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Understanding Mi'kmaq Women's Experiences Accessing Prenatal Care in Rural Nova Scotia

Burns, Laura, BScN, RN; Whitty-Rogers, Joanne, PhD, RN; MacDonald, Cathy, PhD, RN

doi: 10.1097/ANS.0000000000000248
Section: Culture, Race & Discrimination

Indigenous women experience a higher incidence of maternal complications compared with non-Indigenous women. Despite this, little is known about access to prenatal care for Mi'kmaq women in Nova Scotia. The intent of this study was to gain a more comprehensive understanding of Mi'kmaq women's experiences accessing prenatal care. The findings from this study highlight key implications for nursing practice such as promoting the nurse's role in supporting and advocating for Mi'kmaq women's health and for providing culturally safe care. This research will highlight that access to prenatal care is a complex issue for some women.

St. Francis Xavier University, Antigonish, Nova Scotia, Canada.

Correspondence: Laura Burns, BScN, RN, 25 Bay Street, Antigonish, Nova Scotia, B2G 2G4 (

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

MATERNAL HEALTH is a global priority according to the United Nations millennium development goals. After years of research and education, only one half of pregnant women in the world receive the recommended amount of prenatal care.1 The World Health Organization's (WHO's) prenatal care model recommends 8 contacts between a pregnant woman and her health providers throughout pregnancy. The WHO recommends that pregnant women have their initial contact in the first 12 weeks' gestation, with subsequent contacts every 2 to 4 weeks until delivery. This model increases maternal and fetal assessments to detect problems and increases the likelihood of positive pregnancy outcomes.2

Pregnancy is a major life experience for all women, including Indigenous women, families, and communities.3 The research suggests that Indigenous women are impacted by the adverse effects of historic, social, economic, and political marginalization of Indigenous communities in receiving adequate, culturally safe prenatal care.4,5 Yet, there has been a paucity of research conducted to address appropriate access to prenatal care for Indigenous women.

The major goals of prenatal care include defining the health status of the mother and the fetus, determining the gestational age of the fetus and monitoring fetal development, identifying women at risk for complications, and providing appropriate education.6 The overarching aim of the WHO prenatal care model is to provide pregnant women with respectful, individualized, person-centered care at every contact, with implementation of effective clinical practices, and provis-ion of relevant and timely information, and psychosocial and emotional support, by practitioners with good clinical and interpersonal skills within a well-functioning health system.7 Although most pregnancies and births are considered low-risk, there are pregnancies categorized as high-risk due to maternal or fetal complications. Identification of the risks, together with appropriate and timely intervention during the perinatal period, can prevent morbidity and mortality among mothers and infants.6

The purpose of this qualitative study was to generate knowledge about Mi'kmaq women's prenatal care experiences. The study provided a more comprehensive understanding of what is important to Mi'kmaq women when accessing prenatal care. The following research question was addressed: What are the experiences of Mi'kmaq women accessing prenatal care in rural Nova Scotia? Although the First Nations women in this study have access to prenatal classes at the Health Centre in their community, they are referred to a clinic in the regional hospital located 25 minutes from the community for their prenatal care and follow-up appointments. Prenatal care services are not typically offered at the Health Centre due to the limited availability of these health services. This often results in Mi'kmaq women receiving prenatal care from non–Indigenous health care providers, who may have minimal knowledge of their culture and may not be knowledgeable on how to care for Mi'kmaq women in a culturally safe manner.8

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Statements of Significance

What is known or assumed to be true about this topic:

The number of pregnant Indigenous women who have limited access to prenatal care is substantial, which contributes to the increasing incidence of high-risk pregnancies. Despite the importance of prenatal care, there are significant gaps in specific health data regarding the maternal health status and maternity experiences of Indigenous women. It is known that the availability and quality of prenatal care varies considerably with geographic region. In remote and rural areas, where many Indigenous communities are located, there is a documented lack of access to health services because of the population density being too low to support wide ranging health services, lack of transportation infrastructure, and difficulties in communicating health issues and needs as a result of language and cultural barriers. Indigenous women often experience limited opportunities for specialized care due to the distance they must travel, and consequently have higher incidences of maternal complications.

What this article adds:

The purpose of this qualitative study was to generate knowledge about Mi'kmaq women's prenatal care experiences. The study provided a better understanding of what is important to Mi'kmaq women when accessing prenatal care. The following research question was addressed: What are the experiences of Mi'kmaq women accessing prenatal care in rural Nova Scotia? The findings of this study provided information to better understand the needs of Indigenous people. The findings may help inform health care professionals of culturally safe policies and programs to provide care for Mi'kmaq women during pregnancy.

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An extensive amount of literature exists pertaining to Indigenous health inequities and disparities, including maternal health. Maternal health is defined as “the range of health care needs and services required by women during their childbearing years, including sexual and reproductive health, prenatal, labour and delivery care, post-partum and healthy parenting.”9(p16) Although there is a significant amount of research highlighting the importance of prenatal care, there is a gap in the literature regarding access to prenatal care for Mi'kmaq women in Nova Scotia.

