Ohpikihâwasowin (grounding and guiding on the path to be a healthy parent): virtual adaptation of an Elders mentoring program to support maternal and child wellbeing during the COVID-19 pandemic

Abstract

Background

The Elders Mentoring Program (EMP) is part of a strengths-based community-based participatory research partnership with the Cree communities of Maskwacîs, Alberta, Canada. The EMP objective is to promote maternal and child health through traditional Cree teachings and support from community Elders to pregnant women and their partners. During the COVID-19 pandemic, the Elders decided to shift the program to an online format in early 2021. The Elders continued to offer mentorship to program participants virtually by Zoom and telephone, and online workshops. The objective of this study was to qualitatively explore the experiences of women that took part in the virtual EMP.

Methods

We utilized qualitative description as our method, informed by our overarching community-led research partnership. Semi-structured phone interviews were conducted by Maskwacîs research assistants (RAs) with 11 women who participated in the virtual program. Interviews were conducted between December 2021 and June 2022. The participants were asked about their perceptions of the program and its benefits. The interviews were recorded, transcribed, and coded by four RAs using thematic analysis.

Results

Although cultural teachings are traditionally offered in person, the shift to the virtual platform was greatly appreciated by all the women. Technology can be a useful tool for cultural teachings and language to be shared among community members when they cannot be physically together. Four main themes emerged from the data, representing the participants’ experiences, and learning through their interactions with the Elders from the EMP. The themes are: Ohpikihâwasowin (grounding and guiding on the path to be a healthy parent); Indigenous ways of healing; On the path of cultural learning; and Identity for self and baby.

Conclusion

The virtual adaptation of the EMP allowed a space for Elders to offer support to women living in and out of the community to provide guidance with their pregnancies and into motherhood. The workshops and one-on-one calls allowed for cultural revitalization which is critical for Indigenous well-being. All the participants found that the teachings and interactions positively impacted their pregnancy and parenthood. Overall, the virtual program demonstrated a venue for intergenerational healing and resilience.

Background

Indigenous peoples across Canada have made significant efforts to revitalize their traditional teachings and practices relating to pregnancy, birth and parenting [1,2,3,4]. Due to the intergenerational and ongoing consequences of colonialism, Indigenous women are at heightened risk of experiencing complications during pregnancy resulting in higher rates of maternal morbidity and mortality [5]. Pregnant Indigenous women also frequently need to manage a range of socio-psychological stressors such as stressful life events and social disadvantage that may negatively impact their well-being [6, 7]. The Truth and Reconciliation Commission of Canada Calls to Action includes a series of actions intended to “redress the legacy of residential schools and advance the process of Canadian reconciliation.” [8] Call to Action 22 calls upon “those who can effect change within the Canadian health care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients in collaboration with Aboriginal healers and Elders where requested by Aboriginal patients” [8]. This study demonstrates the value of incorporating Elders and Indigenous cultural teachings into prenatal programming and services. This work builds upon a long-term and established community-based participatory research (CBPR) partnership between Maskwacîs community members, and researchers at the University of Alberta. This study examined the program participants perceptions of the online format of the in-person Elders Mentoring Program (EMP). The EMP provided traditional Nêhiyawak (Cree) teachings and support to pregnant women and their partners.

Birth workers across Canada have reported that pregnant Indigenous women were more impacted by the COVID-19 measures in comparison to non-Indigenous pregnant women [9]. Public health restrictions resulted in many medical appointments being shifted from in-person to virtual, which was inaccessible for many Indigenous women who did not have adequate speed or stability in their internet connection [9]. Others avoided healthcare services out of fear of contracting the virus and potentially passing it onto Elders since many Indigenous people live in multi-generational households [9]. COVID-19 impacted the availability of options, health services, and cultural supports for family planning, prenatal care, delivery and postpartum health and wellness [9, 10]. Social distancing measures may also reduce social supports and access to ceremony being constrained by physical distancing requirements [11]. Moreover, throughout history, due to social inequalities and the intergenerational impacts of colonialism, Indigenous peoples have been disproportionately impacted by pandemics and infectious diseases such as smallpox, influenza, cholera, tuberculosis and measles, and most recently, COVID-19 [12]. Despite the disproportionate impact of pandemics on Indigenous peoples throughout history, Indigenous communities and peoples have also demonstrated resiliency demonstrated by the survival of their oral histories, tribal memories and traditional stories [12].

