“I wanted to have my babies at home.” Brenda Atlookan rubs her nine-months-pregnant belly, soothing a Braxton Hicks contraction. Atlookan is three days away from her due date and 360 kilometres from home, at a hostel in Thunder Bay, Ont. Three weeks ago, she got on a small plane at Eabametoong First Nation, accessible only by plane (or, for a few months of the year, by ice roads), for the four-hour flight south. (The trip takes a while because the route stops at several other small communities on the way.) Her husband, Waylon, and her three kids—two sons ages 4 and 19, and her two-year-old daughter—are all back at home. In the meantime, she’s posting brief “Still waiting…” updates on Facebook, and trying to keep in touch with phone calls. Her chats with her four-year-old, while amusing, leave her feeling wistful: “Mom, did the baby come out yet? No? OK, bye!”
She’s one of at least 40,000 Canadian women each year who have to travel from rural and remote areas, mostly in the North, to have a hospital birth. And if you’re an Indigenous Canadian woman who lives on a remote or rural reserve, federal regulations require you to leave your home at 36 to 38 weeks—or earlier, if you have a high-risk pregnancy—to await the birth of your baby in an unfamiliar city. This means that across northern Canada, hundreds of heavily pregnant women board buses, planes, boats and snowmobiles to travel hundreds of kilometres from home.
Instead of provincial health care, Atlookan, like all Indigenous people who live on reserves, receives federal health care through Health Canada’s Non-Insured Health Benefits (NHIB) program. The evacuation policy, as it’s commonly known, became commonplace by the 1960s and 1970s, and the cultural, social and health effects of this practice have been far-reaching and profound.
While there’s still lots to be done, there have been some promising recent changes to prenatal and obstetric care in Northern communities. The overarching goal is to make giving birth in the North less stressful, more joyful and better linked to Indigenous culture.
The evacuation policy, sometimes also referred to as confinement, plays out differently across Canada. NHIB pays for travel and in some cases—like births—for accommodations and meals for people travelling for health care, but options for that room and board vary greatly (and sometimes, there’s no choice at all). Pregnant women awaiting their due dates can be limited to one designated motel, boarding house or hospital, often sharing space with people who are pretty sick. Atlookan is staying at Wedequong Lodge in Thunder Bay, a 52-room, 110-bed non-profit hostel funded by First Nations and Inuit Health (a branch of Health Canada), for Indigenous people travelling for health care. It has a no-frills motel feel to it, with a common room with a couple of TVs and computers, a cafeteria area, staff to assist with travel arrangements and vans to shuttle people to medical appointments.
Atlookan knows her kids are in good hands at home with their dad, but while she’s been in Thunder Bay, she misses them, and her community. “I walk around a lot because I want to go into labour and go home,” she says. She often goes to a nearby park and watches school kids playing baseball, but she’s unfamiliar with navigating a city and isn’t comfortable venturing too far from the lodge. Cabs in Thunder Bay are expensive, and the bus system isn’t great. She’s also on a tight budget, because she left her job as a heavy equipment operator early in her pregnancy.
Waiting for weeks to go into labour, so far from home, often adds up to an unsettling combination of homesickness, boredom, loneliness and worry for many women.
“Travelling for birth is absolutely stressful,” says Dr. Patrick Laflèche, a family physician who has provided obstetric care in northern British Columbia and Inuvik, in the Northwest Territories, for the last two years. Laflèche points to a number of studies connecting late prenatal travel to poor outcomes. “The further women have to travel and be away from families, the more complications there are, in particular, higher rates of prematurity.”
Compared to pregnant patients in urban centres, rural and remote pregnant patients are also twice as likely to be low-income teen moms, and twice as likely to be from communities lacking educational and employment opportunities—in other words, they are often young women who could really use some extra support and familiar surroundings.
There’s another wrinkle, this time at the provincial level: in the past 30 years, more and more rural hospitals have closed in favour of centralizing services in bigger cities, which means more travel time. Sometimes, this is the difference between travelling one hour to get to the hospital for a regular prenatal appointment versus travelling four hours or longer.
In its 2010 policy statement, the Society for Obstetricians and Gynecologists of Canada (SOGC) didn’t mince words criticizing the evacuation policy: “The SOGC strongly supports and promotes the return of birth to rural and remote communities for women at low risk of complications.” The SOGC also wants all women to feel involved in decisions about their own health, and their own birth plan preferences. “Women must be fully informed of the risks and benefits so they can make an informed choice about where to give birth. A woman’s right to choose should be respected.” But even though Canadian obstetricians are on board in theory, changes must come at the federal level—which can be slow and hard-won.
