International Journal of Health Governance

“Lost births,” service delivery, and human resources to health: Bringing maternal
primary health care back to Canada’s North
Melissa Cora Cardinal,
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Melissa Cora Cardinal, (2018) "“Lost births,” service delivery, and human resources to health:
Bringing maternal primary health care back to Canada’s North", International Journal of Health
Governance, Vol. 23 Issue: 1, pp.70-80, https://doi.org/10.1108/IJHG-12-2016-0057
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IJHG
23,1
70
Received 29 December 2016
Revised 27 April 2017
22 August 2017
Accepted 8 September 2017
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International Journal of Health
Governance
Vol. 23 No. 1, 2018
pp. 70-80
© Emerald Publishing Limited
2059-4631
DOI 10.1108/IJHG-12-2016-0057
The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/2059-4631.htm
“Lost births,” service delivery,
and human resources to health
Bringing maternal primary health care
back to Canada’s North
Melissa Cora Cardinal
School of Public Health, University of Alberta, Edmonton, Canada
Abstract
Purpose – The purpose of this paper is to advocate for improved service delivery of maternal-newborn care
in northern Indigenous communities. This is done through critical examination of the loss of pregnancy and
birthing knowledge and practice in these communities, from both a historical and contemporary lens.
Supporting the return of traditional midwifery practices to the communities is the recommended solution.
Design/methodology/approach – The paper is a general review of the available literature regarding
Indigenous birthing practices, historical and contemporary Canadian maternal health service provision,
and midwifery.
Findings – Current maternal health care practice in these northern communities is not resolving service
delivery and human resource inadequacies, highlighting the need for a community-based and midwifery-driven
primary health care approach. Potential recommendations include implementing a comprehensive birthing
initiative, innovative midwifery training, and promotion and support of the role of the community midwife.
Originality/value – “Lost births” is a largely unrecognized issue in Canadian public health literature. The
value of this paper lies in its potential to stimulate discourse and advocacy.
Keywords Canada, Services, Rural health, Midwifery, First nations/Indigenous people health,
Inadequacies
Paper type Viewpoint
Introduction
When a pregnant woman from a remote northern community reaches term, the current
practice is to transport her, usually via medical air evacuation, to a larger medical facility
that has an established obstetrical program. This has been an expected intervention since
the 1960s and 1970s (Public Health Agency of Canada (PHAC), 2009, p. 110). The intention
is to provide universal access to safe obstetrical care for both the mother and the baby she
is delivering. Although this may appear altruistic and practical, it is rife with negative
consequences. An expensive medical evacuation followed by a lonely delivery pales in
comparison to the effects that this practice has had on Indigenous families and
communities. Traditionally, Indigenous births embedded comprehensive midwifery
practices in these communities, as well as community traditions, ceremonies, gatherings,
and celebrations. The notion of “lost births” henceforth refers to the loss of this
community knowledge and celebration regarding the birth of a new member. It can be
argued that lost births are a result of historical, systemic oppression of Indigenous culture
by the Canadian Government, and the monopoly of formal health education and services
by the medical profession.
The purpose of this viewpoint paper is not to discredit the medical profession or modern
best obstetrical practices; this knowledge is highly valuable, respectable, life saving, and
essential to our current health care system. Rather, the purpose is to promote discussion
about health disparities, challenges, and potential solutions. This paper will also critically
examine the midwifery profession in Canada, current maternal health care practice in the
North, and the need for a midwife-driven, comprehensive primary health care approach in
these rural or remote communities.
 Background Maternal
History primary health
The mid-twentieth century brought about detrimental changes to both the midwifery care
profession and Indigenous birthing practices. By the 1950s, there was increased accessibility
to hospital births for women of all socioeconomic status. The medical profession had an
outlawed midwifery practice in many jurisdictions across North America, reinforcing the
growing public perception that midwife-attended births were unsafe (National Aboriginal 71
Health Organization (NAHO), 2008). This has set the midwifery profession back by decades,
as access to formal women’s health education was restricted to the medical profession. Thus,
midwifery research and regulation has only come about relatively recently. In Alberta,
midwifery was recognized as a profession in 1994 under the Health Disciplines Act, but it was
not a publicly funded health service until April of 2009 (Alberta Health, 2016).
The lack of Canadian midwives and public funding for their services becomes even more
relevant and concerning when Aboriginal and Inuit women’s health is taken into consideration.
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Prior to the post-Second World War era, there was still a wealth of midwifery knowledge that
had survived colonization in Indigenous communities. Although there were many different
practices and ceremonies associated with the birth of a child amongst different tribes and
communities, there is a general historical consensus of relatively safe and culturally-appropriate
care. The following excerpt is an example of one tribe’s historical approach to birth:
A long time ago, every community had midwives. At the same time, everyone, every woman and
even every man, was taught what to do at birth because the Crees were nomadic, and they lived on
the trap lines and they were on the move all the time, so a birth could happen any time, anywhere.
Every adult had to have some basic skill, including the husband. Sometimes, a woman would go
into labor and the only person there to help her was her husband, so they had to be taught. This
was very important. At the same time there were women who gained experience, became more and
more experienced, and really became the midwives. Sometimes people would go to get them, but
only if the birth seemed to be a bit more complicated. If the birth was going really nice and fast, they
would give birth with the people that were around them, and if they felt they needed to, they would
go get the midwives – Christine Roy (NAHO, 2008).
The women’s health monopoly by the medical profession did much harm to Indigenous
midwifery, and Indigenous women’s health in general. Although this was not the intended
effect, it nonetheless has led to the severe shortage of maternal primary health care services
in the North. The cultural genocide of the Indian residential school policy combined with
outlawed or highly discouraged midwifery practices has resulted in this profound loss of
knowledge. In regards to Inuit women’s health, a rich cultural heritage and knowledge about
pregnancy and birthing has the potential to be completely lost, only to be replaced with the
inadequacies of modern health care delivery in the North (NAHO, 2006, p. 1).