A systematic review of Indigenous approaches to treatment of perinatal mental health found that perinatal social supports that are culturally relevant are critical for the well-being of Indigenous mothers [13]. Social supports that included extended kinship networks constituted models of perinatal care that were culturally grounded and regarded culture as health. Indigenous self-determination, identity and custom were also critical for positive health outcomes for Indigenous mothers [13]. Strong relationships with Elders has been found to improve and strengthen perinatal care for Indigenous women [3, 14]. The inclusion of Elders in healthcare has benefits for the mental well-being of parents as it provides a space for parents to speak openly about the challenges of pregnancy and parenting that can be connected to intergenerational trauma, poverty, and ongoing colonization, filling an important gap in perinatal care for Indigenous women [3].

Ethics

This research received ethics approval from the University of Alberta Research Ethics Board (Pro00091138) which adheres to the Tri-Council Policy Statement 2, Chap. 9: Research Involving the First Nations, Inuit and Métis Peoples of Canada [15]. The research team also obtained community approval from key Elders, knowledge keepers, and community members who were specifically identified by the Community Advisory Committee (CAC) for this project. Those identified were approached with community-appropriate protocol and engaged in one-to-one meetings to discuss the intent of the CBPR partnership, the EMP, and the planned research. Verbal approval was given in these meetings. Also, prior to the generation of data, a research agreement was collaboratively drafted by the CAC and signed by the Elders on the CAC as well as the Chief Executive Officer of Maskwacîs Health Services, whom liaises all research within the community to leaders of the four Nations of Maskwacîs. The research agreement described, at the behest of Maskwacîs Health Services and the Elders on the CAC, that all generated data is co-owned between the community and researchers, with storage during active research at the University of Alberta and is made available to the community, if needed. Long-term storage of study data is at Maskwacîs Health Services, within the community. The CAC was involved and made decisions at all stages of the project, providing ethical counsel, and ensuring research moved forward in culturally and community appropriate ways. All interview participants provided written or verbal informed consent.

Study design

Research partnership

This phase of the research was part of a larger ongoing CBPR project in partnership with the Cree communities of Maskwacîs (which includes Samson, Montana, Louis Bull, and Ermineskin Cree Nations) and researchers at the University of Alberta. Maskwacîs is a rural community located in central Alberta in Treaty 6 territory. The researchers have been working in partnership with the community since 2013, uniting as the Wâhkohtowin research group [3]. The research team is based on the guiding principle of Wâhkohtowin - we are all related, and therefore trusting relationships are foundational to the team’s aim to understand the unique needs of women and families within the community and to improve women’s perinatal health and family well-being using community-led and strengths-based strategies. For our research group, a strengths-based approach meant avoiding focusing our research on community deficits, problems, health disparities, or pathologizing Indigenous peoples, and rather utilize a lens that leverages community resilience, opportunity, hope, and capacity and centers on Indigenous knowledges and cultures [16, 17]. The CBPR approach uses an experiential, participative-knowing epistemology [18]. Fundamental to this approach is the knowledge that community members are in the best position to realize and understand their own context with the knowledge necessary for research that will benefit their own community [19].

Elders Mentoring Program background

The EMP is a strengths-based community-derived program with the objective of Elders promoting maternal and child health through traditional Cree teachings and multi-dimensional support [3]. The program was developed through our research group with the intention of expanding beyond what is typically offered in mainstream healthcare for pregnant women and their partners [3]. The EMP was first launched in 2016. The program was offered solely at an off-reserve clinical setting where most of the pregnant women from the community receive prenatal services in a neighboring town. The EMP currently includes three Elders and is guided by the CAC which includes Elders, university researchers and community members. The CAC coalesced based on established kinship and relationships, and met regularly to review and decide on all aspects of the research. The details of the in-person EMP has been described in detail in a previous publication by the authors [3].

