Skip to main contentSkip to main content
You are the owner of this article.
You have permission to edit this article.
Edit
'We have no specialized care here': Reservations struggle with limited prenatal care
editor's pick topical alert

'We have no specialized care here': Reservations struggle with limited prenatal care

  • 0

Editor's note: This story is part one of a two-part series on the state of perinatal health care in Indian Country. Look out for part two, which will focus on maternal care, in Monday's paper and online at Missoulian.com

BROWNING — When Samantha Mack woke up one morning in 2013 and saw the snow, she grimaced. 

Mack, who was 19 and about 6 months pregnant with her first child, had a prenatal appointment scheduled at the Indian Health Service clinic in Lame Deer. The clinic was a little more than an hour’s drive from her home in Hysham, a southeast Montana town of 331. But the snow made the trip impossible.

Mack canceled her appointment, and it took about a month for the clinic to reschedule. When the next appointment finally arrived, so too did the snow. Mack had to cancel again.

Mack, who is Northern Cheyenne, felt anxious and started having nightmares about her unborn son. She still remembers dreaming that he was no longer alive, and in the weeks that followed, Mack was convinced a dead fetus was inside her.

"It was really hard," she said. "I could sometimes feel him moving around, but as soon as he'd stop, I'd get worried. You always hear about people that lost their babies who say they felt those phantom movements. When he would stop moving, I would start thinking I had imagined his movements. My mind was playing tricks on me. I kept imagining he wasn't OK."

samantha 2.jpg

Samantha Mack poses with a pregnant belly. Mack, like many Native people, faced barriers in accessing perinatal care. 

The Indian Health Service (IHS) unit in Lame Deer was supposed to transfer Mack to St. Vincent Healthcare in Billings, as is customary, since the IHS facility is not equipped to deliver babies. But because Mack couldn’t get to her appointments in Lame Deer, IHS never initiated the transfer.

As a result, in her final three months of pregnancy she went without prenatal care.

Mack isn’t alone in her experiences. Obstetric care, especially specialized care, is limited in rural communities. On reservations in Montana, it’s nearly nonexistent. Most IHS facilities are not equipped to deliver babies. As a result, these clinics refer Native patients to larger hospitals, but the referral process is prone to failure.

samantha 3.jpg

Samantha Mack, who is Northern Cheyenne, did not receive any prenatal care in her third trimester. She is among many Native people who face barriers in receiving perinatal care. 

As a consequence of decades of disinvestment and oppressive federal policies, Native Americans are also more likely to have riskier pregnancies. If Native patients do get referred for specialized care, they must drive long distances to access it.

Barriers to care compound during Montana winters. Heavy snowfall and below-freezing temperatures make travel dangerous and, at times, impossible. Native Americans have the highest poverty rate among all minority groups in the U.S. Many Native people living on reservations in Montana don’t have reliable vehicles or can’t afford to travel, especially when gas prices soar.

As a result, many Native people go without prenatal care. When Indigenous people don’t get the right care at the right time in the right place, mothers-to-be, their children, families and communities suffer.

Typically, in the third trimester, pregnant people have more frequent checkups, sometimes weekly. During this time, providers usually monitor weight and blood pressure and conduct screening tests for gestational diabetes or iron deficiencies. Providers may also check the baby’s size and heart rate as well as its position and monitor any problems that might arise.

Mack didn’t receive that care.

One morning, when she was helping her siblings prepare for school, her water broke. 

“Did I just pee my pants?” she wondered. “Should I go to the hospital?”

Samantha Mack

Samantha Mack, sitting with her sons Dustin, age 8, and Sebastian, age 4, at their home in Hysham, faced barriers in accessing prenatal care.

Nobody had told her what to expect. Mack’s mom drove her to Billings, where they confirmed she was in labor. The doctors flooded her with questions. What tests had she done? Did she get the glucose test? Was she able to get IV antibiotics?

But Mack couldn’t give answers. With her gap in prenatal care, she didn’t receive many of the standard tests.

Unable to respond, Mack said she felt dumb.

“I’m the one who’s pregnant,” she thought. “Shouldn’t I be able to answer them?”

Mack was relieved when her baby was born healthy, but other Native mothers and their children aren’t so lucky.

The Supreme Court’s decision to restrict abortion access has consequences for prenatal care everywhere. If more people become pregnant, more will seek care, potentially burdening hospitals and clinics even more. And if people aren’t able to terminate risky pregnancies, more will seek specialized care, which may or may not be available.

