On today's show...
We start the episode with SDPB's Jackie Hendry's interview with Susan Wicks for South Dakota Focus. Wicks is a behavioral health therapist at Sanford Health.
They discuss perinatal mood and anxiety disorders, including how to reduce stigma and the symptoms to watch for.
Plus, we have a roundtable discussion on Indigenous prenatal and postpartum health needs in the state.
Zintkala Black Owl is a traditional Indigenous midwife. She is facilitator of the He Sapa Birth Circle located in the Black Hills and serving all of the Oceti Sakowin territory.
Natalie Stites Means was a committee member of the South Dakota Advisory Committee to the U.S. Commission on Civil Rights, which published the report on maternal mortality and health disparities of American Indian Women in South Dakota.
Amanda Youngers is a certified nurse midwife at the Great Plains Tribal Health Leaders Board at the Oyate Health Center. She also spent 13 years practicing as a midwife in the Pine Ridge Indian Reservation.
Michaela Seiber is the CEO of South Dakota Urban Indian Health. She is a former adjunct instructor at the University of South Dakota, where she taught Native American Communities and Public Health.
The following transcript was autogenerated.
Lori Walsh:
You are listening to In the Moment on South Dakota Public Broadcasting. I'm Lori Walsh.
Lori Walsh:
Well, we are spending the rest of this hour talking about prenatal and postpartum care in South Dakota, focusing now on the care provided to indigenous mothers and children. We have four guests convened across the state for this conversation. Joining us from SDPB's Black Hill Surgical Hospital Studio, we have Zintkala Blackowl. Zintkala is a traditional indigenous midwife. She's facilitator of the He Sapa Birth Circle located in the Black Hills, serving all of the Oceti Sakowin territory. Zintkala, I invite you to introduce yourself to our listeners?
Zintkala Blackowl:
Good morning. My name is Zintkalamahpiyahwin Blackowl. Happy to be here.
Lori Walsh:
Also with us from the Rapid City Studio, Natalie Stites Means. Natalie was a committee member for the South Dakota Advisory Committee to the US Commission on Civil Rights. This is a committee that put forth a report on maternal mortality and health disparities of American Indian women in South Dakota. Natalie, welcome. You can introduce yourself as well if you like?
Natalie Stites Means:
Hello, I'm really happy to be here today to talk about this important topic and my name is Natalie Stites Means and I'm a tribal member from the Cheyenne River Sioux Tribe.
Lori Walsh:
Also with us in Rapid City, Amanda Youngers. Amanda is a certified nurse midwife at the Great Plains Tribal Health Leaders Board at the Oyate Health Center. She also spent 13 years practicing as a midwife in the Pine Ridge Indian Reservation. Amanda, welcome as well. Thanks for being here.
Amanda Youngers:
Hi, good afternoon. Thank you so much for having us. I think this is a very pertinent and important topic for all of us to address today.
Lori Walsh:
Yeah, thank you for that. Now, over here in Sioux Falls, in SDP's Kirby Family Studio, we have Michaela Seiber. Michaela is the CEO of South Dakota Urban Indian Health. She's a former adjunct instructor at the University of South Dakota where she taught Native American communities and public health. Welcome back. Say hello.
Michaela Seiber:
Hello. Yes, happy to be here. I am a tribal member of the Sisseton-Wahpeton Oyate and I've been CEO at Urban Indian Health for three years now.
Lori Walsh:
All right, let's get started. And just because we have four voices on different sides of the state and we can't all see each other, you're welcome to jump in and interrupt, but if you do, go ahead and let listeners know who's speaking so they can keep track on who all these powerful female sounding voices are.
Lori Walsh:
And Natalie, I want to start with you. Tell me a little bit about what we know and what we don't know about disparities on maternal mortality and health. We study it, but not in a way that is meaningful and sustained. Where do you want to begin with that, Natalie?
Natalie Stites Means:
Well, the Maternal Mortality and Health Disparities of American Indian Women in South Dakota report that we issued in July of 2021 identified a broad spectrum of shortcomings and challenges that are facing native women in South Dakota, both rooted in rural, being rural, being remote, as well as in being indigenous and facing racial discrimination. And so I often... And we heard through the course of at least four hearings I want to say, and this was during the pandemic, we heard from a number of advocates, health professionals and providers on the issues relating to maternal mortality and prenatal care ended up being definitely a focus that was important.