There are extensive epidemiological data related to Indigenous population birth rate, fertility rate, infant mortality rate, substance abuse, and chronic illness during pregnancy available.5,10 These epidemiological data tend to stigmatize and construct Indigenous women negatively as reckless, unsafe risk-takers.11 Within the health care context, assumptions about Indigenous patients as dependent on pain medications, or as struggling with addictions, or as irresponsible in relation to their families or children negatively impact the health outcomes of Indigenous peoples.11

It is necessary to understand the historical, political, and cultural contexts in addressing prenatal care for Indigenous women.5 The contemporary outcome of the colonial process can be seen in political, social, and economic domains, which have shaped the health and well-being of individuals, families, communities, and nations.12 The social determinants of health, including Indigenous status, gender, and social exclusion, were also explored as a means of understanding the context in which the women and their families live.12

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Indigenous peoples of Canada

Indigenous peoples” is a collective name for the original peoples of North America and their descendants. The Canadian constitution recognizes 3 groups of Indigenous peoples: First Nations, Métis, and Inuit.13 The term “Micmac” has been in existence for approximately 350 years. The Micmac people were known as the “Souriquois, ‘the salt water men',” according to French settlers. The Mi'kmaq people have occupied the northeastern part of North America for approximately 5000 to 10 000 years.14 Prior to the Europeans settling in North America, the Mi'kmaq had a culture that was rooted in 3 principles: the supremacy of the Great Spirit, respect for Mother Earth, and people power.14

Indigenous peoples represent a sizeable, youthful, and growing population group.5 The majority of the First Nations people in Nova Scotia are from the Mi'kmaq nation, with the median age being 25.4, compared with 41.6 for the total population.15 In 2011, the fertility rate of Indigenous women was 2.2 children per woman, compared with 1.6 children per woman for the non-Indigenous population.15 Indigenous women are more likely than non-Indigenous women to have been diagnosed with at least 1 chronic condition. In 2012, 65% of Aboriginal women aged 15 years reported that they had been diagnosed with at least 1 chronic condition.15

These statistics indicate a need for health interventions to promote the health of Indigenous women, especially of childbearing age. Building a trusting relationship between health care providers and Indigenous women, honoring Indigenous practices, providing better access to health care services, and emphasizing the importance of education are some of the major areas needing attention.9

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Historical context

To gain an understanding of the health inequities Indigenous peoples confront when accessing and navigating through the mainstream health care system, an analysis of the historical implications affecting their way of life is necessary. The concept of historical trauma serves as a way to think about intergenerational effects, and there is growing evidence to support that trauma exposure may accelerate cellular aging and lead to premature morbidity and neurocognitive decline.16 The traumatic events endured by Indigenous communities negatively impact individual lives in ways that result in future challenges for their descendants. Historical trauma explains continuing inequities in health and a focus for social, cultural, and psychological interventions.17

The initial impact of European contact on the Indigenous populations of Canada was a massive loss of life through infectious diseases and violent encounters. Born out of the colonial relationship between the Canadian state and Indigenous people, the residential school system was one of the most destructive and longstanding methods designed by the federal government in its attempts to forcibly assimilate Indigenous people.17,18 Many children, including those who attended the Shubenacadie residential school in Nova Scotia, were physically, emotionally, and sexually abused.18 Children who were abused and shamed for their Indigenous identity and culture in residential schools often became parents who had difficulty forming healthy relationships with their partners and children, which frequently resulted in poverty, mental health issues, addictions, and domestic violence.9 Many Indigenous people may not access required health care services due to the historical trauma that they and their ancestors experienced as a result of colonization and residential schools. This contributes to the gap in health care status between Indigenous and non-Indigenous peoples.19

The residential school system was hidden in most of Canada's history, until survivors of the system were able to find the strength, courage, and support to bring their experiences to light in several thousand court cases that ultimately led to the largest class-action lawsuit in Canada's history.20 Numerous documents provided by the Truth and Reconciliation Commission have shed light on the truth of residential schools. ‘The Survivors Speak' report is an example of such documents, which includes the testimonies of hundreds of survivors. In this report, survivors tell personal stories related to the loss of traditional language and culture, estrangement from parents, and emotional neglect that many children experienced during their time in residential schools.20 Alan Knockwood, a Mi'kmaq Elder in Nova Scotia, reflected on how lonely and isolated he felt during his time at the Shubenacadie residential school in the report.20 Ultimately, the Commission's focus on truth determination was intended to lay the foundation for reconciliation. Reconciliation requires that a new vision, based on a commitment to mutual respect, be developed.20 The ultimate objective must be to transform our country and restore mutual respect between peoples and nations.20

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Political context

Although comprehensiveness, universality, portability, public administration, and accessibility are the 5 principles of the Canada Health Act,21 rural and isolated First Nations communities continue to struggle to obtain adequate health services.22 There are 13 Mi'kmaq communities in Nova Scotia, and 64% of Mi'kmaq people live on reserve.15 Access is widely regarded as an important social determinant of health.9 There are multiple government and nongovernment organizations responsible for providing maternal health care for on-reserve populations. Many Mi'kmaq communities do not receive the resources or funding to provide prenatal support and education to Mi'kmaq women. A lack of a unified communication system linking these organizations creates a gap in the delivery of services and compromises the prenatal care for Indigenous Canadians.23

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Cultural context

To achieve effective interactions with clients, health care providers must move towards cultural safety to promote ethical and appropriate care.24 Culturally safe care involves building trust with Indigenous clients and ensuring that the client is a partner in decision-making.9 Cultural safety makes a significant difference to health, and Indigenous people are more likely to use health care services when they trust their health care providers.9

The mainstream health care system and non-Indigenous health care providers must develop approaches that are non-judgmental and incorporate traditional Indigenous knowledge and practices. Some women experience discouraging encounters with health care providers. These experiences may deter women from utilizing the mainstream health care system, which may result in adverse maternal outcomes.25 These approaches must be established in ways that consider the individual and collective experiences of Indigenous women to have a trusting and respectful relationship.

