Clients’ needs
Patients’ needs were identified by IBSWs as physical, emotional, cultural, and spiritual support. Acknowledging that many of their clients are going through difficult times, an IBSW said:
“Lots of people come from very difficult situations, like domestic violence, and they’re having stressful pregnancies.”
Clients and IBSWs expressed a concern that women—particularly those travelling from rural and isolated areas—may lack family support. Families frequently have work and family responsibilities and birth evacuation policies that only bring the patient, leaving them without support. Out-of-town patients may be left alone in an unfamiliar medical setting; thus, one client noted:
“I have a support person here, but she’s actually back on the reserve to handle her home situation, and then she’ll be back in a couple of days.”
This is also evident from another IBSW’s statement:
“I also feel like the people that come from remote communities or from up north; usually get flown in for emergencies, so they’re all alone, and they stay alone. Whereas people from Saskatoon can bring support or get support to come in if needed.”
As one client mentioned, health concerns, lack of family support, and unexpected surroundings can all contribute to increased stress:
“It’s pretty boring in the hospital. Since I’ve been here, I lacked sleep, tossing and turning. But, I had a good sleep last night, finally.”
IBSWs noted that clients’ health concerns, especially pain, may be overlooked or inadequately addressed. Both IBSWs and clients expressed concerns about ineffective pain management. An IBSW mentioned:
“I think, too, that sometimes when people [patients] say something about their pain, it’s dismissed. And they’re [patient] like, “I’ll just deal with it.” So they don’t even wanna own that they are in pain… they are quiet out of fear of worse treatment.”
Clients frequently required financial assistance or connections to community resources to manage additional needs such as childcare or transportation; accordingly, one client mentioned:
“I need to get on the assist program or the disability program, something like that, ‘cause I don’t want to apply for the CERB anymore. So, I want to get on whatever social support system while I’m here. And, I was trying to ask people if there’s any help in the government area, see if I can get a babysitting cheque for the person babysitting [other children at home] for me.”
Since clients may require assistance with childcare, housing, or other living expenses, one client described:
“That was my concern, being away from home. I need some assistance to pay my rent and then help my sitter out with the groceries and stuff.”
When clients are physically and mentally vulnerable without adequate support, daily living necessities can be more demanding. One of the clients indicated that cultural support would be valuable during difficult times:
“I would love more information and for [ceremonies] to be happening, for that to be arranged. I am going through a lot, and having some elder support would be very effective for helping me get through this time.”
IBSWs stated that they provide various services during pregnancy, labor, and postpartum. The clients are also referred by healthcare professionals familiar with the IBSW program. Prenatal education, birth plan development, labor and delivery support, nonpharmacological pain management, postpartum education and support, breastfeeding assistance, and other services. As an IBSW commented:
“It depends on when they come into the hospital. Some women come in as prenatal. Sometimes we catch ladies when they’re laboring and agree to have our support during their labor. So we’re there to help keep them calm and guide them through their labor. And even post-partum, sometimes we don’t meet the ladies until they’ve already had their babies. We’re there to help them with breastfeeding.”
IBSWs provide companionship and emotional support by creating a safe space and practicing empathetic listening. As one IBSW noticed, many clients may have experienced challenging life situations and require additional support, as reflected by this comment:
“When we work with prenatal patients, one of the biggest things we do is offer emotional support. People often come in from very difficult situations requiring someone to listen. And I feel like, with us, they’re more open. We just tell them, “I’m not going to judge you. You can tell me whatever you need to. I’ll help, however, I can.” They confide in us so much. So, lots of emotional support, lots of smudging.”
The clients expressed gratitude for the emotional assistance received during stressful times, particularly during the COVID-19 pandemic, when family visits were limited and family support, which is generally offered to most clients, was absent. A client mentioned:
“It’s just hard. But the support worker last night, she stayed with me late, keeping me company. We talked, and she was very helpful.”
IBSWs visited patients frequently throughout their hospital stay, educating them and entertaining them. This was helpful for out-of-town patients without family support. According to an IBSW:
“We all try to pop in every day, on a shift, to go see them, say hello. Introduce ourselves; We see if they need anything, like snacks or drinks. Ask if they want to try any of our activity stuff we have ‘cause we have adult calming coloring books, word search, and a bunch of things they could do. A lot of our kits are geared towards the prenatal to prepare for their babies.”
