The Fireweed Project: Recommendations for Improving Abortion Access and Experiences by and for Indigenous Peoples in Canada

The Fireweed Project: Recommendations for Improving Abortion Access and Experiences by and for Indigenous Peoples in Canada | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Fireweed Project: Recommendations for Improving Abortion Access and Experiences by and for Indigenous Peoples in Canada Renée Monchalin, Shannon Hardy, Willow Paul, Madison Wells, Emma Antoine-Allan, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5278379/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Indigenous Peoples in Canada face significant barriers to accessing abortion services, attributed to colonial policies, systemic racism, and geographic isolation. Despite the presence of intergenerational reproductive knowledge, barriers persist. The Fireweed Project seeks to address barriers by gathering recommendations from Indigenous abortion seekers to improve access and experiences. Methods Forty-one-on-one conversations were conducted with Indigenous abortion seekers across Canada. Data was analyzed using the DEPICT participatory qualitative analysis model, ensuring that the voices of Indigenous communities were central to the process. The Indigenous Gender-Based Analysis Plus (IGBA+) framework further informed analysis, considering intersections of race, gender, and socio-economic status. Results Six key themes emerged from the data, including the need for Indigenous-led reproductive health services, ongoing cultural safety training for healthcare providers, enhanced follow-up and support services, and dismantling abortion stigma within Indigenous communities. Participants also recommended expanding abortion education in schools and improving maternal-child health supports through policy change. Conclusion This study highlights the importance of centering Indigenous voices in the improvement of abortion services. Implementing the recommendations from Indigenous abortion seekers can help dismantle systemic barriers and improve cultural safety and accessibility of care. These findings contribute to ongoing efforts to ensure equitable reproductive health services for Indigenous communities in Canada. Background Indigenous communities in Canada hold intergenerational reproductive health knowledges that emphasize choice, holistic well-being, and community care ( 1 , 2 ). Despite this, barriers to accessing abortion persist, rooted in historical and ongoing systemic inequities( 3 , 4 ). Colonial policies prohibiting Indigenous ceremonies and practices, coupled with geographic isolation, financial constraints, and the scarcity of healthcare providers in rural and remote areas, hinder access to reproductive health services, including abortion ( 5 , 6 ). These barriers are compounded by racism and discrimination within healthcare settings toward Indigenous peoples, highlighted by forced sterilizations and reproductive coercion, resulting in mistrust and avoidance of medical services ( 7 – 9 ). While addressing inequities in abortion access necessitates systemic reforms, Indigenous abortion seekers' voices are often missing from access solutions. Integrating Indigenous voices is vital for achieving equitable access and reproductive health outcomes ( 3 , 4 ). Through a community-led approach, this paper centers the voices of Indigenous abortion seekers, highlighting their recommendations to improve access to and experiences with abortion services in Canada. The Fireweed Project The Fireweed project aims to investigate experiences of abortion access and support among Indigenous Women, Two-Spirit, and lesbian, gay, bisexual, transgender, queer, intersex, asexual and other sexually and gender diverse (LGBTQIA+) people in Canada. The project name was inspired by teachings of the fireweed plant, shared by a participant from the 'Global Goal Local Impact' study ( 3 ) There’s one plant called fire weed … I know that we traditionally used that as birth control, but also as a medicine to implement abortion… I kind of have a philosophy that … with the knowledge of herbal methods ending a pregnancy, Indigenous culture suggests a tradition of honoring pregnant people’s self-determination of their own bodies… (p.3) Through the application of an Indigenous feminist framework, which highlights the intersections of gender, colonialism, and Indigenous body sovereignty in health research ( 10 ), Fireweed centers the voices of Indigenous abortion seekers to identify and address systemic barriers within healthcare settings. It is led by four community partners, including Abortion Support Services Atlantic, ekw’í7tl Indigenous doula collective, Northern Reproductive Justice Network, and Northern Manitoba Abortion Support. It is guided by an Advisory Circle which encompasses a group of fourteen Indigenous and allied service providers working in the realm of abortion support and care in Canada. Methods Data collection Utilizing a conversational interview method informed by Ojibway scholar Kathy Absolon’s (2011) ( 11 ) Indigenous methodology, we collaboratively developed an open-ended conversational interview guide with our four partners. The guide encompassed eight open-ended questions centered around themes including abortion access experiences, stigma, support, Indigenous-specific services, community perceptions, traditional teachings, and how participants wished to see project results utilized. Recruitment commenced September 2022, with the research team and partners sharing the recruitment poster through personal and organizational Instagram accounts and the Fireweed webpage. Our team allocated funding to conduct conversations with 40 individuals on a first-come, first-served basis, based on eligibility requirements. This number was determined based on the number of participants who had to be turned away from our Global Goal, Local Impact exploratory study due to funding constraints ( 3 ), while ensuring a diversity of experiences across geography. Once each potential participant was screened for eligibility, a date and time to meet over Zoom was arranged. Selection criteria included participants who self-identified as First Nations, Inuit, and/or Métis; were 19 years old or older; and have accessed, or tried to access, an abortion in Canada. Participants received a $ 100 CAD honorarium via e-transfer at the beginning of their conversation and were each gifted a custom cotton throw blanket, made through a collaboration between the Fireweed team, Eighth Generation, and an artist from the W̱SÁNEĆ nation, on whose territories many of the researchers reside. Data Analysis Beginning September 2023, our team employed the DEPICT model by Flicker and Nixon ( 12 ), a participatory approach to qualitative health research, to ensure a collaborative and inclusive data analysis process. The DEPICT model comprises six sequential steps: Dynamic Reading, Engaged Codebook Development, Participatory Coding, Inclusive Reviewing and Summarizing of Categories, Collaborative Analyzing, and Translating Findings. Our analysis team was composed of nine Indigenous and allied team members from the Fireweed advisory circle, research team, and community partners, all with lived or front-line abortion support experience. This enriched the analysis by incorporating varied perspectives and expertise, ensuring that the findings were culturally relevant and grounded in real-world experiences. The process began with a (D)ynamic Reading, where team members immersed themselves in subsets of the data to identify key themes. (E)ngaged Codebook Development followed, involving a collaborative