Reclaiming American Indian maternal and infant health.

For the first six years of my life, Mother's thoughts were so largely centered upon me that she sacrificed even companionship with my father in order to give nee her full time. A weak or puny baby was a disgrace to a Lakota mother. It would be evidence to the tribes that she was not giving her child proper time and attention and not fulfilling her duty to the tribe. More than that, it was evidence that she has not used proper social discretion and defied age-old tradition. It was a law with the Lakotas that for the first six years of a child's life it should have the unrestricted care of the mother and that no other children should be born within this six-year period. To break this law was to lose the respect of the Tribe, and both father and mother suffered the penalty. A fine, healthy child was therefore a badge of pride and respect, and healthy babies were the rule.

Luther Standing Bear "Land of the Spotted Eagle," Copyright 1933

Traditionally, Northern Plains and Rocky Mountain region Indian tribes considered their children sacred. Regrettably, childrearing practices, like so many other aspects of American Indian culture, have suffered over the past 100 to 150 years as a result of white America's westward expansion. The traditional norms described above are no longer observed by Luther Standing Bear's descendants or tribe, with great implications for maternal and child health.

Medical research and technology have made great strides in the United States during this same time period. Still, American Indian infants in the Rocky Mountains and on the Northern Plains die more frequently than white infants in the region, making infant death one of the major health problems facing tribes and urban Indians in the area.

Infant Characteristics and Maternal Risk Factors

Infant characteristics at birth provide information regarding the health of a pregnancy and an infant's risk of illness, death, or long-term disability. Some of the factors considered include birth weight, gestational period, and infant mortality.

Low birth weight and very low birth weight--defined as weighing less than 5 lbs 8 oz and 3 lbs 4 oz, respectively, at birth--are both associated with a multitude of health problems, including greater risk of increased chronic conditions and limitations of activity (Overpeck 1989). All low birth-weight infants are more likely to experience long-term disability or to die during the first year of life than are infants of normal weight, with very low birth weight infants having the lowest survival rate of all. Major contributors to low birth weight are births--infants born before 37 weeks of gestation--and multiple births (MCHB 2006). Reducing the number of both low birth weight and very low birth-weight infants are goals of the Healthy People 2010 initiative (www.healthypeople.gov).

The infant mortality rate, which relates the number of infant deaths to the number of live births for a population, is one of the most commonly used measures of the overall health of a population and serves as a fundamental measure of development. In fact, overall reduction of infant mortality in the United States has been hailed as one of the 10 greatest public health achievements of the 20th century (MMWR 1999). However, there is great disparity between the infant mortality rate in non-Hispanic white and other racial and ethnic populations, American Indians among them, a disparity to which differences in the rate of very low birth weight is a major contributor (MCHB 2006).

When considering infant mortality, a distinction is made between neonatal and postneonatal mortality. Neonatal deaths happen before an infant reaches 28 days of age, and one contributor is low or very low birth weight. Postneonatal deaths, on the other hand, happen when an infant is between the ages of 28 days and 1 year and are less frequently connected to birth weight issues (MCHB 2006).

[ILLUSTRATION OMITTED]

In Montana, the measures for infant mortality and low birth weight are both slightly higher for American Indians than for the population as a whole (Table 1).

However, when it comes to birth weight, it is important to keep in mind that large infants can also be unhealthy. When a baby is born large for gestational age, it is most often caused by maternal diabetes. Pre-existing, as well as pregnancy-onset (gestational) diabetes, if not monitored and managed during a pregnancy, can lead to excessive growth in an infant. Such babies often need to be delivered via Caesarean section, increasing the risk of complications and prolonging the mother's recovery time.

Additionally, pre-existing diabetes can cause problems early in the pregnancy (the first two months) as out-of-control blood sugar levels can affect the formation of a baby's organs, causing serious birth defects (MCHB 2007). Infants born to diabetic mothers may also be at higher risk of illness and death during infancy, as well as for the development of Type 1 diabetes later in life. The mother, if not already a diabetic herself, can go on to develop Type 2 diabetes (Pitkin 2003).

All of these factors are more common within the American Indian population, but Indian mothers face additional challenges as well. In Montana, for example, Indian women have babies at a younger age than the overall state population, and they exhibit a higher incidence of alcohol, drug, and tobacco use during pregnancy, indicating that mothers and infants have stresses and challenges beyond the general Montana population.

Obviously, healthy and thriving American Indian children are desirable for more reasons than just the traditional cultural values described in the introduction. For American Indian infants to grow up to become healthy and fully participating members of today's society, they need a life start equal to that of white children. However, bringing attention to these traditional values illustrates the changes in Indian child populations, while also emphasizing that the health conditions seen in today's Indian infant and maternal populations are a recent development and clearly at odds with traditional American Indian values and ideals concerning mothers and babies.

Conventional wisdom, as well as research, tells us that for a woman to deliver and raise healthy babies, she needs to be healthy herself. With higher rates of teen pregnancies and poverty, lower levels of education and employment, and more limited access to quality health care among Montana's American Indian population, health outcomes compare unfavorably with those of the total population. For example, the median age at death for American Indian women is 64 years, while it is 81--a full 17 years more--for the overall female Montana population. However, it is worth noting that a shorter life expectancy is not related to a higher death rate. in Montana, American Indians have a lower death rate than the population as a whole (6.5 versus 9.1 deaths per 1,000 population).

Recently, public health efforts have been focused on improving the overall pre-conception health of American Indian women between the ages of 15 and 44 in order to improve pregnancy-related outcomes. For example, American Indian women would benefit from improved access to prenatal care, as they currently start care later and complete fewer doctors' visits than their counterparts in the general population. Among births to American Indian women, 65 percent were to women who started prenatal care in the first trimester, while in the general population, the corresponding number is 83 percent.

Similarly, 50 percent of American Indian new mothers had received adequate prenatal care, while 73 percent of all Montana births were to women who had received adequate prenatal care (Table 2).

While the importance of early, high-quality prenatal care cannot be underestimated, the importance of overall health prior to becoming pregnant is heightened as over half of pregnancies are unplanned (Finer, 2006). The adverse effects associated by waiting to address health issues until a woman becomes pregnant or starts prenatal care get further compounded the longer she waits to see a doctor when she becomes pregnant.

Focusing on a woman's health before pregnancy can reduce the adverse effects of chronic conditions such as obesity, diabetes, hyperthyroidism, and hypertension on both herself and her infant. Regular medical attention can also help in reducing the consumption of tobacco, alcohol, and certain medicines that all have adverse effects on fetal development before a woman knows she is pregnant. Certain birth defects can be prevented by adequate intake of folic acid (a B vitamin) intake prior to pregnancy, and by avoiding alcohol and drug use (CDC 2008).

Preconception health, however, does not end with the birth of a child. Postpartum care provides an opportunity to monitor and sustain a woman's health in anticipation of her next pregnancy. Health care providers who treat women of reproductive age should make use of every opportunity to provide guidance that may improve the outcome of possible future pregnancies. Health programs that focus on maternal and child health, such as WIC, Healthy Start, and public health clinics providing immunization and well-child visits, do in fact have a unique opportunity to ensure not only the well-being of the infant but also to improve and sustain the health of the mother, ensuring that her next pregnancy is healthy.

Data: Availability and Gaps

Health data are used to define the scope of a health program; provide information about sub-groups that are at highest risk; evaluate the effectiveness of programs and services; and, over time, assist health planners to determine whether health is improving or declining. An essential element in improving American Indian maternal and infant health in Montana is the access to high-quality and timely health data.

Print Get the Mag Weekly Updates