The patients also valued the one-on-one attention and assistance they received from IBSWs, particularly during the COVID-19 pandemic, as evidenced by a client's comment:
“The girls [IBSW] are super friendly and easy to get along with, so that was nice. My husband wasn’t able to be in the hospital much. So, they came in, so I wasn’t alone as much. And they had taught me how to bead, so that was nice to have something to do while I was just sittin’ around. Then they would run and grab me snacks and stuff if I needed it.”
As demonstrated by this comment made by an IBSW, respectful, culturally safe, and trauma-informed care improved the quality of the patient experience:
“I found them supportive, received a moss bag and beaded earrings. I came to the hospital in shorts and didn’t have anything. They brought me shoes and shampoo. I came to the hospital alone, so it was nice to have them. They were supportive, friendly and made me feel comfortable. It was great that IBSW took me upstairs (NICU) to see my baby right after delivery. She didn’t have to, but she did. I enjoyed my time with them.”
As evidenced by the IBSW’s response, they prioritized the client’s physical and mental health and respected their decision to seek services.
“I think it depends on their personal personality. Some people want to keep their birth process private, with just them and their spouse. So we’re fine with that.”
IBSWs also knew that many clients had previous negative experiences with the healthcare system and felt vulnerable. IBSWs asked permission before providing services, respecting clients' rights to choose the services they wanted. According to an IBSW, services were tailored to the clients' needs while giving trauma-informed care:
“We introduce ourselves. Tell them we’re on for our shift, and we’ll pop in now and then if they allow us to. Again, we always ask for permission. I think that’s really important.”
IBSW observed that many clients were unaware of their rights or their eligible services. IBSWs frequently assisted clients in obtaining additional services they required, as demonstrated by the following client comment:
“Also, they put me in touch with a couple of people able to come and advocate for me, on my behalf, with the CFS, to help me get my daughter back into my care. So that was really good. They’ve been helpful for everything.”
IBSWs are familiar with the negative encounters, racism, and substandard care encountered by many indigenous women in healthcare settings and recognize that clients may be reluctant to express their needs. IBSWs ensured that clients felt safe and received the required care during hospitalization. An IBSW provided the following account:
“A lot of Indigenous women are just happy there’s added support for them. Because many indigenous women, from anywhere, have often felt displaced in the medical and hospital settings. Many have experienced prejudices towards them, mistreatment, or just not feeling safe within the healthcare system.”
As attested by the following comment, clients expressed relief at the prospect of receiving assistance from IBSWs if their family members could not be present during delivery:
“It was nice to know that if my husband couldn’t come in, to make it had I gone into labor. If he couldn’t make it in time, there would be someone I already had a relationship with who could come in and be a support if he couldn’t be there. That helped my mental health, for sure.”
IBSWs understood the importance of establishing trustworthy relationships with clients to comprehend their needs and provide necessary services. IBSWs seek to provide a welcoming and nonjudgmental environment for clients and their families. As indigenous people, IBSWs are familiar with cultural protocols and the importance of establishing relationships to foster trust with clients and their families, as demonstrated by this comment:
“When I go into a room and introduce myself, I often try to be a part of their family. I just say, think of me as your sister, your aunty, your Kookum, your friend.” And I do whatever I can to make their stay comfortable and safe.”
IBSWs ensured that clients' healthcare concerns were adequately addressed. IBSW staff educated patients on how care is coordinated and connected them to appropriate hospital and community services. They advocated for their rights and ensured that mistreatment or substandard care incidents were addressed. This is clear from an IBSW's statements:
“If they felt like they were mistreated during their experience in the hospital, we let the managers know so they could further investigate and talk to those patients about why things were done the way they were done. So, they’re not being sent out traumatized from their experience in the hospital.”
IBSWs informed clients about postpartum health warning signs and urged them to notify healthcare providers if their health concerns worsened. IBSWs aided clients in managing their pain and advocated for their healthcare needs, ensuring they were met promptly. This is demonstrated by the following comment made by an IBSW:
“I have gone to a nurse, saying, “This patient is in pain, but she’s scared to ask for any medication because she feels like there are prejudices against her.” And the nurse is fine with checking her over and getting her some pain medications she needed. But some women are too timid to even ask because many women are labelled [as drug seeking].”