and comprehensive codebook. (P)articipatory Coding assigned each team member specific transcripts based on their area of interest and expertise, promoting a multifaceted examination of the data. (I)nclusive Reviewing and Summarizing involved team members working in pairs to distill coded data into summaries. During (C)ollaborative Analyzing, the team met to synthesize these summaries, interpreting the findings collectively. At the time of writing this paper, our team is focused on the (T)ranslating phase and developing a dissemination plan to share the results with relevant communities, policy makers, and abortion providers. Congruent with our Indigenous feminist framework, our DEPICT analysis was informed by integrating an Indigenous Gender-Based Analysis Plus (IGBA+) ( 13 , 14 ). The IGBA + framework, which considers intersecting factors such as gender, race, and socio-economic status, provided critical insights into the multiple dimensions of participants' experiences. This integration emphasized relationality, balance, and respect, while ensuring our analysis was methodologically rigorous, culturally sensitive and intersectional. Results We conducted interviews with 40 participants that averaged one hour in length, between February and July 2023. One recording was lost and therefore not included in the analysis, resulting in a total of 39 interviews. The Indigenous identities represented among the participants include Salteaux, Cree, Métis, Michif, Dene, Algonquin, Mohawk, Ojibwe, Inuvialuit, Mi'kmaq, Coast Salish, Anishinaabe, and Haudenosaunee. Of the three federally recognized Indigenous groups in Canada represented in this study ( 7 ), twenty-five participants (n = 25) identified as First Nations, six participants identified as Métis (n = 6), three participants identified as both First Nations and Métis (n = 3), one participant identified as Inuit (n = 1), and four participants identified as Indigenous (n = 4), not specifying a specific group. Interviews took place between three months and nine years since the participants' abortions, with one outlier being sixteen years. The average age at the time of the interviews was 30 years old. The age range at time of abortion was between 16 to 35 years old. Out of the 39 participants, 36 had procedural abortions, 2 had medication abortions, and 1 experienced a miscarriage, resulting in them not needing their scheduled procedural abortion. Geographically, 28 participants were from urban areas, 6 from rural areas, and 5 from remote areas. The interviews represented participants from 11 provinces and territories, with every province and territory included except Prince Edward Island and Yukon. Based on the first two steps of the DEPICT model, Dynamic Reading and Engaged Codebook Development, the analysis team chose six overarching themes to represent participant recommendations arising from the conversations. These themes included: ( 1 ) Ongoing cultural safety training and establishing Indigenous-led or informed reproductive health clinics; ( 2 ) Enhancing mainstream abortion services through enhanced transparency, follow-up, and wraparound supports; ( 3 ) Informative resources and tailored support tools; ( 4 ) Dismantling abortion stigma within Indigenous communities and enhancing culturally rooted community support systems; ( 5 ) Integrating abortion education into public school curriculums; and ( 6 ) Expand maternal-child health supports to be responsive to the needs of abortion seekers though policy change. These themes are interwoven and overlapping, reflecting the multifaceted nature of participant recommendations. The analysis team recognized that while these themes intersect, presenting them separately allows for more nuanced insights shared by participants, offering clear pathways for targeted actions and interventions. Ongoing cultural safety training and establishing Indigenous-led or informed reproductive health clinics (n = 28) Twenty-eight participants emphasized ongoing Indigenous cultural safety training and Indigenous-led or informed reproductive health clinics to provide trauma-informed care. Participants shared how medical professionals often are unaware of the history of medical trauma among Indigenous peoples, and that effective care requires recognizing intersectional identities. Medical professionals I don’t think understand the impact of cultural safety which is interesting to me because it’s actually in the medical profession where … this concept of cultural safety originated. Right in New Zealand, and yet, it’s still just so frustratingly not helpful for folks. Right? Because they don’t understand the trauma that’s involved there, they don’t understand the number of First Nations, Inuit and Métis people who were forced to be sterilized, who have all kind of trauma, trying to work through a colonial system… If you don’t understand that, how can you possibly make sure that you’re providing good care to different people? This translates across… Because there’s lots of intersectionality that needs to be included in that… like are they Afro-Indigenous? Are they queer-Indigenous? … Do they have disabilities? It’s the intersectionality, and using trauma informed approach is just so necessary, especially in this kind of a space. Because it is traumatic. It’s not something that you want to choose or ever think, ‘one day I’ll just have an abortion and I’ll be fine.’ That is not how that happens. So … if you don’t understand that, how can you possibly provide good care? (03) Recommendations for cultural safety included Indigenous-led or informed clinics that incorporate intergenerational, full-spectrum, family planning teachings, and “ care for folks from womb to tomb in terms of reproductive health” ( 27 ). As one participant shared, “if there was an Indigenous-focused clinic I would have 100 percent accessed that because I feel like the cultural awareness, sensitivity, competence would have been there” ( 18 ). In an Indigenous-led or informed space, participants shared that this may include having access to traditional medicines, “having that open space where people can be culturally themselves.” (05) , and access to pro-choice Indigenous service providers, such as Elders, Grandmothers, Indigenous liaisons, doulas, and aunties. These providers were identified by participants to help with reducing abortion stigma, offering non-judgmental support, and sharing intergenerational knowledge around abortion to alleviate shame. As one participant shared, Indigenous abortion support providers may hold “… stories about how before colonization and before the women were removed of their power in the community, how we used plants to have abortions … so you don’t feel like this is wrong.” ( 14 ). One participant highlighted that they wish they had an Indigenous person who understands their unique experience, I wish I had an Elder, I wish I had a knowledge keeper, I wish I had another community member… an Indigenous person… Who understands what it’s like for me to exist in this world and to access this western medicine. This is the most sterile western thing I’ve ever done in my life [in] terms of medicine, and I wish I had somebody there with me, that could help me with the feelings that I was feeling… through my own cultural values and my own teachings and my own understanding and my own world view. ( 36 ) Another participant shared that while a service provider may not be Indigenous, the space that provides abortions must have an Indigenous approach to care. This would incorporate elements of being trauma informed, culturally safe, low barrier, and accessible: In accessing … sexual reproductive healthcare... if it’s not an Indigenous service provider or somebody with an Indigenous approach or understanding of care, and I mean I’m calling an Indigenous approach, but I think lots of people use words like trauma informed, or culturally safe, or low barrier, accessible… When I think of Indigenous approaches to care, they include elements of all of those things, but they also just include a cultural understanding of what it means to actually engage in taking care of yourself and how revolutionary that is in the context of colonialism in history that we have... Any Indigenous person seeking any kind of care, that in a way that’s like deliberate or agreeing to care… for their betterment, emotionally, mentally, physically, spiritually, that is totally an act of revolution and should be celebrated and supported. And I just don’t think that there’s … capacity to do that within the regular healthcare system. I would have liked for somebody to recognise what a big deal it was that I was actively making a decision that was for the betterment of my life and my family’s life in a way that was like very rooted in a cultural context. ( 39 ) While having access to Indigenous-led or informed clinics was identified as significant, participants also acknowledged abortion stigma within Indigenous focused health services and identified this as a barrier for Indigenous abortion seekers. I mean we have a decent health center in my community, and they do offer good services but because of the stigma around abortion, I wouldn’t seek those services because this town is so small. Everyone would know in the next week what I’ve been talking about. (05) Enhancing mainstream abortion services through enhanced transparency, follow-up, and wraparound supports (n = 24) Twenty-four participants spoke to improving mainstream abortion services, including clinics and hospitals, by providing follow-up care, non-judgmental support, and comprehensive wraparound services like mental health referrals, transportation, and childcare. For follow-up services in mainstream settings, participants asked for clear communication on what to expect from providers to understand potential symptoms. Participants shared that this could involve receiving detailed instructions during intake, receiving an email, or a follow-up phone call. One participant highlights the need for support to handle the emotional and practical aspects of their abortion experience: I think that that was never really explained to me and that it was always either the one, you’re fine. There’s nothing to be sad about. Or two, you’re a terrible person, you should feel like shit. There was no in between. So it’s like not even knowing where to find a resource, not a pamphlet, nothing. There’s nobody to call when you’re feeling sad or nobody to celebrate with even. Nobody fucking makes you a cake. You know what I mean? […] There’s no follow-up. There’s no anything. There’s not even a way to reach the doctor and say like hey, I’m bleeding a lot. What do I do? There was no number to follow up... It was just expected that I would know what to do if that happened, and as a teenager I didn’t know. I was like, do I just go to bed… or do you call an ambulance? […]. Even if it’s just information about emotions and what to expect. ( 10 ) Participants highlighted the need for non-judgemental service providers. Ultrasound technicians and receptionists within mainstream settings were described by participants as most likely to hold judgement around abortion, impacting Indigenous participants' experiences. After travelling hours by plane for an ultrasound, one participant shared, The ultrasound tech I remember them telling me … they’re like ‘do you want to see?’ and I said ‘no I don’t want to see’ and she was just like ‘are you sure?’ That to me wasn’t very supportive. I think she knew on paper what my decision was. And then I was sent back home to [remote community]. ( 15 ) Another participant recalls the long wait, in addition to the lab technician and ultrasound technician making them feel as though they should be celebrating getting pregnant. It was a very cold sterile place. Yeah, obviously that lab technician. I would change that… I waited about four weeks for that appointment… And that felt like an eternity for me. I had an alien inside me… I had to go for an ultrasound too. And I remember them asking if I wanted to see it and I was like absolutely not. That’s the last thing I want to see right now. Between the ultrasound and the lab technician… it was only them that made me feel like I should be celebrating something. But other than that, everyone was fine. Very supportive. Like the actual clinic staff and my family doctor were all lovely. ( 34 ) This participant continues and recommends how lab and ultrasound technicians should avoid being congratulatory, acknowledging that everyone’s circumstances are different. I told you about the lab technician, the ultrasound technician. I think that definitely should be taught because you don’t know anyone’s circumstance. You don’t know how they feel about it… how they got into that circumstance, into the situation so … the congratulatory or the warning of don’t do it because I regret it. Like no. That should never happen to anybody. ( 34 ) Participants highlighted the need for mainstream services to offer wraparound supports, such as mental health care, transportation, or childcare to mitigate access barriers and complex emotions. As one participant shared, “You’re not allowed to bring kids to the abortion … how am I supposed to get an abortion if I don’t have anybody to help me?” ( 11 ). Another participant shared: Definitely transportation, some kind of care plan. Even for that to be part of the process when you schedule your abortion, maybe there’s a follow up call from a community partner who talks to you about what’s your strategy, how can we support you on that day? Do you have a ride? Do you have childcare? You know, maybe that person is in crisis in other ways that can be you know, any form of intervention is good. Because with stress especially, you can get so much sicker, it just adds to the physical toll that the person experiences... And I would love to see little care kits, similar to what a sexual assault survivor in a hospital might receive. New clothing… a voucher for a store. Something to help them meet their personal needs... A little care package just goes a long way… giving people a little extra boost, I think is important in that process. And then, maybe some of the clinical pieces could be revised, that would be great. The whole clinical part is very much about assessing if you’re being coerced … making sure that this person is fully consenting... But I feel like there’s a way to do that without judgement. ( 32 ) Informative resources and tailored support tools (n = 22) Twenty-two participants highlighted the need for informative abortion resources, Indigenous-specific abortion support tools, and resources targeted at men. First, participants asked for accessible, clear, and informative materials about abortion procedures, processes, and symptoms. They expressed the need for more explanation and support, highlighting the lack of information provided about their options, procedures, and follow up. One participant recommended receiving information over email in advance of their abortion to describe the process, I feel like if I had like an email the day before or something like kind of like giving me the information of what’s going to happen and how they do it. Like to be well informed would have been really helpful. ( 31 ). Following the abortion, this participant also described being sent home and “…not knowing how to find those supports… [with providers] just sliding over a pamphlet [and saying] ‘call the number on the back’”. ( 31 ). Participants often described how after their abortion, providers said “you’re on your own.” (05) , being told, “Good luck, safe travels on your way home. And that was it.” (05) Another participant expressed frustration over the lack of detailed information and explanations regarding their abortion procedure and options. They felt uninformed and wished for more clarity and opportunity to ask questions, comparing it to the thorough explanations provided during a dental exam. Nobody ever at any point handed me a pamphlet about my options or what they looked like or what the actual procedure was…No one ever really explained any of that. I just was like ‘oh, surgery.’ … I didn’t really understand what was happening and maybe that’s my fault for not asking but I feel like there should have been more explanation... Like now that I have the ultrasound, show me what I’m looking at. It’s still very much my body. I’d like to know what it was doing, if it was… even a dental exam, they’ll show you on your x-ray, ‘Oh, we’re taking out this tooth. This is the cavity. This is what we’re doing.’ Nobody showed you that... I just wish there was a little bit more explanation about everything, so I had the opportunity to ask questions. ( 10 ) Participants recommended developing tools tailored to supporting Indigenous peoples’ access abortion care in the form of an app, hotline, or website. One participant expressed the need for an Indigenous-specific hotline or app to provide support and guidance for Indigenous people needing to access an abortion. Some kind of Indigenous hotline or something, an app that is advertised so that somebody who wouldn’t think to google would have that support … it’s easier to figure out what to do for Indigenous girls because we’re lucky if we have a doctor in our community. Like we have a nurse practitioner. We don’t have a doctor. And you don’t know who’s going to talk and you don’t know who’s going to judge you if you were to ask for help… I wish that there was an Indigenous-specific hotline or something that our young girls could access. ( 22 ) This participant continues and describes the benefit of having a national hotline and website to connect Indigenous abortion seekers with Indigenous abortion doulas and safe, non-judgemental support: I remember growing up, those frigging Kids Help phones stickers were everywhere. If there were a national hotline that could even direct you to somebody safe to speak with that’s Indigenous in your province that would be great. Even more great if that person were … an abortion doula who is Indigenous. If there could be abortion doulas in every province and territory that would be beautiful. Having funds available via this hotline or via these doulas to make sure that all of those needs could be met so that somebody wouldn’t have to go through the awkwardness of going through their community health centre. I would really like to see … a hotline, website, a list of services on the website like where people could call, directions as to how to access services. ( 22 ) Lastly, participants called for resources targeted at men to destigmatize abortion. As one participant shared, “Is there a way to include more men in the conversation?... It’s good to have women and femmes obviously in the inner circle, but I feel like… more awareness for the men too...” (09). Including men in conversations was shared by participants to foster support and understanding, helping to reduce shame. One participant describes the value of transferring this knowledge to include men of all ages: Transferring … teachings about how our grandmothers and aunties and ancestors, what their teachings were surrounding abortion… to the generations that have lost it, I think that’s really important… And not just for women who are accessing abortions or people with uteruses that are accessing abortions but for all of us, like my son, my brother, my dad… to help destigmatise the shame or just to remember these stories. Because they are so important and so vital and somehow getting them out there would be really valuable. ( 14 ). Dismantling abortion stigma within Indigenous communities and enhancing culturally rooted community support systems (n = 21) Twenty-one participants emphasized the importance of addressing abortion stigma in Indigenous communities by fostering open dialogue to create a more accepting and supportive environment for those seeking abortion care. This included emphasizing choice and development of materials that share how abortion was practiced traditionally. As one participant shared, I think it would be really great for the stigma in communities, because let’s be real, a lot of our communities do not accept this… it’s not celebrated, it’s not really acknowledged at all. I think if we had more of these resources available to specifically us, it would cause communities to stop and think. It would put them in a position where they have to reflect. ( 36 ) Building on the above quote, another participant speaks to acknowledging resistance to the topic of abortion due to reproductive violence and coercion. Just normalising [abortion] more within community. Having campaigns in community. It’s so tough because… birth control and abortion is something that is thrust onto our people because we’re told that society doesn’t want more of us. You have forced sterilization, and you have healthcare providers that are gung-ho to get an IUD in you as quick as possible. Indian Affairs, sometimes they’ll cover barely anything, but they’ll cover IUDs. Because they don’t want more of you. So, people are really resistant to hearing those narratives around ‘we want to see less of you in this world’. So, you’re up against that to normalise abortions. But thinking about what are culturally normative ways we can normalise abortions within community, looking more around choice... ( 23 ). Another participant further expressed that discussing abortion support within the community is challenging due to colonial trauma. Survivors are focused on ensuring the survival of the next generation. I don’t know if that conversation is ready to happen yet in the community… That’ll create more division because … people who’ve gone through - like my family has … residential school or 60s scoop, I was millennial scoop… people who’ve gone through that, they survived, right? And they want to make sure their kids survive. So, they’re not ready for that discussion because their brain is still in the survival mode of making sure the next generation is allowed to exist. (08) . Another recommendation surrounded having respected community members act as advocates. One participant speaks about how abortion conflicts with their teachings, later emphasizing the importance of hearing from a respected community member that this is not the case. My Anishinaabe teachings and in my Haudenosaunee teachings, abortion is very taboo in the sense of it conflicts with some of people’s main beliefs and teachings of the life span - where we come from. That’s concrete, that’s foundational to our stories and our creation stories. ( 36 ) This participant continues, I wish… I could have talked to an Elder with my family, maybe I could have had a better way of explaining that my choice wasn’t wrong, my choice isn’t in conflict with our teachings, it isn’t in conflict with our culture and our beliefs. Have them hear it from a … highly respected community member. Like an Elder