Separating Birth from Community: Colonialism and Historical Institutionalism in Indigenous Pregnancy Evacuation Policies

Abstract

Key Messages

Background

Policy Analysis

Intersectional frameworks aim to recognize that lived experiences cannot be whittled down to individual identities (Hankivsky and Christoffersen 2008). In fact, they recognize that our experiences and the effect of systemic oppression exists at the intersection of all the social positions interacting at once in any given setting. This type of analysis recognizes the deeply social determinants of health and how socioeconomic position influences one’s health on every level (Siddiqi et al. 2018) and, in particular, the harms of colonialism, systemic racism, and gender discrimination that Indigenous women experience. These harms place them at higher risk of suffering from stigma and barriers related to mental health, poverty, and remote living. Using de-colonial and intersectional lenses, together with the policy triangle and multiple streams frameworks to explore specific elements of this health systems issue that can lead to an Indigenous-led solution.

Policy triangle

The policy triangle proposed by Walt and Gilson (1994) explicates policies by examining four components: content (what the policy entails), context (why the policy is needed), actors (who participates in and influences formulation and implementation of the policy), and process (how the policy was brought forward and implemented). This framework provides a comprehensive overview of a policy, enabling deeper analysis of factors contributing to policy inertia or facilitating reform.

Content

The Government of Canada defines remote communities as having fewer than 10,000 inhabitants with “no residents that commute to an urban location for work or are located in the Yukon, Northwest Territories, Nunavut, Nunavik or Nunatsiavut” (Vodden and Cunsolo 2021, 109). Health Canada recommendations on maternal evacuation result in the vast majority of pregnant people living in remote communities getting flown to larger centres for childbirth regardless of risk profile (First Nations and Inuit Health Branch 2011; Lawford et al. 2018). Without providing any rationale, Health Canada ‘asks’ all remote and rural pregnant Indigenous and non-Indigenous peoples to travel between 36 and 38 weeks gestational age to an urban centre, although the ramifications of declining transfer remain unclear (Cidro et al. 2020). For example, in Manitoba, Indigenous women with low-risk pregnancies are transferred to either Winnipeg, Thompson, or The Pas (Lawford et al. 2019). Few Indigenous women refuse the evacuation as they worry about consequences of not leaving (Dreaddy 2019). Although they are transported for childbirth, many Indigenous women receive their prenatal care in clinics closer to home, provided either by nurses or visiting doctors (Lawford et al. 2019).

Most transfers occur between 36 and 38 weeks gestational age, but anyone with a past experience of preterm delivery or experiencing obstetrical complications will be transferred to the city even earlier (Lawford and Giles 2012a). According to experts in Indigenous midwifery, current policies do not appear to serve Indigenous women well, and may be tied to the observed inequities in obstetrical and neonatal outcomes (Lawford and Giles 2012a). The practise of restricting childbirth to hospital settings began in the mid-twentieth century as childbirth became increasingly medicalized and pathologized in the setting of high maternal mortality (Olson and Couchie 2013). According to Cidro et al. (2020), traditional midwifery was outlawed and devalued by biomedical professionals. This phenomenon was not specific to Indigenous communities, as the marginalization of midwifery resulted in non-Indigenous women living remotely also getting transferred to large centres for their obstetrical care. By the 1970s, the practise of flying women to cities for childbirth was widespread and included all pregnant people regardless of Indigenous ancestry.

