Transcript Reducing Infant Mortality in a Vulnerable Burmese Chin Population Marty Handly, RN, MSN District Coordinator Jessica Craig, MPH Epidemiologist Nunmawi Bualteng, RN, BSN Public Health Nurse Khawl Puii,

Reducing Infant Mortality in a
Vulnerable Burmese Chin Population
Marty Handly, RN, MSN
District Coordinator
Jessica Craig, MPH
Epidemiologist
Nunmawi Bualteng, RN, BSN
Public Health Nurse
Khawl Puii, BLA
Prenatal Community Health Worker
Pam Desir, MS, RD, CD, IBCLC
District Nutritionist
 Bulgaria
 Burma
 China
 Cuba
 Egypt
 Eritrea
 Ethiopia
 Guinea
 Iran
 Iraq
3
870
11
12
4
2
18
5
2
38
 Liberia
 Malaysia
 Rwanda
 Somalia
 Thailand
 Unknown
 Total
1
2
1
1
1
10
981
 Afghanistan
 Burma
 China
 Congo
 Congo, Dem Rep
 Cuba
 Egypt
 Eritrea
 Ethiopia
 Indonesia
 Iraq
 Kenya
 Liberia
 Malaysia
1
1156
6
15
9
3
19
8
6
1
35
3
1
26
 Nepal
 Pakistan
 Russian Federation
 Rwanda
 Saudi Arabia
 Somalia
 South Africa
 Sudan
 Syrian Arab Rep.
 Thailand
 Turks & Calcos Islands
 Zimbabwe
 Unknown
 Total
7
11
1
6
1
44
1
14
4
5
7
3
9
1402
Primitive Refugee Camp
Hut Style Camp
 Occurs fairly soon after arriving to Indianapolis
 Feel safe
-- Humane housing/living conditions
-- Strong Chin presence and community
network
-- Different to become pregnant in Burma vs.
U.S.
 Trends emerging – issues with nutrition, prenatal care,
L&D, LBW infants, & infant mortality
Jessica Craig, MPH
Epidemiologist
Birth Outcomes: Burmese Chin
• All birth and infant death data
originates from the MCPHD’s vital
records department
– Birth and death certificates
• How Burmese records were located
– Burma
– Malaysia
– Thailand
– Myanmar
Birth Outcomes: Low Birth Weight
• Low Birth Weight: Any birth weight
below 2500 grams
• Very Low Birth Weight: Any birth at or
below 1500 grams
Birth Outcomes: Very Low Birth Weight
• Very Low Birth Weight: Any birth at or
below 1500 grams
Birth Outcomes: Maternal Smoking
• Maternal Smoking: Any smoking by the
mother during pregnancy
Birth Outcomes: First Trimester PNC
• First Trimester Prenatal Care: Prenatal care
that is initiated in the first 3 months of
pregnancy
Birth Outcomes: Breastfeeding
• Breastfeeding: Any mother that initiates
breastfeeding upon hospital release
Burmese Infant Mortality Rate
• Infant Mortality Rate: The number of
infant deaths per 1000 live births
Burmese MCH Outcomes: Highlights
• Below HP2020 targets for LBW, VLBW,
Preterm delivery, and maternal smoking
-Maternal smoking does not include chewing
tobacco use
• Less likely to receive first trimester PNC
• Burmese women are close to meeting
HP2020 target for breastfeeding
Data Limitations
• There is not a good way to find
Burmese, specifically Chin, on birth and
death certificates
– Race/ethnicity fields lack specific
information, often times literal fields are
not completed
• For this analysis, births from Malaysia,
Burma, Thailand, and Myanmar were
included
– Likely will cause and overestimation
Pregnancy
• Family = Father + Mother + Children
• More children = more members in the
family/clan = more powerful
• Does not delay to conceive pregnancy once one
is married.
• Repeated pregnancies with minimal time gaps
not uncommon.
Prenatal care in Burma
• Healthcare facilities available in most towns
and cities only. (Not enough
medicines/supplies/staff)
• Access to care may also depends on
socioeconomic status.
• Little or absolutely no prenatal care in rural
areas.
• No prenatal vitamins/not enough nutrition
• Lack of knowledge in taking care of self
during pregnancy.
Labor and Delivery
• Not uncommon to deliver at Home (by elderly
women who has more experience in helping
childbirths in the village/or Midwives)
• Natural birth is common. (may have epidural
in cities)
• Death d/t hemorrhage during and after
childbirth is seen especially in rural areas
and especially among low socioeconomic
groups. (no resource for blood transfusion)
Labor and Delivery
Post-partum
• Stay home for about 3 months and does no
household chores(considered unclean/weak).
Stillbirth/ Infant death
• “Dry Birth” : considered some kind of
spiritual force; believed to have Good
wealth if followed the instructions given in
dreams by the “ Hminsa” “a chaut”
meaning “dried baby”
• Not inform to public, not even to friends
and relatives (considered has no
spirit/unclean yet if the infant died before
3 months of age)
Stillbirth/ Infant death cont.
• Funeral is quiet and only immediate family
members involved.
• 7 days mourning period (traditionally) and
move on with daily lives.
