Prenatal Care for American Indian Women Notes
Abstract
Early and regular prenatal care is crucial for preventing complications in pregnancy, birth, and newborn health, leading to improved health outcomes for both pregnant women and their infants. This care encompasses several key components, including health education, risk factor identification, and management of existing complications. American Indian/Alaska Native (AI/AN) women face a higher risk of such complications due to health disparities like poverty, lower education levels, limited access to healthcare services, and a higher incidence of adverse childhood events (ACEs). These disparities are often compounded by historical trauma, which includes the loss of land, culture, and spiritual traditions. These women encounter specific barriers to accessing and utilizing prenatal care, including geographical access issues, differing communication styles between healthcare providers and patients, and inconsistent care continuity, often resulting in a lack of trust in the healthcare system.
Culturally appropriate prenatal care and community-based interventions, such as home visiting programs tailored to the specific needs and beliefs of AI/AN communities, are vital to reduce maternal and newborn morbidity and mortality. These interventions should incorporate traditional healing practices and involve community elders to foster trust and improve engagement. Special attention is given to the American Indian tribes of the Northern Great Plains, such as those in North Dakota, where health disparities are particularly pronounced, necessitating targeted and culturally sensitive interventions.
Introduction
There are 573 federally recognized AI/AN tribes in the United States, with approximately 5.2 million members enrolled in Indian Health Services (IHS, 2019). These tribes vary significantly in culture, language, and geographic location, requiring a nuanced approach to healthcare delivery. AI/AN people experience lower health status compared to the general U.S. population, with a life expectancy 5.5 years lower and a higher disease burden due to factors like inadequate education, poverty, discrimination, and cultural differences (IHS). Discrimination within the healthcare system and a lack of cultural competency among healthcare providers further exacerbate these disparities. These health disparities manifest early in life, as evidenced by a high infant mortality rate of 9.21 deaths per 1,000 live births in the AI/AN population, compared to 4.67 deaths per 1,000 live births among non-Hispanic whites and the overall U.S. average of 5.79 deaths per 1,000 live births (Ely & Driscoll, 2019). This elevated infant mortality rate underscores the urgent need for improved maternal and child health services. A recent study revealed that severe maternal morbidity and mortality rates were twice as high among AI/AN women compared to non-Hispanic white women, with rates higher in rural settings than urban settings (Kozhimannil et al., 2020). Factors contributing to this include limited access to emergency services and specialized care in rural areas.
Importance of Prenatal Care
Early and regular prenatal care is essential for the health of childbearing women and infants, helping to prevent complications during pregnancy, birth, and the newborn period. This care includes regular check-ups, screenings for potential health issues, and education on nutrition and healthy behaviors. AI/AN women face significant risks for pregnancy, birth, and newborn health complications due to health disparities and comorbidities like chronic hypertension and preexisting diabetes (Hanson, 2011; Kozhimannil et al.). The prevalence of these conditions highlights the need for integrated healthcare approaches that address both chronic disease management and prenatal care. They experience barriers to prenatal care, including lack of access to healthcare facilities, dissimilar communication styles between providers and patients (e.g., differing expectations around directness and eye contact), and inconsistent continuity of care, often due to high turnover among healthcare staff in IHS facilities. Therefore, culturally appropriate prenatal care should be provided to reduce maternal and newborn morbidity and mortality. This care should incorporate traditional healing practices, involve community health workers, and provide education in the patient's native language. Community-based, evidence-based interventions such as home visiting are presented as potential strategies to improve prenatal care, particularly focusing on the American Indian tribes of the Northern Great Plains, specifically North Dakota. These programs can provide personalized support and education in a familiar setting, helping to overcome barriers to care and improve health outcomes.
