Experts, advocates stress importance of cultural bias training in improving pregnancy care access for immigrants
Though a language barrier may be the most obvious barrier to pregnancy care access, experts and advocates say cultural barriers are just as big of an issue and deserve the same amount of attention and discussion.
They said that education, or a lack thereof, specifically, is one of the biggest issues when it comes to a cultural barrier.
Datia Rosenberg, licensed psychologist in Mexico and birth doula in the Champaign-Urbana community, said part of this issue lies in the gap that exists in the way people view pregnancy in the U.S. versus in Spanish-speaking countries.
In Mexico, for example, Rosenberg said people call contractions dolores, or pains.
“People who don't have the access to education, or who come from very humble, low economical status, they don't call contractions, contractions, they call them pain,” she said. “So they're approaching childbirth already in a negative way.”
This, she said, can then lead them, culturally, to fear childbirth, which might make it harder for them to speak up during hospital visits.
“Then they're very submissive to the medical team, to the staff, to the providers,” Rosenberg said. “Why? Because they see them as the law, as the boss – I have to do what they say.”
Kora Maldonado, assistant clinical professor in Anthropology and American Indian Studies at the University of Illinois, said there’s also a lack of knowledge about the specific communities immigrants may be used to.
She said that healthcare workers don’t always know that their patients don’t know how the healthcare system in the U.S. works.
“I think they've been in many cases left out or (doctors) have failed them or do a lot of assumptions of what they need or don't need,” she said. “That history just kind of gets compounded. It gets lived through every time they go to the doctor.”
At the same time, she said, immigrants are also often having their experiences questioned because they don’t line up with what’s accepted or practiced in the U.S.
For example, Maldonado, who’s worked in rural areas and is from rural Mexico City, said the entire process of giving birth can be very different in Mexico than in the U.S.
In Mexico, she said, pregnancy is often very commual, and there are often multiple women taking care of the pregnant person, and they’re not always doctors.
She said that’s very different from how pregnancy works in the U.S., which is a much more individualized culture.
“It’s scary when you have to go by yourself or with your husband or your partner, and that's it, when it's usually the whole community bringing and building and helping and making sure that you are taken care of,” she said.
A lot of these women, she said, have given birth before in their home countries but just through a different process that doesn’t involve being surrounded by healthcare providers they’ve never met before.
“In many cases, they have three or four kids, you know, five kids” Maldonado said. “They have gone through it, they know it. They have had their moms and their grandmothers and their community walk them through it.”
She said that since this isn’t the culturally approved or accepted way of giving birth, though, those experiences and knowledge are often invalidated.
Maldonado said this piece of bias training that medical professionals go through is missing.
“They really do need a lot more training, cultural sensitivity training to be able to bridge those anxieties and those knowledges and those are the places where these women are coming from,” she said.
Alicia Settle, registered nurse and midwife at Christie Clinic, said at Christie Clinic’s nursing training, she went through cultural bias training and learned a lot about knowing her own personal bias.
“I feel like that's an area that, as far as nursing goes, we have a pretty good kind of background education about it,” she said.
She also said that it’s up to each nurse, though, to decide how much they apply what they learned from training and work through that with every patient.
Ricardo Diaz, who serves on the boards of the Immigration Forum, the Immigration Project and the New American Welcome Center, said that beyond basic bias training, there is a deeper cultural understanding that needs attention.
For example, he said that in rural Latin America (where many immigrants who come to the U.S. are from), pregnancy-related care is either very simple or doesn’t exist at all.
This, he says, creates a cultural barrier for immigrant patients.
“They don't come from situations in which there would be lots of prenatal care,” he said. “If you don't know it exists, or if you don't know that you're supposed to have it, you don't go get it.”
Margarita Teran-Garcia, assistant dean for Integrated Health Disparities Programs at U of I, said that these barriers, language and cultural, work together to create mistrust from Hispanic women towards the healthcare system.
To Teran-Garcia, this mistrust in the healthcare system is a whole other barrier on its own that needs to be addressed.
“It is easy to be affected by issues of discrimination and racism with health care providers,” she said. “As much as you try to educate, there are un-assumed biases that could have a big impact in the care of women.”
Teran-Garcia said if women don’t have trust in the healthcare system or are intimidated by the unfamiliarity of the system, they’ll be less likely or inclined to seek out care or follow up on appointments.
Jonas Swartz, assistant professor of OB/GYN at Duke University, said that this is problematic because it could lead to untreated health problems that may occur during pregnancy, which he said is a time when a lot of health problems surface.
“If they're not able to get that sort of basic primary care after pregnancy, then they aren't able to prevent worsening of those conditions or the development of conditions that can come on later in life,” he said.
To fully more thoroughly explore the consequences of limited access to pregnancy care, Swartz conducted a study that specially looked at the effects of expanded prenatal care on immigrant women and their babies.
He said he found that an increase in access to care during pregnancy resulted in an increased number of well-child visits and increased recommended screenings and vaccines during well-child care.
He said there was also a small but significant reduction in infant mortality and reduced rates of extremely low birth weight.
These findings, he said, hold some pretty strong implications.
“What our results show is not only does providing prenatal care to people during pregnancy improve their access to care and improve utilization of care, but also can improve health outcomes for the next generation,” Swartz said.
Swartz’s suggestion for improvement is about to be tested in several states across the U.S. that offer Medicaid.
On April 1, a Medicaid expansion went into effect under the American Rescue Plan Act of 2021.
A provision in the act states that this postpartum care extension now gives states the option to extend Medicaid postpartum coverage from 60 days to 12 months.
This means that any type of pregnancy care needed after birth will be covered by Medicaid up to a year after birth instead of just 60 days.
Swartz says this could be a game changer for increasing the quality of care for immigrant women.
“If you think about the difference between losing your Medicaid at 60 days after you've given birth versus a year after you've given birth, that makes a huge difference in terms of your ability to access care,” he said.
This, he said, includes increased access to contraception and care to any chronic illnesses that may have been identified during the pregnancy, among other things.
The plan also covers those under the CHIP unborn child program, which includes pregnant women and their children regardless of immigration status.
Locally, advocates and community members are figuring out their own ways to increase both access to pregnancy care and quality of care for immigrants.
Ann Abbott, a Spanish professor at the University of Illinois, started a class at the University last year called Health Professionals and U.S. Latinx Communities.
The idea for the class, she said, came out of the disproportionate effects COVID-19 was having on Latinx communities.
She said one goal of the class is to foster cultural awareness and humility in students and to help them understand some of the specifics of certain backgrounds, specifically in the local C-U community.
When it comes to understanding some of the different cultural perspectives of birth and pregnancy, Abbott said it’s important to remember how intimate pregnancy is and what different themes can come up during that time.
“You're talking about sexuality; You're talking about reproduction; You're talking about maybe organs, your reproductive organs,” she said. “That level of intimacy, if you have a language barrier on top of that and cultural differences on top of that, is very complex.”
She said to increase this awareness in clinics and hospitals, students, and medical students specifically, should be taking classes with similar themes as Abbott’s as early as college so that they’re exposed to language and biases before med school.
This way, she said, you’re not having practicing professionals who don’t have any language skills or who have never thought about cultural awareness and differences before.
“If our educational system could offer these foundational opportunities, while they're still college students, that’s something that's very valuable because that's laying a foundation that they can take with them forward,” Abbott said.
Carolina Garibay is a student reporter with the Illinois Student Newsroom. Follow her on Twitter @carigaribay.