Skip to main content Skip to footer

Perinatal health indicators of women, living in roma settlements in slovenia

Original Research Article

Perinatal health indicators of women, living in roma settlements in slovenia

Original Research Article

XML

Table of Contents

    Barbara Mihevc Ponikvar, Nacionalni inštitut za javno zdravje ,

    Tatjana Krajnc Nikolić, Nacionalni inštitut za javno zdravje

    Viktoria Zakrajšek, Nacionalni inštitut za javno zdravje


    Abstract

    Background: The health of Roma is worse compared to the majority population. Roma women often live with multiple disadvantages and experience the lack of empowerment in Roma community and society in general. The data on reproductive health of Roma women are scarce.

    Methods: A cross-sectional population-based survey was conducted, thatincluded the data analysis from the national health statistical database of thePerinatal Information System of the Republic of Slovenia for the period 2012–2014.The variables presenting mothers’ socioeconomic characteristics,lifestyle, use of preventive healthcare services and pregnancy outcomes wereincluded in the analysis.The statistical characteristics of thedifferences in the incidence rates of the variables between the observed groupsof Roma and non-Roma women were verified using a chi-square test and FisherExact test.

    Results: There is a statistically significant difference in all observedindicators between the observed groups. The education level was lower, smokingduring pregnancy was higher, the use of prenatal services was lower, and thenumber of pregnancies was higher and pre-term deliveries and low birth weightwere more frequent in the group of Roma women and their new-borns.

    Conclusions: The observed perinatal health indicatorsof Roma women differ significantly compared to non-Roma women. There is a needfor development of tailored approaches in the provision of health services forimprovement of reproductive health. It is necessary to improve livingconditions, education level and social inclusion of Roma women by means ofbroad society and community health approach.


    Keywords

    • Rominje
    • statistična podatkovna zbirka
    • obporodno zdravje
    • kazalniki perinatalnega zdravja
    • raba preventivnih storitev

    research-article

    Kazalniki perinatalnega zdravja žensk, ki živijo v Romskih naseljih v Sloveniji

    Tatjana.Krajnc-Nikolic@nijz.si
    DOI: [DOI]: 10.26318/JZ-2023-1
    2591-0906 Nacionalni inštitut za Javno zdravje
    29 05 2023
    29 05 2023
    Keywords: Rominjestatistična podatkovna zbirkaobporodno zdravjekazalniki perinatalnega zdravjaraba preventivnih storitev
    Cite as: Mihevc Ponikvar, B. & Krajnc Nikolić, T. & Zakrajšek, V., (2023) “Kazalniki perinatalnega zdravja žensk, ki živijo v Romskih naseljih v Sloveniji”, Javno zdravje 2023(1). doi: https://doi.org/10.26318/JZ-2023-1

    Izhodišča: Zdravje Romov je slabše od zdravja večinske populacije. Zdravje romskih žensk pa je še slabše kot zdravje romskih moških. Romske ženske se pogosteje soočajo s številnimi prikrajšanostmi in pomanjkanjem opolnomočenja, tako znotraj romske skupnosti kot na splošno v družbi. Podatki o reproduktivnem zdravju Rominj so redki.

    Metode: Uporabljena je metoda presečne populacijske raziskave z analizo podatkov nacionalne zdravstvene statistične zbirke Perinatalni informacijski sistem Republike Slovenije za obdobje 2012–2014. V analizo so bile vključene spremenljivke, ki opredeljujejo socialno-ekonomske značilnosti porodnic, njihov življenjski slog, koriščenje preventivnih zdravstvenih storitev in izide nosečnosti. Statistična značilnost razlik med romskimi ženskami in ostalimi prebivalkami je bila preverjena s pomočjo hi-kvadrat testa in Fisher Exact testa.

    Rezultati: Vsi opazovani kazalniki se statistično značilno razlikujejo med obema skupinama. Romske ženske so imele v povprečju nižjo izobrazbo, pogosteje so kadile v nosečnosti, slabše so koristile predporodno zdravstveno varstvo, rodile so več otrok, ki so bili pogosteje rojeni prezgodaj in z nizko porodno težo.

