Making a difference in remote Inuit communities: The Inuulitsivik

Midwifery ServiceBrenda Epoo, RM

Elisapi Tukalak, SMSerge Provencal, DHS

P-1131

Introduction

• I am Brenda Epoo from Inukjuak a small village in the remote Arctic region of Nunavik,Quebec

• I am the coordinator of Inuulitsivik Perinatal Services on Hudson Bay coast

• I will talk about our history, philosophy & outcomes

• Elisapi Tukalak from Puvirnituq, is the Inuulitsiviksenior student midwife and will talk about oureducation program

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Arctic communities/Inuit life• The Inuit peoples of Canada live in Nunavut, Nunavik,

Nunatsiavut , and the Inuvialuit region• We are part of northern circumpolar peoples• The Inuit population in Canada is > 69,000• We live above the tree-line on the tundra • Our coastal communities accessible only by plane • Traditional culture and way of life is still strong-

hunting and fishing is important to our way of life• We are living with the impact of colonialism and

rapid cultural change

History and philosophy • The midwifery service started in 1986 in Puvirnituq

prior to midwifery regulation in Canada• We grew to include birth centres we call “Maternities”

in Inukjuak (1998) and Salluit (2004)

• Women from the smaller villages come to one of the birth centres at 37-8 weeks for birth

• The Maternities were inspired by community organizing by Inuit women’s organizations to stop sending pregnant women to southern hospitals

• Linked with strengthening Inuit culture and healing from colonization

HISTORY AND BACKGROUNDA PROVINTIAL EVACUATION POLICY FOR ALL PREGNANT WOMEN BEGAN IN 1970’S WITH THE ASSUMPTION THAT SOUITHERN HEALTH CARE WOULD BE BETTER FOR INUIT WOMEN AND FAMILIES

Birth away from home

Increased social and medical risk:• Women lost self-confidence and confidence in birth• Communities lost traditional knowledge about birth • Family stress because mother away 4-8 weeks• Woman had poor diet away from home• Substance abuse increased away from home• High rates of intervention in birth • Loneliness, lack of information, support and respect• Loss of cultural values and meaning

Background• Our team of 14 midwives serves 7 villages on the

Hudson coast (population 6,700) each with a small health centre

• The largest health centre is in Puvirnituq (PUV) with 25 inpatient beds & an emergency jet landing strip

• Doctors are available in 24/7 in PUV, in Inukjuak and Salluit 9-5, and take turns being on call by phone for the smaller villages

• Blood, laboratory & newborn admission in Puv only• OB consultation, cesarean section is available in

Montreal by plane 1,500 -2000 kms away• Average transport time is 8 hours weather permitting

History and philosophy • Inuulitsivik Health Centre (IHC) is governed by an Inuit

community board• IHC is committed to the education of Inuit health

workers and to community development • There were consultations with elders, childbearing

women and young women to establish the Maternities• The IHC midwifery service is supported by community

leaders, physicians, nurses • IHC is dedicated to preserving and using traditional

Inuit midwifery knowledge and skills

History and philosophy

• The first Inuit midwifery students were selected by the community

• Qallunaaq (non-Inuit) midwives were hired to support development of Inuit midwifery service

• One of the leaders Mina Tulugak said:“we tried to find teachers who understood that their role is to teach and not to lead”

• Midwives and student midwives worked together as a team to provide care

Midwifery-led Interdisciplinary Model

• Midwives are the leaders of care for maternity, well woman and newborn care

• Midwives work closely with health & social services

• Midwives do prenatal, postnatal, newborn & sexual health care for the whole population

• Midwives have a broad scope of practice and do community health, well woman and baby care

Place of birth

• Low risk births are planned in Inukjuak and Salluit

• Low and medium risk are planned in Puvirnituq, weather permitting

• Midwives in all villages have to be prepared to care for births at all levels of risk

• Weather, preterm labour and emergencies may not allow transfer

Outcomes 2000-2018

Methods

• We did a retrospective review of all births from 2000-2015

• Statistics forms are completed after each birth and at 6 weeks postpartum

• Statistics are entered into an Access© database• We checked for completion by comparing with

