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1 Association of American Indian Physicians 1225 Sovereign Row, Suite 103 Oklahoma City, OK RETURN RECEIPT REQUESTED Non-Profit Org. U.S. Postage PAID Oklahoma City, OK Permit No. 741 ASSOCIATION OF AMERICAN INDIAN PHYSICIANS NEWSLETTER INSIDE WINTER 2014 UPCOMING AAIP EVENTS 2015 Page 1. Message from the President Page 2. Cancer Solutions based on Community Wisdom Page 6. The Family as a Thinking Body Page 13. AICAF Clinical Cancer Screening Network Page 14. From the Desk of the Executive Director Pre-Admission Workshop - March University of Arizona - Tucson, AZ 23rd Annual Cross Cultural Medicine Workshop - April 23-26, Hotel Santa Fe, Santa Fe, NM National Native American Youth Initiative - June Washington, D.C. 44th Annual Meeting and National Workshop - July/August Seattle, WA For more information visit

2 Message from the President AAIP Mission: to pursue excellence in Native American health care by promoting education in the medical disciplines, honoring traditional healing principles and restoring the balance of mind, body, and spirit. I hope this letter finds all of you well. I am excited for the plans the Membership, Board, and I have put in place for the coming year. This year is both an exciting and challenging time for our organization. As many of you are aware our Executive Director but also and more importantly Our Friend, Confidante, Crises Manager, Organizational Historian, Margaret Knight, is retiring this year. She will never be replaced but nonetheless we are moving forward actively in the process of recruiting and choosing a new Director. Large changes to an organizational leadership prompt time for reflection and the board and I are grateful for the input from many of you. Each of you are an integral part to the success of our mission and your input and participation is essential. Ongoing even now is the Annual Meeting planning process. I hope that you will join us in the Seattle area and I know it will be a great event of learning, meeting new friends, visiting with old friends, and working for our mission. It is a great time and place to incorporate a family vacation as well. I always reflect that the true tie that binds each of us in this organization is Love of Native People and the desire to serve and improve the lives that we touch through this process. To that end it is so very obvious that we need the help of every single member and potential member. The unique contributions each of us has been blessed with when shared with all of us will make our work more meaningful and more successful. A large group of happy warriors working together can accomplish so much. My tentative meeting theme is: AAIP Homecoming 2015 Coming Back to the Heart of Medicine: A Legacy of Wisdom, A Future of Excellence Looking to the future it is clear that we must embrace a larger organizational footprint. This in no small measure is why I chose to call this meeting a homecoming. I am asking our members, all of you, to please come back and help us. Those who are traditional and can teach us the wisdom of the elderswe need you. The scientific Gurus who know how to design studies and inform paths of excellence- we need you. IHS Physicians who lead by example in the greatest service to our people- we need you. Private Physicians who love Indian people and have a heart of service- we need you. Our students, residents, pre-meds who are our future- we need you. I have a special group I want to reach out to as well. Those who may not have been blessed with a traditional upbringing and are not sure how to come home to the part of your heart which is Indian- we need you. To that end we are developing a curriculum to help new members and students gain some insight to the wisdom and traditions of our elders. I hope for all of you to feel at home in our organization as well. Reflecting on many of the issues of the modern world I often realize that the way of our elders and our people had a wisdom and strength that is as essential now as ever. We were environmentalists before there was a green movement. We honored Women and their role in governance before suffrage was even a concept. We believed in the essential need of community for health and wellness well before new thoughts of holistic wellness were talked about. We knew how to feed and provide for ourselves and also flourish through all time with sustainable agriculture before organic options were even named. I only bring this up as a small reminder that we are descendents of a great and proud people, a strong people, a self-reliant people, a wise and relevant people and as stewards of this great legacy I know that we will continue to find a better way forward in the service of our people and world. How could we do anything less? From the Desk of the Executive Director Dear Friends, After 27 years and the last 19 years as the Executive Director of the Association of American Indian Physicians, I am announcing my retirement at the end of this year. I am honored to have served this association through the many successes and challenges over the years. I truly appreciate the AAIP presidents and board members that I have worked with and whose support made many things possible. I looked forward each year to AAIP Annual Meeting and National Health Conference and making sure that each detail and activity was carried out to the best of our ability. Meeting AAIP members, students, speakers and attendees was a highlight of the conference for me and knowing that they are dedicated to improving the