Birthing on Rural America’s Margins: Maternal Health Disparities

Authored by: Sumedha Shastry

Art by: Joshua Choi

Giving birth takes an immense toll on a woman’s life. Not only does it require a significant amount of time to properly prepare for the baby, but it also takes a toll on her body. With all the check-up appointments, pre-birth classes, post-birth lactation consultations, and other such appointments, the mother-to-be must essentially put her life on hold for nine months in preparation for the day that the baby comes. After the stressful couple of months surrounding the newborn phase have passed, the extensive lengths that the mother had to go to prepare for the baby seem worth it. However, this picture-perfect reality is not the case for many Indigenous women in America. 

In Indigenous populations, there is evidence of higher maternal mortality and morbidity rates compared to other ethnic populations in the United States [1]. According to the Eunice Kennedy Shriver National Institute of Child Health and Human Development, maternal mortality refers to the death of a woman following complications of pregnancy or childbirth, and it spans the length of pregnancy up to six months postpartum [2]. Additionally, maternal morbidity refers to any short- or long-term health problems that result from a woman being pregnant or giving birth [2]. According to 2007-2016 CDC data, the pregnancy-related mortality ratio (the number of pregnancy-related deaths per 100,000 live births) was 12.7 in white women and 16.7 in the general population. Meanwhile, it was 29.7 in indigenous women [3]. This statistic is alarming for two main reasons. One, it shows that current maternal mortality and morbidity trends have persisted for many years. Two, the disproportionate nature of this rate is indicative of system-wide inequities. 

This trend is even more pronounced for rural Indigenous women, who suffer from maternal mortality and morbidity at even higher rates than non-rural Indigenous women. A 2020 study looking at maternal morbidity and mortality among Indigenous women compared with non-Hispanic White women found two important findings: the ​​incidence of maternal morbidity and mortality was greater among Indigenous women (2.0%) compared to White women (1.1%) and incidence was higher in rural Indigenous women (2.3%) compared to urban Indigenous women (1.8%) [1]. Rural Indigenous women, therefore, will be the focus of this piece. Despite the advancements that have been made in terms of technology in the medical field, it is clear there are still equity issues that must be addressed.

There are many possible reasons for this trend in rural Indigenous women. Some include poor social determinants of health that lead to pre-existing, chronic conditions complicating childbirth, low access to obstetric services and weak incentives for provider retention in rural areas, and a lack of insurance coverage. 

Social determinants of health, according to the World Health Organization, refer to the conditions in which people are born, grow up, live, work, and age and they influence one’s health and contribute to health inequities [4]. Access to healthcare, availability of healthy foods, and the ability to stay physically active are significant social determinants of health that can influence a woman’s health prior to pregnancy and childbirth. When these determinants are not ideal, conditions that complicate pregnancy and childbirth develop, including diabetes, infection, and hypertensive (high blood pressure) disorders [5]. Access to obstetric services is declining in rural areas and combined with the fact that Medicaid coverage deters some providers from working in rural areas, it is very difficult for rural Indigenous women to access quality healthcare [10]. This further complicates their pregnancy and childbirth, leading to adverse outcomes like maternal mortality and morbidity. 

As alluded to earlier, many rural Indigenous women are Medicaid beneficiaries. In fact, three-quarters of the women in the 2020 study had childbirth hospitalizations paid for by Medicaid [1]. This becomes an important fact when considering that Medicaid has strict insurance coverage periods for pregnant women. Specifically, it limits the covered period as the time from conception to 60 days postpartum, making long-term conditions that affect pregnancy and childbirth difficult to properly address. If a woman has been suffering from diabetes for many years, it is unlikely that targeting complications only nine months before birth will be effectively cared for. Beyond the issue of limited insurance coverage, continuous insurance remains an issue for rural Indigenous populations, who had the lowest prevalence of continuous insurance (62%) compared to urban Indigenous (68%), White rural (78%), and White urban (82%) populations [6]. 

In addition to insurance issues, another systemic issue that harms Indigenous women is the ineffective Indian Health Service (IHS) [6]. The IHS was created to fulfill a treaty made between U.S. tribes and the federal government by providing health care to Indigenous people who are enrolled members of federally recognized tribes. However, IHS’ lack of delivered quality healthcare, limitations on services, and participation in reproductive injustices, such as forced sterilization, call into question how reliable the service is in caring for Indigenous pregnant women [6]. 

Taken together, these barriers make pregnancy and childbirth disproportionately dangerous for many rural Indigenous women. Ensuring safe, equitable maternal care is not only a matter of health, but of dignity, reproductive justice, and the well-being of future generations in Indigenous communities.

References:

1. Kozhimannil, K. B., Interrante, J. D., Tofte, A. N., & Admon, L. K. (2020). Severe Maternal Morbidity and Mortality Among Indigenous Women in the United States. Obstetrics and Gynecology, 135(2), 294–300. https://doi.org/10.1097/AOG.0000000000003647

2. Eunice Kennedy Shriver National Institute of Child Health and Human Development. (2021). Maternal Morbidity and Mortality. https://www.nichd.nih.gov/health/topics/maternal-morbidity-mortality

3. Petersen E. E., Davis N. L., Goodman D. (2019). Racial/Ethnic Disparities in Pregnancy-Related Deaths— United States, 2007–2016. MMWR Morb Mortal Wkly Rep, 68:762–765. http://dx.doi.org/10.15585/mmwr.mm6835a3

4. World Health Organization. Social determinants of health.  https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1

5. National Council of Urban Indian Health. Maternal Health. https://ncuih.org/maternal-health/

6. Liddell, J. L., Interrante, J. D., Sheffield, E. C., Baker, H. A., Kozhimannil, K. B. (2024). Health Insurance Type and Access to the Indian Health Service Before, During, and After Childbirth Among American Indian and Alaska Native People in the United States. Women’s Health Issues, 34(6), 562-571. https://doi.org/10.1016/j.whi.2024.08.002