or a knowledge keeper, it would have been a lot easier for me and for them to hear it and understand. Even for myself… I still have the same teachings that they do. I still live my life according to my beliefs and my cultural values. I do second guess myself… did I do the right thing? Based off of what I’ve been taught and things that I still hold value to, just because I didn’t choose to keep a child that I didn’t want … That’s the type of stuff that would have actually had an impact because at this point in my life… I’m not going to change all of this intergenerational trauma that comes with a decision like this, I’m not going to change it in my lifetime, it’s not going to change in my parent’s lifetime. I might not have to hide this for the rest of my life… But at this point, I feel like I will take this to the grave in terms of like telling my family. I simply can’t bear the consequence of what might happen because of the ongoing effects of what residential school did to my family and what systemic racism is continually doing. This is… so much bigger than just abortions and accessing abortions. This is talking about way more than just that and the way it affects Indigenous people, especially Indigenous women, is way more complex than… any white person could imagine. ( 36 ) Participants highlighted the need for availability of culturally rooted community-based abortion supports. Participants spoke to sweats and healing circles and suggested these be offered in urban spaces such as Friendship Centres. One participant emphasizes the importance of having a communal healing space to feel less isolated. I feel like that would have been really cool to just have that healing space circle in community to work through whatever it is that we’re healing from. Like collectively. Less lonely. I’m realizing that it was very lonely, I felt a lot of guilt and shame around it too. Like I don’t know if that’s societal or my own mind coming up with these ridiculous accusations, but it’s definitely a societal blame shame, especially as a young Indigenous woman. ( 31 ) Another participant reflected on their conflicted feelings because they couldn’t openly share their abortion with their community. They expressed a desire for community support, highlighting a lack of such services, especially in urban areas. I felt very conflicted with my decision, not because it wasn’t the right one, more because I can’t tell my community this. At the same time was like, my community should support this. It would be nice to be able to go after the treatment be like okay, you’re all healed up. Everything’s good… you’re not bleeding any more. We’re going to go out to the bush and we’re going to do cultural land-based teachings about how do you deal with the stress or how do you deal with guilt that you’re feeling… I just feel like there’s no services like that. Especially now I’m in [an urban location], there’s services here but it’s a concrete fucking jungle. (08) Integrating abortion education into public school curriculums (n = 18) Eighteen participants highlighted the need for public school curriculums to incorporate comprehensive information about abortion into regular sex education. Participants highlighted the importance of teaching young people about making informed choices for their bodies and addressing societal pressures with accurate information. For example, one participant emphasizes incorporating detailed abortion care information into public school sex education to reduce stigma. More information incorporated into regular sex education in public schools around abortion care. And not just that it terminates a pregnancy but what it is and other reasons why you might do it. …. They should know about the process; they should know about what it is and how it works… I think the younger we can target people so that they understand about the medically necessary decisions, I think will help remove some of that moral issue stigma around it. (03). Another participant advocates teaching school children about bodily autonomy, emphasizing that individuals have the right to make choices for their bodies, wellbeing, and families, and supporting people in their decisions. Teach … school kiddos around what that is. And that choice that we, as humans, we are allowed to make choices for ourselves, for our bodies, for our wellbeing, for our families, all of those pieces. And just I think one of the last things is just to really hold folks where they’re at in the choices that they make. ( 18 ) Another participant stresses the need for better sex education, highlighting that information provided earlier could help counteract community pressures and improve contraceptive and abortion knowledge. I just think better sex ed too. I feel like it comes down to a lot of more education… especially just younger folks too. I just know that there’s so much pressure… to carry on with a pregnancy from my community and my family experience. So … more information earlier would have been just helpful combating some of the information that I was getting from family… not combatting it but just something to compliment it or something to even just you saying that there were different contraceptive and abortion practices, like I didn’t ever know that. And that actually makes me feel so… just better knowing that. [Crying] (09) Expand maternal-child health supports to be responsive to the needs of abortion seekers though policy change (n = 13) Thirteen participants recommended expanding maternal-child health supports to address abortion seekers' needs, emphasizing increased providers in underserved areas and policy changes to authorize midwives and improve abortion training. Participants also highlighted that policy must change to accommodate travel expense reimbursement. For example, one participant advocates for midwives to be recognized and incorporated into abortion provision: Sometimes we think that midwives are only supportive of folks who are in pregnancy and labour and delivery. Same thing with doulas, but those folks who are taught in school around midwifery, they also talk about abortion. They also talk about miscarriage. They have that knowledge and those skills too from a different perspective, but we only hone into like ‘oh, well they birth babies and that’s all that they do, and it’s beautiful because they bring life into the world’ and it’s like, ‘no, no, no. They support folks who are also birthing life into a different world. And they have that expertise, knowledge from a different perspective.’ So also acknowledging those gifts… They know the uterus - that’s their jam. ( 18 ). In the event that abortion seekers must travel for an abortion, participants suggested implementing a policy for reimbursement. One participant described a policy similar to Jordan’s Principle ( 15 ). If there’s travel involved, they should have resources, some kind of reimbursement. Something like Jordan’s Principle, maybe where there is a set fund. … some kind of resources where folks can get a place to stay… take at least an overnight to recover and follow up care. ( 32 ) Another participant described being denied travel reimbursement from the Non-Insured Health Benefits (NIHB) Program, offered to registered First Nation and Inuit members in Canada( 7 ). I had called the flight agency, and I was trying to figure out, I was like should I tell them that I miscarried, or should I tell them that I had an abortion as a thing that was covered under the policy. And I never got my money back for that because I had decided to tell them that I had an abortion because I was like… fuck it. I don’t care. I’ll tell them the truth. Like I have nothing to hide. (01) Participants recommended that reproductive leave policies be more comprehensive, including everything from abortion to menstruation, and include abortion aftercare support, such as funding for abortion doulas to provide wraparound support. Normalizing it as necessary support, one participant advocates for organizational leave policies to include abortion. I think Human Resources and organizational leave needs to have a space for abortion. It needs to be normalized as something women require, especially with how there is still workplace shame with pregnancy… some people don’t want to have children. ( 30 ). Discussion Addressing abortion access for Indigenous peoples in Canada requires tackling systemic barriers, stigma, and logistical hurdles. This study highlights the need for culturally safe healthcare, education, policy reform, and the integration of Indigenous knowledge. While rooted in Indigenous experiences, these recommendations align with broader public demands for equitable abortion care. Suggestions like wraparound support, culturally relevant care, improved service distribution, sex education, and reproductive leave reflect national concerns ( 6 , 16 ). Participants highlighted the need for annual Indigenous cultural safety training, supported by studies showing its role in improving healthcare experiences ( 17 , 18 ). Smylie and colleagues ( 18 )found that healthcare providers who underwent cultural safety training were significantly more likely to be recommended by Indigenous patients. Despite the Truth and Reconciliation Commission's recommendations to implement such training, inappropriate care for Indigenous peoples accessing health services persists ( 18 – 20 ). Participants called for Indigenous-led clinics to provide stigma-free abortion services. Mainstream care often subjects Indigenous abortion seekers to discrimination and racism, increasing isolation ( 3 , 7 ). Indigenous-informed care models are found to improve patient outcomes by fostering trust and creating supportive environments ( 21 , 22 ). Integrating wraparound abortion support was shared to enhance accessibility. Browne and colleagues ( 23 ) found that comprehensive support, like transportation and childcare, is essential for improving health outcomes for Indigenous populations by addressing broader social determinants of health. Literature further highlights the importance of accessible health services, as logistical and financial barriers are shown to significantly impact timely abortion care ( 24 , 25 ). Participants highlighted the need for funding allocated towards travel reimbursement. Indigenous peoples in Canada face significant challenges in accessing healthcare due to travel barriers ( 26 ). Travel is not always covered by the NIHB program, as highlighted by one of our participants. NIHB provides limited coverage and often excludes services related to abortion, reflecting broader systemic discrimination ( 23 , 27 ). Comprehensive sex education was highlighted to reduce abortion stigma and promote informed choice. Sexual and reproductive health stigma in Indigenous communities stems from colonial legacies, including residential schools, which disrupted traditional knowledge transfer ( 28 – 30 ). This fuels misinformation and shame around sexual health, worsening health disparities ( 31 , 32 ). Accurate, culturally relevant sex education is essential for dismantling stigma and empowering Indigenous youth to make informed decisions ( 29 , 30 ). Educational initiatives led by respected community leaders, such as Elders and Knowledge Keepers, as they are custodians of traditional knowledge ( 33 ), was further recommended. Participants shared that learning about reproductive and sexual health from these community members may help overcome abortion stigma. Elders have been shown to translate sexual health education that is culturally relevant, thus fostering a holistic approach that respects, normalizes, and integrates Indigenous values and knowledge systems ( 33 , 34 ). Participants further recommended that abortion education resources target men. Engaging men in conversations about sexual and reproductive health has been found to help dismantle harmful stereotypes and promote a more inclusive understanding of abortion ( 35 , 36 ). Such initiatives are shown to improve reproductive health knowledge and encourage supportive attitudes, thereby reducing stigma and fostering a more supportive environment ( 37 ). Participants highlighted community-based strategies to reduce abortion stigma and promote cultural healing, fostering a supportive environment and reducing loneliness, guilt, and shame ( 38 , 39 ). Integrating healing practices into urban settings, like Friendship Centres, nonprofit community organizations providing services to urban Indigenous people, can help bridge the gap for Indigenous individuals living in cities ( 40 , 41 ). Friendship Centres facilitate the continuity of cultural teachings and practices, essential for the well-being and identity of Indigenous peoples ( 42 ) Participants recommended increasing providers in rural and remote areas, where limited access to abortion services poses significant barriers, especially for Indigenous communities ( 43 – 45 ). While telehealth improved access to medication abortions during COVID-19, issues like limited broadband and specialized training remain ( 46 ). Indigenous-specific tools, such as a hotline, were suggested to address judgment and confidentiality concerns, with lack of anonymity often discouraging service access in close-knit communities ( 34 ). The Call Auntie Clinic, a hotline run by Seventh Generation Midwives Toronto, exemplifies culturally safe services, offering abortion counseling, birth control consultations, and harm reduction ( 47 ). Participants noted authorizing midwives to provide abortions to improve access in rural and remote regions. Midwifery is provincially regulated, and abortion care is currently outside its scope in Canada ( 3 , 4 ). Expanding this scope may enhance access and offer more holistic, culturally sensitive care ( 48 ). Midwives are well-positioned to offer abortions due to their training in reproductive health and their ability to provide trauma-informed care, attributes crucial for supporting individuals through abortion experiences ( 16 ). Lastly, participants recommended comprehensive reproductive leave policies with aftercare support, which are rare, especially for abortion services ( 49 , 50 ). Funding for abortion doulas was also suggested, as they provide emotional, physical, and informational support, reducing stress and shame ( 51 , 52 ). Indigenous doulas offer culturally relevant care that fosters holistic healing, crucial for Indigenous abortion seekers facing systemic barriers ( 4 , 53 , 54 ). Funding these services ensures compassionate, comprehensive care that promotes well-being and positive health outcomes ( 54 , 55 ). Limitations Due to the limited sample size across provinces and territories, a limitation of this research is the inability to differentiate specific needs and experiences of urban versus rural Indigenous abortion seekers based on geographic location. Geographic disparities, known to affect abortion access due to fewer healthcare resources in rural areas, were not fully captured ( 6 , 43 , 44 ). Another limitation is the underrepresentation of medication abortion experiences, which have become increasingly prevalent since the COVID-19 pandemic as telemedicine has expanded access to this form of care ( 56 ). Finally, the study also lacks Inuit and Métis perspectives, limiting