Present day
Maternal-newborn health disparities between Indigenous and non-indigenous Canadians are
often referenced. In Quebec, perinatal and infant mortality rates have been persistent or
worsening between 1996 and 2010, particularly amongst Inuit people (Chen et al., 2015). In
rural and northern Quebec, there have been recent and significant increases in low birth
weights amongst infants whose maternal tongue is an Inuit language, as well as perinatal
death rate increases amongst those whose maternal tongue is a First Nations language
(Simonet et al., 2012). Furthermore, there is an association between very remote Quebec First
Nations communities and a significantly higher risk of fetal and infant death, particularly
postnatal death (Wassimi et al., 2010). Despite these data coming out of Quebec, birth
outcomes are inconsistently tracked and reported Canada-wide (Smylie, 2011). These findings
indicate a need for improved perinatal surveillance and programming. However, this is made
quite complicated by the realities of remote living as well as evolving agendas in Ottawa.
 IJHG The following table was created using information and statistics provided by the PHAC
23,1 (2009) in the Canadian Maternal Experiences Survey. Of survey participants, 25.6 percent
reported having to travel to another city, town, or community to give birth. Overall,
2.5 percent of women reported having to travel more than 100 km to give birth.
In addition to Nunavut’s values being underestimated, the survey did not account for
women living on reservations, and is therefore entirely underestimated, especially in
72 regards to areas where there is a high number of remote reserves (PHAC, 2009, p. 112).
Consider the financial consequences of traveling to give birth. Medevac Canada, an air
and ground ambulance service provider, quoted a single medical evacuation flight from
Rankin Inlet, NU, to Yellowknife, NWT, at $27,000 (Medevac Canada, personal
communication, March 31, 2016). Although this is a longer flight and likely on the high
end of transport fees, it is not uncommon for women from remote northern communities to
fly into Yellowknife or even further south to deliver. See Table I. Additional financial
resources are needed to house women while they are away from home, as they either wait to
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go into labor, or are induced. On top of housing are the other fees associated with
accommodation, such as food, internet, and/or long-distance phone calls. This practice is
unsustainable, exorbitant, and potentially unnecessary.
Another consideration is the psychological stress that may result from a woman
being removed from her family and community during this vulnerable period in her life
(PHAC, 2009, p. 109). Imagine having to give birth in a foreign place by yourself and with
no support system. Any medical escort or support person is expected to pay for their own
travel and accommodation; few people living in remote areas have the financial means to
do so. Most likely, you will end up sitting in a hotel room for a few days to a few weeks,
then labor unaccompanied until the baby is born. Breastfeeding support may or may not
be initiated by hospital staff. Sufficient emotional support may or may not be offered by
hospital staff.
The Nunavut Health Department recently announced that Indigenous women traveling
out of their communities to give birth would not have to go alone; travel escorts are now
funded by the territory. Health Canada has followed suite, claiming similar policy change is
in the works for all northern Canadian Indigenous women, but is unclear as to how or when
(Bird, 2017, April 12). Prior to these policy changes, many transportation births likely
occurred with no support person, or a support person who had to accept the financial
consequences. Nonetheless, having a funded support person at the bedside does not
necessarily address lost income or childcare issues, especially if that support person is the
pregnant woman’s partner. It also does not address the lack of northern maternal primary
care services, which is currently the main reason why transportation practices exist. It is a
welcomed policy change; however, it is a secondary and downstream measure. Although
transportation has become a common and accepted practice, it’s financial and psychological
strains may outweigh the benefits. High-risk pregnancies may warrant transportation or

