At 3:12 p.m. last Wednesday, 16-year-old Sherrie Akammak was getting dressed for her first-ever trip to a real movie theatre when her eyes widened and her jaw dropped.
She looked across the drab boarding-house room in Winnipeg where she had been confined for three weeks and yelled to her mother.
"It's ready. We have to go."
Her mother, Theresa Akammak, had been in this position before - 12 times before, to be precise, nine for herself and three for another daughter. Yet her familiarity with the ritual of childbirth did little to allay her anxiety. In a panic, she phoned downstairs to reception at the Kivalliq Inuit Centre.
"My daughter's going into labour," she said. "We need a van. Now."
In the Akammaks' world - the world of Inuit women living 1,200 kilometres north of Winnipeg in Arviat, Nunavut - the anticipation of birth is often tinged with premonitions of death.
Like most communities in the North, Arviat, the third-largest settlement in the territory (population 2,100) and home to Canada's highest birth rate (roughly 35 per 1,000 people, compared to a national average of 10.3) has no permanent doctor, no hospital, no midwife, no public health nurse - no one to help the 70 or so women who get pregnant every year, save for seven overworked nurses at the health centre. That's why most pregnant women here, like Sherrie, are flown south to cities like Winnipeg in order to give birth. But even then, there are problems.
Sherrie's sister miscarried once and then lost a premature child when the Medevac plane didn't arrive on time. The family knows dozens of women - many barely past puberty - with similar stories.
The statistics on aboriginal infant care in Canada are similarly bleak. An Inuit baby is 3½ times more likely to die before its first birthday than a non-Inuit newborn. (The infant mortality rate in Nunavut is the highest in the country, at 15.1 deaths for every 1,000 live births, compared with a national average of 5.1.) Inuit children have the highest rate of hospital admission for lower respiratory tract infections in the world. Compared with other children, aboriginal offspring are 50 times more likely to contract pneumonia, 80 times more likely to catch chicken pox and seven times more likely to be born to a teenage mother. Around 40 per cent report chronic illness.
Canada will invite close international scrutiny of those dismal numbers at this month's G8 summit when it quarterbacks a multibillion-dollar plan to improve maternal health in the developing world.
Prime Minister Stephen Harper has spoken passionately about his desire to improve the lot of women and children in poor nations, but critics say there is a desperate maternal plight right here, in his own country.
"I was absolutely shocked," said Shirley Tagalik, a member of Arviat's health committee, of the moment she heard about Mr. Harper's international maternal health initiative. "I don't deny that other countries need help, but don't they know what's going on up here in their own backyard? We can't take care of our mothers and we need help."
'I'm very, very homesick'
The day before her water broke, Sherrie Akammak sat in a booth in Winnipeg's famed Pancake House, desultorily pushing a hamburger and fries around her plate. She wasn't hungry, but couldn't refuse a rare opportunity to leave the centre - her own personal "jail cell" as she calls it.
She feigned shyness, preferring to speak with her body in the Inuit custom - raised eyebrows for ii, or yes; a squint for nau, or no; and shrugged shoulders, universal teen-speak for "Don't know, don't care, enough with the dumb questions already." Yes, Sherrie Akammak - she of teal fingernails, broad child-like cheeks, short black hair and faded hoodie - is 16 and acts 16, even when it comes to this whole pregnancy thing.
"Boring," she says of the last nine months, as she stares out the booth window towards Arviat, 1,226 kilometres due north. "I want to go home."
She's here because she has to be. Aside from Iqaluit, Rankin Inlet and Cambridge Bay, communities in physician-starved Nunavut shuttle roughly 85 per cent of their pregnant women to faraway hospitals to give birth.
Every year this same "boarding-out" ritual takes thousands of mothers from isolated aboriginal communities across the country. For periods of up to a month, they are confined to boarding houses like the Kivalliq Inuit Centre, where Internet time costs $5 for 40 minutes, the food doesn't hold a candle to raw caribou, and there's little more to do than sit around and think about cigarettes.
Boarding out is one of those antiquated quirks of northern health care that temporarily splits families, strains expectant mothers and racks up a $12,000 tab for even the lowest-risk birth. Altogether, the maternity flights comprise roughly one-third of all medical travel expenses in Nunavut.
