Indigenous women’s experiences of prenatal stress and support during pregnancy and childbirth in Northwest Territories: Findings from the Maternal and Infant Health Project

Abstract

Background

Prenatal stress is linked to adverse perinatal outcomes. Indigenous women in Canada face high risks for adverse maternal and perinatal health.

Objectives

This project aimed to understand levels and sources of stress experienced by Indigenous women during pregnancy and utilization of and experiences with available support.

Design

The project employed a mixed-methods cross-sectional design.

Methods

The project was conducted in three communities in Northwest Territories, Canada with varying road and healthcare accessibility. Indigenous women who were pregnant or had given birth within three years were invited to participate in a semi-structured interviewer-administered questionnaire, which included open and close-ended questions on pregnancy history, stress levels, healthcare access, available support, and experiences during and after giving birth. Descriptive statistics, regression modelling, and deductive thematic analysis were used.

Results

Of 156 participants between the ages of 17 and 47 years (mean age: 29.7 years; SD=6.0), 93.0% had given birth in the past three years, 18.0% were pregnant, and 85.3% were multiparous. Most participants reported pregnancy as somewhat stressful (49.7%) or very stressful (27.5%). Multiparity was associated with greater odds of reporting stressful pregnancy compared to first-time pregnancies (OR = 3.31, 95% CI: 1.22-8.97, p = 0.0186). Qualitative themes included reaction to pregnancy, stress during pregnancy, community support, and professional support. Factors contributing to prenatal stress included personal responsibilities, financial insecurity, housing concerns, and family issues. Support varied, with some feeling inadequately supported.

Conclusion

While various social supports exist, some participants reported inadequate support. The findings suggest the urgent need to expand community support programs in remote areas, both in numbers and access, is crucial for addressing maternal health concerns. Including kin and community supports and supporting community-driven initiatives would be effective strategies and require future exploration as to the impacts on addressing prenatal stress in Indigenous women in remote communities.

Introduction

Maternal health encompasses the health of a woman throughout the stages of pregnancy, childbirth, and the postnatal period.¹ Comprehensive clinical prenatal and postnatal care, including routine examinations and disease screening, is crucial for ensuring maternal health.^2,3 In addition to the physical aspects of maternal health, stress during the prenatal period can also impact the health of mothers and infants.⁴ Stress during pregnancy has a lasting impact on childhood growth and development.^5–7 Specifically, stress during pregnancy is associated with low birth weight,⁸ preterm birth,⁹ gestational hypertension,¹⁰ altered fetal development, an increased risk of psychiatric disorders in the child,¹¹ and an altering of inflammatory activity within the body, which adversely affects maternal and fetal physiology.^12–14 Psychosocial, cultural, pregnancy-specific, and environmental factors can impact prenatal stress^12,15–17; community and social support may mitigate prenatal stress.^18,19

Indigenous women in Canada are at higher risk for adverse maternal and perinatal health outcomes,^20,21 including poorer mental health,²² than non-Indigenous women.²³ The legacy of colonialism continues to disproportionately result in poverty, food insecurity, unemployment, domestic violence, and limited access to healthcare services for Indigenous community members (First Nations, Métis, and Inuit)²⁴ compared to non-Indigenous individuals in Canada.^25–30 The Northern territories of Canada are sparsely populated^31,32 and have a higher proportion of residents who are Indigenous (86% in Nunavut, 51% in Northwest Territories (NWT), and 23% in Yukon). Communities in the three territories have unique geography, healthcare needs, and sociocultural contexts.^33,34 NWT, specifically, is a large territory with 33 widely dispersed communities: 19 are accessible via permanent all-season roads, 10 are accessible via winter roads, and four have no road accessibility.^35,36

The limited accessibility and remoteness of NWT communities affect the availability of maternal healthcare services,³⁷ with women frequently required to travel outside of the communities and even the territory for prenatal appointments and childbirth.³⁶ While timely access to comprehensive healthcare during pregnancy and childbirth is essential for newborn health,³⁸ emerging evidence shows that solely increasing the accessibility and utilization of facility-based healthcare services does not necessarily guarantee better health outcomes.^39,40 Other factors can impair maternal and child health, including the limited availability of culturally relevant medical information^41–43 and limited community and family presence/support, which play important roles in reducing prenatal stress.^18,19,44,45 As such, community involvement and support during pregnancy and childbirth, as well as the integration of culture, beliefs, and traditions into healthcare services, may be essential to improving the maternal health of Indigenous women in Canada.⁴⁶ Indeed, social support during pregnancy and childbirth improves maternal well-being.^25,47,48 Such support is crucial in remote communities, even in communities that are well-resourced, as many women, regardless of environment, may feel stressed for the experiences of first-time mothering.⁴⁹ Within rural and remote communities where the centralization of healthcare services in metropolitan areas has resulted in a shortage of rural maternity healthcare professionals and services,⁵⁰ it is especially vital for Indigenous women to have some form of support within the community during pregnancy.⁵¹