health of Indian people and communities. I especially cherish and value the Cross Cultural Medicine Workshops, listening to traditional healers and other speakers collaborating to bridge the gap between western and traditional healing. I am thankful for the many traditional healers willing to participate in the workshop sharing their wisdom and healing. This was a special time. The many students I have met through the Pre- Admission Workshops, National Native American Youth Initiative and Association of Native American Medical Students. They were a constant motivation to do my very best in providing support and resources that could assist them on their difficult journey to a health career. I so appreciate and will always be thankful for my time with students, listening to their hopes and dreams, smiles and energy. Finally, securing grants over the years from the various federal and non-federal sources was difficult, time consuming and at times frustrating and not always successful. But we secured a number of grants that enabled AAIP to provide health promotion activities and other services to Indian Country. I am thankful to my dedicated, competent, professional and motivated staff in successfully administering and achieving the goals and objectives of all our grants. It s impossible to name the many friends/colleagues I have made throughout this journey with AAIP, but I will always be thankful for your support and most of all your friendship. Dahwaeh for allowing me to serve you and a great organization. I will be returning to my village on the Laguna Pueblo reservation in New Mexico to spend time with my father, grandsons and other relatives. Playing tennis and golf will also be on my new agenda. Please keep in touch and I remain your friend forever. Margaret Knight AAIP Executive Director 1 14

3 Cancer is now the leading cause of death for American Indians in the Northern Plains. While cancer rates have been steadily declining for the general population, they continue to rise in the American Indian population. The American Indian Cancer Foundation (AICAF) is a national, Native-governed, non-profit organization dedicated to eliminating the cancer burdens on American Indian families through education, prevention, early detection, treatment and survivor support. Colorectal Cancer in the Northern Plains American Indians Colorectal cancer is the second most common cancer among American Indians (following lung cancer), and it is the second leading cause of cancer death. In the Northern Plains, the colorectal cancer incidence rate is 53% higher for American Indians compared to non-hispanic whites. Getting screened for colorectal cancer has a tremendous impact on both incidence and mortality. Though rates are improving, unfortunately less than half of Northern Plain American Indians ages 50 years and older have completed a colorectal cancer screening. Clinical Cancer Screening Network The cancer mortality rates are a result of a complex set of factors that AICAF is beginning to address though a comprehensive set of approaches. One of our approaches is clinical systems innovation work that supports the advancement in clinical system capacity at Indian Health Service, Tribal and Urban (ITU) clinics to develop and implement comprehensive, customized clinical systems strategies, policies and practices. AICAF engages individual clinics to improve cancer outcomes through improved screening rates. In order to impact the high colorectal cancer mortality, resulting from disproportionate late stage diagnoses, AICAF s Clinical Cancer Screening Network engages participating clinic teams to develop a tailored approach to improve colorectal cancer screening rates by providing clinical systems support, educational materials and tools for patients and clinical teams. The approach is based on AICAF s recent assessment of colorectal cancer screening systems and practices learned from ITU clinics that participated in the Improving Northern Plains American Indian Colorectal Cancer Screening (INPACS) project. INPACS comprehensively assessed quality assurance measures both on the provider-level and systems-level, such as colorectal cancer policies and clinic systems for provider and patient reminders. A clear, overarching finding of INPACS is the need for system-level strategies to impact colorectal cancer screening rates in clinics across Indian Country. Therefore, AICAF partners with clinic teams to address the development of clinic policies, EMR system support, provider training and the development of culturally appropriate patient education and outreach materials. This approach is resulting in effective and sustainable solutions to increase screening, early detection and eventually impact cancer mortality rates among American Indians served by these clinics. Learn More Information Efforts are underway, and AICAF welcomes interested ITU clinics to join the Clinical Cancer Screening Network. Participating clinics in the network identify a clinic team and attend clinic support activities over a 12-month period. For further information, please contact Anne Walaszek at the American Indian Cancer Foundation at awalaszek@aicaf.org or The Clinical Cancer Screening Network is funded by the Centers for Disease Control and Prevention through a contract with the Association of American Indian Physicians. American Indian Cancer Foundation: Cancer Solutions based on Community Wisdom American Indian Cancer Foundation Vision and Mission Our vision is a world where cancer is no longer the leading cause of death for American