Natalie Stites Means:
I do think that there's an adequacy of data adequacy. A lot of times the inadequacy of data is something that is an academic perception and rather than what the reality of everyday indigenous women who are pregnant who need access to healthcare to preserve their lives and the lives of their infants because both incidences are extraordinarily high for Lakota women in particular in South Dakota. And that is dying during childbirth or having an infant die during childbirth. And it's overall high in South Dakota, a big part of that is our lives.
Lori Walsh:
So you think we have, what I'm hearing you say, we have enough information to make meaningful change. Did I hear that correctly?
Natalie Stites Means:
Absolutely.
Lori Walsh:
Zintkala, I want you to jump in here and tell us a little bit about the He Sapa Birth Circle first and how that intersects with the work that you do and the overall obstacles that we have to getting good prenatal care and good maternal care?
Zintkala Blackowl:
Thank you. I think that a lot of times when we look at the state of experience, the landscape of birth, the approach is to medicalize it more and to maybe bring in more hospitals, more medical care, get women more medical care. And our approach at He Sapa Birth Circle is more rooted in community and rooted... We call ourselves a grassroots organization because we're rooted in being with the community. Our care is rooted in more of a wraparound, getting to know people. People know that they can reach out to us for more than just their needs in birth and in reproduction. They can reach out to us for needs that have to do with their quality of life.
Zintkala Blackowl:
So it's definitely more a holistic approach to prenatal care and also very focused on bringing knowledge to the people, bringing the knowledge and skill of what's going on when you're pregnant, what's going on in your reproductive cycle. Because most people go to the doctor because they don't have any real idea about what's going to happen to them while they're pregnant. They don't know what they need to be eating or how to take care of themselves, and that puts people in a position where they must have medical care, they must have a doctor, and that creates more danger, especially in rural remote communities like where we live in South Dakota.
Lori Walsh:
So let's dive deeper into that, Zintkala. That knowledge might have been what you received from your mother or from your grandmother or from your aunt or from your sister. And because of boarding schools, because of genocide, because of racism and oppression, sometimes that knowledge was erased intentionally. How difficult is it for native women today to tap into the human relative resources that are going to help them navigate a journey versus just an app on your phone that would tell you what nutrition you need at the first trimester?
Zintkala Blackowl:
I think our biggest obstacle and struggle is when we go to develop these relationships that have been severed, we have to interact with trauma, we have to interact with pain, and we have to create space for people to create relationship with each other and with the information, with the knowledge. And we do that by... This year we completed the second annual traditional birth work gathering here in the Black Hills, and that's a five-day intentional gathering. So it takes time. It takes time being together. The more time that we spend together, we do need to meet more regularly.
Zintkala Blackowl:
We also have support circles and groups throughout the year where we just gather throughout the month and cook and spend several hours together just talking and visiting, sharing song, sharing birth stories, sharing struggle. And in those spaces, people access healing that they need to be able to tap into that knowledge that is within all of our bodies. It's in our DNA, it's in ourselves, it's in our memory. So I would say that while we have the struggle of overcoming the trauma that is so close and recent in our lives and still happening, we also have this immense gift of being very close to these memories. Most women, when we sit in circle and talk, we'll share that all of their grandmothers were born at home. Maybe their mom was born at home. I have uncles that will tell me that they were born at home and oftentimes it's surrounding the wintertime, being born out of necessity at home.
Zintkala Blackowl:
And I find that in places where this knowledge is strong still and easier... I wouldn't say easier, but closer to tap into, are in communities where birthing at home has been a necessity. It's been a choice that's been preserved out of necessity, which in our communities you do hear stories, more stories of women still birthing at home just purely out of necessity. They can't get to the hospital fast enough or the weather permits because we have extreme winter weather here where you can't travel three hours to a hospital to give birth to your baby.
Lori Walsh:
So I'd love to come back to that a little bit later and talk about the opportunities of that and then also the obstacles and challenges of that because that would mean different solutions, right?
Zintkala Blackowl:
Absolutely.