The ripple effects will disproportionately hurt Indian Country, where prenatal and maternal care is virtually nonexistent and where Native people already must drive long distances for specialized care.

What’s race got to do with it?

annie glover 1.png

Annie Glover is a senior research scientist at Rural Institute for Inclusive Communities at the University of Montana.

Annie Glover, a senior research scientist at Rural Institute for Inclusive Communities at the University of Montana, said it’s critical for people to understand that racial disparities do not exist because of some kind of “genetic marker that makes people of color at greater risk.”

“It’s most likely a compilation of factors that are related to historical trauma, generational trauma and that are related to access and care issues as well as socioeconomic issues,” she said. “It’s all intertwined.”

When studying race, Glover said racism is always a variable. The U.S. government in the 1970s authorized the forced sterilization of Native women, prompting a mistrust of the medical system. Glover said documented and undocumented biases in the health-care system persist today. People of color, for example, are more likely to receive unnecessary C-sections. And Native people report getting substance-use screenings at higher rates than white individuals in Montana, though the screenings are meant to be universal. A study showed that about half of white medical students endorsed the false “thick skin” myth, which incorrectly states that Black skin is thicker than white skin and therefore Black patients feel less pain.

Glover said perceived bias might also prompt pregnant people to bypass certain hospitals to get care at another.

“If you’ve lived with that kind of bias your whole life, you might feel that you’re going to be profiled and you might have less trust,” she said. “And that can start a whole sequence of events where you’re not getting the care you need because you’re afraid to.”

Obstetric care in decline

Access to hospital obstetric care — which concerns childbirth and the care of a person giving birth — in rural America is declining. One study found that 45% of rural counties had no hospital obstetric services at all. The same study revealed that from 2004 to 2014, 9% of rural counties in America lost all hospital obstetric services.

Hospital obstetric units are expensive. They require comprehensive liability insurance that lasts at least 18 years, as a child has the ability to sue a facility for something related to their birth until that age.

Experts say for these hospitals to break even on the money they spend on obstetric services, they need to see a certain number of births each year. But in rural communities where there might not be a lot of births, these facilities become especially hard to sustain.

Logan Health in Cut Bank, formerly called Northern Rockies Medical Center, encountered this problem in 2019. Then-CEO Cherie Taylor told the Cut Bank Pioneer Press that only about 32 patients from Cut Bank and surrounding areas used the facility to give birth. But for the clinic to break even on its investment, it needed to see at least 50 births annually.

Rich Rasmussen, president and CEO of the Montana Hospital Association, said at places where more babies are delivered, there is a lower incidence of bad outcomes. So, if a hospital only delivers a few babies a year, insurance companies take notice. In the case of a bad outcome, a hospital will pay the award for pain and suffering and face higher insurance rates.

Rich Rasmussen

Rich Rasmussen

“If you have one bad outcome, the bottom line is it can impact the cost of insurance for everything that you provide within that facility,” Rasmussen said.

Hospitals also want their obstetric staff to be proficient, constantly refining their skills and staying up-to-date on the latest medical guidance, he added. That can be challenging when there aren’t many births.

Additionally, Montana hospitals compete nationally and internationally for skilled medical professionals. Specialized providers don’t always want to move to rural areas.

 “If you’re an obstetrician, you want to deliver babies,” Rasmussen said. “And moving to a remote community where you’re not going to deliver many babies isn’t what called you into the profession.” 

‘What happens if something goes wrong?’

071722-mis-nws-prenatal-health

The Blackfeet Indian Health Service service unit in Browning is the only IHS facility on a reservation in Montana that has an obstetric hospital.

Indian Health Service (IHS), the federal agency responsible for providing medical care to federally recognized tribes, has seven service areas on reservations in Montana. Of those, only the Blackfeet Service Unit in Browning has a hospital obstetric unit. While many face barriers to care, at the Blackfeet IHS facility, a solution exists.  

The Crow/Northern Cheyenne IHS hospital once offered obstetric services, but in 2011 the Little Big Horn River flooded, surrounding the hospital with water and forcing it to close. When it reopened, obstetric services no longer were offered. Bryce Redgrave, IHS Billings area director, said after the flood, the facility “lost key medical personnel that supported the obstetric program.”