Social Determinants of Health
An individual's or community's health depends on access to social and economic opportunities, resources, support, quality education, environmental safety, and positive social interactions (Healthy People 2020). These factors collectively shape health outcomes and contribute to health equity. The five social determinants of health, as defined by Healthy People 2020, include economic stability, education, social and community context, health and healthcare, and neighborhood and environment. These determinants are interconnected and influence a wide range of health outcomes. The Centers for Disease Control and Prevention notes that disparities exist when differences in health outcomes are observed between populations (2013). Addressing these disparities requires targeted interventions that address the underlying social and economic factors contributing to poor health. Poverty and health are inextricably linked. People living in poverty often lack access to nutritious food, safe housing, and quality healthcare, all of which negatively impact their health. Statistics on social determinants of health in the AI/AN population are concerning. Seventy-two percent of AI/AN individuals earn a high school diploma, compared with 78% of non-Hispanic blacks and a national average of 85% (National Center for Educational Statistics, 2019). This lower educational attainment limits employment opportunities and contributes to economic instability. The 2019 Kids Count Data Book notes that 33% of AI/AN and non-Hispanic black children live in poverty, compared with the U.S. average of 18% (Annie E. Casey Foundation, 2019). This high rate of child poverty has long-lasting consequences for health and well-being. In 2017, the unemployment rate in the United States was , but the unemployment rate for the AI/AN population was , slightly above the non-Hispanic black unemployment percentage of (National Center for Educational Statistics). These high unemployment rates contribute to economic hardship and limit access to essential resources.
The AI/AN population is one of the most economically impoverished populations in the United States (Weinstein et al., 2017). This economic hardship is rooted in historical injustices and ongoing systemic inequities. U.S. Census Bureau data of 2015 show a median income of dollars and a poverty rate for the AI/AN group, compared with a dollar median income and a poverty rate for the nation (Weinstein et al.). This significant disparity in income has a profound impact on health and well-being. Disparity in income has a significant impact on health and well-being. Limited financial resources can restrict access to healthy food, safe housing, and quality healthcare. The Great Plains tribes (North Dakota, South Dakota, Nebraska, and Iowa) are prone to poorer health outcomes and shorter life expectancy than many other service areas (Weinstein et al.). This is due to a combination of factors, including geographic isolation, limited access to resources, and historical trauma. An example of this disparity is Sioux County, located within the Standing Rock Sioux Reservation, which ranks 49th of 49 North Dakota reporting counties in overall health outcomes, including a life expectancy of years, with of children living in poverty and of households being single-parent households (University of Wisconsin Population of Health Institute, 2019). These statistics highlight the dire need for targeted interventions to improve health and well-being in this community.
Prenatal Care Focus
The focus of prenatal care is to educate pregnant women, identify risk factors in both mother and baby, alleviate preventable risk factors, and treat complications (National Academies of Sciences, Engineering, and Medicine [NASEM], 2020). This includes providing education on nutrition, exercise, and avoiding harmful substances, as well as screening for conditions like gestational diabetes and preeclampsia. Ideally, prenatal care should begin within the first trimester of pregnancy (American Academy of Pediatrics & American College of Obstetrics and Gynecology, 2017). Early prenatal care allows for the identification and management of potential health issues, improving outcomes for both mother and baby. The percentage of women receiving prenatal care has steadily increased, with receiving prenatal care in the first trimester in 2018 (Martin et al., 2019). However, disparities persist across different racial and ethnic groups. First trimester prenatal care varies greatly by race, with non-Hispanic whites receiving care at , non-Hispanic blacks at , and AI/AN at (decreased from in 2017) in 2018 (Martin et al.). This disparity highlights the need for targeted interventions to improve access to early prenatal care for AI/AN women. Although the percentage of AI/AN pregnant women receiving early prenatal care has risen from in 2010, the growth continues to lag other population groups (Johnson et al., 2010; Martin et al.). This slow growth underscores the persistent barriers to care faced by AI/AN women. U.S. data in 2018 revealed an overall late or no prenatal care percentage of for non-Hispanic whites, whereas this percentage was in the AI/AN population (Martin et al.). This significant difference highlights the critical need for interventions to improve access to and utilization of prenatal care among AI/AN women.