There is a knowledge gap regarding the prenatal stress experienced by and the support available to Indigenous women in NWT. To the authors’ knowledge, there has not been a study exploring the prevalence of prenatal stress and factors contributing to or mitigating prenatal stress in Indigenous women in NWT. To close this gap, this project aimed to understand levels and sources of stress experienced by Indigenous women during pregnancy, as well as the utilization of and experiences with available community and health/wellness support services. This evidence could help inform community-driven, evidence-based practices and interventions aimed at improving maternal and infant health and quality of life.

Methods

Setting

This project was part of the Maternal and Infant Health Project, which aimed to improve maternal and infant health among Indigenous community members in NWT, Canada.⁵² Community A is a remote fly-in community and has 90% of community members self-identifying as Indigenous.^53,54 Healthcare services are provided by nurses at the health centre, and women are required to travel for prenatal care including ultrasound and scheduled delivery at a hospital. Community B is a semi-remote administrative centre with 67% of the residents self-identify as Indigenous, and has limited road access, one health centre and one hospital.^55,56 Community C is a major city with medical clinics and a hospital, with 23% of residents self-identifying as Indigenous.^56,57 Details about the project have been previously published.⁵²

Design and data collection

A convergent mixed-methods cross-sectional design was used to capture the level of Indigenous women’s self-reported stress experiences during pregnancy and associated factors, and qualitatively explore experiences with stress during pregnancy. The project’s quality assurance was informed by the Mixed Methods Appraisal Tool (MMAT) guidelines.⁵⁸ Eligible participants in this project were self-identifying Indigenous women of childbearing age,⁵⁹ who were pregnant or who had given birth within three years prior to data collection, and who resided in one of the three communities. An initial sample size calculation was conducted to estimate the number of participants required for adequate statistical power in logistic regression analyses. However, given the geographic isolation, severe winter conditions, and the community-driven research approach, purposive sampling was utilized. The final sample size was determined in consultation with the Community Advisory Board to balance methodological rigour with practical constraints and community priorities. Potentially eligible Indigenous women were approached in partnership with local organizations that support pregnant and postpartum women and infants, and the project was also advertised through community social media, local radio, and television. These recruitment methods were guided by the Community Advisory Board and have been successfully employed in previous projects by the study team, achieving high response rates given the size of the communities.

Between October 28 and November 9, 2019, trained interviewers conducted interviews using a questionnaire, meticulously designed in alignment with the project objectives, a comprehensive literature review, and the researchers’ extensive community engagement. The questionnaire’s development was further refined and validated by the Community Advisory Board and underwent pilot testing by community members before the project commenced. It included both closed and open-ended questions addressing various aspects such as pregnancy experiences and history, health status, health literacy, maternal healthcare services, access to healthcare during pregnancy, childbirth, and the postnatal period, as well as potential areas for service enhancement. Additionally, the questionnaire gathered socio-demographic data and information on food insecurity.

Interviews were conducted in the local language or in English. Each participant provided written informed consent. In NWT, individuals under the age of majority may be considered ‘mature minors’ and provide informed consent to participate in health studies when sufficient understanding of the study is demonstrated. Participants were informed of the purpose, benefits, and risks of the study utilizing the approved consent form and were welcomed to ask questions before providing consent. One participant was a mature minor (17 years old) and our community organization partners were consulted to determine her intellectual ability and level of maturity. Interviews were audio-recorded with participant permission, while questionnaire responses were recorded on electronic tablets utilizing REDCap version 8.1.1.