Lori Walsh:
But I want to bring Amanda into the conversation now. Amanda, you spent more than a decade as a midwife in Pine Ridge and you're working with the Tribal Health Leaders Board now. Tell me a little bit about what you're seeing change, what sort of trends you're seeing?
Amanda Youngers:
I have seen so many things change, but a big part of it is the revolving circle of providers, especially in Indian Health Service. Women come in and they don't know who they can trust or what their provider is going to say because of a revolving system of care. And so women don't necessarily have that one OB-GYN or that one midwife that can really answer their questions and the person that's providing care may not have local knowledge of what to buy at the grocery store or the actual cost of shopping at a local grocery store on the reservation or how far it actually takes to get to Walmart and Chadron or Rapid City, and the obstacles that are surrounding even just socioeconomic things such as travel.
Amanda Youngers:
Somebody might want to get prenatal care, but there's only one car for a whole family. And if somebody works, the chance of an income is going to be more important sometimes than accessing a prenatal visit because they also may not have childcare for their other children. So there's lots of factors in women being able to access well woman care, prenatal care, and well childcare because of transportation. We know in South Dakota that 56% of counties, not only just reservations but across the state, are defined as maternity care deserts. And that means that there is no reproductive health provider in that county. In South Dakota, that statistic is about 32%. So we're almost double what the rest of the nation is facing.
Lori Walsh:
Amanda, my question that pops into my head is how did we get here? And that might be the wrong question, it might be an impossible question, but do you have any thoughts of how do you get to a place where those are the numbers? And I'm not saying they're acceptable, but they're accepted in some way because we're not seeing sweeping change or massive upheaval. So in some ways this is allowed to happen. Do you have a sense of why?
Amanda Youngers:
I think the urbanization of medicine and what Zintkala also said is the medicalization of birth have really forced women and families to birth at bigger facilities. On the same hand, tort claims and the fear of litigation on the birth side of the medical community has also caused urbanization of women's health and obstetrics. So that most hospitals, you have small town hospitals like Kadoka or Martin or Gordon, Nebraska that used to deliver babies and now don't do so because of the fear of litigation, the amount that insurance costs to provide malpractice for providers, and the necessary means to provide surgical options should a cesarean section or neonatal resuscitation or emergency services occur.
Amanda Youngers:
So we now only have 23%... Sorry, 23% of counties that actually offer birthing facilities in the state. So the modernization and urbanization of that medicine has pushed out family practitioners and midwives from practicing. It was not just until recently, maybe five years ago, that even nurse midwives were allowed to practice independently in South Dakota without a physician co-signing their practice agreement. So that really limited the amount of nurse midwives that could provide care in these rural communities.
Amanda Youngers:
Additionally, even though our medical school in South Dakota trains family practice physicians to do deliveries, many hospitals that these providers are going to go out to don't offer the birthing services that women need. Thus, they're not practicing that care to maintain the proficiency to continue to do birth and cesarean sections.
Amanda Youngers:
Additionally, our South Dakota Medicaid, unlike some of our neighbors like Minnesota, don't reimburse for out-of-hospital delivery. A birth in general in a facility might cost $6,000 and upwards. However, a home birth, if South Dakota Medicaid was to reimburse that, is only reimbursed at a rate of $300 or that's the facility fee that is reimbursed to the provider. So for birth centers that are delivering babies, the women that most need the care through Medicare and Medicaid are not reimbursed at a rate that they would be in a hospital.
Lori Walsh:
Michaela over here on the east side of the state, South Dakota Urban Indian Health, what do you want to add to what these women have already said that also puts in context your work?
Michaela Seiber:
Yeah, they've provided such a great picture of so many things. I do sit on our state's Maternal Mortality Review Committee and something that surprised me is that so many of the deaths happening after delivery aren't related to the delivery itself. There are other factors that their suicides, homicides, accidental deaths, that surprised me a lot. And so that shows me that our systems aren't where they need to be to provide those wraparound cares for our relatives and just adds onto the fact that our systems here in Sioux Falls, so our clinic is in Sioux Falls and Pier, so those are our "urban", Pier is urban. But we see our systems, our health systems, our social service systems, they're not trauma-informed or culturally sensitive to our relatives that are going there for care. So we see people avoiding care.
