The Impacts of Racial Discrimination on Native American Birth and Midwifery

“Continued underfunding from the US Government to the Indian Health Services, has forced the closure of clinics and labor and delivery units serving Native American communities in rural and urban areas, which has exacerbated known health disparities. Despite healthcare medical advancements 20% of Native American people are considered to have “poor health.” Currently Indian Health Services is failing to provide baseline “adequate” health care to Native American people. Native American birthing people have the 2nd highest maternal mortality rate compared to our Black counterparts. The maternal death rate has tripled since 1987. IHS does not consistently provide reproductive healthcare for Native American women and with the recent ruling of Roe Vs. Wade, Native American women will face increased limitations in accessing abortion care. Today, sovereign, equitable, thoughtful, and culturally relevant care is not accessible.”

UNCERD Hearing Statement- Nicolle L Gonzales
Founder & Midwifery Director of CWI
The Silent Crisis

As more parts of the United States become maternal healthcare deserts, due to the closure of regional healthcare centers and lack of obstetrical providers willing to work in those areas, where does that leave birthing people to access care? For those unaware, this has been the situation for Native American people all over the United States, before it became a problem for everyone.  It is common for Native American birthing people to travel more than 30 minutes to access care and in Alaska, Native American women are still evacuated to maternal health homes at 36 weeks, to live, until they go into labor and then can go home after they have given birth.
With maternal mortality rates going up for Native American women, despite medical advances, new consideration is being given to all the ways that racism, discrimination, and social determinants of health are impacting outcomes for birthing people. According to the 2018 NM Maternal Mortality report, “structural and institutional racism, as well as interpersonal racism, impact health outcomes and that Black and American Indian/Alaska Native women are 2 to 3 times more likely to die from pregnancy-related causes than non-Hispanic white women” (2018, NM Maternal Mortality report). 
We know racial disparities have existed in the United States for centuries, however racial disparities in itself leaves an area of vagueness and the ties it has to racial oppression. According to Hardeman & Kerbeah, “By separating health disparities from racism, we fail to recognize disparities as inequalities-that are avoidable injustices. Instead we focus on individual differences rather than the systems and structures that uphold and replicate them”(2020, Health Service Research).  There is building evidence that we have to acknowledge white supremacist ideologies within healthcare, which stems from inferiority and a framework that upholds and sustains a belief system and worldviews where minority groups are disempowered, devalued, and denied equal access to resources. Further, that the US Healthcare system is structured to serve a White Population. 
Through the intentional colonization of Native American communities, 90% of Native American women give birth in hospital settings and are unlikely to have a provider or birth attendant be Native American. In midwifery, Native Americans make up <1% of the workforce. It is also common practice for Native American birthing people not to access care in the first trimester or to have less than 4 prenatal visits prior to birth. They are more likely to travel longer distances to access care and to be retraumatized during birth by unconsented medical procedures, by providers who have no regard for informed consent. With increasing closures of Indian Health Service hospitals labor and delivery, Native American women may even wait up to 6 weeks to see a healthcare provider for prenatal care. 
Limited Access to Abortion Care
According to Indigenous Women’s Reproductive Rights “When abortion was legalized in 1973, federal money became available to pay for abortion services for all women relying on federal healthcare programs. These funds for abortion services initially were not subject to restrictions, until 1976 when Congress renewed the Hyde Amendment. In its current version, enacted in 1997, the Hyde Amendment, which allows public funding for abortion only if the pregnancy 1) to save a mothers life; 2) when pregnancy is the result of rape; 3) when pregnancy is the result of incest” (2002).
“In June and July 2002, the Native American Women’s Health Education Resource Center (NAWHERC) conducted a survey to assess Native American women’s access to legal abortions through the Indian Health Service.ix The survey findings showed that 85% of the surveyed Service Units were noncompliant with the official IHS abortion policy and thus in violation of the Hyde Amendment. In 62% of the surveyed Service Units, personnel stated that in cases where the woman’s life is endangered by the pregnancy, they do not provide either abortion services or funding.”
While it might be 2022, Native American women still experience limited access to abortion care and with the recent overturning of Roe v. Wade, it eliminates an individual’s constitutional right to end their own pregnancy. This has made way for individual states to enforce abortion bans that criminalize healthcare providers and women if they provide abortion care or access it. 
While Black birth workers and reproductive justice advocates have mobilized nationally to address their maternal mortality crisis, Native American communities lack the support of tribal leadership to take action against this silent crisis. The lack of community and legislative response to the new ruling, even if backed by data, reinforces that the health and wellness of Native American mothers is not a priority.
Our Call to Action

