Indigenous Peoples’ evaluation of health risks when facing mandatory evacuation for birth during the COVID-19 pandemic: an indigenous feminist analysis

Abstract

Background

Indigenous Peoples living on the land known as Canada are comprised of First Nations, Inuit, and Métis people and because of the Government of Canada’s mandatory evacuation policy, those living in rural and remote regions of Ontario are required to travel to urban, tertiary care centres to give birth. When evaluating the risk of travelling for birth, Indigenous Peoples understand, evaluate, and conceptualise health risks differently than Eurocentric biomedical models of health. Also, the global COVID-19 pandemic changed how people perceived risks to their health. Our research goal was to better understand how Indigenous parturients living in rural and remote communities conceptualised the risks associated with evacuation for birth before and during the COVID-19 pandemic.

Methods

To achieve this goal, we conducted semi-structured interviews with 11 parturients who travelled for birth during the pandemic and with 5 family members of those who were evacuated for birth.

Results

Participants conceptualised evacuation for birth as riskier during the COVID-19 pandemic and identified how the pandemic exacerbated existing risks of travelling for birth. In fact, Indigenous parturients noted the increased risk of contracting COVID-19 when travelling to urban centres for perinatal care, the impact of public health restrictions on increased isolation from family and community, the emotional impact of fear during the pandemic, and the decreased availability of quality healthcare.

Conclusions

Using Indigenous Feminist Methodology and Indigenous Feminist Theory, we critically analysed how mandatory evacuation for birth functions as a colonial tool and how conceptualizations of risk empowered Indigenous Peoples to make decisions that reduced risks to their health during the pandemic. With the results of this study, policy makers and governments can better understand how Indigenous Peoples conceptualise risks related to evacuation for birth before and during the pandemic, and prioritise further consultation with Indigenous Peoples to collaborate in the delivery of the health and care they need and desire.

Introduction

Background

On the land known as Canada, settler colonialism introduced and imposed a Euro-Canadian biomedical model on the pregnancy, birthing, and postpartum care of Indigenous Peoples [1]. Indigenous Peoples living on the land known as Canada are comprised of First Nations, Métis, and Inuit people. For those living on rural and remote reserves, healthcare services are mostly provided by the Government of Canada’s First Nations and Inuit Health Branch [2].

Despite having traditional care providers, caring practices, and ceremonies since time immemorial, colonisation intentionally undermined and erased Indigenous birthing traditions. For instance, Indigenous midwives and birth attendants such as family members, community Elders, and healers are unrecognised in Western literature and healthcare systems [3]. However, Indigenous midwives and other birth attendants have unique knowledge and skills, and historically and contemporarily, they played an integral role in supporting perinatal health and care in their communities [4]. Significantly, Indigenous midwives and birth attendants reaffirmed health, kinship, and ceremony and: “it was often the community grandmothers (in some places, Two Spirit community members and men were also midwives) who acted as the custodians of life’s doorways- being present and supporting life cycle events [like birth]” [4] (pS260−S261). Despite the work of traditional care providers in sustaining the existence of Indigenous Peoples for tens of thousands of years, the Canadian government implemented a healthcare model that removed community birthing, undermined Indigenous midwives, and coerced Indigenous people to assimilate to Euro-Canadian principles of health and care [1].

Canada’s evacuation policy

As a colonial effort to assimilate, marginalise, undermine, and harm Indigenous Peoples, Canada implemented a blanket policy mandating evacuation for birth for Indigenous people living in rural and remote regions [1]. Colonialism in Canada resulted in the removal of health services from Indigenous communities, the centralisation of healthcare to urban areas, and the fragmented communication between federal and provincial jurisdictions of healthcare systems [5]. Due to the decreasing availability of health services in rural and remote regions, Health Canada’s evacuation policy instructs nurses in rural and remote communities to initiate evacuation for birth at 36 to 38 weeks’ gestation according to regional policy, regardless of obstetrical history [5]. Hospitals are often hundreds of kilometres away in urban cities where Indigenous childbearing people must stay in hostels, hotels, or community centres awaiting the onset of labour with or without an escort from home [6, 7]. Being forced to birth away from their families and communities leaves Indigenous parents feeling lonely, isolated, and separated from community traditions and celebrations around birth [6]. Moreover, Indigenous parturients describe facing racism, discrimination, colonialist approaches to birth and reproductive coercion when receiving care in urban hospitals [8, 9].

Conceptualising risk

The evacuation policy was presented to Indigenous Peoples as a way to decrease their health risks, such as infant and maternal mortality, by providing them access to medicalized care in urban hospitals [1]. Despite the evacuation policy being framed as a strategy to reduce health risks to Indigenous Peoples and to support their health and wellbeing, Indigenous people have voiced that it is risky for them to leave their community to give birth in other settings [1, 10]. For some Indigenous people, the importance of birthing in their community to receive support and to celebrate birth exceeded their concerns about not having immediate access to biomedical intervention [11]. With a strong trust in the skills and knowledge of community care providers, Kornelsen et al. found that Indigenous parturients preferred having their baby in community rather than taking the risk of accessing medicalized care away from home [11].

