Across the Americas, 2023 set numerous migration records. December 2023 had the highest number of migrant encounters at the United States-Mexico border in one month, at 249,735.1 The fiscal year had the highest number of encounters at the US-Mexico border, at 2.5 million. (Both of these figures may be inflated as they include repeat encounters.) Last year also saw the highest number of migrants crossing the Darién Gap, at around 520,000 individuals.
The Specifics of Venezuelan Prenatal and Delivery Care
By Claire Hutkins Seda and Mónica Fossi
Understanding what patients expect from the clinic is an important part of providing culturally aware care. In Venezuela, health care services experience frequent disruptions and shortages. Prior to the economic crisis, however, most women received basic prenatal care with physicians and then delivered in the hospital; midwifery and home-provided care are extremely rare. A very small number of people can afford private care, which may include more personalized care and access to more advanced diagnostics like genetic testing and 3D sonograms. After a hospital birth, the patient and newborn stayed in the hospital for between 24 and 72 hours, during which they were provided basic postpartum and newborn support and counseled for contraception.
For over a decade, infant and maternal mortality have been on the rise. Between 2012 and 2016, infant mortality rose by 63% and maternal mortality doubled.8 More recent figures are unknown; the country’s growing political instability and economic fallout caused the humanitarian crisis and collapse of the health system, and national health statistics have since become unavailable.9 At least 7.72 million people have emigrated from Venezuela, with roughly 6.5 million settling across Latin America and the Caribbean.10 Among these millions are tens of thousands of physicians and other clinicians, leading to personnel shortages in health care.11 In addition to a lack of clinicians, Venezuela’s hospitals face shortages of supplies and medications, lack of consistent clean water, inability to maintain hygiene, and frequent power outages, further interrupting and endangering care. Many pregnant women leave Venezuela for nearby countries including Brazil, Peru, and Colombia, where they can access prenatal care. Between 9 and 12% of newborns born at term in Colombia to Venezuelan mothers have low birth weight, indicating the impact of social and economic conditions, including maternal nutrition.12
Learn more about culturally contextual prenatal care by watching our recent webinar, Prenatal Care for Migrants: Services and Practices in Their Home Country and What Can Be Expected Throughout the Migrant’s Route to the US, which focused on pregnant Venezuelan asylum seekers. It was presented primarily in Spanish with English interpretation.
In English: https://www.migrantclinician.org/
webinar/prenatal-care-migrants-services-and-practices-their-home-country-and-what-can-be-expected
In Spanish: https://www.migrantclinician.org/
es/webinar/atencion-prenatal-para-migrantes-servicios-y-practicas-en-su-pais-de-origen-y-que-se-puede
The increased number of crossings in this dangerous strip of rainforest from the border of Colombia and into Panama signaled another noted shift in 2023, in addition to the greater numbers: the rapid change in demographics among those asking for asylum. In 2020, almost 90% of migrant encounters were with individuals from Mexico and the Northern Triangle of El Salvador, Guatemala, and Honduras. For the first time in recent history, in 2023, the percentage of encounters from those four countries together dropped below 50%.2 Because the number of encounters has greatly increased, the percentage change does not indicate a drop in the number of people from each of these countries seeking asylum; in fact, the numbers are growing across the board. For example, the number of encounters with migrants from Mexico in 2020 was 297,711 – 74% of the total number of encounters.34 In 2023, the number of encounters with migrants from Mexico leapt to 717,333, but was just 29% of the total.5 The percentage change reflects a change in demographics among the asylum seekers released into the US after detention, who then may seek care across the nation’s community health centers. Countries that have seen increased percentages of encounters are those experiencing instability, including Haiti, Cuba, Colombia, Peru, Ukraine, India, Ecuador, Brazil, Romania, and China. Encounters with migrants from Venezuela, for example, grew from 2,787 in 2020 to 334,914 in 2023.
How can health centers prepare for the shifting demographics among their patients?
