Authors: Rhea Manohar MPH MS2, Meghan Etsey MS3, Sharon Griswold MD MPH on behalf of the Gender Equity Task Force

Maternal mortality remains a significant public health crisis in the United States. The US has the highest Pregnancy-Related Mortality Ratios (PRMR) among developed nations (CDC, 2023; Melillo, 2020). The U.S. maternal mortality rate was 23.8 deaths per 100,000 live births in 2020, with even higher rates for marginalized communities, such as American Indian/Alaska Native (AI/AN), Black and African American, Hispanic (CDC, 2023). This is considerably higher than the WHO’s estimate of 10 deaths per 100,000 live births in high-income countries. The WHO reports 346 deaths per 100,000 live births in low-income countries (World Health Organization, 2025). AI/AN women experience maternal mortality rates that are two to three times higher than non-Hispanic White women due to systemic healthcare inequities, implicit biases, and socioeconomic barriers (Singh, 2020).

Many AI/AN women live in rural or remote areas where hospitals and maternal healthcare facilities are scarce, leading to limited access to prenatal and emergency obstetric care (Heck et al., 2020). Studies indicate that even when AI/AN women seek medical assistance, they frequently encounter racial discrimination and dismissive treatment from healthcare providers, which can result in delayed diagnoses and inadequate care (Heck et al., 2020). Additionally, historical trauma and mistrust of medical institutions, stemming from past injustices such as forced sterilizations, contribute to hesitancy in seeking maternal healthcare services (Thorsen et al., 2022). These factors collectively exacerbate maternal health disparities and increase the likelihood of preventable pregnancy-related deaths.

The loss of a mother has profound emotional, social, and economic effects on families and communities.  The psychological toll on families is immense, as traditional family and community support structures are disrupted, further perpetuating cycles of trauma and poor health outcomes.Children of mothers who die during childbirth are at greater risk for poor health, economic instability, and adverse developmental outcomes (Kozhimannil et al., 2020). AI/AN communities, already experiencing disproportionate health and economic burdens, suffer long-term consequences when maternal mortality rates remain high.

The causes of maternal mortality are complex and often preventable. Leading medical causes include severe hemorrhage, hypertensive disorders, infections, thrombotic embolisms, and cardiomyopathy (Tikkanen et al., 2020). Hemorrhage and hypertension-related complications account for nearly 50% of all pregnancy-related deaths, yet many of these fatalities could be avoided with timely intervention (CDC, 2023). However, non-medical factors significantly contribute to disparities in maternal outcomes.

AI/AN women often receive inadequate prenatal care due to geographic isolation, economic constraints, and healthcare provider shortages (Zuckerwise et al., 2017). Additionally, a lack of culturally appropriate healthcare services results in delayed diagnoses and insufficient treatment, worsening maternal health outcomes (Thorsen et al., 2022). Chronic conditions such as obesity, hypertension, and diabetes are highly prevalent in AI/AN populations due to historical and structural inequities. These comorbidities can exacerbate pregnancy risks (Singh, 2020).

Racial and ethnic disparities in maternal mortality are driven by multiple interrelated factors:

  • Limited Access to Care: AI/AN women are more likely to live in rural areas with fewer healthcare facilities, leading to delays in receiving prenatal and emergency obstetric care (Thorsen et al., 2022).
  • Implicit Bias in Healthcare: Research shows that AI/AN women frequently experience racial bias in medical settings, leading to inadequate pain management and dismissal of symptoms (Sebens & Williams, 2022)
  • Socioeconomic Barriers: Higher poverty rates, food insecurity, and unstable housing contribute to poor maternal health outcomes (Sebens & Williams, 2022; Thorsen et al., 2022).
  • Higher Rates of Chronic Conditions: AI/AN women experience higher rates of hypertension, diabetes, and obesity, increasing the risk of pregnancy-related complications (Singh, 2020).
  • Mental Health and Substance Use Disorders: The impact of historical trauma and limited access to mental health services elevate risks for postpartum depression and substance use-related maternal deaths (Thorsen et al., 2022).
  • Deficiencies in Health Education: Lack of culturally relevant maternal health education reduces awareness of risk factors and available healthcare services (Wagner et al., 2020).

Addressing maternal mortality disparities requires systemic changes that prioritize equitable access to care, culturally competent medical practices, and robust community-based support systems. Policymakers must work to expand Medicaid coverage for maternal healthcare, including postpartum care beyond the standard six-week period, to ensure continuous medical support (Till et al., 2015). Increased funding for Indian Health Services (IHS) and tribal healthcare programs can improve access to quality obstetric care and preventive health services for AI/AN women (Trost et al., 2022). Additionally, implementing community-based doula and midwifery programs can help bridge gaps in culturally appropriate care, reducing medical interventions and improving maternal outcomes (Thorsen et al., 2022). Expanding telehealth services and mobile clinics in rural AI/AN communities can also enhance access to prenatal and postpartum care, reducing transportation-related barriers (Singh, 2020).

Healthcare providers must receive training to recognize and address implicit biases that contribute to disparities in maternal healthcare (Till et al., 2015). Additionally, healthcare providers can help bridge the gap by focusing on maternal health literacy and education throughout the care experience from prenatal to delivery to postpartum (Wagner et al., 2020).

Equity in maternal healthcare requires a patient-centered approach that respects the cultural and historical experiences of marginalized populations. Integrating traditional AI/AN birthing practices within medical settings, improving patient-provider communication, and fostering trust through increased AI/AN representation in the medical workforce are crucial steps toward reducing maternal mortality disparities (Hughson et al., 2018).

