Prenatal Care

In order to bring awareness to the importance of prenatal care for mothers and babies across the Navajo Nation, we have invited Amber-Rose and Jamie to discuss their experience with prenatal care. In addition to Amber-Rose discussing  prenatal and postpartum care, including traditional birthing with special guest Nicole Gonzalez, a Navajo Nurse-Midwife from the Changing Woman Initiative. 

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This podcast was sponsored by the Arizona Department of Health Services through federal funding from the Health Resources & Services Administration, with support from the Navajo Native American Research Centers for Health (NARCH) Partnership between Diné College and Northern Arizona University through federal funding from the National Institute of Health’s National Institute of General Medical Sciences, award number S06GM142121. The views expressed are the sole responsibility of the program staff and do not necessarily reflect the views of the Arizona Department of Health Services or the United States Government.

Transcript

Ya'at'eeh. Welcome to the MCH podcast, where we discuss maternal and child health topics and provide strategies for improving the health of Navajo families. Amá dóó áłchíní ats’íís baa áháyá baa yadelti (Translation, we will be talking about the health of mothers and children).

Amber-Rose
Thank you for joining us today to learn more about maternal and child health on the Navajo Nation. I am your host ARW.
Earlier we spoke with Nicolle Gonzalez, who talked about the importance of prenatal care during pregnancy.
Today we will be talking about prenatal care from a former health educator and a Dine mother’s perspective. And just to recap, prenatal care is the care you receive while you are pregnant. Jamie, could you tell us about your work experience in prenatal care?

Jamie
Well, in a previous job, I worked for an early childhood program and we were huge advocates for prenatal care. Prenatal care is crucial for good fetal development, especially in that first trimester (which is the first 13 weeks of pregnancy - this is really early and before most women even know that they are pregnant). Not only is prenatal care important for the baby’s development, but it is also important for mom’s health because mothers need folic acid/prenatal vitamins to stay strong and healthy. In the first few weeks of life, the baby’s brain and spine are developing, including the neural tube, which actually develops 3-4 wks after conception. So, taking folic acid daily can ensure the baby’s brain and spine will develop properly. Also, once it is confirmed that a woman is pregnant a series of appointments are set-up. Usually, the prenatal appointments are less frequent in the early part of pregnancy.   The first appointment is usually around 8 weeks and then once per month until 6 months. Then the appointments are every 2 weeks in the last few months. But this could be different depending on mom and baby’s health. They always check on mom’s blood pressure, blood sugar, weight and make sure she is doing well. Same with baby, the providers check baby’s heartbeat, weight, growth to assess their health and make sure everything is going good.

Amber-Rose
As a mother of two, I do know that folic acid is important for baby’s development and it prevents birth defects. I also remember learning from my provider, when I was pregnant with Leo, that women that are not pregnant should be taking folic acid even before they get pregnant, so with my second pregnancy that’s exactly what I did. I also noticed that my hair, skin and nails were in better shape the second time.

Jamie
Exactly Amber! Folic acid and folate are great for moms. Our bodies are so amazing that if we eat healthy and take prenatal vitamins we will have extra vitamins to support our health too. A lot of nutrients are stored in our bones, like calcium but folic acid is not stored, it stays in the blood for new cell growth but doesn’t get stored, which is why taking prenatal vitamins daily is recommended. Eating foods with folate (like dark leafy green vegetables, beans, citrus, avocados and nuts) are also recommended. You’ll also notice that foods from WIC are fortified or enriched with folic acid. "Fortified" with folic acid means the nutrient is added because it is not naturally found in the food item. "Enriched" means folic acid is added back in after it's lost during processing of the food item. A lot of our food has been fortified or enriched specifically because we don’t consume enough folic acid, so again taking prenatal vitamins even before pregnancy is so important.

Amber-Rose
Good to know! Those are some good points for sure and it’s always good to know why these recommendations are in place. So for anyone that is considering or thinking about having a baby, they should start taking prenatal vitamins as soon as they can. Also we learned that approximately 76% of women in Arizona reported receiving prenatal care in the first trimester, so it truly is important to spread awareness that preconception care (before pregnancy) is just as important as prenatal care (care during pregnancy). How are your prenatal visits going right now?

