Indigenous mothers’ perspectives on improving maternal healthcare in Northwest Territories,Canada: Results from the Maternal and Infant Health Project

Abstract

Background

Improving global maternal health is a key goal within the United Nations’ Sustainable Development Goals. In Northwest Territories, Indigenous mothers face significant disparities in maternal healthcare, with higher risks of maternal mortality and healthcare access challenges.

Objective

To explore Indigenous mothers’ perspectives on opportunities to improve maternal healthcare services in Northwest Territories, Canada, using qualitative data from the Maternal and Infant Health study.

Design

Qualitative design.

Methods

Self-identifying Indigenous women of childbearing age (17-49 years) who were pregnant at the time of the interview or had given birth within the last three years were invited to participate. A culturally appropriate, interviewer-administered, semi-structured questionnaire was utilized for quantitative and qualitative data collection. Qualitative data were analyzed using reflexive thematic analysis.

Results

In total, 156 Indigenous women participated (mean age =29.7 years, SD=6; age range 17-47 years). 93% gave birth in the past three years, and 18% were pregnant. Three themes emerged regarding areas in which to improve maternal healthcare: experiences and challenges with service delivery, support networks, including more connections with Elders, and cultural sensitivity. Specifically, participants reported a preference for childbirth to take place within home communities, aided by midwives and family members and utilizing Indigenous maternal care practices. Participants also voiced the necessity of increasing the provision of mental healthcare, postpartum care, and support group services that incorporate traditional local languages.

Conclusion

To improve maternal healthcare services within Indigenous communities, building trusting relationships with healthcare professionals that honour Indigenous practices, improving healthcare accessibility, and increasing the delivery of local healthcare services and support are of priority. This paper contributes to the sparse literature currently available, providing Indigenous-informed evidence to guide the conceptualization, practice, and policy of maternal healthcare in Northwest Territories.

Keywords

Canada healthcare access Indigenous maternal healthcare post partum care Northwest Territories

Introduction

As a member of the World Health Organization, Canada committed to achieving universal health coverage in 2015¹ as part of the United Nations’ (UN) Sustainable Development Goals (Target 3.8).² Universal health coverage aims to ensure that everyone can access high-quality healthcare services. Canada’s universal healthcare system provides healthcare services to some of the most remote and least densely populated areas in Northern Canada, where an estimated 18% of Canada’s population resides. One such area is Northwest Territories (NWT), the second-largest and most populous of the three territories in Northern Canada, covering over more than 1,346,106 km² and including 33 communities that extend into the Arctic Circle. The estimated population of NWT is 41,070 people,³ with the second highest proportion of Indigenous individuals (51%) amongst the Northern territories.⁴

Improving global maternal health is a priority outlined in the UN Millennium Sustainable Development Goals.⁵ However, disparities in perinatal health provision exist between Indigenous and non-Indigenous mothers in Canada.⁶ The risk of maternal mortality is twice as high for Indigenous mothers compared with the general population,⁷ and Indigenous mothers living in remote communities face additional barriers to accessing maternal healthcare.⁸ In NWT, the infant mortality rate (IMR) (6.1 deaths per 1000 live births) is higher than the national average (4.6 deaths per 1000 live births).⁴ The health disparities are associated with the historical and ongoing impacts of colonization, such as the introduction of Western ideology and medicine to Indigenous communities, resulting in the loss of Indigenous knowledge through cultural assimilation, often displacing traditional birthing practices.⁹

One policy introduced to address maternal health disparities in Canada is the maternal evacuation policy,⁶ which requires pregnant Indigenous women in remote communities to travel to urban tertiary centres between 36 and 38 weeks gestation to give birth.¹⁰ While intended to improve clinical outcomes, this maternal evacuation policy has contributed to a loss of cultural identity, decline of Indigenous midwifery practices, separation from kinship,⁹ and the undermining of important factors supporting Indigenous health.¹¹ This out-of-territory medical travel contributes to NWT having the second highest age-adjusted public health spending per capita in Canada.¹² Medical travelers report needing more information, support, and culturally appropriate communication before and during travel to navigate the difficult and long medical travel journeys.¹³ Given that many Indigenous women view childbirth as part of a connection to the world and community,¹⁴ there is a clear and expressed need for locally accessible, culturally grounded, and continuous maternal healthcare.⁶

This paper aims to explore Indigenous mothers’ perspectives on improving maternal healthcare experiences and access in NWT, and to identify practical suggestions to inform culturally safe, community-based maternal healthcare models that reflect Indigenous values and priorities, thereby supporting improved maternal and infant health outcomes in NWT.

