Outsourcing births

The Network speaks with health advocate Shirley Tagalik about why her northern town is fighting to bring maternity care back to their community

By Signy Gerrard

One year after the high-profile announcement of the Canadian Government’s Maternal Health Initiative, Nunavut health activist, education advocate, and mother Shirley Tagalik wonders when maternity in her community will become a priority again.

Tagalik lives in Arviat, a community of close to 3,000 in Nunavut that is consistently home to Canada’s highest birthrate. Approximately 70 Arviat women give birth each year – but none of them in Arviat itself. Instead, when women reach their final weeks of pregnancy, they pack a bag and get on a plane, to be flown to a larger centre such as Winnipeg or Rankin Inlet and spend the remainder of their pregnancy waiting to give birth in a hospital. These flights are part of northern Canada’s boarding-out medical system, and even for a low-risk delivery, can cost the health system $12,000 and have a new mother spend a month or more away from her home and family.

For a brief period in 2008, however, Arviat hoped that many of these flights might no longer be needed. For a few months, they had a birthing centre under construction, two midwives working, and for the first time in years, three babies born in their town.

These births came after years of hoping and agitating by the town. They first formed a local health committee back in the 1980s to take on the task of lobbying the Northern Medical Unit for a birth centre that would allow pregnant women to remain in the community. When the Nunavut government made local births a priority and began a pilot birthing centre program in Rankin Inlet, they lobbied to make their town home to one of the next Centres. Two decades later, federal funding was finally made available in 2005 and 2006 for Nunavut Arctic College to train midwives and maternity care workers, and for the creation of some new positions in Arviat. One maternity care worker was trained, and funding to renovate their old health centre into a birthing facility was allocated in 2006 - 2007. Two midwives were hired from the south, and along with the local maternity care worker, got to work in the health centre while they waited for the birthing centre construction to finish.

But with prenatal and postnatal care for the 45 women pregnant at any one time in Arviat, births, and community work, all in a cramped shared space, the two midwives quickly found themselves burning out. Even with the support of a maternity care worker, they felt the number of clients they had required a third or even fourth midwife. When more were not hired, one eventually resigned, and the second followed suit shortly after. Instead of restaffing in Arviat, the midwife positions were relocated to Rankin Inlet. Arviat is now served by occasional midwife visits and the remaining maternity care worker. The town’s nurses have taken back all the prenatal care, with the maternity care worker providing assistance with basic procedures and tests like weighing. Renovations to the birthing centre have ceased and the incomplete building sits mostly empty.

We spoke with Shirley Tagalik about what this closing has meant for maternity care, health care, and the community as a whole.

Network: What was it that the midwives brought to Arviat?
Tagalik: From the health committee’s perspective, the midwives were able to give really comprehensive services. It wasn’t just birth, it was care before and after. It was nutrition, prepping women for breastfeeding, yoga, a chance to talk about stress management, if you had other children talking about how to involve and prep them for the new baby. And there was follow up care – even for those who gave birth in the south, they did home visiting, created networking groups for mothers to share and support each other. A recent outbreak of RSV/pneumonia in our community meant that about 30 babies were sent out to hospitals in the south with one death occurring. Had there been post-natal follow-up home visits happening in the community as should happen with midwifery services, the community strongly believes that the extent of this illness could have been reduced. There were all the things you want to see out of a public health approach. wellness issues instead of making birth into a medical illness. There’s been a real separation of birth from family and community and we wanted to change that.

While the midwives were already working in Arviat, the town was also building a birthing centre separate from the community’s health centre. Why was the physical space of a centre such a priority?
It was important to us to make birth a time of wellness, instead of something associated with illness. We wanted to have a separate place for births outside of the overcrowded health centre, a safe space that wasn’t focused on illness. One of the most frequent comments we got from women was that they wanted to be away from the health centre. We’re affected by the same chronic health concerns that affect many other northern communities, like tuberculosis [TB] and respiratory illnesses. It’s stressful for an expecting mother to be sharing space in a small health centre that deals with all these concerns.

