1. Heck, Jennifer L. PhD, RNC-NIC, CNE

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Worldwide, maternal mortality is a marker of a society's health. Maternal mortality is defined as the "death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from unintentional or incidental causes" (United Nations Maternal Mortality Estimation Inter-Agency Group [UNMMEIG], 2019, p. 8). Although maternal mortality globally has decreased by 38% from 2000 to 2017, it remains high, with most deaths deemed preventable. Recent reports estimate the global maternal mortality ratio (MMR), number of maternal deaths per 100,000 live births, at 211. Ratios vary widely, with least developed countries like Sub-Saharan Africa (542) carrying a disproportionate burden of deaths compared with other nations like Australia (7) and in Europe (10). In some regions with low maternal mortality like Northern America, MMR increased from 12 in 2000 to 18 in 2017 (UNMMEIG).


There is a racial and ethnic distribution of MMR. The 2007-2016 U.S. data revealed worrisome racial and ethnic disparities in maternal mortality. American Indian/Alaska Native women had a pregnancy-related mortality ratio (pregnancy-related deaths per 100,000 live births) of 29.7 compared with 12.7 for White women and 16.7 for all U.S. women (Petersen et al., 2019).


Indigenous women are members of an Indigenous tribe, band, or nation, as compared with women who have settled in or colonized an area later. Depending on location, Indigenous women may also be labeled Aboriginal, American Indian, First Nations, Inuit, or Native. Indigenous women have markedly worse maternal outcomes than their non-Indigenous counterparts, including maternal mortality (United Nations [UN], 2020). Significant differences in maternal mortality between Indigenous and non-Indigenous women are documented in Australia, Colombia, New Zealand, Panama (UN), and the United States (Petersen et al., 2019).


Existing disparities in prenatal and antenatal care, skilled birth attendance, and many social determinants of health adversely affect Indigenous women's outcomes, ultimately increasing their risk for maternal death. Indigenous women in Australia and the United States are less likely to receive prenatal care in the first trimester than their non-Indigenous counterparts (Martin et al., 2019; UN, 2020). In Guatemala in 2015, 50% of Indigenous women experienced a skilled birth attendance, compared with 82% of non-Indigenous women (UN).


Challenges to improving Indigenous maternal mortality include data issues like racial and ethnic misclassification and aggregation. In the United States, racial and ethnic misclassification has resulted in underestimation of diseases like cancer and cardiovascular disease for Indigenous people (Rhoades, 2006) as well as maternal mortality. For analysis, data are often aggregated to achieve a sufficiently large sample size to detect statistical significance. However, when data are not disaggregated by ethnicity (and other factors), lack of understanding about experiences of Indigenous people results (UN, 2020), contributing to their continued marginalization.


Nurses can expand their understanding of unique Indigenous issues through cultural humility and learning about and addressing implicit bias. Nurses can integrate trauma-informed care and evidence-based quality improvement activities into daily routines. Nurses can join collaborative interdisciplinary research teams (which include Indigenous membership) to seek grants and conduct participatory and inclusive action research to identify and address barriers that keep Indigenous women from receiving timely, appropriate, and high-quality healthcare. Nurses can contribute to the breakdown of identified barriers by advocating for social reform. Only then can we expect to see improved outcomes and maternal mortality for Indigenous women.




Martin J. A., Hamilton B. E., Osterman M. J. K., Driscoll A. K.(2019). Births: Final data for 2018. National Vital Statistics Reports, 68(13), 1-47.[Context Link]


Petersen E. E., Davis N. L., Goodman D., Cox S., Syverson C., Seed K., Shapiro-Mendoza C., Callaghan W. M., Barfield W. (2019). Racial/Ethnic disparities in pregnancy-related deaths - United States, 2007-2016. Morbidity and Mortality Weekly Report, 68(35), 762-765.[Context Link]


Rhoades D. A. (2006). Commentary: Disparities in data for American Indians and Alaska Natives. American Indian and Alaska Native Mental Health Research, 13(1), 70-74.[Context Link]


United Nations. (2020). Fact sheet: Indigenous women's maternal health and maternal mortality.[Context Link]


United Nations Maternal Mortality Estimation Inter-Agency Group. (2019). Trends in maternal mortality 2000 to 2017: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. World Health Organization.[Context Link]