ABSTRACT

Objective.

To understand the sexual and reproductive health (SRH) experiences of migrant women and girls of reproductive age (15–49 years) from the Northern Triangle of Central America (El Salvador, Guatemala and Honduras) during their journey to the United States.

Methods.

A descriptive, qualitative research design included 39 in-depth interviews with migrant women and unaccompanied migrant girls from El Salvador, Guatemala and Honduras from January to June 2022. Participants were recruited using purposive sampling. Interviews were transcribed, coded and analyzed using thematic analysis.

Results.

Migrant women and girls lack information and resources to manage their SRH during migration. The SRH of those traveling with smugglers is compromised due to their limited access to menstrual pads, water and sanitation services; the risks of transactional sex and sexual violence; the high risk of sexually transmitted infections; the inability to report sexual violence; the lack of access to SRH and prenatal services; and limited knowledge about their sexual and reproductive rights.

Conclusions.

There is a significant need for improved interventions during the predeparture phase of migration to inform migrant women and girls about the SRH risks they may encounter and to provide information and resources to support their SRH throughout their journey. Special attention should be directed towards trying to reach girls and women who will travel with smugglers.

Keywords
Women’s health; reproductive health; sexual health; undocumented immigrants; qualitative research; El Salvador; Guatemala; Honduras

RESUMEN

Objetivo.

Conocer las experiencias relacionadas con la salud sexual y reproductiva (SSR) de mujeres y niñas migrantes en edad reproductiva (15-49 años) del Triángulo Norte de América Central (El Salvador, Guatemala y Honduras) durante su viaje hacia Estados Unidos.

Métodos.

Se llevó a cabo una investigación descriptiva y cualitativa que incluyó 39 entrevistas en profundidad a mujeres y niñas no acompañadas migrantes de El Salvador, Guatemala y Honduras, entre enero y junio de 2022. El reclutamiento de las participantes se llevó a cabo mediante un muestreo intencional. Las entrevistas fueron transcritas, codificadas y analizadas mediante análisis temático.

Resultados.

Las mujeres y niñas migrantes carecen de información y recursos para cuidar su SSR durante la migración. La SSR de las personas que viajan con traficantes de personas se ve afectada por un acceso limitado a toallas menstruales, agua y servicios sanitarios; los riesgos del sexo transaccional y la violencia sexual; el alto riesgo de infecciones de transmisión sexual; la imposibilidad de denunciar la violencia sexual; la falta de acceso a servicios de SSR y prenatales; y el conocimiento limitado sobre sus derechos sexuales y reproductivos.

Conclusiones.

Existe una necesidad significativa de mejorar las intervenciones durante la fase previa a la migración para informar a las mujeres y niñas migrantes sobre los riesgos relacionados con la SSR que pueden encontrar y proporcionar información y recursos para apoyar su SSR a lo largo de su viaje. Debe prestarse especial atención a intentar llegar a las niñas y mujeres que viajarán con traficantes de personas.

Palabras clave
Salud de la mujer; salud reproductiva; salud sexual; inmigrantes indocumentados; investigación cualitativa; El Salvador; Guatemala; Honduras

RESUMO

Objetivo.

Conhecer as experiências de saúde sexual e reprodutiva (SSR) de mulheres e meninas migrantes na idade reprodutiva (15-49 anos) do Triângulo Norte da América Central (El Salvador, Guatemala e Honduras) durante sua viagem aos Estados Unidos.

Método.

Foi realizada uma pesquisa descritiva e qualitativa que incluiu 39 entrevistas em profundidade com mulheres e meninas não acompanhadas migrantes de El Salvador, Guatemala e Honduras, entre janeiro e junho de 2022. As entrevistas foram transcritas, codificadas e analisadas mediante análise temática.

Resultados.