Maternal evacuation policies exemplify how Euro-Canadian biomedical systems paternalistically assume they can determine what is best for Indigenous women and two-spirited people. A review of the Inuit maternal health literature by Brubacher et al. (2020) found almost two out of every five articles (n=28) related to obstetrical evacuation or location of birth. Considering this review included any study relating to clinical management of any obstetrical condition in Inuit people, maternal displacement occupies an important focus in the biomedical discourse. Paradoxically, the biomedical knowledge production has predominantly misaligned with established maternal evacuation policies. Although the validation of biomedical research methodology centres non-Indigenous epistemologies, the biomedical literature has supported low-risk deliveries as being safe and feasible in communities for decades (Baskett 1978; Chatwood-Affleck et al. 1998; England 1998). The Society of Obstetricians and Gynaecologists of Canada released an article in 2013 stating that all health care providers should recognize the necessary role of Indigenous midwives in the provision of obstetrical care to Indigenous women and two-spirited individuals who can become pregnant (Wilson et al. 2013). The Indigenous Physicians Association of Canada, the Aboriginal Council of Midwives, the Canadian Association of Midwives, and the Society of Obstetricians and Gynaecologists of Canada united their voices to overtly support the return of birthing to First Nations and Inuit communities in low-risk deliveries (Society of Obstetricians and Gynaecologists of Canada 2017). The Public Health Agency of Canada released national guidelines on maternity care which echoed the calls in this guideline and reinforced the importance of cultural safety in maternity and newborn care (Public Health Agency of Canada 2018). Despite these unified calls, disheartening examples of unsuccessful attempts to repatriate birthing to communities continue to surface. For example, two Inuuk midwives in Rankin Inlet were pushed to step away from their roles due to persistent discrimination and undermining of their skills, leading Rankin Inlet to lose their only Indigenous midwifery services (Tranter 2021). The contrast between the maternal evacuation policy content and the positions of prominent Indigenous and non-Indigenous voices raises questions as to the barriers to policy change.

Context

Lawford and Giles (2012b) suggest that the policy of maternal evacuation served as one of the many tools used by Canadian government in the assimilation of Indigenous Peoples. By removing pregnant Indigenous women from their communities, Indigenous Peoples were coerced into accepting Euro-Canadian biomedical models of care and lost Traditional Knowledge that informed their birthing practises before colonial contact. Although the use of Euro-Canadian biomedical medicine has certainly saved Indigenous lives, broad imposition of this model of care perpetuates colonial harm by ignoring the importance of community and land in the experiences of Indigenous childbirth (Lawford and Giles 2012a).

Furthermore, this policy aligns with the prioritization of hospitals in the delivery of health care in Canada. Hospitals have been the central unit of provincial health care systems, with universal coverage and reimbursement designed primarily around inpatient and diagnostic services (Government of Canada 2019). Although not directly tied to colonialism, the decision to build our health care system around tertiary care hospitals in settler colonial cities inherently disadvantages anyone living in remote Indigenous communities.

Actors

The actors with the greatest to gain or lose are Indigenous women and Indigenous midwives. Prior to settler colonial contact, Indigenous women delivered babies surrounded by community members such as their family, midwives, Elders, and neighbours (Lawford and Giles 2012b). Today, however, they must deliver in city hospitals with doctors and nurses present, sometimes accompanied by an escort (partner or family member) or community members who are in the city awaiting their respective confinement for delivery. The absence of choice in being able to deliver elsewhere was notable across the literature on this topic (Lawford and Giles 2012a). This lack of options rang particularly strong given the ongoing popularization of midwifery and doula services among non-Indigenous women living in the city. Does the lack of institutional support for Indigenous midwifery and birthing in community relate to issues of racism, sexism, both, or neither? Despite broad consensus from established (mainly biomedical) organizations, organizational barriers in the delivery of health services to remote communities appear to persist in supporting Indigenous-led birthing services. This could be an area for further investigation.

Several qualitative studies describe the physical, emotional, and financial stresses contributed to the negative experiences of Indigenous birthing persons (Chamberlain and Barclay 2000; Kornelsen et al. 2010). Having to leave their other children behind was often cited as the cause of significant emotional distress and logistical hardships (Chamberlain and Barclay 2000; Kornelsen et al. 2010). Boredom and disconnection were described as affecting their time in the city. The financial cost of staying in the city or bringing support people with them were routinely reported in these first-person accounts (Chamberlain and Barclay 2000; Kornelsen et al. 2010). In worst-case scenarios, some Indigenous women needed to turn to gang recruitment and sex work to survive while awaiting the onset of labour away from their homes (Lawford et al. 2019). More broadly, experiences of anti-Indigenous racism when receiving care outside of their communities were reported as negatively impacting their birthing process (Vang et al. 2018).

