Providers’ perspectives of barriers experienced in maternal health care among Marshallese women

Abstract

Problem: Pacific Islanders are disproportionately burdened by poorer maternal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care. Purpose: The purpose of this study was twofold: 1) to explore maternal health care providers’ perceptions and experiences of barriers in providing care to Marshallese women, and 2) providers perceived barriers of access to care among Marshallese women. This is the first paper to explore perceived barriers to maternal health care among a Marshallese community from maternal health care providers’ perspectives in the United States. Methods: A phenomenological, qualitative design, using a focus group and in-depth interviews with 20 maternal health care providers residing in northwest Arkansas was chosen. Findings: Several perceived barriers were noted, including transportation, lack of health insurance, communication and language, and socio-cultural barriers that described an incongruence between traditional and Western medical models of care. There was an overall discord between the collectivist cultural identity of Marshallese families and the individualistic maternal health care system that merits further research. Discussion: Solutions to these barriers, such as increased cultural competency training for maternal health care providers and the incorporation of community health workers are discussed.

Introduction

The promotion of adequate and consistent maternal health care, starting in the first trimester of pregnancy, is a United States (US) Healthy People 2020 priority.^1,2 Over the past two decades there have been numerous policy initiatives at the federal and state levels intended to increase access and early utilization of quality maternal health care, especially among women who are a racial and/or ethnic minority who have the greatest disparities in maternal outcomes.^3–8 Although these policy efforts have resulted in significant improvements in maternal care access, when data are disaggregated there is evidence of continuing disparities among women who are a racial and/or ethnic minority.^4–6,9–11

There is increasing recognition that addressing maternal health disparities requires a greater understanding of the barriers to maternal care. For example, African American, Cree, Malawain, and Hispanic mothers in the US report experiencing numerous barriers to accessing care such as lack of language services, transportation, and economic constraints.^10,12–16 Additionally, women who are a racial and/or ethnic minority cite socio-cultural barriers such as fear, paternalistic and prejudiced care from providers, models of care that are incongruent with cultural beliefs, perceptions of mistreatment, and an overall lack of trust for maternal health care providers as barriers to accessing maternal care.^{9,12,13,15–18}

Pacific Islanders are disproportionately burdened by poorer maternal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care compared to other racial and/or ethnic minorities.^10,11,19,20 Within the US, Pacific Islander groups, including the Samoan, Marshallese, and Tongan communities, are less likely to receive maternal health care in the first trimester compared to other racial and ethnic groups.¹¹ There is limited literature on perceived barriers to maternal health care among Pacific Islanders residing in the US. However, the available literature on perceived barriers to maternal health care among Pacific Islanders residing outside the US identified: 1) having multiple children; 2) mother’s occupation; 3)employment status of both parents; 4) transportation; 5)stressful life events during pregnancy; 6) a lack of respect from health care providers; and 7) limited options to carry out cultural practices as barriers influencing their utilization of early and consistent maternal health care.^10,21,22

Background

Between the 2000 and 2010 census, Pacific Islanders were the second fastest growing population in the US with the fastest growth occurring in the South (66%), primarily in Arkansas (252%), where a majority of Pacific Islanders are Marshallese.^23,24 The US controlled the Marshall Islands as part of the Trust Territory of the Pacific Islands from 1947 to 1986.²⁵

Upon signing of a Compact of Free Association (COFA) between the Republic of the Marshall Islands (RMI) and the US in 1986, the RMI became a sovereign nation.²⁶ The COFA grants Marshallese citizens’ rights to enter the US to reside and work without a visa or permanent resident card. Although COFA migrants were eligible for Medicaid when the compact was signed in 1986, in 1996 Marshallese migrants became ineligible for Medicaid with the implementation of the federal Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA).²⁷ The PRWORA did not include COFA migrants in the category of qualified immigrants. Although Medicaid coverage can be implemented by states with no federal monies, Arkansas has not funded Medicaid for COFA migrant adults. While non-pregnant persons (adults or children) are not covered by Medicaid, pregnant COFA woman are eligible for Medicaid.²³

