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Help bring back the celebration of life: A community-based participatory study of rural Aboriginal women’s… Varcoe, Colleen; Brown, Helen; Calam, Betty; Harvey, Thelma; Tallio, Miranda Jan 29, 2013

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RESEARCH ARTICLE Open AccessHelp bring back the celebration of life: Acommunity-based participatory study of ruralAboriginal women’s maternity experiences andoutcomesColleen Varcoe1*, Helen Brown1, Betty Calam2, Thelma Harvey3 and Miranda Tallio4AbstractBackground: Despite clear evidence regarding how social determinants of health and structural inequities shapehealth, Aboriginal women’s birth outcomes are not adequately understood as arising from the historical, economicand social circumstances of their lives. The purpose of this study was to understand rural Aboriginal women’sexperiences of maternity care and factors shaping those experiences.Methods: Aboriginal women from the Nuxalk, Haida and 'Namgis First Nations and academics from the Universityof British Columbia in nursing, medicine and counselling psychology used ethnographic methods within aparticipatory action research framework. We interviewed over 100 women, and involved additional communitymembers through interviews and community meetings. Data were analyzed within each community and acrosscommunities.Results: Most participants described distressing experiences during pregnancy and birthing as they grappled withdiminishing local maternity care choices, racism and challenging economic circumstances. Rural Aboriginalwomen’s birthing experiences are shaped by the intersections among rural circumstances, the effects of historicaland ongoing colonization, and concurrent efforts toward self-determination and more vibrant cultures andcommunities.Conclusion: Women’s experiences and birth outcomes could be significantly improved if health care providerslearned about and accounted for Aboriginal people’s varied encounters with historical and ongoing colonizationthat unequivocally shapes health and health care. Practitioners who better understand Aboriginal women’s birthoutcomes in context can better care in every interaction, particularly by enhancing women’s power, choice, andcontrol over their experiences. Efforts to improve maternity care that account for the social and historicalproduction of health inequities are crucial.Keywords: Aboriginal, Rural, Maternity care, Outcomes, Colonialism, Critical ethnography* Correspondence: colleen.varcoe@nursing.ubc.ca1University of British Columbia School of Nursing, T149 - 2211 WesbrookMall, Vancouver, BC V6T 2B5, CanadaFull list of author information is available at the end of the article© 2013 Varcoe et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Varcoe et al. BMC Pregnancy and Childbirth 2013, 13:26http://www.biomedcentral.com/1471-2393/13/26BackgroundDespite clear evidence indicating that social determi-nants of health and structural inequities shape health,Aboriginala women’s birth outcomes may be presentedwithout accounting for historical and current economicand social circumstances. For every indicator of healthypregnancy and infancy (e. g. teen pregnancy, pretermbirth, low and high birth weight, infant and neonatalmortality), outcomes are 2 to 5 times worse for Aborigi-nal people in Canada, with low birth weight and pretermbirth rates worsening [1]. Although research confirmsthat multiple factors contribute to such outcomes, thesocial context of women’s lives has been neglected infavor of attention to behaviors (e.g. smoking, diet andprenatal access), psychological factors, immune status,genetic/family history, nutrition, and medical conditionsand interventions [2]. However, recent research stressesthe mechanisms preceding and underlying these differ-ences. For example, after controlling for income, smoking,and cervicovaginal infection, differences between Aborigi-nal and non Aboriginal women in low birth weight, pre-maturity, or macrosomia were statistically non-significant[3]. A study of postpartum depression in single low in-come women found no differences between pregnantAboriginal and non-Aboriginal women, pointing to arange of stressors, including income [4]. Similarly, poverty,stress, and low self esteem influenced the relatively highnumbers of Aboriginal women who received inadequateprenatal care [5]. Kendall [1] recently argued that:A long history of colonization, systemic discrimin-ation, the degrading experience of residential schools,and other experiences have led to adverse, multigener-ational health effects on Aboriginal families. Theseexperiences have been the root of inequities in thehealth and well-being of the Aboriginal population, andthese inequities have continued through the generations(p. xxxvi).Increasingly, analyses illustrate how colonizing and ra-cializing processes explain poorer health outcomes, in-cluding maternity outcomes, for Aboriginal people inCanada [6-8]. Because studies examining the relationshipbetween chronic psychological stress and pregnancy out-comes typically focus on the 9 month period of gesta-tion, research is required to understand how adverseoutcomes