What makes Inuulitsivik midwifery successful and sustainable? How an Inuit-led care model brought birth back to our remote arctic communities

Abstract

Nunavik (Québec, Canada) has been inhabited by Inuit for over 4,000 years. Inuit midwives assisted in childbirth for centuries before colonization removed birth from our communities. In the 1980s, after years of evacuation for birth to southern hospitals, local women and Inuit leaders brought birth back to our remote Hudson Coast and Hudson Strait villages. As Inuit midwives, we have continuously offered local midwifery care to the population since that time, supported by southern midwives and an interprofessional team. Our midwifery service is nationally and internationally recognized as a model for returning childbirth to remote communities and reclaiming Indigenous midwifery. Inuulitsivik midwifery demonstrates that birth services and midwifery education can be integrated into health care systems in remote communities with safe outcomes. To understand the factors that contribute to our success and sustainability, we brought together experienced midwives and student midwives and met in person, by teleconference and online. Themes that emerged include Inuit values and language; Inuit leadership; local midwifery education; an adapted role for midwives in remote communities; flexibility in the organization and implementation of practice; midwifery-led interdisciplinary care and strategic collaboration with southern Canadian and international allies. We explore these themes and use common frameworks for policy analysis to consider effectiveness; impacts on the experience of pregnant women and families; health equity and access to services; costs; feasibility and acceptability. Our local midwifery service makes an important contribution to meeting the calls to Action of the Truth and Reconciliation Commission of Canada.

Introduction

This article expresses the perspectives of the team of midwives from the Inuulitsivik Health Centre (IHC) in Nunavik, the Inuit territory of Québec, Canada. By reflecting factors that contribute to the success and sustainability of our remote midwifery service, we hope to contribute to policy discussions in Canada and internationally about birth in remote and Indigenous communities. Our goal is to support others to return birth to communities and reclaim Indigenous midwifery. Our reflections are informed by 40 years of experience providing care in Nunavik.

Inuit midwives assisted in childbirth for centuries before colonization removed birth from our communities. In the 1980s, after decades of evacuation for birth to southern hospitals imposed by non-Inuit health care providers, local women and Inuit leaders brought birth back home to our remote Hudson Coast and Hudson Strait villages. We established a midwifery service and local training for Inuit midwives as part of the IHC in 1986. We have continuously offered local midwifery care to the population since that time. Our midwifery service is a nationally and internationally recognized approach to returning childbirth to remote communities [1–7] and as a model for those wanting to reclaim Indigenous midwifery [6–11]. Our published and unpublished outcomes demonstrate that local birth services and midwifery education can be safely integrated into remote health care [12,13].

We are often asked “What makes midwifery in Nunavik work?” by health workers, policy makers and community members who want to return birth to their communities. This article articulates what IHC midwives consider the essential elements of our midwifery service and the principles, policies and practices that support our work.

Materials and methods

We brought together a group of experienced midwives and student midwives to explore this question to prepare a presentation to the International Confederation of Midwives in 2017 [14] and the Arctic Maternal and Pediatric Challenges conference in Iqaluit in 2019 [15]. The group represents several generations of Inuit midwives, educators, community leaders, mothers and grandmothers. Kim Moorhouse, from Inukjuak, has been both coordinator of perinatal services and education coordinator at IHC. Eileen Moorhouse is the current coordinator of perinatal services. Brenda Epoo is past coordinator of perinatal services and, with Eileen Moorhouse is a founding midwife of the Inukjuak Maternity. Akinisie Qumaluk and Leah Qinuajuak are founding midwives from Puvirnituq and are now elder midwives and teachers. Louissa Pauyungie, from Salluit was a student midwife when we began our writing and is now a graduate. Our team also included Jennifer Stonier and Vicki Van Wagner, southern midwives who have worked in Nunavik and supported the Inuulitsivik education program for decades, helping to make links with southern education programs. Kellie Thiessen supported the work to create an article that could inform policy discussions, as principal investigator for the CIHR project “Welcoming the ‘Sacred Spirit’ (child): Connecting Indigenous and Western ‘ways of knowing’ to optimize maternal child health service delivery in remote Canadian regions” and lead the development of the policy analysis section.

We met together in person, by teleconference and at online coastal meetings. We identified themes and examples that would best tell our story. The data has been gathered over the course of nearly 40 years. Our main source of data is our lived experience and includes historic and ongoing consultation with the community, published and grey literature about the development and evaluation of Inuulitsivik midwifery, as well as quantitative outcomes data. We compiled our reflections and then used an adapted public health policy framework with an Inuit lens to assist our analysis.

Themes that emerged from our reflections on sustainability and success include foundational Inuit values and language; Inuit leadership; local midwifery education; an adapted role for midwives in remote communities; flexibility in the organization and implementation of practice; midwifery-led interdisciplinary care and strategic collaboration with southern Canadian and international allies. We explore these themes and then consider effectiveness; the experience of pregnant women and families; health equity and access to services; costs; feasibility and acceptability [16]. In addition, we consider the contribution of our service in relationship to the Calls to Action of the Truth and Reconciliation Commission of Canada [16], Joyce’s Principle [17,18], the National Inquiry into Missing and Murdered Indigenous Women and Girls, [19] and the Public Inquiry Commission on relations between Indigenous Peoples and certain public services in Québec [20].