Geographical Differences
Geographical differences have been noted in the percentages of AI/AN women receiving late or inadequate (infrequent visits) prenatal care. Access to care is often more limited in rural and remote areas. Johnson et al. (2010) reported a notable disparity occurring in the Midwest cluster of states, including North Dakota, with the percentage of inadequate prenatal care (inconsistent care) of in the United States for non-Hispanic whites and for AI/AN; the North Dakota percentage for AI/AN women receiving inadequate prenatal care was . This high percentage in North Dakota underscores the urgent need for targeted interventions in this region. Late or inadequate prenatal care increases the risk factors for poor birth outcomes, premature birth, and increased rates of infant mortality (Hanson, 2011). These poor outcomes have long-lasting consequences for individuals, families, and communities. Given the infant mortality rate of 9.21 deaths per 1,000 live births in the AI/AN population versus the overall U.S. average of 5.79 deaths per 1,000 live births, obtaining early and regular prenatal care is a critical aspect for pregnant AI/AN women (Ely & Driscoll, 2019). This data emphasizes the importance of addressing the barriers to prenatal care faced by AI/AN women. The American Indians of the Northern Great Plains (North Dakota and South Dakota) consistently rank highest for AI/AN health disparities (Danielson et al., 2018). This is due to a complex interplay of factors, including poverty, limited access to healthcare, and historical trauma. A 2018 study using 2007–2012 live birth data in North Dakota describes numerous racial disparities for high risk factors and poorer birth outcomes in American Indian women compared with white women including:
1. 4 times higher preterm birth rate (<37 weeks gestation)
1. 3 times higher low birthweight (<2,500 g)
2. 5 times higher infant mortality rate
3. 3 times less likely to receive adequate prenatal care
4. 7 times higher birth to teen mothers
5. 3 times higher use of illegal drug use
6. 2 times higher incidence of sexually transmitted infections present during pregnancy (Danielson et al.).
Maternal risk factors leading to poor birth outcomes among AI/AN women include psychosocial, behavioral, sociodemographic, and medical variables (Raglan et al., 2016). Addressing these risk factors requires comprehensive and culturally sensitive interventions.
Risk Factors
Psychosocial and Behavioral Factors
Brave Heart (1998) explored the historical trauma theory as it applies to the American Indian population’s loss of life related to warfare and infectious diseases, homeland, culture, and spiritual traditions due to colonization by the advancing settlement by Europeans of North America. This historical trauma has had a devastating and long-lasting impact on AI/AN communities. The resulting historical trauma or unresolved grief, which has been described as a “soul wound,” has affected subsequent generations as family units were separated and cultural practices forbidden (Brave Heart, 1998). This has led to a cycle of trauma, poverty, and poor health outcomes. American Indian children were taken from their homes and placed in boarding schools for assimilation into the dominant culture well into the 1950s (Whitbeck et al., 2009). These boarding schools were often sites of abuse and cultural suppression. Several generations of those children were deprived of traditional parental role models, thus interrupting the intergenerational transmission of healthy child-rearing practices (Warne & Lajimodiere, 2015). This has had a profound impact on parenting skills and family relationships. In addition to separation from family and homeland, many of those in the boarding schools were exposed to physical, sexual, and emotional abuse leading to mental health trauma and the subsequent high rates of alcohol-related health statistics, including injuries, domestic violence, homicide, and suicide (Warne & Lajimodiere, p. 571). These issues continue to plague AI/AN communities today.
