Podcast: Long-distance travel for birth for Indigenous People
Transcript
Kirsten Patrick: Welcome to the CMAJ Podcast. In this episode...
Janet Smylie: ...of course, a big issue for Indigenous families is that because of colonial policies, Indigenous pregnant people often don't have options to birth close to home. This has particular relevance for First Nations, Inuit and Métis People where actually being born, where you're from, because the land is a relative. If you have to move away from where you're from, it's like leaving a very important relative out of the birth experience.
Kirsten Patrick: I'm Dr. Kirsten Patrick, interim editor-in-chief of CMAJ. A new research study has used data from the Canadian Maternity Experiences Survey to look at how far pregnant people traveled to give birth in Canada, and to look specifically at differences between Indigenous Peoples and the general Canadian population with regard to travel for birth. With me today to discuss the striking findings of their research, the problems that these findings highlight, and the potential solutions to the disparities that they noted are authors Janet Smylie, a family practitioner and Professor of Public Health, and Evelyn George, a registered midwife. But first a word from our sponsors.
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Kirsten Patrick: Janet and Evelyn, thank you so much for joining us on the CMAJ Podcast today.
Evelyn George: Thank you for having us.
Janet Smylie: Thank you for the invitation.
Kirsten Patrick: I'm gonna ask you to tell our listeners a little bit about who you are.
Janet Smylie: Sure. So Janet Smylie. I'm a Métis-Cree woman with a long and broken maternal kin line of mixed ancestry. My paternal kin lines route back to Ireland, County Down Ireland is where the Smylies came from and we're sixth generation settlers. I've been a family doctor and practicing medicine across geographies and contexts since 2003. After about five years of practicing family medicine, I went back and did a master's in public health. And since then, I've had an increasingly research-focused career. Currently, I'm a professor in the Dalla Lana School of Public Health, and the Faculty of Medicine Department of Family and Community Medicine at the University of Toronto, a tier one Canada Research Chair in advancing generative health services for Indigenous populations in Canada, and also the director of the Well Living Health Action Research Center and an active staff physician at St. Michael's Hospital in Toronto.
Kirsten Patrick: Evelyn, could you tell us about you?
Evelyn George: My name is Evelyn George. I'm Nbissing-Anishinaabe from Nipissing First Nation on my dad's side and French Canadian on my mom's side, and I'm a non-practicing registered midwife living in Syilx territory in BC in a community called Snpinktn. I'm a community engagement lead for NACM, National Aboriginal Council of Midwives and I work closely with Indigenous communities and nations working to restore birth and midwifery. And I am also Indigenous student coordinator for the UBC midwifery program where I work closely with Indigenous midwifery students.
Kirsten Patrick: Now we're discussing this really interesting study that you've conducted on the distance that women travel to give birth and how that's different for Indigenous women versus those of the general community. Can you tell me a little bit about why you wanted to study this?
Janet Smylie: Sure. Actually, I had the fortune of being involved with the Canadian Maternity Experiences Survey since its inception. And when we were done this study, and we were trying to think about what kinds of analyses would be relevant and useful for First Nations, Inuit and Métis people, we asked various First Nations, Inuit and Métis and national Indigenous organizations, and we in particular work with the Native Women's Association of Canada, who has representatives on this paper as well. And of course a big issue for Indigenous families is that because of colonial policies, Indigenous pregnant people often don't have options to birth close to home. This has particular relevance for First Nations, Inuit and Métis people where actually being born where you're from, because the land is a relative. If you have to move away from where you're from, it's like leaving a very important relative out of the birth experience. And for Indigenous Peoples, of course, we have a lot of diversity. But I'm not aware of an Indigenous community where it is very important to be birthing close to home or on the land where you're from. So the Native Women's Association of Canada, we had some emerging qualitative evidence that was showing that this historic and ongoing colonial policy was harmful to Indigenous Peoples, Indigenous identity, causing a breakdown in our web of relations. Very stressful, practically stressful, because children were then having to be left with caregivers who weren't their birth parents, mothers were often having to travel without any family or partners. So they wanted us to take this opportunity to understand quantitatively how common this was, that was community identified priority. That's a good approach in Indigenous research. Unfortunately, even when we have strong evidence through our community members, of course, it's the numbers that will be acceptable to policy. So this gave us a opportunity to do a rigorous scientific study that would support the much needed policy change, and actually quantify our hypothesis that the maternity care services in rural areas, our hypothesis was that they were disproportionately nearer and set up closer to non-Indigenous communities.