Michaela Seiber:
We don't provide any prenatal services at our clinics right now. So we refer out and we hear back that they won't go to those appointments or they interacted with providers there that were racist or didn't understand their circumstances or just assumed they were drunk Indians or using drugs or all of these things. And so that contributes to not wanting to receive services.
Michaela Seiber:
And also, all of the things Amanda said about funding, we are so underfunded at Urban Indian Health. We get less than a quarter of Medicaid reimbursements that other health systems get. So even if we were to be able to provide prenatal services at all, we would still get... We're so underfunded, we would still be struggling to try to provide the services that we could. But what we are really trying to work on in our little bubble is training to these other systems so that we can try to move the needle on making sure that when we do refer our relatives out is that they're not getting discriminated against when they go to the other health systems to get care.
Michaela Seiber:
So it's a systems problem overall, and that's something our colonization created and our medical schools aren't helping in any way with not providing cultural competency care when our students are going through their classrooms.
Lori Walsh:
Let's give some examples, Michaela, and what that cultural competency might look like. It might be something as simple as changing your position during labor. It could be that easy. It could be about family members coming in and being present with you in a way that is important to you culturally. What else? Because this is not an elaborate change it seems. Some of these are very basic dignity issues to me.
Michaela Seiber:
Yeah. One of my staff members went to an appointment once and the receptionist asked, "What's your Medicaid number?" And she isn't on Medicaid. There's nothing wrong with being on Medicaid, but just immediately seeing a native person and assuming that they're on Medicaid and that just immediately put her on the defensive of, "Why am I here if you just see me and assume one thing of me?" And so there's just so many things that we need to reset as a system and as a society of what we think of when we see native people. And that is just one thing that happens to my staff when they go into shelters as they're trying to help people. They think that my staff are there to seek services at the shelters and not there to assist our relatives in getting out of those shelters to get into homes.
Michaela Seiber:
So our town is struggling. We're in a really big battle right now, and it's just we're going into these places and providing 101, how many tribes are in the state? What languages are said? What is smudging? What does that mean? Why is it important? So those are the steps we're taking right now on a base level but it's hard work.
Lori Walsh:
We are going to take a quick break and come back and have more of this conversation when we come back and really focus on some of the empowering things about childbirth, when I think of childbirth, there are so many wonderful things of reclaiming your own body and beginning a family. And let's talk about that when we come back. You're on listener supported SDPB Radio.
Lori Walsh:
We'll return to our conversation now. Our guests are Zintkala Blackowl, Natalie Stites Means, Amanda Youngers and Michaela Seiber. And Zintkala, I've been reading about your birth story, which I'm hoping you'll share with our listeners in whatever way you feel comfortable doing that. But I remember becoming a mother, and now of course, as a woman with cisgender Northern European ancestors and I had health insurance, I came at it from a place of great privilege, but it was the most empowering return to your body, return to who you are as a person experience for me. That seems to be a basic right for anyone giving birth to be in that space as much as possible.
Lori Walsh:
You also have some incredible stories of giving birth in ways that might be unexpected to people. Tell us a little bit about what's possible with childbirth? It doesn't have to be a nightmare.
Zintkala Blackowl:
No, no, it doesn't at all. And I think that too often, it is. Too often it is a traumatic experience for our relatives. I'm a mother of seven, so I do have several birth stories as you mentioned. I would like to just really quickly go back. My first births were in Oregon. I grew up a lot of my younger years in Oregon and moved there as a young adult. And in Oregon, not only is midwifery normalized and highly available. It's having access to midwifery through state issued insurance is also very normalized and available.
Zintkala Blackowl:
And also if you are a member of a federally recognized tribe there, you got what was called... This was 20 years ago. You got what was called an open card for OHP, and that was the state issued insurance that everybody could sign up for. And so at 20 weeks, you could transfer to any provider you wanted. So it was easy to go to a midwife with your OHP card and have your birth be fully paid for. So that in itself is a privilege that I was able to experience.
