Relationality and Responsibility: Exploring the Integration of an Indigenous-Led Midwife Hospitalist to Increase Access to Culturally Safe Care for Indigenous Families

Abstract

Cultural safety training and practices are increasingly being called for to address Indigenous health inequities, with limited research to understand if and how these work to improve health outcomes. The creation of an Indigenous-led midwife hospitalist role at a tertiary-level urban hospital is one such example. Through semi-structured interviews with nine health care providers, we explore the integration of the midwife hospitalist into the hospital-based health care team. The analysis of interviews identified contradictory themes: an abdication of responsibility; acknowledgement of a unique contribution to the team; and a lack of understanding of the role. The contradiction stems from a fundamental difference in Indigenous and Western understandings of health. This difference results in a different understanding of the role and responsibility of health care providers. Indigenous health inequities will continue until there is a systemic shift in understandings of health, wellbeing, and the role of health care providers.

Introduction

The health disparities between Indigenous and non-Indigenous people in Canada are appalling. Colonization, assimilation, and racism experienced by Indigenous people actively contribute to poor health outcomes (Allan & Smylie, 2015; Statistics Canada, 2024; Turpel-Lafond, 2020). Widespread systemic racism has lasting health impacts. Despite many Indigenous families living in well-resourced settler-colonial countries, Indigenous pregnant people commonly experience higher rates of complications in pregnancy, maternal morbidity, and mortality, as they remain unable to access adequate clinical or culturally safe perinatal care (Kozhimannil, 2020). The aim of this study was to explore the integration of an Indigenous-led midwife hospitalist into a hospital-based health care team, to improve culturally safe obstetric and newborn care.

Racism, or the expectation of racism, in the health care system affects Indigenous pregnant people’s access to critically important sexual and reproductive health care services. An unwelcoming environment, stereotyping, stigmatizing, and practices informed by racism are specific conditions created by the health care system that have been identified as leading to experiences of discrimination (Wylie & McConkey, 2019). In Australia, Aotearoa (New Zealand), Canada, the United States, Sámpi and Kalaalit Nunaat (Greenland), Indigenous pregnant people report experiences of poor relationships, discrimination, racism and improper care (Sivertsen et al., 2025). Critically, Indigenous people who have experienced racism, discrimination, or marginalization in the health care setting are less likely to access care in the future, resulting in delayed access to care. The Our Health Counts Toronto research project found that Indigenous pregnant people who had experienced discrimination from a health care professional were two and a half times more likely to only access prenatal care in the third trimester or to avoid prenatal care entirely (Wolfe et al., 2018). Varcoe et al. (2013) also found that previous negative health care experiences affected future access to prenatal care. Increasing access to culturally safe perinatal care is a necessary step to improving access to sexual and reproductive health care and addressing Indigenous perinatal health outcomes (National Aboriginal Council of Midwives, 2016; Sivertsen et al., 2025).

Multiple reports investigating the lasting impacts of colonization on Indigenous people in Canada have included recommendations for the health care system (National Inquiry into Missing and Murdered Indigenous Women and Girls, 2019; Truth and Reconciliation Commission of Canada, 2015; Turpel-Lafond, 2020). The widespread response has been to encourage training and uptake of cultural safety practices. Cultural safety calls on health care practitioners to reflect on the power imbalances between themselves and their patients, and to recognize the historical processes resulting in social, political, and economic inequities for Indigenous people (Papps & Ramsden, 1996). While cultural safety has been identified as a relevant approach to transforming the discriminatory provision of health care, there is a great variety in theory and practice (Curtis et al., 2019; Tremblay et al., 2020). For example, Tremblay et al. (2020) identified that culturally safe interventions in diabetes care increased patient satisfaction, health care provider confidence in providing care, and patient access to care. Ray et al. (2022), however, highlight how broader systemic change that includes anti-colonial and anti-racist approaches is necessary to substantively address health inequities. The implementation of a culturally safe approach to care requires shifts in attitudes, knowledge, and skills of health care providers, as well as the establishment of accountability for health care organizations (Wylie & McConkey, 2019).

Another increasingly popular strategy to improve cultural safety is the use of Indigenous patient navigators. The patient navigator functions to address barriers to health and wellbeing in the colonial biomedical setting (Wells & Nuhaily, 2018). Professional patient navigators are regulated health care professionals, such as registered nurses or midwives, who provide expertise within their scope of practice. In the context of serving Indigenous clients, professional patient navigators function to support the physical health, mental health, and social needs of clients in the health care system (Rankin et al., 2022). Navigating the field of obstetrics for Indigenous clients can present experiences of systemic racism and violence. Indigenous midwives are well-suited to meet the needs of Indigenous communities by providing accessible, culturally safe care. In addition, midwives have the knowledge and skills for comprehensive, person-centred pregnancy, birth, and postpartum care. The unique role of the midwife hospitalist does not fit clearly in the category of patient navigator as the midwife hospitalist role spans both patient navigation and clinical care provision.