Measures

The outcome of interest

The outcome of interest was having a stressful pregnancy, which denotes the overall psychological and emotional strain experienced by participants during pregnancy. This included various personal, social, financial, and health-related stressors. The concept was communicated to participants and measured by the question, “Thinking about the amount of stress in your life during your pregnancy, would you say that most days were: not stressful, somewhat stressful, very stressful, I don’t know, or prefer not to answer.” The question is closely modeled after a question in the Canadian Maternity Experiences Survey.⁶⁰

Independent variables

Age at first pregnancy was measured by the question, “How old were you when you became pregnant for the first time?” The number of pregnancies was measured using the question, “How many times have you been pregnant?” Having support during pregnancy was measured by the question, “What family, friends, or kin support do/did you have in your community related to your pregnancy?” Food insecurity was measured by the question, “In the past month, did you have to eat less than you wanted or not eat at all because there wasn’t enough food for you or your family?”

Statistical analysis

Descriptive statistics for quantitative variables were produced. Chi-Square tests of independence and logistic regression modelling were performed to explore the associations between the independent variables and the outcome of interest. Simple, multiple, and multinomial models were created. Statistical analysis was done using SAS statistical software, version 9.4 (SAS Institute Inc, Cary, NC). Qualitative data were analyzed using deductive thematic analysis and coded by MZ and RS utilizing NVivo, version 14 (Lumivero, Denver, CO). Interview questions guided the coding categories and subcategories,⁶¹ allowing the integration of quantitative findings and qualitative themes at the stage of analyzing the data. Qualitative data were analyzed in tandem with preliminary quantitative results for authors to explore lived experiences relating to the outcome of interest and gain a deeper understanding of prenatal stress. Upon completing coding of all interviews, data saturation was confirmed.

Mixed methods integration

A convergent design with concurrent, equal-priority qualitative and quantitative strands was employed within the same interviewer-administered session. Integration occurred during analysis by aligning survey estimates with deductively coded themes to examine convergence, complementarity, and expansion. Results for each strand are presented in separate subsections. At the interpretation stage, integrated inferences were derived by synthesizing evidence across strands and assessing the degree of fit between qualitative and quantitative findings.

Ethics : The University of Alberta’s Research Ethics Board granted ethical approval for the project (Pro00085941). The research licence was obtained from the Aurora Research Institute in NWT, and a formal research agreement with all participating communities was also obtained.

Results

Quantitative results

A total of 156 participants completed an interview, each approximately 30 minutes in duration; 145 participants had given birth within three years prior to data collection, and 28 were pregnant at the time of data collection.

The age of the participants ranged between 17 and 47 years old, with the mean age of participants being 29.7 years (SD=6.0). The majority of participants self-identified as First Nations (53.6%) or Inuit (32.7%). In terms of education, 43.0% completed less than or some high school. Approximately 27.7% of participants worked full-time, 43.2% were not working, and 19.9% reported experiencing food insecurity in the past month (Table 1).

Table 1.

Demographic characteristics of Indigenous women in three communities in Northwest Territories: results from the Maternal and Infant Health Project (n=156).

	Community
	A	B	C	All communities
Participants, n (%)	24 (15.4)	68 (43.6)	64 (41.0)	156 (100)
Mean, Age (SD)	32.0 (5.8)	29.3 (6.0)	29.1 (6.0)	29.7 (6.0)
	n (%)	n (%)	n (%)	n (%)
Age categories (years) §
<25	2 (8.7)	14 (20.6)	15 (23.4)	31 (20.0)
25-35	14 (60.9)	45 (66.2)	39 (60.9)	98 (63.2)
>35	7 (30.4)	9 (13.2)	10 (15.6)	26 (16.8)
Ethnicity * §
First Nations	24 (100)	17 (25.4)	41 (66.1)	82 (53.6)
Inuit	0	43 (64.2)	7 (11.3)	50 (32.7)
Inuit and First Nations	0	5 (7.5)	3 (4.8)	8 (5.2)
Métis	0	0	11 (17.7)	11 (7.2)
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 (50.0)	26 (38.8)	29 (45.3)	67 (43.2)
Food insecurity
Yes	5 (20.8)	12 (17.7)	14 (21.9)	31 (19.9)
No	19 (79.2)	56 (82.4)	50 (78.1)	125 (80.1)

- Percentages are column percentages.

*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.

Multiple pregnancies were reported by 85.3% of the participants, and 51.8% gave birth for the first time before the age of 20 years. Most participants had a partner or spouse (70.5%) and had support from family, kin, or friends during pregnancy (89.5%). Most participants reported pregnancy as somewhat stressful (49.7%) or very stressful (27.5%) (Table 2).

