Indigenous women are more likely to experience complications from pregnancy and childbirth than non-Indigenous women, leading to higher rates of anxiety and depression within those communities. In this conversation, Jennifer Richards, Ph.D., assistant professor at the Center for Indigenous Health, Johns Hopkins Bloomberg School of Public Health, and Jennifer Crawford, Ph.D., clinical psychologist and assistant professor at the University of New Mexico Health Sciences Center, discuss the perspectives needed to provide maternal care for Indigenous peoples, and the importance of awareness of their cultural and spiritual practices.

Tom Haederle

Experts acknowledge that mental health has a strong correlation with maternal morbidity and mortality. Indigenous women are more likely to experience complications from pregnancy and childbirth, so higher rates of anxiety and depression are of special concern in this community. But it is a problem that care providers can recognize and address.

Tom Haederle

Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA communications. Different cultures have different traditions surrounding birth and motherhood. And providers may not be aware of their indigenous patients' cultural and spiritual practices. In this podcast hosted by the AHA's Julia Resnick, director of strategic initiatives, we hear from two experts about the role that culturally safe care can play in mitigating perinatal mental health conditions and other challenges that indigenous women face.

Julia Resnick

So, Dr. Crawford and Dr. Richards, thanks so much for being here. To kick things off, I'd like each of you to introduce yourself to our listeners. Can you tell us a bit about your personal professional background and what communities you and your organization serve? So, Dr. Richards, I'll start with you.

Jennifer Richards

Good morning. (First introduces herself in her native Navajo). So I'm Jennifer Richards, I'm an assistant professor at Johns Hopkins Bloomberg School for Public Health, The Center for Indigenous Health. What I said in my Navajo language is that I'm Salt Clan, which comes through my mother's line.

Jennifer Richards

My father is Oglala Lakota from Pine Ridge, South Dakota, and my maternal grandfather is Taos Pueblo from northern New Mexico. And I have worked at our center for almost 12 years now. And I'm a community based participatory researcher primarily focused on maternal and child health initiatives in the southwest, but primarily the Navajo Nation.

Julia Resnick

Wonderful. And Dr. Crawford?

Jennifer Crawford

I'm Jennifer Crawford, I'm a clinical psychologist and assistant professor in psychiatry and behavioral sciences here at the University of New Mexico School of Medicine and Health Sciences Center. We serve New Mexico here, with our hospital and our School of Medicine and a lot of other training programs and services. And happy to be with you this morning.

Julia Resnick

Happy to have you here and looking forward to getting into it. So let's start by talking about maternal mental health in indigenous communities. So what is the scope and prevalence of perinatal depression and anxiety among indigenous women, and how does that compare to other races and ethnicities? Dr. Richards, I can start with you on that one.

Jennifer Richards

Yeah. Thank you. There are over 575 federally recognized tribal nations in this country, and everyone is very different. So we have approximately 70% of our population is urban and the rest are living in rural areas, including their home tribal nations. So it is hard to kind of put a number on that. I will say, depending on the region, it is 3 to 4 times the rate of non-Hispanic white women for perinatal mood and anxiety disorder.

Jennifer Richards

And we know that that's already a problem throughout, regardless of race and ethnicity, that perinatal depression occurs in approximately 1 in 7 women, while perinatal anxiety ranges from 11 to 21%. And so, depending on where you're at, it could be much higher. In Arizona it's 4 to 7 times higher. So it just depends on what Indian Health Service area you're looking at

Jennifer Richards

and we have various throughout the country and what, urban area you're looking at. But regardless, it is much higher and we'll kind of get into why that is and how our mental health status might differ from other races and ethnicities.

Julia Resnick

Dr. Crawford, anything you want to add?

Jennifer Crawford

I think I'll just add that the data sort of lags the lived experience, I think, in this area. And so especially for indigenous women, the data I think it's safe to say doesn't capture the full extent of the problem. And I think when we look at international data on indigenous maternal mental health, the numbers are even bigger.

Jennifer Crawford

And so we would expect some of that to play out in the U.S., too, as the data catches up. I think there's been some strong efforts to try to improve that process, and there are some challenges to it that are likely to continue. And so I think we just can't always rest on just the data to understand what's going on in communities.

Julia Resnick

So thinking about those individual experiences that you see in your practice every day. What aspects of maternal mental health are you seeing that are unique or specific to Native American communities? Dr. Richards, we can start with you.

Jennifer Richards

The aspects that are very unique to native women are definitely lived experiences, and I agree, I think it's really hard to kind of capture that in the data. What we do know in the data is mortality, unfortunately. So maternal mortality, for example, in my state of Arizona is four times higher for native women than non-Hispanic white women.

Jennifer Richards

So that's one statistic that would kind of reflect. And we know that mental health is strongly correlated with maternal mortality. In terms of how we might differ, experiences of historical trauma is the first thing that we should talk about. There was a time in history when there was forced sterilization of native women, and even though that might be a long time ago to many, for many of our women, that is we're only 1 or 2 generations removed.