Background and context

Nunavik, Québec, Canada, is 407,346 square kilometers of Arctic tundra just south of the Canadian Territory of Nunavut which has been inhabited by Inuit for over 4,000 years. The population of Nunavik is 14,050. Ninety percent are Inuit and 92.1% speak Inuktitut [21]. Most of the population also speaks English or French [22]. The population is growing with more than 60% of the population under the age of 30 [22]. The seven communities served by IHC line the eastern coast of Hudson Bay and Hudson Strait (Figure 1). There is no road access to the communities, which are connected to the rest of Nunavik as well as Québec and Canada by plane [1,12].

Figure 1.

Map of villages in the Nunavik region. Reprinted with permission from Makivik Corporation [1].

The lifestyle of the community is a mix of traditional and southern ways of living. Our communities live with the impacts of colonialism and intergeneration trauma from loss of culture and autonomy and the residential school system. We are resilient people, and our communities make strong efforts to reclaim culture and advocate for Inuit governance of our lives.

Despite colonization, babies continued to be born on the land, in igloos (snow houses) or tupiqs (summer tents) into the 1950s. As Inuit, we had skilled people from our communities who gave care during pregnancy, birth and postpartum. Even though midwifery was an integral part of traditional Inuit culture, the “standard” medical maternity care that developed in Canada was imposed on northern communities across the country [1,23,24]. Midwifery and traditional healing were prohibited by priests and government officials. Communities hid traditional knowledge about birth when Qallunaaq (white people/non-Inuit) were present. With the assumption that southern health care would be better for Inuit women and families, governments initiated the practice of removing pregnant women for birth as early as the 1960s [1,5,23–25]. Nunavimmiut (people of Nunavik) were transferred to Ontario (Moose Factory) or southern Québec to give birth weeks or months before their due date and stayed for a minimum of two weeks after the birth.

We know from our own lived experiences that birth away from home had many negative consequences for women, families, and our communities. Some of the founding midwives at IHC experienced evacuation and others heard the stories of evacuation from family members and refused to leave for birth. We saw how evacuation increased social and medical risk in many ways. Community consultations revealed that Nunavimmiut were angry about how evacuation undermined self-confidence and autonomy and the strong Inuit cultural value of confidence in birth. Women had poor diets when they were away from home, without access to country food. Often stressed and lonely, many worried about the well-being of family left at home. The community worried that substance use and family violence increased because of family separation. We experienced what seemed to be unnecessary birth interventions, with a lack of information and a lack of support and respect. Many found the experiences profoundly racist. Some women came home unaware of the fact that they had been sterilized. They feared their children might be apprehended.

Without traditional midwives, elders and family present for birth, evacuation contributed to the disruption of systems for passing down cultural knowledge and values from one generation to the next. Local leader, Annie Palliser Tulugak, who was Director General of IHC, told the Québec Ministry of Health:

“This intimate, integral part of our life was taken from us and replaced by a medical model that separated our families, stole the power of the birthing experience from our women, and weakened the health, strength, and spirit of our communities.” [5]

Before establishing the midwifery service, 91% of Hudson Coast women were evacuated to hospitals outside Nunavik [12].

Women’s groups organized to stop sending pregnant women to southern hospitals, to keep families together at the time of birth and to have babies born on Inuit territory. Establishing local “maternities” and training Inuit midwives was widely supported by the communities as an important step in strengthening Inuit culture and healing from colonization [1,24,25].

The Inuulitsivik Health Centre and Midwifery Services

The first birth centre or “maternity” opened in 1986 in Puvirnituq (current population 2,129) [17] before the legal recognition of midwifery in Québec or anywhere in Canada. From the start, the maternities were linked with broad community activism for self-determination. Inuit and Cree communities’ resistance to the development of the James Bay Hydro-Electric Facility and protest about the lack of consultation by the Bourassa government set the stage for negotiations towards the 1978 James Bay Northern Québec Agreement (JBNQA), seen as the first “modern” treaty in Canada. During the negotiations communities asserted the right to direct the development and delivery of health services, education and the land [26]. The JRNQA established self-governance structures in Nunavik such as the Kativik regional government, the Makivvik corporation and the Nunavik Board of Health and Social Services. The opening of the Inuulitsivik Health Centre and Ungava Tulattavik Health Hentre followed. Community activism on the Hudson coast led to the inclusion of midwifery services at IHC. Despite initial and ongoing divisions about, and critiques of, the JBNQA [26], the structures of self-government have provided important support to the Inuulitsivik midwives.

When midwifery was regulated in Québec in 1999, IHC midwives had been working for over a decade and were “grandmothered” into regulated midwifery. IHC midwives worked under a Nunavik-specific license until 2008 [25], when the Ordre des Sages Femmes du Québec (OSFQ) determined that graduates of the education process in Nunavik were eligible for registration equivalent to graduates of university programs in Québec and Canada.

As a result of ongoing activism, the midwifery service grew to include maternities in Inukjuak in 1998 (current population 1,821) and Salluit in 2004 (current population 1,580) [21]. A team of eight to fourteen midwives staff the three maternities. The largest health centre is Puvirnituq, with 25 inpatient beds and an emergency jet landing strip. There is a blood bank, laboratory, and newborn admission in Puvirnituq. None of the other villages have inpatient care. When ongoing admission is needed or if transfer to secondary or tertiary care is needed, women and babies are first transferred to Puvirnituq and to a southern centre if needed.

The maternities were established in the 3 larger communities based on annual births in the range of 30−50 births per year. This was a large enough volume to allow the employment of a team of midwives and students. The workload includes prenatal and postnatal care for all, including those with planned transfer for birth. Sexual and reproductive health, community health and health promotion are also part of midwives’ daily practice.

