Children born into their home community are more likely to develop a clear sense of identity, which helps to promote resilience and build strong community bonds. However, most Indigenous women are forced to travel to urban centres to give birth in settings that may not feel culturally secure. Careproviders and administrators need to value and incorporate birth traditions, rituals, and ceremonies, provide different options for safe maternity care outside of major centres, and increase the number of Indigenous maternity careproviders (e.g., midwives, doulas, birth workers). This chapter briefly explores the state of Indigenous birth and the impact on the mother and community in Canada and increasing the cultural competence of careproviders.
Key Terms: birth, motherhood, Indigenous, traditional
Childbirth can be a positive, empowering experience for a woman, which can promote kinship and strengthen community bonds; however, if the care a mother receives lacks cultural safety, she may experience confusion, anxiety, depression, and trauma that can stay with her throughout her life, which can affect how she parents her baby and in turn impact her child’s growth and development (Bowen et al., 2014; Kornelsen, Kostaka, Waterfall, Willie & Wilson, 2011).
Until the 1970s, many Indigenous women gave birth in their home communities with some mothers birthing on the land; the centralization of health care has resulted in the loss of traditional birthing practices that had previously assured strong community roots for women and their families. Children born into their home community are more likely to develop a clear sense of identity, which helps to promote resilience and build strong community bonds (SOGC, 2017).
This chapter briefly explores the state of Indigenous birth in Canada, the impact on the maternal and infant health, and the importance of increasing culturally-safe care.
Support for Culturally Safe Indigenous Birth
Canada has fully endorsed the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP), which asserts that Indigenous people have the right to practice and revitalize their cultural traditions and customs (United Nations, 2008). The Canadian Government has endorsed the Truth and Reconciliation Commission Report (TRC) (2015) to increase healing and establish and maintain a mutually respectful relationship between Indigenous and non-Indigenous peoples. Amongst the TRC Calls to Action, two are particularly compelling for reclaiming traditional birth: 1) “We call upon those who can effect change within the Canadian health-care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients” (#22); and 2) “increasing the number of Aboriginal health care providers working in Aboriginal communities” (#23.1).
Impact on Health
The Society of Obstetricians and Gynecologists of Canada (SOGC) acknowledges that there are gaps between birth outcomes for Indigenous and non-Indigenous families and that the organization of maternity services contributes to a lack of access to care (SOGC, 2017). Indigenous people are more burdened by chronic diseases, such as cancer, cardiovascular disease, diabetes, and mental illness in comparison to non-Indigenous people (Wilk, Maltby & Cooke, 2017) and many of these conditions have their origins in early life, i.e., conception, pregnancy, birth, and early childhood (Barker, 1995). One study in Australia showed Indigenous mothers appear to experience higher rates of stress during pregnancy than non-Indigenous women (Parker, McKinnon, & Kruske, 2014). Stress in pregnancy is associated with adverse outcomes, resulting in expensive neonatal care and lifelong complications (Kornelson, Stoll, & Grzybowski, 2011; Tarlier, Johnson, Browne & Sheps, 2013).
Given the social and historical contexts of colonization in Canada, it is necessary to consider the impacts of intergenerational trauma, a phenomenon which impacts all Indigenous populations; but, due to the intersection of sexism and racism, especially hurts Indigenous women (Roy, 2014). Stresses of pregnancy can exacerbate existing symptoms of trauma in women, therefore pregnancy may be an especially important time to provide interventions as it can be a powerful time for mothers to choose a healing path and break cycles of intergenerational trauma (Roy, 2014).
