Indigenous Birth Support and Reproductive Health: Theses and Dissertations

This thesis argues that since prenatal education and care is a right of all prospective parents in Canada, making prenatal care for First Nations peoples not only accessible but culturally sensitive is paramount. One method for instituting change could be to provide information and establish awareness throughout First Nations communities about the practice and benefits of traditional midwifery. To revitalize the tradition of midwifery the author suggests raising awareness of community midwifery as a profession, providing information on midwifery training and encouraging youth to consider midwifery as a profession.

Since colonial contact, settlers have been targeting the Indigenous female reproductive body. They attempted to severe the inherent connection between the Indigenous female body and the land through extreme resource extraction. This project investigates the impacts of colonization on Indigenous birthing practices and the current Indigenous birth resurgence happening within the colonial confines of Canada. In this context Indigenous birth resurgence is defined as the honouring and reclaiming of Indigenous teachings that support sovereignty over the Indigenous female body. This investigation is presented through semi-structured interviews with seven Indigenous birthworkers residing and practicing on Ktunaxa and Sinixt land. Three key themes were observed throughout these interviews the first being that each birthworker had a very hard time finding any traditional teachings surrounding birth from their communities due to colonization displacing this vital information, secondly all of the birthworkers had to go through Western Eurocentric education in order to be granted "qualifications" to practice birthwork, and finally each of the birthworkers stated that if Indigenous birth resurgence is fully realized it would have a profoundly positive effect on Indigenous families and Indigenous health in general.. The interviews and key findings are further investigated through a podcast entitled Reclaiming Birth in a Settler State.

Birth in North America has become increasingly medicalized. Indigenous communities experienced a loss of communal ownership and a loss of personal sovereignty for women and families as births moved to clinics and hospitals. The ceremonial knowledge surrounding birth became restricted by clinical settings and protocols. This research explores how Indigenous people understand birth as a ceremony within the context of Indigenous medicine. It examines how birthing stories, ceremonies and cultural teachings have been mass communicated to succeeding generations. It explores how related signs, symbols and material culture of Mesoamerica connect meaning to persisting values in Mexican Traditional Medicine. It examines the principle of regeneration through symbols of feminine functions in nature and the iconography of the Mesoamerican Spiderwoman—Tlazolteotl. Indigenous communication is established with humans as well as plants, animals and the universe in a multi-channel call and response. This study finds that symbols and practices surrounding the umbilical cord, placenta, umbilicus and Trees of Life reflect the relationships between place and wellbeing. Using a collaborative design with the input of ceremonial leaders, parents and midwives, the research suggests ways to promote the idea of birth as a ceremony as part of health promotions. It concludes that when Indigenous women assert their right to birth as a ceremony, they establish their womb as a site of self determination. This research contributes to contemporary Indigenous knowledge and how birthing knowledge reflects a bio-cultural and bio-ritual understanding of life and is embedded in Aboriginal culture and medicinal practices.