Seventh Generation Midwives Toronto (SGMT) is an urban midwifery practice with a focus on providing care to Indigenous families. The practice is made up of Indigenous and non-Indigenous registered midwives and Indigenous midwives working under an exemption clause. This research is grounded in the experiences of Indigenous and non-Indigenous midwives providing care in a colonial health care system, and our attempts to decolonize the care that we provide to Indigenous families.

In Canada, midwives, family doctors, and obstetricians provide prenatal, intrapartum, and postpartum care. In 2023, the rate of midwife-led births in Canada was 12%, and in Ontario, it was 17.9% (Canadian Association of Midwives, 2023). In 2022, approximately 8–10% of family physicians participated in obstetrical care (College of Family Physicians of Canada, 2022). Obstetricians remain the largest group of obstetrical care providers; the number varies across provinces and territories, with rates up to 68% (Guliani, 2015). Across Canada, the availability of prenatal health care practitioners depends on the size of the community, its location and resources. Despite the availability of research highlighting the harms of birth evacuation, many Indigenous people living in rural and remote areas of Canada must leave their communities to access prenatal and intrapartum care (Lawford et al., 2018). Promoted by Health Canada’s evacuation policy, Indigenous pregnant people routinely leave their communities at 36–38 weeks, or earlier if pregnancies are deemed high risk, to travel to urban centres to give birth (Lawford et al., 2018). Though Indigenous midwifery across the country is growing, and slowly birth is returning to communities, birth evacuation is still a routine component of care for many Indigenous people.

Registered midwives in Canada are self-regulated, autonomous professionals who provide prenatal, intrapartum and postpartum care for low-risk pregnant people and their newborns. They mainly work in practices with other midwives, providing care in clients’ homes, in clinics and in hospitals. In the Ontario Midwifery Act, there is an exemption for Indigenous midwives to work within their communities, providing midwifery services and, in some cases, expanded sexual and reproductive health care for families. There is a growing number of midwives who are working in different models, including interprofessional teams, to expand the sexual and reproductive health care options for families and communities.

In response to community feedback, SGMT developed a midwife hospitalist role in 2018. The objective was to increase the cultural safety of obstetrical and neonatal care provision for Indigenous clients at Sunnybrook Health Sciences Centre, an urban tertiary care hospital in Toronto, Ontario, Canada. There are two registered midwives from SGMT working in the midwife hospitalist role: one non-Indigenous midwife who has been in the role since its inception, and one Indigenous midwife. They receive referrals from the community midwives for midwifery clients accessing specialist care in the hospital, as well as from hospital staff for physician patients including patients transferred to the hospital from other areas of Ontario for high-risk obstetrical complications. They work in both the out-patient clinics and in-patient units, providing care to clients prenatally, intrapartum, and postpartum often on the high-risk obstetric and the neonatal intensive care unit. The midwife hospitalists provide clinical care within their scope, case management for families with medically and/or socially complex care needs, and act as cultural support and resource for staff and patients. This includes navigation of hospital systems and expectations, knowledge translation, prioritizing family decision-making, and supporting collaboration between the patient and the health care team.

Hospital integration is a key factor in the effectiveness of the midwife hospitalist position in increasing access to culturally safe care for Indigenous patients. This study investigates the integration of the midwife hospitalist into the hospital system from the perspective of health care providers.

