Evacuating women out of remote communities to give birth is traumatic, harmful to communities and costly. So why is it still happening?

By Elizabeth Payne

Mary Kumarluk’s children are grown now, but memories of their births are tinged with sadness. “I cried a lot,” she says of the weeks she spent in a hospital ward in Moose Factory, northern Ontario, alone and far from home.

Kumarluk, 50, would talk on the phone to her partner in Inukjuak, more than 1,000 kilometres north, on the shores of Hudson Bay. The conversations would end in tears. Along the ward, she could hear other mothers in the same state. They’d all been forced to leave their villages and families weeks before their due dates. Like her, they stressed and worried.

The memories flooded back seven years ago when Kumarluk and her husband flew from Nunavik, the Inuit region of northern Quebec, to Moose Factory for a dance festival. “I cried, remembering everything.”

Kumarluk’s story is common in remote and northern Canada where the legacy of obstetric evacuation has taken its toll. She considers herself lucky to live in one of only a handful of northern villages that no longer routinely fly all pregnant women out of the community.

In Nunavut, next door, close to one-fifth of the territorial government’s annual health budget is spent flying patients — including pregnant women — out of their communities for health care.

While some will accept obstetric evacuation as a necessary, if imperfect, way to deliver health care to remote parts of Canada, the practice that began as a way to improve the health of mothers and babies has had profoundly negative effects.

Momentum is growing to end evacuation as a step to improving dismal levels of maternal and infant health in Canada’s North.

For starters, the current setup is costly. Building a health-care system around long-distance patient and doctor travel diverts money from other priorities — such as hiring and training health-care workers for small communities and public health campaigns.

“The cost implications are staggering,” says a 2008 report published by Nunavut Tunngavik, the organization the represents Inuit in Nunavut.

Evacuation is partly driven by a shortage of doctors and nurses. However, successful midwife clinics in Nunavik as well as Nunavut have demonstrated that returning birth to communities can be done.

Lack of political will, lack of financial support, even lack of support among women — some of whom are nervous about giving birth in their own communities after generations of obstetric evacuation — have hampered progress. Nunavut has a Maternal and Newborn Health Care Strategy that calls for fewer evacuations, more births in communities and more midwives, but the health minister warns progress will be slow because the territory doesn’t have the money it needs to make it happen.

At a time when the federal government has committed $1.1 billion to reduce maternal and infant mortality rates around the world, Canada’s poor maternal health outcomes in northern and remote aboriginal communities are in the spotlight. In Canada, Inuit babies are about three times more likely to die during their first year of life than non-Inuit babies.

Many consider the repatriation of birth a key to revitalizing aboriginal communities and improving maternal health. Others say the federal government needs to recognize the damage done by evacuation and create a national birth strategy that pays special attention to aboriginal communities.

Liberal Senator Charlie Watt, an Inuk from northern Quebec, has raised the issue.

“What is the government doing to support the training and hiring of midwives in the North, and how can we find a way for Inuit midwives to work across the Inuit territories?” he asked Senate Majority Leader Marjory LeBreton.

Health care, she responded, is the responsibility of provincial and territorial governments.

That may be. But the federal government directly funds much of the cost through non-insured health benefit contributions to Inuit health care in Nunavut. More than half of the $100 million the federal government spent on those benefits between 1996 and 2006 went to transportation costs.

“This is not so much a health-care expenditure as a subsidy to the airline industry,” scolded the Nunavut Tunngavik report on health.

André Lalonde, executive vice-president of the Society of Obstetricians and Gynecologists of Canada, calls routine evacuation “the residential schools of medicine.” He says flying low-risk pregnant women out of their communities four or six weeks before their due dates “was an error.”

Because of the “emotional, social and financial costs to these women,” the SOGC says, health providers need to offer services as close to home as possible. And, with a chronic shortage of physicians and nurses, the organization says midwives, especially those trained in aboriginal programs, are the best hope for improving maternal health in remote areas.

For years, the de facto policy meant virtually all pregnant women in remote, northern communities had to get on an airplane, a month or more before they were due to give birth.

Some women hid their pregnancies, lied about their due dates or simply refused to go. There are stories of women heading off on their own to give birth.

Since it began in earnest in the late 1960s and early 1970s, the policy of forced evacuation has been widely criticized. But, for lack of alternatives, it remains in place in many parts of remote Canada. The result, according to the organization that represents Inuit in Nunavut is a “crisis in maternity care.”

Inuk midwife Nellie Tooliguk was quoted by the Society of Obstetricians and Gynecologist of Canada in a document supporting the return of birth to remote communities.

