Reclaiming American Indian maternal and infant health.
For the first six years of my life, Mother's thoughts were so largely centered upon me that she sacrificed even companionship with my father in order to give nee her full time. A weak or puny pu·ny
adj. pu·ni·er, pu·ni·est
1. Of inferior size, strength, or significance; weak: a puny physique; puny excuses.
2. Chiefly Southern U.S. Sickly; ill. baby was a disgrace to a Lakota mother. It would be evidence to the tribes that she was not giving her child proper time and attention and not fulfilling her duty to the tribe. More than that, it was evidence that she has not used proper social discretion and defied age-old tradition. It was a law with the Lakotas that for the first six years of a child's life it should have the unrestricted care of the mother and that no other children should be born within this six-year period. To break this law was to lose the respect of the Tribe, and both father and mother suffered the penalty. A fine, healthy child was therefore a badge of pride and respect, and healthy babies were the rule.
Luther Standing Bear Luther Standing Bear (1868–1939), also known as Ota Kte, was a Native American writer and actor.
Born in South Dakota to an Oglala Lakota family, Standing Bear was educated at the Carlisle Indian Industrial School, an Indian Boarding School in Pennsylvania. "Land of the Spotted Eagle," Copyright 1933
Traditionally, Northern Plains and Rocky Mountain region The Rocky Mountain Region is a floristic region within the Holarctic Kingdom in western North America (Canada and the United States) delineated by Armen Takhtajan and Robert F. Thorne. Indian tribes INDIAN TRIBE. A separate and distinct community or body of the aboriginal Indian race of men found in the United States.
2. Such a tribe, situated within the boundaries of a state, and exercising the powers of government and, sovereignty, under the national considered their children sacred. Regrettably, childrearing practices, like so many other aspects of American Indian American Indian
or Native American or Amerindian or indigenous American
Any member of the various aboriginal peoples of the Western Hemisphere, with the exception of the Eskimos (Inuit) and the Aleuts. culture, have suffered over the past 100 to 150 years as a result of white America's westward expansion. The traditional norms described above are no longer observed by Luther Standing Bear's descendants DESCENDANTS. Those who have issued from an individual, and include his children, grandchildren, and their children to the remotest degree. Ambl. 327 2 Bro. C. C. 30; Id. 230 3 Bro. C. C. 367; 1 Rop. Leg. 115; 2 Bouv. n. 1956.
2. or tribe, with great implications for maternal and child health.
Medical research and technology have made great strides in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. during this same time period. Still, American Indian infants in the Rocky Mountains Rocky Mountains, major mountain system of W North America and easternmost belt of the North American cordillera, extending more than 3,000 mi (4,800 km) from central N.Mex. to NW Alaska; Mt. Elbert (14,431 ft/4,399 m) in Colorado is the highest peak. and on the Northern Plains die more frequently than white infants in the region, making infant death Noun 1. infant death - sudden and unexpected death of an apparently healthy infant during sleep
cot death, crib death, SIDS, sudden infant death syndrome one of the major health problems facing tribes and urban Indians in the area.
Infant Characteristics and Maternal Risk Factors
Infant characteristics at birth provide information regarding the health of a pregnancy and an infant's risk of illness, death, or long-term disability. Some of the factors considered include birth weight, gestational gestational
pertaining to or emanating from gestation.
the age of the fetus in terms of time lapse, e.g. three month fetus, or in terms of proportion of total gestational duration, e.g. first trimester fetus. period, and infant mortality (hardware) infant mortality - It is common lore among hackers (and in the electronics industry at large) that the chances of sudden hardware failure drop off exponentially with a machine's time since first use (that is, until the relatively distant time at which enough mechanical .
Low birth weight and very low birth weight--defined as weighing less than 5 lbs 8 oz and 3 lbs 4 oz, respectively, at birth--are both associated with a multitude of health problems, including greater risk of increased chronic conditions and limitations of activity (Overpeck 1989). All low birth-weight infants are more likely to experience long-term disability or to die during the first year of life than are infants of normal weight, with very low birth weight infants having the lowest survival rate of all. Major contributors to low birth weight are births--infants born before 37 weeks of gestation--and multiple births (MCHB MCHB Maternal and Child Health Bureau
MCHB Monte Carlo Harmonic-Balance
MCHB Maintenance Channel Buffer 2006). Reducing the number of both low birth weight and very low birth-weight infants are goals of the Healthy People 2010 initiative (www.healthypeople.gov).
