User:KittyJolee/Childbirth and Pregnancy in Inuit Communities

The Inuit are a group of indigenous people located in the Artic regions of Alaska, Canada, and Greenland. This group primarily speaks Inuktitut, with some speaking in regional dialects known by different names. Within these communities there is expansive and diverse culture. This culture has remained preserved despite colonization efforts, assimilation policies, and environmental degradation.

In Inuit communities, childbirth and pregnancy were and continue to be incredibly important. There are many culturally significant aspects to pregnancy and childbirth in Inuit communities, and today activists in these communities are calling for recognition of the health issues that affect the health of pregnant women and infants in their communities and a return to their birthing traditions. This article primarily focuses on traditional birthing, pregnancy, and childcare practices in Inuit communities and modern health concerns pertaining to this group.

Childcare and Motherhood
Childbirth and childcare were two of the most important responsibilities for an Inuit woman. Inuit parents showed a very high level of warmth and affection to their children. Inuit children usually began to contribute to the family and community by the age of 12 through activities like picking berries and hunting small game. During this period, they learned skills from their parents through close observation. Learning through observation was the chosen method because it was not practical for children to practice their skills by sewing valuable skins or accompanying men on important hunting trips.

Women raised boys and girls. Men taught boys certain skills, such as hunting, and women taught girls certain skills, such as sewing.

Kinship is an important factor to an Inuit child's cultural belonging. From birth, children are introduced to their duties and ties of kinship. One way Inuit achieve this is by the practice referred to as name-soul. After a member of the family has passed away, their name is used as the name for a child of the same family line. The name provides a child with a cultural tie, belonging within their community, and personal identity. In addition, name-soul allows for prior family members to carry on their legacy in their family lineage even after passing. The children are raised in a family-oriented environment, as their name serves as a reminder that the group comes first. There were no boy's and girl's names in Inuit culture, so it was common for a girl to have the name of her grandfather, for example.

Children were taught at a young age to listen to their parents and respect their elders, and were treated with more autonomy than non-Inuit children. Over disciplining a child was seen as counterproductive, so children were rarely punished for transgressions. Learning was regarded as a partnership between child and adult, with children being more guided through life than directly taught or lectured.

Pregnancy
In regard to conception and pregnancy, young Inuit women were discouraged from engaging in sexual intercourse during puberty, ages 11 to 13 years, until they reached "prime maternity age", after marriage, about 15. Similar to menarche, many young Inuit women were unaware of the indications of their first pregnancy. Elders recount that young woman often thought that they had been cured of their menses when they experienced amenorrhoea for the first time. It was not uncommon for the young woman to learn about her first pregnancy from her mother or grandmother when she began to show (or carry weight). According to elders, pregnancy was also determined by, "looking into the face" of the young woman and/or feeling her stomach for a fetus. Once aware, it was important that the woman immediately divulge her pregnancy status to her mother, husband, and close community, as the Inuit believed that her status demanded special considerations and/or treatment to ensure the health of the mother, baby, and camp.

To prevent miscarriage, the husband and camp were to assure that the woman did not become mentally stressed or exhausted during the pregnancy. This taboo extended to include not allowing the husband to get angry with his wife at any time during the pregnancy. If miscarriage did occur, the woman was expected to inform her mother and the camp right away. According to traditional Inuit beliefs, hiding such a secret would bring bad luck for the camp such as hunger, lack of food, or illness.

Taboos (Pittailiniq) in Pregnancy
In pregnancy, women's care was traditionally guided by the taboos, known as pittailliniq, from the elders in the community. These taboos, which were passed down through generations and varied somewhat across geographic regions or camps, informed the woman's behaviors and activities in order to prevent complications, promote a healthy birth, and ensure desired characteristics of the infant. For example, in regards to activity, the Inuit had many pittailiniq about maintaining physical activity throughout pregnancy and resisting idleness or laziness, which was believed to adversely affect labor and birth. The Inuit words sailliq and sailliqtuq, distinguished between the women who relaxed (sailliq) as appropriate, and those who relaxed too much, sailliqtuq. Another common pittailiniq instructed the woman to massage her stomach until she felt the fetus move so that the baby wouldn't "stick" to the uterus.

In interviews with Inuit elders, numerous pittailiniq about the woman's activity and behavior in pregnancy are discussed. Some of these are listed below.

