Birth across Borders: Migueleña Maternal Experience in Palm Beach County, Florida

Dangers for pregnant Maya women in San Miguel Acatán, Guatemala are exceptionally high. Migueleñas who migrate to Palm Beach County, Florida also face significant risks during pregnancy. However, conceptualizing migrants as vulnerable and non-agentive dismisses the opportunity to explore other dimensions of their experiences. Interviews with Migueleña mothers and midwives and health professionals and advocates in both regions reveal resilience strategies women create and employ as they navigate linguistically and culturally foreign medical systems. This essay is primarily focused on the Palm Beach County findings, which demonstrate that over time, Migueleñas are able to adapt to the new environment through a network of support and a combination of familiar birth practices and those in the new system. They become agents of change by virtue of the manner in which they negotiate between their previous knowledge of birth and the new sources present in Palm Beach County and the support they provide each other, resulting in more favorable maternal experiences under arduous circumstances.

Spanish well and were accompanied by daughters who translated from Acateko when they had difficulty expressing an idea in Spanish, which was seldom. The data provides a detailed view of transnational maternal care seeking behavior from the women's own perspectives as well as that of health advocates interviewed in San Miguel and Palm Beach County.
Interviews with Migueleña mothers, health professionals, midwives, and advocates reveal resilience strategies Migueleña migrants create and employ as they navigate linguistically and culturally through foreign medical systems. They become agents of change by virtue of the manner in which they negotiate between their previous knowledge of birth and the new sources present in Palm Beach County and the support they provide each other, resulting in more favorable maternal experiences under arduous circumstances.
Though their views vary, the women employed similar strategies to navigate a culturally and medically different system than previously familiar. Resources available to migrant women in Palm Beach County and barriers to utilizing them are presented in this essay along with various functions of social networks, specifically networks women used to gain support and access to services. Migueleña migrant perceptions of maternal care and coping and resilience methods they employ to adjust to a 2 With the exception of one Palm Beach County participant and one participant in San Miguel, each Migueleña mother and at least one family member who was also a mother were interviewed across both locations.

Migueleña Maternal Experiences in Palm Beach County and San Miguel
Entering and embracing an unfamiliar medical system requires a variety of decisions relying upon new and previous birthing knowledge. Migrant women do not simply adapt to new prenatal resources available, it is a complex and multifaceted process in which decisions are grounded on experiences in their place of origin and settlement (Almeida et al, 2013;Gálvez, 2011;Im and Yang, 2006

Healthy Mothers Healthy Babies and the Guatemala-Maya Center Services
The main function of Healthy Mothers Healthy Babies (HMHB) is to improve access to prenatal care in the first trimester and to link women with early care, familiarizing them and connecting them to free and low-cost services. The agency's main concern is that women are waiting to access services until their second or third trimesters, resulting in issues such as gestational diabetes, high blood pressure, preterm labor, low birth weight, birth defects and infant mortality. HMHB has staff knowledgeable of Maya women's specific needs and obstacles and caters to the Maya population in several ways.
CenteringPregnancy is a group prenatal and early postpartum care program offered by HMHB to improve birth outcomes for low-income minority at-risk women.
A practitioner or midwife checks women individually during group meetings while a moderator facilitates group discussions about pregnancy, delivery and infant care.
CenteringPregnancy has shown positive results among Hispanic migrant women; those who joined CenteringPregnancy were significantly less likely to experience preterm births, were more satisfied with and participated more actively in their prenatal care and their homes were more medically prepared for infants. While more Central American women selected traditional care over CenteringPregnancy, a larger number of Guatemalan women opted to receive group care (Tandon et al., 2012 Since 1992, the Guatemalan-Maya center (GMC) has provided services and programs that identify and assist individuals at risk of poor birth outcomes and inform them about and connect them with available services (Guatemalan-Maya Center). Services are similar to those of HMHB, but geared specifically to the Maya community, including literacy classes, legal assistance and translation and interpretation services, which are particularly useful in medical settings. Many participants used the GMC to better understand prenatal care options and for paperwork assistance and filing for government aid. When consulted in 2014, the GMC did not have an annual report containing specific information on services provided nor the amount of people who utilized them.
Executive assistant Jill Skok (personal communication, November 17, 2014) shared that approximately 1,500 people seek various services monthly and that they planned to create a report. The GMC is a well-known resource among the Maya community, every Migueleña interviewed was aware of its services.

