Dorene Waubanewquay Day knows the birth stories of her 16 siblings by heart.
For her mother’s first five children, she gave birth at home on the Bois Forte Reservation. She said her mother felt comfortable there and could take part in Indigenous birth ceremonies.
“She was happy,” Day said. “She was well taken care of.”
But then traditional birth practices and home births were discouraged on reservations. The changes meant that Native women were pressured to give birth in hospitals.
For Day’s family, they were told to go to the Indian Health Service hospital two and a half hours away in Cloquet. Sometimes her mother went into labor and didn’t make it there. She gave birth to one of her sons prematurely in a blizzard. Day’s father placed him in a shoebox with blankets to keep him warm on the way to the hospital.
Her last pregnancy ended traumatically. She contracted a staph infection inside the hospital, which caused gangrene. Doctors performed an emergency hysterectomy to remove her uterus. She was in the hospital for three days and was told to finish recovering at home.
Day’s mother survived all of her pregnancies. But many other Native women did not.
“Luckily, she lived. But how many other women … How many of them lived?” Day said.
A recent report from the Minnesota Department of Health (MDH) found that maternal mortality among Native American women is 12 times higher than the overall statewide rate. Researchers, health care workers and community members say the statistic reflects the ongoing impact of trauma, a lack of access to care and other systemic inequities.
“The boarding schools, the relocation, the taking us off of our land, the smothering of our cultural ways, all of those things we continue to suffer from,” said Dr. Mary Owen, director of the University of Minnesota’s Center of American Indian and Minority Health.
Majority of deaths were preventable
The report was put together by MDH’s Minnesota Maternal Mortality Review Committee, which analyzed the deaths of those who died during or within one year after the end of a pregnancy between 2017 and 2021 in Minnesota.
Of those 162 deaths, 59 were determined to be related to the pregnancy.
The report calculated a ratio, which adjusts the number of deaths to the number of births, meaning there were 17.9 pregnancy-related deaths for every 100,000 births.
When the ratio is broken down by race, significant disparities in the data are revealed.
The pregnancy-related death ratio for Native American women was 12 times higher than the overall statewide rate, and nearly 22 times higher when compared to white women.
For Black women, the ratio was more than two times higher than the statewide rate, and about four times higher when compared to white women.
Ratios could not be calculated for Asian and Hispanic women due to the small number of deaths in those groups.
The report examined whether discrimination was a factor in the deaths, and found that Native women have the highest rates of discrimination, with more than 90% of deaths involving discrimination. For Black women it was nearly 70% of deaths. The committee can identify discrimination in documents such as medical records which can show bias, stereotyping or prejudice.
Jennifer Almanza, who served on the review committee for seven years and was co-chair when the report was released, said it’s important to note that the number of Native women who have died is likely higher, as many have detribalized and live in more urban areas.
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The report also found that 95% of all the pregnancy-related deaths that occurred in Minnesota were preventable. While that finding can be troubling, Rachael McGraw, a women’s health consultant with the Minnesota Department of Health who coordinates the review committee, said it emphasizes that the state can work on solutions.
“It’s so sad to think that someone died of a preventable cause, but it also tells us there’s so much we can do,” McGraw said. “There are changes that could improve outcomes in Minnesota, and I think that’s really hopeful.”
This is the committee’s first report that has looked at five years worth of data, which McGraw said helps paint a bigger picture and allows the data to be broken down by racial groups. Because Native people make up a small population of Minnesota, publishing yearly data could make the people included in the data set identifiable, she said. There is also lag when data is released due to the time-consuming task of examining each death carefully and reviewing reports before publication.
Katy Backes Kozhimannil, a professor at the University of Minnesota and co-director of the school’s Rural Health Research Center, said she’d like to see the data released more quickly, emphasizing that each death leaves behind a child and a family.
“We can’t be talking about children that are 5 years old now, that lost their moms in 2021, and the children that are 9 years old now,” Kozhimannil said.
Why is maternal mortality among Native women higher?
For Native researchers, health care workers and community members, the findings in the study were dismaying, but not surprising. Many have heard anecdotally and through other research that Native women face high rates of maternal mortality. But they say Native people and the issues they face are frequently dismissed and overlooked.
“I’m disappointed,” said Lisa Skjefte, who serves on the Minnesota Maternal Mortality Review Committee and is the executive director of the Nawayee Center School. “I can’t help but feel that this is like a modern-day genocide, because preventable deaths should indicate effort and intention to stop … I don’t think the state is paying enough attention. I don’t think local organizations like hospitals are paying attention.”
The reasons why Native women have higher rates of maternal mortality are not due to their genetic makeup. Instead, researchers and community members say it lies in systemic inequities that have impacted them for decades.
“What’s happening here isn’t based in biology,” Kris Rhodes, the director of MDH’s Office of American Indian Health, said. “It’s not a Native woman problem, and it’s not based on personal choices, but it is the social determinants of health, the living conditions where we all live, work, play and pray together.”
Rhodes said factors like lack of access to stable housing, food and health care all play a part.
Many Native women don’t receive quality and culturally competent health care, and don’t trust the health systems that are in place.
“I think the reality of it is, we don’t really prioritize the health and well-being of families, even as kind of medically progressive as our state is, there’s obviously a big gap in how our Native women are experiencing care,” Almanza said.
