Maternal Mortality Among American Indian/Alaska Native Women: A Scoping Review

Abstract

Background: Maternal mortality decreased globally by about 38% between 2000 and 2017, yet, it continues to climb in the United States. Gaping disparities exist in U.S. maternal mortality between white (referent group) and minority women. Despite important and appropriate attention to disparities for black women, almost no attention has been given to American Indian/Alaska Native (AI/AN) women. The purpose of this scoping review is to synthesize available literature concerning AI/AN maternal mortality. Methods: Databases were searched using the terms maternal mortality and pregnancy-related death, each paired with American Indian, Native American, Alaska Native, Inuit, and Indigenous. Criteria (e.g., hemorrhage) were paired with initial search terms. Next, pregnancy-associated death was paired with American Indian, Native American, Alaska Native, Inuit, and Indigenous. Criteria in this category were homicide, suicide, and substance use. Results: The three leading causes of AI/AN pregnancy-related maternal mortality are hemorrhage, cardiomyopathies, and hypertensive disorders of pregnancy. AI/AN maternal mortality data for homicide and suicide consistently include small samples and often categorize AI/AN maternal deaths in an ''Other'' race/ethnicity, which precludes targeted AI/AN data analysis. No studies that reported AI/AN maternal mortality as a result of substance use were found. Health care characteristics such as quality, access, and location also may influence maternal outcomes and maternal mortality. Conclusions: Despite AI/AN maternal mortality being disproportionately high compared to other racial/ethnic groups, relatively little is known about root causes.

Summary and Conclusion: Framing a New Research Agenda on Maternal Morbidities and Mortality in the United States

“…For example, Heck et al 5 deplore the dearth of reliable data on the causes of increased mortality risks among American Indian/Alaska Native women, especially for pregnancy-associated deaths. They suspect that homicide, suicide, and substance abuse and misuse—all linked to intimate partner violence—may play a role, but note that “severe data limitations prohibit our understanding of true incidence and prevalence.” 5 Similarly, Signore et al 6 observe that “[d]espite the size of the disability population, the sexual and reproductive health needs of this population largely have been ignored.” Available information on reproductive and pregnancy outcomes among women with disabilities suggests increased risks, especially as they relate to infection or cardiovascular conditions, some of which may be related to prepregnancy health status and social determinants, but much remains unknown. Patel and Sweeney 7 raise concerns about the paucity of research on the reproductive health of transgender and gender nonconforming patients, who may face a whole host of health issues and risks from fertility treatments (which necessitate stoppage of gender-affirming hormone therapy), pregnancy, delivery, and lactation, including postpartum depression from gender dysphoria for transgender men.…”

“…Several articles [5][6][7][8][9][10] in this special issue focus on vulnerable populations that are at greater risk of maternal morbidities and mortality. How little we know about some vulnerable populations is troubling.…”

“…How little we know about some vulnerable populations is troubling. For example, Heck et al 5 deplore the dearth of reliable data on the causes of increased mortality risks among American Indian/Alaska Native women, especially for pregnancy-associated deaths. They suspect that homicide, suicide, and substance abuse and misuse-all linked to intimate partner violence-may play a role, but note that ''severe data limitations prohibit our understanding of true incidence and prevalence.''…”

“…They suspect that homicide, suicide, and substance abuse and misuse-all linked to intimate partner violence-may play a role, but note that ''severe data limitations prohibit our understanding of true incidence and prevalence.'' 5 Similarly, Signore et al 6 observe that '' [d]espite the size of the disability population, the sexual and reproductive health needs of this population largely have been ignored.'' Available information on reproductive and pregnancy outcomes among women with disabilities suggests increased risks, especially as they relate to infection or cardiovascular conditions, some of which may be related to prepregnancy health status and social determinants, but much remains unknown.…”

Correlates of Early Prenatal Care Access among U.S. Women: Data from the Pregnancy Risk Assessment Monitoring System (PRAMS)

“…Specifically, women who identified as Black and Native American learned of pregnancy significantly later and established prenatal care later compared to women who identified as white. Given the higher burden of adverse outcomes among Black and Native American women (Heck et al, 2021 ; Kuehn, 2019 ; Kuriya et al, 2016 ; Singh, 2021 ), changes in policy (e.g. recommendations for a specific week to start prenatal care from professional organization) and insurance coverage will be necessary to prioritize early prenatal care in these populations.…”