Cultural competence as a process described by Campinha-Bacote26 in which one moves through the stages of (a) cultural awareness, which involves a deeper understanding of self and others; (b) cultural knowledge, which addresses health beliefs and cultural values; (c) cultural skill, which is the ability to collect data relevant to clients' concerns; (d) cultural encounter, which is the process of engaging in cross-cultural interactions; and (e) cultural desire, which is the motivation to engage in the process of working with diverse populations.26 The outcome of cultural competence is said to be a set of congruent behaviors, attitudes, and policies that come together in a system or agency or among professionals to enable them to work effectively in a cross-cultural situation.26 Culturally competent care, including an understanding of cultural, emotional, historical, and spiritual aspects of Indigenous peoples' experience and beliefs about health and health care, is important to the provision of quality care.27

Cultural safety fosters the self-discovery of attitudes and biases by tracing them to their origins in health care practice.24 Nurses' responsibility for cultural safety must include addressing the disparities in health care, more specifically, improving health care access for all nations.24 Cultural safety requires health care providers to critique the issues of institutional racism and discrimination in the health care system.24 In order to provide culturally safe care, health care providers can promote partnership with pregnant Indigenous women to help them actively participate in decision-making processes and have control over improving their own health.4

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Indigenous status and gender as social determinants of health

Individuals, communities, and nations that experience inequalities in the social determinants of health not only carry an additional burden of health problems, but they are often restricted from access to resources that might improve problems.12 Indigenous status is one of these social determinants of health, as Indigenous people continue to face discriminatory practices while attempting to obtain care, compromising their ability to achieve good health.27

Indigenous mothers encounter significant perinatal and infant health challenges including teen pregnancy and excess infant mortality from preventable causes including injuries and infections.27 A major goal of prenatal care is to identify those women who are at risk for complications and minimize the risk and potential harms whenever possible by providing appropriate health care.6 Indigenous women often feel vulnerable accessing care due to the imposition of the presumed superiority of Western models of mothering, and fear being labelled as “bad mothers.”25 Health care professionals must provide care in a way that acknowledges the personal agency of women by working alongside them to support them. This includes mutual investment of both the service provider and women to build a positive, therapeutic relationship to help women feel safe returning for care.25

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Social exclusion as a social determinant of health

Social exclusion physically and socially isolates racialized groups from equally participating in and benefiting from educational, economic, political, and health systems.12 Education, income, economy, and health care accessibility are driven by social policies, making the inequitable distribution of these determinants a social justice issue for Indigenous peoples.12 Without equitable distribution of resources and determinants of health, Indigenous peoples are not able to realize the same possibilities for health compared with non-Indigenous peoples.12 Much of the Canadian health care system and health research fails to appreciate the dimension of social exclusion on women's health outcomes. There is a need for tailored Indigenous community–led maternity services and programs located where Indigenous women live to combat issues such as social exclusion.4 An example of a health promotion program offered in Nova Scotia to support Mi'kmaq women during pregnancy is the Grassroots Grandmothers Circle. The Mi'Kmaki Nugumijk are L'nu grassroots grandmothers. Based on Sacred Teachings, grandmothers provide guidance and advice for parents, advocate for communities, strengthen traditions, empower families, and instill pride.9 Programs that develop Indigenous community investment and thus achieve a sense of community program ownership and subsequent sustained program participation are often successful in positively impacting a diverse range of prenatal outcomes across a range of Indigenous populations and settings.28

The overview of the background and context of the study attempts to illustrate that the Mi'kmaq people of Nova Scotia are a distinct First Nations people. The identified inequities Indigenous women face in accessing culturally appropriate prenatal care was explored through the contexts of historical, political, socioeconomic, and cultural perspectives. The social determinants of health that influence availability and access to care, such as Indigenous status, gender, and social exclusion was also considered. A gap has been identified from the literature regarding the experiences of Mi'kmaq women accessing prenatal care in Nova Scotia. The methodology and methods used, theoretical framework, and research design will be explored.

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Qualitative research

Qualitative description offers a comprehensive summary of an event in the everyday terms of those events.29 This method of inquiry is frequently adopted in practice disciplines such as nursing.29 For the purposes of this study, a qualitative research design was used to attain knowledge about Mi'kmaq women's experiences with accessing prenatal care from historical, political, and cultural contexts.

