Professional Documents
Culture Documents
Indigenous Birth As Ceremony and A Human Right: Ashley Hayward and Jaime Cidro
Indigenous Birth As Ceremony and A Human Right: Ashley Hayward and Jaime Cidro
Abstract
Birthing can be an empowering experience for women. Within many Indigenous cultures around the
world, birth is a ceremony to celebrate new life, acknowledging the passing from the spiritual world into
the physical world. While initiatives to “indigenize” health care have been made, this paper argues that
the United Nations Declaration on the Rights of Indigenous Peoples and the United Nations Sustainable
Development Goals contain frameworks for Indigenous rights that include the right to incorporate
Indigenous childbirth ceremonies into clinical practice. Examining the importance of birthplace, this
paper details a current movement in Manitoba, Canada, to “bring birth home,” which recognizes that
the determinants of health experienced in the early stages of a child’s development can have health
Ashley Hayward, MA, is a PhD student in the Peace and Conflict Studies program at the University of Manitoba, Winnipeg, Canada, and a 2020
Vanier Scholar.
Jaime Cidro, PhD, is Professor of Anthropology, Director of the Master’s in Development Practice Program, and Canada Research Chair in
Health and Culture, and Associate Vice President, Research and Innovation at the University of Winnipeg, Canada.
Please address correspondence to Ashley Hayward. Email: a.hayward@uwinnipeg.ca.
Competing interests: None declared.
Copyright © 2021 Hayward and Cidro. This is an open access article distributed under the terms of the Creative Commons Attribution Non-
Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted noncommercial use, distribution, and
reproduction.
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practices, including the conservation of their vital of childbirth, physicians are promoted as superior
medicinal plants, animals and minerals. Indigenous birth attendants, having been trained in Western
individuals also have the right to access, without
science and technology.19 As Colleen Varcoe and
any discrimination, to all social and health services.
colleagues state, the dominance of biomedicine re-
24.2 Indigenous individuals have an equal right to sults in the imposition of medically based maternity
the enjoyment of the highest attainable standard technologies, with Indigenous women being told
of physical and mental health. States shall take that “their time honored midwifery and birthing
the necessary steps with a view to achieving practices [are] unsafe and that they must turn to
progressively the full realization of this right.11
the advances of western medical practice for ‘mod-
ern’ maternity care.”20 The impact of this message,
This provision is especially important for In-
and how it is operationalized, is significant for the
digenous peoples in Canada, whose historical
physical and mental health of Indigenous women
experience with health care access in the country
and families, and Indigenous women still face less
involves traumatization, experimental procedures,
desirable birth outcomes compared to other groups
and segregation.12 Prior to the mid-20th century,
in Canada.21
pregnant Indigenous women gave birth in their
The disparities in maternal health for Indige-
communities, supported by family members,
nous women in Canada that are intertwined with
friends, Knowledge Keepers, traditional midwives,
colonization and the resulting deep inequalities
and birth workers.13 Often, the role of a midwife was
in socioeconomic status and health outcomes are
viewed as a calling; it was a very spiritual and pow-
erful position.14 The midwife continued supporting exacerbated by violations of article 24. Across
the family following the birth by living in the home Canada, infant mortality rates are more than twice
for a period of time to tend to the infant and moth- as high for each Indigenous group (First Nation,
er and to assist with the new mother’s work.15 Métis, and Inuit) compared with the non-Indige-
Despite article 24’s call to protect the health nous population.22 For First Nations women living
rights of Indigenous peoples, there continue to be on reserves, more than half of the women (56.6%)