Kenney and Singh (2016) studied the prevalence of parent-reported adverse childhood events (ACEs) in AI/AN children from 0 to 17 years of age. Adverse childhood events (ACEs) are traumatic experiences that occur before the age of 18 and can have long-lasting negative effects on health and well-being. Results revealed that AI/AN children experience higher instances than non-Hispanic white children in eight of nine ACEs: income deprivation, witnessing or experiencing violent victimization, racial/ethnic discrimination, household substance abuse, domestic violence, parental incarceration, divorce, and death of a parent (Kenney & Singh, 2016, p. 9). This high prevalence of ACEs underscores the significant challenges faced by AI/AN children. Higher accumulation of ACEs increases the prevalence of lack of emotional control, school problems, depression, and anxiety (Kenney & Singh). These mental health issues can have a significant impact on academic achievement, social relationships, and overall well-being. Historical trauma, including the implementation of boarding schools, has led to the interruption of traditional parenting skills, intergenerational depression, increases in alcohol and substance abuse, and mistrust of the dominant white population related to government relocation and broken treaties, and a response to a profound denial of a culture’s right to exist and the attempt to eradicate cultural identity (Whitbeck et al., 2009, p. 12). Addressing this historical trauma is essential for promoting healing and improving health outcomes. The prevalence, role, and impact of ACEs on health disparities in the AI/AN population must be thoroughly evaluated to redistribute health resources toward health promotion rather than chronic disease management (Warne & Lajimodiere, 2015). This requires a shift from a disease-focused approach to a holistic approach that addresses the underlying social and economic factors contributing to poor health. Although prenatal care is well recognized as preventative care, factors of depression, substance abuse, and family disruption due to historical trauma and adverse childhood events in the lives of American Indian women have neither fostered nor supported an environment of health promotion but rather led to poor outcomes for maternal and newborn care. Addressing these issues is critical for improving maternal and child health outcomes.
Sociodemographic Factors
Access to prenatal care may be limited due to a lack of healthcare providers, a lack of or unreliable transportation, and household instability. These factors create significant barriers to care, particularly in rural and remote areas. An example is Sioux County, North Dakota, with a primary care provider to resident ratio of 1,460:1 as compared with the state ratio of 775:1 and a severe housing problem (defined as a percentage of households with at least one of four housing problems: overcrowding, high housing costs, lack of kitchen facilities, or lack of plumbing facilities) of 23% as compared with the state percentage of 11% (University of Wisconsin Population of Health Institute, 2019). These statistics highlight the challenges faced by residents of Sioux County. Maternal age less than 18 years of age and unmarried pregnant women are associated with a greater risk for preterm birth (Raglan et al., 2016). Teen pregnancies and single parenthood often lead to increased stress and limited access to resources. According to 2018 birth data, of AI/AN births were to mothers less than 20 years of age (U.S. average ) and of AI/AN births were to unmarried women (U.S. average of ; Martin et al., 2019). These statistics underscore the need for targeted interventions to support teen mothers and single parents. Factors such as poor housing may not have a direct impact on a woman’s access to prenatal care; however, components of a potentially chaotic household (>four members), a young maternal age, and unmarried status (potentially less support) may negatively influence implementation and consistency of prenatal care. Addressing these social and economic factors is essential for improving maternal and child health outcomes.
Cultural Factors
Although the great majority of AI/AN women have access to prenatal care and participate in prenatal care, it is necessary to gain a better understanding as to why this care may be late or inadequate. This requires addressing cultural barriers and building trust between healthcare providers and patients. Hanson (2011) interviewed 58 Northern Plains American Indian women of childbearing age who had given birth to a live infant. Themes identified were communication, institutional, and interpersonal barriers. These barriers can significantly impact access to and utilization of prenatal care. Communication barriers included: physicians who seemed too busy to respond to questions, physicians who seemed not to care about the woman as an individual, and a lack of trust in physicians and their “modern ways” (Hanson, 2011). Addressing these communication barriers requires cultural competency training for healthcare providers. These substandard communication experiences not only deterred women from seeking care during pregnancy but experiences were also shared with other women thus creating distrust of the provider or healthcare system. Building trust is essential for improving healthcare access and outcomes. Institutional barriers identified in the clinic setting during prenatal visits or postpartum visits included: long waiting times followed by a short visit with the provider, lack of a separate waiting room for pregnant women and young infants, and inconsistency in seeing the same provider from visit to visit leading to the inability to form a trust relationship (Hanson). Addressing these institutional barriers requires systemic changes to improve the patient experience. Interpersonal barriers included unreliable transportation; personal problems such as abuse, depression, or substance abuse overriding prenatal visits; and discomfort with seeing a male physician during pregnancy (Hanson). Addressing these interpersonal barriers requires comprehensive support services, including transportation assistance, mental health counseling, and substance abuse treatment. This study provides valuable information as to how barriers to prenatal care for American Indian women could be overcome. Implementing these strategies is essential for improving maternal and child health outcomes. McGary (2012) describes the impact of minority populations’ distrust of the healthcare system has upon health; whether this distrust is warranted or not, in a just society it must be addressed. Building trust requires transparency, accountability, and a commitment to cultural competency.
