An Indigenous and Western paradigm to understand gestational diabetes mellitus: Reflections and insights

Abstract

Indigenous women face many barriers to maternal care during pregnancy in Canada. A participatory study was conducted in two First Nations Communities in Nova Scotia, Canada to gain new knowledge about Mi’kmaw women’s experiences of living with gestational diabetes mellitus (GDM). Relational ethics helped guide this journey. In this paper we describe how Indigenous and Western approaches were used to understand Mi’kmaw women’s experiences with GDM. It was important to us that the research methodology facilitated building relationship and trust. This led to an openness and willingness of the women to express their concerns and offer ways to address GDM in their communities. The challenges of blending Indigenous approaches with Western research are also discussed in the paper. The foundational principles that were used during this research included: 1) Staying true to my word; 2) Mutual Trust; 3) Mutual Respect; 4) Being Flexible; 5) Being Non judgemental; 6) Working in partnership; 7) Taking time to explain; 8) Promoting autonomy; and 9) Genuine connectiveness. The findings revealed that the research assisted the Mi’kmaw women in understanding their experiences in new ways and helped to build capacity so that they could take action to improve their health, while sustaining their Mi’kmaw culture.

Keywords

Indigenous women gestational diabetes mellitus relational ethics participatory action research principles indigenous and western approaches research partnership principles

Returning to my doctoral study, the authors used a participatory study approach to gain knowledge regarding Mi’kmaw women’s experiences with gestational diabetes mellitus (GDM). This approach provided an opportunity to reflect upon important aspects of conducting research with Indigenous communities. This study grew from my experiences of working in neonatal and maternal/child nursing as a beginning non-Indigenous Registered Nurse. We refers to my doctoral co-supervisors, the co-authors of this paper. We describe the process of undertaking this study with a focus on showing the elements of blending Indigenous and western paradigms.

Indigenous women face many barriers to maternal care such as access, language barriers, racism, and discrimination which often creates a feeling of isolation for them (Browne et al., 2016; Varcoe et al., 2013; Whitty-Rogers et al., 2016; Whitty-Rogers et al., 2006). When I began my nursing career, many healthcare providers were not aware of the colonial impact on Indigenous people and may not have understood the needs of Indigenous women and families and/or were unaware of the importance of providing culturally safe care. However, lack of culturally safe care negatively affected the care women and families received.

Although many Indigenous communities prospered over time, they continue to experience the effects of colonialism in their lives (Battiste, 2000, 2013; Browne et al., 2016; Iwawa et al., 2009; MacDonald & Steenbeek, 2015; Reading, 2018; Varcoe et al., 2020, 2013). Varcoe and Browne (2015) define colonialism as “the takeover of a majority population (often Indigenous) by another nation and the resulting unequal relationships between them” (p. 216). Despite educated health care providers and extensive research in health care, Indigenous women continue to experience racism, discrimination, and marginalization in healthcare settings across Canada (Browne, 2017; Browne et al., 2012; Denison et al., 2013; Nelson & Wilson, 2018; Whitty-Rogers et al., 2006). Recognizing racism and injustices embedded in life experiences provides a beginning point for health care providers and researchers to respond in a culturally safe way to Indigenous women and families when providing health care.

In Canada, many Indigenous people continue to receive health care from care providers who do not understand the cultural beliefs, values and traditions of minority groups such as the Mi’kmaw (Dell et al., 2016; Mahar et al., 2011; Whitty-Rogers et al., 2006). Cultural differences related to the meaning of health, economic, and social conditions must be a public health priority when addressing health disparities in the Indigenous population. (Adelson, 2005; Browne, 2017; Browne et al., 2012).

Indigenous people must be included in research studies to identify key priorities and effective strategies to promote Indigenous health (Boffa, et al., 2011; Stout et al., 2001; Whitty-Rogers et al., 2016). The Royal Commission on Aboriginal Peoples (RCAP) (1996) recommended that governments and organizations give Indigenous Peoples fair opportunities to participate in areas that effect their health and healing. The Truth and Reconciliation Commission of Canada (TRC, 2015) report calls for progress on closing the gaps in areas such as maternal and child health.

Since there was a paucity of research in the experiences of Mi’kmaw women with GDM, a study was undertaken to gain knowledge and insight that would assist Mi’kmaw women, their communities and healthcare providers to address health inequities. The purpose of this paper is to describe how Indigenous and Western approaches/methodologies were used to try to understand Mi’kmaw women’s experiences with GDM and how the research methodology facilitated building relationships and trust with the participants and the communities. The challenges of blending the Indigenous approaches with Western research methodologies are also discussed.

Background to the study

Aboriginal is a term used to refer to the First Nations, Inuit, and Métis people according to the Canadian Constitution (Government of Canada, 2019). Indigenous peoples' “is a collective name for the original peoples of North America and their descendants. Often, ‘Aboriginal peoples' is also used” (Government of Canada, 2019, para1). Both Indigenous and Aboriginal terms will be used throughout this paper. Aboriginal people belong to Nations and identify themselves with specific names such as Mi’kmaq, Cree, or Ojibwa (Smylie, 2000).

Aboriginal people in Canada have had a long history of colonialization and discrimination, including the experience of living in residential schools which has had negative generational effects on their health (Browne et al., 2016; Varcoe et al., 2013). Health inequities can not be associated with individual’s lifestyles, behaviours or cultural factors, but rather they are attributed to the historical, political and economic factors that affect their health (Browne, 2017; Browne et al., 2016; King et al., 2009). The loss of Aboriginal traditions, language and beliefs in addition to health policies that are devised and implemented by non-Aboriginal people are factors that have led to poor health (King et al., 2009; Reading, 2018; Richmond & Ross, 2009).

GDM is a serious health concern for Indigenous women. This condition is defined as increased glucose levels that are first seen in pregnancy (Basso, 2017; Government of Canada, 2017; Public Health Agency of Canada, 2017). GDM places women at a greater risk of developing glucose intolerance later in life (Government of Canada, 2017). According to Harris et al. (2013), diabetes is a serious chronic disease in the Aboriginal population in Canada with a 3–5 times higher incidence in Aboriginal communities than in non-Aboriginal communities (Health Canada, 2012). This condition has an increased risk of maternal complications such as pre-eclampsia, fetal macrosomia which may cause perinatal lacerations, shoulder dystocia and caesarean section birth while the babies are at risk for hypoglycemia, intrauterine growth retardation and intrauterine fetal death (Basso, 2017). Therefore, further research is needed to understand how health care providers can care for women with GDM.