may originate long before conception. Emer-ging literature on allostasisb provides much-needed at-tention to the cumulative effects of stressors [9] and itmay be that low socioeconomic status, racism, exposureto violence, loss, and historical trauma contribute toincreased allostatic load and by extension adverse birthoutcomes [10,11].While social determinants of health frameworks in-creasingly are being integrated in maternity research, andattention is drawn to the specific needs of Aboriginalwomen, few studies include Aboriginal women or theirperspectives. The purpose of this study was to understandrural Aboriginal women’s experiences of maternity care,their desires for future care and what shaped their birthexperiences and outcomes.MethodsUsing a critical ethnographic approach [12,13] within aparticipatory framework [14], community researchersfrom Aboriginal communities in Alert Bay, Bella Coola,Old Massett and Skidegate partnered with academicresearchers. Ethical approval was obtained from theUniversity of British Columbia (Certificate #H04-80415),and from each of the communities. Our field work drewon both ethnographic and Aboriginal traditions [15,16]so that observations and interviews were conducted ineach community observing local protocols and capacitybuilding was considered “a two-way street” [17]. Academicresearchers spent time in each community and the en-tire team met in several times Vancouver and Alert Bay.Community researchers interviewed over 100 womenindividually or in focus groups. Sampling began purpos-ively with women who had given birth in the previousthree years. Women were invited through word ofmouth and snowball techniques. Interviews were semi-structured, including questions about the women’s peri-natal health care experiences. As early analysis sug-gested that the perspectives of others would bevaluable, particularly men, youth and elders, samplingwas expanded to include additional community mem-bers through focus groups, informal interviews andcommunity meetings (see Table 1). All individual inter-views were conducted by the community basedresearchers who were members of the local FirstNations and trained in ethnographic interviewing bythe academic researchers; academic researchers weresecondary interviewers in about one-third of the indi-vidual interviews and two initial focus groups. All inter-views and focus groups were tape recorded andtranscribed. All mothers and fathers interviewed identi-fied as belonging to the First Nation in their commu-nity, although some were “non-status”c. We analyzeddata within each community and conducted a cross-community analysis with all members of the team.Transcripts were read individually by each team mem-ber within a given community (comprised of two commu-nity researchers and two academic researchers percommunity) and coded into meaning units. Each commu-nity team met to identify themes, develop the themes intoa conceptual framework and to write a narrative explain-ing the themes. The community teams then met and com-pared their analyses, a process which served to challengeand provoke revision of each interpretation, and thusstrengthen the rigour of the analysis. Community-specificVarcoe et al. BMC Pregnancy and Childbirth 2013, 13:26 Page 2 of 10http://www.biomedcentral.com/1471-2393/13/26analyses and recommendations were presented to eachcommunity; this paper presents the cross-communityanalysis.Results and discussionAcross these diverse communities the overarchingtheme was stresses on birth experiences arising fromvaried expectations and different levels of power, choice,and control within the context of different resources andhistories of colonization and decolonization (see Figure 1:Across Community Analysis of Birthing Experiences inFour Communities). Geography, ease of access, and nat-ural resources available shaped historical patterns ofcolonization and continue to shape neo-colonial dynam-ics. Most of these First Nations’ traditional territories arelocated on remote coastal British Columbia with moun-tain ranges, storms, fog, steep roads, and great distancesbetween communities. Resources such as fishing and for-ests have been depleted, leading to high unemployment.As for other First Nations in BC, mineral exploration,Table 1 Sample and Data collectionData Collection Method SampleIndividual interviews • 66 mothers• 1 father• 9 health care /community leaders (e.g. physicians, CEO’s)Focus groups • 42 mothers and 2 fathers in 5 groups• 11 elders• 5 youth (men and women)Community Meetings • Small group meetings with health professionals• Meetings with cultural centre staff• Community meetingsObservations and invited participation at community events(>1000 hours)• Mother’s and Tots groups and drop ins;• Christmas school celebration;• Field visit to ancestral village• Mother’s Day luncheon with about 60 mothers, fathers and children• Baby Welcoming Ceremony• Cultural Centre Opening ceremonies• Participation in language classes, traditional weaving, salmonpreparationBirthing expectationsStresses on birthing and birth outcomes and experiencesDecolonization:Cultural revitalization, reclamation, self determination ColonizationRural