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Context: The Indian Health Service (IHS), whose per capita expenditure for American Indian and Alaska Native (AI/AN) health services is about half that of the US civilian population, is the only source of health care funding for many rural AI/ANs. Specialty services, largely funded through contracts with outside practitioners, may be limited by low IHS funding levels. Purpose: To examine specialty service access among rural Indian populations in two states. Methods: A 31-item mail survey addressing perceived access to specialty physicians, barriers to access, and access to non-physician clinical services was sent to 106 primary care providers in rural Indian health clinics in Montana and New Mexico (overall response rate 60.4%) and 95 primary care providers in rural non-Indian clinics within 25 miles of the Indian clinics (overall response rate 57.9%). Findings: Substantial proportions of rural Indian clinic providers in both states reported fair or poor non-emergent specialty service access for their patients. Montana's rural Indian clinic providers reported poorer patient access to specialty care than rural non-Indian clinic providers, while New Mexico's rural Indian and non-Indian providers reported comparable access. Indian clinic providers in both states most frequently cited financial barriers to specialty care. Indian clinic providers reported better access to most non-physician services than non-Indian clinic providers. Conclusions: Reported limitations in specialty care access for rural Indian clinic patients appear to be influenced by financial constraints. Health care systems factors may play a role in perceived differences in specialty access between rural Indian and non-Indian clinic patients.

Objectives. We examined disparities in perinatal care, birth outcomes, and infant health between rural American Indian and Alaska Native (ALAN) persons and rural Whites over time. Methods. We compared perinatal and infant health measures for 217064 rural AIAN births and 5032533 rural non-Hispanic White births. Results. Among American Indians and Alaska Natives, unadjusted rates of inadequate prenatal care (1985-1987, 36.3%; 1995-1997, 26.3%) and postneonatal death (1985-1987, 7.1 per 1000; 1995-1997, 4.8 per 1000) improved significantly. However, disparities between American Indians and Alaska Natives and Whites in adjusted odds ratios (AORs) of postneonatal death (1985-1987, AOR=1.65; 95% confidence interval [Cl]=1.41, 1.71; 1995-1997, AQR=1.46; 95% CI=1.31, 1.64) and adjusted risk ratios (ARRs) of inadequate prenatal care (1985-1987, ARR=1.67; 95% Cl=1.65, 1.69; 1995-1997, ARR=1.84; 95% Cl=1.81, 1.87) persisted. Conclusions. Despite significant decreases in inadequate prenatal care and postneonatal death among American Indians and Alaska Natives, additional measures are needed to close persistent health gaps for this group. (doi:10.2105/AJPH.2007.119735)

Objectives. We sought to provide a national profile of rural and urban American Indian/ Alaska Native (Al/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 [less than or equal to] .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.

Objective. To determine geographic variation in urban American Indian and Alaska Native (AI/AN) rates of infant mortality, low birth weight, prenatal care use, and maternal-child health care service availability. Methods. This was a retrospective cohort study using data from the 1989 to 1991 birth-death linked database from the National Center for Health Statistics. We examined births from metropolitan areas with a minimum of 300 AI/AN births during the study period. Key outcomes of interest included rates of low birth weight, neonatal mortality, postneonatal mortality, and women receiving inadequate prenatal care using the modified Kessner index. To determine the type of health services tailored to AI/AN mothers residing in these urban areas, we conducted a telephone survey of the 36 urban Indian health programs operating in 1997 using a semistructured survey. Items in the survey included questions about the availability of prenatal and infant health care. Results. During the 1989 to 1991 study period, there were 72 730 singleton births to AI/AN mothers and/or fathers residing in urban areas, representing 49% of all AI/AN births in the United States. Overall 14.4% of urban AI/AN births were to women who received inadequate care during pregnancy, 5.7% of pregnancies resulted in low birth weight infants, and 11.0 infants died per 1000 live births. Death rates for the neonatal period (5.5 per 1000 births) and postneonatal period (5.4 per 1000 births) were similar. Marked disparity in these indicators exist between pregnancies to AI/AN and white women. Among the 54 metropolitan areas, 46 had a rate ratio (AI/AN: white) for inadequate care of [greater than or equal to] 1.5 (range: 0.9-8.5). The mean rate ratios for neonatal and postneonatal mortality were 1.6 (range: 0.3-4.0) and 2.0 (range: 0.5-5.5). There was also considerable geographic variation of AI/AN mortality rates between metropolitan areas in all of the outcomes studied. All of the 20 metropolitan areas with the highest birth counts had some type of direct medical care or outreach services available from an urban clinic targeted toward AI/AN patients. Conclusions. Considerable variation also exists among rates of AI/ANs between metropolitan areas. Disparity exists in rates of perinatal outcomes between AI/ ANs and whites living in the same metropolitan areas Although AI/AN urban health programs exist in most cities with large birth counts, it seems that many have inadequate resources to meet existing needs to improve perinatal outcomes and infant health. Pediatrics 2002;109: 627-633; American Indians, Alaska Natives, health status, urban health, infant mortality, prenatal care. ABBREVIATIONS. AI/AN, American Indian and Alaska Native; IHS, Indian Health Service; MSA, Metropolitan Statistical Area; RR, rate ratio., Despite considerable improvements over the past 40 years, the health status of American Indian and Alaska Native (AI/AN) children is lower compared with most children in the United States. (1) [...]