1. More Indigenous mothers travelled 200km or more to give birth compared to non-Indigenous mothers based on proximity to birthing care.
2. Indigenous pregnant people are disproportionately affected by healthcare inequities due to disparities in geographic access.
Evidence Rating Level: 3 (Average)
Study Rundown: Previous studies have demonstrated the importance of access to obstetrical services close to home and emotional support from loved ones. Indigenous Peoples in Canada have an additional cultural component whereby a connection to the traditional land has a social and spiritual impact on birth experience. However, Indigenous people in Canada in rural and small urban areas are faced with geographic challenges due to lack of healthcare and obstetrical services, and often forced to evacuate their traditional territory in order to seek birth support. This study aimed to evaluate the association between Indigenous identity and distance travelled for birth to quantify these disparities.
Data was derived from the Canadian Maternity Experiences Survey (MES) which was conducted in 2006-2007. Respondents were Canadians over the age of 15 who had given birth (defined as mothers). The primary outcome measured was distance travelled for birth and it was found that distance over 200km was more common among Indigenous mothers compared to non-Indigenous mothers in both rural and small urban areas. Independent variables were controlled in the analysis to account for sociodemographic characteristics that may have influenced the birth such as maternal age at birth, marital status, education level, and income. Women were separated into Indigenous and non-Indigenous Canadian born mothers and further stratified into large urban, small urban, or rural living. It was found that within the total cohort, 9.8% of Indigenous mothers travelled 200+ km to give birth, whereas only 2.0% of non-Indigenous mothers travelled 200+ km. Furthermore, in rural areas the difference was even greater with 23.2% of Indigenous mothers compared to 2.1% of non-Indigenous mothers having travelled 200+ km to give birth.
A strength of this study was the extensive nature of its analyses, accounting for many variables such as NICU admissions, and income levels, as well as for covariances in education levels, prenatal hospital stays, history of abuse, maternal stress levels, and delivery type. Despite this however, the outdated nature of the data, collected in 2006-2007 included should be noted as a limitation, as changes in governments in power, policy implementations, healthcare evolution will not be reflected in this study. Another limitation of this study was the dichotomous labeling of participants as “Indigenous” or “non-Indigenous”, failing to differentiate between Métis, First Nations, or Inuit People in Canada. Additionally, First Nations mothers living on reserve were excluded from the initial survey despite the fact that this cohort represented 25% of the total Indigenous population in Canada at the time. Overall, the study demonstrated the dire need for high qualiy, equitable health care services in remote and rural communities and traditional territories. Unfortunately, the healthcare inequalities between Indigenous peoples and other Canadians are well documented, and this instance serves as another example of how systemic racism and social determinants of health present themselves in Canada. Health policies that favour Indigenous people in rural and remote communities are imperative in order to offer quality health services, resources for Indigenous health care providers, and midwifery closer to home.
Click to read the study in CMAJ
United Nations Declaration on the Rights of Indigenous Peoples, www.un.org/esa/socdev/unpfii/documents/DRIPS_en.pdf
Calls to Action of the Truth and Reconciliation Commission of Canada www.trc.ca/assets/pdf/Honouring_the_Truth_Reconciling_for_the_Future_July_23_2015.pdf
Calls for Justice of the National Inquiry into Missing and Murdered Indigenous Women and Girls www.mmiwg-ffada.ca/final-report/
In-Depth [survey]: A total of 6241 (weighted to represent 76 178) mothers responded to the survey which was a representative stratified random sample from the Canadian Census. Of the Indigenous mothers (n=1800), 34.2% lived in rural areas and 65.8% lived in small urban areas. Comparatively, of the non-Indigenous mothers (n=29300), 41.6% lived in rural areas and 58.4% lived in small urban areas (p = 0.06).Multivariate logistic regression stratified the cohort by urban and rural as well as Indigenous and Non-Indigenous identities. Other variables included in successive stratification included distance travelled for birth, maternal health, and infant health. Analysis was done using SAS 9.4. The study found that 9.8% of Indigenous Mothers had travelled over 200km to give birth compared to 2% non-indigenous mothers (odds ratio 5.46, 95% CI 3.52-8.48). In rural areas, this was increased even more with 23.3% of Indigenous mothers travelling over 200km compared to 2.1% of non-indigenous mothers (OR 16.59, 95%CI 8.98-30.65).
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