Feminist research seeks to respect, understand, and empower women. Therefore, feminist methodologies embody an ethic of caring through the process of sharing their stories.30 Many theorists agree that feminism refers to research that aims to “capture women's lived experiences in a respectful manner that legitimates women's voices as sources of knowledge.”30(p773) In this study, feminist methodology was a suitable theoretical perspective, as it focused on Mi'kmaq women's lives, thus valuing women and their experiential knowledge. By using a feminist approach, the hierarchical relationship is avoided and power differences between the researcher and the participants are reduced.31 A feminist lens was used to help reduce the power imbalance, which in turn facilitates a mutually respectful and positive relationship between the researcher and participants. The importance of developing and strengthening relationships with participants and building partnership through trust has been studied.32 Building trust with Indigenous women and using a partnership approach have the potential to sustain collaborative efforts toward health improvement.32

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Research design: Two-eyed seeing approach

The Two-Eyed Seeing approach developed by Mi'kmaq Elder Albert Marshall was used to guide the research process. The guiding principle of Two-Eyed Seeing refers to learning to see from one eye with the strengths of Indigenous knowledge and ways of knowing, and from the other eye with the strengths of Western knowledge and ways of knowing.33 The power in this approach is learning to use both eyes together and bringing the strengths from both perspectives to view the world. The strengths of participatory action research (PAR) principles and Indigenous principles were used in this Two-Eyed Seeing approach.

Participatory Action Research is considered democratic, equitable, liberating, and life-enhancing qualitative inquiry.34 These principles were included to serve as a guide while conducting research in a First Nations community with Mi'kmaq women. The principle of democracy promoted the participants' autonomy and enabled them to make informed decisions related to their role in the research study. This was achieved by ensuring that participants understood the purpose of the study and also their role in the research process as a voluntary participant. The principle of equity ensured that all participants who shared their stories and experiences were valued. This was achieved by practicing self-awareness, which included having awareness of potential biases or assumptions made regarding participants' experiences. Indigenous women in Canada have faced and continue to face many injustices, and the principle of liberation ensured that the research environment was a safe and supportive environment. The researcher provided a safe space for participants to speak freely about their experiences and to speak their truth about access to prenatal care in their community. Participants may have also experienced life enhancement by contributing to the research process, as they were able to express themselves and make contributions to potentially improve their health and the health of their community.

Indigenous principles identified include but are not limited to the following: (1) protect the heritage of the Indigenous peoples; (2) heritage includes principles of self-determination, meaning that Indigenous people have the right to develop their own cultures; (3) Indigenous people are the primary guardians of their culture; (4) respect and recognition for Indigenous peoples culture; and (5) ownership of their heritage.35 These principles also guided the study.

Using PAR principles and Indigenous principles in a Two-Eyed Seeing Approach was beneficial to conduct reciprocal and respectful research and also reduced hierarchical relationships during the research process. The participants engaged in a back-and-forth conversation in a participatory manner.

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My early education of the Mi'kmaq people of Nova Scotia, including their experiences with past and ongoing colonial policies and systems, was essentially through the lens of Caucasian, Euro-Canadian perspectives. The importance of gaining an understanding of Mi'kmaq people's experiences from their own perspectives became important to me during my first year of Nursing School, when I was introduced to the concept of cultural safety in the curriculum. I recognized that nurses have the responsibility to continuously learn, and by listening to the stories of Mi'kmaq women's experiences accessing prenatal care I continued to develop my understanding of what it is like to navigate the Canadian health care system from a perspective that is much different from my own. I remained aware of potential perceived power imbalances, as a non-Indigenous undergraduate student, I asked participants to share details of their personal maternal experiences. The participants' willingness and eagerness to share their experiences and offer suggestions to combat issues with access to prenatal care confirmed the importance of establishing partnerships with Mi'kmaq women, as they are the knowledge keepers of their lives and know what they need to improve their own health and the health of their community.

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The setting

This research was conducted in a First Nations Community in rural Nova Scotia. The Health Centre is located in the community and offers numerous health supports. The Community Health Nurse addresses the health care needs of all ages and stages of life, from birth to palliative care and end of life. However, prenatal care is not included in these services. During the postnatal period, the Community Health Nurse monitors the status of the mother and infant for 24 hours after discharge from the hospital. A recruitment poster was placed in the Health Centre inviting eligible Mi'kmaq women to participate. Before commencing the study, the researcher met with the Community Health Nurse and the Health Director of the facility to discuss the proposed study and request permission to conduct research in the community. The Health Director provided written approval.

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The participants

The participants of this study were purposively selected on the basis of the following criteria: Mi'kmaq women aged 19 years or older, living in the Mi'kmaq nation of interest in Nova Scotia, who have received prenatal care within the last 5 years. In purposeful sampling, the researcher selects participants based on the quality of their insights about and willingness to reflect upon the phenomenon of interest.36 Participants who met the inclusion criteria and who were willing to participate following an explanation of the requirements and purpose of the study were selected. Data were collected from 4 participants. Qualitative research often relies on small sample sizes so that in-depth accounts of people's lives are explored.36 In most qualitative studies, the number of participants is not predetermined, and the sampling of participants concludes when saturation is obtained. Because of the researcher being an undergraduate bachelor of science in nursing honors student and time restrictions, only a limited number of participants could be interviewed.