The infant mortality rate infant mortality rate
The ratio of the number of deaths in the first year of life to the number of live births occurring in the same population during the same period of time. , which relates the number of infant deaths to the number of live births for a population, is one of the most commonly used measures of the overall health of a population and serves as a fundamental measure of development. In fact, overall reduction of infant mortality in the United States has been hailed as one of the 10 greatest public health achievements of the 20th century (MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, 1999). However, there is great disparity between the infant mortality rate in non-Hispanic white and other racial and ethnic populations, American Indians American Indians: see Americas, antiquity and prehistory of the; Natives, Middle American; Natives, North American; Natives, South American. among them, a disparity to which differences in the rate of very low birth weight is a major contributor (MCHB 2006).
When considering infant mortality, a distinction is made between neonatal and postneonatal mortality postneonatal mortality Public health A standard indicator of health, defined as the number of infant deaths occurring between 28 days and 11 months of life. Cf Infant mortality. . Neonatal deaths happen before an infant reaches 28 days of age, and one contributor is low or very low birth weight. Postneonatal deaths, on the other hand, happen when an infant is between the ages of 28 days and 1 year and are less frequently connected to birth weight issues (MCHB 2006).
In Montana, the measures for infant mortality and low birth weight are both slightly higher for American Indians than for the population as a whole (Table 1).
However, when it comes to birth weight, it is important to keep in mind that large infants can also be unhealthy. When a baby is born large for gestational age large for gestational age Neonatology adjective Referring to a fetus weighing ≥ 4.0 kg, 9lbs or ≥ 90 percentile for weight , it is most often caused by maternal diabetes. Pre-existing, as well as pregnancy-onset (gestational) diabetes, if not monitored and managed during a pregnancy, can lead to excessive growth in an infant. Such babies often need to be delivered via Caesarean section caesarean section: see cesarean section. , increasing the risk of complications and prolonging the mother's recovery time.
Additionally, pre-existing diabetes can cause problems early in the pregnancy (the first two months) as out-of-control blood sugar levels can affect the formation of a baby's organs, causing serious birth defects birth defects, abnormalities in physical or mental structure or function that are present at birth. They range from minor to seriously deforming or life-threatening. A major defect of some type occurs in approximately 3% of all births. (MCHB 2007). Infants born to diabetic mothers may also be at higher risk of illness and death during infancy, as well as for the development of Type 1 diabetes type 1 diabetes
See diabetes mellitus. later in life. The mother, if not already a diabetic herself, can go on to develop Type 2 diabetes type 2 diabetes
See diabetes mellitus. (Pitkin 2003).
All of these factors are more common within the American Indian population, but Indian mothers face additional challenges as well. In Montana, for example, Indian women have babies at a younger age than the overall state population, and they exhibit a higher incidence of alcohol, drug, and tobacco use during pregnancy, indicating that mothers and infants have stresses and challenges beyond the general Montana population.
Obviously, healthy and thriving American Indian children are desirable for more reasons than just the traditional cultural values described in the introduction. For American Indian infants to grow up to become healthy and fully participating members of today's society, they need a life start equal to that of white children. However, bringing attention to these traditional values Traditional values refer to those beliefs, moral codes, and mores that are passed down from generation to generation within a culture, subculture or community. Since the late 1970s in the U.S. illustrates the changes in Indian child populations, while also emphasizing that the health conditions seen in today's Indian infant and maternal populations are a recent development and clearly at odds with traditional American Indian values and ideals concerning mothers and babies.
Conventional wisdom, as well as research, tells us that for a woman to deliver and raise healthy babies, she needs to be healthy herself. With higher rates of teen pregnancies and poverty, lower levels of education and employment, and more limited access to quality health care among Montana's American Indian population, health outcomes compare unfavorably with those of the total population. For example, the median age at death for American Indian women is 64 years, while it is 81--a full 17 years more--for the overall female Montana population. However, it is worth noting that a shorter life expectancy Life Expectancy
1. The age until which a person is expected to live.
2. The remaining number of years an individual is expected to live, based on IRS issued life expectancy tables. is not related to a higher death rate. in Montana, American Indians have a lower death rate than the population as a whole (6.5 versus 9.1 deaths per 1,000 population).