distinct risk factors that may affect Indigenous must travel between 50 and 350 kilometers to give
women’s experience with pregnancy and child- birth.23 Further, in urban areas, the preterm birth
birth. These include reduced access to standard rate is higher among First Nations infants com-
prenatal care; inaccurate estimation of gestational pared to all other Manitoban infants living in the
age and subsequent complications of post-term lowest- and highest-income areas.24 Sudden infant
pregnancies; preexisting medical conditions; death syndrome is the leading cause of death for
young maternal age; marital status; malnutrition; First Nations and Inuit children, whose rates are
and low educational attainment.16 While some may more than seven times higher than that of the
argue that the moving of Indigenous births from non-Indigenous population.25 In the province of
the home to the hospital in the 1920s by the De- Manitoba, which has one of the highest Indigenous
partment of Indian Affairs supports Indigenous populations in Canada, “infant mortality rates for
access to health services, this shift has led to a First Nations (FN) people range from 2.1 – 2.9 times
Western-based overmedicalization of Indigenous higher than the rate for other Manitobans.”26 These
childbirth that often focuses solely on the physi- statistics demonstrate that distinct needs are likely
cal component of well-being to the detriment of remaining unaddressed for the Canadian Indige-
the emotional, mental, and spiritual components nous population. One explanation for the disparity,
that are crucial to Indigenous health.17 The World offered by Robert Allec, is culture, but the author
Health Organization has confirmed that childbirth fails to identify exactly what aspects of culture
is becoming overmedicalized, particularly in low- might explain the difference.27 Other explanations
risk pregnancies, including through the overuse have been put forward in documents such as the
of caesarean section.18 Under this medicalization United Nations factsheet “Indigenous Women’s
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a. hayward and j. cidro / general papers, 213-224
Maternal Health and Maternal Mortality,” arguing needs of women, their newborns, and their fami-
that Indigenous women have an increased risk for lies.34 FCMNC recommends integrating cultural
maternal mortality compared to “other women”; safety into prenatal care for Indigenous women and
however, these studies do not examine Canada details some of the barriers to prenatal care, such as
specifically.28 physical distance from care, lack of child care for
Internationally and irrespective of ethnicity, other children, and fear or distrust of the health
women’s experiences during childbirth within care system.35 In its recommendation that hospitals
medical institutions are often distressing due to and birthing centers develop protocols and poli-
discrimination and overmedicalization. In 2010, a cies to “support traditional birthing customs and
report by Diana Bowser and Kathleen Hill, which cultural practices,” the Public Health Agency of
gathered stories from women in 18 countries, Canada could be seen as attempting to implement
including Canada, revealed that many women UNDRIP’s article 24(1), though it does not make
felt disrespected and abused during institutional this explicit connection.36 An understanding of
childbirth; their study revealed “subtle humiliation birthing as ceremony—one that includes distinct
of women, discrimination against certain sub- customs, rituals, and traditions for Indigenous
groups of women, overt humiliation, abandonment women—must be achieved as countries move to
of care and physical and verbal abuse.”29 Medical fully adopt and implement UNDRIP.37 UNDRIP
interventions have made childbirth a negative, and recognizes the inherent right of Indigenous peoples
potentially damaging, experience. In Canada, there to practice and revitalize their cultural traditions
has been an increase in the use of induction, vacu- and customs, and it can be argued that the loss
um extraction, and caesarean section, in addition to of community birth is a cultural loss.39 The loss of
the risk of injury from operative vaginal deliveries culture can also be categorized both as “distal (e.g.
