Long-distance travel for birthing among Indigenous and non-Indigenous pregnant people in Canada

BACKGROUND:For Indigenous Peoples in Canada, birthing on or near traditional territories in the presence of family and community is of foundational cultural and social importance. We aimed to evaluate the association between Indigenous identity and distance travelled for birth in Canada.METHODS:We obtained data from the Maternity Experiences Survey, a national population-based sample of new Canadian people aged 15 years or older who gave birth (defined as mothers) and were interviewed in 2006–2007. We compared Indigenous with non-Indigenous Canadian-born mothers and adjusted for geographic and sociodemographic factors and medical complications of pregnancy using multivariable logistic regression. We categorized the primary outcome, distance travelled for birth, as 0 to 49, 50 to 199 or 200 km or more.RESULTS:We included 3100 mothers living in rural or small urban areas, weighted to represent 31 100 (1800 Indigenous and 29 300 non-Indigenous Canadian-born mothers). We found that travelling 200 km or more for birth was more common among Indigenous compared with non-Indigenous mothers (9.8% v. 2.0%, odds ratio [OR] 5.45, 95% confidence interval [CI] 3.52–8.48). In adjusted analyses, the association between Indigenous identity and travelling more than 200 km for birth was even stronger (adjusted OR 16.44, 95% CI 8.07–33.50) in rural regions; however, this was not observed in small urban regions (adjusted OR 1.04, 95% CI 0.37–2.91).INTERPRETATION:Indigenous people in Canada experience striking inequities in access to birth close to home compared with non-Indigenous people, primarily in rural areas and independently of medical complications of pregnancy. This suggests inequities are rooted in the geographic distribution of and proximal access to birthing facilities and providers for Indigenous people.

Access to birth close to home, surrounded by loved ones, is taken for granted by most Canadians. The societal importance of family support during birthing has been highlighted during the severe acute respiratory syndrome and COVID-19 pandemics, despite the known and potentially fatal risks to hospital visitors, because people in labour have been one of the few patient groups exempt from visitor restrictions.^1,2 For residents living in rural areas of Canada, long-distance travel for birth is a reality that is becoming increasingly common in some regions because of closures of obstetrical services in smaller community hospitals.³ This is only partially mitigated by the revitalization of rural midwifery practice.^4,5Emerging evidence shows that the frequency of adverse medical events during labour and delivery for rural populations is similar for births that take place close to home and births for which people travel because of an absence of services close to home.^3,4,6 Less is known about the impacts of travel for birth on breastfeeding rates, maternal mental health and family functioning. Several studies have documented the negative impacts of birthing away from home with respect to maternal satisfaction and birth experience.^7–10 This evidence is particularly compelling for Indigenous populations for whom birthing on or near traditional territories in the presence of family and community is a long-standing practice of foundational cultural and social importance that contributes to well-being, cultural continuity and kinship.^7–12The striking isolation, family disruption and racism experienced by Indigenous people who are forced to travel alone for birth as a result of externally imposed federal “evacuation for birth” policies¹¹ has been met with a series of policy initiatives to support return of birth to rural and remote Indigenous communities. ^13–15 In April 2017, then federal Minister of Health Dr. Jane Philpott, committed to “a path to be able to return the cries of birth” to Indigenous communities and funding to support travel for a companion when Indigenous people living in rural and remote areas needed to travel away from home for birth.¹⁶ Before 2017, Indigenous pregnant people often travelled and birthed away from home alone without family or community support, because escorts were not deemed medically necessary. Although these initiatives have improved access to Indigenous perinatal programming and Indigenous birth attendant support in some local areas, over the past decade there has not been any substantial expansion of Indigenous birthing facilities outside of urban centres in Canada and at least 1 remote Indigenous birthing facility has closed.¹⁷Given this dynamic policy context, the national scope and Indigenous identifiers in the Canadian Maternity Experiences Survey (MES) provides a unique opportunity to quantify how often Indigenous and non-Indigenous people are travelling away from home for birth and to evaluate the association between Indigenous and non-Indigenous identity and distance travelled for birth in Canada.