That being said, Indigenous people have also voiced a notion of risk that is different from the Euro-Canadian biomedical model of risk [10]. In the biomedical model, birth is believed to be “a pathological process requiring intensive monitoring and the use of medical interventions such as electronic fetal monitoring (EFM), epidural analgesia, amniotomy, induced labour, episiotomy, and elective caesarean deliveries” [12] (p2). With the goal of improving obstetrical outcomes, all birthing people are provided the same high level of medical intervention, no matter their health or individual risks of complications [12] (p2). Indigenous people have articulated that: “[this] concept of risk has been used by colonisers in many contexts to remove Indigenous people from their communities, which extends to the medicalization of birth and the forced removal of [parturients] to give birth away from their community” [10] (p17). Indeed, Indigenous Midwives in Canada have been advocating for a return to birthing in community because birth is understood to be a normal process, rather than an illness in need of treatment [10]. Ultimately, evaluating risk is a process influenced by numerous individual, social, cultural, and contextual factors and thus, Indigenous people best understand what health services they desire [13]. Considering that Indigenous Peoples conceptualise risk differently and that this impacts their decision-making, it is important to understand how they conceptualise risk about travelling for birth in order to offer health and care that meets their needs [14].

COVID-19 pandemic: impact on perception of risk and birth

With the onset of the coronavirus pandemic in 2019 (COVID-19), people became more aware of health risks and risks to accessing health care [15]. By evaluating the risk of exposure to or infection with COVID-19, people changed their behaviours [15]. For instance, people evaluated the risk of contracting the coronavirus when interacting with people outside their immediate household, when in public spaces, or when accessing essential services [15]. Moreover, people responded to their evaluation of health risks and adopted practices to prevent the transmission of the virus by “maintaining social distancing, reducing travel, washing hands more frequently, wearing masks when away from home (.), and performing additional household cleaning and sanitation” [15] (p8,9). Importantly, people who were pregnant during the pandemic were more likely to view travelling outside their homes as risky because they perceived themselves to be at a higher risk of contracting COVID-19 [15].

During the early stages of the pandemic, pregnant people were defined as a high-risk group by public health authorities and were informed of an increased risk of adverse outcomes from COVID-19 including pneumonia, preterm birth, preeclampsia, caesarean delivery, and perinatal death [16]. In response to an increased risk during the COVID-19 pandemic, pregnant people experienced more anxiety and were more likely to make decisions to reduce their risk of infection [15, 17]. Pregnant people also reported increased anxiety due to concerns about the risk of infection to their baby [18, 19]. For instance, a study at Mount Sinai Hospital in Toronto, Canada, explored the experiences of pregnant people during the pandemic and found that they experienced increased worry, uncertainty, and fear about their employment, financial security, access to food, and using transportation or other services [19]. Further adding to the turmoil, pregnant people experienced challenges accessing quality healthcare services during the pandemic [19]. In response to increased stress due to COVID-19, participants in Kokler et al.’s study adapted their approach to evaluating risk and to decision-making in order to support themselves during their pregnancy. Some pregnant people surrounded themselves with community and family support because they evaluated the risk of COVID-19 as being lower than the risk of isolation was to their mental health [19].

Considering that Indigenous Peoples conceptualise health risks differently outside of the context of a pandemic, it is important to understand the impact of the COVID-19 pandemic on how Indigenous people conceptualised risk and their risk when travelling for birth. That being said, the objective of this study is to collaborate with Indigenous people to determine how they conceptualise health and risk before and during the COVID-19 pandemic in the context of reproductive care and travelling for birth, and how this impacted their decision-making. Understanding how Indigenous Peoples conceptualise health and risk from a social, cultural, traditional, and community standpoint will support our goal to help inform policy and program change that return health and care home to Indigenous communities.

Methodology and methods

Ethics

Our research project was approved by the Health Sciences and Affiliated Teaching Hospitals Research Ethics Board at Queen’s University, reference number 6,035,334. Also, the project was guided by the knowledge and wisdom of Indigenous bioethicist and author, Dr. Lisa Boivin, PhD, who helped us ensure that we uphold Indigenous ethical principles in all aspects of our research.

Indigenous feminist theory

Our study employs Indigenous feminist theory as a critical framework to examine how the experiences of Indigenous people who faced mandatory evacuation for birth during the COVID-19 pandemic is impacted by settler colonialism. While using Indigenous feminist theory to understand and challenge settler colonialism, our focus is on sharing the stories of Indigenous Peoples to showcase their resistance and strength to challenge ongoing attempts to their erasure. Notably, Anishinaabe scholar and feminist, Tricia McGuire-Adams, explains that Indigenous feminist theory focuses on the struggle for sovereignty and decolonisation while supporting the revival of Indigenous communities [20]. With a greater understanding of the ongoing impact of colonisation on Indigenous communities and on mandatory evacuation for birth, our goal is to speak out against injustices and challenge health and care structures that maintain settler colonialism [20].

We applied Indigenous feminist theory using an Indigenous reproductive mobilities framework as described by Indigenous researchers Cidro, Bach, and their settler colleague Frohlick [21]. In their scholarship examining Canada’s mandatory evacuation policy for birth, the authors applied a lens of feminist Indigenous reproductive mobilities to consider how travelling for birth is embedded in “historical colonisation, ongoing settler colonialism, white dominance, and national-patriarchy” [21] (p174). Particularly, feminist Indigenous reproductive mobilities examine how movement works in a globalising biomedical healthcare and therapeutic systems [21]. In the context of mandatory birth travel for Indigenous people in rural and remote regions, this framework helps us determine how evacuation for birth is a type of displacement, dispossession, and subjugation of Indigenous knowledge and traditional birth practices [21]. As a strategy to understand and counter these systems, a feminist Indigenous reproductive mobility framework can facilitate the conditions in which Indigenous people are empowered to reclaim their bodies and their birthing experiences by mobilising desire-based and culturally-based care in their communities [21]. So, we applied Indigenous feminist theory and a feminist Indigenous reproductive mobility framework to understand how the COVID-19 pandemic impacted Indigenous Peoples’ conceptualisation of health risk when travelling for birth and to identify strategies to help return care home.

