Strategies needed to cut ‘unacceptably high’ maternal deaths of Indigenous women
Key takeaways:
- Clinicians should encourage Native American and Alaska Native women to embrace pregnancy as a time to improve CV health.
- Indigenous community stakeholders can help identify and dismantle barriers to care.
Editor’s Note: This is part three of a three-part Healio Exclusive series on maternal and cardiovascular outcomes among Indigenous women living in the United States. Part one can be viewed here. Part two can be viewed here.
Pregnancy can be a dangerous time for American Indian and Alaska Native women living in the United States, who are more likely to have suboptimal CV health and face multiple barriers to accessing even routine prenatal care.
The American Heart Association’s first scientific statement on the status of maternal CV health among American Indian and Alaska Native women, published in 2023, highlighted stark differences in the maternal outcomes of Indigenous women vs. women of other races, driven by a high prevalence of CVD risk factors. 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.
To begin to address the health disparities, stakeholders must improve preventive health services and cultural competency, researchers wrote in the statement. This includes enlisting help from women who hold traditional tribal leadership roles and treating pregnancy as a “window of opportunity” for CVD prevention and a time to motivate women to make health changes.
“Native American and Alaska Native women have their own traditions and ideas. We have to respect them,” Healio | Cardiology Today Editorial Board Member Annabelle Santos Volgman, MD, FACC, FAHA, the Madeleine and James M. McMullan – Carl E. Eybel, MD, Chair of Excellence in Clinical Cardiology and the co-founder and medical director of the Rush Heart Center for Women, said during an interview. “Health care professionals Western medicine must collaborate with community stakeholders. That is one of the proposed solutions in the scientific statement, to work within those existing cultures and tribal rituals in order to gain trust with these women. You cannot just say, ‘No, this is how you do it.’ You cannot build trust that way.”
‘Change the messaging’
In an editorial that accompanied the AHA scientific statement, published in Circulation: Cardiovascular Quality and Outcomes, Volgman and colleagues wrote that maternal mortality is “unacceptably high” in American Indian and Alaska Native women and called for key stakeholders in government, public health, health care systems and public policy to work on mitigating disparities.
Volgman said culturally sensitive care should include a provider that represents a person’s lived experience, if possible, to help build trust with Indigenous patients early on — even before pregnancy.
“Maybe it is a midwife from their culture who is seen as part of the group,” Volgman said. “That can help build trust and perhaps the patient will not be as anxious. It has to begin early with prenatal care. That is the most difficult part — telling an adolescent or a 20-year-old to adopt healthy habits, such as smoking cessation.”
As CVD is the leading cause of maternal morbidity and mortality, education is increasingly centered on the importance of preconception counseling, Rachel M. Bond, MD, FACC, systems director of women’s heart health at Dignity Health in Arizona, told Healio.
“We know that marginalized communities, such as the Native American and Alaska Native populations, often come into the pregnancy with less-than-ideal cardiac health,” Bond said. “They often have higher rates of high BP, diabetes and obesity. They also may have higher rates of substance abuse disorder, due to a history of trauma. This is an opportunity for us to ensure that we are educating women well before they are even thinking about starting or growing a family.”
Bond said it is also important to educate women about CV complications during pregnancy, like preeclampsia, which is not just about the health of the mother.
“Preeclampsia may also be influenced by the health of the individual’s partner involved in conceiving the child,” Bond said. “We are trying to change the narative by emphasizing that it has to be everyone involved when it comes to the health of any future child.”
Embrace culturally humble care
Studies suggest that patient and provider racial concordance — connecting a patient with someone who shares their race and identity — improves communication, trust and health outcomes, according to Jason Deen, MD, FAAP, FAAC, founding director of the Center for Indigenous Health at University of Washington School of Medicine and pediatric cardiologist at Seattle Children’s. For Indigenous people in the U.S. seeking care, race concordance is particularly rare. Data from the 2022 U.S. Physician Workforce Data Dashboard, published by the Association of American Medical Colleges, show just 0.3% of practicing physicians identified as American Indian or Alaska Native.