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The interviews

A fundamental method for data collection in qualitative inquiry is the in-depth interview, in which the researcher talks with the study participant about the study topics. In this process, the researcher engages the participants in an open-ended conversation to extract ideas and allow participants to express their beliefs and ideas.36

Participants were interviewed in a private room at the Health Centre in the community. Data were collected through one-on-one, face-to-face interviews. The interviews lasted between 1 and 2.5 hours with participants. The follow-up discussions with 3 of the participants by telephone were approximately 1 hour each. A semistructured interview provides the opportunity to elicit the in-depth detail required to understand the phenomenon. An interview guide was specifically developed from the literature to aid in guiding the conversation between the participant and the researcher. Probe questions were used to seek clarification and detailed exploration of the participant's experiences. Participants were given as much latitude as possible during the conversation to provide their perspectives on the research topic.

The interviews were audio-recorded with permission from the participants and transcribed verbatim by the researcher to ensure accuracy of the findings. Following the development of themes from preliminary data interpretation, the researcher requested to follow up with participants to validate the findings and receive feedback on the accuracy of the themes.

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Thematic analysis

Data were examined using the method of thematic analysis. Thematic analysis is mainly described as a method for identifying, analyzing, and reporting patterns within data.36 Thematic analysis involves the search for and identification of common threads that extend across an entire interview or a set of interviews. Nurses are discovering the richness of in-depth description in developing culturally appropriate interventions and in gaining increased competence in the care of diverse and vulnerable populations.29

The first step of thematic analysis is for the researcher to familiarize with the data. Next, the researcher must begin to generate initial codes. This results in searching for themes by collating codes into potential themes and gathering all data relevant to each potential theme. The next step involves defining and naming themes. This includes ongoing analysis for refining the specifics of each theme and the overall story that the analysis reveals, generating clear definitions and names for each theme. The researcher selects vivid, compelling excerpt examples from the data and relates the analysis back to the research question and literature, producing a report of the analysis.36 This process was implemented to capture the essence of the data, and the unique stories of each Mi'kmaq woman's experience accessing prenatal care.

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Trustworthiness of the data

Participatory research and, increasingly, feminist research highlight the use of the research process to empower participants through emphasis on catalytic validity. Catalytic validity refers to the degree to which the research process re-orients, focuses, and energizes participants so that they appreciate their reality to better transform it.37

Catalytic validity is appropriate to determine trustworthiness of these data, as participants gain a self-understanding and, ideally, self-determination through participation in a research study with feminist methodology and PAR principles guiding how research was conducted with Mi'kmaq women in a First Nations community. Feminist researchers often attempt to see the world from the perspective of the woman being studied and are critical in examination of the issues and active in improving the condition of those being studied through partnerships.38 The research process provided an opportunity for participants to grow through thoughtful assessment of their experiences.37 The participants in this study reflected on their experiences with access to prenatal care and informed the researcher what was needed to better support them during pregnancy. For example, during Anna's interview, she expressed the need for more information on gestational diabetes during prenatal classes, as she recognized that the Indigenous population experiences a higher incidence of this maternal complication. She also expressed that family physicians should provide prenatal care for women at the Health Centre in her community, which is supported in the literature.5

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Ethical approval was obtained from the School of Nursing, Review Ethics Board at St. Francis Xavier University and from the Mi'kmaq Ethics Watch Committee, an ethics board composed of Mi'kmaq leaders, Elders, educators, and other professionals in Nova Scotia before commencing the study. Participant consent forms were signed before the researcher engaged in the study with participants. Participants were informed that they might withdraw from the study at any time without influencing the health care they receive. To ensure anonymity, a pseudonym was used during transcription, publishing, and for presentation of research results. To protect the identities of participants, information about each participant was minimal to avoid the reader recognition.

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Following the data analysis process, 3 themes were identified and developed in collaboration with study participants. Although their pregnancy experiences varied with each baby and among each other, the women had comparable experiences with access to prenatal care.

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Access to safe and appropriate health care has been internationally recognized as a basic human right.39 However, Indigenous women experience alarming health disparities and barriers to health care.40 The identified barriers to health care are a result of disadvantages in the social determinants of health. These include lower socioeconomic status, lower levels of education, and social exclusion.41

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Travelling the distance

For the Indigenous population that live in rural and remote locations, low population density, lack of transportation, and poor climate conditions act as significant barriers to health care access.3 All 4 participants in this study were referred to a physician who works within a family-centered system known as Primary Maternity Care. This physician offers prenatal care and delivery to women and accepts prenatal referrals from other family physicians. The clinic where all 4 women were referred is a 25-minute drive from their community.

Medical transportation is available to residents of the Mi'kmaq community should they require a drive to appointments. However, there is 1 driver and 2 support drivers for the entire community. Katie and Josie explained that because of the limited number of medical drivers, difficulties scheduling transportation for appointments exist. Participants reported other barriers that made travelling for prenatal appointments difficult, including inclement weather and other commitments.

Inequitable health services in some communities are a factor that increases the amount of travel some Mi'kmaq women must make during pregnancy. Katie's sister lives in another First Nations community, where prenatal classes are not offered, and she must travel 2 hours to see a physician. “This is her first baby. Yeah, so she's going into it blind,” stated Katie.

Katie described the challenges associated with inequitable services among Mi'kmaq communities due to funding. It is well known in the literature that jurisdictional issues impede access to health care services.41 This creates situations in which women must travel in some instances long distances to receive adequate prenatal care. Anna suggested that physicians offer prenatal appointments at the Health Centre in the community to reduce the barriers associated with travelling. Having access to prenatal care appointments in her community would provide additional support to Anna during pregnancy, as she does not have a vehicle.