Over 500 federally recognized AI/AN tribes exist in the United States, each with their own unique, culturally significant spiritual and ceremonial traditions, but some similarities among them are identifiable. Understanding these cultural traditions is essential for providing culturally sensitive care. In many tribes, physical and spiritual health are closely related with mind, body, and spirit all contributing to health and well-being (Valdez et al., 2009). This holistic approach to health should be incorporated into prenatal care. American Indian/Alaska Native belief systems hold that children are a gift from the Creator; therefore, childbearing women are to be honored and respected as givers of this sacred life (IHS, n.d.). This belief system should be respected and incorporated into prenatal care. Family kinships are very important to AI/AN people with elders playing an important role during the pregnancy and in the rearing of children and often includes an extended family of grandmas, “aunties,” and cousins (Hanson, 2011). Involving elders and extended family members in prenatal care can provide valuable support and guidance. As tribal beliefs and traditions vary greatly, the key to culturally sensitive care is to talk to AI/AN women about their unique spiritual beliefs, ceremonies, and use of complementary medicine. This requires open communication and a willingness to learn about different cultural perspectives.
Potential Solutions for Improving Maternal–Newborn Outcomes
Mortality among U.S. children has declined significantly over the past several decades; however, substantial disparities still exist for those living in poorer communities (Olds et al., 2014). Addressing these disparities requires targeted interventions that focus on the needs of low-income families. A nurse home visiting program, the Nurse-Family Partnership (NFP) for low-income, first-time mothers with home visits during pregnancy through the first 2 years of the child’s life began in 1990 (Olds et al.). Nurse-Family Partnership (NFP) is an evidence-based community health program that supports vulnerable first-time mothers and their families. Children visited by nurses demonstrated higher intellectual functioning, greater vocabulary scores, and fewer behavioral problems (Olds, Kitzman, et al., 2004). These positive outcomes highlight the benefits of early intervention. Follow-up data 2 decades later revealed lower mortality rates in both mothers and children in the NFP (Olds et al.). This demonstrates the long-term impact of home visiting programs. A similar study examining differences between nurse home visits and paraprofessional home visits in pregnancy and infants through 2 years of age revealed interesting though complex results. Though results were positive for both types of home visitation, nurse home visit children scored higher in language development, behavioral adaptation, and executive functioning, whereas the paraprofessional home visit mothers reported a greater sense of mastery and better mental health (Olds, Robinson, et al., 2004). These findings suggest that different types of home visiting programs may have different strengths. Olds, Robinson, et al. (2004) theorized the nurse visitors perhaps focused more on infant development, whereas the paraprofessionals focused more on maternal well-being. This highlights the importance of tailoring home visiting programs to meet the specific needs of mothers and children.