Pittailiniq on Activity in Pregnancy

 * In the morning when waking, go outside as fast as possible, to ensure a short labor and fast delivery
 * Don't relax too much or the placenta might stick to the womb
 * Don't lie around or take naps or the labor will be long
 * When you stretch sealskin on a frame, don't wind the rope around your hands because this would cause the umbilical cord to be wrapped around the baby's neck.
 * Don't put anything bowl-shaped on your head so the placenta won't get stuck on the baby's head.
 * Don't walk backward or the baby will be breech
 * Don't put your head or arm partway through a doorway or into a hole because during birth the baby will present and retreat back and forth, or the baby will come out arm first

Pittailiniq on Behavior in Pregnancy

 * When called outside or asked to perform a task, do so immediately to ensure a speedy delivery
 * When beginning a project such as sewing, finish it or the labor will be longer
 * Don't scratch the stomach so that stretch marks will be less noticeable
 * Don't speak about or stare at other peoples' physical oddities such as a big nose, or the baby will have even more serious oddities
 * Untie everything that is tied up so as to be more dilated when the baby is ready
 * Don't wear tight pants while pregnant for an easier delivery
 * Don't clean hands with an ulu or knife in order to prevent a dry, painful birth and risk of perineal tears
 * Don't make bubbles with gum or blow up a balloon or the membranes might rupture
 * Face the bed toward a doorway. If it is sideways toward the door the baby will be transverse
 * Don't allow the legs to get cold during pregnancy, because this will cause hemorrhaging after birth

Diet in Pregnancy
The Inuit also followed many taboos (pittailiniq) about diet and consumption in pregnancy. Consistently, elders report that pregnant women were to abstain from raw meat, eating only boiled or cooked meat, during pregnancy. Men were also expected to observe this rule, but only when in the presence of their wives. The preferential treatment of pregnant women also extended to food, and the best pieces of meat and food were always reserved for the pregnant woman.

The pittailiniq regarding the diet of pregnant women demonstrates the strong emphasis on maternal diet affecting infant beauty and/or appearance. Some of these pittailiniq are listed below.

Pittailiniq on Diet in Pregnancy

 * When eating, be sure to finish the meal and lick the plate. This ensures that your baby will be beautiful.
 * Eat caribou kidneys to ensure that you have beautiful babies
 * When eating seal, swallow a seal cap to have a nice round baby
 * Do not drink directly from a soup bowl or the baby will have dark skin
 * Do not chew candle wax during pregnancy or the baby will be covered with a white coating at birth
 * Eat seaweed if you want to have a boy

Preparation for Birth
According to elders, the women were not taught how to prepare for birth. Women expected and trusted that they would receive instruction and advice from their midwife and other birth attendants (i.e. mother and/or mother-in-law) during the event. When labor and birth were perceived imminent, the woman and/or her attendants would set up a soft bed of caribou skins or heathers nearby. A thick layer of caribou fur on top of the heathers was desired in order to soak up the blood lost during birth.

Birth Attendant(s)
According to elders, birth ideally occurred with both an assistant and midwife, but due to hunting-based economy/survival, many births occurred in transit or at a hunting camp. In these cases, the elders report that either the men would assist or the woman would endure birth alone. Due to the uncertainty of their location at the time of birth, the woman often did not know who her midwife would be until birth.

In the community, a midwife (Kisuliuq, Sanariak) or "maker" was a highly revered female member of the community, who had acquired experience and skills in birth by attending births with their mother, an elder, or another midwife of the community; often beginning at a young age. The responsibilities of the midwife varied somewhat by geographic region and camp, but often included, 1) comforting the woman, 2) knowing a woman's body, including 'what was inside', 3) instructing the woman during labor on what to expect, 4) repositioning the woman to promote quick deliveries, and 5) dealing with complications.

In most communities, the only man who became intentionally involved in birth was an angakkuq. In cases when the midwife or elder suspected a "spiritual or supernatural interference", the angakkuq would intervene to remove the spiritual interference of a spirit or another malicious angakkuq, to restore the spiritual balance and normal birth conditions.

Labor
labor and birth were times of great celebration in the Inuit community. Traditionally, when a woman began having contractions, her midwife would gather other women of the community to help the laboring woman through the birthing process. Additional signs of labor noted by the Inuit midwife included a brown strip of discharge, broken water, stomachache, or the urge to pass a bowel movement. Although it was cause for great celebration, labor is traditionally a time of quiet and calm in the Inuit community, and the midwife would commonly whisper her counsel to the mother-to-be. If the woman had followed the traditions throughout her pregnancy, she could expect her labor to be quick and easy. Many of these also extended to the actions of the woman's midwife, who was also commanded to be swift in all aspects of her life so that her client would enjoy a quick delivery. Very often, women were expected to continue their daily chores up until the late stages of labor and endure labor pains without the aid of pain management.

