 And then with this, I am going to go ahead and I'm going to hand it over to Lizzie for her wonderful presentation. Hello, hello. Oh, there. Okay, now I can see I can drive. Alright, everyone's going to forgive me a little bit for learning this new software. Caitlin and I practiced. My name is Lizzie, and I'm really honored to be included as a speaker at this year's virtual International Day of the Midwife. As is true for a lot of us growing into our roles in midwifery, I stand on the shoulders of the midwives who've mentored me. And so I joined today as the newest in a lineage of Georgetown University midwifery students who've been mentored by Dr. Cindy Farley and who have participated in VIDM for the past seven years running. So we've got a tradition at this point. And not only this, but I'm speaking to you on the eve of the annual meeting of the American College of Nurse Midwives. So we're here in Orlando and the air is thick with us. There's lots of us. All right, I am a student of many things at Georgetown, not least of midwifery. So today I'm going to talk a bit about what makes midwives so perfectly poised to relate across cultures in the way that we're doing today as we gather in a global community. If we're discussing the art and science of midwifery, as is our theme this year. As a resident of the Circumpolar North, which is that region of the north of the globe, it feels like there's no better way to explore this idea than to look to the first peoples of this region who've practiced these birthing traditions and principles for millennia. I'm speaking to you today as an individual who lives, works, recreates and partakes in the harvest of unceded Dena'ina land in the place known as Anchorage, Alaska. I just wanted to mention off the bat that I don't identify as a member of any of the indigenous groups that I discussed today. And so I speak from a position of humility of curiosity and of commitment to doing what I can to elevate native voices. I'm speaking with you today about what maternity and childbearing looks like in the remote Circumpolar North, including some of the pervasive health disparities in these remote regions. I'll touch on how the examination of childbirth in this region challenges those of us who have been raised in the western colonial medical tradition to adopt a more global approach to care and to ethics. And then I'll share some selected traditional birth practices from the first peoples of the Circumpolar North. As Caitlin mentioned, we do have time for questions at the end. So I invite the yes. Um, okay, so first I was just about to set the stage. So I'm going to keep setting the stage. Um, when we talk about exploring other birthing cultures from our positions as midwives, I emphasize that it's not to become an expert in that culture. So much as it's renewing our commitment to health equity and exploring these ideas from a position of humility, right? We talk about cultural humility versus cultural competence. And I emphasize this because the historical trauma from colonialism, from structural racism, from casual and intentional researcher misconduct on indigenous populations is still felt acutely. And we could argue that this is no more true than in the care of women and birthing people. So I think it's fair to say that while the deep foundations for our work lie in the steady hands of granny midwives and of wise women and other revered female elders, in the modern era, we do know that the care of childbearing people is heavily influenced by the white and the patriarchal and the medical systems. So while we focus daily on advocating for physiologic birth on health equity within that western framework, on a broader scale, we do have a lot of work to do in making room for incorporating these culturally valued traditions into pregnancy in the birthing sphere. So how we reclaim these ancient, these really rich ancient ways of knowing about pregnancy and birth and childbearing is really exciting and a long overdue initiative that we as midwives are perfectly poised to undertake. Here's a few reasons why. First of all, we as midwives, we care for the whole person. We are advocates with that wide angle lens. We're really good at talking about how can I support this whole person and this person in the context of their circumstances. We support physiologic birth practices, which also means unlearning or re-exploring a lot of modern bias and reclaiming older ways. We are nimble both literally and figuratively in adapting the shifting pressures and powers and passages and passengers of our profession. And then finally, we're humbled on a daily basis by the power and the unpredictability of birth. And I think that humility that we practice on a daily basis is the key to us being allies and the reclamation and the sovereignty of birth by indigenous women and birthing people and indigenous midwives. So as we shift our lens northward, let's break down the title of this presentation just a little bit. When I say circumpolar, I'm referring to the land that borders the Arctic Ocean. So you can see on this map here, it's made up of the nine countries on the map, which include the United States by virtue of Alaska, Russia, Finland, Sweden, Norway, Canada, Iceland, and then Denmark by virtue of the Faroe Islands in