Proportion of women who reported Overall proportion of women who had to

Province/territory traveling to give birth (%) travel more than 100 km (%)

Nunavut 64.5 37.9a

Northwest territories 50.8 40.3
Ontario 22.8 –
Table I.
Manitoba 22.2 –
Proportion of women
who report necessary Yukon – 23.0
travel to access Note: aNunavut’s proportion of women who had to travel more than 100 km is most likely higher than the
birth services, by given value, as 23.9 percent of women who traveled to give birth reported unknown distance of travel
province/territory Source: PHAC (2009, p. 111)
 evacuation, but the same cannot be said for healthy, low risk, term deliveries. Low risk Maternal
deliveries attended by community midwives within remote northern communities may be a primary health
better solution. care
Service delivery and human resources for health
The World Health Organization (WHO, 2010) identifies several key components of a
well-functioning health system. Of those components, the most relevant to maternal primary 73
health care in Canada’s north are service delivery and human resources for health.
Inadequacy of maternal health care service delivery is apparent when one considers the
practice of evacuation/transportation. Service delivery is dependent on “networks of
close-to-client primary care, organized as health districts or local area networks with
the back-up of specialized and hospital services, responsible for defined populations”
(WHO, 2010). As evidenced by Table I, close-to-client primary care is unavailable for a large
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proportion of pregnant women living in rural areas.

Another key component that is missing in this scenario is human resources. This stems
from the degradation of midwifery knowledge and practice, not just in remote northern
communities, but across Canada. Addressing this inadequacy requires arrangements to
achieve competencies and numbers, appropriate payment incentives, regulatory
mechanisms, establishment of job-related norms, and the cooperation of stakeholders
(WHO, 2010).
The Health Force Ontario Northern and Rural Recruitment and Retention Initiative
(Ontario Ministry of Health and Long-Term Care, 2013) attempts to address human resource
inadequacies by offering $80,000-116,600 in taxable grants over four years to physicians who
set up their practice in eligible remote communities. However, consider the expense of such
initiatives and the practicality. Large financial incentives for individual health care providers in
the long term are not sustainable and come with ethical considerations. In the long term, one of
these grants may save money on evacuation/transportation costs, but it is nonetheless a large
expense. Also, this may motivate individuals to practice and work in remote communities for
the wrong reasons. There is high potential for limited involvement in and commitment to the
community, followed by leaving the community once the contract is fulfilled.
Given the available information, how can provinces and territories better address or even
resolve service delivery and human resource inadequacies? Instead of relying on people and
services to be “flown in,” or for people who need those services to be “flown out,” perhaps
start building upon existing resources. It is time to look at these remote northern community
members as more than just service users. Creating self-sustaining service providers takes a
proactive, upstream approach. In regards to women’s health, this is where the role of the
community midwife comes in.