Indian and Alaska Natives. Through hard work, culturally appropriate community-based programs, and policy change that affords Native people access to the best prevention and treatment strategies we see a day where American Indian communities are free of the burdens of cancer. Our mission is to eliminate the cancer burdens on American Indian families through education, prevention, early detection, treatment and survivor support. Kris Rhodes, MPH, spent 10 years with the University of Minnesota s Division of Epidemiology and Community Health conducting community health education, program evaluation and epidemiological and public health research in Native communities in the Northern Plains and Great Lakes areas before taking the leap to follow her dream. She wanted to focus on capacity building in Native communities and community based health improvement initiatives to address the burden of cancer faced by Native people. She takes pride in having recruited a strong, passionate and professional Native team with knowledge, education and expertise in serving the health needs of the Native people. Rhodes, an enrolled member of the Bad River Band of Lake Superior Chippewa was born and raised on the Fond du Lac Reservation in Minnesota. She and her team draw on the rich culture and tradition of their tribal communities to better understand and address the needs of the Native populations. The common values of American Indian and Alaskan Natives are mirrored in the core values of AICAF, they are; community-centered, respectful of tradition, advancing knowledge, native directed and empowering. THE PUBLIC HEALTH PROBLEM American Indians and Alaska Natives face alarming inequities in cancer incidence and mortality. Cancer incidence rates vary by tribe, region and gender, but are often much higher than in the Caucasian population. Cervical cancer - up to 69% higher Lung cancer - up to 83% higher Colon cancer - up to 162% higher Liver cancer - up to 198% higher Stomach cancer - up to 490% higher Gallbladder cancer - up to 691% higher (Cancer, Sept 2008) According to the Centers for Disease Control, the national percentage of adult American Indians/ Alaska Natives who smoke is 21.8% vs the US average of 18.1% (CDC, 2013). The leading cause of death among AI/AN women nationally is now cancer, and lung cancer accounts for most of these cancer deaths (CDC, 2010). In Minnesota a reported 59% of American Indians are smokers (Tribal Tobacco Use Survey, 2013). Cancer is Minnesota s leading cause of death; and for Indians, their risk of dying from lung cancer is more than two times higher than among non-hispanic whites. According to the Minnesota Cancer Surveillance System and the Minnesota Department of Health American Indian rates of cervical and larynx cancer are four times higher. THE PROGRAM The American Indian Cancer Foundation (AICAF) located in Minneapolis, Minnesota currently offers its programming and services to the 54 tribes and urban Indian centers across the Northern Plains area. The AICAF efforts are expanding nationally with new partnerships and programs with tribes and urban communities in other parts of the country. The organization was established in 2010 as a collaborative effort of Dr. David Perdue, Chickasaw Nation member and a gastroenterologist at the University of Minnesota and Jackie Dionne, Turtle Mountain Chippewa, with 13 2

4 the Minnesota Board on Aging s American Indian Elder Desk. They recognized the growing cancer rate among American Indians in Minnesota and specifically, colorectal cancer was a major issue in Indian communities and there was little attention being given to the issue. Starting in 2011 with a staff of three and two grants to work on colorectal cancer, the staff quickly expanded to 12 American Indian public health professionals ready to take on the ambitious plans to ensure education, prevention, early detection and treatment, and survivor support across all types of cancers across the spectrum from beginning to end of treatment was carried out in partnership with tribes across the country. The work of the AICAF falls into three categories: the strategic partnerships and investments for American Indian cancer solutions; training and technical assistance and resource development for American Indian solutions; and a priority area around research, evaluation and evidence based data and solutions for American Indians. Each program area is critical to AICAF staff member providing the success of cancer screening education to the foundation community elders and its work. Partnerships are key to delivering community based programs, AICAF with its limited staff would not achieve its objectives without the cooperation and collaboration of partners. The focus on training and technical assistance is to enhance the capacity of tribal groups and service providers to ensure they have the requisite skills and resources to do the job as efficiently as possible. The third area focuses on the development of an evidence base to support American Indian solutions. The need to demonstrate American Indian cancer burden inequities is through the effective use of data. Research and evaluation develop the evidence based data which supports 3 proposal applications to address the inequities and demonstrates effectiveness. Part of strategic partnerships includes community engagement, AICAF works with the community to organize the Annual Powwow for Hope. Community involvement and active participation is a way to engage communities in coping with the cancer burden. Teams of community members