Documentation of Traditional Inuit Practices Related to Pregnancy and Childbirth

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OBSTETRICS

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DOCUMENTATION OF TRADITIONAL INUIT PRACTICES RELATED TO PREGNANCY AND CHILDBIRTH Linda Archibald, Phillip Bird, Claudia Brann, Martha Greig, Eeta Kanayuk, Patricia Kaufert, John O'Neil, Sally Webster The authors are listed alphabetically in order to reflect the highly collaborative and non-hierarchical relationship among the research team. As a matter of research ethics, the Pauktuutit Inuit Women's Association is committed to integrating traditional Inuit knowledge and life experiences into the research process. Consequently, the omission of academic credentials is intentional.

ABSTRACT

Between Ocwber 1992 and]anuary 1993, Pauktuutit (Inuit Women's Association of Canada) conducted interviews with seventy-seven Inuit elders as part of a research project on traditional Inuit practices related w pregnancy and childbirth. Except for a few interviews in the Western Arctic region, all of the elders spoke in their own dialect of Inuktitut. The interviews wok the form of oral narratives and were recorded on audio tape. For two years, Inuit translators worked w produce English transcripts of the interViews. To assist in the qualitative analysis of such a large database, a computer programme was employed. The interviews contain data on Inuit mUiwifery, traditional birthing techniques, and health promotion practices as well as ethnographic, historical, and linguistic material and life histories. RESUME

Entre ocwbre 1992 etjanvier 1993, Pauktuutit (association des femmes inuit du Canada) a interviewe soixante-dix-sept Inuit runes dans Ie cadre d'un projet de recherche sur les pradques traditionneUes inuit uees it la grossesse et it {'accouchement. A {' exception de quelques entrevues dans la region de {'Arctique de l'Ouest, wus les runes se sont exprimes dans leur propre dialecte inuktitut. Les entrevues avaient lieu sous forme de recits oraux qui ont ete enregistres sur bande audio. Pendant deux annees, des traducteurs inuit ont transcrit les entrevues en anglais. Pour favoriser l' analyse qualitative d' une base de donnees aussi vaste, on a utilise un programme d' ordinateur. Les entrevues

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KEY WORDS Inuit, pregnancy, childbirth, midwifery.

BACKGROUND

series of interviews, a letter supporting this choice stated: "It is very evident that your approach to gathering this information was proper and it also reinforces my belief that research of Inuit should be conducted by Inuit."3 Pauktuutit, as a trusted Inuit organization, contributed further to community acceptance.

Throughout Northern Canada, Inuit women are evacuated routinely from their communities to give birth in hospitals hundreds of kilometres from home. Their elders are among the last generation of Inuit to have experienced giving birth on the land. Inuit women are concerned about the loss of traditional midwifery, the insensitivity of the medical system to traditional childbearing, and the very disruptive effects of evacuation on family and community life.! In 1992, the Pauktuutit Inuit Women's Association initiated the first systematic study to document fully traditional Inuit knowledge of pregnancy and childbirth. Elders in ten communities recounted their experiences of giving birth on the land, and of assisting others. The project exemplifies true participatory research; it was designed and implemented by the population being studied. This paper offers an overview of the rich body of data gathered.

THE INTERVIEW PROCESS

The seventy-seven elders who were interviewed were identified in a variety of ways. After the project was announced in the northern media, word of the researcher's upcoming visit was circulated in the ten participating communities (Figure O. After the mayors endorsed the project, a contact person gathered the names of potential participants. On arrival, the interviewer spoke on the local radio, answered questions, and informed people on where she could be contacted. All of these activities took place in Inuktitut, and everyone who came forward was interviewed. Table 1 provides a summary of the translated interviews. The interviews proceeded as long conversations. The interview schedule allowed each elder to tell her childbirth stories and to pass on knowledge that she felt was most important. The interviews were audio-taped and lasted between one and three hours. Participants signed consent forms allowing Pauktuutit to publish the material.

