By Amy Harris
On May 14, families around the world will celebrate Mother’s Day. Tragically – at a maternal death rate higher than in any other economically developed country – too many U.S. mothers who died because of complications of childbirth will be missing from the celebration. Data from 2018 reflect that only 60% of Mainers identifying as Black, African, or African American received prenatal care, compared to nearly all white Mainers (90%). Yet decades of research show that mothers and babies are healthier when they receive ongoing prenatal care.
Providing culturally competent interpretation services is an essential part of improving maternal health in Maine for non-English speakers.— Malvina Gregory, Director of Interpreter and Cross-Cultural Services at MaineHealth
Data is not available to shed light on complications of childbirth among immigrant and refugee women in the U.S., however nationwide, Black women are three times more likely to die of pregnancy-related causes than white women. In addition, according to the U.S. Centers for Disease Control, Black women are more likely to go into labor early and have a first-birth cesarean (C-section) delivery.
Thirty-three-year-old Malembo M., whose nickname is Elegance, flew from Angola to Brazil in February 2022 with her husband and 1-year-old daughter. On arrival in Brazil, she started bleeding. A pregnancy test done in the airport bathroom revealed she was pregnant for a second time. Still bleeding, she traveled for weeks in land vehicles, by boat, and on foot. Her journey on foot through the jungle lasted five days. Finally, after days living in tents at the Texas border, churches – she wasn’t quite sure which ones – arranged to put her, her husband, and her daughter on a bus to Maine. She never asked to see a doctor during this whole time – she was too terrified. Elegance survived her grueling journey and pregnancy, delivering a healthy child in September 2023.
Federal and state public health agencies do not distinguish between African Americans and African-born immigrants living in the U.S., so U.S. data on maternal health for immigrants and refugees like Elegance is limited. However, European data from countries with growing immigrant and refugee populations, such as Sweden, show that immigrant and refugee women are more likely to die during pregnancy or in the year afterward when compared to Swedish-born mothers. They are also more likely to experience pregnancy-related health complications, have smaller babies, and suffer from postpartum depression. Immigrant women in Sweden were also more likely to report receiving biased care or experiencing discrimination.
In the U.S., many immigrant and refugee women lack the extended family and community support they might have had in their countries of origin. This is true for Elegance, who has lived in a Saco-area hotel room with her husband and young daughter for the past year, uncertain of her citizenship status, housing options, or access to other social supports. Medical research shows that stress and the social determinants of health, such as racism or being unhoused, increase women’s risk for pregnancy complications – such as blood pressure problems, going into labor too early, needing a C-section, or having a baby born too small.
Misinformation destroys trust
A March 9 Black History Month Community Wellness seminar organized by Cross Cultural Services of Lewiston centered the U.S. Black maternal health crisis in Maine by addressing racial disparities in the healthcare experience of mothers. Nadi Kaonga, a fourth-year resident in Obstetrics and Gynecology at Maine Medical Center, was a panelist at the seminar. Structural and institutional racism within the healthcare system means that immigrant and refugee women are less likely to be cared for by someone who looks like them or speaks their language, Kaonga said, and this is stressful for mothers. She described the importance of cultural sensitivity when working with mothers. In speaking of her own practice, she said she is “always trying to keep in mind my patient’s journey before they landed in the emergency department or my exam room.”
In the U.S., most women with a low-risk pregnancy are encouraged to see their maternity care providers for 10-15 prenatal appointments. However, all doctors interviewed for this article reported that pregnant immigrant and refugee women they cared for approached medical care from a place of distrust, believing that something bad was going to be done to them or their baby. Another frequently expressed fear is that everyone giving birth in the U.S. has a cesarean section. Only one in every three women who give birth in Maine has a C-section, but this misinformation feeds the distrust, leading some women to avoid the healthcare system. “A lack of trust limits their access to quality maternity care,” said Dr. Anne M. van Hengel, a member of the Maine Perinatal Quality Committee, a state network of teams working to improve the quality of care for mothers and babies.
Staying out of the doctor’s office because of fear can be dangerous to the mother and the baby. Yet according to Kaonga of Maine Medical Center and Dr. Lisa Parsons, who practices both at MMC and in private practice, the first point of contact with the U.S. healthcare system for many pregnant immigrant mothers is the emergency department. And community members may inadvertently spread misinformation. For example, other women advised Elegance not to take the vitamins prescribed by the emergency room doctor when she first arrived in Maine.
Then during her second trimester, with an undersized baby and suffering from dizziness, Elegance realized something was wrong. She said she “chose not to listen to the rumors” and returned to the doctor, who – with the help of an interpreter – convinced her to take the vitamins. She now advises all pregnant women she meets at the hotel to ignore rumors and consider being seen at a hospital early in pregnancy. Happily, her baby boy was born healthy.
Community health workers and cultural competency build trust
Maine maternal healthcare providers such as van Hengel, Parsons, and Kaonga believe community health workers (CHWs) are a critical means to improving access to quality perinatal care for refugee and immigrant women. Grace Lapika is a CHW from the Democratic Republic of Congo. She speaks five languages and was hired as part of MaineHealth’s Community-Informed Care Initiative. In her role as a CHW, she has helped pregnant mothers access clothing and diapers, negotiated transportation, and ensured that any medications prescribed have instructions translated into the correct language. She also works to counteract rumors and misinformation about prenatal care, such as “Don’t go to the hospital, especially in early pregnancy, because people might not treat you well, and you could end up having a miscarriage.”
Providing culturally competent interpretation services is an essential part of improving maternal health in Maine for non-English speakers. According to Malvina Gregory, Director of Interpreter and Cross-Cultural Services at MaineHealth, “In OB/GYN situations, the calming presence of an in-person interpreter can vastly improve a patient’s birth experience.”
Unfortunately, not all non-English speakers know they have a right to have an interpreter present for all medical appointments or interactions. Also, there is a statewide shortage of interpreters. MaineHealth is actively recruiting and hiring Arabic, French, Kinyarwanda, Lingala, and Spanish interpreters, Gregory said.
Local practitioners suggest that group prenatal care could be a cost-effective way to increase prenatal care acceptance. Group prenatal care builds a supportive community for expectant mothers that may be culturally familiar. And advocates suggest that cultural doulas could be another part of a more inclusive care community for Maine’s pregnant immigrant and refugee women. Doulas are nonclinical birth workers trained to provide physical, emotional, and informational support to pregnant people in the prenatal, birthing, and postpartum periods. According to the New York Times, trained cultural doulas in Sweden who work alongside midwives have been shown to reduce the risk of complications and interventions during childbirth among refugee and immigrant women.
While Elegance did not interact with any CHWs, attend group prenatal care, or have a cultural doula, she said she was “very happy and relieved when she realized that there were interpreters available to her.” At the emergency room, she was reassured that her bleeding was most likely related to her arduous journey and lack of adequate food. Care providers and translators built enough trust through translation and culturally sensitive care that Elegance returned for regular prenatal appointments right up until the birth of her son.
Maine CDC Maternal and Child Health Program, a collaborative team of statewide experts and stakeholders working to improve the quality of care for mothers and babies in Maine, believes a critical gap in data exists in perinatal health in Maine. To help the collaboration understand Maine’s maternal health picture, they offer stipends and translation for residents like Elegance who are interested in telling their birth stories. The hope is that by approaching the problem on all fronts – including gathering better data, providing group prenatal care and cultural doulas, and adding more CHWs and interpreters – expectant mothers will trust the health system more, seek healthcare, and thereby improve outcomes for themselves and their babies.