Highlights in AI/AN Reproductive and Maternal and Child Health Formative Research
A History of Collaboration Between Tribes and the Centers for Disease Control and Prevention’s Division of Reproductive Health
Since 1989, the Centers for Disease Control and Prevention’s (CDC) Division of Reproductive Health (DRH) has provided technical assistance in the design, implementation, and analysis of Behavioral Risk Factor Surveillance System surveys on maternal and child health, and related population-based surveys to more than 30 tribes throughout the United States. Currently, the Navajo Behavioral Risk Factor Survey is being planned with Navajo Tribe and Navajo Epidemiology Center staff.
The survey topics include—
- Tobacco use.
- Alcohol use.
- Diet and weight.
- Physical activity.
- Cardiovascular health.
- Maternal and child health (MCH).
- Use of health services.
CDC’s DRH works with tribes to build survey capacity by—
- Developing questionnaires.
- Designing the sampling approach.
- Training interviewers.
- Developing data entry programs.
- Analyzing the collected information.
- Producing reports on survey findings.
Tribal community members administer the surveys. This work is not well known beyond tribal communities because data remain with participating tribes to use in health program planning. Honoring tribal data ownership has helped to establish and maintain a foundation of trust between CDC and tribes.
In 1992, CDC, the Indian Health Service (IHS), the National Institute of Child Health and Human Development, and the Aberdeen Area Tribal Chairmen’s Health Board began a multiyear collaboration to investigate high rates of infant mortality among American Indians (AI) in the Northern Plains, that include the states of Iowa, Nebraska, North Dakota, and South Dakota.
The Aberdeen Area Indian Health Service Infant Mortality Study: Design, Methodology and Implementation [PDF - 293KB], published in 2001 was a 4-year study of infant deaths in 10 of the 19 tribes in the Northern Plains, representing 66% of the area population.
- Results of the study were published in a 2002 article, "Risk Factors for Sudden Infant Death Syndrome (SIDS) Among Northern Plains’ Indians", and shows significant associations between SIDS and 2 or more layers of clothing on the infant, any visits by a public health nurse, maternal alcohol use just before and during early pregnancy, and maternal binge drinking the first 13 weeks of pregnancy.
- Another element of the research included examining cerebral tissue from 33 Northern Plains infants who died from SIDS. In 2003, findings were published in the article, "Serotonergic Brainstem Abnormalities in Northern Plains Indians with the Sudden Infant Death Syndrome". This study shows a correlation with developmental abnormalities and exposure to adverse prenatal exposures like cigarette smoking and alcohol just before and during early pregnancy.
A March 2010 news story in Indian Country Today Media Network shared the story of the return of the sacred remains of the 33 infants, who were included in this study, to tribal lands. The collaborative nature of the project, tribal involvement, and cultural respect with which the research was conducted, made this project possible.
Using Data to Advance Knowledge in Maternal and Child Health Among American Indians and Alaska Natives
One of four American Indian and Alaska Native (AI/AN) infants born annually in the United States is delivered in an IHS facility. Through collaboration between CDC and IHS, IHS administrative data were used to examine complications at delivery among women who gave birth in 5 IHS hospitals from 2002 through 2004, representing more than 30% of IHS’s annual deliveries. The study shows that the rate of hemorrhage after giving birth (postpartum) was 4 times higher, the rate of gestational diabetes was 3 times higher, and the rate of preeclampsia was 2 times higher among AI/AN women compared with all women in the general U.S. population. In 2007, the IHS Primary Care Provider published these study findings in the publication Maternal Morbidity During Delivery Hospitalizations in American Indian and Alaska Native Women [PDF - 6.06MB].