    Zaključki: Opazovani kazalniki obporodnega zdravja romskih žensk so statistično značilno različni kot pri ostali populaciji. Potreben je razvoj prilagojenih pristopov pri zagotavljanju zdravstvenih storitev za varovanje in krepitev reproduktivnega zdravja. Prav tako je potrebno v okviru širšega družbenega in skupnostnega pristopa k zdravju izboljšati življenjske razmere, raven izobrazbe in socialno vključenost romskih žensk.

    Kaj je znanega?

    [[Zdravje Romov je močno odvisno od njihovega socialno-ekonomskega položaja, s tem povezanih neustreznih življenjskih pogojev in infrastrukture. Romi so slabšega zdravja od večinskega prebivalstva, obstajajo tudi razlike v zdravju med romskimi ženskami in moškimi v prid slednjih.]]

    Kaj je novega?

    [[Ženske, ki živijo v romskih naseljih v Sloveniji, imajo pomembno slabše perinatalne izzide v primerjavi z ostalimi prebivalkami.]]

    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.

    Reference

    1. European Commission Directorate-General for Health and Consumers Roma health report, health status of the Roma population: data collection in the Member States of the European Union: Executive Summary Publications Office, 2015 Assessed February 15th, 2022 at: https://dataeuropaeu/doi/102772/31384
    2. European Union Agency for Fundamental Rights (FRA) Second European Union Minorities and Discrimination Survey Roma women in nine EU Member States Assessed February 15th, 2022 at: https://fraeuropaeu/en/publication/2019/roma-women-nine-eu-member-states
    3. Magyari Vincze E Social Exclusion at the Crossroads of Gender, Ethnicity and Class A View of Romani Women’s Reproductive Health Assessed January 8th, 2022 at: http://pdcceuhu/archive/00003117/
    4. Mavrin B, Sulič T, Kolev D, Krumova T(editor), Cultraro C, Antonucci M, Jobbagy S, Mustafa D Early Marriage – Culture or Abuse (JUST/2013/DAP/AG/5556), 2016 Assessed February 16th, 2022 at: http://wwwlu-kocevjesi/daphne-zgodnja-poroka-kultura-ali-zloraba/
    5. European Union Agency for Fundamental Rights FRA The situation of Roma in 11 EU member states Survey results at a glance Luxembourg: Publication Office of the European Union, 2012 Assessed February 17th, 2022 at: https://fraeuropaeu/en/publication/2012/situation-roma-11-eu-member-states-survey-results-glance
    6. Projekt Predupre Položaj Romov v Sloveniji International project identifying and reducing prejudices as a source of conflict between Roma and non-Roma population Pridobljeno 7 6 2016 s spletne strani: http://wwwproject-redupreeu/datoteke/Slovenia/REDUPRE-AnalizapoloajaRomovvSlovenijipdf
    7. Klopčič V Projekt CRP »Romi v procesih evropske integracije/razvoj modelov izobraževanja in usposabljanja Romov za povečanje rednega zaposlovanja« Vsebinsko poročilo Inštitut za narodnostna vprašanja Pridobljeno 9 8 2016 s spletne strani http://www2arnessi/~ljinv16/mp_vkhtm
    8. Šupínová M, Sonkolyová G, Klement C Reproductive health of Roma women in Slovakia Cent Eur J Public Health 2020; 28 (2): 143/8 doiorg/1021101/cejpha5817
    9. Šegregur J, Šegregur D Antenatal characteristics of Roma female population in Virovitica-Podravina County, Croatia Zdr Varst 2016 Nov 7; 56(1): 47–54 doi: 101515/sjph-2017-0007 PMID: 28289463; PMCID: PMC5329785
    10. Carrasco Garrido P, Lopez de Andres A, Hernandez Barrera V, Jimenez Trujillo I, Jimenez Garcıa R Health status of Roma women in Spain Eur J Public Health 2011; 21(6): 793–8 doi:101093/eurpub/ckq153
    11. Balazs P, Rakoczi I, Grenczer A, Foley KL Risk factors of preterm birth and low birth weight babies among Roma and non-Roma mothers: a population-based study-2012 Eur J Public Health; 2013 doi: 101093/eurpub/cks089