As mulheres e meninas migrantes carecem de informações e recursos para cuidar seu SSR durante a migração. La SSR das pessoas que viajam com traficantes de pessoas é afetada pelo acesso limitado a absorventes menstruais, água e serviços sanitários; os riscos de sexo transacional e violência sexual; o alto risco de infecções de transmissão sexual; a impossibilidade de denunciar a violência sexual; a falta de acesso a serviços de SSR e pré-natais; e o conhecimento limitado sobre seus direitos sexuais e reprodutivos.

Conclusões.

Há uma necessidade significativa de melhorar as intervenções durante a fase anterior à migração para informar as mulheres e meninas migrantes sobre os riscos de SSR que podem encontrar e fornecer informações e recursos para apoiar seu SSR ao longo de sua viagem. Deve ser dada atenção especial para tentar chegar as meninas e mulheres que viajarão com traficantes de pessoas.

Palavras-chave
Saúde da mulher; saúde reprodutiva; saúde sexual; imigrantes indocumentados; pesquisa qualitativa; El Salvador; Guatemala; Honduras

For decades, the United States of America has been the primary migration destination for Latin Americans. Until recently, Mexican migrants were the most frequently apprehended group at the United States–Mexico border. However, starting in 2014, the arrests of individuals from El Salvador, Guatemala and Honduras – an area known collectively as the Northern Triangle of Central America – have surpassed those of Mexicans (¹1. Gonzalez-Barrera A, Krogstad JM. Apprehensions of migrants at U.S.–Mexico border rose sharply in October and November [Internet]. Washington (DC): Pew Research Center; 2016 [cited 2022 August 15]. Available from: https://www.pewresearch.org/fact-tank/2016/12/21/apprehensions-of-migrants-at-u-s-mexico-border-rose-sharply-in-october-and-november/
https://www.pewresearch.org/fact-tank/20... ). In 2022, nearly 521 000 individuals from these three countries were encountered by the United States Border Patrol (²2. Meyer JP. Central American migration: root causes and U.S. policy. Washington (DC): Congressional Research Service; 2022.).

El Salvador, Guatemala and Honduras are countries of both origin and transit because of their geographical proximity to the United States. They also have some of the world’s highest homicide rates, and extortion and youth gangs are common. Socioeconomic and security conditions are the main drivers of migration to the United States (²2. Meyer JP. Central American migration: root causes and U.S. policy. Washington (DC): Congressional Research Service; 2022.).

During the past 8 years, the profile of Central American migrants has evolved towards including more vulnerable groups. The number of minors who migrate alone or as members of family units has increased. Likewise, more women, single mothers and female heads of household migrate to contribute financially (³3. Isaacs A. Migration in Central America: an analysis of migration trends, drivers, policy and actors. Seattle (WA): Seattle International Foundation; 2018.) or to become the sole provider for their family (⁴4. Zimmerman C, Kiss L, Hossain M. Migration and health: a framework for 21st century policy-making. PLoS Med. 2011;8(5):e1001034.).

Migrants are vulnerable throughout the process of migration, as they are often subjected to different forms of abuse, including kidnapping, robbery, extortion and rape (⁵5. Médecins Sans Frontières. Forced to flee Central America’s Northern Triangle: a neglected humanitarian crisis. Geneva: Médecins Sans Frontières; 2017.). This vulnerability is exacerbated for migrant women. When women lack documentation, their access is hindered to information, assistance and their guaranteed rights (⁶6. Secretaría General del Sistema de la Integración Centroamericana. Factores de riesgo y necesidades de atención para las mujeres migrantes en Centroamérica, Estudio de actualización sobre la situación de la violencia contra las mujeres migrantes en la ruta migratoria en Centroamérica [Risk factors and care needs of migrant women in Central America: update study on the situation of violence against migrant women on the migration route in Central America]. Santiago: Observatorio de Igualdad de Género de América Latina y el Caribe; 2016. Spanish.). They are exposed to risks that threaten their sexual and reproductive health (SRH) and increase their biological vulnerability to disease (⁷7. Organización Internacional para las Migraciones. Informe regional sobre determinantes de la salud de las personas migrantes retornadas o en tránsito y sus familias en Centroamérica [Regional report on health determinants of returned or in-transit migrants and their families in Central America]. San Salvador: Organización Internacional para las Migraciones; 2015. Spanish.).