where vacuums or forceps are used.30 Injuries range historic, political, social and economic contexts)”
from minor cuts to more serious issues that might and as an “intermediate (e.g. community infra-
affect the woman’s long-term quality of life, includ- structure, resources, systems and capacities)” social
ing bladder and bowel control, sexual dysfunction, determinant of health.40
and perineal pain.31 According to one ethnograph- Traditionally, pregnant Indigenous women
ic study of hospital birth in a Canadian setting, had an important role in “carrying the spirit,” and
“Whilst women are treated kindly and attention the community came together to honor the spirit by
is paid to them in this hospital, there is very little “invest[ing] in the well-being of the mother.”41 The
respect for the birth process and the physiological pregnant mother is viewed as a conduit between
nature of this event.”32 These issues, combined with the spiritual world and the physical world, thereby
the historically fraught relationship that Indigenous making prenatal care a community endeavor.42
peoples have with medical institutions, leads many Therefore, a woman’s pregnancy and birth were
Indigenous women to seek non-facility alternatives the responsibility of the entire community rather
for the birthing process. than an individual family event. The community
was expected to support the mother not only in
antenatal care but also in emotional and spiritual
Indigenous birth ceremony as compliance
support. Furthermore, cultural practices around
with article 24
birth, including ceremonies for welcoming and cel-
A recent movement in clinical care seeks to offer ebrating the new life and the sharing of traditional
family-centered maternity and newborn care knowledge and teachings, helped establish strong
(FCMNC) that recognizes that “Indigenous peo- community roots for the mother and newborn
ples have distinctive needs during pregnancy and by encouraging healthy lifestyles and a sense of
birth.”33 FCMNC was originally created to address belonging for the family.43 The child would have a
the physical, emotional, psychosocial, and spiritual clear sense of their identity and place within the
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community, which, according to the Society of Ob- ment,” which came into effect on January 1, 2016.51
stetricians and Gynaecologists of Canada, “helps This document, which “provides a global blueprint
them to become resilient and responsible members for dignity, peace and prosperity for people and the
of that community.”44 planet,” consists of 17 goals and 169 correspond-
Ceremonies in birth can also be in the form of ing targets.52 The SDGs were a response to the
stories that show a connection to the land. Rachel Millennium Development Goals (MDGs), which
Olson details “the water ceremony” and the con- were perceived as embracing a top-down approach
nection to birthplace and landscapes.45 Pregnancy is and which failed to involve Indigenous peoples in
understood as carrying “sacred water,” metaphori- identifying the health issues that most affect their
cally referring to the amniotic fluid surrounding well-being.53 Both iterations of the Development
and protecting the baby but also connecting to the Goals prioritize health care for mothers and chil-
important role of the water breaking in labor. An- dren in the global arena: Goals 4 and 5 of the MDGs
ishinaabekwe (Anishinaabe women) are considered aimed to reduce child mortality and improve ma-
the caretakers of water, which is one of their most ternal health, while Goal 3 of the SDGs seeks to
important roles in society.46 Midwife and activist “ensure healthy lives and promote well-being for all
Katsi Cook echoes this significance, stating: at all ages” and sets specific targets for a reduction
in maternal and child mortality.54 These goals can
In the Mohawk language, one word for midwife is be reached only by implementing a rights-based
iewirokwas. This word describes that “she’s pulling and culturally sensitive approach that respects tra-
the baby out of the Earth,” out of the water, or a
ditional health practices and supports Indigenous
dark wet place. It is full of ecological context. We
know from our traditional teachings that the waters peoples’ own methods of providing services.55
of the earth and the waters of our bodies are the Pregnancy and childbirth pose risks for
same water.47 mothers, with 830 women dying each day from
preventable causes related to pregnancy and child-
Anishinaabekwe traditionally were encouraged to birth around the world.56 Although Canada boasts
maintain a “good frame of mind,” since emotions one of the world’s lowest maternal mortality rates,
would influence the baby.48 In First Nations com- better access to health services in rural and remote
munities in northwestern Ontario, women began communities, as well as improved funding and
learning obstetrical care and cultural practices, culturally safe health care services, are among the
such as “careful attention to the sacred handling of keys to improving the health disparities, including
the placenta and umbilical cord; and [the] careful maternal mortality ratios, between Indigenous
wrapping of the newborn in fur” by observation in and non-Indigenous women.57 Further, as stated in
their teenage years.49 the previous section, there are striking disparities
As Canada works to protect the inherent rights between Indigenous and non-Indigenous birth
of Indigenous peoples across the country by fully outcomes, including infant mortality rates. Some
implementing UNDRIP, it must also recognize the studies indicate that “on-reserve First Nations,
cultural significance of birth and ceremonies that off-reserve status Indians, and Inuit have rates of