You mentioned family – what did the midwives mean for those relationships?
It opened a space for fathers to come in and participate if they wanted to. If you’re a woman just going to a medical checkup at the health centre, the father can’t really participate in getting tests. With the midwives, there was a recognition that fathers and husbands have a role in supporting a healthy pregnancy, and some of those ways they can support women were being talked about. If you’re talking about things like nutrition and development, prep for delivery – those are things dads can participate in. They could learn about behaviours you can expect, how you can help. The longer we had them, the more involvement there was – our hope is that birth will go back to being a family-centred celebration as opposed to an appointment in the health centre. There was more support in general because it was a more public thing, a more community event.

When mothers do fly out for care as they do again now, how do the families who stay behind cope?
It’s very stressful to have mothers gone. First, if there are other children staying home, there’s often no reliable child care available. So if a woman is going out to give birth, the father may not be able to have them go into day care –depending on the age of the child, there are waiting lists. There’s also the cost of childcare to consider – keep in mind the mother may have reduced income because of maternity leave. That just leaves family members to care for them. Dad may become Mr. Mom, and a suddenly single parent who may not have support to draw on. Because he’s caring for the kids, he can’t leave to hunt and bring in country food. That means more store food, which is expensive and not as healthy.
The mother is aware of all this when she’s sitting in Winnipeg, in a transient centre with a TV and little else to do. Moms are under considerable stress, and they have little or no money there in case they need to take a taxi for example. And it’s not always easy to communicate with the family back home – when families don’t have a telephone, some women end up phoning the radio station to try to get messages to their family via the broadcast.

Some of the prenatal and postnatal appointments obviously can’t be done in the 2 months just before birth. Who is handling them?
We’re supposed to have 7 nurses, but are usually missing some – there are 5 at the moment. It’s these nurses who are now picking up the prenatal and postnatal work. So the kind of care that prenatal moms were able to receive –education, info care, nutrition training, fitness and health, breastfeeding benefits – has been replaced by back-to-the-basics tests and iron pills.

Has this affected care for others in the community?
We have no mental health positions, so nurses also pick that up, and it’s a significant load – they have 40 clients on injectable medications and another 60 on oral medications. All our public health challenges – TB, respiratory illnesses – it all falls to the health centre. So there are no preventative measures going on, they just don’t have the time or resources. Our Home & Community Care Nurse position has also been vacant for the past four years so the health centre nurses also pick up those duties. Ideally our community health rep should be doing public health, but they get swallowed up doing things in the health centre and don’t get out on the front line a lot of the time. The same thing has happened with the maternity care worker who is still here. She may be involved with immunizations for infants, but there’s no home visiting or outreach, and in terms of infant care, [no] infant checks.

Part of the reason a birth centre was so important to Arviat was the high birth rate. Is the rate itself a concern in the community?
It is, and was discussed with the midwives. There was interest in having some family planning work going on in the community and work with the high schools. It’s another area of public health where they were willing to do some basic things on sexual health that were beyond the scope of the birthing centre. Those are the sorts of opportunities that were lost.

Looking forward – do you still hope that the centre will open one day?
We do. We were told that there was a plan for rolling out the birthing centres that will dot them all over Nunavut, and after they’re all open they’ll come back to Arviat. People were very excited they finally had the midwives, but kept waiting for the actual centre, we were going to have a big opening and community celebration, but it kept getting delayed and never happened. We still can’t open it because of renovations. But even though they [the midwives] came in a low-key way, the people involved in the program were very positive in the community. There were spin-off nutrition programs in the school; they worked alongside the Canada Prenatal Nutrition Program. They fit into places where they would have an audience in existing programs. It was a real community based approach.

Arviat health advocates wrote to their Minister of Health and were told the birthing centre and another midwifery training program would be looked at in 2011. Check back at www.cwhn.ca [1] for updates.

Signy Gerrard is the Director of Communications at the Canadian Women’s Health Network.