Jamie
They are going good. I learn something new everytime I go. My last visit we talked about my health and baby’s health. I was able to ask some questions. Usually, it feels rushed on both ends (from my side, I’m a working mom at the hospital with my toddler and on the provider’s end, they need to see other patients), but it’s important to ask questions. So I usually have a list of questions on my phone, so I don’t forget to ask.  My most recent visit, just last week, I asked about what the plan was for my delivery. My first pregnancy, I was induced early, so I wanted to know what to expect this time around. So far everything looks good and we made sure my blood sugar and blood pressure were good. Baby also looks good, which is the fun part of prenatal visits, the ultrasound and listening to baby’s heartbeat.

Amber-Rose
I know what you mean! I loved seeing my girls while I was pregnant. I loved being pregnant. I remember having more appointments the further I got in pregnancy, which was always exciting because you get to see them grow. Well, thank you Jamie for sharing your experience and knowledge about prenatal health.

Jamie
Yes, it’s always fun talking about babies. And I hope our listeners learned why taking prenatal vitamins and eating well are important, especially for those that are thinking about having a baby or those that are pregnant already.

Amber-Rose
Yes, please share the importance of prenatal health with your loved ones. And don’t forget to listen to our next episode on breastfeeding. Until next time, take care and please stay safe.

Amber-Rose
Today, I will be talking about the importance of prenatal care for pregnant women and their babies. We've invited Nicole Gonzalez from the Changing Woman Initiative to discuss prenatal care and postpartum care, including traditional birthing. Let's jump right in. Nicole, thank you for joining us today. Could you tell us a little bit about yourself?

Nicole
Hi. I'm so excited to be on today's podcast. My name is Nicole Gonzalez, and I'm Navajo from the Shiprock area. Shi ei Nicole Gonzales nishłį́.Tł’ááshchí’í nishłį́, doo Táchii'nii bashishchiin, Hashk’aanHadzohí dashicheii, Naaneesht' ézhi dashinalí.  I am the founder and midwifery director of the organization called Changing Women Initiative.

Amber-Rose
Okay. Great. Thank you. So it's a pleasure to have you join us today and have you a part of this effort to bring awareness to prenatal care and maternal health overall. Can you tell us about the Changing Woman Initiative and the services you offer?

Nicole
Absolutley! So Change Women Initiative is a 501 C three nonprofit that was incorporated in 2015, and it really came from a place for me, personally, of trying to create some sort of way to serve Native American families in New Mexico, specifically around maternal health, prenatal care, birth services, women's health, reproductive, those sort of things. And I've been a nurse midwife for the last ten years, and I've been a nurse for the last 17 years. So this work that I'm doing with Change Women Initiative is something I'm very passionate about. And so the work that we do is primarily focused on three areas. One is our direct services. Which is our home birth services. Training Indigenous midwife students, providing plant medicine teaching, but also service like people can receive that during our care, as well as like, including, like, food, access to healthy foods and foods grown by local farmers here in New Mexico, specifically, like tribes, Pueblo farmers. We work a lot with them. And then our other area focus is community outreach. So doing training and supporting our Indigenous, Native communities to really learn more about birth work, whether it's breastfeeding midwifery, doula, reproductive justice, sexuality. We kind of focus on those areas. And then our last focus is policy, advocacy, and change. Just because since I've been doing this work for the last ten years, there's not a lot of legislation that supports maternal health for our Native people. And so if we're going to create innovative work like we're doing, we have to create policies that support those innovative changes in our community. So those are the three years that we focus on.

Amber-Rose
Awesome.Thank you. My next question is, can you share with us what happens? Actually, I take that back. What are some things mothers need to know about prenatal care?