Community Partnerships and Community Health Worker Programs
Once released from border detention, asylum seekers often travel to towns and cities where they have relatives, former neighbors, or friends from the same ethnicity or nationality. Clear and regular communication and partnership with community-based organizations that serve the diverse ethnicities in the health center’s town can assist the health center in assessing and responding to the growth in those communities with services and outreach that are culturally contextual. Well-established community health worker/promotora (CHW/P) programs can equip a health center with the infrastructure needed to build trust and increase care access among new community members. For example, Venezuelans, as for many from across Latin America, find the CHW/P model to be a familiar and trusted avenue to access health education and connect with the community clinic. Their prenatal care is similar to that provided in the US. (See sidebar.)
Specific Health Needs
Understanding the specific health and social needs common among the incoming migrant population can fast-track a health center’s ability to serve that community. For example, in decades past, with most migrants coming from Mexico and the Northern Triangle, many migrants experienced health risks while crossing the deserts of northern Mexico and the southwestern US. Clinicians serving patients who recently migrated through desert areas may consider issues like heat stress, malnutrition, and exposure to environment-specific risks and exposures endemic to that area of the world, like Valley Fever and chikungunya, in addition to social risks like exploitation, sexual violence and harassment, and trauma. In contrast, Venezuelans start their journeys thousands of miles further south, crossing tracts of rainforest and encountering numerous ecosystems with unique health risks. Those crossing the Darien Gap, for example, have reported parasites and gastrointestinal issues, foot funguses, and respiratory infections.6 While post-traumatic stress disorder, depression, and anxiety are prevalent among asylum seekers, those with longer-duration journeys endure the stress of migration for longer, and have more susceptibility to exploitative situations, which may increase the risk of trauma.
Uncovering The Bigger Picture through a Comprehensive Medical History
Once settled in their new location and after receiving work authorization, asylum seekers often find jobs among the nation’s most dangerous, since there are few opportunities available to them. Farmwork and associated food work like packing, dairy, and seafood; day labor and construction; house cleaning and janitorial work; and food service are some of the industries in which they work. With significant work exposures, clinicians may focus on recent hazards in diagnosing an asylum seeker’s health concern. However, a comprehensive clinical history remains the most valuable and powerful diagnostic tool in the medical toolbox, which would uncover the migration experience and any medical history prior to migration that may provide a more complete picture. When taking a clinical history:7
- Take into account the cultural aspects of the history. Could the patient be feeling fear or stigma around the health issue she is presenting? Are there local superstitions or misunderstandings about the disease or disease process? Patients may consequently hide or be less forthcoming around certain symptoms.
- Evaluate the timing. If a patient has decided to come in with an issue that has been persistent, what finally brought her to be evaluated now? Did a family member insist on her coming in – and if so, why? Patients may give clues to other issues or symptoms that they didn’t yet disclose when asked about the timing.
- Read body language. What can you assess from the body language of the patient and family members? Even if a clinician is utilizing an interpreter, pay attention to the way the patient responds to questions.
- Does it all add up? If the patient didn’t fit the criteria for the diagnosis, or the history and the symptoms don’t line up the way a clinician thinks they should, the clinician should follow up with the patient soon after to check on progress and symptom status.
- Re-interview at a later time – patient history is not a one-time process. Ask the patient and the family members who attend with the patient about the medical history again, at a later appointment. As the patient gains familiarity and trust with the clinician, the patient may provide more detail or clarifications.
Despite familiarity with the culture of the patient or the patient themselves, clinicians are likely to still have gaps in understanding and knowledge, cautions Laszlo Madaras, MD, MPH, Chief Medical Officer for Migrant Clinicians Network, who keeps this in mind in his own work. “For myself, I like to remind myself that I may never be able to understand the whole picture, only the parts, but by active listening and, over time, building a trusting doctor-patient relationship, that should be enough to make a very positive impact of the health and welfare of the migrant patient.”
