The educational structure of the Roma community in Slovenia was low – on average, more than 65% of Roma did not attain primary school education. The economic status of the Roma was poor, as they represent one of the hardest-to-employ groups in Slovenia – just under 8% of employed Roma were regularly employed, and more than 42% are officially unemployed (15, 16, 17).

Roma communities of different Slovenian regions differ from each other in socioeconomic engagement with broader community and in health outcomes, namely the Roma in north-eastern Pomurje region are in significantly better health than in south-eastern Slovenia. The social impact of the surrounding local communities on Roma health has not been sufficiently studied (18, 19).

Statistically significant regional differences in the health indicators of Roma women may be the result of Roma historical background, better integration into the local environment and general society and better living conditions in Roma settlements in north east (18).

The data on the use of preventive healthcare services aimed at strengthening the reproductive health of Roma women in Slovenia are scarce. Domestic researchers found that just under 70% of Roma women, aged 15–64 years, have a personal gynaecologist and 75% have supplementary health insurance. In addition, they visited a gynaecologist mainly during pregnancy and less often after childbirth (19, 20).

Figure 1: Demographic structure of the Roma and general population in Slovenia, 2014.¹

The purpose of this research was to determine for the first time in Slovenia whether there is a significant difference in selected health indicators between women living in Roma settlements and women of the majority Slovenian population and to present the findings on selected indicators of antenatal and perinatal health by using existing national database.

2 METHODS

We conducted a cross-sectional population based survey. The research included the analysis of data from the national health statistical database of the Perinatal Information System of the Republic of Slovenia (hereinafter PIS RS) for the period 2012–2014. PIS RS is a national health register that contains yearly data on all pregnancies, labours and births in the country. All live births, regardless of birth weight, and stillbirths with a birth weight of 500 grams or more OR a gestational age of 22 weeks or more are reported and included to the PIS RS. All Slovenian hospitals and certified midwives who assist in home births report data to PIS RS (15).

Since PIS RS originally does not include data on mothers´ ethnicity, we identified Roma women by linking data from Geodetic Institute of Slovenia to PIS RS. Geodetic Institute of Slovenia in its survey form 2013 identified 74 Roma settlements scattered across 31 municipalities in five Slovenian regions (Pomurska, Savinjska, Spodnjeposavska, Osrednjeslovenska and Jugovzhodna Slovenija). The observed population was persons who were registered as residents of selected settlements, determined based on available data as the settlements occupied by members of the Roma ethnic community in Slovenia. GIS prepared a list of the house numbers at which these persons were registered. The analysed areas contained 917 house numbers and included the persons registered at these house numbers. Through the identifiers of these persons, data from the national database, managed by the NIJZ, were linked. The data was subsequently anonymized. The target population included persons aged 0 to 89 years who have permanent residence in five geographic regions: Pomurska, Savinjska, Spodnjeposavska, Osrednjeslovenska and Jugovzhodna Slovenia. The observed population of Roma registered in identified Roma settlements amounted to 6,456 persons. Women with permanent residence in each of the Roma settlements were defined as Roma women and all other women as non-Roma women (18).

The variables included in the analysis represent mothers’ socioeconomic characteristics, lifestyle, use of preventive healthcare services and pregnancy outcomes:

• Maternal age per 5 years intervals.

• Level of maternal educational attainment divided in five categories: tertiary, secondary, vocational, primary or less, unknown.

• Parity with three categories: first birth, second birth, third birth or more.

• Smoking during pregnancy with two categories: no, yes.

• Gestational week of first preventive examination with four categories: 12 weeks or less, 13–23 weeks, 24 weeks or more, without preventive examinations in pregnancy.

• Attendance to the prenatal classes for future parents (only first-time mothers) with two categories: yes, no.

• The mode of labour onset with three categories: spontaneous, induced, elective Caesarean section.

• The condition of the new-born with three categories: live birth, stillbirth (mors fetus in utero), stillbirth (died in labour).

In addition, for live births we also compared:

• Prematurity divided in two categories: no (37 gestational weeks or more), yes (less than 37 gestational weeks).

