Improving Maternity Care for Indigenous Populations

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00:00:00:28 - 00:00:40:18
Tom Haederle
According to the Centers for Disease Control and Prevention, people of American Indian and Alaska Native descent, also known as indigenous, are twice as likely to experience pregnancy related deaths as white women. Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. November is National Native American Heritage Month, and November 16th is National Rural Health Day.

00:00:40:20 - 00:01:09:08
Tom Haederle
Making this a fitting time for this podcast discussion of the experiences of American Indian and Alaska Native Communities indigenous to the United States. In this podcast, Julia Resnick, AHA's director of Strategic Initiatives, is speaking with Dr. Dr. Tina Pattara-Lau a maternal and child health consultant with the Indian Health Service Office of Clinical and Preventive Services, and Dr. Johnna Nynas, an obstetrics and gynecology specialist from Sanford, Bemidji Medical Center.

00:01:09:10 - 00:01:26:02
Tom Haederle
The group explores some of the common challenges, disparities and systemic barriers indigenous people experience in pregnancy and postpartum, and discusses ways hospitals and health care organizations are combating these challenges to provide adequate and culturally competent care.

00:01:26:04 - 00:01:45:25
Julia Resnick
Welcome, Dr. Pattara-Lau and Dr. Dr. Nynas. We're so happy to have both of you here today to talk about maternal health for American Indian and Alaska Native communities. So let's start with Dr. Pattara-Lau. Can you share with our listeners some background and recent statistics on the state of maternal health for indigenous communities in America?

00:01:45:27 - 00:02:07:23
Dr. Tina Pattara-Lau
Thank you and thanks for the opportunity to elevate this important topic today. We know that maternal morbidity, mortality for American Indian and Alaska Native birthing persons is usually 2 to 3 times that of the white non-Hispanic population. And we see these disparities when we provide care in the community. But several new studies have recently highlighted some inequities among indigenous birthing persons nationwide.

00:02:07:25 - 00:02:31:18
Dr. Tina Pattara-Lau
I'll note that while some studies do use gender specific pronouns, IHS is inclusive of all birthing persons. So last year, a CDC report from the State Maternal Mortality Review Committee found that 93% of American Indian and Alaska Native pregnancy related deaths were preventable. 64% occur postpartum. The leading causes of death included mental health conditions such as death by suicide or overdose, as well as hemorrhage.

00:02:31:20 - 00:02:58:18
Dr. Tina Pattara-Lau
And earlier this year, two studies published in JAMA found that while maternal deaths in U.S. hospitals have declined. So there more maternal morbidity has actually increased. And specifically, American Indian and Alaska native mortality decreased over the study period, but pregnant patients still experienced a higher risk of maternal death compared with white patients. In a second study found that severe maternal mortality in more states was higher among American, Indian and Black populations.

00:02:58:20 - 00:03:18:07
Dr. Tina Pattara-Lau
And so while the data doesn't provide us with the full story, we need to acknowledge that there are systemic gaps and barriers to maternity care that contribute to the inequities for indigenous birthing persons. And so IHS, along with other health care systems, have turned to innovative approaches and increasing care in the community and support before, during and after pregnancy.

00:03:18:09 - 00:03:29:20
Julia Resnick
That is absolutely heartbreaking and thinking about those communities, what are some of the common challenges or barriers to getting proper pregnancy care and postpartum care?

00:03:29:22 - 00:03:56:13
Dr. Tina Pattara-Lau
Certainly the effects of historical trauma, including systemic racism, can actually last generations. And so together with adverse childhood experiences or aces and social determinants of health such as transportation, housing or access to electricity or clean running water, they disproportionately affect American Indian and Alaska native birthing persons. And so this can contribute to a higher rate of co-morbidities during pregnancy, including the mental health conditions and substance use.