    12. Diabelkova J, Rimárova K, Urdzik P, Dorko E, Bušova A Risk factors of preterm birth and low birth weight neonates among Roma and non-Roma mothers Cent Eur J Public Health 2018; 26 (Suppl): S25–S31 doi: 1021101/cejpha5273
    13. Rosicova K, Madarasova Geckova A, van Dijk JP, Kollarova J, Rosic M, Groothoff JW Regional socioeconomic indicators and ethnicity as predictors of regional infant mortality rate in Slovakia Int J Public Health2011; 56: 523–31 doi101007/s00038-010-0199-3
    14. Watson HL, Downe S Discrimination against childbearing Romani women in maternity care in Europe: a mixed-methods systematic review Reprod Health 2017 Jan 5; 14(1): 1 doi: 101186/s12978-016-0263-4 PMID: 28057003; PMCID: PMC5217576
    15. Kühlbrandt C Confronting racism in family planning: a critical ethnography of Roma health mediation Sexual and Reproductive Health Matters 2019; 27(1): 83–92 doi:101080/0968808020191571324)
    16. Perinatalni informacijski sistem Nacionalni inštitut za javno zdravje https://wwwnijzsi/sl/podatki/perinatalni-informacijski-sistem
    17. K Žagar, B Barborič, (2013).  Tematski atlas romske poselitve v Sloveniji.  Ljubljana: Geodetski Inštitut Slovenije, : .
    18. Statistični urad Republike Slovenije, Popis prebivalstva, gospodinjstev in stanovanj 2002 https://wwwstatsi/popis2002/si/rezultati/rezultati_redaspter=OBC=5
    19. Zakrajšek V Prikaz koriščenja zdravstvenih storitev Romov v sistemu zdravstvenega varstva Slovenije Specialistično delo Ljubljana: Zdravniška zbornica Slovenije, 2018
    20. Šelb J Ocena rabe zdravstvenih storitev v populaciji romskih žensk in otrok v Sloveniji - prispevek k zmanjševanju neenakosti v zdravju Zavod za Zdravstveno Varstvo Murska Sobota 2011; Assessed February 16th, 2022 at: http://wwwdlibsi/URN=URN:NBN:SI:DOC-WG7BOOBP
    21. Logar M, Rotar Pavlič D, Maksuti A Standpoints of Roma women regarding reproductive health BMC Women's Health2015; 15: 38 Doi: 101186 / s12905-015-0195-016
    22. Silvestrin S, Silva CH, Hirakata VN, Goldani AA, Silveira PP, Goldani MZ Maternal education level and low birth weight: a meta-analysis J Pediatr (Rio J) 2013 Jul-Aug; 89(4): 339–45 doi: 101016/jjped201301003 Epub 2013 Jun 26 PMID: 23809705
    23. M Gabrijelčič Blenkuš, T Kofol Bric, M Zaletel, A Hočevar Grom, T Lesnik, (2021).  Inequalities in health: future challenges for intersectoral cooperation.  Ljubljana: National institute of public health, : .
    24. Babinská I, Madarasová Gecková A, Jarčuška P, Pella D, Mareková M, Štefková G, Dankulincová Veselská Z; HepaMeta Team Does the population living in romasettlements differ in physical activity, smoking and alcohol consumption from the majority population in Slovakia Cent Eur J Public Health 2014 ; 22(Suppl): S22–7 doi : 1021101/cejpha3897
    25. Bobak M, Dejmek J, Solansky I, J Sram RJ Unfavourable birth outcomes of the Roma women in the Czech Republic and the potential explanations: a population-based study BMC Public Health 2005; 5: 106 doi:101186/1471-2458-5-106
    26. Communication from the commission to the European parliament, the council, the European economic and social committee and the committee of the region Assessing the implementation of the EU Framework for National Roma Integration Strategies and the Council Recommendation on effective Roma integration measures in the Member States — 2016 COM (2016) 424 Assessed 12th March 2022 at: https://eurlexeuropaeu/legalcontent/en/TXT/uri=CELEX:52016DC0424