The midwife's goals during labor typically included keeping the woman from becoming irritable or screaming, preventing her legs from opening, preventing her from peeing or having a bowel movement, and encouraging activity and position changes. The positions in which an Inuk woman labored varied according to the midwife's preferences and her own comfort. These include lithotomy, side-lying, squatting, and standing positions have all been described in the literature. Often, a caribou pelt was placed under the woman and she was allowed to choose a bed or the floor. Some communities' midwives employed the use of equipment such as ropes to pull on or a box to lean over to help ease the pains of labor, but little evidence of either pharmacologic or medicinal herb pain relief is described. Traditionally, the woman was required to have her spine completely straight for the entirety of her labor and delivery. To facilitate this, the midwife would often place a wooden board behind the woman to keep her back aligned. Additionally, a rolled towel or block of wood was used to keep the woman's legs and feet apart during labor, which, in the midwives' view, helped to speed the labor along.

Birth
In traditional Inuit birth culture, the birth event was handled almost exclusively by the midwife. However, the woman played an active role in her own birth experience and was encouraged to follow her body's own physiologic cues regarding pushing and rest. When she was ready to push, the midwife would tell the woman to pull on her hair with both hands and bear down. While most Inuit women gave birth at home, in some Alaskan communities women gave birth in separate birthing huts (aanigutyak) built exclusively for this purpose. If this was not done, the place where the woman gave birth had to be abandoned.

Once the baby had crowned and was born, the midwife would cut the still-pulsating umbilical cord with a special knife and tie it with caribou sinew. The midwives knew that the sinew carried a much lower risk of infection than other materials available to them. The cord was cut with enough length to pull out the placenta by hand if necessary. After the child was born and the placenta was ready for delivery, many Inuit midwives would instruct the woman to get on all fours and push in this position. Midwives were also versed in providing fundal massage to reduce the risk of postpartum hemorrhage. Some Inuit communities wrapped the placenta in cloth and buried it among the rocks of the tundra.

Postpartum
Sources on traditional Inuit birth practices provide little reference to the postpartum period. One elder midwife in Nunavut described that after birth, her mother-in-law very briefly cared for the house and chores until she felt better. She also described, however, that she was feeling better soon after birth and eagerly performing chores behind her mother-in-law's back.

In regard to physical care after birth, the information is also minimal. Women, who are able to breastfeed, do so immediately after birth, often continuing for two years or longer. Breastfeeding served as their only method of contraception and birth spacing. While breastfeeding, the elders describe the importance of keeping the breasts warm to prevent cracking and drinking broth for nutrition. If perineal tears have occurred during the delivery, they are left to heal on their own; the Inuit do not traditionally perform episiotomies or suture tears.

Adoption was very common in Inuit culture, and it was often very informal. Unwanted babies, or babies a family could not support, could be offered to another family. If the other family accepted, the adoption was complete.

Infanticide only occurred when conditions were desperate and the group was threatened by starvation. A mother abandoned an infant in hopes that someone less desperate might find and adopt the child before the cold or animals killed it. The belief that the Inuit regularly resorted to infanticide may be due in part to studies done by Asen Balikci, Milton Freeman, and David Riches among the Netsilik, along with the trial of Kikkik.

The Newborn
The birth of a newborn into the camp is cause for widespread celebration in the community and everyone, including children, would shake hands at its arrival. And it was believed that if the mother followed the pittailiniq in pregnancy, the child would be healthy and follow a good life in the community.

Immediately after birth, the infant was assessed for breathing. If the infant was not breathing, then the midwife would hang the infant upside by his feet and slap his buttocks. The midwife also removed mucus from the infant's mouth, using either a wipe or her own mouth, to ensure that the baby was able to "fatten" in the coming days. The exposed cord stump was then covered with burnt arctic moss and the infant was placed in a rabbit fur or cloth pouch, sewn by the sinaji. The pouch served not only to keep the infant warm but also as a diaper and protection for the healing umbilical cord stump. It was believed that the cord stump should fall off on its own and not be looked for by the parents. If the mother found the cord stump, it indicated that the child would become hyperactive around age four. The infant was not routinely washed after birth.

Traditional Inuit midwives describe that the first stool (meconium) should be observed outside the womb, as it could cause clotting and complications if left in the mother. The treatment for which was to massage the woman's stomach, promoting blood flow. The midwives also expected the infant to urinate almost immediately after birth, indicating that there was no obstruction or genital abnormality. Infants, as well as the rabbit or cloth pouch, were always dried promptly after urinating or having a bowel movement. And by a year of age, elders claim that children were toilet trained.