While there is a body of literature documenting the SRH needs of women refugees and migrants in humanitarian settings around the world (⁸8. Amroussia N. Providing sexual and reproductive health services to migrants in southern Sweden: a qualitative exploration of healthcare providers’ experiences. BMC Health Serv Res. 2022;22(1):1562.–¹¹11. Soeiro RE, Rocha L, Surita FG, Bahamondes L, Costa ML. Period poverty: menstrual health hygiene issues among adolescent and young Venezuelan migrant women at the northwestern border of Brazil. Reprod Health. 2021;18(1):238.), there is insufficient evidence about migrant women’s and girl’s SRH needs during the transit phase of migration. This lack, in turn, makes it challenging to develop effective interventions that can support their SRH throughout their journey. The aim of this study is to understand the SRH experiences of migrant women and girls of reproductive age (15–49 years) from El Salvador, Guatemala and Honduras during their journey to the United States. The study centers on three research questions: (i) what information do migrant women and girls receive in relation to their SRH before departing? (ii) What self-care behaviors and coping strategies do migrant women and girls employ to ensure their SRH during their journey? (iii) How and where do migrant women and girls seek care for their SRH during their journey?

METHODS

This study was conducted from January to June 2022 in the three departments of Guatemala (i.e. Guatemala, Huehuetenango and San Marcos) known for having the largest number of returnees from the United States and from where most people from El Salvador, Guatemala and Honduras transit to Mexico and the United States (¹²12. Organización Internacional para las Migraciones. Caracterización de la migración internacional en Guatemala [Characterization of international migration in Guatemala]. Guatemala City: Organización Internacional para las Migraciones; 2021. Spanish.).

A descriptive, qualitative research design that included face-to-face in-depth interviews was employed to capture the unique SRH experiences of migrant women and girls traveling to the United States and the contextual factors that impact those experiences.

Study population

The study used purposive sampling to recruit Guatemalan, Honduran and Salvadoran migrant women and girls of reproductive age who were in Guatemala at the time of the study and who were at different stages of the migration process. Recruitment was achieved with the support of local organizations and community leaders who work directly with migrants. Only unaccompanied migrant girls who were traveling or had travelled without a legal guardian were included in this study because they are at greater risk of poor physical and mental health and gender-based violence (¹³13. Corona Maioli S, Bhabha J, Wickramage K, Wood LCN, Erragne L, Ortega García O, et al. International migration of unaccompanied minors: trends, health risks, and legal protection. Lancet Child Adolesc Health. 2021;5(12):882–95., ¹⁴14. Radjenovic A. Vulnerability of unaccompanied and separated child migrants. Brussels: European Parliamentary Research Service; 2021.).

Procedures

A total of 39 face-to-face in-depth interviews were conducted, and audio was recorded by trained female interviewers using an interview guide that explored reasons for migrating, SRH information sources, preparation for the journey, self-care behaviors related to SRH, access to health services and knowledge of SRH rights. Six images of SRH topics (i.e. the female reproductive system, menstrual pad, contraceptive methods, sexually transmitted infections [STIs], pregnant woman, health facility) were used as visual prompts to facilitate discussion of these topics within the context of their journey.

Audio recordings were transcribed verbatim in Spanish. Transcripts were coded line-by-line using deductive and inductive codes based on the study’s objective. Themes were identified using an applied thematic approach.

Data management, coding and analysis were performed in Dedoose v. 9.0.54 (Dedoose, Los Angeles, CA, USA) by PL (a bilingual Guatemalan researcher) who translated into English the excerpts in the manuscript and supplementary material. Translations were back-translated by coauthors to ensure accuracy.

