AHA: Heart health of American Indian/Alaska Native women often suboptimal
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Key takeaways:
- American Indian and Alaska Native women face significantly higher risk for CVD, particularly during reproductive-age years.
- A legacy of generational trauma, violence and racism has compounded risks.
Women who identify as American Indian or Alaska Native are more likely to have type 2 diabetes, to have obesity, to smoke and to report exposure to trauma and violence than white women, significantly increasing their risk for CVD.
In a new scientific statement from the American Heart Association, researchers reported that more than 60% of American Indian or Alaska Native women already have suboptimal CV health when entering pregnancy, further compounding risks for a CV event, according to Healio | Cardiology Today Editorial Board Member Garima Sharma, MD, FAHA, director of women’s cardiovascular health and cardio-obstetrics at Inova Health System in Falls Church, Virginia, and adjunct associate professor of medicine at Johns Hopkins Medicine. The data suggest that complex interventions are needed for women with Native American or Alaska Native ancestry to address both risk reduction and the effects of structural racism.
Data were derived from Sharma G, et al. Circ Cardiovasc Qual Outcomes. 2023;doi:10.1161/HCQ.0000000000000117.
The scientific statement was published in Circulation: Cardiovascular Quality & Outcomes.
“If you have poor CV health to begin, it is not shocking that with pregnancy you are going to have a high risk for complications that are pregnancy-associated, and we see that,” Sharma told Healio. “CV health is suboptimal because preventive care and social-cultural influences from childhood are suboptimal. Families are stricken with emotional abuse, family substance abuse, intimate partner violence. Then, where are these individuals giving birth? Most are on native land, rural areas where there may not be access to specialized cardiac care services or maternal health services. It is a place-based disparity, a race-based disparity and a sex- or gender-based disparity.”
Factors impacting outcomes, access to care
Data show that only 60.4% of American Indian and Alaska Native women sought prenatal care in the first trimester, according to the statement, whereas women of native backgrounds have a significantly higher likelihood of infections, postpartum hemorrhage and gestational diabetes compared with white women. Native women are also at substantially higher risk for preeclampsia and developing peripartum cardiomyopathy compared with white women; cardiomyopathy accounted for 14.5% of pregnancy-related maternal deaths for native women.
Factors contributing to poor maternal outcomes are multifaceted and include limited access to prenatal care, socioeconomic status, high rates of obesity and hypertension, coexisting stress, and trauma, including mood disorders, racism and impaired health literacy.
“Suboptimal CV health during pregnancy is also strongly associated with the development of future CVD,” the researchers wrote. “Hence, there is a critical need to track and characterize CV health from preconception and pregnancy to the postpartum period and to identify modifiable factors and intervention opportunities that can significantly improve pregnancy outcomes.”
Impact of generational trauma
The scientific statement, the first to provide a deep analysis of issues affecting the CV health for women of American Indian and Alaska Native backgrounds, acknowledges that a legacy of colonialism, structural and institutional racism has had a generational impact on CVD risk, particularly during the reproductive years.
“A multitude of social determinants of health and historical determinants of health, including history of genocide, decimation of tribal governance, forced removal from homelands, breach of treaty obligations, and forced boarding school participation among American Indian/Alaska Native children, have led to intergenerational trauma and its associated poor health outcomes,” the researchers wrote in the statement. “Unfulfilled treaty agreements and the destruction of peoples and cultures have contributed to a general mistrust in the government among many American Indian/Alaska Native communities. In addition, American Indian/Alaska Native individuals have experienced unethical research practices, including forced sterilization, and culturally insensitive studies have resulted in mistrust of the research community that requires resolution to identify strategies that can improve health outcomes, including CVD and maternal death.”
The statement notes that stakeholders across the spectrum of government, public health, health care systems and public policy must recognize these important disparities and work on ways to collaborate and devise policies for improving the CV health of this high-risk group of women.
Multilevel interventions needed
To begin to address the health disparities, stakeholders must improve preventive health services and cultural competency, the researchers wrote; enlisting help from women who hold traditional leadership roles is “critical.” Pregnancy should likewise be treated as a “window of opportunity” for CVD prevention and a time to motivate women to make health changes.
The first step, however, should be looking at the numbers, Sharma said.
“There is a multi-step process and it starts with data,” Sharma said. “The CDC has only recently started to look at these populations. Most of the population reported is American Indian; there is very little information on Alaska Native women, so we have to combine these groups. Disaggregation of the data in terms of CVD rates and CV health, considering population-specific social-cultural physical environments, will inform what to do.”
More research funding is also vital, Sharma said.
“We can talk about improving education and competency, but after data comes funding research,” Sharma said. “It is funding the Indian Health Services, which are providing preventive care and pregnancy care. Make sure they are funded and connected and have staff support.”
Third is peer support, Sharma said.
“Peer support in rural areas, home visiting nurses, midwife-led care, incorporating community voices into care is important in rural areas,” Sharm said. “There is a lot of mistrust, and traditional beliefs must be respected. Incorporating community beliefs in what we do will be important.”
For more information:
Garima Sharma, MD, FAHA, can be reached at gsharma8@jhmi.edu.
Reference:
- Heart health is sub-optimal among American Indian/Alaska Native women, supports needed. https://newsroom.heart.org/news/heart-health-is-sub-optimal-among-american-indianalaska-native-women-supports-needed. Published on May 31, 2023. Accessed on May 31, 2023.
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