Author Positionality

Indigenous scholar Kathy Absolon (2011) speaks to the importance of self as researcher in Indigenous methodologies. Not only do Indigenous researchers choose topics that are central to ourselves, our communities and future generations; our experiences and knowledge are also woven throughout our work. As an Indigenous scholar, Patricia McGuire, writes, “you have to speak from your own experience. This is done so your truth is apparent” (Absolon, 2011, p. 72). Our research is grounded in our experiences as Indigenous and non-Indigenous midwives providing care in a colonial health care system, and our attempts to decolonize the care that we provide to Indigenous families. I, Claire Dion-Fletcher, am a Lenape Potawatomi and mixed settler cisgendered woman. My mother and grandmother are Status First Nations; my grandmother was born at Moravian of the Thames Reserve #47. I am part of the urban Indigenous community of Toronto, where I grew up and currently live and work. I am an assistant professor and emerging researcher, and I previously worked as the midwife hospitalist. I, Claire Osepchook, am a third/fourth-generation settler in Canada from Eastern Europe and the United Kingdom. I have worked in an Indigenous-led midwifery practice for over 15 years and am currently the midwife hospitalist. I am committed to person-centred care and advocating for change in policies and standards to reflect and respect the cultural diversity of clients. I, Darcey Pearson, am a queer midwifery student of Mohawk, Irish, and English descent. My maternal grandmother’s family arrived in the Ottawa Valley from Kanesatake in the 1910s, where they went on to raise four generations of non-status, mixed settler and First Nations people. I was raised in Ottawa by my parents and maternal grandmother, and I currently reside in Toronto, where I learn and work towards becoming a registered midwife. We are committed to reflecting on and improving the care we provide to Indigenous families. Seeking and responding to community feedback is crucial to our approach to care and an important aspect of providing culturally safe care. It was important to us as a research team to explore the midwife hospitalist role and whether it was meeting its goals.

Methods

To examine the outcomes of this role for clients and the integration of the role in the hospital setting through uptake by health care providers, participants were asked to take part in semi-structured interviews. The interview questions were designed to develop an understanding of how health care providers and clients understood culturally safe care, the successes of the role of the hospitalist midwife, and areas for improvement. Client interviews will be reported elsewhere.

A purposive sampling strategy was used to select participants to receive diverse testimonies by recruiting participants of varying work and life experiences. To be included in the interviews, participants must have worked alongside the midwife hospitalist. Criteria that were considered in choosing which health care providers would participate included: being on an interdisciplinary care team with midwife hospitalists; having provided care in the high-risk clinic, high-risk obstetrics unit, birthing unit and/or neonatal intensive care unit; or being a part of the midwifery practice group. Nine health care provider interviews were conducted. The participants’ roles were one maternal foetal medicine physician, one maternal foetal medicine fellow, four nurses, from the postpartum unit, high risk clinic, high risk obstetrical unit, and birthing unit, one neonatal intensive care unit nurse practitioner, and two Indigenous midwives. Participants were given the option to self-identify their racial identity to provide context to their social location. The following racial demographics made up the pool of participants: Indigenous, South Asian, Black and White, further breakdown is not reported to protect participant confidentiality. Prioritizing the shared construction of knowledge over anonymity can be a key component of Indigenous research, and vital to understanding what it means to be an Indigenous person working in service of our communities (Absolon, 2011; Kovach, 2009). Due to the relatively small size of the Indigenous midwifery community, and respecting Indigenous research methodology, Indigenous midwife participants were given the option of being identified by their name (Cheryllee and Odaemin) in the research, to which they both agreed. All other participant interviews were anonymized by the research assistant and pseudonyms were used in the data analysis and writing process.

The principles outlined in The Ontario Federation of Indigenous Friendship Centres’ Utility, Self-voicing, Access, Inter-relationality Research Framework guided our research and fit with our urban context of Indigenous-led research. Core research team members also undertook Ownership, Control Access and Possession, OCAP^® training. Ethics approval was received by the Toronto Metropolitan University Research Ethics Board and the Sunnybrook Health Sciences Centre Research Ethics Board.

Our research process was also guided by an Indigenous advisory committee to increase the Indigenous perspectives in our work. The committee provided valuable insight at different stages of our project, including design, participant selection, interview questions, and analysis. The committee members included a past client of the midwifery practice, a community member, and an Indigenous midwife from outside the community. We are grateful for their contribution to our understanding of this work.

Data Collection and Analysis

Semi-structured interviews were conducted with nine health care provider participants on a virtual platform. The interviews were initially transcribed by the transcription function of the platform and subsequently reviewed and edited for errors by a research assistant. The interview transcripts were sent to the participants for their review and to make changes if needed. One participant elected to make changes to their transcript.

Reflexive thematic analysis (RTA), as outlined by Braun and Clarke (2006, 2019, 2021), was used by the research team to analyse the interviews. Thematic analysis is a recognized approach to qualitative analysis. Benoit et al. (2003) demonstrate that “by placing participant’s own perspectives front and centre, thematic analysis gives voice to those who are usually silenced” (p. 823). Thematic analysis is an approach that provides a systematic framework for coding qualitative data to identify patterns across the dataset in relation to the research question, with analysis focusing on lived experience and perspectives of the research participants and the underpinnings of their behaviours and choices (Braun & Clarke, 2014). We chose RTA as it is an approach that acknowledges the subjectivity and storytelling role of the researchers in data interpretation (Braun & Clarke, 2019). We believe that knowledge is created through our interactions with each other and our worlds and is affected by who we are as individuals. Our understanding of this research is grounded in an Indigenous feminist perspective and our shared commitment to reproductive justice as midwives and learners. We understand the health care system to be part of a colonial and patriarchal system, where power and social location affect how individuals, both clients and health care providers, experience the health care system. As past and current midwife hospitalists, our interpretation of this research is impacted by our understanding of the role, what culturally safe care looks like, and our familiarity with those participating in the study.