Recently, public health efforts have been focused on improving the overall pre-conception health of American Indian women between the ages of 15 and 44 in order to improve pregnancy-related outcomes. For example, American Indian women would benefit from improved access to prenatal care prenatal care,
n the health care provided the mother and fetus before childbirth. , as they currently start care later and complete fewer doctors' visits than their counterparts in the general population. Among births to American Indian women, 65 percent were to women who started prenatal care in the first trimester Noun 1. first trimester - time period extending from the first day of the last menstrual period through 12 weeks of gestation
trimester - a period of three months; especially one of the three three-month periods into which human pregnancy is divided , while in the general population, the corresponding number is 83 percent.
Similarly, 50 percent of American Indian new mothers had received adequate prenatal care, while 73 percent of all Montana births were to women who had received adequate prenatal care (Table 2).
While the importance of early, high-quality prenatal care cannot be underestimated, the importance of overall health prior to becoming pregnant is heightened as over half of pregnancies are unplanned (Finer, 2006). The adverse effects associated by waiting to address health issues until a woman becomes pregnant or starts prenatal care get further compounded the longer she waits to see a doctor when she becomes pregnant.
Focusing on a woman's health before pregnancy can reduce the adverse effects of chronic conditions such as obesity, diabetes, hyperthyroidism hyperthyroidism: see thyroid gland. , and hypertension on both herself and her infant. Regular medical attention can also help in reducing the consumption of tobacco, alcohol, and certain medicines that all have adverse effects on fetal development before a woman knows she is pregnant. Certain birth defects can be prevented by adequate intake adequate intake (AI),
n the consumption and absorption of sufficient food, vitamins, and essential minerals necessary to maintain health. See also dietary reference intakes; estimated average requirement; recommended dietary allowances; and upper intake of folic acid folic acid: see coenzyme; vitamin.
Organic compound essential to animal growth and health and needed by bacteria as a growth factor. (a B vitamin) intake prior to pregnancy, and by avoiding alcohol and drug use (CDC See Control Data, century date change and Back Orifice.
CDC - Control Data Corporation 2008).
An opinion or conception formed in advance of adequate knowledge or experience, especially a prejudice or bias.
Noun 1. health, however, does not end with the birth of a child. Postpartum postpartum /post·par·tum/ (post-pahr´tum) occurring after childbirth, with reference to the mother.
Of or occurring in the period shortly after childbirth. care provides an opportunity to monitor and sustain a woman's health in anticipation of her next pregnancy. Health care providers who treat women of reproductive age should make use of every opportunity to provide guidance that may improve the outcome of possible future pregnancies. Health programs that focus on maternal and child health, such as WIC WIC - WAN Interface Card , Healthy Start, and public health clinics providing immunization immunization: see immunity; vaccination. and well-child visits, do in fact have a unique opportunity to ensure not only the well-being of the infant but also to improve and sustain the health of the mother, ensuring that her next pregnancy is healthy.
Data: Availability and Gaps
Health data are used to define the scope of a health program; provide information about sub-groups that are at highest risk; evaluate the effectiveness of programs and services; and, over time, assist health planners to determine whether health is improving or declining. An essential element in improving American Indian maternal and infant health in Montana is the access to high-quality and timely health data.
While data for Montana's total population are readily available in practically every health area, they are sorely lacking for racial group populations, American Indians among them. Most data available on Montanans and their health are not provided for each race or ethnicity, making evaluation of the unique needs of specific populations impossible. Furthermore, where data specific to American Indians are available, they are rarely provided at the tribal or reservation level, again complicating the task of determining if one tribe or reservation requires more attention than another.
For non-Indians, this latter need may be dismissed as unnecessary, assuming that the state's American Indian population should be considered as one entity. But each tribe, or at the very least each reservation, should be considered one racial group with unique characteristics and needs. While some tribes and reservations are financially wealthy, many are not, having poverty and unemployment rates much higher than off-reservation populations.
For example, employment rates vary from 83.4 percent on the Flathead Reservation, a relatively wealthy reservation, to 70.6 percent on Rocky Boy's Reservation. Likewise, poverty rates vary from 28.2 percent for the landless land·less
Owning or having no land.