Expanding community-driven initiatives is essential in reducing maternal mortality disparities. AI/AN-led health programs that incorporate traditional knowledge and holistic maternal care approaches can improve outcomes by fostering culturally safe environments for expectant mothers. Strengthening partnerships between tribal governments, public health agencies, and nonprofit organizations can ensure long-term support for maternal health initiatives. Furthermore, increasing funding for maternal health research focused on AI/AN populations can provide valuable data to inform future policies and healthcare strategies tailored to their specific needs.

Maternal mortality among AI/AN and other marginalized communities is a preventable crisis rooted in systemic inequities. Addressing this issue requires a comprehensive approach, including healthcare system reforms, expanded access to culturally competent care, and targeted community interventions. By prioritizing equity in maternal health, policymakers, healthcare providers, and community leaders can work together to improve outcomes and reduce the long-term burden of maternal mortality in underserved populations.While this crisis is particularly urgent among AI/AN communities, it’s important to recognize that Black women also face disproportionately high maternal mortality rates, underscoring the broader need for systemic change across all marginalized groups.

References:

  1. Centers for Disease Control and Prevention. (2023, March 16). Maternal mortality rates in the United States, 2021. https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-2021.htm 
  2. Heck, J. L., Jones, E. J., Bohn, D., McCage, S., Parker, J. G., Parker, M., Pierce, S. L., & Campbell, J. (2020, November 18). Maternal mortality among American Indian/alaska native women: A scoping review. Journal of women’s health. https://pubmed.ncbi.nlm.nih.gov/33211616/ 
  3. Hughson, J.-A., Marshall, F., Daly, J. O., Woodward-Kron , R., Hajek, J., & Story, D. (2018, February). Health professionals’ views on health literacy issues for culturally and linguistically diverse women in maternity care: Barriers, enablers and the need for an integrated approach. Australian health review: a publication of the Australian Hospital Association. https://pubmed.ncbi.nlm.nih.gov/29081348/ 
  4. Kozhimannil, K. B. (2020a, May 18). Indigenous maternal health—a crisis demanding attention. JAMA Network. https://jamanetwork.com/journals/jama-health-forum/fullarticle/2766339
  5. Melillo, G. (2020, December 3). US ranks worst in maternal care, mortality compared with 10 other developed nations. AJMC. https://www.ajmc.com/view/us-ranks-worst-in-maternal-care-mortality-compared-with-10-other-developed-nations 
  6. Sebens, Z., & Williams, A. D. (2022, February 14). Disparities in early prenatal care and barriers to access among American Indian and White Women in North Dakota. The Journal of rural health: official journal of the American Rural Health Association and the National Rural Health Care Association. https://pubmed.ncbi.nlm.nih.gov/35165911/ 
  7. Thorsen, M. L., Harris, S., McGarvey, R., Palacios, J., & Thorsen, A. (2022, January). Evaluating disparities in access to obstetric services for American Indian women across Montana. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. https://pubmed.ncbi.nlm.nih.gov/33754411/ 
  8. Till, S. R., Everetts, D., & Haas, D. M. (2015, December 15). Incentives for increasing prenatal care use by women in order to improve maternal and neonatal outcomes. The Cochrane database of systematic reviews. Retrieved November 7, 2022, from https://pubmed.ncbi.nlm.nih.gov/26671418/ 
  9. Tikkanen, R., Gunja, M. Z., FitzGerald, M., & Zephyrin, L. (2020, November 18). Maternal mortality and maternity care in the United States compared to 10 other developed countries. Commonwealth Fund. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries 
  10. Trost, S., Beauregard, J., Chandra, G., Njie, F., Harvey, A., Berry, J., & Goodman, D. A. (2022, September 19). Pregnancy-related deaths among American Indian or Alaska native persons: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019. Centers for Disease Control and Prevention. https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/data-mmrc-aian.html 
  11. Wagner, T., Stark, M., & Milenkov, A. R. (2020, February 11). What about mom? Health Literacy and maternal mortality. Journal of consumer health on the Internet. https://pubmed.ncbi.nlm.nih.gov/33402879/ 
  12. World Health Organization. (2025, April 7). Maternal mortality. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality 
  13. Zuckerwise, L. C., & Lipkind, H. S. (2017, April 14). Maternal early warning systems-towards reducing preventable maternal mortality and severe maternal morbidity through improved clinical surveillance and responsiveness. Seminars in Perinatology. https://www.sciencedirect.com/science/article/pii/S0146000517300186 

About the Authors

Rhea Manohar, MS2
Rhea Manohar is a second year medical student from St. George’s University. She has a Masters in Public Health with a concentration in Maternal and Child Health from George Washington University Milken Institute of Public Health and a Bachelors of Science in Microbiology, Immunology, and Public Health from the University of Miami. She served as Co-VP of OB/GYN Education for St. George’s University’s Women in Medicine chapter in St. George, Grenada where she developed and implemented hands-on workshops to further reproductive health issues and bolstered medical students abilities to navigate physician-patient communication. Prior to medical school, she was a Research Associate for Fors Marsh Group, where she led qualitative and quantitative public health research and campaign development for federal agencies (e.g., CDC, NIH, DHHS, CPSC). She is also a member of the Gender Equity Task Force and Reproductive Health Coalition within the American Medical Women’s Association. When she is not pursuing medicine, you can find her reading, exploring artistic passions, and spending time connecting with friends and family.

Meghan Etsey, MS3
Meghan is a third year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world.

Sharon Griswold, MD, MPH

 

 

 

Formatting, publication management, and editorial support for the AMWA GETF Blog by Vaishnavi J. Patel