Nearly two thirds of Indigenous people surveyed in Canada described mistreatment and disrespect during pregnancy and childbirth, a new report showed.

In addition, close to three-quarters reported disrespect from healthcare providers, according to findings from RESPCCT (Research Examining the Stories of Pregnancy and Childbearing in Canada Today), the country’s first national survey to examine respectful maternity care.

“It is surprising and dismaying to see the large gaps between the [Truth and Reconciliation Commission’s] Calls to Action and the continuing reports of loss of autonomy, disrespect, mistreatment, stigma, and discrimination during pregnancy and childbirth,” study leader Saraswathi Vedam, PhD, a midwifery professor at The University of British Columbia’s Birth Place Lab in Vancouver, told Medscape News Canada.

Overall, Indigenous respondents were more likely than White or other racialized respondents to report being ignored or refused care, having treatment withheld or forced on them, or hearing negative comments about their ethnicity or culture. Younger Indigenous respondents and those with Indigenous partners reported the highest rates of mistreatment and disrespect.

The study was published online on July 1 in Frontiers in Global Women’s Health.

‘Every Person Deserves to Feel Safe’

A Community Steering Council and a multistakeholder team codesigned the RESPCCT Study. The team includes current and future parents, clinician researchers (eg, doctors, midwives, nurses), sociologists, health professional association and hospital systems leaders, and community partners, Vedam said.

Data were collected from 6096 participants across all Canadian provinces and territories about their experiences with maternity care for pregnancies occurring between 2009 and 2022. Of the full sample, 309 people, or 6.7%, self-identified as indigenous to Canada, including First Nations, Inuit, and Métis respondents.

Using two measures developed for the study, an 11-item mistreatment index and a nine-item disrespect index, researchers compared the experiences of Indigenous, other racialized, and White respondents. Two hundred and thirty Indigenous participants completed the mistreatment items, and 232 the disrespect items.

The authors mapped the findings against Canada’s Truth and Reconciliation Commission Calls to Action and the United Nations Declaration on the Rights of Indigenous Peoples, identifying gaps related to the rights to security of the person, freedom from discrimination, culturally safe care, and free, prior, and informed consent.

Sixty-three percent of Indigenous respondents reported at least one form of mistreatment compared with 49.4% of White and 51.5% of other racialized respondents. Nearly 75% of Indigenous respondents reported at least one form of disrespect compared with 58.4% of White and 69.2% of other racialized respondents.

Regarding mistreatment, specific experiences reported more often by Indigenous respondents included being shouted at or scolded by a provider (28%), having treatment withheld or forced on them (31%), having requests for help ignored or go unanswered (34.8%), and having personal information shared without consent (19.4%).

Forced sterilization, though rare overall, was reported more often by Indigenous respondents than by the other two groups.

On the disrespect measures, 8.4% of Indigenous respondents said a provider made negative comments about their ethnicity, heritage, or culture compared with 0.6% of White respondents; 39.6% said they felt neglected during childbirth.

Within the Indigenous subgroup, respondents whose main intrapartum provider was a midwife reported lower rates of mistreatment (41.3%) than those cared for by a family physician or obstetrician (68.5%).

“These are not isolated incidents,” first author Wanda Phillips-Beck, PhD, adjunct professor of nursing at the University of Manitoba in Winnipeg, said. “They are manifestations of structural and interpersonal racism embedded within healthcare systems that continue to exert control over Indigenous bodies and decision-making. The data reveal egregious violations of Indigenous peoples’ rights within healthcare settings, exposing the profound failure of healthcare systems to uphold the protections affirmed in international human rights law.”

“Every person deserves to feel safe, respected, and supported when bringing a child into the world,” Vedam added. “Our hope is that this research contributes to meaningful change for Indigenous families and communities.”

‘Deeply Embedded’ in the Healthcare System

Addressing mistreatment and disrespect will require the kind of accountability systems already in place for other patient-safety issues, such as mandatory training tied to hospital privileging, alongside “community-controlled approaches to care that center safety, autonomy, and self-determination,” Vedam said. She pointed to concrete steps that health systems could take, including expanding access to Indigenous midwives, funding time for culturally specific practices such as ceremony, and building reporting systems in partnership with Indigenous communities and elders.

Providers can help by working with social services to reduce harmful interactions with or referrals to child protection services, she said, and advocating for system reforms that enable providers to spend more time with patients, accommodate ceremony, and compensate elders and knowledge keepers for their expertise.

Phillips-Beck told Medscape News Canada, “[n]othing about Indigenous health should be done merely for Indigenous peoples. It must be done with Indigenous peoples, led by Indigenous peoples, and ultimately benefit Indigenous peoples. We are challenging systems to move beyond measuring disparities toward changing the conditions that create them.”

Karen Lawford, PhD, Canada Research Chair (Tier II) in Indigenous Midwifery and associate professor in the Midwifery Education Program at McMaster University in Hamilton, Ontario, who was not involved in the study, told Medscape News Canada that the country “has an anti-Indigenous racism problem [that] is deeply embedded in our healthcare systems, including education, the health workforce, and within health institutions.” The study findings, she said, “should surprise no one.”

The paper should prompt hard questions, she said. “Why are there no repercussions for anti-Indigenous racism? Why are doctors, nurses, and midwives who enact anti-Indigenous racism allowed to keep working in their field?

“How can individual clinicians interrupt systemic anti-Indigenous racism?” she continued. “What are the roles and responsibilities of the board of directors and other institutional leaders where these acts of anti-Indigenous racism occur? What are the roles and responsibilities of healthcare provider colleges and associations, which are entrusted to keep patients safe?

“How does Canada benefit from anti-Indigenous racism, especially during pregnancy and childbirth? How many more research papers will it take before the Canadian public, healthcare providers included, believe Indigenous peoples?”

“To perpetrate anti-Indigenous racism during pregnancy and childbirth is deplorable, and foundationally violent toward all Indigenous peoples,” Lawford concluded.

The study was funded by the Canadian Institutes of Health Research. Vedam, Phillips-Beck, and Lawford declared no relevant financial relationships.

Marilynn Larkin, MA, is an award-winning medical writer and editor based in New York City whose work has appeared in numerous publications, including Medscape Medical News and its sister publication MDedge, The Lancet (where she was a contributing editor), and Reuters Health.