GeographyEconomic resourcesBirthing resourcesPower, Choice, ControlFigure 1 Across Community Analysis of Birthing Experiences in Four Communities.Varcoe et al. BMC Pregnancy and Childbirth 2013, 13:26 Page 3 of 10http://www.biomedcentral.com/1471-2393/13/26resource management practices, and unresolved landclaims create conflict. This geography has shaped birthingexperiences through the availability of economic resourcesgenerally, through the availability of maternity care ser-vices, and through challenges to travel.Birthing resourcesEuropean contact and ensuing colonization decimatedtraditional birthing practices and Aboriginal midwiferyacross Canada and imposed Western approaches to ma-ternity care [18,19]. However, following three decades ofdeclining rural maternity services in Canada [20-22]each community was grappling with stresses associatedwith birthing including dwindling birth and economicresources. Although all communities had some prenataleducation and care, there was variation in other servicessuch as ultrasound, transportation for prenatal diagnos-tic services, and supplementary income for nutrition.While one community had physicians providing full-time “low risk” care, others depended on locums andpart-time physicians with varied intrapartum skills. Inone community women could give birth in a hospitalclose to the reserved; in another all women had to leaveweeks ahead of their due date to birth in more urbansettings. One community had intermittent Caesareansection capacity, but none had reliable access to epiduralanaesthesia. The effects of these variations depended ona women’s family and circumstances. For example,women with limited resources associated their postpar-tum depression primarily with a lack of family and com-munity support before, during and after birth. One said“I went through the depression really bad, because Ihad to be in Vancouver so long by myself. . .I didn’tknow anyone”.Women with resources that enabled them to labor andbirth with family present connected those experiences tobetter outcomes.“I think it’s better to have [deliveries] in thecommunity, because you can have the whole support ofthe community and that can help with post-partumdepression”.Depletion of birthing resources was evident in the al-most total destruction of traditional birthing practices inall four communities; only a few surviving elders couldrecall customs, and this knowledge was being continu-ally lost as elders died. The dominance of the biomedi-cally based health care system, colonizing efforts toeradicate indigenous languages and culture, and theforcible separation of families have hindered efforts topass on such knowledge in these communities. Theextent to which birthing resources beyond the dominantmedical system were available varied, and the medicalsystem was constrained by colonial relations betweenAboriginal people and the state. Resulting tensionsshaped resistance to medical and health care systemcontrol of pregnancy and the birthing process.Colonial and race relationsAlthough each community had unique experiences ofcolonization, there were significant commonalities. TheHaida, Kwakwaka’wakw and Nuxalk peoples all suffereddevastating population losses from diseases introducedpost contact [23,24]. Appropriation and control ofresources has affected each community differently. Dif-ferent levels of affluence shaped power, control, andchoice in each community, and the resources availableto individual women. For many, very low incomes haddirect effects on perinatal nutrition and health, and con-strained birthing and “lifestyle” options. For example,without a car or money, many could not get to the near-est town with secondary services to give birth; theystayed in the community regardless of medical recom-mendations or their own preferences. Those who had“status” and were eligible found the travel allowance wasinadequate to eat properly and did not cover bringingtheir children or childcare. Often the band could not af-ford an escort (partner or support person).These dynamics had indirect effects on women’s andfamilies’ sense of power. As a woman in one communitydescribed it, “poverty has no power”. In another commu-nity women were often unable to afford basic nutrition.In contrast, several women from another communityappreciated their relative affluence. One said, “thankGod for the Band Council” referring to the support shereceived for travel related to a complicated birth.Racism, the constant companion of colonialism, playedout differently in each community. Overt racism wasmost clearly described in one community. For example,three different women told us that they had overheardhealth care providers commenting on non-Aboriginalbabies’ “tax status”, with one reporting overhearing aprovider referring to a Caucasian baby, saying “at leastthis is a tax paying baby”e. In contrast, participants fromanother community made no references to racism re-gardless of where they gave birth. Those who experiencedracism understood such experiences as contributing tostressful relations with health care providers.Relations with health care providersAcross the communities there were commonalities in bothpositive and stressful aspects of women’s relationships withproviders in community and referral centres. Positive rela-tions were characterized by respect, understanding of cul-tural context, and connection with communities.Varcoe et al. BMC Pregnancy and Childbirth 2013, 13:26 Page 4 of 10http://www.biomedcentral.com/1471-2393/13/26I just wanted to give birth here, because I knew itwould be a better experience just because the doctorsand the nurses here know the families more andthey’re more relaxed. Like they wouldn’t limit thenumber of people who were allowed in the birthingroom or they would respect whatever wishes I had.Conversely, negative experiences showed distancing.