Background Indigenous women in Guerrero, Mexico, face poor maternal health outcomes. They live at or beyond the periphery of the Western health system, where health services often lack human and financial resources. For several centuries, traditional midwives accompanied women through motherhood in these communities, but the colonial history and modern economic development have weakened their role in safe motherhood. Mutual mistrust between Western providers and traditional midwives hampers collaboration that could afford indigenous women the best of both worlds. The consequence for indigenous mothers is low-quality Western health care services and attenuated traditional resources. Interventional studies have explored assimilating birth attendants into the Western system, but not much research has focused on supporting traditional midwifery. Objectives This thesis explores the role of authentic traditional midwives in promoting safe birth in cultural safety among indigenous communities of Guerrero, Mexico. It has several specific objectives: 1.Understand how traditional midwives and intercultural researchers contextualise safe birth in local indigenous cultures; 2.Test the impact of supporting traditional midwives, in their own terms, in a cluster randomised controlled trial; 3.Reflect on generalisable implications of the evidence and engagement in these settings. Methods This doctoral project applied a participatory research approach and was part of a bigger initiative in partnership with academics at the Centro de Investigación de Enfermedades Tropicales and four indigenous groups in Guerrero (Nahua, Na savi (Mixteco), Me'phaa (Tlapaneco), and Nancue ñomndaa (Amuzgo)). Specific objective 1: I used a synthesis procedure based on fuzzy cognitive mapping (FCM) to collate knowledge of 29 traditional midwives about risk and protective factors for maternal health in their communities. In a second application of FCM, I explored the perspectives of eight intercultural Western researchers on factors affecting maternal health in indigenous communities. These maps served to develop a method based on Harris' discourse analysis to weight factors' influence based on their frequency. I used FCM to portray a scoping review of studies reporting influences on maternal health in indigenous communities with traditional midwives in the Americas and adapted the Weight of Evidence technique to ground the literature in local stakeholder perspectives. Specific objective 2: I analysed a parallel-group non-inferiority cluster randomised controlled trial (RCT) that tested whether supporting traditional midwives on their own terms increased cultural safety (respect of indigenous traditions) without worsening maternal health outcomes. In forty communities in two intervention municipalities, traditional midwives and their apprentices received a monthly stipend and support from a trained intercultural broker, and local official health personnel attended a workshop for improving attitudes towards traditional midwifery. Forty communities in two control municipalities continued with usual health services. Specific Objective 3: I described and reflected on the experience in Guerrero in support of cultural safety and intercultural dialogue to inform future practice of intercultural research. The project received ethical approval from the participating communities, the Universidad Autónoma de Guerrero, and McGill's Faculty of Medicine Institutional Review Board. Results Specific objective 1: For traditional midwives, the strongest risks for maternal health were not following traditional self-care practices, traditional diseases, and women's mental health and experience of violence. The strongest protectors were male involvement, support of traditional healers, and protective rituals. Participating researchers shared attitudes of respect for indigenous traditions and assigned indigenous cultural continuity and cultural safety the strongest positive influence on maternal health. Operator-independent weighting, based on Harris' discourse analysis, produced similar results to participant-weighting of influences. Most of the 87 selected studies in the scoping review focussed on access to Western health care, and they included a wide variety of practitioners described as traditional midwives. In the map produced from the findings of the scoping review, self-care practices and traditional midwifery had the strongest positive effects on maternal health, followed by the negative effect of disempowerment of communities, families and women. The literature, traditional midwives and researchers all identified promotion of cultural practices as important to protect Indigenous maternal health. Specific objective 2: Among 872 births, mothers in intervention communities had lower rates of perinatal deaths or childbirth or neonatal complications (Risk Difference (RD) -0.06 95% Confidence Intervals (CI) -0.11- -0.01) and more births at home with a traditional midwife and family present (RD 0.10 95%CI 0.02-0.18). Among institutional childbirths, women from intervention communities had more traditional management of the placenta (RD 0.34 95%CI 0.21- 0.48) but also more non-traditional cold-water baths (RD 0.10 95%CI 0.02-0.19). Specific objective 3: Three steps contribute to intercultural dialogue: (1) trust building and partnership, (2) listening and adjusting lexicon to identify contributions from traditional midwives and (3) codesign, evaluation and discussion to identify benefits of supporting traditional practices. Conclusions Traditional midwives have detailed knowledge of what affects maternal health that complements published research and can inform culturally safe interventions in their communities. This thesis developed an approach and specific tools to facilitate intercultural dialogue between stakeholders with differing perspectives. To my knowledge, the cluster RCT was the first published trial to test the impact of supporting traditional midwifery rather than replacing it. It confirmed non-inferior maternal health outcomes with more births at home with a traditional midwife and family present. The experience provides a starting point for advancing collaboration with traditional midwives to promote maternal health in indigenous communities.

While much as been written about how colonization has been accomplished through the disruption of motherhood, less is known about how Indigenous women's birthing experiences have been shaped by continual colonization, or how birthing is, or can be part of the decolonizing movement. This thesis, while focusing broadly on the relationship between motherhood, health, and the effects of colonization, explores urban Indigenous women's birthing experiences in Nova Scotia. This inquiry was framed by the Indigenous theoretical concept of Two-Eyed Seeing that is used to examine pressing health and social problems experienced by Indigenous people, as well as postcolonial and Indigenous feminist theory. Employing an Indigenous informed methodology, a talking circle with ten self-identified urban Indigenous mothers was held in a community gathering space in Halifax, Nova Scotia. In addition, seven qualitative interviews were conducted with mothers that attended the talking circle in order to determine their perceptions and experiences of birth in hospital settings. The results show that mothers experienced individual and institutional discrimination, and that Indigenous birthing practices were desired, yet unrealized due to structural barriers. This thesis argues that the current healthcare system in Nova Scotia fails to meet the needs of urban Indigenous mothers during the birthing experience because it fails to embrace culturally informed birthing knowledges. The incorporation of Indigenous birth knowledges into practice can address these shortcomings, redefine how we come to understand birth, and better support women of all cultural backgrounds in hospital. This thesis also argues that Indigenous informed midwifery care is the pathway best suited for decolonizing birth.

