Reclaiming Indigenous birth: research framework to assess the economic costs and outcomes of obstetric evacuation and experiences of Indigenous midwifery in Canada

Abstract

Background

Indigenous communities in Canada (First Nations, Inuit, and Métis peoples) have distinct traditional knowledge and practices for pregnancy and birth, and these have sustained healthy and thriving Indigenous communities for millennia. Indigenous midwives historically held a leading role as primary providers of sexual and reproductive healthcare. However, colonial practices severely disrupted the role of Indigenous midwives and the transfer of their knowledge from generation to generation. The obstetric evacuation policy in Canada requires people who live in rural and remote locations to leave their community to have a hospital delivery. Evidence suggests this policy negatively impacts Indigenous people who desire to give birth in their communities. To implement optimal perinatal care for Indigenous people, Indigenous midwives in Canada seek evidence to answer the following questions: (1) What is the cost of obstetric evacuation, compared to Indigenous midwifery? And (2) What are the health outcomes for obstetric evacuation versus Indigenous midwifery?

Methods

We present our framework for Reclaiming Indigenous Birth, a study using multiple methods. Our framework brought together researchers, midwives (National Council of Indigenous Midwives, Association of Ontario Midwives, and Juniper Midwives), community organizations (Native Women’s Association of Canada and Pauktuutit Inuit Women of Canada) and knowledge users (Indigenous Services Canada). We used Gwayakgooshgawin (balance) to bring four disciplines together in a theoretical framework: Indigenous methodologies, gender-based analysis, critical medical anthropology, and population and public health. We then created a relational framework with guidance of the Seven Grandparent Teachings, which taught us to nurture relations with research team members, partner organizations, and individuals whose data was included in this study. We upheld standards for Indigenous research ethics. The specific objectives of this study were to: (1) examine economic costs and outcomes of obstetric evacuation and Indigenous midwifery; (2) understand experiences of Indigenous midwifery; and (3) conduct knowledge translation activities to inform policy and programming for perinatal health in Indigenous communities.

Discussion

This research framework will contribute evidence to support calls to action to reclaim Indigenous ways of birth and address disparities between Indigenous and non-Indigenous people in birth outcomes.

Background

“Our most sacred ceremony is no longer being ran by midwives in our own communities. It’s time to reclaim, restore, resurge. But in order to resurge and restore what was, we must first begin to reclaim what was taken” –Carol Couchie, 2018.

Community-specific traditional practices around pregnancy and birth have promoted healthy and thriving Indigenous communities in what is now known as Canada for millennia. Indigenous peoples in Canada are known as First Nations, Inuit and Métis and comprise at least 5% of the population [1]. Community-specific traditional knowledge and practices reflect the diversity of social, cultural, economic, political, and spiritual practices that distinguish Indigenous Peoples from dominant settler society [2] There are more than 70 Indigenous languages spoken across more than 630 First Nations communities, Inuit and Métis peoples [3]. Birth is a sacred ceremony in Indigenous communities and Indigenous midwives historically held a leading role in supporting this ceremony as primary providers of care throughout the perinatal period [4]. However, colonization has severely disrupted the role of Indigenous midwives and transfer of their knowledge from generation to generation.

Colonial policies and practices toward Indigenous people are rooted in racism and White supremacy, with the intention to kill or assimilate Indigenous peoples into settler society and to control their lives [5]. Despite recent progress toward revealing the truth of historical and ongoing colonialism and reconciling this legacy [6], many of these policies and practices remain in place and continue to harm Indigenous peoples [7–9]. For example, reports indicate that physicians were hired by the federal government to provide labour and delivery services on reserve as early as the 1890s [4]. Indigenous midwives were prohibited from practicing or their role was delegitimized [4]. In the 1970s, provincial governments increasingly sought to mitigate maternal and infant mortality through hospital births for all populations, and promoted tertiary centres for births, whether low or high risk [10]. Perinatal services were centralized in larger urban centres and services in rural and remote communities were closed, requiring those living in these communities to travel greater distances to access perinatal care. This movement of birth away from communities was intensified by the “obstetric evacuation policy.” Though not a law in Canada, the policy is reinforced by the First Nations Inuit Health Branch Clinical Practice Guidelines for Nurses in Primary Care that require those who live in rural and remote locations to leave their community at 36−38 weeks gestational age to have a hospital delivery, or earlier if the pregnancy is high risk [11]. Funding for travel comes from Indigenous Services Canada, formerly administered through the First Nations and Inuit Health Branch (FNIHB), a federal agency that aims to “provide effective, sustainable, and culturally appropriate health programs and services that contribute to the reduction of gaps in health status between First Nations and Inuit and other Canadians” [12]. Indigenous Services Canada now administers the policy through the Non-Insured Health Benefits (NIHB) but contracts services to third-party providers who operate within a provincial health system. This policy, referred to as an “invisible policy,” falls between federal and provincial jurisdiction and remains minimally examined, despite its considerable and disproportionate impact on generations of Indigenous peoples [13].