CDC sponsors the Pregnancy Risk Assessment Monitoring System (PRAMS), a joint CDC and state health department surveillance project, which gathers state-specific information about maternal behaviors and risk factors to gain a better understanding of mothers’ attitudes and experiences before, during, and shortly after pregnancy. From these data, AN patterns of cigarette smoking and smokeless tobacco use were analyzed. "Prenatal Cigarette Smoking and Smokeless Tobacco Use Among Alaska Native and White Women in Alaska, 1996–2003" [PDF - 320KB] was published in 2008 in the Maternal and Child Health Journal, in collaboration with Alaska PRAMS. This study shows that the prevalence of tobacco use decreased between 1996 and 2003, but remained higher among AN women, compared with white women, especially for smokeless tobacco. Subsequently, an article titled "Patterns of Cigarette and Smokeless Tobacco Use Before, During, and After Pregnancy Among Alaska Native and White Women in Alaska, 2000–2003" [PDF- 220KB] was published in 2009. The findings show that during 2000–2003, the prevalence of tobacco use was 2 to 3 times higher among AN women than among white women before, during, and after pregnancy. In addition, AN women had lower quit rates and higher relapse rates than white women.
To learn about chronic disease risk factors and conditions among nonpregnant AI/AN women, data were analyzed from the 2005 and 2007 Behavioral Risk Factor Surveillance System surveys. This analysis compared AI/AN and white women aged 18–44 years (women of reproductive age), and examines the prevalence of high cholesterol, high blood pressure, diabetes, overweight and obesity, physical inactivity, smoking, excessive alcohol consumption, frequent mental distress, and cumulative number of chronic conditions and risk factors. An article, "Chronic Disease Risk Factors Among American Indian/Alaska Native Women of Reproductive Age" [PDF - 633KB], was published in the journal Preventing Chronic Disease in 2011, and shows that 3 out of every 5 AI/AN women live with 3 or more chronic conditions or risk factors. Screening, treating, and referring women of reproductive age to broad-scope prevention programs may help avoid adverse pregnancy and long-term health outcomes for women and their future children.
Between 2010–2014, CDC has been working with 3 key partners to address the rates of chronic disease in AI/AN women. A project titled Native Women Wellness Initiative: Working Together to Improve Health Outcomes aims to address rates of chronic disease in AI/AN women of reproductive age by partnering with the University of Washington, Seattle Indian Health Board, and a Northern Plains tribe in South Dakota.
In this project, the prevalence of cardiovascular disease and related risk factors will be estimated among nonpregnant AI/AN women, aged 18–44 years, in 1 urban and 1 rural clinic health care setting. Additionally, at each clinic, a randomized controlled trial will be conducted with an intervention that provides incentives for women to stop smoking and lose weight. This is a 4-year project (2010–2014)—planning and protocol development began in fall 2010 and enrollment into the randomized controlled trial began in 2012. Findings from the project are expected to be released in 2015.
Geographic Variation in Trends and Characteristics of Teen Childbearing Among American Indians and Alaska Natives [PDF - 475KB], published in 2011, examines birth certificate data for females younger than 20 years of age in order to calculate AI/AN teen birth rates. This is the first national study to describe AI/AN teen birth rate trends by age and geographic region. Teen birth rates for AI/AN varied widely by region. Among AI/AN females aged 15–19 years, birth rates (live births per 1,000) ranged from 24.35 in California and Hawaii, to 123.24 in the Aberdeen region (Iowa, Nebraska, North Dakota, and South Dakota). The national birth rate for females aged 15–19 years is 34.2 (live births per 1,000).
Another example of research that has the ability to build Maternal and Child Health surveillance capacity and response in Indian Country is a recent joint CDC and IHS study that validates the use of IHS electronic health records to identify pregnant women. The IHS database code for pregnancy was used to identify, in near-real time, AI/AN women who were pregnant and at high risk of severe morbidity during the 2009–2010 H1N1 influenza pandemic. The study shows that electronic health records may prove beneficial for preparedness and surveillance during future epidemics and for targeting at-risk pregnant women and infants for interventions. The article "Validating an Algorithm for Identifying American Indian/Alaska Native Pregnant Women at Risk for Severe Illness from Pandemic H1N1 Influenza" (2011), is included in a supplemental issue of the American Journal of Obstetrics and Gynecology titled Emerging Issues in the Prevention, Detection, and Treatment of Influenza Among Pregnant Women in the United States.