Conceptualising cultural safety at an Indigenous-focused midwifery practice in Toronto, Canada: qualitative interviews with Indigenous and non-Indigenous clients.

OBJECTIVE: Cultural safety is an Indigenous concept that can improve how healthcare services are delivered to both Indigenous and non-Indigenous peoples in Canada. This study explored how Indigenous and non-Indigenous clients at an urban, Indigenous-focused midwifery practice in Toronto, Canada (Seventh Generation Midwives Toronto, SGMT) conceptualised and experienced culturally safe care. DESIGN AND SETTING: Interviews were conducted with former clients of SGMT as a part of a larger evaluation of the practice. Participants were purposefully recruited. Interviews were transcribed and analysed thematically using an iterative, consensus-based approach and a critical, naturalistic, and decolonising lens. PARTICIPANTS: Saturation was reached after 20 interviews (n=9 Indigenous participants, n=11 non-Indigenous participants). RESULTS: Three domains of cultural safety emerged. Each domain included several themes: Relationships and Communication (respect and support for choices; personalised and continuous relationships with midwives; and being different from past experiences); Sharing Knowledge and Practice (feeling informed about the basics of pregnancy, birth, and the postpartum period; and having access to Indigenous knowledge and protocols), and Culturally Safe Spaces (feeling at home in practice; and having relationships interconnected with the physical space). While some ideas were shared across groups, the distinctions between the Indigenous and non-Indigenous participants were prominent. CONCLUSION: The Indigenous participants conceptualised cultural safety in ways that highlight the survival and resurgence of Indigenous values, understandings, and approaches in cities like Toronto, and affirm the need for Indigenous midwives. The non-Indigenous participants conceptualised cultural safety with both congruence, illuminating Black-Indigenous community solidarities in cultural safety, and divergence, demonstrating the potential of Indigenous spaces and Indigenous-focused midwifery care to also benefit midwifery clients of white European descent. We hope that the positive impacts documented here motivate evaluators and healthcare providers to work towards a future where 'cultural safety' becomes a standard of care.

Our Health Counts Toronto: using respondent-driven sampling to unmask census undercounts of an urban indigenous population in Toronto, Canada.

OBJECTIVES: To provide evidence of the magnitude of census undercounts of 'hard-to-reach' subpopulations and to improve estimation of the size of the urban indigenous population in Toronto, Canada, using respondent-driven sampling (RDS). DESIGN: Respondent-driven sampling. SETTING: The study took place in the urban indigenous community in Toronto, Canada. Three locations within the city were used to recruit study participants. PARTICIPANTS: 908 adult participants (15+) who self-identified as indigenous (First Nation, Inuit or Métis) and lived in the city of Toronto. Study participants were generally young with over 60% of indigenous adults under the age of 45 years. Household income was low with approximately two-thirds of the sample living in households which earned less than $C20 000 last year. PRIMARY AND SECONDARY OUTCOME MEASURES: We collected baseline data on demographic characteristics, including indigenous identity, age, gender, income, household type and household size. Our primary outcome asked: 'Did you complete the 2011 Census Canada questionnaire?' RESULTS: Using RDS and our large-scale survey of the urban indigenous population in Toronto, Canada, we have shown that the most recent Canadian census underestimated the size of the indigenous population in Toronto by a factor of 2 to 4. Specifically, under conservative assumptions, there are approximately 55 000 (95% CI 45 000 to 73 000) indigenous people living in Toronto, at least double the current estimate of 19 270. CONCLUSIONS: Our indigenous enumeration methods, including RDS and census completion information will have broad impacts across governmental and health policy, potentially improving healthcare access for this community. These novel applications of RDS may be relevant for the enumeration of other 'hard-to-reach' populations, such as illegal immigrants or homeless individuals in Canada and beyond.