In March 2020, the COVID-19 pandemic healthcare guidelines resulted in the suspension of the EMP. The Elders, who wanted to continue to offer their support to Maskwacîs pregnant women, decided to launch a virtual version of the EMP, and the CAC worked together to devise how virtual interactions could occur. The Elders preferred to offer their support by phone or Zoom calls. In January 2021, social media (Facebook and Instagram) was used to promote the new virtual version of the program in the community. Elders started connecting with women online to offer their support. Although the program focused on maternal health, during the pandemic, Elders provided broader advice to the program participants in need of cultural guidance. The Elders recognized that there were other methods that they could provide support which led to the creation of Pimatisiwin Mamahtâwan - Life is scared/wondrous workshops, which were a series of six bi-weekly 90-minute Zoom sessions centered around the medicine wheel and traditional teachings on preconception, pregnancy, postpartum, early years, and parenthood. Between January 2021 and June 2022, the EMP Elders interacted with more than 30 women through one-on-one calls and workshops. Some of them were Maskwacîs community members but living off-reserve, and others were Cree women living in other areas of the province.

Data generation and analysis

We used qualitative description to understand experiences of participants, a method that stays close to participants’ words to generate rich, straight descriptions with ‘low interference’ data interpretation [20]. Qualitative description fit specifically with the wishes of the CAC for the portrayal of the genuine voices of participants, and yielded findings in a language similar to that of participants. Between December 2021 and June 2022, semi-structured phone interviews were conducted with women that interacted with the Elders either through one-on-one phone or Zoom calls and/or participated in the online workshops led by the Elders. For recruitment, research assistants briefly discussed the possibility of being involved in the qualitative study with women that engaged the virtual EMP to interact with Elders. Not all women were interested in taking part in the research component, and only interested potential participants ‘self-selected’ and provided their contract information to the research team. Those that provided their contact for research were later contacted for recruitment. To be eligible, participants had to have had at least one interaction with the Elders in the program either through attending a workshop or by connecting with an Elder over zoom or the phone. The objective of the interviews was to learn about their experiences of the new format of the program. A total of 11 interviews were needed to reach data saturation, the point when no new information or insight emerged, and when the categories were well defined [21].

The interview guide was developed with the CAC, and has not been published elsewhere (see supplementary file). Three research assistants (RAs), two Maskwacîs-based RAs and one university-based RA, conducted interviews over the phone. All interviews were audio recorded and transcribed verbatim. None of the participants were fluent in their ancestral Indigenous language, and all participants preferred their interviews were conducted in English. Interviews were between 20 and 60 min in length, with an average of 35 min. Both manual transcription and Otter.ai software-based transcription was used.

Four RAs analyzed the transcripts using an approach informed by thematic analysis [21] and adapted to the CBPR context in Maskwacîs. The four RAs had different backgrounds, with two of them being community members, one a mom and the other a young woman. Their backgrounds and knowledge of the community helped to get a better understanding of the data and context of the participants’ voices and experiences. The RAs utilized NVivo software to organize the data, code the data, and categorize themes. The data generation/collection and thematic analysis occurred concurrently. The thematic analysis steps followed were:

• 1. General coding/theming of transcripts, focusing on the guiding question.

• 2. Identifying emerging themes from participants’ quotes around participants’ experiences with the virtual format of the EMP.

• 3. Providing context to the quotes based on lived experiences from community RAs.

• 4. Building a data analysis matrix on Excel with the themes, categories, and quotes representative of the data to better conceptualize the themes that encompassed participants’ experiences with the virtual version of the EMP.

• 5. Verifying the findings, reducing redundancy, and ensuring accuracy and community appropriateness with research participants, the Elders, and members of the CAC.