Dylan Daniels, who works as a nursing cultural care coordinator at the Indian Health Board Clinic in Minneapolis, said there is still mistrust among Native people toward the Indian Health Service. In the 1960s and 1970s, IHS sterilized thousands of Native women, many of them without their knowledge or consent. Many IHS locations are underfunded and underresourced, and the majority of Native people do not live near one.
“Just because we’re a Native clinic doesn’t mean that trust is guaranteed,” Daniels said. “There’s a lot of work to be done to build that trust.”
Native women are also disproportionately impacted by substance use disorder which is higher in communities facing discrimination and poverty.
“When you take a group of people and you do terrible things to them over and over and over and never let them get their feet up under them, you’re going to get things like substance abuse,” Owen said.
McGraw said the majority of Minnesota’s pregnancy-related deaths occur postpartum and due to mental health factors. Oftentimes women stop using substances when they are pregnant to protect the health of their baby, but then encounter issues like postpartum depression and return to substance use.
“When someone returns to use postpartum, that’s a really, really dangerous time … That return to use is often related to coping or to manage mental health symptoms,” McGraw said.
Women are often scared to get help for substance use, fearing they might be separated from their children. Minnesota law historically required health care providers to report suspected substance use during pregnancy to local welfare agencies, but laws have changed more recently. The Hennepin County Attorney’s Office announced in 2024 that it will no longer criminally charge people for drug use during pregnancy.
Health care visits also drop for women after they give birth. While their newborn child has frequent visits in their first weeks and months of life, women typically receive one checkup at six weeks postpartum.
“Parenting is hard. Being postpartum is hard. There are just so many additional stressors when you are bringing a child into the world and recovering from that,” said Dr. Cresta Jones, co-chair of the review committee and a high-risk pregnancy physician at the University of Minnesota.
Moving forward
The report lists recommendations to improve outcomes, including having the government provide financial support for pregnant women and their families; improving the screening and assessment process for mental illness and substance use disorders; and having more follow-up with patients who are referred for mental health treatment or medication.
It also recommends that communities provide more resources for Native and Black survivors of trauma, racism and violence and that government bodies like the Legislature invest in addressing the root causes of poverty.
Those who study maternal mortality say the impacts on Native women are not discussed enough by leaders, the government or by the public in general. A small step is just getting people to talk about the issues facing Native women more.
Kozhimannil said there has been a sentiment, particularly among non-Native people, that sharing statistics like these would harm and traumatize the community. But she argues that not speaking about it can be even more dangerous.
“Silence is more traumatic, much more traumatic. It is so much worse to watch mothers die around you and then have reports come out that say Minnesota is a great place to give birth and raise a kid, or just not having statistics about your community,” she said.
Sen. Mary Kunesh, DFL-New Brighton, the first Indigenous woman to serve in the Minnesota Senate, has been trying to get more funding for resources that help Native women. She also brought forward legislation to create the state’s Missing and Murdered Indigenous Relatives Office.
She said when she brings these issues forward, there is still a lack of understanding about the disparities that Native people face.
“If it was any other group, people would be up in arms, but there just aren’t enough people to bang that drum about what is happening, and why is it happening, and why does it continue to happen,” she said.
The Birth Justice Collaborative, created in 2022, is a coalition of organizations hoping to improve outcomes for Black and Indigenous mothers. Kunesh helped to introduce a bill to give the group funding to build birth centers that would provide culturally competent care.
Ruth Buffalo, who leads the Minnesota Indian Women’s Resource Center and is part of the collaborative, said the plan is still moving forward, but has been complex to plan. She said many Native women may not meet the criteria to have a home birth, which is primarily what birth centers offer.
“We can’t lose sight of our target population, our most vulnerable who need help the most,” she said.
Those who work at hospitals and clinics are trying to build trust with Native communities, and encourage people to come and get help if they need it.
M Health Fairview created a Birth Justice Initiative to address racial disparities in maternal mortality. Last year, Fairview held a summit to focus on culturally rooted doula care for Native communities.
Heather Fahey works as a clinical pharmacist at Fairview and has been leading the organization’s Native health equity work. She said it’s important to show up in the community and try to let people know that they can come in for care. That includes attending powwows and meetings and connecting with tribal liaisons.
“We can make all these changes internally, but if people don’t trust Fairview, they’re not going to come here,” she said. “We’re continually showing up in the spaces.”
The Indian Health Board of Minneapolis clinic has been trying to improve the continuity of care for pregnant women by checking in on those who miss appointments, offering counseling and providing supplies they might need after giving birth. Clinic staff have also been offering cultural workshops like cradleboard-making to engage the community. Looking forward, the clinic is considering expanding its postpartum care.
“I think for us, it’s a call to action, really, the numbers in the report,” said Monica Streater, a certified nurse midwife at the clinic.
Day, who saw the health care system fail her own mother, is now a traditional midwife and healer. She has devoted her work to improving pregnancy outcomes for Native women and keeping Indigenous birthing ceremonies alive. She said the report shows that the state still has a long way to go.
But the community is resilient, and she and others are working to look after each other as best they can.
“We’re still at the bottom of the pole,” she said. “But it doesn’t matter, because we have our own pole, and we’re climbing up very gently and carefully taking care of ourselves.”
