Infant mortality among American Indian and Alaska native populations: successes and challenges

Children Today, March-April, 1990

One winter night in 1966, a young Eskimo woman started labor in her home village, 150 miles from the nearest Indian Health Service hospital. She gave birth to a healthy newborn, but the lay attendants were unable to successfully deliver the unexpected twin. After the mother was flown to the hospital-a risky evacuation in the winter-the twin was delivered stillborn. A few months later, the healthy firstborn died from Haemophilus influenzae type b meningitis. Many Indian Health Service health workers who served American Indian and Alaska Native communities 20 to 50 years ago can relate similar clinical anecdotes. Between 1964 and 1967, the infant mortality rate in one region in western Alaska was 104 per 1,000 live births. More than 60 percent of these deaths were due to infectious diseases.

Over the past 20 years there have been remarkable improvements in the health status of American Indian and Alaska Native mothers and infants, making experiences like the one related here now a rarity. Between 1966 and 1985, for example, infant mortality rates for the American Indian/Alaska Native Al/AN) population fell from 36.8 deaths for every 1,000 live births to 9.7 per 1,000 live births-the same as the infant mortality rate for all races in the U. S. (see Fig. 1).

Neonatal mortality (deaths occurring between birth and 28 days) in 1985 was 4.4 deaths per 1,000 live births. For the past 20 years, AL/AN neonatal mortality rates were consistently lower than the rates for all races in the U. S.

However, much of the reduction in infant mortality during this time can be attributed to a sharp decline in AL/AN postneonatal mortality (deaths occurring between 28 days to 11 months after birth). Over the 20-year period, the AI/AN postneonatal mortality rate decreased by 75 percent: from 20.7 per 1,000 live births in 1966 to 5.2 in 1985. Despite these gains, however, the Al/ AN postneonatality rate is still 1.4 times above the rate for all races in the U. S. (3.7 per 1,000 live births).

This achievement in postneonatal mortality followed vigorous efforts by the Indian Health Service (IHS) to improve sanitation in Indian and Native communities and to immunize infants and children against infectious diseases. As a result, death rates due to diarrhea are now lower than national rates, and the yearly immunization levels among Al/AN infants are consistently around 90 to 95 percent.

The improved health status of this population is primarily a tribute to the strength and involvement of the native peoples themselves. AI/AN mothers give birth to fewer premature and low birth weight babies. Low birth weight (2,500 grams, or about 5 1/2 pounds or less) is the leading cause of neonatal mortality. The overall low birth weight rate for the AI/AN population is 6.0 percent, in contrast to 6.8 percent for 211 races in the U. S.

The low birth weight rate is also considerably lower among AI/AN teenagers than for adolescents of all races in the U.S.-a group that tends to have a disproportionate number of low birth weight infants. For AL/AN adolescents, the low birth weight rate is 6.4 percent, compared to 9.4 percent for adolescents of all races in the U. S.

This relatively low birth weight rate may be attributed in part to the high value placed on children that is generally evident in Indian and Alaska Native families and communities. Pregnancy is valued as the potential addition of not only a new family member but also an addition to the community. The arrival of a new individual brings new strength to the community and assures preservation of tribal or community heritage. Community involvement in pregnancy ensures that there is support for the pregnant woman regardless of her status, that the birth is received with joy, and that the newborn is lovingly nurtured. Pregnancy in this supportive environment is a healthier experience and produces healthier babies.

Generally, native communities in Alaska have readily accepted the benefits of medical technology. For example, more than 95 percent of AI/AN mothers deliver their babies in a hospital setting.

In many communities, traditional healing concepts are combined with technical medical practices. In one region in Alaska, a highly respected Native Healer, in cooperation with IHS physicians and at the request of parents, examined and helped care for hospitalized children. The healer also advised pregnant women on traditional attitudes toward pregnancy and prenatal care.

In other areas, the use of traditional herbs and nutritional practices during pregnancy are encouraged, so long as they are not in conflict with medically proven principles of prenatal care, and IHS professionals encourage traditional mother-infant bonding practices. Through such practices, Indian and Native communities are able to maintain the meaningful values from their heritage, and IHS health professionals respect those values. The IHS Health Care System

Several unique features of the IHS health care system enhance the delivery of maternal and child health services to Indian and Native families in Alaska. First, although health care delivery varies considerably from region to region in the IHS, there are nationally consistent standards, an overall organizational similarity, and centralized policy direction. Established policy is based on recommendations and standards set by nationally recognized organizations and professional groups (including the Joint Commission on Accreditation of Health Organizations, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics). In every IHS area office and service unit, standardized procedures are established for risk assessment and referrals to secondary and tertiary care facilities. In addition, essentially every family knows where this care can be obtained.