The RMI was the central site of the US’s nuclear testing program from 1946 until 1958.²⁶ The nuclear tests were equivalent in payload to ~7,200 times that of Hiroshima-sized bombs.²⁷ The RMI is documented as having very high levels of nuclear contamination, which exposed islanders to significant levels of nuclear radiation. Researchers conducted studies to assess the effects of the nuclear radiation fallout without informed consent or appropriate language translation, adding to the historical trauma of the Marshallese community.²⁶ Like other cultures who have experienced historical trauma, the Marshallese community exhibits distrust in health professionals and health research, which may affect the Marshallese community’s perceptions of maternal health care providers.^28–32 To overcome these challenges a community-based participatory research (CBPR) team was developed that has been working with the Marshallese community in northwest Arkansas since 2012.³³ CBPR was uniquely suited to engage equitable collaboration among both the community co-investigators and all the research partners thus improving study design, data collection and analysis, interpretation, and dissemination of results.³⁴ The CBPR approach used in this study has helped the academic and community co-investigators build trust within the community and help improve the capacity to conduct further research on topics the community identified as most important.³⁵

There has been a dearth of literature exploring Pacific Islanders perceived barriers to maternal health care residing in the US.³⁶ This study extends the researchers’ CBPR work with the Marshallese community residing in the US that documented Marshallese women’s perceptions and experiences with structural barriers to maternal health care such as language barriers, transportation, health insurance, and socio-cultural barriers such as a lack of understanding of the importance of maternal health care, social stigma, and fear.³⁶ Maternal health care providers are integral to successful perinatal care, birthing experience, and perinatal outcomes; therefore, it is important to understand providers’ perspectives. The purpose of this study was twofold: 1) to explore maternal health care providers’ perspectives of barriers in providing care to Marshallese women; and 2) providers perceived barriers of access to care among Marshallese women.

Methods

A phenomenological, qualitative design, using focus groups and in-depth interviews with maternal health care providers was chosen. The inclusion criteria were that the providers: provided maternal health care, worked with the Marshallese community, were 18 years or older, and practiced in northwest Arkansas. Local providers who were known to work with the Marshallese community were recruited via email and phone calls and additional providers were approached via snowball sampling (i.e. asking maternal health care providers who were interviewed to recommend additional participants for the interviews). Written and verbal information about the study was provided English, and verbal consent was obtained prior to data collection. After consent, providers completed a brief survey that included questions on demographic characteristics, credentials, and the number of years they have provided care to the Marshallese community. (Table 1) Three participants did not complete surveys. Study procedures were reviewed and approved by the University of Arkansas for Medical Sciences (UAMS) Institutional Review Board (IRB) # V4362017.

Table 1.

Maternal Health Care Provider Demographics

Provider Characteristic	Number (%)
Sex
Female	15 (88.2)
Male	2 (11.8)
Race/Ethnicity
White Non-Hispanic	15 (88.2)
Hispanic	2 (11.8)
Credentials
RN	8 (53.3)
APRN	4 (26.7)
MD	3 (20.0)
Years of Experience (Mean ± SD)	10.97 ± 8.10
Provides On-Site Translation
Yes	11 (64.7)
No	6 (35.3)
Provides Cultural Training
Yes	10 (58.8)
No	7 (41.2)

Note: Only valid percentages shown. SD = standard deviation.

From March of 2015 to March of 2017, a purposive sample of 20 maternal health care providers were interviewed using a focus group and individual interviews until saturation was achieved. The focus group included 12 providers, and 8 providers chose individual interviews. Three female researchers trained in qualitative research methods, facilitated the focus group and individual interviews. A semi-structured interview guide with open-ended questions was used to encourage providers to speak candidly while maintaining consistent inquiries across the focus group and interviews. (Table 2) Questions focused on maternal health care providers’ perceptions and experiences of barriers in providing care to Marshallese women, and providers’ perceived barriers of access to care among Marshallese women. The focus group and interviews took approximately thirty minutes to one hour and were conducted in maternal health care providers’ offices.

Table 2.