There is a need for maternity services and programs, such as prenatal education and assessments, located where Indigenous women live.5 The WHO recommends the implementation of community mobilization with women's groups to improve maternal and newborn health, particularly in rural settings with low access to health services. Community mobilization may be implemented locally by inviting Mi'kmaq women to the Health Centre in their community to discuss their needs during pregnancy, including barriers to reaching care, with the Community Health Nurse, Family Support Worker, and Health Director. The implementation of interventions that include household and community mobilization and prenatal home visits are recommended to improve perinatal health outcomes.7 The Community Health Nurse can provide effective and safe prenatal care in women's homes, including drawing laboratory work and providing prenatal education, which may help reduce barriers for some women in receiving adequate prenatal care.

Successful practices are based on Indigenous ownership of the knowledge, service, and the development of local programs that address each community's distinct needs. As Anna recommended, coordinating the efforts between health care providers and the community may improve access to prenatal care for Mi'kmaq women.

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Indigenous women often feel their pregnancy is healthy when they have a strong support system, including family, health care provider, and culture/community.39 Family support and professional support are considered fundamental components to Mi'kmaq women's social support networks according to the 4 participants in the study.

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Family support

Ensuring that pregnant women's physical, mental, emotional, and spiritual needs are met has always been a family priority for Indigenous peoples.5 All 4 participants in this study emphasized the importance of family support when accessing prenatal care, especially from mothers, sisters, aunties, and grandmothers.

Families support these Mi'kmaq women during pregnancy by sharing their personal prenatal experiences, their knowledge of prenatal care, and providing reassurance. For instance, Anna stated, “If something was different I would go to my mom and my sisters and they'd be like, ‘that's all normal with pregnancy, it's okay.' I felt so relieved to know that it was normal.” Anna felt comforted and supported after disclosing her uncertainty to her mother and sisters.

Katie discussed her family's tradition of story-telling as a way of preparing women throughout pregnancy. “So we talk a lot about our own experiences and what we did, and what happened to us, and what we would suggest for other women,” explained Katie. Katie expressed her appreciation for having access to the experiential knowledge of her mother and grandmother. The participants described a practice among Indigenous families that is well cited in the literature. Indigenous knowledge systems are the foundations upon which cultures are built, and the transmission of knowledge is at the heart of cultural survival.3 The transmission of language, customs, and culture by Indigenous women has a positive impact on healthy child development. This transmission of knowledge is a source of strength among Indigenous families and communities.42

There are numerous ways families support Mi'kmaq women in accessing prenatal care. The 4 participants described this support in terms of helping care for older children, providing financial support, and emotional support. The fundamental message all women conveyed was that their family could be counted on to support them and their baby during pregnancy. Josie affirmed this message by expressing, “That's a big part of our community. Like no matter what... even if I don't see their family very often I know that I'll still have their support no matter what.”

Having supportive and caring relationships is a significant determinant of pregnancy outcomes. Indigenous peoples have always celebrated extended families and lauded the wisdom of matriarchs as it applied and was transmitted to younger generations of a community.3 Josie reflected on her own extended family and what this meant to her. “Yeah, even if we don't see each other that often, they're still there. Very extended families, and open to welcoming other people.” Josie feels supported in her community, as she and her children are not limited to her immediate family for support.

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Professional support

Indigenous peoples value access to a team of health care professionals that support and deliver coordinated care for communities.9 Primary health care models that work collaboratively with First Nations communities to develop programs and coordinate access to team-based, holistic, and culturally sensitive care leads to better prenatal outcomes and relationships.9 Katie stated, “If I had any concerns about my pregnancy I would go to the Health Centre first because we have a Community Health Nurse and the Family Support Worker. They're really accommodating. If you need them, they're there.”

Katie valued having access to dependable information related to pregnancy concerns from the professionals at the Health Centre. The accommodation and flexibility provided by these professionals also facilitated access to care. The participants in this study attended the prenatal classes at the Health Centre for all of their pregnancies. Two of the women had 3 children, and 2 women had 6 children. Each participant described how the support from the health care professionals enabled them to access the prenatal care they needed.

The Community Health Nurse's role includes linking women with resources in the community. Anna explained how the nurses helped her access prenatal care. She commented, “The nurses here supported me to get prenatal care. They made sure I had a way to get to my appointments in town and made sure I knew about the prenatal classes at the Health Centre.” Anna values the nurses at the Health Centre, as indicated by how the support made her feel. “It felt really good knowing that I wasn't alone trying to figure it all out on my own ‘cause when I first became a mother I was only 16,” explained Anna.

Katie, Anna, and Marie expressed that the Community Health Nurse was easily accessible if they had any pregnancy-related concerns. One study described the importance of support from health care professionals during pregnancy.39 First Nations women who receive positive and validating support often experience pleasant pregnancies and feel more optimistic about their health.39

Many Indigenous specific programs currently exist and are funded through investments at the federal, provincial/territorial, and municipal levels.28 The prenatal classes in this community are held once a week at the Health Centre, and cover numerous topics including car safety, nutrition, gestational diabetes, the labor process, and the effects of substance use during pregnancy.