Methods

Project design and setting

The Maternal & Infant Health Project (ethics approval number: Pro00085941) aimed to improve maternal and infant health in NWT, Canada.^15–17 Quantitative and qualitative data were collected across three communities in NWT, each with different levels of access to the Health Family Program.¹⁸ This program offers support to families with children aged 0-6 years through various services, including parenting groups and workshops. A large proportion of the population in the communities is Indigenous (48-65%).^19–21

The Maternal & Infant Health Project utilized community-based participatory research (CBPR) methodology^22,23 and was supported by a Community Advisory Board (CAB), comprised of Elders, community members, and local governance organizations, which provided guidance for all aspects of the project. The CBPR²⁴ approach acknowledges that conventional research models often overlook historical, social, political, and cultural aspects and do not often allow enough time for establishing trust between communities and researchers.^25,26 CBPR facilitates ethical conduct, advances positive social change, strengthens community capacity, encourages sustainable practices,^27,28 and enhances the relevance and effectiveness of research topics.^29,30 In this project, communities were involved from the onset of the research process as equal partners and co-researchers, and all aspects of the project incorporated inclusive languages.

Recruitment

Participants were eligible if self-identifying as Indigenous women, aged 17-49 years, residing in one of the participating communities, and either pregnant at the time of the interview or having given birth within the previous three years. This project utilized convenience sampling methods and community-specific recruitment strategies as previously described.^15–17 Strategies included an Indigenous community coordinator, telephone outreach, community-based presentations, and partnerships with local community agencies. Passive advertising was also utilized. Recruitment concluded when data saturation was reached. Extensive travel to remote locations and coordination in geographically isolated settings were required. Over twenty years of research experience in Northern Canada enabled the team to adopt the flexible recruitment strategies, which were supported by established, long-term relationships with community partners.

Data collection

Data collection took place between October and November 2019, utilizing a semi-structured questionnaire. In-person interviews were led by local research assistants who had completed structured training that addressed informed consent, confidentiality, and standardized procedures for accurately documenting and completing questionnaires in accordance with project protocols. Written informed consent was obtained from all participants prior to the start of the interview, after the project’s objectives and procedures were explained to participants in the preferred language. Interviews were conducted in the participant’s preferred language and at a location of the participant’s choosing (the local project office, the participant’s home, or another such private location) to ensure comfort and confidentiality. The questionnaire comprised closed and open-ended questions aligned with the project objectives and informed by relevant literature and the research team’s community experience. The questionnaire was pilot tested with Indigenous women aged 21-44 years (n=10) residing in a predominantly Indigenous community in NWT. Feedback from the pilot test informed the refinement of the questionnaire, which was then validated by the CAB to confirm its cultural relevance and appropriateness.

In this paper, we report information related to improving maternal healthcare experiences, focusing on the qualitative component of the project. Three open-ended questions were asked: 1) “What can be done to improve pregnancy and prenatal services in your community?”; 2) “What can be done to improve labour and delivery services in your community?”; and 3) “What can be done to improve postnatal and early parenting services in your community?”.

Interviews were audio-recorded and transcribed verbatim, with each transcription being verified against the audio-recording. Unique identification numbers linked each participant’s anonymous data to an electronic case report form in REDCap (Research Electronic Data Capture, version 8.1.1).³¹ Interviewers used an interview guide and field notes, and the data were continuously reviewed during the collection process. Participants could decline to answer questions, withdraw at any point without consequences, and take breaks at any point during the interview. Local language interpreters were available to assist if required. Each participant received a $25 gift card honorarium to express gratitude for participation.

In collaboration with the CAB and Indigenous partners, the collective decision was made to exclude participant IDs when presenting qualitative quotes. This approach was chosen to honour the lived experiences of Indigenous community members, as historically numbers were used in place of names for Indigenous individuals within institutional systems, a dehumanizing practice rooted in Canada’s colonial legacy. Furthermore, demographic details such as age have been omitted, as the small size of some participating communities could make it possible to identify individuals through quotations.