Zintkala Blackowl:
I also, myself was born at home, so I grew up hearing the story of my own birth and my mom's experience with pregnancy. From my father, I heard a lot of it from my father because I was raised by my father. So birth and the experience of home birth was very normalized for me growing up. And when I became pregnant with my first child, it was instinctual too. I didn't consider a hospital birth at all. "I am going to birth why I was born." And it was other people's opinions that I quickly learned were the most detrimental to that experience. It was the outside influence of other people's fears for me. Even people who I had aunts who were lay midwives who had delivered cousins and who I grew up all my life knowing as midwives, and they weren't attending births anymore.
Zintkala Blackowl:
So their advice to me was to go to the hospital for my first birth. And it was my father who told me that it was because I didn't have what medical professionals referred to as a proven pelvis. I hadn't given birth yet. So they weren't sure that I could actually do it. And so even my OB-GYN that I had been seeing since I was 18, who was from Denmark, was very kind enough to explain to me at six months that she would could not guarantee attending my birth. And that in her country, everybody gives birth at home and she understands my desire to do that. But that in America, medicalized birth is the norm and that birthing in the hospital is the norm. And that she couldn't as a medical professional, support me through that.
Zintkala Blackowl:
And I left her practice and that's when I started my journey with only seeing midwives for the rest of my pregnancies. And the week I was due, I received a letter from her practice stating that I was putting myself in danger and putting my unborn child's life in danger and that she needed to tell me these things. And it was very devastating for me at 22 years old to receive this letter from a medical professional who I trusted so much.
Zintkala Blackowl:
And my midwives at the time explained to me that she was covering her own liability because she needed to make sure that as a medical professional, that she told me these things because of the way liability works and the way the relationship that we have with reproduction, with birth, with the experience of birth in this country is so encased in fear and so colonized that that was how her mind worked. She needed to make sure that I might not come back around and try to blame her for not warning me of the dangers of birthing at home. And really the only danger was her fear, was the anxiety and fear and emotional disrupt that I felt from her letter. And my midwives explained all these things to me and helped me to understand it so that I could put it away and not give it any more power.
Zintkala Blackowl:
But fast-forward to my sixth and seventh births here in South Dakota. I gave birth unassisted here because I couldn't access a midwife. I would've loved to have a midwife, but there were none. There were no practicing home birth midwives that were available and accessible to me because I couldn't get state insurance that was going to pay for that birth. And I also didn't qualify at the time, and there's no options at IHS. So I chose to rely on the knowledge that I had gathered from my previous five births to give birth to my sixth and seventh children.
Zintkala Blackowl:
And one of those babies is Mni Wicon that the world knows about. She was born in 2016 at the Dakota Access Pipeline Resistance Camp, and she was born in a teepee along the river, and early morning hours in our camp where her dad was sleeping in the bed with our other baby. And I brought her into the world in a quiet, peaceful, very powerful way. And I do believe that that birth... I always shared with by Goji Cook that those kinds of births are like a form of resistance and the resistance to the medical industrial complex that right now controls our experience with birth. It's the norm here, in American culture.
Zintkala Blackowl:
And my experience with birth was definitely every birth brought me closer to myself, brought me closer to trusting my own intuition and my body and knowing my body and knowing how my body functions, and also getting care for my children from traditional midwives, from home birth midwives is a completely other experience as well. As a mother, I was guided to trust my own intuition and to lean into the experience because I know my baby better than anybody. And that's what my midwives would reflect back to me, just like they reflect back to me in birth and pregnancy that I know my body better than they do.
Zintkala Blackowl:
And so they were relying on my knowledge of what I was telling them about what was going on rather than when you're in the hospital, the doctor is telling you what's going on with your body and you relying on their knowledge of what they tell you based on tests that they run and different technologies that they use. So in one instance, it's a completely out of body experience where you're relying on knowledge and information completely outside of yourself. And on the other experience, you learn to rely and trust completely on the knowledge of your own body and people who reflect back to you that they trust your body.
Lori Walsh:
Amanda, what do you see? What have you seen as a midwife over the years, this experience of women in birth that can be such a privilege to attend to, I'm guessing?