• Low birth weight with two categories: no (2,500 grams or more), yes (less than 2,500 grams).

• Breastfeeding in maternity hospital was categorized with four categories: yes – exclusive, yes – partial, no, unknown.

We compared the data of subgroup of women living in registered Roma settlements with all other women registered in PIS RS.

Data analysis included the calculation and comparison of the gross incidence rate for each variable in both observed groups. The statistical characteristic of the differences in the incidence rates of the variables between the observed groups was verified using a chi-square test and Fisher Exact test. Two tailed p-value <0.05 was considered statistically significant.

Data processing took place in the SPSS 21 program. MS-Office Excel was used to create graphical and tabular displays.

3 RESULTS

62,422 women delivered babies in Slovenia in the 2012–2014 period. Among them, there were 424 (0.7%) identified as Roma women and 61,998 (99.3%) as non-Roma women. 63,521 children were born in the same period, 429 to Roma women. 63,293 children were live births and among them there were 424 live born Roma children. The results also contain data on stillbirths, which are otherwise quite small and are excluded from the analysis.

The youngest Roma women in the observed group were 14 years old, and the oldest 44 years old. The average age of women giving birth was almost five years younger for Roma women (24.6 years) than for women in the general population (29.1 years).

The total fertility rate, which shows the average number of children per woman of childbearing age, was on average 2.8 for Roma, while for non-Roma women it was Slovenia 1.6.

The comparison of selected indicators for Roma and non-Roma population is presented in Figures 2, 3, 4 and in Tables 1 and 2.

Figure 2: Percentage of births by age group, Roma and non-Roma women, 2012–2014.

Figure 3: Percentage of births by maternal education, Roma and non-Roma women, 2012–2014

Figure 4: Percentage of birth by parity, Roma and non-Roma women, 2012–2014.

Tabela 1: Selected perinatal health and healthcare indicators of Roma and non-Roma women, Slovenia, 2012–2014.

Tabela 2: Selected health variables of Roma and non-Roma new-borns born in the 2012–2014 period.

The difference in the level of educational attainment between the observed groups is extremely large. Roma women were significantly less educated than the non-Roma. There were almost 12 times more Roma women with primary or lower educational attainment than non-Roma women. Less than 1% of Roma women had the tertiary educational attainment compared to 45% of non-Roma.

Roma women smoked almost 6 times more often during pregnancy than non-Roma women.

Roma women came to the first prenatal examination four times more often after the 12th gestation week and 12 times more often only after the 24th gestation week, compared to non-Roma women. They were also 19 times more likely to be completely without prenatal examinations during pregnancy than the majority women were.

Roma women very rarely attended prenatal classes for future parents. The risk of not attending the course was five times higher in the population of primiparous Roma women compared to primiparous women of the majority population.

Roma children had a 59% higher risk of premature birth and a 2.7 times higher risk of low birth weight than other children did.

Roma children were almost five times more likely not breastfed at all in the maternity hospital. There is also a difference in the other two categories, namely, there are fewer Roma children who are partially or exclusively breastfed.

4 DISCUSSION

The results of our study are consistent with the results of research elsewhere in Europe and confirm poorer health outcomes for Roma women related to childbirth and for Roma new-borns compared to the majority population.

Roma women have higher number of children and the younger age at birth. These may be result of several factors: ethnic tradition, lack of health literacy regarding family planning, or lack of empowerment of Roma women to make independent decisions about pregnancy control (18).

Slovenian Roma women have significantly lower levels of educational attainment than the rest of female population. Past research have already shown an association between educational attainment and a less healthy lifestyle during pregnancy, poorer use of health services and poorer perinatal outcomes. High maternal education has protective effect against low birth weight compared to low maternal education (21, 22, 23, 24). However, the differences in these outcomes between Roma and non-Roma women are greater compared to differences between the lowest and highest educated non-Roma women, which indicates that in addition to low level of literacy and poor socioeconomic status, other unfavourable factors are also present in Roma women (25, 26). Health literacy depends on the position on the social scale, educational level attainment, the influence of culture and the environment. The low level of health literacy contributes to less healthy choices, risky behaviours, poorer health, and hospitalizations (24, 25, 27).

