What the U.S. healthcare system could learn from the Indian Health Service & the National Indian Health Board to help prevent maternal mortality

A recent study published in the Journal of Obstetrics & Gynecology found that maternal mortality rates amongst American Indian and Alaska Native (“AI/AN”) individuals were higher than among White individuals. AI/AN maternal mortality rates are also higher within their rural populations (for previous blog posts on maternal health in rural areas, look here and here). However, when looking at births within the Indian Health System (“IHS”), these statistics reveal a disparity in outcomes between white individuals and AI/AN individuals. While 90% of AI/AN births take place outside IHS facilities, those 10% that do are having a decrease in maternal mortality rates, with no maternal deaths reported in 2016, 2017, or 2018.

To understand this good news about the IHS, we must look at the primary contributing factors to maternal mortality amongst AI/AN and rural populations:

• Rural areas are often medical deserts (previous posts discussing this phenomenon, especially in the context of COVID-19, are here, here, here, and here). Not only do rural areas have fewer medical facilities, they also have fewer medical providers. 
• AI/AN individuals, especially those residing in rural areas, are more likely to rely on Medicaid, because they are more likely to live in poverty. Medicaid makes individuals eligible for pregnancy coverage only from conception to 60-days postpartum. This means that many long-term effects of pregnancy do not get evaluated or treated. 
• While most states, have implemented maternal mortality review boards, they continue to neglect rural areas. Only three states have directed their legislation towards rural areas, and just two of those require rural representation on the related committees, as of 2018. Of the three states with legislation directed at rural areas, only one is “highly rural” (with 30% or more of the population living in rural areas). The others, Pennsylvania and Texas, require rural representation but are not “highly rural” under the linked studies definition. These two states also have relatively low native populations, less than 3% each. The Maternal Mortality Review Act of Pennsylvania, for instance, makes a point of including rural representatives, likely because of its goal to represent those from areas that are most affected by maternal mortality. This kind of legislation creates the committees mentioned above, which work to review all maternal deaths, identify root causes of said deaths, and develop strategies to reduce maternal mortality. 

IHS has worked on tackling the issues of clinician shortages, lack of sufficient medical insurance, and representation, which likely accounts for their stellar record. They are educating their clinicians on diabetes, which is twice as common in AI/AN populations as in white populations. They have created postpartum care programs to assist individuals with myriad issues, including but not limited to postpartum depression, hyper-/hypo-tension, and lactation. They focus on care for those with opioid dependency (for blogposts on the opiate epidemic as it affects rural areas look here, here, here, here, here, here, here, here, here, and here). This focus is appropriate because AI/AN communities, as of 2017, had the second-highest rate of opioid overdose of any ethnic group in the U.S. White individuals have the highest rates of opioid overdose, though African-American populations have seen an uptick in recent years. 

The National Indian Health Board is also on working to lower maternal mortality. Alongside the CDC, the NIH, has have implemented a campaign, HearHer, to support healthy native pregnancies and maternal health Their main facets are the Tribally Led Maternal Mortality Review Boards, as established and supported by the federal Preventing Maternal Deaths Act (PL115-344). These boards ensure that maternal deaths are reviewed within a year of the child’s birth. They also tackle other AI/AN specific maternal mortality issues such as a lack of prenatal visits, which could discover the risk of hemorrhage and cardiomyopathy.

These native entities have likely succeeded, not only because of their focus on ethnically and geographically specific issues but because of their cultural competency in those areas. This is important not only because cultural differences account for many of the health care discrepancies we see in the United States, but also because they ensure that pregnant people feel comfortable coming back for further health care. Non-native health providers could take a lesson from these entities and try to: employ more culturally competent practices, focus on rural areas and the individuals who make up large swaths of the rural population, and work on creating healthcare that is more accessible financially (specifically to those with Medicaid or entirely uninsured).