Indigenous feminist methodology

In order to centre the experiences of Indigenous Peoples and to share them genuinely for the purpose of advocacy, policy change, and to uplift Indigenous people to know what their rights and choices are, our study applies an Indigenous feminist methodology. Indigenous research methodologies support research that is ethical for Indigenous communities, recognize the importance of relationality and kinship, and prioritise Indigenous ways of knowing [22]. For instance, Indigenous feminist methodologies are used to apply Indigenous ethical principles that support Indigenous Peoples to exercise control over information relating to their knowledge and experiences [23]. By bringing together a team of Indigenous midwives, healthcare providers, bioethicists, Elders, students, researchers, and community members to guide our project’s inception and implementation, our work uplifted Indigenous Peoples in determining how the project unfolded and it provided Indigenous people opportunities generated from the research [23]. For instance, our team prioritises the mentorship of students to uplift them in their work advocating for Indigenous Peoples. Speaking to the importance of mentorship in Indigenous research, Knowledge Gifter Sherry Copenace says: “If there are certain people who want to work with you, then it becomes your responsibility to pass on that knowledge so our way of life can continue forever” [22] (p194).

To further consider how Indigenous ethical principles can be applied in our research while working in a Western academic knowledge system impacted by colonialism and racism, we partnered with Indigenous bioethicist Lisa Boivin, PhD. Understanding that Indigenous ethical principles for research are different and much more comprehensive than university ethics, Dr. Boivin guided our project to ensure that we were responsible in how we care for Indigenous community knowledge and the people involved in our work [22]. Our research employed Indigenous feminist methodologies to highlight relationality and kinship in the stories shared. Copenace underscored the importance of recognizing stories and relationships that prioritise Indigenous ways of knowing in research and wrote: “[Make] space for whatever knowledge they have, [so] they can share it in a good way- and not just for a specific amount of time (.)” [22] (p194). To do so, our research approach prioritised open-ended discussions with Indigenous people who were evacuated for birth and conversations with Elders, family members, or support persons of people who travelled for birth. In fact, Elders and grandmothers: “are key knowledge holders and researchers, key in knowledge sharing” and their contributions were strongly valued in our project [22] (p196). People of all gender and sexual identities were invited to participate. Copenace et al. noted the importance of engaging people of all genders including men, who in some teachings and ceremonies, were part of birth work and preparation for birth [22]. Similarly, Denetdale suggests that feminist Indigenous practices include gender diversity to examine the intersection of gender with Indigeneity and to celebrate genders beyond the binary of man and woman [24].

As an important principle of feminist Indigenous research methodology, our project prioritised reciprocity [22]. To demonstrate reciprocity to participants, participants were offered an honorarium of $50 and Elders received $500. Each participant also received a gift prepared by Dr. Karen Lawford containing tobacco, beads, fabrics, and more. Offering this gift was in recognition of participants’ time and knowledge while acknowledging the powerful role of ceremony when performing research [22]. Our team’s final and ongoing commitment to reciprocity is demonstrated through our continued advocacy to return care and health home and to reciprocally share the fruits of our efforts with Indigenous communities.

Study objectives

Our study’s objectives are (1) to understand how Indigenous Peoples in Ontario conceptualise pregnancy-related health risk and how this informs their navigation of health measures before and during the COVID-19 pandemic, (2) to document the strategies employed by Indigenous Peoples to maintain their spiritual, emotional, physical, and mental health and wellness when facing evacuation for birth and how this was affected by the COVID-19 pandemic, and (3) to explore the effects of the COVID-19 restrictions in relation to evacuation for birth and its impacts on the cultural webbing of Indigenous communities in Ontario during the perinatal period. While our study had distinct goals, we do not seek definitive or static answers to our research questions. Employing Indigenous theories and methodologies, we are instead dedicated to hearing, sharing, and uplifting the stories of Indigenous Peoples.

Participants

People who self-identified as Indigenous (First Nations, Métis, and Inuit) and who experienced evacuation for birth in Ontario, Canada during the COVID-19 pandemic were invited to participate in our study. Also, partners or family members of Indigenous people who were evacuated for birth in Ontario during the COVID-19 pandemic were eligible to participate. Our focus was on those who lived in rural and remote areas and who have experienced, or supported someone who has experienced, evacuation for birth during the COVID-19 pandemic. Anyone under the age of fifteen, or who did not have the capacity to consent was excluded from participating.

Methods

To recruit participants, we used social media, emails, and word of mouth. To begin, study details and recruitment posters were circulated within the well-established Indigenous midwifery and registered midwifery network in Ontario through communications shared by the Association of Ontario Midwives (AOM). More specifically, the AOM sent an email with our study’s recruitment documents to all registered midwives (n = 1,012) and Indigenous registered midwives (n = 65) in the province and they were encouraged to share our study with their clients. Study details were shared using social media channels like Facebook and Twitter. To share the study by word of mouth, an Indigenous midwife and member of the research team shared details of the study in 2022 with Indigenous people attending a pow wow, an Indigenous gathering where people come together to engage in traditional practices, share food, and celebrate their culture. Finally, we asked Community Health Representatives in rural and remote reserves to share study details with members of their community. Some participants who were recruited to our study knew of other community members who met the inclusion criteria and who would be interested in participating. In total, 11 participants were recruited who were evacuated for birth during the COVID-19 pandemic or who were in the early postpartum period when the pandemic was officially declared. We were able to recruit another five participants, including grandmothers, grandfathers, and siblings, whose family members were evacuated for birth during the COVID-19 pandemic. From the stories shared by these 16 participants, thematic saturation was achieved.