All three authors participated in theme generation. We used Braun et al.’s (2018) six-step process as a guide for our data analysis. We individually familiarized (Step 1) ourselves with the data, through multiple readings of the transcripts, and generated initial codes (Step 2). Constructing, revising and defining (Steps 3–5) themes occurred together over the course of 5 months. Thematic mapping was used to help clarify and define themes. Theme generation from the client interviews was completed before the writing stage of this article (Step 6) to allow for possible revision of themes based on client interviews. Our draft themes were then presented to the Indigenous advisory committee, who provided valuable perspectives that helped to shape our final themes and definitions.

Findings

Three predominant themes were generated by the research team related to the integration of the midwife hospitalist into the hospital system: Abdication of responsibility, acknowledgement of unique contributions to the team, and lack of understanding of the role.

Abdication of Responsibility

With the ongoing crisis in health care of staffing and retention, it is undoubtedly true that the workforce is experiencing burn out and struggling to maintain an overwhelming workload. Throughout the interviews, it became apparent that hospital-based health care providers often referred Indigenous clients’ social, emotional, and spiritual needs to the midwife hospitalist, but not their clinical needs. While the midwife hospitalist acts as a useful resource in bridging client needs within the hospital system, the referral of cultural, spiritual and resource needs to the midwife hospitalist may be a means of avoiding the care provider’s own discomfort in not knowing how to adequately care for Indigenous clients. As Brooke explained,

I think my own practice has changed because I’m more aware now, and I am offering to have [the midwife hospitalist] come and see patients more than I did before. . . because there was nobody around to help before. A patient would be asking if we could smudge [a cultural ceremony where traditional medicines are burned for cleansing and spiritual grounding], and we’d be like [lifts eyebrows] yeah, I just need to organize to turn the smoke alarms off and stuff like that. Whereas now it’s coordinated through the hospitalist, and the patients have the one-on-one relationship with [the midwife hospitalist] to do that.

The approach of delegating tasks to the midwife hospitalist, who the hospital care providers perceived as being more qualified and equipped, was associated with a number of factors. One explanation that was observed in the interviews was their responsiveness and ease of access. This allowed clients to receive the care they needed quickly and reduced the workload for the referring provider. The midwife hospitalist was also frequently described as being more culturally knowledgeable, as Sasha explained:

Because [the midwife hospitalist] is so accessible, it’s a great benefit to us. Especially with the Indigenous population, if there are certain things that we’re not sure of, you know, culturally. They do a lot of smudging.

Participants recognized that the midwife hospitalist had an alternative approach to practice, which they attributed to more time and a different scope of practice. This allowed the midwife hospitalist to provide care they saw as different from routine hospital care. Riley said,

We’re not looking after the patient as a whole. I think midwives have a really important role in that, to look at the patients as a whole. They’re looking after their journey through the pregnancy, of supporting them. Whereas our role is different. And I think as long as you recognize that there’s a separation there, that’s important.

The hospital-based providers frequently emphasized the division of clinical care from care that addressed social and cultural needs, with the latter often being assigned to the midwife hospitalist, as Vivian described:

The social gaps are a really big deal, currently I see the hospitalist as doing that. For clinical gaps they’re supported by the OB and the high-risk [team]. I see them as being well supported, in terms of they have their guidelines. . . . I don’t see that as a problem in the clinical aspect, because that clinical aspect is kind of black and white.. . . The social aspect is very subjective.

The separation of clinical care from the social needs of clients was discussed in many interviews. The provision of social and cultural care was often placed in the realm of the hospitalist midwife and not with the rest of the hospital team.

There was a frequent misunderstanding that emerged in the interviews in which it was expressed that the midwife hospitalist was an Indigenous person themself, and as such more qualified and capable of providing client-centred and specialized care for Indigenous clients. Brooke was among those who held this misconception, “I think the patients have got more comfort level with somebody who’s got the same background as them. Perhaps they are willing to share a little bit more than they would necessarily with us.”

Hospital-based providers indicated that the midwife hospitalist was well-equipped to meet the needs of Indigenous clients due to an increased knowledge base, a perceived greater availability and an alternative approach to care. There was also an expression of relief in being able to refer these responsibilities to the hospitalist midwife rather than taking on the work of learning these skills or new approaches. Learning new skills and approaches in caring for Indigenous patients takes time and requires system changes to become fully integrated.

