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Southwest Tribes’ Women Have Cesarean Births at Lowest Rate in U.S.

A column by Tekatsitsiakwa Katsi Cook about the health effects of American Indian women having Cesarean births at a lower rate than the rest of the U.S. population.

Among the privileged few early “outsider” observers of Native American birth is anthropologist Matilda Coxe Stevenson who published on Pueblo cosmogony and “Sia Pueblo Rites With Childbirth” for the Bureau of American Ethnology in 1884. Stevenson’s historical record is perhaps the most intriguing documentation of a birthing story in Native America from that time:

The father clasped his hands around his knees, holding a stone fetich of a cougar in the palm of the right hand, and the sister-in-law, standing to the left of the woman, placed the ear of corn to the right of the sufferer’s head and blew upon it during the periods of pain, to hasten the birth of the child. The prayer that was blown into the head was supposed to pass directly through the passageway of life.… The woman would sit for a time either upon a low stool or a chair, and then pass about in evident pain, but no word of complaint escaped her lips; she was majestic in her dignity…all minds seemed centered on the important event to come. It was a sacred hour, too sacred for spoken words.…

Today, Native American women of the Southwest tribes—including nine Pueblo communities of New Mexico—have, along with Alaska Natives, the lowest primary cesarean delivery rate of all populations in the United States.

Despite a higher prevalence of medical risk factors, the total cesarean section rate for Pueblo women at the Santa Fe Indian Health Service Hospital was 9.6 percent compared to a 16.4 All Races rate in New Mexico, and a 21.2 percent All Races rate in the United States for 1998. Thus when, in 2007, the obstetrical unit at the Santa Fe Indian Hospital—where practice-related factors like midwifery care accounted for the low cesarean rates among Pueblo mothers—was closed, it seemed that this policy shift would have a negative impact on the reproductive health of these mothers and their babies. This might have resulted in weakening the strength and spirit of their kinship communities. That it didn’t is testimony of indigenous community resilience.

The overall incidence of cesarean delivery in the United States reached 32.9 percent in 2009 for a number of reasons, including medical induction of labor and maternal choice. Recent research in reproductive science at the University of California at San Francisco finds that if trends in the U.S. continue, the cesarean delivery rate will be 56.2 percent by 2020. In the cascade of medical intervention, a primary, or first-time cesarean section, leads to repeat cesareans. Researchers predict the escalating cesarean sections (and increased placental problems) will raise maternal mortality. We will see more women die from childbirth.

At the recent Second International Meeting on Indigenous Women’s Health in Albuquerque, presentations featured birth practices in rural, remote Native communities in New Mexico. Regional networks, innovative-care models and appropriate technologies to support safety in rural maternity care were discussed. Evidence presented indicated that good outcomes for mothers and their babies can be sustained within a regionalized obstetrical system even without local access to cesarean sections. Individuals and their tribal communities themselves can determine whether to support such a maternity care unit based on personal choice, geographic and financial reasons. Professional consensus statements on these critical points are in keeping with key articles in the United Nations Declaration on the Rights of Indigenous Peoples. These recognize the right to the full enjoyment, as a collective or as individuals, of all human rights and fundamental freedoms in the Charter of the United Nations, the Universal Declaration of Human Rights and international human rights law. These recognitions clearly include the right to sexual and reproductive health.

The closing in 2007 of the obstetrical unit at the Santa Fe Indian Hospital, which might have severely disrupted Native women’s reproductive rights, actually ushered positive changes, strengthening the self-empowering practice of family-oriented birth again in the communities.

Working at the community level in Northern New Mexico is licensed professional midwife Michelle Peixinho, a governor-appointed member of the New Mexico Women’s Health Advisory Council who helped establish the Yiya Vi Kagingdi Community Doula Program through Tewa Women United in Española, New Mexico.

“Setting up our midwifery practice here in 2010 was the right thing to do even though we had so few clients once we did,” says Michelle. “Now, more Native families are calling us for home birth, and I am so proud of the strength of these young parents. It is worth all the patience.”

The regeneration of home births in the Pueblo communities is an important moment; it illuminates a pathway for a new generation of Pueblo parents who are re-storying their experience of birth and its power to strengthen cultural identity.

Native American nations are critical communities from which strategies for improving reproductive practices, such as reducing unnecessary cesareans, can identify positive changes for themselves and for other populations. We must restore the reproductive health of our generations by re-storying birth in such a way that honors both science as the servant of the rational mind and our own cultures’ sacred gift of the intuitive.

Tekatsitsiakwa Katsi Cook, Akwesasne Mohawk, is an elder member of the National Aboriginal Council of Midwives of the Canadian Association of Midwives and director of First Environment Collaborative. Katsi is the founding aboriginal midwife of the Six Nations Birthing Centre, and she is the 2011 recipient of the Sage Femme Award of the Midwives Alliance of North America.