For years, many pregnant women had to labour and deliver at the hospital without their partner or family members with them, unless they could foot the bill themselves. This is because partners or family members (in official terms, they’re called “escorts”) were only covered if you fell into the following categories: pregnant minors, women with high-risk pregnancies, women who required translators, or for patients deemed mentally incapacitated. If you were considered low-risk, and your partner couldn’t afford to miss work or to pay his own way to the city—flights can easily be more than $500, plus weeks of paying for meals and accommodations—or there wasn’t someone back at home to look after your other kids for a few weeks, you were on your own. For years, Indigenous community leaders and health care providers have been saying that not providing a grant for an escort to accompany a woman for her delivery had all kinds of negative social, cultural and medical fallout. Finally, in April 2017, federal health minister Jane Philpott announced an immediately effective change to what she called the “extremely unhelpful” policy: escort travel grants will now be available for all women, not just women with high-risk pregnancies or those who are underage.
For her first two away-from-home deliveries in Sioux Lookout, Ont., a community of 5,000 northwest of Thunder Bay, Atlookan had her mom or husband with her, because they paid their own way. But when she had her daughter, it was just her and the hospital staff. “It was lonely and weird, but all right,” she says. She was glad her eight-hour labour was uncomplicated. “Going home alone with the baby was the hardest part, because that’s a long flight when you’ve just delivered a few days ago, and you have to carry your stuff and carry your baby.”
For Rhea Klengenberg, a mom from Sachs Harbour, a tiny community on Banks Island in the Northwest Territories, having her mom and boyfriend with her made all the difference. A year and a half ago, when she was 36 weeks pregnant, she flew 500 km southwest to Inuvik, and stayed in the local hospital’s “transient unit,” which has eight rooms with two single beds each. “My roommate was also young and very pregnant, and our sons were born four days apart. We’re still friends today,” she says. “But still, it would have been nice to have my own space.” When her partner arrived 10 days later (at his own expense) they moved to a friend’s house for a while for a little more privacy and home-cooked meals, instead of hospital-style food. “He brought ‘country food’ with him, some caribou that he hunted himself. I was so happy!” she remembers. Shortly before Klengenberg’s son was born, her mom joined them and they all moved to a hotel. Her mom had saved up for the whole pregnancy to be able to afford it. “Staying at the hotel took a lot out of our pockets,” she says. “But it was OK being away from home to have my baby because my mom and my partner were there. If I was alone, I would have felt lost.”
In contrast, Northern women who are covered under provincial health care, and not by NHIB (this could include off-reserve Indigenous women, or non-Indigenous women who live in the North), policies and coverage varies by province or territory. Non-Indigenous Northern residents travelling for health care who require an escort are partially reimbursed for the escort’s travel, accommodations and meals, through a program such as Ontario’s Northern Health Travel Grant. Still, gaps in the system remain. For example, if you’re a non-Indigenous mom with a baby in the NICU long-term, you’re low-income, and the city you’re staying in doesn’t have a Ronald McDonald House or something similar, you can face real financial hardship.
The change in the federal escort policy this past spring came midway through Atlookan’s current pregnancy. She and her husband decided he would stay at home to care for their older children, and she asked her niece to come to Thunder Bay with her as her escort instead. “It’s easier this time, because I have Marcy with me. She helps me with things and I don’t feel as lonely when I have somebody else in the room. We go for walks and we talk together,” she says.
In a lot of communities, the idea of leaving home to give birth has become an accepted, if not exactly welcomed, part of living in the North, as government policy morphs into family tradition. When Atlookan came alone to Thunder Bay to have her third child, she thought of her own mother. “I remember thinking, ‘now I know how my mom felt!’ because she would go to the city by herself to have us kids.”
Klengenberg says she didn’t even consider an alternative. “I never thought about being at home. I’m just used to this—having to travel to have your baby,” she says.
That feeling of not having a choice can weigh heavily, though. In 2014, the Winnipeg Regional Health Authority gathered comments from women who came from northern Manitoba and the far North to deliver: “They normally ship the mother here to Winnipeg one month in advance,” replied one mom, as if she were talking about a package. “Just do what the nurses say, the doctor. Just make an agreement and everything’s gonna be fine,” said another. A mother of five explained her situation this way: “I became confined here and [I’m] not allowed to go home.” A mother of two from Nunavut said, “I didn’t expect anything. I just stay here.”