The aim of this qualitative study was to explore how Mi’kmaw women’s experiences with GDM were shaped and affected by a variety of social determinants of health (SDOH) and existing health policies in two First Nations Communities in Nova Scotia. The objectives include: 1) to explore with Mi’kmaw women and community members, including Elders, how to begin a conversation about GDM; 2) to gather the stories of Mi’kmaw women’s experiences with GDM through conversation and dialogue; 3) to explore in collaboration with the women the meanings and implications of the women’s experiences of GDM; 4) to mobilize possible actions in relation to decisions around GDM within each community.

Critical ontology

Recognizing the privileging of whiteness is essential for Indigenous and non-Indigenous scholars to understand when engaging in Indigenous research (Martin-MacDonald & McCarthy, 2008; Wilson, 2003). I am cognizant of power relations when conducting research with Indigenous women because it can be seen as a form of domination and oppression. Taking a critical ontology perspective helped the first author connect with Indigenous people. New ways of being and different ways of connecting shaped my way of thinking (Kincheloe, 2006). I was able to understand how my beliefs and values were influenced by religion, gender, race, sexual orientation, and social-political structures (Kincheloe, 2006). It provided direction so I could move beyond my current state of being. Often people begin to develop an ontological vision about ethics, politics, and feelings to help them navigate the system and to discover ways of being human. This approach helped me to be open to the worlds of Indigenous women and assisted in creating synergy between the participants, communities and myself.

Research design

The first author chose a participatory approach in consultation with Indigenous people, including a Public Health Nurse working in a First Nations community and others who identified as Indigenous and/or had experience working with Mi’kmaw people. Consultation with people knowledgeable in Indigenous communities was a critical factor during all phases of the research. A participatory approach is considered a philosophical and guiding approach in engaging in research with Indigenous peoples (Canadian Institutes of Health Research (CIHR) Guidelines, 2014; The First Nations Information Governance Center, 2014).

The research design also incorporated a Two-Eyed Seeing approach (Marshall, 2007), an umbrella approach that blends Western and Indigenous knowledge systems. Bartlett et al. (2012) “acknowledge that we need each other and must engage in a co-learning journey” (p. 331). Two-Eyed Seeing (Sesatuk Etuaptmnkl) was developed by Albert Marshall, a well-respected Mi’kmaw educator, Elder and survivor of the Indian Residential School (Hatcher et al., 2009; Marshall et al., 2018).

Two-Eyed seeing does not unite two knowledge systems, nor does it inform one and try to merge the other (Iwama et al., 2009). Indigenous approaches to research and Western methodologies are necessary to explore and understand the multiple realities of Indigenous experiences. When these perspectives are presented together, there is not a full view of the world but one that is diverse enough to “offer a new way of thinking about how knowledge is produced, one that could not emerge if we looked through “one eye” only” (Martin, 2012, p. 38).

As Hatcher and colleagues (2009) state “many of the principles of Western Sciences rely on a type of logic that assumes hierarchical thinking” (p. 144). Western science searches to find how things work; it focuses on knowledge. In contrast, Indigenous knowledge and Indigenous learners are closely connected, and information is accurately and naturally connected (Hatcher et al., 2009). Indigenous approaches also value the importance of “talking about relationship accountability” (Wilson, 2001, p. 177). Researchers’ bonds with the community are critical in scholarly work (Wilson, 2008). For example, I knew the Health Director, the former chief, community health nurse and a member of the community who worked as an Aboriginal Student Advisor in one First Nations community, while in the other community I knew the Health Director. These connections helped the first author build trust and respect with community members. This process took several months but it was essential to be accepted and trusted before engaging in this research. Becoming acquainted with the communities prior to the study made the process easier when I met with the participants as they knew what to expect and were open to sharing their experiences with GDM.

Participatory action research principles

The authors approached this study using five Participatory Action Research (PAR) principles, namely, collaboration, democracy, equity, improved social practice and reciprocity. Koch and Kralik (2006) claim that PAR principles guide researchers in articulating people’s strengths, which helps people feel more at ease. By providing people with new knowledge, they can critique this information, helping them to feel more empowered (Esienumoh et al., 2018; Houh & Kalsem, 2015). According to Wilson (2001, 2008), PAR is a useful approach for conducting Indigenous research because it resembles Indigenous values which include relationships, respect, self-determination among others (Battiste, 2000) and interconnectiveness (Henderson, 2000). By using PAR, the qualitative features of an individual’s feelings and viewpoints are revealed without any control from the researcher (MacDonald, 2012).

The first PAR principle collaboration refers to working together for a common goal (Koch & Kralik, 2006). While collaboration does not equal harmony, every effort was made to develop a relationship with others and try to find a way to work together. The participants valued the importance of working together as a team to improve their health and/or prevent GDM from occurring in future pregnancies.

A second PAR principle democracy means that individuals choose to freely participate at all stages of the research process (Koch & Kralik, 2006). The participants were informed of the research design and they provided input where possible. They were informed that they had a choice on whether to participate or not, participate as much as they wished or speak when they preferred.

The third principle, equity, recognizes Mi’kmaw women’s self-determination. PAR provides an opportunity for participants and researchers to decide together on the outcome of the study and the dissemination process (Ammentorp et al., 2018; Koch & Kralik, 2006). The participants implemented actions for themselves, their families and communities that fit with their beliefs and which worked to keep them healthy once diagnosed with GDM. For example, one participant, Veronica was anxious to begin a garden even though there was a trailer on part of the land that would be otherwise available to use. Veronica explained: “just make a spot and start a garden …I was thinking of doing it next year. I grew up not eating my vegetables and stuff, but when after I had [son] I wanted him to eat all of that”.

The fourth PAR principle improved social practice can bring about social change which may address unequal distribution of power (Koch & Kralik, 2006). The intent was to affect the lives of the participants in a manner that they perceived beneficial. The social change in many instances raised consciousness or behavior changes of the participants. The dialogue that occurred with consciousness-raising helped the participants gain insight into how to take action to challenge some of their health barriers (Henderson, 1995).

A fifth PAR principle reciprocity helps to dispel the hierarchical structure that often exists between the researcher and participants (Koch & Kralik, 2006), giving researchers and participants a sense of their own identity (Bannister, 1999). During the research, the participants were engaged and seemed at ease. For example, with participant Anne, I felt I should be talking but instead realized that I should be reflecting as I listened to her story. As I sat in the living room holding her twin babies, I felt she was giving me time to spend with her babies as we developed a sense of trust and sharing, something I was not aware of in the past.