Table 2.

Pregnancy history of Indigenous women in three communities in Northwest Territories: results from the Maternal and Infant Health Project (n=156).

	Community
	A	B	C	All communities
Mean age at first pregnancy (SD)	20.35 (5.0)	20.61 (4.1)	21.48 (5.8)	20.95 (5.0)
Mean number of pregnancies (SD)	3.63 (1.6)	3.1 (1.7)	3 (1.7)	3.13 (1.7)
	n (%)	n (%)	n (%)	n (%)
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)
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 and given birth in last 3 years
Yes	1 (4.2)	9 (13.2)	7 (10.9)	17 (10.9)
First Time pregnancy §
Yes	2 (10.5)	9 (15.3)	9 (15.5)	20 (14.7)
No	17 (89.5)	50 (84.8)	49 (84.5)	116 (85.3)
Missing				20
Number of pregnancies §
1	2 (10.5)	9 (15.3)	9 (15.5)	20 (14.7)
2–4	12 (63.2)	41 (69.5)	40 (69.0)	93 (68.4)
5–7	5 (26.3)	7 (11.9)	7 (12.1)	19 (14.0)
>7	0	2 (3.4)	2 (3.5)	4 (2.9)
Missing				20
Age at first pregnancy (years) §
<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
First pregnancy was during teenage (<18 years old)
Yes	12 (50.0)	23 (33.8)	24 (37.5)	59 (37.8)
No	12 (50.0)	45 (66.2)	40 (62.5)	97 (62.2)
Currently having a partner or 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)
Having family, kin, or friends support in your community related to your pregnancy *
Yes	18 (81.8)	62 (92.5)	56 (88.9)	136 (89.5)
No	4 (18.2)	5 (7.5)	7 (11.1)	16 (10.5)
Stress level during your pregnancy *
Not stressful	5 (22.7)	18 (26.9)	12 (18.8)	35 (22.9)
Somewhat stressful	10 (45.5)	34 (50.8)	32 (50.0)	76 (49.7)
Very stressful	7 (31.8)	15 (22.4)	20 (31.3)	42 (27.5)

- Percentages are column percentages.

*Levels of five or fewer observations were omitted.

§Missing data were omitted from all analyses.

Chi-square and Fisher’s exact tests showed that multiparity and food insecurity were associated with experiencing stress during pregnancy (Table 3). Age at first pregnancy was not associated with stress. The logistic regression model found an association between multiparity and experiencing stress during pregnancy (OR = 3.31, 95% CI: 1.22-8.97, p = 0.0186) (Table 4).

Table 3.

Association between self-reported stress levels during pregnancy among Indigenous women in three communities in Northwest Territories: results from the Maternal and Infant Health Project (n=156).

	Stress during pregnancy n (%)
	Not stressful	Somewhat stressful	Very stressful	p-value*
Community				0.7076
A	5 (22.7)	10 (45.5)	7 (31.8)
B	18 (26.9)	34 (50.8)	15 (22.4)
C	12 (18.8)	32 (50.0)	20 (31.3)
Age at first pregnancy (years) **				0.2805
< 20 years	13 (18.3)	32 (45.1)	26 (36.6)
20-29 years	16 (28.6)	27 (48.2)	13 (23.2)
30-39 years	2 (22.2)	6 (66.7)	1 (11.1)
First pregnancy was during teenage (<18 years old) **				0.6972
Yes	11 (19.3)	29 (50.9)	17 (29.8)
No	24 (25.0)	47 (49.0)	25 (26.0)
First-time pregnancy **				0.0438
Yes	9 (45)	8 (40)	3 (15)
No	23 (20)	57 (49.6)	35 (30.4)
Having family, kin, or friends support in your community related to your pregnancy **				0.4482
Yes	33 (24.4)	67 (49.6)	35 (25.9)
No	2 (12.5)	8 (50.0)	6 (37.5)
Food insecurity **				0.0080
Yes	4 (13.3)	11 (36.7)	15 (50.0)
No	31 (25.2)	65 (52.9)	27 (22.0)

- Percentages are row percentages.

*Chi-square and Fisher’s exact tests.

**Levels of five or fewer observations were omitted.

Table 4.

Simple Logistic Regression of multiparity and stress during pregnancy among Indigenous women in three communities in Northwest Territories: results from the Maternal and Infant Health Project (n=156).

