The efforts to draft a specific instrument dealing with the protection of indigenous peoples worldwide date back over several decades. In 1982, the Working Group on Indigenous Populations was established and was one of the six working groups overseen by the Sub-Commission on the Promotion and Protection of Human Rights, the main subsidiary body of the United Nations Commission on Human Rights (defunct 2006).
The Working Group was established as result of a study by José R. Martinez Cobo on the problem of discrimination faced by indigenous peoples throughout the world. The study outlined the oppression, marginalization and exploitation suffered by indigenous peoples.
The Working Group submitted a first draft declaration on the rights of indigenous peoples to the Sub-Commission on the Prevention of Discrimination and Protection of Minorities, which was later approved in 1994. The Draft was sent for consideration to the then U.N. Commission on Human Rights for further discussion and if it was deemed to be appropriate, to approve the proposed declaration before its submission to ECOSOC and the U.N. General Assembly.
After the film screenings, the two indigenous film makers, Reahan Tarbell and Doris Loyaza, were joined by Segundo Angagamarca who runs a Kichwa Radio Programme in New York. The three engaged in a Q&A session with the moderator, Damian Cardona Onses, Acting Chief of the Communications Campaigns Service in the United Nations Department of Public Information.
Francisco Cali Tzay was appointed Special Rapporteur on the rights of indigenous peoples in March 2020 and took up the role on 1 May 2020. A Mayan Cakchiquel from Guatemala, he has represented indigenous peoples at the United Nations since the early 1980s, addressing human rights violations against the Indigenous Peoples in Guatemala and around the world.
The Department of Justice is committed to addressing the persistent violence endured by Native American families and communities across the country, including by working with Tribal nations to address the important issues of missing or murdered indigenous persons. The Department views this work as a priority for its law enforcement components. It also recognizes the broader public safety and public health concerns that underlie many of these cases and require solutions from across the Department's components.
We identified all hospital deliveries that occurred between 2012 and 2015 using standard methods.16 In 2015, International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses codes were available only for the first three quarters. We adjusted the survey weights in 2015 to generate annualized estimates from the first three quarters of data. Our analyses included deliveries occurring among indigenous and white women. For each year in the study period, approximately 6% of observations had missing data for race or ethnicity. The Healthcare Cost and Utilization Project reports that race and ethnicity data in the National Inpatient Sample are not missing at random.17 We kept with other recent reports and chose not to impute missing data for race or ethnicity.8,18 Instead, we used complete case-based analyses.
We used weighted multivariable logistic regression and predictive population margins to generate prevalence and incidence estimates and relative risks (RRs) with 95% CIs for comorbid physical health conditions and delivery-related outcomes, including severe maternal morbidity and mortality. The incidence of blood transfusion, disseminated intravascular coagulation, and hysterectomy were also estimated for each group. These were the only individual indicators of severe maternal morbidity and mortality with a large enough unweighted sample size to present for each group of women. We used multivariate models to test for statistical differences in study outcomes between indigenous women and white women and conducted stratified analyses between rural and urban residents within each racial category (comparing rural and urban indigenous women, for example). Finally, we estimated the excess incidence of severe maternal morbidity and mortality among rural, indigenous, and rural indigenous women. We did so by multiplying the total number of weighted cases for each group by that group's adjusted incidence rate of severe maternal morbidity and mortality and subtracting the number of cases calculated when instead using the adjusted incidence rate for the appropriate referent group.
Addressing the intersection of risks based on both race- and place-based inequities requires 1) inclusion of rural and indigenous people in planning and implementation of maternity care improvement, 2) measuring maternal health outcomes based on race and geography, and 3) recognizing that indigenous populations are heterogeneous groups with salient individual characteristics. Profound disadvantage was identified among indigenous women residing in rural counties, with two thirds living in counties with median incomes in the bottom national income quartile. Concordantly, three quarters of these women had childbirth hospitalizations paid for by Medicaid. Indigenous women residing in rural counties also incurred the greatest risk for preexisting, chronic conditions complicating childbirth, including diabetes and substance use disorders. Improving maternal outcomes for indigenous women requires engagement with medical and social determinants of health in both clinical and policy efforts aimed at addressing these inequities. In many ways, these findings shed light on the perfect storm of conditions that create difficulty for both patients and clinicians who aim to meaningfully improve maternal health outcomes. Access to obstetric services is declining in rural areas, and efforts to expand health care provider incentives and resources aimed at recruiting and retaining rural providers have been slow to take shape. These policies are integral to the sustainability of rural maternity care and to improving health outcomes among rural residents, including indigenous women.
Next, the findings of this study suggest that blood transfusion is largely driving the high incidence of severe maternal morbidity and mortality among indigenous women who reside in rural counties. Blood transfusion is frequently associated with obstetric hemorrhage in the context of childbirth, and a significant proportion of obstetric hemorrhages are considered preventable.8 The implementation of quality improvement initiatives addressing obstetric hemorrhage, such as the Alliance for Innovation in Maternity Care's Obstetric Hemorrhage Safety Bundle,30 should focus on geographic equity in implementation by improving quality of care for populations at the greatest risk of adverse outcomes, including rural indigenous women.
Finally, maternal mortality review committees have been established in almost every state to review cases of maternal death and to identify and make recommendations on ways to prevent future cases of morbidity and mortality.31 However, as of December 2018, only three states had legislation directing their maternal mortality review committees to explicitly focus review on rural communities, and only two states required rural representation on their committees.31 Many tribes have deep traditions of healing and a broad understanding of both personal and historical trauma, which could helpfully inform strategies for improving health outcomes for indigenous women during pregnancy. Specifically addressing the unique needs and challenges of rural residents, particularly rural indigenous residents, is essential to addressing inequities in maternal outcomes. Additionally, including attention to severe maternal morbidity in mortality review proceedings may improve prevention efforts.
The findings of this study should be interpreted in light of the limitations of the data source and study design. These data derive from the childbirth hospitalization, and severe maternal morbidity and mortality may occur up to 1 year after childbirth. Further, as with the use of any claims database, codes that do not generate a specific payment, such as codes for comorbid conditions or severe maternal morbidity and mortality codes not indicating a procedure was performed, may be associated with low sensitivity. Such coding irregularity can differentially affect different groups of women. Challenges exist in generalizing these findings, even when stratified by rural and urban residence, to broader groups of indigenous women owing to vast social differences among tribal governances, local health care resources, and social structures. Local differences are hard to discern in many nationally available survey and administrative data sources, which often include relatively low numbers of indigenous women, making it difficult to detect differences across subgroups. Data on race or ethnicity were missing in 6% of cases included in this analysis. Additionally, hospitals administered by the Indian Health Service cannot be distinguished in these data. Understanding and addressing the challenges faced in local contexts where excess morbidity and mortality is identified will be important for addressing the troubling patterns identified in this study, and maternal mortality review committees may be an important avenue for this work.
The Indigenous Peoples Pilot engages with indigenous communities to foster ethical and culturally relevant space for the use of Earth observations in monitoring, mapping, and managing natural and cultural resources. The pillars of this work include community engagement and the co-production of place-based remote sensing trainings specific to Indigenous lands and territories.
We aim to strengthen the relationships between NASA and Indigenous communities through meetings and knowledge sharing activities, as well as co-developing a global Indigenous geospatial community of practice through the Group on Earth Observations (GEO). Through dialogue and discussion focused on indigenous needs and priorities, our remote sensing trainings provide participants with the data and resources needed to address specific natural resource issues facing their lands. 59ce067264