Greenland. The Planix Arctic region is home to about four million people, about 500,000 of whom are indigenous today with higher densities of indigenous populations in those darker regions visible on the map. Indigenous is the term that I'm using to refer to the first peoples to continuously populate these regions, starting mostly after the last Ice Age. I have to emphasize these groups are not a monolith. The circumpolar north includes 27 regions and myriad indigenous nations and tribes who use different names to represent themselves and are recognized as sovereign to varying degrees by colonizing governments. A small percentage of originally nomadic peoples, for example, the Nanets in Russia, do remain nomadic today. So given the size of the region we're talking about, it does make sense that maternity care access is really challenging. Part of the reason the majority of these regions are considered maternity care deserts is because of that systematic displacement of indigenous midwives over the past several centuries. The systematic pathologizing of birth removed this integral ritual from the home and the community where it was traditionally often presided over by experienced birth attendants and steeped in those traditions. And it moved into the hospitals, which in this case are hundreds of miles away and which is where it remains today. In terms of population health, even though the countries of the north are some of the world's wealthiest, the chiefly indigenous regions of the remote Arctic still experience large health disparities. Some patterns of note in nations where indigenous people comprise the biggest proportion of the population, the disparity in health outcomes in this region also tends to be higher. These circumpolar regions with large indigenous populations experience high fertility rates and generally a younger median population, but they also experience lower life expectancy and higher rates of pregnancy loss. We see broad variation in infant mortality across this region with indigenous dyads mortality rate for indigenous dyads in certain areas of Russia being 14 times higher than we see in Iceland, for example, which is the best among the region. Maternal mortality rates are more challenging to find in the US, we're able to see that among American Indian and Alaska Native, the rate of mortality among Native women is two times higher than the national average. To honor traditional birth practices, I do think it's important to understand that the modern circumstances of birth in the north. In the current area, as I mentioned, the vast majority of pregnant people in the circumpolar north do give birth in hospitals. This is due in large part to policies regarding maternal transport. So mothers are moved, mothers are birthing people are moved at 36 weeks gestation by bush plane or by jet or whatever conveyance from their remote community to a maternal home or a hospital in a regional hub. What this looks like in practice is that a person's final month of pregnancy and even the birth is often spent hundreds of miles away from family and from community. Anecdotally, in my own personal clinical experience and from interviews and studies such as this New York Times article that I've screen capped here, mothers do describe a type of community that develops in these sort of dormitory like environments, but you can imagine the profound disruption that happens and that is inherent in this new Western custom around birth, which in many countries is actually reinforced by law or at least by insurance policy. So, for example, in regions where transport to outside services doesn't arrive in time or parents elect not to travel to maternity center, they might give birth at home. In the case of the Nenets who remain nomadic in Russia, they may birth on sledges or tents as they're following caribou herds, but it may also happen as we see in Alaska, for example, where families may decline the flight or they may go into preterm labor and start to labor before the flight happens. We are beginning to reach a bit of a tipping point in birth care in the north where it's increasingly clear how policies that evacuate these geographically remote families to hubs or to hospital centers in that last month of pregnancy can be harmful and expose individuals to bias to racism and to trauma. Well, the practices enable a more rapid access to those higher levels of care. I'm a NICU nurse by training and neonatal intensive care. So while we do see the benefits of this more rapid escalation to higher levels of medical care, it also prevents individuals from accessing those resources and that community support and those skills that they have in their community to navigate this really vulnerable perinatal period. So as I mentioned, I saw this play out this on a daily basis in the neonatal intensive care unit as a nurse in Anchorage. And in fact, this is largely what motivated me to become a midwife and also motivated my doctoral work in perinatal mental health. What is encouraging is that we see that policy being challenged and changed by indigenous and professional organizations across the circumpolar north. Recently, there are a few promising studies that have explored community birth led by indigenous midwives in Quebec and in Greenland. And when the majority