Risky pregnancies, driven by CVD risk factors, remain common for Native women
Key takeaways:
- American Indian and Alaska Native women face substantially higher risk for heart disease, particularly during reproductive-age years.
- Generational trauma, violence and racism have compounded risks.
Editor’s Note: This is part one of a three-part Healio Exclusive series on maternal and cardiovascular outcomes among Indigenous women living in the United States. Part two can be viewed here. Part three can be viewed here.
American Indian and Alaska Native communities are some of the most underserved minoritized groups in the United States, and Indigenous women are most likely to confront the health-related consequences, particularly during pregnancy.
For Indigenous women living in the United States, the costs of pregnancy and birth are high, on top of statistics that show this nation already leads the industrialized world in rates of maternal deaths. Compared with white mothers, American Indian and Alaska Native women are twice as likely to die of pregnancy-related causes, according to the CDC. In 2020, the highest pregnancy-related mortality ratio was among American Indian or Alaska Native persons. The COVID-19 pandemic likely worsened outcomes and further highlighted race disparities: From 2020 to 2021, maternal mortality rates doubled among American Indian and Alaska Native women compared with 2019 data. Cardiomyopathy accounted for 14.5% of American Indian/Alaska Native maternal deaths — the highest percentage of all racial and ethnic groups. Native women also have the highest rate of risk factors for stroke and are significantly more likely to have gestational diabetes and develop infections and postpartum hemorrhage than white women.
“Maternal mortality, that is a very hard metric, but it is just the tip of the iceberg,” Healio | Cardiology Today Editorial Board Member Garima Sharma, MD, FAHA, director of preventive cardiology and women’s cardiovascular health at Inova Health System in Falls Church, Virginia, and adjunct associate professor of medicine at Johns Hopkins Medicine, said during an interview. “The bigger issue here is severe maternal morbidity: any unexpected outcome during pregnancy which leads to an ICU admission or hospitalization for the patient. The patient does not have to die from that. But the fact that they are admitted for this problem, and the care that they receive during that timeframe, has a big impact on the infant’s health and on the mother’s postpartum care.”
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.
“As rural health providers, we know what we are seeing firsthand daily, but we need to highlight for the larger community to understand how high the burdens are,” Lauren A. Eberly, MD, MPH, assistant professor of medicine in the division of cardiovascular medicine at the University of Pennsylvania and a staff cardiologist for the Indian Health Service at Gallup Indian Medical Center, on the border of the Navajo reservation, told Healio. “Most people do not realize the challenges. We do talk about rural medicine, but this has so many other layers of historic context and complexity.”
High cardiometabolic risk burden
In 2023, the American Heart Association published its first scientific statement that provided a deep analysis of issues affecting the CV health for women of American Indian and Alaska Native backgrounds. Researchers reported 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. 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, all of which significantly increase the odds of poor pregnancy outcomes such as preeclampsia and preterm birth. Native women also have much higher odds of developing peripartum cardiomyopathy, also dependent on many of the same risk factors.
Data on life expectancy show the long-term impact of those risk factors. According to the most recently available data from the CDC’s National Center for Health Statistics provisional life-expectancy estimates, the non-Hispanic American Indian and Alaska Native population experienced the largest decline in life expectancy of any racial group, falling from age 67.1 years in 2020 to age 65.2 years in 2021 — the same life expectancy of the total U.S. population in 1944. Mortality due to COVID-19 contributed 21.4% to the decline in life expectancy for the American Indian/Alaska Native populations.
“That is striking and it is important to contextualize these inequities,” Eberly said. “Often, academic discourse has been dominated by erroneously attributing biologic differences as a main driver of Indigenous health inequities, or access to care as a piece of it. We must call out what we call Indigenous determinants of health — or settler colonialism determinants of health — as the root cause of this disease burden and these health inequities.”
Lack of basic services
In an analysis on CVD burden and outcomes among American Indian and Alaska Native Medicare beneficiaries published in September 2023 in JAMA Network Open, Eberly and colleagues noted that people living in Indigenous communities face daily challenges that prevent access to the most basic health care services. One-third of residents living in Navajo Nation, for example, lack running water or electricity, Eberly said.
“Sometimes that is hard for people to grasp — that in the United States, this could be the case,” Eberly said. “In most rural places on the reservation, there are no paved roads. Roads are often impassible, especially during winter seasons or during any kind of bad rains. And although [Indian Health Service] sites are located rurally to reach this population, even then, it is a 2-hour drive.”
According to the CDC’s National Vital Statistics Report, 60.4% of American Indian/Alaska Native women received prenatal care during the first trimester, much lower than the 81.6% of non-Hispanic White women. Reasons include barriers in communication with physicians, lack of continuity of care and sociodemographic barriers.
“They are not even making their first-trimester appointments,” Sharma said. “The number of OB/GYNs is very low. Patients living in rural America can travel anywhere from 60 to 80 miles to get basic maternity care. American Indian and Alaska Native women are living on reservations. Access is very limited. When they are presenting in their third trimester or in labor, there may be cardiovascular risk factors that could have been improved or optimized during pregnancy or during prepregnancy planning. But it is already too late.”
Role of historical trauma
The AHA’s scientific statement acknowledges that a legacy of colonialism and structural and institutional racism has had a generational impact on CVD risk, particularly during the reproductive years. These historical determinants of health include a history of Native genocide, forced removal from homelands, breach of treaty obligations and forced boarding school participation among American Indian and Alaska Native children.
“There is a lot of historical trauma that stems from colonization and forced assimilation and mistreatment by the health care system that has led to this deep-seated mistrust of Western medicine,” Rachel M. Bond, MD, FACC, systems director of women’s heart health at Dignity Health in Arizona, told Healio. “We are trying our best to reeducate our medical students and nursing students so they understand the historical context and begin to understand the ongoing contemporary mistrust that many of these marginalized communities have.”
The effects of historical trauma are also seen in other ways across generations that disproportionately impact Native women, Sharma said.
“Intimate partner violence, substance misuse, adverse childhood experiences and toxic stress is rampant in this community, and they do not talk about it,” Sharma said. “So, where do we start? We start by training people from the community who understand that culture. That is how we improve access.”
Editor’s Note: Part two of this Healio Exclusive series will explore a lack of consistent data reporting on maternal deaths among Native women and how that impacts the design of interventions to reduce these outcomes.
We want to hear from you:
Healio wants to hear from you: Do you care for pregnant patients who identify as Native American or Alaska Native? What are you seeing and what might complicate care? Share your thoughts with Healio by emailing the author at rschaffer@healio.com or posting on social media at @CardiologyToday on X (Twitter). We will contact you if we wish to publish any part of your story.
References:
- Arias E, et al. Vital Statistics Rapid Release. 2022;doi:10.15620/cdc:118999.
- CDC. Pregnancy Mortality Surveillance System. https://www.cdc.gov/maternal-mortality/php/pregnancy-mortality-surveillance/index.html. Accessed Dec. 18, 2024.
- Eberly LA, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.34923.
- Sharma G, et al. Circ Cardiovasc Qual Outcomes. 2023;doi:10.1161/HCQ.0000000000000117.
For more information:
Rachel M. Bond, MD, FACC, can be reached at rachel.bond@commonspirit.org; X (Twitter): @DrRachelMBond.
Lauren A. Eberly, MD, MPH, can be reached at lauren.eberly@ihs.gov; X (Twitter): @eberly_lauren.
Garima Sharma, MD, FAHA, can be reached at garima.sharma@inova.org; X (Twitter): @GarimaVSharmaMD.
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