Kirsten Patrick: So in the beginning of your answer, you talked about the data instruments that you used. Now, can you tell us a little bit about the survey?
Janet Smylie: Yeah, so the Canadian Maternity Experiences Survey is the one and only comprehensive maternity experiences survey that we have in Canada. And actually, it happened in 2006–2007. So we're very much overdue for another one. And in fact, in our recommendations, were talking about the need even for Indigenous specific reproductive health surveys. This survey actually did include several hundred First Nations, Inuit and Métis women, it excluded First Nations mothers living on reserve, which is a strong reason why we need a repeat survey. It was designed by a multidisciplinary group of people under the umbrella of the Canadian Perinatal Surveillance System, and I was a member of that group, which was part of the Public Health Agency of Canada at that time. And we designed a survey, a comprehensive survey to better understand maternity experiences for pregnant people in Canada. And we interviewed parents who had given birth. The Maternity Experiences Survey itself interviewed mothers – so I think it was actually defined as mothers at that time in 2005-2006 – who had had infants that were living with them three months before the 2006 Canadian census, and the mothers were actually interviewed then, when their infants were between the ages of five months to 14 months.
Kirsten Patrick: And Evelyn...different birthing options for people living in rural Canada. What do they look like?
Evelyn George: Well, I guess it depends on where you are. And our study has shown that it also depends on who you are. But we know that increasingly, maternity services have been leaving the smaller rural areas and people have been needing to leave to go to the urban areas to have reproductive health services, and particularly around birth services. There aren't a whole lot of options. We know that in different parts of the country, family physicians are more active in providing maternity care, and in some places, not so much. In some parts of the country, there are midwifery practices that are located rurally where that might be an option and in other parts of the country, midwifery practices are quite scarce and especially in rural communities can be very far distances from one to the other. So it can, it just really depends on where you are.
Janet Smylie: Yes, it really does depend on where you live. And that was kind of our hypothesis was then that it will be privileging non-Indigenous Canadian-born people living in rural areas, which actually was our comparison group. So we compared Indigenous people to non-Indigenous Canadian born population, just because we know people who have immigrated to Canada more recently have different birth outcomes. In terms of access to services, the options in rural areas are community-based midwifery but that's not available in all rural areas, it's probably only available in the minority of rural areas, and then to give birth in like a birth center, or a hospital. So as family physicians we're trained to attend births at birth centers and in hospitals, midwives are trained to attend births at homes and birth centers and in hospitals. One thing for all women living in rural areas is that your opportunities to be born outside of a larger urban center might be limited by any complications you might have in the current or previous pregnancies. One of the things we were able to do in this study, because the data set was large enough, because I think there's often an assumption that the reason Indigenous women more often have to have birth experiences far from home, is because they have more medical complications. But in fact, we were able to control for medical complications, and show that once medical complications were taken into account, they were still much more likely to give birth away from home compared to non-Indigenous Canadian-born women living in rural areas.
Kirsten Patrick: Do you want to give us a kind of broad overview of the things that you found in this study?
Janet Smylie: Yes, as I mentioned, our hypothesis going in was that Indigenous women would more often have to travel for birth compared to non-Indigenous Canadian born women. When we looked at what was happening in urban areas, in fact, there was just very small numbers, because of course, some, there's lots of options for birthing in urban areas, they're not all culturally safe. But when midwives, family doctors and birthing centers exist, they're most commonly existing in urban centers. So we focused on rural and remote areas, with the limitation that the Maternity Experienced Survey excluded First Nations women living on reserve, what we found in the study, so our study results, actually, I never imagined, I knew there would be a disparity but I never imagined that the disparity would be so extreme, particularly since we weren't including First Nations women on reserve, because to exclude them would actually moderate the effect, right, because there's very few First Nations on reserve communities that have a birthing facility or a hospital there. So by definition, moms would have to travel. So what we actually found is that Indigenous women were more than five times more likely to have to travel 200 kilometers for birth compared to non-Indigenous mothers. And as I mentioned, though, a common assumption is the reason why that happens is because Indigenous mothers might have higher rates of medical complication in pregnancy. So then what we did was what's called an adjusted analysis. And then even more strikingly, we found that when we took into account medical complications of pregnancy, the result was even stronger, Indigenous women were 16 times more likely to have to travel more than 200 kilometers for birth, compared to non-Indigenous Canadian born women living in rural areas. By that time, our numbers were getting a little small. So the 95% confidence interval is eight to 33 times, but that was much higher. And it's extremely striking, to see that disparity in a rigorous quantitative study.