00:03:56:15 - 00:04:21:06
Dr. Tina Pattara-Lau
I must acknowledge that this history does contribute to mistrust as well as avoidance seeking care within institutionalized health care systems. And as a non-native provider, I have learned it's important to be open and curious and practice humility. Acknowledge the trauma and the bias across generations, along with resiliency of cultural practices to help build trust and provide culturally safe care. Specifically in the rural setting

00:04:21:09 - 00:04:44:06
Dr. Tina Pattara-Lau
significant barriers the closure of rural obstetric hospitals. March of Dimes reports that one third of U.S. counties are considered maternity care deserts. 300 birthing units are closed since 2018, about 70 in the last year. Many American Indian and Alaska Native families live in rural communities. So 13% delivery, maternity care, deserts and about a quarter of babies are born in areas of limited or no access to maternity care.

00:04:44:09 - 00:05:06:09
Dr. Tina Pattara-Lau
So while IHS provides care to the 574 federally recognized tribes, births occur in all 50 states and the District of Columbia, and 25% of those American Indian Alaska Native births occur at an IHS or tribal facility, which means that 75% occur outside our system. So we've worked to maintain rural access by working in close collaboration with family practice physicians, midwives.

00:05:06:11 - 00:05:43:21
Dr. Tina Pattara-Lau
We realize that birth is commonly attended by relatives, including elders and aunties. So indigenous birth workers also have an important role to play in providing care. And then in urban areas, about 70% of Americans or Alaska Natives reside in those communities, often living apart from family and traditional cultural environments. And that presents a mental and physical challenge. So urban clinics will try to meet the needs of the community by incorporating culturally specific activities or provide things like mandatory health care, community-based outreach programs like health fairs, and then afterschool programs for youth who are focused on nutrition and fitness or native arts and crafts dance.

00:05:43:24 - 00:05:50:29
Julia Resnick
That's wonderful to hear. So turning to you, Dr. Nynas, can you talk to us about your hospital and the communities you serve?

00:05:51:01 - 00:06:21:06
Dr. Johnna Nynas
Sure. So I work for Sanford Health in Bemidji, Minnesota, which is located in the far northern part of the state. And we have three surrounding American Indian reservations that patients do receive care from our facility in coordination with their local facilities at their IHS site. And within our region, we're basically located in one of the most socially kind of deprived and poorest regions of the state and also very geographically isolated.

00:06:21:07 - 00:06:50:12
Dr. Johnna Nynas
So in keeping with the national trends that we're seeing, we face the same kind of barriers. We're seeing a lot of adverse impact related to those social determinants of health, high rates of poverty, substance use, domestic violence, trauma in the home. Subsequent issues related to generational trauma. The geographic isolation is particularly problematic. Thinking of northern Minnesota, we're heading into winter and in addition to just distance being a barrier, a weather is a huge barrier for us.

00:06:50:13 - 00:07:12:23
Dr. Johnna Nynas
So when you have a patient that travels 60 miles to get to an appointment and has transportation difficulties and then we throw a snowstorm in the middle, that's a completely unseen barrier that other places of the country don't have to consider. And then again, within the community, we're working really hard to acknowledge that there is still systemic racism within the community and implicit bias.

00:07:12:26 - 00:07:40:02
Dr. Johnna Nynas
And we're really trying to be mindful of our role within that. And again, be curious and ask those questions and really make some efforts to train our staff and our our nurses and collaborate not just within the health care systems themselves, but also with community organizations that are supporting indigenous birthing persons and improving our own cultural competence, if you will, within the community and try to rebuild that trust.

00:07:40:05 - 00:08:00:12
Julia Resnick
Yeah. So I want to dig into some of those opportunities because you both really outlined what the challenges are. But as we're seeing is we're talking to health care organizations. I'd love to hear more about what you think hospitals and health care organizations can do to address those challenges and disparities when they're treating American Indian and Alaska Native individuals.

00:08:00:14 - 00:08:03:01
Julia Resnick
Dr. Pattara-Lau I will start with you.

00:08:03:03 - 00:08:27:13
Dr. Tina Pattara-Lau
Well, we know pregnancy is a stress test for the body, you know, physically, mentally and spiritually. And underlying comorbidities, mental health conditions may become more acute. Some examples of where the additional stressors can affect American-Indian, Alaska Native populations are that in some states, substance use during pregnancy can result in involvement of the legal system, including incarceration or child protective services.

