Mental health is the No. 1 reason Native mothers die after giving birth, according to a new report on maternal mortality released earlier this year by the Centers for Disease Control and Prevention (CDC).
Deaths from mental health account for 35% of the maternal mortality in Native communities — and 95% of those deaths are preventable.
Abra Nungasuk Patkotak (Iñupiaq) is the co-director of Alaska Native Birthworkers Community (ANBC) and a committee member of the Maternal Child Death Review in the state of Alaska, where Native people make up around 20% of the population but account for 50% of maternal deaths. Patkotak told Native News Online that barriers to accessing care compound mental health issues that can lead to death, like postpartum depression, anxiety, depressive and bipolar disorders, suicide, and substance use disorders.
“It means that we have a huge issue with the systems, and that there’s a great lack of access to care for Indigenous families in the United States, and that we need to do better,” Patkotak said. “We’re letting people down.”
The United States has a shockingly poor record on maternal health. In 2023, as maternal deaths were dropping worldwide, the U.S. was one of seven countries to report a significant rise in maternal mortality. Communities of color are the most affected, with Native American families and Black families seeing the most deaths.
“I’m not too surprised at the rates we have,” Patkotak said. “There’s a lack of support for pregnant people in the United States right now.”
The typical stressors of pregnancy and a new baby are exacerbated in Native communities by a number of factors.
The CDC report analyzed data from vital, medical and social service records collected in 2022 by maternal mortality review committees in 45 states. Lack of access and inconsistent care were the main drivers behind the deaths for Native families. Discrimination was a factor in 20% of cases.
While Alaska is unique in the extreme geographic isolation of its Native villages, many of which are completely cut off from road systems, the same story echoes across Indian Country. Patkotak has heard providers claim that Native families don’t want to go to their perinatal appointments. The issue, she says, is deeper than that.
“We need improved access to care, and we need to remove that burden from the family,” Patkotak said. “We also need to look at why. So, if people aren’t accessing care, why is that? Let’s look at that. Let’s understand why people aren’t going to their appointments, because there’s got to be a reason there.”
Native people have been subject to a medical system that abused them for generations. The Indian Health Service (IHS), the federal agency that provides health care to Indian Country, sterilized tens of thousands of Native women without their free, prior and informed consent from 1907 to at least 2018, a dark legacy that casts a long shadow across maternal care.
Tess Abrahamson-Richards is a citizen of the Spokane Tribe and the director of data sovereignty at Hummingbird Indigenous Family Resources, a Washington-based nonprofit that supports Native families in childbirth.
“It’s not that we are inherently mistrustful,” Abrahamson-Richards told Native News Online. “It’s that these systems are not trustworthy and have and continue to be harmful in so many ways. Communities are really well aware that the sterilization era was not that long ago. There are women in our families who are still alive today who have had their own experiences sometimes of medical racism.”
Coupled with the lack of financial and policy investment in women’s health care, the result is a massive system gap through which Native families fall.
“There is a lack of investment at a structural level in women’s health care — a total divestment of resources in the Indian Health Service towards maternal health,” Abrahamson-Richards said.
The IHS system includes 45 hospitals and more than 300 health clinics across Indian Country. Only 13 of those have birthing centers. About 90% of Native families give birth at non-IHS facilities.
Patkotak and Abrahamson-Richards both say preventing maternal deaths in Native communities lies in policies that support families pre- and post-birth — the U.S. is one of just seven countries worldwide that have federally mandated paid maternity leave — and bringing Native birthworkers into the health care system.
“We need a systems overhaul,” Patkotak said. “We need more midwives. We need more birth workers. We need more birth helpers. We need parental leave.”
ANBC operates on what it calls a “Three Sisters Model,” designed to create both systemic and immediate change. The First Sister offers support before, during and after birth. The Second Sister trains birth helpers to serve Native families. The Third Sister focuses on policy to improve outcomes and experiences for Native mothers and babies. The group works with the Alaska Native Medical Center, where around 800 Native families give birth each year.
Along with supporting families through the birthing process with doulas, they support families post-birth. That might look like providing food if a family is struggling with groceries and connecting them to resources to soothe the symptoms of postpartum depression.
Patkotak teaches childhood preparation retreats for ANBC to help families anticipate all of the short- and long-term changes that come with a new baby, including signs of postpartum depression, which affects one in eight new mothers, and postpartum psychosis, a rare but potentially fatal psychiatric emergency. Both conditions are treatable but often go undiagnosed.
Patkotak’s goal is to destigmatize the conditions and encourage families to ask for help and tap into their support networks as soon as they feel like they are struggling. While postpartum psychosis is typically seen within days to months of giving birth, postpartum depression can last for years if left untreated.
“Postpartum is forever,” Patkotak said. “When you become a parent, when you’ve given birth to a baby, it changes your body, and it changes your brain, and it changes your hormones. We really try to destigmatize that. Like, if you have a 4-year-old, you might still need help, and that is OK.”
In Washington state, where Native people experienced the highest rate of poverty of any demographic, Hummingbird Indigenous Family Resources is in the final stages of a universal basic income pilot program that provides $1,250 to 150 Native families for the first three years of their child’s life, with no strings attached. The funds have eased the financial burden of new babies.
Abrahamson-Richards pointed out that many Native families are conditioned to not ask for help, especially when a parent is struggling with substance abuse disorder.
“There’s a lot of serious stigma around that and fear of child welfare involvement, and very well-founded fears because child removal happens a lot,” she said.
The Seattle Indian Health Board recently opened the Thunderbird Treatment Center, where mothers seeking treatment for mental health conditions and substance abuse disorder can bring their children up to age 5 with them.
“It’s a holistic, multigenerational approach. It’s the future of what we would dream of for better care for people experiencing more severe forms of struggles during this time period,” Abrahamson-Richards said.
The solutions to the maternal care crisis in Indian Country are plenty, and Native people are leading the way with innovative approaches that fit the specific trauma Native Americans have been subject to for centuries. Those who hold the purse strings — Congress, philanthropists and even tribal leadership — just need to catch up.
“I like to always point out that like people are already building these things, and that’s what I would look to leadership to really resource those things,” Abrahamson-Richards said. “If I had an endless budget, I would be investing in and learning from the people who’ve been building that and sustaining these solutions throughout time.”
If you or someone you know is struggling, please reach out to Postpartum Support International at https://postpartum.net, or call 1-800-944-4773.