The lack of Native American representation within maternal and reproductive healthcare was one of the many reasons Changing Woman Initiative was formed in 2015. Over the last 8 years, CWI  has been very vocal about this silent crisis that has led to the increase in maternal mortality in Native American communities. Further, CWI has engaged and navigated multiple healthcare systems with birth families, centering The Right To Health through an Indigenous Community Midwifery Wellness Framework based on the 5 R’s of rematriation, which is Rooted, Relational, Restorative, Regenerative and Revolutionary by focusing on these areas:

• Native and Indigenous maternal health disparities contributing to maternal mortality
• Access to culturally centered gender inclusive sexual, reproductive and maternal healthcare
• Providing Maternal Health care in what is considered “healthcare deserts” in rural New Mexico and Arizona.
• Supporting the right to access and use of Native and Indigenous traditional herbal medicines, cultural healers and practices through education, service delivery, and community building and policy/advocacy.
• Strengthening and supporting the inclusion of holistic family and community centered care.

According to the 1946 Constitution of the World Health Organization, health is defined as “a  state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” It also affirms that the highest attainable health is a fundamental human right of every human being without distinction of race, religion, political belief, economic or social condition.

United Nations Committee on the Elimination of Racial Discrimination
It is through this present day understanding in regards to the communities we serve and the structural racism we are forced to engage in for and with our families that we believed the United Nations Committee on the Elimination of Racial Discrimination needed to hear from us directly. In preparation for this week long event, we also participated in a shadow report (Systemic Racism and Reproductive Injustice in the United States: A Report for the UN Committee on the Elimination of Racial Discrimination) outlining all the ways that the United States is not upholding their treaty obligations to the United Nations around our reproductive rights, while urging the UN CERD committee to condemn these violations:

1. Ensure the meaningful participation of women of color in all decision-making processes that impact their reproductive health.
2. Remove barriers to accessible, high quality, comprehensive reproductive healthcare.
3. Address and eliminate racial and intersectional discrimination in reproductive health care settings, including birthing facilities and criminal and immigration detention settings.
4. Ensure that communities of color can access and provide culturally aligned services that improve maternal health, including midwifery and doula care.
5. Halt and remedy retrogression of the right to abortion, and ensure abortion access.
6. Address the impact of environmental racism on reproductive health.

Following a week of advocacy, connecting with other Indigenous Justice groups, the final report was published and here are some highlights from the concluding observations report published by the CERD. You can access the full report here: Concluding Observations on the combined tenth to twelfth reports of the United States of America
Right to health 

33. The Committee welcomes the adoption of the American Rescue Plan that has facilitated access to affordable care to people with lower and moderate income, including persons of racial and ethnic minorities. However, the Committee remains concerned at: a) the high number of persons belonging to ethnic and racial minorities who do not have access to affordable and quality health care because they live in states that have not adopted the Medicaid expansion programme; and b) the exclusion of undocumented migrants from coverage under the Affordable Care Act and the limited coverage under Medicaid for migrants residing in the country for less than five years. While taking note of the increase of funding, the Committee is still concerned at the lack of adequate resources provided to the Indian Health Service (I) and the lack of medical facilities within reasonable distances for Indigenous Peoples (art. 5).

34. The Committee recommends that the State party adopt all necessary measures, including legislation to expand coverage for existing health care programs, to ensure that all individuals, in particular those belonging to racial and ethnic minorities, Indigenous Peoples, and non-citizens have effective access to affordable and adequate health care services.