Kirsten Patrick: So you're looking not across the board, you're looking at people who live in rural areas, and this great discrepancy holds for only people who live in rural areas. It is very, very striking.
Janet Smylie: Yeah, with respect to this striking disparity, I think it's an important finding, because often what we hear about and I see that Indigenous health gets conflated with rural health, because of course, for all families in rural regions, Indigenous and non-Indigenous, there's fewer hospitals, fewer midwives for your family docs and fewer specialists and birth facilities per capita. But here we see that actually, it may not be appropriate to be conflating rural health inequities and Indigenous health inequities in rural areas. Because as often happens, there's an intersection happening so that Indigenous people living in rural areas actually are experiencing like a synergistic disadvantage. So it will be very important moving forward to not conflate Indigenous health disparities in rural areas with more general rural health disparities. We need to actually look very specifically at these striking Indigenous health disparities.
Evelyn George: And I think too, when we see the results of this and see how extreme the disparity is, and then we think, well, that doesn't include people from on reserve, which is going to add to that also. But it also doesn't include people who are incarcerated or people who've had had their babies apprehended. And we know that in those populations, we have an over representation of Indigenous people as well. And so take that number that already looks extreme and and add to it and add to it and add to it again. And it's very striking.
Kirsten Patrick: Evelyn, you make an important point there that Janet raised as well, that this is very likely an underestimate of the discrepancy because the population of the study is is fairly limited. That speaks to some of the challenges and barriers to studying this question. Perhaps you could talk about those a little bit.
Janet Smylie: So the opportunity was the Canadian Maternity Experience Survey. And the survey itself was actually committed to specifically looking at the birth experiences of Canadian youth as well as First Nations, Inuit and Métis people. But the first challenge and barrier was even though it would be very important to get samples that were large enough so we could understand, across diversities, the specific experiences of First Nations, Inuit and Métis women. So that would have required an over sampling of First Nations, Inuit and Métis women, and even though that was a stated study objective at the time, a policy decision was made not to oversample, First Nations, Inuit and Métis women. So we're not adequately powered to give us the data that we actually need to respond. So we know that there's this big disparity. But we do not know, you know, is this problem mostly for Inuit women and First Nations women? Or is it a problem, mostly for Métis women, because it's not adequately powered to disaggregate the data. So the Indigenous sample was inadequate. Another barrier is that just the way that a lot of the surveys are structured that come out of Statistics Canada, they build on a census sample. So we know at least for First Nations, Métis living in urban and related geographies, for example, only one out of four, or only one out of five Indigenous people does the census. I'm imagining there's under participation in rural and remote areas as well. And actually, it would be a biased under participation, because the people who are participating will be different than the people who don't participate in order to participate, you need to feel safe picking up the phone and answering it when Stats Canada or the Federal Government gives you a call. We did try to mitigate some of these things. We had the opportunity for people to have interpreters. But still even it would require you to have a phone, which is something that we don't take for granted in First Nations, Inuit and Métis communities where there's a disproportionate socio economic challenge. So one opportunity, because the challenge also just is the way that traditional quantitative epi methods work. They often leave out Indigenous ideas, paradigms, and perspectives. But actually, I feel good about this study. And I'm interested to hear what Evelyn thinks as well. But I think what we've tried to do is bring an Indigenous lens, Indigenous paradigm to a quantitative epidemiologic study. So of course, as First Nations, Inuit and Métis people, I'm a Métis woman, but where I come from, we were empiricists. To live on the land, you have to be an expert at empirical observation and tracking, because we were surviving on the land. So here, we tried to actually ground this study as much as we could in Indigenous processes. So for example, coming up with a question that was prioritized by Indigenous community, and show that we can use quantitative methods and we always have as Indigenous people as a way of understanding and then planning for better health and wellbeing in our communities. So like, what is the experience of birthing? How far are people having to travel? If we can quantify that then we can plan, you know, what kind of services and I imagine our midwives traditionally and healers would have done that as well, even just to survive. How big is our community, right? How many babies are being born this year? Do we need to move our community somewhere else where there's more food to support us because there's changes in this environment.