Adj. 1. Little Shell Tribe, to 45.2 percent on the Fort Peck Reservation, where 50 percent of children under 18 live below the Federal Poverty Level (Table 3). The Census figures underlying these statistics, though considered reliable, are disadvantaged by being untimely as they are only collected through the decennial de·cen·ni·al
1. Relating to or lasting for ten years.
2. Occurring every ten years.
A tenth anniversary. Census, the last of which took place in 2000.
With varying economic conditions, geographic location, and group size, it stands to reason that there will be differences related to health issues as well, including prenatal prenatal /pre·na·tal/ (-na´tal) preceding birth.
Preceding birth. Also called antenatal.
preceding birth. and infant health. The only detailed health statistics that are readily available are the immunization rates for 2-year-olds who have been seen by a health care provider, which can be obtained for each health care facility within the Billings Indian Health Services The Indian Health Service (IHS) is an Operating Division (OPDIV) within the U.S. Department of Health and Human Services responsible for providing federal health services to American Indians and Alaska Natives. Area (Table 4).
There are considerable differences among the reservations, differences that do not necessarily follow economic patterns of prosperity. For example, the Flathead Reservation, which has a relatively low poverty rate and the highest rate of employment among the Montana tribes and reservations, shows the lowest immunization rate at 63 percent. Fort Peck, on the other hand, has the lowest levels of employment and a relatively high poverty rate, yet can boast an immunization rate of 91 percent, slightly higher than the overall Montana rate.
Even though surveillance systems exist both at the state and federal levels, tribes and reservations are not benefiting from timely access to detailed health data for their jurisdictions. However, in the areas of maternal and infant health, there is some good news in the several efforts that are under way to improve access to such data for tribes. Some examples include:
Vital statistics encompass health data collected from infants' birth and death certificates and are maintained by state vital registries. Birth and infant death data can describe the size and characteristics of newborns and their parents and can provide insight into the scope of infant mortality and leading causes of infant death.
Before 2008, Montana birth certificates did not include information on the mother's tribal affiliation. However, starting in 2008, in keeping with the 2003 revision of the U.S. Standard Certificates of Live Birth by the Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS , an option is included for the mother to indicate the name of her enrolled or principal tribe. This option has been included on Montana death certificates for some time, though it is to be completed by the funeral home director, which can render the information unreliable and difficult to analyze.
Additionally, Indian Health Services' Office of Program Statistics publishes a report, Regional Differences in Indian Health, comparing the health status of IHS IHS
(I.H.S.) first three letters of Greek spelling of Jesus; also taken as acronym of Iesus Hominum Salvator ‘Jesus, Savior of Mankind.’ [Christian Symbolism: Brewer Dictionary, 480]
See : Christ
IHS areas, including maternal and infant health. The most recently published report uses data that are 10 years old. Efforts of the Northern Plains and Rocky Mountain Tribal Epidemiology Centers are under way to collaborate with state departments of health to develop systems of vital records reporting to tribes.
Pregnancy Risk Assessment Monitoring System (PRAMS PRAMS Pregnancy Risk Assessment Monitoring System
PRAMS Passenger Reservation And Manifesting System )
The goal of PRAMS is to reduce infant mortality and improve maternal and infant health through collecting population-based information on maternal experiences and attitudes before, during, and after the most recent pregnancy, issues covered include access to and utilization of services, content of prenatal care, breastfeeding, nutrition, depression, abuse, and tobacco use and exposure. Data are available at the state level, though not for all states, and for certain sub-groups, provided that minimum response rate for a group is achieved. The State of Montana conducted a PRAMS survey in 2002. The resulting sample included 128 women of American Indian heritage, representing a response rate of 68 percent, as reported by the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC). The CDC requires a response rate of 70 percent or more to publicly release any data. Thus no data for American Indians are available from this effort.
As a result, the Rocky Mountain Tribal Epidemiological Center (RMTEC) is working to implement an American Indian Pilot PRAMS in 2008, involving two Montana Tribes. The purpose of this pilot is two-fold:
* To collect methodological information to aid Montana Maternal and Child Health (MCH See Intel Hub Architecture. ) staff in increasing American Indian response rates in future PRAMS efforts; and
* To gather currently unavailable maternal and child health data for use by RMTEC and the tribes in program planning.