Acknowledgement of Unique Contribution to the Team

The frequent referral of clients to the midwife hospitalist also reflected an admiration and respect for the role’s unique contribution to the hospital team. In the interviews, the midwife hospitalist was frequently recognized as having an exceptional relationship with the clients that fostered trust and connection. This unique provision of care reassured the referring providers that their client was receiving the care they needed to be well. Cheryllee, an Indigenous midwife, described this in her interview:

It’s a warm referral pathway where there’s a transfer of trust that can happen between the midwife providing care in community, which would be me, and what’s happening at the hospital, which would be under the supervision of the midwife hospitalist.

It was also acknowledged that the midwife hospitalist role extended the care that the team was able to provide to Indigenous clients overall, which made accessing meaningful wholistic care more possible. Carmen expressed this thoughtfully:

Helping them navigate where their partner can stay. Helping them, if they want to smudge, if they want to have help communicating with their family at home. Just to make them feel like somebody is there, because I can’t often help them with the social stuff that they’re facing, because I’m focusing on the medical side of things.

Participants also discussed the midwife hospitalist’s ability to address the colonial system of the hospital. Several interviews mentioned the ability of the midwife hospitalist to make Indigenous patients feel safe and more comfortable during their stay at the hospital, Carmen mentioned it directly in the context of colonization:

I know what it [colonialism] does to populations, and I think that we have to acknowledge that. We have to see what that means in our context as a hospital. If people don’t feel safe coming to the hospital, then we can’t provide care to them. To have somebody who makes them feel more safe getting care from me, I think, is best for everybody. Then I can also provide clinically safe care to somebody who is willing to accept it because there’s somebody in between who’s making them feel culturally safe as well.

The health care providers frequently mentioned in the interviews that the midwife hospitalist improved the entire team’s ability to provide care by educating and raising their awareness of Indigenous issues. As Brooke explained,

There’s a lot of stuff that I think links all together. It’s the awareness of what has happened in people’s past, that these programs have educated us on, and the reasoning why you smudge, and the reasoning why the ceremonies occur. It makes it a little bit more of a bigger picture. You become more aware of people’s history, how it affects them, how it really does affect their childbirth experience.

The health care providers interviewed clearly expressed an appreciation for the role and an understanding that the midwife hospitalist was able to add to the client’s overall care, even if they were unable to articulate how they achieved this.

Lack of Understanding of the Role

It became apparent that participants of the study struggled to understand the role of the midwife hospitalist and how they are integrated into the hospital team; this is not surprising given the fact that hospital staff generally function solely within the context of the hospital system. This often presented as a lack of knowledge surrounding the technical aspects of the role, such as not knowing if or where the midwife hospitalist documents, not understanding their schedule, and requesting additional information about the role during the interview, even though these details had been shared with the hospital team members on multiple occasions in various formats. Cheryllee commented on how the function of midwives’ roles in general is often regarded by other health care providers:

If you’re asking about the program itself, I think that it’s not as well integrated as it could be. I think, mostly that’s a systems issue, and frankly, the hospital just undervaluing the actual role and, on large, the role of midwives. I think they just don’t understand how we fit into their team or structure. We’re always treated as outside. . . I think when you’re asking how integrated it is, I don’t think that it’s integrated to the point of sustainability of the role. I think that it is integrated because of the valuing of the individual person in the role.

Furthermore, when discussing the tasks and responsibilities of the midwife hospitalist, participants placed a significant emphasis on the cultural and spiritual care and the provision of physical resources. Frequently not recognizing that the midwife hospitalist provides clinical care. Harlyn made one of several comments emphasizing the value placed on non-clinical skills:

Well, I’m hoping a number of things, I’m hoping that she can meet the cultural needs, spiritual needs, even practical needs. What are the things that an Indigenous family would wish to have around them, either at the birth or shortly thereafter? Or unfortunately, sometimes, if we’re talking about the last hours of life, what would be meaningful? I know that the hospitalists can come and help me in that regard to ensure that I’m providing wholistic care.

The Indigenous midwives interviewed acknowledged a wider role of the midwife hospitalist in improving care for clients, for example, Odaemin explained, “I think understanding the barriers that clients can face, understanding the trauma that a lot of clients have faced, whether in the health care system or just in life is culturally safe care.” The hospital-based health care providers focused on the midwife hospitalist’s ability to address the practical and cultural needs of the clients, and rarely on how the midwife hospitalist participated in providing improved clinical care.

