Joanne General gave birth to her first son in a bathtub at the Six Nations Maternal and Child Care Centre in Ohsweken, Ont., in 2014. From the time that she got pregnant, Ms. General knew that she wanted a “holistic and traditional birth,” but she was hesitant when a friend suggested using a midwife. For one thing, she wasn’t sure if it was safe to give birth outside of a hospital.
Curious, she made a visit to the centre, a converted two-storey house painted purple in the middle of Six Nations, which straddles the Grand River north of Lake Erie. It didn’t take her long to decide. “As soon as I met the midwives, I knew it was just a calm, spiritual building to be in,” said Ms. General, who has now used the centre’s services through three pregnancies.
The Six Nations Birth Centre is one successful example of how Indigenous women are working to bring native pregnancy care and birth practices back to their communities, after decades of enforced estrangement.
Beginning in the 19th century, home births and midwifery, once fairly commonplace, became stigmatized across North America while hospital births rose. A number of Canadian provinces to this day do not pay for midwifery care. Even in Ontario, which has the most number of practicing midwives, only 40 per cent of women who want to receive prenatal care from a midwife are able to do so.
This is the legacy of what midwives call the “medicalization of birth” and for Indigenous women, it had additional impacts. Those in the remote North are most affected: To this day, most must leave their communities to give birth, weakening family ties at a crucial time.
Indigenous women across Canada say that the loss of local, culturally appropriate pregnancy and prenatal care has had damaging results. Health outcomes for Indigenous newborns and mothers are far below those of non-Indigenous people across Canada: According to 2016 data from the National Aboriginal Council of Midwives (NACM), infant deaths in aboriginal communities are at least twice the national average and Indigenous mothers are more likely to experience postnatal depression. In 2017, Statistics Canada reported that Indigenous babies are more likely than non-Indigenous babies to be stillborn or premature, or to be larger than average. StatsCan researchers also found that rates for sudden infant death syndrome are over seven times as high in First Nations and Inuit populations than in the general population.
The Six Nations Birthing Centre is one attempt to undo this trend. Its midwives believe that their knowledge can help address a host of challenges, from diabetes to domestic violence. They and other Indigenous midwives across the country are finding ways to use their skills despite a host of challenges, including funding concerns.
Like other prenatal caregivers, Ms. General’s two midwives checked her blood pressure, took urine samples and let her listen to the baby’s heartbeat. But they also taught her traditional beliefs about why and how to create a peaceful home environment before welcoming a new baby. “For those of us that never were raised in a cultural environment, they really share with us that our stories and our language and our culture is so sacred,” Ms. General said. “Our midwives are First Nations people and hold that knowledge as grandmothers, as elders. They’re breaking colonialism every single day.”
At 25, Ms. General is a hands-on mom to her three children and, on weekends, her two stepchildren. That’s much different than how she grew up: in foster care, “bouncing around” between four non-Indigenous homes.
Ms. General is Cayuga, one of the six nations in the Haudenosaunee confederacy, but says she only began to understand what that means through her midwives. They were both Haudenosaunee women such as her – and she credits them for helping her become the first (and, so far, only) woman in her family to breastfeed, which studies say strengthens infants’ immune systems and helps support emotional bonding. During her first pregnancy, Ms. General made her home an alcohol-free environment. During her second, her partner quit smoking.
“I feel like I won the lottery,” Ms. General said about finding the birthing centre. It’s Mohawk name is Tsi Non:We Ionnakeratstha, which translates to “the place where they will be born.”
The goal of the National Aboriginal Council of Midwives, according to chair Evelyn George, is to put “Indigenous midwives in every indigenous community.” And the first challenge, as always, is funding. Midwifery – as opposed to medicalized prenatal care – comes with a particular set of financial hurdles in Canada, since each province chooses whether or not to fund it.
But Indigenous mothers must deal with another layer of bureaucracy. While most citizens’ health care is provincially funded, the federal government is constitutionally responsible for Indigenous health care. It currently does not fund any midwives or midwifery practices.
That includes money from the Liberals’ June, 2017, budget, which made the first-ever federal commitment toward Indigenous midwifery – $6-million over five years. So far, Indigenous Services Canada has provided $360,000 in February for regional engagement and preparatory work; money allocated for 2018 and 2019 will continue funding those projects and, finally, begin to support demonstration projects.
Lack of government funding has forced many Indigenous midwives to operate on a shoestring. Dorothy Green remortgaged her house to open Kenthe:ke Midwives, in Tyendinaga Mohawk Territory, in 2012. “This is not a job, it’s a way of life,” said Ms. Green, who works with Indigenous families in Ontario’s Bay of Quinte region.
