Marty Handly, RN, MSN District Coordinator Jessica Craig, MPH Epidemiologist Nunmawi Bualteng, RN, BSN Public Health Nurse Khawl Puii, BLA Prenatal Community Health Worker Pam Desir, MS, RD, CD, IBCLC District Nutritionist
Occurs fairly soon after arriving to Indianapolis Feel safe -- Humane housing/living conditions -- Strong Chin presence and community network -- Different to become pregnant in Burma vs. U.S. Trends emerging – issues with nutrition, prenatal care, L&D, LBW infants, & infant mortality
Birth Outcomes: Burmese Chin All birth and infant death data originates from the MCPHD’s vital records department – Birth and death certificates How Burmese records were located – Burma – Malaysia – Thailand – Myanmar
Very Low Birth Weight: Any birth at or below 1500 grams
Birth Outcomes: Very Low Birth Weight Very Low Birth Weight: Any birth at or below 1500 grams
Birth Outcomes: Maternal Smoking Maternal Smoking: Any smoking by the mother during pregnancy
Birth Outcomes: First Trimester PNC First Trimester Prenatal Care: Prenatal care that is initiated in the first 3 months of pregnancy
Birth Outcomes: Breastfeeding Breastfeeding: Any mother that initiates breastfeeding upon hospital release
Burmese Infant Mortality Rate Infant Mortality Rate: The number of infant deaths per 1000 live births
Burmese MCH Outcomes: Highlights Below HP2020 targets for LBW, VLBW, Preterm delivery, and maternal smoking -Maternal smoking does not include chewing tobacco use Less likely to receive first trimester PNC Burmese women are close to meeting HP2020 target for breastfeeding
Data Limitations There is not a good way to find Burmese, specifically Chin, on birth and death certificates – Race/ethnicity fields lack specific information, often times literal fields are not completed For this analysis, births from Malaysia, Burma, Thailand, and Myanmar were included – Likely will cause and overestimation
Pregnancy Family = Father + Mother + Children More children = more members in the family/clan = more powerful Does not delay to conceive pregnancy once one is married. Repeated pregnancies with minimal time gaps not uncommon.
Prenatal care in Burma Healthcare facilities available in most towns and cities only. (Not enough medicines/supplies/staff) Access to care may also depends on socioeconomic status. Little or absolutely no prenatal care in rural areas. No prenatal vitamins/not enough nutrition Lack of knowledge in taking care of self during pregnancy.
Labor and Delivery Not uncommon to deliver at Home (by elderly women who has more experience in helping childbirths in the village/or Midwives) Natural birth is common. (may have epidural in cities) Death d/t hemorrhage during and after childbirth is seen especially in rural areas and especially among low socioeconomic groups. (no resource for blood transfusion)
Labor and Delivery Post-partum Stay home for about 3 months and does no household chores(considered unclean/weak).
Stillbirth/ Infant death “Dry Birth” : considered some kind of spiritual force; believed to have Good wealth if followed the instructions given in dreams by the “ Hminsa” “a chaut” meaning “dried baby” Not inform to public, not even to friends and relatives (considered has no spirit/unclean yet if the infant died before 3 months of age)
Stillbirth/ Infant death cont. Funeral is quiet and only immediate family members involved. 7 days mourning period (traditionally) and move on with daily lives.
Naming the child Burman: Buddhist rituals, involve Monks, astrologers, name given depending on the day of the week and date the child is born (according Burmese calendar) May have birth/nick- name and Given name. No Surname. Chins: Names given by Grandparents or someone honorable to the family. Names not spoken and kept secret until the child is born.
Myths No spicy food- child will have less hair if not bald Having sex during pregnancy may kill fetus Taking Vitamin will make Moms eat more and will have Big babies One tribe (Asho-Chin) abstain from meat during pregnancy due to the believe that the child will look like the meat taken.
Khawl Puii, BLA Prenatal Community Health Worker
As a CHW I enroll clients in the Prenatal Care Coordination Program during a home visit. I also discuss WIC Program, Medicaid/Hoosier Health wise, breastfeeding/nutrition, smoking cessation, English class.
