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On a recent afternoon, Nicolle Gonzales attended a birth on the Navajo Nation inside a hogan, a traditional Navajo shelter, where the woman in labor squatted over a sheepskin next to a roaring fire. When the labor became difficult, Gonzales burned cedar and sage with two doulas she had helped train from the local community. The woman’s mother, sisters, nieces and nephews, also in attendance, had prepared an altar with ceremonial items in advance of the birth, Gonzales said.

After multiple days of labor, Gonzales said, the woman laid herself down next to the fire with her baby, while her own mother spoke her first words to the infant in their Navajo language.

It’s the kind of birth grounded in community and traditional knowledge that Gonzales wishes more Native women could experience, and what she’s working to expand access to as the founder and midwifery director of the Changing Woman Initiative, a nonprofit working to address maternal and infant health disparities among Native Americans by renewing cultural birth knowledge.

The organization serves 23 federally recognized tribes in New Mexico, including parts of the Navajo Nation, as well as urban Native communities in Albuquerque and Santa Fe, Gonzales said. Sometimes her work involves assisting home births in remote areas — she’ll drive two to three hours to rural communities after prepping with her team for days in advance, she said, including mapping routes to hospitals and EMT services in case of complications. She also trains doulas (which are shown to improve maternal outcomes), helps staff their walk-in clinic and is working to build a birthing center.

This work is crucial, she believes, because American Indian and Alaska Native women are more than twice as likely to die because of pregnancy-related causes than White women.

“Some of the stuff you read about our communities and why our outcomes are bad feels like they’re blaming Native women for it, as if we don’t really care about our health, when there’s actually a lot of systemic barriers that limit our ability to access care,” Gonzales said.

Maternal mortality, or deaths related to pregnancy, decreased by almost 40 percent around the world between 2000 and 2017. But in the United States, these deaths have climbed steadily upward. Despite spending more on health care than any other wealthy nation, the United States has the highest number of maternal deaths among those countries, with about 700 people dying from pregnancy-related complications every year and another 60,000 experiencing life-threatening complications.

Racial disparities in these deaths are stark, with Black women dying at more than three times the rate of White women. Research has found that 60 percent of pregnancy-related deaths are preventable.

Addressing racial inequalities in maternal health is one aim of the Build Back Better Act, President Biden’s proposed $2 trillion spending package focused on education, climate change, immigration and health. It passed in the House earlier this month.

Should it pass the Senate intact — a far from assured prospect given Republican opposition and uncertain support from Democratic Sens. Kyrsten Sinema (Ariz.) and Joe Manchin III (W.Va.) — the bill would fund a series of initiatives meant to decrease the racial disparities in maternal health, particularly for Black and Native women: expanding care for maternal mental health and substance use; training more women of color to work in maternal health; and addressing preexisting health conditions that affect birth outcomes, as well as social determinants of health like pollution, racism and housing instability.

It would also require states to extend Medicaid coverage to 12 months after birth, an expansion likely to affect Native communities, given that more than 1 in 4 non-elderly American Indian and Alaska Native adults and half of children rely on Medicaid. Right now, that coverage is only required for the pregnant parent up to 60 days after birth. While 17 percent of maternal deaths occur on the same day as delivery, 12 percent occur between six weeks and one year after birth.

An analysis by the liberal think tank Century Foundation estimates that the bill’s passage would mean Medicaid coverage for 117,000 new mothers a year, as well as funding for 92,000 nurses and perinatal nursing students, 30,000 doulas and 46,000 maternal mental health and substance abuse professionals over 10 years.

Many experts in Indigenous maternal health say that genuinely addressing this crisis, however, is a complex prospect — one that the federal government isn’t necessarily well-situated to address.

“If you think about legislative laws passed in Washington, you don’t see a lot of Native people lobbying for our rights there,” Gonzales said. “People who know very little about our communities are making decisions for us, but without us.”