For her first five years of practice, Ms. Green relied on donated supplies and equipment from the midwifery team at Six Nations and the Quinte Midwives’ practice in nearby Belleville. Even though money was tight, she accepted clients who could pay only through barter: If someone gave her artwork, for example, she would sell it at a fundraiser.
“I’m not going to leave our women vulnerable,” Ms. Green said.
Like many Indigenous midwives, she works with clients that non-Indigenous midwives usually pass on to obstetricians: those with challenges such as diabetes, addiction or involvement with children’s services. This often means extra work, such as accompanying clients to meetings with other doctors, visiting them at home if they miss an appointment or buying a bag of groceries to feed a hungry family.
In February, 2017, Ontario’s Ministry of Health chose Kenthe:ke as one of six Indigenous midwifery practices to receive sustaining funding, making it financially stable for the first time. “I’ve finally hired a second midwife,” Ms. Green said. “It’s awesome, it’s not just me anymore.” Her practice also includes a case worker, for clients who need help navigating social services such as child welfare, and a full-time practitioner of traditional medicine.
Not all provinces fund midwifery, Indigenous or otherwise. PEI and the Yukon do not. British Columbia and Quebec do, and both have practicing Indigenous midwives. New Brunswick opened its first provincially funded midwife practice last fall, and hopes to have an Indigenous midwife by this fall. So far, it’s been easiest for Indigenous midwives to set up in Ontario, thanks to a clause included in the province’s first legislation around the profession.
Since 1991, practicing Ontario midwives must have a university degree and to be registered with the College of Midwives. The Midwifery Act included an exception clause, though, which stated that “aboriginal midwives” could legally practice as long as their skills are recognized by their community. That’s been a boon both for those who want to practice legally and for those wanting to learn midwifery from other Indigenous women.
The birth centre at Six Nations opened in 1996, five years after the act was passed (it has since welcomed 1,300 or so babies). In 2000, it launched an apprenticeship program with a curriculum that integrates Western and Haudenosaunee practices that has since graduated 15 midwives, including Ms. Green of Kenthe:ke.
Clinic supervisor Julie Wilson, who studied at McMaster University, designed the program. “During a birth we do use the typical Western anti-hemorraghic medicine…but we use traditional medicines at the same time,” said Ms. Wilson, who is Mohawk, and also a part-time midwife at the centre. “It’s a real asset for us that we have two tool bags that we can pull from and use together. We really love this model.”
While the exception clause means that Ontario recognizes that Indigenous midwives have needed skills, this doesn’t mean the province automatically pays them. Ms. Wilson’s salary and all of the costs of Six Nations’ birth centre have always been funded by its band council, not the Ministry of Health. The province has turned down requests to pay for ultrasounds and other lab work.
Lack of funding is the biggest hurdle to getting more midwives into remote communities. The federal government (usually FNIH) pays travel expenses, housing costs and salaries for doctors, nurses and dentists working in the north (and even so, many northern reserves do not have any full-time medical care). It does not fund midwifery at all, even if a community says its need is desperate. Instead, it pays the cost of flying women to southern hospitals to give birth, a practice known as medical evacuation, which became common sometime in the 1960s.
Today, most northern women have no choice but to head out on a Medevac plane two to four weeks before their due date. The government decides the destination – even if a woman has family in a town with a good hospital, she might end up in a hotel somewhere else. She also has to find care for her other children. Only in April, 2017, did FNIH begin paying travel expenses for someone to go with her.
Evacuation is dreaded, said Christine Roy, a Québécois midwife who lives and works in the Cree community of Attawapiskat, Ont., near James Bay. She said that as late as 2012, the year she opened her practice, women would attempt to hide from the MedEvac plane. They were sometimes escorted on to it by police.
“If I’m a woman who plans to give birth in community and I know they’re going to send the police to force me on to the plane, what am I going to do?” Ms. Roy said. One tactic was to fudge the date of conception: women would pretend to be an earlier state of pregnancy than they actually were, so that their evacuation would be scheduled too late.
“She’d go into labour and wait at her house until it got very, very strong, and then she’d show up in full labour at the nursing station, too late to be transferred,” Ms. Roy said. This was dangerous, but for many women, it was still preferable to leaving home.
The number of annual birth evacuations in Canada is unknown: FNIH reports that 568 clients had “childbirth” travel expenses paid between June, 2017, and March, 2018, but adds that some of the 4,763 trips recorded as “prenatal” in that time period could have been for a birth as well. Neither number accounts for birth trips taken by women who live in communities that are self-governing, such as the Labrador Inuit, or evacuations in B.C., which has its own First Nations Health Authority.
