Understanding Barriers to Healthcare Among Resettled Refugees

Midwifery, Midwifery students, Reflections on racism and oppression in midwifery

Written by Olivia Kimble, Student Midwife at Bastyr University for the first class in the Midwifery Care series

The life of a refugee is inarguably more difficult than most healthcare workers probably imagine. It is easy to forget about the challenges refugees face because many of our own communities are made up of homogeneous, native-born citizens. Citizens are more likely to understand and exercise their access to healthcare through private or community clinics, or, as a last resort, the emergency department. In contrast, a refugee has to overcome additional obstacles before accessing healthcare, and then might only have access to racist and xenophobic providers.  

The people displaced because of civil war, political oppression, and economic instability face many challenges and traumas in their attempt to seek liberty and safety. Once these people have made it to a new location, usually illegally, they face hurdle after hurdle trying to establish a life. Refugees are subject to sweeping employment discrimination because they cannot speak the native language (or are easily recognized because of an accent), are undocumented and therefore cannot demand better working conditions or livable salaries, and cannot setup informal businesses without attracting law enforcement (Langa, 2011).

Langa (2011) reports that “by and large refugee women live in fear, and feel dislocated, and displaced” (p. 2). As a provider it’s important to recognize how a refugee’s health status is tied directly to their plight as a refugee. Understandably, refugees are probably not the most reliable patients because they have to spend such an inordinate amount of time finding or creating livable income to support themselves and their families.

What some health care providers might describe as uncooperative or difficult patient behavior was clearly visible in The Spirit Catches You and You Fall Down (Fadiman, 1997). Lia’s parents are continually seen as disagreeable because their Hmong customs and ideas conflict with American ideals of personal responsibility and hierarchical submission to their doctors’ orders. The Lee family relied on state assistance and thus did not have the freedom of movement, time, and resources that the doctors expected from their patients. Foua’s culturally-motivated rapt attention to Lia and her determination to carry her, clothe her, feed her, and love her regardless of her physical health status created a strange tension between her doctors who were also trying to care for Lia in their own American, individual way (Fadiman, 1997). Unfortunately the doctors who treated Lia were somehow immune to the family’s plight as refugees and saw their battle for economic security as a hindrance to their care instead of informing how to best care for the Lee family.

Refugees are often among the hardest working people in any country because they have to be. Finding a new home, creating economic stability, and rebuilding a community are monumental tasks to undertake even with good health. Unfortunately, needing and seeking healthcare as a refugee might be as costly and dangerous as remaining ill.


Fadiman, Anne. (1997). The spirit catches you and you fall down: A Hmong child, her American doctors, and the collision of two cultures. New York, NY: The Noonday Press.

Langa, M. (2011). Women empowerment: A case study of a refugee women’s group at the Centre for the Study of Violence and Reconciliation. Retrieved from http://www.csvr.org.za/images/docs/Other/women_empowerment_a%20case_study_of_a_refugee_women_s_group_appendix_e.pdf

Written by Olivia Kimble, Student Midwife at Bastyr University for the first class in the Midwifery Care series

Health care in the US’ biggest colony

Healthcare in the US, Midwifery students, Reflections on racism and oppression in midwifery

By Tamara Trinidad-Gonzalez, Student Midwife

First, I must confess that making this post has taken longer in time and energy than I had anticipated. Writing about this subject and all its layers is a huge trigger of all the frustrations that living in a colony entails.  Pointing out one preexisting factor of why the care system in Puerto Rico has been so inefficient is not that easy as there is no such thing as one factor. This is more a cascade of effects, in fact, a very complex one than an isolated situation. I will try my best to explain it.

All this inefficiency goes back to the origins of our colonial politic situation (starting in 1898), which opens the biggest gate for Puerto Rico to not being treated equal as the other US territories and jurisdictions. In addition to this, the predominant political corruption for decades, have been a fertile ground to make this a major disaster. You may have heard already through the media that there is a huge, and unfair $73 billion debt that Puerto Ricans are being blamed for. Economists keep studying this socio-economic issue and it is evident that the colonial control over the economy of Puerto Rico has contributed to create this crisis. This crisis is affecting the daily quality of lives of Puerto Rican’s especially when it comes to educations and health. Alvarez and Goodnough (2015) emphasize that the disparity of federal fund is responsible for $25 billion of the total debt because the government of Puerto Rico was forced to borrow money to be able to keep the Medicaid program running. They also explain in this article that the misery of Puerto Rico’s health care began in the late 60’s with the initiation of the Managed Care health system and the Medicaid Cap placed by the U.S. Congress for all of its territories. The managed care health system in Puerto Rico has proven to be very ineffective for decades. This type of health care plan only works in favor of the insurance companies and not to benefit the people nor the health care providers.