METHODOLOGY PARTICIPATORY RESEARCH

Participatory research emphasizes community participation in the research process. "The researched ... become themselves the researchers."2 Through Pauktuutit, Inuit women identified the need for research, designed the study, gathered and analyzed the data, and identified the resources to be created. Adopting a participatory methodology enhanced the quality of the data generated. Early in the research design, we decided that the interviewer had to speak Inuktitut, thus, interviews proceeded without the interruption of lengthy translations. The interviewer was a respected Inuk woman with extensive experience in health care. Following the first

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TRANSLATION OF THE INTERVIEWS

The translation process proved long and arduous, given the volume of material and the need to match translators to each elder's community or region. There are distinct regional dialects as well as distinctions within regions, and elders were recorded in their own dialects. The decision to use English for analysis stemmed from the volume of material and the need to use computers to process the data. Nonetheless, Pauktuutit recognizes the need to preserve the regional dialects. The language of

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, , , TABLE 1 SUMMARY OF INTERVIEWS ON PREGNANCY AND CHILDBIRTH PRACTICES* Total # People

Total # Births

Average # Births**

4 6

22 60

5.5 10.0

Kitikmeot Coppermine Taloyoak

N/A 8

N/ A 77

N/A 9.6

Keewatin Baker Lake Whale Cove

14 4

133 44

9.5 11 .0

Baffin Hall Beach Pond Inlet

7 8

65 60

9.3 8.6

Quebec Kangigsualujjuaq

2

16

8.0

Labrador Nain

9

45

5.6

68.0

62

522

8.7

63.8

Region/ Community

Western Arctic Sachs Harbour Aklavik

Regional Total # Births

Regional Average # Births**

82

8.2

9.6

60.7

8.9

68.4

8.0

66.0

5.6

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18.5 18.5

68.0

LOCATION OF PARTICIPATING COMMUNITIES

Baker Lake •

16.0 16.0 16.0

66.0 45

17.8 17.8 18.0

61 .2 73.6 16

20.7 N/A 20.7

61 .3 58.8 125

19.0

63 .5

9.8

Regional Avg. Age 1st Birth***

18.8 19.3

N/A 63.4 177

Average Age of 1st Birth ***

61.7

Out of the total of 77 interviews, only 62 have been translated to date. * ** Calculated values are based on female respondents only. *** Calculations are based only on those interviews where an age was provided.

FIGUREl

Regional Average Age***

57 .3 64.7 77

Totals

Average Age***

15.7 15.7 17.4

, , , the elders is more complex and specialized than is commonly spoken today, especially with respect to terms traditionally used to discuss women's bodies and experiences. If funds can be obtained, the tapes are to be placed in the archives to preserve the traditional terms, dialects, and rich ethnographic material which they contain.

is a wealth of data about births on the land. Shelters range from igloos, tents, and temporary houses, to hybrid shelters that are halfhouse half tent, or igloos with tents for roofs. Mabel Kootoo of T aloyoak noted: "The tradition in those days was to build a new igloo just prior to giving birth." There are accounts of births in the open, in boats, and on moving sleds. Generally, traditional births were in a kneeling or squatting position, with the use of caribou skins for blankets and mats. Umbilical cords were cut with scissors, and occasionally pieces of broken glass, quartz stone, or ulus, (the ulu is the traditional woman's knife) and were tied with caribou sinew. One elder noted, "Before the scissors were born, that was when I was born and we used ulus."

MAJOR FINDINGS OVERVIEW

This study has captured the knowledge of a population which grew up on the land and moved, in adulthood, into permanent settlements. Many of the women gave birth under a variety of circumstances. Early births took place on the land while many later births occurred in hospitals. In the intervening years, women gave birth in their homes assisted by midwives, or at community nursing stations assisted by Inuit midwives and nurses (see Table 2). The interviews provide information on where births took place (location and shelters), who assisted, the season, the birthing position, the props or tools used, and other details about labour. Information also was sought on growing up female, problem births, the training of midwives, and on traditional health promotion. There

TABLE 2

TRADITIONAL INUIT MIDWIFERY

Midwives were expected to have knowledge of women's bodies including "what's inside;" to know how to cut and tie the umbilical cord; to have the ability to instruct the woman in labour to make her mentally and physically comfortable; to know which positions promoted quick deliveries; and to have the ability to deal with complications. The interviews suggest midwifery was not viewed as a "profession" in the sense that knowledge and expertise resided only in individuals with specialized training. Rather, the knowledge was