00:08:27:16 - 00:08:58:15
Dr. Tina Pattara-Lau
There is a mistrust of the health care and legal systems, and that's a barrier to establishing prenatal care, but also to timely interventions such as treatment to prevent congenital syphilis. So some families are fearful there will be hurt by their health care provider due to this underlying systemic racism. The CDC also recently released a report: one in five women reporting mistreatment while receiving maternity care, one in three of black, Hispanic, multiracial women watching this treatment and 45% women held back from asking questions or sharing concerns.

00:08:58:17 - 00:09:19:01
Dr. Tina Pattara-Lau
So what can we do? Well, while we hope all pregnant, postpartum patients are treated with respect, we know this is not always the case. And so starting with the patients, I share with my patients as well, please continue to advocate for yourselves and your relatives. You know your body best. When something feels wrong, tell someone, get help. Bring a trusted family member or friend.

00:09:19:04 - 00:09:42:25
Dr. Tina Pattara-Lau
Many patients, as Dr. Nynas mentioned, have access to tribal MCH programs and organizations such as the Alaska Native Birth Workers Community or the Navajo Breastfeeding Coalition to provide that support. And then looking at ourselves within our care systems, what am I doing to promote cultural safety? Am I elevating Indigenous leaders, elders, members of the community to create systems by the people for the people they serve?

00:09:42:27 - 00:10:10:09
Dr. Tina Pattara-Lau
Am I talking about things like first foods and medicines, indigenous birth and traditional healing practices. And so you may be familiar with the CDC's HRSA campaign that was launched in January for American Indian Alaska Native people provide resources and education, specifically from tribal communities as well as urgent maternal warning signs. But also as a society, as we begin to share more of our stories around mental health and reducing the stigma around mental health and seeking support. HRSA

00:10:10:09 - 00:10:39:25
Dr. Tina Pattara-Lau
recently launched last year, the Maternal Mental Health Hotline for 20/7 confidential support before, during and after pregnancy. It's available to patients and families with call or text translation services in 60 languages, including Navajo. Their number is 1-833-TLC-MAMA. So again, just some examples of the community and the national level support that we can find for our patients in the field.

00:10:39:27 - 00:10:56:06
Julia Resnick
And that national maternal mental health hotline started by HRSA, really crucially important. So, Dr. Nynas can you talk more about what you're doing at your hospital to increase access and availability of resources to improve maternal health outcomes for Indigenous women in your community?

00:10:56:09 - 00:11:45:05
Dr. Johnna Nynas
Sure. We've been really fortunate. Back in 2021, a group of health care providers within northern Minnesota, which included Sanford Health, as well as our IHS partners at Red Lake Nation and Leech Lake Nation and several community organizations came together and developed a program that we're calling Families First. And we were the 2021 recipient of a rural maternity and obstetric management services grant from HRSA to support development of this collaborative to really look at how we can target those issues that contribute most to adverse maternal outcomes, particularly among American Indian women within our region, and also how to create a foundation and to keep this sustainable for years to come.

00:11:45:08 - 00:12:07:23
Dr. Johnna Nynas
And so what came out of this is we've partnered together with several organizations to make sure that we are providing high quality and culturally related health care for moms and their families. We're trying to build trust and basically ensure that the care that these patients deserve is available. And our goal is for the next seven generations. So within that, there's several different moving programing pieces.

00:12:07:25 - 00:12:32:02
Dr. Johnna Nynas
The most critical one has been establishing high risk OB care coordinators at all of the sites that are providing obstetric care services. So we created the position and provided the initial funding for these positions and really what they're responsible for is their nurses who know all of the high risk patients within provider services and really kind of does the double checking to make sure nobody falls through the cracks.

00:12:32:04 - 00:12:50:01
Dr. Johnna Nynas
So if a patient hasn't been sending in their blood sugars or has missed an appointment with a consultant or missed an ultrasound, they're reaching out to the patient to find out what was that barrier that was difficult for you to come in for that appointment or to finish that part of your care and get them reconnected with care.