Smylie5,28 explained that Indigenous women value culturally secure and community-relevant services. The Family Support Worker, who is a Mi'kmaq woman from the community, develops the topics for prenatal classes. This ensures that the topics covered are relevant for the specific population attending the classes. The participants in this study indicated that the health care professionals and programs offered at the Health Centre are significant sources of support during pregnancy.

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According to the Health Council of Canada,9 honoring Indigenous practices and beliefs, and integrating them with modern health care, has significant health benefits. The participants in this study shared their beliefs on the meaning of health, pregnancy, and prenatal care to inform this research.

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Importance of traditions

Many Indigenous people believe that good-quality health care for expectant mothers does not only include prenatal care, delivery, postnatal care, and check-ups, but also involve looking at the woman's life as a whole.9 Participants articulated that health includes physical, mental, spiritual, and emotional dimensions. Katie explained that all dimensions of health impact pregnancy outcomes: “Prenatal care means taking care of your body, but also your mind and your spirit when you're pregnant.”

The traditions practiced by Indigenous women and families were abruptly interrupted by the colonial experience.3 An emphasis on rebuilding knowledge of language and traditional processes, including the support of Indigenous women, becomes paramount in ensuring the health and well-being of communities. Despite these devastating changes, women's ways of knowing, traditions, and ceremonies related to mothering continue today.3

The participants in this study described various traditional practices they view as important during pregnancy. Katie experienced emotional difficulties during her first pregnancy and used the tradition of sweating to help gain emotional and spiritual strength. Many First Nations peoples practice traditional ceremonies that can offer powerful forms of healing within a social setting, which includes the sweat lodge.43 By reconnecting with cultural practices and teachings, Indigenous women have a powerful role to play in moving towards wellness and healing.3

Traditionally, pregnant Indigenous women were considered medicinal women because of the new life they carried and were honored as a bridge between the spirit life and life on earth.3 Josie reflected on her personal experiences of sweating during pregnancy, and the respect she was given as a pregnant woman in the community. Prior to a sweat, Josie's father would state, “It is an honour to sweat with a pregnant woman because she is bringing life into the world.” Josie's account of her experiences sweating during pregnancy exemplifies the respect and consideration that is given to women as bearers of children. Many Indigenous societies perceived children to arrive in the world in perfect harmony and embody innate wisdom because they had close ties to the spirit world.3

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Providing culturally safe care

Cultural competence refers to a set of congruent behaviors, attitudes, and policies that enable systems, agencies, and professionals to work effectively in a cross-cultural situation.26 According to Bearskin,24 cultural competency means respecting differences and being willing to accept the idea that there are many ways to view the world. Josie explained how her family's cultural beliefs and traditions were respected while accessing mainstream health care. “I found at the hospital here they're very open and embrace our differences. There was no limit to how many people in the room when I was in labour. Which I know, you know, they don't allow for everyone but it's important for us. Just very respectful.”

Josie's experiences within the health care system highlight positive and validating interactions with health care professionals. She acknowledged the respect she received during her delivery, as her family was able to be a part of this important life event. Van Herk25 stated that building positive and respectful, therapeutic relationships is about the mutual investment of both the service provider and the woman. Acknowledging and respecting clients' identities and providing care in such a way as to incorporate women's values encourage them to access care in the future.25 Similarly, one study conducted in Nova Scotia found that Mi'kmaq women value building meaningful, trusting, and respectful relationships with health care providers, which positively influenced their access to pap screening in the study.19

Cultural safety involves considering the social determinants of health and understanding how these determinants impact client's lives. Nurses' responsibility for cultural safety includes improving health care access for all nations, exposing the social, political, and historical context of health care, and disrupting unequal power relations.24 The participants in this study indicated the significance of having a Community Health Nurse available to them at the Health Centre. The nurses at the Health Centre have taken steps to provide culturally safe care by improving access for Mi'kmaq women. A common statement among all the participants was that the nurses were “always there.” Cultural safety connects the dynamics of individual encounters to broader social issues.24 Having access to a Community Health Nurse in the community takes these political, economic, and social issues into account and improves access for Mi'kmaq women.

Providing culturally safe care involves reflecting deeply on your own cultural values and beliefs, questioning assumptions and biases in practice, engaging in relationship building, and creating open, trusting environments.24 Katie explained the uncertainty she experienced as a result of not fully understanding a potential pregnancy complication. Katie explained, “I don't know... I didn't really get a gist of like... what exactly was going on. Or what they were saying.” Katie indicated that she was not properly educated during her prenatal check-up appointments. Although it is unclear what factors exactly caused this miscommunication between Katie and her health care provider, it is well cited in the literature that presumed cultural differences and language barriers impact client care.44

Miscommunications have significant implications in the clinical area.44 In a study conducted by Browne,44 the dangers of presumed cultural differences in regard to approaches in interacting and communicating were explored. The nurses in this study interpreted differences in communication styles as “cultural issues.”44 In some circumstances, quietness may represent a culturally specific way of conveying respect to people in positions of authority. However, interpreting quietness in this way draws attention away from the power inequities that may be shaping how patients relate to providers who are in positions of influence.44 The quietness that some of the nurses interpreted as “cultural” may in fact reflect ways of responding to long-standing relations of power and paternalism with non-Indigenous health care providers. Those who do not speak up or pose frequent questions risk having their needs overlooked. Although Katie was able to read, write, and speak English, she also grew up learning and speaking Mi'kmaq. According to a study conducted in Nova Scotia, some Mi'kmaq women do not feel comfortable communicating with health care providers, as they find it difficult to express their feelings due to the language barrier.45

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Advocacy may manifest itself in various ways. According to the Canadian Nurses' Association,46 advocacy involves engaging others and mobilizing evidence to influence policy and practice. It means speaking out against inequity and inequality. Although improvements have been made, access to health care continues to be a significant issue for many Mi'kmaq communities.

