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Primary birthing attendants and birth outcomes in remote Inuit communities—a natural “experiment” in Nunavik, Canada
  1. F Simonet1,
  2. R Wilkins2,3,
  3. E Labranche4,
  4. J Smylie5,
  5. M Heaman6,
  6. P Martens7,
  7. W D Fraser1,
  8. K Minich8,
  9. Y Wu1,
  10. C Carry9,
  11. Z-C Luo1
  1. 1
    Department of Obstetrics and Gynecology, Sainte-Justine Hospital, University of Montreal, Montreal, Quebec, Canada
  2. 2
    Health Information and Research Division, Statistics Canada, Ottawa, Ontario, Canada
  3. 3
    Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
  4. 4
    Nunavik Regional Board of Health and Social Services, Nunavik, Quebec, Canada
  5. 5
    Department of Public Health Sciences, University of Toronto, and Centre for Research on Inner City Health, St. Michael’s Hospital, Toronto, Ontario, Canada
  6. 6
    Faculty of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada
  7. 7
    Manitoba Centre for Health Policy, Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
  8. 8
    Department of Community Health Sciences, University of Toronto, Toronto, Ontario, Canada
  9. 9
    Inuit Tuttarvingat, National Aboriginal Health Organization, Ottawa, Ontario, Canada
  1. Dr Z-C Luo, Department of Obstetrics and Gynecology, Room 4986, CHU Sainte-Justine Hospital, 3175, chemin Côte-Sainte-Catherine, Montreal, Quebec, Canada H3T 1C5; zhong-cheng.luo{at}


Background: There is a lack of data on the safety of midwife-led maternity care in remote or indigenous communities. In a de facto natural “experiment”, birth outcomes were assessed by primary birthing attendant in two sets of remote Inuit communities.

Methods: A geocoding-based retrospective birth cohort study in 14 Inuit communities of Nunavik, Canada, 1989–2000: primary birth attendants were Inuit midwives in the Hudson Bay (1529 Inuit births) vs western physicians in Ungava Bay communities (1197 Inuit births). The primary outcome was perinatal death. Secondary outcomes included stillbirth, neonatal death, post-neonatal death, preterm, small-for-gestational-age and low birthweight birth. Multilevel logistic regression was used to obtain the adjusted odds ratios (aOR) controlling for maternal age, marital status, parity, education, infant sex and plurality, community size and community-level random effects.

Results: The aORs (95% confidence interval) for perinatal death comparing the Hudson Bay vs Ungava Bay communities were 1.29 (0.63 to 2.64) for all Inuit births and 1.13 (0.48 to 2.47) for Inuit births at ⩾28 weeks of gestation. There were no statistically significant differences in the crude or adjusted risks of any of the outcomes examined.

Conclusion: Risks of perinatal death were somewhat but not significantly higher in the Hudson Bay communities with midwife-led maternity care compared with the Ungava Bay communities with physician-led maternity care. These findings are inconclusive, although the results excluding extremely preterm births are more reassuring concerning the safety of midwife-led maternity care in remote indigenous communities.

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  • Competing interests: None.

  • Funding: This work was supported by a research grant from the Canadian Institutes of Health Research—Institute of Aboriginal Peoples’ Health (CIHR-IAPH, grant reference no. 73551- ZCL). Miss Simonet was supported by a PhD studentship from the CIHR Strategic Training Initiative in Research in Reproductive Health Science. Dr Luo was supported by a Clinical Epidemiology Junior Scholar Award from the Fonds de Recherche en Santé du Québec (FRSQ), and a CIHR New Investigator award. Dr Heaman was supported by a CIHR New Investigator award, Dr Smylie by a CIHR-IAPH-AMS Senior Research Fellowship, Dr Martens by a CIHR New Investigator award and a CIHR/Public Health Agency of Canada Applied Public Health Chair, and Dr Fraser by a CIHR Canada Research Chair award.

  • Ethics approval: The study was approved by the research ethics board of Sainte-Justine Hospital, University of Montreal, and the Nunavik Nutrition and Health Committee.