On December 1, 2022, the U.S. Department of Health and Human Services(HHS) Secretary Xavier Becerra attended the White House Tribal Nations Summit where he discussed the Department’s commitment to addressing mental and maternal health in American Indian and Alaska Native (AI/AN) communities. As part of HHS’ commitment, the Centers for Disease Control and Prevention (CDC) and the Office of Minority Health (OMH) launched a new Hear Her campaign segment that works to improve AI/AN maternal health outcomes by raising awareness of life-threatening warning signs during and after pregnancy and improving communication between health care providers and their patients.

Background on Hear Her Campaign

The CDC’s Division of Reproductive Health launched the Hear Her in 2020 as a national campaign that brings attention to pregnancy-related deaths and provide education and encouragement to pregnant and postpartum women (within one year of delivery).  The campaign supports CDC’s efforts to prevent pregnancy-related deaths by sharing potentially life-saving messages about urgent warning signs.

The Hear Her campaign was launched because too many people die from pregnancy-related complications. Alarmingly over 700 women die each year in this country from problems related to pregnancy or delivery complications. Every death is a tragedy, especially when two thirds of pregnancy-related deaths could be prevented. As many as 50,000 women experience severe, unexpected health problems related to pregnancy that may have long-term health consequences. Additionally, there are significant racial and ethnic disparities in pregnancy-related complications and deaths.  The Hear Her campaign centers on the stories of women who have experienced pregnancy-related complications.  Recognizing urgent maternal warning signs and getting an accurate and timely diagnosis can save lives during pregnancy and up to a year after delivery.

AI/AN Infant and Maternal Health Disparities

According to the OMH, Native infants have almost twice the infant mortality rate as non-Hispanic whites.  Native infants are also almost three times more likely than non-Hispanic whites to die from accidental deaths before the age of one year. Contributing factors to these disparities include cost, discrimination, and lack of cultural competency during prenatal care. Additional ongoing and historical trauma due to colonization, genocide, forced migration, and cultural erasure also contribute to health inequities, including pregnancy-related deaths and other maternal health conditions. Approximately 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits and 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN. Consequently, AI/AN people are more likely to have underlying chronic health conditions, and they face systemic barriers to care including higher rates of poverty and needing to travel long distances to receive quality health care services.

Given the maternal health disparities that AI/AN people and communities experience, it is a priority for CDC and OMH to reach tribal communities with resources CDC and OMH have worked to include the voices and perspectives of AI/AN throughout the development of the campaign and will continue to do so over time. As the campaign moves forward into implementation, the focus will be on building capacity for tribes and tribal serving organizations to implement the campaign and improve maternal outcomes.

UIO and NCUIH work in AI/AN Infant and Maternal Health

Urban Indian organizations (UIOs) provide a range of services such as primary care, behavioral health, traditional, and social services— including those for infants, children, and mothers. At least 23 of these clinics provide care for maternal health, infant health, prenatal, and/or family planning. They also provide pediatric services and participate in maternal-child care programs such as WIC and the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting program (MIECHV).

Furthermore, the National Council of Urban Indian Health (NCUIH) has engaged in extensive advocacy on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants.  In March 2022, NCUIH signed onto a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and doubling the Tribal set-aside – which includes UIOs. Additionally, NCUIH submitted comments to HRSA Advisory Committee on Infant and Maternal Mortality (ACIMM), which advises the Secretary of HHS on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality, and sever maternal morbidity and improving the health status of infants and women before, during, and after pregnancy. Moreover, in August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations. NCUIH also recently released an infographic showcasing data on infant and maternal health disparities in AI/AN communities.

In addition to written advocacy, NCUIH has been invited to present on urban AI/AN maternal and infant health. On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, testified before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.”