Limitations

Limitations of this study include the small sample size of participants. A larger sample size of participants could increase the diversity of experiences and perspectives included. The relationship between the researchers and the participants may also have affected the participants’ ability to answer questions freely. Multiple steps were taken to protect the confidentiality and anonymity of participants, including using research assistants to conduct and anonymize the interviews.

Discussion

The three themes from the health care provider interviews offer an interesting examination of the integration of a midwife hospitalist into a hospital setting with a focus on improving Indigenous cultural safety. These three themes: abdication of responsibility, acknowledgement of the unique contribution to the team, and lack of understanding of the role, may seem to be in contradiction to each other. This apparent contradiction can be explained when we approach the interviews and the experiences of the health care providers with the recognition of a fundamental difference between Indigenous and colonial biomedical understandings of health, and a recognition of the conflation of cultural competency and cultural safety. These different approaches to health and wellbeing result in conflicting understandings of the roles and responsibilities of health care providers, leading to the hospital-based health care providers simultaneously not understanding while also appreciating the role of the midwife hospitalist.

Throughout the interviews, health care providers frequently referenced the midwife hospitalist taking on roles that the providers felt they did not have time for. As an Indigenous-led research team and health care providers, we view this as an abdication of provider responsibility. However, the referral of social, emotional, and cultural care to the midwife hospitalist is understandable when viewed from the perspective of a colonial biomedical system. In this model, each care provider has a specific job with a defined scope of practice that fits into a hierarchy of roles and responsibilities. This is a normal approach from a colonial worldview of health and wellbeing, where concerns unrelated to direct clinical care are referred to another person with specific expertise, such as a social worker. The approach of dividing health into discrete and hierarchical roles does not fit within an Indigenous worldview or understanding of health (Allen et al., 2020). While recognizing the diversity across Indigenous nations, we can also acknowledge the similarities in worldviews, shared knowledges, and values that are the bases of Indigenous conceptions of health (Dion Stout & Downey, 2006). Indigenous understandings of health are often wholistic taking into consideration a balance of spiritual, physical, emotional, and mental health. Indigenous understandings of health include a notion of interconnectedness; the health of individuals is linked to the land, the community, and intergenerationally to one another (Dion Stout & Downey, 2006; Eni et al., 2021; Gee et al., 2014; Greenwood & Lindsay, 2019). The midwife hospitalist prioritizes a relationship with clients where this understanding of health is the basis of the care they provide. Many scholars have acknowledged the contradictory Indigenous and colonial understandings of health and highlight the incompatibility of addressing Indigenous people’s health in a colonial biomedical system (Allen et al., 2020; Campbell et al., 2020; Horrill et al., 2018; Komene et al., 2023). The siloing of different aspects of care into different care provider’s responsibilities is a biomedical approach to health care that is based in hegemony and individualism; it does not fit with a wholistic, relational understanding of health, where it is the responsibility of all care providers to attend all aspects of health and wellbeing.

In their interviews, hospital-based providers frequently referenced the unique relationship that the midwife hospitalist had with clients. The midwife hospitalist’s unique approach reflects the importance of relationship and kinship between health care provider and client. The prioritization of relationship building is an important aspect of culturally safe care that reflects the relational worldview of Indigenous people (Greenwood & Lindsay, 2019; Komene et al., 2023). In their article, Campbell et al. (2020) explore, “Indigenous relationality and kinship as essential qualities of genuine and authentic understandings of Indigenous health and health care” (p. 8). Without prioritizing relationality and Indigenous ways of being in care, care will not be culturally safe, particularly from non-Indigenous care providers (Tomkins et al., 2024). The different understandings of health in Indigenous and colonial worldviews lead to divergent beliefs about the role of the health care provider. The tension between these approaches contributes to a contradiction wherein health care providers value the role of the midwife hospitalist while simultaneously abdicating responsibility for taking on similar provision of care.

