ᎢᏧᎳᎭ ᏓᎾᏓᏘᏅᏍᎬ: Birthing Together
American Indian and Alaska Native women have historically experienced disparities in pregnancy-related deaths and maternal morbidity compared to national averages and to other racial and ethnic groups in the United States, and the alarming trend persists. The readers of this editorial presumably have some understanding of this public health problem and recognize that Indigenous and Black women disproportionally bear the burden of this crisis. However, the general lack of attention to the disparities endured by American Indian and Alaska Native women during pregnancy, childbirth, and the postpartum period demands urgent action and presents a challenge to nurses’ collective professional values regarding the promotion of health equity. The content of this editorial was shaped by the firsthand experiences of a nurse and maternal health leader from the Cherokee Nation, and our purpose is to propose a shift in the approach to maternal health care.
Current Statistics
The pregnancy-related mortality ratio (pregnancy-related deaths for every 100,000 live births) for American Indian and Alaska Native women is about two times greater than the rate for non-Hispanic White women, and this disparity increases with maternal age (
). For example, the pregnancy-related mortality ratio for American Indian and Alaskan Native women between the ages of 30 and 34 years is nearly four times as great as the ratio for non-Hispanic White women: 41.2 per 100,000 live births versus 11.3 per 100,000 live births, respectively (
). Additionally, it is crucial to highlight a recent report in which the Centers for Disease Control and Prevention recognized the longstanding data collection issues surrounding accurate and representative health statistics for American Indian and Native Americans and the potential for underreporting of maternal deaths (
). This underreporting can result from difficulties in accurately determining race and ethnicity in vital records data; as a result, the pregnancy-related deaths of Native American women are categorized as “other” race/ethnicity. Consequently, the actual rates of maternal morbidity and mortality among Native American women may exceed the figures currently documented.
Indigenous women, specifically American Indian and Alaska Native women, also experience elevated rates of maternal morbidity compared to White women.
used population-level data from the National Inpatient Sample database from 2016 to 2018 to examine disparities in adverse maternal outcomes among five racial and ethnic groups. Their findings revealed that Native American women had greater odds of postpartum hemorrhage compared to White women. This study supports the research of
, who also found that Native American women had heightened risk of postpartum hemorrhage after vaginal birth compared to non–Native American women.
found that Native American women had greater risk of experiencing preterm labor, gestational hypertension and diabetes, premature rupture of membranes, infection of the amniotic cavity, and placental abruption than White women.
Our Story Beyond the Statistics
Despite the narrative communicated by these facts and statistics, the essence of the story concerning the health of Indigenous women lies beyond the boundaries of the available data. Along with other tribal nations, the Cherokee people have faced the hardships of forced displacement from their ancestral lands, the suppression of well-established traditional practices related to nutrition and health, and the erasure of language and familial traditions. Within the United States, Cherokee Nation Health Services stands as the largest health care system operated by a tribal entity. Specifically for maternity services, multiple clinics are available throughout the Cherokee Nation reservation along with an inpatient birthing unit that adheres to the practices recommended in the Baby-Friendly Hospital Initiative (
). Although the hospital on the Cherokee Nation reservation is considered rural, a high-risk level of care is provided. For example, staff have onsite trainers to promote best practices, and at the time of this publication, three Cherokee nurse leaders are preparing for fetal heart rate monitoring instructor training. Their goal is to be able to provide the highest level of evidence-based care for their patients. Members of the Cherokee Nation and of other tribes sometimes travel more than 100 miles to give birth at the inpatient birthing unit.
Women who come to Cherokee Nation to give birth deserve the highest quality of care, and the obstetric leaders strive to provide that care. These efforts are made in an attempt to mitigate the longstanding disparities faced by patients and their families and manifested in the maternal morbidity and mortality statistics. Across the country, American Indian and Alaska Native people often reside in maternity deserts with limited access to prenatal and postpartum services. This situational disparity intersects with the other entrenched disparities that affect American Indian and Alaska Native people.
Improving Maternity Care for Indigenous Women
Recent data from maternal mortality review committees reveals that a significant number of pregnancy-related deaths among American Indian and Alaskan Native populations could have been prevented (
).