Also occurring immediately after birth, a designated person, often the midwife, felt the infant's genitalia to determine its gender. This person then became the infant's sanaji (for an infant boy) or arnaliaq (for an infant girl) and assumed a lifelong role in the child's life. If the infant was a boy, he would later call this person his arnaquti and give her his first catch as a child. The sanaji was also responsible for cutting the umbilical cord, providing the infant's first clothes, naming the child (tuqurausiq), blessing the child (kipliituajuq) and conferring the desired characteristics onto the child. It was believed that the child's direction was shaped from the earliest days of life and consequently, these practices were held in high esteem as they determined the child's future.

In rare instances, the child might be considered sipiniq (ᓯᐱᓂᖅ), meaning the infant is believed to have changed their physical sex from male to female at the moment of birth. This concept has primarily been historically attested in areas of the Canadian Arctic, such as Igloolik and Nunavik. Sipiniq (ᓯᐱᓂᖅ) children were regarded as socially male, and would be named after a male relative, perform a male's tasks, and would wear traditional Inuit clothing tailored for men's tasks. This generally lasted until puberty, but in some cases continued into adulthood and even after the sipiniq (ᓯᐱᓂᖅ) person married a man.

Once assessed by the midwife and/or sanaji, the infant was promptly given to the mother for initiation of breastfeeding. According to elders, the infant remained in nearly constant physical contact with her mother from the day of birth; sleeping on the family platform, riding in the amauti (baby carrier and parka worn by the mother), or nestled in her parka for feeding.

Naming the Newborn
Performed by the sanaji or midwife, the tuqurausiq was the highly-valued naming practice that linked the child to a relative or deceased family friend. The Inuit believed that when the infant was born, he/she took on the soul or spirit of a recently deceased relative or community member. Through the name, the child literally assumed the relationship of his/her namesake. For example, if a child were named for someone's mother, family members would then call that child "mother" and give the child the same respect given to that mother. The infant's name also represented an important factor in his/her behavior. In particular, the Inuit believed that crying was an indication that the infant wanted to have a particular name. And that often once named, the infant would stop crying. In addition, as the infant or child is a representative of their namesake, they are considered to generally know what they want or need. For example, when they are hungry or tired. Given this belief, it was also considered inappropriate to tell an infant or child what to do, as it was similar to commanding an elder or another adult, which violated social rule in Inuit culture. When an infant or child exhibited the same behavior as their namesake it was called atiqsuqtuq. Children in the 21st century are still named for other family members but the name may be an English one rather than a traditional Inuit name.

Teen Pregnancy
According to studies looking at highly Inuit-populated areas, teen pregnancy rates of Inuit women are much higher than in other parts of Canada. In Nunavut, the area of Canada containing the most Inuit women, has the highest birthrate of women from age 15 to 19. 24% of births were attributed to teenagers in Nunavut, compared to the Canadian national average of 5% in 2004. It is important to recognize that this data is not solely for the Inuit populations in Canada, but of an area that has a high population of Inuit peoples.

Based off of a qualitative study by Gwen Heely, which interviewed Inuit women on their perspectives on women's health issues in their community, these women describe perspective that could attribute to the higher rate of teen pregnancy in these communities. They describe teen pregnancy in Inuit communities as being generally perceived to be a positive thing. Childbearing is seen as a way to celebrate one’s femininity despite age. Dropping out of school to care for a child is not seen as negative compared to non-Inuit communities. Young indigenous people in similar studies have expressed an idealism surrounding pregnancy and becoming parents. Young mothers in these communities speak of their pregnancies as a transformative event to help them get on a healthy path. Adoption is seen as a positive thing in these communities, so teenagers who become pregnant in these circumstances are more likely to seek adoption as an alternative to motherhood. The positivity surrounding childbearing and parenthood can contribute to societal pressure to carry through with the pregnancy. These attitudes also discourage many indigenous women from getting an abortion. There are many socio-economic factors attributed to inhibiting the ability for Inuit women to get abortions. Many services available to rural indigenous communities are only accessible by car or plane. There is conflicting information about the availability of these services and the travel to get there can be expensive.

Many common determinates of teen pregnancy are found in high numbers in Inuit communities. Factors such as not graduating high school, parents not graduating high school or getting higher education, single parent households, household in need of repair, and overcrowded households are associated with teen pregnancy.

Certain sexual behaviors are also associated with higher rates of teen pregnancy. Alaskan natives are more likely to participate in these sexual behaviors than urban populations. The rate of substance abuse before or during sex is more prevalent. Alaskan natives are more likely to have multiple sexual partners, have sexual intercourse before the age of 13, and be a victim of rape, than white female youth.

