Prenatal Health Across Cultures at the Community Health Center of Burlington

“The baby is in my stomach, so what I eat, the baby eats,” the interpreter translated for us. Emily and I looked at each other. How do you explain the concept of a uterus and placenta to someone who became a mother at age 12, was pulled out of school in the second grade, and literally watches her stomach grow every time she gets pregnant? Thinking the baby is in the stomach makes so much more sense than imaginary organs.

My UVM College of Medicine classmate, Emily Rosen, and I taught a prenatal health class at the Community Health Center in Burlington. This was not your typical prenatal health class. We did a Schweitzer Fellowship, which is a national organization that funds graduate students to design and implement a project that targets a specific community and their particular health needs. We worked with pregnant Somali and Somali-Bantu refugee women in an attempt to improve perinatal outcomes. These women have a much higher rate of cesarean sections and other childbirth complications even compared to some of the other refugee populations in Burlington. Aside from the fact that many of the women speak little to no English and do not understand the U.S. healthcare system, many women do not go to the doctor until they are seven or eight months pregnant, meaning they receive no screening or prenatal health care. For many of the women, it is culturally unacceptable for them to admit they are pregnant until they go into labor. Another reason for the high rate of complications is the practice of female circumcision in the Somali and Somali-Bantu cultures. Although not commonly done in the U.S., female circumcision was an almost uniform practice for these women who had all been born in Somalia or refugee camps in Kenya. Emily and I wanted to attempt to bridge some of the knowledge gap and integrate some of the practices the women knew from Africa with the practices commonly accepted in the American healthcare system to help the women feel more confident about the birthing process and more included in decisions about their bodies.

Classes were on Tuesdays. For the first three weeks, not one woman came. We were frustrated, but I don’t think either one of us was particularly surprised. These women didn’t know us, so why would they trust us enough to talk to us about intimate topics such as pregnancy and their bodies? The topic is taboo even between sisters. Many of the women were on baby number six or seven, so I imagine it was difficult to believe a prenatal health class could be important or beneficial. Some of the women even found us suspicious in our motivations for doing the class. During one early class, we learned that a group of five women was sitting over at the Somali community center trying to decide if they should come or not, as they believed we were associated with an organization they did not trust. However, we were lucky to have two phenomenal interpreters on our side who were known and trusted within the community. They were able to finally convince the women that we had something beneficial to offer, and once the soon-to-be moms came, we had 100 percent attendance for all six classes.

We were anxious to address some of the difficult and sensitive topics with our students, such as female circumcision. We did an incredible amount of research on the topic, and solicited help from practitioners in the area. We also worked to establish trust with the women, reminding them that everything was private, and approaching all of the subjects in a non-judgmental way. We knew we had gained their trust when one of the women asked a question about sexual practices during pregnancy. All of the women giggled and hid behind their headscarves, but then peered at us expectantly, eagerly awaiting the answer. So we delved into some of the scarier topics, and read the reactions of the women as we went along.

Not everything we tried went over so well. During our initial conversation about female circumcision, Emily and I thought it would be a good idea to show a diagram explaining the anatomy of all the different types of female circumcisions. All the women shifted in their seats. There were no questions and the room was dead silent. One woman got up and walked out. We immediately knew we had taken it too far, so we scrapped the diagram and backpedaled until the women were asking questions again and we had resumed our girl-talk.

When it came down to it, our sessions usually contained about an hour of teaching, and an hour of gossiping. We gabbed about husbands and children, and Emily and I were often deeply probed about why we were not married with many children already. I think we both often forgot that we were not all speaking the same language (in fact there were three languages present), and I frequently knew exactly what one of the moms meant purely from her gestures and facial expressions. Emily made fun of me for laughing or nodding my head before the words were even interpreted.

After the six weeks had passed and we had completed our first run-through of the class, I got a text message from one of the women telling me that she was on her way to the hospital to give birth. She continued to update me as the birth progressed, and then sent me a picture of her baby. She trusted me and wanted to share her experience with me. At that point, Emily and I both knew that what we were doing was worth it. In our final class, some of the moms gave us verbal feedback on the experience, telling us things like, “I was nervous before I took the class, but after the class I was comfortable and ready to have my baby because they explained it so well and showed us pictures” or, “When I had my baby I used all the things I learned in class. In my culture we don’t go to childbirth classes….they created a class that was so good because we all came from Africa and all learned together for the first time.” In the end, even if we just helped improve the process for one woman, it was worth it. However, a healthy baby was born to a healthy mother for each of the women in our group, and each woman told us that she would go home and share what she had learned with her sisters and neighbors. We had no doubt that we were reaching at least a small part of the Somali and Somali-Bantu refugee communities.

We taught our students to be more comfortable taking ownership of their own bodies, and to be able to ask questions of their providers if they did not understand something. We helped them prepare to make difficult decisions, and to be ready in case a birth did not go perfectly. We taught them more about prenatal health, birthing practices, and women’s health, which the majority of the women shared with their husbands, families, and neighbors. However, the women taught us far more than we possibly could have taught them. They reminded me about the solidarity of women regardless of background and culture. They taught me about the importance of trying to truly understand where someone comes from before trying to help improve their health. They taught me that in all cultures, women want to know if they can have sexual intercourse while they are pregnant. Teaching this class reminded me that there is life away from being a medical student and that the world is so much larger than the one I saw from the lecture hall. Every single thing I learned from the project I will be able to take with me to my future as a physician. I think I will be a much better communicator and will be more understanding of the various backgrounds my patients bring to me. Although the preparation was such hard work, for the two hours a week I spent with the women, I totally forgot about whatever was stressing me out or the other things I had to do. The women we met and worked with in this class will stay with me throughout my career. They are some of my greatest teachers and influencers as I move forward.