Karen Alexander, Associate Director, Public Health Policy and Programs, National Indian Health Board
Preetha Raj, Public Health Policy & Programs Lead, National Indian Health Board
Maternal health is a cornerstone of any community’s well-being, yet American Indian and Alaska Native (AI/AN) women face disproportionate challenges in achieving safe and healthy pregnancies. Historical inequities, systemic barriers, and the enduring effects of colonization have resulted in significant maternal health disparities within Native communities. However, these same communities are also sources of resilience, creativity, and innovation. Maternal health programs aimed at centering community in tradition, culture, and resiliency can offer unique, cross-sectoral solutions to complex systemic health barriers for AI/AN families.
AI/AN women experience some of the highest rates of maternal mortality and morbidity in the United States. According to the Centers for Disease Control and Prevention (CDC), Native women are more than twice as likely to die from pregnancy-related complications as non-Hispanic white women (CDC 2024). Despite regional differences, the maternal health crisis extends to both urban and rural AI/AN communities. Misclassification and underrepresentation in data, lack of accessible and culturally congruent health services, and the necessity to navigate fragmented care are all shared challenges across urban and rural AI/AN communities. Although the majority of AI/AN people live in urban settings, they are often severely unrepresented in AI/AN maternal health data, preventing timely solutions and interventions. Urban AI/AN women may face more challenges receiving culturally congruent care as well as access to traditional birthing practices and rituals. Tribes in rural regions are challenged with hospital closures, chronic shortages of resources and staff, and the necessity to travel long distances for care, often delaying or preventing access altogether. Rural communities are often in regions with maternity care deserts, or “counties where there is no access to birthing hospitals, birth centers offering obstetric care, or obstetric providers,” significantly impacting access to timely medical care (March of Dimes 2024). Though the challenges vary, AI/AN people living in both rural and urban areas are forced to navigate a fragmented health system rooted in systemic neglect.
Cultural insensitivity within health care systems also remains a significant hurdle. Many providers lack the cultural competence to address the specific needs of AI/AN mothers, resulting in mistrust and reluctance to seek care. Socioeconomic barriers further compound these issues. Poverty, food insecurity, and inadequate housing contribute to higher risks during pregnancy, while systemic underfunding of Tribal health care systems leaves many women without the support they need. Historical trauma—rooted in forced sterilizations, the removal of children from families, and other injustices—continues to foster deep mistrust of government and health care institutions. Adding to this is the prevalence of mental health challenges and substance use, which are often tied to systemic oppression and create additional barriers to maternal health.
Despite these challenges, AI/AN communities have demonstrated remarkable resilience and innovation in addressing maternal health disparities. Communities in both rural and urban settings integrate traditional birthing practices, rituals, and ceremonials into their care. Women can receive care from specialists like Indigenous Doulas that can improve maternal and infant health outcomes (Ireland et al. 2019). The Navajo Nation, for instance, has embraced traditional midwifery programs that integrate cultural rituals with modern medical practices, creating a holistic approach to maternal care. Similarly, the St. Regis Mohawk Health Services in New York provides comprehensive support for pregnant women, including prenatal education, nutrition counseling, and cultural practices. These programs underscore the importance of cultural connection and community support during pregnancy.
Across the country, Indigenous doulas are playing a pivotal role in providing culturally sensitive birth support. These doulas not only assist with childbirth but also serve as advocates, ensuring that Native mothers receive respectful and culturally informed care. The Changing Woman Initiative, based in New Mexico, is one such organization that trains Indigenous doulas and midwives while promoting traditional birthing knowledge. Federally funded Tribal health clinics, such as those operated by the Indian Health Service (IHS), have also made strides in providing maternal and child health services. Although funding remains a challenge, these clinics serve as a critical lifeline for many Native women.