Generally, people only give birth at IHS facilities without an obstetric unit in an emergency. IHS, which is chronically underfunded, reported that in 2017 and 2018 more than 90% of American Indian births occurred outside its federal facilities.

jade 1.jpg

Jade Sooktis with her baby.

Jade Sooktis, however, was among the 10%. Sooktis, who is Northern Cheyenne, drove from Billings to Lame Deer for what was supposed to be a quick weekend trip. But when she got to the Northern Cheyenne Reservation, her water broke.

There wasn’t enough time for Sooktis, who was in her early 20s, to return to Billings for delivery. Instead, she rushed to the IHS clinic in Lame Deer. Sooktis knew the clinic wasn’t specialized, and she was worried.

“What happens if something goes wrong?” she remembers thinking. “What if I need a specialty doctor? Where will I go? What will I do?”

Sooktis’ daughter was born healthy, but she still remembers the anxiety she felt at the clinic.

“I was very scared,” she said. “It was a pretty intense situation.”

‘I just can’t afford to do this’

Because their facilities aren’t equipped, IHS often refers patients, especially those with high-risk pregnancies, to larger hospitals. But those transfers often don’t go according to plan.

When Mack became pregnant a second time, she went to the IHS clinic in Lame Deer right away. She’d had a pulmonary embolism a few months earlier and knew her pregnancy would be high-risk. She was determined to be on top of her care. 

The IHS doctors found a uterine hemorrhage and immediately transferred Mack to St. Vincent Healthcare in Billings for specialized care.

samantha.jpg

Samantha Mack poses with her sons. She faced barriers and complications in both pregnancies. 

“That’s when the issues started,” Mack said.

For the second time, it seemed there was a miscommunication surrounding her transfer from the Lame Deer IHS clinic to the Billings hospital.

Mack suffered from morning sickness and was losing weight. The Billings doctors weighed Mack every time she came in for an appointment, and as she watched the number on the scale decrease, she wondered why no one said anything.

“At what point will they be concerned?” Mack wondered. “I was 23, and I was worried. But I didn’t know how worried I should be because no one said anything.”

Mack suspects her doctors at St. Vincent Healthcare thought their sole job was to care for the baby. She thinks they may have assumed Mack had a separate doctor monitoring her condition. But that wasn’t the case.

Mack was already seeing a hematologist in Billings, and she didn’t have the time or money to add another doctor in Lame Deer to her schedule.

St. Vincent Healthcare

St. Vincent Healthcare.

“I had a hard time just trying to get those two appointments in Billings scheduled on the same day,” she said, referencing her hematologist and prenatal appointments. “When I had to make that trip to Billings every week, I was like, ‘I just can’t afford to do this.’”

Tescha Hawley — founder and executive director of Day Eagle Hope Project, an organization that helps rural Montanans navigate the complexities of the health care system — said it’s not uncommon for the IHS referral process to fail.

“It happens all the time,” she said. “And it’s not just with maternal care. … Their internal system is obviously broken. They don’t communicate all the information that needs to be shared, and they have a high turnover rate so things just sit on desks and don’t get processed in a timely manner.”

Hawley, a member of the Aaniiih and Nakoda tribes, said that while the process is frustrating and prone to failure, people are incentivized to seek care at IHS first because such a referral means the federal agency will pay for, or subsidize, the patient’s care elsewhere.

Because six of the seven IHS facilities on Montana reservations don’t have hospital obstetric units, people living on reservations must often travel long distances for adequate care.

A study examining birth certificate data from 2014 through 2018 found that Indigenous people are 20 times more likely to give birth at a hospital without an obstetric unit, demonstrating that the lack of access to care influences where people give birth.

American Indian people in Montana traveled “significantly farther” — on average 24.2 minutes farther — than white individuals to access obstetric care.

maggie thorsen 1.jpg

Maggie Thorsen is an associate professor at Montana State University.

Montana is the fourth largest state and the ninth least populated. The state’s remote infrastructure, complete with long, winding, unlit roads that often lack cell service makes travel difficult. Winter conditions can make it dangerous.

“If your closest facility or the facility that you’ve chosen to give birth is two or three hours away, either you’re going to risk giving birth on the side of the road and make that drive when you’re in labor or you have to plan your whole life around the fact that this is where you have to give birth,” said Maggie Thorsen, an associate professor at Montana State University who co-authored the study.