Beyond causing isolation and family disruption, giving birth outside their communities robs women of their cultures, said Ms. George of the National Aboriginal Council of Midwives. Each nation has its own important ceremonies: In her home community, Nippissing First Nation in Northern Ontario, postbirth rituals around the placenta are thought to affect a baby’s entire life.
“Reclaiming these practices that are ours is really profound,” said Ms. George, who now lives in the B.C. Interior. “I think it goes beyond avoiding evacuations. It’s a much deeper, more profound revitalization and reclamation. It’s becoming self-determined again.”
One traditional ceremony that Ms. General learned from the midwives at Six Nations was how to formally welcome her first son to the world. “It’s just like when you walk into a room, you want to be greeted, you want to be acknowledged, you want to have somebody say ‘Hello, it’s nice to see you,’” she said. After lighting tobacco and sage, an elder speaking Cayuga thanked the newborn for taking its journey to be with them.
It’s a ceremony she repeated for the two babies she’s had since, both times at home, assisted by Six Nations midwives. The youngest was born just this past March and accompanies Ms. General to the centre’s weekly mom-and-tot meetups, even though she no longer lives on Six Nations.
“To drive half an hour there and back to any appointment is nothing to me because I know the value of it,” Ms. General said. “I’m first person to use a midwife in my family and I’m the first person to breastfeed in my family. It’s amazing to see the results.”
Two practices to know
Way up north: Inuulitsivik Midwives, Nunavik
The oldest Indigenous midwifery practice in Canada is also its most remote.
Inuulitsivik was set up in 1986 by Inuit women from communities along Hudson Bay. Because they won political autonomy (and a source of funding) from the province of Quebec in 1978, they were able to set up years before provincial governments began legislating midwifery. They recruited midwives from the south, university graduates who worked with elder women versed in traditional ways to develop a groundbreaking practice now held up as an example around the world.
The practice now has three birth centres serving a population of about 12,000 people. Today, 49 per cent of women in Nunavik don’t have to leave their communities to give birth and only about 14 per cent have to be evacuated out of the territory entirely. In 2008, Inuulitsivik’s training program, which allows local women to learn a skill and provide prenatal care in the local language, Inuktitut, was recognized by the province, meaning its graduates have the same license to practice as university trainees.
“The first [birth] I attended, it made me feel woman power,” said Louisa Pauyungie, a 30-year-old student. “I was amazed at how the midwives were very gentle and were able to keep the lady calm.”
Ms. Pauyungie lives in the community of Salluit, and had her first baby before the practice opened a centre there in 2004. She had to be flown three and a half hours away but was happy that “all the midwives who attended my birth were Inuit,” she said. Even better was not having to get on a MedEvac at all to have her second or third.
Regular, local prenatal care and the chance to participate in Inuit ceremonies has had positive results. For example, Caesarean sections, which are linked to mother morbidity: only 1.8 per cent of Inuulitsivik clients require a Caesarean section, compared to 29 per cent of women across Canada over all.
“This program was started by Inuit,” Ms. Pauyungie said. “We have a lot of community support and a lot of confidence.”
The City Practice: Seventh Generation, Toronto
Soon after Sara Wolfe started practicing midwifery, she became overwhelmed with requests from Indigenous clients.
“One of the big myths about Indigenous health care is that our outcomes get better when we move out of isolated rural communities into this major urban centre,” said Ms. Wolfe, who is Ojibwe, from Brunswick House First Nation near Lake Superior. But 87 per cent of Indigenous adults in Toronto live in poverty, which obviously affects pregnant women, she said.
Gestational diabetes, for example, is twice as likely to be an issue for Indigenous women as other women in Canada. Ms. Wolfe says that’s a problem made worse for those who are homeless or underhoused, without a kitchen in which to cook healthy food.
Seventh Generation opened in 2005 and had 380 clients last year. Nine of its 19 midwives are Indigenous. Its funded by Ontario’s Ministry of Health and works with clients of any ethnicity, though Indigenous families are prioritized.
The practice is designed to provide what Ms. Wolfe calls “wraparound” care, which links expectant families with whatever social services they need, from housing support to transit fare. This spring, Seventh Generation kicked off the three-year Baby Bundle study, which will follow 50 pregnant clients to collect data on this full-service model.
Ms. Wolfe wants to prove to potential funders what she’s seen anecdotally: that comprehensive care for newborns’ families helps reduce the number of Indigenous babies that end up in protective care by as much as 50 per cent.