The Journal of the Arkansas Medical Society Med Journal June 2020 | Page 20

Case Study
by Britni Ayers, PhD 1 , Cari Bogulski, PhD 1 , Cari Bogulski, PhD 1 ,
Lauren Haggard-Duff PhD, RN, CNE 1 , Pearl Anna McElfish, PhD, MBA 1
1
University of Arkansas for Medical Sciences, Northwest, Fayetteville, Ark.
Marshallese Pacific Islander Maternal Health Context
Abstract
Arkansas birth records (n=2,488) show that
Marshallese in Arkansas experience a high rate
of maternal and infant health disparities. Early
and consistent prenatal care is strongly associated
with positive birth outcomes and is a state
health priority. However, Marshallese are less
likely to receive prenatal care in the first trimester
compared to other racial/ethnic groups.
UAMS has engaged with community health
care partners and the Marshallese community
to overcome these barriers and address the
prenatal and perinatal health disparities through
the development of a Healthy Start program.
Marshallese Pacific Islander Maternal
Health Context
The Pacific Islander population in the U.S. increased
by 40% from 2000 to 2010, making it
the second-fastest growing population in the
U.S. Majority of the growth occurred in the South
(66%), specifically in Arkansas (252%), where
majority of Pacific Islanders are Marshallese.1
Arkansas has the largest population of Marshallese
Pacific Islanders living in the continental
U.S. (~14,000 people). 2-6
Pacific Islanders residing in the U.S. have disproportionally
higher rates of preterm birth (<37
completed weeks) and lower birthweight infants
(<2,500 grams). 7-9 Additionally, the Pacific Islander
population is more likely to experience
preeclampsia, primary cesarean delivery, excessive
gestational weight gain, gestational diabetes
mellitus (GDM), and low exclusive breastfeeding
initiation and duration at six months compared
to other racial/ethnic minorities, and the
U.S. population in general.7-9 Pilot analysis of
Arkansas birth records (n=2,488) has shown
that Marshallese in Arkansas experience a high
rate of maternal and infant health disparities:
15% of Marshallese women received no prenatal
care (compared to 1.6% women nationally);
19% of Marshallese infants were born preterm
(compared to 9.6% nationally), and 15% of
Marshallese infants were low birthweight (compared
to 8.3% nationally). 9 Early and consistent
prenatal care is strongly associated with positive
birth outcomes and is a state, national, and
global health priority. However, Pacific Islanders
are less likely to receive prenatal care in the first
trimester compared to other racial/ethnic groups,
and are thus at a higher risk for maternal and infant
health disparities. 7
Qualitative data demonstrate that Marshallese
women report numerous structural and social-cultural
barriers that constrain obtaining prenatal
care. 10 Structural barriers include challenges
negotiating health insurance, transportation,
and language. Social-cultural barriers include
lack of understanding of the importance of seeking
early and consistent prenatal care, perceived
discrimination from prenatal care providers, and
an overall fear of the health care process. 10
Development of a Healthy Start Program
UAMS has engaged with community health care
partners and the Marshallese community to overcome
these barriers and address the prenatal
and perinatal health disparities through the development
of a Healthy Start program, translated
“Jined ilo Kobo” in the Marshallese language.
“Jined” means mother, and “Kobo” refers to
the concept of preserving, preparing, shaping,
safekeeping, protecting, and warmth from the
mother’s breast. The program builds upon the
Marshallese’s matriarchal culture in which mothers
are recognized as the givers and sustainers
of life. In the traditional oral stories, Marshallese
mothers held positions of power as the leaders
who established new clans (jowi) and new lineages
(bwij). The term “Jined ilo Kobo” is used
to describe a position of power where a mother
holds her child close to her breasts for warmth
and protection. It was believed that as a Marshallese
mother held her child close and guided
her/his development, the child would grow up
and continue to thrive and serve the Marshallese
community. Jined ilo Kobo signifies the highest
position in the Marshallese culture, and all mothers
who attain Jined ilo Kobo are revered.
The Jined ilo Kobo program seeks to ensure access
to culturally sensitive, community-based
health care and social services for Marshallese
women, pregnant mothers, infants, and families.
UAMS will work with community service
providers to improve coordination. Community
coordination will be accomplished through the
use of bilingual Marshallese Care Coordinators
who will help women, pregnant mothers, infants,
and families 1) sign up for health insurance; 2)
understand how to utilize their insurance; 3) access
culturally-appropriate health care and social
services; and 4) ensure pregnant mothers receive
early prenatal care.
Marshallese Care Coordinators will help Marshallese
families connect with resources such as
the Special Supplemental Nutrition Program for
Women, Infants and Children (WIC), the Children’s
Safety Center, and other community programs
supporting families. Bilingual Marshallese
Care Coordinators will also support pregnant
women and families with translation and health
navigation throughout their pregnancy, regardless
of which health care provider women are using.
Jined ilo Kobo will partner with the community
to promote health education and activities.
One of the primary objectives of Jined ilo Kobo
will be to provide parenting education that leverages
Marshallese cultural values. The program
will also engage fathers and partners in the process
and provide fatherhood support services.
In short, Jined ilo Kobo focuses on supporting
pregnant mothers, infants, and families with the
key resources they need to thrive.
Community partners involved in the Jined ilo
Kobo program include: Arkansas Coalition of
Marshallese (ACOM); Marshallese Education
Initiative (MEI); and Family Network. Health care
providers involved in the Jined ilo Kobo program
284 • The Journal of the Arkansas Medical Society www.ArkMed.org