There is a huge disparity of federal funding available for Puerto Rico in comparison to what is available to the rest of the US jurisdictions and territories.  The federal funding and commonwealth funding need to be equally paired, but the Commonwealth pocket does not have the capacity to pair sufficient amounts so, substantially less amounts of funding are given to Puerto Rico. The problem is that in Puerto Rico, more than 60% of its residents (which used to be 3.5 million people before Hurricane Maria), receive Medicare or Medicaid. Thus, the funding allocated is just not enough to properly care for the health of people. Alvarez and Goodnoug (2015) make a comparison of how much funding is given to two other states equal in population, but wealthier than Puerto Rico, and I created this table to see it better.

State/ Jurisdiction Population Medicaid funding/year
Puerto Rico 3.5 million $373 million
Oklahoma 3.49 million $3 billion
Mississippi 3 million $3.6 billion

Because of this situation, we (Puerto Ricans) grow accustomed to hearing of doctors leaving the island motivated for better income and work conditions. There are great physicians in Puerto Rico (PR), so they are being offered an income that is 3 or 4 times what they are earning, with moving expenses covered, health insurance, vacations and even with their liability insurance paid. To have a clearer idea of the magnitude of this problem, an article from 2016, a year before hurricane Maria, was already revealing the dangerous migration of Puerto Rican physicians to the mainland. From 2006 to 2016, around 5,000 physicians had stopped working in PR. By the summer of 2016, there were only 9,000 physicians with active licenses. And with a population of 3.5 million people, this meant having like 5 doctors for every 2,000 people. The chaos that this causes in the daily lives of Puerto Ricans is very present and evident.  Some examples of this is when patients must wait many months to have an appointment with a specialist, or when someone that is sick, does not get treated for something simple, and then dies; or when there is an urge for a treatment and people opt to travel to the US to get the needed treatment.

If this already sounded like a shortage and terrible health conditions, after hurricane Maria, a massive amount doctors left the island, abandoned their practices and their patients and many hospitals closed. This includes OBs which left many women without adequate prenatal care. Although the midwives stepped in to help as they could, they lack the resources to help everyone as they would like and deserve.

In conclusion, although we pay the same Medicare and Social Security taxes as the rest of the US, we are not treated equally. All this produces an unbalanced health system that is not fair for the people nor for the health providers that are compromising their humanity and their Hippocratic Oath.


Alvarez, L. & Goodnough, A. (2015). Puerto Ricans Brace for Crisis in Health Care. Accessed online at https://www.nytimes.com/2015/08/03/us/health-providers-brace-for-more-cuts-to-medicare-in-puerto-rico.html?_r=0

Bodenheimer, T. & Grumbach, K. (2012). Understanding Health Policy: A Clinical Approach, 6th Edition. McGraw-Hill, New York, NY.

GFR Media (2016). Peligrosa fuga de miles de médicos. Retrieved from https://www.elnuevodia.com/noticias/locales/nota/peligrosafugademilesdemedicos-2225024/

Written by Tamara Trinidad-Gonzalez, Student Midwife at Bastyr University originally for a class in the Professional Issues series: Health Care Systems and Health Policy

Racial Disparities Persist

Healthcare in the US, Reflections on racism and oppression in midwifery

Despite the national Healthy People objectives established every ten years for the last three decades by the Office of Disease Prevention and Health Promotion, maternal and infant health indicators in this country continue to demonstrate a significant need for improvement, particularly among racial and ethnic minorities (Mathews & MacDorman, 2006).  In their call to action to the public health profession, Garcia and Sharif (2015) commented that “the health consequences of living in a racially stratified society are illustrated by a myriad of health outcomes that systematically occur along racial lines, such as disproportionately higher rates of infant mortality” (p. e28).

Two areas of concern, in particular, have been identified as leading health indicators with regard to maternal and infant health in the US: all infant deaths and total preterm live births.  These two health indicators, in addition to many others, provide clear examples of the health disparities faced by people of color in the US.  The rate of infant deaths (within the first year of life) is more than doubled for black or African American babies when compared to white infants (10.8 per 1,000 vs 5.1 per 1,000 in 2013).  Infants of persons identified as American Indian or Alaska Native are also disproportionately affected (7.6 deaths/1,000 live births in 2013) (Mathews & MacDorman, 2006).  While overall infant deaths have been decreasing, the health care disparities outlined above have persisted since at least 2006, the earliest year analysis by race/ethnicity is provided publicly by HealthyPeople.gov.  Preterm birth rates (before 37 completed weeks gestation) are also consistently found to be higher for mothers who are black or African American (16.0%), American Indian or Alaska Native (13.1%), and Hispanic or Latina (11.3%) when compared to white mothers (10.5%) in the US  (data from 2013).  While the causes of health care disparities and inequities are multifactorial, racial disparities are a well-documented factor.