“In the United States, we make up 2% of the population and it is going to take us a long time to work our way up to 2% of Indigenous doctors, so this is an aspirational thing,” Deen, a cardiologist of the Blackfeet Nation, told Healio. “Another strategy is to make sure that folks who are caring for Indigenous communities go through bias-reduction training so they are aware of the cultural factors, including historical trauma, mental health issues and some of the health inequities suffered by Indigenous communities. Then, they can approach these patients with that knowledge. That is the only way folks can gain that trust.”
Address underfunded facilities, lack of obstetric services
In a perspective paper published in 2021 in The New England Journal of Medicine, researchers outlined a history of underfunding and widespread structural issues within the Indian Health Service (IHS) system, including outdated clinics and hospitals and chronically high staff vacancy levels. The IHS budget permits annual health care expenditures of about $4,000 per patient, compared with the national average of $9,409, a revenue discrepancy researchers stated is “insufficient to put them on even ground with the rest of the U.S. health care system.”
“The average IHS hospital is 40 years old, as compared with the national average of 10.6 years, which translates into episodes such as a sewage leak in an operating room and risks to patients from vintage medical equipment,” the researchers wrote. “At current funding levels, a newly built IHS or tribal facility would not be replaced for another 400 years.”
Due to the long-term underfunding of the IHS, many IHS facilities do not provide obstetric care; consequently, many American Indian/Alaska Native people give birth outside of the IHS, according to 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.
“We must train community health workers to provide the care of doulas and midwives,” Sharma, also the lead author of the AHA scientific statement, told Healio. “Many give birth at home. How do you make sure that, if that is what they are doing, it is a safe procedure? No one recommends home births, so how do you encourage Native women to seek the care? You cannot have someone trained in Western medicine with no understanding of the culture, the history of the population, the spiritual connection between their land and their lives.”
Incorporating traditional Native medicine into the framework of care can also improve maternal outcomes, according to 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.
“Reclaiming health requires promoting tribal sovereignty and centering Indigenous frameworks of health. Integrating traditional medicine into care plans is critically important,” Eberly told Healio. “At IHS, we are fortunate to be able to refer patients to Native medicine for collaborative care. It is very much a part of the IHS. The challenge is, similar to the IHS as a whole, it remains underfunded and understaffed.”
Pregnancy as an opportunity for CV health promotion
The AHA scientific statement recommends that clinicians treat pregnancy as a window of opportunity for CV health promotion among Native women, noting that CVD raises risk not only for early disability and death, but also for passing on risk factors to their children, including obesity and type 2 diabetes.
Deen said it is important that clinicians partner with Indigenous women who are entering pregnancy or planning to become pregnant. Approach any conversations with the understanding that Native women may view their pregnancies differently.
“An important strategy to address CV health in Native women is to leverage their pregnancies,” Deen said. “Many Native women treat pregnancy as a sacred time. They may be more likely to make healthier lifestyle choices, if not for themselves, then for the baby.”
We want to hear from you:
Healio wants to hear from you: Have you been involved in interventions to help improve health outcomes among Native women? What makes your program successful? 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:
- AAMC. U.S. Physician Workforce Data Dashboard. https://www.aamc.org/data-reports/report/us-physician-workforce-data-dashboard. Accessed Dec. 18, 2024.
- Arias E, et al. Vital Statistics Rapid Release. 2022;doi:10.15620/cdc:118999.
- Leston J, et al. N Engl J Med. 2021;doi:10.1056/NEJMp2108894.
- 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.
Jason Deen, MD, FAAP, FAAC, can be reached at jason.deen@seattlechildrens.org; X (Twitter): @UWDeptMedicine.
Lauren A. Eberly, MD, MPH, can be reached at lauren.eberly@ihs.gov; X (Twitter): @eberly_lauren.
Garima Sharma, MD, FAHA, can be reached atgarima.sharma@inova.org; X (Twitter): @GarimaVSharmaMD.
Annabelle Santos Volgman, MD, FACC, FAHA, can be reached at annabelle_volgman@rush.edu; X (Twitter): @avolgman.
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