Semi-structured interview guide: topics and example sub-questions

Maternal Child Health Providers What are some of the health issues most commonly encountered within your Marshallese patient population related to prenatal/postnatal care? In terms of “compliance” what are some of the most common issues seen among your Marshallese patients related to prenatal/postnatal care? How much and what kind of feedback have you received from your Marshallese patients regarding barriers to care related to prenatal/postnatal care? Structural/policy barriers Socio-cultural barriers As providers, what do you perceive to be the biggest barriers to providing quality prenatal/postnatal care to your Marshallese patients? What Marshallese health beliefs and behaviors have you observed that you feel are contradictory to recommended best practices for prenatal/postnatal care? In what way(s) do you feel that you and/or your facility could improve prenatal/postnatal care for your Marshallese patients?

The focus group and individual interviews were audio recorded and transcribed verbatim by two female researchers. Data was managed using MAXQDA12 software.³⁷ A phenomenological qualitative approach was used to examine focus group and individual interview data. The authors started with initial coding that consisted of naming each data segment with short summations of emergent themes. This process helped organize the data for focused thematic coding. The focused thematic codes that emerged were used to identify and develop the most salient thematic categories of the data, which became the thematic codes.^38,39 The authors coded transcripts for the emergent thematic codes that were identified and collaboratively discussed the themes in order to ensure scientific rigor and intercoder agreement. Codes were organized into a codebook. There were two primary coders and one confirmation coder. The qualitative data was organized into nine emergent themes that revealed maternal health care providers’ perceptions of barriers to maternal health care among Marshallese mothers within three broader themes that include: 1) structural barriers; 2) communication and language barriers; and 3) socio-cultural barriers.

Results

The majority of the maternal health care providers were female (88.2%). Two providers identified as Hispanic (11.8%) and the other providers identified as Caucasian (88.2%). The majority of the providers (79.7%) were nurses with one advanced practice registered nurse. Three providers did not provide their credentials. The other providers (20%) were medical doctors with a focus in obstetrics and gynecology (OBGYN). The mean length of practice was 10.97 years (SD=8.10). Slightly over half of the providers (64.7%) stated that they provided on-site translation services, and slightly less than half of the providers (41.2%) had participated in a cultural competency training at some point prior to the interview.

Structural Barriers

Providers described perceived structural barriers to maternal health care access among their Marshallese patients. Two structural subthemes emerged including a) transportation as a barrier to attending health care appointments; and b) a lack of health insurance that delayed prenatal care initiation and limited birth control options.

Transportation

Providers discussed transportation as a barrier to Marshallese patients’ access to maternal health care and stated:

Some of the barriers are transportation. A lot of them [Marshallese patients] don’t drive. We had one that rescheduled and rescheduled and rescheduled and most of the time when we get back with her then they are just a no show. They don’t call and cancel. They just [are a] no show, so we call them and they say, ‘I didn’t have a ride.’ We hear that a lot! So transportation is huge. (FG:12)

Another provider stated:

You’ll even say sometimes ‘I see you haven’t been for the last three visits what’s going on?’ Often it’s just ‘I couldn’t get here.’ And I think often it’s just that they can’t. They don’t have transportation. (P5:4)

Providers discussed that shared transportation was often prioritized for work and school over clinic appointments. “Because I think there is only one car for many families.” (FG:12) Additionally, providers described challenges with many patients and patient’s families not having driver’s licenses. Providers also noted that their patients had a fear of driving.

Some of the women don’t like to drive, some do, and some don’t have driver’s licenses. Definitely they don’t like to drive on the bypass because it’s scary. I mean they only have 25 miles of paved roads in the Marshall Islands so when we ask them to go across town that is huge, especially the newer ones. (P10:4)

Health Insurance

Lack of health insurance was also described as a barrier to accessing early and consistent maternal health care. Providers described how the lack of health insurance created a delay in maternal health care use because many Marshallese patients only have access to insurance through Medicaid when they are pregnant, and approval for Medicaid can take several months. One provider stated:

A lot of them don’t have insurance at all. So that means their access to our care is basically pregnancy. That sucks but that is the reality. So we don’t see these patients until they’re pregnant typically. (P6:2)

Providers also described how their Marshallese patients had limited access to insurance for delaying or preventing pregnancy. When Medicaid was only available during pregnancy, Marshallese women have limited access to “birth control or sterilization.” (P9:4) Providers discussed trying to have conversations about pregnancy planning, and the limited options available for their Marshallese patients. One provider said:

You try to capture them at their post-partum visit and say ‘here’s your options or here’s what you can do.’ But the problem is the way the Medicaid system works is sometimes their Medicaid will cover delivery, but it will not cover birth control, which is ridiculous. So sometimes they don’t have a lot of options. (P5:4)

Communication and Language Barriers

A majority of the providers discussed communication and language as a primary barrier to providing maternal health care. There were several factors related to communication and language including: a)interpretation and translation; b) the limited number of words in the Marshallese language; c) stoicism of Marshallese patients; and d) open and trusting communication.

Interpretation and translation

Many Marshallese patients do not speak English, which posed a significant barrier to providers communicating with patients. Although a majority of the providers discussed having language interpretation services at their facilities, providers described this as inadequate because there was not always a Marshallese language option. One respondent stated “We have automated call-in [for interpretation services]; unfortunately it’s only built for English and Spanish. Every year we can get English, we can get Spanish, we can even get Arabic and Farsi but you can’t… get Marshallese.” (FG:20)

Providers described interpretation challenges even when they could access a Marshallese interpreter. One provider said “we try to use the blue phone, but I mean the translator is usually a male translator, and I’m talking to a female about female things. I don’t think I got my message across, so that’s a problem.” (FG:2) Another provider agreed and said “sometimes they still don’t seem to understand even if it is a Marshallese interpreter. I don’t know what it is. But there are some issues even with Marshallese interpreters.” (P8:1)

Limited words in the Marshallese language

Providers described communication as challenging even when using a Marshallese language interpreter because “there is such a limit in their words.” (FG, p.9) The Marshallese language does not have many words for internal anatomy or organs; nor are there common words used to describe how internal organs function. For example, one provider described the challenge of describing human anatomy through her conversation with an interpreter. The interpreter asked her “how do you explain an adrenal gland? And I said, well this is what it does and this is where it’s located, and she said, well we don’t have these words.” (FG:21)

Stoicism

Providers discussed their inability to read their Marshallese patients’ nonverbal communication as a significant barrier that providers coined stoicism. Providers discussed what they described as high pain tolerance with admiration, but also discussed their lack of ability to interpret their patient’s emotional affect. Providers consistently stated that inability to read patients’ emotional expressions made it challenging to assess physical pain during birth, which left the providers unable to know when the baby is coming during childbirth. One provider described “especially the less Americanized they are, they may potentially not have an epidural or anything and you can’t tell. You can’t tell if the baby is coming.” (P7:6) Another provider stated:

I’ve noticed a lot of them have a really good pain tolerance. You can’t just lay your eyes on them and see certain behaviors. You can’t always lay your eyes on them and say ‘oh well she is probably pretty far along.’ I kind of admire it almost. You know it really shows a lot of strength. (P11:1)

Another provider agreed and said “they are incredibly strong, incredibly strong. They would come in and as a triage nurse we would check them and think they are not in labor and they would be complete [referring to dilation of the cervix].” (P9:3) However, providers found the stoicism during child birth challenging. One provider stated:

But, sometimes they are so stoic we can’t get the provider there in time so that is a challenge. They won’t always give us feedback when they are feeling pressure or when they feel like they need to bare down and stuff. (P11:1)

Providers felt this stoicism hindered their ability to gage how their patient was coping emotionally, which left the providers feeling disconnected to their patients.