Women from the four smaller villages of Ivujivik, Akulavik, Umiuaq and Kuujjuarapik (current populations 400−800) [21] come to one of the birth centres by small plane at about 38 weeks. Although this means some residents leave their village for birth, they can remain in Nunavik, be cared for within their language and culture and often stay with family in Inukjuak, Puvirnituq or Salluit. Prenatal care in the smaller villages is provided by nurses who staff the local nursing stations, in collaboration with the midwifery and medical teams. When staffing allows, midwives visit the smaller villages to provide prenatal and postpartum care.

Family doctors are available for in-person consultation 24 hours a day and 7 days a week in Puvirnituq and during daytime hours in Inukjuak and Salluit. The medical team take turns being on call by phone after hours and 24/7 for the other villages. Tertiary care, including obstetric consultation and cesarean section, is available in Montreal by plane 1000–2000 km away. The average transport time is about twelve hours, weather permitting, and often longer from Salluit [1].

An Inuit community board governs the IHC, committed to community development and the education of local Inuit health workers. The decision to return birth to the Hudson coast reflected extensive community consultations. The community wanted Inuit midwives to preserve our culture by using traditional skills and to learn skills used in the southern health care system. With support from the community and the board, the health centre had a solid mandate to establish the Inuulitsivik Midwifery Service [1].

Outcomes

We serve a young, multiparous, all risk population with an average age of 19 for first babies and 25 years overall. Outcomes have been studied since we opened [1,12,14]. We maintain a database for midwifery care provided during pregnancy, birth and up to 6 weeks postpartum. Most births are in Nunavik (86%) with 14% transferred to southern hospitals, mainly in Montreal [12,14]. Our success in providing care in Nunavik has been consistent over time. A review of our outcomes from 2000 to 2015 shows that 92% of Puvirnituq residents gave birth in Puvirnituq. Seventy per cent (70%) of Inukjuak residents gave birth in Inukjuak, with 79% in Nunavik. Sixty-nine per cent of Salluit residents gave birth in Salluit, with 82% in Nunavik [14].

The outcomes for 2000−2015 reported in Table 1 include transfers to southern hospitals and show low rates of intervention with good outcomes. Despite our remote location and low resource setting, perinatal mortality is 6.6 per 1000, compared to 6.0 in Canada. [27] The perinatal mortality rate in Nunavut is reported as 7.4 in 2010 and was 23.8 in 2011 [27]. Results for a single year in small populations can be non-representative. Our outcomes are broadly comparable to recent reports of childbirth among the Inuit of East Greenland [28].

Table 1.

Outcomes for the Inuulitsivik Midwifery Service 2000−2015.

Outcome	% of births	# of births
Total births	100	2738
Spontaneous birth	97.5	2677
Caesarean section	2	53
Any pain relief	91	191
Epidural	4	113
Intact perineum	66.5	1824
PPH	14%	392
PPH > 1000 mls	6.0	165
Blood transfusion	1.4	37
Preterm birth	10	280
Perinatal mortalitya	6.6 per 1000

^a Fetal loss ≥ 28 weeks plus early neonatal death (0−6 days).

Preterm birth is higher than the Canadian average (8.2%) but lower than rates reported for the Inuit territory of Nunavut (12.8) and other Indigenous communities [23]. Of note, almost 40 percent of preterm births in our population are between 36 and 37 weeks. Although a significant proportion of stillbirth and neonatal deaths we report are early preterm, it is unlikely that these losses could be prevented by routine evacuation.

Results (learnings & reflections)

What factors have promoted success and sustainability?

Inuit Culture, Values and Worldview

In our view, a strong grounding in and respect for Inuit culture and values is key to our success. Supporting Inuit values, worldview and language is part of our mandate and is our guiding principle. Care is provided in Inuktitut by Inuit care providers who pass on Inuit knowledge about pregnancy birth and parenting. The midwifery service is part of a wider movement to maintain and apply Qaujimajatuqangit (Inuit cultural knowledge). Our culture sees birth as a healthy part of life and values women’s strength and ability to give birth. We do not see the pain of childbirth as a problem to be fixed with medications, but as a normal part of life. We have a culture of family support during labour, birth, and early parenting. Our communities retained confidence in birth despite colonial suppression of midwifery and decades of evacuation. That confidence was foundational in returning birth to the community. Strengthening Qaujimajatuqangit is a way to reverse the harms caused by the evacuation policy, residential schools and other colonialist practices and policies.

“Because childbirth was a normal part of everyday life, women grew up hearing stories about births. Through these stories, knowledge was passed from one generation to the next. It is a very precious thing to give birth. It needs to be shared within the community. It is good for everyone.” Salluit elder, Salluit Health Board and IHC Board of Directors [5]

We believe application of Inuit cultural values has created a cycle that reinforces healthy physiologic birth and cultural safety. This is key to our good outcomes and low rates of intervention. These good outcomes in turn maintain confidence in birth and in the care provided by the midwifery service (Figure 2). This cycle goes beyond our service because as Inuit midwives we are models for Inuit reclaiming important roles in the community and breaking a cycle of dependence on southern health workers and services.

Figure 2.

Cycle of confidence in healthy birth close to home.

We help preserve our language and culture every day providing care in Inuktitut. Inuit midwives translate both language and worldview. Our work includes translation of documentation in the health care record from our second and third languages of English and/or French. We translate not only language but culture. Every time we interact with southern health professionals, we ensure pregnant women, and their families, understand and are understood by health workers who do not know our language or our ways of seeing and knowing. A report commissioned by the Royal Commission on Aboriginal Peoples stated: “Part of the role of the Inuit midwives is translating ideas from western medicine into practice in their own communities. This is a very difficult task, far more difficult than translating one word for another” [24].