of births took place in the community, parents valued the cultural support, they value the continuity of care, and we saw fewer obstetrical interventions were necessary. So that's who that's always really validating outcome. When we think about health disparities in the circumpolar region, they are due to a large part to these enormous treks of land that are sparsely populated. And so access to maternity care services, even in the best of circumstances, would be challenging. But further complicating this is the continued influence of colonialism that I mentioned before. And this is manifested through a lot of different ways. We see the forced relocation and centralization efforts. So this isn't just the maternity home model. This is also the historical forced settlement of nomadic peoples into fixed villages. We see this all throughout the modern day in history and development and resource extraction that's impacting access to subsistence foods. In Alaska, for example, we're talking about the Willow Project these days. We see it in the historical assimilation efforts that were aimed at erasing systematically erasing indigenous culture and language. And then, of course, the ever increasing burden of climate change. I do have to emphasize that climate in this case is not a tangential discussion. It's actually critically important if not the most critical critically important factor influencing long term maternity health. And that's because the poles of the planet actually experience climate change at twice the rate of the rest of the world. Meaning that this ongoing effect of rising seas and intensifying storms and thawing permafrost and enormous forest fires and changing migratory patterns, they're all impacting the health and well-being of indigenous peoples and all the peoples living in these regions to an outsized and disproportionate degree. So here on this map, for example, you see what access to maternity care looks like in Alaska where these darker regions on the map indicate zero resources, minimal or zero resources. And then, clockwise, you can see some of these dramatic impacts of climate change. Major floods in 2019, millions of acres of the Arctic burned in forest fires. And these are all threats to fresh air and clean water and access to food and reliable transport, whether planes can get in and out, that have immediate impacts on maternity care and care of preconception care, prenatal care, and postnatal and childcare. And especially for peoples who rely on this land. Okay, so I think that the pictures of the fires and floods are really important to ground us, but also can get a little bit bleak because they are. So I want to focus back on what we as midwives can do for communities experiencing the vulnerability that we work with every day in the remote and rural regions, such as those in the circumpolar north, but really everywhere. So when I mentioned valuing cultural support, this means the intentional and relatively seamless introduction of cultural values into the modern delivery of care. Members of a dominant culture often don't realize how often their cultural practices are seamlessly integrated with their health care. So for example, in my doctoral work, the depression screening scales that we use for perinatal mood disorders are not actually validated for nonwhite, nonwestern birthing people. And so that impacts our ability to accurately evaluate coping in this population. Talking circles are a way that traditional indigenous practices are not only being incorporated into modern medical care, but are supported in the literature as particularly effective. Talking circles are not necessarily unique specifically to the circumpolar north, but they do hold a sacred place in native communities throughout the US and Canada and elsewhere. So a talking circle starts with a prayer, usually by the person who calls a circle or by an elder, a sacred object such as a talking stick or a feather is passed around, the person who holds the object speaks, and all others in the circle can only listen. And this method prevents reactive communication and it promotes deep listening, and it's been explored in really cool ways in both Alaska and Canada, centering pregnancy models but sort of with indigenous roots, both in person and then in the COVID era, virtually to broaden access over large distances. Now, this is a little side plug. Among my other roles at Georgetown, I also a scholar of bioethics in the Pellegrino school of bioethics. And so I would be remiss if I didn't also mention how we can adopt this work of reintegrating ancient ways of knowing with the miracles of modern science in our approach to bioethics too. So one of the reasons that it's really important to promote indigenous reclamation of childbirth and of sovereignty over childbirth is that it brings with it the imperative to re-examine the ethical frameworks that we use to shape delivery of care in birthing families. So the principles of bioethics, as I learn them, and as most nurses in the US learn them, is grounded in fundamentally Western American colonial principles. Here in the US, it usually focuses on the individual. We talk about the principles of beneficence, of non-maleficence, of justice, autonomy, and we frame these historically from the perspective of