Open and trusting communication

Providers also described an inability to facilitate open and trusting communication with their Marshallese patients, and described this as constraining their ability to provide care. Providers described receiving monosyllabic responses and a lack of questions from patients. This concerned providers because they felt they were not fully understanding their patients’ needs and concerns:

You start asking them questions, so a lot of times it will be ‘are you feeling your baby move,’ and they say ‘yes.’ ‘Are you feeling any contractions?’ ‘No.’ So they will answer your questions and they answer it appropriately. Then if I say ‘do you have any questions at all?’ Very rarely will they ask questions, very rarely. (P5:4)

Another provider agreed and said:

Specific to being an obstetrician, you know so much of what we do in delivery and prenatal care is meeting not just the physical needs of the woman who is pregnant but the emotional needs for her too. So a lot of those visits you are listening to the heart beat and measuring a tummy but you also [are] like ‘alright, tell me how you are doing?’ ‘Are you nervous? Are you scared? Are you having depression issues?’ And I find that culturally that is hard. You almost feel like you are inadequate in doing your job because I am not making a connection. I am struggling knowing how this person is doing. (P5:9)

Providers also discussed the lack of open and trusting communication as a constraint on providers’ ability to bond with their patients and ultimately affecting the care they provide patients. One respondent stated that “this is the crappy part of taking care of a population that you don’t ever bond with because of the communication barrier. I mean I don’t hang around.” [Referring to postpartum] (P6:6)

Other providers described attempts to overcome barriers to open and trusting communication. Providers described using the Marshallese language to say hello to patients and encourage communication:

They don’t connect in the same way as our culture perceives connection. There are some things that I know that nurses have done that I have worked with and I have tried to do when I can think of it to try and help them. Like I learned to say ‘Yokwe’ [Hello in Marshallese] and that usually throws them off and they are a little more receptive. We started that in the labor room but in the clinic it doesn’t happen as often. (P9:2)

Socio-Cultural Barriers

Providers’ described socio-cultural barriers to maternal health care such as: a) delayed prenatal care; b) lack of scheduling or “island time” that was described as incongruent to Western time scheduling; and c) collectivist culture vs. individualistic culture.

Delayed Care

Providers discussed significant delays in prenatal care among Marshallese patients and described how many Marshallese mothers come in for their first appointment late in their third trimester. Many of the providers recounted that some of their patients do not receive any prenatal care and their first clinical visit is at delivery. “We almost never get them [Marshallese patients] in the first trimester, and we definitely have a higher percentage of them [Marshallese patients] coming in almost term, which really doesn’t happen with any other population at all.” (P9:1) The providers described delay in care as more prominent in the Marshallese culture. Providers described that the late term care left the providers feeling “shackled a little bit” (P6:3) when trying to provide late-term care. Another provider stated:

There is a lot of times we get them [Marshallese patients] very late for care. They are 34 weeks or 36 weeks along because it takes a while to get everything together. Some just arrive here at 35 weeks or 36 weeks so you are going to start everything in the 3^rd trimester. (P7:1)

The delay in care was described as challenging to providers as this affected accurate assessment of the gestational age of the infant. “A lot of the times we don’t know when her last menstrual period was because we are basing everything on a third trimester ultrasound, and that is not as accurate as a first trimester ultrasound.” (P7:3) Another provider described the challenges of delayed care and treating gestational diabetes and stated:

By the time we see them [Marshallese patients] there is absolutely nothing we can do. The thing about gestational diabetes screening, and why it is done when it is done, is because you should be able to affect change in the outcome that comes with the pregnancy. But if you don’t start seeing them until 35 weeks you got nothing at that point. (P6:2)

Island Time

Another socio-cultural barrier that emerged was the concept that providers described as “island time.” Providers discussed challenges with the Marshallese community’s concept of time. Providers consistently discussed their frustrations with patients showing up late and as one stated “they will show up an hour late” (FG:3). One provider said “their time is just totally different. They are on a different time schedule.” (P7:7) Another provider stated:

They are on Island time. They do better with later appointments than earlier appointments. I find the culture and population to be rather interesting but a lot of them are just primed for third shift work because of the fact that back home with the extreme heats and things of that nature they tend to be less active during the day and sleep more during the day and wake more during the night so they just bring that here when they come here. So, island time, definitely on island time. (P6:7)

