Pregnant Indigenous women in Canada have suffered from COVID-19 measures more than others, say birth workers across the country. The disproportionate harm has amplified long-standing discrimination and mistreatment, they add.

The treatment of Indigenous people in Canadian healthcare has recently come under scrutiny after Joyce Echaquan, a mother of seven, recorded degrading treatment by staff on video at a Quebec hospital shortly before her death in late September.

The federal government told openDemocracy it “recognises that Indigenous women face unique, complex challenges in many areas of their lives” – but doulas, midwives and other health workers in Ontario, Alberta and Saskatchewan said pandemic policies do not seem to have been designed or implemented with these challenges in mind.

For example, many medical appointments have shifted online, but only 24% of households in Indigenous communities have fast enough internet connections for basic functions like sending images. Julie Wilson, an Indigenous midwife in southern Ontario, says this has left some Indigenous women unable to get vital antenatal care.

Nadia Houle, a doula and founder of the advocacy group Indigenous Birth of Alberta, said that restrictions on support services have disproportionately impacted Indigenous women. She described this as “like torture” for new families. “It's tenfold [harder] with Indigenous families,” she said. “And then during the pandemic, I think that it's like fiftyfold.”

Several birth workers said that fear of discrimination and mistreatment in Canadian hospitals, compounded by new fears of contracting COVID-19 and passing the virus on to elders in often crowded, multi-generational homes, have led more Indigenous women to avoid public health centres for as long as possible.

As a result, “You end up with pregnancies that have problems that weren't diagnosed,” says Patrick Laflèche, a family doctor who worked in Prince Albert, Saskatchewan, for several months during the pandemic.

He described one patient with serious complications who waited eight hours before going to hospital, because she was afraid of contracting COVID-19. Her baby died about a month after birth, an outcome he said could have been avoided had she had medical care sooner.

“A lot of our clients have a ton of anxiety about the virus, because they want so badly to keep their elders safe,” said Jessica Swain, a Cree-Métis midwife in Calgary, Alberta. She said there has been increased demand for home births as a result, but this isn’t an option for many clients who live in overcrowded homes on reserves.

In Canada, many Indigenous people live on reserves where the federal government has chronically underfunded services for years. Many residents have long struggled to meet basic needs including decent housing and clean water. Some reserves are also located far from cities and public hospitals.

Lack of support made worse

In Edmonton, Alberta, Cree-Métis doula Desirée Solberg says Indigenous women faced little or poor communication and support from health workers before the pandemic, and that this has only got worse during COVID-19. She has seen her own clients neglected by hospital staff who have not properly explained the stricter policies imposed.

One woman, an 18-year-old sexual violence survivor who gave birth to her first child in June, was “left waiting for a room for hours”. Solberg said: “I've never seen them leave a woman in labour for so long without coming to talk about pain management.”

This client gave Solberg consent to tell her story to the media. Solberg said the teenager had never had a vaginal exam before and had requested minimal people at the birth and that she not be touched by men – but staff denied these requests.

When a doctor finally came to give the teenager an epidural, they were accompanied by several medical students. Solberg said her client was shaking and in tears. But, “she was brave, the strongest – for a tiny little thing and a baby that big… that was the longest labour I've ever attended.”

Restrictions on hospital visitors and birth companions appear to have also disproportionately affected Indigenous women.

Alycia Two Bears, an Indigenous doula in Calgary, Alberta, said it’s particularly important for Indigenous women to be accompanied by people they trust because “the way that you’re already treated in a Canadian hospital can be unfair”. Having to choose between a doula and a family member can be very upsetting, she said.

Such restrictions have also made it harder, or impossible, to perform traditional birth ceremonies. Two Bears describes the ceremonies she would perform before the pandemic as a way to “bring our indigeneity with us into a hospital setting”.