BAKER LAKE: BIRTH ATTENDANTS AS A MEASURE OF CHANGES TO CHILDBIRTH PATTERNS OVER TIME*

Attendant/ Assistant

Birth #1

Birth #2

1. Midwife Total

85.7% 12

78.6% 11

Birth #3 76.9% 10

Birth #4

Birth #5

Birth #6

Birth #7

61 .5% 8

54.5% 6

27 .3% 3

27.3% 3

9.1% 1

9.1% 1

2. Husband Only Tota l 3. Alone Tota l

7.1% 1

7.1% 1

4. Medical Attendants** Total

7.1% 1

14.2% 2

23.0% 3

Birth #9

Birth #10

Birth #11

Birth #12+

20.0% 2

7.7% 1

9.1% 1

9.1% 1

9.1% 1

20.0% 2

30.8% 4

36.4% 4

54.5% 6

54.5 6

40.0% 100.0% 100.0% 100.0% 4 8 8 3

5. Midwife & Medical** Total Total

Birth #8

100.0% 2

20.0% 2 99.9% 14

99.9% 14

99.9% 13

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 13 11 11 11 10 8 8 3

100.0% 2

BAKER LAKE: Percentage of Described Births Attended by Non-Medical People. Non-Medical Attendants Midwife, Husband or Alone (1+2+3)

Birth #1

Birth #2

Birth #3

Birth #4

Birth #5

Birth #6

Birth #7

92 .8%

85.7%

76.9%

69.2%

63.6%

45.5%

45.5%

Birth #8 40.0%

Birth #9 0.0%

* Calculations are based only upon described births that included information on those who assisted.

** The category of Medical Attendants includes doctors and nurses .

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Birth #10

Birth #11

Birth #12+

0 .0%

0.0%

0.0%

, , , "My daughter had a difficult labour ... her child moved up rather than down. I had to try and move the child around to induce labour. I tied her around the waist to stop the child from moving upwards. I had watched my husband assist the delivery of one of his dogs where the puppies were moving upwards. He had tied it (the bitch) with a rope around the middle. I used the same technique on my daughter. The breech position was adjusted and she delivered normally after." Lena Kingmiaqtua of T aloyoak described how a new mother was told to put her hands against her abdomen and push out the afterbirth. "They knew in those days that if the placenta was to stay inside the woman it can rot and even kill the woman." To expel her afterbirth, Madeline Ivalu from Hall Beach said "I was told to stick my hand in my mouth to vomit; as soon as I did that, the afterbirth expelled." Clara Etok from Kangigsualujjuaq described a plant called Aittigtuyaijut used for loss of blood. The leaves were boiled and the juice consumed. She stated " ... you can even see your vein line after drinking that juice."

shared among all those who had need of it. While women were usually assisted by family members, especially mothers and mothers-in-law, there were enough births in the larger camps for the expertise of particular midwives to gain recognition. Anyone, however, who was available might be required to assist at a birth, and there are even accounts of women giving birth entirely on their own. Where more than one midwife was present, there appeared to be no hierarchical relationship. Often the first person to arrive took control, with others helping out as required. The exception seems to have been with elder midwives; then the tradition of deferring to one's elders took over. TRADITIONAL MIDWIFERY TECHNIQUES

While the practice of midwifery tended to be informal, a high level of skill and knowledge was required. The interviews offer detailed accounts of how to massage a fetus into position for birth, how to tum a breech baby, and what to do if the placenta is retained, or if there is post-partum bleeding. The following paragraphs illustrate the nature of this knowledge. Before massaging, Clara Fox from N ain determined the position of the fetus by noting the "kicks being felt." Miriam Fox, also from Nain, stated that the massage was to be gentle and slow, and was to be applied, when labour pains eased, to the side where the baby protruded by raising and pushing upwards. She stresssed that the baby was prone to return to its previous position after a massage and that the midwife had to watch for this constantly. Nancy Pamak of Nain noted that, if necessary, a midwife could reposition a breech baby during the delivery: "If only the arm, belly, or some other unusual part of the body was coming out, it could be moved and better positioned by a midwife who had the smallest hands .... " Penina Assevak of Kangigsualjjuag described a delivery where the "... baby's leg came out first and I had to tell the mother that I was sorry and that I was going to have to push the baby back in. So she agreed and then it came out in the right position .... " Therese Ijjangiaq of Hall Beach noted that "... in those days if the midwife was going to have to reach inside she had to cut her nails and clean them." When describing a difficult birth, Apphia Awa from Pond Inlet offered insight into her source of practical knowledge:

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EDUCATION OF A MIDWIFE

Young women learned about childbirth by listening to stories, receiving verbal instruction, and by watching births. This was part of preparing for womanhood. It laid the foundation for knowledge to be gained as personal experience grew. Simonie Kanayok of Pond Inlet noted " ... Inuit have no education in delivery; they do learn a lot more from experience and helping, actually helping women... Mind you, it took me a long time to be good." Similarly, Annie Saltuk of Taloyoak stated " ... I didn't get officially educated on it, but it was from watching and experiencing birth myself... My father was also a midwife .... " As a young man, Isapik Kanguk was carefully instructed by an elder woman in order to assist his future wife. He recalled: "She used to instruct me by using examples. Such as when you skin a rabbit or other animals like a fox .... Slowly taking the skin off the flesh. And it could happen that way when a woman is in labour and you're trying to take the placenta out." CHILDBIRTH AND THE FAMILY