Data analysis

Descriptive statistics for the quantitative variables were produced using SAS^® statistical software (SAS Institute Inc. Version 9.4, Cary, NC., 2023). Themes in the qualitative data were identified³² through reflexive thematic analysis³³ utilizing an open coding method.³⁴ A recursive process was followed for reading the data, coding the data, generating themes, and reviewing and finalizing themes and subthemes.³⁵ All transcripts were read several times to ensure familiarization with the data prior to inductive code generation. Initial codes were developed iteratively and organized into potential themes, which were reviewed, refined, and clearly defined through ongoing discussion. Analysis was recursive, with movement between data, codes, and themes to ensure coherence and depth of interpretation. The initial coding was independently completed by three research team members utilizing NVivo Pro version 12 (QSR International Pty Ltd, 2018).^35,36 The initial codes were then refined, interpreted, and collated into named and defined themes by a fourth team member. Qualitative research quality standards were maintained by following the Trustworthiness Criteria and Consolidated Criteria for Reporting Qualitative Research (COREQ) standards³⁷ (Supplementary File 1). This approach allowed for objectivity throughout data analysis, enhancing the credibility and transparency of the findings.

Results

Quantitative results

The mean interview length was 30 minutes per participant (range 7-85 minutes). A total of 156 Indigenous women participated with a mean age of 29.7 years (SD=6), age range 17-47 years. Most participants had a partner or spouse (70.5%), and 37.8% had completed post-secondary education, 18.6% high school, and 43.0% less than or some high school. Of the participants, 38.0% were employed full or part-time. 93.0% gave birth in the past three years, and 18.0% were pregnant at the time of data collection. Approximately half of the participants (51.8%) became pregnant for the first time before the age of 20 years, whilst 41.6% became mothers for the first time between the ages of 20 and 29 years (Table 1).

Table 1.

Sociodemographic characteristics of participating Indigenous mothers in three communities in the Northwest Territories, Canada (n=156).

	Community (n=156)
	A	B	C	All
Mean Age (SD)	32.0 (5.8)	29.3 (6)	29.1 (6.0)	29.7 (6.0)
Age (years): 1^st pregnancy - mean (SD)	20.35 (5)	20.61 (4.1)	21.48 (5.8)	20.95 (5)
	n (%)	n (%)	n (%)	n (%)
Participants	24 (15.4)	68 (43.6)	64 (41.0)	156 (100)
Age categories (years)§
17-18			3 (4.69)	3 (1.94)
19-24	2 (8.7)	14 (20.59)	12 (18.75)	28 (18.06)
25-39	19 (82.61)	49 (72.06)	47 (73.44)	115 (74.19)
40-47	2 (8.7)	5 (7.35)	2 (3.13)	9 (5.81)
Having a partner/spouse*
Yes	19 (79.2)	49 (72.1)	42 (65.6)	110 (70.5)
No	4 (16.7)	18 (26.5)	21 (32.8)	43 (27.6)
Education*
Less than or some high school	17 (70.8)	29 (42.7)	21 (32.8)	67 (43.0)
High school diploma or equivalent	3 (12.5)	12 (17.7)	14 (21.9)	29 (18.6)
Post-secondary education	4 (16.7)	27 (39.7)	28 (43.8)	59 (37.8)
Employment Status*^,§
Full time	5 (20.8)	17 (25.4)	21 (32.8)	43 (27.7)
Part time	5 (20.8)	9 (13.4)	2 (3.1)	16 (10.3)
Maternity	2 (8.3)	9 (13.4)	9 (14.1)	20 (12.9)
Student	0	6 (9.0)	3 (4.7)	9 (5.8)
Not working**	12 (50)	26 (38.8)	29 (45.3)	67 (43.2)
Gave birth in last 3 years
Yes	22 (91.7)	64 (94.1)	59 (92.2)	145 (93.0)
No	2 (8.3)	4 (5.9)	5 (7.8)	11 (7.1)
Currently pregnant *
Yes	3 (12.5)	13 (19.1)	12 (18.8)	28 (18.0)
No	20 (83.3)	54 (79.4)	52 (81.3)	126 (80.8)
How old were you when you became pregnant for the first time?§
< 20	11 (64.7)	29 (47.5)	31 (52.5)	71 (51.8)
20 – 29	4 (23.5)	32 (52.5)	21 (35.6)	57 (41.6)
30 – 39	2 (11.8)		7 (11.9)	9 (6.6)
Missing				19

*Levels of five or fewer observations were omitted.