In recent years, Indigenous midwifery has reemerged as a vital form of maternity care in Canada. With the majority of practices being situated in rural and remote areas, Seventh Generation Midwives Toronto (SGMT) remains the only urban-based Indigenous focused midwifery practice in the country. Looking to develop a culturally relevant performance measurement system for the practice, SGMT partnered with the Well Living House (WLH) - an Indigenous action research centre in Toronto - to undertake a community-based, participatory, realist, and utilization-focused evaluation study. This thesis project was nested in one of the qualitative branches of this evaluation. Semi-structured interviews were conducted with nine former clients of SGMT who self-identified as Indigenous to determine (1) how Indigenous women conceptualize cultural safety and (2) the extent to which their experiences at SGMT aligned with these conceptualizations. The interviews were transcribed verbatim, and the transcripts were analyzed using collaborative, consensus-based, iterative, and decolonizing methods. Twelve core themes that were grouped into four thematic pillars or containers emerged from this process. Even though the women participants were unique in their backgrounds, insights, and experiences, when taken together, culturally safe Indigenous midwifery care meant (1) "culturally continuous care", (2) being able to access both Indigenous knowledge and practice and practical reproductive health information, (3) being connected to the community, and (4) feeling "at home" in a health care setting. There was also widespread support for SGMT as a practice; most - although not all - women felt that their pregnancy, birthing, and reproductive needs were fully met, and that they were made to feel culturally safe. All of the women offered constructive and loving feedback for the practice, even if they had experiences that fell short of their expectations. This confirms that SGMT can and does provide culturally safe care, and that cultural safety both has benefits and a place in the mainstream health care system. This project also sheds light on the roles and responsibilities of contemporary Indigenous midwives and the ways in which they can be supported. Altogether, herein lies a compelling argument for the continued support and expansion of urban-based Indigenous midwifery, and the application of cultural safety in a Canadian context.

This participatory action research (PAR) study with Nisichawayasihk Cree Nation (NCN) integrated scientific investigation and action to develop a community-based childbearing model in NCN. The multi-method ethnographic PAR study involved qualitative and quantitative methods. Qualitative methods included participant observation, modified focus group meetings, key informant and semi-structured interviews, an analysis of documents (historical NCN texts, studies, and community assessments) in addition to a field-study trip with two participants as co-researchers. A quantitative retrospective chart audit of women who received antenatal care during the years 1997-1999 was carried out to determine antenatal clinic utilization and maternal behaviors around smoking, alcohol and recreational drug use. Current childbearing services that are being provided by the federal government were found to be a continuation of other colonialist policies that have been detrimental to community life. Infrastructural barriers, as well as the lack of midwifery education opportunities in Manitoba are obstacles to returning birth to NCN. The research resulted in a project that employs women as maternity workers in preparation for the return of birth to the community. Participants envisioned an alternative community-based Aboriginal childbearing model that integrates Western expertise and knowledge. The PAR process proved an empowering means to explore this issue with women.

This paper presents the approach taken by the Sioux Lookout Meno Ya Win Health Centre (SLMHC) to improve maternal and newborn care for First Nations peoples in Northwestern Ontario. I use a cultural safety lens to explore whether the SLMHC's focus on birthing meanings, beliefs, attitudes, and practices as described by elders may contribute to the development of a more culturally safe hospital birth model. Findings suggest that a transcultural approach aimed at understanding and involving birthing beliefs, practices, and meanings into the health care setting is a necessary aspect of returning control back to the community and is thus an important preliminary step in achieving cultural safety in the clinical realm. In areas in which health and social challenges prevent women from giving birth in their home communities, efforts such as the SLMHC initiative should be made to ensure that existing health care settings are more culturally safe.

This thesis explores the subject of Aboriginal birth knowledge from Wasauksing First Nation in Ontario. The intent is to document and generate positive representations of traditional birth knowledge in response to processes of colonization, which in the past have worked to silence them. Three Wasauksing mothers share their understandings of traditional birth knowledge and where the origins of their knowledges lie. A brief historical examination of Aboriginal birth knowledge and experience, and its relationship to colonization and colonial education are presented as part of a literature review. A short video documentary accompanies the thesis to best capture and convey the oral tradition and make the research findings more accessible for community members that might not otherwise engage with this discourse. The author approaches the work from her own personal standpoint: that of a Native woman from Wasauksing First Nation seeking information about her identity as a new mother.