RMTEC is seeking to support Montana in its next application for statewide funding for a PRAMS survey that fully includes the Tribes and uses innovative techniques (following the CDC's guidelines) to ensure adequate American Indian response rates.
Pregnancy Nutrition Surveillance System (PNSS PNSS Pregnancy Nutrition Surveillance System
PNSS Pilot Night Sight System )/Pediatric Nutrition Surveillance System (PedNSS)
These two program-based systems monitor the nutritional status nutritional status,
n the assessment of the state of nourishment of a patient or subject. of infants, children, and mothers who participate in federally-funded maternal and child health programs, such as WIC. Data collected for pregnant women include information on diabetes and hypertension during pregnancy, interpregnancy intervals, and smoking, while for children data are collected on birth weight, anemia, breastfeeding, overweight, and underweight Underweight
An situation where a portfolio does not hold a sufficient amount of securities to satisfy the accepted benchmark of the portfolio's asset allocation strategy.
Notes: . Data collected by PNSS/PedNSS are reported for the nation and for any contributor of data. Contributors can be a state or a tribal government, and data can be reported at the county, agency, or clinic levels. Montana regularly contributes state-level data to the PNSS/PedNSS.
Without detailed knowledge of this kind, existing disparities cannot be addressed through individualized in·di·vid·u·al·ize
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.
2. To consider or treat individually; particularize.
3. programs, and blanket solutions may be applied that are less than effective for the populations that are worst off and completely superfluous where conditions are better. For example, given the data available on immunization rates for the individual reservations, a targeted immunization campaign can be developed that would focus more on the Flathead Reservation, where immunization rates are lowest, and less on the Black-feet Reservation, where rates are highest. Only by recognizing disparities in health conditions among Montana's various populations can we create solutions that target every resident of our state rather than some arbitrary average.
Centers for Disease Control and Prevention. Preventing Birth Defects. www.cdc.gov/ncbddd/bd/prevention.htm, accessed April 25, 2008.
Centers for Disease Control and Prevention. Ten Great Public Health Achievements United States, 1900-1999. Morbidity and Mortality Weekly Report Morbidity and Mortality Weekly Report (MMWR) is a weekly epidemiological digest for the United States published by the Centers for Disease Control and Prevention. The 5 June 1981 issue of the MMWR published the cases of five men in what turned out to be the first report of AIDS. , 1999 48 (12): 241 243.
Finer, Lawrence B. Disparities in Rates of Unintended Pregnancy In the United States, 1994 and 2001. Perspectives on Sexual and Reproductive Health Within the framework of WHO's definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene , 2006 38 (2): 90-96.
Kotelchuck, Milton. Overview of Adequacy of Prenatal Care Utilization Index. University of South Carolina
• • at Chapel Hill, 1994.
Overpeck, Mary P., A. J. Moss, H. J. Hoffman, G. E. Hendershot. A Comparison of the Childhood Health Status of Normal Birthweight and Low Birth Weight Infants. Public Health Reports. 1989 104 (1): 58-70.
Pitkin, Joan, A.B. Peattie, B. Magowan. Obstetrics and Gynecology obstetrics and gynecology
Medical and surgical specialty concerned with the management of pregnancy and childbirth and with the health of the female reproductive system. : An Illustrated Colour Text. Oxford, England: Churchill Livingstone Imprint of a medical publishing company owned by Elsevier Ltd, but previously owned by Harcourt and Pearsons. Originally formed from Livingstone, Edinburgh, Scotland, and J & A Churchill, London, UK, and subsequently with an office in New York, but now integrated with the rest of , 2003.
U.S. Department of Health and Human Services, Health Resources and Services Administration The Health Resources and Services Administration (HRSA) is an agency within the United States Department of Health and Human Services whose goal is to improve access to health care for those without insurance. . Women's Health Women's Health Definition
Women's health is the effect of gender on disease and health that encompasses a broad range of biological and psychosocial issues. USA 2007. Rockville, Maryland Rockville is the county seat of Montgomery County, Maryland, United States. According to the 2006 census update, the city had a total population of 59,114, making it the second largest city in Maryland. : U.S. Department of Health and Human Services, 2007.
U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Child Health USA 2006. Rockville, Maryland: U.S. Department of Health and Human Services, 2006.