“Just imagine this: You are having a baby. A group of people with PhDs has decided that Denmark’s perinatal statistics are better than Canada’s. They decide it will improve the medical outcome for you and your baby if you are flown to Denmark three weeks before your expected delivery date. You will remain there, without your family, until your baby is born. You arrive alone in this place where you have never been. You can’t adjust to their strange food, so you eat very little for your last weeks of pregnancy. Everything is in a different language. Sometimes an interpreter is available. Your family calls after two weeks to say that your children have been taken to another relative’s. The house, you know, is already over-crowded. The children cry on the phone to you, and you know you can’t pay for this phone bill when you return home.

“If you refuse this new plan, which has no evaluation of impact, you are considered selfish, undereducated and willing to put your family’s health at risk. When you ask if this money could be used to simply improve the health care at home, you are told studies need to be done first to see if it is possible.”

Decades later, some consider the evacuations a trauma that has yet to heal — similar to residential schools.

In a report released by the National Aboriginal Health Association in 2008, Carol Couchie talked about the effect of being sent away. “A lot of people don’t even know what it is they are missing because it has been gone so long. But once they start to get it back, that memory comes back … they start to cry and we know with tears that that is healing.”

Nearly 15 years ago, Canada’s Royal Commission on Aboriginal Peoples heard about the struggle. Martha Greig, then president of Paktuitit, the Inuit women’s association, testified at commission hearings. “To us, healthy children are born into their family and their community; they are not born thousands of miles from home to an unhappy, frightened mother.”

In their report, commissioners supported an end to enforced evacuation:

“No doubt lives have been saved,” they acknowledged. “However, for women with no apparent risk of medical complication … it interferes with Indigenous birthing knowledge, local midwifery skills and traditional family-centred ceremonies.

“In a minority of pregnancies, where there are risks to the health of the pregnant woman or the newborn, transporting the woman to hospital is appropriate. But for healthy Aboriginal women, enforced evacuation has profoundly negative consequences.”

Things are changing, but slowly. In Nunavik, there are four community birth centres staffed by midwives who work with nurses and doctors. Southern midwives originally staffed the clinics, but as a result of an Inuit midwifery-training program, clinics in three of the four communities have Inuk midwives.

The program, which blends traditional Inuit knowledge with modern medicine, is considered one of the most innovative in the world because it blends traditional Inuit knowledge with modern medicine.

Today in Nunavik, pregnant women are assessed by midwives and physicians at 34 weeks. High-risk cases will be sent to Montreal, usually accompanied by a family member. The vast majority give birth in their own village. Obstetric evacuations have been reduced by close to 90 per cent.

Evacuation is more than a lonely experience. Women separated from family and friends during the final weeks of their pregnancies and during birth are likely to have small or premature babies as well as their own health complications, according to research cited by the National Aboriginal Health Organization. They are also more likely to suffer from postpartum depression and less likely to have success breastfeeding. While research is limited and sometimes contradictory, the experience in Greenland, where nearly all Inuit women have the option of giving birth near where they live, suggests repatriating birth is a factor in improving overall health. Greenland’s infant mortality rates declined steadily in recent years. Infants in Inuit regions of Canada are four times as likely to die as those in the rest of Canada and about twice as likely to die as those in Greenland.

Harry Tulugak, a former mayor of Puvirnituq and an activist who played a role in returning birth there in 1986, believes repercussions are felt today.

Fifty-three-year-old Tulugak, like many of his generation, was born in an igloo. A generation later, each of his five children was born in Moose Factory. “My kids were born to strangers,” he says. “I felt a bit angry about not being there.”

Tulugak believes that dislocation among fathers and family members contributed to “social and cultural upheaval,” as well as domestic violence, substance abuse and, in some cases, suicide.

Lalonde says the federal government should actively promote an aboriginal birth policy that emphasizes collaboration. When women must be evacuated, Lalonde says health officials must ensure their experience is culturally appropriate.

Aboriginal women, many of them pregnant teenagers, are still evacuated to locations far from home, especially Inuit mothers whose small communities are spread across the North. They come to southern hospitals, including The Ottawa Hospital, when it is a matter of life and death.

In Nunavut, some low-risk mothers can now stay in their villages to give birth. But the majority must still leave home four weeks before their due date.

In 2002, researcher Dawn Smith found that evacuation was hurting mothers and babies in several ways: In the Kivalliq region of Nunavut, according to one report, some mothers don’t consider children born in Manitoba to be “real Inuit.”

“An essential component of traditional Inuit health is their connection with the land,” says University of Alberta nursing professor Vasiliki K. Douglas.

“One of the most important components of this connection is birth within the community.”

It’s a connection residents of the Hudson Bay coast of Nunavik, like Mina Tulugak, understand.

Tulugak travelled to Moose Factory to have her five children. She and her husband, Harry, were among the activists who helped bring birth back to the region. Today she works as a midwife in the Puvirnituq maternity, helping other women celebrate birth.

“This is what was robbed from us,” she says. “We took it back.”