begin fund raising efforts in advance and raised over $25,000 annually in donations, Great Lakes area traditional sometimes one dollar dancing at the May 2014 at a time. This really PowWow for Hope engages so many people in being a real part of the solution says Rhodes. The Powwow continues to grow each year and it s a way for the community to have an active role in both raising needed funds and in prioritizing and direct the funds to community needs. AICAF is working on the development of a toolkit to be made available nationally so that other communities can host their own Powwow for Hope. Another facet of the work involves developing supports for clinical systems to enable the innovations and improvements that help ensure that all cancer related issues are addressed in an efficient and systematic way. This involves moving the emphasis from urgent care needs to one of prevention and wellness. For example in the Northern Plains where more than half of the adult population are smokers; clinics need an efficient system to not only ask about smoking but have a way to follow up and offer effective quit smoking support Fun Run (Annual Meeting) 2014 Student Endoscopy Workshop (Annual Meeting) 2014 AAIP Pow-Wow (Grand Entry) RAISON D ETRE The AICAF is a 501(c)3 non-profit organization established to address the growing cancer burden in American Indian communities and the lack of resources to address cancer and the cancer inequities faced by American Indian and Alaska Native communities. AICAF s board members and 12

5 2014 Annual Meeting and National Health Conference Denver, CO 11 cigarettes? Too often the stores in our community sell cigarettes but not fresh fruit and vegetables. Cigarette advertising is still everywhere. Where are the ads for our indigenous foods, the foods that will heal us? AICAF is working with partners to make PROGRAM CHALLENGES these changes. The number one risk factor for cancer is Funding for the organization is a constant commercial challenge but never as critical as in the first couple tobacco, usually of years before funding started to come in. Rhodes in the form questioned the wisdom and her ability to continue operating without funding. Relying on her personal of cigarettes. commitment, determination, persistence, an equally The AICAF is clear about this committed staff and on a line-of-credit, AICAF was fact; tobacco is able to continue operations through the financially challenging times. We were able to make it through a challenging topic to address and are in a much better place today. There are in American resources out there and we re asking funders to invest in our communities and strengthen the health Indian Garden greens are cancer prevention. communities. Eat up! of our communities says Rhodes. She sees it as an Tobacco has economic issue and asks businesses that have been financially successful in Indian Country to re-invest a huge effect on just about everything in tribal communities that make it politically charged in the health of these communities. and brings unique complexities when discussing One of the biggest challenges relates to the lack of resources beyond those specifically designated for the impacts within any given tribal community. programmatic activities. It is challenging to operate Tobacco has economic impacts, health impacts, and is central to our spirituality and every ceremony a business with little to no discretionary funds for that we conduct. We must discuss the true impacts administrative, fund raising and strategic planning of tobacco on us as Native people and separate expenses. To this point this obstacle has been out the traditional uses from the destructive uses managed by staff working harder, longer and more says Rhodes. In this work, AICAF consults with off-hours. American Indian elders and youth to guide the The other major challenge has been the broad tobacco control work. The AICAF supports many mission of wanting to address all cancer needs for tribal programs to develop and implement tobacco all tribes across the country. The organization has been successful in its programming with its focus on control programs and policies that are based on tribal teachings, sovereignty and self-determination. the Northern Plains area but expanding the reach This is how we find the solutions to the challenges and making the resources available to other tribes around the country is the next challenge. AICAF is in faced by our communities; we reach back into the community and highlight the wisdom that is the process of addressing the issue and has recently within. This is how we establish our evidence-base, engaged a national partnership manager in these what works in Indian Country is what has worked efforts. for time immemorial. The strategies that have ACCOMPLISHMENTS AND IMPACT been implemented within tribal communities by mainstream haven t worked so well, we need to find Wouldn t it be great if all Indian children our own solutions states Rhodes. had as much access to fresh food as they do to employees are American Indian, with an array of experience serving the health needs of American Indians and Alaska Natives in the Northern Plains area. 4

