Maternal Health Beliefs, Perceptions, and Experiences in a U.S. Marshallese Community

Abstract

Introduction:

The purpose of this article is to review the beliefs, perceptions, and experience of maternal health among Marshallese women.

Methodology:

The study utilized a qualitative descriptive design with a brief survey of participant demographics. A purposive sample of 43 participants were enrolled.

Results:

The mean age of participants was 40 years. Four a priori themes were identified as follows: (a) family planning beliefs and experiences, (b) prenatal beliefs and experiences, (c) birthing beliefs and experiences, and (d) postpartum beliefs and experiences.

Discussion:

This study identified beliefs, perceptions, and experiences among Marshallese that have implications for policy and practice related to culturally congruent health care for Marshallese mothers.

Background

Pacific Islanders residing in the United States have disproportionally higher rates of preterm birth (<37 completed weeks) and low birthweight infants (<2,500 grams) and are also more likely to experience preeclampsia, primary cesarean birth, excessive gestational weight gain, and gestational diabetes mellitus compared with other racial/ethnic minorities and the general U.S. population (Chang, Hurwitz, Miyamura, Kaneshiro, & Sentell, 2015; Hawley et al., 2014; Schempf, Mendola, Hamilton, Hayes, & Makuc, 2010). Early and consistent prenatal care is strongly associated with positive birth outcomes and is a global health priority (World Health Organization, 2019). However, Pacific Islanders, are less likely to receive early and consistent prenatal care compared with other racial/ethnic groups and are thus at a higher risk for maternal and infant health disparities (Ayers et al., 2018; Hawley et al., 2014; Schempf et al., 2010). Data with other Pacific Islander women document sociocultural barriers to utilizing maternal health care (Ayers et al., 2018; Hawley et al., 2014; Schempf et al., 2010).

From 2000 to 2010, the Pacific Islander population in the United States increased by 40%, making it the second fastest growing population in the United States. The fastest growth occurred in the South (66%), especially in Arkansas (252%), where the majority of Pacific Islanders are Marshallese (Hixson, Hepler, & Kim, 2012). The United States controlled the Republic of the Marshall Islands (RMI) as part of the Trust Territory of the Pacific Islands from 1944 to 1986. During this time, the U.S. military conducted extensive nuclear testing in the RMI between 1946 and 1958 (Barker, 2012). Then, the United States conducted research on exposed Marshallese regarding the effects of nuclear radiation. The research was conducted without informed consent and without information being provided in the Marshallese native language (Barker, 2012).

As a result, the Marshallese community exhibits distrust of research due to this historical trauma. To overcome the challenges of the historical trauma experienced by the Marshallese, the University of Arkansas for Medical Science established a community-based participatory research (CBPR) partnership with the Marshallese community in 2012 (McElfish, Moore, Laelan, & Ayers, 2018). The purpose of this study is to understand the beliefs, perceptions, and experience of maternal health among Marshallese women in Arkansas.

Method

Design

The study utilized a qualitative descriptive design with a brief quantitative survey focused on participant demographics, prenatal care beliefs, and maternal characteristics of participants.

Sample

Forty-three participants were recruited through a CBPR partnership. Participants were recruited via face-to-face, e-mail, and Facebook messenger contact. The inclusion criteria were adults, aged 18 years or older, who self-reported as Marshallese. Based on Marshallese community coinvestigator input, the CBPR team intentionally included both Marshallese mothers and older women (“aunties”). Marshallese community coinvestigators felt it was important to include aunties because they have a significant influence over maternal care.

Setting

Focus groups took place in the Center for Non-Profit in Springdale, AR or church leaders’ homes. These locations were chosen by Marshallese CBPR coinvestigators because the locations were identified as the most comfortable for participants. Each focus group (FG) lasted approximately 60 minutes.

Procedure

Detailed information about the study was provided prior to obtaining informed consent. Before engaging in the FG interview, participants completed a brief survey (see Tables 1, 2, and 3). All study information was presented in the Marshallese language by a female bilingual (Marshallese and English) community health worker trained in research methods. Study procedures were reviewed and approved by the University of Arkansas for Medical Science Institutional Review Board (No. 204813).

Table 1.

Participants Demographics.

