Bienvenido, bienvenue, hello and welcome to the website, www.elementarymydearmd.com, and blog of the Elementary My Dear Humanities in Medicine Podcast Experience.

My name is Dr. Michelle K. Watson, my pronouns are she/her/hers/ela/ella/elle, and as your bold, unabashedly intrepid host, I am pleased to have you accompany me on this sublime audio journey where the belief is that equity in medicine can be both evolutionary and revolutionary.

Our mission in healthcare is to include and stay divine, every single time. 

I am thrilled to have you accompany me on this journey to educate, investigate, evaluate, and create an open think tank for solutions necessary for achieving healthcare equity for BIPOC populations around the world.

Native American Maternal-Fetal health in the United States fares no better than what was mentioned previously.

There is no surprise here, is it?

It is a grim statistic, and one that is often recounted: American women are more likely to die of childbirth or pregnancy-related causes than other women in the developed world.

As The Humanities in Medicine Podcast Experience stated previously:

The United States far outspends any other nation on health care, measured both in per capita spending and as a percentage of GDP. Despite this, the country has significantly worse healthcare outcomes when compared to peer nations. The United States is the only developed nation without a system of universal health care, with a large proportion of its population not carrying health insurance, a substantial factor in the country’s excess mortality.

A 2017 survey of the healthcare systems of 11 developed countries found the US healthcare system to be the most expensive and worst-performing in terms of health access, efficiency, and equity. 

And although recent investigations have drawn the attention of Congress and put a national spotlight on the issue – especially among African-American women – 

Native American mothers, infants, and children like Pompy and Sacajawea, are often left out of the conversation.

According to federal statistics, American Indian women are more than twice as likely to die from pregnancy-related causes than white women and lag behind only black women as those most at risk.

From 2011 through 2016, according to the Centers for Disease Control and Prevention, the ratio of pregnancy-related deaths among American Indian and Alaska Native women was:

30.4 deaths per 100,000 births, 

compared with 

13 deaths per 100,000 births for Caucasian women and 

42.4 deaths per 100,000 births for African American women.

In Arizona, maternal death rates are highest among Native American women: 70.8 deaths per 100,000 births.

Extremely concerning, isn’t it?

Overall, the U.S. maternal mortality rate jumped to 16.7 deaths per 100,000 births from 7.2 deaths per 100,000 births in 1987.

As many as 60% of these deaths are preventable. 

Nevertheless, about 700 women in America die each year due to complications of pregnancy – and for every death, there are many more women at risk.

The CDC defines a pregnancy-related death as the death of a woman while pregnant, or within one year after pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

For American Indian, or Native American women, hemorrhage and hypertensive disorders of pregnancy are among the biggest contributors to these deaths, according to the CDC. In addition, lack of access to proper health care due to rural, isolated  locations and transportation issues particularly affects American Indian and Alaska Native women.

A lack of access to specialized care for high-risk pregnancies is another problem. As a result, many Native American women may miss screenings, prenatal checkups and other appointments at which early problems might be identified. On average, expectant women should have 10 to 12 prenatal visits before delivery, but indigenous women are lucky to have half that many.

That makes it difficult to identify health problems like diabetes and hypertension and obesity, or a fetus that is not maturing well in the uterus. There’s a multitude of missed opportunities to screen for issues that could come up in pregnancy.

Congress and numerous state legislatures have taken steps recently to address these deaths.

In December 2018, then President Donald Trump signed the Preventing Maternal Deaths Act, authorizing the CDC to help support maternal mortality review committees established by states and tribes to collect more data about what’s happening and identify possible solutions. 

A first round of grant money was awarded in August to 25 states.

This past fall, legislation meant to specifically help women in rural America was introduced to expand federal telehealth programs to include birth and postnatal services and further identifying gaps in care. Pregnant women in rural districts often have to spend hours on the road and cross state lines to attend the necessary prenatal appointments. 

In April, the Arizona Governor signed legislation establishing an advisory committee to work with the state Department of Health Services to produce annual reports about maternal deaths and identify solutions. The committee is finalizing a report that includes:

• Recommendations for improving the timeliness of maternal death identification. 
• Establishing partnerships so that records are more quickly shared.
• Finding ways to partner with tribes and the Indian Health Service to better understand the underlying risks to Native mothers.

The March of Dimes, a nonprofit that works to improve the health of mothers and babies, is rolling out training on implicit bias to try to address the problem. The organization has mobile health units deployed to assist rural areas.

These expectant mothers should have the peace of mind that no matter where they choose to start a family, they will have access to the resources they need to bring healthy offspring into the world.

For my allied Health Care Professionals who are listening in:

Women play a major role in Native American communities, because many tribes are matrilineal. In a matrilineal nation, children belong to the mother’s clan, and women are the decision makers.

In fact, many Native American tribes believed that the women had more healing power and were able to soothe ill souls with their chants and connection to the spirit world. Medicine women gathered herbs to create healing medicines for those who fell sick within the tribe. Additionally, most Native American women were master craftsman who made beautiful blankets, baskets, pottery, and jewelry.