Simple logistic regression - multiparity (independent variable) and stress during pregnancy
Parameter	DF	β	Standard error	Wald chi-square	p-value	Odds ratio (95% CI)
Intercept	1	0.2007	0.4495	0.1993	0.6553
Multiparity (Yes vs No)	1	1.1969	0.5086	5.5376	0.0186	3.31 (1.221, 8.970)

Qualitative results

Qualitative analysis revealed four themes (Figure 1).

Figure 1.

Four qualitative themes summarizing factors contributing to or alleviating stress during or after pregnancy.

Theme: Reaction to pregnancy

Participants reported varied initial reactions to being pregnant.

Many participants who were trying to have a baby reported being very excited about being pregnant:

“Excitement; we were trying for a long time.”

“Very excited, we were planning this one for quite a while. It did not happen for a number of months; we are definitely excited and very happy. As with all of them.”

For some, the reaction was related to the number of previous pregnancies:

“The very first one I was very scared because I was so young. I actually aborted the first one. The others I was excited.”

“I had mixed emotions. This is my third baby. And they are close apart. They are two years apart. I have two toddlers at home. I'm quite busy already.”

Some participants also reported experiencing stress. This stress sometimes resulted from surrounding circumstances, such as the pregnancy being unplanned:

“It was stressful, just given the age gap. My daughters are 11, and 7, you know just not planning for it. We were excited but at the same time, we were new homeowners, I was new to my job, my husband was new to his job. Personally, on a family level we were ecstatic but given those factors it was a lot.”

“I was like, ‘not again’. I had no idea, she wasn’t planned. At the time we were in a tough situation, living with my mom and weren’t really on our feet.”

Theme: Stress during pregnancy

Factors that resulted in stress during pregnancy included the demands of managing both work and family life while being pregnant and the symptoms of, and expected events related to, pregnancy, such as severe morning sickness and labour:

“I already had a kid. So somewhat stressful. Cause I had to work, you know, raise another child.”

“Balancing being a mom of a young daughter and working while pregnant.”

“First 3 months pregnancy [I had] intense morning sickness; last 3 months [I had] intense heartburn.”

“Just around the end I wasn’t sure how it was going to be during labor. I was worried about it but everything just came so natural.”

“I had a rough pregnancy, outside of the pregnancy, not as much, but the pregnancy brought on a lot of stress.”

Some participants also mentioned that being in school during pregnancy contributed to stress:

“Between full work and online school. I’m taking five courses [in the college]!”

“It was really hard to go through this and to also keep going on with my regular life because I was a college student so I couldn’t just come and go as I wanted to. Even though it probably would have been okay but I was worried about my standing. You have to meet certain criteria to stay in your programs. I was really stressed out.”

One participant specifically mentioned that travelling for ultrasonography was the only stressful event during her pregnancy.

Financial concerns were also a source of stress during pregnancy:

“I was scared about not having money to buy stuff.”

“Worrying about money.”

Additionally, housing concerns, relocating during pregnancy, worrying about providing for a child, and difficult family relationships were described as sources of stress.

A few participants reported a very relaxed pregnancy, utilizing coping strategies such as an improved diet and increased rest:

“My pregnancy was really nice. I was getting taken care of really well. I was also eating a lot healthier because of my diabetes diagnosis. I ended up losing weight during my pregnancy because I ate so well. I stopped all travelling for work.”

“I was just trying to be positive. I was like, ‘I’m getting a girl!’”

“I felt I was really aware of my stress because I was pregnant. So I was doing things to manage that like have downtime, naps.”

Theme: Community support

Participants described receiving community support during pregnancy and childbirth from three main sources: family, friends, and social support groups.

Family

Family support during pregnancy came from spouses, immediate family, and extended family.

Most participants reported receiving support from many family members:

“His dad. Mom and grandma. Sisters and aunties and friends.”

“Mom, his father, his grandparents, my sisters, brothers. Lots of family back home.”

“My mom, my sister and auntie they were always by my side.…Initially my partner really struggled with it, but by about 12-14 weeks he was on board. I had my family, my mom, my dad and my sister, several friends. I felt quite supported.”

