2019 Salus Global Patient Safety Award Winner

Hospital: Cree Board of Health and Social Services of James Bay
City: Chisasibi , Quebec, Canada
Initiative: Culturally safe and dignified care respecting the Eeyou/Eenou ways of life during childbirth

Background and Overview

The Cree Board of Health and Social Services of James Bay has undertake the process to return birth back in Eeyou Istchee. It has been near 20 years that women have to go away from their families outside of their territory to have their children. In the process, the ceremonies and Eeyou/Eenou knowledge developed to sustain women’s and newborn health has been put aside. The return of births to the territory with midwives and the cultural re-appropriation of childbirth by the women and families of Eeyou Istchee are at the heart of this project. MoreOb has been a component identified to foster a healthy culture supportive of safe birth. Since its implementation in 2018, it has been a cornerstone to make the dream of women and families to have their babies on their land among health professionals supporting their choice and more equipped in case of emergencies.

The colonization process has historically entailed systemic racism towards Indigenous peoples. The testimonials and conclusions of the Truth and ReconciliationCommission of Canada (2015) attest the far-ranging impacts of cultural genocide. The loss of identity and the break-up of families and communities, as perpetuated by assimilation practices, have intergenerational impacts that impede the passing on of values, belief systems and cultural customs, including parental practices.  Families have been prevented from passing their cultural values and identity on from one generation to the next. This collective, intergenerational trauma has impaired Indigenous identity. The current climate of post-colonialism continues to significantly affect the health and well-being of Indigenous people. The Truth and Reconciliation Commission of Canada (2015) found that the after-effects of residential schools persist to this day and are reflected in health care disparities and systemic discrimination.

Being born on their own territory carries the hope to support the Eeyou/Eenou connection to their land and restore their pride in their identity. In addition, allowing children to be born amidst their loved ones will strengthen family bonds. Parents would then enjoy uninterrupted extended family support. Bringing childbirth back into the fold of the Cree Nation, with the elders assisting the process, will greatly help the healing and decolonization process.

“Many Survivors told the Commission that reconnecting with traditional Indigenous spiritual teachings and practices has been essential to their healing, with some going so far as to say ‘it saved my life.’ [. . .] Land, language, culture, and identity are inseparable from spirituality; all are necessary elements of a whole way of being, of living on the land as Indigenous peoples.” (Truth and Reconciliation Commission of Canada, 2015).

This project will help revitalize and transmit traditional knowledge accumulated since the beginning of life.

“Traditional Knowledge Keepers and Elders have long dealt with conflicts and harms using spiritual ceremonies and peacemaking practices, and by retelling oral history stories that reveal how their ancestors restored harmony to families and communities. These traditions and practices are the foundation of Indigenous law; they contain wisdom and practical guidance for moving towards reconciliation across this land.” (Truth and Reconciliation Commission of Canada, 2015).

At our first core team foundation meeting in November 2018, we have identified the following statement as our main goal:

As a care team, we are committed to providing culturally safe and dignified care, respecting the Cree way of life using a collaborative approach. We will support women, families, and our community during pregnancy and beyond, building confidence in normal births, empowered by informed choice.

Body of Submission

moreOB was part of the process of bringing birth back in a safe way. The Board of Directors of our organization voted unanimously to include Eeyou Istchee into the MoreOB provincial contract as supported by the Council of Physicians, Dentists and Pharmacist and the Head of Midwifery Services recommendation. We had set up our first core team on November 2018 after receiving support from all directors in charge of quality assurance. Guided by MoreOB provincial consultants, the Eeyou Istchee core team was supported to make cultural safety as an important element of safe and competent care. To revive the cultural practices around birthing and increase confidence, we have done workshops in Chisasibi hospital. Throughout the year, we had 4 workshops involving an Elder, nurses, doctors, midwives, community health representatives and new parents. The Elder were pivotal to explain the Eeyou/Eenou meaning of having a baby. They imparted how being born means welcoming a divine spirit into the world. It requires respect and to acknowledge woman at the center of the care. The women carry the future generations and the community has the responsibility to protect her from harm and not disturb the baby. They also transmitted the power of storytelling as a teaching tool. Through birth stories, they communicated the sacred aspect of being the first hands to touch a new life, being pregnant as part of life and learning through observation. By being the first one to speak during the workshops, the Elder were setting the tone on the birthing being a part of the emotional, physical, mental and spiritual journey ingrained in the Eenou/Eeyou Ways of life. It was an opportunity for the health care workers to dive in the Cree culture. It was also a moment to discuss how we can bring key elements within the work culture to revive Eenou/Eeyou Ways and keep its meaning alive. After the Elder, a midwife and a family physician were explaining the physiology of birth, how to support it, discussing birth as a meaningful event and celebration of life and the privilege we have to witness it. At two of these workshops, a family that had giving birth in Chisasibi volunteered as actors. It created an opportunity for the healthcare workers to ask questions about their birthing experience in a remote and rural region with midwives. After one of the workshop, a nurse commented that it gave her confidence to support birth as a life passage.

