Although the U.S. Surgeon General declared in the late 1980s the goal of a low birthweight rate of 6 percent or less among ethnic minority groups by 1990, low birthweights among black Americans continue to be between 10 percent and 12 percent. Georgia is near the bottom, ranking 48th among states in low birthweight rates.
The problem is not necessarily availability of care, but rather the lack of prenatal care that is culturally sensitive or relevant to ethnically diverse and rural populations, according to Dean of the School of Nursing Dyanne Affonso. Through a nationally recognized innovative community approach to prenatal care on the island of Hawaii, Affonso has demonstrated that prenatal care is much more effective if it takes into account the particular needs of diverse minority groups. Based on the program's success, it recently has received new funding for expansion to another Hawaiian island. And Affonso plans to bring a similar prenatal care approach to Georgia in the near future.
In 1985, prior to coming to Emory, Affonso launched the Malama Na Wahine Hapai Project with funding from the National Institutes of Health. "Malama" means "caring" in Hawaiian. Three ethnic groups (Hawaiian/part Hawaiian, Filipino and Japanese) in the rural Hilo-Puna district of the island of Hawaii were included in the project.
These groups had low birthweight rates ranging from 7.9 percent to 8.4 percent. Exclusive of income and education, these women often were failing to seek prenatal care until their third trimester of pregnancy, or were seeking care only sporadically or when they were ill.
When the women were asked through focus groups to help design a new prenatal care program, many reported that current prenatal care services were not acceptable, and at times were in direct conflict with their cultural beliefs and family values.
"Today's prenatal care model is a technical one of looking for disease, taking blood pressure, and focusing on the fetus and placenta to the exclusion of the mother," said Affonso.
Health professionals, she said, are being called on to design care-giving models that make a difference in the lives of pregnant and postpartum women and their families, and community-based health care has been shown to carve new pathways for disease prevention and health promotion among the nation's diverse cultural subgroups.
"It is only when women find a sense of meaning and self-esteem that they are motivated to engage in healthy behaviors to produce a healthy infant," Affonso explained.
Prenatal care Malama-style is indeed a community affair and not merely an obstetrical event or a women's health issue. The program uses outreach workers to help recruit women to prenatal care and encourage them to remain throughout their pregnancies. Local ethnic healers, who are highly respected scholars of the ethnic beliefs, rituals and healing systems of the Hawaiian people, became partners in the program. The healers understand the importance of relationship and emotions in the total health of women.
The staff offers free counseling and support in all aspects of pregnancy, childbirth and postchildbirth, including comprehensive individual, family and community assessments of stresses and strengths. Mobile health stations in neighborhoods and places of employment make it easier for women to seek care, and community partners, such as the Kiwanis club, help with marketing the program and offering incentives for participation.
"The people have claimed this program; we do not own it," Affonso said.
The initial Malama Project not only had a 98 percent patient satisfaction rate, but it also greatly increased the rates of earlier entry and retention into prenatal care.
This year, the Queen Emma Foundation, a charitable trust devoted to promoting the health of Hawaiians, has given the School of Nursing, through Affonso, $804,000 to coordinate the expansion of Malama, first to an Oahu site. The larger plan, said Affonso, is "to improve the access, availability and acceptability of preventive health care services, including prenatal care, for ethnically diverse and rural populations throughout the United States." Within two years, she hopes that the Malama Project will come to Georgia.
"The Malama Project puts the focus back on women," she said, "because the health care system cannot expect healthy children without healthy mothers."
--Holly Korschun