For instance, many Indigenous people desire to give birth closer to their home community with their familial, traditional and cultural supports. Though the obstetric evacuation policy may increase access to obstetric services, those who are forced to evacuate for birth report feeling “plagued by insecurity, insufficient or inadequate food, unfamiliar and strange surroundings, missing family and other children, and an overall stressful experience” when required to evacuate for birth [14, 15]. Smylie and colleagues (2021) found that Indigenous people were more likely to travel 200 km or further for birth compared to non-Indigenous people [16]. A recent scoping review of factors related to evacuation to childbirth and outcomes of evaluation found just a handful of studies had evaluated maternal-child health impacts [17]. Other evacuation-related outcomes included women’s negative experience of evacuation, financial hardships, family disruption, cultural continuity and community wellness, engagement with health services, self-determination, and quality of health services [17]. We are not aware of research or reports about the number of obstetric evacuations that occur each year across Canada. The extent of the comprehensive costs, harms, and benefits of this policy on Indigenous communities is not fully explored.

The intention to assimilate and control Indigenous birthing people’s lives is evident in other examples of colonial policies and practices. For instance, the occurrence of forced and coerced sterilization of Indigenous people has led to lifelong harm, and this harm continues today [18, 19]. The “birth alert” policy in Canada, banned within the last five years in each province, contributed to the forced removal of infants and children from their families and disproportionately impacted Indigenous people [20]. The result of these policies and practices is long-lasting harm to Indigenous people and communities and reinforced distrust of the health care system [21, 22].

Indigenous midwifery care is associated with increased access to health services throughout the perinatal period and is recognized as a best practice for perinatal health care for Indigenous communities across Canada [23, 24]. The National Council of Indigenous Midwives (NCIM) is a diverse group of Indigenous midwives, midwife Elders, and student midwives from across Canada. Members include both registered midwives and midwives practicing under exemption clauses of provincial health legislation. With eleven Indigenous midwifery practices in Canada, Indigenous midwives are building a perinatal healthcare continuum for Indigenous people in their home communities and reclaiming traditional and cultural ways of supporting birth [24–26]. Recognizing the individual and community-level benefits of bringing birth closer to home to Indigenous people in rural and remote regions, the Society of Obstetricians and Gynaecologists of Canada issued a policy statement in 2010 (and renewed in 2015 with no changes) to support the return of midwifery and collaborative community care to rural and remote regions for low-risk births [27]. In 2017, Health Canada allocated $6 million over five years to support the development and sustainability of Indigenous community-based midwifery projects to address and improve the health outcomes of Indigenous peoples. Despite this recent support, a lack of evidence about the outcomes and cost of Indigenous midwifery as compared to the obstetric evacuation policy prevents meaningful investments in Indigenous midwifery models of care.

In response, we launched, “Reclaiming Indigenous Birth,” a study to contribute evidence that may advance calls to action [20, 28, 29] to reclaim Indigenous ways of birth from settler colonial models. We will begin to answer two overarching questions from Indigenous midwives who seek evidence to implement the best possible model of care for Indigenous communities: (1) What is the cost of obstetric evacuation, compared to Indigenous midwifery? And (2) What are the health outcomes for obstetric evacuation versus Indigenous midwifery? The specific objectives guiding this study are to: (1) examine economic costs and outcomes of obstetric evacuation and Indigenous midwifery; (2) understand experiences of Indigenous midwifery; and (3) conduct knowledge translation activities to inform policy and programming for perinatal health in Indigenous communities. This paper describes the research framework we created to pursue these objectives.

Methods

We used multiple methods to conduct this study, described in Study Procedures.