“I was a little worried about having 2. I was a single mom for the first five months then I had help with my former partner”

“I didn’t stress out too much during pregnancy but sometimes happens right… little bit… cause my husband is very supportive”

One participant explained how being from the North resulted in feeling closer to family and the community as whole:

“Mom, my mom’s still around. She doesn’t leave me alone. And I have aunties. I have a really large family. That’s the great thing about being born in the North. I feel like I’m related to all of [community]. But I had my mom’s sisters.”

One participant came back into the community to receive family support:

“I just moved back from Winnipeg. I was kind of between places. At my cousins and then my mom’s. They took me in.”

Friends

Friends within the community were described as an important form of support during pregnancy and giving birth, especially for individuals who did not have support from larger family circles:

“Nobody really, just my partner and my one friend. She was in the delivery room with both my kids, she pretty much just helped us out. She took us off the street when I was pregnant with my first one.”

“My other half; towards the end he ditched us. I have my mom and friend. Just mainly those ones that I would go to.”

Some participants spoke about the benefits of having support from friends in addition to family:

“I had my family, my mom, my dad and my sister, several friends. I felt quite supported. Elders.…Friends as well.”

Social support groups

A few participants spoke about receiving both emotional and tangible support from different organizations and groups providing social supports within the community:

“I didn’t really have support, cause my mom, she’s in her own addiction and plus she works every day. My auntie helped just a little bit but not very much, but I was ok with it because she has her own kids and grandkids. But other people from AA (Alcoholics Anonymous) meeting or other groups and YWCA (Young Women’s Christian Association), I had support. My social worker comes.”

“So, there’s lots of programs. Like the one at [organization name], I used to go a lot with my 7-year when he was a baby, with him not as much because I feel like the lower income moms benefit from that and I just feel like I’m taking away so I just stopped going there. It’s great, the vouchers they get.”

However, some participants indicated receiving little to no support from organizations and groups within the community:

“Not much support throughout my pregnancy.”

“Not a lot of support. Just my partner in the first and third trimester.”

Theme: Health and wellness support services during pregnancy and after delivery

Participants stated that health and wellness support within the communities primarily came in the form of hospital visits, support groups, and home visits by healthcare professionals:

“They have the Arctic Family Centre. Can go when pregnant or after born. [And] Healthy Babies.”

“The prenatal course. A lot of people here are very open and interested in babies and helping you through it.”

“There was an RN (registered nurse) that did all of the prenatal. She was up at the hospital and did all of my check-ins. If there was something she would phone me. I was offered extra tests because of my age to ensure there was no abnormalities.”

However, many participants reported receiving very limited or no medical support:

“People were flying in and out and it was all confusing. I wish there was one doctor you could stay with at all times. Like every prenatal.”

“Just the prenatal appointments.”

“Nobody except nurses and once a month doctor who flies in.”

Discussion

This paper explored Indigenous women’s experiences of prenatal stress and support during pregnancy and childbirth in NWT. Participants’ initial reactions to being pregnant, experiences of prenatal stress, and the types of support that participants received were all discussed. Participants’ initial reactions to being pregnant seemed to vary according to the expectation of pregnancy and the number of children already in the family; while most reactions were positive, some participants reported experiencing more negative reactions, including stress. The project findings revealed many factors of prenatal stress, including balancing work/school and family responsibilities, financial insecurity, pregnancy itself, issues within the family, and medical travel, all of which may affect the health of mothers and children, as well as implications for maternal programs and policies (Figure 2).

Figure 2.

Suggestions to address stress during pregnancy and childbirth in Indigenous women in NWT.

In Canada, most national estimates regarding prenatal stress do not include Yukon, NWT, or Nunavut. In the Canadian Maternity Experiences Survey (2014), 12.5% of women reported that most days during pregnancy were very stressful,⁶² which is much lower than the rate found in this project. Indeed, in Canada, mothers from Indigenous and Black communities are more likely to experience pre-and-postnatal stress compared to White mothers, which may be related to low socioeconomic status, inequitable social determinants of health, and experiences of racism.⁶³ Our findings are concerning, as stress can lead to impaired perinatal outcomes and affects the growth and development of the child.^5–10 Women identifying as First Nations are more likely to report poor health status during pregnancy than other women in Canada.³⁰ We found that multiparity may be associated with increased stress during pregnancy. Participants reported that as the number of children in the family increased, so did the mothers’ responsibilities and exhaustion, resulting in more stress. We found no significant association between age at first pregnancy and stress levels. However, other evidence indicates that younger women may experience elevated stress during pregnancy due to factors such as financial instability, insufficient social support, and limited life experience.^64,65 Within an Indigenous context, there is a notable gap in the literature concerning the relationship between age at first pregnancy and stress, highlighting the need for further research in this area. After accounting for age at first pregnancy, multiparity showed a significant positive association with stress during pregnancy. The observed wide confidence interval for the odds ratio of experiencing stress among multiparous participants can be attributed to several factors. First, the number of participants of the study may have been relatively small, leading to greater variability and less precise estimates. Additionally, the inherent variability in the data, including differences in participant characteristics and experiences, could have contributed to the wide interval. Despite the wide confidence interval, the odds ratio still indicates a significant association between multiparity and pregnancy stress, underscoring the findings’ importance.