**Not working includes the following response options: not working and looking; not working and not looking, and unable to work.

§Missing data were omitted from all analyses.

Qualitative results

Through qualitative data analyses, three themes were identified that captured the suggestions of Indigenous mothers regarding ways to improve maternal healthcare experiences during the perinatal period: experiences and challenges with service delivery; holistic wellness and postpartum support, including more connection with Elders; and cultural safety and revitalization.

Theme 1: Experiences and challenges with service delivery

This theme highlights both the supportive and challenging maternal healthcare experiences of participating Indigenous mothers in NWT, noting limited local services, the stress of medical travel for birth, and inconsistent care. The need for community-based midwifery and better communication about available services to support safe, culturally grounded birthing options close to home was desired.

Some mothers had overall positive healthcare experiences:

“I had a good experience and felt informed from doctor and nurses.

“No it was really nice. I felt taken care of it. There was no issue with my delivery.”

The absence of local specialized services, medical expertise, and equipment were described:

“Only one of the nurses had labour and delivery experience and they had no supplies. They’re just not equipped.”

Participants specifically identified the limited accessibility of birthing pools and the choice of healthcare provider as issues to be addressed. One participant suggested that initial prenatal clinic appointments need to occur before the end of the first trimester of pregnancy:

“Get the tubs working. The new hospital doesn’t have a policy right now for the labouring tubs to be used. They have the tubs, but not the policies.”

“Probably just sooner appointments. I didn’t see anyone until my first trimester was over.”

Some participants described birth evacuation as stressful and expressed a preference to not travel for birth to receive specialized care; additionally, being separated from family, children, and spouses while awaiting giving birth led to feelings of isolation and anxiety:

“I was worried about care for my children and being alone. They wanted me to stay there for 2 months but I couldn’t be away from my children for so long.”

Participants felt that women should be able to choose where childbirth took place, such as within the communities, aided by family support:

“be good to have baby at home instead of travelling to somewhere else”.

Two participants described difficulties accessing the childcare necessary for travel and travelling long distances from remote communities to boarding homes and centres for maternal care:

“a lot of people come from isolated communities, single mothers who don’t have anyone to watch their child back home”.

“I find that place to be very distant from everything and the distance was hard to get anywhere. So isolated there. Maybe relocating that boarding home to where things are easier.”

Input and support from midwives and doulas were highly valued and desired by participants, and there was strong support for the reintroduction or improvement of midwifery services in the communities. Importantly, as described by participants, increasing the availability of midwives would allow mothers to give birth within the communities:

“Have a robust midwifery program. Cause women shouldn’t have to leave their community to have children. That’s not how things were traditionally. Unless they want to leave. But you shouldn’t have to leave.”

Some participants also explained that midwives and doulas offer unique skills and knowledge to mothers during birthing classes and labour, including coaching regarding alternative natural forms of pain management, such as breathing techniques and meditation. One participant also noted that midwifery was traditionally practiced by Elder women in the communities, who had acquired midwifery skills through generational knowledge translation:

“Having a doula or midwife… to coach them, how to be distracted or imagery, meditating or the breathing”.

“That midwifery... like if I had that is an option I would have just stayed at home and done it in a pool as natural as possible. That is what I wanted.”

Participants highly valued the role of public health nurses in community-based maternal care; nurses were described as an important factor in providing maternal support and monitoring newborn infants. One participant emphasized that home visits by public health nurses enhance understanding of a mother’s’ overall condition:

“When they come to your house, they have a better sense of how you’re doing.”

Limited continuity of care was identified as an issue by participants. Participants explained how being seen by transient locum healthcare professionals meant having to repeatedly explain one’s medical history:

“The only thing that I wish for is to have one doctor. It's hard having to explain stuff over and over.”