Members of the CAC had access to raw data if need be. Data collection and analysis ended when no additional insights emerged and when categories were well defined and refined. Our research group and CAC identified core CBPR principles specific to Maskwacîs: trust, building strong relationships, mutual benefits, equitable partnership, shared knowledge, incorporating cultural teachings, and action-oriented and strengths-based research. Adhering to these principles ensured rigor in our study.

Findings

Of the 11 total participants, three were pregnant while participating in the EMP and eight were parents. The interviews revealed four key themes about the EMP participants’ experiences and learning through their interactions with the Elders from the EMP. The four themes are: Ohpikihâwasowin (grounding and guiding on the path to be a healthy parent); Indigenous ways of healing; On the path of cultural learning; and Identity for self and baby. The findings also show that a virtual format for connecting to Elders was effective in supporting wellbeing for Indigenous women.

Theme 1: Ohpikihâwasowin (grounding and guiding on the path to be a healthy parent)

Women that participated in the virtual format of the EMP found that the time they spent with the Elders grounded them within their culture, and therefore supported their path to become healthier parents. Their interactions with the Elders, both individually and/or as a group, were something they looked forward to. All the cultural guidance that the Elders provided was taken as an opportunity to remind themselves that their jobs as parents is being done, and that they are doing the best they can to raise a healthy child.

I think the prayers, every single session helped to rebalance and refocus and remind all the moms like that we are all gonna be fine, and you know like that, that was special to me. That just happens to you know ground us with our culture. – Participant 01.

My kids are older, but the Elders were still open to answering questions about how to teach these things to my kids and make sure that they have a grounding in culture, more than I did of course. So yeah it does impact my parenting. Well, I think the grounding and the importance again of being part of ceremony, was emphasized a lot. – Participant 02.

Overall, participants appreciated the routine of the program and looked forward to the cultural teachings because it helped ground them due to heightened uncertainty from the pandemic.

[The EMP] gave me something positive to look forward to. You know, being pregnant during the pandemic. Just weird times? You know, it was so unpredictable but having knowing that I would have at least a 10-minute call with an Elder every other week kind of kept me grounded. – Participant 09.

Theme 2: Indigenous ways of Healing

Participants also expressed that the Elders supported their personal healing journeys. Through sharing cultural teachings and their lived experiences, Elders were continuously supporting moms to heal their trauma. Participant 07 explained, “nobody in the community knows how to guide me to my healing. Besides the moment when I met [Elder] and she could just through her lived experiences, she could see my pain and teach me how to address them.” Elders were able to pray and share Cree language teachings with the moms. In the interviews, the participants noted the importance that Cree language had in their talks with the Elders and how this supported their healing. Many of the interview participants expressed that the Elders words in Cree were medicine to them and hearing the Elders pray or when they would share Cree words and their meaning facilitated healing. One interviewee reflected on the importance of language,

I learned so much. Just learning like one word and the meaning that it has, it’s medicine, like I would feel instant healing and medicine, like this actually was a big part of my healing as well from all the traumas that I experienced. – Participant 05.

The EMP allowed space for healing intergenerational trauma through cultural teachings and language.

Definitely I learned a lot about the importance of language and the importance to reconnect with language. I understand, you know, that we live and follow natural law. Like, that is just in me, I just know that, but having not grown up in my community I’ve been disconnected from language and I don’t speak the language at all. So, to understand the spiritual relationship with language, that was good to hear and that it’s important for me to go back and learn some of the language… to heal through the language. – Participant 02.

Theme 3: on the path of Cultural Learning

Participants appreciated the opportunity to interact with the Elders and learn about Cree culture through the teachings. The participants valued the opportunity to learn about traditional parenting teachings, ceremonies, and self-care during pregnancy to bring a healthy child into the world. Participants found these teachings valuable. Participant 04 reflected, “[Teachings] helps young mothers know, learn things that they didn’t know before… and it teaches us about our culture and stuff… and how to take care of yourself while you’re pregnant and, and afterwards.”