00:12:50:08 - 00:13:18:26
Dr. Johnna Nynas
And as we are seeing just a nationwide shortage of real health care providers and in particular a significant shortage of rural obstetric care providers, we need to support our practices in any way we can, and this has been a helpful way to do that. One of the extensions of this is increasing our home visiting nursing program capacity. One of the extensions of that was a partnership with Bemidji County Public Health to increase home visiting nursing programs.

00:13:18:26 - 00:13:40:18
Dr. Johnna Nynas
And so they established a goal of trying to complete 40 in-home visits for 2023. And as of June of this year, they had completed 143 home visits going way beyond their goal. And that is the direct result of the work that our high risk OB care coordinators are doing. For transportation barriers, obviously, that's a huge issue in our region.

00:13:40:20 - 00:14:07:03
Dr. Johnna Nynas
We have purchased a van that is going to be providing transportation for patients to appointments and ultrasounds. We are taking some lessons we've learned from Sanford Bemidji Behavioral Health Program, which did a similar program where they would provide transportation. What they found was when you provide the transportation for the patients, you can operationalize the cost of the van and the driver by decreasing your no-show rates.

00:14:07:06 - 00:14:32:21
Dr. Johnna Nynas
So that's something that we're going to implement for prenatal care and hopefully use that as a model for other health care agencies and also within our health care system as well. We are developing a specific, culturally competent group prenatal care program within our IHS site. So that prenatal care is a different model of providing traditional prenatal care. Patients still have their individual assessments.

00:14:32:21 - 00:15:13:23
Dr. Johnna Nynas
They still receive the American College of OB-GYN recommended evaluations and testing at the appropriate intervals, but they also get an additional 2 hours of education on any topic related to pregnancy and postpartum. So we're using that as an opportunity to weave together kind of traditional beliefs of birthing and child care and postpartum and those customs that exist within our tribes, along with the teachings that are out there and accepted by the national organizations as best practice. And weaving them together in a way. And also helping to really foster some support within the community itself,

00:15:13:25 - 00:15:35:24
Dr. Johnna Nynas
so women are also working together and supporting each other to keep those relationships going. And it's really about not only educating the individual person, but also making sure that they have the tools. So if they have a friend down the road or someone they know reporting symptoms, hey, that sounds like preeclampsia. You should really call your doctor. Maybe we should get you to the E.R. that's familiar to me.

00:15:35:26 - 00:16:17:01
Dr. Johnna Nynas
And that's where we can really make an impact, is improving health literacy and knowledge within our communities and then improving our access to virtual care. Broadband access can be really limited in rural areas, can be cost prohibitive for many people. And we are looking at putting infrastructure into some of the satellite clinics within our region to improve access for virtual visits, to decrease some of those transportation needs and really bring obstetric care to where women live rather than expecting all patients to come to us. And then internally we're doing a lot of work surrounding trauma stewardship and trauma informed care, a lot of education for our staff and our nurses education regarding low intervention, birth

00:16:17:01 - 00:16:49:06
Dr. Johnna Nynas
processes and how to support a low intervention birth. And we're really starting to see some improvement in some of our outcomes since doing those. And we've seen from 2017 to 2023, we've seen a 77% decline in CPS holds for babies for cases of neonatal abstinence syndrome in maternal substance abuse. We've also implemented within our hospital a different way of monitoring for neonatal abstinence when women have been using substances in pregnancy called eat sleep console.

00:16:49:08 - 00:17:15:06
Dr. Johnna Nynas
And what we're seeing coming out of that is we're seeing decreased neonatal length of stay, fewer admissions to our special care nursery for morphine administration. And we're seeing a higher number of referrals of women to drug and alcohol treatment programs and increased use and referrals to medication assisted therapy programs. So many good outcomes coming out of multifaceted work that we're doing as a collaborative team within our community.

00:17:15:09 - 00:17:30:10
Julia Resnick
That's wonderful and I love hearing about how you're weaving together traditional practices alongside medical ones to really meet the needs of the pregnant people in your community. I wonder if you have any stories that you can share that can really bring this program to life for our listeners.

00:17:30:12 - 00:17:54:18
Dr. Johnna Nynas
We're still in the phases where we're building the programing, but this is the idea. Where it came from is if I can have a patients who might be seeing a provider up in Red Lake with her local provider receiving group prenatal care up there, forming relationships with other women in her community and then transition to our hospital, which is the regional kind of birthing hub for our region.

