摘要：Objectives . We sought to provide a national profile of rural and urban American Indian/Alaska Native (AI/AN) maternal and infant health. Methods . In this cross-sectional study of all 1989–1991 singleton AI/AN births to US residents, we compared receipt of an inadequate pattern of prenatal care, low birthweight (< 2500 g), infant mortality, and cause of death for US rural and urban AI/AN and non-AI/AN populations. Results . Receipt of an inadequate pattern of prenatal care was significantly higher for rural than for urban mothers of AI/AN infants (18.1% vs 14.4%, P ≤ .001); rates for both groups were over twice that for Whites (6.8%). AI/AN postneonatal death rates (rural = 6.7 per 1000; urban = 5.4 per 1000) were more than twice that of Whites (2.6 per 1000). Conclusions . Preventable disparities between AI/ANs and Whites in maternal and infant health status persist. American Indians and Alaska Natives (AI/ANs) are known to have decreased life expectancy and disproportionately high rates of morbidity associated with a broad range of health problems. 1, 2 Nonetheless, considerable gains have been realized since the Indian Health Service (IHS) was established as the lead health agency commissioned to improve AI/AN health status. 2 Some of the greatest gains have been made in the area of infant and child health. Since 1955, when the IHS was created, reported infant mortality rates among AI/ANs in IHS areas have dropped dramatically, from 62.7 per 1000 live births in 1955 to 8.7 per 1000 live births in 1993. The reported neonatal mortality rate in IHS areas in 1992 through 1994 was 4.1 per 1000 live births, compared with 5.3 per 1000 live births for the entire United States and 4.3 per 1000 live births for Whites. 2, 3 The postneonatal mortality rate among AI/ANs (4.6 per 1000 live births) continues to lag behind that of Whites (2.5 per 1000 live births) but is approaching the overall US rate (3.1 per 1000 live births). Despite these encouraging trends, little is known about how different subpopulations of the entire AI/AN population have fared. The IHS tracks health indicators only in those geographic areas where it has service obligations (all or part of 35 states). 2, 4 Most of these areas are nonmetropolitan counties with tribal lands that have either IHS-administered or tribally run health programs. Approximately 56% of the AI/AN population lives in urban areas, 5 however, and many who live away from their home reservations have limited access to tribal health services. In recognition of the increasing urban demographic shift, the US Congress authorized the Urban Indian Program under Title V of the 1976 Indian Health Improvement Act. 6 This legislation led to the establishment of urban health programs outside IHS service boundaries where substantial AI/AN populations lived. This program, accounting for less than 2% of the current IHS budget, 7 supports 34 individual urban programs outside IHS service areas, many of which provide referral information and health education only. In addition, some urban areas (e.g., Anchorage, Oklahoma City, Phoenix) have IHS or tribally run clinical programs that are supported by regular IHS hospital and clinic budgets. The health status and trends within the urban AI/AN population are largely unknown. IHS statistical reports do not stratify health status reports by rural/urban location of residence, and AI/ANs not residing in defined service areas are not included in aggregate statistical reports. Although several studies have used selected data (e.g., from individual counties or metropolitan areas) to examine the maternal or infant health status of urban AI/ANs and differences between rural and urban AI/AN maternal and infant health status, none have used population-based data 8, 9 to examine national urban maternal and infant health status. A full picture of rural and urban AI/AN maternal and infant health, both inside and outside the IHS system, is needed to assess unmet needs and progress toward national health objectives. In addition, until recently, reports by the IHS and others have underestimated AI/AN infant mortality rates because of misclassification of race on the death certificate. Although this problem and its solution have been clearly identified, 10– 14 few studies have reported AI/AN mortality nationally and stratified by residence location using data linking birth and death certificates. This study aims to provide a complete picture of the differences in maternal risk, prenatal care use, and birth outcomes between AI/AN populations living in rural and urban counties of the United States, both inside and outside IHS areas.
