Attitudes of Marshallese
Women Toward and Barriers
to Prenatal Care
Emily Starr, BSN
What is Prenatal
Care?
Prenatal care: any health care given to a pregnant
woman after conception and before birth.
Usually commences during the first trimester of
pregnancy and includes 10-14 visits throughout the
course of the pregnancy.
Visits usually involve medical screening, physical
exams, education and counseling, and help with
social services for women.
Benefits of Prenatal
Care
Can reduce the likelihood of a woman giving birth early
or to a low-birth-weight baby, as well as detect various
anomalies that can be treated in-utero.
Can decrease the time a neonate spends in the hospital,
thereby reducing overall costs which is especially
important for low-income women.
Improve the mother’s health by detection of conditions
that the woman may develop during pregnancy (e.g.
hypertension and diabetes) which could pose a potential
threat to the fetus.
Republic of the Marshall
Islands
Population:67,182 (July 2011 est.)
Infant mortality:23.74 deaths/1,000
live births (2011 est.)
Life expectancy:71.76 years (2011
est.)
Fertility rate:3.44 children
born/woman (2011 est.)
Median age: 21.8 years (2011 est.)
Net migration rate:-5.19
migrant(s)/1,000 population (2011
est.)
rm-map.gif
Health Status in the
RMI
“Dual epidemic:” chronic health issues (e.g. heart
problems and diabetes) and communicable diseases
(e.g. Hansen’s disease, tuberculosis, etc.)
Transition from marine foraging to more sedentary
lifestyles plus American dietary principles has led to
increases in obesity, cardiovascular disease, diabetes,
etc.
Malnutrition: diet poor in vitamins and minerals
Radiation related issues: thyroid, some cancers, etc.
Marshallese Health
Beliefs
Family
“Untraditional” when compared to American
notion of “normal”
Multiple families living in same households; 8-12
kids common
“Clan raised”
Circular migration
Health Beliefs Cont’d
Time
Focus on the present, little regard for future
Makes preventative care difficult
Frustrates appointment schedules
Illness
Illness=pain. Therefore, if no pain, no illness. Will discontinue
treatment when begin to feel better
Sick are often shunned and feel ashamed so do not readily admit
illness
Gender Roles
Women:
Men:
Raising children
Protect family
Home maintenance
Provide food and
shelter
Direct decision making
Speak for the family
Health issues related
to women and children
Share in decision
making
Compact of Free
Association
Issued in 1986, outlines relationship between U.S. and RMI:
U.S.: provides defense protection, financial aid, the ability to enter
and exit the country without visa or time limit
RMI: continues to serve as a nuclear testing site and provide
exclusive military rights to the United States
A Marshallese individual may enter the U.S. with only a passport,
obtain a social security number, work, attend school, and serve in the
U.S. military.
The compact does not provide a pathway to citizenship and prohibits
most state or federal funding.
Reasons for Leaving
RMI
Physical lack of land
Better health care
Population explosion
Poor economy
Better educational
opportunities for
children
Employment
opportunities in U.S.
Family members living
in U.S.
Background
The Marshallese population of NWA is estimated to
be between 6,000 and 10,000 (the highest number
outside of the Marshall Islands)
The incidences of tuberculosis, Hansen’s disease,
diabetes, HIV, syphilis (including congenital), and
perinatal hepatitis B are all increased in the
Marshallese population when compared to the
general population
Health Profile
67% of congenital syphilis cases in NWA were of
Marshallese ethnicity
54% of these cases were identified at birth (only
31% were identified during prenatal screening)
The incidence of perinatal hepatitis B among
Marshallese increased from 8.1 cases per 1000
live births in 2003 to 16.8 cases per 1000 live
births in 2005
Trends in Prenatal
Care
Less likely to seek prenatal care: 34% of
Marshallese women do not seek prenatal care
whereas only 2% of non-Marshallese women do not
Less likely to be screened for HBsAG: 57% of
Marshallese women were screened, as compared
to 91% of non-Marshallese women
More likely to test positive when screened for
HBsAG: 10% of Marshallese women tested
positive, as compared to 0% of non-Marshallese
women
Purpose
The purpose of this study is to investigate
the attitudes toward and impediments to
prenatal care among women of childbearing age in the Marshallese population
in Northwest Arkansas.