Nicole
It’s definitely a way to check in with your body and yourself with your baby. There's many schedules. I know the schedule, the standardized schedule that a lot of clinics take on when it comes to prenatal care is that women will get seen initially in the first trimester and then every month leading up to their 28th week in their pregnancy. And then it's every two weeks after that. And then the last month of their pregnancy, which is still 36 weeks. They'll get seen every week for prenatal care. And really the prenatal visits can be used in a lot of different ways. You know, if women are getting care in a hospital setting, their visits are pretty short. So like, a 15 minutes visit is much what they might experience. But if they're choosing to get maternal health care with a midwife who does home birth or birth center care, their visits might last 30 minutes to an hour. So it's really interesting because the different perspective around prenatal care really depends on, like, who is dictating the information, how much time you have. It's really an opportunity to provide education. And so I think it's important to talk about the two different places that or, I would say, perspective around maternal health, but more or less antenatal care. So like prenatal care, midwifery is really focused on normal, natural birth and pregnancy. A normal natural process of, like women's bodies, are a continuum of our lifeways. Like pregnancy is one of those things. But the challenge is sometimes because of how obstetrics has changed historically. It's really been turned into this very medicalized management of a normal process. And a lot of women who start prenatal care hopefully in our first semester, will normally get a full physical. There might be some time for education. There's definitely a full set of labs that are ordered to check blood, blood type and rebel immunity HIV status. So those blood that is ordered in the first visit is really to, like, evaluate a woman's health. And there's, like, how they're doing if anything, could be passed on to the baby. That's something that we want to know as clinicians. What isn't always talked about is the importance of prenatal care starting in the first semester. And this is kind of my big push because I know for our Navajo women, like our rates of accessing prenatal care in the first semester not great. I do have the highest number of late to prenatal care or starting prenatal care in the second trimester.And the reason that's concerning is there's a lot of really important health information we gather when we first see women, when they first find out they're pregnant, some women can be on medications, for seizures or migraines or mental health issues that could affect the growth of their baby. And so it's important for us to know that if they're on harmful medications, they need to stop them or change them. And the earlier we know they're pregnant, the sooner we can make that change. The other thing is if there are risks that we know that could affect their pregnancy outcome, which all of us want healthy, happy babies that are born on time if they have a risk for diabetes or hypertension, or maybe some sort of drug dependency in their history or currently, or if they have some sort of mental illness or depression, anxiety that's or PTSD. Those are important things that we want to know immediately, because we want to make sure that we refer them to an appropriate care providers, so they're fully supported.  As well as their home Situation, so if they are living in a multi-family space or they have transportation, or they're homeless like all of those things are discussed and evaluated in a first-trimester appointment. And so that gives us time to bring in resources to support them through their pregnancy. Also, if there's any nutrition or habits that could be harmful to their bodies while they're growing their babies, that's an opportunity to implement change. And so that's why, for me, the first-trimester prenatal visit is the most important, because then you get to have this very long, thorough assessment of their physical health, their emotional health, their spiritual health, their social health, and then really try and work on those things through their pregnancy. If we get to them later and they have less prenatal appointments, they actually miss those are missed opportunities to integrate other programs to support them, but more importantly, to really build trust with the person working with you. And I think people don't recognize that as a very priority. An important part of their care. I know a lot of hospitals; you see different providers, or the person might not be on call to catch your baby. So we just kind of accept that we're not going to have a very special relationship with our health care provider or our team, but we still trust that we're in good hands. But the more we see women prenatally like we really get to build