Providing culturally safe care is important in the delivery of professional nursing practice.6 Nurses must be competent in transcultural nursing knowledge so that they may provide safe and meaningful care to clients. The results from this study provided insight into what is important to Mi'kmaq women during pregnancy, and their views of health. In order to provide culturally competent care, Mi'kmaq women's beliefs and values must be respected. By respecting and understanding that there are many ways to view the world, nurses may facilitate the development of a therapeutic relationship with Mi'kmaq women during pregnancy. Nurses must also recognize the significance of community engagement during the implementation of programs in First Nations communities. After centuries of historic and current colonial policies undermining Indigenous self-determination, many Indigenous peoples have developed an acute and critical sensibility as to whether or not an intervention, such as a health program has been autonomously initiated or externally imposed.28

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More research highlights the importance of providing culturally safe care. Therefore, workshops and educational sessions must be promoted among health care professionals to enhance the understanding of what is means to provide culturally safe nursing care. This research study delved into the significance of exploring the historical, social, and political contexts associated with power imbalances in the health care system. The findings from the study illustrated how power imbalances and perceived cultural differences might impact Mi'kmaq women's ability to ask questions related to their pregnancy concerns. Nurses often function within the framework of a professional culture with its own values and traditions.6 The Canadian health care system may be considered one of these professional cultures, which has a history of perpetrating power imbalances and paternalistic values.44 Perhaps more education is required regarding these issues, so that nurses and other health care professionals may enter the workforce prepared to address the needs of their clients.

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Although the women in this study were able to access the prenatal care they needed, it would have been insightful to hear the voices and concerns of Mi'kmaq women who live in more remote and isolated Mi'kmaq communities. A few of the participants expressed that Mi'kmaq women living in other communities experience more difficulty accessing this care and must travel up to 3 hours to see their physician. Expanding the population of interest to Mi'kmaq women in multiple First Nations communities may provide more understanding into issues related to access to prenatal care.

Further research is also required to include the perspectives of Mi'kmaq Elders and other community members, to gain a better understanding of what is needed to provide better health care access in Mi'kmaq communities. Health care professionals, such as Community Health Nurses and family physicians, may also provide valuable insight into access-related issues for Mi'kmaq women.

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Health policy must be considered and developed within the context of present-day issues. The nursing profession contributes to the delivery of care and the health status of the population. The ultimate reason for enhancing nurses' political influence is to improve the health care received by individuals, communities, and populations.47 Nurses are in a position to bring attention to the health care needs of underserved populations.47 Nurses are often caught in the pressure of knowing what is needed and knowing that these resources and funding are not forthcoming. This disparity is what motivates political action to challenge existing processes that limit access to health care for underserved Canadians, including Indigenous peoples.47 Through clinical encounters and research, nurses may collaborate with Mi'kmaq women to identify barriers in accessing maternal health care, and therefore contribute evidence to policy development.47

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The purpose of this research study was to better understand the experiences of Mi'kmaq women accessing prenatal care in rural Nova Scotia. This was achieved using a Two-Eyed Seeing approach, by incorporating Indigenous and PAR principles to conduct research in a Mi'kmaq community. By using a feminist lens, Mi'kmaq women's lived experiences were captured in a respectful manner, so as to legitimate their voices as sources of knowledge. Their experiences with access to prenatal care were used as a basis for building knowledge.

This research provided an understanding into the everyday lives of Mi'kmaq women and indicated that access to prenatal care is a complex issue for some women. Some of the issues related to access to prenatal care included difficulties organizing transportation and inequitable services among Mi'kmaq communities. Through this research process, it became evident that inequities in the social determinants of health impact women in accessing adequate prenatal care. Although barriers were identified, it is important to mention that all the participants in this study felt that they received the best prenatal care possible and were pleased with the care they received. This was especially true for the care and education the women received from the Health Centre in their community.

Throughout this study, it was evident that mothers, sisters, grandmothers, and aunties are significantly relied on for support, especially in regard to seeking reassurance and information. Colonization did much to destroy women's ways of knowing about motherhood; however, many of these traditions still carry on, highlighting Indigenous mother's strength and resiliency over time.42

There were identified limitations to this study. The results from this study may not be considered transferable to other contexts because the data came from one First Nations community and the sample size was small. Also, the results cannot be transferable as there are significant variances among First Nations communities, based on available resources and other factors.

In an otherwise affluent society, Canada's Indigenous women experience a disproportionate burden of maternal complications due to negative social determinants of health. Nurses have the responsibility to recognize these health inequities in practice, and advocate for clients and families. Nurses must play a key role in recognizing and addressing power imbalances within the health care system, so that equitable care may be achieved for all Canadians.

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access; cultural safety; health; Indigenous; Mi'kmaq women; pregnancy; prenatal; social determinants of health

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