The interviews reveal how important traditional childbearing practices were to the social fabric of Inuit

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, , , society. The data include information on the traditional roles of husbands, families, and extended family members. Apphia Awa stated that her husband used to get everything ready and be at hand when she was due, making a point of not hunting too far away. She recalled one occasion when he: "... cut a hole in the wooden bed and placed a caribou skin over it for me to release the baby. He also had me lean against the wall for support. Once my labour was over, he repaired the bed ... We were happy with the delivery and the birth." Rebecca Arnagnajuaq from Hall Beach recalled that her husband made sure that she ate well and hunted for her "cravings." Family members often prepared special broths for the new mother. The newborn was formally welcomed with words spoken by the midwife, and occasionally, with a gift. The bond between the two would last for a lifetime. No one in Inuit society was sheltered from birthing knowledge. Children and young adults gained experience from watching, and men often assisted their wives. The entire family was involved more actively in the events surrounding pregnancy and birth than is the case today.

to eat plants or seaweed during the latter stages of pregnancy. Some were advised not to eat too many berries, because berries picked in a following spring will have fermented, and never to eat aged food. A few interviews suggest prohibitions may have been more common in the past. Winnie Putumegatuk of Baker Lake said: "I was born when people had started attending church services and my father. .. told me ... I do not have to refrain from eating certain foods anymore because I was now a Christian." Elders complained that young women today eat poorly and fail to keep active enough to ensure healthy pregnancies. One said that she found southern food distasteful while pregnant. When available, a traditional diet can provide a valuable source of protein and nutrients, yet many women today only have access to storebought foods. Some of the advice given to pregnant women is related to beliefs about how behaviour could affect the length of labour or the health of the baby. Dragging ones kamik (winter boots) laces could lead to the umbilical cord wrapping around the baby's neck, lingering in doorways could lead to a long labour, and exiting a dwelling backwards could lead to a breech birth. The proper placement of clothing at night and the sleeping position of the pregnant woman also could affect the position of the baby at birth. Making fun of someone could cause the newborn to look like the person who was mocked. Overall, the advice pregnant women received about physical activities and the directives related to behaviour indicate a concern for their health and that of the unborn child. This concern was expressed in reminders to eat regularly and nutritiously as well as in direct action-hunting for, or preparing special foods. The responsibility for the health of pregnant women in Inuit society clearly rested with both the woman and her husband, parents, in-laws, and elders. While young women were frequently overwhelmed with advice, they were surrounded by a caring family from the first sign of pregnancy until after birth.

TRADITIONAL HEALTH PROMOTION

Traditionally, pregnant women throughout the north were advised to rise early each morning and go immediately outside to "smell the fresh air." Keeping active was essential for promoting quick labours and for ensuring that the placenta would not "stick in the womb." They were warned, however, not to over-exert themselves, fall, or walk in deep snow. Young women were given basic information about what to expect during their pregnancies and how to recognize the first signs of labour. One woman recalled her mother's instructions to practise the squatting position so she would be comfortable during her first labour. Women ate a variety of healthy foods, especially caribou, char, muktuk (whale blubber), and seal. Cold and frozen food helped to alleviate heartburn. To promote milk production, nursing mothers were fed caribou broth, often made with blood, and sometimes fish soup. One woman stated that in Labrador hunting camps, seal blood was given as a drink immediately after the birth. There appeared to be few prohibitions against eating specific foods, although one woman was instructed not

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CHANGES TO THE INUIT EXPERIENCE OF CHILDBIRTH

When asked about the changes that have taken place in the way that Inuit women give birth, many stated that they would prefer to labour at home or in the community if there were no complications. They desired the best of both worlds: problem births were recognized as

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, , , "Right after the birth as we were cleaning up someone came to tell us why we have not informed anybody and they said if we ever practised midwifery again inside a private home we could be charged. After that incident Iga Harris never practised her midwifery skills again when every pregnant woman was told to go to hospital." Younger women are no longer being exposed to childbirth in the natural course of Inuit life. In light of the evidence that midwives learned much of their craft by watching and doing, this has implications for the future oftraditional Inuit midwifery. Fortunately, there are exceptions including the birthing centre in Povungnituk, Quebec where Inuit midwives receive formal training. Other women, including Annie Napoyak of Whale Cove, spoke of their continued involvement in midwifery: " ... I actually assisted in three births .... When ... I became more vocal about my interest ... people recognized this interest and began asking me to be [their] midwife .... And ... nurses began asking me more about the traditional way of birthing or on midwifery. This was a positive thing and I was happy about their interest."