;
JointCommission International, 2018
) consistently underscores the significance of effective communication and teamwork to ensure patient safety and quality. A new initiative, TeamBirth, was designed to address issues related to behavior and communication in maternity care (
). It is important to note that TeamBirth is not focused on introducing new equipment, technology, treatment protocols, or medications but, rather, on improving interpersonal dynamics within the health care team. When introducing TeamBirth to the Cherokee Nation, maternity care leaders purposefully sought ways to ensure that the initiative was adapted to the tribal context. Through thoughtful reflection and collaboration with esteemed community matriarchs who have preserved the Cherokee language, a word was identified to encapsulate the essence of TeamBirth at Cherokee Nation: ᎢᏧᎳᎭ ᏓᎾᏓᏘᏅᏍᎬ.
This Cherokee term, loosely translated as “birthing together,” will be interwoven through many TeamBirth resources, including the materials displayed in the rooms at the birthing unit. Through the contribution of the language matriarchs, an existing initiative was transformed to be culturally responsive to the women of the Cherokee nation. In an unprecedented way, the local community shaped TeamBirth in a manner unique to their history, context, heritage, and place.
Through lessons learned from introducing and implementing this initiative and with respect for the inherent connection between culture and the birthing process, all birthing facilities in the United States can be regarded as Indigenous birth spaces for Indigenous women. This perspective allows us to acknowledge the historical and cultural significance of childbirth within Indigenous communities and to emphasize the importance of honoring Indigenous traditions, practices, and beliefs during the childbirth. Considering all birthing facilities as Indigenous birth spaces will promote inclusivity, cultural sensitivity, and culturally appropriate care for Indigenous women and their families. In an approach such as this, the unique needs and perspectives of Indigenous communities are acknowledged to foster a more equitable and respectful health care environment.
If maternity care for Indigenous women is to evolve and improve, intentional steps toward trauma-informed care and collaboration must be taken. Anticipating and adapting care to account for hidden trauma within the lives of patients or populations is a fundamental principle of trauma-informed care (
). Merely incorporating cultural considerations onto an oppressive structure is insufficient. As nurses, we hold positions as advocates, leaders, experts, educators, and researchers, and these roles empower us to promptly transform our approach. It is crucial to assess each program, policy, and project within our respective realms with a reflexive mindset. We need to ask hard questions such as the following: Might this intervention exacerbate marginalization among those who are most in need of support? Could this policy amplify preexisting disparities and biases? Has a proactive, asset-based approach been employed to carefully evaluate the existing dynamics within the community?
Conclusion
Before undertaking any research, designing a project, or implementing a program, it is imperative to acknowledge the hidden benefits, risks, and unintended consequences involved. As nurses, we are faced with a choice: perpetuate the flawed and oppressive health care system or actively contribute to constructing a completely new paradigm. There is no alternative middle ground.
Although it is critical to prioritize research on this topic, we must center the experiences and perspectives of Indigenous women in efforts to address maternal health outcomes. This requires a commitment to decolonizing research and health care practices, acknowledging the historical and ongoing trauma experienced by Indigenous communities that has resulted in distrust and engaging in community-led and culturally grounded approaches to address health disparities. As an example, in this issue,
describe a participatory process of establishing an academically and tribally supported community advisory board with tribal members from the Chickasaw Nation to prevent and improve care for postpartum depression. Importance is placed on ensuring that research agendas are led by Indigenous stakeholders and that collaborations between academia and tribes prioritize the voices of the community in identifying solutions.
In addition to research, it is necessary to ensure that Indigenous women have equitable access to comprehensive health care that respects their cultural needs at every stage of life, including in the preconception, prenatal, and postpartum periods. This necessitates addressing social inequities that contribute to poor health outcomes and maternal complications, such as poverty, limited education, inadequate housing, and environmental risks. To achieve this, we must enhance access to health care services and ensure that health care providers receive training in culturally responsive care. As nursing professionals, it is critical for us to enhance, promote, and broaden our dedication to the transformation of our education, our innovation, our research, and the implementation of new approaches to care.
Conflict of Interest
The authors report no conflicts of interest or relevant financial relationships.
Funding
The TeamBirth project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award to the Oklahoma State Department of Health. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government.