On December 29, 2022, the Jackie Walorski Maternal and Child Home Visiting Reauthorization Act of 2022 (H.R. 8876) was included in the final appropriations package, also known as the omnibus, for Fiscal Year (FY) 2023. Notably, the omnibus reauthorized the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) and increased funding through FY 2027. The program supports home visit programs, including the Tribal Home Visiting Program (THVP), for expectant and new parents who live in communities that are at risk for poor maternal and child health outcomes. To continue improving the infant and maternal health of American Indian/Alaska Native (AI/AN) communities, the bill provides a notable improvement to the THVP program by (from 3% to 6%) starting in FY 2023. The National Council of Urban Indian Health (NCUIH) has advocated for the reauthorization of MIECHV and increasing funding for the Tribal set-aside and continues to advocate on behalf of AI/AN mothers and infants.

In addition, the bill makes several to the MIECHV program overall, such as:

• $500,000,000starting grant base in FY23, scheduled funding increases of $50,000,000 through FY 2027.
• Dedicates a 2% set-aside for workforce support, retention, and case management.
• Allows set-asides for research, evaluation, and administration (3%) and technical assistance (2%).
• Creates an “outcomes dashboard” to help Congress and the public track MIECHV’s success in improving family outcomes.
• Annual report to Congress to better oversee the program and make improvements in the future.

Background

The Tribal Home Visiting Program

Since 2010, a 3% set-aside has been allotted to the THVP, a program administered within MIECHV to specifically support and promote the health and well-being of AI/AN families.

From the MIECHV 2015 Congressional Report, THVP grantees, including urban Indian organizations (UIOs), served 870 families—5 times the number served in FY 2012. Nearly 20,000 home visits were provided to 3,197 adult participants and children between FY 2012 and FY 2014. After 3 years of implementation, 77% of grantees also demonstrated overall improvement in several benchmark areas. These include:

• 62% improvements in maternal and newborn health
• 85% increase in the prevention of child injuries, child abuse, neglect, or maltreatment, and reduction of emergency department visits
• 69% improvement in school readiness and achievement
• 77% reduction in crime or domestic violence
• 77% improvement in family economic self-sufficiency
• 69% improvements in the coordination and referrals for other community resources

Since its inception, the THVP has been an influential program to help improve the development of healthy AI/AN children and families through coordinated, culturally relevant, and evidence-based home-visiting strategies addressing critical maternal and child health needs.

NCUIH Advocacy

NCUIH has engaged in extensive advocacy on behalf of AI/AN mothers and infants for increased funding and support to the UIOs that provide maternal health, infant health, prenatal, and family planning services. On March 9, 2022, NCUIH signed on to a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing the MIECHV program and doubling the Tribal set-aside, which includes UIOs.

NCUIH also submitted comments on March 10, 2022, to the Health Resources and Services Administration (HRSA) Advisory Committee on Infant and Maternal Mortality (ACIMM), which advises the Secretary of Health and Human Services (HHS) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. On August 31, 2022, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In those comments, NCUIH continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations.

On September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, presented before the HRSA ACIMM on urban Indian disparities and policy changes to address these disparities. Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.”

Thanks to this NCUIH advocacy, H.R. 8876 included language to double the Tribal set-aside from 3% to 6% in FY 2023, which was ultimately included in the final appropriations package for FY 2023.

AI/AN Maternal Health Disparities

American Indian and Alaska Native (AI/AN) communities throughout the country, including urban AI/AN communities, experience significant maternal and infant health disparities compared to the general population. A report by the National Center for Health Statistics noted that between 2005 and 2014, AI/ANs were the group that did not experience a decline in infant mortality.

Over half of UIOs provide care for maternal health, infant health, prenatal, and/or family planning. A study of Natives in UIO service areas found that while birth rates, in general, were lower in the urban Native population (12.8 and 16.5 per 1,000 population, respectively), premature birth rates for both urban and non-urban AI/AN were higher than those of all other races and ethnicities combined (12.3% of live births among AI/AI in urban areas and 10.9% among the general population in the same area).

Through expanded research efforts, many factors have been directly identified as reasons for AI/AN infant and maternal health disparities. These include:

• 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits.
• AI/AN women are 3-4x more likely to begin prenatal care in the third trimester.
• 21% of AI/AN women ages 15-44 are uninsured, compared to 8% of white women.
• 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN.
• 15% report avoiding medical care for themselves or family members due to fear of discrimination.
• Access to culturally appropriate care can be difficult for AI/ANs living in urban areas, as most IHS clinics and hospitals, as well as Tribal healthcare facilities, are located on reservations.