“I’m sure I wouldn’t have been as scared if I’d had myown doctor around, to be able to talk to me. . . thedoctors [in the referral centre]. . . especially thespecialists, they kind of looked down their noses atpeople.”Relations with individual providers were shaped by thestructure and funding of the health care system. In onecommunity women talked about a “revolving door” thatcreated anxiety because they could not develop a rela-tionship with one or two providers:“I saw a different doctor every month. . . because thedoctors were changing so much here.”“We both wanted to stay here. . . but there was. . .nobody, well no doctors around to actually deliver. . .”The structures of funding and availability of resourcesin one community resulted in induction being used as ascheduling mechanism to accommodate the physician’sschedules, resulting in considerable stress for all womenbecause they did not know until the last minute whetherthey would need to relocate to give birth. One womandescribed how she felt being forced to leave her commu-nity to give birth to her fourth child and her thoughtsabout the provider’s roles:It was heartbreaking. . . I was mad. I was angry. Andit was unfair, I think, to me, for them to make thatchoice for me. It wasn’t fair at all. And I didn’t wantto go. The only way I could stay here was if I gotinduced. Yeah, that’s what they told me. So, but thatwas. . .yeah. So I said, “No thank you, I’d rather gothrough the natural labouring and everything,” ratherthan be induced to have him [her son] on their time,and not when he wanted to come out. So, yeah, that’swhat I was told. If I wanted him here, I had to beinduced that evening, and then just go from there. So Isaid no. And then, um, they gave me no other choicethen, ‘cause the doctor that was here, he was able toperform natural birth, but not a C-section. . . So, evenwith my medical record. . . I had all of themnatural. . . and so I was confident that I was going tohave him natural, too. But no, they weren’t confidentenough for themselves, I guess.In that community the women described multipleways in which what they wanted and needed was over-ridden: “I wasn’t allowed an escort”, “I was refused care”,“I was all alone”. “They said, you can be sent out, or youcan be induced now. . . I had a choice, if you call that achoice”Tensions characterized many of the women’s birthingexperiences, whether they were in local or referral healthcare centers. One woman who delivered in a referralcentre described how dismissive practices affected her:“The doctor seemed to be in a big hurry. He made itseem like I was inconveniencing him by being inlabour at five in the morning. I told him I didn’t wantan episiotomy and he gave it to me anyway.”On the other hand, when women reported positiveexperiences with providers, it was in contrast to negativeexperiences, and usually was about what should be con-sidered routine care. For example:They were, like, bringing me apple juice, and orangejuice, and even coffee! I can’t even handle the smell ofcoffee during labour, so no, thank you. But, yeah, sothey were really nice there. I. . .. it was different fromhereWhen I was in labor I was really scared ‘cause I didn’tknow what was happening and I think it was one ofthe nurses that was so helpful and so nice to me. Sheshowed me what to do and when not to push andwhen to push.Thus, relationships with health care providers reflectedwider structural issues and social and health care con-texts, and shaped the women’s experiences, including asense of limited power, choice and control, and theirbirth outcomes.Stressful birthIn all communities women described stresses on birthingspecific to rural settings and associated with limited eco-nomic resources. In one community, birthing wasdescribed as highly stressful by all women interviewed.Here, women described having “no power, no choice,and no control” in their birth experiences and consider-able racism in their health care encounters (see Figure 2:One Community-Specific Analysis of Birthing Experi-ences). They routinely described practices as dismissive.In one focus group all seven young mothers criedthrough most of the interview, describing the effects ofgiving birth outside their communities: loneliness, dis-connection from community, isolation from family andculture, and discrimination. These were not only shortVarcoe et al. BMC Pregnancy and Childbirth 2013, 13:26 Page 5 of 10http://www.biomedcentral.com/1471-2393/13/26term, ‘acute’ stressors; all seven thought these