Malama mama: Rhonda Matsuno and daughter Dorienne

Hawaii is home to diverse ethnic groups with complex and often ancient belief systems--including faith in methods of traditional healing.

"In Hawaii, my native state," says School of Nursing Dean Dyanne D. Affonso, "beliefs have everything to do with decision-making, but professionals sometimes act as though these beliefs don't count."

In 1985, some alarming statistics showed the professional approach wasn't working, at least not for pregnant women and babies of Hawaiian, Filipino, and Japanese descent in the Hilo-Puna district of Hawaii. The birth weights for those groups were the lowest in the state. The mothers rarely came in for early prenatal care, and far too many showed up irregularly, or only when their due date approached.

Armed with what she calls "mere ideas" and a grant from the National Institutes of Health, Affonso (at the time, professor of nursing at the University of California-San Francisco) launched the Malama Na Wahine Hapai (Caring for Pregnant Women) project to find solutions. The project has changed the face of prenatal and postpartum care in parts of Hawaii and has helped create a model of nursing that incorporates community involvement and culturally specific care.

Empowering a community

An early offshoot of the Malama project was the formation of the Neighborhood Women's Health Watch (NWHW), a collective of local women with childbearing experience who wanted to promote the health of women and infants.

"These women have great ideas about how to motivate and take care of their own kind," Affonso says. "They became our community partners."

For instance, the NWHW developed an irregular-menses service to track and offer counseling to women in the earliest weeks of pregnancy. Women were referred to the Community Health Nursing Prenatal Care Program (CHN-PCP), designed by Malama researchers to be culturally and ethnically sensitive; if their pregnancy test was positive, they were directed to local obstetrics services.

"Previously, entry into prenatal care took 20 to 24 weeks," Affonso says. "This approach brings women into prenatal care in as early as six weeks."

The community as teacher

The Malama style of caregiving involves far more than simply helping pregnant women access care. Researchers also conducted a formal community needs assessment by doing something unfamiliar to many Western health care workers--asking pregnant women what kind of care they wanted.

"Obviously, with the statistics we had, we knew nurses and obstetricians weren't doing a good job with these women," says June Shibuya, coordinator of the Malama project. "So we said, now we are the learners. You--the clients, the community--are our teachers."

Women from the three at-risk ethnic groups met in 15 well-attended focus sessions to discuss unique stressors, cultural mores, and health care needs. Each group gave a different response: The Hawaiians and Filipinos, for instance, found accessing care difficult because clinics were friendly only to those who knew how to ask the proper questions.

"These are ethnic groups who are taught not to ask questions of authority figures, because doing so shows disrespect," says Shibuya. "Therefore, if a receptionist sounded impatient, they wouldn't question her and wouldn't make an appointment."

Women of Japanese heritage had other concerns, like striving for upward mobility. "When pregnant, they're worried about sending the child to college," she says, "or how they will pay for the mortgage. Yet they couldn't articulate their stressors to their family. In the Japanese tradition, you show strength by being stoic. Some said they felt like a volcano ready to erupt. We have enough studies that deal with vasoconstriction to know how that kind of stress can affect the fetus."

Going beyond culturally sensitive care

Ongoing sessions, conducted by the neighborhood group and guided by CHN-PCP nurses, gave women a place to feel comfortable sharing their stories. Men also were encouraged to come and discuss relationships. The Malama researchers discovered several dominant issues.

"Women felt lost during the first trimester," says Affonso. "Everyone says, 'Do this for the baby,' but no one takes the time to hear what the mother has in mind for herself. How can we expect a woman to grow a healthy fetus when we don't take care of her first? So we started working in protocols, on the first three visits, that focus on giving the woman time to talk about how she feels, about her worries.

"Our three constructs are the search for meaning, the sense of mastery or coping, and self-esteem," Affonso continues. "They aren't fancy, but they are incredibly relevant to the people we serve. The women loved the idea that no question is stupid."

Another insight was the importance of legitimizing symptom distress.

"We learned we must start much earlier on the continuum between symptoms and disease," says Dr. Linda Mayberry, adjunct professor of nursing at Emory and a Malama researcher. "A symptom may not add up to a disease in the eyes of a physician, but if it is causing distress in a woman's life and body, ultimately it will affect her fetus."

Interestingly, researchers also found that ethnic healers, and not doctors and nurses, were the pros at healing and reconciling distress.

"We learned new caregiving strategies from the healers," Affonso says. "The more we became the novices, the more successful our project grew. We went beyond culturally sensitive care to culturally competent care."

The lessons of Malama

The Malama project will continue, thanks to the support of the Queen Emma Foundation, a public trust devoted to promoting Hawaiian health, which gave money to Emory's School of Nursing to fund the expansion of Malama to the island of Oahu.

"In our final report, we found that retention in prenatal care, gestational age, and other indices improved in the Malama cohort," Shibuya says. "We believe this approach will work across ethnic groups and in urban as well as rural settings."

Affonso agrees.

"We are having a dialogue with the state of Georgia to find ways to bring the Malama model here," she says. "Pregnancy outcomes in Georgia are poor in terms of national rankings. Whatever we are doing now is not good enough."

Deanna Ige, a mother who participated in the Malama project, says the experience had a profound effect on her well-being during pregnancy: "I could go to the Malama nurse and have my concerns answered. I was comforted, nurtured. They made me feel I was important enough to be heard."

Shibuya notes that Ige is now a "neighborhood woman," and is recruiting other women to participate in Malama care.

"People talk about cycles of violence and abuse," she says, "but what has happened with Malama shows you can also create cycles of caring and nurturing, cycles that go on and on."

Reprinted from Emory Nursing, Spring 1997

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