Typically, CHIN women do not seek prenatal care at the beginning of pregnancy. Reason why: 1.Women do not realize the importance of early Prenatal care.
2.Fear of going to the doctor—bad experience-torture in Malaysia and Burma. 3.Language bearer 4. Lack of Medicaid 5.No transportation 6.No child care 7.No Prenatal care where they come from Burma, Refugee Camp. 2.Fear of going to the doctor—bad experience-torture in Malaysia and Burma. 3.Language bearer 4. Lack of Medicaid 5.No transportation 6.No child care 7.No Prenatal care where they come from Burma, Refugee Camp.
In addition during TB home visits and enrolling clients in the Prenatal Care Coordination Program, I will mention the Program is also available for others. Women then call me regarding enrolling in the program and a home visit is scheduled.
Pam Desir, MS, RD, CD, IBCLC District Nutritionist
Areas of Need Referrals from PHNs, WIC RDs, and CHWs requesting dietary assessment and education Main reason(s) for request: – Prenatal weight gain – Breastfeeding – Underweight child
Nutrition and Food The staple food for the Chins in the U.S. is rice. Rice is eaten at every meal, usually with vegetables and meat. – White rice is preferred by the refugee community as the brown rice in the U.S. is not considered as tasty as the brown rice grown at home in Burma. – Additionally, brown rice is less desirable because the grain is not polished. Meat is typically boiled with vegetables (mustard greens or cabbage) or fried with oil. The typical ingredients used by Chins for their meals are available in most Asian food markets in the United States.
Nutrition and Food Traditionally, refugee families have two meals/day Meal is built around rice, with some meat and some vegetables Often a porridge Skip “breakfast”
Areas of Need Prenatal women need more calories and nutrients – Third meal – Healthy snacks – More vegetables and fruits – Iron rich foods Breastfeeding women need support and nutrients – Third meal – Iron rich foods – Continue prenatal supplements – Lactation support
Areas of Need Families need more balance in each meal – Less rice – More vegetables and fruits – Healthy snacks – Non-sugary beverages Children need more opportunities to eat – Third meal – Healthy snacks – Need more vegetables and fruits – Toddlers need to discontinue a nursing bottle
Three Apartment Communities Regency Park Green Tree Berkley Commons These three communities had the bulk of referrals Decided to do monthly classes here – Nutrition in pregnancy and after – Breastfeeding – Feeding your family
Class Topics Prenatal nutrition and breastfeeding How to feed your family Classes alternated monthly One class session per community Served Mango Yogurt Lassi
Future Plans Need for preconceptual and interconceptual nutrition education Partner with WIC to develop and implement classes
Requires -- Cultural Understanding -- Patience -- Overcoming the language barriers -- Ongoing education on the U.S. health care system and standards of care -- Use of Chin experts in the community
Increased screening labs being drawn in the initial refugee screening clinic which includes Comprehensive chemistry panel CBC with differential Hepatitis A & B – screen for C if risk factors present Urinalysis Pregnancy testing QuantiFeron gold for TB screening Syphilis HIV screening
Care Coordination referrals written on the day of the refugee initial screening appointment if pregnancy test is positive Host Care Coordination health fairs in apartment complexes Education classes to the Chin churches on why early prenatal care is important Educational partnership classes monthly at the Chin Community Center with St. Francis Hospital staff Care Coordination classes to be offered by tribe at the Chin Community Center early 2015
Regular meetings with St. Francis Hospital staff to ensure referrals are generated on all Chin women delivering babies in their hospital Continue case finding efforts on all home visits to enroll Chin women into the Care Coordination program Continue and grow the nutrition and breastfeeding classes in the apartment complexes where Chin reside Continue to monitor the infant mortality statistics Genetic counseling as appropriate Regular meetings with St. Francis Hospital staff to ensure referrals are generated on all Chin women delivering babies in their hospital Continue case finding efforts on all home visits to enroll Chin women into the Care Coordination program Continue and grow the nutrition and breastfeeding classes in the apartment complexes where Chin reside Continue to monitor the infant mortality statistics Genetic counseling as appropriate