When the Data Gets It Wrong: Racial Misclassification of American Indian and Alaska Native Pregnant and Postpartum People

Authors: Navneet Kaur and Nahla Holland

A citizen of a Tribal Nation goes to their primary care provider. During the clinic visit the nurse assumes the patient’s race and ethnicity as Black and records that in their chart. The same patient goes to a specialist, they select both ‘Black’ and ‘American Indian or Alaska Native’ when filling out their paperwork. However, the specialists’ electronic health record (EHR) changes the patient’s race to a non-specific ‘multiracial’ category, hiding the patients’ selected race/ethnicity.

	Self Identification	Identified at Primary Care Provider	Identified Specialists’ EHR
	Black & Citizen of Tribal Nation	Black or African American	Black or African American AND American Indian or Alaska Native Multiracial

Often American Indian and Alaska Native people are indicated in official health, government, or other records as a race/ethnicity that they themselves did not choose and/or may not identify with (National Council of Urban Indian Health, 2019; Rusk et al., 2025). This can be due to someone else assuming an individual’s race/ethnicity, form questions not allowing for multiple races/ethnicities to be selected or even excluding American Indian and Alaska Native as an available race/ethnicity category to select altogether. This incorrect identification is called racial misclassification. Even when patients can identify their own race/ethnicity, standard data practices and antiquated classification systems will often automatically group American Indian and Alaska Native people into non-specific categories such as ‘other,’ ‘multiracial,’ ‘Hispanic,’ or entirely suppress any American Indian and Alaska Native data due to small population size (Agency for Healthcare Research and Quality, 2012; Haozous et al., 2014).

Impact of Racial Misclassification on American Indian and Alaska Native people

Public health surveillance data and vital statistics cannot accurately reflect the communities they are supposed to represent when racial misclassification occurs. Racial misclassification can be amplified in urban settings, where Native people may be a less visible population to others (Arias et al, 2016). This contributes to numerous problems and exacerbates the perception of American Indian and Alaska Native people not being a part of the current population and reduces the availability of data for any needed support or resources.

• Misclassification causes underestimates of population counts, inaccurate health trends and other important statistics. This weakens epidemiological evidence and the understanding of disparities, improvements, and strengths within our Native communities (Arias et al., 2016; Bertolli et al., 2007; Sugarman et al., 1993).
• Public health surveillance data and population counts are used by policy makers, funders, and other stakeholders to monitor trends, identify public health needs, and allocate resources. Underestimates due to racial misclassification limits the visibility of health crises, the availability of resources, and the overall ability to respond to urgent health needs in our communities (Bertolli et al., 2007 Burhansstipanov & Satter, 2000).

Racial Misclassification and Maternal Mortality Review Committees (MMRCs)

State or local Maternal Mortality Review Committees (MMRCs) are tasked with identifying and understanding pregnancy-related deaths within their area and then sharing accurate cumulative data to establish evidence of demonstrated needs and providing recommendations to improve pregnancy and postpartum health outcomes (Centers for Disease Control and Prevention, 2024b). When the race and ethnicity records that MMRCs receive or fill out themselves are misclassified, it further erases data for American Indian and Alaska Native communities to properly identify, understand, and respond to critical pregnancy and postpartum health factors (MacDorman et al., 2021).

Racial misclassification decreases the visibility of American Indian and Alaska Native pregnancy-related deaths and makes it harder to address and determine useful recommendations (MacDorman et al., 2021). Previously, the Centers for Disease Control and Prevention (CDC) used MMRC data to examine American Indian and Alaska Native pregnancy-related deaths in 36 U.S. states from 2017-2019 (Trost et al., 2022). When racial classifications allowed for broader representation of people identified as American Indian and Alaska Native, the number of American Indian and Alaska Native people nearly doubled in size. However, this adjustment for previously misclassified American Indian and Alaska Native identified individuals could still exclude even more American Indian and Alaska Native people that their MMRC’s overlooked as American Indian and Alaska Native (Trost et al., 2022).