that relationship with them around, like how they see their birth experience going. And I think that's really important to part of their care. And as they're turning and going through that transition is becoming new moms. So the prenatal care for me I just talked about the schedule. I talked about why it's important to get in, to see your provider or your midwife immediately, or finding your pregnancy. It's because, in our minds, those are all the things that we're thinking about. We want to support you. But also, each time we see you for prenatal care is an opportunity to connect with you on what's happening in your life. It's education because a lot of women, especially having your first baby, don't really know what to expect, right? Like, there's a lot of emphasis on the birth. And of course, I get lots of questions about pain, but there isn't a lot of support sometimes around, like, even just the emotional changes of going through being on your mom, right, and your body's changing your family is changing. And sometimes pregnancy a lot of times, pregnancy is unplanned and so really adjusting to your life-changing and sometimes not having support systems around you is the biggest hurdle in pregnancy and prenatal care. And that's where a lot of our attention is focused. It's kind of interesting because I always tell people, like listening to the baby, measuring women like their weights, blood pressure like that takes 5-10 minutes of the whole appointment time. I mean, that's measuring the physical changes their bodies experiencing for our purposes. But like the communication, the storytelling, the relationship, like all of that is really the really important part of the prenatal care. And so if you haven't had a really good relationship with your health care provider, where you trusted them and had felt like if things went in a way and the birth, that you didn't expect, that you have some level of trust with who's taking care of you, that it was the right decision or that they were thorough enough with you to discuss all of these changes, right. There's a big push right now in maternal health around informed consent, I know in the past our communities have experienced harmful reproductive practices that we've not been informed about until later. So unfortunately, when I read research about these things that are still actually ongoing, where there's a high number of unconsented care that's happening versus like, what I mean by that is we get blood drawn, right for prenatal care visits. Sometimes for many, there isn't even a discussion of, like, why we're drawing blood. There's just an assumption, like, here's your lab slip, go get blood drawn versus okay, what are we looking at? Like, why are you needing all of this to look at my blood? Like that part is missing. And sometimes there isn't even an opportunity for women to say, like, well, I've been tested for HIV or I don't feel like I need to know or no, I don't need that test. There isn't an opportunity to have that discussion. It's just assumed that here's a lab slip to get blood drawn. So there's that and also even around, like, weight like our bodies as women. I'm not really happy with the current BMI standards for our communities because they're actually based on how they say colonialistic perspectives because they're white women with a certain weight, like when we talk about we're not also talking about food insecurity and the resources available in our community. And so those discussions can actually happen prenatally as well. But I think it's important to know these things just because statistically, as a clinician, we read research, we read about our communities. You go to conferences, and you hear all these stats about how our health is not the best, but there's never a follow-up of food and security contributes to obesity. It also contributes to diabetes because there are habits you, as a child, that hurt your food or you eat whatever you can because you have a big family. And so how do you teach nutrition versus just getting blamed like this is how we are. So there's that I always consider when I'm reading research about our communities. For me, prenatal care is really important. It's also a measure of health that Department of Health used to measure how birth outcomes. There are correlations with improved or better birth outcomes for mom and baby with women who have more prenatal visits. So more than, like, ten prenatal visits through their entire pregnancy, because those are opportunities again to catch things. To talk, to educate. ​​To also build trust. And so women who have less prenatal care. We are seeing trends and have been seeing trends on low birth weight or large size as pre-term delivery, undiagnosed diabetes. So there's all these opportunities to catch these things sooner and then if women don't come to prenatal visits, those are missed opportunities to check in with their bodies and their babies.