Our study also shows that almost two thirds of Roma women smoke during pregnancy, which is significantly more than 11% of smokers among other pregnant women. Smoking was a widespread habit among Roma men in Slovenia contributing significantly to the exposure of Roma women and children to passive smoking, that is an important risk factor not only for the health of pregnant women but also for foetuses (28). The Roma themselves stated various reasons for this phenomenon, such as the old Roma tradition, shortening boredom, smoking decreases the feeling of hunger, stress relief, smoking helps against worms, community affiliation (18). Higher prevalence of unhealthy lifestyle, such as insufficient daily physical activity and smoking among Roma women compared to non-Roma was found elsewhere too (8, 10, 11, 24).

Previous research showed that Roma women in Slovenia insufficiently use preventive healthcare services, which are available free of charge and are a part of the programmed approach to strengthening health of pregnant women. A study also showed the need to consider the cultural characteristics of Roma women in using healthcare services, including improving communication and reducing discrimination, and respecting the specific needs of Roma women concerning reproductive health (20, 28, 30).

Our study shows that the first visit by gynaecologist in pregnancy was performed four times more often after the 12th week of pregnancy than in the rest of the population, and 5% of pregnant Roma women did not undergo a preventive examination at all. The reasons for this could lay in distrust in healthcare professionals, fear and language barriers (18, 20). A literature review has shown that discrimination against pregnant Roma women, which occurs in some parts of Europe, and racism in family planning services, are among the factors hindering access to antenatal services (2, 4, 13, 14).

Current results confirm the higher frequency of third and further births in Roma compared to non-Roma. The previous study showed that the birth rate among Roma women in Slovenia is higher than among non-Roma (18). Furthermore, the occurrence of spontaneous labour onset is more common in Roma women, while caesarean delivery is less common. This may be because there are more multiparous women among them.

The risk of premature birth is 59% higher in the sample of Roma children. It is similar with the birth weight of children, with 2.7 times higher risk of low birth weight. Higher frequency of low birth weight and premature birth of Roma children were observed in other European countries as well (10, 11, 12, 21). Breastfeeding is the most suitable way of feeding a new-born.

There is a higher risk of not being breastfed in hospital among Roma new-borns, although breastfeeding is actively promoted in Slovenian hospitals. The Slovenian survey from 2018 also showed that breastfeeding of babies decreases by young Roma women, as according to their opinion, the purchase of adapted dairy products is a sign of good economic status of the family (18). Noteworthy, breastfeeding among Roma in west Balkan countries was more widespread than among non-Roma (29).

Roma women very rarely attended prenatal classes for future parents. The risk of not attending the course was five times higher in the population of primiparous Roma women compared to primiparous women of the majority population. In other countries, the use of preventive antenatal services is lower among Roma than among other women also (24, 30).

There are several good practice examples identified by the European Commission targeting improvement of Roma health care. The examples of good practice addressed, among others, the prejudices of health professionals towards Roma, development of healthy communities, and promotion of vaccination and communal hygiene (29, 30, 31, 32).

Roma women formally enjoy the same rights in the field of basic health care as other citizens, but the results of the study showed that Roma women in Slovenia have worse indicators of perinatal health than women of the majority population. The influence of Roma culture and customs on the health of Roma in Pomurje region has already been described (33). We would like to stress, that belonging to the Roma ethnic community by itself does not affect health, but socioeconomic determinants of health, such as low education and life in poverty have increasingly important role. Many factors, such as geographical remoteness of Roma settlements, difficulties related to transport to health facilities, absence of health insurance, insufficient understanding of the healthcare system and cultural or lingual misunderstandings with healthcare professionals contributed to the fact, that Roma are often reserved to general society and to the use of health system services (7, 20, 36). Although the attitudes of Roma toward healthcare system improved during last decades, for example the relationship between Roma and younger medical doctors is described by Roma as better (33), the results of the past and present research support the need for programmes adapted to the specificities of the Roma ethnic group in Slovenia (25, 31).