	N (or M ± SD)	Percentage of sample
Age	39.8 ± 11.8
Education level
Elementary	8	18.6
Some high school	11	25.6
High school graduate	14	32.6
Some college or tech school	9	20.9
College graduate	1	2.3
Income
Below $10,000	15	41.7
$10,001–$20,000	12	33.3
$20,001–$30,000	4	11.1
$30,001–$40,000	4	11.1
Above $40,000	1	2.8
Place of birth
Marshall Islands	40	95.2
The United States	2	4.8
How long have you lived in the United States (years)?	13.0 ± 8.0
Did you have health insurance at the time of your last pregnancy?a
Yes	28	66.7
No	14	33.3
What type of insurance?
Medicaid/Medicare	17	60.7
Private insurance	4	14.3
Employer-sponsored plan	4	14.3
Covered by spouse’s plan	3	10.7

Note. Only valid percentages shown. Percentages may not total to 100 due to rounding.

Table 2.

Participants Beliefs Related to Prenatal Care.

	N	Percentage of sample
What does “prenatal care” mean to you?
Going to the doctor	32	74.4
Support from family/friends	8	18.6
Good diet and exercise	17	39.5
Community health workers	7	16.3
Midwives	11	25.6
Other (breastfeeding)	1	2.3
Other (checkups/tests)	1	2.3
Other (medical care)	1	2.3

Note. Respondents could select more than one answer.

Table 3.

Maternal Characteristics of Participants.

	N (or M ± SD)	Percentage of sample
How many times have you been pregnant?	4.5 ± 2.5
How long has it been since you were pregnant (months)?	137.3 ± 127.6
Did you see a doctor during your most recent pregnancy?
Yes	35	83.3
No	7	16.7
Does seeing the doctor help your unborn baby to be healthy?
Yes	40	97.6
No	1	2.4
How much does seeing the doctor help your unborn baby to be healthy?
Very much	40	95.2
It does not make a difference	2	4.8
How soon should a woman see the doctor if she is pregnant?
Month 1	27	67.5
Month 2	4	10.0
Month 3	6	15.0
Month 4	0	0.0
Month 5	1	2.5
Month 6	0	0.0
Month 7	0	0.0
Month 8	0	0.0
Month 9	0	0.0
Only at delivery	2	5.0
When did you first see the doctor when you found out you were pregnant?
Month 1	15	37.5
Month 2	11	27.5
Month 3	8	20.0
Month 4	1	2.5
Month 5	1	2.5
Month 6	0	0.0
Month 7	1	2.5
Month 8	0	0.0
Month 9	0	0.0
Only at delivery	3	7.5
In the Marshall Islands, when do pregnant women see the doctor?
Month 1	13	34.2
Month 2	2	5.3
Month 3	6	15.8
Month 4	3	7.9
Month 5	4	10.5
Month 6	1	2.6
Month 7	0	0.0
Month 8	0	0.0
Month 9	2	5.3
Only at delivery	7	18.4

Note. Only valid percentages shown. Percentages may not total 100 due to rounding.

From January to March 2016, participants were enrolled into one of three focus groups. Although the focus groups were larger than recommended, when the additional participants came to the focus group, the CBPR team followed the community coinvestigators’ advice to include all additional participants rather than asking them to leave. Care was taken to ensure all participants’ voices were heard. A FG discussion guide with semistructured questions was used to encourage participants to speak candidly about their maternal health beliefs, perceptions, and experiences while maintaining consistent inquiries (see Table 4).

Table 4.

Semistructured Interview Guide: Topics and Example Subquestions.