Women, therefore, are respected, influential, and often the most verbal in making health care and family decisions. When providing care to families in an agency or in the home, it is important for the health provider to include the family matriarch in the care and teaching. Gaining her approval and support for a care plan will aid in the family’s adherence to the plan.

If written consent is required, the planned procedure should be explained in detail and include all possible side effects, consequences, and implications. Historically, written agreements between Native Americans and agencies or individuals have been misused or obtained under a false pretense. This has led to distrust of such documents in the Native American community. To establish or maintain a trusting relationship, the nonnative health care provider should be patient and allow sufficient time for the family to consult with a tribal elder or matriarch before the written signature can be obtained. 

Native Americans value passive learning and photographic memory techniques, and to not actively engage the doctor with questions, instead choosing to listen intently.  It is imperative for the physician to give explicit, detailed treatment and plan of care instructions with a solid structure for follow up to this group of patients.

Children are highly valued in Native American families, and are raised in an atmosphere of permissiveness where physical punishment is rare. Children are allowed to explore the world and learn at their own pace, much like how Sacajawea raised her son, Pompy. Although safety is considered and children are protected from life-threatening situations, the child is free to choose a wide variety of behaviors and learn from their consequences rather than from parental direction. In addition, guilt is not a tool used in the education or discipline of Native American children. 

The healthcare professional should strive to offer guidance to children and families in a flexible fashion that allows for a culturally appropriate method of setting limits and providing learning opportunities. The judgment that the parents are inattentive and uncaring should not be made.

Effective practice strategies in the care of Native American women depend on the health care provider’s understanding of the concept of time within this culture. 

Generally, most tribes are “present oriented.” 

However, this definition does not focus on the linear concept of here and now but on personal and seasonal rhythms, making present time a more flexible concept. 

Childbearing is viewed as part of the life cycle and therefore rhythmic. The pregnant woman’s focus at this time will be on the pregnancy and not on other issues or events that follow the pregnancy, such as child rearing or contraception.

It is not unusual for Native American homes to be without a clock, even in this time of seemingly ubiquitous smartphones. Time is believed to be a continuum and relative to what needs to be accomplished. This belief has implications for appointment times, medication administration, and preparation of specialty diets for conditions such as diabetes. The Native American family may eat two meals one day and three or four meals the next. Therefore, if the client is instructed to take medications with meals, the health care provider must be aware of the potential consequences of such teaching.

Missing or being late for appointments may be addressed by examining the client’s orientation to time. Seeking to understand why the patient was late rather than admonishing her for tardiness can enhance the relationship between the health care provider and client. Making her feel guilty may result in the client’s avoidance of the situation and result in lack of needed health care. 

Avoid the use of guilt at all costs.

Native Americans do, however, practice preventive health care. Often, rituals involving sacred foods such as cornmeal or herbs may be performed to restore harmony or ward off evil. Prayer meetings, “sings,” and sweat lodges may be incorporated into urban health care practices for health promotion and disease prevention and emphasize the interrelatedness of spirituality and health care.

Among traditional Native Americans, the medicine man or woman continues to play an important role in health care. This traditional healer is viewed as wise in the ways of nature and the relationships between humans and the environment. Items such as feathers, cornmeal, grasses, rocks, or medicine bags may be used in healing rituals by the traditional healers. When these items are placed on the patient, at the bedside, or in a crib or isolette, every effort should be made to avoid disturbing them. 

Usually, conventional health care practices can be carried out in the presence of these traditional sacred objects. 

Medicine persons can be found in urban and rural settings throughout the United States and should be welcomed as spiritual and medicinal collaborators in health care. Traditional use of herbs is not necessarily contraindicated in the care of patients receiving other medications, but the compatibility and strength of all compounds should be investigated.

In other words, the physician should ideally have patients provide a listing of all medications, prescribed, over the counter, and herbal in advance of initial treatment contact.

Response to pain differs from culture to culture and within cultural groups. Native Americans are often viewed as stoic during labor or other painful procedures. This stoicism should not be confused with lack of pain. Native American clients should be assessed for the amount of pain they are experiencing and offered pain relief options even if they are not openly verbal or physical in their expression of pain. Traditional healers can be included in the health care of Native Americans.

Do no harm, my doctors.

Do no harm, my people.

All Humanities in Medicine Podcast Experience blog articles and podcast episodes illustrate the significance and virtues of the diversity, equity, and inclusion (DEI) concepts of cultural competence and cultural humility with an extensive healthcare literature review, and touches of world culture, humor and musicality.

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Custom-created and curated for an informed listener base.

For a more informed future.

Elementary my dear listeners.

I am Dr. Michelle K. Watson, innovator, producer, host, and creator of the Elementary My Dear Humanities in Medicine Podcast Experience. Join me on this audio revolution for a new episode every month on all major podcast hosting platforms. 

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I thank you for allowing me to be of service to you.

This is Dr. Michelle K. Watson, signing off, wishing all of you a safe and equitable life journey.

Until we meet again, for the next episode in this revolution.

Evolve safely. 

Be the change you want to see in the world.

Namaste.