Municipal pregnancy lists & Maternity birth books and did we logic checks to clean the data

• Outcomes for 2000-2007 published in Birth 2012• This is the first presentation of the 2008-15 data

Place of Birth and Birth Attendants

• We studied outcomes for 2725 births • 86% of births were in Nunavik

• 63% were in the resident’s own village• Inukjuak 76%, Puv 92%, Salluit 67%

• 14% of births were outside of Nunavik• in Montreal or other southern hospital

• 86% of births were attended by midwives• 75% of births were attended by Inuit Midwives • Doctors attended 14% of births and nurses <1%

Demographics and Risk Factors• Average age at birth is 25 years, primips 20 years• 99% are Inuit, 73% are multips• Midwives care for all levels of risk• Common risk factors are:

• Anemia 52%• STIs 20%• UTIs 11%• Hypertension 7.4%• Smoking 85%• Alcohol 20%, Drugs 12%• Gestational Diabetes 3%

Labour and Birth

• Spontaneous vaginal birth 97%• Augmentation 6%• Cesarean sections 1.9%• Epidural 4.5%• Preterm birth 10.4%• Breech 2.5%, twins .9%• Meconium 5.5%, abnormal FHR 1.4%

Maternal Postpartum

• Perineum intact in 71.6% of cases• 1st/2nd degree tear in 20.5% of cases• 3rd/ 4th degree tear in 8% of cases• PPH happened in 15% of cases• Estimated blood loss over 1000 mls in 8.2%• Manual removal of placenta in 3.7%• Blood transfusions in 1.4%

Neonatal

• Average birthweight 3366 gms, >37 weeks 3460 gms• Intra Uterine Growth Retardation in 1.6% of cases• Low Birth Weight (<2500 gms) in 4.9% of cases• Large Gestational Age (> 4000 gms) in 9.7% of cases• Apgar < 7at 5min in 1.4% of cases• Babies had congenital anomalies in 1.8% of cases• There were 13 stillbirths and 9 neonatal deaths• Perinatal mortality is 7.7 per 1,000 (12.9 in Nunavut)• Most of our perinatal deaths are preterm babies

Transfers• 23% of births involve transfers

• 30% of transfers are to PUV • 70% are to Montreal

• 43% of transfers are antenatal • 14% are intrapartum• 3.8% are maternal PP• 10% are neonatal

• 60% of transfers are planned or non-urgent• 10% of all cases involve urgent transfer

Reasons for TransferAntenatal • Suspected preterm labour or PPROM• HTN/pre-eclampsia • Current medical problems• History of previous PPH, medical problems, previous CS Intrapartum• Preterm labourPostpartum Mother • PPH or retained placenta• 4th degree tearNeonatal • Preterm birth• Suspected infection• Congenital anomaly

Learning to be a Midwife in Nunavik

Elisapi TukalakStudent midwife

Nunavik students’ quotes

“Midwifery is an interesting job. I wanted to see babies be born. I wanted to help women stay in

the community for birth and stay with their families.”

• “Midwifery chose me. I would be very upset if I couldn’t [give birth in Salluit] because I would not have anyone around me to help when I go into labour. I need a lot of help. It comforts me.”

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Midwifery Education in Nunavik

• Inuulitsiviup Nutarataatsijingta Ilisarningata Aulagusinga started before the recognition of midwifery in Canada

• Student midwives learn in their own communities

• Education is offered as part of the midwifery service

• Our program is recognized by the Ordre des Sage-Femmes du Québec for registration as a midwife

• We are supported by faculty from Midwifery Education Programs at universities across the country

• Students learn from midwives & inter-professional team

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Ways of learning

Our program• has a competency-based curriculum • has learning through mentorship in practice• has content consistent with southern midwifery education

programs• is adapted for realities of practice in remote setting • is adapted for expanded roles & scope of practice compared

to southern Canadian midwives• has Inuit culture as the foundation of practice and education