are crucial for protecting the maternal health and infant mortality ranging from 1.4 to 4 times that of
birthing rights of Indigenous women.50 non-Indigenous infants.”58
In Canada, programs to “promote well-being
for all at all ages” include the Strengthening Fami-
Sustainable Development Goals
lies Maternal Child Health Program, the Canadian
On September 25, 2015, the United Nations General Prenatal Nutrition Program, and the Aboriginal
Assembly adopted the 2030 Agenda for Sustainable Head Start Program, but many Indigenous com-
Development Goals, titled “Transforming Our munities operate without these supports. In fact,
World: The 2030 Agenda for Sustainable Develop- only 14 of 63 First Nation communities in Mani-
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toba offer the Strengthening Families Maternal health personnel can prevent women from access-
Child Health Program.59 Though Canada has a long ing the same level of maternity care as Indigenous
history of being a leader in the global arena with women living in urban areas.66 Lack of access to
respect to maternal, newborn, and child health health care and systemic conditions can lead wom-
and has committed to focus on prevention and en to feel mistreated during childbirth.67 This lack
early intervention, health disparities for Indige- of local health care support for First Nations and
nous women continue to exist. Determining who Inuit women has been used to justify the First Na-
is responsible and accountable for providing health tions and Inuit Health Branch of Health Canada’s
care services in Canada to First Nations and Inuit maternal medical evacuation policy, according to
is often difficult and compromised by competing which pregnant Indigenous women are routinely
financial demands.60 Each provincial and territorial evacuated from rural or isolated communities to
government is required to provide health care un- urban centers at 36 weeks’ gestation.68 This policy
der the Canada Health Act; however, Canada also separates women from their support networks and
has a constitutional responsibility to provide health places them in unfamiliar environments as they
care to First Nations (“Indian”) and Inuit peoples.61 prepare for labor and delivery.69 Being alone and
Moreover, as some have argued, there is a unsupported creates unnecessary stress and can
direct correlation between the lack of supports for create negative health consequences for both the
Indigenous maternal health and the overrepresen- woman and baby, such as anxiety, preterm birth,
tation of Indigenous children in government care and low or high birth weights. This policy prioritiz-
and government-appointed foster families who are es Western biomedicine in obstetrical management
often non-Indigenous.62 Marni D. Brownell and of pregnancy and is inconsistently applied because
colleagues analyzed data from the Manitoba Child it lacks clear documentation and details.70
and Family Services, Department of Justice, and One tangible way to address these issues is
Population Health Registry to explore the relation- through the use of Indigenous doulas, birth atten-
ship between having a history of Child and Family dants, and midwives. Indigenous birth workers,
Services involvement during childhood (0–17 years) both traditionally and in the modern context,
and being charged with a crime as a youth (12–17 provide support for women during active labor
years).63 They found a substantial overlap between and throughout the birthing process. The resur-
the child welfare and youth justice systems, with gence of trainings for Indigenous women to act as
overrepresentation of Indigenous youth in both helpers in birthwork or to provide full-spectrum
systems.64 doula care can be viewed as a significant step to-
Implementing these UN human rights dec- ward compliance with UNDRIP and the SDGs.
larations and goals to address health disparities The role of an older female relative is documented
between Indigenous and non-Indigenous peoples as a key component of pregnancy and childbirth,
in Canada is important, and reclaiming Indigenous and critical cultural practices are essential to
birth practices is a palpable way in which to imple- establishing and revitalizing the strong cultural
ment these rights. connection and spiritual path for Indigenous
children.73 Doulas extend their role of emotional
support companion to advocate for various social
Reclaiming Indigenous birth practices in
supports following the birth. Although doulas do
Manitoba
not help with the delivery of a baby, they do support
Though adverse birth outcomes are more likely for women with antenatal care. Midwives and tradi-
Indigenous (compared to non-Indigenous) women tional birth attendants (sometimes referred to as
in Canada, they are even more prominent for First community-based midwives) overlap with doulas
Nations and Inuit women who live in rural or in many respects, as they are individuals hired to
isolated communities.65 The shortage of maternal support women during the birthing process. The
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amount of formal training may be the most obvi- and robust self-care plans, given that many Indig-
ous difference.71 Support for women during active enous women are brought to this work in response
labor and birth has been proven to reduce the use to their own negative birthing experiences. Though
of medications and interventions, and the right to these results are not about the improvement of
appropriate and respectful care during pregnancy mothers’ experiences, they do affect the support
and birthing is imperative to ensure positive long- offered to Indigenous mothers.
