Transport and referral from the north

Heading out the door at 430am - the start of 18 hours of daylight

Student Susan May, with her baby Peter 'Nanuq' - born at home with the midwives. (Peter is wearing his cool sealskin boots made by grandmother Eva).

One of two delivery rooms.

Transport equipment and supplies at the back door ready for medevac. There's a heater to the right that holds expired iv bags - used as hot water bottles to pack around the patient for the trip out.

But what about the 6 hour transport time on a good day and the inherent risk of giving birth. It seems that with good prenatal care, preventative measures, and referring at-risk women to deliver in PUV with a little extra technology available, or in Montreal with a lot of technology available, the outcomes are very good. And when something comes up quickly, you manage it and it resolves, or stabilize them and move them, or you stabilize them and then sit tight through the night until the skies clear.

The most recent data by Luo, up to 2000, found that there was no difference in perinatal mortality rates among infants born in the north, compared to aboriginal infants and non-aboriginal infants born in the south (Montreal). They did however find that infants born to Inuit mothers, when adjusted for infant's sex, parity, maternal age and education, and marital status, had 4x higher risk of postnatal infections and sudden infant death compared to non-aboriginal infants in the south. Limitations in the data did not permit the researchers to control for maternal smoking in pregnancy. And 99% of women here smoke in pregnancy, and presumably in the postpartum too - though in the last 10 years, there has been a very successful public health campaign to get people to smoke outside (yes, all year) if they have young children in the house.

What is somewhat hidden in this paper is that ~70% of all women in the north and aboriginal women in the south had <11 years of schooling, whereas ~10% of non-aboriginal women in the south had <11 years of schooling...and given that the Auditor General of Canada in 2004 estimated that if all things remain the same - this gap will take another 28 years to close...we likely won't see a change in these numbers for a generation, as maternal education is closely linked to both neonatal deaths (<28 days), and infant deaths (<1 year).

Meeting their great grand daughter, less than an hour after she was born

Inukjuak in Spring

I explain to the woman that since we don’t have a lot of information about her pregnancy so far, she should consider having an ultrasound so we can try to figure out when she is due. The ultrasound is in Puvunituq, an hour north of Inukjuak by plane - the regional government will pay for the flight there on one afternoon, the overnight at a transit house, the meals, and the flight back the next afternoon after the ultrasound at the PUV hospital. She seems hesitant - "but when should I go?"…I explain that the sooner the better since the scan is more accurate earlier in the pregnancy…she pauses and asks if it can wait until after goose hunting season. "When does goose hunting season end?" She smiles widely, as if to say "Oh girlfriend, what are you missing in life?"

And it’s true - I never knew about a place like Inukjuak existed in Canada. It’s a calm well-governed community, where families go away to camp/hunt/fish out on the tundra - where timeframes are governed by migration of wildlife. The cb radio is on all the time, and caribou migration is reported daily. Everyone speaks Inuktitut, most speak English, and some speak a bit of French. Familes are large and women start having babies young. A third of babies are adopted to extended family in a process that has only recently been tracked by any paperwork.

This sounds like a romantic image of the nobel savage but what I mean is that it is nothing like I was expecting. I arrived in northern Quebec at the beginning of May to work in the maternity wing at the Inukjuak Health Centre. The maternity is run by two Inuit midwives, apprentice-trained and registered with the College of Midwives of Quebec. There are also three students doing their apprenticeship. This is a major success story since other areas of Canada have attempted to have local registered midwives, and the training never got off the ground. The midwives scope of practice is broader than in the south - they cover all the reproductive and newborn healthcare and can consult with one of the two family physicians on staff.

Inukjuak is a village of 1500 people. If you look at the Hudson Bay east coast, at 58˚North, it looks like a side view of a pregnant woman and Inukjuak is at her xyphoid. The health centre has a busy out-patient ward, occasional dental and psychiatric services, social services, and the maternity wing.

The health centre serves the immediate community and outlying communities, which have a nursing station. The healthcare staff are mostly Quebecois, and the frontline staff and translators are Inuk. There are ‘first responders’ on staff to call for transport to the airport, and emergencies can be medivac’d to Puvunituq or Montreal if needed - you plan for 6 hours transport time if the skies are clear (no blizzard, no fog), and the winds are calm (I have never been in a windier place in my life).

But apparently Inukjuak was called 'the Bosnia' by locum physicians willing to come for a week or two in the mid-90s...and this is what I was expecting.

I don’t really know what all the problems were but there were more suicides, gun accidents, people lost on the tundra, and alcoholism than there is now. Inukjuak is the village that used to be called Port Harrison. In the 1950s, the federal government relocated families to the high Arctic of Resolute Bay and Grise Fiord, to act as 'permanent residents' in order to claim territorial sovereignty in the Arctic…families were split up, and some have returned to Inukjuak after 30 years. The community received a government apology last year and the story was depicted in the NFB film, Martha of the North.

Lisa with her first grandson, baby Charlie, number 424 born at the maternity

The other issue, a similar story as the rest of the far north, in which women were sent to Moose Factory or Montreal a month prior to delivery. And the profound experience of birth was taken out of communities. This sounds a wee bit dramatic, but the opening of the Inukjuak maternity corresponds with the improved social conditions of the community, 13 years and 428 births later, Inukjuak is considered a success story of Inuit self-government and the professionlization of the traditionally trained midwife.

Dalacia with 3 week old baby Ethan in her amati

This is an apt quote from PUV midwife Nellie Tooliguk, in the SOGC guidelines on returning birth to the north. "Just imagine this: You are having a baby. A group of people with PhDs have 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. This is just a small

piece of what injustice we have been put through by

health care policies and policy makers."