00:17:54:20 - 00:18:17:25
Dr. Johnna Nynas
She's coming in basically having appropriate screenings. Any chronic medical conditions have been addressed and are controlled going into her pregnancy and delivery? We are doing a lot of work around what are some of those spiritual practices and cultural practices that are really important to me? Who are the people who are going to support me during my birth process and what should that look like?

00:18:17:28 - 00:18:44:22
Dr. Johnna Nynas
And sending that with the medical record, as we would lab results or other test results, because it's an important part of the care piece. And when those patients come to us for that transition of care and delivery, making sure that we're incorporating those practices at the bedside and providing those necessary resources. And the goal is that when all of our patients end up delivering, we're going to see better outcomes for moms, better outcomes for babies.

00:18:44:22 - 00:19:31:15
Dr. Johnna Nynas
We're working to get good coordination so those women can be seen by their initial OB provider at their IHS clinic locally within two weeks of delivery for that supportive postpartum care. We're also working with other community groups who do similar work. Some Indigenous doulas, lactation consultants within the region to really support that in-home care that happens postpartum. And we can identify those women who are at risk for postpartum depression, substance abuse, relapse, who may have different needs just within their own household, be it access to water, to heating, to clothing, shelter and meeting those needs and ultimately graduating them from the program with an established primary care provider to manage their ongoing medical concerns for

00:19:31:15 - 00:19:43:21
Dr. Johnna Nynas
the rest of their lives. And that's the work that takes a lot of time and effort in the short term. But the long term game is what's going to really move that needle in terms of maternal outcomes overall.

00:19:43:24 - 00:20:05:20
Julia Resnick
Absolutely. So as we wrap up, I want us to look forward towards the future and thinking about what are some things that our hospitals and health care systems should consider doing when serving pregnant and postpartum Indigenous individuals. So, Dr. Pattara-Lau, I'll ask you to answer that from the national perspective. And Dr. Nynas I'll ask you to address that from your hospital community's perspective.

00:20:05:22 - 00:20:08:03
Julia Resnick
Dr. Pattara-Lau, I'll start with you.

00:20:08:05 - 00:20:28:22
Dr. Tina Pattara-Lau
So at the national level, in response to the closure of rural labor and delivery units and the decline in birth national birth volumes, IHS has developed an obstetric readiness in the emergency department. We're calling it OB-Red, for short, manual and training programs. This is a collaborative, multidisciplinary team effort across our service areas Phenix, Navajo, Great Plains.

00:20:28:22 - 00:20:49:02
Dr. Tina Pattara-Lau
And we actually had some input from Alaska. We're fortunate enough to travel to South Dakota recently to provide some on new ground training as well. It provides a site, some maternity care deserts where an OB provider is not readily available with readiness checklists, quick reference protocols and training curriculum essentially for safe triage, stabilization, transfer of pregnant patients and newborns.

00:20:49:04 - 00:21:16:01
Dr. Tina Pattara-Lau
And so, as I mentioned, several IHS areas have implemented O.B. Red and demonstrated increased confidence with both triaging management of patients and newborns. We're also working as well to increase access to care during that critical pregnancy and postpartum transition period by piloting a maternity care coordinator program or MCC. And similar to what Dr. Nynas described, this is really an way to utilize telehealth and home visitation support, some of which does exist.

00:21:16:04 - 00:21:46:18
Dr. Tina Pattara-Lau
Alaska is a great example in the interior. Utilizing StarLink, we're able to increase broadband access. While not perfect, but certainly increases the amount of specialty care that you can get into the rural space. And really utilizing those approaches to increase screening education intervention, including the distribution of self-monitoring blood pressure cuffs, which we know can often save patients the time to schedule an appointment or obtain child care, gas for the car and then transport themselves to the clinic.

00:21:46:20 - 00:22:08:25
Dr. Tina Pattara-Lau
During the pandemic, we also expanded our virtual echo curriculum, which was a vital way for us to essentially reach providers across IHS to provide continuing education, but also specialty consultation. And we'll be partnering with the Northwest Portland Area Indian Health Board to launch a monthly Indian country, Echo on care and access for pregnant persons. And our goal is to bridge traditional practice with evidence based care models.

