Commentary

Building Brave Spaces in Midwifery: Reflections of the IBPOC Peer Review Initiative

Construire des espaces courageux dans la profession de sage-femme : Réflexions sur l’initiative IBPOC d’évaluation par les pairs de l’IBPOC

Claire Ramlogan-Salanga, RM, MSc*, Natasha Singleton-Bassaragh, RM, BSc

Midwifery Education Program, McMaster University, Hamilton, Ontario, Canada

Abstract

We look forward to watching our collaboration grow and inviting more racialized midwives to present their expertise, and continuing to enjoy the camaraderie of Indigenous, Black, and People of Colour (racialized) midwives and midwifery students nationally. We hope this commentary will inspire other equity deserving groups to come together and learn from our experience so that more brave spaces can be borne and nourished.

Résumé

Nous avons hâte de voir notre collaboration se développer et d’inviter d’autres sages-femmes racialisées à présenter leur expertise, et de continuer à profiter de la camaraderie des sages-femmes autochtones, noires et de couleur (racialisées) à l’échelle nationale. Nous espérons que ce commentaire incitera d’autres groupes méritant l’équité à se réunir et à apprendre de notre expérience afin que d’autres espaces courageux puissent voir le jour et être nourris.

Key words: IBPOC, Peer Review, Affinity Group, Concordant Care, Grass Roots, Equity Deserving

Corresponding author: Claire Ramlogan-Salanga: [email protected]

Submitted: 26 July 2023; Accepted: 1 October 2023; Published: 9 December 2023

All articles published in DPG Open Access journals
This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0)(https://creativecommons.org/licenses/by-nc/4.0/).

Will I get reprimanded or ignored if I talk about social issues again? Where can I talk about the experiences of racialized clients and get culturally appropriate responses? Where can I just be me?

Collective experiences of being labelled “unprofessional” due to our “aggressive” or “troublemaking” participation during inter- and intra-professional clinical case reviews, that is, peer reviews, have forced many of us, Indigenous, Black, and People of Colour (IBPOC) midwives and midwifery students, into the margins of many professional spaces, both physically and mentally. Locating spaces that encourage discussions about the interplay of clinical care and complex topics, such as social and systemic oppression, is a rarity. In this commentary, we share how we envisioned and eventually created a brave space where Indigenous, IBPOC midwives and midwifery students could discuss these entangled issues without judgement.

The IBPOC peer review is a midwifery-led, grassroots initiative borne from a need to be heard, supported, and validated. This intra-professional clinical case review provides a place for community-building through acts of leadership and mentorship as well as sharing our unique expertise. After a few years into the successful stewardship of this initiative, we find ourselves at the end of the fourth year, being supported through allyship by the Toronto Birth Centre (TBC). This collaboration fosters autonomy and kindles a shared desire to apply cultural safety principles and an anti-oppressive praxis to our professional lives. It is our aim to continually nourish this brave space for midwives and midwifery students so that we can see ourselves flourish.

We started the IBPOC Peer Review in 2019 with five other midwives in the lunchroom of Amma Midwives in Brampton, Ontario, Canada. Our humble beginnings were inspired by the concept of concordant care, and its related positive outcomes.13 Concordant care occurs in healthcare settings when the healthcare dyad is comprised of a healthcare provider and client with a shared demographic similarity or shared identity.4 Positive outcomes have included improved communication, trust-building, and better patient satisfaction.2,5 Through extension of this concept, we believe that we are able to echo these positive outcomes through the mutual sharing of professional case reviews in spaces with racially or culturally concordant peers and colleagues. The IBPOC Peer Review exists to support shared learning, encourage mentorship by strengthening relationships between racialized midwives and students, and foster a space that reflects its participants’ ways of knowing and being. It also exists to counter our collective experiences in discordant spaces where we are forced to contend with being silenced, tone policed, and gaslit.

Before the pandemic, we would gather in person every couple of months to share clinical cases, break bread, and support one another in ways that were unique and familiar. In retrospect, the space had many intangible characteristics and qualities that defy description; a subtle appeal that encouraged candour and liberty. We laughed, we cried, we analyzed, and we were real. We did what occurred in other peer review spaces in a clinical sense, but in that physical space, we felt we could be ourselves and exhale. What we had found—what we had created—was community.