The Institutional Ethics Committee of the Institute of Nutrition of Central America and Panama in Guatemala City, Guatemala, the Population Services International Research Ethics Board, and the Pan American Health Organization’s Ethics Review Committee all approved the study. Informed consent was sought from all participants. Pseudonyms were used during the interviews for those who preferred not to be called by their first name, and transcripts were deidentified to maintain anonymity and the confidentiality of the data.

RESULTS

Of the 39 migrant women and girls who participated in the study, 16 were from Guatemala, 11 from El Salvador and 12 from Honduras. Participants’ ages ranged from 15 to 46 years, and 13 participants were under the age of legal majority in Guatemala, which is 18 years.

The decision to migrate

All participants perceived that living in the United States would provide a better future for them and their families. The main reasons for migrating were economic difficulties, including not finding work, low wages, parents who were no longer capable of meeting the family’s basic needs or the death of the sole provider. Emotional distress was another common reason cited for migration. Respondents reported wanting to “leave everything behind” due to the death of a close family member, separation or divorce, or loss of custody of a child. Violent events, such as the assassination of a loved one, were cross-cutting and often prompted the economic difficulties or emotional distress that motivated the decision to migrate, especially in women with young children.

The thought of traveling to the United States originated with the participants themselves, particularly among adult migrant women. A friend or family member living in the United States often motivated the women or facilitated decision-making by providing guidance and contacts for “trustworthy” migrant smugglers and by paying the smuggling fee. Parents made the decision for most of the migrant girls, usually without consulting them.

Preparing for the journey

Once participants decided to migrate, they usually had 1 to 7 days to prepare. None of the participants searched for information online about the migration process, and they relied solely on information from others who had previously migrated (e.g. smuggler, family member).

Most of the information they received was about which items to carry in their backpack. This commonly included two to three changes of clothes, with the suggestions that they bring dark colors to avoid detection and baggy clothes to avoid attracting men, as well as underwear, socks and a jacket or poncho; water; identification documents; and menstrual pads. Some mothers also provided recommendations about how girls should behave (e.g. be discreet, don’t talk with people from other migrant groups) and took them to receive an injectable contraceptive. No information regarding sexual and reproductive rights was provided to migrants, nor did they express knowledge about their rights.

The journey

Each journey was unique, including the mechanism used to enter the United States, how the participant traveled (e.g. with a smuggler or without one), and how long the journey lasted (ranging from 15 days to 4 months).

Most participants travelled with migrant smugglers. Some travelled in small groups, others in large groups (more than 8 people); some were transported in cars, buses or cargo trailers, while others walked through mountains and unpopulated areas; and some stayed in hotels, while others had housing only every few days. Most migrant girls travelled as part of a group of mostly minors.

Participants traveling with smugglers were forbidden to seek health services. Those traveling without a smuggler had access to shelters that provided items such as food, clothes, condoms and menstrual pads. They also had more freedom of movement – that is, without gatekeepers limiting their access to health services.

Sexual and reproductive health

Five domains were explored regarding participants’ experiences and what they saw happen with other migrant women and girls regarding SRH (Table 1).

Menstruation.

Most participants brought menstrual pads with them during their journey. Some experienced challenges, including not being able to change their pads or having a shortage of pads after sharing with others, having their pads stolen, the trip lasting longer than expected or having early menstrual cycles, attributed to stress. Migrant women and girls in need of pads would ask other women for pads or use small towels, toilet paper, socks or pieces of cloth cut from their own clothing.

Participants traveling with smugglers perceived menstrual pads as difficult to access due to the mountainous, unpopulated travel routes taken and the need to maintain a low profile as a group. Women who paid smugglers for a premium package, described as having all expenses paid (e.g. three meals a day, menstrual pads), and those traveling independently (who could access pads in stores) had better access to menstrual supplies. In some cases, migrant women who had cash on hand asked the smuggler to purchase pads when needed.