00:22:08:28 - 00:22:30:19
Dr. Tina Pattara-Lau
So our first webinar will highlight the work of one of our first Indigenous midwives and teachers. And so we invite you and your listeners to visit our website, newly launched with last month. www.ihs.gov/ach and to learn more about resources available for American-Indian, Alaska, Native communities and the people who provide care for them. So thank you again for the opportunity to share with you today.

00:22:30:19 - 00:22:33:06
Dr. Tina Pattara-Lau
And thank you to Dr. Nynas as well for the work that you do.

00:22:33:06 - 00:22:38:13
Julia Resnick
That’s wonderful. Dr. Nynas, turning to you for some final thoughts.

00:22:38:15 - 00:23:05:13
Dr. Johnna Nynas
Yeah, we're piggybacking on that exact same work. We are hoping to launch what we're calling an OB virtual hospitalist program to bring kind of a telemedicine view similar to telestroke into our regional EHRs to support those local providers in stabilization and assessment in an emergency situation, because I can't function as a successful OB-GYN if I don't have a provider who can successfully stabilize a patient prior to our transfer.

00:23:05:14 - 00:23:37:15
Dr. Johnna Nynas
So thank you for all the work that you're doing, Dr. Pattara-Lau, it's wonderful. In thinking about how to move forward for communities, I think really important part of this is improving our knowledge and understanding of trauma, informed care and implicit bias training for your team. I think that is a really critical part, not only to acknowledge the historical trauma and the disparities that exist within our community, but to move forward with it from a place of humility and trying to understand those barriers and respond to them appropriately.

00:23:37:15 - 00:24:06:13
Dr. Johnna Nynas
So I think that's really critical for hospital systems to consider. I would also encourage health care providers and hospital systems to really look within their own regions and communities and who else is providing this work and really working to form those collaborative relationships within your region. And they're going to look different place to place. But the more that you develop that collaborative team and that strong relationship and promote referrals back and forth between agencies.

00:24:06:16 - 00:24:24:03
Dr. Johnna Nynas
I would encourage meetings face to face, if you can, at least a couple of times a year to keep each other informed. But that has been really critical in trying to move the needle in terms of outcomes and connect patients to the right resources in care. And you can't do that unless we know what's out there and what everyone's trying to do without recreating the wheel.

00:24:24:06 - 00:24:45:21
Dr. Johnna Nynas
And then the other thing that I really learned throughout this process is we need to stop the the mindset of we're trying to solve this problem right now. And that's happening today. What we're trying to do is set the foundation of what our options to sustain this care for 20 years. What do I want the outcomes to look like 30 years from now?

00:24:45:21 - 00:25:08:11
Dr. Johnna Nynas
What is this going to look like in seven generations? Because that's really the changes we want to make is really improve the health of our communities over time. So we're really trying to think about this is what should this look like 50 years from now down the road to support women and birthing persons and also that culture. So I think really having that forward thinking mindset is really critical.

00:25:08:13 - 00:25:34:12
Julia Resnick
Absolutely and I think that's a big part of why we're here to build that foundation so that over the next years, months, years, generations ahead, we can provide better care for our American Indian and Alaska Native pregnant people. So I want to thank you, Dr. Pattara-Lau and Dr. Nynas for your time for sharing your expertise and insights and for all the work that you are doing to improve outcomes for indigenous moms in your communities.

00:25:34:15 - 00:26:00:17
Julia Resnick
And to our listeners, you've heard us mention a few different resources over the past few minutes. So I encourage you to visit CDC’s Hear Her campaign specific for America Indian and Alaska Native Communities. The campaign offers educational information and tools for pregnant and postpartum indigenous women, their partners, friends and families, and for health care providers as well. You also heard us mention HRSA's National Maternal Mental Health Hotline.

00:26:00:19 - 00:26:10:06
Julia Resnick
Again, that number is 1-833-TLC-MAMA. So thank you again to both of you for joining us and your expertise. And to all of you for listening in.