During the postpartum period, participants described experiencing rushed hospital discharges and having few postpartum care options, which were often delivered by locum staff:

“Just that post care was the biggest thing I found and struggled with. Just that you get no help. Soon as you’re done from the hospital you’re pretty much on your own.”

Importantly, having permanent healthcare professionals invested in the community was described as beneficial to the healthcare services being provided:

“So having retaining staff that are invested in the community.”

One participant expressed her gratitude for having received continuous healthcare from a single healthcare professional:

“Here, I’m really fortunate. I have a really great healthcare professional that knows me really well.”

Participants also described a need for improved communication and suggested increasing the advertisement of available services, such as through social media platforms:

“It just kept happening with the communication. People didn’t have other information.”

“Maybe it could be advertised a little bit better.”

“More social media”.

Theme 2: Holistic wellness and postpartum support

Within this theme, the mothers emphasized the need for holistic care that supports mental, emotional, and spiritual well-being. Participants desired more accessible mental health services, culturally grounded maternal health programs with Elders, extended postpartum follow-up, and informal peer support to enhance wellness for mothers and families.

Physical, mental, spiritual, and emotional dimensions of health were articulated. Participants voiced the need for an increase in the availability of mental health services and relevant information during the postpartum period. Several triggers for postpartum depression were described, including giving birth during the winter months and returning to work soon after childbirth. Some participants reported utilizing medication to treat anxiety; midwives were also considered a notable source of spiritual support:

Maybe I was suffering from postpartum depression. I'm on medication now for anxiety. I think going back to work after 6 months was a mistake. Maybe if they could follow up for a longer period of time for postpartum. Ask like how are you feeling. I only started reading up on my own symptoms. The first winter after having him was a really dark time for me.

“with the midwife we had and hour long home visit talking about everything spiritual and physical.”

While some participants were satisfied with community-based parenting programs and support groups, others reported a need to recommence such programs with full-time prenatal program coordinators:

“They have good prenatal services, other than maybe adding midwife.”

“we need a full time prenatal coordinator”.

“start back up the prenatal programs”.

Infant feeding options were one desired topic of discussion. As well, participants specifically identified an absence of support and education for fathers during pregnancy and after childbirth:

More information about breastfeeding and formula feeding in general. They're actually very proactive about breastfeeding at the arctic family centre. I don't feel bad about taking out my boob anywhere here. The opposite is when there is a mom who is heartbroken about not being able to breastfeed, or doesn't want to, formula is very expensive. More info about the reality of breastfeeding. Ending the stigma about formula. Baby is going to be ok, doesn't mean you're a horrible parent.

“More get-togethers for new parents. Talk about breastfeeding and how it’s important. Put it out there that you can’t be drinking and smoking while breastfeeding.”

Participants expressed a desire for Indigenous wellness classes that incorporate traditional skills and foods, as well as community Elders teaching traditional parenting skills and Indigenous mothering:

“more people to learn from that can share experience of raising a family, Elders teaching traditional parenting.”

“Bebia, teaches us how to connect with our Indigenous side and with raising our babies. They teach us how to make moccasins and traditional foods. A lot of traditional foods are healthier for kids and us. I love that group. I think they should have more groups like that in town.”

“not a lot of topics were focused around Indigenous mothering.”

Participants explained that providing mothers access to informal social activities and support groups would create safe spaces for mothers and allow for discussions regarding breastfeeding, feelings, and shared experiences:

“I felt so alone in the process. I don’t know if they can do more of a support group. Something where, at least, the people who are going through it at the same time can come together.”

What I would like is something more informal, like informal programming, where women can get together over and tea and coffee and bannock or soup and stew where they can socialize and do something low key. Or sewing. Just having safe spaces for that sort of thing.

Care packages were described as helpful sources of good information and baby supplies; such supplies helped alleviate the financial expenses of caring for a newborn:

“they have a care package with a whole bunch of stuff in it which is pretty awesome.”

Since I’m enrolled in IRC (Inuvialuit Regional Corporation), they gifted me and my baby books and a calendar with all of his growth spurts and how much he should be weighing at this age. They gave us a $100 gift card. Really came in handy with pampers hella expensive around here and formula.

Participants recommended school-based sex education for young mothers and the parents of adolescent mothers:

“Sexual education classes in junior high and high schools. Doing presentations to parents on how to talk about it and bring it into the homes.”