moreOB also created a space to assess the level of comfort in birth of nurses, midwives and physicians. The core team has developed a survey called «Comfort level in vaginal birth» that was distributed during the spring and summer 2019. The hospital nurse coordinator and the assistant head nurse undertook a strong leadership to ensure a high participation level. We had a 74% participation rate. It was an opportunity to assess the confidence and competence of healthcare workers and share seven recommendations on how to improve it. We have included a section on cultural safety in the survey, which revealed a marked interest to learn how to facilitate access to traditional practices. Our previous explained workshops took place after this survey in a way to increase competence and confidence in birthing in a culturally safe way.

Within our first year of moreOB implementation, we have initiated neonatal resuscitation program certification as a way to increase competence and confidence level at births. It is also to ensure that if midwives need support providing newborn resuscitation, they can call a trained professionals. This year, we have trained two instructors in Chisasibi (one family physician and one midwife) who delivered three NRP certification trainings to nurses, physicians and midwives.

In the process of bringing birth back in Eeyou Istchee, collaborative care has been a cornerstone. A perinatal collaborative group was created comprising of a family physician, nurses, community health representatives, midwives, community worker, social worker and Nishiiyuu representative. Nishiiyuu is the department within our organization leading the integration of Eeyou/Eenou culture into the services and cultural safety. As part of bringing birth back safely and the emphasis on multidisciplinary partnership by MoreOB, this group has been meeting once per two weeks to have case discussions including everyone’s perspective. The inclusion of the Nishiiyuu representative is to ensure Eeyou/Eenou culture are integrated in our recommendations.

A Nishiiyuu representative is also part of the core team. During a meeting, it has been mentioned that nurses and family physicians can be invited to observe a birth as a mean to increase confidence and trust in the birthing process. It was identified as a way to understand better the cultural importance of bringing birth back and putting into practice the Elders advice: observing as a learning tool. During two separate occasions, the midwives have invited a nurse and a physician after ensuring the women’s consent. We have implemented the debriefing culture. Bringing birth back has involved setting diverse communication systems. The debriefing has been one of the tool used to examine, to improve these systems and to open a dialogue on birth confidence. During one of the debriefing, a nurse commented that what she had witnessed was not only a woman giving birth, but a whole community welcoming a new life.

By implementing moreOB, it is supporting the implementation of a safe organizational birthing culture which integrates Eeyou/Eenou culture. It has been a vessel supportive of the Eenou/Eeyou self-determination and healing, contributing to bring the children home from the beginning of life.

Summary

The Cree Board of Health and Social Services of James Bay has undertake the process to return birth back in Eeyou Istchee. The return of births to the territory with midwives and the cultural re-appropriation of childbirth by the women and families of Eeyou Istchee are at the heart of this project. moreOb has been a component identified to foster a healthy culture supportive of safe birth. moreOB created a space for the core team to develop a survey assessing the level of comfort in birth of nurses, midwives and physicians which we had a 74% participation rate including a section on cultural safety identifying the need to learn more about the traditional practices. To revive the cultural practices around birthing and increase confidence, we have done workshops in Chisasibi Hospital. Throughout the year, we had 4 workshops on normal birth involving an Elder, nurses, doctors, midwives, community health representatives and new parents. The Elder were pivotal to explain the Eeyou/Eenou meaning of having a baby. We had three training sessions for neonatal resuscitation program certification from our two newly certified instructor as part of bringing birth back in a safe way. In the process of bringing birth back in Eeyou Istchee, collaborative care has been a cornerstone. A perinatal collaborative group was created for case discussions comprising of a family physician, nurses, community health representatives, midwives, community worker, social worker and Nishiiyuu representative. Nishiiyuu is the department within our organization leading the integration of Eeyou/Eenou culture into the services and cultural safety. During our moreOB core team, it has been mentioned that nurses and family physicians can be invited to observe a birth as a mean to increase confidence and trust in the birthing process and put into practice the Elders advice: observing as a learning tool. With the implementation of the debriefing culture, a nurse commented, after a birth, that what she had witnessed was not only a woman giving birth, but a whole community welcoming a new life. By implementing MoreOB, it is supporting the implementation of a safe organizational birthing culture which integrates Eeyou/Eenou culture. It has been a vessel supportive of the Eenou/Eeyou self-determination and healing, contributing to bring the children home from the beginning of life.

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More than OB

We can apply a similar approach to communication and teamwork that we bring to OB to adjacent maternal/infant care departments and even other hospital units such as emergency, ICU, cardiology, and other risk management areas.