Theoretical framework

We began with Mi’kmaq Elder Albert Marshall’s conceptualization of Etuaptmumk, or ‘Two-Eyed Seeing,’ which is the ability to “see from one eye with the strengths of Indigenous knowledge and ways of knowing and, from the other eye, with the strengths of Western knowledge and ways of knowing” [30]. Adapting from Leason (2017) framework to examine Indigenous women’s maternity experiences [31], Etuaptmumk taught us to bring together four disciplines to examine the cost and outcomes of the obstetric evacuation policy and contrast this with experiences of Indigenous midwifery. This created our theoretical framework, Gwayakgooshgawin, (Fig. 1) a Anishinaabemowin word for ‘balance,’ whereby where we found balance through a combination of the following disciplines: (1) Indigenous methodologies, (2) Indigenous feminist scholarship, (3) critical medical anthropology, and (4) population and public health.

Fig. 1.

Gwayakgooshgawin

Indigenous theory and methods (Indigenous methodologies) [32–34] are as diverse as Indigenous communities, but there are several common approaches that we incorporated. For instance, we prioritized Indigenous ways of knowing to centre the perspectives and cultures of Indigenous peoples, communities, midwives, organizations and leaders. Below, we describe our approach to relational accountability and respecting ethical standards of each community that was involved in this research. We centered Indigenous methodologies in our framework as the majority of research about Indigenous people has used Western methodologies and been conducted by non-Indigenous people who were unaware of, or discounted, Indigenous knowledges to study the health of Indigenous people [35, 36]. As a consequence, research has often excluded or minimized Indigenous ways of knowing and perpetuated incorrect, and oftentimes racist, evidence about Indigenous peoples’ health [36].

Using gender-based analysis [37] promoted a critical examination of how the interplay of factors such as gender, age, racism, sexism, and colonialism influence Indigenous women and gender diverse folks’ lives. We considered the determinants of health that influence experiences of birth and perinatal health and wellness outcomes of Indigenous people. For instance, we recognize that colonization is an intentionally gendered process, and that attacks on Indigenous women, girls and gender diverse people, including their knowledge and their role in community, are not an accidental outcome of colonization. These are intentional attacks on Indigenous ways of knowing and being about gender, governance and relationality [38]. The removal of birth from Indigenous communities and the attempted destruction of Indigenous midwifery are an intentional aspect of colonization. We approach the reclamation of Indigenous midwifery and birth as a crucial part of Indigenous resurgence.

We framed our understanding of the cost of the obstetric evacuation policy through the lens of critical medical anthropology [39], a discipline that examines how culture shapes health, illness experiences, and well-being. This discipline gave us insight to understand that Indigenous women have endured blame, victimization and pathologizing with disregard for the social, political, and economic origins of health and wellness [31]. Using this insight, we envisioned ways to optimally support Indigenous people who give birth.

Several members of our team were trained in population and public health [40], which is a discipline that uses quantitative and qualitative methodologies to understand health patterns in populations. Similar to medical anthropology, this discipline recognizes a broad range of factors that influence health, such as policy, economic status, gender, age, race, religion and spiritual practices, mental and physical abilities, and social structures. Situating this work from a population and public health perspective allowed us to use data collection and analysis strategies, such as health economic analysis, to generate evidence that is applicable to health system decision makers.

Bringing these disciplines together offered balance to examine obstetric evacuation and Indigenous midwifery.

Creating a relational framework

Indigenous scholars have illustrated how our own teachings and ways of being guide our relational approach to all aspects of life, including the conduct of research [33, 41]. The Seven Grandparent Teachings of Dbaadendiziwin (Humility), Aakwa’ode’ewin (Bravery), Gwekwaadziwin (Honesty), Nbwaakaawin (Wisdom), Debwewin (Truth), Mnaadendimowin (Respect), Zaagidwin (Love) are rooted in Anishinaabe teachings, taught to the first author (JL), and these guided our relational framework. The Seven Grandparent Teachings instructed how to build and nurture relations with research team members, partner organizations, and individuals whose data was included in this study.

Relationality and kinship are also critical in shaping the roles and responsibilities of Indigenous midwives [42]. Indigenous midwives have a deep connection and responsibility to the communities that they serve, and this role can include knowledge creation and protection that in the present-day manifests as a role in research. The Indigenous midwives’ responsibilities to the clients, communities, and Nations they serve include understanding the economic cost and outcomes associated with obstetric evacuation and Indigenous midwifery care. Meeting the needs of the communities they serve was crucial in the Indigenous midwives’ contribution to our relational framework.