We share pride in preserving midwifery skills and traditional Inuit attitudes and approaches to birth and parenting [1]. Qaujimajatuqangit regarding pregnancy, birth, and caring for babies is passed down from generation to generation through elders and Inuit midwives to students, midwives and parents who pass it on to their children [26]. Students are taught by midwife mentors and elders how to be the next leaders in their community and to hold the commitment to honour culture.

An important part of the Inuit worldview is our approach to health, safety and risk, which we define within a cultural context. We had extensive community-wide discussions about the risks and benefits of birth in a remote community and open discussions about the implications of being far from tertiary care. Community members and elders wanted Inuit midwives to work well within the health care system and be skilled at managing emergencies when they happen. Local medical and nursing staff were included in the consultations and the risk of poor outcomes without ready access to obstetric and neonatal care were openly acknowledged.

The Inuit worldview is rooted in our relationship with our land and climate. It contextualizes risk differently than southern Canadian culture. We evaluate the risks of birth considering Inuit culture and the realities of living in the north. Our communities understand that there are risks in all parts of life and know that health care in the north is different than in large urban centres. This impacts all aspects of our lives. We see the risks of birth without immediate access to surgery and neonatal intensive care differently than people in southern communities who are accustomed to ready access to large hospitals and medical technologies. We accept there is a degree of risk, or different risks, to birth in both the north and the south. We see that for our communities there are great benefits to our children being born in our communities. Our priorities include cultural safety, family and community cohesion, capacity building and resilience [1].

“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, Elder, Salluit Health Board and IHC Board of Directors [1]

Inuit and indigenous leadership

Strong support from local and national leaders and Inuit organizations has been important to the continuity of our service. We have faced many challenges over the past 40 years, and all levels of Inuit leadership have consistently supported the need for the midwifery service. At times our leadership has been called to defend the midwifery service to southern institutions. We have had support from the Director General and the Inuit Board of the IHC when southern health care providers have not respected the role of Inuit midwives. The IHC Board has expressed great pride in our work. Elders on the board who themselves were born on the land into the hands of Inuit midwives told us about how meaningful it is to Inuit culture that as midwives, we continue our work so that babies can be born in our territory into the hands of Inuit.

Our mayors and other local political leaders have also spoken up in situations where we needed to explain the context for our practice and the need for education of midwives in our own communities. This support has been key when southern administrators or health providers have wanted to fit the IHC midwifery service into a southern model of care, funding or education. Makivik, the organization responsible for defending rights under the James Bay Northern Québec Agreement, plays an important role in holding other governments accountable to the historic roots of the midwifery service.

National Inuit organizations like Pauktuutit Inuit Women’s organization and Indigenous organizations such as the National Council of Indigenous Midwives (NCIM) also play an important role. IHC midwifery features as an important model for both organizations. IHC midwives contribute knowledge about Inuit culture and clinical practice in remote settings. The IHC midwives contribute by sitting as leaders and on committees for both organizations and are frequent speakers at both Pauktuutit and NCIM conferences.

Local midwifery education

Like the midwifery service, the education process for midwives at IHC, called Inuulitsiviup Nutarataatitsijingita Ilisarningata Aulagusinga (INIA) is recognized as a model for local Indigenous midwifery education [29,30]. Education of Inuit midwives was a priority from the beginning of the midwifery service with a clear goal of creating a team of Inuit midwives to provide the service. This policy of centering the education of local midwives is based on commitment to developing local capacity. Consultations with community members and elders envisioned student midwives as key team members, providing knowledge of the community and culture when working with Qallunaat. As a result, paid positions for student midwives as full and contributing members of the health system were created. This structure has been maintained for nearly 40 years with support from IHC and local government.

The community established a process to select the first Inuit midwifery students in each village, with careful consideration of the ability to be not only a skilled care provider but also a role model and leader. Qallunaaq midwives were hired to support the development of the Inuit students. Elders provided teaching about traditional knowledge. The first group of Inuit students worked as a team with the Qallunaaq midwives not only to learn midwifery skills but to provide culturally safe care and guide the development of the midwifery service and education process. We learned from each other how best to provide care in our remote context. The student’s leadership role was to ensure consistency with Inuit knowledge and values. One of the first student midwives and leaders, Mina Tulugak, said:

“We tried to find teachers who understood that their role is to teach and not to lead.” [29]

Since the start of the education program, Inuit students have been clinicians, leaders, and teachers [4]. Now those of us who are Inuit graduates of the INIA have become the main teachers and mentors of new students. This collaboration between students and teachers to learn together as they work together is consistent with Inuit pedagogy.

Local education is vital to our sustainability. We believe local education is the foundation of our success in providing clinically and culturally safe services, with Inuit students and graduates providing care within language and culture. Implementing local education, from the start, based in the midwifery service rather than an outside institution is a distinguishing factor of Inuulitsivik midwifery. Having both midwifery services and education as core principles of the service, established from the outset, is in our view a key factor in explaining why our service has had long term success when other remote midwifery services have struggled to be sustainable.