On November 22, 2022, the Health and Resources and Services Administration (HRSA) issued a notice seeking nominations of qualified candidates for consideration to serve as members of the Advisory Committee on Infant and Maternal Mortality (ACIMM). ACIMM advises the Secretary of Health and Human Services (HHS) (Secretary) on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants of women before, during, or after pregnancy. Written nominations for membership on the ACIMM must be received on or before January 23, 2022, and nomination packages must be submitted electronically as email attachments to Vanessa Lee, MPH, the ACIMM’s Designated Federal Official, at: SACIM@hrsa.gov. NCUIH strongly encourages UIO staff working in the areas of infant and maternal health to submit nomination materials.

Background

The ACIMM was established in 1991 and advises the Secretary on department activities, partnerships, policies, and programs directed at reducing infant mortality, maternal mortality and severe maternal morbidity, and improving the health status of infants and women before, during, and after pregnancy. The ACIMM provides advice on how to coordinate federal, state, local, tribal, and territorial governmental efforts designed to improve infant mortality, related adverse birth outcomes, and maternal health, as well as influence similar efforts in the private and voluntary sectors. The ACIMM provides guidance and recommendations on the policies, programs, and resources required to address the disparities and inequities in infant mortality, related adverse birth outcomes and maternal health outcomes, including maternal mortality and severe maternal morbidity. With its focus on underlying causes of the disparities and inequities seen in birth outcomes for women and infants, the ACIMM advises the Secretary on the health, social, economic, and environmental factors contributing to the inequities and proposes structural, policy, and/or systems level changes. The ACIMM meets approximately four times per year, or at the discretion of the Designated Federal Officer in consultation with the Chair.

Nomination Eligibility and Information

HRSA is requesting nominations for voting members to serve as Special Government Employees (SGEs) on the ACIMM to fill open positions. The Secretary appoints ACIMM members with the expertise needed to fulfill the duties of the Advisory Committee. Nominees sought are medical, technical, or scientific professionals with special expertise in the field of maternal and child health, in particular, infant and/or maternal mortality and related health disparities; members of the public having special expertise about or concern with infant and/or maternal mortality; and/or representatives from such public health constituencies, consumers, and medical professional societies. Interested applicants may self-nominate or be nominated by another individual or organization.

Individuals selected for appointment to the Committee will be invited to serve for up to 4 years. Members appointed as SGEs receive a stipend and reimbursement for per diem and travel expenses incurred for attending ACIMM meetings and/or conducting other business on behalf of the ACIMM, as authorized by 5 U.S.C. 5703 for persons employed intermittently in government service

Nomination Package Materials

The following information must be included in the package of materials submitted for each individual nominated for consideration:

1. A statement that includes the name and affiliation of the nominee and a clear statement regarding the basis for the nomination, including the area(s) of expertise and/or experience that may qualify a nominee for service on the ACIMM, as described above;
2. confirmation the nominee is willing to serve as a member of the ACIMM;
3. the nominee’s contact information (please include home address, work address, daytime telephone number, and an email address); and
4. A current copy of the nominee’s curriculum vitae or resume. Nomination packages may be submitted directly by the individual being nominated or by the person/organization recommending the candidate.

Individuals who are selected to be considered for appointment will be required to provide detailed information regarding their financial holdings, consultancies, and research grants or contracts. Disclosure of this information is required in order for HRSA ethics officials to determine whether there is a potential conflict of interest between the SGE’s public duties as a member of the ACIMM and their private interests, including an appearance of a loss of impartiality as defined by federal laws and regulations, and to identify any required remedial action needed to address the potential conflict.

