1. Informed choice, power and the normalization of traveling for birth: An action research study Ashley Struthers CHI Evaluation Platform, Winnipeg Regional Health Authority Darlene Girard Population and Public Health Program, Winnipeg Regional Health Authority Evaluation Platform

2. Objectives 1.Review research process and findings 2.Describe how the research findings are reflected in day-to-day service provision

3. Background The Maternal and Child Healthcare Services (MACHS) Task Force in Manitoba identified challenges and gaps in services for women who travel for birth: – Women report feeling lonely, bored, isolated, overwhelmed and fearful for their health and safety – No prenatal referral to public health (The Maternal and Child Health Care Services (MACHS) Task Force, 2008)

4. Purpose The purpose of this study was to gain an understanding of the strengths, resources and needs of women from rural and remote communities who temporarily relocate to Winnipeg for birth in order to design an effective and culturally safe range of prenatal services and supports to meet these needs.

5. Methods Action Research – Literature Review – Interviews and one focus group with women/families (n=25) – Interviews with care providers in Winnipeg (n=22) – Interviews with HCPs in Northern Manitoba (n=5) and Nunavut (n=8)

6. Findings

7. 9 themes emerged: The normalization of traveling for birth* Challenges managing daily life in Winnipeg The importance of social support Informed choice and power* The importance of cultural awareness Health and health care challenges Perceived consequences of birthing away from home Coping strategies Suggestions for improved care

8. The normalization of traveling for birth “It is just normal, how it’s always been, you have your baby in Winnipeg and then you come home.” (HCP Nunavut)

9. An ordinary experience It wasn’t a huge burden, huge, it wasn’t fun, but it wasn’t a huge burden to come down either. (Mother of 3, Northern Manitoba) Well, I was just happy I was here cause I wanted to go shopping. (Mother of 4, Nunavut)

10. Fear of birthing locally There was the option to stay in Rankin and have the baby there but … mom was quite, was more worried that I should have the first baby down there where there was better medical service. (Mother of 1, Nunavut) It is not that we can’t deliver a baby here but if there are complications we don’t have a chance of saving them. (HCP Nunavut)

11. But it’s still scary I was seventeen when I had my first baby and I was confused and alone, it was very hard. (Mother of 5, Nunavut) They experienced anguish when they were sent away for birth. (HCP Winnipeg)

12. Choice and Power “Women who must travel for birth have lost all power.” (HCP Winnipeg)

13. Not being in control I became confined here and not allowed to go home. (Mother of 5, Northern Manitoba) They normally ship the mother here to Winnipeg one month in advance. (Mother of 2, Nunavut) Just do what the nurses say, the doctor. Just make an agreement and everything’s gonna be fine. (Mother of 4, Nunavut)

14. Lack of free choice I wanted to stay home but the doctor said the hospital isn’t equipped to deliver babies. I was threatened that if I didn’t come to Winnipeg they would bring in the police to make me. (Mother of 4, Northern Manitoba) They are only given money for transportation to medical appointments, and they check to see if they attended. If not, they don’t get a flight or money. (HCP Winnipeg)

15. Reasserting power They tried to make me come to Winnipeg on the bus on Sunday, but I refused. (Mother of 4, Northern Manitoba) Some of the women do hide in the community or out on the land so you can’t find them to send them at 36 weeks. (HCP Nunavut)

16. Prenatal Connections

17. Service Delivery Model 2-3 Prenatal visits Prenatal Standards and Clinical Practice Guidelines Postpartum visit Bi-weekly Healthy Parenting/Prenatal Education Group Access to community services ie swimming, Healthy Baby group, library Primary Care

18. Needs Assessment Validates Experiences and Guides Service Delivery Relationships Policies and Advocacy Continuum of care Mutual respect

19. Conclusions-Next Steps Long-term goal: Repatriation of birth Needs Assessment: 1 st step in Action Research Cycle Evaluation plan drafted

20. Acknowledgements Co-authors: Shannon Winters & Colleen Metge, CHI Evaluation Platform, Winnipeg Regional Health Authority Thank you to all members of the WRHA Prenatal Connections Steering Committee! References: Kornelsen, J. (2004). Canadian Woman Studies, 24(1). ; Kornelsen, J. (2006). Journal of Midwifery and Women's Health, 51(4); Kornelsen, (2010). Health and Place, 16(4); Lee Sinden, J. (2013). International Review for the Sociology of Sport, 48(5); Phillips-Beck, W. (2010). (Unpublished Master of Science). University of Manitoba, Winnipeg, MB; Telford Gold, S. (2007). Canadian Journal of Midwifery Research and Practice, 6(2), 5; The Maternal and Child Health Care Services (MACHS) Task Force. (2008). Advice to the minister of health.