generalizability across Indigenous communities in Canada (Allan and Smylie 2015). Future research must target diverse Indigenous groups and geographic areas to better capture these nuances. Conclusion This research emphasizes the need to center Indigenous voices in abortion access and care in Canada. Recommendations from Indigenous abortion seekers reveal gaps in culturally safe, accessible, and stigma-free services. Despite barriers like colonial legacies, geographic isolation, and limited culturally informed care, the proposed recommendations align with broader calls for systemic change across Canada’s healthcare system. Prioritizing the needs of Indigenous communities will enhance health equity nationwide. Declarations Ethics approval and consent to participate In accordance with the Declaration of Helsinki, this research has been approved by the University of Victoria Research Ethics Board #BC22-0581 and the UBC Behavioural Research Ethics Board #H22-02465. Consent for publication Not applicable Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to the sensitive nature of the information shared by participants and the ethical requirements to protect their confidentiality. Competing Interests The authors declare that they have no competing interests. Funding Social Sciences and Humanities Research Council of Canada (SSHRC) # 936-2021- 00728 Authors' contributions RM led the project conception, overall study design, manuscript writing and supported qualitative analysis. SH, WP, MW, EA, HP, PC, and CF contributed to data collection, qualitative analysis and manuscript editing. DJ provided methodological support and assisted with data interpretation. CL and SM contributed to the manuscript’s conceptualization and reviewed drafts. EP supported manuscript editing. APP provided project conception, overall study design, qualitative analysis, critical input on data interpretation and manuscript editing. All authors read and approved the final manuscript. Acknowledgements We are grateful to the participants who generously shared their experiences and to our community partners, including Abortion Support Services Atlantic, ekw’í7tl Indigenous Doula Collective, Northern Reproductive Justice Network, and Northern Manitoba Abortion Support. We would like to extend our deepest gratitude to our Analysis Team, whose dedication, lived experience, and invaluable insights made this paper possible. Also, our heartfelt thanks goes out to the members of the Advisory Circle for their tireless commitment to centering Indigenous voices and advocating for reproductive justice. Your contributions, rooted in both professional expertise and personal experience, have profoundly shaped the analysis and outcomes of this work. References Anderson K. Life Stages and Native Women: Memory, Teachings, and Story Medicine. University of Manitoba Press; 2011. Monchalin R. Novel Coronavirus, Access to Abortion Services, and Bridging Western and Indigenous Knowledges in a Postpandemic World. Women’s Health Issues. 2020; Monchalin R, Pérez Piñán A V., Wells M, Paul W, Jubinville D, Law K, et al. A qualitative study exploring access barriers to abortion services among Indigenous Peoples in Canada. Contraception. 2023 Aug;124:110056. Monchalin R, Jubinville D, Pérez Piñán A V., Paul W, Wells M, Ross A, et al. “I would love for there not to be so many hoops … ”: recommendations to improve abortion service access and experiences made by Indigenous women and 2SLGTBQIA+ people in Canada. Sex Reprod Health Matters. 2023 Dec 31;31(1). Burnett K. Different Histories: Reprodroduction, Colonialism, and Treaty 7 Communities in Southern Alberta, 1880-1940. In: Stettner S, Brunett K, Hay T, editors. Abortion: History, Politics, and Reproductive Justice after Morgentaler. Vancouver, BC: UBC Press; 2017. p. 35–54. Shaw D, Norman W V. When there are no abortion laws: A case study of Canada. Best Pract Res Clin Obstet Gynaecol [Internet]. 2020;62:49–62. Available from: https://doi.org/10.1016/j.bpobgyn.2019.05.010 Allan B, Smylie J. First Peoples, second class treatment: The role of racism in the health and well-being of Indigenous peoples in Canada. Toronto, ON: the Wellesley Institute. 2015. Stote K. From Eugenics to Family Planning: The Coerced Sterilization of Indigenous Women in Post-1970 Saskatchewan. Native American and Indigenous Studies. 2022;9(1):102–32. Boyer YLR. Forced Sterilization: A Malicious Determinant of Health. In: Margo Greenwood, Sarah de Leeuw, Roberta Stout, Roseann Larstone, Julie Sutherland, editors. Introduction to Determinants of First Nations, Inuit, and Métis Peoples’ Health in Canada. Toronto, Ontario: Canadian Scholars Press; 2022. p. 37–50. Green J. Chapter 1: Taking More Account of Indigenous Feminism: An Introduction. In: Green J, editor. Making Space for Indigenous Feminism. 2nd Editio. Fernwood Publishing; 2017. p. 1–20. Absolon K. Kaandossiwin: How we come to know. Fernwood Publishing; 2011. Flicker S, Nixon S. The DEPICT model for participatory qualitative health promotion research analysis piloted in Canada, Zambia and South Africa. Health Promot Int. 2014;30(3):616–24. Clark N, Davis-Alphonse C. Indigenous Gender Based Analysis Plus (IGBA+) Toolkit. 2023 Mar. Sanchez-Pimienta CE, Masuda JR, Doucette MB, Lewis D, Rotz S, Neufeld HT, et al. Implementing indigenous gender-based analysis in research: Principles, practices and lessons learned. Int J Environ Res Public Health. 2021 Nov 1;18(21). Blackstock C. Toward the full and proper implementation of Jordan’s Principle: An elusive goal to date. Paediatr Child Health [Internet]. 2016 Jun 1;21(5):245–6. Available from: https://academic.oup.com/pch/article/21/5/245/2647378 Canadian Association of Midwives. CAM ACFF. 2019 [cited 2021 Feb 9]. Midwifery Across Canada. Available from: https://canadianmidwives.org/midwifery-across-canada/#1464901229059-08aa6afc-6b5c Browne AJ, Varcoe C, Lavoie J, Smye V, Wong ST, Krause M, et al. Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study. BMC Health Serv Res. 2016;16(1). Smylie J, Rotondi MA, Filipenko S, Cox WTL, Smylie D, Ward C, et al. Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training. BMC Med. 2024 Jan 9;22(1):3. Churchill M, Parent-Bergeron M, Smylie JK, Ward C, Fridkin A, Smylie D, et al. Evidence Brief: Wise Practices for Indigenous-specific Cultural Safety Training Programs [Internet]. Toronto, ON; 2017. Available from: https://www.iphcc.ca/wp-content/uploads/2020/02/CS_WisePractices_FINAL_11.02.17.pdf Wylie L, McConkey S, Corrado AM. It’s a Journey Not a Check Box: Indigenous Cultural Safety From Training to Transformation. Int J Indig Health. 2021;16(1):314–32. Smylie J, Kirst M, McShane K, Firestone M, Wolfe S, O’Campo P. Understanding the role of Indigenous community participation in Indigenous prenatal and infant-toddler health promotion programs in Canada: A realist review. Vol. 150, Social Science and Medicine. 2016. Monchalin R, Smylie J, Bourgeois C, Firestone M. “I would prefer to have my health care provided over a cup of tea any day”: recommendations by urban Métis women to improve access to health and social services in Toronto for the Métis community. AlterNative. 2019 Sep 1;15(3):217–25. Browne AJ, Varcoe C, Lavoie J, Smye V, Wong ST, Krause M, et al. Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study. BMC Health Serv Res. 2016 Dec 4;16(1):544. Mosley EA, Ayala S, Jah Z, Hailstorks T, Hairston I, Rice WS, et al. “I don’t regret it at all. It’s just I wish the process had a bit more humanity to it … a bit more holistic”: A qualitative, community-led medication abortion study with Black and Latinx Women in Georgia, USA. Sex Reprod Health Matters. 