Once participants were recruited, their informed consent was obtained to participate in interviews and for the interview audio to be recorded. Semi-structured interviews were performed in-person in rural or remote communities by Carol Couchie, an Anishinaabe Elder midwife, and inspired by an interview guide that we developed for this study (Appendix A). Two participants were interviewed using Zoom technology and these interviews were led by Anishinaabe midwife and scholar, Dr. Karen Lawford. Using a semi-structured interview guide, participants were asked open-ended questions to determine the impact of the COVID-19 pandemic on mandatory evacuation for birth and their conceptualization of health risk. As needed, participants were asked additional questions to encourage an in-depth response. Our goal was to allow participants to guide the discussion, share their experiences openly, and to genuinely tell their stories.

Data analysis

After the interviews were completed, audio recordings were uploaded to Otter AI, a virtual transcription service. Otter AI automatically generated a transcript from the audio files. Each transcript was reviewed with its associated audio recording to ensure the accuracy of transcription. As transcripts were reviewed, participants were assigned a numeric code. Before beginning data analysis, each transcript was returned to the participant for review, edits, or deletions to ensure the participant had access to and control over their interview data. Once participants approved their transcripts, the research team performed a data familiarisation activity where each member was assigned a number of transcripts to read and to reflect on the experiences of participants. After sharing general findings from the transcripts reviewed, a strategy for data-analysis was created and the analysis began.

First, interview transcripts were transferred from Otter AI to Dedoose, a qualitative research coding application. To analyse the data, we used reflexive thematic content analysis as described by Braun and Clarke [25]. In reflexive thematic analysis, researchers must first meaningfully reflect on their own positionalities and the power relations in the project [25]. Considering that both team members performing the data analysis, Melanie Murdock and Dr. Erika Campbell, identify as white settler women, Sarah Durant, an Indigenous university student from Akwesasne Mohawk Territory, oversaw the data analysis. In fact, we used member-checking throughout our analysis to ensure that the themes we identified in the transcripts accurately reflected the experiences shared by Indigenous participants. During our analysis, we identified shared meanings and experiences across transcripts from which initial codes were generated. Once all transcripts were coded, the coding was reviewed by another team member to ensure accuracy and to facilitate a group discussion of what themes were emerging. We used this approach to encourage an organic emergence of themes that genuinely reflected the experiences of participants. Once themes and sub-themes were collaboratively identified and reviewed by the research team, representative participant quotes were collected for each theme. Finally, themes were examined using Indigenous feminist theory and feminist Indigenous reproductive mobilities as critical frameworks to explore their social implications [26].

Results

Before the onset of the COVID-19 pandemic, Indigenous Peoples evaluated the risks of travelling for birth including the possibility of needing to travel alone without an escort, the impact of being away from their children and families while they were evacuated, and the quality of care they received in large urban centres. For many Indigenous birthing people, travelling for birth became normalized as the only option to receive birthing care, and its many harms became necessary challenges to overcome in order to access health services. During the COVID-19 pandemic however, the risk of viral infection and the impact of public health restrictions were an added risk for Indigenous Peoples to evaluate when travelling for birth or perinatal care.

Evaluating COVID-19 as an added risk

When making decisions for their prenatal, birthing, and postpartum care, Indigenous parturients perceived COVID-19 as an added risk to travelling outside their community and perceived the virus, and associated public health restrictions, as added risks to their own health and to their newborns’ health.

Risk of contracting COVID-19 made travelling outside the community riskier

During the COVID-19 pandemic, people were instructed to limit their travel and movement outside their home community. However, for Indigenous parturients living in rural and remote communities, they continued to face mandatory evacuation to give birth in large, urban tertiary-level hospitals. In preparation for this mandatory evacuation, some participants described trying to travel to smaller urban centres to avoid large ones. They also wanted to avoid being evacuated to communities where there were high rates of COVID-19 infections. When asked about the risk of travelling to a larger city, one participant shared how COVID-19 impacted their decision-making:

When COVID started, it was like: ‘Don’t go to Sioux Lookout [Ontario], there’s a lot of cases there.’ Like we… I was scared to go to Sioux Lookout and that was where I felt the most safe. Because my… when I had my third child, I started the Suboxone program and I felt safe in Sioux Lookout because of that. That was my safe spot and when COVID hit, it was like we can’t go to Sioux Lookout anymore because like, we could get sick. (Participant 14, Evacuee)

As a result of high rates of the COVID-19 virus, Indigenous people had to make decisions to avoid urban centres with high rates of infection and were unable to access health services and supports. Even though the above participant wanted to access the Suboxone program in Sioux Lookout, they evaluated the risk of catching COVID-19 while traveling as being higher than the possible risks to their health if they didn’t obtain support from the program.