Maternal mortality and sexual and reproductive health

36. The Committee takes note of the measures adopted by the State party to address the high maternal mortality rates and to improve access to sexual and reproductive health services, such as the White House Blueprint for addressing the maternal health crisis of 22 June 2022; Executive Order 14076 on Protecting access to reproductive healthcare services of 8 July 2022; and Executive Order 14079 on Securing Access to Reproductive and Other Healthcare Services of 3 August 2022. However, the Committee is concerned that systemic racism along with intersecting factors such as gender, race, ethnicity and migration status have a profound impact on the ability of women and girls to access the full range of sexual and reproductive health services in the State party without discrimination. It is also concerned about the limited availability of culturally sensitive and respectful maternal health care, including midwifery care for low-income, rural and people of African descent and Indigenous communities. It further notes with concern that racial and ethnic minorities are disproportionately impacted by higher rates of maternal mortality and morbidity; higher risk of unwanted pregnancies and lack of means to overcome socioeconomic and other barriers to access safe abortion. In this context, the Committee is deeply concerned at the Supreme Court’s ruling in Dobbs v JWHO of 24 June 2022, which overturned nearly fifty years of protection of women’s access to safe and legal abortion in the State party, and the consequent profound disparate Impact on the sexual and reproductive health and rights of racial and ethnic minorities, in particular those with low incomes; as well as at the disparate impact of legislation and other measures at the state level restricting access to safe and legal abortion or criminalizing abortion (art. 5).
37. The Committee recommends that the State party take further steps to eliminate racial and ethnic disparities in the field of sexual and reproductive health and rights, while integrating an intersectional and culturally respectful approach in, for instance, policies and programs aimed at removing barriers to access comprehensive sexual and reproductive health services; and, at reducing the high rates of maternal mortality and morbidity affecting racial and ethnic minorities, including through midwifery care. The Committee also recommends that the State party adopt all necessary measures, at the Federal and state level, to address the profound disparate impact of Dobbs v JWHO on women of racial and ethnic minorities, Indigenous women and those with low incomes, and to provide safe, legal and effective access to abortion in line with the international human rights obligations of the State party. It further recommends that the State party take all necessary measures to mitigate the risks faced by women seeking an abortion and by health providers assisting them, and to ensure that they are not subjected to criminal penalties. In that respect, the Committee draws the State party’s attention to the WHO abortion care guidelines.

The final days of the NGO hearings, we had the honor to be present and listen to CERD members  ask the U.S. Federal government representatives questions. Here is a brief summary of excerpts (transcribed) and shared by Center For Reproductive Rights, who helped convene our US Reproductive Justice delegate party.
Questions to the U.S. during the review:
Here are some excerpts (transcribed) from the actual review on August 12th (during which members of CERD asked the U.S. federal government representatives questions that echoed the concerns and framing of our delegation):
From Pansy Tlakula, CERD:

• Maternal Health:  “According to the information that has reached the committee, black women are three times more likely to die from pregnancy related causes than their white counterparts and blank infants are more than twice as likely to die than white infants. There are also acute racial disparities in cervical cancer rates affecting black women. What further measures are being taken to address the persistence of high mortality rates among racial and ethnic minorities, women of African descent, who are often victims of multiple forms of discrimination, indigenous peoples and immigrant women—who are not covered by the Affordable Care Act because they have been residing in the country for less than five years— to ensure that they access health and reproductive health services without discrimination? Kindly provide the committee with the latest statistical information on maternal and infant mortality rates in the last 10 years disaggregated by race and ethnic origin.” 

• Abortion access: “The committee has received numerous submissions expressing concern about the regression concerning abortion following the Supreme Court ruling of Dobbs vs. JWHO issued on the 24th of June 2022, which the UN High Commissioner for Human Rights and many Special Rapporteurs have described as, (I quote), “a major setback after five decades of protection for sexual and reproductive health and rights in the US through Roe vs. Wade and as a serious regression of an existing right that will jeopardize women’s health and lives” (close quote) in particular, those with low incomes and those belonging to racial and ethnic minorities. In this regard, what measures have been taken to address the impact of intersectional discrimination and systemic racism on the sexual and reproductive health and rights of racial and ethnic minorities? In particular, given the crisis in maternal mortality, and access to care for women of African descent Indigenous and migrant women, what steps have been taken to address the profound and deadly impact on women and girls, notably of racial and ethnic minorities of the Supreme Court ruling in Dobbs vs. JWHO, and of the state laws and court decisions which restrict women’s access to reproductive health and abortion services and create new barriers, including criminal sanctions to women and girls who undergo abortion and to abortion services providers, particularly in the light of the international obligation of the state party under international human rights law? In this regard, yesterday, I read media reports that Meta formally known as Facebook, gave police the private data of a mother and a daughter facing criminal charges for allegedly carrying out an illegal abortion in Nebraska. So it appears that, if these media reports are true, that prosecutions are already starting. What measures will be taken by the state party to safeguard the rights to interstate travel to access abortion services in states that offer such services?”