Governments are important actors in this policy. Provincial governments provide the funding and infrastructure for the hospitals and health care professionals who provide the obstetrical care that Indigenous women are flown to. The federal government is involved through the funding of medical transportation for Indigenous women and their support persons, and through the provision of health care in nursing stations situated in remote Indigenous communities. More distal actors include the broader Indigenous communities, the non-Indigenous health care professionals involved, the organizations in charge of housing and feeding Indigenous women while they await labour, civil societies who may be involved in advocating for Indigenous women or provide social services for them, and professional organizations like the Society of Obstetricians and Gynaecologists of Canada or the Aboriginal Council of Midwives.

Indigenous actors should be central and at the forefront of this policy area, supported by current proximal actors such as the involved governments and biomedical health care providers. As shown by the high satisfaction reported after receiving culturally safe birthing services directly in community, Indigenous self-determination in reforming maternity care to Nations-specific needs would improve experiences of pregnancy and childbirth for many Indigenous people (Chamberlain et al. 1998). However, due to fluctuations in allocated resources, programming to support birthing in community has varied over time. Currently, the most notable examples of sustainable self-determined Indigenous obstetrical services exist in Nunavik and the James Bay Cree Nation (Cree Board of Health and Social Services of James Bay 2018; Longchap 2022).

Process

Despite the use of a decentralized model within the federal country that is known as Canada, every participating health care authority adopted their version of expatriating birth away from First Nations and Inuit communities. This was done incrementally, through gradual changes over time which led to the ultimate implementation of clinical guidelines, such as the aforementioned First Nations and Inuit Health Branch Clinical Practice Guidelines for Nurses in Primary Care (First Nations and Inuit Health Branch 2011), advising the transfer of every pregnant person to the nearest urban centre to await childbirth.

When interviewing First Nations women in Manitoba, a common theme of feeling resigned emerged, with many interviewees stating there was no other choice or possibility when delivering their babies (Lawford et al. 2018). Nonetheless, participants speaking to Lawford et al. (2018) demonstrated inexorable resilience in withstanding these forced evacuations, and themes of resistance to the policies emerged as they questioned the necessity of the status quo. Yet, reversing this established policy and enacting a completely different approach to obstetrical care for women in remote Indigenous communities represents a formidable task.

Historical institutionalism, or the way decisions in the past influence processes in the present, can create a type of policy inertia that makes it harder to enact policy change when something has been done a certain way for a long period of time (Browne et al. 2019). The power dynamic between Indigenous communities and the governments that serve them may also contribute to the policy inertia being observed when it comes to maternal evacuation policies. The conflicting responsibilities between provincial and federal governments in providing health care services to Indigenous communities may contribute to impasses when looking to provide support for Indigenous-led initiatives to return birthing to communities for low risk-deliveries and better integrate Indigenous midwifery into the health care system.

Multiple streams framework

The multiple streams framework (MSF) is a useful tool to elucidate the factors underlying outlined policy change impasses. The MSF states that the convergence of an established problem, a known solution (policy), and the right political context may create a window of opportunity for potential policy-making or policy change (Browne et al. 2019). When all three do not come together at the same time, policy inertia continues. Although prominent biomedical organizations have issued calls to accommodate birthing practices in community, few services exist in alignment with their supportive stances.

Problem

Problems are policy issues deemed to require attention by stakeholders. Loss of Indigenous culture, disconnection from community and land, and inequities in obstetrical outcomes represent significant policy issues recognized by Indigenous scholars (Lawford and Giles 2012a). However, viewing these issues from a settler colonial mindset has resulted in one seeing the transfer of Indigenous women to Euro-Canadian biomedical hospitals as appropriate and desirable. When the practice was implemented and included all women regardless of risk profile, it was framed as offering Indigenous women the same quality of care as non-Indigenous women (Olson and Couchie 2013).