term impacts for mothers and children.72 Moreover, the Northern Manitoba Indige-
This type of birth support is proposed by two nous Doulas Project has found that doulas provide
Manitoba-based research projects. The first is the necessary boundaries within the medical birthing
Winnipeg Boldness Project, a research and eval- experience (for example, by ensuring that nurses
uation center that uses social innovation research and doctors are respectful of women’s need for pri-
as an incubator to develop ideas to improve out- vacy and space to observe cultural practices) and
comes for people in the Point Douglas inner-city empower Indigenous women to create a positive
community in Winnipeg. The Winnipeg Boldness experience for themselves by choosing birthing ex-
Project initiated the first urban Indigenous doula periences that incorporate rituals and celebrations.
short-term pilot program in Winnipeg, in which 12 The doulas from the urban project also described
Indigenous women were trained as birth helpers to their experience of personal transformation that
support pregnant Indigenous women and families “nourishe[s] [them] through this training and prac-
over a one-year period in order to understand the tice.”73 Empowerment is a process by which those
gaps in support for urban-based pregnant Indige- who have been historically disempowered are able
nous women. to “increase their self-efficacy, make life-enhancing
The second Manitoba-based research project decisions, and obtain control over resources.”74 In
is titled “Indigenous Doulas as a Culturally Based traditional societies, matriarchs played an import-
Health Intervention to Improve Health and Birth ant role, but through colonization, women’s place
Outcomes for First Nations Women in Remote within society changed. “Broad[er] historical forces
Communities Who Travel for Birth” (hereafter and policies that shaped [Indigenous women’s,
referred to as the Northern Manitoba Indigenous girls’, and 2SLGBTQQIA people’s] individual expe-
Doulas Project). This project is a partnership be- rience” are recognized as a tool of disempowerment
tween Wiijii’idiwag Ikwewag (formerly known of community structure.75
as the Manitoba Indigenous Doula Initiative), There is a movement throughout medical care
the First Nations Health and Social Secretariat of to empower patients to become more involved in
Manitoba, and the University of Winnipeg that in- their medical treatments and processes. The Cana-
volves three northern First Nations communities. dian Medical Association (CMA) “recognizes that
It pairs expectant First Nations women with local collaborative care is a desired and necessary part
and urban Indigenous doulas and examines how of health care delivery in Canada and an important
Indigenous doulas can support First Nations wom- element of quality, patient centred care.”76 Collab-
en who are forced to travel for birth in Manitoba. orative decision making is also a cornerstone of
While the project is currently collecting data on the patient-centered care.77 According to CMA, collab-
experiences of Indigenous women who give birth orative care encourages providers to work together
with and without doulas, preliminary findings have to provide the best care to patients based on trust,
emerged that concern the Indigenous doulas them- respect, and an understanding of one another’s
selves. These findings demonstrate that Indigenous skills and knowledge.78 This model includes em-
birth workers require multiple provisions to enable powering patients to make choices related to their
their support of mothers, including a stable service care in conjunction with their health care team.
delivery model with concrete processes for referrals “The medical profession supports collaborative
and payment, ongoing professional development, care, both in the hospital and in the community, as
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a. hayward and j. cidro / general papers, 213-224
one of the essential elements of health care delivery ning to see attempts to shift biomedicine toward
in Canada,” demonstrating that reclaiming birth a more holistic approach based on Indigenous
ceremony is possible for Indigenous communities; knowledge. In Akwesasne, Ontario, a group called
however, the principles outlined by CMA show Onkwehon:we Midwives Collective uses Indige-
that more ideological shifts still need to be made.79 nous knowledge to ensure a safe birthing process.