1.	Prenatal beliefs
	How long should you wait to go to the doctor for prenatal care after you find out you are pregnant? When do your friends and family say that you should go to the doctor for prenatal care if you are pregnant? How long do you wait to go to the doctor for prenatal care after you find out you are pregnant? What do you think the purpose of prenatal care is? Do you think going to a doctor/provider when you are pregnant is a good idea?
2.	Prenatal barriers
	Why might going to a doctor/provider when you are pregnant be bad idea? What are some of the things that have kept you or someone you know from seeing a doctor or some other health care provider when you found out you were pregnant? When you think about going to the doctor/provider during your pregnancy, what concerns do you have?
3.	Prenatal knowledge
	What things do you know to do to stay healthy during your pregnancy? Who do/would you seek advice from regarding staying healthy during pregnancy? What advice would you give a pregnant friend or family member concerning her health during pregnancy? Did you know that it is recommended that you receive medical care within the first 3 months of your pregnancy?
4.	Birthing beliefs
	In what setting do/would you prefer to give birth? (i.e., hospital, home, birthing center, etc.). Have you given birth in the United States? If so, can you tell me about that experience? Do you have concerns about giving birth in the hospital? What are those concerns? What do others in the community say about giving birth in the hospital?
5.	Postpartum beliefs
	After you have a baby (postnatal), what types of things do you do to care for yourself? Do you think that you should go back to the doctor after you have the baby? What advice would you give a pregnant friend or family member concerning her health after she has a baby during the postnatal period? In your opinion, for which women is it important to seek care after she has a baby?
6.	Family planning beliefs
	Before you became pregnant did you plan to have a baby at that time, or did it just happen? Before, you became pregnant, were you doing something to prevent pregnancy (using birth control)? What kind of birth control or conceptive practices were you using? Did you talk to a doctor about having a baby before you starting trying to get pregnant? How long should you wait after you have a baby to get pregnant again?
7.	Maternal influences
	Who has the greatest influence on prenatal care decisions? Who decides were you or a female family member delivers? Who has the greatest influence on decisions about the place of delivery? Who would decide if you, or a female family member, should seek care if a complication were to arise during pregnancy? Who has the greatest influence on decisions concerning postnatal care?

Participants were given a $20 gift card as remuneration for participation. Focus groups were audio recorded and transcribed verbatim. The transcripts were translated from Marshallese to English by a female bilingual translator and verified for accuracy by a second translator.

Data Analysis

The CBPR team started by coding each data segment with short summations. Then, focused codes that emerged were used to identify and develop the most salient categories of the data. The CBPR team coded the data for four a priori and emergent subthemes, and collaboratively discussed the themes to ensure scientific rigor and intercoder agreement (Blair, 2015). There were two primary coders who coded simultaneously but independently, and a third confirmation coder who reviewed and evaluated the codes for accuracy and to control for bias. The coders discussed discrepancies until conciseness was achieved. Two female Marshallese community coinvestigators provided feedback in a formal member check meeting. Member checking is an important part of CBPR to ensure cultural accuracy (Chung-Do et al., 2016). No quotes or themes were withdrawn but the member checking allowed concepts to be clarified within the cultural context. Direct quotes from participants were included to facilitate transparency.

Results

The mean age of participants was 40 years. Indeed, 41 participants were born in the RMI, while 2 were born in the United States. Participants reported being in the United States for an average of 13 years (SD = 8). The mean number of pregnancies was 4.46 (SD = 2.5). Two thirds (66.7%) of the participants reported having health insurance, with Medicaid/Medicare (60.7%) being the most common. The majority of participants (75%) had an income of $20,000 or below, and almost half (44%) of the participants had not completed high school. Responses to survey items regarding what prenatal care means showed 75% of participants said prenatal care means going to the doctor during pregnancy and 26% said seeing a midwife. The responses regarding when to seek prenatal care in the United States varied: 63% of mothers stated the first month and 5% stated only at birth. Regarding when to seek prenatal care in the RMI also varied: 30.2% of mothers stated the first month and 16.3% stated only at birth.

Maternal Health Beliefs and Experiences

Four a priori themes were identified as follows: (a) family planning beliefs and experiences, (b) prenatal beliefs and experiences, (c) birthing beliefs and experiences, and (d) postpartum beliefs and experiences. Subthemes emerged within the a priori themes. Findings are reported by FG 1, FG 2, and FG 3.

Family Planning Beliefs and Experiences.

Consistent with the World Health Organization, the term family planning is defined as considerations and/or steps taken to influence timing of pregnancy by some form of contraception (World Health Organization, 2018). Within the family planning beliefs and experiences a priori theme, two subthemes emerged as follows: (a) lack of family planning and (b) and lack of family planning knowledge.

Lack of family planning.