stressescontributed to their post-partum depression and affectedtheir capacities to bond with and nurture their infants.They also felt distressed and guilty about the childrenremaining at home while the women gave birth.It’s hard not to get depressed, it’s hard not to you knowfeel. . . stress [being] by yourself and alone and it’shard to eat when you’re feeling all those things.Elders who had given birth generations earlier echoedsimilar concerns. Indeed Elders in one focus groupdescribed how their relationships to their children hadbeen disrupted by stressful birth experiences. Onewoman described how her doctor did not tell her shewas having twins, and did not tell her she had to have aCaesarean Section. She then had a harrowing emergencyflight to Vancouver, where “the plane literally flippedover because the wind so bad” and the accompanyingnurse started to “freak out herself” the situation was sobad. The woman contrasted her relationship with herdaughter with her relationship with her sons, attributingthe difference to the circumstances of their birth:I never had the bonds with my sons that I should havehad. But I had to work on the bond with my boys. Itwas a really big difference. Plus having them inVancouver made it even worse.Bringing back the celebration of lifeDespite the challenges and stressors, in each communitywomen were motivated, resourceful, and passionate aboutimproving birthing experiences. Community-specificreports with recommendations were developed and pre-sented at community meetings that included Aboriginalleadership, Elders and health care administrators and pro-viders. Researchers from the community in which allbirths were seen as stressful described their vision as beingable to “bring back the celebration of life”. In each com-munity, this involved working toward more respectfulrelationships, helping health care providers understandhistory and culture, and strengthening Aboriginal self de-termination. A teenager in one focus group said:“. . .everyone is so happy to go and give to thebaby. . .even if you are not closely related. . .because itis another member of the Haida Nation, and it justmakes the community bigger and richer. In the longrun it will make it stronger.”Within the diverse and unique context of each commu-nity, participants identified various strategies for improv-ing birthing experiences. The women’s recommendationsvaried with their communities, and their individual experi-ences. Many women were interested in “traditional” and“natural” approaches, although the meaning of naturalvaried [25]. Some were supportive of the idea ofexpanding the range of providers, including Doulas andmidwives, including Aboriginal midwives, a directionadvocated by other researchers [19,26,27] and presentlybeing championed by the National Council of Aborigi-nal Midwives in Canada (http://www.aboriginalmid-wives.ca/). This was particularly the case where womenhad exposure to alternatives. For example, althoughmidwives were not available in any of the communities,with small numbers of births, and midwifery onlyColonial RelationsDisruption of economic resources, traditions, culture, familiesHealth Care SystemStigma, judgment, blame, racism, stereotypingNo PowerNo ChoiceNo ControlDehumanizing RelationsNormalizationDiscriminationDismissive PracticesRespectful RelationsBring back the Celebration of  LifeCapacitiesResources Stressful BirthFigure 2 One Community-Specific Analysis of Birthing Experiences.Varcoe et al. BMC Pregnancy and Childbirth 2013, 13:26 Page 6 of 10http://www.biomedcentral.com/1471-2393/13/26recently being re-established in the province, in a com-munity with an active and well-liked doula, this optionwas frequently suggested by the women. At the sametime, having engaged with the language of “risk”, mostwomen emphasized that they wanted access to birthtechnologies when needed, particularly epidurals andemergency C-sections, with the presence of family, asclose to home as possible and within their traditionalterritories.Overarching all recommendations, participating Abo-riginal women and members of their communitieswanted choice and control. They wished to restore asense of power after centuries of losses in the wake ofcolonization, and also to move beyond tokenism to au-thentic participation and leadership in research, planningand decision-making, particularly around issues as cen-tral to Aboriginal communities as birthing.The dominance of biomedicine and the developmentof western technological interventions in maternity careover the last century have created a situation whereAboriginal communities were told that their time hon-oured midwifery and birthing practices were unsafe, andthat they must turn to the advances of western medicalpractice for “modern” maternity care. At the same time,community members observed steady erosion in thosesupposed safety advances to the point where some oftheir communities are now left with very little of eithertraditional or western birthing options. Birthing womenmust undergo further hardships and travel in order toaccess even the most basic maternity care in a“foreign” environment, or make decisions, sometimescovertly, to take the situation into their