Aim 1
Aim 1: Explore the attitudes of Marshallese women
towards prenatal care.
Research question 1: How does the Marshallese
culture view prenatal care?
Research question 2: How do Marshallese women
describe their experience with prenatal care in
northwest Arkansas?
Aim 2
Aim 2: Explore barriers to prenatal care as
viewed by Marshallese women.
Research question 1: How knowledgeable are
Marshallese women of child-bearing age about
opportunities for prenatal care in northwest
Arkansas?
Research question 2: What environmental factors
impact noncompliance (e.g. money,
transportation, etc)?
Aim 3
Aim 3: Identify ways to improve Marshallese
women’s experience with prenatal care.
Research question 1: What suggestions to
improve prenatal compliance do Marshallese
women have?
Research question 2: What measures by health
care professionals and institutions do
Marshallese women identify would promote a
better prenatal experience?
Sample
Qualifications for participation in the study:
Female
Marshallese ethnicity
Between the ages of 18-45 (child-bearing age)
15 participants ranging in age from 19 to 45
Mean age = 33.13 years; Standard deviation: 7.298
years
Design
An interview was developed based on the
health belief model
Accompanied nurse from the Washington
County Health Department on Marshallese
home visits to interview participants
Accompanied member of the Marshallese
community associated with the Marshallese
consulate to conduct interviews
Interview Details
Qualitative exploratory interview process
Each interview occurred face-to-face and an
interpreter was present for each interview
Each interview took about 30 minutes
Each participant had her own copy of the interview
on which responses were recorded
Informed consent was acquired at the beginning of
each interview
Health Belief
Model
Individuals will not take action to treat,
control, or prevent a health problem
unless they perceive that the problem
is serious in nature and consequences,
that taking action will produce a
desired outcome beneficial to them,
and that few obstacles exist in taking
said action
to which an individual perceives a
condition to be serious)
Components:
Perceived barriers (i.e. the degree
to which negative features of an
action deter an individual from
compliance)
Perceived susceptibility (i.e. the
degree to which an individual feels
personally susceptible to
developing a particular condition)
Perceived severity (i.e. the degree
Perceived benefits (i.e. the degree
to which an individual believes that
an action will have an outcome that
is personally beneficial)
Other variables and cues to action
(e.g. demographic, sociopsychological, and structural
variables)
Interview Breakdown
43 questions
13 questions involved demographic inquiries (e.g. age, time lived in United
States, number of children, etc.)
10 questions were related to potential barriers to receiving prenatal care (e.g.
transportation, money, etc.)
12 questions were related to prenatal health beliefs:
2 questions addressed perceived susceptibility, 4 questions addressed
perceived severity, 4 questions addressed perceived benefits, and 2
questions addressed perceived barriers
6 questions involved evaluation of reasons to seek prenatal care
2 questions inviting participants to share other thoughts, experiences, etc.
related to prenatal care
Approval and
Funding
Interview approved by Department of Health
nurse as well as member of the Marshallese
community
University of Arkansas Institutional Review
Board (IRB) approval
Experimental Program to Stimulate
Competitive Research (EPSCoR) grant funding
Data Analysis
Mean, median, standard deviation, and frequencies
were performed on all of the data to assess for
initial patterns and trends
Non-parametric correlation test utilizing Spearman
rho was done to identify significant relationships
between data
Some items asked the same question in different
ways, so variables were combined. Reliability
analysis was run for each combination
Time Spent in the
U.S.
Ranged from one month to 360 months (30 years)(M=91.27,
SD=101.321)
The longer one spends in the country, the less likely it is that
the pregnancy was planned (p<0.023)
The more time spent in the U.S., the less likely it is to be
afraid to talk to strangers, especially male doctors (p<0.004)
Many participants said that they would be willing to go to a
foreign male doctor, but not a Marshallese male doctor
Atoll Distribution
The majority of
participants were from
Majuro
Health Insurance
46.7% (n=7) of participants do not have any form of
health insurance.