Teen mothers are at a higher risk for becoming pregnant as a teen again and are less likely to seek prenatal care.

In Inuit communities there is a lack of health literacy and specialized medical professionals to provide reproductive care and education. The lack of qualified medical professionals and comprehensive sex education is a possible reason for teen pregnancy.

Maternal Mortality
Maternal Mortality is elevated amongst indigenous residents compared to white residents. It is important to recognize that data on indigenous people, including the Inuit are not consistently reported due to underrepresentation in studies looking at racial disparities and there being a lack of access to care to report these deaths. It is also important to recognize that the risk of dying from homicide for indigenous pregnant women is two-fold higher than any obstetrical cause. Maternal Mortality for obstetrical reasons is often linked to lack of health access, which is seen as an issue in many rural Inuit communities.

Infant Mortality
Infant mortality is defined as deaths in children under 1 year of age. Areas with a high Inuit population have much higher rates of stillbirth and infant death compared with the rest of Canada and other rural areas. It is important to note that there is a lack of comparative data between First Nations and Non-First Nations due to the absence of data to differentiate these two groups within this region. Sudden Infant Death Syndrome or SIDS and infection tend to be the largest causes of infant mortality based off of a 2010 study done on Inuit inhabited areas. These disparities have been linked to poverty and limited access to health education and services.

Dr. Russel Kirby's 2010 study at USF college of public health shows a link between poverty stricken and rural areas to sudden death in infancy. They found that the rate of infant death as being as much as 2.3 times higher in high-poverty areas compared to low-poverty areas. They also found that rural communities rate of infant death was 2.8 times higher than large urban areas. Kirby attributes these disparities to the lack of availability of health care facilities in rural areas that can care for high-risk infants, and health literacy in impoverished communities on safe sleep and other environmental factors that contribute to Infant death.

Push for a Return to Community Birth
Many Inuit women are calling for a return of traditional ways when it comes to birth in their communities. Beginning in the late 1970s and 1980s, women in Nunavut and the other areas of Nunangat began a push to end the practice of being flown to the south of Canada (Douglas- Rankin Inlet). This was based on a widely held belief in the region that birth of Inuit children within the Inuit homeland would strengthen the family unit and increase social cohesion. A large anthropological study confirmed strong correlations between the social dissonance caused by birth evacuation and a spectrum of social ills facing Inuit society. Inuit women wanted to return to their traditional practice of woman-centered midwifery, using knowledge passed down through the generations to complement a community-centered birthing experience. Many women in these communities see current childbirth practices as “medicalized” as most Inuit births are done in emergency room setting with a physician centered approach. In 2008, the government of Nunavut passed the Midwifery Professions Act. This far-reaching provision extended a full scope of practice regarding prenatal, birth, postpartum, and primary care to registered midwives. The act also permitted Nunavut Arctic College to open a midwifery-training program, the curriculum of which is required to include traditional Inuit midwifery knowledge. Midwives are vital for this process, and many believe elders knowledge will provide guidance on how to incorporate traditions into modern Inuit births.

Birth Centers in Nunavut
In 1993, the first birth center in Nunavut opened its doors in Rankin Inlet. Heralded as a first step in returning birth to the North, the Rankin Inlet Birth Centre was a fledgling operation for most of its first decade. Today, more than half of Nunavummiut women give birth in southern hospitals- mostly in Yellowknife, Churchill or Ottawa. Only about 20% of the women in the surrounding Kivalliq region of central Nunavut give birth in the centre and less than half (47%) of the births of Rankin Inlet itself take place there. Its marginal success has been linked to its relatively low capacity, having only two maternity care workers employed there at any one time- both of whom are almost always southern Canadian midwives there on short-term assignments. The birth centre has handled approximately 600 births since its opening. A University of Manitoba audit in 2008 found that the centre has provided consistently safe maternity care since its opening, with not one case of maternal mortality.

A second birth centre is housed within the Qikiqtani Hospital in Iqaluit. The Qikiqtani birth centre handles the majority of births, which occur in Nunavut, about 400 per year. The centre, opened in 2007, houses four birthing suites and a full surgical backup should the woman need it. The centre is equipped to handle breech, VBAC, and other complicated vaginal births using a physician-led team as well as midwives. At eight percent, the centre's cesarean rate is the lowest of any hospital in country. The Qikitqtani birth centre has reduced the evacuation rate on Baffin Island considerably, and there is little need for low-risk women to leave the territory to give birth. The centre's intervention rate is lower than the national average and is considered a model for the rest of the territory.