the physician toward the patient. And I use those terms deliberately because this has historically been characteristic of the medical model. We think of the moral dilemmas of the good physician in service to a vulnerable patient. And so we think of the flow of information in this model in the shape of a triangle. It comes from the expert physician at the top and it goes toward the rest of the team and that team includes the patient somewhere in there. However, when we look at other cultures approaches to ethics, we often instead see a pluralistic model. So what does this mean? This means pluralistic means acceptance of multiple conflicting options as equally viable paths to moral good. So this is a really cool idea to me because when we take a pluralistic approach, there's no sole arbiter of the patient's fate, right? We don't have one person trying to cure a patient's illness because the goal isn't necessarily curative action by the physician toward the patient. And instead, success is defined by honoring a patient's values, by health promotion, by harm reduction, by prevention. All these things are really good at. So in this case, we can think of the flow of information as moving around a circle with the healthcare provider, such as the midwife, as part of that circle. And the patient we can think of either as part of that circle or more often right at the middle. And depending how complex we want this model to get, we can think about concentric rings of influence, right? The patient, the family, the community. In their 2007 book, African American Bioethics, Culture, Race and Identity, preeminent bioethics scholars, doctors Progre and Pellegrino, explore the question of whether in the United States there is a uniquely African American bioethical experience. And a host of American experts ultimately conclude that there is. The experience of black Americans is distinctive by virtue of systemic racism, of colonialism, slavery, with its own schema for what constitutes moral good. And this is really valuable for thinking about care in these environments with different populations. And so as a student of ethics myself and someone who chose to become a midwife and to work in the service of indigenous communities, I think it's also really important to consider how indigenous first peoples may also have a unique bioethical experience. And so adopting this pluralistic mindset could fundamentally reshape our approach to the care of indigenous birthing people. And I think a lot of the health disparities we see are direct results of that hierarchical triangle model that we see on the left and the systemic injustices that that model enables. So my thinking is what if we just as systemically adopt the model on the right? So that's my proposal for today. And of course, here's the big asterisk. When I say re-adopt, I really when I say adopt, I really mean re-adopt or restore this pluralistic approach to bioethics, because of course this idea comes from the ancient indigenous traditions of communal decision making, of storytelling as tools of healing and collaboration from this willingness to hold simultaneously these multiple perspectives as equally true. And so in this way, I think we're challenging ourselves. I think that challenging ourselves as midwives, as medical providers to adopt a pluralistic ethical approach, which aligns you'll find quite naturally with the midwifery model of care that we know and love, enables us to become partners in this ongoing work of reclamation of birth and promotion of birth sovereignty among our indigenous colleagues and communities. So re-centering the indigenous voices in the birthing sphere and also leveraging the capacities of modern technology. So we're thinking about telehealth, we're thinking about mobile ultrasound, home testing kits, medications by mail, all these modern miracles that we have to work with. They allow us to promote evidence-based care but grounded in the values and voices of our rural and indigenous communities. And so I think we can't talk about where we're going from here without honoring the practice and the passing of the talking stick. And so this brings me a little bit to sort of this next section of our time together where we talk about, we reflect about child birthing practices and different cultures and why we do it. Firstly we do it because it's really fun to learn how different groups celebrate momentous events across the world. But, and from an anthropological perspective, childbirth traditions facilitate social acknowledgement of milestone events and they foster community at the same time. Ceremonies that honor pregnancy and birth allow communities to formally welcome newborns and to support growing families. And they offer new families a sense of belonging and they signal to both parties the tangible and emotional assistance that's available that's being offered. Two families during the period of adjustment, which in the modern day is often quite a challenge. Knowledge of cultural practices is handed down through generations and so this continuity strengthens communities both laterally in the now time, but also longitudinally across that generational continuum. Traditional birth work is experiencing a grassroots revival right now as the recognition of these, the healing and