Principle three demonstrates the belief that physi- The group’s objective is to “provide assistance to
cians are the most powerful in the relationship: “In Indigenous expectant moms and their families
the CMA’s opinion, the physician is best equipped with reclaiming control of their birth plans, along
to provide clinical leadership.”80 This power im- with continued education and support throughout
balance that places medical professionals above all the phases of an Indigenous woman’s life.”83
patients continues to create a significant barrier for Another promising intervention is the Indigenous
Indigenous women to have a voice in the care they Women’s Health Initiative within the Society of
are seeking. Obstetricians and Gynaecologists of Canada.84
Generally, midwives use the dichotomy of This online space offers resources for health care
natural versus medical birth as part of an informed professionals and community members to be more
choice ideology when promoting their services to informed about providing culturally safe care re-
pregnant women. Though the movement in mid- lated to Indigenous sexual and reproductive health
wifery focuses on informed choice, it is distinctive and promoting and advancing health equity for
from the informed consent model, which would Indigenous women.
allow Indigenous women to have a stronger voice These interventions show how appropriate
in their health care. One distinction is that care for Indigenous mothers and their children
must look beyond health care outcomes to include
what counts as authoritative knowledge in informed
social and cultural factors, such as identity and
consent versus informed choice in midwives care
differs; with the former, patients listen to health care connection to place, when implementing new strat-
providers impart “evidence” and clinical options to egies to address the complex and distinct needs of
them in an accessible way and then must make a an Indigenous population. This appropriate care, in
choice; the latter involves this too but midwives turn, addresses the calls and declarations for Indig-
also grant authority to other kinds of knowledge—a
enous rights in Canada.
woman’s own knowledge, feelings, and past
experience about her body and previous pregnancies
as well as her lifestyle and moral orientation.81 Conclusion
Women’s informed choice includes privileging Returning birthing traditions to Indigenous com-
other forms of knowledge and understanding, munities in Canada—despite the complexities of
including that of Indigenous epistemologies. In funding and health care access—would respect and
Western traditions, there is a recognized hierarchy implement the commitments detailed in UNDRIP
of beings, with humans at the top. Within Indig- and the SDGs. Further exploration is needed on
enous ways of knowing, humans are understood the correlation between the lack of supports for
as “the younger brothers [or sisters] of Creation,” Indigenous women and the overrepresentation of
meaning that we need to learn from other species Indigenous children in government care. Moreover,
that have been on Earth longer and have had time to the literature would benefit from additional reviews
figure out how to live in harmony and reciprocity.82 on how privileging Indigenous epistemologies and
By allowing for these knowledges in the process of ways of knowing in the context of Indigenous birth
informed choice, Indigenous women may be more and maternal health can lead to positive health
empowered and feel like collaborators in their own outcomes. Finally, further inquiry is required to
birth journeys. explore encounters where tensions exist between
In some cases within Canada, we are begin- health rights and cultural rights.
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a. hayward and j. cidro / general papers, 213-224
and colonial contact in southern Alberta, 1880–1930 (Vancou- 34. Public Health Agency of Canada, “Chapter 1: Fam-
ver: UBC Press, 2010). ily-centred maternity and newborn Care in Canada:
18. A. Phelan and R. O’Connell, Childbirth: Myths and Underlying philosophy and principles,” in Family-centred
medicalization (Copenhagen: EntreNous, 2015), pp. 18–19. maternity and newborn care: National guidelines (2017).
19. C. Biggs, “The case of the missing midwives: A his- 35. Ibid.
tory of midwifery in Ontario from 1795–1900,” Ontario 36. Public Health Agency of Canada (2017, see note 33).
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