These responses hint at a troubling theme of powerlessness over their own bodies and birth experiences—as well as generations of top-down medical decisions that don’t include the mom-to-be.
Some Indigenous communities are bringing choice back to expectant moms. There are a handful of birth centres across the country where Indigenous and non-Indigenous midwives are part of the health care provider team, and where women from remote, fly-in-only communities can get prenatal and obstetric care closer to home (if not actually in their home communities), surrounded by other Inuit or Dene women. The Inuulitsivik Health Centre in Nunavik, Quebec, was one of the first to open in 1986, and now has two other maternity wards along the Hudson Bay coast. Only about eight per cent of women—those with higher-risk pregnancies—are flown out to bigger centres to deliver.
At the heart of the issue: it’s not simply the inconvenience of travel, or the lack of social support at a vulnerable and often anxious time. It’s also about a deep desire to feel a connection to home, and for a child to be born on traditional lands.
“The amount of stress and worry on some mothers affects the whole labour and birth experience,” says Dr. Laflèche. “But that’s not even counting the social isolation and being absent from their community and the land.”
Norway House Cree Nation in northern Manitoba, with a population of about 8,000, has an Indigenous registered midwife that does pre- and postnatal care, but the maternity ward in the small, aging federally-run hospital (which used to be referred to as an “Indian Hospital”) has been closed for years. About 200 women a year still take a long bus ride to Winnipeg or to Thomson to deliver.
“The community members want birthing back here in Norway House,” says Gilbert Fredette, a councillor and the acting chief, who holds the portfolios for Health, Child and Family for Norway House Cree Nation. He hopes to see a new hospital built. “The balance is not there anymore. We’re seeing people passing on and we honour them with funerals here, but we’re not celebrating birth. That should be a joy in our community.”
Jaime Cidro, an associate professor in the department of anthropology at the University of Winnipeg, has studied the social and cultural impacts of birth evacuation on Norway House women and children. “We know there’s a link between the idea of being connected with home and overall family hardiness and resiliency,” she says.
Thankfully, there are some new programs that are attempting to restore those connections and offer culturally appropriate care. The Ontario government recently announced it would provide funding to establish six Aboriginal midwifery programs in the province, where Aboriginal midwives will work independently or with existing health teams to provide obstetric care. Lisa Bishop, an Indigenous registered midwife, will start providing services this fall, travelling to at least nine different remote and rural communities in the area to offer prenatal care, and working at two clinics in Thunder Bay and Fort William First Nation. “An Aboriginal midwife gives a different level of comfort; she’s a care provider who understands the culture and life experiences,” she says.
And in June 2017, during the International Confederation of Midwives Congress in Toronto, Health Canada unexpectedly announced new funding: $6 million over five years to support “culturally-safe” midwifery in Indigenous communities across Canada.
In Manitoba, there’s a unique new program called the Manitoba Indigenous Doula Initiative. The idea: partner Indigenous doulas in remote and rural communities with Indigenous doulas in Winnipeg or Thomson. That way, a mom can have pre- and postnatal care with a doula in her community, and when she comes south to have her baby with a doctor in the city, she can still be supported by a doula who is more familiar with her pregnancy. Currently the program has 12 trained doulas and they plan to train another 25 over the next two years, ultimately working with 100 pregnant women a year.
In addition to being a shoulder to lean on before, during and after birth, an Indigenous doula can help clients navigate the hospital system and, if they’re interested, introduce then to various Indigenous birth traditions that have been lost, or aren’t usually permitted in hospitals.
“It comes back to cultural identity and being grounded in that identity,” says Jolene Mercer, one of the co-founders of MIDI and a certified First Nations health manager. “There are different teachings around the umbilical cord for example: some people bury the stump, some keep it in a pouch, some put it in a turtle shell. It’s not something to be thrown in the garbage, because it’s part of that child.” Another important tradition is that the grandmother, or an aunt, is the first to speak to the child as he’s born, welcoming him in their own language and thanking the Creator, rather than a nurse saying, “It’s a boy!”
“Health starts in the womb,” adds Kathleen BlueSky, another MIDI co-founder. Cultural identity is the foundation of health and wellness. If people are spiritually well and spiritually connected, we know they can find the resources and the ways to keep themselves well throughout their lives.” And ultimately, it’s about women having choices, she says. “We’re trying to empower them. Instead of birth being something that’s sterile and cold, where you’re not in control of anything, it should be a sacred bond, and a loving and beautiful ceremony.”