Amanda Youngers:
Yeah, I completely agree with Zintkala, that knowledge that's generational for these women, for every woman to trust. And I think trying to tap into that generational knowledge as well as support is incredibly important. We can't ignore the fact that we have a lot of young mothers in Indian country as well as in the state that may not have supportive families. They may have been kicked out of their family, they may be living with in-laws that they're not necessarily comfortable with. And so getting that birth knowledge can be very, very difficult.
Amanda Youngers:
And so I see a lot of young mothers coming into birth with fear and through my years of practice just teaching them. I say to them while they're pushing, "Think of all the grandmothers that are just surrounding you right now." All of these women or they come to me in prenatal care and they're like, "I don't know if I can give birth." Or their partner will be like, "She's moving a couch. She can't move that couch." I said, "Think of your ancestors packing up the whole travoy and the camp in the middle of winter and riding miles to set up another camp and they were pregnant and you wouldn't be here if that wasn't safe."
Amanda Youngers:
So trusting your body as a safe carrier for that child is incredibly important. And yeah, you can move that couch. You can go walk the dog and lift those other children because empowering women to use their bodies and trust their bodies is so incredibly important. I think our medical community has a sense of distrust. Even myself, I experienced discrimination. I always joke that I'm as white as Wonder Bread. I'd come up to Rapid City after ANCC unsuccessful birth at home with my first child in Pine Ridge. And I hadn't progressed, and it's been two days since my water had broken, and I knew my OB-GYN, and I transferred to the hospital and she knew I was coming. And I went to the emergency room and I checked in. I said, "My name is Amanda. I'm here to see my doctor for an induction because my water's broke for two days." And I could hear the labor and delivery nurse on the back phone of triage, say, "Two days? Where is she coming from?"
Amanda Youngers:
And of course, because I was coming from Pine Ridge and because they didn't know that I was a nurse midwife, that I'd been giving myself antibiotics with my nurse midwife at home, that I was transferring in the safest place possible. But because of where I was coming from or because they didn't know that I was educated, I face discrimination right at the emergency room. And I can't imagine how our other relatives are treated if they're coming from a place where they haven't been able to access care.
Amanda Youngers:
And so it's not that they don't want to access care. It's because they don't have the access, and that's a huge issue, especially in Western South Dakota where distances... Most women have to travel 70 to a 100 miles to go to the nearest birthing facility.
Natalie Stites Means:
This is Natalie.
Lori Walsh:
Thank you.
Natalie Stites Means:
I wanted to say that your previous speaker had, or guest had mentioned DSS removal, being a fear in terms of seeking postpartum and prenatal care, mental health care in particular. But that's a very realistic fear that won't be reassured by a provider because of mandatory reporting laws that are facing indigenous women, mandatory reporting laws that basically require a provider to interpret active drug use as child abuse. And so based on their reasonable suspicion and their mechanisms for reporting, I have been present when our native babies have been removed from mothers, and not just based on positive drug tests, but on suspicions on a blood cord test for six weeks. They want those results and then they put the children or the babies, the infants into foster care. And that itself, that causes huge risk factors for both the newborn and the mother.
Natalie Stites Means:
And we see that general lack of care in the death, the fatalities of indigenous women who've given birth, who have small children, who have infants. And I think that can't be underestimated in terms of being a deterrent, and not just a deterrent, but a suspicion. So I'm sitting there with my provider when I'm pregnant and I bring in my baby for my six-week check with her well baby check and her dark spots, her blue spots were interpreted as bruises.
Natalie Stites Means:
And right when I heard the nurse practitioner began to say that, I went into... I didn't get historical, I got mean, but I went into a protective defensive mode that I shouldn't have to be in when I'm accessing healthcare for me and my baby, in which I know, just like Amanda mentioned, that that is going to deter you. And that frames your whole interaction there in that provider office. And I found becoming a mother. Go ahead. Sorry.
Lori Walsh:
Yeah, we are going to run up on time, and this is an incredibly powerful group of people that we have across the state here. So we're going to reach out to you after the show, see about getting you to come back and continuing this conversation. South Dakota listeners is going to focus on the American trial throughout the entire season. So we're going to have plenty of opportunities to dig deeper into what it is like to give birth in the state to raise children in this state. So more on this later. Thank you to all my panelists today. We'll talk to you next time. Thank you, listeners for tuning in.