When clients collaborated with IBSWs, they felt a sense of security. IBSWs assisted clients in resolving their concerns when they expressed dissatisfaction with their treatment or believed they were being mistreated, as evidenced by the following client comment:
“I have had been experiencing some stigma, specifically last night, and I made a complaint, and a different doctor was put to take care of me instead of the other one. But the support worker helped advocate that for me and helped me make that complaint. And I don’t think I would’ve if she wasn’t there.”
IBSWs assisted clients who may require additional assistance in monitoring their health status, advocating for themselves in the healthcare system, and receiving timely care.
Cultural support
IBSW program components include culturally responsive treatment, access to indigenous health, traditional birthing practices, and education. IBSWs provided elder connections and cultural access, such as smudging. IBSWs arranged elders, prayers, and ceremonies as requested by clients. They use storytelling to connect clients to traditional preconception, pregnancy, labor, and postpartum teachings. Patients could participate in beading, artwork, and traditional crafts. Traditional arts were introduced to help patients avoid undue stress during hospitalization. The artwork is a memento the mother can take home after childbirth. IBSWs connected clients to their cultural background through activities, reintroducing birthing as a ceremony. An IBSW illuminated:
“We try our best to gift belly button pouches; any Indigenous person with a baby is gifted a pouch to keep the umbilical cord. It’s a small thing that might seem like- it doesn’t mean much to anybody else, but it’s part of you and your baby. It’s a sacred item to look after. We’re trying to make that more mainstream here. We try our best to touch base and give them those pouches.”
These activities were well received by clients, who valued the cultural education and personalized gifts made for them and their infants, as evidenced by the following client comment:
“I received a moss bag and beaded earrings. I really like the Indigenous support. Mom is Cree, and Dad is Dene. I really liked the moss bag. I liked that it was made for me, and they helped me understand its meaning as I didn’t know what it meant, but I knew I would want one for my baby someday.”
IBSWs recognize the rich and diverse cultural heritage of indigenous peoples. They provided cultural support and services but acknowledged that they lacked knowledge and understanding of the various indigenous cultures and languages. While they could offer prayers and smudging, they respectfully informed clients they lacked the same knowledge and wisdom as community elders and Knowledge Keepers. The IBSWs' perspectives are reflected in the following comments:
“There are so many tribes. There’s Cree, Dene, Saulteaux, and Dakota. We don’t know everybody’s specifics except for our own. We’re not all fluent in our languages; we’re all learning. And I can’t do a full-on prayer [in the language]. I can’t provide them with spiritual comfort like that. Yes, I can bring in smudge; I can sit there and smudge with them, pray in my mind. But I can’t do all the things an elder can do.”
As an IBSW remarked, cultural services are frequently sought by clients. "I have gone into rooms, brought moms to smudge occasionally, and they ask, "Can you say a prayer for me?" Clients who received such assistance expressed gratitude acknowledging that it made them feel better; as one client stated, "I smudged today, and it made me feel better." Clients and families felt that their culture and traditions were recognized and respected, as evidenced by a client:
“I like she’s thorough. She makes sure that we have the information we need. I like that she gave us pamphlets on the different traditional teachings and the little belly button pouch. And it was comforting to know those were offered services here at the hospital, ‘cause I felt like it represented us as a family and what we would want in our baby’s care.”
While promoting the culture, IBSWs had to navigate the tensions between evidence-based Western practices and Indigenous ways of knowing, as an IBSW revealed.
"Fathers have asked me, 'Can you teach me how to make a moss bag?' I've also instructed the fathers on how to construct an Indian swing, as this is another of our teachings. However, we should not promote it because it can result in liabilities within Western care models. However, we have followed these practices for hundreds of thousands of years. Therefore, it's not that bad. I always inquire; I always attempt to include men. And if a sister or Kookum is involved, I incorporate their ideas. Typically, they already know, so they are already performing the tasks we assist with. It's wonderful to observe that.”
