Call the Midwife
For years, the women of Norway House, in northern Manitoba, have been forced to travel hundreds of kilometres to give birth. Now they’re refusing to leave home, turning to Darlene Birch for support instead.
Freed from the mitten of a plush onesie, a walnut-sized fist finds its way to suckling lips as if by magnetic force. Leaning over, the midwife gushes to the newborn on the bed, holding a stethoscope to his chest as he does his best to devour his curled fingers without opening his eyes.
Two days earlier, Darlene Birch helped deliver seven-pound Josiah-Kristine Clarke’s fourth child-during an intense two-hour natural birth that progressed relatively smoothly but for the baby’s predilection to press his fisted arm up alongside his head. (Proud dad Deon has nicknamed his progeny Superman.)
“He was sucking his hands when he was inside-you can see little blister spots here,” the midwife tells Clarke, pointing out faint lesions on new skin. “It heals so quickly,” she says reassuringly before turning to the infant with a smile. “You know that hand very well!”
Birch works and lives in Norway House, Man., where getting pregnant still means facing “confinement” for two to four weeks in a distant city-an 800-kilometre drive south to Winnipeg or 300 kilometres north to Thompson-while waiting to give birth. It’s a practice the 59-year-old has been struggling to change since she arrived in the area almost a decade ago. Her efforts have fostered a grassroots movement led by women refusing to leave home to deliver their children-“rebels,” Birch calls them. The group’s push-back has begun to pay off: researchers out of the University of Winnipeg are now studying, among other things, clinical feasibility, by examining how many women with low-risk pregnancies could have delivered in Norway House-if the appropriate services had existed.
Recognizing the need to improve access to midwifery care in the community, Norway House Cree Nation, along with local health professionals, is supporting the new research. In mid-2014, Jaime Cidro, an assistant professor in the University of Winnipeg’s department of anthropology, received a two-year federal grant to study the psychosocial experiences of women who give birth in the community, as well as of those who are evacuated to Winnipeg or Thompson to give birth. The study will also look at the risks of staying, as perceived by doctors and other community members, and the costs associated with sending pregnant women to larger centres for weeks at a time versus providing them with a safe place to give birth at home.
“Communities do a great job of getting together when somebody dies, in celebrating the life of that person,” says Cidro. But birth deserves just as much celebration, she adds. “Birthing is where it all starts.”
Wider support can’t come soon enough. Birch, who is Métis, is the only aboriginal midwife providing traditional care in a First Nations community in Manitoba. She’s been practising traditional midwifery since 1981, 19 years before it became a regulated profession across the province. Birch’s great-grandmother had been a midwife, and her grandmother was adept at using traditional medicines. Her own call to midwifery occurred in her mid-20s, when she’d already had three of her four babies. Birch and her husband delivered them in their Winnipeg-area home-she wanted to shield her children from the institutionalized isolation that had traumatized her during a year-long stay in a tuberculosis sanatorium as a small child.
Birch is also one of only four self-identified aboriginal midwives in Manitoba-and one of 75 or so aboriginal midwives across Canada, accounting for less than six per cent of working midwives nationwide. As Birch nears retirement, a new generation will need to take over the fight to bring birth home.
Made up of five islands and a few thousand people along the Nelson River, the expansive community of Norway House encompasses the Norway House Cree Nation reserve and a smaller non-treaty population. In Manitoba’s Northern Regional Health Authority (NRHA), which includes Norway House and covers the largest geographical area of the province, the 2012-2013 pregnancy rate was approximately 65 per cent higher than the provincial average. The 2011-2012 birth rate was almost double, at 22.5 births per 1,000 compared to 12.6 provincially; infant and child mortality rates were also much higher. Residents in the NRHA consistently face housing shortages, unemployment, transportation challenges and a lack of affordable, healthy food. Giving birth here is seen by many residents as something best avoided, something that happens by mistake-not something women would choose.
It wasn’t always this way.
The community’s definitive schism on maternal health happened in 1999, according to Birch. A nurse was blamed for the alleged death of a baby at the local hospital and ordered out of the community by the band council, prompting a number of doctors to leave in protest. In January 2012, the hospital reopened in-patient beds and increased medical staff, but the maternity ward remained shuttered. Pregnant women could see doctors for checkups, but as their due dates approached, off they went, even if their pregnancies posed little risk.
That solution wasn’t satisfactory to Birch, who moved to Norway House in 2006 to help develop an aboriginal-focused midwifery curriculum for students based in northern Manitoba. When the program relocated south to Winnipeg in 2010, Birch had a choice to make: go with the school or stay in the community that was becoming her home. She remained, convinced it was how she could make the biggest difference.
Employed by the NRHA, the midwife offered prenatal and postnatal care in Norway House for four years, slowly building relationships, before she attended a single birth. Now midwifery isn’t simply an alternative option. Birch is a primary caregiver for about half of the area’s women of child-bearing age, providing everything from testing for sexually transmitted infections and family-planning advice to breastfeeding support and postpartum checkups. Now some women with low-risk pregnancies are staying in the community to deliver, attended by Birch and one of the hospital’s doctors. The advantages of this shift are more than logistical. “Being able to bring birthing back to Norway House provides a lot of joy to our community, especially our mothers,” says band councillor Samantha Folster.
In her eight and a half years as Norway House’s midwife, Birch has become a valued confidante and unofficial counsellor, developing a level of trust with the local women that would be hard to come by in an unfamiliar, big-city hospital.