AI/AN Infant and Maternal Health

AI/AN communities throughout the country, including urban AI/AN communities, experience significant maternal and infant health disparities compared to the general population. According to HHS’ Office of Minority Health (OMH), AI/AN infants have almost twice the infant mortality rate as non-Hispanic whites.  Native infants are also almost three times more likely than non-Hispanic whites to die from accidental deaths before the age of one year. Contributing factors to these disparities include cost, discrimination, and lack of cultural competency during prenatal care. Additional ongoing and historical trauma due to colonization, genocide, forced migration, and cultural erasure also contribute to health inequities, including pregnancy-related deaths and other maternal health conditions. Approximately 41% of AI/AN women cite cost as a barrier to receiving the recommended number of prenatal visits and 23% of AI/ANs report they have faced discrimination in clinical settings due to being an AI/AN. Consequently, AI/AN people are more likely to have underlying chronic health conditions, and they face systemic barriers to care including higher rates of poverty and needing to travel long distances to receive quality health care services.

Recognizing the infant and maternal health disparities that AI/AN people and communities experience, the HHS Secretary Xavier Becerra attended the White House Tribal Nations Summit on December 1, 2022, where he discussed the Department’s commitment to addressing mental and maternal health in AI/AN communities. As part of HHS’ commitment, the Centers for Disease Control and Prevention (CDC) and the Office of Minority Health (OMH) launched a new Hear Her campaign segment that works to improve AI/AN maternal health outcomes by raising awareness of life-threatening warning signs during and after pregnancy and improving communication between health care providers and their patients.  Given HHS’ current focus on addressing Native infant and maternal health, it is highly recommended that UIO staff submit applications to the ACIMM to ensure that the voice of urban Native communities continues to be heard in this work.

UIO and NCUIH work in AI/AN Infant and Maternal Mortality

UIOs provide a range of services such as primary care, behavioral health, and traditional, and social services— including those for infants, children, and mothers. Several UIOs provide care for maternal health, infant health, prenatal, and/or family planning. They also provide pediatric services and participate in maternal-child care programs such as WIC and the Health Resources and Services Administration (HRSA) Maternal, Infant, and Early Childhood Home Visiting program (MIECHV).

NCUIH has engaged in extensive policy work on behalf of AI/AN mothers and infants and for increased funding and support to the UIOs which provide maternal health, infant health, prenatal, and family planning services to AI/AN mothers and infants. On March 9, 2022, NCUIH signed on to a letter to Congress led by the National Home Visiting Coalition in support of reauthorizing HRSA’s  MIECHV and doubling the Tribal set-aside— which includes UIOs.

Also, in March, NCUIH submitted comments to the ACIMM, and on September 14, 2022, NCUIH’s Vice President of Public Policy, Meredith Raimondi, testified before the ACIMM on urban Indian disparities and policy changes to address these disparities.  Raimondi highlighted that “over half of urban Indian health centers provide care for maternal health, infant health, prenatal, and/or family planning. However, due to chronic underfunding, many of these health centers only have the capacity to carry out these services for the early stages of pregnancy.” She continued to say, “despite desiring to do so, many urban Indian health clinics cannot expand their services to provide complete care for mothers and infants from conception to birth due to underfunding.” Raimondi provided the following recommendations to the Advisory Committee:

• Reauthorize MIECHV at a higher amount and double the Tribal set-aside from 3% to 6%.
• ACIMM and other stakeholders should collaborate with UIOs to gather critical and accurate information on urban AI/AN populations.
• Advise the HHS Secretary to lead the establishment of an urban confer policy across all HHS agencies.
• Include a Tribal and UIO health provider representative on the ACIMM and create an ACIMM subcommittee dedicated to addressing AI/AN infant and maternal health disparities.

In August, NCUIH submitted comments to HRSA’s Maternal and Child Health Bureau (MCHB) regarding the Pediatric Mental Health Care Access Program. In our comments, we have continued to stress the critical importance of including urban Natives populations in HRSA’s overall efforts of improving health outcomes for all AI/ANs living on and off reservations.

• MIECHV Reauthorization Letter
• NCUIH Comments to HRSA ACIMM
• NCUIH Comments to HRSA MCHB

Furthermore, NCUIH recently released an infographic showcasing data on infant and maternal health disparities in American Indian/Alaska Native (AI/AN) communities.