Providing mothers, especially working mothers, with access to 24-hour hotlines or group chats for support was an additional suggestion:

“Do they offer anything after working hours? Maybe do a hotline or something, or a group chat on social media.”

“A tip line would be great for that. Just cause I know I didn’t feel super comfortable with the healthy families’ program. Not really into group settings.”

Participants explained that a hotline would offer privacy and the opportunity to ask questions:

“The appointments are always so rushed. You always forget you had questions. Even if they had a tip line. Call and ask a question if you forget.”

Theme 3: Cultural safety and revitalization

This theme highlights the importance of culturally safe maternal healthcare for Indigenous mothers, emphasizing the need for improving healthcare professionals' cultural awareness, increasing the presence of Indigenous staff, support workers, and Elders, and revitalizing traditional maternal practices, language, and teachings. The mothers’ suggestions aim to preserve Indigenous knowledge whilst reducing discrimination, stigma, and misunderstanding within the healthcare system.

Participants described increasing cultural awareness and sensitivity among healthcare professionals as necessary. Training Indigenous individuals in healthcare and increasing the presence of Indigenous support workers, especially for young and inexperienced mothers, was recommended. The need for Indigenous wellness classes that incorporate traditional local languages was also reported:

“I think more cultural awareness training for professionals.”

“More Aboriginals in the healthcare system.”

I think what the hospital needs is an Indigenous personal support worker. If we had a room for Indigenous Mom's with an Indigenous support worker. The young moms come from other communities and I feel bad for the other moms that have no voice.

Participants expressed a desire for traditional Indigenous maternal care practices and the presence of Elders; the scarcity of culturally relevant information was also noted. Participants described an urgent need to record the wisdom of Elders before the Elders “pass on”:

“It would be really wonderful to have an Indigenous group wellness class and one that incorporates our languages into it.”

I wish that these older women - land use people - Indigenous maternity. Help you before, during and after pregnancy. There are protocols that go into them. Bring back these old systems to help nurture our mothers and even becoming women. Groom the young women for menstrual transition and during pregnancy. There is a lot of non-Indigenous information but not a lot of Indigenous information.

“And having midwives is huge. And having doulas. Especially Indigenous midwives and doulas.”

We need a lot of research before the Elders pass on and take the information with them. They know these unique Indigenous systems that help young women become women and mothers help develop and go through stages in their life including menopause. Researchers who are not Indigenous need to recognize this.

Some participants experienced stigma based on Indigenous cultural identity, leading to feelings of neglect, discrimination, and being misunderstood:

So what I feel like is that they didn't understand that value of Dene women having composure over themselves. Even around pain. Understanding that when you [Dene women] experiencing painful things you [Dene women] are expected to just endure it. To be strong and not to complain. I felt that they didn't understand me as an Indigenous person or Indigenous women and because of that I was kind of neglected. They didn't take my pain seriously.

“I just feel like there’s race, racism involved. It’s a big issue.”

Discussion

In this project, the earlier maternal age reported is concerning, as younger motherhood has been previously described as contributing to limited health literacy³⁸ and reduced familiarity with maternal healthcare systems. This may be further compounded by the lower educational attainment (less than or some high school) reported by some participants. Lower educational attainment has been associated with decreased awareness of available services, reduced confidence during healthcare interactions, and diminished health literacy.^39,40 Employment status represents an additional barrier to maternal healthcare. Unemployment may contribute to financial instability and the absence of employer-based health benefits, impeding maternal healthcare travel and the ability to pay out-of-pocket expenses. While an estimated two-thirds of participants had a partner who may offer support, this may not resolve persistent challenges such as transportation, childcare, or the travel required to access specialized maternal healthcare services in remote NWT communities. Collectively, the demographics highlight the importance of addressing socioeconomic, educational, and geographic barriers to ensure equitable, sustained access to culturally safe healthcare for Indigenous mothers in NWT.