Challenges of PAR

A number of challenges allowed important learnings to come forward, namely, designing a process to understand the participants living with GDM, active participation, power imbalance, communication and analysis of Indigenous data. Wadsworth (1998) states that a major challenge for individuals using PAR is designing a process, which is innovative and calls forth imagination. Clausen and colleagues (2019) found that PAR, including social imagination and visual approaches, helped children ages 6–9 years articulate their ideas about how to create a healthier school environment. The strategies had to come from within their communities and not from any external individuals and groups. Although some participants discussed strategies with family members and their community, others were overwhelmed with having had GDM and feared developing diabetes. The participants required additional education about GDM and support during the study. However, sustaining their own health, often limited the women in being able to create change for others.

Another challenge is ensuring community members are active participants in the research process (Gillis & Jackson, 2002; MacDonald, 2012). It was important to include participants who wanted to participate, as well as community members, who were interested. I welcomed anyone from the community who wished to join the talking circle and informed the participants that family members could stay during the interviews if it was agreeable with the participants. However, no additional community members or family members attended. I also met with one of the Elders in the community and included her views of GDM in the study.

Power imbalance was another challenge. I was aware that power might shift during the research because community members could change as a result of moving or electing not to participate. Issues concerning power imbalances and egalitarian relations require constant monitoring (Gillis & Jackson, 2002). There were times when the community members took the lead, especially at the implementation stage, while at other times I took the lead during the information and talking circles. However, PAR principles were followed whereby the Mi’kmaw women were given an opportunity to pose questions, provide comments, and have a back and forth conversation (Bergum, 2002; Koch & Kralik, 2006). I tried to ensure there was a power balance as much as possible by providing everyone with equal time to speak and ask questions.

Communication was challenging at times because I was a non-Indigenous researcher and I wanted to ensure that I was explaining the process and answering the participants’ questions clearly. Greenwood and Levin (1998) caution that participatory research approaches are constructed on a “political analysis of power relations” (p. 175) and the belief that change happens if people relinquish their power and address the oppression they experience. I was vigilant in making certain that communication was continuous, accessible, transparent, and there was clear understanding with the community during the research process.

The analysis of Indigenous data was another challenge. While often a straightforward approach such as qualitative data analysis, in being true to the Indigenous principles and the PAR research process, I needed to look at the deeper meaning of the experiences. Therefore, hermeneutic phenomenology was selected for data analysis, to search for essential and peripheral themes of the phenomena being studied in order to structure the data (van Manen, 1990). This process will be further discussed under the data analysis section.

Research partnership principles

As I introduced the study to potential participants and other members of the Mi’kmaw community, relational ethics helped guide this journey. Relational ethics are rooted in emphasizing the importance of developing a trusting, genuine, and respectful relationship with patients, families, and Mi’kmaw participants. According to Lahman et al. (2011), when research is conducted in different cultures, the authors recommend integrating Three R’s into practice. They include: 1) culturally responsive ethics meaning to respond quickly to something, 2) relational ethics which refers to recognizing mutual respect, 3) reflexive ethics which means that the researcher quickly responds to the reactions in a research situation where the participants’ safety and autonomy are concerned, thus improving the trustworthiness of the study. These Three R’s are reflected in the actions during the study.

The Research Partnership Principles include: (Figure 1):

Figure 1.

Research partnership.

Staying true to my word. This meant being loyal and committed to the participants’ best interests and ensuring that what I told them about the research process, would not change. For example, I informed the participants that they would have an active voice in this research process. They had an opportunity to select actions they thought might help to address GDM. The participants wanted to be part of decisions such as daycare issues, funding levels for women not working, transportation issues and educational sessions offered at the health center rather than have someone else institute changes that may not address their concerns. As Battiste (2013) claims there must be respectful dialogue between Indigenous and non-Indigenous educators and researchers that benefits Indigenous peoples.

Mutual Trust. According to Austin et al. (2003), mutual trust originates from being dependent on each other. There is a need to understand each other’s situation and vulnerability from an ethical perspective (Austin et al., 2003; Pollard, 2015). As Charlotte Jesty, an Aboriginal Community Health Nurse, who I consulted with during the study explained that First Nations people need to trust you before they consider engaging in research. Genuine research collaboration develops when researchers and Aboriginal people enter into a partnership where there is mutual trust and respect (CIHR, 2007; CIHR Guidelines, Natural Sciences and Engineering Research Council of Canada Social Sciences and Humanities Research Council of Canada, 2014). One participant, Annette said she would not have participated in the study if she sensed I judged her as a mother during our initial conversations. Annette was concerned that I may not approve of giving fast food [hamburgers and pop] to her children for lunch when they arrived for the interview. Annette said that she was relieved when she saw that her choice of lunch for her children was respected, thus building a feeling of respect and trust between us.

Respect. Respectful research means to understand and respect Aboriginal worldviews and to ensure protection of their culture and knowledge (Boffa et al., 2011; CIHR, 2007; Kirkness & Barnhardt, 1991; Stout, 2018). Respect is a powerful word and one that carries responsibility, an honor, and a high regard for the person. The participants informed me on several occasions that respect what was important to them. One participant, Veronica experienced excruciating pain early in labor and explained that when she asked the nurse for pain medication “They only gave me laughing gas”… Nothing funny about this”. She was referring to Entonox, a combination of nitrous oxide and oxygen given to mothers who are in the latter part of the first or second stage of labor to inhale for the purpose of minimizing or eliminating labor pain (Wong et al., 2006). Because Veronica was unfamiliar with the terms ‘laughing gas, she interpreted it as meaning something disrespectful to her.

Being Flexible. I gave the participants opportunities to change the time of the meeting and time to respond to the questions. Some participants attended to their children and talked at the same time about GDM. Giving these mothers an opportunity to spend time with their children during the meetings helped them become comfortable. As Kovach (2019) explains, the conversational method in Indigenous research is different than in the Western approach as the former values Indigenous knowledge, is relational, is purposeful, involves specific protocol, and involves an informality and flexibility, among others while the latter views it as a story and focuses on inquiry.

Being Non judgemental. This principle meant listening to the participants without forming opinions about their health practices and decisions they made about their pregnancy and/or personal lives. One participant, Carol, conveyed the meaning of low energy she experienced when she was pregnant. Carol tried hard to make sure I understood what she was saying and how it affected her children. The children had to adjust to their mother’s changed behavior, something they were not accustomed to. Lack of energy meant Carol was unable to do the things she did as a mother such as playing with her children. She did not want to be judged as not being a good parent.

Working in Partnership. PAR promoted a strong partnership, allowing for participation, equal power relations between participants and researchers, and involvement in the decision-making process (CIHR, 2007). The participants were encouraged to have a voice in exploring GDM with the researcher.