"I wish she could be doing schoolwork," Theresa says of her daughter, who should be finishing Grade 9 this month. "But the school didn't have any correspondence materials. So she's here missing school. We go out and smoke to pass time. We know it's not good."
The solution may seem obvious - train and hire locals to deliver babies in communities - but Arviat offers an example of a town, like so many in the North, that flouts easy fixes. This is, after all, a hamlet that's a nine-hour Ski-Doo ride away from the nearest bank, and where government job openings go unfilled for years. Administering health care here, and in other equally remote northern towns, has always been bedevilling.
In 2007, work began to transform the town's former health centre into a state-of-the-art birthing centre. The idea was to emulate similar efforts in northern Quebec and Greenland, where government investment has brought midwives to towns of little over 100 people. In Greenland alone, this has helped slash the Inuit infant mortality rate to half that of Canada.
Arviat began modestly, hiring two midwives to give classes on breathing, nutrition, breastfeeding and even yoga - lessons that had been lost over previous decades as responsibility for birth was taken from the hands of traditional Inuit midwives and placed with itinerant doctors.
And then the whole effort stalled. The two midwives burned out on Arviat's overwhelming birth rate, and the Nunavut government denied requests to lay out another $90,000 annual salary to hire an extra midwife. Today the new birthing centre lies unfinished and empty, an aborted effort to improve the lot of expectant mothers.
Pauline Copeland gave birth in Arviat with the help of these midwives two years ago, and recalled the excitement she felt at being able to remain at home and avail herself of a choice many Inuit have not been able to make for decades. Last week, she found herself in Winnipeg again, preparing to give birth to her fifth child.
"I'm very, very homesick," she confessed, over her umpteenth southern breakfast of plain white toast. "We have the big fishing derby this week and I'm missing it… Some moms, they hide their bellies just so they don't have to come down here. Maybe that's not such a bad idea."
Putting money where it matters
Given the social and financial costs of the boarding out initiative, reviving the Arviat birthing centre would seem a smart, reasonable policy objective. Thus far, however, its future has remained in limbo, the subject of finger-pointing among different levels of government.
Ms. Tagalik, Arviat's health committee member, knows the anguish of boarding out firsthand. She moved North to teach in the 1970s, and at 27 she was forced to fly to Churchill, Man., to give birth.
That experience has informed her pleas for a renewal of the midwife program - pleas she says are being ignored by the government of Nunavut, which has responded by removing the whole program.
"Flying women out is a bandage solution and we've put so many bandages on the problem they won't stick to the sores any more," she said. "We have to invest in a different way."
Eva Aariak, Nunavut's Premier, agrees that local births are important - she was born in a hunting camp with the aid of a traditional midwife, and laments that new generations can't be. Yet she places the blame at the feet of Ottawa, and argues that until the federal government grants Nunavut the power to collect its own resource revenue - a hotly debated process known as devolution - the cash-strapped territory will struggle to make any significant investments in maternal health.
"We have a long-term strategy to add midwives and birthing centres," she said during an interview in Yellowknife. "Unfortunately, this [federal] government is concentrating, because it's a minority, more on short-term investment."
In an e-mailed response, a spokeswoman for federal Health Minister Leona Aglukkaq insisted that the Conservatives had committed $285-million over two years toward improving aboriginal health - including maternal well-being - and $60-million aimed at improving community-level access to health services in the North.
The numbers and the politics don't seem to matter much to the women who are routinely uprooted and displaced during their pregnancies.
"I don't know," said Theresa Akammak when asked about the recent health investments. "We are always hearing about improvements. We are not always seeing them."
She had accompanied her daughter, Sherrie, to the third floor of the Winnipeg Health Sciences Centre Women's Hospital shortly before 4 p.m. that Wednesday afternoon, not long after her water broke.
An obstetrician conducted an ultrasound, then closely considered Sherrie's age, size and health before deciding to perform a C-section. Theresa fretted for hours. By morning, however, she was a gleaming grandmother. At 12:45 a.m., Sherrie gave birth to Tuni Mary, named after a friend who died of the H1N1 virus.
"A little girl," Theresa gloated in a room several worlds away from home. "She's big, 8½ pounds. And everyone's fine. My daughter is healthy. Hopefully we can go home very soon. We are too long away."
Patrick White