From Tina Stravrinaki, CERD:

•       So, I would like to focus on the right to health. . .  Indigenous peoples and African descendant communities reported to the committee that removing structural barriers and facilitating access to reproductive health care, including abortion and midwifery care, would require, inter alia, to provide the free choice – and I repeat the free choice— of every person to have access to culturally respectful care free from coercion, stigma, and other forms of discrimination. So, in light of undisputed health related data reported also by the country rapporteur, did the state party take any measures to integrate traditional community-based and culturally respectful medicine in the health system?”

The U.S. government response from Jessica Swafford Marcella:

•       “I want to focus on how health and well being are fundamental to dignity, respect, and human rights.”
•       “I also want to acknowledge and appreciate what was an unstated but clear recognition by the committee. That reproductive health care is health care. So as we talked about, as we talk about reproductive health rights, and justice, my intention is not to silo that from our discussion of access to health care, access to coverage, the important support that people need. I’ll begin with the questions related to maternal mortality and morbidity because it is a crisis in the United States. And the Biden Harris administration is committed to combating cutting the rates of maternal mortality and morbidity, reducing the disparities in maternal health outcomes, and improving the overall experience of pregnancy, birth and postpartum care for people across the country.”
•       “In June of this year, on June 24, the same day that the dobs decision came out, the White House issued a blueprint on addressing our nation’s maternal health crisis. And this whole government approach includes over 50 actions that over a dozen agencies will undertake to help improve maternal health care. And this administration has also requested more than $470 million for investments to support maternal health.”
•       “The second part of the blueprint action plan is to focus on what was raised about ensuring those giving birth are hard and our decision makers and these accountable systems of care.”
•       “We’re going to work on that in a number of ways with funds from the fiscal year 23 president’s budget. Our plan includes training providers on implicit biases, as well as culturally and linguistically appropriate care. We also intend to bolster the voices of communities of color when analyzing the factors contributing to pregnancy related deaths and really the goal here is to educate and empower more women and families to know the early warning signs of pregnancy related complications and behavioral health disorders.”
•       “Fourth, we’re expanding and diversifying the perinatal workforce, including the doula workforce, because as we heard a number of times and we agree, representation matters and having providers particularly trusted providers that understand the complex identities and experiences of people and who can center them is critical to success as we think about health equity, and what we can do to achieve it and make meaningful progress.”

Looking Forward
Now more than ever our birth stories and reproductive health experiences are making slow rippling impacts on policy change. 10 years ago, these discussions weren’t happening, many stories and experiences stayed in communities and were passed on through relatives. This is how trauma is passed on from one generation to the next. The feeling of “helplessness” takes root and our stories never go beyond our friends and homes.  It is vital we continue to be in these spaces to share our experiences, so that our future relatives have better experiences than we did.  Since the UN CERD convening, there have been numerous reports published around improving maternal and reproductive healthcare. 
In June of 2022, the White House released 
White House Blue Print For Addressing The Maternal Health Crisis,
Addressing 5 Goals:

1. Increasing Access to and Coverage of Comprehensive High-Quality Maternal Health Services, Including Behavioral health services.
2. Ensure those giving birth are heard and are decision makers in accountable systems of care.
3. Advance data collection, standardization, harmonization, transparency, and research.
4. Expand and diversify the perinatal workforce.
5. Strengthen Economic and Social Supports for people before, during and after pregnancy.