Taking Time to Explain. There were teachable moments for me as a nurse and occasionally I shared information about labor, delivery, birth, taking insulin among others in a back and forth conversation with the mothers. Access to culturally sensitive information and being surrounded by mothers from the same culture helped the women feel at ease.

Promoting Autonomy. This study provided insight in areas where participants previously did not have a voice, where they were inappropriately treated, misunderstood and not valued for their knowledge. For example, one participant Kate was angry and felt powerless as she could not convince the doctor that she had a broken ankle when she was pregnant. Lazarus (1997) explains that medical knowledge, similar to most knowledge, is rooted in social relationships. In the doctor-patient relationship, power dominates, and often leaves the patient dependent and not cared for appropriately. I explained to her the importance of having a voice and she made the decision to pursue appropriate health care.

Genuine Connectiveness. Sincere communication and understanding made a positive difference in increasing trust and respect between the participants and care providers. The women appreciated an explanation about their prenatal care, including how to adjust to living with GDM. They were unhappy when the doctors or nurses disregarded their concerns or did not give them a voice to ask questions or give their opinion.

Critical hermeneutics

Critical hermeneutics assisted in interpreting areas that seemed vague during the analysis process. Critical hermeneutics is defined by Morrow and Torres (2002) as “attempts to ground social inquiry in the understandings of agents (hence its hermeneutic or interpretive dimension), as well as taking into account the social structural contexts of action” (p. 7). Critical hermeneutics works on the premise that not all “social actors” are recognized and many traditions are socially accepted by a few people as gospel (Thompson, 1990, p. 258). Therefore, it is important to expose their oppressive meanings that many may not recognize. For example. I often found myself imparting education or teachings, as participants discussed their concerns about not receiving appropriate medical treatment [insulin and/or diabetic diet] when they were diagnosed earlier in pregnancy. The mothers were dismayed at the entire situation because they placed their health in the hands of competent health care professionals but did not always receive high quality care. By discussing this situation, it was a way to critically examine their lived experiences of being oppressed. It was as though they had to endure GDM without questioning their physician.

Indigenous approaches

We incorporated Indigenous approaches using the work of Loppie (2007), Battiste (2000, 2007, 2013), and Wilson (2001, 2008). Knowledge is considered relational in an Indigenous paradigm; it is shared, and interpersonal relationships are integral to the research (Hatcher et al., 2009; Wilson, 2001, 2008). The terms ‘Indigenous approaches’ were used instead of Indigenous methodologies because the former was in the process of development. The etymology of the word methodology refers to “the abstract theoretical assumptions and principles that underpin a particular research approach, often developed with a specific scientific or social science disciplines” (Grant and Giddings, 2002, p. 12). Relationships are not just with the participants; they encompass the cosmos, as knowledge is shared within the universe which includes animals and plants (Wilson, 2001). Using an Indigenous approach, I asked myself how I was fulfilling my relationship within the world (Wilson, 2001). Healing occurs when Aboriginal people maintain a balance and connection to one’s life and when they envision where they are going (Regnier, 1995). As Loppie and Wein (2009) note, Indigenous beliefs and values embrace a holistic concept of health that incorporates physical, emotional, mental and spiritual wellbeing. Therefore, with the loss of Mi’kmaw language, there is a loss of understanding of how to take care of one’s body with GDM, how to access traditional foods, traditional healing, lose of knowledge of their everyday culture for eating and little financial means to buy the foods needed to remain healthy. To help to address this, I discussed the importance of maintaining the Mi’kmaw language during dissemination of results and other research and educational forums.

Integrating indigenous knowledge and indigenous principles into the research

Indigenous knowledge is protected by Indigenous principles (Battiste & Henderson, 2000). This knowledge comes from creation, is considered sacred, and gaining knowledge is a life-long journey. Indigenous principles that guided the study, but are not limited to, the following: 1) protect the heritage of Indigenous peoples; 2) heritage includes principles of self-determination, meaning that Indigenous people have the right to develop their own cultures; 3) Indigenous people are the primary guardians of their culture; 4) respect and recognition for Indigenous peoples culture; 5) ownership of their heritage; 6) control over their lands and resources so that they can discover, use, and teach Indigenous knowledge, art, and culture to their people (Battiste, 2000). These Indigenous principles represented a holistic paradigm that includes the physical, emotional, spiritual, and mental domains of human life which help to maintain Indigenous quality life.

Two-eyed seeing challenges

Working with Two-Eyed Seeing which encompasses Indigenous and Western approaches were both enlightening and cumbersome. First, by enlightening, we are referring to the importance of knowing that the Indigenous paradigm is so strongly connected to the earth and the value that Mi’kmaw women place on getting food from their land. Being grounded in the Indigenous approaches of Battiste (2000), Loppie (2007), Marshall (2007, 2009), and Wilson (2001) assisted in providing the knowledge and understanding to undertake this research.

Secondly, it was enlightening to know that the Indigenous principles represent a holistic paradigm that includes the physical, emotional, spiritual, and mental domains of human life and the maintenance of quality life. Pidgeon (2008) reminds us that in various Indigenous groups’ ways of knowing differ from mainstream society and the way to address this is to bridge the gap using a holistic approach.

Thirdly, I realized coming together in the meeting of language and culture (Iwama et al., 2009), we come together to solve the problems that were “done to health by the loss of traditional language and connectiveness” (p. 5). Although I knew I was responsible to empower Aboriginal women through inviting them to be active participants in the research (Kirkness & Barnhardt, 1991), I am not sure I was consistently doing this. I was aware that a two-way learning process needs to occur between the researcher and the participants (Kirkness & Barnhardt, 1991). However, it takes time and I had to remind myself to slow the conversation during the interviews so I could listen and clarify my understanding of the discussions and ensure the participants had an active voice in the process.

Fourthly, another cumbersome factor was capturing the full meaning of the Mi’kmaw women’s experiences. I would check back and forth with the participants to ensure I was capturing what they were saying along with reviewing the transcripts with them. Using a critical ontological approach assisted with understanding myself further and how my beliefs and values have been influenced by my culture and society. However, knowing that it is influenced by religion, gender, race, sexual orientation, and politics in the western world (Kincheloe, 2006), I was continually reflecting on the Indigenous principles throughout the study. In the future, I would build in more reflection time on the Indigenous principles and link them to participants’ experiences.