Three main themes emerged from the qualitative analysis: experiences and challenges with service delivery, holistic wellness and postpartum support, and cultural safety and revitalization in maternal care. A notable challenge in service delivery discussed in this project was discontinuity in communication, which has been previously described for Indigenous communities.⁴¹ Continuity within healthcare helps to build trust with Indigenous community members where a legacy of distrust exists. The improvement of coordination and continuity along the care pathway is encouraged. Evidence indicates that prearranged perinatal appointments and increased availability of information may reduce the isolation and marginalization often experienced by women during perinatal care,⁴² thereby helping to lessen associated fear and anxiety.

The inaccessibility of maternal healthcare services, as described by participants in this project, has been reported to contribute to maternal mortality and morbidity in remote regions.⁴³ The World Health Organization recommends the implementation of community mobilization with women’s groups to improve maternal and newborn health, particularly in rural settings with low access to healthcare services.⁴⁴ Community-based programs such as ‘Mums, Boobs, and Babies’ (breastfeeding support), ‘Mama n Bebia’ (food and social support), and the Healthy Families program are available to some Indigenous communities. Notably, ‘Mama n Bebia’ is culturally adapted and taught in local languages. Previous research indicates that flexible, walk-in models of maternal care for First Nations in Alberta, Canada enhanced accessibility and fostered culturally safe healthcare environments.⁴⁵ Hui et al. (2021) found that delivering remote maternal health education through chat and community support groups increased participation among Indigenous pregnant women in rural and remote Manitoba from 36% to 54% within the first year of implementation.⁴⁶ However, with high proportions of adolescent mothers within Indigenous communities, maternal healthcare services may require adaptation to meet unique needs, such as those of high-risk pregnancies. The continued development of maternal healthcare services, as well as the adaptation of existing services, is recommended; services should be flexible, community-based, and culturally safe to ensure accessibility, appropriateness, and responsiveness to the community’s needs, particularly for younger mothers.

The findings of this project also illustrate the multi-dimensional nature of maternal health, which involves an interaction between psychosocial, emotional, and cultural elements. Birthing in Indigenous communities has traditionally been considered a part of familial and community relations.⁴⁷ The project findings support the importance of Indigenous doulas using culturally centred knowledge and practices during pregnancy and birthing, which has been previously described.⁴⁸ Supporting childbirth within home communities will help improve community dignity, self-esteem, and trust,⁴⁹ and promote health, kinship, and Indigenous community culture.⁴⁷ One study based in Ottawa, Ontario, also found that healthcare professionals did not consistently provide culturally safe maternal healthcare.⁵⁰ It is recommended to support communities in increasing the availability and training of local midwives, doulas, and public health nurses. Furthermore, enhancing the capacity of community-based health centres to deliver culturally sensitive quality care could further ensure adequate support for Indigenous mothers in NWT.

Participants in this project also expressed a desire for traditional Indigenous maternal care practices and information. The transmission of inter-generational wisdom was a role celebrated by matriarchal Elders, who passed on skills and knowledge of traditional perinatal medicines.⁵¹ Notably, such knowledge transmission has a positive impact on the development of children.⁵² Indigenous women should be encouraged to and supported in sharing Indigenous ways of knowing and being so that this knowledge transmission continues. Facilitating the Increased availability of Indigenous doulas and expanding access to training may be beneficial. Previous research has highlighted the important role of Indigenous doulas in helping to redress the colonization of Indigenous childbirth and in promoting inter-generational healing within Canada,⁵³ as many best practices align with Indigenous Healing Programs.⁵⁴ The Nunavut Arctic College does offer maternal care training grounded in cultural beliefs and values, and incorporates both traditional and modern maternal care practices.⁵⁵

The findings of this project also support previous work where feelings of loneliness, sadness, and anxiety accompanied childbirth within Indigenous communities.⁶ To address the mental health challenges in Indigenous women,⁵⁶ routine screening for mood disorders during pregnancy may be beneficial. The Edinburgh Postnatal Depression Scale screening tool has been effectively utilized during pregnancy and the postpartum phase with Indigenous mothers.⁵⁷ The findings of this project also suggest that Indigenous mothers are disconnected from traditional extended family structures and support. Social support is a strong determinant of thriving health in Indigenous women.⁵² The literature shows that social networks strengthen resilience, build community connection, and lessen experiences of stress.⁵⁸ Notably, Indigenous mothers often report feeling that a pregnancy is healthy when a support system exists, which includes family, healthcare professionals, and the community.⁵⁹ Maternal health initiatives in NWT focusing on strengthening social support for Indigenous women, fostering connections among family, healthcare providers, and community members, could provide invaluable support to mothers.