The positioning of student midwives as central, paid members of the health care team helps to recruit and retain students who are usually parents and need to support their families. Students provide not only language and cultural interpretation but also institutional and relational continuity since southern health workers often stay for limited periods in the north. Like local midwives, students provide stability, sustainability, and continuity of perinatal services where the turnover of southern health workers is high. The local midwives and students are supported as needed by southern midwives who provide care and contribute to teaching when the local midwifery team needs time off. Over 75% of births are attended by Inuit midwives and students [12–14].

The education program is competency based and flexible. Many students are part-time which supports the needs of students and their families. Not all who start the process become midwives but go on to work in public health and social services education or health administration. This is seen as contributing to community capacity. Nunavik communities agree that sending Inuit students to southern Canada for education would make midwifery education inaccessible and threaten the sustainability of midwifery care in the north [29].

“I would not have been able to become a midwife if I had to go south to learn”. Kimberly Moorhouse, midwife, Inukjuak, IHC Education Coordinator

The program is based on Inuit ways of knowing, learning, and teaching [28]. Inuit pedagogy focuses on ‘being shown rather than told.’ Storytelling is a respected Inuit way of sharing knowledge. Teachers and students integrate the acquisition of knowledge and skills as they listen and tell stories based on clinical situations. Weekly report of all women and babies that have been seen and the review of all cases at 34 weeks are used as opportunities to gain theoretical knowledge regarding clinical assessment, diagnosis, and management [29]. Inuit midwifery teachers support and pass on traditional practices around pregnancy, birth, and parenting as well as the advanced clinical skills needed in a remote setting to handle emergencies. Elder’s gatherings and land-based learning events pass on knowledge not only of Qaujimajatuqangit but also of the importance and history of the maternities.

Midwifery-led interprofessional care model

Inuulitsivik midwives lead local perinatal care. We follow all pregnant women, including being on call for assessments and emergencies, regardless of medical condition or social situation, with a collaborative approach in complex cases. We are often the most experienced perinatal care providers available on site, backed up by our team of nurses and doctors who are experienced in providing emergency care. As part of interprofessional collaboration for our all-risk population, each woman in care sees one of our physicians in early pregnancy, with ongoing care from the midwives.

An example of how our interprofessional approach works is the Perinatal Committee, where midwives, students, nurses and doctors review all cases at 32−34 weeks. This committee was established from the outset of the midwifery service, long before interprofessional collaboration was seen as an ideal approach to health care. Led by the midwife assigned to the woman’s care, this formal review considers medical and social factors and creates a care plan, including place of birth, for each person as they approach term. Risk screening and careful care planning is a core principle of safe care in our remote setting, bringing all of the care team into the decision-making process. The thorough assessment we do at the Perinatal Committee considers not only conventional obstetric risk factors but also the strengths of the person giving birth, the family and community support in place, and the risks of leaving the community. Through this interdisciplinary perinatal committee, the team becomes familiar with the care required for each pregnant woman. The report of the review is filed in the health record in the village where the woman lives and also in Puvirnituq which is the first level of referral. The report is used to guide weekly report of those at term to the nursing and medical staff and guides the on-call care provider when labour begins or when transfer is needed.

We have recently collaborated with researchers from McGill University and staff from the Royal Victoria Hospital to understand experiences of transfer and to orient hospital staff to Inuit culture and northern realities. We have presented at Grand Rounds and created a program to make Nunavimmiut who travel south for birth feel welcome and supported, including offering country food and Inuit art during hospital stays [31].

Evaluation and ongoing monitoring of our outcomes encourages ongoing learning and improvement [12–14]. The interdisciplinary team, including students, works together to develop protocols and learn together in workshops such as neonatal resuscitation and emergency simulations [15].

Midwifery roles adapted to the remote setting

Due to the remoteness of our communities, Inuulitsivik midwives take on a different role than many southern midwives. We provide care in situations that would be referred to specialists or to an emergency department in the south. We manage emergencies prior to transport and when distance and weather conditions make transport to southern hospitals and consultants difficult or impossible [12]. Developing skills in perinatal and newborn emergencies has made us respected and valued members of the health care team. Physicians and nurses in remote communities are often overworked and may not have experience in pregnancy, birth and newborn care. In our growing and predominantly young communities, a significant proportion of the population is pregnant or caring for a newborn. Having midwives on call as part of the system not only makes our service less reliant on southern care but also makes all aspects of the local health service safer, more resilient and sustainable.

Our practice is also devoted to well-woman, well-baby, and sexual health care. Since the outset of the midwifery service, we have played a role in care often provided by family physicians and public health nurses in the rest of Canada. Providing sexual and reproductive health care is increasingly a part of midwifery practice in southern Canada. IHC midwives are leaders in providing this integrated care. Prevention and community health education are central to the work of the Inuulitsivik midwives. We provide care to adolescents and elders, in areas such as contraception, STBBI prevention and cancer screening. Using midwives in this flexible way helps to cover the workload of the health care team and to provide culturally safe care in Inuktitut.

We believe that taking on roles that respond to the needs of our community and the limited resources of the health system is essential to our success. The expanded role of midwives helps to create a job description and workload suitable for a larger call team in a low volume setting. This is an important adaptation to care in remote communities that supports employment of a team of midwives to share on call and ensure two midwives are available for each birth. IHC midwives often work part-time and play important roles in the community beyond midwifery care. Both the larger call team and part-time work contribute to preventing burn-out and to our long-term sustainability.