Native women face a host of unique issues the federal government has failed to address, according to Gonzales. The impact bears out in the fact that American Indian and Alaskan Native peoples’ life expectancy is more than five years shorter than the general American population and that Native women face a murder rate 10 times higher than the national average in some places. Native people also face the highest suicide rate of any racial or ethnic group in the United States.

While these struggles vary significantly across the country, a central challenge to most Native communities is their violent history with the U.S. government, including treaties that promised to trade health care for land and natural resources, researchers say.

While today the Indian Health Service (IHS), a national agency, provides health care to 574 federally recognized tribes (this leaves out many people from non-recognized tribes or those living in urban areas), it is chronically underfunded. The IHS spent $4,078 per person in 2019, but U.S. health-care spending was, on average, $11,582 per person that year. Many IHS facilities don’t offer obstetric services, and some have closed birthing facilities or cut services in recent years.

“The socio-economic determinants of health underlie many disparities in maternal health outcomes for Native people. Many Native maternal deaths are deaths of despair and disparity, with overdose, suicide and homicide as common themes,” said Capt. Stacey Dawson, women’s health/advanced practice nurse consultant at IHS headquarters. “These deaths of despair and disparities represent underlying effects of poverty and structural racism. The limited resources for acute care and mental health and substance use disorder treatment in rural areas contribute to higher rural maternal death rates.”

Dawson said that a decline in rural birth numbers has caused many rural hospitals to discontinue labor and delivery services and that the retention of medical providers in rural areas is difficult. She says that IHS is working with their facilities to increase access to training, equipment, and to increase telehealth services for emergency departments without on-site maternity care providers.

But what may be more insidious, advocates say, is Native communities’ distrust of government-sponsored programs.

“The services that are there do a good job of providing for people who walk through the door, but that’s a hard door to walk through for many patients,” said Art Martinez, senior program specialist at the Tribal Law and Policy Institute. “It’s important to remember the intergenerational trauma that we’ve all experienced as a community. The whole world becomes threatening when you have trauma responses.”

According to advocates, there are many reasons Native parents may not trust the U.S. government with their children. For one, there’s the history of the government in the 19th century forcing thousands of children to go to boarding schools, where they were stripped of their language and many died, disappeared or experienced sexual assault.

While Congress passed the Indian Child Welfare Act (ICWA) in 1978 to stop the removal of children from Native families, Native children today are still four times more likely to be removed from their parents than non-Native children.

Today, advocates say, the criminalization of substance use during pregnancy in much of the country means that many Native Americans, who experience the highest rates of substance use in the country, fear getting prenatal care or giving birth in hospitals (at least half of infant foster care placements are due to substance use).

There are other reasons women in these communities may mistrust the country’s medical systems. In 1970, Congress passed the Family Planning Services and Population Research Act, which subsidized sterilizations for Medicaid and IHS patients. Close to 25 percent of Native American women were sterilized as a result.

Native communities have always relied on community-based care to keep mothers safe, but experts say this history is why grass-roots and Indigenous-led efforts are necessary to improve these grim statistics.

Martinez is a project leader on a Tribal Family Services Indian Health Council project called My Two Aunties, a community-led home visitation program rooted in Indigenous cultural values that supports families, including pregnant people and new mothers, in Southern California.

Janai Reyes and Elizabeth Schenker, the program’s two “Aunties,” each have a caseload of about 20 patients they visit regularly. The maternal health problems they say they’ve helped clients navigate using their trauma-informed and culturally relevant curriculum range from depression to substance use to gestational diabetes to preeclampsia and uterine rupture.

“The historical trauma goes back generations and creates generational cycles. We have to be able to re-tap into our indigeneity and re-tap into the teachings of our people to counteract that,” Schenker said.

Given the legacy of systemic health inequities in the United States, Martinez and Gonzales both say that federal legislation like the Build Back Better Act must support localized, community-based work rather than the top-down solutions that can be typical of national legislation.

“It’s really the strength of the community that’s going to bring about the change,” Martinez said. “We tend to change together as a family, we also tend to change together as communities, which is something that’s a little bit foreign to public health services or social services.”

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