Ethnolinguistic Concordance and the Provision of Postpartum IUD Counseling Services in Sri Lanka

Poor communication and a lack of mutual trust have long been cited as contributors to a weak patient-physician relationship and may contribute to the provision of ineffective medical care. In particular, interpersonal barriers resulting from linguistic, racial, ethnic or cultural differences between patients and providers may exacerbate disparities in utilization, care-seeking behavior and health experienced by minority groups relative to the majority. Sri Lanka presents an interesting case study for the effect of differences such as ethnicity and language on healthcare, as the conflict between its majority Sinhalese population and the minority Tamil population dates back thousands of years. 

In a new journal article, published in International Perspectives on Sexual and Reproductive Health, Mahesh Karra and colleagues examine the relationship between ethnolinguistic concordance and the provision of postpartum contraception counseling services in Sri Lanka. To examine how concordance between women and their primary health midwife is associated with women’s receipt of postpartum intrauterine device counseling, the authors merged data on 4,497 women who gave birth at six hospitals in Sri Lanka between September 2015 and March 2017 with data on 245 primary health midwives, generating indicators of linguistic concordance, ethnic concordance and the patient-midwife interaction.

Main findings:

• Women from non-Sinhalese groups in Sri Lanka face disparities in the receipt of postpartum IUD counseling. Indian Tamils had the highest proportion of women not counseled before hospital admission (58 percent), compared with 44 percent of Sinhalese women, 42 percent of Sri Lankan Tamil women and 36 percent of Sri Lankan Moor women.
• Compared with the ethnolinguistic majority (Sinhalese women who speak only Sinhala), non-Sinhalese women have lower odds of having received postpartum IUD counseling, whether they speak both Sinhala and Tamil, or only Tamil. 
• Ethnic discordance— rather than linguistic discordance—is the primary driver of this disparity.

There are several possible reasons that could explain differences in receipt of care. It is possible differences are driven by unobservable biases against ethnic minorities, or Sinhalese providers may be more hesitant to offer family planning counseling and services to non-Sinhalese patients for fear of reprisal from the non-Sinhalese population. By the same token, it may also be non-Sinhalese women are more reluctant to receive services from Sinhalese primary health midwives due to mistrust. Regardless of the reasons, the findings imply differences in service provision cannot be eliminated simply by matching providers and patients on language alone. Matching on ethnicity may also be required to further reduce disparities in service provision until such underlying ethnic tensions are addressed.