caring methods in this work grows. And so we know that temporary relocation for childbirth has deleterious social effects and there's, as we mentioned, considerable support and desire for traditional communal birthing in combination with our modern techniques and technology. We know climate has had a really big impact on these northern communities. And so gaining a sense of the importance of birthing traditions and how historically birth has worked in these communities allows us to refocus on the Indigenous individuals at the center of their own care and work towards reclaiming the power and sovereignty over birth. Importantly, it signals to us as allies who are not necessarily part of these ancestral traditions to consider how we might help and have positive influence in that work as part of our clinical roles. So now we'll touch on some traditional cultural practices from around the polar region. I have select examples from the Nanetz people as in Russia, the Sami in Scandinavia and the American Indian and Alaska Native peoples in Alaska and the Inui of U.S. Canada and Greenland. These groups, I reemphasize, have ties that cross sociopolitical boundaries that are imposed and influenced by colonizers. So within each of these groups are different nations and tribes that carry their own customs, their own norms. And so while many folks share common ancestors, their separation from modern borders and tons of water and tons of land has resulted in changes. So as you can imagine, there is no way, no way at all to capture the nuance and breadth of tradition in this enormous region and this enormous time period that we're talking about in this super short little presentation. So I'm really just offering select examples of birth traditions in some of these regions on the theory that the awareness of these backgrounds could benefit midwives working with families from these regions and help make more person-centered care. Many of the traditions have been gleaned through stories from elders and they may or may not be part of the traditions of birthing peoples who present to care today. So I like to say this is just the tip of the iceberg, which feels like an apt analogy and just a quick reminder that while I honor the cultural traditions, they are not part of my own ancestral heritage. So when we get to questions, please pipe up with additions or corrections or updates if you haven't. Okay, first things first, how do we view pregnancy? One of the most lasting traditions to the extent that broad generalization is possible is that pregnancy is not infirmity and that hospitals can be a touch excessive in terms of approach to birth as a normal part of the life cycle. And in keeping with that idea, we see that often pregnancy is approached with pragmatism in traditional indigenous communities throughout the north, pregnant people more or less continue about their daily activities. You may know people who do that very gracefully. Traditionally frequent exercise and a nutritious diet have been honored responsibilities of the birthing person. For example, in Alaska, Alaska Native American Indian communities and Inuit communities in the north have encouraged pregnant women to be active after waking and also after eating. So we're thinking about walks or berry picking and the goal here being quite intentionally to ensure that the baby develops a strong heart and doesn't gain too much weight, all of which are known over long periods of time to complicate labor. The role of the father does vary by region. So in some cases he's very involved in preparations and in other communities such as the Nenets, the birthing preparations may not even be seen by the men. And so preparations can historically include collecting of sphagnum bark and birch pulp for diapers or maybe having a steam bath to promote circulation and also to avoid malpositioning of the fetus. In terms of nourishment, apart from berries, many of this subsistence cultures don't necessarily emphasize specific foods for pregnancy or birth other than a varied diet rich in protein during pregnancy. Because of course this diversity of diet is readily supplied by a subsistence diet. And then after birth, we see emphasis on easy to digest broths with protein for recovery and promoting lactation. And then there are some traditions of abstinence from certain types of food but traditionally have having more to do with the role of Christianity. In terms of laboring practices, the Nenets traditions focus around fire, which is considered the symbol of life. So a woman may labor on her hands and knees or squatting to position the baby's head towards the fire. And then when the baby crowns, she will turn her face to the fire alongside her newborn. Throughout the period of birth, the Sami honor the goddess Madaradka, the mother deity, she lives in the farthest place in the house from the hearth. And then Saratka is a fertility goddess and a protector of the family and the home. And she lives under the hearth. We see in the Inuit traditions stories and art pieces that illustrate a kneeling position of the midwife. So you see that here in the soapstone carving with support from behind. And we also hear stories about sawing a hole in the bed to prepare for the baby to descend through. So I think of that as like the