A similar sentiment was echoed across participants who voiced a concern for contracting the virus while travelling to larger cities for specialised prenatal care or to give birth. For instance, one parent shared:

I’d be more scared there [in the larger city]. Because here [in my community], it was more safe, everyone wears their mask. [Down there] is like nobody wearing a mask and they’d be so close to you (…). Yeah, I think here would be safer for me (…). Even on a plane, just at the airport and stuff, people catch COVID there. (Participant 1, Evacuee)

That being said, Indigenous Peoples living in rural and remote areas were concerned about the risk of being infected with COVID-19, or transmitting the virus to their fetus or newborn, when facing government-mandated evacuation for birth or specialised perinatal care. As a result, Indigenous parturients made decisions to reduce the risk of infection with COVID-19 by choosing to travel to centres with lower rates of infection and by adhering to public health guidelines to protect themselves and their families while travelling.

COVID-19 public health restrictions created an added risk during evacuation

In order to reduce the likelihood of infection with COVID-19 for themselves, their baby, or their family, participants described following public health guidelines and restrictions during evacuation for birth. For example, participants determined that there was an increased risk of contracting COVID-19 when travelling and arriving at their accommodation in the urban centre. To mitigate the risk of contracting COVID-19, they followed public health recommendations on social distancing, isolation protocols, hand hygiene, and mask wearing; however, participants also conceptualised public health restrictions as an added risk that made evacuation even more challenging. For one parent, they shared how they managed the risk of COVID-19 during evacuation and the impact of public health restrictions:

Um… it was quite hard because just going to the hospital you had to go through everything: all the protocols, you couldn’t even go outside for fresh air, and the swab… the swab is awful. Every time, every single time I would say… I just be hurting, because it’s quite hard. Because you have to wait at the lodge too, to get accommodated, for hours. Because when I was staying at the lodge, I had to stay in a room that had no bathroom, no shower. You had to walk down the hall and it was kind of hard going back and forth through the night trying to bathe my four-year-old in the public washroom. (Participant 1, Evacuee)

Thus, public health restrictions during the COVID-19 pandemic made evacuation for birth more challenging to navigate inside and outside of the hospital where they faced necessary but painful COVID-19 testing and restricted movement.

During evacuation for birth, participants felt more empowered when they had the ability to make choices for their health, when they had freedom of movement, and when they could easily access resources to support their wellbeing. Public health restrictions during COVID-19 reduced and/or prevented the ability for Indigenous Peoples to exercise choice and to access what they needed while travelling for healthcare. Furthermore, the burden of adhering to public health restrictions and protecting themselves and their families was often left to Indigenous Peoples to navigate. As described above, urban accommodations were poorly-equipped to support social distancing because people did not always have access to private living spaces, including bathrooms, so people experienced the additional challenge of finding strategies to adhere to public health guidelines to protect themselves and their families.

Even more, the increased pressure on the Ontario healthcare system during the pandemic resulted in a lack of space in hospitals, a lack of staff, and an increased focus on social distancing, which meant that parturients were hurried to leave urban hospitals quickly after birth. One participant remembered how they and their escort were pressured to leave:

For her, she was pregnant also but she was my escort still. She wasn’t due yet (…) and she had to wait outside because she had her bags and my baby in the stroller. And they kept telling her: ‘You gotta… you gotta go, you gotta leave.’ And then she kept messaging me, she said: ‘They’re telling me to leave. I can’t move, I’m pregnant. They see that and I have a baby and there’s big bags of stuff.’. (Participant 17, Evacuee)

By pressuring Indigenous Peoples who were evacuated for birth to leave quickly, they experienced increased stress travelling home while managing their newborn, their belongings, and their own health in the early postpartum. While needing to travel long distances in the early postpartum is already challenging, being hurried to leave increased stress for participants, made them feel unwelcome in urban health centres, and made them feel unable to receive the postpartum care they needed before returning home. In other words, guidelines and restrictions around COVID-19 made evacuation for birth riskier because they needed to navigate protecting themselves and their families with little support, adhere to restrictions without the resources to do so, all the while receiving limited health care that did not wholistically meet their needs.

The COVID-19 pandemic had a negative impact on birthing

During the COVID-19 pandemic, the virus and its associated public health restrictions had a negative impact on birthing for Indigenous Peoples living in rural and remote areas including increased isolation from their families and communities, added fear from the risk of contracting COVID-19, and reduced access to quality care. The pandemic further perpetuated the existing harms of mandatory evacuation for birth and thus, Indigenous Peoples felt that birthing was riskier.

Feeling more isolated from family and community

When facing evacuation for specialised perinatal care and for birth, Indigenous parturients have described how isolating and lonely it is to birth away from their family and community (Kornelsen et al., 2011). Participants who travelled for birth in Ontario during the COVID-19 pandemic experienced even further isolation from family and community and stated that this negatively impacted their pregnancy, birth, and postpartum experience. Due to restrictions on unnecessary travel in the province of Ontario and hospital visitor restrictions, some participants were not allowed to have a support person or family member escort them when travelling for birth. Notably, when explaining how evacuation for birth was different during the pandemic, one parent said:

From my other trips? (…) [It was different because I couldn’t have visitors, like anyone to come and… Like in the hospital, or around, over there for like a week or so because [the baby] was sick. So, I was by myself. (Participant 13, Evacuee)

Not having the ability to travel with a loved one or to have a support person in the hospital made evacuation lonelier during the pandemic. The theme of isolation is illustrated by Dr. Lisa Boivin in Fig. 1.