Structure of the program

• Clinical skills lists are signed off by mentors as observed, performed with assistance or competent

• Structured modules, workshops and quizzes cover academic learning at four levels

• Students keep a birth journal and birth evaluations • Student binders are reviewed regularly• Students do final oral, written and OSCE exams for graduation• Students attend at least 40 primaries and 60 as baby midwife

– most attend over 100 births by graduation

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Inuit knowledge & ways of learning

• Learning is in Inuktitut whenever possible• Learning starts with observation: “being shown rather than

being told”• Learning is by doing: clinical care and hands on practice • We use story-telling, oral teaching and case reviews • Most mentors are Inuit midwives who pass on cultural

knowledge about pregnancy, birth and caring for babies• Students also learn from the communities’ elders• Program is flexible to student’s family roles and participation

in community and culture

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Midwifery Education in NunavikLa pratique des sage-femmes au Nunavik

• Learning by mentoring just as Inuit midwives have always learned

• 11 Inuit midwives and 10 Inuit students in training

• Inclusion of traditional and modern knowledge about pregnancy and birth

• La formation des sage-femmes est inspirée par la pédagogie Inuit

• À date il y a 11 sage-femmes et 10 étudiantes Inuites

• Environ 3000 naissances ont eu lieu dans les Maternités

Expanded Roles and Scope of Practice

• Students learn community health role of midwives• They participate in and lead health education and health

promotion activities • Students and midwives work in close partnership with public

health workers and teachers on sexual health, nutrition, addictions, FASD

• Student midwives are very active in community education through schools and community events

• Students learn well woman care PAPs, STI screening, and contraception

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Expanded role and scope of practice

• Students are educated to play an expanded role in emergency care

• Students do NRP and Nunavik ESW at least every 2 years • Students must pass Nunavik ESW and NRP before graduation• Students must show they are able to lead care in emergencies

and complex cases before graduation and that they can work with the inter-professional team

• For example students learn to provide care prior to transfer in PTL, pre-eclampsia, PPH, care of pre-term babies

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Inuulitsivik Emergency Skills

Workshop

• Adaptation of CAM ESW, ALARM and ALSO, NRP, to remote practice

• Focus on when to transfer/ management prior to transfer

• Expanded scope for midwives e.g. vacuum, manual removal of placenta, intubation, umbilical vein catheterization, care during miscarriage

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Challenges of local education

• We have no dedicated funding for teachers• Education is supported by the clinical budget • It is a challenge for mentor midwives to balance

clinical care responsibilities and education• There are few resources for student midwives

working in remote setting• Work and learning is often across language and

culture

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Strengths of Local Education

• Students get financial support from the regional government and health board and are employed members of the health care team

• Local education provides access for women who are responsible for families and have strong ties to the community

• 17 graduates from 4 villages and 10 students• Local education is part of strengthening Inuit culture

and language• Midwives are community leaders

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Strengths of local education

• We have much less reliance on southern health workers and a more stable team

• Midwifery education in the community means keeping families together

• All benefit from collaboration with the inter-professional team and midwives across Canada

• Local education is part of reconciliation and healing from colonization and residential schools

• Nunavik midwifery education is a model for the local education of Indigenous midwives

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Nakurmik

Meegwetch

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What Makes Inuulitsivik Midwifery Work?

Louisa PauyungieICM June 2017

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What Makes Inuulitsivik Midwifery Work?

Louisa PauyungieICM June 2017

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Because childbirth was a normal part of everyday life,women grew up hearing stories about births.Through these stories, knowledge was passed fromone generation to the next...

“It is a very precious thing to give birth. It needs to be shared within the community. It is good for everyone.”

