3.5.1. One Stop Crisis Centre Linked with Police

One Stop Crisis Centres (OSCC) were established in Malaysia since 1996 to assist survivors of gender-based violence (GBV), to obtain comprehensive care from multiple agencies in a common venue. The OSCC are located at the emergency departments of Ministry of Health hospitals in Malaysia and provide immediate treatment, while facilitating protection, counselling, medico-legal, and social support services for survivors of GBV, rape, sodomy and sexual assault, domestic violence, and child abuse.

Legally, citizens and non-citizens can use GBV-associated healthcare services, which are available free of charge regardless of citizenship status at OSCCs. However, reporting violence to the police is a pre-requisite to seeking care at the OSCC. This participant explains that the procedure for reporting to the police is not always consistent. Survivors of violence are supposed to go directly to the OSCC, and the police report should be done at the hospital. However, some survivors are asked by hospitals to go to the police station first before coming to hospital for treatment.

*"I have heard di*ff*erent information, at di*ff*erent times. Previously, I have heard [that] people should just go to the emergency [department] and then be referred to the OSCC. Then the police report will be lodged there. So, the police will go [there], to take the report. But I have also heard another story when they go to the emergency [department] and want to be directed to the OSCC, and they were asked to lodge [a police] report first, before they come [into OSCC]." CSO-8*

This participant explained that fear of the police is a hindrance faced by many non-citizen women seeking care or justice. Law enforcement personnel were described as lacking sensitization in dealing with GBV, and migrant women face additional discrimination.

*"I would say on the whole, there is definitely a lack of sensitisation amongst the police. I think in general, when it comes to gender-based violence, there is a lot of 'victim blaming' and those kinds of attitudes that are pretty pervasive. For non-Malaysian women, there is another layer of discrimination and some xenophobia. So, I think the quality of services is even lower for them! And then sometimes, if it is a situation where the employer has not done what they need to do to renew the work permit or the visa, then they might be afraid to go to the police because they can get reported to immigration! So, that is often a reason for women not to access help." CSO-7*

Study participants informed that undocumented migrants were particularly afraid to come forward to report incidences of violence, due to their immigration status.

### 3.5.2. Limited Shelters for Non-Citizens

While government and CSOs provide shelters, those interviewed informed that there is a shortage of shelters specifically designed for survivors of GBV. Study participants informed that government shelters provided by the Welfare Department are general shelters, which may also house the homeless or elderly populations, and may lack comprehensive case management of GBV.

Furthermore, not all government shelters accept non-citizen women. Participants informed that government shelters only accept non-citizens that have been issued protection orders by the courts.

*"There are two types of shelters, shelters run by the NGO and then shelters by [the] government, especially [the] Women Ministry [Ministry of Women, Family and Community Development] and the Jabatan Kebajikan [Welfare Department]. But government shelters that takes migrants are limited to migrant workers who have already been given a protection order; after the case has been determined by [the] police and court. Let's say the charges [pending] can be categorised as human tra*ffi*cking, then* . . . *the person will be given a protection order or an interim protection order during the investigation. Only then, will they be put in the government shelters." CSO-8*

Participants informed that migrants may also be reluctant to obtain refuge and protection at shelters, as they would have to make a report with the police. As government shelters are limited for migrant women, CSOs are an important source of assistance, also providing legal aid and counselling.

#### **4. Discussion**

In Malaysia, female migrant workers are subject to regulation of their reproductive rights with pre-employment and annual screenings for pregnancy, and face termination from employment if found pregnant.

Premature dismissals from employment are financially detrimental to both employers and migrant workers. Nevertheless, we found that information and access to family planning are seldom supplied to migrant workers by employers and not provided for by the government [20]. The state and employers essentially deny that migrant workers are sexually active adults, with the intent of avoiding being seen as promoting promiscuity by raising the topic of SRH. This outdated approach must change towards a pragmatic one, whereby migrant workers, including men, are provided with education and access to low-cost contraceptives. The low contraception prevalence in Malaysia (33.1% for all methods and 23.3% for modern methods) compared to the global estimate for 2019 (48.5% for all methods and 44.3% for modern methods) [27,28] may be explained by social, cultural, and structural barriers and lack of knowledge on contraception [29–32].

Our findings suggest that the choice of contraceptive methods among migrants may be influenced by the perceived risk of pregnancy and its consequences borne by women; hence, female-controlled methods like injectable steroids may be preferable, with less uptake of male-controlled barrier methods like male condoms. Poor uptake of condoms may also be explained by a worrying lack of awareness of STD and HIV prevention [33,34].

Although Malaysia has relatively liberal abortion laws, its interpretation is subject to cultural and religious resistance in the predominantly Muslim nation [35,36]. The Penal Code Act 574 (revised 1997) Section 312 permits safe abortion if performed by a registered medical practitioner and the medical practitioner determines that continuance of the pregnancy endangers the life of the pregnant woman or harms her physical or mental health [37–39].

