Examining Midwifery-based Options to Improve Continuity of Maternity Care Services in Remote Nunavut Communities

by Sara Tedford Gold, John O'Neil | Mar 01, 2005

Key Implications for Decision Makers

  • Continuity of maternity care for remote Nunavut communities is not simply about continuity of the provider-patient relationship. Continuity of maternity care is also about a range of services and their availability, relationships between providers, families, and communities, and continuity of place - where the care and childbirth take place.
  • The crisis in maternity care for Nunavut communities is best described by the lack of sustainability brought about by the erosion of local capacity and participation through the gradual separation of family and community from childbirth. This separation is characterized by a lack of dialogue between communities and the institutions that govern them, as well as the divide between the widely held collective memory of an Inuit history of birthing in the North and the imposed southern approach to childbirth.
  • Across Nunavut, maternity care is fragmented and inconsistent where the perinatal services (pre-natal nutrition and education programs, post-natal mother and baby support) that are available are often community-based with little integration or territorial/federal support apart from funding.
  • Project participants describe a sustainable model of maternity for their communities as a comprehensive, collaborative, community-based continuum of care that builds on and develops local capacity.
    • As a comprehensive approach, it must reflect a broad continuum of integrated perinatal services and begin with the development of perinatal education and resources as defined by communities.
    • As a collaborative approach, policy makers, planners, and providers must foster collaboration by recognizing and supporting the range of providers involved in maternity care: traditional midwives, southern-trained midwives, nurses, perinatal educators and resource providers, maternity care workers, elders, and consulting physicians/obstetricians. This support will come through respective recognition of roles and expertise, collaborative training curricula, local training, and training that prepares providers for northern and remote practice, peer support, legislation and regulation, and remuneration processes that fit northern, remote practice.
    • As a community-based approach, it must recognize the importance of place and be informed by Inuit knowledge, experience, expertise, and Inuit Qaujimajatuqangit. It must include local training opportunities and community-based funding processes.
  • Finally, to achieve this comprehensive, collaborative, community-based model of care we must attend to the roles of and relationships between communities, providers, researchers, non-governmental Inuit-representative organizations, as well as regional, provincial/territorial, and federal governments.

Executive Summary

Researchers and maternity care leaders across Canada have identified a crisis in maternity care, characterized by a shortage of skilled providers. For remote Inuit communities, this crisis is not only about a shortage of providers but also about a lack of local capacity and, as a result, program sustainability. Systemic dependence on evacuating women for childbirth has effectively removed childbirth from Nunavut families and communities. Efforts to return childbirth to

communities have been challenged by a lack of mobilization of providers and communities, safety concerns, and relationships between communities, providers, decision makers, and various levels of government. Health planners struggle with how to shape new models of maternity care that reflect the importance the communities place on a long history of Inuit midwifery.

This research developed out of discussions between researchers, communities, Inuit-representative organizations, and the territorial government. Through these discussions the need to better understand how Nunavut communities were talking about current maternity care and their visions for change emerged. From November 2002 to December 2004, through a qualitative consultative methodology, we examined current maternity care and interruptions or problems in maternity care across 10 Nunavut communities and explored possible solutions to the problems as identified by project participants. We employed three primary methods : (1) semi-structured, in-depth interviews; (2) community consultation workshops; and (3) document analysis.

We found that maternity care talk - the ways that Nunavummiut talk about maternity care - is characterized by several phenomena. The first is the divide between the strong and widely held collective memory of an Inuit history of birthing in the North and the imposed southern approach to childbirth. The second is the lack of dialogue between communities and the institutions that govern and provide for certain services and programs. The third phenomenon is the resulting marginalization of Inuit knowledge and practice and the rendering of the local as unfit for childbirth. The silos that characterize maternity care talk permeate its governance at several levels - system, planning, provision, and community.

Across study communities, Nunavummiut define maternity care as necessarily encompassing a broad, community-based, perinatal continuum including reproductive and sexual health, family health, family planning, prenatal education and support, childbirth, postnatal health, support for mother and baby, and participation of family and community. Moreover, they suggest that to be continuous, maternity care must involve continuity of place. Project participants describe a sustainable model of maternity care as a comprehensive, collaborative, community-based continuum of care that builds on and develops local capacity.

As a comprehensive approach , it must reflect a broad continuum of integrated perinatal services and begin with the development of perinatal education and resources as defined by communities. The centrality of nursing in current Nunavut healthcare and the salience of midwifery in the provision of maternity care for Inuit communities suggest that both need to be considered in addressing maternity care.

As a collaborative approach , policy makers, planners, and providers must foster collaboration by recognizing and supporting the range of providers involved in maternity care: traditional midwives, southern-trained midwives, nurses, perinatal educators and resource providers, maternity care workers, elders, and consulting family physicians and obstetricians.

As a community-based approach , it must be rooted in the communities it services. This will require recognition of the importance of place, as well as Inuit knowledge, experience, expertise, and Inuit Qaujimajatuqangit . Such an approach will build on local capacity to develop perinatal education and resources and, ultimately, bring birth back to families and communities.

To achieve this comprehensive, collaborative, community-based model of care we must attend to the roles of and relationships between communities, providers, researchers, non-governmental Inuit-representative organizations, as well as regional, provincial/territorial, and federal governments. These roles and relationships must ultimately contribute to local capacity to sustain programs that fit communities. Finally, local training will be crucial to the development and maintenance of local capacity.

While the Rankin Inlet Birthing Centre has not offered training for skilled attendants, this is slowly changing. In late 2003 it hired a second maternity care worker and the regional Department of Health and Social Services supports the development of maternity care worker training, and potentially midwifery training, to be offered at Nunavut Arctic College . With the possibility of territorial expansion and collaboration with Manitoba 's Aboriginal Midwifery Education Program, Nunavut could eventually see local training for midwives. Moreover, efforts to develop regional birthing by building on the Rankin Inlet Birthing Centre model in the other two Nunavut regions may succeed in bringing childbirth closer to communities. However, to contribute to sustainable continuity of maternity care that fits with Nunavummiut visions, such efforts need to be part of a comprehensive, community-based, and collaborative approach.