Jennifer Richards

And that is still a very traumatic experience for our families. Another one is rurality. A lot of our native women, especially the ones with some of the higher inequities, are living in very rural and remote tribal communities. Sometimes the transportation isn't there, the quality of the roads isn't there. And then, of course, we have some of the same factors as other women with childcare, you know, trouble having childcare to attend prenatal care appointments and postpartum appointments.

Jennifer Richards

We also have cultural barriers, language barriers, and we have a lot of protective factors as well. But off the top of my head, those are the three main areas.

Julia Resnick

Before we move on, can you talk about some of those protective factors?

Jennifer Richards

Yeah, yeah. So in my work I'm a researcher, I'm not a clinical provider. So I try to work upstream, ideally with young women before they become pregnant. So preconception health. But in doing all the work that I do, we also do home visiting. And it's really interesting when best practices or evidence based practice comes out and it's oftentimes things that we've been doing since time immemorial.

Jennifer Richards

For example, for a while there, the Back to Sleep campaign was going very strong. And in our tribal communities, you know, we already did that. We already did separate but proximal. We were doing cradle boards. Many tribal nations were doing the swings, which inherently were protective. We were also very big on breastfeeding. Culturally, we had always promoted breastfeeding.

Jennifer Richards

We also had a social structure net. So, you know, the whole coining of it takes a village. That's something that we've been doing for a very long time. And then even the role of the doula, which is the research that I'm focusing on right now, we've always had that role of a doula or women especially, who've helped other women during labor delivery and really the whole perinatal process.

Jennifer Richards

So those are just a few examples of some inherently protective practices that we've had embedded within our culture.

Julia Resnick

That's wonderful. And I want to pick up - I think there's a link there between the generational trauma and the cultural safety and how women engage with the health care system. So can you talk a little bit about what culturally safe care means, what it looks like when it's missing, and then what it looks like when it's present?

Jennifer Richards

Yeah. So I really like that the term cultural safety is really picking up lately. It's something that had really originated in - I believe it was, Australia, New Zealand and, you know, some of the among the nursing community in those areas. And we're starting to see it more, which is great. It differs from cultural competency. And I've I must say, I've never really cared for the term cultural competency, because as someone who's not from that community, you're never going to be, you know, checking a checklist that we're thereby competent now that we took this class.

Jennifer Richards

But cultural safety is a feasible goal to have. And what that means is it shifts the provider/patient experience to whether or not the patient determines if that clinical encounter is safe. And so that means it acknowledges the power imbalance that's there between the provider and the patient. It rejects the notion that health providers should focus on learning cultural customs, but rather seeking to just achieve better care by being aware of, you know, implicit bias, power imbalances, historical trauma, colonization, what all of that means on that environment between the patient and the provider.

Jennifer Richards

So it's really a shift in looking at the quality of care focusing on the patient's experience.

Julia Resnick

So for people who are less familiar with that concept, can you talk about, you know, what care would look like if it wasn't culturally safe versus like what culturally safe care looks and feels like?

Jennifer Richards

Yeah, well, one example is I come from the Navajo Nation and we're a tribe that has a lot of natural laws throughout the perinatal period. Some people would say taboos. I call them natural laws. One example is women don't tie knots and we have a reason for that. You know, there's a really big emphasis on thinking positively during that pregnancy period.

Jennifer Richards

The husband or the partner, he has a lot of things that he has to do, a lot of natural laws. There's not supposed to be any hunting. There's not supposed to be any talk of death. In fact, as a people, we're really careful in how we talk about that. So for a woman who's in pregnancy and she's Navajo or Dine, and she is going to a provider who might not know that, and they immediately start talking about, let's say, stillbirth or miscarriage.

Jennifer Richards

That can be really upsetting for a Navajo woman. And that's something that may be no fault of the provider. Maybe they didn't receive the training. They don't know that it's not polite or it's not proper. It's not traditionally appropriate to talk about that right off the bat. And there are ways to go around it. And I'd like to think that if they're working in a tribal clinic, they're going to receive that information.

Jennifer Richards

But that's just an example. Versus a culturally safe, environment is where the provider understands these natural laws. They don't have to understand why, they don't have to believe in them, but they have to be aware of them, and how that can be really upsetting for the patient. Appointment like that would be, you know, the women going in and the provider really taking the time to listen to them and to understand, you know, their traditional background, their beliefs and really working around those kind of boundaries, those cultural boundaries for the woman. In our tribal communities

Jennifer Richards

a lot of times we do view the doctors and the nurses as healers, and it's a really revered role. But I also think that when you come on to a tribal community, you're not from there, it's really important to take the role of a student and listen, and take the opportunity to really understand, you know, what are the concerns that they have?

Jennifer Richards

What is the background? What was forced sterilization? Why did it happen? You know, what was the boarding school and forced relocation? Why is this hesitancy there? Because on paper we just see, you know, x percent of Native women have a lack of prenatal care or lack of adherence to prenatal care. I think truly understanding why that is, is really important.