NOTE: The phrase ‘maternal and infant health’ is used above due to its widespread use and recognition in public health literature.  The use of this phrase is not intended to exclude or ignore the health issues faced by transgender and genderqueer persons who may not identify as mothers.


García, J., & Sharif, M. Z. (2015). Black Lives Matter: A commentary on racism and public health. American Journal of Public Health, 105(8), e27-e30. doi://10.2105/AJPH.2015.302706

Mathews T. J., & MacDorman M. F. (2010). Infant mortality statistics from the 2006 period linked birth/infant death data set. National Vital Statistics Report, 58:17, 1-31. Hyattsville, MD: National Center for Health Statistics. Available from: https://www.researchgate.net/publication/46146499_Infant_mortality_statistics_from_the_2006_period_linked_birthinfant_death_data_set .

If All Lives Really Mattered

black lives matter, Healthcare in the US, Midwifery, Reflections on racism and oppression in midwifery

The main strand of the alternative birth movement in the US which has been lead primarily by white, middle class women since the 1970s often conceptualizes their work as a pursuit of liberty and happiness.  Publications and participants characterize the movement as ensuring a woman’s right to an empowering pregnancy and birth experience.  The concepts of one’s rights are inexorably tied to notions of liberty, but much like the historical roots of freedom (and lack thereof based on race and gender) in our country, rights have been granted by the powerful only to those deemed fully human and deserving of happiness.  Happiness and rights are permitted by the systems of power currently in place only in forms still confined within the status quo.

Oparah and Bonaparte (2016) point out the ways in which the birthing consumer’s right to empowerment narrative has emerged and succeeded in public discourse precisely because it doesn’t challenge the deeper social and economic forces at work which serve to subjugate and ignore the most vulnerable pregnant people (15).  Indeed they argue that “legislators opposed to feminism…and to left-wing countercultural tendencies have found it possible to support the consumer right of (white, middle-class) mothers to ‘purchase’ the birth experience they desire”  (14).   

Empowerment is presumed by many in the modern white, middle class midwifery movement to be a desirable goal leading to happiness and therefore to be pursued in the name of all women.  The tendency in the second-wave feminist movement to claim to speak for all women while not taking “black women’s concerns seriously” (13) has emerged throughout the movement for reproductive rights.  In 2003, the Feminist Majority Foundation and others agreed to change the name of the protest march they were planning in response to criticisms from diverse stakeholders that the movement needs to broaden its perspectives and goals.  Black women and others on the margins, it was argued, are not available to simply protest for their right to safe abortion.  Instead, the diverse organizations courted wanted recognition that they are literally fighting for women’s lives.  As a result of the broad coalition formed, the March for Women’s Lives (2004) was one of the largest protests of all time in Washington, DC.  I see this example as illustrative of the ways in which the birth justice movement is more about life than about liberty and happiness.  Interestingly, life is the banner taken up by the inspiring present day grassroots movement Black Lives Matter.  Of course this second Civil Rights movement is also about liberty and happiness (in the form of dignity and respect), but who has time to espouse liberty when you and your loved ones are so busy fighting for your lives.    

An ignorant response to the Black Lives Matter movement has been “#alllivesmatter.”  If “all lives matter”ed as much as the lives of white wealthy people, particularly men, then the health care disparities in the US based on race could not possibly exist to the extent that they do.  Reforms to the US healthcare system have consistently benefited racial and ethnic minorities less than their white counterparts and this trend continues today.  US statistics on maternal and infant mortality and morbidity demonstrate that babies and women, especially black and brown babies and women, do not fare nearly as well as whites.  While the US healthcare system is in many ways failing women and infants in general when compared to other developed countries, women and babies of color are dying at alarmingly higher rates than white women and babies.  The statistics on which my above claims rest have been around since the previous century.  Despite awareness of health care disparities and social determinants of health in some sectors of the US health care non-system, meaningful changes that affect peoples’ lives on the ground have been slow to develop.  

So what do we do with this information?  Where do we go from here?  Visit our blog post titled Plugging Into this Important Work


Oparah, J. C., & Bonaparte, A. D. (Eds.). (2015). Birthing Justice: Black Women, Pregnancy, and Childbirth. Routledge.