Many Americans know very little about the people who are Indigenous to the lands they inhabit. A recent survey reported that 40% of Americans believed that Native American/Alaska Native (Indigenous) people no longer existed. In reality, there are 574 federally recognized tribes and more than 5.2 million people who identify as Indigenous in the United States. I am one of them. Indigenous women, like me, face disproportionate risks across the life span, including around the time of childbirth.
Giving birth in the US is more deadly now than it was a generation ago. Deaths that occur during pregnancy, childbirth, or in the postpartum year are increasingly common. Approximately 60% of US maternal deaths are preventable. Maternal morbidity and mortality rates in the US highlight the fault lines of geography and race: people of color and rural residents face higher risks than their non-Hispanic white and urban counterparts. These inequities are the inevitable and tragic result of health insurance and health care systems shaped by structural racism1 and structural urbanism2 or the unequal allocation of opportunities and resources based on race and geography.
Some aspects of maternal health equity are starting to receive the policy attention they deserve, including crises in black maternal health and rural maternity care. Yet there is little attention to the intersection of race and geography and to the safety and vitality of Indigenous mothers, who are dying at a rate 2 to 3 times higher than non-Hispanic white mothers nationally.
Loss of life in Indigenous communities has deep cultural and historical resonance.3,4 Literature is notably limited, but research shows that in 2020, such trauma is ongoing in the context of maternal and child health. Approximately 40% of all Indigenous people are rural residents (a substantially higher percentage than other racial/ethnic groups), and rural residents face heightened risks of severe maternal morbidity and mortality.5 Pregnant Indigenous women living in rural areas are at a substantially elevated risk of maternal death or serious complications in childbirth compared with non-Hispanic white or urban women.6 Among Indigenous mothers, factors such as financial and partner stress are particularly predictive of infant risk.7 But risk is not destiny; if Indigenous women experienced severe maternal morbidity and mortality at the same rate as non-Hispanic white women, it would result in a 43.9% reduction in deaths and near misses among Indigenous mothers.6
In order to protect the lives of Indigenous women and children, it is essential to document the problem and identify contributing factors. This is difficult for many reasons. First, data on maternal mortality among Indigenous women are not consistently reported. Indeed, when the Centers for Disease Control and Prevention recently published 2018 statistics on maternal mortality, which included statistics on racial disparities, data on Indigenous women were not separately described. Second, there are limited community-based Indigenous voices in policy discussions on maternal health. Third, resources and access to local and culturally centered services and supports are limited.3,7 Particularly with chronic underfunding of the Indian Health Service (IHS), many IHS facilities do not provide obstetric care, and consequentially many Indigenous women give birth outside of IHS facilities or culturally centered health care systems. Fourth, the pregnancy and childbirth care workforce (physicians, midwives, nurses, social workers, mental health counselors, addiction counselors, lactation consultants, doulas, etc) does not reflect the demographic characteristics of pregnant patients, and Indigenous people are particularly underrepresented. Finally, recent data from Louisiana showed that mothers were more likely to die of homicide than any specific obstetric cause.8 Intimate partner violence disproportionately affects rural and Indigenous women, yet many programs designed to address maternal mortality center on clinical risk mitigation.
Addressing our nation’s maternal health crisis requires attention to the experiences of Indigenous people and communities. Moving forward, there are several crucial steps to take:
Collecting and reporting data with and among Indigenous people and tribal nations. All possible efforts should be made to ensure maternal health data are reported for Indigenous people.
Ensuring decision-making that includes Indigenous and tribal representation. For example, maternal mortality reviews can address the structural roots of the maternal mortality crisis only if they include Indigenous people and recognize the specific historical and contemporary trauma of Indigenous people.
Making money available. Financial resources currently being deployed to address this crisis could be strategically invested in tribes, IHS facilities, and culturally safe community-based programs by earmarking funds for this purpose.
Improving workforce diversity. Additional investment in Indigenous workforce development programs should include a focus on maternal health and on a broader range of clinicians, beyond physicians.
Paying attention to violence as a maternal health issue, especially for Indigenous women. Policy action, such as reauthorization of the Violence Against Women Act and passage of the Not Invisible Act and Savanna’s Act, as well as attention to integration of programs that address violence and maternal mortality is warranted.
Positive change is possible and is already happening in communities across the lands traditionally known as Turtle Island. Inuit midwives in the village of Inukjuak, Quebec, provide care that recognizes cultural and language traditions and facilitate local births surrounded by family members. Farther south, Diné midwife Nicolle Gonzales in New Mexico leads a practice that focuses on re-establishing links to Indigenous birth practices as well as creating connections to local Women, Infant, and Children rograms.
Few points in the lifespan highlight more clearly both the dysfunction and the potential in the US health care system as childbirth. Recent data clearly indicate the need to prioritize Indigenous maternal health. It is an urgent task to address our collective responsibility for Indigenous women, the founding mothers of this land.
Corresponding Author: Katy B. Kozhimannil, PhD, MPA, Division of Health Policy and Management, University of Minnesota, 420 Delaware St SE, MMC 729, Minneapolis MN 55455 (email@example.com).
Conflict of Interest Disclosures: None reported.
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