Strengthening Risk-Appropriate Care in American Indian and Alaska Native Communities

October 11, 2022

Risk-appropriate care involves developing a system to ensure that pregnant people receive care at facilities that best align with the level of risk associated with their pregnancy. Implementing and further strengthening risk-appropriate care systems can reduce maternal and infant morbidity and mortality, improving health outcomes for pregnant people and infants.

Accessing Risk-Appropriate Care

American Indian and Alaska Native (AI/AN) populations experience unique challenges in accessing risk-appropriate care, such as clinical workforce shortages and lack of healthcare access. These challenges contribute to health disparities among AI/AN communities and include transportation inequities, experiences with racism, and distrust of the medical system.

Pregnant AI/AN people encounter difficulties in accessing risk-appropriate care due to lack of geographic access. One report indicated that one in three AI/AN women do not live within a 50-mile radius of critical care obstetric units. For those requiring a higher level of care, ensuring timely transportation to these critical care facilities is a major barrier to receiving risk-appropriate care as the loss of time in these instances can be life-threatening. Additionally, underdeveloped hospital and clinic referral networks along with insufficient collaboration between hospital systems and transport programs creates communication barriers and follow-up care challenges that impact access.

Furthermore, pregnant AI/AN people can face implicit bias, and/or lack access to culturally competent care that respects and allows AI/AN birthing practices. This can result in the dismissal of their concerns in the prenatal stage and discouragement from seeking further prenatal care throughout the pregnancy.

How States are Strengthening Risk-Appropriate Care

The Alaska Department of Health (ADOH) is enhancing risk-appropriate care for AI/AN communities by collaborating with health systems, providers, and community organizations. To regionalize referral and transport systems, ADOH is fortifying relationships between AI/AN health system providers and providers servicing other health systems across the state. ADOH is also establishing initiatives focused on prenatal care for AI/AN pregnant people by identifying provisions for pregnant AI/AN people to stay in maternal homes near appropriate level of care facilities, using health aides in villages to identify risks requiring higher levels of care, and utilizing telehealth opportunities.

The New Mexico Department of Health (NMDH) is promoting risk-appropriate care in AI/AN communities, specifically through data collection on maternal and infant health. Enhanced AI/AN data collection is beneficial for establishing an evidence base to inform how to best move forward in strengthening risk-appropriate care. NMDH is also working to develop strong agreements and working relationships with AI/AN centers to support this objective.

The Montana Department of Public Health and Human Services (MDPHHS) is including tribal nations in their state’s perinatal quality collaborative, to understand and identify specific challenges facing AI/AN communities in accessing quality care. Additionally, MDPHHS is providing indigenous doula training to increase the availability of culturally competent care. Doulas can help identify early risks in pregnancy and advocate on the birthing person’s behalf, thus better ensuring the receipt of risk-appropriate care.


Enhance data collection to understand gaps in the provision of quality services to the AI/AN population. AI/AN people make up 2% of the U.S. population but are often not included in research as their population is too small in statistical terms. This population is also commonly racially misclassified on birth and death certificates, resulting in undercounting of statistics for AI/AN people.

  • Comprehensive data collection that measures race and ethnicity data in a disaggregated format is essential to better understanding disparities in maternal and infant health. This will inform risk-appropriate care best practices for the AI/AN population based on their specific needs.

Promote people-centered care through culturally competent services and implicit bias training to foster trust in the medical system. For pregnant AI/AN people, receiving care that is respectful of their birthing practices increases the likelihood of attending prenatal visits and identifying complications throughout their pregnancy. Furthermore, state health departments and their staff should leverage the perinatal workforce, including supporting access to doulas and midwives.

  • State health departments and their staff should engage community-based organizations to improve access to risk-appropriate care for pregnant AI/AN people. By partnering directly with community organizations, the needs of the community guide the process of developing and implementing effective interventions.

Many thanks to Lily Lou, MD (alumni-AK), New Mexico Department of Health, and Montana Department of Public Health and Human Services for sharing information about their respective jurisdictions.