Numerous studies have supported the short- and long-term benefits of home visiting programs during pregnancy and infancy in low-income, at-risk families with limited access to care (Barlow et al., 2006). Home visiting programs can improve maternal and child health outcomes by providing education, support, and access to resources. In 2001, Barlow et al. implemented a paraprofessional home visiting program on two reservations in the Southwest; paraprofessionals were chosen due to a shortage of nurses on the reservations, greater cost of a nurse versus a paraprofessional, and ability to train tribal community members who were familiar with the culture as paraprofessionals (Barlow et al.). This approach leverages the knowledge and expertise of community members to deliver culturally sensitive care. The paraprofessionals received 500 hours of training and testing after the protocols (25 visits in 41 lessons from 28 weeks gestation to 6 months postpartum) and lessons were developed (prenatal care, breastfeeding, infant care, parenting, etc.). This comprehensive training ensures that paraprofessionals are well-equipped to provide high-quality support. Cultural adaptation to lesson material including style, graphics, and content was made through community-based participation (Barlow et al.). This ensures that the program is relevant and acceptable to the community it serves. Results found mothers were significantly more knowledgeable about infant care at 2 and 6 months postpartum. This demonstrates the effectiveness of paraprofessional home visiting programs in improving maternal knowledge.
Two additional studies have been completed because the initial 2001–2002 study as the paraprofessional home visitation program has made several expansions and minor revisions to the original program (Mullany et al., 2012; Walkup et al., 2009). This ongoing evaluation and refinement ensures that the program remains effective and responsive to the needs of the community. In 2006, the paraprofessional home visiting program became known as the Family Spirit Program (n.d.) through a collaborative process known as Community Based Participatory Research (CBPR), involving the Johns Hopkins Center for American Indian Health and the tribal communities receiving the home visiting program (Mullany et al.). Community Based Participatory Research (CBPR) is a collaborative approach to research that involves community members in all aspects of the research process. Given the history of mistrust of government and the historical trauma experienced by AI/AN people, obtaining the full participation and decision-making of the communities was essential. This ensures that the program is culturally appropriate and addresses the specific needs of the community. Community Based Participatory Research engages community members and their local knowledge to understand health problems and design interventions to better address specific barriers of a population (Montag et al., 2012; Mullany et al.). This approach empowers community members to take ownership of their health. A 2015 study of paraprofessional home visiting assessed the 3-year outcomes of the Family Spirit Program in the domains of parental competence, maternal emotional and behavioral functioning, and children’s emotional and behavioral functioning (Barlow et al., 2015). This comprehensive evaluation provides valuable data on the effectiveness of the program. Results of 320 participants (mothers) found the group receiving the Family Spirit Program reported higher parenting knowledge and lower scores for depression and externalizing problems (opposition/defiance, rule breaking, and social problems); child outcomes at 12 months and 36 months of age revealed lower scores for externalizing behavior (activity/impulsivity; defiance/aggression), internalizing behavior (distress/anxiety; inhibition/withdrawal), and dysregulation (of sleeping, eating, emotions, and sensory experiences) (Barlow et al.). These positive outcomes demonstrate the effectiveness of the Family Spirit Program in improving maternal and child well-being.
Recent tribal Maternal Infant Early Childhood Home Visiting (MIECHV) federal funding has been set aside to improve knowledge on how to best provide evidence-based home visiting interventions to low-income AI/AN communities (Barlow et al., 2018). This funding supports the development and implementation of culturally appropriate home visiting programs. Four tribal settings have begun the Family Spirit home visiting program: the Choctaw Nation of Oklahoma, the White Mountain Apache Tribe in Arizona, the Kodiak Area Native Association in Alaska, and an urban Indian center in Oakland, California (Barlow et al.). These sites reflect the vast diversity of land, culture, language, and population density of AI/AN people in the United States. This diversity highlights the importance of tailoring programs to meet the specific needs of each community. Lessons learned from these four sites and other tribal-based home visiting programs will advance the positive outcomes noted in previous Family Spirit home visiting programs to better address the health, economic, and educational disparities of the AI/AN people. By sharing best practices and lessons learned, these programs can contribute to improved health outcomes for AI/AN communities nationwide.