IBSWs and clients reported that family participation was reduced due to COVID-19 safety protocols, which had a detrimental influence on the client's well-being because assistance from family members was unavailable. Lack of support can be especially traumatic with prenatal bereavement, as evidenced by a comment made by an IBSW:
“COVID changed a lot of things for how our people like to celebrate and how we also mourn when there’s a loss. ‘Cause it’s big to have your support there. Even with a delivery. Even with a loss. It balances itself all out with all that stuff when you have your family and friends there to support you.”
Experience with healthcare
IBSWs found that clients frequently struggle to communicate their needs to healthcare practitioners and that their requests are commonly ignored or unmet. As an IBSW reflects:
“There have been prenatal patients who come in with a lot of pain, and they feel like they don’t want to ask the nurses for pain medication ‘cause they feel like they’re being labelled as drug seekers, but they don’t know the cause of their pain until it’s diagnosed. So, a lot of times, some women didn’t feel… safe or heard in telling their nurses.”
IBSWs observed poor pain management or delays in treating health conditions, which can result in more intensive procedures later or become potentially life-threatening, ending in suboptimal care for the patient, as illustrated by an IBSW:
“She [patient] was suffering from a hematoma. So, it’s like an internal hemorrhage that could’ve been caught sooner. However, luckily, they controlled it in the OR. So, her and her partner were complaining about that ‘cause they didn’t feel they were treated fairly. They felt like the nurse was rude to them.”
Clients also mention instances when their pain was not addressed adequately, increasing their discomfort, making them feel helpless, and minimizing their concerns leading to suboptimal care and dissatisfaction. This is evident from a client’s comment:
“She [doctor] wasn’t taking me seriously when the doctor came back in; she was being very condescending about my pain. And I, again, would try to make eye contact with her, try to explain, “Yes, I’m still in pain. I’ve told you this often now.” And she wasn’t giving me a good standard of care. But I was getting very hurt because it felt like she was intentionally not taking what I was going through seriously.”
Other clients were reportedly satisfied with the care received, as evidenced by a client's comment: “Everybody has been very kind and let me know, communicating properly and everything. It’s been good so far.” Another client mentioned, “Some of the nurses I have are good, and they check in frequently.”
IBSWs mentioned that sometimes the client’s involvement was minimized during labour and delivery. Clients often felt ignored and excluded, leading to dissatisfaction with the care received. This was evident from the IBSW comment:
“Just making them feel important. ‘Cause sometimes it’s just like, Hi, I’m blah, blah,” and then deliver the baby and they’re [healthcare provider] gone. “Okay, I’m onto the next delivery! So that connection with them is important. It’s just validating that woman’s presence. She’s there to have the baby, but she’s also there- she’s gonna remember everything here. They [patients] feel like they blend in with everything else like they’re not important enough.”
All clients were very satisfied with the care, support, and services received from the IBSWs. One client mentioned, “I enjoyed my time with them; it's good; they were the most help out of everyone.” Other clients commented that the IBSWs were approachable and compassionate, as is evident from this client’s comment: “They’re really helpful, and they’re supportive. They check on me daily and make sure that I’m doing okay, they’ve been very helpful during my stay here.”
Communication
IBSWs stated that many healthcare providers were uninformed of the IBSW practice. Occasionally, IBSWs were mistaken for nursing personnel or social workers, causing confusion, as evidenced by an IBSW comment:
“I’ve been confused with- I’d be in with a client, in the room, and a doctor would walk in and ask the questions she needed to, and then looked at me and said, “Did I do everything? Is there anything else?” I always have to say, “No, I’m just the IBSW.” And then she’s like, “Okay,” and then leave the room. So not everybody knows who we are.”
According to IBSWs, sharing information on indigenous birth practices and the procedures they follow will increase the understanding of indigenous birth traditions among healthcare teams. IBSWs assert that this will ensure the reliability of those practices and teachings. As evidenced by this IBSW's remark, improved communication between healthcare teams and IBSWs will increase referrals, uptake, and the quality of care provided:
“We do have a strict way of doing things. .. the teachings of our knowledge. I think that’s where the knowledge is lacking. If the staff have questions or if they don’t know what we’re doing is right, they can ask us or our knowledge keepers, who have trained us, for more information. Just so we can get that ground-level understanding and not second-guessing one another, we can work as a team to deliver that care.”