Fig. 1

“Uproot, to remove from home” (Lisa Boivin, 2023). This image illustrates the stark reality of giving birth in a hospital away from community. The cold colors purposely capture the isolation experienced in a bare hospital room; a birthplace imposed by mandatory evacuation during the COVID-19 pandemic. The image serves as a conceptualisation of risks related to evacuation for birth during the pandemic. For example, the artwork illustrates a lack of communication, such as not being informed appropriately of COVID-19 protocols, and a lack of care pre- and post-birth. I emphasize the past and present vulnerabilities that Indigenous women and birthing people experience in clinical spaces at the hands of healthcare providers. People have been sterilized; babies are apprehended. These vulnerabilities are heightened when family and community are not around. To secure safe healthcare for Indigenous patients, such harms cannot be forgotten (Lisa Boivin, 2023)

Another participant explained why COVID-19 made evacuation for birth harder:

It was just me in my hotel room almost a whole month. I just stayed in my room. (…) I would walk across this street by myself to go eat because I wasn’t getting meals at the hotel I was staying at. (Participant 8, Evacuee)

In this case, the participant identified how COVID-19 restrictions led to increased isolation from family during travel for birth, more loneliness during their hotel stay, and more difficulty accessing support in the city alone during the pandemic. Other participants echoed this sentiment and confirmed that hospitals were not allowing extended family, like parents or grandparents, to enter the hospital. One participant whose grandchild was born during the pandemic explained:

I think it was COVID that [was the risky part because] they were like… they didn’t want anybody in the hospital, you know, that wasn’t supposed to be there. Like it would be just [the pregnant person] and they eventually let my son. So, my son had to… he went in until she left. He had to stay in the hospital. (Participant 9, Elder and grandparent)

Because of COVID-19 restrictions in hospitals, people were not always able to have support persons during birth and the resulting solitude was perceived as risky by parturients and by their extended family members. Having extended family with them in the hospital was important for participants to feel safe, loved, supported, and surrounded by tradition during and after birth. Added restrictions also meant participants were required to leave older children at home during their travel and parents expressed the difficulty in leaving them behind. Moreover, participants spoke negatively about the isolation experienced by their newborn, who would normally be introduced to family and community members in the first days of their lives. The evacuation policy, combined with added hospital restrictions during the pandemic, created an accentuated environment of confinement for those who travelled for labour and birthing services.

When participants returned home to their community, increased isolation due to COVID-19 public health guidelines continued. For Indigenous Peoples travelling home after mandatory evacuation for birth, they were required to undergo COVID-19 testing upon arrival in their community and to self-isolate in their home. One participant said: “Um, I think we got tested when we got back [home], when I got off the plane. But we still had to isolate for two weeks after that” (Participant 1, Evacuee). As expressed by many participants, being in isolation at home when returning from an urban centre was a lonely experience because they were not able to visit with family, to introduce their newborn to the community, nor receive support from others in the early postpartum.

Fear of contracting COVID-19

During the COVID-19 pandemic, all pregnant people were identified as being high-risk of severe COVID-19 infection. Participants described being more fearful during pregnancy, birth, and the postpartum period because of the risk of contracting the virus and this feeling negatively impacted their perinatal experience. For example, one participant shared that their fear of COVID-19 was one of the most difficult parts of the pandemic:

Yeah [it was hard] because with my third [baby] we were… we were the first family to have COVID when it first came, when there was no vaccines. And it was so scary that time (…). We weren’t the first people to bring it in, but we were the first family to have it. You could probably ask them, you know? (Participant 15, Evacuee)

For this participant, contracting COVID-19 during pregnancy was especially scary in the beginning of the pandemic when there was little information about vaccines, how to protect themselves, how to care for themselves when healing from the infection, and the potential impact of infection on their unborn baby. Also, the stigma of being infected with COVID-19 meant that participants were fearful of contracting the virus because others would be afraid to interact with them, which results in even more isolation from loved ones. Alongside the fear of contracting COVID-19 in pregnancy was that of being exposed during evacuation for birth.

Another participant explained that they were afraid to interact with family, friends, or loved ones who could expose them and their baby to the virus during the postpartum period and said:

Yeah and I didn’t know what to do at home and like didn’t… I couldn’t… I was scared to ask people to like come and help me and come do things with me, or for me, because of COVID and I’m not sure if they had it or not. (Participant 2, Evacuee)

Because of the increased risk of contracting COVID-19 and the fear of being exposed to the virus, some participants avoided asking for help in the postpartum period. As a result, many participants experienced the postpartum period in isolation and did not receive support from others, spend time with loved ones, or access healthcare in their community. During the postpartum period, it is important for parents to safely access support in caring for their newborn and in maintaining their own wellbeing; however, the pandemic created an additional barrier for Indigenous Peoples to be supported during the postpartum period, which negatively impacted their wellbeing. The same participant as quoted above confirmed that having a baby during the COVID pandemic was worse than before the pandemic and shared:

When she was a baby, I couldn’t go out. Or like sometimes, they weren’t even sure if you could like leave your house. Like nobody knew how it started. Like everyone was freaking out at first thinking it was just in the air or something. My brain thought that for quite a while (…) and yeah, I was just not [visiting people]. But I was staying at home all the time (…) I was kind of like scared all the time. (Participant 2, Evacuee)

That being said, the risk of being exposed or infected with COVID-19 negatively impacted Indigenous Peoples’ experiences of pregnancy, birth, and the postpartum period by causing increased fear among parturients.

Not being able to access the care they need and want

Another difficulty experienced by Indigenous participants was that the COVID-19 pandemic made it more challenging to access the health care they needed and wanted in their community, or in urban centres.