own hands andgive birth locally against the advice of western medicalpractitioners.One of the major stressors for women who partici-pated in this study was the juxtaposition of diminishinglocal birthing choices, with loss of connection to family,clan and culture when they left their communities togive birth. Many women struggled to come to grips withthis, giving examples in interviews and focus groups ofnegotiating and considering the “risks” inherent in stay-ing or leaving, particularly with respect to disconnectionfrom their people, territory, and traditions. They won-dered why medical maternity services were introduced,and then withdrawn from their communities, and whomakes these decisions. The struggle itself added greatlyto the stresses on birthing. The health impacts ofcolonization, the effects of medical paternalism, and thestruggle to control the bodies of women intersected tomagnify the stresses for many rural Aboriginal women,families, and communities. As Couchie et al. state,“Aboriginal women in remote and rural communitiesshould not have to choose between their culture andtheir safety” [26].Our findings reflect Couchie and Sanderson’s [26]recommendations that rural Aboriginal communitiesand health organizations must collaborate to changeexisting maternity services, and wherever safe and prac-tical, support the return of birthing to rural and remoteAboriginal communities. What constitutes “practical”and “safe” must be informed by birthing women andtheir communities. Collaboration must occur in healthcare interactions at the level of practice, teaching, policyand research levels.In practice contexts health care providers should pur-sue culturally safe care by seeking to infuse their ownpractice and their practice contexts with the knowledge,skills and actions that help them to (1) practice acrosscultural differences (i.e. biomedical and Aboriginalknowledge of childbirth) and (2) optimize women’sbirthing experiences and perinatal outcomes through arecognition of how both are shaped by historical and on-going colonization, diminished local maternity choicesand women’s access to respectful and responsive carethat meet their needs. Such practice requires health pro-fessional education that will help providers understandhow women’s birth experiences, willingness and abilityto access care, and perinatal outcomes are shaped by thesocial, cultural, political, and economic contexts. Partici-pants emphasized that trainees and faculty must gainknowledge of the impacts of colonization, and theywould benefit from learning about how specific commu-nities have enacted effective and culturally safe healthinitiatives. As one of the community researchers said,“Health care professionals can be guided to be morecompassionate to First Nations people and moreunderstanding of our history.”The overarching implication for policy from this pro-ject is that Aboriginal people must have more controlover maternity care and birthing experiences. This, ofcourse, echoes the quest of indigenous people globallyand throughout Canada to reclaim their lives from colo-nial intrusion. As reflected in the Canadian NationalCouncil of Aboriginal Midwives’ mission statement(http://www.aboriginalmidwives.ca/), the choice of birthplace for all Aboriginal communities is consistent withthe UN Declaration on the Rights of Indigenous Peoples.Birthing is no ‘small aspect’ of life and health for thecommunities involved in this study; rather, it is centralto culture and wellness. Reclaiming birthing is integralto reclaiming culture and control over people’s ownlives. Importantly women and elders must be central tosuch increasing control. Thus, the findings of this studyalign with calls for the devolution of control over gov-ernance emanating from the Indian Act to Aboriginalpeople themselves, particularly with respect to economicVarcoe et al. BMC Pregnancy and Childbirth 2013, 13:26 Page 7 of 10http://www.biomedcentral.com/1471-2393/13/26resources. At the provincial and local levels this projectsupports the need for increasing control, beyond tokenrepresentation by Aboriginal people over their economicwell-being, and the health care services provided tothem. In health care contexts specifically, anti-racist, de-colonizing, and indigenous orientation and trainingshould be required for all employees. Both Aboriginaland non-Aboriginal health care workers can contributeto fostering more respectful, less dismissive, harmfulrelations. Continued efforts should be made to increasethe workforce of Aboriginal health care providers. Newmodels of funding physicians, and new models of care(e.g. doulas and midwives) should be developed underthe guidance of local Aboriginal people. Health care con-texts should be ‘indigenized’, not only by including cul-turally safe and appropriate care and practices, but byactively taking into account the history of colonizationand trauma experienced by Aboriginal people, and theongoing colonizing practices within Canadian society.Finally, the findings of this study underscore importantdirections for both how health research should be done,and what further research should be done. As we havewritten elsewhere [17] our experiences