She explains: “I’d make an ancestor plate when I come, we’d sing songs together, I’d bring a drum, any food preparation that is significant. Or just bringing sage, and there's rose bath waters that can be done after the baby's born.”

Travelling far and alone

Martine Stevens, a spokesperson for Indigenous Services Canada, said that many Indigenous women have to travel from remote communities to get decent obstetric care.

Since 2017, the federal department has covered travel, meals and accommodation for the pregnant woman and one companion if she needs to travel for medical care. The government said it has not changed this policy during the pandemic, but official figures show some women have travelled unaccompanied. It is unclear if this was their decision.

In Ontario, the Ministry of Health told openDemocracy that more than half (38) of 61 women in labour who travelled for medical care between April and July went without companions. It is unknown how many of them were Indigenous, as this data is not collected. However, 23 were transported by the government from a First Nations community in northern Ontario. Seven of these women did not have an escort.

In June, Alookie Otuk travelled 2,000 kilometres to Ottawa for surgery for her infant daughter following a difficult birth at a hospital in Iqaluit where she herself had also undergone gallbladder surgery. Otuk said that despite requesting three times that her husband be allowed to accompany her, she and the baby had to make the trip alone.

Otuk describes staying in a tiny room in a boarding house in Ottawa for two months, with no one to watch the baby while she showered or ate, or help them while they recovered from their surgeries. “It was really mentally draining,” she says.

Before returning home, Otuk had to quarantine for fourteen days in an Ottawa hotel, which she says didn’t have laundry or hot meals. The food she was given had to be microwaved and was “like dog food”. As a result, she said “I haven't really been eating much.”

Chris Puglia, communications manager for the Nunavut territory’s health department, said Otuk should contact its patient relations service about her case. She did this, and received a response in September: she was told she had been denied a companion to Ottawa because her daughter was already born, and she was considered the escort for her child.

Accommodation for pregnant women while they are away has also been impacted by COVID-19. In Saskatchewan, Patrick Laflèche, the family doctor, said a boarding house run by the charity Ronald McDonald House had closed, leaving some patients “in a bit of a lurch in terms of trying to figure out housing”.

Tammy Forrester, CEO of Ronald McDonald House Charities Saskatchewan, said that in lieu of free housing, patients have been offered a discounted rate of $50 a night at a nearby hotel. Though she said she didn’t think that everyone in need of their services could afford this without public assistance.

Long-standing challenges and stereotypes

Birth workers across the country told openDemocracy that pregnant Indigenous women have long been marginalised in Canadian hospitals. Alycia Two Bears, the Indigenous doula in Alberta, said: “We have to battle racism the minute that we come into a hospital.”

The birth workers said that pregnant Indigenous women have faced racism and been denied pain medicine; stereotyped as drug addicts and thieves; disproportionately put under the watch of social workers; and subjected to medical treatment without consent.

Midwife Julie Wilson is the supervisor of Six Nations Maternal and Child Centre. It is located on a reserve called Six Nations of Grand River in southern Ontario, which has one of the largest on-reserve populations of nearly 13,000 from six Iroquois nations. She attends births at several hospitals in the local area.

She says she has repeatedly observed a difference in how staff act around her Indigenous clients. “It comes out in body language, in not giving them the full information, just being quick and short, and not as understanding,” she said. ”You almost get the impression it's harder for them to care for some of our clients.”

Nadia Houle from the Indigenous Birth of Alberta group added that Indigenous women are also regularly questioned on their ability to provide homes for their new babies. “I had clients in the postpartum [ward who] had a fixed address, and the nurses kept asking them if they were homeless.”

The World Health Organization (WHO) deems failing to obtain informed consent from women disrespectful and abusive treatment during childbirth. But Houle says this is how some hospital staff treat Indigenous clients: “What I noticed is no asking for consent to touch, talking to them like they’re children, ignoring their questions and concerns.”