Lack of care in communities

During the pandemic, many healthcare centres across the province prioritised emergency care in an effort to safeguard resources, staff time, and space for patients being treated for COVID-19. This prioritisation meant that many non-urgent healthcare services were either unavailable or less accessible for patients, including access to perinatal care and other healthcare services. In rural and remote Indigenous communities, participants shared that the pandemic increased the risk of not being able to access the health care services they needed and wanted. For instance, one participant with a history of postpartum depression shared:

But the nursing station, I did tell them with my (…) second youngest that I was starting to feel… I thought it was postpartum depression. And they didn’t take it seriously. And then, I had my last child, and I feel like I have… I had it bad with him. And because of COVID, I couldn’t do anything about it. So, I just felt like I had to suffer through it. (Participant 15, Evacuee)

When healthcare services prioritised urgent care and caring for COVID-19 patients during the pandemic, services like postpartum support were more difficult for participants to access. For this participant, not being able to access care for postpartum depression meant that they were unable to receive support and that their depression was worse than with their children born before the pandemic. Other participants confirmed that postpartum healthcare was limited in rural and remote communities during the pandemic such as support with chestfeeding, social support, and mental health support. Participants who were pregnant during the pandemic also noted a reduction in health promotion programs in their communities. While some were able to access virtual programs like prenatal education, birthing classes, or lactation classes, others were unable to access any programming at all. Because accessing care and health programs was more challenging, participants described having experienced an increased risk of not receiving timely healthcare in their community and of navigating health concerns alone.

Lack of resources in urban centres

In urban centres experiencing high rates of COVID-19 infections and decreased hospital capacities, resources for Indigenous Peoples who travelled for specialised care was limited. While people who were travelling for birth were considered urgent patients and were provided care in the hospital, some participants described not being able to access specialised routine perinatal care in urban centres. For example, one parent shared their experience of travelling for ultrasounds in previous pregnancies because urban centres had more specialised high-technology ultrasound machines. However, travelling for ultrasounds was not permitted for their pregnancy during the pandemic and they said:

Yeah with (…) my last kid I had to stay here until I…till I left. So, I was unable to go to town and have ultrasounds [because of COVID]. I have to go to the nursing station to have my ultrasounds. With my first two kids, I was able to go out of town and have the proper care. (Participant 1, Evacuee)

In this case, the participant wanted to travel to an urban centre during the pandemic to receive higher-quality ultrasounds than what was routinely offered in their community. However, because of COVID-19 restrictions for travel, this participant had no choice but to receive what they believed was the substandard care offered in their community. For participants who did travel to urban areas, they noticed a decrease in staff and resources in hospitals. So, participants understood that COVID-19 increased the risk of receiving suboptimal care in urban hospitals and/or being denied access to the care they desired because of staffing issues and/or pandemic-related isolation measures.

Discussion points

Competent response

Indigenous people who experienced mandatory evacuation for birth during the pandemic conceptualise this Government of Canada policy as riskier during the COVID-19 pandemic compared to pre-pandemic experiences. Through constant assessment and evaluation of the risk of exposure to coronavirus when travelling for birth, Indigenous parturients juggled the isolating impacts of public health restrictions and making decisions to mitigate their risk of infection, all while desiring to receive health and care that best supported their perinatal needs. Their decision making was informed by publicly available information and guidance with respect to the pandemic, and reflected their contextual perinatal healthcare needs in conjunction with their family and community safety, and with available healthcare services within and outside their community.

Individual and communal resistance

Perinatal healthcare services for Indigenous people who were evacuated for birth during the COVID-19 pandemic were less available and less resourced by healthcare professionals. Our study findings demonstrate that participants showcased incredible individual and communal resistance in the face of a pandemic and actively advocated for the care they wanted and needed. So, in addition to managing the usual lack of wholistic support and care while travelling for birth in Canada as an Indigenous person, the participants displayed astounding agency in protecting themselves and their families from COVID-19 despite their understandable fear of infection. In turn, and in response to the increase in isolation and loneliness, the formation of “bubbles’’, wherein family units supported and provided care to one another while maintaining separation from larger groups, is an example of resistance that is both individual and communal.

Furthermore, many family members of evacuees actively helped their loved ones navigate travelling for birth by assisting with preparations before they leave, escorting them or supporting them virtually while they were gone, and being there to assist them in the postpartum period. When struggling to access support programs during the pandemic, networks of friends, family, and community members became available to share knowledge about pregnancy, birth, and parenting and to guide them in caring for themselves wholistically. These responses show that Indigenous people are deeply engaged in their healthcare as individuals and at the community level, and is illustrated by Dr. Lisa Boivin in Fig. 2 below.

Fig. 2

“Heart roots run deep” (Lisa Boivin, 2023). This image is lush and represents the support of community. In contrast to Fig. 1, this illustration has a background that is a warm and dark. Darker colors are warm because they absorb light. More importantly life begins in the warm, sacred dark. In this image, roots represent access to family, culture and appropriate healthcare at the sacred time where life begins. Flowers represent medicine and the ceremony of birth while offering protection from infection in urban centers where infection rates were higher during the COVID-19 pandemic. I include strawberries like little hearts to remind us that we are loved and supported by the land as we are by our families and community providers (Lisa Boivin, 2023)

Decreased quality of care

Based on how healthcare systems across the world responded to the coronavirus, as well as the scheduled closure of perinatal care units in Canada, it is not surprising that Indigenous participants in our study reported they did not receive the healthcare that they wanted and needed. Participants recognized that the lack of services is a response exacerbated by the pandemic, but navigated these changes often without the assistance of healthcare providers. In other words, Indigenous people recognize the relationship between travelling for perinatal care and the impact of the pandemic, which resulted in fewer available healthcare services and decreased quality of healthcare. Despite their individual and communal supports, the various healthcare systems remain a challenge to navigate for Indigenous people who participated in our research. In the end, it is clear that the pandemic made travelling for perinatal care more challenging, but the source of the problem is not just a result of the pandemic. Rather, it is the continuation of the Government of Canada’s evacuation policy, which is a contemporary policy underpinned by “historical colonisation, ongoing settler colonialism, white dominance, and national-patriarchy” [21] (p174). We strongly assert that these origins must be recognized and understood; while the general perception is that these ideologies are from a distant past, they remain the foundations of contemporary healthcare systems in Canada that Indigenous Peoples negotiate.