Some participants that were not living in Maskwacîs but had family connections to the community, and they valued the opportunity to learn about Cree culture and therefore discover a part of their identity. This cultural discovery of themselves also supported their personal healing journey. One participant shared,

I guess with having an Elder, I really enjoy that connection. I’m really grateful for it because it helps it helps… I have family in Maskwacîs. My dad’s side. I think really growing up, I didn’t get the opportunity to really meet them, the culture, or learn who I was. And when I met [Elder], it helped. It helped heal a lot of childhood wounds, just from her being from Maskwacîs herself. – Participant 07.

I’m on my own path of like learning more of my culture. It wasn’t, it wasn’t always something that we talked about a lot when I was growing up and a lot of my family members aren’t around anymore from that side of my family. So just a really good opportunity, I thought to kind of get back to my roots, and I was just really curious to see if I could learn anything differently. I know I said that I’m Metis but my husband is First Nations. So, it’s something that I would like to be present in my child’s whole life and that he feels comfortable with expressing like, who he really is and getting in touch with those other cultural and spiritual options that maybe aren’t talked about so much. – Participant 11.

Theme 4: identity for self and Baby

Participants spoke about how the EMP supported the development of a positive identity as Indigenous women. The participants conversations with the Elders allowed them to gain cultural teachings that were able to revitalize their Indigenous identity that had been lost due to colonization and assimilation policies.

I think [the Elders are] helpful for sure because I mean the present history of Indigenous people is that the government wanted to strip us of our identities and so we all struggle with identity, and there’s been a lot of disconnection from cultural, so anywhere there’s cultural teachings that the Elders are willing to give. – Participant 02.

The participants conversations with the Elders allowed some of the women to feel more confident in their roles as Indigenous women in their community.

[Connection to Elders] made me feel better, like, I’m a whole, as my role even as a Native woman made me feel better and made me feel better about like, just moving forward and being positive and a lot more confident. – Participant 08.

I feel like I learned a lot from the Elders and their experiences and, again, like that, that role of life and who I am as a mother. I am able to use that with my own baby and also to help others. If, if I was ever to have the opportunity to teach somebody like [another woman], - so I think I can. – Participant 06.

Women also shared that as their identity was impacted by their connection to the Elders, this would also have an impact on their babies’ and children’s identities will be impacted because they will grow to become strong, resilient, and proud of their Indigenous identity. As one participant spoke about how the teachings would benefit her son, “teach him if you can be proud of yourself, he will be proud of himself” (Participant 10).

Discussion

The research findings build on a previous study by the research team of the in-person EMP as well as other studies that have found that Indigenous women and their families can benefit from culturally grounded support [3, 13, 14, 22]. Although traditional teachings are most often given in-person, the present study demonstrates that whether the connection occurs in person or virtually, the opportunity to develop an ongoing relationship with an Elder during pregnancy had a positive impact on the project participants. Both studies of the EMP demonstrate that the program provided an important resource for Indigenous women to connect to their language and culture, which they found healing and able to address the intergenerational harms of colonialism [3]. A recent scoping review of international literature published between 2006 and 2022 on perinatal supports for Indigenous women similarly found that culturally grounded supports were critical for promoting positive health outcomes [13]. Another study in Saskatoon, Canada also concluded that providing pregnant women access to Indigenous specific birthing supports had a positive experience resulting in more effective pain management and strengthened their relationships with Elders and community health personnel, which in turn improved access to post-natal care [14]. The findings of the present study corroborate that culturally grounded maternal health supports for Indigenous women can promote health and well-being, and indicate that a virtual format for connecting to Elders is effective.