Nurturing strategic allies

We recognized from the outset the importance of creating partnerships both within and outside our communities to ensure the viability of the service. Traditional Inuit values encourage an approach of optimism, perseverance, togetherness, and creativity in the face of challenges. Partnerships with southern midwives, physicians and nurses who share this spirit have supported the return of birth to our communities. Partnerships and allies were key to establishing and maintaining both the midwifery service and the education program. Countless southern midwives from across Canada and the world have contributed to our success by coming to do locums and contribute to education or research. These partnerships have been an innovative part of the program plan and have not only helped sustain us directly but have helped to grow understanding about how remote midwifery services and local education of Indigenous midwives can work. These partnerships and recruitment of southern midwives have been nurtured through active participation of Inuit midwives in national and international conferences. Midwives from across the world have been inspired by our success. IHC midwives have been keynote speakers, invited presenters and have played other important roles in many international gatherings of midwives including the International Confederation of Midwives (ICM).

INIA is not formally part of a university but is linked with and supported by faculty from several of Canada’s university programs. We are recognized by L'Ordre des Sages-Femmes du Québec (OSFQ) and the Regroupement ls sages-femmes du Québec (RSFQ) [29]. These partnerships have helped to demonstrate that the curriculum is consistent with Canadian university-based education programs and with core competencies for midwifery in Québec and Canada, and as well as global midwifery standards from the ICM.

Ongoing challenges

Even with a successful program, challenges and opportunities for improvement remain. Ongoing turnover of southern health workers and continued exposure to workers with little understanding of Inuit history, values, and the social, political, or environmental context can be discouraging and leads to the re-infiltration of colonialist attitudes. There is a risk of burnout when local midwives take on the burden of ongoing orientation of new midwives, doctors, and nurses. Many non-Inuit administrative staff at the IHC are southern-oriented and this can sometimes lead to feeling that our language and northern perspective is not understood or valued.

We are well supported by many parts of our institution, but like most health services we need more space and funding to provide quality care, particularly with our growing population. We have funded our education program through the clinical budget since the maternities started and we would like to work towards formal education funding.

Since the pandemic, we have fewer Inuit midwives working. Qallunaaq midwives are harder to recruit, given shortages in the south. We would like funding for better orientation and cultural safety training for all health workers coming to IHC. Although working part-time has been a strategy we have used to increase our on-call team and give us more flexibility for family responsibilities, part-time status means that as local midwives, we do not receive the same benefits as co-workers.

“The whole world is looking up to the Inuulitsivik model, but we do not have the resources and space needed.” Eileen Moorhouse, Midwife Inukjuak, IHC Coordinator of Perinatal Services

The importance of Inuit midwives working in our communities is evident, and this needs to be supported with fair pay, benefits, and incentives for our continued work in the community. Our population is growing, and the number of midwives and the space in all three birth centres needs to be increased in response. The dream is to have midwives in each village. However, keeping even the three current birth centres continually well-staffed is challenging and has been even more difficult since the pandemic. Work is in progress to open a fourth birth centre in the next largest community, Kuujjuarapik, which could serve both the Cree and Inuit populations who live there. Collaboration from the two different health boards in the region makes this more complex but is an exciting development.

Another ongoing challenge is that care for women and babies needing to be transferred south is very often fragmented. There is a clear need for an increased understanding of Inuit culture by southern healthcare providers. We recommend that all southern health care providers participate in cultural safety courses and be trained in trauma aware care. There is a need for increased resources for Inuit people to have loved ones accompanying them if they need to transfer for tertiary care [31].

Discussion

To further understanding of our findings and support application to other settings by policy makers we used a public policy analysis framework adapted from the National Collaborating Centre for Healthy Public Policy (Table 2) [32]. The framework was adapted by Kellie Thiessen, alongside Indigenous co-lead (Elder Katherine Whitecloud) for use in the CIHR project “Welcoming the ‘Sacred Spirit’ (child): Connecting Indigenous and Western ‘ways of knowing’ to optimize maternal child health service delivery in remote Canadian regions.

Table 2.

National Collaborating Centre for Healthy Public Policy Framework.

Effectiveness	What effects does the policy have on the targeted health problem?
Unintended Effects	What are the unintended effects of this policy?
Equity	What are the effects of this policy on different groups?
Cost	Is this policy technically feasible?
Acceptability	Do the relevant stakeholders view the policy as acceptable?

This type of framework does not measure ‘wellness’ or align with the realities in many Indigenous communities across Canada. The rationale for adapting the framework is grounded in different understandings of health and wellness. Unfortunately, healthcare prevention strategies are often entangled in Western ways of knowing [33] which underlie ideological constructs of what makes a community ‘well’ and drive healthcare policy initiatives [34]. It is “believed alternate strategies that begin with the re-integration of Indigenous knowledge, values, teachings, and stories are the essence of a healthy life in Indigenous communities.” [35] Healthy public policy is defined by Milio as:

“Healthy public policy improves the conditions under which people live: secure, safe, adequate and sustainable livelihoods, lifestyles, and environments, including, housing, education, nutrition, information exchange, childcare, transportation, and necessary community and personal social and health services.”[36]

Despite this definition, Western ways of public health policy analysis are often structured and focused according to decision-maker priorities but do not reflect Indigenous knowledge, values and practices. Furthermore, these types of policy analysis do little to yield systemic changes that support the return of birth and other maternal/child services to communities.

For these reasons we adapted the framework. Our reflections on the success of Inuulitsivik midwifery provided us an opportunity to test the adapted policy framework and contribute to its evolution. We used the adapted framework to organize and analyze our results and to further understand if this framework could be applied with an Indigenous lens. This process was consistent with the project goal of understanding Indigenous and Westerns ‘ways of learning’ and “two-eyed seeing” and is in keeping with the intent of the IHC midwifery service to integrate Inuit and Qallunaaq approaches.

