“Can I Ask That?”: Perspectives on Perinatal Care After Resettlement Among Karen Refugee Women, Medical Providers, and Community-Based Doulas


This study characterized the perspectives of Karen refugee women in Buffalo, NY, their medical providers, and Karen interpreters/doulas on perinatal care for Karen women in resettlement. In-depth qualitative interviews with Karen women (14), Karen doulas/interpreters and key informants (8), and medical providers (6) were informed by the social contextual model and focused on women’s questions about and opinions of perinatal care in Buffalo and on providers’ experiences caring for Karen patients. Karen women expressed gratitude for and understanding of perinatal care in Buffalo, and providers described Karen patients as agreeable but shy. Karen doulas offered an alternative view that exposed women’s many questions and concerns, and described how doula training empowered them as patients’ advocates. Low self-efficacy, trauma histories, and cultural expectations may contribute to Karen women’s seeming agreeability. Doulas/interpreters possess insider knowledge of women’s concerns and facilitate communication between patients and the care team.

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  1. 1.

    Office of Admissions, Department of State Bureau of Population, Refugees, and Migration, Refugee Processing Center. Summary of Refugee Admissions as of February 28, 2014. http://www.wrapsnet.org/Reports/AdmissionsArrivals. Accessed 8 Mar 2014.

  2. 2.

    Office of Admissions, Department of State Bureau of Population, Refugees, and Migration, Refugee Processing Center. Top 10 languages spoken by arrived Refugees as of September 30, 2013. http://www.wrapsnet.org/Reports/AdmissionsArrivals. Accessed 8 Mar 2014.

  3. 3.

    Harkins B. Beyond “temporary shelter”: a case study of Karen refugee resettlement in St. Paul, Minnesota. J Immigr Refug Stud. 2012;10:184–203.

    Article  Google Scholar 

  4. 4.

    Checchi F, Elder G, Schäfer M, Drouhin E, Legros D. Consequences of armed conflict for an ethnic Karen population. Lancet. 2003;362:74–5.

    Article  PubMed  Google Scholar 

  5. 5.

    Kenny P, Lockwood-Kenny K. A mixed blessing: Karen resettlement to the United States. J Refug Stud. 2011;24:217–38.

    Article  Google Scholar 

  6. 6.

    Cardozo BL, Talley L, Burton A, Crawford C. Karenni refugees living in Thai–Burmese border camps: traumatic experiences, mental health outcomes, and social functioning. Soc Sci Med. 2004;58:2637–44.

    Article  Google Scholar 

  7. 7.

    Mullany LC, Richards AK, Lee CI, Suwanvanichkij V, Maung C, Mahn M, Beyrer C, Lee TJ. Population-based survey methods to quantify associations between human rights violations and health outcomes among internally displaced persons in eastern Burma. J Epidemiol Community Health. 2007;61:908–14.

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Al Gasseer N, Dresden E, Keeney GB, Warren N. Status of women and infants in complex humanitarian emergencies. J Midwifery Womens Health. 2004;49:7–13.

    Article  PubMed  Google Scholar 

  9. 9.

    Falb KL, McCormick MC, Hemenway D, Anfinson K, Silverman JG. Symptoms associated with pregnancy complications along the Thai–Burma border: the role of conflict violence and intimate partner violence. Matern Child Health J. 2014;18:29–37.

    Article  PubMed  Google Scholar 

  10. 10.

    Falb KL, McCormick MC, Hemenway D, Anfinson K, Silverman JG. Violence against refugee women along the Thai–Burma border. Int J Gynecol Obstet. 2013;120:279–83.

    Article  Google Scholar 

  11. 11.

    Barnes DM, Harrison CL. Refugee women’s reproductive health in early resettlement. J Obstet Gynecol Neonatal Nurs. 2004;33:723–8.

    Article  PubMed  Google Scholar 

  12. 12.