The EMP provides evidence to support The Truth and Reconciliation Commission of Canada Call to Action 22 by demonstrating how Elders knowledge and expertise can enhance maternal health for Indigenous women and advance reconciliation [8]. The present study shows that even connecting virtually with an Elder can be beneficial for pregnant Indigenous women when meeting face-to-face is not possible. Providing multiple ways for Indigenous women to connect with Elders can also enhance accessibility, especially for those who may be living away from their home territory or if meeting in person may be inaccessible for a range of reasons such as childcare needs or a lack of transportation. A systematic review of literature on how young Indigenous peoples use of digital technology contributed to their mental wellness also found that the use of technology can improve cultural connection, emotional wellbeing, and social connection [23]. A 13-week study of an online language revitalization program had key findings which are also relevant to the present study: relational technology enables ongoing cultural and community connections; and access to cultural and linguistic support aides in self-discovery [24]. While digital connection to healthcare programming such as the EMP can be beneficial for Indigenous peoples, especially for those who may live in communities with limited specialized services, it is also critical to note that Indigenous peoples may also experience disproportionate obstacles to accessing reliable internet connection which may also limit their participation and can further exacerbate divides among those with access to reliable internet and other technologies and those who do not [25]. Therefore, it is critical that more targeted policies and funding streams are available to promote digital technologies that include programs aimed at improving mental health and maintaining cultural connections [23].

The findings here strengthen our earlier findings that The EMP can be one avenue to help fill gaps in perinatal care for Indigenous women, especially in turbulent times such as a global pandemic. Indigenous families already face intersecting structural barriers due to the continued impacts of colonialism, which was heightened due to the stress and uncertainty of the pandemic [9, 10]. The connection to Elders provided the project participants with continuity and a culturally safe space to be supported and discuss their concerns relating to their pregnancy and more broadly. Indigenous-led studies have demonstrated that Indigenous cultures and traditions are a protective factor for Indigenous families and communities. By increasing protective factors, cultural practices can build resilience and prevent negative health outcomes [26, 27].

In January 2023, the EMP officially ended, both online and in-person at the Wetaskiwin Primary Care Network. There were several reasons for the CAC’s decision to end the program. Post COVID-19, the EMP became less feasible in-person due to changes to patient flow within the clinic, and Elders had less time to interact with parents. Research funding specifically for the EMP also ended in 2023. Moreover, based on feedback through community engagement, the CAC felt that the program would better serve parents if the EMP was offered within Maskwacîs and that it needed to evolve to focus more specifically on cultural teachings, language, and ceremony. While the EMP funding has now ended, the research group and CAC have secured funding to ensure that the program can continue to be offered directly in the community as opposed to an off-site healthcare centre. The next iteration of the research will focus on ensuring sustainability for future generations to have similar access to Elders during their pregnancy.

This study has several limitations. As every community has distinct needs and cultural practices, these findings cannot necessarily be generalized to other Indigenous communities. The program participants and Elders were from the same community in Alberta, which means that this cannot necessarily be translated to urban Indigenous organizations where there may be more diversity of Indigenous peoples accessing maternal health services. Another limitation is that not all The EMP program participants agreed to participate in an interview, which limits the findings due to self-selection of those who were available for an interview. Finally, we did not consider ‘dose’ of interaction with the virtual program. Thus, we were unable to explore differences in wellbeing impacts according to the number or type of interaction with the program.

Conclusion

The qualitative analysis of the EMP offered virtually demonstrates the critical need for perinatal and maternal care for Indigenous women to incorporate cultural teachings from Elders. The interview participants report that the Cree teachings positively impacted their parenting and assisted them in their own personal healing journey including developing their identities as Cree women and mothers. The adaptation of the EMP to the virtual setting provided a safe space for moms and Elders to meet during the pandemic. Although teachings are traditionally offered in person, the openness of the Elders to pivot to an online model was greatly appreciated by all the participants. This also demonstrates the utility of technology to provide cultural teachings and language even in cases when physical proximity is not possible, for example, those who did not live in Maskwacîs, were able to participate in the program. The findings demonstrate that the virtual connection to Elders was important to the participants. The EMP is one approach that can provide meaningful cultural revitalization and built intergenerational relationships to support mothers, their partners, and their children.