The Canadian midwifery situation

Education: university degree
To become a professional midwife in Canada, one must complete a four-year baccalaureate
degree in midwifery offered by one of the following seven universities: Laurentian
(Sudbury, ON), McMaster (Hamilton, ON), Ryerson (Toronto, ON), Universite du Quebec a
Trois Rivieres (Trois Rivieres, QC), University of British Columbia (Vancouver, BC),
University College of the North (The Pas, MB), and Mount Royal (Calgary, AB)
(Canadian Association of Midwives, 2016).
Only one of the Canadian university programs provides Aboriginal midwifery content in
the curriculum i (University College of the North, 2015). Graduates are eligible to write the
Canadian Midwifery Registration Exam, which tests competencies. Those passing can enter
practice (Canadian Midwifery Regulators Council, n.d.).
 IJHG Education: community-based
23,1 There exists an “informal” route to becoming a midwife, which does not involve formal
university education, or a credentialing examination. This option is only available to
Indigenous women living in or around one of the eight communities. These community-
based programs were designed to specifically educate Aboriginal and Inuit midwives who
wish to remain and practice in their communities. There are currently eight community-
74 based programs being offered in mostly remote communities across Nunavut, Ontario, and
Quebec (National Aboriginal Council of Midwives (NACM), 2016, p. 7). While these are not
recognized as credentialed programs by the Canadian Association of Midwives (CAM),
graduates are recognized as midwives within their communities. Graduates can apply for
recognition outside of their community if they wish (Annie Hibbert of CAM, personal
communication, March 31, 2016).
Midwives apply for registration with the governing body (the college) of their province or
territory to practice midwifery. However, Nunavut, British Columbia, Ontario, and Quebec
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all have legislation that provides an exemption from registration for Aboriginal midwives
(NACM, 2012a, b). Although this does benefit the community-based programs, it also raises
two major concerns: lack of regulation can become synonymous with lack of educational
standards and lack of professional accountability; and this is a major barrier for graduates
of community programs who want to become registered in their province or territory.
Community-based programs attempt to address these concerns by reporting curriculum
that is also rooted in western science, and having experienced midwives as instructors.
These programs are a small-scale example of what can potentially be achieved in various
places across the North. Training Aboriginal midwives either within their community
settings, or relatively close-by, can remove financial, geographical, and cultural barriers all
at once. This will be discussed further in the Recommendations section.

Lack of professional midwifery services

Per the Canadian maternity experiences survey, only 4.3 percent of participants had their
labor and delivery attended by a midwife (PHAC, 2009, p. 115). This is a sharp contrast to
other wealthy nations such as the UK, where midwives attend 62 percent of all births
(PHAC, 2009, p. 114). This can be attributed to Canada’s delay in midwifery regulation, poor
public funding, and overall lack of midwives. The province of Alberta provides an example
of this human resource and service delivery deficit.
On September 15, 2015, the Alberta government agreed to fund midwifery services by an
additional $1.8 million, which would support 400 additional courses of midwifery care
(prenatal, birth, and postpartum), raising the number of publicly supported births by
midwives in Alberta to 2,774 (Alberta Association of Midwives (AAM), 2015). Regardless of
this increase, Alberta’s proportion of midwife-attended births echoes that of the national
average: 4 percent in 2014, and 5 percent in 2015 (AAM, 2015). The preliminary birth
estimate for 2014/2015 in Alberta was 57,677 births (Statistics Canada, 2015), which is
consistent with the proportions provided above.
Currently in Alberta, there are 23 midwifery practices, 17 of which are in the greater
Edmonton and Calgary areas (AAM, 2017). This serves as a reminder that rural, remote, and
northern regions are often neglected, although Alberta is fortunate enough to have one
practice as far north as high level (AAM, 2017).
The northern territory of Nunavut has a higher proportion of midwife-attended
deliveries than the other territories, as well as several other provinces (PHAC, 2009, p. 116).
This could be due to the existing community-based midwifery program at Arctic College, as
well as positive attitudes toward midwifery. However, there is an overall low proportion of
midwife-attended births in Canada, with the clear majority of births being attended by
obstetricians/gynecologists (PHAC, 2009, p. 116).
 In summary, regulation and funding for midwifery services has been historically delayed Maternal
and limited. There are only 7 credentialed bachelor midwifery degrees in the entire country, primary health
6 of which are in cities with populations greater than 100,000 people. This promotes care
competitiveness, exclusivity, and an urban-centered focus. Furthermore, this makes it
extremely challenging for Indigenous women from remote northern communities to: apply
to and be accepted into a credentialed program; have the financial resources to travel, live,
and study in the south; and cope with personal circumstances such as child care and 75
separation from family and the community.