Birthing Away from Community
Through a systematic review and semi-structured interviews with mothers who travelled out of community for birth, O’Driscoll and colleagues determined the loss of community birth is a cultural loss (O’Driscoll et al., 2014). By the late 1960s, births in community were deemed unsafe due to distance and isolation (Chamberlain, 1999) and policies arose to support medical evacuation to regional and tertiary care hospitals (Douglas, 2006) including moving women to urban centres at approximately 37 weeks gestation (Chamberlain, 1999). Though sometimes clinically warranted, medical evacuation is often associated with colonialization (O’Driscoll et al., 2014). In some cases where women don’t want to leave their family and community, resistance to medical evacuation is evidenced by mothers not reporting their pregnancies, which allows them to birth in their community (Douglas, 2006), and stories of women remaining in community until it is too late to be transferred to urban hospitals to give birth or receive specialized care. Indigenous women often feel lonely and vulnerable when forced to leave their home communities and families, and find themselves in situations that do not incorporate traditional practices or ceremonies into their birth experiences or newborn care (Kornelsen et al., 2011; SOGC, 2017). A study with Indigenous women giving birth in a large tertiary care facility showed that lack of choice in place of birth, type of delivery, and other birth decisions caused them distress, enhanced by lack of support from staff and trauma associated with going through labour without support from their partner, family, or culture (Chamberlain & Barclay, 2000). In Northwestern Ontario, Indigenous mothers reported incurring monetary costs from medical evacuation including airfare, babysitters, long distance calls, along with the challenge of reintegrating into the family and community when they return home with their baby (O’Driscoll et al., 2014).
Birthing in Community
In contrast, mothers who were able to birth in their home community by midwives said they appreciated the care and follow-up provided (Chamberlain & Barclay, 2000; Chamberlain, Barclay, & Moyer, 2001). Most women, regardless of ethnicity, prefer to give birth within their own culture and close to family (Chamberlain & Barclay, 2000). An Indigenous midwifery clinic in Quebec showed a dramatic reduction in the number of women who leave the community for birth, along with improved antenatal visit rates and fewer obstetrical interventions (Van Wagner, Osepchook, Harney, Crosbie & Tulugak, 2012).
The SOGC supports returning birth to women’s home communities as one way to improve their health through the promotion of traditional and cultural practices. They stress that women birthing in their home community establishes roots for the mother, her infant, and the family, and that children born in their home community develop a clear sense of identity that helps them to become resilient and responsible (SOGC, 2017). Improving access to midwifery and culturally-safe maternity care in their home community is considered best practice for the health of the woman and Indigenous communities, and to support the regeneration of strong families (National Aboriginal Council of Midwives, 2016; SOGC, 2017).
While there is professional support for birthing in community, there must always be a balance between cultural and physical safety, which are most critical in remote areas due to delays in treatment if evacuation to a tertiary centre is necessary (Simonet et al., 2009). There is a lack of biomedical research on the safety of midwife led maternity care in remote settings, especially from the period before the introduction of southern medical services (Douglas, 1999). Furthermore, most studies utilize perinatal mortality as the primary outcome, which may not be adequate to understand the safety of community perinatal and obstetric health (Grzybowski, 1991).
Despite the lack of scientific data, there is evidence of positive outcomes of returning the birth experience to remote communities. According to O’Driscoll et al. (2014), “the return of the birthing experience to remote Inuit communities has been very successful since 1986, and excellent outcomes have been demonstrated in the 3-existing birthing centres [of that region] without the capability for cesarean delivery” (p.127). A de facto experiment in Nunavik compared two communities of geographical similarity, one had midwives and one had physicians as the primary birthing attendants. The risk of perinatal death in midwife compared to physician attended births was not significant. In Hudson Bay, Canada, 73% of births were attended by midwives and the perinatal death rate was 14.4 per 1000; in Ungava Bay, 95% of births were attended by western physicians, and the perinatal death rate was 10.0 per 1000 (Simonet et al., 2009). After accounting for preterm birth and evacuation rates (9.4% and 28% in in Hudson Bay and Ungava Bay, respectively), the difference in perinatal death rates were comparable. Regardless of type of birthing attendant, perinatal and infant mortality rates were 1.6 – 4.8 times higher for the Inuit speaking versus French speaking women (Simonet et al., 2009). This disparity indicates a need to “improve perinatal and infant health and address broader and more fundamental social and environmental determinants of health in [Indigenous] communities” (Simonet et al., p. 548).