Indigenous feminism and reproductive mobilities

Canada’s mandatory evacuation policy for all Indigenous parturients living in rural and remote communities is a colonial tool that displaces Indigenous Peoples and dispossesses them from their cultural and ceremonial traditions, and their homelands. By not supporting sexual and reproductive care in Indigenous communities and forcing parturients to travel to urban centres for care, the government is displacing Indigenous people because they are being removed from their community and consequently, Indigenous self-governance and self-determination is impeded. Moreover, the colonial healthcare system promotes medicalization and devalues the knowledge and skills of Indigenous birth workers, including Indigenous midwives. We strongly assert that the settler state is continuing to force Indigenous Peoples to conform to a Eurocentric biomedical model of care, to subjugate Indigenous knowledges, and to systematically erase traditional birthing practices.

In the context of the COVID-19 pandemic, people across Ontario were ordered to stay at home unless accessing essential services and to avoid travelling outside their home community. For most Ontarians living in the southern part of the province, hospitals were still accessible within 30 min from home compared to Ontarians living in the central and northern areas, or compared to rural and remote Indigenous communities who must travel more than 120 min to access a hospital [27]. Indigenous Peoples living in rural and remote communities, however, were not given the choice to limit their travel during the pandemic because they were forced to be evacuated to a distant centre to give birth. In doing so, the mandatory evacuation policy exposed Indigenous parturients and their families to a greater risk of contracting the coronavirus while travelling to centres with higher rates of COVID-19 infection. Also, after travelling for birth, Indigenous parturients faced an increased risk of spreading the coronavirus in their communities when they returned home. Some participants in our study experienced this problem and were required to be evacuated again to receive care for COVID-19 because their home communities were not equipped with healthcare services to treat severe infections.

In forcing Indigenous Peoples living in rural and remote communities to travel for care during a global pandemic, and not providing them resources or accommodations to keep themselves safe during travel, the Canadian healthcare system was negligent in protecting the wellbeing of Indigenous people and instead discriminated against them by putting their health and wellbeing at risk. The reproductive mobility of Indigenous Peoples was, therefore, manipulated as a colonial tool before and during the COVID-19 pandemic. Understanding how Indigenous Peoples conceptualise risk related to evacuation for birth during this time puts us all in a better position to mobilise desire-based care for Indigenous Peoples.

Conclusion

In our study, Indigenous Peoples describe how they conceptualised health risks when travelling for birth before and during the COVID-19 pandemic. While evacuation for birth is presented to Indigenous Peoples as an opportunity to access modern medicalized obstetrical care and to decrease their health risks, participants share how the coronavirus made evacuation for birth even more risky due to the risk of infection with COVID-19 to their health, the challenge of increased isolation, increased feelings of fear, and the lack of access to quality healthcare. Despite this, people impacted by the evacuation policy demonstrate resistance and agency in protecting themselves and their families while advocating for support that meets their needs.

As a colonial tool to the displacement, dispossession, and subjugation of Indigenous birthing practices, Canada’s mandatory evacuation policy was exacerbated by the COVID-19 pandemic and increased the risk of travelling for birth for parents, their children, their families, and their communities. To achieve change that better meets the needs and desires of Indigenous parturients living in rural and remote communities, Indigenous Peoples should lead discussions on the type of health care they need and want. By consulting Indigenous Peoples and making visible how they imagine desire-based health and care, recommendations can be made to policy makers and governments to facilitate much needed changes to Canada’s mandatory evacuation policy and to better support people while travelling. We acknowledge that travelling to hospitals in larger centres will continue to be appropriate for people needing specialised perinatal care and we support the decision of those who choose to travel for birthing services. We continue to strongly advocate for the Government of Canada and everyone involved with healthcare service delivery to engage with Indigenous Peoples in making visible the next steps to better support Indigenous self-determination in health.

Strengths & limitations

Our study is limited by the impact of colonial narratives around health and the lasting impact of colonial assimilation strategies. After generations of being subjected to mandatory evacuation for birth, some participants found it difficult to imagine receiving perinatal care any other way, or they perceived biomedical care to be normal and their only option. However, many participants recalled stories of Indigenous midwives who attended deliveries in the community and they dreamed of returning birth home. Our study has many strengths including our application of Indigenous Feminist Methodologies which supported us to consult Indigenous Peoples in a culturally sensitive and respectful way. We engaged directly with people who were impacted by the evacuation policy during the COVID-19 pandemic and used a wholistic, strength-based approach to showcase their knowledge and experiences in this piece. Indigenous ways of knowing were foundational to our research design and supported us to collaborate with all research partners reciprocally, including participants. We believe that our work and our findings are strengthened by our approach, our commitment to Indigenous ethical principles, and our dedication to mobilizing the knowledge gained to achieve meaningful change.