Naming the child
• Burman: Buddhist rituals, involve Monks,
astrologers, name given depending on the day
of the week and date the child is born
(according Burmese calendar) May have
birth/nick- name and Given name. No Surname.
• Chins: Names given by Grandparents or
someone honorable to the family. Names not
spoken and kept secret until the child is born.
Myths
• No spicy food- child will have less hair if not
bald
• Having sex during pregnancy may kill fetus
• Taking Vitamin will make Moms eat more and
will have Big babies
• One tribe (Asho-Chin) abstain from meat during
pregnancy due to the believe that the child will
look like the meat taken.
Khawl Puii, BLA
Prenatal Community
Health Worker
As a CHW I enroll clients in the
Prenatal Care Coordination
Program during a home visit.
I also discuss WIC Program,
Medicaid/Hoosier Health
wise,
breastfeeding/nutrition,
smoking cessation, English
class.
• Resources for mom and
the unborn baby,
doctor for the baby and
the importance of OB
care to avoid
miscarriage and to have
a healthy baby and
healthy pregnant mom.
Typically, CHIN
women do not
seek prenatal care
at the beginning of
pregnancy.
Reason why:
1.Women do not
realize the
importance of early
Prenatal care.
2.Fear of going to the
doctor—bad
experience-torture in
Malaysia and Burma.
3.Language bearer
4.Lack of Medicaid
5.No transportation
6.No child care
7.No Prenatal care
where they come from
Burma, Refugee Camp.
 I discuss the program with
women through the
churches and Chin
Community. As an active
Women’s Ministry Leader
I talk with women about
the program and ask they
share the information
with others.
 In addition during TB home
visits and enrolling clients in
the Prenatal Care Coordination
Program, I will mention the
Program is also available for
others.
Women then call me regarding
enrolling in the program and a
home visit is scheduled.
Pam Desir, MS, RD, CD, IBCLC
District Nutritionist
Areas of Need
• Referrals from PHNs,
WIC RDs, and CHWs
requesting dietary
assessment and
education
• Main reason(s) for
request:
– Prenatal weight gain
– Breastfeeding
– Underweight child
Nutrition and Food
• The staple food for the Chins in
the U.S. is rice.
• Rice is eaten at every meal,
usually with vegetables and
meat.
– White rice is preferred by the
refugee community as the brown
rice in the U.S. is not considered
as tasty as the brown rice grown
at home in Burma.
– Additionally, brown rice is less
desirable because the grain is
not polished.
•
•
Meat is typically boiled with
vegetables (mustard greens or
cabbage) or fried with oil.
The typical ingredients used
by Chins for their meals are
available in most Asian food
markets in the United States.
Nutrition and Food
• Traditionally, refugee
families have two
meals/day
• Meal is built around
rice, with some meat
and some vegetables
• Often a porridge
• Skip “breakfast”
Areas of Need
•
Prenatal women need
more calories and
nutrients
–
–
–
–
Third meal
Healthy snacks
More vegetables and fruits
Iron rich foods
• Breastfeeding women need
support and nutrients
–
–
–
–
Third meal
Iron rich foods
Continue prenatal
supplements
Lactation support
Areas of Need
• Families need more balance in
each meal
–
–
–
–
Less rice
More vegetables and fruits
Healthy snacks
Non-sugary beverages
• Children need more
opportunities to eat
– Third meal
– Healthy snacks
– Need more vegetables and
fruits
– Toddlers need to discontinue a
nursing bottle
Three Apartment Communities
• Regency Park
• Green Tree
• Berkley Commons
• These three communities
had the bulk of referrals
• Decided to do monthly
classes here
– Nutrition in pregnancy and
after
– Breastfeeding
– Feeding your family
Class Topics
• Prenatal nutrition and
breastfeeding
• How to feed your family
• Classes alternated
monthly
• One class session per
community
• Served Mango Yogurt Lassi
Future Plans
• Need for preconceptual
and interconceptual
nutrition education
• Partner with WIC to
develop and implement
classes
Marty Handly, RN, MSN
District Coordinator
Future Prenatal Program
Plans & Initiatives
 Requires
-- Cultural Understanding
-- Patience
-- Overcoming the language barriers
-- Ongoing education on the U.S. health care
system and standards of care
-- Use of Chin experts in the community
 Increased screening labs being drawn in the initial
refugee screening clinic which includes
 Comprehensive chemistry panel
 CBC with differential
 Hepatitis A & B – screen for C if risk factors present
 Urinalysis
 Pregnancy testing
 QuantiFeron gold for TB screening
 Syphilis
 HIV screening
 Care Coordination referrals written on the day of the
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


refugee initial screening appointment if pregnancy
test is positive
Host Care Coordination health fairs in apartment
complexes
Education classes to the Chin churches on why early
prenatal care is important
Educational partnership classes monthly at the Chin
Community Center with St. Francis Hospital staff
Care Coordination classes to be offered by tribe at the
Chin Community Center early 2015
 Regular meetings with St. Francis Hospital staff to
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
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ensure referrals are generated on all Chin women
delivering babies in their hospital
Continue case finding efforts on all home visits to
enroll Chin women into the Care Coordination
program
Continue and grow the nutrition and
breastfeeding classes in the apartment complexes
where Chin reside
Continue to monitor the infant mortality
statistics
Genetic counseling as appropriate