Amber-Rose
Yeah, I agree. And you touched on some great points. So for the 2020 Navajo MCH needs assessments,we identified prenatal care in the first trimester as one of the top priorities that we should be addressing among Navajo. And so that's just something that I'm glad that you talked about important as to why our Navajo should get prenatal visits done as soon as possible, as soon as they find out they are with child. I'm glad that you pointed out, kind of like the emotional, the emotional aspect of pregnancy, that I feel like sometimes, when I would go to my prenatal visits or appointments when I was pregnant with my two children, that was the only time I kind of had support. I kind of had reassurance that I was doing taking good care of my child. I was a young mother with my first child. And one thing, I was wondering if the Changing Woman Initiative offers any kind of family planning education?

Nicole
So as a nurse-midwife, I think I want to touch a little bit on that because I think sometimes people don't know what our scope of work is. So Midwife is a Masters trained nurse-midwife. We are basically considered nurse practitioners, but with a specialty in women's health, we have prescriptive authority. We have independent practice authority so we can work independently without having to work alongside a physician. We also have the capability of writing for birth control, antibiotics as well as controlled substances like narcotics. So we really are a special level of midwifery in the sense that we have such a large scope of practice to provide services to women. And obviously part of our scope is, yes, prenatal care, you know, attending burst postpartum care, taking care of them. But we also take care of mom and babies, assuming that the kind of practice they work with up to six weeks postpartum, if it's healthy and normal, where we can and will be responsible for both of them as a couple. As well as like the gyn like the reproductive women's health side. We also can do preconception counseling or like pre-pregnancy type counseling. So talking about diet and health and nutrition and preparing and getting ready to have a baby. So there's suspicions I have with women. I also talk with a lot of young women anywhere from the age of, like, eleven to 50 or 60 about their periods, whether they're normal or irregular, heavy, birth control, all the options, like pills. IUDs, Nexplanon. I talk to them about it. But I also insert and remove them. There's also a specialty work around women who are going through menopause. So like hormone testing to check for hormone fluctuations or if they're going through menopause, hormone replacement therapy like those are also parts of their scope of practice that we can provide, including, like, well and care. So if you're between the ages of 30 and 60, right, you would come see me for your PAP smear, talk about your mammogram, and when you should do that, talk about work, stress, exercise, diet, talk about your cholesterol, any type of health-related things that's the discussion we have, and then I can order blood work and review it with you if you're having thyroid issues. So it's a lot of things outside of just baby catching and prenatal care. And so that's basically what I do. And that's what I do with Changing Women initiative. So I do have a walkin clinic where I see women for all of those issues or one of those issues women who also can have very painful periods or regular periods, if they're having painful intercourse. That's a discussion I have with them. Any testing or screening or treatment. They can come to me to see those things. So this is a very clinical, medicalized things, right. And it's neat because there's different ways to manage all of those things I just talked about. I'm very well knowledgeable because of my training about Pharmaceuticals. So like birth control, like there's pills or things that are we've been known to treat problems, but sometimes and most of the time I see women who prefer not to go the pharmaceutical route to treat their issue. And so we'll talk about other possible options. So like acupuncture, naturopath as well as, like, plant and herb medicine, like I'll send them tothe herbal list to talk about if there's an alternative to taking a pharmaceutical if they're having issues. So there's all of these other, I hate to say alternative medicine, but Allied Health natural medicines that I would say more people are interested in. And so I don't have specialty in all of those things. Clearly, I can't. But I do have relationships with people in the community who offer those things. We really closely with red root acupuncture here in Albuquerque, and they use a lot of acupuncture and cupping and bodywork for any type of PTSD that we see with women, depression, anxiety, even very mild or moderate hormone irregularities that we experience that they can correct with acupuncture, even just some changes to some herbs they want to take versus fully going going on to some sort of pharmaceutical to treat the problem they're experiencing. So that's where I kind of work with them, asking them where they want. I guess how they want to manage this issue, because sometimes people come in ready to talk to me about a problem that they have questions about. And I can't assume that they're ready to go all out and try all these very pharmaceutical options. And so I always like to ask them, is this a problem enough for you that you want to do something about it or you want to know if it's normal is interfering with your life, that we need to do something? Or would you like to try a more natural first? Okay.
do you have any specific recommendations for younger mothers versusolder mothers when it comes to prental care? Are there any anything that you would recommend for them, assuming there might be a difference in age groups?
