Race and Place Matter: Inequity in Prenatal Care for Reservation-Dwelling American Indian People.

Early initiation and consistent use of prenatal care is linked with improved health outcomes. American Indian birthing people have higher rates of inadequate prenatal care (IPNC), but limited research has examined IPNC among people living on American Indian reservations. The current study uses birth certificate data from the state of Montana (n = 57,006) to examine predictors of IPNC. Data on the community context is integrated to examine the role of community health in mediating the associations between reservation status and IPNC. Results suggest that reservation-dwelling birthers are more likely to have IPNC, an association partially mediated by community health. Odds of IPNC are higher for reservation-dwelling American Indian people compared to reservation-dwelling White birthers, highlighting intersecting inequalities of race and place.

The Effect of an Oxytocin Decision Support Checklist on Oxytocin Use and Maternal and Neonatal Outcomes: A Retrospective Cohort Study.

OBJECTIVE: To assess the association between use of an oxytocin decision support checklist with oxytocin usage and clinical outcomes. STUDY DESIGN: We conducted a retrospective cohort study of patients with singleton gestations at 370/7 weeks or greater who received oxytocin during labor from October 2012 to February 2017 at an integrated community health care system during three exposure periods: (1) pre-checklist; (2) after paper checklist implementation; and (3) after checklist integration into the electronic medical record (EMR). The checklist was a clinical decision support tool to standardize the dosing and management of oxytocin. Thus, our primary outcomes included oxytocin infusion rates and cumulative dose. Secondary outcomes included maternal and neonatal outcomes. We controlled for maternal risk factors with multivariable regression analysis and stratified by mode of delivery. RESULTS: A total of 34,269 deliveries were included. Unadjusted analyses showed that compared with pre-checklist, deliveries during the paper and EMR-integrated periods had a lower cumulative dose (4,670 ± 6,174 vs. 4,318 ± 5,719 and 4,286 ± 5,579 mU, p < 0.001 for both), lower maximal infusion rate (9.9 ± 6.8 vs. 8.7 ± 5.8 and 8.4 ± 5.6 mU/min, p < 0.001 for both), and longer duration of oxytocin use (576 ± 442 vs. 609 ± 476 and 627 ± 488 minutes, p < 0.001 and p = 0.01, respectively). The unadjusted rates of cesarean, 5-minute Apgar <7, mechanical ventilation, and neonatal hospital length of stay were similar between periods. The adjusted mean difference in time from admission to delivery was longer during the EMR-integrated period compared with pre-checklist (3.0 [95% confidence interval: 2.7-3.3] hours, p < 0.001). CONCLUSION: Oxytocin checklist use was associated with decreased oxytocin use patterns at the expense of longer labor times. Findings were more pronounced with EMR integration. KEY POINTS: · An oxytocin decision support checklist is associated with reduced amounts of oxytocin used.. · However, checklists were associated with longer duration of oxytocin use and of labor.. · Results were more pronounced in the EMR-integrated checklist compared with paper checklist..

American Indians travel great distances for obstetrical care: Examining rural and racial disparities.

Rural, American Indian/Alaska Native (AI/AN) people, a population at elevated risk for complex pregnancies, have limited access to risk-appropriate obstetric care. Obstetrical bypassing, seeking care at a non-local obstetric unit, is an important feature of perinatal regionalization that can alleviate some challenges faced by this rural population, at the cost of increased travel to give birth. Data from five years (2014-2018) of birth certificates from Montana, along with the 2018 annual survey of the American Hospital Association (AHA) were used in logistic regression models to identify predictors of bypassing, with ordinary least squares regression models used to predict factors associated with the distance (in miles) birthing people drove beyond their local obstetric unit to give birth. Logit analyses focused on hospital-based births to Montana residents delivered during this time period (n = 54,146 births). Distance analyses focused on births to individuals who bypassed their local obstetric unit to deliver (n = 5,991 births). Individual-level predictors included maternal sociodemographic characteristics, location, perinatal health characteristics, and health care utilization. Facility-related measures included level of obstetric care of the closest and delivery hospitals, and distance to the closest hospital-based obstetric unit. Findings suggest that birthing people living in rural areas and on American Indian reservations were more likely to bypass to give birth, with bypassing likelihood depending on health risk, insurance, and rurality. AI/AN and reservation-dwelling birthing people traveled significantly farther when bypassing. Findings highlight that distance traveled was even farther for AI/AN people facing pregnancy health risks (23.8 miles farther than White people with pregnancy risks) or when delivering at facilities offering complex care (14-44 miles farther than White people). While bypassing may connect rural birthing people to more risk-appropriate care, rural and racial inequities in access persist, with rural, reservation-dwelling AI/AN birthing people experiencing greater likelihood of bypassing and traveling greater distances when bypassing.

Evaluating disparities in access to obstetric services for American Indian women across Montana.

PURPOSE: Pregnant women across the rural United States have increasingly limited access to obstetric care, especially specialty care for high-risk women and infants. Limited research focuses on access for rural American Indian/Alaskan Native (AIAN) women, a population warranting attention given persistent inequalities in birth outcomes. METHODS: Using Montana birth certificate data (2014-2018), we examined variation in travel time to give birth and access to different levels of obstetric care (i.e., the proportion of individuals living within 1- and 2-h drives to facilities), by rurality (Rural-Urban Continuum Code) and race (White and AIAN people). FINDINGS: Results point to limited obstetric care access in remote rural areas in Montana, especially higher-level specialty care, compared to urban or urban-adjacent rural areas. AIAN women traveled significantly farther than White women to access care (24.2 min farther on average), even compared to White women from similarly rural areas (5-13 min farther, after controlling for sociodemographic characteristics, risk factors, and health care utilization). AIAN women were 20 times more likely to give birth at a hospital without obstetric services and had less access to complex obstetric care. Poor access was particularly pronounced among reservation-dwelling AIAN women. CONCLUSIONS: It is imperative to consider racial disparities and health inequities underlying poor access to obstetric services across rural America. Current federal policies aim to reduce maternity care professional shortages. Our findings suggest that racial disparities in access to complex obstetric care will persist in Montana unless facility-level infrastructure is also expanded to reach areas serving AIAN women.

