Mainstream Urban Maternity Care
With reference to Canada’s colonial past and changing legislation around midwifery practice, Aboriginal women face specific social, economic, and political barriers to accessing culturally appropriate maternal health care due to an intersection of location, ethnicity and gender. Although Aboriginal women's experiences with mainstream maternity services is an extensive topic, I feel it is important to highlight some common themes that emerge from their narratives in order to better understand why it is significant to create nation wide health care policies that allow for the returning of birth to Indigenous communities. Thus, using a range of ethnographic research, I have attempted to draw comparisons between the stories that women have told and to provide a space here for their own voices to speak. In doing so, I am not attempting to encapsulate the whole range of experiences that Aboriginal women have shared, especially given variation between cultures across Canada. Nor do I think this is the space to contextualize each of the aims and methods of the individual studies. Instead, if you would like to learn more about location-specific experiences of Aboriginal women's experiences under mainstream maternity care services I encourage you to click through to the individual articles.
A prevailing theme throughout each of the studies suggest that conventional maternal health services are largely ineffective and inappropriate because they ignore the needs and desires of Aboriginal women. Specifically, the biomedical health system undermines an indigenous knowledge system that recognizes multiple truths and emphasizes a holistic view of health. While most First Nations are collectivist, medical services are provided on an individualist model that renders family and culture relatively unimportant. Furthermore, although the mainstream services claim to be “culture free”, the model is saturated with Euro-American cultural values that reinforce power asymmetries between doctors and patients. Thus, participants expressed a tendency to feel objectified when viewed through the gaze of the current biomedical model. Moreover, health providers in the current system rarely consider poverty or community structure as relevant to health (Mehl-Madrona, 2012). Through the following accounts of Aboriginal women’s experience of birth in urban settings- based on a combination of interviews and quantitative research- I especially aim to highlight three emerging themes of displacement, trauma, and cultural tension between Native values and the paternalistic values of the Colonial state.
Vancouver's Downtown Eastside (DTES):
70% of Vancouver’s total Aboriginal population live in the city’s poorest neighbourhood, the Downtown Eastside. Although the ratio of males to females in the DTES is estimated at 3:1, the neighbourhood’s Aboriginal population is roughly balanced along gender lines. As a result, a number of Urban Aboriginal Health Centres (UAHCs) have emerged over the past two decades, along with the rise of neoliberal healthcare in Canada. Aboriginal women in the DTES have expressed concern over the UAHCs focus on mainstream risk management models at the expense of sensitivity to the needs specific to Aboriginal peoples. Specifically, they have expressed dismay over lack of Native healers and respect for Native values. One woman criticized such programs by saying “it’s like the same White system with just a different name on it”. Furthermore, some participants expressed a desire for more female physicians, due in part to the high rate of family violence, physical and sexual abuse issues, and high-risk behaviours in their earlier or present lives. Fear of authority figures, especially for residential school survivors, means many Aboriginal women are unable to get the basic medical and social treatment they need. Thus, there is also an urgent need for meaningful counselling and emotional support that is inclusive of First Nations spiritual beliefs.
In relation to maternity care, participants identified the midwifery services available through, Sheway- a distinct program for substance-using pregnant women in the DTES- as being particularly useful, as it allowed patients to know who would be attending their birth and to establish a relationship with the care provider prior to the event. The women expressed that the Sheway model is more akin to traditional Aboriginal health structures in that it includes a fluid and informal service delivery, a collective, non-hierarchical staff structure, and horizontal relationships between staff and clients, all of which reflect the holistic values and structures of the more communal, traditional Aboriginal societies. Unfortunately the midwifery program at Sheway was closed in 1997, at the same time that the midwifery profession was granted legal standing and public funding in British Columbia. Despite evidence of cost-effectiveness and lower risks of complications in midwifery-assisted childbirth, the service has yet to be replaced for Aboriginal women living in Vancouver’s DTES.
(Torchalla, Linden, Strehlau, Neilson, & Krausz, 2015)
Building off Benoit & Chamberlain's research on Aboriginal women's access to maternal health care in Vancouver's DTES, Torchalla et. al's research identified violence and trauma as major factors in women's access to resources. Specifically, they identified that many of the women that they interviewed struggle with addiction, are involved in the sex trade and experience homelessness and gender-based violence. Such evidence suggests that psychological trauma is also a common experience for these women. The authors conclude that in offering health care services for poor and marginalized women, it is clear that an understanding of trauma must be integrated in order to offer services in a trusted environment. Furthermore, it is necessary to shift the focus from the individual to include environmental, social, economic, and policy interventions on multiple levels from reduction of harm related behaviour to the inclusion of issues of gendered and racialized vulnerabilities.