Clinical Implications
Research has shown that prenatal and early childhood home visiting programs in low-income, at-risk mothers and their children have positive maternal and child outcomes (Olds, Kitzman, et al., 2004; Olds et al., 2014; Olds, Robinson, et al., 2004). This evidence supports the widespread implementation of home visiting programs. Research has also shown that paraprofessional home visiting programs (Family Spirit) to pregnant American Indian women and their young children have positive outcomes, including an increase in parental competence and improvement in maternal and children’s emotional and behavioral functioning (Barlow et al., 2015; Mullany et al., 2012; Walkup et al., 2009). These findings highlight the effectiveness of culturally tailored home visiting programs. Given the concerning statistics related to late entry into prenatal care or inadequate prenatal care for AI/AN women compared with the general U.S. population, it is obvious that changes need to be made. Addressing this disparity requires a multi-faceted approach that includes improving access to care, addressing cultural barriers, and building trust between healthcare providers and patients. Further research is needed to determine the impact of home visiting programs on earlier entry and increased consistency in prenatal care. This research should focus on identifying best practices for implementing and evaluating home visiting programs in AI/AN communities. Social determinants of health have been identified that have an impact on the likelihood of AI/AN women receiving early and adequate prenatal care, including socioeconomic, psychosocial, behavioral, and sociodemographic factors. Addressing these social determinants of health is essential for improving maternal and child health outcomes. Historical trauma has exacerbated the distrust of government, healthcare, and the dominant white society. Building trust requires transparency, accountability, and a commitment to cultural competency. Barriers to prenatal care related to communication, institutional policies, and interpersonal problems have been identified. Addressing these barriers requires systemic changes to improve the patient experience. Collaboration between maternal newborn healthcare providers, the public health community, and IHS facilities could remove these barriers to prenatal care. This collaboration should involve community members and tribal leaders.
Maternal–child nurses and public health nurses are well-versed in preventative care and could initiate conversations within their respective entities to work toward the development of the Family Spirit paraprofessional home visiting program on each tribal reservation. Nurses can play a key role in advocating for and implementing home visiting programs. Funding of evidence-based home visiting interventions is available through tribal MIECHV (Barlow et al., 2018). This funding provides an opportunity to expand access to home visiting programs in AI/AN communities. A CBPR approach, engaging the tribal council, community members, IHS representatives, and the public health community, would garner support for such a program. This collaborative approach ensures that the program is culturally appropriate and addresses the specific needs of the community. According to Butts and Rich (2013, p. 46), the mission to define and attain some measure of social justice is an ongoing and difficult activity. Achieving health equity for AI/AN communities requires a sustained and dedicated effort. Nurses are known to be strong patient advocates; advocacy must move from the individual patient bedside to the community setting when unmet patient needs have been identified (Butts & Rich, 2013). Nurses can advocate for policies and programs that support maternal and child health in AI/AN communities. Adequate and consistent prenatal care for AI/AN women has been identified as one of those unmet needs; maternal–child and community and public health nurses must become stronger advocates for AI/AN women and their young children. By advocating for improved access to prenatal care, nurses can help to reduce health disparities and improve outcomes for AI/AN women and their children. Research has shown that a paraprofessional home visiting program for pregnant women and their young infants that engages the knowledge and participation of the tribal community will bring about positive maternal and infant outcomes in American Indian women. This evidence supports the implementation of culturally tailored home visiting programs. Although prenatal care and maternal infant outcomes have steadily improved in the United States in the past 20 years, this positive trend in health has not been realized by the AI/AN population (Ely & Driscoll, 2019; Kozhimannil et al., 2020). This disparity highlights the urgent need for action to address the health needs of AI/AN communities. The health disparities of the AI/AN population, specifically the population of Sioux County, ND, have been provided. This data underscores the challenges faced by this community. It is noted that an evidence-based home visiting program is absent from this region. Implementing a home visiting program in Sioux County could have a significant impact on maternal and child health outcomes. The Family Spirit paraprofessional home visiting program for childbearing women and infants could bring positive health outcomes to Sioux County. This program is a