The concept of “island time” was used by several providers and discussed as being a challenge when scheduling appointments. One provider said “if I have to schedule an induction they just show up whenever. So they don’t usually come in during the time they are scheduled. I’m sure it is the same way in the clinic.” (P8:2) Providers discussed how island time made routine procedures difficult and stated:

There is a certain amount of stuff that you have to do. Like we have to do an interview process and we have to do a blood draw you know? So for the task oriented person it’s challenging just because they [referring to the maternal health care providers] have to do things in a particular order. (P11:5)

Some providers discussed accommodating Marshallese patients’ schedules. One provider said “We just roll with it.” (P8:2) Another provider stated “well, I am very lucky to work with a fantastic physician, and if a Marshallese patient comes in anytime on the day or around the days that they are scheduled, we just see them.” (P9:2)

Collectivist Culture vs. Individualistic Culture

The last theme that emerged among the providers was their perceptions of the Marshallese community’s collectivist culture being in discord with American individualistic culture. Providers discussed their discomfort with the presence of a large number of family members in the hospital room and at the birth. Providers often interpreted the large number of family members as inappropriate rather than supportive. One provider said:

When I work night shift, that’s when you get to see them all, because they visit and are awake at night. And if you’re a day shifter, then they are sleeping all over the floors, just like on the labor room floor, just sleeping everywhere. (Laughter) I wouldn’t walk around barefoot here, let alone sleep. (Laughter) So yes, and many people in the bed. Yes, different. (FG:11)

Another provider stated:

It’s like is this a celebration of the birth or did they have no other place to be? You know? Is this an opportunity for them to have a mini-vacation and go to the hospital and have an air conditioned place to stay? (P6:7)

The lack of understanding of the collectivist, supportive nature of the Marshallese community was described as being challenging to providers in regards to hospital protocol or typical procedures. For example, one provider said:

I have even seen extended family members, who it wasn’t crucial to have there for the birth, ask for a note saying they were there. I’m sure they need it for work because they wanted to be there for their family. But, you know, ‘I’m not sure that I can excuse you for these whole three days.’ Especially since they are not the father of the baby. If I witness them being the primary support person I will write them a note. (P11:4)

This provider additionally said:

One thing I have noticed with a few of my patients is they will bring in a lot of food and it’s not always the healthiest. I mean sometimes they will bring in their traditional stuff. It’s like two liter bottles of coke. Normally we just don’t see people bringing in that much food. We usually see the dad go and get a sandwich or something like that. Of course they have a lot more people who want to be there and stay for longer periods. (P11:4)

Providers also described interactions with their Marshallese patients as manipulative rather than as a miscommunication. For example, one provider said “They don’t talk to us very much. A lot of times they speak English but they pretend like they don’t and we find out later that they do.” (P12:1) Providers also discussed feeling taken advantage of by the Marshallese community with regard to arranging appointments. One provider said:

I don’t want to enable them. I have so many parents that are used to me making their appointments. They’ll say ‘you go ahead and call and tell me when the appointment is.’ We get taken advantage of sometimes. They have learned. If they have been here for 20 years they know. (P10:6)

Providers discussed the cultural misunderstandings that this caused in relation to communal living situations, the communal concepts employed when raising children, and the collectivist support that extends beyond the typical American family dynamic. For example, one provider stated:

I had this pediatric nurse who had a Marshallese family and a boy that was four years old. She called me, and said ‘I have this Marshallese family and they just left their four year old.’ You know on the peds floor they require that the parent stay with the child the whole time I mean we can’t provide a sitter. They were like ‘well we will be right back.’ She was under the impression that they were going to go down to the car and do something and then they didn’t come back. It was several hours. I mean I know the baby was going to be ok. We just have a different view of it. So they may not have an understanding of the flip side of what it takes for me to provide for them. (P11:5)

Another provider stated:

I think one of the harder things to understand is that we don’t understand letting someone else take care of our kid, and they do. It’s fine for them. They look at their aunt as a mother figure or their grandmother as their mother. One of [patient’s name removed] friends went and lived with his grandma for a year. . . I said ‘oh you don’t live there anymore.’ He said ‘no I live with grandma now.’ I said ‘you do, how come?’ He said ‘that’s what we do.’ I said ‘why, did something happen? Is your grandma ok?’ He said ‘the oldest is expected to go live with grandma.’ So he did that for a year and now he’s back home. (P10:8)

Beyond a lack of cultural awareness and sensitivity for the collectivist culture of the Marshallese community the providers described Marshallese families who assimilated as normal. For example, one provider said:

I was totally shocked. I had never met a [Marshallese] man that acted like an American man, like normal facial expressions and their little toddler spoke English and I was like totally shocked. I was like, ‘Y’all must have lived here your whole life, in a different family.’ (Laughter) They were amazing! They were great! (FG: 7)

Discussion

The purpose of this study was twofold: 1) to explore maternal health care providers’ perspectives and experiences of barriers in providing care to Marshallese women; and 2) providers perceived barriers of access to care among Marshallese women. Prior to this study, there was no published literature to document maternal health care providers’ perceptions and experience related to barriers to maternal care among Marshallese women. The findings from this study are consistent with existing literature on Pacific Islander women’s perceived barriers to maternal health care.^10,21,22,36 Structural barriers, such as transportation and health insurance, are commonly identified barriers to maternal health care access for Pacific Islander communities. These structural barriers were dominant findings in our previous research with Marshallese participants.³⁶ Importantly, the exclusion of Marshallese COFA migrants from Medicaid leaves many of the most vulnerable community members uninsured until pregnancy, and providers believe it may affect child spacing and increase overall pregnancies because of a lack of birth control options.

Consistent with other research focused on providers who work with women in racial and/or ethnic minority communities, there were considerable communication barriers identified.^12–16 However, the findings were unique insofar as the communications barriers went beyond language differences. The survey results showed that, even though over half of the facilities had on-site translational services, communication was a consistent and dynamic barrier for the providers and patients. Providers articulated that they were unable to engage in open and trusting communication. Furthermore, providers felt Marshallese patients’ stoicism hindered their ability to bond with their patients, which affected perceived quality of care. Effective communication is a consistent barrier among women who are in a racial and/or ethnic minority, even among those that speak English, suggesting there are socio-cultural barriers interwoven into communication between patient and provider.⁴⁰ Positive patient-provider relationships characterized by effective communication and trust have been associated with higher overall patient satisfaction and quality of care and are therefore a necessary, although complex, component to address.⁴¹

There was frustration with what providers perceived as resistance to western models of maternal health care. Much of the discourse attributed the lack of early and consistent maternal health care among Marshallese patients to a lack of patients prioritizing care rather than the intersection of numerous dynamic structural and communication barriers. Additionally, providers often used negative and judgmental discourse when discussing the collectivist nature of the Marshallese community. Previous studies of Pacific Islander women outside the US, also identified perceived discrimination from maternal health care providers regarding communal and cultural practices and this was cited as contributing to fear and delayed care.^10,22,36 This research reinforces prior literature that document a lack of providers’ cultural sensitivity regarding Pacific Islanders’ communal and culture practices requires attention.^21,22

More research is needed regarding transcultural care and communication between maternal health care providers and Marshallese women. Future research should compare and contrast the barriers identified by Marshallese mothers and their maternal health care providers to ascertain a more comprehensive understanding of the perceived challenges. Understanding how patients’ and providers’ perceptions and experience are similar and different could provide the foundation for better understanding and could be used to design culturally-appropriate interventions and implement changes to policy and practice.

Limitations and Strengths

The results of this study may or may not be generalizable to other Pacific Islander communities or the health care providers who care for them. The providers in this study were a reasonably homogenous group as they all work in the same geographic region and with the same Marshallese population. Combining nurses and obstetricians in the sample was valuable and added more diverse perspectives. The qualitative methods allowed providers to explore the research topic in their own words outside the bonds of a strictly defined survey. However, in knowing the focus of this research, providers may have tempered their responses to make them more socially acceptable. The survey instrument implemented did not include clarification on what type of cultural competency training was being offered in these facilities. Despite these limitations, this study is the first research to explore: 1) providers’ perceptions and experiences related to barriers experienced when providing maternal health care to the Marshallese community; and 2) to explore maternal health care providers’ perceptions of barriers experienced among the Marshallese community in accessing maternal health care. Additionally, this is the first study with maternal health care providers of Pacific Islanders in the southern part of the continental US. Therefore, it adds substantially to the literature and fills a gap in knowledge of providers’ perspectives to barriers to maternal health care among Marshallese women.