Data collection

I engaged in conversational interviews with nine Mi’kmaw women, in addition to talking circles with the participants along with a conversation with an Elder. Data was collected using purposive and snowball sampling (Patton, 2002). The stakeholders included the participants and their families as well as the health centers and the two First Nations communities where the study was conducted. I asked the informants to organize an information session at both health centers to introduce the study. Potential participants, Elders, community health nurses among others were invited to the information sessions.

Ethical consideration

Ethical approval was obtained from the Health Research Ethics Board, Panel B (HREB) Review Committee at the University of Alberta and from the Mi’kmaw Ethics Watch in Nova Scotia comprised of Mi’kmaw leaders, Elders, educators, and other professionals in Nova Scotia. The research was guided by CIHR (2007) guidelines for health research involving Indigenous people and the OCAP principles (ownership, control, access, and possession) for conducting research with Indigenous people.

Written consent from each of the participants was obtained prior to participating in this study. To guarantee anonymity, pseudonyms were used for transcription, publishing and presentation at conferences. The participants agreed with using pseudonyms. The following pseudonyms cited in this paper include: Annette, Carol, Kate, Jane and Veronica. The other pseudonyms were not named in this paper but they were referenced as the participants in various places throughout the paper.

Data analysis

A hermeneutic phenomenological approach was used for data analysis. Hermeneutic phenomenology is “a reflection on the basic structures of the lived experience of human experience” (van Manen, 2014, p. 26). According to Errasti-Ibarrondo et al. (2018), van Manen has been inspired by phenomenology of previous philosophers such as Husserl, Heidegger and Merleau-Ponty to focus on the “practice orientation” thus valuing the importance of people’s own experiences (p. 1725). Traditional scientific research aims to hypothesize and generalize, whereas phenomenology has a broad focus and is interested in things that are not replaceable, but rather unique (van Manen, 1990). Gadamer (1976) claims that hermeneutics helps to integrate the known and unknown worlds. Hermeneutic phenomenology can be used to describe people’s health and illness, and in this study the experiences of Mi’kmaw women with GDM. This approach was used to search for themes and subthemes and the women’s life experiences were interpreted in terms of life existentials of space, body, time, and relation. These fundamental existential themes tend to permeate the lifeworlds of people regardless of the history or culture (van Manen, 1990).

Van Manen (2014) claims that phenomenology is a method for questioning, drawing insights and not for determining answers. Life experiences were described, checked with the participants, and interpreted in terms of life existential, body, time, space, and relation, as a framework to present the findings (van Manen, 1990). This meant listening to the women’s experiences of trying to change eating habits on a limited budget and poor access to close grocery stores. The transcribed experience was then examined for are the life existentials present in this description, what one is foremost, and why. While these life existentials occur simultaneously in a situation, it is useful to look at each one as they show themselves in a particular description of an experience or a story. Wilson (2008) states, “the foundation of Indigenous research lies within the reality of the lived Indigenous experience” (p. 60), fitting with the analysis process of van Manen (1990).

The first fundamental existential lived space (spatiality) referred to the participants’ home and community where they live. van Manen (1990) states that when we want to understand a person, we ask about his/her world which may include the person’s interests, background, or childhood. The lived space helps to discover some central facets of people’s lives, which in this study the participants’ experiences with GDM. Their lived space (van Manen, 1998) became one of worry and fear about their GDM. This worry was in terms of their children and themselves developing diabetes later in life and dying of complications from diabetes. Their relationships with their mothers, husband/partners, relatives and community including health care providers became closer as they sought advice and support to cope with this condition.

A second fundamental existential is lived body (corporeality) which refers to recognizing that when we meet individuals, we meet them through their body. Persons may disclose or conceal something about themselves without deliberate consideration. It was as though the needs of their pregnant body became more paramount as the pregnancy progressed. The women needed to continually adjust their lived space and bodily habits to attend to their children and family needs as their body grew and inserted itself as a presence in their lived world. As van Manen (1990) states: “Seeing prompts me to do something” (p. 105). For example, Annette tried to quit smoking during pregnancy because she knew it was an unhealthy practice. Yet she knew if she quit, she was going to gain more weight, which affected regulating her insulin, controlling her blood sugar and affected her unborn baby as Annette states: “It was just so hard so… even if you want to quit during your pregnancy …you know you’re gonna gain more weight, you know you’re gonna eat more…what do I do, up my insulin or gain”.

The third fundamental existential is lived time (temporality) which is subjective as opposed to objective clock time. When researchers get to know people, they ask about their past and explore where they see their life unfolding. In both instances, diagnosed with GDM altered the way they lived their lives during their pregnancy and the changes they had to make in their life as GDM required following a healthy diet, taking insulin and constant monitoring of their glucose levels. For example, Carol described her concerns about developing diabetes. She states, “because I am big I am going to get GDM. Felt good when the pregnancy was over, always in my head what a good job I was doing taking insulin. I am trying my best not to get diabetes”. Although Carol worked hard to control her glucose by eating healthy and taking her insulin, she was worried she would develop diabetes later in life.

A fourth fundamental existential is lived other (relationality) which refers to the interpersonal space that is shared with someone. This relationship can be an acquaintance such as a handshake or being present and/or learning about someone through the media, books, or other modes. We are introduced to the other by a greeting (van Manen, 1990). For example, Jane was discouraged by the nurses and doctors to discuss what was ailing her health and well-being during pregnancy, reflecting how much misunderstanding occurs in Indigenous populations.

I was reminded by van Manen’s (1990) work, how “close observation involves an attitude of assuming a relation that is as close as possible while retaining a hermeneutic alertness to situations” (p. 69). This reminder made me cognizant of interpreting the data slowly, reflecting, and looking for places where I did not understand.

Findings of the study

Four major themes include: a) Uncovering the Experiences of GDM; b) Barriers Limiting Access to Health Care; c) Social Support During Pregnancy; d) Feeling Compelled to Take Action (Whitty-Rogers et al., 2016). This study revealed that Mi’kmaw women did not consistently receive culturally safe health care. They were uncertain about what nursing and medical care they could expect to receive. Many participants reported that supportive care from nurses and other health care providers would have made a positive difference in their experiences and health outcomes. For instance, the Mi’kmaw women may have experienced less fear and pain in labor if they received care that reflected their cultural traditions and beliefs. The women did not receive timely access to diabetic care or little teaching as they began to take insulin during their pregnancy. Based on these findings using the SDOH as a framework (Government of Canada, 2019), the women’s stories help to inform others about the complexities of their lives.

Emanating from the research findings, the women collectively decided on community actions they wanted to undertake. This included establishing a community garden, seeking teaching from the Elders and healthcare professionals on nutritious diets for pregnant women, restoring cultural knowledge and language, reviewing current recipes for more nutritional substitutes, eating more traditional foods, supporting men in the community to attend cooking classes and increasing walking in their community were among the major actions. The Mi’kmaw women wanted to take on leadership roles to seek answers to their questions and gaining insight into their experiences, thus benefiting their families’ and communities’ health.