The abdication of provider responsibility is also rationalized by the misconception that both the midwife hospitalists are Indigenous. Their assumed indigeneity is used to explain their enhanced ability to provide care for Indigenous clients and shift the responsibility for care away from other health care providers. Placing the responsibility for cultural care onto the Indigenous – or perceived Indigenous – health care providers is a pattern identified by other Indigenous health care providers (Komene et al., 2023; Mentsen Ness & Mehus, 2024). In their study exploring the experiences of Māori nurses, Komene et al. (2023) found that all the nurses described the experience of cultural loading. Māori nurses reported an expectation that they take on educating non-Māori colleagues while providing culturally safe care for Māori patients and their family. Indigenous health care providers report taking on this responsibility to ensure that their community members receive safe care and have good experiences in the health care setting. However, this cultural load is additional labour and responsibility for Indigenous providers; it is frequently unrecognized and unpaid work (Komene et al., 2023). This pattern reinforces a dichotomy of cultural versus clinical care, where priority is given to clinical care. It reinforces power imbalances between Indigenous and non-Indigenous health care providers, where less valued cultural work is seen to be the purview of Indigenous care providers, and the more valued clinical care is the purview of non-Indigenous care providers. In the quotes above from Carmen, a hospital-based health care provider, this distinction is highlighted in the way they dichotomize clinically safe and culturally safe care. However, the work of providing culturally safe care is the responsibility of all health care providers. As the midwife hospitalists, we argue that health care providers are not actually providing clinically safe care if their care is not also culturally safe.

The misconception that both midwife hospitalists are Indigenous sets up an insider/outsider dichotomy, where non-Indigenous health care providers think the midwife hospitalist’s skills in caring for Indigenous clients are due to their shared background. This reinforces the idea that non-Indigenous care providers do not have to or are unable to acquire the knowledge and skills necessary to adequately care for Indigenous clients. It is important to acknowledge that the non-Indigenous midwife hospitalist does have different skills and training and has spent years learning from Indigenous midwives. However, the mischaracterization of the midwife hospitalist as Indigenous, or the presentation of them as being more equipped in scope or skill than other health care providers because of their assumed indigeneity, allows for health care providers to take the position of what Dion (2009) calls the “perfect stranger.” Dion (2009) explains that Canadians can claim to have no knowledge of relationships with Indigenous people and therefore little responsibility to engage. This is particularly true when there is an understanding of a need to be respectful of Indigenous people and, from this, a fear of offending by doing the wrong thing. This often results in people doing nothing at all. In the hospital setting, health care providers exemplify this dynamic by putting the responsibility for the social, emotional and cultural needs of Indigenous clients completely on the midwife hospitalist, who they position as being Indigenous and therefore better equipped to address these needs. The ability to refer to the midwife hospitalist removes their responsibility to learn more about their relationship to Indigenous clients and how to provide better care. The client needs get met; however, there is not a deeper shared understanding of why these needs are important and whose responsibility it is to meet them. The assumption that the midwife hospitalist is able to develop a unique relationship with the clients due to them being Indigenous – which they are not – takes away responsibility from other non-Indigenous health care providers to work towards establishing this relationship. The trust built with the midwife hospitalist is not inherent to their cultural or racial identity but is instead due to several factors that other health care providers could learn and enact.

Throughout the interviews, the hospital-based health care providers indicated a lack of understanding of the role of the midwife hospitalist. The non-Indigenous care providers frequently referenced the cultural care that the midwife hospitalist provided as the most important role that they bring to the team. This is highlighted in the frequent reference to increasing client access to smudging in all the interviews. Within the last 10 years, smudging has been a focus of many hospital-led initiatives. In 2021, Sunnybrook Health Science Centre instituted an Indigenous ceremonial practices policy that is often highlighted as a way to address cultural safety. We recognize that access to cultural ceremonies such as smudging is an important aspect of care for Indigenous clients. However, we also believe this is one of the easier aspects of care to identify and address; it is not the most important aspect of care for many clients, and therefore risks being a tokenistic response to health inequities and racism in the health care system. Increased access to cultural ceremonies was not what the Indigenous midwives, the Indigenous clients, or the midwife hospitalists indicated as the most important way to improve the safety and experience for Indigenous clients. The relationships between the community midwives and the midwife hospitalist, and between the midwife hospitalist and the clients, were highlighted as one of the most important aspects of care. This relationship allowed for a “transfer of trust” from the community midwives to the midwife hospitalists, increasing client comfort and trust in the midwife hospitalist. The clients valued the relationship the midwife hospitalist built with them, which resulted in increased knowledge translation, led to more active participation in their care, and created a buffer for racism directed at clients. Access to cultural care was rarely the focus of client interviews.

It is understandable that the non-Indigenous hospital-based providers would focus on the aspects of cultural care due to changing understandings of health and a confusion of cultural competency and cultural safety. There is a lack of importance placed on cultural and spiritual needs in the colonial biomedical system, resulting in poorly integrated cultural and spiritual care. It is only relatively recently that understandings of health have moved beyond simply an absence of disease and included aspects of emotional, cultural, and spiritual health (Allan & Smylie, 2015). It takes time for a shift such as this to occur in education, training, policies, and everyday practice, and we have yet to fully integrate this into the health care system. Increasingly, this is becoming a recognized gap in care and is therefore more easily recognizable to the health care providers interviewed as a role of the midwife hospitalist. The aspects of care that clients and the Indigenous midwives prioritized as important – being a buffer against anti-Indigenous racism, knowledge translation, and providing more accessible clinical care – are all aspects of care that hospital-based health care providers recognize as part of their role. What they do not recognize is that the midwife hospitalist provides these aspects of care in a way that is better taken up by Indigenous clients.