Barriers to Seeking Maternal Care in Palm Beach County
Migrant women avoid seeking care in host communities and urban settings for numerous reasons. Major barriers to healthcare for migrants include lack of information, cultural and linguistic barriers, fear of fees and bureaucratic processes, and fear of being detained or deported by Immigration and Customs Enforcement (ICE) (Portes et al., 2012). A survey of migrant maternal care studies reveled that miscommunication between migrant women and healthcare providers resulted in less than optimal prenatal care, such as undiagnosed symptoms and poor compliance with treatment (Almeida et al., 2003). In the particular case of maternal care, undocumented women in the United States tend to underutilize services and receive less prenatal and postpartum care since they generally have restricted access to government health services, no private insurance and negative attitudes toward medical practitioners (Sargent and Larchanché, 2011 most women held physically intensive jobs either handling and preparing flowers or in the agriculture industry, where their health and pregnancies were affected due to pesticides and lack of necessary rest and food intake (Mazar, 2015). Loss of income is problematic for women whose livelihood and that of remittance recipients depends heavily on their hourly wages. For those who are away from their family, the need to work is also attributed to lack of family support. Whereas in San Miguel women rely on family support during pregnancy, especially during the recovery period, without family nearby, migrants cannot afford to stop working. Migrant women encounter a different set of dangers when pregnant, especially those who continue to work while pregnant, and employment hindered formal care for every participant on some level during at least one of their pregnancies. Routine or necessary clinic checkups may be skipped by Migueleñas that hold labor intensive jobs throughout their pregnancy due to discomfort with procedures. Therefore, work is not only a barrier to seeking care, but provides further reasons for which pregnancies ought to be closely monitored. Physically demanding jobs may also result in tragic consequences, including miscarriage (Mazar, 2015). Although work presents dangers to pregnancies, it also provides women with a social environment in which necessary support and advice may become inaccessible otherwise.

Influence of Social Networks, Support and Information Exchange
Migrant networks are "sets of interpersonal ties that connect migrants, former migrants, and non-migrants to one another through relations of kinship, friendship, and shared community origin" (Palloni et al., 2010(Palloni et al., , p.1263(Palloni et al., -1264. As researchers have long recognized, and as this case study confirms, migrant networks are critical to migrant success in the host nation. Networks are also essential to opening migration possibilities via funding, employment and housing. The premise of the network hypothesis of social capital theory is that migrants' relatives have higher odds of migrating on account of access to social capital made possible by prior migration (Massey, 1987;Massey, Goldring, and Durand, 1994;Palloni et al., 2001). Networks increase the likelihood of international migration due to reduced costs necessary for and risks associated with migration, information dissemination and increased expectations of future net returns (Palloni et al., 2001). In addition to financial and housing assistance, social networks serve the important function of providing emotional support and advice on system navigation. Migrant women employed in live-in domestic jobs are at a disadvantage when it comes to social networks and support as they lack interaction with other migrants (Hondagneu-Sotelo, 1994;Hagan, 1998). Study participants were not employed in domestic work and many were able to secure essential support and information from coworkers and contacts at work. For example, two participants were informed about their options and encouraged to attend a clinic during work interactions with coworkers who had delivered in the area. Experiences and knowledge women share with each other become a major factor in system navigation. HMHB promotes services in numerous ways, and in our 2012 interview, the program director agreed that word of mouth stands as the most common way to spread resource information and advice. Negative experiences can lead to distrust and