IBSWs successfully created a trusting relationship with their clients, especially while providing prenatal support, which is beneficial when clients return for delivery. The following comment from an IBSW demonstrates this:
“We have seen a few where they’ve been prenatal for a while; we’ve all gotten into contact, all got to visit with this certain individual. They had their baby post-partum care. They came back again because of issues with the surgery they had. They look forward to seeing us. And I look forward to seeing them, even though the circumstances aren’t great for her to be back here. She knows we’re there. I think they appreciate that too.”
Clients expressed satisfaction with their interactions with the IBSW, who was approachable, empathetic, and assured that the clients' needs were addressed, as indicated by these client's comments:
“They come and talk if I want to get something off my chest; they want to talk. They let me know they’re there whenever I need them. I feel like it’s just warm welcoming with them. All of them came and introduced themselves.
Recommendations suggested by IBSWs and clients
IBSWs proposed notifying clients about the program and establishing a link before arriving at the hospital. This will particularly benefit women travelling from remote areas. A client reflected:
“I was actually surprised there was a program happening here. And then I thought it was a great idea to have that. I asked if there were any more programs, maybe in the north or elsewhere. And it’d be cool if there was. I think its really good, you guys are doing that.”
IBSWs say many Indigenous communities have limited prenatal and other healthcare services. Due to lack of transportation, childcare, and racism, some urban residents cannot attend prenatal classes, which can prepare them for delivery and parenthood. IBSWs acknowledged the importance of prenatal education for women in isolated and rural regions. They proposed that engaging with women earlier in pregnancy could provide opportunities to discuss previous trauma and healthcare concerns and build rapport. This will guarantee that women are supported and feel more comfortable in hospital settings. An IBSW noted:
“It would be nice to get to know them during prenatal. So, if they have past traumas, to help them heal from so their birth experience can become pleasant, instead of always going into it scared and traumatized.”
Indigenous peoples are a diverse group with distinct languages, traditions, and cultural practices. IBSWs who know their own culture may lack the information to provide specific spiritual support to women from other backgrounds. Elders from their respective communities are needed to conduct ceremonies and prayers and spiritually guide women. IBSWs recognized that through mentorship from Elders, they could adequately support the clients. A female elder was needed to assist pregnant and postpartum women. An IBSW expressed:
“To have an elder come in, as we’re not all fluent in our languages; we’re all learning. And I can’t do a full-on prayer [in the language]. And I can’t provide them with that spiritual comfort like that. But I can’t do all the stuff an elder can do. We’re not qualified [elder] for that. And a lot of times, women need that. Our women need that here. It doesn’t matter if they’re Dene. It doesn’t matter if they’re Saulteaux. Cree. Sometimes just having that person [elder] there to do that as a spiritual advisor is super important for us.”
According to IBSWs, clients often seek help from elders or spiritual advisors during prenatal loss. Elders' support is critical in providing spiritual direction, consolation, and healing and was not available in the IBSW program: “during losses, some people want a priest, or they want an elder, and we don’t have an elder to provide women when going through miscarriages or anything.”
IBSW underlined the need to build relationships with communities and community birthing knowledge keepers so that women, particularly those from isolated and rural communities, feel comfortable and protected while in the hospital. Creating relationships can help clients adjust to their new surroundings. An IBSW illustrated:
“If we integrate with the community, their elders, and their ways of knowing...Communicating with traditional midwives in communities or birth doulas and allowing the space to connect and work with them and build that relationship so we can call upon them. When a community member comes into our space, we can have that communication and that relationship with the community; I feel like it would benefit the women. So they don’t feel like they’re in a foreign place, away from their people. And they’re seeing new faces; they don’t know if they can trust or open up to seek services. Because a lot of them are closed off in that way.”
IBSWs indicated a need for improved communication and training of health care providers and client education about pain management. IBSWs confirmed that clients encountered discrimination, substandard care, and dissatisfaction with pain management. As is evident from this comment:
“They just felt like they were being labelled when something was going on, and they were in pain... they felt that the nurses treated them wrongly or like their pain wasn’t valid. So those have had to be dealt with.”
IBSWs suggested increasing healthcare professionals' and clients' awareness of the program's scope and services and improving system integration.