needing special attention and intervention, while normal births were viewed as requiring little medical interference. Pregnant women should not have to endure the separation, homesickness, and alienation associated with hospital births unless absolutely necessary. Births in hospitals were viewed as uncomfortable and the labours as taking too long. This discomfort was due, in part, to giving birth lying down rather than in a traditional position. Two women from the Baffin region stated that such births felt like the baby pushed unnaturally upward and, thus, prolonged labour. Three women described the trauma of being tied up while giving birth. Others noted the language barrier as an alienating factor. Interestingly, women across the Arctic felt that children born in hospitals were different. At its simplest, the change to hospital births is viewed as a marker in time that locates the shift away from life on the land. One woman suggested that today's children have a different lifestyle, another noted that it takes longer to toilet train when diapers are used instead of skins. Hospital newborns were viewed as bigger and weighing more, while one woman suggested that there were more birth defects with hospital births. Another woman worried about the relationship between newborn babies travelling by air and the high incidence of ear infections among young children. There is a clear sense of loss at the displacement of Inuit midwives by health professionals and the resulting loss of childbirth as a family-centred event. The most positive attitude towards doctors was found in Nain, Labrador; however, all Inuit women recognize the contribution of doctors and nurses to their communities. Consistently, it was stated that childbirth is not an illness. Hospital admission is viewed as an over-reaction to a natural process like childbirth.

CONCLUSIONS

The timeliness of this study cannot be overstated. The knowledge that Inuit elders have of midwifery and traditional health care is threatened with extinction. In fact, some of the old ways already have been lost. In her interview, elder Elizabeth Ootoova of Pond Inlet stated: "By the time I was able to have children we weren't living the way our ancestors had so we weren't really informed about traditional ways of pregnancy-what to do and what not to do. Also that my mother and grandmother had been christened and baptized that we didn't believe in the traditional ways anymore because they were considered unChristian." In light of the small number of midwives practising today, questions arise about how the surviving knowledge will be passed on to future generations. In addition to the need for written resource materials, we must find ways of transmitting knowledge that complements educational practices within an oral culture. This study gathered an abundance of information that can contribute to culturally appropriate educational resources and strategies. Working within cultural norms and practices may substantially increase levels of personal and community responsibility for health and well-being, and, thus,

DISPLACEMENT OF INUIT MIDWIVES

Most of the elders interviewed are no longer practising midwifery. When asked, many stated that, though willing, they were no longer invited to assist. Changing circumstances-the move to established communities where nurses were in residence, and the increasing number of evacuations to hospitals---created fewer opportunities for midwives to practise. The "fear of reprimand by the nurses" led some to retire. In one case, a midwife was threatened with legal charges:

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, , , reverse the growing dependency on external health professionals and technologies. A workable obstetric practice did exist in the north prior to the introduction of Western medicine, and recognition of this by health practitioners may lead to a greater respect for the preferences of individual women. Inuit women advocate the return of childbirth to their community, particularly within a system that can combine the best of Inuit and Western knowledge. The current evacuation policy has fostered alienation of the expectant mothers and has denied them the support of their families during an important emotional stage in family life. Returning birth to the community may result in stronger family and community ties, and a reduction in family-related social problems including violence and abuse. ACKNOWLEDGEMENTS

Pauktuutit gratefully acknowledges the contribution of the following translators: Simona Arnatsiaq-Barnes, Ruby Arngna'naaq, Deborah Evaluarjuk, Sadie Hill, Sally Ikuutaq, Rhoda Kayakjuak, Sam Metcalfe, Mary Nashook, Leah Idlout Paulson, Muati Qitsualik. Funding for this study was provided by the National Health Research and Development Program "Community Initiatives North of 60." File # 6606--4710-T. REFERENCES 1.

2. 3.

See for example Kaufert, O'Neil et al. Final Report to NHRDP. A Study of the Impact of Obstetric Policy on Inuit Women and Families in the Keewatin Region, NWT, September 1990. "Participatory Research" in IDRC Working Paper, Ottawa, September 1988, p.9. Knute Hansen of the Aklavik Community Corporation.

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