Get access



  • Karin Downs snm, ms,

    Search for more papers by this author
    • Karin Downs is pursuing a master's degree in public health and nurse-midwifery education in the Maternal and Child Health Department at the Boston University School of Public Health. She received a bachelor of arts degree in anthropology from Carleton College in 1977 and a master of science degree in nursing from Pace University in 1985. After serving as a Peace Corps volunteer in a maternal and child health program in Nepal, she worked with Cambodian refugees in Thailand from 1980 to 1982. Ms. Downs served with the American Friends Service Committee in Phnom Penh, Cambodia, from 1987 to 1991, and as co–field director for relief and development projects in Laos from 1993 to 1995. In New England, she has worked extensively with American sponsors of unaccompanied minors and Cambodian families and has served as a public health nurse for Cambodian women.

  • Judith Bernstein PhD, rnc,

    Search for more papers by this author
    • Judith Bernstein is assistant professor and director of the MCH Certificate Program in the Department of Maternal and Child Health at the Boston University School of Public Health. She has been involved extensively in women's health care in both inner-city and rural contexts and is co-editor of two recent texts: Women's Health: A Relational Perspective Across the Life Cycle (Lewis and Bernstein, 1996) and Emergency Medicine and the Health of the Public (Bernstein and Bernstein, 1996). Dr. Bernstein has also been a member of the Committee on Ethics of the American College of Obstetricians and Gynecologists since 1991, has chaired both the nursing and mental health sections of the Abstract Review Committee for the American Society of Reproductive Medicine, and is a guest associate editor of this Home Study Program.

  • Teresa Marchese cnm, PhD, facnm

    Corresponding authorSearch for more papers by this author
    • Teresa Marchese is assistant professor and director of the Nurse-Midwifery Education Program in the Department of Maternal and Child Health at Boston University School of Public Health. Dr. Marchese has 20 years of teaching experience in nurse-midwifery education, previously at the University of Illinois and Georgetown University. She has expertise in qualitative research and evaluation methodology and has many years of experience providing clinical care for immigrant women. Dr. Marchese is a site visitor for the ACNM Division of Accreditation; she is also a guest assistant editor of this Home Study Program.

Department of Maternal and Child Health, Boston University School of Public Health, 715 Albany Street, A206, Boston, MA 02118.


Currently, one of every 13 U.S. residents is foreign born. A 1991 survey of certified nurse-midwives (CNMs) indicated that 51% of the respondents serve immigrant women. Using a case study approach, this article illustrates barriers to health care experienced by foreign-born women and demonstrates how cultural competence increases provider effectiveness in meeting the unique needs of this population. Effective primary care requires understanding the context of the refugee experience and its physical and emotional sequelae; addressing geographic, linguistic, economic, and cultural barriers; and providing high-quality care through the efficient use of resources without unduly controlling women's choices. Providing care within the context of the traditional family structure, gender roles, family support systems, and community services and resources further enhances health care services. Equally important is the establishment of a sustained partnership with clients, based on the support of protective traditional health practices and the recognition that a woman is expert in her own health. By respecting the complex cultural, political, economic, and personal backgrounds that contribute to immigrant women's perceptions of health, illness, and health care needs, culturally competent primary care providers serve diverse populations more effectively and help to enrich the communities in which they live and work.