Table 3 organizes our learnings and reflections (results) under the dimensions of the adapted policy analysis for Indigenous maternity care service delivery models that in turn gives understanding to our original question related to Inuit led maternity services: What makes Inuulitsivik midwifery successful and sustainable?”

Table 3.

Our reflections using the National Collaborating Centre Framework.

ADAPTATION: Program/Policy analysis for maternity care service delivery models

Inuit community reflections

Effectiveness Effects of policy (macro, meso, micro) related to patient experience, health, and health equity: maternity services close to community, well-being of community, etc. (physical, social, emotional, spiritual) Timing of implementation of programs and policies (macro, meso, micro) and observed effects. Intended effects What is the patient’s perspective of the system experience and health (physical, social, emotional, spiritual)? How have programs and policies (macro, meso, micro) affected choice, patient experience and overall community health (physical, social, emotional, spiritual)? Equity How is health equity defined by the community? What is community perspective on existing programs and policies and their effects on access to services?Cost How does the community define the cost of existing programs and policies that effect maternity service delivery? What is the community’s perception of ‘cost’ (physical, social emotional and spiritual cost) in relation to lack of services or need for services? In terms of cost per effectiveness, where do jurisdictions differ and what specific programs or policies (macro, meso, micro) can be compared across jurisdictions by cost-effectiveness to improve efficiency of maternity care? Feasibility What data sources have informed policies and programs (macro, meso, micro) and how are they linked? How is the population represented in the data, what are the reporting mechanisms and are current programs and policies deemed feasible and by whom? What is the community’s perspective of indicators of ‘wellness’ What is the community’s perspective of what and how data should inform policies related to maternity services and how reporting of data could support programs and policies to be feasible. Does the data reflect physical, social emotional and spiritual aspects of health? How long is it feasible? Can you continue with the current system under the current programs and policies (macro, meso, micro)? Acceptability What exemplar models of maternity care service delivery models exist (macro, meso, micro)? Are these models acceptable and desired in relation what is not deemed acceptable by the community? What are the differences between jurisdictions regarding what is deemed acceptable or not acceptable and their effect on health (physical, social, emotional, spiritual)?

Effectiveness Strong grounding in and respect for Inuit culture and values Midwifery services as Qaujimajatuqangit (Inuit cultural knowledge) Consistent with Inuit worldview Health, safety, and risk defined by community within a cultural context Safe local perinatal care Educating and maintaining a core staff of Inuit midwives An exemplar model nationally and internationally Integrates Inuit and Qallunaat knowledge and skills Intended effects Inuit values, worldview and language are strengthened Reduces dependent colonialism Support for birth as healthy part of life Highlights Inuit resilience and women’s strengths Supports interprofessional team Increased cultural safety and family and community cohesion Increased access with expansion to three Hudson communities and to the Ungava coast and in Eeyou Itschee James Bay Cree territory Equity Local education supports access to quality care in Inuktitut Health equity is defined as access to Inuit care providers 86% of the Hudson coast population gives birth in Nunavik Student midwives are paid members of the health care team Local care keeps families together and reduces risks of evacuation Routine travel away from home for birth is associated with harms to individuals, families and the community as a whole Cost The costs of evacuation for birth are in many ways immeasurable and linked with the harms of residential schools and loss of language and culture The cost to families of leaving home for birth is dramatically reduced by providing local care The cost effectiveness of birth close to home is also to some extent immeasurable using traditional metrics The value of the midwifery service in Nunavik is evidenced by the long-term commitment of the local community Feasibility Community consultation was foundational in returning birth to the community Ongoing evaluation of outcomes informs the evolution of policy Strengthening Qaujimajatuqangit is a way to reverse the harms caused by the evacuation policy, residential schools and other colonialist practices and policies Supporting families to ensure they understand and are understood by health workers who do not understand our language and culture. Even with a successful program, ongoing challenges and improvement opportunities remain with ongoing turnover of southern health workers and administrative staff and continued exposure to workers with little understanding of Inuit culture and northern realities Resources have not kept pace with population growth and more space and funding is needed to provide quality care and midwifery education Care is very often fragmented from north to south when a mother or baby must be transferred Acceptability National Inuit organizations like Pauktuutit Inuit Women’s organization and Indigenous organizations such as the National Council of Indigenous Midwives (NCIM) consider IHC midwifery an important model for health care and education Community consultation has supported expansion of the service​​​​​​ Inuit leadership and political leaders have consistently supported the need for the midwifery service and link to Inuit rights under the James Bay Northern Québec Agreement Elders on the board who themselves were born on the land have expressed how meaningful it is to Inuit culture for babies to be born into the hands of Inuit, on Inuit land Communities and the health centre staff hope to have midwives in each village

In summary, the effectiveness and feasibility of returning birth to remote Indigenous communities is demonstrated by the long-term sustainability and strong community and health system support for our midwifery service. Over four decades we have had consistent success in providing safe perinatal care and educating and maintaining a core staff of Inuit midwives. We are considered an exemplary model nationally and internationally [1–7]. The expansion of our service from one to three communities increased access to prenatal and postnatal care by Inuit midwives and the number of women who have the choice to give birth in their home communities. The establishment of midwifery services on the Ungava coast in Nunavik and in Eeyou Itschee James Bay Cree territory has been inspired by our model of care and we collaborate with both services. Plans to open a birth centre and educate midwives in a fourth village will increase this opportunity further.