It is important to consider that pregnancy risk assessments are often culturally biased, based on western health models that do not address differences in physiology and heath (Chamberlain, 2000). For example, one study found shoulder dystocia is rare for Inuit women, yet all primiparous women were sent out of community as they were deemed at risk for this potential complication along with other poor outcomes; furthermore, adolescent Inuit women had healthy babies compared to the risks identified for non-Inuit women of the same age (Chamberlain, 2000).
While midwife led maternity care may be preferable for cultural and medical reasons, not all women can give birth in their home community for accessibility or medical/obstetrical reasons, pointing to an urgent need to provide culturally-safe care not only in her community, but wherever the woman feels comfortable giving birth.
Culturally Safe Care
Care providers may be well-meaning in their intentions to care for the Indigenous mother and her infant based on their professional training, but this has also resulted in birth being medicalized in Western ways with subsequent loss of traditional birth practices, ceremonies, and rituals for Indigenous families (National Aboriginal Council of Midwives, 2016). To offer quality maternity care to Indigenous mothers and their families, providers should work towards practicing cultural safety. Cultural safety addresses inequities arising from sociocultural factors and power differentials between service providers and those they care for; clinical practice without cultural safety contributes to the continued oppression of Indigenous peoples (Roy, 2014). Learning about different peoples and cultures is a key component of gaining cultural competence for careproviders (Kirmayer, 2012; Tervalon & Murray-García, 1998). Therefore, increasing careprovider understanding about traditional maternal and newborn Indigenous birthing practices and ceremonies is essential to promote cultural security for childbearing women.
According to Douglas (2006), there is “significant cultural variation across the Canadian Arctic, but there is also cultural continuity (p. 119)”. For example, although specific birth traditions vary between communities, Douglas (2006) reports Inuit births traditionally occurred within the family group, with assistance from either an experienced midwife (or the husband, when no one else was available), and was traditionally a communal responsibility. Douglas (2006) discusses the traditional attendant’s role of cutting the umbilical cord, and how that person would have an important connection to the family thereafter. O’Driscoll and colleagues (2014) found most women knew about some form of umbilical and cradleboard teachings, but they also report that traditional knowledge was not usually received by young mothers (O’Driscoll, 2014). Roy also discusses the importance of holism in Indigenous healing practices (Roy, 2014).
Uniting Indigenous Ways with Western Biophysical Models
Roy (2014) reports the importance of complementing mainstream therapies with traditional healing practices that allow connection with Indigenous identity, and promote healing through balance, kinship nature, spirituality, along with rituals and traditions. Careproviders should understand the knowledge and emotional needs of Indigenous mothers and their families, and develop culturally appropriate responses (O’Driscoll et al., 2011). Providing culturally safe care may help bridge between gap in western medicine and Indigenous knowledge (Simonet et al., 2009).
There is an urgent need to find ways to support cultural birth experiences to increase comfort for women wherever they give birth, either in their home community, regional centre, or in an urban hospital. This requires that care providers and administrators honour the UNDRIP and the TRC by valuing birth traditions and by increasing the number of Indigenous maternity care providers.
National Aboriginal Council of Midwives: www.aboriginalmidwives.ca
Strong Women, Strong Nations: Aboriginal Midwifery in British Columbia: https://www.ccnsa-nccah.ca/docs/health/FS-AboriginalMaternalHealth-Smylie-EN.pdf
Barker, D. J. P. (1995). The foetal origins of adult disease. Biol Science, 262, 37-43.
Bowen, A., Duncan, V., Peacock, S., Bowen, R., Campbell, D., Gawley, L., & Muhajarine, N. (2014). Mood and anxiety problems in perinatal Indigenous women in Australia, New Zealand, and North America (including Hawaii). Transcultural Psychiatry, 51(1), 93-111.
Chamberlain, M., & Barclay, K. (2000). Psychosocial costs of transferring Indigenous women from their community for birth. Midwifery, 16, 116-122.