The sources of support to ensure the changes suggested by the women are sustainable include the community health nurse, health director, band council, dietitian for the First Nations communities and the first author. The communities are in various stages of carrying out the actions as outlined above. The first author continues to communicate with both communities to support diabetes education and conduct research. Charlotte Jesty, a Mi’kmaw Community Health Nurse who we mentioned earlier in this paper, and a member of the first authors’ PhD research committee, continues to be a valuable resource to the participants and community.

Rigour, credibility and trustworthiness of the study

The research by Kirkness and Barnhardt (1991) on the Four R’s (respect, relevance, reciprocity, and responsibility), in addition to the core principles of PAR, assisted with increasing the trustworthiness and credibility of this research. Respect refers to acknowledging and accepting Indigenous people’s traditional knowledge, values, and beliefs and work with them in a collaborative manner. Relevance means to have regard for the cultural integrity and recognize what they value as Indigenous knowledge (Kirkness & Barnhardt, 1991). Reciprocity refers to a two-way mode as a means of learning and exchanging ideas (Kirkness & Barnhardt, 1991). The aim of responsibility is to empower Indigenous people by inviting them to be active participants in the research (Kirkness & Barnhardt, 1991).

Rigor was an important part of the PAR process. For example, in relation to reciprocity, when the participants asked me about information on (GDM), the participants and the researcher shared knowledge which helped them gain insight into GDM and ways to improve their health such as eating fruits and vegetables and minimizing/avoiding high fat foods, learning how to regulate insulin, increasing physical activity among others to improve their health. The community members were active participants in this research process. The first author had longstanding relationships with First Nations communities, which went beyond this particular research study. There was a sincere trust and willingness to participate in the research when I began recruitment and continued through the study. The strategies and changes as the study began were encouraged from within the communities and not from external individuals and groups. The participants were eager to participate as they wanted to help themselves, their families and their communities.

Recommendations

Further research is required to determine how poverty, food security, employment and social inclusion impacts First Nations communities, including policy changes related to the social determinants of health. Interactions with healthcare professionals must be furthered studied as the Indigenous women reported several untoward experiences when accessing healthcare. Additional research is required to examine which health promotion interventions would help Indigenous women and their families develop lifestyle programs such as exercise programs for all ages among others following GDM and to prevent Type II diabetes. Further research is needed to identify the needs of teenage pregnant women. Prenatal education aims at providing general education to all ages. Cultural competence and cultural safety models are another area where further research is required to explore appropriate ways to care for Indigenous women with GDM.

Conclusion

A Two-Eyed Seeing approach provided a way to engage in this study on the experiences of Indigenous women living with GDM in a manner that acknowledged and respected their ways of knowing. Bartlett et al. (2012) remind us that it is necessary to “[a]cknowledge that we need each other and must engage in a co-learning journey” (p. 4). We need to shift one’s thinking to seeing the Mi’kmaw women’s experiences from both eyes required time and attentiveness during the research process. The Indigenous principles as outlined by Battiste (2000) helped recognize and understand the importance of self-determination for Mi’kmaw women. The principles of PAR opened the way for greater participation for the women, while hermeneutic phenomenology opened up a reflective interpretive discussion. This research assisted Mi’kmaw women to understand their experiences in new ways and acted as a way to build capacity so that they could begin to take actions to improve their health and maintain their Mi’kmaw culture.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Joanne Whitty-Rogers

Author biographies

Joanne Whitty-Rogers is a senior research professor at St. Francis Xavier University, Rankin School of Nursing, and formerly an Associate Professor in the School. Her research interests are in Indigenous women’s health with a focus on gestational diabetes mellitus and diabetes, social determinants of health, Indigenous student mentorship and quality of care in the stroke and also myocardial infarct patients in all cultures. She uses Indigenous approaches with Western research methodologies to learn further and build relationships with Indigenous peoples.

Brenda Cameron is a professor emeritus in the Faculty of Nursing at the University of Alberta. She is an influential thinker, leader, and researcher who has enjoyed wide Canadian and international recognition for her contributions to nursing, philosophy, and health care. In her research program on access to health care for Indigenous and marginalized populations, she led the implementation of innovative modalities to improve peoples’ access experiences in the health care system. Rooted in the philosophical tradition of the human sciences, her seminal work involves a treatise of nursing practices in contemporary Canada.

Vera Caine is a professor in the Faculty of Nursing at the University of Alberta. As a Registered Nurse and community advocate she is interested in the relational and ethical aspects of narrative inquiry, as well as community based and participatory research methods and methodologies.

References

Adelson

(2005). The embodiment of inequity: Health disparities in aboriginal Canada. Canadian Journal of Public Health, 96, S45–S61.

Austin

Bergum

Dossetor

(2003). Relational ethics. An action ethic as a foundation for healthcare. In Tshudin

(Ed.), Approaches to ethics (pp. 45–52). Butterworth-Heinemann.

Ammentorp

Wolderslund

Timmermann

Larsen

Steffensen

K. D.

Nielsen

, Lau, M. E., Winther, B., Jensen, L. H., Hvidt, E. A., Hvidt, N. C., Gulbrandsen

(2018). How participatory action research changed our view of the challenges of shared decision-making training. Patient Education and Counseling, 101, 639–646.

Bartlett

Marshall

(2012). Two-eyed seeing and other lessons learned within a co-learning journey of bringing together indigenous and mainstream knowledges and ways of knowing. Journal of Environmental Studies and Sciences, 2, 331–340. https://doi.org/10.1007/s13412-012-0086-8

Basso

(2017). Pregnancy at risk: Gestational conditions. In S. E. Perry, M. J. Hockenberry, D. L. Lowdermilk, D. Wilson, L. Keenan-Lindsay, & C. A. Sams (Eds.), Maternal child nursing care in Canada (2nd ed., pp. 311–357). Elsevier Canada.

Battiste

(2000). Reclaiming indigenous voice and vision. University of British Columbia Press.

Battiste

(2007). Research ethics for protecting indigenous knowledge and heritage institutional and researcher responsibilities. In K. Norman & M. D. Giardina (Eds.), Ethical futures in qualitative research: Decolonizing the politics of knowledge (pp. 111–132). Routledge Taylor & Francis Group.

Battiste

(2013). Decolonizing education: Nourishing the learning spirit. UBC Press.