To respect self-determination of First Nations people and communities included in our research, we incorporated the widely used principles of Ownership, Control, Access and Possession (OCAP^®), a code of research ethics that specifies that First Nations must determine all aspects of research, data, and knowledge in research involving them [43]. We created a unique agreement with each community who opted in to participate in the study. Agreements included community presentations, Band Council Resolutions and Community Research Agreements and each provided the study team with permission to access data of community members. To respect Inuit standards for research, we adhered to the National Inuit Strategy on Research [44] that guided our research involving Inuit. Partners from Inuit organizations guided governance of components including Inuit and we worked together to respect Inuit requirements for ownership, control and access of data and information [44]. Though our research did not specifically include Métis, our overall approach incorporated Métis principles, such as “reciprocal relationships” and “respect” for individual and collective environments [45]. We learned from other Indigenous academic researchers about how to bring distinct First Nations, Inuit, and Métis frameworks together [46, 47].

We established three standards of quality and accountability for the conduct of this study. The first standard was to incorporate Indigenous ways of knowing and being in our methodology. To achieve this, we selected a study team where most people identified as an Indigenous person. Indigenous team members determined the priorities, direction, and methodologies used in all components of the project. We included four Indigenous Elders and Knowledge Keepers and eight Indigenous midwives to advise on processes, outcomes, and knowledge translation activities. All team members regularly examined how their worldviews influenced their perspectives and relationships to this study. Team members who were non-Indigenous people dedicated routine time and attention to “translate White and settler privilege into tangible change” [48].

The second standard was to conduct a study that was “Community-driven, and Nation-based,” which is one of the 7 Directives of the British Columbia First Nations Health Authority [49]. This meant that we conducted research that was responsive to community priorities and prioritized self-determination of communities [50]. The three Indigenous-led organizations that partnered on this project guided all aspects of the initiative. Indigenous midwifery is centred on community and based in community need, so it was important to the midwives that the research take this approach as well. We engaged with First Nations communities about outcomes that would be relevant to their community and created a knowledge translation plan to ensure that knowledge generated from this initiative was returned to communities and Nations.

Our third standard was to honour the diversity of birthing persons’ experiences and contexts. This meant that we partnered with Indigenous organizations whose mandate was to consider a diversity of Indigenous birthing person’s experiences and contexts.

To strengthen our adherence to these standards, we held a weeklong gathering in Kananaskis, Alberta with project team members and partners to share preliminary results and discuss progress on each component of Reclaiming Indigenous Birth. This gathering enabled us to get to know one another as public health restrictions due to the COVID-19 pandemic had previously prevented us from meeting in person.

Several components of the study involved use of individual or community-level data and we received research ethics board approval from University of Calgary (REB #: 21-1205; REB #: 22-1239) and the Hamilton Integrated Research Ethics Board (REB #: 17880).

Study team and partnerships

We selected a diverse, multisectoral and interdisciplinary study team (Fig. 2). Indigenous women, midwives, community partners, and Indigenous organizations (NCIM, Native Women’s Association of Canada, and Pauktuutit) brought leadership experience in community-based research to ensure the project was community-led, community-driven and was responsive and representative of Indigenous women and birthing people. Academics, including clinician-scientists, were the link between community contexts and research, and led the creation of our research framework, data collection and analysis, and preparation of knowledge translation activities to respond to research questions from our community organization partners. We partnered with federal government agencies (i.e., Indigenous Services Canada) to understand data availability and access and to generate research questions that were feasible within the data that was available and the scope of this study.

Fig. 2.

Study Team

Study procedures

To pursue Objective 1, which was to examine economic costs and outcomes of obstetric evacuation and Indigenous midwifery, we began with a systematic review. Members of our study team, Radhaa and colleagues (2024), synthesized costs related to medical transportation or evacuation in rural and remote Indigenous communities, as well as indirect costs, such as lost income and lack of family or cultural support during birth [51]. The review identified nineteen studies and found that costs for obstetric evacuation are high, ranging from CAD $7714 to CAD $31,794 [51]. This systematic review enhanced our understanding of available literature and identified important gaps that informed our subsequent analyses.

We conducted geographic information systems (GIS) mapping to determine community location, where perinatal services were located for Indigenous people, the distance required to travel to access these services, and the level of care of each health service (First Nations community level of care; Level I, II, III; or Midwifery practice). This mapping supported a visualization of location and proximity to perinatal healthcare. Our analysis focused on Ontario, where we conducted a model-based study using GIS mapping and a decision-tree of the cost of obstetric evacuation for First Nation communities in the province with no year-round road access (fly-in communities). The model provided an initial estimate of the economic costs of obstetric evacuations in Ontario. Subsequent analyses to assess the cost and outcomes of obstetric evacuation and comparison of obstetric evacuation and Indigenous midwifery care models will be conducted with ICES, discussed below.