Social support played a crucial role for many participants. Specifically, family, Elders, friends, and community members were key sources of social and emotional support, corroborating existing evidence.⁶⁶ Traditionally, pregnancy and giving birth was an important part of sacred ceremony in Indigenous communities; the journey strengthens women individually, and connects families and generations.⁶⁷ Relationships and community were among essential features of Indigenous pregnancy care.⁶⁸ Clinical utilization of relational pregnancy care for Indigenous women has recently been explored. For instance, the COVID-19 pandemic sparked interest in virtually connecting Elders and pregnant women in clinical settings in Alberta, and the program had a positive impact on pregnancy through multigenerational resilience and healing.⁶⁹ This was described and acknowledged by many women in this project to be lessening stress relating to pregnancy and impending parenthood while navigating complex life situations. However, a small percentage of participants indicated receiving very little or no social support during pregnancy, and many reported having minimal access to maternal support services or receiving inadequate medical social support (i.e., from nurses, doctors, and healthcare staff). The limited availability of health services in rural areas, especially in Northern Canada, is well-documented.^36,70–72 This is concerning given the inequitable social determinants of health experienced in Northern communities and the relationship between limited support and poorer health outcomes,⁷³ and suggests that additional support from and implementation of prenatal programs is necessary. Participants indicated that both first-time mothers and mothers who have multiple children have a great need for such support during pregnancy. There are likely similarities in the type and amount of support needed by all first-time mothers in terms of preparedness, but this may vary by family circumstance. For example, in areas with high rates of poverty,⁷⁴ the effect of pregnancy on a family is different.⁷⁵ Low-income women with multiple children may need additional emotional and tangible support.⁷⁶ However, this can be difficult to access in remote Northern communities.^77,78 The limited accessibility of such social support can also contribute to delays or irregularities in attending medical appointments.⁷⁹ Many Indigenous women in the North are affected by unequal social determinants of health, which are linked to poorer health outcomes, including lower income, rural settings, crowded housing, and limited access to clean water, all of which can affect the health of both mothers and children.⁷³ Social support circles are protective, as individuals who report better health profiles often have larger support circles, frequently participate socially, and have close-knit families.⁷³

Some participants appreciated community programs, such as support groups and healthcare professionals’ home visits, while many participants in the remote communities found such programs were very limited. There may be a need to provide community-based programs in remote communities, as a recent review of these types of support programs has shown that the majority seem to be successful, resulting in positive clinical and health outcomes.⁸⁰ Evidence shows that programs that have local community ownership report better chances of successful outcomes,⁸⁰ which should be considered when implementing support programs within communities. There have been successful attempts to bring additional community support programs and services to rural communities to reduce disparities in maternal care. For example, the expansion of community midwifery services for Indigenous women has improved the cultural safety, experiences, and maternal and perinatal outcomes of maternal care. This program has received support from Indigenous women living in the North since the mid-1980s, when medical evacuation from communities became the standard of care.^81,82 Additionally, the Canada Prenatal Nutrition Program: First Nations and Inuit Component, launched in 1994, supports low-income mothers by ensuring access to adequate nutrition, nutrition knowledge, and breastfeeding education.⁸³ However, despite these promising effects, implementation of these practices and programs is limited to a few communities in NWT. This could be related in part to high per capita healthcare costs, limited cultural relevancy, limited healthcare workforce, and low population density barring the reachability of practices and programs.^84–86 Strategies to implement feasible community-based programs must partner with Indigenous leadership and appropriate research approaches. Further evaluation is needed to fully understand the impact of such programs.