6 Just like tobacco, the choices we make about the food we eat can make a difference in future cancer diagnoses or even cancer survival. Access to good healthy food is difficult for many American Indian people. The AICAF is committed to working with partners to better understand how this happens and how we can again use tribal teachings, sovereignty and self-determination to make sure that American Indian people have access to our own indigenous foods. AICAF initially targeted the 54 Indian Health Service, tribal and urban Indian health clinics within the seven states of the Northern Plains area. In the first two years, , AICAF staff, Anne Walaszek, White Earth Ojibwe, led the efforts to conduct on-site visits with the clinical staff of 40 of the 54 sovereign nations. One of the major accomplishments according to Rhodes is being able to support overworked and underfunded health systems with tools and education on cancer prevention and early detection to make them more effective at their jobs. Colorectal screening presents unique challenges for health care providers who work with American Indian patients. In a two year period, AICAF engaged the Twin Cities American Indian community to encourage and promote colorectal screening. With a small pilot grant, the AICAF Colon Cancer Screening Navigator, Joy Rivera, Haudenosaunee, convinced 200+ Native people to complete a colonoscopy. A clinician shared stories of her attempts to get her patients in for colonoscopies for several years, then all of a sudden they re showing up requesting colonoscopy appointments. What are you doing to get them to come in? It was the direct result of a trusted community member talking about the ways in which colon cancer can be prevented. A colonoscopy can actually prevent colon cancer by finding polyps in the earliest stages and removing them before they cause any problems. As an organization, AICAF has taken the position that it will not compete with tribes for limited grant funding. In funding applications AICAF either applies for funding in partnership with tribes and when seeking funds independently, AICAF will 5 request that if tribes have an application in, AICAF will remove its application from the competition don t want to take the limited resources away from tribes. Pow-Wow For Hope We want to be a resource to tribes and work in partnership with tribes not in competition. It s a matter of ethics and doing the right thing says Rhodes. Finally, some of the biggest successes have resulted from working with community leaders to do things differently. Tribal communities are so much more self-determined and stronger than they have ever been, and we see tribal leaders who are using sovereignty to protect the health and strength of our communities. I think it s amazing to see our people leading in new ways says Rhodes. She sites her staff as having a positive impact on the issue of cancer in Indian country and as contributing to this new way of thinking. My team is an incredible bunch of people that are working really hard on behalf of Indian Country to make things better. Rhodes takes pride in having recruited a team of native health professionals with strong science and cultural competency skills, which facilitates the rapid dissemination of evidence based programs. Cultural competency is an important facet of the AICAF approach. By focusing heavily on training and technical assistance to tribal communities, community capacity to do the job is enhanced and communities are able to sustain the programs Presidential Reception (Annual Meeting) Rhodes says five things that make the organization work: Partnerships are key to how we get things done. We don t do anything alone; everything we do is in partnership. Diversity in partnerships including tribes, federal agencies, state governments, other non-profit organizations, health care institutions, and academic researchers. 10

7 Don t be intimidated to think outside the box, she added. Don t be afraid to get community involved (referring to her communitybased steering committee). When asked about the future, Cook responded, Our challenges are now to implement Five of the 197 babies born through the Centering Pregnancy Program the Centering Parenting Program and secure a full-time pediatrician. Since diabetes is on the rise on the reservation, it s important to strengthen the program component that focuses on chronic diseases, to ensure that young women fully understand the link between healthy pregnancy and chronic disease prevention. Cook is a part of the curricula development team and has integrated components of the Ohero:kon program, a traditional rites of passage ceremony that translates to under the husk. into the Centering Pregnancy program. It is a culturally based program that works to build respectful, caring, responsible Mohawk teenage girls and boys. Mohawk culture and tradition includes providing education and preparing youth for their roles as responsible adults including family formation and considering generations to come as they transition to adolescence and adulthood, rather than wait for pregnancy to occur. Bear Clan Mother Louise Tewakierahkwa McDonald, the principal coordinator of Ohero:kon, saw a need to bridge the development into adulthood with traditional teaching and support from female knowledge holders. Women are the architects of our social change, McDonald says. The Ohero:kon focuses on the emotional, mental, physical and spiritual growth of youth as they enter into adulthood. Coming-of-age ceremonies are held to provide psychological comfort at this transitional time, formalize the youths new roles and statuses, and reinforce social connections, customs, and values. McDonald realized that when youth have a lack of connection to culture, problematic behavior can result. The 20-week program includes ceremonies; traditional hunting and fishing rites; traditional activities and games; sweat lodges for the boys