Hygiene practices when women and girls are on the move are nonexistent. Many women reported not having access to water for several days, and they were not able to wash their hands, much less their genital area. Privacy is also an issue: women often changed menstrual pads in front of the group.

Sex, transactional sex and sexual violence.

Sex commonly occurred among migrants. While some migrant women travel with their partners or form sexual partnerships during transit, sex is typically transactional, with smugglers or other migrants. Participants described transactional sex occurring when a woman runs out of money or feels that her life or means to continue her journey are threatened. Two participants were approached by their smuggler and offered additional protection and increased comfort in exchange for sex. Both rejected the proposal without any consequences. Another participant voluntarily engaged in condomless sex in exchange for basic needs.

While primary accounts of sexual violence among the study participants were few, two participants (one a migrant girl) reported sexual violence in the form of inappropriate touching by a man traveling in the same group. Another woman, who was traveling with her five children, reported that the smuggler tried to rape her, but she was protected by a woman resident of the town where the group was staying. Secondary accounts of sexual violence were common. Participants witnessed the consequences of women who were raped and were unable to access support or health services. Only one participant mentioned seeing a woman take a pill after being raped. Silence from the victims is always demanded by the aggressors.

Contraceptive methods.

Most of the migrant women were advised to use contraception to prevent an unwanted pregnancy during the journey. As one participant explained, contraception was recommended “just in case anything happens,” referring to the possibility of being raped.

The 3-month injectable contraceptive was the most common contraceptive used by migrant women. In some cases, girls were taken by their mothers without explanation to receive an injection prior to departing. The oral contraceptive was also mentioned, but it was less commonly used. Participants explained that the pill was less practical during migration due to the potential lack of drinking water and because it could be easily misplaced or stolen. Furthermore, women could forget to take it due to the stressful situation. Some married women and women who already had children stated that they were already using an IUD or implant or had been sterilized. Emergency contraception (e.g. the morning-after pill) was not mentioned as a method that the participants had with them or used. However, some women reported seeing other female migrants carrying emergency contraception.

STIs were not a concern that migrant women and girls spontaneously shared. Their primary concern was unwanted pregnancy. Condoms were not seen as an option in the context of rape or transactional sex.

It was uncommon for migrant women and girls to mention seeing a health facility or a pharmacy where they could access contraceptive methods. Most considered contraception difficult to obtain. In some instances, the smuggler provided contraception to female migrants. Only participants traveling independently reported having easy access to contraception through pharmacies.

Pregnancy.

One participant discovered that she was pregnant during the journey due to her symptoms and lack of menstruation. Other participants saw pregnant women in transit, most of whom were traveling with children younger than 5 years and without a partner. There are many risks to pregnant women during migration, including uneven terrain, overcrowded transportation, extreme physical activity, and the lack of food and prenatal care. Some pregnant women were seen reporting pain and bleeding, having swollen feet, having difficulty running and engaging in high-risk behaviors (e.g. transactional sex, drinking alcohol, self-harm).

Participants shared that some pregnant women “took pills,” assuming they were vitamins, but did not have access to prenatal care or medical attention. Two reported exceptions were a pregnant woman who went into preterm labor and a participant who fell while running away from a group of migrants that she perceived as a threat; the fall caused her to lose consciousness and miscarry. Both of these women were admitted to a hospital in Mexico.

Health services.

Access to health and SRH services was limited. Many participants did not see a facility during transit and thought that they could not access health services in foreign countries; one said, “We are here illegally. It is obvious that we cannot [go to a health facility].”

Women reported mistrusting health care providers, often believing that the providers worked with immigration and would inform local authorities of their whereabouts. Only migrant women who were captured and detained by United States immigration authorities mentioned receiving medical attention.

While seeking health services was forbidden for the majority of those who traveled with smugglers, there were reports of smugglers who were willing to take migrants to a health facility if there was an emergency. In such cases, the migrant was left behind.