Cost effectiveness and perinatal outcomes

A pilot study performed in Alberta by O’Brien et al. (2010) matched women receiving
standard perinatal care with women receiving midwifery care, and found average savings of
$1,172 per course of care. This reduction was mainly due to out-of-hospital health services,
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and did not adversely affect maternal or newborn outcomes. However, this study was too
limited to have widely generalizable findings.
An evaluation of the Ontario midwifery program found that midwife-attended births in
the hospital were $800 less than a birth with a family physician. For a midwife-attended
birth in the home, it was $1,800 less. Savings were attributed to fewer interventions, fewer
readmissions, and shorter hospital stays (Association of Ontario Midwives, 2007).
In the documentary Birth Rites (2000), an Inuit midwife working out of a birth center in
remote Puvirnituk anecdotally describes improved perinatal outcomes, despite unexpected
labor complications such as breech presentation and postpartum hemorrhage. Decreased
infant mortality, culturally-appropriate births, and choice of support person(s) are but a few
of the improvements that have occurred since the establishment of this birth center
(Gherardi, 2000).
The comprehensive literature regarding the cost effectiveness of midwifery care in remote
northern communities is severely limited, but the available evidence consistently suggests
that midwife-attended births are significantly cheaper than births attended by a physician in
the hospital. Taking away the cost of evacuation already saves tens of thousands of dollars
per woman. Subtract additional accommodation costs as well as hospital-related costs.
These costs will differ between provinces or territories, and from circumstance to
circumstance (i.e. communities that are closer or further away from Yellowknife).
In the UK, where professional midwifery is well established, a study by Schroeder et al.
(2012) found the total unadjusted mean costs were £1,066 for births planned at home, £1,435
in freestanding midwifery clinics, £1,461 in alongside (hospital) midwifery units, and £1631
in obstetrical units. However, while multiparous women benefited from home births in
regards to both cost effectiveness and perinatal outcomes, nulliparous women had higher
incidences of adverse perinatal outcomes (Schroeder et al., 2012). This raises an obvious
concern: while home births and midwifery care may be more practical and cost effective, are
they safe for mother and baby?
A study performed in Ontario compared the outcomes of planned home births and
planned hospital births. There was no difference in rates of neonatal mortality, maternal
mortality, or serious morbidity. Another finding was that nulliparous women in both
groups were more likely to have complications such as postpartum hemorrhage, perineal
tearing, or cesarean section (Hutton et al., 2009). A similar study performed in
British Columbia found low and comparable rates of perinatal death between planned
home births with a midwife vs a planned hospital birth with a midwife or physician
( Janssen et al., 2009). This study did not account for maternal parity or hospital care
provider, which limits the findings.
As Canadian midwifery services are relatively new, information regarding cost
effectiveness of these services is relatively limited (CAM, 2010). The above-mentioned
 IJHG preliminary findings are promising, but more research is needed in the Canadian context
23,1 before we can make conclusive statements about the cost effectiveness and desirable
perinatal outcomes of midwifery care.

Recommendations to address service delivery and human resource

inadequacies
76 Given the available information, it is time to approach recommendations that will address
the issue of “lost births.”
A review of on-reserve programming yielded the following recommendations in regards
to our topic:
(1) training should be made available closer-to-home in remote/rural areas and
incentives investigated for retaining/recruiting trained workers in their
communities;
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(2) The Society of Obstetricians and Gynecologists of Canada (SOGC)’s Birthing

Initiative should be looked upon as best practice in moving Aboriginal
midwifery forward toward the repatriation of birthing to Aboriginal
communities; and
(3) midwifery should be promoted and supported as an educational and career choice
for Aboriginal people (Stout and Harp, 2009).
Using knowledge of midwifery in Canada, as well as historical and cultural contexts of
Indigenous midwifery, let us elaborate and expand upon these recommendations.

Implementing a comprehensive birthing initiative

The idea to bring culturally sensitive, collaborative maternal primary health care to the
North is not a new one. The SOGC has proposed an Aboriginal Birthing Initiative: its
primary goal is to begin the process of returning birthing to Aboriginal communities. It is
recognized that this can only be done through genuine collaboration between the SOGC
(2008, p. 23), Aboriginal organizations, communities, key Aboriginal health professionals,
provinces, territories, and relevant agencies. However, personal communications with
SOGC have revealed a lack of action and leadership in regard to this initiative, even so far as
to question if the initiative still exists. Therefore, advocacy for continued collaboration
between the above-listed stakeholders is necessary. Furthermore, accountability is required
of the SOGC to fulfill their statements and promises.
The National Aboriginal Council of Midwives has emerged as the strongest and most
vocal organization for supporting midwifery and culturally safe care for Aboriginal
communities. Their recently published report utilized a mixed-methods approach to
describe the current landscape of Indigenous midwifery in Canada, including interviews
from Indigenous midwives and recommendations to improve Indigenous midwifery
practices (NACM, 2016). It is a highly recommended to read. When implementing a
comprehensive birthing initiative, the recommendations made in this comprehensive report
should, ideally, be the priority. See Figure 1.