Storytelling: A Qualitative Tool to Promote Health Among Vulnerable Populations.

Storytelling is a basic cultural phenomenon that has recently been recognized as a valuable method for collecting research data and developing multidisciplinary interventions. The purpose of this article is to present a collection of nursing scholarship wherein the concept of storytelling, underpinned by cultural phenomena, is explored for data collection and intervention. A conceptual analysis of storytelling reveals key variables. Following a brief review of current research focused on storytelling used within health care, three case studies among three vulnerable populations (American Indian teen mothers, American Indian cancer survivors, and African American women at risk for HIV/AIDS) demonstrate the uses of storytelling for data collection and intervention. Implications for transcultural nursing regarding storytelling are discussed.

Blood politics, ethnic identity, and racial misclassification among American Indians and Alaska Natives.

Misclassification of race in medical and mortality records has long been documented as an issue in American Indian/Alaska Native data. Yet, little has been shared in a cohesive narrative which outlines why misclassification of American Indian/Alaska Native identity occurs. The purpose of this paper is to provide a summary of the current state of the science in racial misclassification among American Indians and Alaska Natives. We also provide a historical context on the importance of this problem and describe the ongoing political processes that both affect racial misclassification and contribute to the context of American Indian and Alaska Native identity.

Weaving dreamcatchers: mothering among American Indian women who were teen mothers.

AIMS: The aim of this study was to explore the mothering experience and practice among reservation-based adult American Indian women who had been adolescent mothers. BACKGROUND: Adolescent American Indian women are at an elevated risk for teen pregnancy and poor maternal/child outcomes. Identifying mothering practices among this population may help guide intervention development that will improve health outcomes. DESIGN: A collaborative orientation to community-based participatory research approach. METHODS: Employing interpretive phenomenology, 30 adult American Indian women who resided on a Northwestern reservation were recruited. In-depth, face-to-face and telephone interviews were conducted between 2007-2008. FINDINGS: Women shared their mothering experience and practice, which encompassed a lifespan perspective grounded in their American Indian cultural tradition. Four themes were identified as follows: mother hen, interrupted mothering and second chances, breaking cycles and mothering a community. Mothering originated in childhood, extended across their lifespan and moved beyond mothering their biological offspring. CONCLUSION: These findings challenge the Western construct of mothering and charge nurses to seek culturally sensitive interventions that reinforce positive mothering practices and identify when additional mothering support is needed across a woman's lifespan.

Embodied meanings of early childbearing among American Indian women: a turning point.

INTRODUCTION: American Indian women often have poor perinatal outcomes and are at risk for early childbearing. The purpose of this qualitative study was to understand the experience and meaning of early childbearing among American Indian women. METHODS: Employing interpretive phenomenology and a semistructured interview guide, we interviewed 30 adult American Indian women residing in a northwestern American Indian reservation about their experiences and meaning of early childbearing. RESULTS: Three overarching themes were tied to their eventual positive evaluation of the experience: 1) mourning a lost childhood, 2) seeking fulfillment, and 3) embodying responsibility. DISCUSSION: Women indicated that despite their tumultuous childhoods, early childbearing presented an opportunity to effect positive change in their lives. Women's health care providers are positioned to help women change their lives, thereby, improving health outcomes.

Reflections of Native American teen mothers.

OBJECTIVE: To understand the previously lived experience of early childbearing among adult Native American women. DESIGN: A community-based participatory research approach. SETTING: The first interview took place at a mutually agreed-upon time and place and averaged 120 minutes. Second interviews were conducted 1 to 3 months later. PARTICIPANTS: A convenience sample of 30 self-identified Native American adult women was recruited, and a semistructured interview explored their early childbearing experiences. METHOD: An interpretive phenomenological study was conducted with a Northwestern tribe. RESULTS: All of the women in the study described stressful childhoods. Two primary themes were identified: Chaotic childhoods represented stressful events in youth that introduced or resulted in ongoing chaos in women's lives and diminished childhoods described early maturity as a result of assuming extensive responsibilities at a young age. CONCLUSIONS: The findings suggest that the childhood experiences described by participants may be related to the risk for early childbearing. Prospective research should examine the relationship between young women's lives and early childbearing to design interventions to support them in postponing pregnancy and when they do become pregnant.

Understanding Native women's health: historical legacies.

PURPOSE: Theoretical underpinnings of two theories are examined for their applicability in guiding practice and research when understanding Native American women's health outcomes. METHOD: Published studies testing two independent theories, historical trauma and weathering, are reviewed. Key theoretical concepts that are applicable in the study of Native women and understanding their intergenerational heritage of injustice and cultural context are discussed. RESULTS: The authors infer underlying assumptions and definitions of both theories and present a hypothetical diagram blending both theories. CONCLUSION: By understanding historical legacies and the surrounding context, researchers and clinicians can develop knowledge to improve and enhance optimal health outcomes and life opportunities for Native women.