On September 13, 2022, the Advisory Committee on Infant and Maternal Mortality convened a nation wide meeting with American and Alaska Native leaders, providers, and families to hear first hand stories of the impacts of treaty violations, land theft, toxic Federal policies that create more barriers and trauma when it comes to their health. I was honored to testify during this convening and make recommendations to improve the health and safety of American Indian and Alaska Native Mothers and Infants. 
You can access the final report that was submitted to Xavier Becerra the Secretary of Health and Human Services:
Making Amends: Recommended Strategies and Actions to Improve the Health and Safety of American Indian and Alaska Native Mothers and Infants
Recommended Strategic Actions
Recommended Strategic Actions:

1. Make the Health of AI/AN Mothers and Infants A Priority for Action
2. Improving the Living Conditions of AI/AN Mothers and Infants and Assure Universal Access to High Quality Healthcare.
3. Address Urgent and Immediate Challenges that Disproportionately affect AI/AN women before, during, and after pregnancy.

The report calls out the federal government for falling short of its responsibility to AI/AN’s. The impact of this failure is resulting in negative health outcomes like.
“AI/AN maternal mortality rates ranging from 2 to 4.5 times the rate of non-hispanic White women with regional rates elevated to 7 times the rate of non-Hispanic White women, and an estimated 93% of AI/AN Deaths being preventable”
“Consistently high infant mortality rates, a measure that gauges overall community health.”
“Inadequate prenatal care”
In Conclusion: A Love Letter to Community

We know this is dense information and can be triggering for some. Changing Woman Initiative has a lot of hope for the transformative action that storytelling brings and framing our advocacy through that lens. We are also aware of the tremendous emotional, spiritual, and physical lift we feel called to do with Native American and Indigenous communities. We go into these politically stressful spaces with the prayers of our ancestors and the hopes of our children. Our voices shake and our tears flow, as we tell our own stories, while also trying to be strong. Too often we are the only brown people in the room of politicians and lawmakers. Yet, we show up with our authentic hearts, hoping our stories will make a difference. 

What we know is words do not always reflect actions and so we have to continue showing up in these spaces until words turn into actions. We are calling not only for change, but for reparations for centuries of racism, genocide, and forced sterilization.. Along with reparations, we should be defining and working towards our collective liberation. Having our basic needs met shouldn’t be a RIGHT we have to constantly fight for or even settle for. Our grandmothers and those before that endured so much so we can be here to live a better life. We can be revered for our strength, but what about our joy, our peace, and the love we have with our communities at heart. It is time we tell our own stories and use that power to rebuild our nations through our healing rather than our trauma. Let’s shift the paradigm. 

Resources

Concluding Observations on the combined tenth to twelfth reports of the United States of America.(2022). https://tbinternet.ohchr.org/_layouts/15/treatybodyexternal/Download.aspx?symbolno=CERD%2fC%2fUSA%2fCO%2f10-12&Lang=en

Hardeman, R. R. & Karbeah, J. (2020) Examining racism in health services research: a disciplinary self-critique. Health Service Research, 55(2),777-780.

Making Amends: recommended strategies and actions to improve the health and safety of american indian and alaska native mothers and infants (2022).https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/infant-mortality/birth-outcomes-AI-AN-mothers-infants.pdf

New Mexico Maternal Mortality Review Committee Annual Report (2018). https://www.nmlegis.gov/handouts/LHHS%20103122%20Item%201%20Maternal%20Mortality.pdf

Schindler, K., Jackson, A. E. & Asetoyer C.A (2002) Indigenous women’s reproductive rights: the indian health service and it’s inconsistent application of the hyde amendment.https://www.prochoice.org/pubs_research/publications/downloads/about_abortion/indigenous_women.pdf

Systemic Racism and Reproductive Injustice in the United States: A report for the UN Committee on the Elimination of Racial Discrimination. (2022). https://reproductiverights.org/systemic-racism-and-reproductive-injustice-in-the-united-states

The Right To Health (2008). https://www.ohchr.org/sites/default/files/Documents/Publications/Factsheet31.pdf

The White House BluePrint for Addressing The Maternal Health Crisis (2022).https://www.whitehouse.gov/wp-content/uploads/2022/06/Maternal-Health-Blueprint.pdf

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