Lily is 19-years old and an enrolled member of the Ho-Chunk Winnebago nation in northeastern Nebraska. She graduated recently from high school and is pregnant with her first child and in her 3^rd trimester. Lily and her mother live together and have just moved to a large metropolitan area several hours away to be closer to more job options for her mother who is a registered nurse. While it was difficult to leave the reservation, they decided it was time to relocate where more jobs and further education for Lily would be available. They also wanted to be closer to a variety of hospitals and health care options for their family and her new baby.

Lily has gestational diabetes mellitus (GDM) and her baby boy is larger than normal for his gestational age. There are several concerns with GDM including possible hypertension and pre-eclampsia which can threaten the health of both Lily and her baby. She is grateful her mother is a registered nurse and can help during the prenatal appointments with questions and clarifications regarding her Dr.’s recommendations. Lily’s mother also had GDM when she was pregnant and shares her experiences with her daughter which include understanding that a possible caesarean section may be required to deliver the baby safely.  She and her mother have a close relationship and Lily wants to go to nursing school after the baby is born. Lily’s mother has been an excellent support to guide her daughter as the pregnancy has progressed and Lily is thankful as the father of her baby did not want to be involved with their child. Since Lily is under the age of 24, she will continue to be covered by her mother’s health insurance that is in place for both from her mother’s previous employment.

Lily wants to deliver her baby naturally, to raise her child within the cultural traditions she was raised with, and to find cultural-based support for herself as a single mother in her new location. She is very nervous about a possible caesarean section which can be the doctor’s preference to deliver the baby if her blood sugar is not well-controlled and the baby is too large to deliver naturally.

You are the public health nurse meeting Lily and her mother at their first clinic appointment at the new Obstetrics/Gynecology clinic where the tribal clinic has transferred her health care.  The clinic is in a culturally diverse area of the city and is piloting a holistic assessment tool using an explanatory model to attempt to include more culturally diverse clients and their families’ perspectives in the care and teaching models of the clinic. The explanatory model has been shown to facilitate communication with increased understanding between health practitioners and clients, with a positive effect towards health outcomes.

You are preparing to visit with Lily and her mother, and to interview Lily using the 8 questions of Kleinman’s explanatory model regarding her GDM, perspectives on her health and the health of her baby.

Answer to following questions:

1. How common is GDM in Native American women? What are prevalence rates in recent years and what does current research attribute to these rates?
2. What do you know about the reservation community where Lily and her mother have lived and the overall health disparities there?  Is there information that would be helpful to know and understand to offer cultural and traditional approaches for Lily’s health care? If so, describe how you would obtain this information?  
3. Discuss what you have learned about poverty on the reservation and its possible influence on Lily’s GDM.
4. Research and then describe some traditional Native American cultural perspectives on pregnancy and childbirth.
5. Research and then describe some traditional Native American cultural perspectives on pregnancy and childbirth.
6. The Kleinman Explanatory model provides eight questions to focus on and learn more about the client’s understanding of health and illness. Compare and contrast use of this explanatory model versus OB/GYN health care assessment provided without use of this model.

Root cause of health inequity

Centuries of US federal policy that has threatened natural Native American kinship and family structure and forced assimilation of Native Americans into the White culture. Also, “…health outcomes for Native Americans are adversely impacted by wholly inadequate access to comprehensive health services” (Smith, 2022).

Policy Considerations

1. Include more culturally sensitive and inclusive pre-conception counseling and diabetes risk-reduction education.
2. In 2010, the Centers for Disease Control and Prevention (CDC) funded the American Indian Physician’s Association (AAIP) for five years to partner with rural, reservation and urban community-based coalitions to plan, develop, implement, and evaluate evidence-based and culturally appropriate strategies to address type 2 diabetes and healthier lifestyles. Among the lessons learned from this project were the following:
   • Cultural training to non-Native partners is imperative for success; allow Native community members to provide this insight.
   • Support re-engagement with the land towards developing stronger tribal identities and re-creating opportunities to have traditional ceremony.
   • Transforming narratives of trauma into hope and resilience.
3. Research shows promise at the feasibility of mother-daughter GDM dyads as an approach to diabetes and GDM risk reduction.

Calls to Action

• Consult with tribal and urban health care leaders to increase preconception counseling for those with a history of GDM in the family.
• Stop acceptance of health disparities as the norm in Native communities and transform systems towards greater health equity.

References

Association of American Indian Physicians. (2021). Diabetes – The national program to eliminate diabetes-related health disparities in vulnerable populations. Aaip.com

Johnson-Jennings, M. et al. (2020). Returning to our roots: Tribal health and wellness through land-based healing. Genealogy, 4(3), mdpi.com

Moore, K., et al. (2018). Feasibility of mother–daughter dyadic gestational diabetes (GDM) risk reduction intervention for American Indian and Alaska Native (AIAN) teens. Diabetes, 67 (Supplement 1).  

Stotz, S., et al. (2021). Stopping gestational diabetes in American Indian and Alaska Native girls: Nutrition as a key component to gestational diabetes risk reduction. Current Developments in Nutrition, Volume 5(4), June 2021, p. 13-21.