1. Attitudes of Marshallese Women Toward and Barriers to Prenatal Care
Emily Starr, BSN

2. 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 visits throughout the course of the pregnancy.
Visits usually involve medical screening, physical exams, education and counseling, and help with social services for women.

3. 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.

4. 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: migrant(s)/1,000 population (2011 est.)
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5. 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.

6. Marshallese Health Beliefs
Family
“Untraditional” when compared to American notion of “normal”
Multiple families living in same households; kids common
“Clan raised”
Circular migration

7. 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

8. Gender Roles Women: Raising children Home maintenance
Direct decision making
Health issues related to women and children
Men:
Protect family
Provide food and shelter
Speak for the family
Share in decision making

9. 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.

10. Reasons for Leaving RMI
Better health care
Better educational opportunities for children
Family members living in U.S.
Physical lack of land
Population explosion
Poor economy
Employment opportunities in U.S.

11. 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

12. 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 live births in 2003 to 16.8 cases per 1000 live births in 2005

13. 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

14. Purpose
The purpose of this study is to investigate the attitudes toward and impediments to prenatal care among women of child- bearing age in the Marshallese population in Northwest Arkansas.

15. 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?

16. 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)?

17. 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?

18. Sample Qualifications for participation in the study: Female
Marshallese ethnicity
Between the ages of (child-bearing age)
15 participants ranging in age from 19 to 45
Mean age = years; Standard deviation: years

19. 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

20. 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

21. 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
Perceived severity (i.e. the degree to which an individual perceives a condition to be serious)
Perceived benefits (i.e. the degree to which an individual believes that an action will have an outcome that is personally beneficial)
Perceived barriers (i.e. the degree to which negative features of an action deter an individual from compliance)
Components:
Perceived susceptibility (i.e. the degree to which an individual feels personally susceptible to developing a particular condition)
Other variables and cues to action (e.g. demographic, socio- psychological, and structural variables)

22. 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

23. 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

24. 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

25. Time Spent in the U.S.
Ranged from one month to 360 months (30 years)(M=91.27, SD= )
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

26. Atoll Distribution
The majority of participants were from Majuro

27. 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)

28. 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)

29. 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

30. Prenatal Care Locations
More research needs to be done to determine why participants chose the location that they did.

31. 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)

32. 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

33. 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

34. 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

35. 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

36. Evaluation of Barriers to Prenatal Care
Statement 1 2 3 4 5
I couldn’t get an appointment when I wanted one.
11/73.3%
0/0%
4/26.7%
I didn’t have enough money or insurance to pay for my visits.
2/13.3%
I had no way to get to the clinic or doctor’s office.
I couldn’t take time off from work. (n=14)
13/92.9%
1/7.1%
I had no one to take care of my children. (n=14)
12/85.7%
I have to talk to people I don’t know.
12/80%
1/6.7%
I had no problems with previous pregnancies.
3/20%
I was afraid of the medical exam.
10/66.7%
5/33.3%
I was afraid to see a male doctor.
I had a bad experience with prior care. (n=14)

37. 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

38. Health Belief Responses
Questions 1 2 3 4 5
My baby could develop serious health problems if I don’t come for prenatal care.
2/13.3%
0/0%
1/6.7%
11/73.3%
I could develop serious health problems if I don’t come for prenatal care.
13/86.7%
Prenatal care is important to the health of my baby.
14/93.3%
Prenatal care is important to my health during pregnancy.
My baby is going to be born without complications whether or not I go to the doctor.
6/40%
3/20%
5/33.3%
Going to the doctor improves my baby’s likelihood of survival.
9/60%
Going to the doctor has no effect on my baby.
8/53.3%
1.6.7%
Certain illnesses can be prevented by seeking prenatal care.
It will be easy for me to keep my prenatal appointments.
3/13.3%
It will not be easy for me to go to the doctor for prenatal care.
Whenever I’m ill, no matter how mild the symptoms, I take it seriously.
7/46.7%
4/26.7%
Whenever my baby is ill, no matter how mild the symptoms, I take it seriously.
10/66.7%

39. 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

40. 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%
1/7.7%
I learn about changes in my body.
0/0%
12/92.3%
I learn how my baby is doing.
13/100%
I get to talk with someone about my pregnancy.
7/53.8%
4/30.8%
I learn better health habits, such as better eating and exercise.
I learn about the labor and delivery process.
5/38.5%

41. 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)

42. 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

43. 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.”

44. Limitations Small sample size
Interviews conducted by members of the health care community
Use of translators

45. 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

46. 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

47. References
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