and moon lodges for the girls; team building; survival training, gardening; sexual health education, including HIV and STI awareness and prevention; and discussion on pregnancy. Young girls and boys who enter this program have made a commitment to be respectful, caring, and honorable in their behavior to each other and those around them. The positive environment has encouraged them to live healthy lifestyles that are in keeping with Mohawk tradition. In terms of supporting women and the coming generations, says Cook, we are walking the walk. ADDITIONAL INFORMATION Contact Information: Name: Brittany Blais Title: Program Manager Organization: St. Regis Mohawk Health Services Phone: bblais@regis.nashville.ihs.gov Written by: Doris Cook Dr. Doris Cook has 35 years experience with American Indian and Alaskan Native communities. Her focus is on Indigenous policy development; program and organizational management; program evaluation; public health planning and research ethics. This article was supported by a Cooperative Agreement #1U38OT from The Centers for Disease Control and Prevention, Of?ice of State, Tribal, Local, and Territorial Support. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. Listening to communities and understanding and valuing the wisdom that exists within communities. A hardworking, committed and passionate staff who truly understand American Indian communities inside and out. The size and infrastructure of the organization enables AICAF to be innovative, flexible and responsive to tribal needs. CONCLUSIONS/LESSONS LEARNED Trust that the solutions to the challenges faced by communities are within the communities. Be ambitious in your goals but stay focused on what matters. Contact: Kris Rhodes, MPH Executive Director Address: American Indian Cancer Foundation 615 First Avenue NE, Ste.. 125, Minneapolis, MN Phone: (612) info@aicaf.org Written by: Doris Cook Dr. Doris Cook has 35 years experience with American Indian and Alaskan Native communities. Her focus is on Indigenous policy development; program and organizational management; program evaluation; public health planning and research ethics. This article was supported by a Cooperative Agreement #1U38OT from The Centers for Disease Control and Prevention, Of?ice of State, Tribal, Local, and Territorial Support. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention. Reclaiming Public Health: Stories of Self-Determination from Tribes The Family as a Thinking Body: Centering Health Care in the Akwesasne/St. Regis Mohawk Community The St. Regis Mohawk Indian Reservation, also known by its Mohawk name Akwesasne, is located in northern New York State, and the Canadian provinces of Ontario and Quebec. The US population consists of approximately 12,000 people. The land is majestic, with three major rivers surrounding and flowing through the reservation. PUBLIC HEALTH PROBLEM Tribal Chief Beverly Cook, currently on leave from her job as a family nurse practitioner at St. Regis Mohawk Health Services, began seeing some pregnant women who were unraveling due to changing family dynamics, leading to lack of support, substance and other abuse issues, and overall apprehensiveness Debra Martin (left) with Chief Beverly Cook display first ever tribal Centering Pregnancy Program Certification awarded about the birth process. They were not viewing pregnancy as bringing new life. Pregnancy can be a powerful and transformative time, but the typical prenatal care just didn t serve the needs of these women. What we were doing wasn t working, Cook says. We needed to connect to the whole person and provide a space where women could connect with each other during this critical time. Lacking special funding to tackle the problems, Cook enlisted then St. Regis Mohawk Health Services Director Deborah Martin and Katsi Cook, an aboriginal midwife from the community and executive director of the First Environment Collaborative for Women and Children s Health, 9 6

8 to plan and create a prenatal program that fits the cultural and health needs of local Mohawk women. The resulting program is based on the national Centering Pregnancy model, an alternative method of providing prenatal care with major Mohawk cultural components and adaptations. PROGRAM DESCRIPTION The tribe is the first of the 25 tribally administered Indian health facilities in the Nashville Area Indian Health Service to integrate the Centering Pregnancy program into their tribal healthcare system. The Centering Pregnancy Institute certifies local programs that meet their stringent requirements and standards. The program is the only tribal program to have received certification. Sharon Schindler Rising, CEO and founder of the Centering Healthcare Institute, is thrilled by the progress. Rising designed Centering Pregnancy as a multifaceted model of group care that integrates the three major components of care, health assessment, education, and support, into a unified program within a group setting. St. Regis Mohawk Health Services embraces this concept and has undertaken a mission to guide pregnant mothers through the Centering Pregnancy format that integrates health assessment, education and support in a group care setting, using the power of the circle as its basis. Secure networks of women supporting women in a nurturing, centered atmosphere echo the ancient spirit of Mohawk clan families. Ultimately, through Centering Pregnancy, the women seek to support healthy families. The St. Regis Mohawk Tribal Council was extremely supportive and encouraged pursuing Centering Pregnancy