Bergum

(2002). Ethical challenges of the 21st century: Attending to relations. Canadian Journal of Nursing Research, 34, 9–15.

10.

Boffa

King

McMullin

Long

(2011). A process for the inclusion of aboriginal people in health research: Lessons from the determinants of TB transmission project. Social, Science & Medicine, 72, 733e–738.

11.

Browne

A. J.

(2017). Moving beyond description: Closing the health equity gap by redressing racism impacting indigenous populations. Social Sciences & Medicine, 184, 23–27.

12.

Browne

A. J.

Varcoe

Lavoie

Smye

Wong

S. T.

Krause, M., Tu, D., Khan, K., & Fridkin

(2016). Enhancing health care equity with indigenous populations: Evidenced-based strategies from an ethnographic study. BioMed Central, 16, Article 544. https://doi.org/10.1186/s12913-016-1707-9

13.

Browne

A. J.

Varcoe

C. M.

Wong

S. T.

Smye

V. L.

Lavoie

Littlejohn

, Tu, D., Godwin, W., Krause, M., Khan, K.B., Fridkin, A., Rodney, P., O?Neil, J., & Lennox

(2012). Closing the health equity gap: Evidence-based strategies for primary health care organizations. International Journal for Equity in Health, 11, Article 59.

14.

Canadian Institute of Health Research. (2007). CIHR guidelines for health research involving aboriginal people.

15.

Canadian Institute of Health Research Guidelines. (2014). Tri-council policy statement: Ethical conduct for research involving humans. https://www.mcgill.ca/skillsets/files/skillsets/tcps2updated_workshop4.pdf

16.

Dell

E. M.

Firestone

Smylie

Vaillancourt

(2016). Cultural safety and providing care to aboriginal patients in the emergency department. CJEM-JCMU, 18, 301–305. https://doi.org/10.1017/cem.2015.100

17.

Errasti-Ibarrondo

Jordán

J. A.

Díez-Del-Corral

M. P.

Arantzamendi

(2018). 10Conducting phenomenological research: Rationalizing the methods and rigour of the phenomenology of practice. Journal of Advanced Nursing, 74, 1723–1734. https://doi.org/10.1111/jan.13569.

18.

Esienumoh

E. E.

Allotey

Waterman

(2018). Empowering members of rural Southern community in Nigeria to plan to take action to prevent maternal mortality: A participatory action research project. Journal of Clinical Nursing, 27, e1600–e1611.

19.

Gadamer

H. G.

(1976). Semantics and hermeneutics (1972). philosophical hermeneutics. (P. C. Smith, Trans.) (pp. 82–94). University of California.

20.

Gillis

Jackson

(2002). Research methods for nurses: Methods and interpretation. F. A. Davis Company.

21.

Government of Canada. (2019). Social determinants of health and health inequities. https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

22.

Grant, B. M., &

Giddings, L. S.

(2002). Making Sense of methodologies: A Paradigm Framework for the Novice Researcher. Contemporary Nurse, 13(1), 10–28.

23.

Greenwood

D. J.

Levin

(1998). Introduction to action research: Social research for social change. Sage.

24.

Harris

S. B.

Bhattacharyya

Dyck

Hayward

M. N.

Toth

E. L.

(2013). Type 2 diabetes in aboriginal peoples. Canadian Journal of Diabetes, 37, S191–S196.

25.

Hatcher

Bartlett

Marshall

(2009). Two-eyed seeing in the classroom environment: Concepts, approaches, and challenges. Canadian Journal of Science, Mathematics and Technology Education, 9, 141–153.

26.

Health Canada. (2012). First Nations & Inuit health: Diseases and health conditions. http://www.hc-sc.gc.ca/fniah-spnia/diseases-maladies/index-eng.php

27.

Henderson

D. J.

(1995). Consciousness raising in participatory research: Method and methodology for emancipatory nursing inquiry. Advances in Nursing Science, 17, 58–69.

28.

Henderson

J. Y.

(2000). Postcolonial ledger drawing: Legal reform. In M. Battiste (Ed.), Reclaiming indigenous voice and vision (pp. 161–171). University of British Columbia Press.

29.

Houh

M. S.

Kalsem

(2015). Theorizing legal participatory action research: Critical race/feminism and participatory action research. Qualitative Inquiry, 21, 262–276. https://doi.org/10.1177/1077800414562897 qix.sagepub.com

30.

Iwama

Marshall

Bartlett

(2009). Two-eyed seeing and the language of healing in community-based research. Canadian Journal of Native Education, 32, 3–23.

31.

Kincheloe

J. L.

(2006). Critical ontology and indigenous ways of being: Forging a postcolonial curriculum. In Kanu

(Ed.), Curriculum as cultural practice: Postcolonial imaginations (pp. 181--202). University of Toronto.

32.

King

Smith

Gracey

(2009). Indigenous health part 2: The underlying causes of the health gap. Lancet (London, England), 374, 76–84.

33.

Kirkness

V. J.

Barnhardt

(1991). First nations and higher education: The four Rs respect, relevance, reciprocity, and responsibility. Journal of American Indian Education, 30, 1–10.

34.

Koch

Kralik

(2006). Participatory action research in health care. Blackwell Publishing Inc.

35.

Kovach

(2019). Conversational method in indigenous research. An Interdisciplinary Journal, 14, 123–136.

36.

Lahman

A. K.

Geist

M. R.

Rodriguez

K. L.

Graglia

DeRoche

K. K.

(2011). Culturally responsive relational reflexive ethics in research: The three rs. International Journal of Methodology, 45, 1397–1414.

37.

Lazarus

(1997). What do women want? Issues of choice, control, and class in American pregnancy and childbirth. In Davis-Floyd

R. E.

Sargent

C. F.

(Eds.), Childbirth and authoritative knowledge: Cross-cultural perspectives (pp. 132–158). University of California.

38.

Loppie

(2007). Learning from the grandmothers: Incorporating indigenous principles into qualitative research. Qualitative Health Research, 17, 276–284.

39.

Loppie

R., C.

Wein

(2009). Health inequalities and social determinants of Aboriginal peoples’ health. http://nccah-ccnsa.ca/docs/social%20determinates/nccah-loppie-wien_report.pdf

40.

MacDonald

(2012). Understanding participatory action research: A qualitative research methodology option. Canadian Journal of Action Research, 13, 34–50.

41.

MacDonald

Steenbeek

(2015). The impact of colonization and Western assimilation on health and wellbeing of Canadian aboriginal people. International Journal of Regional and Local History, 10, 32–46.

42.