KFF Report: Immigrant Patients Report Unfair TreatmentA 2023 joint survey by KFF and the Los Angeles Times found that 25% of immigrant adults who have received care in the US reported being treated unfairly by a health care provider. Almost three in ten immigrant adults in the survey reported difficulties accessing culturally attuned care, including:
The report on the survey results is extensive, with data on health insurance accessibility, health conditions, health care access, and access to social services like food and housing, particularly as it relates to immigration status. A companion report found that “although most immigrants are healthy and employed, many face challenges to accessing and using health care in the US due to higher uninsured rates, affordability challenges, linguistic and cultural barriers, and immigration-related fears, which [have] negative implications for their health and financial security.” These issues were higher among certain subgroups of immigrants like those without authorization to work in the US, low-income workers, and those with limited English proficiency. Read the initial survey findings: https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-and-health-care-experiences-of-immigrants-the-2023-kff-la-times-survey-of-immigrants/ Read the companion report: https://www.kff.org/racial-equity-and-health-policy/poll-finding/kff-la-times-survey-of-immigrants |
References
1 Gramlich J. Migrant encounters at the U.S.-Mexico border hit a record high at the end of 2023. Short Reads: Pew Research Center. Published 15 February 2024. Accessed 2 May 2024. https://www.pewresearch.org/short-reads/2024/02/15/migrant-encounters-at-the-us-mexico-border-hit-a-record-high-at-the-end-of-2023/
2 Green MA. Migration: This Time It’s Different. Stubborn Things: A blog of the Wilson Center. Published 23 January 2024. Accessed 2 May 2024. https://www.wilsoncenter.org/blog-post/migration-time-its-different
3 Some Graphics About the Border and Migration. WOLA. Updated 4 September 2023. Accessed 2 May 2024. https://conexionmigrante.com/wp-content/uploads/2023/09/wola_migration_charts.pdf
4 U.S. Customs and Border Protection. Southwest Border Migration FY 2020. Updated 19 September 2023. Accessed 2 May 2024. https://www.cbp.gov/newsroom/stats/sw-border-migration-fy2020
5 U.S. Customs and Border Protection. Nationwide Encounters. Updated 12 April 2024. Accessed 2 May 2024. https://www.cbp.gov/newsroom/stats/nationwide-encounters
6 Suarez A. Rising numbers of migrants risk lives crossing Darien Gap. Associated Press. 17 September 2021. Accessed 2 May 2024. https://apnews.com/article/lifestyle-health-colombia-forests-united-states-c9179be12e415f4b36145f0f29470e3b
7 Zuroweste E. Lessons from the Ebola Crisis: Global Health on your Doorstep. Recorded webinar. Migrant Clinicians Network. 17 December 2014. Accessed 2 May 2024. https://www.migrantclinician.org/webinar/lessons-ebola-crisis-global-health-your-doorstep-2014-12-17.html
8 Venezuelan Humanitarian Crisis Is Now a Regional Emergency, New Analysis Finds. Johns Hopkins Bloomberg School of Public Health. 25 March 2019. Accessed 2 May 2024. https://publichealth.jhu.edu/0219/venezuelan-humanitarian-crisis-is-now-a-regional-emergency-new-analysis-finds
9 Garcia J, S Helleringer, G Correa, M Di Brienza. Updated estimates of infant mortality in Venezuela. The Lancet Global Health. January 2024. Accessed 2 May 2024. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(23)00520-X/fulltext
10 Venezuelan Humanitarian and Refugee Crisis. Center for Disaster Philanthropy. Updated 16 April 2024. Accessed 2 May 2024. https://disasterphilanthropy.org/disasters/venezuelan-refugee-crisis/
11 Zerpa O. Migration of physicians and keys to success. Clin Dermatol. 2020;38(5):523-528. doi:10.1016/j.clindermatol.2020.05.007
12 Garcia D, J Hermida Cordova, M Trujillo, S Kizer. Prenatal C are for Migrants: Services and Practices in Their Home Country and What Can Be Expected Throughout the Migrant’s Route to the US. Recorded Webinar. Migrant Clinicians Network. 29 February 2024. Accessed 2 May 2024. https://www.migrantclinician.org/webinar/prenatal-care-migrants-services-and-practices-their-home-country-and-what-can-be-expected