Moving through her cozy Kinosao Sipi Midwifery Clinic, tucked into a first-floor space within the hospital, Birch passes a red easy chair and quilt-topped examination bed to take a seat at a wooden table. A wall of cabinets is plastered with birth announcements, thank-you notes and photos of smiling moms, sleeping babies and gap-toothed toddlers. A shelf holds two glass jars of tea leaves-nettles for healthy hemoglobin levels and red raspberry leaves for uterine toning-ready to be steeped for clients who request traditional medicine.
Lying on the table beside a stack of patient files, Birch’s BlackBerry chimes with early-morning queries from new mothers and mothers-to-be. A sign on the clinic door says, “No Walk-Ins,” but it’s mostly for show-midwifery isn’t a nine-to-five job. If someone misses her appointment, Birch or her administrative assistant will usually send a quick text to find out why. If patients can’t come to her, Birch will go to them, upholding a tradition set out by generations of midwives before her.
“It’s a demanding job, especially if you’re in a small practice or a solo practice like I am,” says Birch, who typically sees about 30 women each week.
A knock on the clinic door announces the official beginning of a new day. A hoodie-clad teen enters, the pouch pocket accentuated by her protruding belly. She sits down, keeping her face angled so only Birch can see her black eye. The midwife makes subtle inquiries, maintaining an upbeat tone as she readies a blood-pressure cuff and rolls up the young woman’s sleeve, revealing bruises along her arm.
Birch knows about the teen’s turbulent relationship with her boyfriend. In the few minutes it takes to measure her stomach and spread blue gel on the portable ultrasound machine, the midwife has urged the girl to seek help from her family and reduce stress as much as possible. (As part of her practice, Birch also refers women showing signs of abuse to a counsellor and a shelter.) Facing her young patient, Birch makes one more suggestion: “You know,” she says, “your boyfriend can come with you to these visits. It might be good for him to see how the baby’s doing.” Birch’s efforts to involve Norway House men in the process of pregnancy and birth have helped break down strictly defined gender roles in the community. As band councillor Folster says, “The fathers are now accompanying the mothers to their appointments, and most women are feeling more confident as they carry their children.”
A spread of homemade bannock, hot tea, cream-cheese carrot muffins and veggies goes untouched for nearly an hour in an echoing church hall where a handful of mothers have assembled to share stories of giving birth in Norway House despite the evacuation policy. The conversation starts slowly, but anecdotes soon bounce around the table, punctuated by laughter and knowing sighs.
“I had my first one in Winnipeg, and the doctor got there after the delivery,” Dana Muskego offers, keeping her voice low while balancing her five-month-old daughter, Justice, on her lap. The hospital staff kept telling her not to push when she felt like pushing, Muskego remembers. Months and years later, several of the women present still resent having had their bodies managed by strangers in southern hospitals.
While in labour with Justice in Norway House, Muskego could draw on her family for support. “I felt like giving up when I was pushing, and my mom just kept telling me that I could do it. I had my mom on this side and my boyfriend on this side,” she says, sandwiching herself between hand gestures.
Muskego’s sister, Tammy, was one of the first women to give birth in Norway House following Birch’s arrival, and faced judgment-“Why are you still here?!”-from residents who saw her walking around town close to her due date. That was three years ago, and while the women agree disapproving attitudes may have softened, not everyone is comfortable with expectant mothers facing the risks, however minimal they might be, involved in giving birth close to home.
Trudy Simpson, keeping a close eye on her sleeping infant daughter, Miley, tells the group how her plans for a water birth in Winnipeg for her first pregnancy were derailed after her mother got nervous and packed her off to the hospital, an experience she says she found depressing.
“But with Miley it was very calm. I was in labour here in Norway House, and it was nice, peaceful. I was just lying there, breathing. Everything was familiar, soothing.”
Even Simpson’s mother, skeptical at first, has been an advocate for birthing close to home since Miley was born, Simpson says. “Her mind changed completely. She’s telling everybody who’s pregnant, ‘Oh, you should have your baby here!'”
For all the services offered, only 19 of the community’s 123 pregnant women gave birth in Norway House in 2014-a small number, but one that is gradually gaining momentum. The percentage of women for whom Birch is providing prenatal and postpartum care has also grown, from 45 per cent in 2013 to 53 per cent in 2014.
“Once you’ve helped a critical number of people, then the women will start to say, ‘This is what we want.’ But community development takes longer than you would think, I’ve learned,” says Birch, laughing.
Looking to the future, Birch guesses three to four midwives could comfortably serve the Norway House area. For now, she can’t imagine giving up the continuity of care she’s so proud to provide. But Birch is working on a five-year plan for retirement-she intends to return to Winnipeg and spend more time with her five grandchildren. She hopes that a reboot of a Winnipeg-based midwifery education program, set for the fall of 2015, will produce some graduates who can pick up where she leaves off.
With the majority of Canada’s newly minted midwives graduating from programs that do not include indigenous content in their curricula, there is some concern that the traditional midwifery skills Birch possesses could soon be lost.
“It’s just as valid as scientific knowledge,” says Nathalie Pambrun, a member of the National Aboriginal Council of Midwives, who, like the bulk of her colleagues and unlike Birch, wasn’t schooled by elders. “People have a right to know the traditions related to birth in their own communities, and they have a right to choose to use that knowledge where it feels right for them.”
Birch recognizes there’s still a long way to go until birth is repatriated to Norway House, but she believes she’s helped establish support for traditional midwifery care in the northern community.
“In the last few years, I’ve come to realize that this change doesn’t hang on one person. Profound changes like this need to involve a lot more people,” she says. “If I wasn’t here, I’d like to think that the hospital and the staff are at a point where they would continue to work toward repatriating birth, because there’s a core group of women who really want that. And there’s a core group of doctors who do, too.”