Mahar

M. S.

Duncan

Whyte

Brown

(2011). It takes a community to raise a nurse: Educating for culturally safe practice with aboriginal peoples. International Journal of Nursing Education Scholarship, 8, 1–13.

43.

Marshall

(2007). Two-eyed seeing: Science education for children and youth. http://www.turtleisland.org/culture/twoeyed.htm

44.

Marshall

Bartlett

(2018). Two-eyed seeing in medicine. In M. Greenwood, S. de Leeuw, & N. M. Lindsay (Eds.), Determinants of indigenous people’s health: Beyond the social (pp. 3–17). Canadian Scholars.

45.

Martin

D. H.

(2012). Two-Eyed seeing: A framework for understanding indigenous and non-Indigenous approaches to indigenous health research. Canadian Journal of Nursing Research, 44, 20–42.

46.

Martin-MacDonald

McCarthy

(2008). Marking the white terrain in indigenous health research: Literature review. Journal of Advanced Nursing Review Paper, 61, 126–133.

47.

Morrow

R. A.

Torres

C. A.

(2002). Reading friere and habermas: Critical pedagogy and transformative social change. Teacher’s College.

48.

Nelson

S. E.

Wilson

(2018). Understanding barriers to health care access through cultural safety and ethical space: Indigenous people’s experiences in Prince George, Canada. Social Science & Medicine, 218, 21–27.

49.

Patton

M. Q.

(2002). Qualitative research & evaluation methods. Sage.

50.

Pidgeon, M.

(2008). Pushing against the margins: Indigenous theorizing of “success” and retention in higher education. Journal of College Student Retention: Research, Theory & Practice, 10(3), 339–360.

51.

Pollard

C. L.

(2015). What is the right thing to do: Use of a relational ethic framework to guide clinical decision-making. International Journal of Caring Services, 8, 362–368.

52.

Public Health Agency of Canada. (2017). Diabetes in Canada: Highlights from the Canadian chronic disease surveillance system. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/diabetes-canada-highlights-chronic-disease-surveillance-system.html

53.

Reading

(2018). Structural determinants of aboriginal people’s health. In M. Greenwood, S. de Leeuw, & N. M. Lindsay (Eds.), Determinants of indigenous people’s health: Beyond the social (pp. 3–17). Canadian Scholars.

54.

Regnier

(1995). The sacred circle: An aboriginal approach to healing education at an urban high school. In M. Battiste & J. Barman (Eds.), First Nations education in Canada: The circle unfolds (pp. 313–329). University of British Columbia Press.

55.

Richmond

C. A. M.

Ross

N. A.

(2009). The determinants of First Nation and Inuit Health: A critical population health approach. Health & Place, 15, 403–411.

56.

Royal Commission on Aboriginal Peoples. (1996). Highlights from the report of the Royal Commission on Aboriginal Peoples: People to people, nation to nation. http://www.ainc-inac.gc.ca/ap/pubs/rpt/rpt-eng.asp

57.

Smylie , (2000). SOGC policy statement: A guide for health professionals working with aboriginal peoples. The Sociocultural Context of Aboriginal Peoples in Canada, 22, 1070–1081.

58.

Stout

Kipling

Stout

(2001). Aboriginal women’s health research synthesis project. Centres of Excellence for Women’s Health.

59.

Stout

M. D.

(2018). Atikowisimiyw-ayawin, Ascribed health and wellness, to kaskitamasowin miyw-ayawin, achieved health and wellness: Shifting the paradigm. In M. Greenwood, S. de Leeuw, & N. M. Lindsay (Eds.), Determinants of indigenous people’s health: Beyond the social (pp. 63–72). Canadian Scholars.

60.

The First Nations Information Governance Center. (2014). Ownership, control, access and possession (OCAP™): The path to First Nations information governance. https://fnigc.ca/sites/default/files/docs/ocap_path_to_fn_information_governance_en_final.pdf

61.

Thompson

L. E.

(1990). Hermeneutic inquiry. In L. E. Moody (Ed.), Advancing nursing science through research (pp. 223–280). Sage Publications.

62.

Truth and Reconciliation Commission of Canada. (2015). Honouring the truth, reconciling for the future: Summary of the final report of the truth and reconciliation commission of Canada. http://caid.ca/TRCFinExeSum2015.pdf

63.

Varcoe

Browne

A. J.

Kang-Dhillon

, (2020). Culture and cultural safety:beyond cultural inventories. In D. Gregory, C. Raymond, L. Patrick, & T. Stephen (Eds.), Perspectives on the art and science of Canadian nursing (2nd ed., pp. 243–261). Wolters Kluwer.

64.

Varcoe

Brown

Calam

Harvey

Tallio

(2013). Help bring back the celebration of life: A community-based participatory study of rural aboriginal women’s experiences and outcomes. Biomed Central Pregnancy and Childbirth, 13, 1–10.

65.

van Manen

(1990). Researching lived experience: Human science for an action sensitive pedagogy. The University of Western Ontario.

66.

van Manen

(1998). Modalities of body experiences in illness and health. Qualitative Health Research, 8, 7–24.

67.

van Manen

(2014). Phenomenology of practice: Meaning-giving methods in phenomenological research and writing. Left Coast Press Inc.

68.

Varcoe, C. & Browne, A. (2015). Culture and cultural safety: Beyond cultural inventories. In D. Gregory, C. Raymond, L. Patrick & T. Stephen (Eds.), Perspectives on the art and science of Canadian nursing (pp. 216–231). Philadelphia, PA: Wolters Kluwer.

69.

Whitty-Rogers

Caine

Cameron

(2016). Aboriginal women’s experiences with gestational diabetes mellitus. Advances in Nursing Science, 39, 181–198.

70.

Whitty-Rogers

Etowa

Evans

(2006). Becoming an aboriginal mother: Childbirth experiences of women from one Mi’kmaq community in Nova Scotia. In D. M. Lavel-Havard & J. C. Lavel (Eds.), Until our hearts are on the ground: Aboriginal mothering, oppression, resistance and rebirth (pp. 34--61). Demeter Press.

71.

Wilson, S.

(2003). Progressing toward an Indigenous Researchparadigm in Canada and Australia. Canadian Journal of Native Education, 27(2), 161–178.

72.

Wilson

(2001). What is an indigenous research methodology? Canadian Journal of Native Education, 25, 175–179.

73.

Wilson

(2008). Research is ceremony: Indigenous research methods. Fernwood Publishing.

74.

Wong, D.L., Perry, S.E., Hockenberry, M.J. Lowdermilk, D.L. & Wilson, D. (2006). Maternal child nursing care (3rd Ed.). St. Louis, MO: Mosby Elsevier.