certification. In 2007, Cook and her staff took the next step and trained on the Centering Pregnancy Model. Katsi Cook was so committed that she used her connections to obtain financial support for the training from the Ford Foundation through its Sexual and Reproductive Health Program and Running Strong for American Indian Youth, a nonprofit organization with a mission to meet the needs of American Indian people with a focus on youth. She also secured added support from Maternal Child Health at Indian Health Services to train and certify all relevant health service program staff and contractual physicians. Her knowledge and networking with the Centering Pregnancy Institute enabled the program to be developed at Akwesasne. Lacking space for the program, health services director Martin committed a small space in the health facility. She overcame internal resistance by focusing on the health providers, who were enthusiastic and willing to take on extra duties. Externally, they used the same approach. So, slowly, obstacles to the program began to fade. In 2010, after three years of persistence and tenacity by Martin and Cook, the Centering Pregnancy program was under way! A pregnant woman, called a Mom by Centering Pregnancy, enters prenatal care through the medical clinic intake process and receives a physical exam. Then she is offered the opportunity to join a group of five to seven women who have similar due dates. If she agrees, she meets other Moms in the softly lit Mind-Body/ Centering Room, where they are taught how to measure and record their own weight, blood MOM participant pressure, and gestational age and to record the results in their own chart. They help themselves to healthy snacks while charting their results and socializing with one another. This Centering Room is magical, says Martin. The lights are low, and it s quiet despite a busy hallway just outside the door. The room hosts a mind/body therapist on the days when the Centering Pregnancy group is not there, which adds to the peaceful energy. In a recent article for the tribe, Randi Barreiro, an early participant in Centering Pregnancy, described one session as follows: They compare growing bellies, chat and laugh as one of them visits privately with the doctor behind a folding screen. Suddenly, the distinct echo of a rapid heartbeat fills the room. The chatter stops for just a brief moment as the women acknowledge the tiny life that is making itself known via fetal Doppler. Then the laughter picks up again. This is the start of another Wednesday morning Centering group at the clinic. Moms join in a circle to share experiences and learn from each other, following a specially designed curriculum under the guidance of the physician or midwife. The sessions are held monthly at first, then every two weeks later in the pregnancy, and are facilitated by a credentialed provider and cofacilitator in a structured but flexible environment. Birthing is normalized (de-medicalized) as the women talk about breast feeding, common discomforts of pregnancy, signs of pre-term labor, domestic violence, and what to expect during labor and delivery. There is a field trip to the hospital birthing rooms, as well as cultural teachings and other social support. The group process promotes positive female relationships and sisterhood, which is in keeping with Mohawk traditions. The sessions include: Relaxation, stress management Nutrition information Lamaze training Dental information Skywoman presentations Breastfeeding consultant Massage Domestic violence discussions Birth plan Hospital tour Home safety training Birth process, labor information Postpartum depression information Birth control information Sharing of birth experiences ACCOMPLISHMENTS AND IMPACT Since it started in 2010, 197 babies have been born through the Centering Pregnancy program, and it continues to gain popularity among pregnant women. Indian Health Service is helping the tribe develop evidence-based evaluation tools. Currently, the program relies on questionnaires for Moms and facilitator evaluation forms to receive feedback on the program. Moms participate in prenatal care in a welcoming environment with others whose due dates are close to their own. It helps to share your experiences with someone who really understands what you re going through, says Cook. That support is essential to Centering and to our community. The Moms seem to agree. It was fantastic, said Niio Perkins, who delivered son Tristan in February I left every session better educated and feeling glad I went, she said. The Moms in her group still keep in touch, she added. The bond is really there. The clinic s former obstetrician, Dr. Sonia Joseph, who helped deliver Centering babies agreed. It s a great way for women to connect, she said. It makes pregnancy more natural than clinical. It is the best thing ever. Dr. Joseph noted that the women raise issues that wouldn t normally come up in the typical doctor-patient prenatal visit, and that they are pretty open during group discussions. When asked what five things made the project work, Cook replied: Persistence and determination Cooperation of administration and the Support of Tribal Council Buy-in of the physicians Enthusiasm of nursing staff Each Mom s willingness to participate CONCLUSIONS/LESSONS LEARNED Cook shared some lessons she learned along the way. She said, Don t be afraid to make it (the project) your own. Don t be afraid to change things. For example, Cook and her colleagues made changes to the curriculum and added Mohawk culture. 7 8