The discussions surrounding family planning highlighted an absence of planning. For example, one participant stated that

… one thing we don’t do is plan our pregnancy.

(FG 2)

There was a consensus among participants that most Marshallese did not utilize contraceptives proactively. One participant described her experience in the excerpt below.

It didn’t even occur to us to family plan. We went through high school without having any issues [and] when we finish school, that’s when we plan to settle down and have families of our own. As for me, no family planning what-so-ever.

(FG 2)

Additionally, one respondent described her lack of options regarding family planning when she said,

… but we stay strong because we had no other choice.

(FG 3)

Lack of family planning knowledge.

Participants also discussed limited knowledge about family planning methods and cultural norms that avoided discussing contraceptives. This led them to feel lost regarding family planning. As one participant stated,

I didn’t plan my pregnancy because I was attending college, but because of us Marshallese, we aren’t open minded [about family planning], I didn’t know there were things that we needed to use to not get pregnant. It’s like we’re lost.

(FG 1)

The lack of family planning appeared to be predicated on lack of knowledge of contraceptives and family planning options. For example, one participant said, “I didn’t know what birth control was” (FG 1). Participants also discussed that the lack of knowledge regarding family planning options also led to the use of culturally specific methods which included ingesting large amounts of water as a birth control method. Participants stated that

after you’re done [referring to sex] you drink water.

eight ounces

one gallon

until you feel sick,

until we fill up our kidneys with water.

(FG 1)

Several participants and community coinvestigators noted that this was a widely held belief within the Marshallese community.

Prenatal Beliefs and Experiences.

Within the prenatal beliefs a priori theme three subthemes emerged: (a) when to seek prenatal care, (b) why to seek prenatal care, and (c) prenatal care meanings: United States versus the RMI.

When to seek prenatal care.

The participants discussed when they thought it was appropriate to obtain prenatal care, and their responses varied greatly from the first realization of pregnancy up to 6 months into their pregnancy. Participants said,

right away.

(FG 1)

in about 3 to 4 months I started to get care.

(FG 2)

For many, the decision to seek care was perpetuated by the physical manifestation and symptoms of pregnancy. Participants stated,

when I feel nauseous, that’s when I know I’m pregnant and go seek maternal doctor and such. Probably when I am three weeks along.

(FG 2)

As for me, when I felt the baby move, as in 6 months. The reason for it, I don’t feel the signs for being pregnant nor knowing that I’m pregnant until my stomach shows.

(FG 2)

Why to seek prenatal care.

The participants agreed that seeking prenatal care was important for understanding the health of the infant. As one participant summarized,

I want to know what’s going on. Is the child in my stomach healthy? Is he or she doing okay? Is there any problems? And I want to know how far along I am.

(FG 1)

There was a consensus among the participants about the importance of maintaining a healthy stature because motherhood is a very important part of a woman’s life. One participant said,

Biggest day for a woman is the birth of a child. And all the sickness and carrying a baby for 9 months, its heavy lifting. Which is why we should meet all our appointments with the doctor to keep the baby safe and the mother too.

(FG 2)

Prenatal Care Meanings—United States Versus RMI.

Some of the meanings participants attached to prenatal care appeared to be normative with Western cultural beliefs (Boerleider et al., 2015). However, participants also described a desire to incorporate culturally specific modes of prenatal care wherein female support systems were more integrated.

With regard to more normative Western medical models of care discourse, participants described prenatal care as meaning:

… take your prenatal vitamins; exercise; do not miss your prenatal care appointments; eat healthy; and do not smoke or drink.

(FG 1, FG 2)

However, the discourse used to describe prenatal care in the RMI was more culturally specific. When discussing prenatal care in the RMI, participants discussed relying on mothers, aunties, grandmothers, older ladies, elders, or midwives for prenatal care versus a physician (FG 1, FG 2, and FG 3). Participants tethered the decision to use the culturally specific support of women, to having hope that all will be well. Participants said,

It’s not because we don’t want to go [to the doctor]. We’re too hopeful because we have our grandmothers, mothers, and midwives who we seek maternal care with, and they’re the ones who help us get through the maternal process, back in the Islands.

(FG 2)

… that hope is with us.