Doula Desirée Solberg says her Indigenous clients have been put in an inferior wing of the Royal Alexandra hospital in Edmonton, Alberta, where access to snacks and ice chips is limited. She says she was told: “They like to steal the food.” She says access to the fridge in that wing requires a key, “like you are in a truck-stop bathroom”.

When openDemocracy asked about this, Sabrina Atwal, spokesperson for Alberta Health Services, said: “This does not happen, and any suggestion that it does happen is completely inaccurate.”

Another stereotype Solberg has repeatedly observed is an assumption that her clients won’t breastfeed, which has led to staff offering them little, or no, support to do so. She said: “Every Indigenous client I've ever had was offered formula.”

Midwife Jessica Swain says she often sees Indigenous women removed from hospital beds sooner after giving birth. “I think there is some kind of... bias that ‘We need to clear a bed and we're going to ask somebody who has less ability to advocate for themselves.’”

Anxieties exacerbated

Two Bears says that even pre-pandemic, her pregnant Indigenous patients would go to hospital worrying “that medication will be withheld because you're immediately stereotyped as an addict”.

Angnakuluk Friesen, in Iqaluit, said she had originally planned to have a home birth, “so that I wouldn’t have the underlying fear of being treated poorly in my vulnerable state” – but a health issue meant that she had to go to hospital.

Her experience was positive, she said, but this was a surprise. She recalls being anxious about being treated “like an Indigenous patient”, and says “COVID-19 exacerbated those anxieties.”

She said that in the past health workers have unfairly suggested that she was seeking medical care in order to get a free flight out of the far-north Nunavut territory, or assumed that she was experiencing a mental health crisis. “It’s a scary world for any Indigenous pregnant women in Canada,” she said.

Following the lead of British Columbia and Manitoba, Ontario recently committed to ending controversial ‘birth alerts’ – a practice by which hospital staff alerted social services when a baby was born into what they deemed a high-risk situation.

In some cases, this led to babies being taken away from their mothers immediately after birth. Rights advocates have long said that staff raised the alarm more readily with Indigenous women and other people of colour – and that fear of social service surveillance has prevented some from accessing medical care they need in a timely manner.

Midwife Jessica Swain in Alberta said: “I've never had one of my non-Indigenous clients be social work consulted.” She blames “deficient narratives” for this contrast – and compares them with how she sees her clients: as resilient. “These people are survivors,” she said.

Indigenous birth workers in Edmonton said the city’s Royal Alexandra hospital is known to community elders as the “baby-snatching hospital” after a number of children were separated from their mothers by social workers.

Sabrina Atwal, the Alberta Health Services representative, said staff are required to take e-learning in “Indigenous awareness and sensitivity”, and Indigenous people have access to special services to make them feel comfortable in hospitals.

However, she acknowledged that “trust is a significant barrier to First Nations, Métis and Inuit people accessing the healthcare system”, and that “institutional racism and stereotyping has kept people from getting the care they need”.

What can be done?

An ongoing global investigation by openDemocracy has documented cases of women in at least 45 countries who have faced traumatic childbirths during the COVID-19 pandemic – in violation of both WHO recommendations and national policies.

Mistreatment and discrimination of pregnant women was already a well-known problem in Canada before the pandemic. In 2016, a CBC News investigation revealed that women had made hundreds of complaints about their maternity care to hospitals and authorities.

Indigenous Services Canada said the government has tried to combat challenges facing Indigenous women in childbirth by partnering with Indigenous women’s groups to help inform women of their rights in healthcare, hosting a forum on informed choice and consent in First Nations, Inuit and Métis Women’s health services, investing in Indigenous midwifery and creating an advisory committee on Indigenous Women’s Wellbeing.

“Compassion is important,” says midwife Julie Wilson. She believes some of the judgment and discrimination she has seen comes from a misunderstanding of cultural values. She says health workers should “actually get to know the Indigenous community they serve”.

* This story is part of an ongoing investigation. If you have further information to share, email the author: [email protected]