in this study sup-port the multiple calls for research that concerns Abo-riginal people to be done under the guidance andleadership of Aboriginal people. The next inquiriessuggested by this study include action studies andevaluations of new policies, practices and educationalstrategies. Action studies to enhance rural maternity carefor Aboriginal women might take this study as the pointof departure. Building on our recommendations regardingpractice and policy, collaborative efforts among health au-thorities, Aboriginal communities and researchers shouldbe undertaken to support the strengthening of birthing toensure adequate resources are available and to ensurefamily presence and engagement prior to, during and fol-lowing birth.Based on the experiences of women in four Aboriginalcommunities in British Columbia, this study does notrepresent the diversity of Aboriginal women in Canada.Nevertheless, the dynamics described suggest directionsfor understanding health outcomes, practice in relationto Aboriginal maternity care, and further research. Thisstudy underscores how socio-political and economiccontexts influence birthing experiences and outcomesfor rural Aboriginal women. In particular, limited mater-ial resources, declining local birthing services and racerelations shaped women’s stressors and relationshipswith providers. Rural Aboriginal women’s birthing ex-periences cannot be disentangled from how the contextof their lives mediates health status in pregnancy andperinatal outcomes. For example, Richmond [28] arguesthat social determinants such as social support play outin the context of colonialism, and although researchhas established social support as an important modifi-able factor for postpartum depression, the meaning ofsocial support within rural Aboriginal women’s lives isnot well understood.The degree to which the conditions of rural Aboriginalwomen’s lives create possibilities for positive birth out-comes is obscured when poor birth outcomes areexplained on an individual basis. For example, inad-equate prenatal care is considered a risk factor for poorbirth outcomes, and Aboriginal women have been foundto have poorer prenatal care than non-Aboriginalwomen [5]. Rather than this being a “choice”, our find-ings show that in addition to geography, prior negativeexperiences and discrimination were deterrents to acces-sing prenatal care. If maternity care practices and policesremain oriented to “lifestyle” changes, and social deter-minants and conditions of women’s lives remain invisibleas mediators of outcomes, inequities in Aboriginalmaternal-infant health will persist. Accounting for his-tory and culture can generate new insights for maternitycare tailored to local contexts.What is not measured as a significant mediator ofwomen’s experiences and birth outcomes also is import-ant. In this study the erosion of birthing and economicresources fostered negative birth outcomes and experi-ences. Disconnection from community fractures socialsupports, including family relationships and culturalpractices; thus the structural and funding conditions thatcompel women to leave their communities warrant ana-lysis and action to mitigate poor birth outcomes. Kleinat al. [29] describe how erosion of local birthing capacitycreates a “cascade of adverse consequences” for mothers,babies, and entire communities. Although not focusingon Aboriginal communities, Klein et al. show how effect-ive maternity and newborn care is fundamental to thesocial and economic sustainability of communities.Emerging evidence about allostatic load in pregnancyand the results of research examining social determi-nants of birth outcomes, suggest that it is necessary to(1) better assess the structural conditions and mechan-isms by which they produce health outcomes and (2)build upon such assessments to generate outcome mea-sures sensitive to the conditions within which outcomesare produced. Most importantly, the structural inequitiesthat produce disproportionately poorer health for Abori-ginal people (e.g. poverty, racism, inferior educationalopportunities) must be redressed. Aboriginal communi-ties must have control over decisions affecting theirhealth and health care, including maternity services.ConclusionHistorical and ongoing colonial relations impact birthingresources and experiences for Aboriginal women.Addressing the mechanisms through which stressesVarcoe et al. BMC Pregnancy and Childbirth 2013, 13:26 Page 8 of 10http://www.biomedcentral.com/1471-2393/13/26influence birth outcomes will require interventions inpolicy and practice. Beyond modifying individual lifestylebehaviours, actions are required to diminish stressorsarising from racism, poverty, and the organization, fund-ing, and delivery of rural care. Individual providers canimprove care for Aboriginal women by learning andaccounting for community and family history, and byenhancing women’s control over their experiences. Indi-cators of maternal and infant outcomes require expan-sion to encompass intermediate mechanisms thatsupport or degrade health. Policies that account for thesocial production of health inequities can also improvematernity care – for example by mitigating