In 2014, a 24-year-old Nepali migrant worker who opted for an abortion for fear of losing her job was arrested when police raided the clinic where she had her abortion. This Nepali worker was the first woman charged and convicted for having an abortion in Malaysia, although her conviction was subsequently acquitted [40–42]. This case illustrates the plight of migrant women under restrictive immigration laws and labour practices, as even after her innocence was proved and despite being no longer pregnant, the Nepali worker was dismissed by employers for being a "bad role model" [43,44].

Many medical practitioners, especially public sector providers, have conservative views and exercise personal judgement that restricts a woman's access to safe abortion [35]. While abortion services are available at certain private clinics, we found that financial constraints were a likely barrier for less skilled migrant women. Furthermore, the lack of information on where to obtain safe abortions and the underlying social stigma [35,45–47] are plausible drivers for migrant women to seek unsafe abortions, including unregulated medical abortions.

Medical abortion is a non-invasive, effective method for early pregnancy termination (within 49 days of the last menstrual period), that gives control to the woman rather than the healthcare provider [48]. Despite the recent classification of misoprostol and mifepristone as essential drugs–"where permitted under national law and culturally acceptable" by the World Health Organization [49,50], the Ministry of Health, Malaysia has yet to approve their use for medical abortions [36,37].

Notably, no participants undertook pre- or post-abortion counselling, either for their decision-making and feelings around abortion or on contraception post-abortion. We have no evidence for the latter in developed countries on increasing contraceptive uptake and acceptability [51].

Prohibition of pregnancy may result in avoidance of needed care due to apprehensions of job loss and deportation, and this may lead to treatment delays or unsafe abortions. It is accepted as a given by employers and healthcare providers that migrant women will want to terminate pregnancies so they can retain employment. Yet, the legal basis to prohibit pregnancy is unclear, as pregnancy as a clause for dismissal from employment is not specifically included in Malaysia's Employment Act or the Immigration Act [52,53]. Women are effectively coerced by policy and employment contracts into abortions, and this may curtail their reproductive rights.

Migrant workers face complex barriers in accessing healthcare in Malaysia, including financial constraints, the need to present legal documents like passports and work permits at public facilities, language barriers, discrimination, and physical inaccessibility [23,54]. Immigration policies in Malaysia essentially deny maternal and child health services for migrant workers at public facilities. Previous studies support our findings that migrant women are late in initiating antenatal care, while many never attend antenatal clinics and have home births with untrained birth attendants [19,55]. These factors may lead to delivery complications, as migrant women only seek care when critically ill, necessitating more advanced and expensive care [56]. As seen in other settings, migrant women are at higher risk of poor obstetric outcomes, including increased maternal and neonatal mortality, as compared to local women [57,58].

Malaysia successfully lowered maternal mortality through health system strengthening and meticulous auditing of all maternal deaths, including non-citizen deaths, through confidential enquiry into maternal deaths (CEMD) [59–61]. Unfortunately, while non-citizen maternal deaths are investigated in Malaysia, maternal mortality among migrants are not captured in national statistics reported internationally [56,60], raising questions if definitive measures to reduce risk in this group have been attempted.

States have the sovereign right to govern migration within national boundaries. However, the detention of new mothers and their babies for immigration offence may conflict with international laws and conventions. According to the Bangkok Rules or "the United Nations Rules for the Treatment

of Women Prisoners", non-custodial measures are preferred to the detention of vulnerable pregnant women and minor children [62]. Malaysia has ratified both the CEDAW and the Convention on the Rights of the Child (CRC) [16] and is under obligation to provide reasonable care and cater to the special needs of pregnant women, breastfeeding mothers, and mothers with children in custody [63].

In Malaysia, OSCC provides integrated services for victims of GBV at public hospitals [64,65]. While services are available to all women, in theory, barriers remain in practice for non-citizen women. Migrant women, especially those with precarious legal status, are reluctant to report violence or seek medical treatment, for fear of arrest and detention for an immigration offence. Lack of uniform implementation, seen here with confusion regarding the need for victims to report violence at police stations before seeking treatment, is an example of a shortfall in service. We would like to stress the importance of gender-sensitisation training among law enforcement agents, in terms of improving gender sensitivity and reducing discrimination against vulnerable non-citizen women [44,66].

This study has several limitations. Due to the sensitive nature of this study, we had difficulties obtaining interviews with migrant workers, employers, and policy stakeholders. Nevertheless, we were able to triangulate study findings by interviewing diverse key informants, including medical doctors, representatives of civil society organisations, trade unions, and academia. While the qualitative nature of this study precludes the generalisation of findings, we were able to illustrate the landscape of SRH services for migrant women in Malaysia by examining different stakeholder viewpoints and perspectives. We were also unable to fully explore the management of STIs and HIV/AIDS among migrant populations, an important component of SRH which would need dedicated future study.

This study has several strengths. Ours is one of few studies in Malaysia that explore the access to SRH services among vulnerable female migrant workers. We hope that this work will provide a vital understanding of some of the barriers faced by this vulnerable population and opportunities for intervention. We suggest that future quantitative research be conducted to fill the gap in SRRH data in Malaysia disaggregated by citizenship, especially on contraceptive usage, abortion, utilisation of SRH services, and maternal mortality.