Evelyn George: From my perspective, living on reserve with the way that you know relationships exist in kind of our colonial context, you know, there are some real barriers there around trust and like what Janet says around, you know, picking up the phone and then continuing a conversation on the phone and being willing to share information that can be very difficult for people to to talk about in the first place. I see, you know, that being a challenge, and I would love to see a future study where we can kind of go about this study from beginning to end, in terms of the data collection, you know, from an Indigenous perspective, because I think that people will potentially be much more open in sharing.
Kirsten Patrick: You were talking a little bit about how the study question here for this quantitative study came out of other work that you had done. And I'm curious to know whether that work elicited understandings of how difficult it is for Indigenous women to travel for birthing.
Janet Smylie: Yeah, so of course, Evelyn and I have attended births in diverse contexts. But I'm sure as any person who's part of a family who's had to experience the impact of traveling for birth far away from home, it's scary, right? I used to even find it scary. So I've worked in rural and remote First Nations and Métis communities for good parts of my career. Even when I was a family physician, I used to find it scary. When I had to walk into the obstetric ward, at the Health Science Center in Winnipeg, right, all of a sudden, I went from being one of the most important people in the hierarchy to disposable. Imagine how the patient feels. And as I mentioned, at the beginning, there's that added component then, not only of leaving behind your family members, because there's like, it's only very recently that we had reversed federal policy that did not fund partners or supportive family members to travel with women, right? We know Winnipeg Health Science Center is where Brian Sinclair was left to die in the emergency room. So we know it's the exception, that Indigenous people actually have a good experience at an urban hospital versus that they are treated in a discriminatory manner. So and then there's the added thing that now you're being taken away, not only from your human relatives, but from the land base, which is also an equally or perhaps even more foundational, relative. And then for families that have multiple kids, you might be in your labor actually worrying about who's taking care of your kids, because we've had generations of family disruption, right. And part of the legacy of that is there isn't always reliable people at home, to provide those supports. So I think that's like a terrible context in which to give birth is combination of having to anticipate and be fearful of attitudinal and systemic racism in a hospital, to be isolated from the other humans in your life, to have to worry about the health and safety of your children, and then to be torn away from the lands where your people have lived for generations, something that actually, we've shown in other work more recently, that relationship to land, for Indigenous people, actually, is something that promotes health. So yeah, if you tried to plan, like, it's almost like a perfect storm of how to activate people, get our systems working in ways that are going to actually undermine a safe labor.
Evelyn George: If we're talking about the the impact of traveling for birth, you know, it's it's very profound. And I think as healthcare providers, we're always placing it in the lens of the birthing person, and we're always focusing on them. And there is definitely multiple layers of trauma that occur for that person. But also, like, they don't exist in a vacuum, they exist within families and communities. And those people have an impact also from that person being removed for that amount of time, for however long it is. For some people, it's a few days for other people, it can be over a month, depending on where you're traveling from. At the community level and at the family level, this is it's really lived out as an experience of family separation. And using the words family separation is important when we talk about Indigenous health, because of history, and because of the impacts that it has intergenerationally and the colonial context around it, I think it's important to frame, to saying that. And we know that you know, those stress responses interfere with bonding, and attachment. And we know that those, all kinds of things can be happening in families. There's never an easy or good time to to leave a family for an extended period of time, you know, for any family. But like what Janet was saying around you know, our family context, it can be really difficult to start with and it can be really challenging for some people to find a care for their children over that length of time that they can feel comfortable and safe about. With the escorts with with, you know, companions for birth, even that, you know, it does support birthing person for sure and there are advantages there, but it's also really difficult because that's not paid time off, right. And, you know, people find it really difficult even to go for short amounts of time. And so it, it really ends up that we just really need to have birth closer to home, we really need to have birth on territory, within our family circles within our kinship circles, within our communities, because that's where we can be intact as people.
Kirsten Patrick: You outlined at the beginning that this is quantitative research to highlight a problem. But what's really needed is some solutions. And you've picked up on a few there. What do you see as the next steps out of this work?