Jennifer Richards

I think also providers who work with large tribal populations can really leverage our community health workforce. We have community health representatives, we have doulas, we have home visitors, we have public health nurses. They're an amazing workforce that speak the language. They're from the community. They understand that, you know, you're not from here and it's okay to not know.

Jennifer Richards

And they're a huge source of information. So I would say for providers working in tribal communities or with a lot of women from tribal communities, to really take the time to, to learn and understand, it's a huge difference. It'll really help in creating a culturally safe environment.

Jennifer Crawford

Could I just chime in a little bit with that? I think it's such an important point to really drive home those sort of holding both things, the knowing and not knowing. So you should be informed and you should learn and you should do some of that work yourself and in your teams and in your systems and institutions, while also being very open and curious and making sure that when you're thinking about how you individually provide care and how care feels to be provided in your immediate clinic or in your hospital, how do you make sure that there's space for respecting indigenous patients agency, and respecting that the way that they make choices may not

Jennifer Crawford

fit the way you like to make choices in that system. Not assuming that you know so much that you can handle any given thing that comes your way, but really being open to asking and being curious and respectful for not just agency, but the power of someone's own way of looking at the world and their truth.

Julia Resnick

Dr. Crawford, I want to bring this up to the hospital perspective, because I know University of New Mexico works closely with their tribal populations, both in the urban and rural setting. So can you talk about what you're doing around perinatal mental health to provide more personalized, culturally safe care?

Jennifer Crawford

One thing I'll add first is that when we think about the maternal mortality and morbidity rates that Dr. Richards mentioned, the I just want to mention that one of the top contributors to pregnancy related death, especially among indigenous women, is mental health and substance use disorder. And so when we talk about what can hospitals do to help with those particular challenges, I think it's really important to remain oriented to cultural safety in terms of what are the strengths of the communities you serve already have, right?

Jennifer Crawford

Like not assuming that everybody needs a hospital or system to jump in with the correct or, or perfect ideas, but really that it's about, a commitment to long term relationship building and listening over time that helps build those programs. And so the University of New Mexico, we're really proud to have our Native American Health Service, which is a longstanding office here.

Jennifer Crawford

You know, the UNM hospital actually started out as an Indian health hospital. And when the School of Medicine identified that as its teaching hospital, there was a commitment to maintaining access to indigenous patients, both urban and rural, to be able to receive care there. And so that office does a lot of work in coordinating care to outpatient services and inpatient services at UNM and our, you know, outlying clinics and outreach clinics.

Jennifer Crawford

But also, more importantly, even than just the care coordination piece, which could be quite complicated. But I would say even more importantly, has a long term commitment to this sort of community liaison. New Mexico's has 23 sovereign nations within the state lines and the Native American Health Service goes out and just listens and asks, how can we help? And that has been really formative, I think, across our system over time in identifying processes, programs, initiatives, ways of making sure that we're meeting the needs of those communities as identified by those communities.

Jennifer Crawford

And certainly there's a lot of expertise and skill and knowledge that's held at the university. And also, I will say, University of New Mexico, we're...I think we're very lucky that a lot of that skill and knowledge actually comes from our own communities in New Mexico, people that stay here and serve their communities that they're from.

Jennifer Crawford

But that's not all of the knowledge, right? And so really going out into communities to ask and listen I think is really important. And something that I would encourage other hospital systems to consider: how might they build that commitment to a long term relationship that really is built around cultural safety, both knowing and not knowing and listening?

Julia Resnick

Absolutely. So I'm just going to wrap this up with a lightning round for each of you. If there's one key thing you want our listeners to take away, what would it be? Dr. Richards.

Jennifer Richards

I would say taking on the role of someone who's learning, a student, a lifelong learner, I think is critical. Also building trust. And people don't really talk about it. But I will say with a lot of the women that we work with when they trust in their provider, that's all the difference in the world. And that means different things for our tribal communities.

Jennifer Richards

It means showing up, you know to the tribal affairs, to the feast, to the you know community events, the game, showing that you're there, you're part of the community. I think that's really critical. But I think just listening to the stories, understanding where they're coming from, I think that will make a huge difference.

Jennifer Crawford

Yeah, I think that's such a great take home. And I think from, sort of a systems hospital perspective, I would really want people to consider the strengths and expertise that they may hold within their system, but really think creatively about how to find out how that body of expertise and service could be helpful to the communities that you serve, and be it sort of a willing helper.

Jennifer Crawford

But always listening first at the same time, right? So that knowing and not knowing at the same time. You don't have to be perfect at cultural safety. You just have to always be working on it. And I think being creative and considering your strengths, but also the strengths of the communities we serve is really important.

Julia Resnick

Yeah, I think listening and learning were really a key theme to this conversation. So Dr. Richards, Dr. Crawford, thank you so much for sharing your expertise with us. Thank you for the work that you do every day to support women in your communities. Really appreciate you being here with us.

Tom Haederle

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