DISCUSSION

This study contributes to the scarce literature (¹⁵15. Leyva R, Quintino F. Migración y salud sexual y reproductiva en la frontera sur de México [Migration and sexual and reproductive health on the southern border of Mexico]. Cuernavaca; Instituto Nacional de Salud Pública; 2011. Spanish.–¹⁷17. Vázquez-Quesada L, Larrea-Schiavon S, Marin T, Muñoz G, Basurto-Alcalde E, Ochoa B, et al. Mujeres migrantes en Tapachula: barreras y facilitadores para el acceso a la salud sexual y reproductiva en 2020 – informe de investigación [Migrant women in Tapachula: barriers to and facilitators of access to sexual and reproductive health in 2020: research report]. Mexico City: Centro Nacional de Equidad de Género y Salud Reproductiva, Ipas CAM, Médicos del Mundo, Population Council; 2021.) about the SRH experiences of migrant women and girls from El Salvador, Guatemala and Honduras during the transit phase of migration. According to the United Nations Population Fund, “Good sexual and reproductive health is a state of complete physical, mental and social well-being in all matters relating to the reproductive system” (¹⁸18. United Nations Population Fund. Sexual &reproductive health [Internet]. New York: United Nations Population Fund; 2022 [cited 2022 August 15]. Available from: https://www.unfpa.org/sexual-reproductive-health
https://www.unfpa.org/sexual-reproductiv... ). However, the results from this study indicate that the SRH of migrant women and girls, especially those traveling with smugglers, is compromised by the precarious conditions of travel. They lack the information and resources needed to manage their SRH appropriately and the capacity to adapt to unpredictable situations that affect their SRH.

Menstrual health and hygiene management proved challenging for many migrant women and girls due to poor access to menstrual pads, clean water and the private sanitation facilities that could ensure safe and dignified menstruation. These barriers have been reported in other humanitarian settings (¹¹11. Soeiro RE, Rocha L, Surita FG, Bahamondes L, Costa ML. Period poverty: menstrual health hygiene issues among adolescent and young Venezuelan migrant women at the northwestern border of Brazil. Reprod Health. 2021;18(1):238., ¹⁹19. Kaur N, Byard RW. Menstrual health management: practices, challenges and human rights violations. Med Leg J. 2021;89(4):241–6.) and contribute to unhygienic practices that can increase the risk of toxic shock syndrome, reproductive and urinary tract infections, and future infertility and birth complications (²⁰20. World Bank. Menstrual health and hygiene resource package: tools and resources for task teams. Washington (DC): International Bank for Reconstruction and Development, World Bank; 2021.–²²22. Narayan KA, Srinivasa DK, Pelto PJ, Veerammal S. Puberty rituals, reproductive knowledge and health of adolescent schoolgirls in South India. Asia Pac Popul J. 2001;16(2):225–38.).

Due to economic hardship and power imbalances, migrant women in this study often found themselves in vulnerable positions while in transit, having to resort to condomless, and often coerced, transactional sex with smugglers and migrant men. Women who travel with smugglers tend to be exposed to heightened risks of transactional sex, reinforcing the perception that transactional sex is inevitable for migrant women (²³23. Infante C, Leyva-Flores R, Gutierrez JP, Quintino-Perez F, Torres-Robles CA, Gomez-Zaldívar M. Rape, transactional sex and related factors among migrants in transit through Mexico to the USA. Cult Health Sex. 2020;22(10):1145–60., ²⁴24. Freedman J. Sexual and gender-based violence against refugee women: a hidden aspect of the refugee “crisis.” Reprod Health Matters. 2016;24(47):18–26.). As evidenced by the interviews with participants and consistent with findings from other studies, many migrant women and girls are subject to solicitation of sex or to sexual violence during migration (²⁵25. Soria-Escalante H, Alday-Santiago A, Alday-Santiago E, Limón-Rodríguez N, Manzanares-Melendres P, Tena-Castro A. “We all get raped”: sexual violence against Latin American women in migratory transit in Mexico. Violence Against Women. 2022;28(5):1259–81.). Women and girls are unlikely to report sexual violence, seek health services after being raped or ask for support within the group due to fear of the repercussions by the aggressor and a lack of access to health services.