    Correa-Velez I, Ryan J. Developing a best practice model of refugee maternity care. Women Birth. 2012;25:13–22.

    Article  PubMed  Google Scholar 

  13. 13.

    Kahler LR, Sobota CM, Hines CK, Griswold K. Pregnant women at risk: an evaluation of the health status of refugee women in Buffalo, New York. Health Care Women Int. 1996;17:15–23.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Akhavan S. Midwives’ views on factors that contribute to health care inequalities among immigrants in Sweden: a qualitative study. Int J Equity Health. 2012;11:47.

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Carroll J, et al. Caring for Somali women: implications for clinician–patient communication. Patient Educ Couns. 2007;66(3):337–45.

    Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Hill N, Hunt E, Hyrkäs K. Somali immigrant women’s health care experiences and beliefs regarding pregnancy and birth in the United States. J Transcult Nurs. 2012;23:72–81.

    Article  PubMed  Google Scholar 

  17. 17.

    Morris MD, Popper ST, Rodwell TC, Brodine SK, Brouwer KC. Healthcare barriers of refugees post-resettlement. J Community Health. 2009;34:529–38.

    Article  PubMed  PubMed Central  Google Scholar 

  18. 18.

    Brach C, Fraser I, Paez K. Crossing the language chasm. Health Aff. 2005;24:424–34.

    Article  Google Scholar 

  19. 19.

    Flores G. The impact of medical interpreter services on the quality of health care: a systematic review. Med Care Res Rev. 2005;62:255–99.

    Article  PubMed  Google Scholar 

  20. 20.

    Ferguson WJ, Candib LM. Culture, language, and the doctor–patient relationship. Fam Med. 2002;34:353–61.

    PubMed  Google Scholar 

  21. 21.

    Schouten BC, Meeuwesen L. Cultural differences in medical communication: a review of the literature. Patient Educ Couns. 2006;64:21–34.

    Article  PubMed  Google Scholar 

  22. 22.

    Hudelson P. Improving patient-provider communication: insights from interpreters. Fam Pract. 2005;22:311–6.

    Article  PubMed  Google Scholar 

  23. 23.

    Shannon P, O’Dougherty M, Mehta E. Refugees’ perspectives on barriers to communication about trauma histories in primary care. Ment Health Fam Med. 2012;9:47–55.

    PubMed  PubMed Central  Google Scholar 

  24. 24.

    Niner S, Kokanovic R, Cuthbert D. Displaced mothers: birth and resettlement, gratitude and complaint. Med Anthropol. 2013;32:535–51.

    Article  PubMed  Google Scholar 

  25. 25.

    Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2013; 15.

  26. 26.

    Parsons L, Day S. Improving obstetric outcomes in ethnic minorities: an evaluation of health advocacy in Hackney. J Public Health Med. 1992;14:183–91.

    CAS  PubMed  Google Scholar 

  27. 27.

    Akhavan S, Edge D. Foreign-born women’s experiences of community-based doulas in Sweden—a qualitative study. Health Care Women Int. 2012;33:833–48.

    Article  PubMed  Google Scholar 

  28. 28.

    Akhavan S, Lundgren I. Midwives’ experiences of doula support for immigrant women in Sweden—a qualitative study. Midwifery. 2012;28:80–5.

    Article  PubMed  Google Scholar 

  29. 29.

    Nagler EM, Pednekar MS, Viswanath K, Sinha DN, Aghi MB, Pischke CR, Ebbeling CB, Lando HA, Gupta PC, Sorensen GC. Designing in the social context: using the social contextual model of health behavior change to develop a tobacco control intervention for teachers in India. Health Educ Res. 2013;28:113–29.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    Sorensen G, Emmons K, Hunt MK, Barbeau E, Goldman R, Peterson K, Kuntz K, Stoddard A, Berkman L. Model for incorporating social context in health behavior interventions: applications for cancer prevention for working-class, multiethnic populations. Prev Med. 2003;37:188–97.