We know that our presence as Indigenous, Black, and Racialized midwives and students in the midwifery profession, and the healthcare system in general, is complex. Factors such as systemic racism, isolation, tone-policing, gaslighting, and toxic power imbalances, add extra layers of stress and burden to our already marginalized population of healthcare workers and students.6,7 Moreover, the lack of IBPOC representation in the profession and education programmes puts into question the physical and mental safety, and sustainability, of IBPOC midwives in the province as well as the country. To put this into perspective, in Ontario, the percentage of visible minorities reported by Canada’s 2021 census was 34.3%.8 According to the Association of Ontario Midwives (AOM) 2022 renewal data, only 19% (n=190) of its members identified as IBPOC.9 This 15% disparity in racial and ethnocultural representation reiterates just how small in numbers we are, and how important it is to create spaces such as the IBPOC Peer Review for marginalized healthcare providers.10

To further the point of our precarious position as racialized midwives and midwifery students, in 2021, Aseffa et al. reported that 86% of racialized midwives and students surveyed in Ontario (n = 36) experienced racism in their work as a midwife.6 Moreover, “over 85% of the study’s participants agreed or strongly agreed that racism or fear of racism impacts how they communicate or express themselves, and their mental health.”6 As a small and diverse community, the presence of IBPOC midwives in the profession places many of us in vulnerable positions, leading us to pick and choose when we communicate our experiences as a matter of self-protection. We also know that our presence is essential as a form of resistance against the systemic inequalities of the profession, education system, and overall healthcare system.57 Therefore, we looked within to create an outlet that encouraged IBPOC midwives and midwifery students to voice their experiences, learn from one another, and protect each other’s mental health. As two racialized midwives, our mission with this peer review space is to nourish our community so that it can flourish.

Returning to that lunchroom at Amma Midwives in Brampton, our first peer reviews were conducted in person and by phone, as this was the standard for midwifery peer reviews in Ontario. Attendance was open to anyone who self-identified as IBPOC and was a midwife or midwifery student in Ontario. For several months attendance remained small, as our only way to spread the word was through our own social media and professional networks. Serendipitously, the pandemic forced the peer review to shift to an exclusively online platform, which increased accessibility and consequently the attendance. Our participant list jumped from 7 to 25! Most importantly, two more racialized midwives joined our small team of two to lend a hand with coordination. This collaboration helped build infrastructure and provide administrative support as we prepared to expand our reach to a national audience.

With our team of four, we were able to create terms of reference (TOR) that outlined our aim, who the space was meant for, and our agreed upon etiquette, and introduced the idea that any participant could facilitate the peer review. The TOR was reviewed at several gatherings and received informal approval by our community. It is reviewed annually and is accessible to participants. As new participants register, we ensure they receive the TOR for orientation purposes. We also agreed that the peer review space needs protection and nurturing; so, while we model professional clinical discussion formats, we also leave room for spontaneous conversation.

In addition to the TOR, we created a digital announcement that has helped to create a recognizable image for the Peer Review. This is shared on various social media platforms, and through the weekly AOM Midwifery Memo. Recently, we have begun advertising in the Canadian Association of Midwives (CAM) weekly email, which has brought midwives from coast to coast to the Peer Review. Since this marketing initiative began, our participant list has grown significantly to more than 100 midwives and midwifery students representing just less than half of the provinces and territories.

The format of the Peer Review includes a wel-come, a land acknowledgement, and announce-ments made up of community news, research projects, and job opportunities. On occasion we reserve time for participants to check in at the beginning of the meetings. This check-in, which in other peer review spaces might be viewed as irrelevant, or even a waste of time, reminds us to slow down, be aware of one another, and know that we are valued as people beyond our roles as midwives. This step reiterates the positive outcomes associated with concordant care that we mentioned earlier and provides an opportunity for self-care. We also incorporated educational and clinical rounds led by racialized participants. Topics have included: Grad School Applications, Management of Hepatitis B in Pregnancy and the Postpartum, Midwifery Practice Groups Best Practices, Race-Based Data for Health Equity, Somatic Abolitionist Healing Practices, and Psychotherapy Support for Midwives and their Clients. We recognize that racial representation matters, and therefore we lean on our participants for expertise to learn from, and teach, one another. This action is fundamental to our goal of nourishing our community of healthcare providers. We expect to schedule future speakers on topics, such as risk management from the Healthcare Insurance Reciprocal of Canada, psychotherapy, policy development, reproductive and sexual healthcare, and more.

It has been just over 4 years since the IBPOC Peer Review took shape. Each year we conduct an annual quality improvement survey using Google forms. These surveys are distributed to midwives and midwifery students that have attended a gathering in the past year from September to June. Repeatedly, participants express their appreciation for the opportunity to learn in a brave space and to be informally mentored by senior midwives who talk and look like them. Most importantly, participants express their gratitude for the community that has been created and that they no longer feel alone.