Chamberlain, M., Barclay, K., & Moyer, A. (2001). Aboriginal birth psychosocial or physiological safety Birth Issue, 10(3), 81-85.
Douglas, V. K. (2006). Childbirth among the Canadian Inuit: a review of the clinical and cultural literature. International Journal of Circumpolar Health, 65(2), 117–132.
Grzybowski, S. C., Cadesky, A. S., & Hogg, W. E. (n.d.). Rural obstetrics: a 5-year prospective study of the outcomes of all pregnancies in a remote northern community. Cmaj, 144(8), 987–994.
Kirmayer, L. (2012). Rethinking cultural competence. Transcultural Psychiatry, 49(2), 149-164. doi:10.1177/1363461512444673
Kornelsen, J., Kostaka, A., Waterfall, P., Willie, L., & Wilson, D. (2011). Alienation and Resilience: The Dynamics of Birth Outside Their Community for Rural First Nations Women. Journal of Aboriginal Health, 55-64.
Kornelson, J., Stoll, K., & Grzybowski, S. (2011). Stress and anxiety associated with lack of access to maternity services for rural parturient women. Australian Journal of Rural Health, 19(9-14). doi:10.1111/j.1440-1584.2010.01170.x
National Aboriginal Council of Midwives. (2016). The Landscape of Midwifery Care for Aboriginal Communities in Canada. Retrieved from aboriginalmidwives.ca
O’Driscoll, T., Kelly, L., Payne, L., St Pierre-Hansen, N., Cromarty, H., Minty, B., & Linkewich, B. (2011). Delivering away from home: the perinatal experiences of First Nations women in northwestern Ontario. Canadian Journal of Rural Medicine: The Official Journal of the Society of Rural Physicians of Canada = Journal Canadien De La Medecine Rurale : Le Journal Officiel De La Societe De Medecine Rurale Du Canada, 16(4), 126–130.
Parker, S., McKinnon, L., & Kruske, S. (2014). Choice, culture, and confidence: Key findings from the 2012 having a baby in Queensland Aboriginal and Torres Strait Islander survey. Health Services Research, 14(1-12).
Roy, A. (2014). Intergenerational Trauma and Aboriginal Women: Implications for Mental Health during Pregnancy. First Peoples Child & Family Review, 9(1), 7–21
Simonet, F., Wilkins, R., Labranche, E., Smylie, J., Heaman, M., Martens, P., et al. (2009). Primary birthing attendants and birth outcomes in remote Inuit communities – A natural “experiment” in Nunavik, Canada. Journal of Epidemiology and Community Health, 63(7), 546–551.
SOGC. (October, 2017). Returning Birth to Aboriginal, Rural, and Remote Communities. The Journal of Obstetrics and Gynaecology of Canada, e395-397.
Tarlier, D. S., Johnson, J. L., Browne, A. J., & Sheps, S. (2013). Maternal infant health outcomes and nursing practice in a remote First Nations community in Northern Canada. Canadian Journal of Nursing Research, 45(2), 76-100.
Tervalon, M., & Murray-García, J. (1998). Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education Journal of Health Care for the Poor and Underserved, 9(2), 117-125. doi:10.1353/hpu.2010.0233
United Nations. (2008). United Nations Declaration on the rights of Indigenous Peoples. Retrieved from Geneva: https://www.un.org/esa/socdev/unpfii/documents/DRIPS_en.pdf
Van Wagner, V., Osepchook, C., Harney, E., Crosbie, C., & Tulugak, M. (2012). Remote midwifery in Nunavik, Québec, Canada: Outcomes of perinatal care for the Inuulitsvivik health centre. Issues in Perinatal Care, 39(3), 230-237.
Wilk, P., Maltby, A., & Cooke, M. (2017). Residential schools and the effects on Indigenous health and well-being in Canada—a scoping review. BMC Public Health, 38(8). doi:https://doi.org/10.1186/s40985-017-0055-6