The results of past research testify to geographical differences in health between Roma living in the southeast compared to Roma living in the northeast of Slovenia in favour of better health indicators in the latter. The reasons for this phenomenon are partly explained by better integration into society due to historic reasons. In addition, kindergartens, which have been systematically including Roma children in preschool education for 60 years, certainly contribute to the early integration of Roma children in north-eastern Slovenia (18, 29, 40, 41). The infrastructure in Roma settlements in the northeast is generally more developed than in the southeast of the country. However, in recent years, the municipalities in the southeast have gradually regulated the basic infrastructure and property relations in Roma settlements, which are prerequisites for health and equal inclusion in society. The above-mentioned municipalities perceived an urgent need for comprehensive intersectoral coordination and action from the local to the national level. The holistic and multisectoral approach toward the improvement of living conditions and health of Roma population in Slovenia has been determined by the National programme of measures for Roma (42).

4.1 Strengths and limitations

The purpose of our cross sectional population based study was to describe the characteristics of two populations and to determine whether there are differences between them, rather than to determine the influence of certain factors and their interactions. Our research is the first of its kind in Slovenia and will serve as a starting point for further in-depth research.

To our best knowledge, the study includes the largest sample of female inhabitants of Roma settlement in the single research in Slovenia, supporting the importance of public health problem of Roma health.

The exact number of Roma in Slovenia is unknown. There is a significant difference between official and unofficial data (38). The data used in the research encompassed the inhabitants who live more or less permanently in Roma settlements. Roma families who live in the larger cities of Slovenia and are mixed among the majority population are not included in the analysis due to their large dispersion and the legal restrictions of recording inhabitants regarding ethnicity. Since the data on the residence of persons is tied to the date of 1/1/2015, the assessment of the indicators is probably less reliable in the case of more groups of Roma residents, which are more prone to migration.

The data presented in the research were obtained 8 years ago and represent the health status of the Roma population in that period. Despite this limitation, we believe that the presented results will serve as a good starting point for further, more in-depth research and observation of significant changes in the development of the Roma population in Slovenia.

5 CONCLUSIONS

The analysis of the results should consider the fact that Roma groups in Slovenia differ from each other concerning the observed health indicators, socioeconomic determinants, in particular living conditions and social inclusion (18, 28, 36). Thus, differences in perinatal outcomes should not be attributed to ethnicity per se, but to poorer socioeconomic status, transgenerational living in multiple disadvantages and exposure to discrimination. These result in less healthy lifestyles and poorer use of preventive healthcare services that are clearly not sufficiently tailored to the needs of Roma women. The need for development of tailored approaches in the provision of healthcare services for Roma, in particular in the field of reproductive health, was also perceived in Slovenia (31, 36). To our best knowledge, all activities aimed at improving the health of Roma in Slovenia, which were carried out in the period from the present research until now, were opportunistic, short-term, carried out in a small sub-region and by different providers, who were not necessarily health professionals. From the long-term public health point of view, it is necessary to work on all the above factors to improve the health of the Roma. It is necessary to improve socioeconomic determinants of health: ensure basic living and housing conditions for all residents of Roma settlements, such as running water in the home, electricity, sewerage, and heating. Appropriate access to educational system and later on employment are necessary to break the vicious circle of multigenerational poverty and social marginalisation (36, 37, 38). This is possible only in combination of legal requirements with community approach, in which local authorities and representatives of the Roma community would participate constructively. In order to improve the public health problems of the Roma, it is necessary to develop an adjusted and comprehensive public health programme based on existing national preventive programmes in Slovenia. Part of the approach is certainly bringing existing services closer to settlements where Roma live; in a way that takes into account both their needs and specificities. At the same time, it is necessary to work on raising the health literacy of Roma women as well as raising the competencies of healthcare professionals in communication with this multiply vulnerable group.

ACKNOWLEDGEMENTS

The authors wish to thank Mrs. Mihaela Törnar for translating and copy editing the text and to Mrs. Andreja Rudolf for the support by the data preparation.