This Peer Review is a labour of love and has been nourished on volunteer time. While we are pleased with how well the IBPOC Peer Review has been received, we are also aware that we can do much more with this platform, such as supporting racialized midwives in developing confidence, leadership skills, networking, and offering other spinoff programmes. This, however, requires more time, human resources, and funding. As a first step in this grand plan, we have established connections with a partner organization within the profession who aligns with our values, goals, and interests. In the spring of 2023, the clinical director of the TBC and our team envisioned a collaboration. They had developed a new guideline to better integrate cultural safety and anti-racism practices into their own peer reviews. Midwives that currently attend TBC monthly peer reviews and present a case are asked to not only think about cultural safety and anti-racism, but also to apply those thoughts during the peer review. They are asked to use the internally developed Cultural Safety Peer Review Guideline that is based on their cultural safety framework. Additionally, TBC leadership recognized and acknowledge that TBC-affiliated racialized midwives should have options for where they attend peer review and present cases. This is where our partnership aligned.

The Cultural Safety Peer Review Guideline addresses and codifies many of the ways that already exist in the IBPOC Peer Review organically. For example, we discuss concepts foundational to our existence as racialized midwives and to the care of our clients, such as concordance and discordance of healthcare provider and client, the life experiences of the client, including inter-generational complexities; structural barriers; building trust; and maintaining client autonomy. This is where the IBPOC Peer Review and the TBC were able to build a relationship that integrated cultural safety and did not ask us to change our foundations or the core of our existence as a grassroots initiative.

We appreciate that the TBC has also recognized the importance of funding to keep this important work going. Our invisible work as racialized midwives and midwifery students usually goes unnoticed and unpaid. In our efforts to seek equity and justice, we slowly erode our physical and mental health, making this work feel at times unsustainable. The financial support that the TBC has committed to enables us the IBPOC Peer Review to provide honorariums to its administrators, facilitators, and presenters. This collaboration with the TBC is allyship in action.

As we begin planning our fifth year, we look forward to watching our collaboration grow, inviting more racialized midwives to present their expertise, and continuing to enjoy the camaraderie of IBPOC midwives and midwifery students nationally. We are hopeful that this commentary will inspire other equity deserving groups to draw our experience and come together so that more brave spaces will be borne and nourished.

Acknowledgements

A few heartfelt acknowledgements to the people, institutions, and associations that have helped us grow to where we are today. We thank our peer supporters and McMaster University for access to the Zoom platform, as well as midwives Bounmy Inthavong and Isomi Henry for their work on building infrastructure and supporting the initiative during the early years. We are grateful to the AOM and CAM for their support in promoting our monthly meetings to the membership both provincially and nationally. We also thank TBC executive director Roberta Pike and clinical director Sarah Booth for extending open arms to our group, giving us space to grow our community, and acknowledging the importance of this initiative with financial support. We also thank Dr. Liz Darling for guidance with this commentary. Last, but certainly not least, we thank our guest speakers, facilitators, midwife and midwifery student participants for making the IBPOC Peer Review a place of bravery and community. We are creating spaces where we are flourishing!

REFERENCES

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2. Greenwood BN, Hardeman RR, Huang L, Sojourner A. Physician–patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci. 2020 Sep;117(35):21194–200. 10.1073/pnas.1913405117

3. Ku L, Vichare A. The association of racial and ethnic concordance in primary care with patient satisfaction and experience of care. J Gen Intern Med. 2023 Feb 1;38(3):727–32. 10.1007/s11606-022-07695-y

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AUTHOR BIOGRAPHIES

Claire Ramlogan-Salanga is Canadian born of Indo-Caribbean ancestry. She is a Registered Midwife and Assistant Professor in the Midwifery Education Program at McMaster University. She has a Master’s degree in Health Professions Education (McMaster) and is starting a PhD in Global Health (McMaster) in September 2023. Her research focuses on social justice curriculum, intersectional approaches to research design, and equitable access to sexual and reproductive health care.

Natasha Singleton-Bassaragh, Natasha Singleton-Bassaragh is a second generation Canadian of Afro-Caribbean ancestry. She is a Registered Midwife in Ontario and holds a Bachelor’s degree in Psychology (York), as well as a Bachelor of Science in Midwifery (Toronto Metropolitan). She currently serves as Secretary for the Board of Directors at the Association of Ontario Midwives (AOM). Her professional interests focus on disability equity for midwives, sustainability in Ontario midwifery, and empowering new parents.