So there are definitely additional tests that women over 35 are offered that women under 35 not offered. Technical women 35 and older are considered advanced maternal age. That's how documented that. Unfortunately, there's even billing codes for that. And it has a lot of relationship to do with basically your ovaries and your hormone fluctuations. Like you're getting closer to menopause. You don't make as many eggs. There's also genetic abnormalities that can show up after the age of 35 that they see a dramatic increase in down syndrome and those sorts of things. And so it's really been pushed or stressed to offer genetic I screening and testing to women over 35 because of these age-related risk factors. I would say it's a standard of care for most clinics to offer that. But as it's changed over the years, I'm seeing genetic screening and testing being offered to all ages now and not just 35 and older. Just because there are trends and outcomes that are related to age. Women of 45 have an increased risk of pre-term delivery, smaller size babies, those sort of things, as well as down syndrome and genetic related abnormalities. So the care for them is a little different because they might get more ultrasounds and be offered more blood. There's other things that are coming up, like undiagnosed at low thyroid levels that can affect the baby's growth. And so there's also now they're starting to do, like cervical length checks. It used again to be over a certain age, and now they're offering for everybody. I want to save the preterm rate for preterm birth for women is not that high. I'm trying to think about the numbers. So the cercival check is the ultrasound that they come in and do a vaginal ultrasound to see how long your cervix is. So if it's shorter than 2 CM, they actually will watch you more closely. And have you come back from ultrasounds require bed rest, those sort of things. So they're actually offering that type of Ultrasound testing more often now than they used to. There's also the sequential screening that's been offered more at 13 weeks, which combines two ultrasounds and then another blood test, and they give you a risk ratio of your risk of this baby having genetic abnormalities. And it's really just a screen. It's not a diagnostic test, honestly, multiple genetic screening testing out there. I would say it's up to us, the clinicians, to read the research and decide which is best to offer to our families. But I think it's just good practice to offer and educate all families on these options, whether they choose to do that testing or not for their babies. And in some places they don't really spend a lot of time educating them. When they come in for their first prenatal visits, they might be like, oh, genetic screening. Yes. And they don't really know what it is. But in other places, it's definitely a consent process where they are either meeting with maternal-fetal medicine physician to get very thorough genetic counseling or the provider who's seeing them is doing it for them. As a midwife, I've done genetic education screening with families at their first prenatal visits just to review their options, because I want them to be aware of when this testing needs to be done. And a lot of it is done in the first to second trimester. It's not very commonly done in the third trimester. There's another opportunity again to get more information and why we have to see people earlier in pregnancy and not later. As far as, like younger women versus women that are older and they're pregnant for them. It's really like, like all things, you know, their social situations, their relationships, supporting them in those situations are maybe they're living in a home with one family members, or they're not working, or they are working a job that maybe doesn't allow them to rest. And so yeah, I would say the younger women's needs are a little bit different. They're more like education, lots of support, making sure their families are supporting them. And if not getting them resources versus the older all these ultrasounds and genetic screening and testing, and there's still a level of education for them. But they're considered a higher-risk group of people. And so that's why there's more emphasis on more ultrasounds and more genetic testing and screening and more blood work. So for younger women, unless there's things that show up that we need to watch for, like, maybe they're A 1 C in the first trimester, which checks for diabetes is like elevated or in a area that puts them to pre diabetes, then closer monitoring is required. Or if they're babies measuring small and they're not measuring at the dates that they're supposed to be like, that might require closer monitoring, etc. Testing that they just happen to do was a little abnormal that were to require more testing. So there's things like if these tests are coming up abnormal, then we would watch them closer. But if they don't want the test and they're healthy and there's nothing wrong, they don't need more than two ultrasounds, if not even one ultrasound through their whole pregnancy.
Okay. So I was curious, do you do any mental health screenings?
So yeah, part of the health assessment is to ask about their mental health. So if they've had a history of suicide attempts, PTSD, depression, anxiety, if they're on any medications that currently are in the past, I usually like to list what they're taking and why they're taking it. If they are being a psychiatrist or mental health person, I usually will get their name and number and ask the client for permission if I can contact their health care provider because we know lots of women experience or can go into relapse during pregnancy and postpartum. Sometimes it's related to hormone fluctuations. But also, again, having a baby is this huge change, right. So I'd like to have a very good conversation with the family and the person I'm taking care of. If she already receiving mental health services, that we can reach out to their healthcare provider so that we're all on the same page with the care we're providing to this one person. I think a challenge that I run into clinically with women with suicidal attempts during pregnancy is finding them a safe place to be when they're in that place. Because a lot of the ways that women enter treatment facilities is through the emergency room, and sometimes because they're pregnant, it's like, where are we going to put you? And so that's been challenging for us. I wouldn’t say it happens a lot, but it has happened. And those for people on substance-using drugs. But there are specific programs in the community to take care of those women because usually it's a full like cocoon of care for people who have substance use or they're on something like suboxone, which helps with their addictions. They usually are seeing a provider who prescribes them the medication because that's a very restrictive medication that only a few providers can prescribe in New Mexico. So there's that. But they also are seeing a counselor; they're seeing they're getting WIC services. There's a whole plan for their whole pregnancy and postpartum if they're on that medication. And so they're not usually a family that we can take care of, especially if their people want to know who is safe to give birth at home and somebody on some sort of Suboxone or medical that could affect their babies, like breathing at the birth like those are not the best situation we want them birthing at home with.