Racial misclassification chips away at the work MMRCs do:

• MMRC members can not properly review and understand an individual’s story that contributed to their death when records are racially misclassified.
  • This allows for cultural factors within Tribal or Urban communities to be overlooked.
  • Native people experience discrimination within the health care system. MMRCs in 2022, determined that 50 percent of identified American Indian and Alaska Native pregnancy-related deaths indicated discrimination as a probable or determined contributing factor to death (Centers for Disease Control and Prevention, 2026). Racism and discrimination towards Native people may not be considered as a contributing factor if someone is racially misclassified in their records.
• If MMRCs do not know that they are reviewing cases of American Indian and Alaska Native people they cannot inform Tribal or urban Indian health leaders of pregnancy-related morbidity and mortality concerns that are impacting their communities.
• Underestimates of American Indian and Alaska Native pregnancy-related deaths undermines the need for American Indian and Alaska Native community or specific Tribal representatives on MMRCs to provide necessary context for reviews or the needs for a Tribal MMRC altogether. Tribally-Led MMRCs will be vital committees capable of providing culturally relevant review that will foster partnerships with Tribal and urban Indian health leaders to develop necessary recommendations that address all contributing factors within Indian Country to promote pregnancy and postpartum health. This misclassification may lead state MMRCs to the misconception that there is not a ‘sufficient’ number, or any number, of American Indian and Alaska Native pregnancy-related death cases to emphasize the need for American Indian and Alaska Native representation on the review committee.

Racial misclassification contributes to inequities in pregnancy and postpartum health that comes from failure to recognize systemic barriers that impact American Indian and Alaska Native people (Centers for Disease Control and Prevention, 2024a; Haozous et al., 2014). If racial misclassification persists in records, MMRCs will overlook or misidentify risk factors, share inaccurate pregnancy-related death trends, and develop recommendations that will not address the needs of American Indian and Alaska Native people.

Best Practices to Avoid Racial Misclassification

• To address systemic biases, there should be self-identification (when possible) in a way a person can record their race by themselves and not by any appearance or assumptions (National Council of Urban Indian Health, 2019).
  • Organizations should always include American Indian and Alaska Native as an option and allow for multi-select when filling out race and ethnicity options.
  • When sharing trends and data for race/ethnicities, report trends for American Indian and Alaska Native populations using American Indian and Alaska Native alone or in combination with one or more races/ethnicities.
• Anyone filling out forms for race/ethnicity for someone else, such as MMRC members, intake staff, or funeral directors and coroners should ask directly to the individual or the individual’s family how they should fill out race/ethnicity on forms. Do not rely on other records for correct race/ethnicity information.
  • It is important to note that being American Indian and Alaska Native is a political status in the United States, not just a race/ethnicity categorization. This underscores the importance of always asking an individual or an individual’s family how they identify and include if they have any Tribal affiliations.
  • Do not ask people to prove race/ethnicity.
  • Allow individuals to correct race/ethnicity information on their own records, or their decedent’s records, without charge or other complicated steps.
• Train health care staff, statisticians, funeral directors, and others on how to properly request and record races/ethnicities, the complexities and importance of American Indian and Alaska Native identity, why to avoid biases, and why such errors harm American Indian and Alaska Native communities (Haozous et al., 2014).
• Collaborate with Tribes, Tribal Epidemiology Centers, and Urban Indian Organizations (UIOs) as data custodians to ensure accurate race/ethnicity standards for forms, improve data quality, support interpretation of American Indian and Alaska Native data, and the development of culturally relevant recommendations.
• Apply data linkages with records from one data source to another data source like Indian Health Service (IHS) records where an individual would have been indicated as an American Indian or Alaska Native person. This can correct racial misclassification that occurs on death certificates or in other forms (BigBack et al., 2015; Gartner et al., 2023).

Racial misclassification is not a simple data issue. It endangers lives by weakening the validity of health trends for American Indian and Alaska Native people. Addressing racial misclassification will improve the evidence needed to identify and communicate with policymakers and other stakeholders about the needs and strengths within our communities. With those improvements made in American Indian and Alaska Native health data, it will support improved investments and resources to promote wellness for our American Indian and Alaska Native communities.

For more resources on racial misclassification, visit: ncuih.org/misclassification