original breaking the bed. And then many peoples in the region, including the Nenets in the Inuit, do value culturally the stoicism during labor. So that presents his limited vocalizations and lesser requests on pain medication or desire for pain medication. So who is there? Who's present at the birth? The major difference we see traditionally between the Nenets and the Sami is the role of the father in the birth. So for the former, the man's not necessarily present or involved at all and nor are male deities. And usually the birthing person is quite solitary in terms of making preparations and throughout the process of birth, with the exception being one helper once the child's been born. And so that person is called the mother of the umbilical cord and she's usually a spiritually pure person beyond childbearing who assists with the placenta and with everything else once the mother and the baby have been born. And the Sami tradition is actually quite the opposite. Men are not only involved in birth but traditionally there's actually lots of stories of men having fulfilled the role of the birth assistant and personally delivering the baby. And so there's broad variation of course across all these different traditions. And then among our Inwi and American Indian Alaska Native communities, we see a strong tradition of indigenous midwives being present at birth. Once the baby is born, all of the cultures of the circumpolar north emphasize immediately getting up and moving to stave off bleeding. This to me is a perfect example of the melding of the ways that ancient ways of knowing are being emphasized by modern science. Because this, here we have ancient knowledge of early ambulation addressing a phenomenon that western medicine has only just formally identified, which is a genetically heightened risk of postpartum hemorrhage and changes in different liver enzymes related to hemorrhage in this population. I think that's really awesome and validating. The Nanets have a postnatal walking tradition and the Sami mothers might immediately join a hunt traditionally. And then we see ritual cleansing after birth throughout the region. Nanets may undergo a ritual chaga wash and an herb smudge for both of the dyad as cleansing. Others may sweat, others may steam. And finally I'll close with blessings and prayers for the baby. There's been a resurgence among indigenous women and birthing people in reclaiming tattoos, which are traditionally bestowed for various rites of passage. And so we see facial tattoos being sewn into the skin for womanhood. And we see thigh tattoos being inscribed on the legs to honor motherhood. And that's so that the first thing the baby sees upon entering the world is beauty. To mark the birth, the Nanets say we managed to catch the running child. And they also rename the mother as well as the child. And in many of the Inui cultures, the baby is given an ancestor's name in order to honor the belief that babies carry the ancestor's spirit into the future. And so this final image is really, I think, one of my favorite in terms of illustrating our work that we're doing in promoting the rebirth of ancient knowledge in a modern world. And I hope to leave that with you today. I hope to leave you with a reminder that relating across cultures and that advocating for indigenous reclamation of birth, that acknowledging the ongoing traumas of colonialism, need not be an obstacle for us in the delivery of care, but it does require intention and humility. And so it's an opportunity, a challenge to all of us, and it's an extension of what we do every single time we manage to catch the running child. We hold the future and this ancient knowledge both in hand. We honor, we educate, we advocate. And as midwives, we always wonder, is there anything I can do to subvert the dominant paradigm today? Thank you. Here is my info. Of course, I can give you references upon request and please let's open up the floor. I welcome any questions and especially additions, corrections and other feedback. Thank you. Thank you so much, Lizzie. One of the questions in the comments is from Peggy and it says, I'm used to working with the Sumi in Norway. They usually do not give birth at home. Which time are you talking in your research? Peggy, thank you. This research is mostly traditional practices. So when we're looking at sort of pre-colonial periods and when we're looking at this idea of reclaiming ancient ways of knowing, the practices that have been ushered out with the advent of modern medicine and the influence of colonialism. And so I would love to hear more about your experiences because of course this is what I'm finding in my own searching in my own conversations. So thank you. And then let's see. Hannah says that was a fantastic talk, Lizzie. Are there any other questions? You can ask either verbally or put it in the chat. I think I mostly have my hype team here. That's just saying hi to me. Hi guys. Thank you everybody. I'm so excited. And of course, since this is recorded and this is just the beginning of this awesome whole conference that we are doing over the next 24 hours. My email, I'll put that in the chat is emj62atgeorgetown.edu. And so anyone who's listening down the line, please feel welcome to reach out and we can have some conversations.