Amber-Rose
And that's good information to know because I wasn't aware of how pregnant mothers were being taken care of if they needed extra attention due to mental health issues. So we talked a lot about prenatal health. Are there any areas in postpartum health that need to be addressed, that you feel need to be addressed?

Nicole
There's still lots of anxiety about whether your baby is getting enough. And also, there's that transition. If you are in the hospital and you're going home and discharged, the day is either on day two or day one, that can be hard. So for home birth clients, like 24 hours after the birth, we will go and see them, and we'll weigh a baby and monitor the peas and props to make sure they're hydrated. We do full set of vitals as well as on the mom as well to check for bleeding and make sure it is nice and firm from the birth. And then, the PKU is done on the baby, which is a metabolic screen that every state, I believe, requires to check for any changes, like genetic issues. So those are things that happen on the date on the second day, and those things actually do happen in a hospital. It's just small families are asleep, or the nurses will do that kind of stuff in the middle of the night. We are really tracking baby's weight and making sure that they're not dehydrated. They're getting enough, and they're not losing too much weight and also supporting breastfeeding. Something I'm so amazed about is like I said, I worked in the hospital for eight years and then, well, I worked in a hospital for more than eight years. But I worked in a hospital as a nurse for ten years and then another eight years, seven years as a midwife. And so what has been really amazing to see is our moms who are beating at home and are uninterrupted with their breastfeeding. It's not an issue that their babies are losing too much weight. Their milk comes in on day two. There's just a very natural process of breastfeeding. I see that I never really got to see in the hospital, even as a nurse. So there's something to be said about hospital schedule and anxiety around with babies, weight and breastfeeding, and all of that. There are also a lot of hands and people coming to watch women breastfeed in the hospital that just doesn't happen at home. And so I'm seeing more successful breastfeeding with people who birth at home uninterrupted and just support it by their partner and then us just leaving them alone to breastfeed with, of course, instructions, but just very gentle information on supporting that at home as far as the postpartum or doula actually sees them a lot as well. So if they're having any pain in their hips or injury from birth, like they're walking to go get bodywork with acupuncture or somebody who does chiropractor work, sometimes your hips can get misaligned, or your back can get misaligned from pushing a baby out. They're part of our postpartum referral and services. But we're looking actually at extending our postpartum care and follow-up to six months because even though many of our families still supported up to six weeks, as many reported, they, would prefer to check in beyond the six weeks. As far as the mental health peace, that's been a challenge to serve people who live in Gallup, Window Rock, out that way because the mental health services that are the behavioral health, I guess they call it the way they enter care, there is either through the emergency room or they have to be seen by one of their providers at one of their hospitals. Right. So it's harder for us to make a referral for them to get mental health support. But I would say that the part that's the most challenging right now is getting that mental health support for them, especially during the postpartum period. We've had some experiences and have traumatic birth experiences. So maybe someone who planned to home birth and ended up in the hospital and had like a C-section or an unplanned outcome that they're pretty traumatized by that requires lots of support postpartum, but really like alternative medicine and mental health support. I think that it's been a challenge for us to try and provide those services but also link them up to what's available in the community.

Amber-Rose
Awesome wow. I always say thank somebody responds, and finally, I do that a lot. But just because I'm so amazed by all the work that you do, and I'm so glad that you see your clients more than one time. Like, I remember just having, like, I think just to actually follow up postpartum and visits at the local IHS here in Shiprock. I guess I wasn't really sure what kind of birthing experiences that I wanted. I just knew I wanted to have a healthy baby, but now that I'm more aware of all these different options and ways to just heal and kind connect and bond with my child during this process, it just expands my idea of what this experience could be, and it just makes it even more wonderful. And I'm really glad that you're able to serve women across New Mexico, especially those that live in the Navajo Nation. So with that, I was wondering if you had any maybe ideas or thoughts of ways that we can improve prenatal health and postpartum health for Dine mothers, aside from what you've already mentioned.