Thorsen said some people arrange hotel stays ahead of their due date to be closer to care but added the option is not available to people who can’t afford a hotel, don’t have a reliable car, have inflexible jobs, or have children in school. When people encounter these barriers, according to Thorsen, their choices “get more constrained.”

When Sooktis was pregnant with her youngest daughter, she drove 104 miles one-way from her home in Lame Deer to Billings for prenatal care each week in her third trimester.

Sooktis estimates she traveled 1,000 miles a month for care alone. She’s thankful she had a flexible job but acknowledged that many people don’t. With soaring gas prices, Sooktis said she “can’t even imagine what it would be like now for pregnant women.”

jade 2.jpg

Jade Sooktis with her children.

“When gas prices weren’t insane, just trying to save funds for gas, food and those appointments was hard,” she said. “In these current times, I just don’t know how women are handling it.”

Hawley, who lives on the Fort Belknap Reservation, has done everything she can think of to help people in the area access high-quality care.

She’s asked IHS to escort patients to larger hospitals in Havre, Great Falls or Billings for specialized care. She’s tried to raise money through her nonprofit to buy a vehicle so she could transport people to hospitals herself. She said people will donate $25 or $50 at a time, but it isn’t enough to purchase a reliable vehicle.

Sometimes, if Hawley has raised enough money, she’ll give gas cards to people seeking medical care.

“But that depends on if they have a reliable car, or if they have a car at all,” she said, adding that about 40% of Fort Belknap Reservation residents live below poverty level.

As Hawley put it, “There are so many big barriers that it’s hard to help.

“When it comes to transportation, it’s a nightmare, and when you talk about maternal care, it’s next to nonexistent here,” she said. “We have no specialized care here.”

Hawley said most people at Fort Belknap will drive 80 to 100 miles northwest to Havre to give birth. But if people aren’t able to drive, she said, “They simply go without care.”

“Or they will only go when they absolutely need to,” she said. “The reality is when women don’t get the quality care they need, that puts them at risk and it puts the unborn fetus at higher risk, too.”

Long distances to specialty care

Benefis

Benefis Hospital in Great Falls.

As of Thorsen’s study in 2018, Montana had three level three hospital obstetric facilities that could handle complex maternal and fetal medical conditions — Benefis Health System in Great Falls, St. Vincent Healthcare in Billings and Missoula Community Medical Center. Rasmussen said Billings Clinic and Logan Health in Kalispell also provide level three maternal care.

According to Thorsen’s study, Native Americans with risky pregnancies, on average, lived more than 3 hours from a level three hospital. 

Even when focusing on the white individuals living in the “most remote rural areas" of Montana, Thorsen’s study found that high-risk Native Americans still traveled “statistically significantly farther than white women to access the same level of care.”

A high-risk pregnant person living in Harlem on the Fort Belknap Reservation, for example, would travel 2 hours and 35 minutes to get specialty care at Benefis in Great Falls. Someone in Browning would travel 2 hours to get to Kalispell for high-level care. And someone living in Poplar on the Fort Peck Reservation would travel 4 hours and 33 minutes to get to St. Vincent Healthcare in Billings.

When Veronika Mack, Samantha’s sister, started feeling contractions, she drove an hour from her home in Hysham to Billings.

“I’d go up there, they’d check me, they’d keep me for a while, and nothing would happen,” she said.

For two days, Veronika’s mother drove Veronika to Billings to get checked and drove an hour home to Hysham. Finally, after their third drive in three days, Veronika gave birth to her son just 17 minutes after setting foot in the emergency room.

“That one was definitely close,” she said. 

veronika.jpg

Veronika Mack, who is Northern Cheyenne, sits with her husband and children. 

When Veronika became pregnant again, she knew she didn’t want to make the nerve-wracking and uncomfortable drives back and forth to the hospital. This time, she was induced and was able to stay at the hospital until she delivered.

“It was so nice,” she recalled. “I got to just stay there and not worry about if I was gonna make it.”

0 Comments
You must be logged in to react.
Click any reaction to login.
0
0
0
1
0

* I understand and agree that registration on or use of this site constitutes agreement to its user agreement and privacy policy.

Related to this story

Listen now and subscribe: Apple Podcasts | Google Podcasts | Spotify | Stitcher | RSS Feed | Omny Studio

Get up-to-the-minute news sent straight to your device.

Topics

News Alert

Breaking News