Reducing Infant Mortality in a Vulnerable Burmese Chin

PopulationMarty Handly, RN, MSN

District Coordinator

Jessica Craig, MPHEpidemiologist

Nunmawi Bualteng, RN, BSNPublic Health NurseKhawl Puii, BLA

Prenatal Community Health WorkerPam Desir, MS, RD, CD, IBCLC

District Nutritionist

Brief Overview of History of Burmese Refugees Resettling to Indianapolis

Trends with Pregnancy in the Burmese Population

Marty Handly, RN, MSNDistrict Coordinator

Military Capture

Military Captivity Camps

Refugees Seeking Exile

Marion County Refugees in 2009

Bulgaria 3Burma 870China 11Cuba 12Egypt 4Eritrea 2Ethiopia 18Guinea 5Iran 2Iraq 38

Liberia 1Malaysia 2Rwanda 1Somalia 1Thailand 1Unknown 10Total 981

Marion County Refugees 2013 Afghanistan

1 Burma 1156 China 6 Congo 15 Congo, Dem Rep 9 Cuba 3 Egypt 19 Eritrea 8 Ethiopia 6 Indonesia 1 Iraq 35 Kenya 3 Liberia 1 Malaysia 26

Nepal 7 Pakistan 11 Russian Federation 1 Rwanda 6 Saudi Arabia 1 Somalia 44 South Africa 1 Sudan 14 Syrian Arab Rep. 4 Thailand 5 Turks & Calcos Islands 7 Zimbabwe 3 Unknown 9 Total 1402

Where Is Burma?

Burma Up Close

Several Types of Chin Refugee Camps

Primitive Refugee Camp

Chin Refugee Camp

Hut Style Camp

Chin Refugee Camp

Occurs fairly soon after arriving to IndianapolisFeel 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

Pregnancy

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

MAWI BUALTENG, RNPUBLIC HEALTH NURSE

PREGNANCY, PRENATAL CARE, LABOR & DELIVERY IN

BURMA

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

CARE COORDINATION ENROLLMENT

AND

ASSERTIVE CASE FINDING

I. Define Care Coordination

This is a program that helps the pregnant woman and unborn child.

This is a service which a registered nurse would visit approximately once every three months - to check on mom, take her blood pressure and make sure she is doing ok with her pregnancy. In addition the nurse would answer questions.

As a CHW I enroll clients in the

Prenatal Care Coordination

Program during a home visit.

Define Care Coordination

I also discuss WIC Program, Medicaid/Hoosier Health wise, breastfeeding/nutrition, smoking cessation, English class.

I. Define Care Coordination

• 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.

Seeking Prenatal Care

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.

Seeking Prenatal Care

2.Fear of going to the doctor—bad experience-torture in Malaysia and Burma.3.Language bearer4.Lack of Medicaid5.No transportation6.No child care7.No Prenatal care where they come from Burma, Refugee Camp.

II. Assertive Case Finding

We do receive referrals from the WIC office for the Prenatal Care Coordination Program, Action Health Center, Hospital, Neighbor-hood Health Center.

In addition, I also do case- finding which is a self referral process.

II. Assertive Case Finding

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.

II. Assertive Case Finding

Pam Desir, MS, RD, CD, IBCLC

District Nutritionist

NUTRITION EDUCATION

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

Marty Handly, RN, MSNDistrict 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

Serving the Burmese Chin Refugee Population

Increased screening labs being drawn in the initial refugee screening clinic which includesComprehensive chemistry panelCBC with differentialHepatitis A & B – screen for C if risk factors

presentUrinalysisPregnancy testingQuantiFeron gold for TB screeningSyphilisHIV screening

Future Plans/Endeavors for Decreasing Infant Mortality in the Burmese Chin Population

Care Coordination referrals written on the day of the 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

Future Plans Cont..

Regular meetings with St. Francis Hospital staff to 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

Future Plans Cont..