Reclaiming birth – Inuit communities of Nunavik, Canada

One of the most successful examples of a midwifery continuity of care within a ‘high-risk’ remote area was introduced in the northern regions of Canada in the mid-1980s.

Since then, midwives have provided holistic, primary maternity care in collaboration with physicians and nurses in the remote villages and at the regional and tertiary referral centers. Care is wrapped around the woman and family, with the midwife facilitating access to additional services for the woman as needed.

Before bringing birth back to the community, women were being routinely evacuated at 36 weeks to hospitals over 1000kms (600 miles) away in the south of Canada – at great expense to families who wanted to be with the woman for her birth and early days of parenting. Women expressed feelings of intense loneliness, isolation and fear as a result of being taken away from home in late pregnancy, especially when leaving young children at home to be looked after by relatives.

Women were told it was ‘too risky’ to give birth in their community. For the women and midwives who led the creation of the community birth centres, ‘risk’ is understood as a much more complex issue. Here an Inuit elder speaks, in ‘Reclaiming Birth, Health, and Community: Midwifery in the Inuit Villages of Nunavik, Canada’:

I can understand that some of you may think that birth in remote areas is dangerous. And we have made it clear what it means for our women to birth in our communities. And you must know that a life without meaning is much more dangerous.

-Jusapie Padlayat, a Salluit elder (Van Wagner, Epoo et al, 2007)

The importance of birthing in the community

Birth in the community is seen as part of healing, restoring skills and pride, and of capacity-building in the community. Participating in birth builds family and community relationships and intergenerational support and learning, through promoting respect for traditional knowledge, and through teaching transcultural skills both within the local community and with non-local health care providers. The Inuit midwives are vital in promoting healthy behavior, as well as in health education. They can be effective in this role in ways that non-Inuit health care workers could not hope to be.

The establishment of the birth centers has been fundamental for community healing, and marks a turning point for many families who suffered from family violence in Nunavik.

Bringing birth back to the community has improved clinical outcomes for Inuit women too, with less preterm birth, babies with higher birth-weights, fewer interventions in birth, higher breastfeeding rates, and less postnatal depression. Some additional community-level benefits have been seen through reintegrating birth and birth care back into Inuit communities: lower rates of divorce and less child abuse by family and community members have been observed.

These outcomes have been achieved despite the considerable socioeconomic challenges and health problems in this community. It is the direct result of a model design that enables strengthening the relationships between all the people involved: midwife to woman, midwife to midwife, women and doctors, a collaborative team available for each woman that is led by her midwife, and strengthened connections with community. Above all – upholding the value of all of these relationships.

The potential for healing a community by bringing birth back home, as evidenced by the Nunavik programs, is powerful. Listening to what women want and need – and an investment in developing relationships and deep levels of trust between all the key players – really does save lives.

Over to you

Fundamental to the success of the Nunavik community birth programs has been the ability for self-determined risk assessment, based on clear protocols and policies. The understanding of risk, however is broader and encompasses physical, emotional, psychosocial, and spiritual risk, rather than simply a physical ‘risk assessment’.

What are your own views on ‘risk’ in maternity care? How is community and individual self-determination balanced with expert advice and risk management for health services?

References

1. Van Wagner, V., Epoo, B., Nastapoka, J., & Harney, E. (2007). Reclaiming birth, health, and community: Midwifery in the inuit villages of nunavik, canada. Journal of Midwifery and Women’s Health, 52(4), 384-391. doi:10.1016/j.jmwh.2007.03.025