American Indian and Alaska Native (AI/AN) people experience some of the starkest disparities in maternal health outcomes in the United States. Compared to white populations, for example, AI/AN individuals experience significant financial, logistical and cultural barriers to perinatal care and face double the risk of maternal morbidity and mortality. In the rural areas where many AI/AN people live, disproportionately long travel distances to access perinatal and other care make the situation particularly challenging.

The Indian Health Service (IHS), a system of federally operated healthcare facilities that provides care to federally-enrolled tribal citizens and other eligible individuals, is critical to providing medical care to AI/AN communities in fulfillment of the government’s federal trust obligation. However, not all AI/AN people are eligible for IHS care or live near an IHS facility, and IHS faces funding shortages that limit the services they provide. IHS is a health care delivery system, not a health insurance program, and most pregnant AI/AN women have coverage through Medicaid, although some have private health insurance and others are uninsured.

A new study from the University of Minnesota School of Public Health (SPH) investigates how well these systems—IHS access as well as private insurance and Medicaid—function for AI/AN pregnant women. The study, published in Health Affairs, looks at the relationship between access to IHS care and health insurance coverage on use of medical services and quality of care during the perinatal period: in the year before pregnancy (preconception), during pregnancy, and postpartum. To conduct the study, researchers analyzed data from AI/AN individuals who gave birth between 2016 and 2020, using information compiled from 44 states as part of the Pregnancy Risk Assessment Monitoring System (PRAMS). In all, the study included 12,920 respondents who identified as AI/AN.

Key findings of the study include:

• IHS access improved use and quality of perinatal care. AI/AN individuals with access to IHS reported higher quality perinatal care compared to those without IHS access. Also, among uninsured AI/AN individuals, IHS access was particularly important and was associated with a 16 percentage point increase in use of preconception care and a 7 percentage point increase in use of prenatal care.
• Across all insurance and IHS categories, over half of AI/AN people were not receiving high-quality perinatal care. Fewer than one in five AI/AN people studied received high-quality preconception care, while fewer than half received high-quality care postpartum.
• Medicaid coverage alone does not guarantee high-quality care. While Medicaid was the most common form of insurance among AI/AN birthing people, it did not guarantee high quality perinatal care. AI/AN pregnant women with Medicaid but no IHS access often received lower-quality care compared to individuals with both Medicaid and IHS access.

“The study is one of very few to analyze the role of IHS and of health insurance coverage in supporting high quality maternal care for AI/AN individuals,” says Dr. Julia Interrante, SPH researcher and lead author. “The lack of health policy research in this critical area inhibits policymakers’ ability to formulate policies that could address these critical gaps in maternal health care. The study showed that the perinatal care received by AI/AN women can vary greatly depending on what type of health insurance they have, and whether they happen to live near IHS facilities that provide perinatal services. We hope policymakers take these facts into consideration as they seek to improve the quality and availability of these services.”

The study recommends sustained and expanded financial support for IHS — which remains underfunded despite its critical role in providing care to AI/AN communities — as well as support for continuous health insurance coverage for AI/AN people, particularly during the perinatal period.

Co-authors of the study include SPH Distinguished McKnight University Professor Katy Backes Kozhimannil, Emily Sheffield SPH researcher and doctoral student, and Hailey Baker, a UMN researcher and medical student.

Funding support for the research was provided by the Robert Wood Johnson Foundation’s Policies for Action (P4A) program.