While we believe that the majority of the hospital-based health care providers aim to provide excellent care to Indigenous clients, they are providing care from the understanding and training of a colonial biomedical model of care, and a continued focus on cultural competency, as opposed to cultural safety. Cultural safety is an approach to care that was developed in the 1990s by Māori nurses, and in the decades since has become widespread in the health care setting (Curtis et al., 2019; Papps & Ramsden, 1996). In our experience, cultural safety is often misunderstood and used interchangeably with cultural competency, with negative effects for Indigenous clients. While varying definitions of cultural competency exist, it is often understood as an individually-focused framework, with a static end goal (Curtis et al., 2019). In many cultural competency frameworks, health care providers are assumed to be white and cultureless; knowledge of Indigenous cultural beliefs, characteristics, and practices can be learned and respected by health care providers; and this knowledge can be used to provide improved care, through empathy and compassion (Curtis et al., 2019). In contrast, cultural safety is focused on power imbalances and recognizes the importance of structural-level changes (Curtis et al., 2019; Papps & Ramsden, 1996). Cultural safety frameworks call on health care providers to reflect on their positions of power and how their relationship to systemic power and privilege affects the care they provide, to be cognizant of how racism is present in the health care system, and to seek to address it (Curtis et al., 2019; Wiapo et al., 2024). It is the responsibility of all health care providers to participate in this reflection and work to change both how they provide care and the greater health care system; we cannot just add in cultural experts in hopes of addressing racism in the health care system. In their systematic review of racism in the nursing profession, Wiapo et al. (2024) argue that despite a “rhetoric of cultural safety and anti-racist systems,” racism in the health care system continues when nurses do not disrupt the status quo (p. 2942). We also see this notion present in our interviews, not out of a cognizant desire to mistreat Indigenous people accessing health care, but in conflating the approach of cultural competency with cultural safety. When the health care providers only recognize what the hospitalist midwife does to meet client’s social, emotional, and cultural needs, when the most frequent benefit cited is that they smudge with clients, when they think the midwife hospitalist is good at their job because they are Indigenous – these represent a profound misunderstanding of what culturally safe care is. This contributes to a further othering of Indigenous clients – and the midwives – positioning them as different from the dominant culture and further entrenching marginalization rather than addressing it (Curtis et al., 2019). The health care providers are not recognizing that what the midwife hospitalist is actually doing is facilitating Indigenous clients’ access to care by building a relationship of trust, based on an understanding of the importance of relationality and kinship, addressing issues such as social barriers, health literacy, and clinical knowledge translation; they do not recognize that these are the things needed to address health inequity. This also serves to remove responsibility for change from individual health care providers. For health care to be culturally safe, we must reflect on the racism and power imbalances promoted by the health care system and how we benefit from colonialism and our positions of power. We must all challenge the prioritization of colonial models of practice, ways of knowing and understandings of health. It is the responsibility of all non-Indigenous health care providers to do this work in relationship with Indigenous people.

Conclusion

The apparent contradiction in the themes from our interviews and in the ways that the hospital-based health care providers understand and discuss the midwife hospitalist job are examples of the inherent difference in approach to health care between an Indigenous and colonial worldview. This results in different perspectives between the health care providers and the Indigenous-led team of what the role of a health care provider should be and what aspects of health care should be prioritized.

Though there is a need to increase the number of Indigenous care providers, we cannot ignore the important role that non-Indigenous care providers need to play in providing culturally safe care that addresses the health needs of Indigenous people (Tomkins et al., 2024). The midwife hospitalist provides an example of an Indigenous-led model that incorporates non-Indigenous care providers into the health care team. The midwife hospitalist’s training as a midwife provides them with a foundation of the importance of client-centred care, knowledge translation, and care for the parent-baby dyad, but it is their over 15 years of learning from and with Indigenous midwives and clients, and an openness to feedback and change, that has contributed to their ability to understand an Indigenous worldview and the ways that colonization and anti-Indigenous racism are built into the health care system. The midwife hospitalist takes an approach to care that centres Indigenous knowledge and ways of being from the client perspective. They approach their role as a health care provider with respect for the relationality that is crucial to Indigenous understandings of health care provision.