Structural vulnerability and maternal health: Qualitative insights into the three delays faced by undocumented migrant women in Tunisia

Abstract

Sub-Saharan African migrant women in North Africa encounter substantial barriers in accessing healthcare services; yet empirical evidence in this context remains scarce. In Tunisia, although existing policy frameworks endorse healthcare rights for migrants, undocumented women continue to experience significant barriers to care. This study explores the perceptions and experiences of pregnant and postpartum migrant women regarding maternal healthcare access and utilization, with the aim of elucidating facilitators and obstacles. A qualitative, interpretative methodology was adopted, involving 23 individual interviews and 2 group interviews with 29 undocumented migrant women across four Tunisian cities between May and December 2023. Data were subjected to thematic analysis, using Fereday and Muir-Cochrane’s hybrid deductive-inductive framework, guided by the “Three Delays Model” and adapted to the socio-political context of Tunisia. The findings reveal, barriers affecting migrant maternal health care. The first delay was shaped by fear of legal consequences, financial insecurity, misinformation, and social isolation. The second delay was driven by geographic, administrative, and economic constraints, mitigated in part by NGO interventions. The third delay was marked by financial burdens, language barriers, and communication difficulties with healthcare providers. Women proposed concrete recommendations, including enhanced health rights awareness, multilingual support services, and strengthened collaboration between NGOs and governmental entities. Our study highlights how intersecting forms of structural vulnerability converge to hinder maternal healthcare access among undocumented migrant women in Tunisia. Addressing these multifaceted barriers requires, community-driven interventions, and broader structural reforms to promote health equity and reproductive justice informed by intersectional theoretical approaches. • First study on maternal healthcare for undocumented Sub-Saharan migrants in Tunisia • “Three Delays Model” reveals legal, social, cultural, and language barriers to care • NGOs networks bridge care barriers, highlighting gaps in public services • Findings highlight the need towards inclusive, rights-based health policies