You’re 36 weeks pregnant. This is your first baby and you have no idea what to expect. Though nervous, your heart skips as you feel tiny legs propel tiny feet into the side of your belly. Here at home, you’re surrounded by family and friends.
But you can’t stay here. Your small community doesn’t have a birthing centre or medical staff, and the nearest hospital is 800 km away.
As the sun oozes over the horizon early the next morning, you bravely step onto a faded mustard-coloured school bus that has been converted to transport you and a few others to a hospital. You feel hot, salty tears cloud your vision. You wanted to stay, but you weren’t allowed. Instead, you have to make the journey south to welcome your child into the world in the company of strangers. Alone.
This is the reality for many aboriginal women in Northern Canada.
All pregnant mothers are routinely evacuated from northern communities and reserves anywhere from 36 to 38 weeks –earlier in emergency cases– to give birth in urban centres like Winnipeg, Ottawa or Vancouver. There they wait in boarding houses for up to one month before delivering their babies.
The provincial and federal governments deem evacuation of all pregnant mothers necessary because of high-risk pregnancies, but also because of a shortage of birthing facilities. A 2006 focus group by the National Aboriginal Health Organization found that almost 80 per cent of northern communities had no birthing facilities.
Instead of being a last resort (to prevent child mortality), medical evacuation has become the cornerstone of maternal health care in remote communities.
The federal and provincial governments don’t sponsor parents, spouses or children to accompany women evacuated for childbirth. Instead, accompanying travel costs are swallowed by the family or community, with some round-trip airfare from reserves to hospitals costing almost $4,000 per ticket. With an average on-reserve income of $14,000 per person, it is nearly impossible for many families to go with the expectant mothers.
“There is no choice,” said Karen Lawford, an aboriginal midwife and gender studies researcher at the University of Ottawa. “The choices that we have, these women do not have.”
The number of high-risk births has risen, due to the sharp increase of diabetes and other health issues that affect pregnancy. And yet, the number of nursing stations and birthing centres aren’t meeting the demand.
Just a few generations ago, women were still giving birth in their homes. But now, they either leave or deliver in improper facilities.
“When babies are born at the La Loche centre, it is done without the proper equipment,” said Georgina Jolibois, one of only 10 indigenous members of the House of Commons and the former mayor of La Loche, Sask.
Jolibois reminisced about the 1980s, when medical evacuation was starting in full swing. She lamented that more than 30 years later, health facilities still aren’t equipped for women to give birth in local communities, even if they wanted to.
Staff is spread thinly across the northern parts of the country, even though about 20 per cent of Canada’s population lives in a remote location, according to Statistics Canada. Not only are the proper facilities unavailable for this 20 per cent of remote communities, but doctors to staff them are also in short supply.
In 2014, Statistics Canada has found that over four million Canadians don’t have a family doctor. The Canadian Medical Association reported it would take 26,000 more physicians to bring Canada to the OECD average of 3.2 per cent of the population, as of 2012. Currently there are only two doctors per 1,000 people, according to the CMA.
Those statistics include southern Canada, meaning the situation is far more bleak for those in the North. Women are not encouraged to give birth at home, but those who want to avoid evacuation have to face decisions about clandestine deliveries. A 2005 report by the University of British Columbia found 20 per cent of rural births are cesarean section deliveries performed by uncertified surgeons, such as general practitioners. “The government must offer commitments to upgrade the facilities,” said Jolibois
UBC also found that between 2000 and 2006, 17 birthing facilities in northern B.C. were permanently closed. The World Health Organization suggests that pregnant women have at least four prenatal visits to an obstetrician, but a 2002 poll of First Nations health discovered that more than half of women said they had difficulty scheduling even one appointment.
Many researchers agree that there are discrepancies in the quality of care a mother receives based on her location. In fact, even when a mother has access to care, the doctors change every few months. “In remote settings, you don’t necessarily have experts in prenatal and perinatal care,” said Heather Heinrichs, a member of the National Aboriginal Council of Midwives. “There’s not necessarily continuity within those care providers.”
In 2015, the National Council of Aboriginal Midwives sent Heinrichs to Hay River, N.W.T to train other midwives to work in their home communities. She said that even when the government sends doctors or nurses to the community, care is very inconsistent. A woman could have several different physicians over the course of her pregnancy, not including the doctor who delivers her baby in the hospital.
“In remote communities you’re not going to have many people who come and stay for many years to provide care,” she continued. Heinrichs said she thinks that training local people to work in their home communities is far more sustainable than flying in healthcare providers.
The evacuation of expecting mothers also takes a toll on aboriginal culture, critics say.
Doctors often make medicine the focus of birth. Hannah Neufeld, an indigenous health scholar at the University of Guelph, said that pregnancy and birth are about more than increasing the population. She said it symbolizes the future of a community. “It’s a spiritual event, it’s a sacred event, and it’s being damaged by processes of colonization and evacuating women from their communities.”
Medical evacuation also leaves mental scars on the mothers. A 2015 study by the University of Alberta found that Aboriginal women who have to leave their communities to give birth often experience racism in hospitals.
“Because of the racist, horrible things that doctors have said, I know women who would rather have an abortion than deal with that,” said Lawford. Aboriginal women are also at a higher risk for depression after pregnancy and often turn to substance abuse as a coping mechanism, according to the Alberta Centre for Child, Family and Community Research.
“Can you imagine the experience of giving birth with no one around you?” asks Jaime Cidro, an indigenous health researcher at the University of Winnipeg, stressing that medical evacuation is “scary, lonely and challenging”.
The first step towards change is to ask the communities what they want, and then evaluate and update the birthing facilities, said Cidro. Making birthing facilities with culturally trained staff available would greatly reduce trauma, she continued.
Despite the fact that provincial and territorial governments are helping make midwives are common in rural locations, there are still gaps in care. The federal government doesn’t fund midwives on reserves, calling them non-essential medical practitioners.
Provincial and territorial governments have been making progress in trying to integrate midwifery into remote indigenous communities. Aboriginal midwives and nurse practitioners are being hired to teach women in their communities to combine medical care with culture traditions in childbirth. Programs like this are why Heinrichs was sent to the Northwest Territories.
The Society of Obstetricians and Gynaecologists of Canada issues a statement supporting the return of birth to these communities, saying that low-risk women should get to choose where they give birth.
Canada prides itself on its healthcare system, but people who live in cities often take these services for granted. Services that are considered basic care aren’t always available to Canadians living a few hours further north.
Even with these holes in health care, it’s mandatory for all mothers from rural communities to be evacuated hundreds of kilometres away, whether their pregnancies are high risk or not.
Investing in local childbirth services in the North also makes economic sense, observers say. The total cost of a medical evacuation can reach almost $5,000 for transportation, boarding fees and the hospital bills. The Ontario Ministry of Health and Long-Term Care estimated the cost of delivering at a birthing centre was averaged at $3,000, almost half the cost of evacuation.
The most sustainable and cost-effective plan would be to end medical evacuation for all but high-risk cases, said Lawford, adding that doctors flown in from the south should work with culturally trained midwives to provide sustainable care to mothers.
A possible solution is for provincial and federal governments to relocate the money the spend on evacuations to help reinstate birthing centres in remote areas, many researchers have concluded. When rural towns and reserves have no experience of birth, all that is left is death.