(FG 2)

The word hope was used consistently when discussing why participants were seeking out maternal figures and midwives rather than Western medical models of care. Some participants described utilizing both medical and culturally specific care. For example, one participant stated,

we seek maternal care in the doctor’s [referring to Western medical doctors] term, but also in our own terms and ways.

(FG 3)

Birthing Beliefs and Experiences.

Within the birthing beliefs and experiences a priori theme three subthemes emerged: (a) birthing in the RMI, (b) birthing in the United States, and (c) language barriers and Western medical models of care.

Birthing in the RMI.

The majority of participants used positive discourse to describe birthing experiences while in the RMI with most of the mothers reporting that they gave birth at home with the support of midwives. Participants said,

At the Marshall Islands, some ladies want the midwives to help them give birth at their homes.

(FG 1)

For me, I have 13 kids, and one of them I gave birth to at the hospital and 12 I gave birth to at my home. It was good for me to give birth at my home with a midwife.

(FG 1)

The participants agreed that their birth experiences were good. The decision to birth at home was described as part of their culture. Furthermore, many of the participants discussed attending births frequently.

I’ve been with seven ladies while they give birth.

(FG 1)

When the mothers are getting ready to give birth, all our relatives and family members come to our home and spend the night and wait for the baby to be born. The reason for it is that we believe that it would possibly [be] the mother’s last day when in labor, because it takes all her being to give birth to the baby, and it’s really important day for her as well.

(FG 3)

The participants discussed how midwives or elder females would attend to breech babies in the RMI by the following:

“… massaging our stomach” or “rotate my belly.”

(FG 1, FG 2, FG 3)

If we’re scared a little they come to massage our stomach and they do it good.

(FG 1)

Birthing in the United States.

Participants ascribed negative emotional discourse to their birthing experiences in the United States versus within the RMI that appeared to be predicated on the lack of female social support specifically. Marshallese culture is highly collectivist and matrilineal in nature, and thus women are highly valued as mothers and a source of social support. However, participants described a lack of female social support in the hospital setting in the United States. Participants described that the lack of social support made them feel depressed, sad, scared, and that their birthing experience was not a good experience (FG 1, FG 2, and FG 3). Furthermore, although participants described their partners or husbands being in the room for the birthing experience, there was still an overarching desire to have a female support system. For example, one participant described feeling depressed despite having her husband present when she said,

For me, the reason why I was depressed is because of [I did not have] my mom because I was alone when I was giving birth. When you give birth and there is nobody by your side you get sad and depressed, but if you have someone next to you, peace will come to you a little bit. For me, when I gave birth and I was alone, it was just me and my husband.

(FG 1)

Marshallese participants reported struggling to recreate the communal birthing support system they are accustom to in their culture. Community coinvestigators and participants discussed that this can be due to multiple factors including hospital policies limiting the number of members in the room and/or being geographically far away from the mothers, aunties, and sisters.

Language barriers and Western medical models of care.

Participants also described negative birthing experiences as influenced by structural barriers such as language barriers and the overall Western medical model of care in the United States. For example, one participant described being:

… scared because I do not know how to speak English.

(FG 1)

Beyond basic language barriers participants discussed challenges with understanding medical vernacular. One participant stated,

We might know how to speak English, but the medical terms being used to explain the conditions by the doctors is like a puzzle waiting to be solved, but we are afraid to ask what the meaning of their terms are.

(FG 3)

Most participants discussed concerns with Western medical models of care and the increase in cesarean births in the United States compared with the RMI.

They will automatically cut you open but at the RMI they will know what to do.

(FG 1)

In the Islands, when we get ready to give birth, the midwife comes and massages us, but here in the U.S., you teach yourself how to give birth.

(FG 3)

Postpartum Beliefs and Experiences.

Similar to previous themes, the participants discussed both about normative Western medical beliefs about what postpartum care should look like and also described preferred culturally specific methods used in the RMI. With regard to normative Western medicinal beliefs participants described postpartum care as:

Don’t fall asleep on the baby.

Don’t do things around the baby that you shouldn’t like smoking,

Don’t do heavy lifting,

Don’t run or exercise long.

(FG 1, FG 2)

Follow your doctor’s orders.