Considered jointly, the findings provide convergent and elaborative insights. The higher odds of reporting prenatal stress among multiparous participants are consistent with accounts of cumulative role strain involving childcare, work, and pregnancy related symptoms. The observed bivariate association with food insecurity accords with narratives of financial constraints and unstable housing. In addition, qualitative descriptions of anxiety around medical travel and fragmented continuity of care add nuance beyond the single item survey measure by identifying system level stressors not reflected quantitatively. Finally, differences between the high prevalence of any reported support and several accounts of insufficient support likely reflect measurement limits of the support item in the questionnaire.

Strengths and limitations

This project is, to the authors’ knowledge, the first study to explore Indigenous women’s experiences of prenatal stress as well as the support systems available during pregnancy and childbirth within NWT communities. One of the major strengths of this project is that it directly reports the perspectives and experiences of Indigenous women in NWT. This project incorporated an Indigenous research paradigm by working closely with Indigenous communities throughout, acknowledging the ongoing impact of colonization on maternal care, recognizing a broad concept of maternal health to include relationality, identifying strength of Indigenous communities, and prioritizing Indigenous communities’ research needs.^87,88 Additionally, the interviews were conducted in three communities diverse in terms of size and healthcare accessibility, which allowed for a broader understanding of Indigenous women’s experiences. However, the use of purposive sampling methods, as well as sociocultural differences between Indigenous communities, limit the generalizability of the findings to all communities in NWT. Despite this, our recruitment approach was deemed the best to recognize communities’ leadership and ownership of research and to gather as much information from eligible participants as possible. The findings may be subject to recall bias, as participants reported experiences up to three years after birth, and selection bias, which could have limited capturing experiences of women who chose not to participate. With an inconsistent definition of stress during pregnancy and no validated tool to measure stress during pregnancy and childbirth in Indigenous communities, there may have been limitations when quantitatively capturing reported stress, and the true experiences of stress could have been under- or over-reported. However, our quantitative results were complemented by qualitative responses, which were gathered from participants freely describing experiences of stress during and after pregnancy. We believe this mixed-methods approach captured real-life experiences of Indigenous women in the North. Future research extending to other remote and rural Indigenous communities throughout all territories and provinces within Canada is recommended.

Conclusion

The level of prenatal stress among Indigenous women in NWT is much higher than the reported national average for non-Indigenous women within Canada. While various forms of support are available for Indigenous women, some participants reported receiving minimal to no support. Community support programs seem to have benefits; thus, there is an urgent need to increase the number of, and access to, these programs within remote communities. These programs should focus on all aspects of maternal health, including physical and mental health, as well as Indigenous traditional pregnancy care that underscores relationships, cultural continuity, and holistic healing, and intergenerational resilience. Working with Indigenous communities and leadership and utilizing community-based approaches to research, implementation, and evaluation of community-based programs is paramount.

Footnotes

Acknowledgements

We would like to acknowledge the Indigenous women who participated in the interviews and shared experiences and motherhood journeys. We are very grateful for the support of several local organizations in Northwest Territories, who provided substantial guidance throughout every stage of this work.

ORCID iDs

Se Lim Jang

Fariba Kolahdooz

Moutasem Zakkar

Rachel Harris

Adrian Wagg

Marie Tarrant

Sangita Sharma

Ethical considerations

The Research Ethics Board at the University of Alberta issued the research ethics certificate (Pro00085941). Following the Scientists Act of Northwest Territories, researchers also obtained a research licence from the Aurora Research Institute.

Consent to participate

The authors obtained informed written consent from the participants. Individuals under the age of majority were considered ‘mature minors’ and provided informed consent to participate in health studies. Participants were informed of the purpose, benefits, and risks of the study utilizing the approved consent form and welcomed to ask questions before providing consent.

Author contributions

SS and FK conceived and designed the study and supervised the whole project including data collection. SLJ, FK, and MZ performed the data analyses. SLJ, FK, MZ, RS, RH, and CM produced the first article draft. AW, AC, SIF, and MT critically reviewed the manuscript. All authors reviewed and revised the manuscript and approved the final version.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors disclosed receipt of the following financial support for the research and publication of this article: this work was supported by the Canadian Institutes of Health Research [grant number FRN 159485]

Declaration of conflicting interests

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

Data Availability Statement

All data supporting the results of this study can be found in the manuscript. De-identified data are owned by the Indigenous communities and may be available upon request with community approval.*

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