Growing out of a demand for health equity, the communities of Nunavik have come to expect access to local services provided by Inuit care providers in Inuktitut. The midwifery service has increased access to local care with 86% of the Hudson coast population giving birth in Nunavik. This keeps families together at the important moment of birth and has reduced the risks of evacuation. Routine travel away from Nunavik for birth is associated with harms to individuals, families and the community as a whole. The Inuit board of the IHC, consultations with the community and ongoing work with elders consistently notes “pride in our midwives” and in the importance of birth on Inuit land for cultural safety and continuity. The midwifery service is seen as part of Qaujimajatuqangit, the preservation of Inuit knowledge. Both birth close to home and the education of Inuit midwives in Inuit communities are valued because they promote physical, social, emotional and spiritual well-being at all levels and serves as a model for other health and social services.

The cost of the IHC midwifery service is integrated into the overall budget of the health centre, like any other local health service. A recent systematic review of the costs of evacuation for birth in Canada estimated the range from CAD $7714 to CAD $31,794 [37]. The cost to both health systems and families of leaving home for birth is dramatically reduced by providing local care. The costs of evacuation for birth are in many ways immeasurable and, in Nunavik, are linked by the community with the harms of residential schools, and loss of language and culture. While the cost effectiveness of birth close to home is also to some extent immeasurable using traditional metrics, the value of the midwifery service in Nunavik is evidenced by the long-term commitment of the local community.

Perhaps more meaningful for our team was to look at how our service intersects with the Calls to Action of the Truth and Reconciliation Commission of Canada (TRC) [16]. We are proud of the way in which our local midwifery service is a model for governments and policy makers seeking to meet TRC recommendations. As our themes demonstrate our service aims to address historic and current causes of health inequity; improve outcomes by providing accessible, local care and education in Inuktitut; by including Elders and Indigenous health practices and by expanding the pool of Inuit health care providers. We demonstrate ways governments and communities can meet Calls to Action 2 (Education), 14 and 16 (Language) and 18 -24 (Health) by bringing birth and midwifery back to Indigenous communities.

Importantly the midwifery service also addresses policy imperatives embedded in Joyce’s Principle [17] and the National Inquiry on Missing and Murdered Indigenous Women and Girls (NIMMIWG). The NIMMIWG points out that institutional violence can result from the failure to understand embedded practices of racism, misogyny and colonialism that harm women and girls in many of our institutions [21] a finding reinforced by the findings of the Public Inquiry Commission on relations between Indigenous Peoples and certain public services in Québec [19]. This was brought into focus in Quebec and across Canada after the death of Joyce Echaquan an Atikamekw woman in a Quebec hospital was linked with poor quality care and racism [20]. Put forward by Chiefs of the Atikamekw Nation Joyce's Principle “aims to guarantee to Indigenous people the right of equitable access, without any discrimination, to all social and health services” and to respect “Indigenous people’s traditional and living knowledge in all aspects of health” [17]. Our model of midwifery rooted in community and culture is designed to provide an alternative to colonial structures that perpetuate institutional violence and create access to care that respects Indigenous people.

Conclusion

Our communities developed and sustained one of the first midwifery services integrated into the modern health system in Canada. We are proud to be approaching the 40th anniversary of midwifery services in Puvirnituq, with over 25 years in Inukjuak and over 20 years in Salluit. We are approaching 5000 births attended by the IHC midwives. For decades, most pregnant women from our communities have been attended by Inuit midwives educated in Nunavik with excellent skills for remote midwifery-led care. Our reflection on what has made our service successful and sustainable has identified that respect for Inuit values, language and leadership; local education; midwifery-led interdisciplinary care; an adapted role for midwives; and strategic allyship have supported and sustained the Inuulitsivik midwifery service. We believe the flexible nature of the program is key to our resilience and sustainability. Our model of care and education adapted to changing circumstances and ongoing challenges, while consistently adhering to essential values. A willingness, embodied in Inuit tradition, to go ahead even when conditions may not be perfect or are uncertain, and to learn from mistakes rather than blaming or dwelling on them, has guided us.

A strong grounding in and respect for our culture and values is key to the delivery of culturally safe maternity care on our territory. Despite ongoing calls to address the harms of historic and ongoing colonization and evidence for local services, routine evacuation for birth persists in many remote communities across Canada [29,38–40]. Inuulitsivik midwifery is a clear example of resistance to colonialist approaches and success in reclaiming Indigenous capacities and governance structures to provide safe and sustainable local perinatal care.

We hope that sharing this story in Canada and globally will bring hope to other remote communities who want to bring birth home.

“This story has no ending. We are on going!” Akinisie Qumaluk, midwife, elder, Puvirnituq

Funding Statement

This work was supported by the Canadian Institute for Health Research (CIHR) as part of the Welcoming the ‘Sacred Spirit’ (child): Connecting Indigenous and Western ‘ways of knowing’ to optimize maternal child health service delivery in remote Canadian regions project. Grant number 162401. Canadian Institutes of Health Research.

Acknowledgements

The leadership of Mina Tulugak and Colleen Crosbie (retired midwives) has been essential to both the articulation and implementation of the ideas expressed in this article. We also want to acknowledge the foundational role of Annie Palliser Tulugak in establishing the service and its core principles. Lissie Sakiaguk Tayara participated in the initial development of the themes. Tama Cross worked as a research assistant and created a first draft based on previous work.

Disclosure statement

No potential conflict of interest was reported by the author(s).