To determine the health outcomes of Indigenous birthing persons, we are creating a retrospective population-based cohort study. We will link data from the Better Outcome Registry and Network (BORN) of Ontario (a pregnancy, birth, and childhood registry in Ontario that includes nearly all births in Ontario), the Discharge Abstract Database that describes hospital discharge (such as clinical, demographic, and administrative factors), and MOMBABY (a dataset derived from the Discharge Abstract Database of birth admission records). Data will be linked through the ICES Data Repository, a repository of health records for over 13 million people in Ontario that is coded and linkable to most publicly funded administrative health service records in the province from 1986 to present [52]. It is possible to link First Nations identity to data held in the ICES Data Repository. In Ontario, an agreement between First Nations Chiefs of Ontario and ICES enables ascertainment of First Nations identity from the Indian Register. To request approval for access to these First Nations identifiers, we engaged and received approval from 49 First Nations communities in Ontario as of January 30, 2025. A Data Creation Plan (DCP), approved by ICES, is required to access the data. Our partnerships with First Nations communities ensured that our DCP reflected principles of ethical engagement and research priorities specific to each community. Once data is linked, we will conduct a descriptive analysis of patterns of health services utilization of status First Nations persons related to maternal care including use of prenatal, intrapartum, postnatal and neonatal services.

To pursue Objective 2, which was to understand experiences of Indigenous midwifery, we conducted a community forum and created digital stories. The forum, led by community partner Pauktuutit, included Inuit midwives, birthers, infants, families, and communities and was conducted to understand the following:

1. Challenges in perinatal care;

2. The role of Inuit midwives and the importance of access to culturally-informed midwifery services to the health and wellness of Inuit and other communities; and.

3. The urgent need for a rights-based framework to facilitate the return and re-integration of Inuit midwifery services across Inuit Nunangat.

A digital storytelling workshop led by Re•Vision, was held to gather stories on the role of Indigenous midwifery for both clients and midwives. Storytelling is an important Indigenous methodological approach to use in research that attends to the multiple layers of “spirit, heart, mind and body” [53]. Digital storytelling is a methodology that allows participants to tell meaningful stories through research, where audio from personal stories is paired with images such as photographs, video clips, music, dance, or artwork [54]. The digital stories have been presented at various forums to promote improved understanding of the role of Indigenous midwifery and the importance of Indigenous knowledge and practices surrounding birth. They will be available on our website [55] for further government and community advocacy to support the growth of Indigenous midwifery and the return of birth to Indigenous communities. The narratives and themes were used to inform policy and program recommendations as a part of Objective 3.

To pursue Objective 3, which was to generate evidence that will inform policy and programming, we conducted several knowledge translation activities. Though there are many definitions of knowledge translation, it is generally considered a set of activities to move research into action. For many Indigenous people, “knowing” (research) and “doing” (action) are intertwined [56]. Knowledge translation is therefore an essential activity, and not supplemental to the research process in Indigenous research contexts. Indigenous scholars have described how Indigenous people who are involved in research must have access to results and, wherever possible, benefit from the research [56, 57]. To link research evidence to action, we created a website [55] to communicate progress, share preliminary findings, and engage collaborators from Indigenous communities who are involved in this study. To ensure that we return results to participants and communities involved in this work, we will generate reports for each First Nations community in Ontario who partnered with us, as well as each community-based organization who participated in this study. Preparation of these reports will include engagement with the relevant community or organizational lead, respectively, to ensure the report contains information that is useful and relevant. To reach policymakers and health system leaders, we are preparing policy briefs [58] and engaging in deliberative dialogue [59], that is, to discuss research findings with key knowledge users. Deliberative dialogue has potential to increase the likelihood of uptake of research evidence. Our policy briefs will target health system organizations who are involved in obstetric evacuations. First author, JL, prepared an art show featuring her own artwork that was installed on a university campus (University of Calgary) to reach a general audience in the university community (students, faculty, and administrators) interested in learning about Indigenous maternal child health and Indigenous midwifery. We will disseminate our findings to academic audiences through conference presentations and peer-reviewed manuscripts.