Thale Dillon is director of economic research for Montana Kads Count. Christine Rinki is an MCH epidemiologist for the Northern Plains Tribal Epidemiology Center. Jennifer Giroux is a medical epidemiologist with the Rocky Mountain Tribal Epidemiology Center.
Table 1 Health Statistics American All Montana Indian Women Women Population 29,111 458,260 Median age (years) 30.2 40.8 Median age at death (years) 64 81 Fertility rates: teens (teen births per 1,000 teen females) 100.9 35.9 Fertility rates: all women (all births per 98.0 60.7 1,000 females of childbearing age) Percentage of births where mother started prenatal care in 1st trimester 65% 83% Percentage of births where mother received adequate prenatal care 50% 73% Percent of babies born with low birth weight (below 5lbs 8oz) 7.3% 6.9% Infant mortality rate (deaths per 1,000 live births) 8.0 6.2 Immunization rate for 2-year-olds who are seen by a health care provider 85% 90% Sources: U.S. Census Bureau, 2000; Office of Vital Statistics, Montana Department of Health and Human Services, 2000-2004; Indian Health Service Immunization Registry, 2005; Communicable Disease Control and Prevention Bureau, Montana Department of Health and Human Services, 2006. Table 2 Level of Prenatal Care Adequate Plus Adequate Intermediate American Indian women (MT) 18% 33% 20% All Montana women 29% 45% 15% Inadequate No Care American Indian women (MT) 27% 2% All Montana women 10% 1% Prenatal Care Prenatal Care Prenatal Care Starting Starting 2nd Starting 3rd 1st Trimester Trimester Trimester American Indian women (MT) 65% 25% 7% All Montana women 83% 14% 2% No Care Unknown American Indian women (MT) 2% 1% All Montana women 1% 1% Note: Adequate prenatal care is based on the Kotelchuck Index and is defined as receiving 80 percent or more of expected visits. Source: Office of Vital Statistics, MT DPHHS, 2000-2004. Table 3 Education, Unemployment, and Poverty High School Graduate/ Bachelor's Total GED Degree Unemployment Montana total population 87% 24% 3.6% American Indian population * 76% 11% 20.2% Blackfeet Reservation 75% 9% 24.3% Crow Reservation 75% 9% 22.9% Flathead Reservation 75% 10% 16.6% Fort Belknap Reservation 75% 10% 22.3% Fort Peck Reservation 72% 9% 28.3% Little Shell Tribe 73% 8% 20.3% Northern Cheyenne Reservation 76% 10% 22.6% Rocky Boy's Reservation 76% 11% 29.4% All Ages in Under 18 in Poverty Poverty Montana total population 4.3% 20.0% American Indian population * 36.9% 43.2% Blackfeet Reservation 27.7% 29.0% Crow Reservation 37.7% 44.0% Flathead Reservation 31.3% 34.0% Fort Belknap Reservation 33.5% 38.0% Fort Peck Reservation 45.2% 50.0% Little Shell Tribe 28.0% 34.0% Northern Cheyenne Reservation 41.8% 47.0% Rocky Boy's Reservation 25.4% 26.0% 18 and Over 65 in Over in Poverty in Poverty Montana total population 13.0% 9.0% American Indian population * 32.9% 26.2% Blackfeet Reservation 27.0% 25.0% Crow Reservation 33.0% 23.0% Flathead Reservation 30.0% 12.0% Fort Belknap Reservation 30.0% 28.0% Fort Peck Reservation 41.0% 30.0% Little Shell Tribe 25.0% 24.0% Northern Cheyenne Reservation 37.0% 38.0% Rocky Boy's Reservation 25.0% 24.0% * Includes reservation residents and nonresidents. Source: U.S. Census Bureau, 2000. Table 4 Immunization Rates Rate Immunization Montana total population 90% American Indian population 85% Blackfeet Reservation 94% Crow Reservation 73% Flathead Reservation 63% Fort Belknap Reservation 83% Fort Peck Reservation 91% Little Shell Tribe NA Northern Cheyenne Reservation 92% Rocky Boy's Reservation 87% * Full immunization (4:3:3:1:3) includes 4 doses diphteria, tetanus & pertussis; 3 doses polio; 3 doses H. influenza type b (Hib); 1 dose measles, mumps & rubella; 3 doses hepatitis B. Source: Indian Health Services, Immunization Registry, 2005.