Several programs across AI/AN communities highlight the innovative ways Tribes are addressing maternal health challenges. The Alaska Native Birthworkers Community is a group of Indigenous Midwives, Doulas, and Birthworkers offering care rooted in culture and tradition. Having an all-AI/AN staff, the group creates opportunities for AI/AN people to enter the maternal health workforce. On the Pine Ridge Reservation in South Dakota, the Mni Wichoni Health Circle addresses maternal health disparities by integrating Lakota cultural practices into maternal and child health services, while also providing mental health support to address the psychological aspects of pregnancy and childbirth. Additionally, home visiting programs like the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program have been adapted by some Tribes to reflect AI/AN values, ensuring that mothers receive consistent care during and after pregnancy.
Despite these innovative efforts, sustained funding and policy support remain critical in addressing maternal health disparities for AI/AN communities. There is an urgent need to invest in Tribal maternal health and build sustainable partnerships. Philanthropy is a critical component to supporting the health of AI/AN communities. Grantmakers could consider investing in the following:
- Tribal-led initiatives are one of the most impactful ways to reduce disparities. Tribal health programs and grassroots organizations are deeply rooted in their communities and are better equipped to address local needs. Flexible, long-term funding can allow these programs to expand their reach and improve their sustainability.
- Workforce development is another crucial area for philanthropic engagement. By increasing funding for training programs for Indigenous doulas, midwives, and health care providers, philanthropy can help build a culturally competent workforce that understands the unique needs of Native mothers. Scholarships for Native students pursuing careers in obstetrics, gynecology, and public health can further strengthen this effort.
- Policy advocacy to increase federal funding for Tribal healthcare systems, improve data collection on maternal health disparities, and ensure that Native voices are represented in policymaking. Collaborating with Tribal leaders and organizations can amplify these efforts, creating systemic changes that benefit Native mothers and their communities.
The National Indian Health Board (NIHB) is actively engaged in enhancing maternal health within Tribal communities through various initiatives and collaborations. One significant effort is their work in establishing Tribally led Maternal Mortality Review Committees (MMRCs). In November 2023, NIHB, in collaboration with the CDC, hosted the 2023 Convening on Tribal Maternal Mortality Review on the sacred lands of the Santa Ana Pueblo. This meeting aimed to address the critical issue of maternal mortality among AI/AN communities, focusing on the development of Tribal MMRCs to better understand and prevent maternal deaths. NIHB will host its 2025 Tribal Maternal Mortality Convening June 2nd to 4th in Denver, Colorado, bringing together Tribal maternal and infant health experts from across Indian Country.
Additionally, NIHB has been involved in adapting and localizing the CDC-led Hear Her campaign to support healthy pregnancies and postpartum health for AI/AN women. In January 2022, they hosted a discussion session titled “Hearing Native Mothers” to gather Tribal input on this campaign, emphasizing the importance of culturally relevant health communications. Through these initiatives, NIHB continues to advocate for and implement strategies that address maternal health disparities in Tribal communities, emphasizing the importance of culturally competent care and Tribal sovereignty in health decision-making.
Maternal health in AI/AN communities is both a pressing challenge and an area ripe with opportunity. While systemic barriers continue to hinder progress, culturally informed care models, community-driven initiatives, and grassroots efforts offer promising solutions. By investing in Tribal-led programs, supporting Indigenous health care workers, and advocating for systemic change, philanthropy can play a transformative role in improving maternal health outcomes for Native women. Together, these efforts can ensure that every Native mother can experience a healthy and empowered pregnancy, honoring the strength and resilience of Indigenous communities.
References
Centers for Disease Control and Prevention (CDC). Disparities and Resilience Among American Indian and Alaska Native Women Who Are Pregnant or Postpartum, Atlanta, GA: May 15, 2024.
Ireland, Sarah, and Ruth Montgomery-Andersen, Sadie Geraghty. Indigenous Doulas: A literature review exploring their role and practice in western maternity care. Midwifery, Volume 75, 2019, ISSN 0266-6138.
March of Dimes. Nowhere to Go: Maternity Care Deserts Across the US (Report No 4), September 2024.