Of the 53.3% (n=8) who do have health insurance,
50%(n=4) identified themselves as possessing
public insurance (e.g. Medicaid) whereas the other
50% (n=4) possess private insurance (e.g. through
job or spouse’s job).
The more children one has, the more likely that the
individual will have some sort of health insurance
(p<0.009)
Number of Children
The number of children per
participant ranged from 1 to 7
(M=4.07, SD=1.831).
The incidence of adoption among
participants can be seen in Table 2.
Only one participant had any
children die.
The more children one has, the less
likely to be afraid of seeing a male
doctor (p<0.043)
Number of
Prenatal Visits
100% (n=3) of participants
who did not receive any
prenatal care had a problem
during delivery (p<0.009)
In 2005, 34% of Marshallese
women received no prenatal
care
Prenatal Care
Locations
More research needs to
be done to determine
why participants chose
the location that they did.
Problems During
Pregnancy
20% (n=3) of participants admitted to having a
problem during pregnancy.
Complications identified: urinary tract infection,
renal issues, diabetes mellitus, and baby in
breech position (Caesarean-section necessitated
upon delivery)
Complications During
Delivery
26.7%(n=4) of participants conceded to having
complications during delivery.
Problems during delivery included: Caesarean-section
(n=2, 13.3%), cord wrapping around baby’s head (n=1,
6.7%), and baby being born prematurely (n=1, 6.7%).
100%(n=4) of participants who had a problem during
delivery strongly agreed (rated as 5) that they were
afraid of the medical exam in the barrier portion of the
interview
Incidence of Regular
Health Care Providers
80%(n=12) of participants do not see a doctor or
health care provider for regular check ups
This correlates to two Marshallese health beliefs:
the absence of pain indicates that they are
healthy, and the focus on the present with little
notion of preventative health care
Incidence of Planned
Pregnancy
20%(n=3) of participants’ most recent pregnancy
was planned.
This could be attributed to a cultural/religious belief
or a lack of awareness about family planning.
More research could be done to ascertain the
reason why women do not plan pregnancies
Methods of Confirming
Pregnancy
80%(n=12) confirmed themselves as pregnant
20%(n=3) of participants confirmed their most recent
pregnancy by going to a doctor or health clinic,
20%(n=3) by experiencing nausea/morning sickness,
33.3%(n=5) by missing a menstrual cycle, and
26.7%(n=4) claimed they “knew” they were pregnant.
Potentially dangerous for mother and fetus
Evaluation of Barriers to
Prenatal Care
Statement
I couldn’t get an appointment when I
wanted one.
1
2
3
4
5
11/73.3%
0/0%
0/0%
0/0%
4/26.7%
I didn’t have enough money or insurance
11/73.3%
to pay for my visits.
0/0%
0/0%
2/13.3%
2/13.3%
I had no way to get to the clinic or
doctor’s office.
11/73.3%
0/0%
0/0%
0/0%
4/26.7%
I couldn’t take time off from work. (n=14) 13/92.9%
0/0%
0/0%
0/0%
1/7.1%
I had no one to take care of my children.
12/85.7%
(n=14)
1/7.1%
0/0%
0/0%
1/7.1%
I have to talk to people I don’t know.
12/80%
0/0%
0/0%
2/13.3%
1/6.7%
I had no problems with previous
pregnancies.
3/20%
0/0%
0/0%
0/0%
12/80%
I was afraid of the medical exam.
10/66.7%
0/0%
0/0%
0/0%
5/33.3%
I was afraid to see a male doctor.
10/66.7%
0/0%
1/6.7%
1/6.7%
3/20%
I had a bad experience with prior care.
(n=14)
12/85.7%
1/7.1%
0/0%
0/0%
1/7.1%
Most Common
Barriers
Top four deterrents to prenatal care were:
No problems with previous pregnancies
Fear of the medical exam
Difficulty getting an appointment
Transportation
Health Belief
Responses
Questions
1
2
3
4
5
My baby could develop serious health problems if I don’t come for
2/13.3%
0/0%
1/6.7%
1/6.7%
11/73.3%
I could develop serious health problems if I don’t come for prenatal care. 1/6.7%
0/0%
1/6.7%
0/0%
13/86.7%
Prenatal care is important to the health of my baby.