Evelyn George: Well, I think that we've had some huge successes in particular parts of the country with community based Indigenous midwifery, returning birth to communities. And, and, of course, the examples that you can maybe look up are the examples in Nunavik, in northern Quebec, and also Six Nations as well known for restoring birth in their community in a community based way. And when we say community based, we mean kind of community owned. The foundation is a cultural foundation and is placed geographically within that community also, and we've had huge successes. Indigenous midwives have important skill sets and knowledge bases and competencies that are really important in restoring birth to communities and communities are safer when there are more care providers in them and not just visiting. And we know, for remote communities, it's often the case that people are kind of in and out and the people themselves who are receiving care are also in and out of the community, it's very disruptive. And we have just really strong examples of how this can still work. And, you know, when we think back to, you know, how did we come to be here in the first place, right? Indigenous midwifery was there, was part of our communities, all the way up until it was removed and replaced, you know, with eventually what has become the current model. And we have strong examples of how this can still work and can be an important way of improving community wellness generally. And you know, Indigenous midwives are expert on our people. And we have important skills and knowledge that can offer cultural approaches to care and approaches that are significant and holds meaning to our community people as well. You know, midwives and Indigenous midwives, we work within the greater landscape of health care in Canada, right? We don't work in isolation, either. And working as collaborative members on teams, whether that is some, people who are placed in the community or not, because we're part of this kind of web of service providers and care providers, you know, and wherever we find ourselves there, there are always other people involved. And it's always important to be thinking about those relationships. And when we think of Indigenous midwifery, I think, you know, maybe people have a certain idea of what that is. And I always encourage people to really get to know, you know, maybe if there's a local practice of midwives, or get to know the examples and how they work and the finer details of how they work within the larger landscape of maternity care, and how those relationships are, because I think that there are always a lot of assumptions that working in isolation or, and that's just not the way that it is done.
Janet Smylie: Just to build on what Evelyn says, to me, it's not a coincidence that birthing facilities and birthing providers in rural areas are concentrated in non-Indigenous communities. So for me, that begs some kind of reconciliatory action. So at this time of TRC, one also has to think about the fact that in Canada, one of the reasons why our infant mortality rate lags behind that of other relatively affluent countries is because we still have this persistent disparity in infant mortality rates where the infant mortality rates for First Nations and Inuit infants are two to four times higher than those for non-Indigenous or the general Canadian population. Basically, there's a need for population-based Indigenous-specific investments and access to birth close to home for First Nations, Inuit and Métis living in rural and remote areas and I see three arms of this. The first would be as Evelyn's mentioned, support Indigenous midwives. And, you know, we've just seen like for example, a concrete policy like Laurentian University is underfunded, like we need to make sure that the Indigenous midwifery program at Laurentian is not shut down. The second is facilities. And as I mentioned, I think, you know, we have very few Indigenous-specific birthing facilities in rural and remote areas. So we need a dramatic investment in these facilities. And, you know, we saw one close. I have great confidence in Indigenous midwives, with the support of other iIndigenous primary care providers and health service providers. I always say that with the leadership of Indigenous midwives, like Indigenous nurses, family doctors and specialists and our allies, and we can work together. So and then the third piece is we do need urgently First Nations, Inuit, Métis Reproductive Maternity Health Survey. I think Canada as a whole urgently needs like another Maternity Experiences Survey, which hopefully would be expanded to a Reproductive Health and Maternity Experiences survey. It was meant to be a longitudinal survey, but it hasn't happened since 2005-2006. I think that this survey needs to include First Nations women on reserve, but also to continue to support participation of First Nations relatives who are living off reserve, Métis and Inuit. So those are the three ways for that I see.
Evelyn George: I think what I can also add to that is just you know, there's always going to be a need for travel for birth, because there was always going to be people who need that extra level of care. But it's more their, their routine, you know, referred to as evacuation for birth, or policies around traveling for birth, and the lack of health services closer to Indigenous communities or in Indigenous communities is the degree to which is happening for low risk birth, that is especially problematic, and there's always going to be a need to travel. And I think this is the thing that people always say they're like, oh, but, you know, it's such a small number of people. And and if half of them are leaving the community, then, you know, do you have enough births to sustain the service of any kind, and it's bigger than the birth itself, it impacts the entire community. And if we can look at it through an expanded lens, around community experiences and trauma and Indigenous rights and Indigenous communities having rights to reclaim their ways and their own, and owning their own health services and things like this, just kind of expanding that view to allow for a deeper conversation about it.
Kirsten Patrick: Well, thank you so much for joining me today on our podcast and talking about your really important and interesting research. It's been great to talk to you both.
Janet Smylie: Thanks, Kirsten.
Evelyn George: Thanks so much for having us.
Kirsten Patrick: I'm Kirsten Patrick, interim editor-in-chief of CMAJ. Thanks for listening to this episode of the CMAJ Podcast. You can read the article I discussed with my guests today at cmaj.ca. The title of the article is "Long distance travel for birthing among Indigenous and non-Indigenous mothers in Canada."
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