Most migrant women and mothers of migrant girls know someone, or have heard stories about someone, who has been a victim of sexual violence during migration. The frequent occurrence of sexual violence has led to normalization of the perception among migrant women and mothers of migrant girls that they or their daughters could be raped during transit. Women reported pre-emptively starting a contraceptive method (predominantly the 3-month injectable contraceptive) before their journey or in the case of mothers, making contraceptive choices on behalf of their migrant daughters. Using contraceptives, carrying condoms and looking for sexual partners within the migrant group for protection are prevention strategies previously identified in this population (²⁶26. Willers S. Migración y violencia: las experiencias de mujeres migrantes centroamericanas en tránsito por México [Migration and violence: Central American migrant women’s experiences in transit through Mexico]. Sociológica (Mex.). 2016;31(89). Available from: https://www.scielo.org.mx/scielo.php?script=sci_arttext&pid=S0187-01732016000300163
https://www.scielo.org.mx/scielo.php?scr... , ²⁷27. Martínez O. Los migrantes que no importan. En el camino con los centroamericanos indocumentados en México [Migrants that don’t matter: on the road with undocumented Central Americans in Mexico]. Barcelona: Icaria Editorial; 2010.). The lack of discussion about STIs and HIV suggests that these are not the main health concerns for migrant women and girls.

It is challenging for migrant women and girls to look for or access SRH services while in transit due to the isolation of migration routes, services not being readily available, restriction of movement imposed by the smugglers, fear of being left behind, mistrust of health care providers and a lack of knowledge about their rights to access health services in other countries. Migrant women who are pregnant face these same challenges, making it difficult for them to access prenatal care or health services despite facing extreme hardship during their journey and increased risks of maternal and neonatal morbidity and mortality (²⁸28. Almeida LM, Caldas JP. Migration and maternal health: experiences of Brazilian women in Portugal. Rev Bras Saúde Matern Infant. 2013;13(4). Available from: https://www.scielo.br/j/rbsmi/a/c85TPmZftsKXsnj8MsYpqgb/?lang=en
https://www.scielo.br/j/rbsmi/a/c85TPmZf... ).

Migrant women and girls interact with several gatekeepers who positively or negatively impact their SRH, including family members, smugglers, fellow migrants and health care providers. Some gatekeepers may provide access to SRH products (e.g. menstrual pads, contraception), protection and medical emergency services, while others restrict access to SRH services, propose transactional sex or become sexual aggressors.

This study is not without limitations. The findings are not representative or generalizable to other migrant women and girls from El Salvador, Guatemala and Honduras or from other countries. Nonetheless, the results provide insight into the SRH experiences of women and girls during transit to the United States. It is possible that participants’ social desirability bias or fear of openly discussing such sensitive topics could affect their responses. To minimize this, we focused on establishing rapport with participants and also used images during the interview to provide a less structured and less formal environment.

In conclusion, there is a significant need to improve interventions targeting women and girls during the predeparture phase of migration, to inform migrant women and girls about the SRH risks they may encounter and to provide the information (e.g. about SRH and rights) and resources (e.g. long-acting contraceptive methods, emergency contraception, prenatal vitamins, wipes) that can support their SRH throughout their journey. Special attention should be directed towards reaching girls and women who will travel with smugglers because they may not be reached during transit.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the Revista Panamericana de Salud Pública/Pan American Journal of Public Health or those of the Pan American Health Organization or the World Health Organization.

Acknowledgements.

We thank all the migrant women and girls who shared their experiences and took part in this study.

REFERENCES

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