Salluit elder

Care In Our Own Land In Our Own Culture

• Care provided in Inutitut language by Inuit women

• Culture that sees birth as a healthy part of life

• Culture that values women’s strength and ability to give birth

• Culture of family support during labour and birth

• Community consensus to reverse the harm caused by the evacuation policy

• Confidence in birth and in returning birth to the community

• Pride in preserving and using traditional Inuit midwifery skills

• Pride in local education

Care in our own land and own culture• Health, security, risk, and meaning all defined

within a cultural context• Ongoing community discussion and acceptance of

risks and benefits of birth in a remote community• Inuit worldview sees risk differently – priority is

community cohesion rather than risk management

• Risk is evaluated in relation to the culture and reality of the north, and takes into account a woman’s strengths, supports, and risks of leaving the community in addition to classical risk factors.

46Spontaneous birth

Pain as part of childbirth

Risk in perspective

Spontaneous labour

Intact perineum

Healthy women, babies

Midwifery care Birth as close to homeand family as possible

Culture of confidence in normal birth

Cascade of

Normal

“With all the changes and women going south, the common knowledge, the things everyone knew about childbirth and health, began to disappear . . . People became very dependent on health care services . . .

We knew birth had to come back to the north. Our aim was to revitalize that common knowledge and community involvement around the birth process, to put the responsibility back in the hands of the Inuit”

Akinisie Qumaluk, midwife

INUIT LEADERSHIP

Southern staff turnover is high in northern health care. Our goal was to care for our own people.

INUIT LEADERSHIP

• Maternities initiated by Communities with ongoing input

• Inuulitsivik is governed by an Inuit board

• Inuulitisivik is committed to the education of Inuit health workers

• Inuit midwives are leaders in administration of perinatal services and education of midwives

• Inuit midwives are community leaders, role models and a bridge between cultures

• Local leaders strongly support the midwifery service

Midwifery Led Interdisciplinary Model of Care

• Combined traditional and modern approach to care • Expanded role and scope of practice, including all well

woman care • Midwives follow all pregnant women regardless of

medical condition or social situation• Careful screening for appropriate place of birth • Perinatal Committee: midwives, students and doctors

review together all cases at 32-34 weeks• Careful monitoring of outcomes with ongoing learning

and improvement

• Collaboration with the inter-professional team

• Respect for local midwives

• Support from OSFQ and RSFQ

• Support from southern Canadian and international midwives

• Integration with NACM and CAM

Midwifery Led Interdisciplinary Model of Care

Local Midwifery Education: Key to sustainable, culturally sensitive services

• Traditional pathways to learning: curriculum not separate from lived experience (and like life sometimes messy)

• On the job experiential model respects the social nature of learning and draws on cultural, practical, and individual knowing as well as theoretical and academic knowledge

• Flexible program and support for the needs of students and their families

• Local midwives provide stability and sustainability of perinatal service where turnover of health workers is high

ChallengesDifferent Ways of Knowing, Seeing, Communicating

“We have a lot of good teamwork with the other health workers here, but sometimes it is not always so easy - mostly because few southern people see these things the same way we do...which is not bad really, just different...and it takes patience...”

Lissie Tayara, RM

“Part of the role of the Inuit midwives is translating ideas from western medicine into

practice in their own communities. This is far more difficult than translating words from one language to another,

and is an invaluable skill which should be developed

for the benefit of all”

Fletcher and O’Neil 94Royal Commission on Aboriginal

Peoples

CHANGING TIMES, CHANGING VALUES

CHALLENGES

• Increased exposure to workers with little exposure or understanding of Inuit history, values, social, political or environmental context leads to increased reinfiltration of colonialist attitudes.

• Increasing southern oriented administration at Inuulitsivik tends to devalue language and northern perspective

• Continued lack of funding for education and Inuit administrative staff (no secretary, office, computer etc)

• Growing population and lack of space in all three maternities

• Care is often fragmented from north to south

Challenges

But We are a Resilient and Determined People

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“ I can understand that some of you may think that birth in

remote areas is dangerous. And we have made it clear

what it means for our women to birth in our communities. And you must know that a

life without meaning is much more dangerous.”

Jusipie PadlayatElder, Salluit Health Board

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“To bring birth back to the communities is to bring back life . . .”

Puvurnituq elder 1988

“This story has no ending.

We are on going!”Akinisie Qumaluk, RM

NAKURMIIK

QUESTIONS???