Migueleña Resilience and Adaptation to Maternal Care in Palm Beach County
Migratory status affects Migueleña maternal health, leading them to resort to several strategies in order to give birth and care for their children. Many Migueleñas, especially new immigrants, choose to combine familiar cultural practices with the clinic environment due to factors such as language barriers and procedures that seem unnecessary. While most women in San Miguel deliver at home, the majority residing in Palm Beach County deliver in a hospital. There is no data available that speaks to the number of women who seek midwife maternal care in the region instead of or in addition to biomedical care. Interviews in both locales revealed that women who seek varying levels of prenatal care-from occasional visits to health centers and clinics to hospital delivery-elected to integrate this experience with traditional midwife practices. In San Miguel, midwives are trusted community members; they are often family members, or personally know the women they are treating prior to their pregnancies, contrasting greatly with care from unknown and culturally different providers. Maya midwives take pride in their Guatemalan training and certification. It is difficult for them to understand why they cannot practice in the United States, but their work has shifted from birth assistants to health and nutrition promoters and prenatal experts who give therapeutic traditional massages which are comforting to women who are accustomed to this cultural practice (Burns, 1993, p.347). Midwives are aware it is illegal to perform services and that there may be consequences if they do.
During interviews with a Migueleña midwife in Palm Beach County, I learned that her responsibilities are a spiritual calling that must be fulfilled and not a choice; she stated that while she is registered with the Justice of the Peace and received minimal training from the Health Center in San Miguel, she knew what to do prior as divine power has guided her in over twenty years of deliveries. She understands her services are limited by law as she is not licensed to practice in Florida and is undocumented, so due to fear, she sends women who want to deliver at her home to the hospital. She believes in her duty to heal, so she accepts visits for minor prenatal and postnatal care and other health concerns and continues providing massages and herbal remedies, because unlike providing birth assistance, this would not call attention to her or jeopardize her status. She told me she does not advertise her services; instead, documented and undocumented Central American women access her through referrals from women who have given birth and those who had infertility issues and miscarriages. She felt that undocumented women who visited her felt more comfortable with midwifes than in clinics, demonstrating that women do not necessarily renounce cultural practices they are accustomed after migrating, nor do they blindly accept the practices of the new culture.
Migueleña migrants initially feel more comfortable with Migueleña midwives over medical staff since it is customary to be seen by a midwife in San Miguel, as treatments are culturally familiar and serve as the only maternal care most have experienced. Midwives' treatments are trusted and familiar, they offer services for little to no cost, and the fear of deportation is not a factor for pregnant Migueleña migrants when seeing a midwife.
Migueleña midwives rarely assist women in delivery in Palm Beach County, yet they serve an important function beyond treating discomfort during pregnancy; they encourage women to visit prenatal clinics and are able to provide information about additional types of care available.

Family and Network Support and Spirituality as Coping Strategies
Formal and informal support systems are a significant factor in successful adaptation during a relocation process. Abraham P Greeff and Joanita Holtzkamp (2007) found that the primary coping resource was intra-familial assistance such as family, emotional and practical support. Support of extended family and friends was the secondary coping resource, followed by activities related to religious and spiritual beliefs. Affirming communication, which calms by transmitting support and caring, was a significant factor in family resiliency. In our interviews, some Palm Beach County participants explained that though their immediate family was lacking or they felt lonely upon arrival, they eventually built their own family and the presence of an involved partner gave them emotional and financial comfort. The women with supportive partners also felt that although they missed their family, they received the knowledge, encouragement and assistance that their family or spouse did not provide them in San Miguel.
Religion and involvement with the church are significant factors to migrant resiliency and settlement (Vlach, 1992;Burns, 1993;Hondagneu-Sotelo, 1994;Kohpahl, 1998;Greef and Holtzkamp, 2007). Religion is of great importance to the Maya in Guatemala and abroad. In Palm Beach County, Evangelical and Catholic churches provide supplies and link migrants to resources and information. Aside from assistance provided by religious organizations to Maya migrants and the support networks created among church members; the data reveal that many found comfort in their spirituality during challenging life moments. Almost every participant mentioned or thanked God as a source of strength.  Miguel with medical services in Florida and the creation of a women's support network stand out as resilience strategies. A hybrid of hometown and host country practices enables an easier transition to the new care setting and the support network enables women to learn from each other about available services and assistance. Over time, these collective strategies allow Migueleña migrants to become comfortable with an initially foreign and intimidating system. They gained confidence despite challenging circumstances experienced in Guatemala and upon migrating to Florida; every participant expressed fear and uncertainty when they first arrived and ultimately, they became confident and now assist others.

Influence of Migueleña Migrant Experiences on Migueleñas in San Miguel
Migueleñas become agents of change by virtue of the manner in which they negotiate between their previous knowledge of birth and the new sources present in Palm Beach County. They employ strategies that have resulted in favorable outcomes, overcoming obstacles to improve their maternal experiences and that of others. By creating networks of financial and emotional support and other essential health-based connections, Migueleña migrants play a critical role in the evolution of transnational Migueleña maternal care in and across both regions. Over time, with the backing of previously established or newly formed networks they display their resilience as they begin to adapt and learn how to navigate the new culture and subsequently affect the culture they departed. This assistance extends beyond borders as the transnational network of support has resulted in positive changes for Migueleñas in San Miguel and in Palm Beach County.
Author Bio: Inbal Mazar is an Assistant Professor of Spanish language and culture at Drake University. She holds a PhD in Comparative Studies with a focus on Gender Studies and Sociology (Florida Atlantic University 2015) and a master's degree in Spanish (Florida Atlantic University 2008). Her research centers on transnational perspectives on gender, migration and health. Living in six countries sparked an appreciation for cultures worldwide. She strives to share this enthusiasm in her courses and enhance student learning through a variety of projects that move beyond the classroom to build connections between students and local, national and international communities.