(FG 1)

However, participants also described a desire to utilize culturally specific models of postpartum care that may be difficult to implement now that they reside in the United States. For example, there was broad discussion of the need to “continue drinking your prenatal,” [referring to herbal remedies] and of herbal baths. Participants said,

As for my oldest sisters, after giving birth, they take herbal baths and such. I think we say that our elders [grandmothers and mothers] are our doctors [traditional healers] when they give us our herbal bath and medicine. And they also give herbal baths for the newborn as well.

(FG 2)

Go jump into the ocean because the salt from the sea itself is a medicine too.

(FG 3)

Discussion

This study identified numerous incongruent beliefs with regard to family planning, prenatal care, birth, and postpartum care, wherein Marshallese women desire components of both culturally specific and Western medical models of maternal health care.

Participants’ responses regarding family planning and contraception suggest that Marshallese women do not use contraceptives as a family planning method. The lack of contraceptive use appeared to be predicated on the lack of knowledge surrounding contraception use and/or Marshallese customs of not discussing sex or family planning options within their culture. Our findings are consistent with previous studies of Pacific Islanders that have elucidated cultural beliefs that pregnancies, whether planned or not, are viewed as a blessing because children are highly valued, and that preventing pregnancy, or questioning the timing of a pregnancy, was seen as questioning the value of the child (Soon, Elia, Beckwith, Kaneshiro, & Dye, 2015). Participants placed great value on pregnancy and this cultural value may dissuade contraception use. Participants described beliefs and practices that included ingesting large amounts of water after sexual intercourse in an attempt to facilitate birth spacing. This unique finding has not been found in other Pacific Islander literature and merits further investigation.

Marshallese mothers’ responses showed an amalgamation of culturally specific and Western beliefs regarding the meaning of prenatal care as well as when and why to seek prenatal care. These findings are similar to previous studies of prenatal care access among Pacific Islander subgroups as they demonstrated an increased understanding of the importance of seeking prenatal care, but unlike other studies, participants in this study discussed seeking prenatal care earlier now that they reside in the United States (Hawley et al., 2014; Parker, McKinnon, & Kruske, 2014). However, it is important to note that although the survey results suggested that the majority of the participants thought it was important to seek prenatal care within the first month, the FG discussions showcased a range from first to second trimester, with the physical symptoms of pregnancy as the impetus.

Participants discussed their desire to incorporate culturally specific prenatal care support. Previous studies, of both Pacific Islander and other immigrant communities such as American Indian and Sudanese, suggested that women are attempting to interweave both Western and culturally specific models of care in their prenatal experiences (Hanson, 2012; Higginbottom et al., 2013; Parker et al., 2014). Incorporating culturally specific prenatal care options have been effective for other immigrant communities (Hanson, 2012; Homer et al., 2012; Parker et al., 2014) and should be incorporated into prenatal care for Marshallese communities.

The discussion surrounding birthing beliefs and experiences showed divergent themes when comparing birth in the RMI and the United States, and the themes were depicted with emotional discourse. The majority of participants used positive discourse to describe birthing experiences in the RMI. Many of the women discussed that births took place at home with a lay midwife or female elder, and giving birth at home made them safe. However, the Marshallese mothers used negative discourse to describe their birthing experiences now that they have migrated to the United States. Much of these negative depictions stemmed from a lack of female social support, linguistic barriers, and Western medical models of care. Previous studies of Pacific Islander birthing experiences in hospital settings revealed only a small percentage of women could carry out cultural practices during their birth (Parker et al., 2014).

Last, the postpartum beliefs of the Marshallese mothers described an understanding of taking care of themselves and their infants by being healthy based on Western medical models of care. However, similar to previous studies of other Pacific Islander groups, our findings suggested a desire to incorporate more culturally specific customs such as massage and herbal medicinal baths in postpartum care (Parker et al., 2014).

Limitations

This study utilized a purposive sample to capture the beliefs, perceptions, and experience of maternal health among Marshallese women in Arkansas that reduces the generalizability of the results to other populations. The differences in age among participants may have affected the participants’ comfort level to discuss beliefs that may have differed by generational groups. Despite these limitations, this study is significant as it contributes to an area where there is little research and provides insights for both policy and practice.