Recommendations for policy and practice

In addition to expanding scientific knowledge, the insights from this study are important to informing health care policy, practice, and interventions. Translating scientific knowledge into action is an important part of the CBPR partnership. The following recommendations provided are based upon the results of this study, and will be used by CBPR team to guide future efforts.

Structural Barriers Policy Recommendations

To address transportation concerns, additional public transportation options and bilingual driver’s education are needed. In addition, information about current public transportation, as well as how and where to take the drivers’ license test could increase use of current programs. It is recommended that social service providers, charities, and faith-based organizations work collaboratively to increase transportation options. In addition, health care providers could ask participants which day of the week is better for the use of transportation or provide transportation vouchers.

To address insurance barriers, Medicaid must be restored for COFA migrants. Health care providers could be important advocates in this process. Although there has been incremental expansion of Medicaid to other groups of legal immigrants, Medicaid is not available for COFA migrants, including Marshallese women, unless they are pregnant. Therefore, many Marshallese women may have limited access to birth control and may not space their pregnancy to optimize the health of mother and child.⁴² Furthermore, because COFA migrants cannot apply for Medicaid until they are pregnant, care is often delayed. Additionally, the need for in-language education campaigns is encouraged to help educate the Marshallese community on how to access and use insurance.

Cultural Competency Recommendations

When considering how to improve communication and social-cultural misunderstanding, recommendations converge and are presented together. It is recommended that Marshallese cultural competency/cultural humility training be developed with community partners specifically for maternal health care providers. The findings from this study suggest a discord between collectivist culture and individualistic culture. Cultural competency training should include education on the collectivist identity among collectivist communities. The authors have used the information from this study to create a cultural competency/cultural humility training for maternal health care providers that is co-presented by a registered nurse and Marshallese community member. In addition, providers should consider ways to engage with the Marshallese community to better understand their culture and to foster more trusting communication with the Marshallese community. For example, health care providers could engage a Marshallese advisory board of Marshallese community members to help advise them on care and program design and implementation.

One of the most important things that health care providers should consider is implementing a community health worker (CHW) program as part of the maternal health care team. CHWs can act as cultural brokers and help patients navigate cultural and health information between a client and the health care system for an effective and beneficial health care plan.⁴³ CHWs can also help patients navigate many of the structural barriers identified, including filling out insurance applications, connecting with transportation resources, and reminders to keep appointments. CHWs could also serve as educational assistants, advisors, interpreters, and aid in the development of culturally-appropriate educational materials and prenatal education sessions as they have demonstrated to be effective methods of increasing maternal health care among Pacific Islanders.^44,45 The utilization of home visitations and CHW programs have demonstrated success in encouraging early and consistent maternal health care among other collectivist cultures and may aid Marshallese women.^46–48 Community-based approaches that better integrate the cultural values of the community with maternal health care providers have been demonstrated to be highly successful among other Pacific Islander communities^49–51 and it is the authors’ intent that the research will be used to improve transcultural maternal care.

Significance.

Problem

Pacific Islanders are disproportionately burdened by poorer maternal health outcomes with higher rates of pre-term births, low birth weight babies, infant mortality, and inadequate or no prenatal care.

What is Already Known

Pacific Islanders have identified structural and socio-cultural barriers influencing their utilization of early and consistent maternal health care.

What this Paper Adds

Although a few articles have described Pacific Islanders’ perspectives of maternal health care beliefs and experiences, our manuscript is the first to present maternal health care providers’ perspectives of the barriers to care among Marshallese women residing in the continental United States.