Figure 1. Sheway Community Program Retrieved from http://sheway.vcn.bc.ca/
Transfers from Arctic Communities:
(Grzybowski & Kornelsen, 2004)
Since the late 1970’s, women in northern areas of Canada have routinely been transferred from their communities to more urban areas to give birth at approximately 36 weeks of gestation. The primary reason that has been given for the routine transferring of aboriginal women has been the view that they are at high risk for adverse birth outcomes. However, measures used for pregnancy risk assessments are culturally biased because they have been based on western health models that do not address differences in physiology and health. For example, Inuit first time mothers were sent out of their communities to urban hospitals because they did not have an obstetric history and were considered to be at risk for shoulder dystocia. An analysis of birth outcomes suggests that shoulder dystocia is a rare occurrence for Inuit women. In interviews around the recent birth experiences of Indigenous mothers who left their Arctic community to give birth in larger regional centres several emotional, physical and economic stressors emerged as common occurrences.
The most frequently mentioned stressor was the enforced separation from family, culture and the community as a result of being sent out for a birth. Mothers expressed concern over the well-being of children left behind and missing the support of their partners during childbirth. These feelings were aggravated by the difficulties of living in a residence with strangers in an unfamiliar environment. Several mothers expressed experiencing distress when their babies were temporarily taken away from them immediately after birth for health problems that were not clearly explained to them by health providers such as doctors and nurses. Furthermore, the problem of reintegration of the mother and baby into the family and community after a prolonged absence (average three weeks) was mentioned frequently.
Many women identified labour as a traumatic event intensified by feelings of isolation and worry about their families. They felt that they got little support from nursing staff in the hospital and had no choice in how they could deliver their babies. Specific physical stress occurred as a result of being unable to navigate resources in the unfamiliar urban settings. For example, one woman suffered when she was unable to get assistance breastfeeding, while another mother suffered from an extremely painful rapid birth wherein she felt that she was given no assistance in managing her pain
A final concern of many of the parents was the economic stresses of being transferred for birth. Specifically, costs associated with arranging childcare for children left at home, telephone calls back to the community, additional costs of airfare if the partner came with the mother and the cost of the partner’s time off work. Ultimately, lack of choice was evident in the perceptions of mothers concerning decisions made regarding the place of delivery, the form of delivery and the amount and type of support they received during the labour and birth. A further complication in transferring Aboriginal women to urban settings for birth is a concern about land claims for unborn children when mothers are sent to another province to birth.
Figur 2. Map of the Canadian Arctic.
Retrieved from wikipedia commons.
Figure 3. 20th Century Nunavut Woman and Child. Retrieved from http://thediscoverblog.com/tag/arctic
Common threads of these experiences are echoed elsewhere in the literature. If you would like to learn more about specific locations or populations of people, please the following links to these articles as a reference point:
Access to Maternal Health Care for Native Canadians on Reserves in Northern Canada
Metis Maternal and Child Health
Strong Women, Strong Nations: Aboriginal Maternal Health in British Columbia
References
Benoit,C., Carroll, D., & Chaudhry, M. (2003). In search of a healing place: Aboriginal women in vancouver's downtown eastside. Social Science & Medicine, 56(4), 821-833.
Chamberlain, M., & Barclay, K. (2000). Psychosocial costs of transferring indigenous women from their community for birth. Midwifery,16(2), 116-122.
Grzybowski, S., & Kornelsen, J. (2004). The costs of separation. Canadian Woman Studies, 24(1), 75.
Mehl-Madrona, L. (2012). Relationships of aboriginal people with conventional health care services. Canadian Journal of Native Studies, 32(2), 1.
Torchalla, I., Linden, I. A., Strehlau, V., Neilson, E. K., & Krausz, M. (2015;2014;). "like a lots happened with my whole childhood": Violence, trauma, and addiction in pregnant and postpartum women from vancouver's downtown eastside. Harm Reduction Journal, 12(1), 1.