Midwifery training is made available closer-to-home

In Puvirnituq, Quebec, where a birthing center and one of the community-based midwifery
programs is located, transfer rates of expectant mothers to the south have decreased from
91 percent in 1983 to less than 9 percent in 1998. Inukjuak, which is just south of Puvirnituq,
has also experienced the benefits of an Inuit midwifery practice, as transfer rates of
56 percent in its first year dropped to 14-21 percent in 2006 (Stout and Harp, 2009, p. 53).
 Maternal
primary health
care

77
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Figure 1.
Policy
recommendations by
the National
Aboriginal Council of
Midwives (2016)

By bringing these culturally appropriate educational programs to the North, midwifery

education has become accessible and feasible for people in the hosting community and
surrounding communities.
With so few community-based midwifery programs in the entire country, it is time to
start evaluating and expanding these programs to other provinces and territories.
This involves undertaking a major process and uprooting many pre-existing ideas and
legislations. The limited availability of formal, urban-centered midwifery education is not
accessible to many would-be Indigenous midwives.
 IJHG Establishing additional community-based programs across Canada would require
23,1 extensive collaboration, funding, and a favorable political-economical climate. While
establishing several new, separate programs remains an option, community-based
midwifery training can be both locally based and standardized. Given current
technologies, the science-based portion of the curriculum can be delivered entirely online
through an accredited institution. The practical and cultural components can be taught and
78 completed within the community.
It is important to note that communities should have the final say in how to educate
their midwives. The final agreed-upon training process(es) may not reflect any of the ideas
listed above.

Promoting and supporting midwifery as a career choice for Indigenous people

Promotion of the role of a community midwife can be undertaken by community
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elders and leaders. This role requires acceptance among community members before a
midwifery practice can flourish. An assumption of bringing midwifery care to the
communities is that community members WANT these services. Before any midwifery
practice exists, and before any person from these communities attends midwifery
training, there must be a foundation of support and acceptance of this role within the
community.
To accommodate increased interest in midwifery, not only community-based programs,
but university programs need to be expanded as well. Public funding for midwives requires
an increase, and legislation for increased midwifery practice must be in place.

Limitations
For Indigenous community midwifery to be possible, a network of midwifery support must
exist. There is also a need for the back-up of specialized and hospital services, in the event of
a high-risk delivery or birth complications. The literature has shown nulliparous women
(first-time mothers) to have more adverse perinatal outcomes. Labors tend to be longer, the
woman is inexperienced and therefore may be more prone to fear or powers of suggestion,
which can lead to more complications and/or interventions.
How then, can we guarantee safety for nulliparous women who deliver in these remote
communities? What if a woman, of any parity, suddenly requires a cesarean section? What if
a pregnant woman acquires a blood pressure disorder? Addressing these concerns puts a lot
of faith on the individual midwife, to make a timely decision to evacuate/transport a woman,
and to provide potentially life-saving care in the meantime. Therefore, while this paper
advocates for comprehensive maternal primary care in the form of Indigenous midwifery, it
also recognizes the inherent risks associated with the nature of obstetrical complications.
High-risk deliveries, or deliveries in danger of becoming high risk, should still take place in
the hospital. This opens an opportunity for the role of Indigenous support persons in the
hospital as well.
Lastly, Metis interests have been largely left out of the discussion because there is little
information on Metis birthing practices and issues, and few Metis settlements across
Canada. More research and advocacy is required for Metis families and culturally safe care.

Summary and conclusion

“Lost births” is a phenomenon that has plagued Indigenous communities only in the last
century, but has caused much harm to Indigenous midwifery and birthing knowledge.
Given the context of colonial history, and current midwifery practices in Canada, fascinating
insights can be made as to how to begin addressing human resource and service delivery
inadequacies in the North, specifically in regards to maternal-newborn care. In closing,
 continued support for Indigenous midwifery practice is essential if we are going to bring Maternal
births home, and develop systems that will sustain them: primary health
I have a dream […] of attending a birth in my own community at Nipissing, I will go to a woman’s care
home where her extended family is there for support. Perhaps even my own daughter will
accompany me to help with younger children. Perhaps the woman’s mother is there to help prepare
food and greet the baby in the Nishnawbe language. The father will light a fire outside and offer
tobacco. We will boil cedar for the postpartum bath. […] Nishnawbe women are the guardians of 79
their culture, families and communities. They will want to be a leading force in the future
development of midwifery on their homelands. The professional practice of midwifery reflects their
traditional values. That is the compassionate and respectful care of the newly emerging mother and
baby. This is the very future of our Nations. – Celebrating Birth. (NAHO, 2008, p. 2)

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Further reading
Government of Alberta (2015), “Midwifery services”, available at: www.health.alberta.ca/services/
midwifery.html

Corresponding author
Melissa Cora Cardinal can be contacted at: mccardin@ualberta.ca

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