Indigenous Leaders Decolonizing the “Shared Space” of State Policy for Reproductive and Perinatal Health Justice

Background and Purpose: Indigenous reproductive and birth justice (RBJ) leaders encounter state government systems regularly in their efforts to serve their communities and improve maternal, infant, and family well-being. They often rely on state funding to implement desired programming, and they play an important role in disseminating policy knowledge to their service populations. This is critical work given the significant RBJ inequities Indigenous communities experience, including among the highest maternal and infant mortality rates, histories of forced sterilization, and barriers to perinatal care access.

Focusing on Washington state, the purpose of this qualitative study was to create a framework describing state policy processes that impact RBJ and the corresponding strategies Indigenous RBJ leaders use to engage with and influence it. The study addresses gaps in what is known about state-Indigenous policy and jurisdictional dynamics, current policy processes that contribute to staggering Indigenous reproductive health inequities in Washington, and policy-facing approaches that can advance justice.

Methods: An Indigenist constructivist grounded theory methodology was used to investigate the holistic policy environment and the outcomes it produces through the lens of Indigenous RBJ leaders. The lead researcher conducted in-depth semi-structured interviews with 13 Indigenous RBJ leaders working across the state of Washington to serve American Indian, Alaska Native, Native Hawaiian, and Pacific Islander communities. Interview data were supplemented with observations of relevant policy discourse within public Indigenous only RBJ spaces as well as convenings between Indigenous RBJ leaders and the state.

Results: The resulting grounded theoretical framework of Indigenous RBJ policy action revolves around the core phenomenon of decolonizing “shared space.” The framework weaves together a detailed analysis of policy system functions that support and undermine Indigenous RBJ and the strategies Indigenous leaders use to navigate this system in their efforts to bring birth back home, connect families with perinatal care services, promote access to culturally based services, and more. Key strategies are described within three themes: (1) Rooting in Indigenous Values and Knowledge reflects the unique epistemological lens that Indigenous leaders carry and advance through their work; (2) Relational Partnership denotes the ways in which study participants continually place relationships and good faith investment in state partnerships at the center of their approach; and (3) Holding the Line includes a set of interlinked practices of personal, collective, and intergenerational strength that must often be deployed alongside relational partnership to say no to and push back on structures and directives that impede sovereignty and Indigenous health justice work.

Conclusions and Implications: This study was designed to inform a series of convenings engaging community and state government partners in applying the framework to policy system improvement planning. Phase two will thus involve interactive meeting facilitation to map specific state agency, legislative, and executive level gaps and opportunities in the current Washington state policy environment and to generate actionable ideas for system improvement to support Indigenous RBJ. The framework has other potential applications to policy systems mapping in diverse domains of Indigenous well-being, Indigenous governance research, and state policy implementation.