1/6.7%
0/0%
0/0%
0/0%
14/93.3%
Prenatal care is important to my health during pregnancy.
1/6.7%
0/0%
1/6.7%
2/13.3%
11/73.3%
1/6.7%
0/0%
6/40%
3/20%
5/33.3%
Going to the doctor improves my baby’s likelihood of survival.
3/20%
1/6.7%
1/6.7%
1/6.7%
9/60%
Going to the doctor has no effect on my baby.
8/53.3%
2/13.3%
1.6.7%
2/13.3%
2/13.3%
Certain illnesses can be prevented by seeking prenatal care.
2/13.3%
0/0%
1/6.7%
1/6.7%
11/73.3%
It will be easy for me to keep my prenatal appointments.
3/13.3%
0/0%
0/0%
1/6.7%
11/73.3%
It will not be easy for me to go to the doctor for prenatal care.
8/53.3%
3/20%
1/6.7%
2/13.3%
1/6.7%
Whenever I’m ill, no matter how mild the symptoms, I take it seriously.
7/46.7%
1/6.7%
2/13.3%
1/6.7%
4/26.7%
2/13.3%
1/6.7%
0/0%
2/13.3%
10/66.7%
prenatal care.
My baby is going to be born without complications whether or not I go to
the doctor.
Whenever my baby is ill, no matter how mild the symptoms, I take it
seriously.
Health Belief Trends
Results in the context of the health belief model:
83.4%(n=12.5) perceived susceptibility for themselves and their baby
90%(n=13.5) perceived the benefits of prenatal care
56.7%(n=8.5) perceived severity
73.2% perceived no barriers
Based on these numbers, it is important to focus on:
Increasing awareness of severity by specifying consequences of the risk and
the condition
Removing identified barriers
Evaluation of Reasons for
Seeking Prenatal Care
Reason for Seeking Prenatal Care
1
2
3
4
5
I get to meet other pregnant women.
6/46.2%
2/15.4%
2/15.4%
1/7.7%
2/15.4%
I learn about changes in my body.
1/7.7%
0/0%
0/0%
0/0%
12/92.3%
I learn how my baby is doing.
0/0%
0/0%
0/0%
0/0%
13/100%
7/53.8%
1/7.7%
1/7.7%
0/0%
4/30.8%
0/0%
0/0%
1/7.7%
0/0%
12/92.3%
5/38.5%
0/0%
1/7.7%
1/7.7%
6/46.2%
I get to talk with someone about my
pregnancy.
I learn better health habits, such as better
eating and exercise.
I learn about the labor and delivery process.
Most and Least Important
Reasons for Seeking Prenatal
Care
Top reasons for seeking prenatal care:
Learning how the fetus is doing, learning better health
habits, and learning about changes in the mother’s
body
Less important reasons for seeking prenatal care:
Being able to talk about pregnancy
Learning about labor and delivery process (if
multipara)
Future Prenatal
Care
All participants said that they would seek prenatal
care in the future
The reasons given were as follows: 26.7%(n=4)
gave no reason, 40%(n=6), claimed that it was
best for the baby’s health, and 33.3%(n=5) stated
that it was necessary for both mother and baby’s
health
Comments on
Prenatal Care
“Prenatal care is too expensive in the United
States.”
“Nurses can be rude and racist. I felt very judged
and uncomfortable.”
“Put God first because He can take care of all of
your health needs.”
“Someone made an error when they were closing
up my belly after my C-section.”
Limitations
Small sample size
Interviews conducted by members of the health
care community
Use of translators
Implications for Further
Research
Expand to larger sample size
Compare health beliefs with other immigrants in
northwest Arkansas
Compare results with other Marshallese populations
Reason behind choice of prenatal care location
Reason why do not have a regular health care
provider
Acknowledgments
Sandy Hainline and the Washington County Health
Department
Melisa Laelan
Dr. Marianne Neighbors and the Eleanor Mann
School of Nursing
Ling Ting from the University of Arkansas
Marshallese community
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