Discussion

We have a history of people putting Māori [Indigenous people] under the microscope in the same way a scientist looks at an insect. The ones doing the looking are giving themselves the power to define. Merata Mita [in Tuhiwai Smith, 2012 [34]].

We drew from multiple disciplines and methods to create a research framework to examine obstetric evacuation and Indigenous midwifery. Through this framework, we sought to remove Indigenous peoples and birthing persons from under the microscope and examine systems that perpetuate the removal of birthing persons and barriers to Indigenous midwifery in the health system.

There are several strengths of our research framework. Our theoretical framework, Gwayakgooshgawin, provides an example of how to combine Indigenous methodologies with Western research disciplines to examine two models of maternity care. We are bringing together novel relationships between community-based organizations, national advocacy programs, government agencies, clinicians, and academic researchers to address health disparities and associated inequities through evidence and information. The inclusion of Indigenous community-based research assistants, organization supervisors and Indigenous undergraduate and graduate students creates a foundation for community-based and community-driven research that builds Indigenous community research capacity. Our collaboration with federal government agencies (i.e., Indigenous Services Canada) enables greater understanding of the gaps in the data required to assess the cost and outcomes of the obstetric evacuation policy. Our partnership with Indigenous community members, organizations and midwives revealed a lack of research about best practices for models of maternity care, particularly in Indigenous communities. This research will contribute to evidence about First Nations, Inuit and Métis women’s experiences of Indigenous midwifery from diverse perspectives.

This study protocol has some limitations. When we established research objectives for this study, the substantial gaps in data and barriers to access were not known to the study team. For instance, we learned that there is no record of the number of obstetric evacuation trips that occur each year, who has participated in an obstetric evacuation, or the reason for the evacuation (e.g., prenatal appointment). It is therefore not possible to determine the cost and outcomes of this policy. We will overcome this limitation through health economic modelling to estimate the cost and outcomes of obstetric evacuation. In addition, there is no identifier in administrative data to determine whether an Indigenous midwife was involved in prenatal care. This data is needed to provide information on outcomes related to Indigenous people’s perinatal health. We also learned that there is a lack of disaggregated data by Métis identity, and this meant that our research was restricted to First Nations and Inuit people. This contributes to further erasure of Métis experience and is a limitation of our study.

Future research directions

Our preparation of this research framework revealed gaps in data and administrative barriers that prevented us from fully examining our two research questions. Numerous reports have called for action to strengthen the health and wellness of Indigenous women and girls in Canada [6, 20, 28, 29, 60, 61], including the return of Indigenous midwifery to all communities. Indigenous people are the youngest and fastest growing demographic population in Canada, with higher fertility rates and a recent increase in self-identification [62]. This study will contribute an important foundation for future research on the benefits and consequences of the obstetric evacuation policy in Canada and opportunity to reclaim Indigenous birth through Indigenous midwifery.

Abbreviations

FNIHB

First Nations and Inuit Health Branch

GIS

Geographic Information Systems

NCIM

National Council of Indigenous Midwives

NIHB

Non-Insured Health Benefits

Authors’ contributions

JL, CDF and CC conceived and designed this project. ED, AJB and KL contributed to design, material preparation, and analysis plan. AJB led the conception and analysis plan for the health economic analysis (Objective 1). JM was the primary writer of this manuscript and incorporated all feedback from authors. EGS guided all aspects of this study as Elder/Knowledge Keeper. All authors are accountable for all contents of this paper.

Funding

This project is funded by the Canadian Institute of Health Research (CIHR #439167).

Data availability

The study is ongoing. Study materials will be made available on our website, https://reclaimingindigenousbirth.ca/, at the conclusion of the study. Due to privacy restrictions, data involving First Nations identifiers will not be made available.

Declarations

Ethics approval and consent to participate

All recruited participants were informed about the content, purpose, and procedures of the study. Where applicable, participants consented to participate in this study through written informed consent. This project has been approved by ethics committee at the University of Calgary (REB #: 21-1205; REB #: 22-1239) and the Hamilton Integrated Research Ethics Board (REB #: 17880).

Consent for publication

Not applicable, as the manuscript does not contain data of any individual person who is not an author of this manuscript.

Competing interests

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: CC, CDF, and KL are current members of the National Council of Indigenous Midwives (NCIM). CC is contracted by NCIM as a midwife educator. CDF and KL are both affiliated with NCIM as members and do not receive financial compensation from NCIM. No author has received financial benefit from this study. All other authors declare they have no competing interests that could have appeared to influence the work reported in this project.