Nicole
I'm always thinking about policy with all of these things because I feel like if our nation is going to talk about women being a priority, are there any resolutions put forth by the Navajo Nation that maternal health is a priority for the tribe? I think when our tribes can put forth resolutions like that, we can allocate and support funding to go to programs and the restrooms organization doing the work because oftentimes, I know there's a healthcare arm that handles some of these issues, but I don't know. I personally don't know if there's a resolution that navigation goes forth towards maternal health for Navajo women because I think that would be an important thing to do. It's kind of like the missing word. Indigenous women. We know we've had some representatives on the Council really push that kind of. And so, who's doing that for eternal Health and our tribe? And so I would like to offer that challenge to our nation to really not just talk about how important our moms and babies are. But is there a policy resolution to make that a priority for the tribe in the nation? Not just say, well, it's IHS handling these things, but like, everybody, like, it should be everybody's priority. So there's what I think that would make me happy. I know there are structural things that make it really challenging to serve women on the Navajo Nation as someone who isn't employed by IHS or a government entity, and I have nothing against them. But some of the structural barriers in place make it very challenging for us just to take care of those women. If there's a prescription or an ultrasound, I need them to get in there in Window Rock or Gallup or somewhere further in the Navajo Nation; there is no free-standing, freelance outside of ages clinic for them to get an ultrasound like they have to go and see another midwife. And IHS to get in order to get an ultrasound. So it's like, how are we improving, educating our families who have to access care in multiple different ways to get their needs met. Like, some of these barriers don't really need to be there if we just normally here, in Albuquerque, if I call in a prescription to Walgreens for a refill of birth control, it just happens like they don't have to see another person. If I put an order for an ultrasound, put in a New Mexico sonographic; it gets honored because I'm a clinician, and there's not another person they have to see for that order. Also because I don't work for it, I have to refer them. They have to go see a provider through their system to put it in the computer, and then they can go for the ultrasound. But it's like it's not going to come from me. It's going to come from them and inside their system. And that's a barrier. So I would say those are my recommendations. What I didn't get to tell you and talk about was that you asked about ceremony, and I know a lot of what I talked about was really medical management, but I didn't get to talk about including plant medicines that support women's wellness during pregnancy, so like nettles and especially now oat straw. There are some teas and pictures they can take to support their wellness because nettles are a very wonderful plan that supports blood building. And why that's important is women. We lose blood, right, once we have our baby. And so we really want to build up their blood and their reserves to prepare for their birth. We know anemia is a problem in pregnancy, regardless of they eat meat or not. But there can be anemia as an issue. And so, like trying to incorporate diet changes as well as plant medicines to fill their blood to keep them healthy during their pregnancy. I think it's not something I always talked about in pregnancy, especially in a clinic. You talked about postpartum. I do send people to medicine people to get listed at ceremonies. Our organization does pay for some of that ceremony as well. We use the quote dismal medicine to do the closing of the bones. There's a medicine person here in Abomey that does that. And so there are traditional medicine modalities that we're accessing to get women in touch with their bodies, but losing their spiritual womb that is open from the time they have their baby at the time like they stop bleeding. And so there's that education and that support that we offer as well. And so that's something I don't see too often. But there's a whole lot of traditional medicine I think that isn't incorporated in the care. And also, I think sometimes people just don't know how in what way to incorporate it, right?

Amber-Rose
Wow. That's awesome work. I'm so glad that you're incorporating that native medicine into these different areas. And so I'm really glad that you mentioned that your program actually pays for some of that to happen. In closing, are there any other programs that you'd like to highlight or shout out?

Nicole
Of course, the Navajo Nation breastfeeding coalition. Amanda Singer is leading that group, but she's also doing a lot of work to support the doula work out there. She works with four different does who attend first with us and others if anyone else is attending. Firstly, she would be with them in the Gallup, Window Rock area right now. I would say she's an amazing person to talk to just because they're not only doing breastfeeding education support for the community, but they're also branching into doula support and birth worker Support. And they really want to support women attending like who birth and hospital and those types of settings. I think it's amazing. And also the Indigenous breastfeeder counselor with Kimberly More-Salas and Camie. I can always give you their information. They do training for peer counselors, breastfeeding be breastfeeding peer counselor training for the community, specifically native Indigenous communities. So there'll be in Window Rock. I know next two weeks to provide some training, and I don't know if you've heard of them already. Just trying to think who else I know. Some of the birth groups are like in other States and other tribes, so they're not always in New Mexico, of course, you know, Tewa United. They're amazing, and they do the program, and we work a lot with their do list. I know there's a Tewa Babies with the program up Taos. I’m always interested in, like, the maternal health or the maternal support programs in each tribal community. I want to say there is a small group in San Felipe Pueblo that they do education support for pregnant moms. I think they're called the Tewa mom or the; I can't remember their name because I'm like, I have to go through my notes. One of our is someone from there? Yeah, I would say right now, that's what I got.
Okay. Awesome. Well, ahéheeʼ, thank you for joining me today, and I really appreciate your time and all the valuable information you provided. I learned something new today, and I'm sure our listeners will learn something new as well. Thank you.
Yeah. Thank you. I'm so happy to be here with you.

Amber-Rose
Ahe’hee. Thanks for listening to the MCH Podcast. For more information about the Dine College MCH Project, please visit Navajo MCH Project at Diné College. Music