    27. Cause of action: Reproductive Rights of Romani Women in Bulgaria Assessed January 7th, 2022 at: http://wwwerrcorg/reports--submissions/cause-of-action-reproductive-rights-of-romani-women-in-bulgaria
    28. WHO Health literacy The solid facts Copenhagen: WHO Regional Office for Europe, 2013
    29. B Belović, L Zaletel Kragelj, J Farkaš Lainščak, (2015).  Health-related Roma lifestyle: contribution to reducing inequalities.  Murska Sobota: Pomurje Society for the Fight against Cancer: National Institute of Public Health, : .
    30. A Bernat, (2015).  The Rights of Roma Children and Women in Bosnia and Herzegovina, the former Yugoslav Republic of Macedonia, and Serbia: A comparative review and further analysis of findings from MICS surveys in Roma settlements in the three countries.  Geneva: Unicef Regional Office for CEE / CIS, : .
    31. Nanu M, Stativa E, Moldovanu F, Nanu I Reproductive health services use by the Roma minority women in Romania European Journal of Public Health, Volume 31, Issue Supplement_3, October 2021, ckab164618, https://doiorg/101093/eurpub/ckab164618
    32. T Krajnc Nikolić, O Stanojević Jerković, M Ranfl, D Jagodic, J Župan, et Copot M, et al, (2020).  Public health approaches for the Roma ethnic community in Slovenia.  Ljubljana: Nacionalni inštitut za javno zdravje, : .
    33. Hudečková H, Stašková J, Mikas J, Mečochová A, Staroňová E, Polčičová A et al Measles outbreak in a Roma community in the Eastern region of Slovakia, May to October 2018 Slovenian Journal of Public Health, vol59, no4, 2020, pp 219–26 https://doiorg/102478/sjph-2020-0028)
    34. Zelko E, Švab I, Maksuti A, Klemenc-Ketiš Z Attitudes of the Prekmurje Roma towards health and healthcare Wiener klinische Wochenschrift The Central European Journal of medicine DOI 101007/s00508-015-0704-z https://linkspringercom/article/101007/s00508-015-0704-z
    35. Petraš T, Rošar J Bivalno okolje v romskih skupnostih Pomurja Romi in zdravje: zbornik prispevkov nacionalnih konferenc Ljubljana: Ministrstvo za zdravje, 2010
    36. Gumilar, Ines Zelko, Erika (2022) Socio-economic structure of patients and their reasons for visiting pro bono clinics in Slovenia https://wwwresearchgatenet/publication/361910365_Socio-economic_structure_of_patients_and_their_reasons_for_visiting_pro_bono_clinics_in_Slovenia/citation/download
    37. Urad za narodnosti RS NACIONALNI PROGRAM UKREPOV VLADE REPUBLIKE SLOVENIJE ZA ROME ZA OBDOBJE 2016-2021 https://wwwgovsi/assets/vladne-sluzbe/UN/NPUR-2017-2021/65d892da3a/NPUR_2017-2021pdf
    38. WHO Ottawa Charter for health promotion Assessed 22nd March 2022 at: https://wwwwhoint/teams/health-promotion/enhanced-wellbeing/first-global-conference
    39. Brochure - Effective Roma integration measures in the Member States – 2016 Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions Assessed April 4th 2022 at: https://eceuropaeu/info/publications/assessment-roma-integration-measures-member-states-2016_en
    40. Horvat JM Romska skupnost v Sloveniji: zgodovina in kultura Romov Murska Sobota: Zveza Romov Slovenije: Romani Union, 2011
    41. Belović B, Krajnc Nikolić T, Verban Buzeti Z, Copot M, Fujs A, Horvat J, Knapp A, Papić J, Vugrinčić M, Törnar M Dejavniki, ki vplivajo na zdravje Romov v Pomurju Murska Sobota: Zavod za zdravstveno varstvo Murska Sobota, 2011
    42. Vlada republike Slovenije Sedmo poročilo Vlade Republike Slovenije o položaju romske skupnosti v Sloveniji-Poročilo o uresničevanju obveznosti na podlagi Zakona o romski skupnosti v republiki Sloveniji (Uradni list RS, št33/07) Številka 00701-1/2020-UN [spletni vir] Pridobljeno 14 2 2023 s spletne strani: https://wwwgovsi/teme/romska-skupnost/