the effects ofpoverty, and housing and food insecurity. While initia-tives to bring birthing closer to communities are import-ant [26], broader approaches are required and healthcare providers can align with communities and womento promote such change.EndnotesaIn Canada, the term “Aboriginal people” refers to in-digenous peoples and encompasses First Nations, Métisand Inuit peoples [30]. These three groups reflect‘organic political and cultural entities that stem historic-ally from the original peoples of North America, ratherthan collections of individuals united by so-called ‘racial’characteristics’ [30](p. xii).bAllostasis is a more precise alternative to the termstress, used to refer to environmental challenges thatcause an organism to begin efforts to maintain stability(allostasis).c“Status” refers to those defined under the Indian Actas “status Indians” who are then governed by the Actd“Reserve” is the term used in Canada to refer to landsset aside for the use of Aboriginal people under theIndian Act of 1867 [31]eA particularly pernicious and pervasive race-baseddiscourse in Canada contends that because “status” FirstNations people do not pay the same taxes as otherCanadians they “get everything for free”. This discourseis often applied a) regardless of whether the people towhom it is being applied are “status” or not, b) withoutunderstanding that most Aboriginal people in Canadapay most taxes, c) without acknowledging that the landon which they do not pay tax is but a fraction of theirtraditional territories appropriated through colonialconquest.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsCV and BC co-led the overall research. HB served as the research coordinatorfor the overall research. TH and MT were community based researchers,conducting all individual interviews and co-conducting all focus groups intheir community, and leading their community-specific analysis, reportwriting and community presentations. All authors participated with thelarger team in the cross-community analysis, and contributed to the researchreport upon which this article is based. All authors read and approved thefinal manuscript.Authors’ informationThis research has been followed up in diverse ways specific to maternitycare and more generally. The 'Namgis community researchers and author HBhave continued to work together to examine how tradition and culture haveprotective and health promoting impacts that are indigenizing approachesto health policy and planning within Alert Bay. Community members in OldMassett initiated and continued baby-naming ceremonies. Author BC hascontinued to collaborate with the Haida communities. Author CV has beeninvolved in research to improve primary health care for Aboriginal people,for example using the Provincial Health Services Authority’s “IndigenousCultural Competency” (an antiracist training for health care providers) as partof an organizational level intervention to promote equity and social justiceand improve care and health outcomes.AcknowledgementsWe honour and acknowledge the Haida of Old Masset and Skidegate, the'Namgis First Nation in Alert Bay and the Nuxalk First Nation in Bella Coolafor inviting us to work together in their communities. We thank the chiefsand band councils in each community who supported this project. To thewomen who shared their stories and wisdom and offered their ideasregarding how to improve healthy birthing in each of these communities,we give our thanks and acknowledge our indebtedness. We alsoacknowledge and thank our other research team members: Laura Bell (OldMassett), Barb Cranmer (Alert Bay), Vera Newman (Alert Bay), Karen Cook(Alert Bay), Melissa Edgars (Skidegate), Mary Ann Wilson (Skidegate), MarlaBuchanan (Vancouver), Jen Eskes (Vancouver), Myrna Bell Wilson (OldMassett). Funding for the research and manuscript publication was providedby the Canadian Institutes for Health Research. The funding body thatprovided support for this study was not involved in any stage of theresearch.Author details1University of British Columbia School of Nursing, T149 - 2211 WesbrookMall, Vancouver, BC V6T 2B5, Canada. 2Department of Family Practice,University of British Columbia, British Columbia, Canada. 3Community HealthRepresentative, Box 463, Bella Coola, BC VOT 1CO, Canada. 4Family SupportWorker, Box 132, Bella Coola, BC VOT 1CO, Canada.Received: 15 September 2012 Accepted: 21 January 2013Published: 29 January 2013References1. 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Royal Commission on Aboriginal Peoples: Report of the Royal Commissionon Aboriginal peoples: Volume 3, Gathering strength. Ottawa, ON, Canada:The Commission; 1996.31. Indian Act. http://laws-lois.justice.gc.ca/PDF/I-5.pdf.doi:10.1186/1471-2393-13-26Cite this article as: Varcoe et al.: Help bring back the celebration of life:A community-based participatory study of rural Aboriginal women’smaternity experiences and outcomes. BMC Pregnancy and Childbirth 201313:26.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitVarcoe et al. BMC Pregnancy and Childbirth 2013, 13:26 Page 10 of 10http://www.biomedcentral.com/1471-2393/13/26

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