    Article  PubMed  Google Scholar 

  31. 31.

    Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191–215.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Kuzel AJ. Sampling in qualitative inquiry. In: Crabtree BF, Miller WL, editors. Doing qualitative research. Thousand Oaks: Sage; 1999. p. 33–46.

    Google Scholar 

  33. 33.

    Lincoln Y, Guba E. Naturalistic inquiry. Newbury Park: Sage; 1985.

    Google Scholar 

  34. 34.

    Borkan J. Immersion/Crystallization. In: Crabtree BF, Miller WL, editors. Doing qualitative research. Thousand Oaks: Sage; 1999. p. 179–94.

    Google Scholar 

  35. 35.

    King N. Template analysis. In: Symon G, Cassell C, editors. Qualitative methods and analysis in organizational research. Thousand Oaks: Sage; 1998. p. 118–34.

    Google Scholar 

  36. 36.

    Weinstein, Matthew TAMS Analyzer for Macintosh OS X. http://sourceforge.net/projects/tamsys/files/. Accessed 25 Jan 2012.

  37. 37.

    Chue A, Carrara V, Paw MK, Pimanpanarak M, Wiladphaingern J, van Vugt M, Lee SJ, Nosten F, McGready R. Is areca innocent? The effect of areca (betel) nut chewing in a population of pregnant women on the Thai–Myanmar border. Int Health. 2012;4:204–9.

    Article  PubMed  Google Scholar 

  38. 38.

    Kluft RP, Bloom SL, Kinzie JD. Treating the traumatized patient and victims of violence. In: Bell CC, editor. Psychiatric aspects of violence: issues in prevention and treatment. New directions in mental health services, 86. San Francisco: Jossey-Bass; 2000. p. 79–102.

    Google Scholar 

  39. 39.

    Claramita M, Utarini A, Soebono H, Van Dalen J, Van der Vleuten C. Doctor-patient communication in a Southeast Asian setting: the conflict between ideal and reality. Adv Health Sci Educ Theory Pract. 2011;16:69–80.

    Article  PubMed  PubMed Central  Google Scholar 

  40. 40.

    Liamputtong P, Watson L. The voices and concerns about prenatal testing of Cambodian, Lao and Vietnamese women in Australia. Midwifery. 2002;18:304–13.

    Article  PubMed  Google Scholar 

  41. 41.

    Ingram M, Reinschmidt KM, Schachter KA, Davidson CL, Sabo SJ, De Zapien JG, Carvajal SC. Establishing a professional profile of community health workers: results from a national study of roles, activities and training. J Community Health. 2012;37:529–37.

    Article  PubMed  Google Scholar 

  42. 42.

    Sulaiman-Hill CM, Thompson SC. Learning to fit in: an exploratory study of general perceived self efficacy in selected refugee groups. J Immigr Minor Health. 2013;15:125–31.

    Article  PubMed  Google Scholar 

  43. 43.

    Wiking E, Saleh-Stattin N, Johansson SE, Sundquist J. A description of some aspects of the triangular meeting between immigrant patients, their interpreters and GPs in primary health care in Stockholm, Sweden. Fam Pract. 2009;26:377–83.

    Article  PubMed  Google Scholar 

  44. 44.

    Wiking E, Sundquist J, Saleh-Stattin N. Consultations between immigrant patients, their interpreters, and their general practitioners: are they real meetings or just encounters? A qualitative study in primary health care. Int J Family Med. 2013.

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Correspondence to Kate LaMancuso.

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LaMancuso, K., Goldman, R.E. & Nothnagle, M. “Can I Ask That?”: Perspectives on Perinatal Care After Resettlement Among Karen Refugee Women, Medical Providers, and Community-Based Doulas. J Immigrant Minority Health 18, 428–435 (2016). https://doi.org/10.1007/s10903-015-0172-6

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  • Perinatal health care
  • Refugee
  • Burma (Myanmar)
  • Community-based doula
  • Cross-cultural communication