The contrast between the Euro-Canadian biomedical and the Indigenous perspectives highlights the importance of problematization – i.e., defining what is a problem – in policy making. Without an adequate understanding of Indigenous epistemologies, displacing someone from their community for an important life event that would normally be underlined with Traditional ceremony and community may not seem like a problem. Pushing this idea further, someone with a colonial mindset would consider the loss of Traditional Healing and Knowledge for the Euro-Canadian biomedical model of care as a positive if they believe in the supremacy of the Euro-Canadian biomedical model. Certainly, under the hegemony of Euro-Canadian biomedicine, the centralization of care to cities is necessary to perform specialized skills such as cesarian sections at a rate that maintains provider proficiency in the technique due to higher procedure volumes. However, this way of thinking fails to recognize the rights of Indigenous Peoples to regain and assert their culture in every aspect of their lives. Indigenous midwives and Traditional Healers safely assisted women in their childbirth since time immemorial. With increasing visibility and awareness of the colonial harms of maternity evacuation policies, the problem of loss of culture, community, land, and ceremony relative to birthing may become increasingly apparent.

Policy

Indigenous scholars and select Indigenous communities have offered solutions to the emotional, financial, spiritual, and physical issues resulting from the maternal evacuation policy. These solutions entail returning birthing to communities (Lawford and Giles 2012b; Lawford et al. 2018). Official consensus between Euro-Canadian biomedical organizations and Indigenous organizations states that supporting communities and training Indigenous midwives should be priorities in the way we move forward in providing care to Indigenous women (Society of Obstetricians and Gynaecologists of Canada 2017).

Successful examples of Indigenous self-determination in reproductive mobility policies have emerged in Nunavik and Manitoba (Cidro et al. 2020). Indeed, Hayward and Cidro (2021) describe how efforts to return birth to community in Manitoba align with the United Nations Declaration on the Rights of Indigenous Peoples and the United Nations Sustainable Development Goals. Modelled on the decades of successful care at the Puvirnituq Maternity Centre in Nunavik, the James Bay Cree Nation have seen their birthing services flourish and expand with the positive response from community members (Cree Board of Health and Social Services of James Bay 2018; Longchap 2022).

Despite these compelling cases, supporting Indigenous midwives has not been central to governmental agendas. Indigenous communities are far from being a monolith and span across the second largest geographical country in the world. Each community will require its own policy distinctions-based or Nations-based solution, thus planning to set up the appropriate human and health resources to support birthing in their communities. Some Indigenous women will likely want to deliver in the cities given the established norm that has persisted through the decades and their choice should be respected and supported.

Politics

Although the problem is becoming more recognized by biomedical organizations and the solution has been laid out by prominent actors in the field, political will within federal and provincial/territorial governments to tangibly address issues with maternal evacuation of Indigenous mothers has not been particularly strong. Perhaps the recent attention garnered by the National Inquiry into Missing and Murdered Indigenous Women and Girls and 2SLGBTQI+ people will bring greater attention to issues affecting the health and wellbeing of Indigenous women. Strong Indigenous advocacy and agency within this policy area would help to ameliorate the inequities experienced by Indigenous women who are subjected to astounding levels of marginalization through their life course.

The Rt. Hon. Paul Martin explained that the Kelowna Accord stemmed from a clear understanding that Indigenous Peoples would be best positioned to govern their own issues (Martin 2021). This approach to consensus building when searching for policy solutions has been applauded as an insightful and appropriate process (Alcantara and Spicer 2015). Centring Indigenous voices in the development of de-colonial policies for maternity care will be key to improving the health and wellbeing of Indigenous women and two-spirited people in Canada.

Conclusion

Endnotes

References