Overall, it is imperative to continue improving the capacity and accessibility of existing maternal health services and infrastructure in NWT. Indigenous women should also have the option of choosing a safe birthing venue close to home; increasing local midwifery services would assist in providing such an option. Evidence suggests that co-designed primary health care models with Indigenous communities and Elders,⁶⁰ emphasizing culturally responsive and well-coordinated services, may contribute to improved maternal health outcomes and trusting patient–provider connections.⁵² The inclusion of Indigenous communities in knowledge translation and the development of culturally sensitive services, including the mentoring and education of existing healthcare providers, should be supported.

Strengths and limitations

This project leveraged a strong CBPR model that included Indigenous communities in an equal partnership on all aspects of the project throughout the research process. Engagement with community members and the Community Advisory Board supported the cultural relevance of the study and informed the design, data collection, and interpretation of findings. The relatively large qualitative sample size, provided confidence that sufficient information was available to support the thematic analysis .⁶¹ The project has several limitations. Firstly, the transferability of qualitative findings may be limited as Indigenous community settings in NWT have distinctive characteristics; however, the project findings do align with previous research and findings from other geographic locations.⁶² Culturally grounded and community-based learning practices were not collected in this project. We recognise this as a limitation in this project. In many Indigenous contexts, knowledge related to maternal health is often transmitted outside of formal institutional settings. Such intergenerational and community-based learning may not be reflected in conventional measures of educational attainment. It is recommended that future research should consider culturally embedded educational experiences, as well as the perspectives of Elders, community members, healthcare professionals, and policy decision-makers, who may provide additional valuable insights.

Conclusion

This project contributes to the limited research available on maternal healthcare in Indigenous communities in Canada. Building trusting relationships that honour Indigenous practices between healthcare providers and mothers, improving healthcare access and delivery, and strengthening midwifery services within the communities are important. This project provides Indigenous-informed evidence that can guide maternal healthcare practices, policies, and program decision-making in NWT and elsewhere in Canada.

Supplemental material

Supplemental material - Indigenous mothers’ perspectives on improving maternal healthcare in Northwest Territories, Canada: Results from the maternal and infant health project

Supplemental material for Indigenous mothers’ perspectives on improving maternal healthcare in Northwest Territories, Canada: Results from the maternal and infant health project by Rachel Harris, Fariba Kolahdooz, Moutasem Zakkar, Claire Manning, Marie Tarrant, André Corriveau, Stephanie Irlbacher-Fox, Adrian Wagg and Sangita Sharma in Women's Health.

Footnotes

Acknowledgments

The project team would like to acknowledge and thank the Indigenous women who shared stories, experiences, and motherhood journeys with us. We are grateful to several organizations in NWT and the CAB, who provided guidance and support throughout the project.

ORCID iDs

Rachel Harris

Fariba Kolahdooz

Moutasem Zakkar

Adrian Wagg

Sangita Sharma

Ethical considerations

Ethical approval was granted by the University of Alberta’s Research Ethics Board (Pro00085941). A NWT research license and a research agreement with the Department of Health and Social Services and the Government of NWT were obtained. Written informed consent was obtained from all participants (including participants 17 years of age) prior to the start of the interview, after trained local research assistants explained the project’s objectives and methods in the participants’ preferred language, in accordance with the ethics protocol.

Consent to participate

In NWT, individuals aged 17 years may be considered ‘mature minors’ who are able to provide informed consent for participation in health-related research if sufficient understanding of the study is demonstrated. Participants were given time to ask questions before agreeing to take part.

Author contributions

FK and SS conceived and designed the project and supervised data collection. RH, MZ, and FK performed the data analyses and interpretation of results. RH, CM, and FK produced the first article draft. All authors critically reviewed and revised the manuscript and read and approved the final version.

Funding

This project was funded by the Canadian Institutes of Health Research (FRN 159485).

Declaration of Conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and/or analysed during the current project are not publicly available due to reasons of sensitivity and the scope of participants’ consent.*

Supplemental material

Supplemental material for this article is available online.

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