2022 Dec 31;30(1). Barr-Walker J, Jayaweera RT, Ramirez AM, Gerdts C. Experiences of women who travel for abortion: A mixed methods systematic review. PLoS One. 2019 Apr 9;14(4):e0209991. Nguyen NH, Subhan FB, Williams K, Chan CB. Barriers and Mitigating Strategies to Healthcare Access in Indigenous Communities of Canada: A Narrative Review. Healthcare. 2020 Apr 26;8(2):112. Danielle Miller. Beyond Legal: A Feminist Intersectional Analysis of the Policy Landscape Shaping Indigenous Women’s Access to Abortion Services in Canada. [Victoria]: University of Victoria; 2023. Flicker S, Wilson C, Monchalin R, Oliver V, Prentice T, Jackson R, et al. “Stay Strong, Stay Sexy, Stay Native”: Storying Indigenous youth HIV prevention activism. Action Research. 2019;17(3). Ross A. “They couldn’t talk to anybody because there’s so much stigma”: A qualitative study exploring Indigenous Peoples’ experience of abortion-related stigma in Canada. [Victoria]: University of Victoria; 2023. Native Youth Sexual Health Network, Lesperance A, Kendrick CT, Flicker S. ‘This is what’s going to heal our kids’: bringing the Sexy Health Carnival into Indigenous cultural gatherings. Cult Health Sex. 2023 Jul 3;25(7):863–78. Loppie Reading C, Wien F. Health Inequalities and Social Determinants of Aboriginal Peoples ’ Health. 2009. Anderson K. Vital Signs: Reading Colonialism in Contemporary Adolescent Family Planning. In: Anderson K, Lawrence B, editors. Strong Women Stories: Native Vision and Community Survival [Internet]. Sumach Press; 2003. p. 174–91. Available from: https://books-scholarsportal-info.subzero.lib.uoguelph.ca/en/read?id=/ebooks/ebooks0/gibson_crkn/2009-12-01/5/412084#page=191 Flicker S, O’Campo P, Monchalin R, Thistle J, Worthington C, Masching R, et al. Research Done in “A Good Way”: The Importance of Indigenous Elder Involvement in HIV Community-Based Research. Am J Public Health. 2015;105(6):1149–1154. Flicker S, Danforth J, Konsmo E, Wilson C, Oliver V, Jackson R, et al. “Because we are Natives and we stand strong to our pride”: Decolonizing HIV Prevention with Aboriginal Youth in Canada Using the Arts. Canadi J Aborig Community Based HIV/AIDS Res. 2013;5:4–24. Strong J. Men’s involvement in women’s abortion-related care: a scoping review of evidence from low- and middle-income countries. Sex Reprod Health Matters. 2022 Dec 31;30(1). Shand T, Marcell A V. Engaging Men in Sexual and Reproductive Health. In: Oxford Research Encyclopedia of Global Public Health. Oxford University Press; 2021. Ruane-McAteer E, Amin A, Hanratty J, Lynn F, Corbijn van Willenswaard K, Reid E, et al. Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews. BMJ Glob Health. 2019 Sep 11;4(5):e001634. Ambtman-Smith VN, Crawford A, D’Hondt J, Lindstone W, Linklater R, Longboat D, et al. Incorporating First Nations, Inuit and Métis Traditional Healing Spaces within a Hospital Context: A Place-Based Study of Three Unique Spaces within Canada’s Oldest and Largest Mental Health Hospital. Int J Environ Res Public Health. 2024 Feb 28;21(3):282. Burnett C, Purkey E, Davison CM, Watson A, Kehoe J, Traviss S, et al. Spirituality, Community Belonging, and Mental Health Outcomes of Indigenous Peoples during the COVID-19 Pandemic. Int J Environ Res Public Health. 2022 Feb 21;19(4):2472. Hatala AR, Njeze C, Morton D, Pearl T, Bird-Naytowhow K. Land and nature as sources of health and resilience among Indigenous youth in an urban Canadian context: a photovoice exploration. BMC Public Health. 2020 Dec 20;20(1):538. Pitts E. A House of Healing: The Importance of Friendship Centres to A House of Healing: The Importance of Friendship Centres to Urban Aboriginal Populations Urban Aboriginal Populations. [London]: The University of Western Ontario; 2018. Simpson A. Siem Qulmuhw Mustimuxw Tze Tzu Wut Tu Mamu’na’tzt: Honoured Indigenous People Helping Our Children: The co-creation of a culturally grounded family wellness curriculum with Tillicum Lelum Aboriginal Friendship Centre and urban-Indigenous families. [Victoria]: University of Victoria; 2022. Dressler J, Maughn N, Soon JA, Norman W V. The Perspective of Rural Physicians Providing Abortion in Canada: Qualitative Findings of the BC Abortion Providers Survey (BCAPS). PLoS One. 2013;8(6):6–10. Norman W V., Soon JA, Maughn N, Dressler J. Barriers to Rural Induced Abortion Services in Canada: Findings of the British Columbia Abortion Providers Survey (BCAPS). PLoS One. 2013 Jun 28;8(6):e67023. Norman W V, Munro S, Brooks M, Devane C, Guilbert E, Renner R, et al. Could implementation of mifepristone address Canada’s urban–rural abortion access disparity: a mixed-methods implementation study protocol. BMJ Open. 2019 Apr 20;9(4):e028443. Jong M, Mendez I, Jong R. Enhancing access to care in northern rural communities via telehealth. Int J Circumpolar Health. 2019 Jan 28;78(2):1554174. Call Auntie Clinic. Call Auntie Clinic. 2022. Our Story. Carla Ciccone. Chatelaine. 2022. Midwives Can Do More—Why Won’t We Let Them? Koert E, Malling GMH, Sylvest R, Krog MC, Kolte AM, Schmidt L, et al. Recurrent pregnancy loss: couples’ perspectives on their need for treatment, support and follow up. Human Reproduction. 2019 Feb 1;34(2):291–6. McGinn T, Casey SE. Why don’t humanitarian organizations provide safe abortion services? Confl Health. 2016 Dec 24;10(1):8. Chor J, Hill B, Martins S, Mistretta S, Patel A, Gilliam M. Doula support during first-trimester surgical abortion: A randomized controlled trial. Am J Obstet Gynecol. 2015 Jan 1;212(1):45.e1-45.e6. Lee S. Hold my Hand: How Abortion Doulas Improve Abortion Care. Voices in Bioethics. 2022;8. Cidro J, Doenmez C, Sinclair S, Nychuk A, Wodtke L, Hayward A. Putting them on a strong spiritual path: Indigenous doulas responding to the needs of Indigenous mothers and communities. Int J Equity Health. 2021 Dec 1;20(1). Doenmez C, Cidro J, Sinclair S, Hayward A, Wodtke L, Nychuk A. Heart work: Indigenous doulas responding to challenges of western systems and revitalizing Indigenous birthing care in Canada. BMC Pregnancy Childbirth. 2022;22(41). Wodtke L, Hayward A, Nychuk A, Doenmez C, Sinclair S, Cidro J. The need for sustainable funding for Indigenous doula services in Canada. Women’s Health. 2022 Apr 1;18. Demont C, Doctoroff J, Neron B, Foster AM. Seeking support for abortion care from national hotlines in Canada: Caller characteristics and call outcomes, 2019–2021. Perspect Sex Reprod Health. 2023 Sep;55(3):192–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 22 Oct, 2024 Editor assigned by journal 21 Oct, 2024 Submission checks completed at journal 21 Oct, 2024 First submitted to journal 16 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5278379","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":368979681,"identity":"7d2c0ab0-22fc-4a42-939e-6c510d8f3212","order_by":0,"name":"Renée Monchalin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtklEQVRIiWNgGAWjYLACxgYGHgb2BgaGBNK08BwgUQsDgwSx6s2nHT724OcOOxlzyTdmEg9qGOT5Gwhokbmdlm7YeyaZx3J2jplEwjEGwxkHCGiRkM4xk2ZsY+YxuJ1jbJDYAPQOkVrqeQxunoFokSdSy2Eegxs8hg9AWgwIa0lLk+xtO85jcCat8EHCMQnDjYS1JB+T+NlWbW9w/PCGgz9qbOTlCGnBMIJE9aNgFIyCUTAKsAIAp4o5ewyPMhsAAAAASUVORK5CYII=","orcid":"","institution":"University of Victoria","correspondingAuthor":true,"prefix":"","firstName":"Renée","middleName":"","lastName":"Monchalin","suffix":""},{"id":368979682,"identity":"0b7a833e-9601-4b67-9df1-7ac4c2c151b6","order_by":1,"name":"Shannon Hardy","email":"","orcid":"","institution":"University of Victoria","correspondingAuthor":false,"prefix":"","firstName":"Shannon","middleName":"","lastName":"Hardy","suffix":""},{"id":368979683,"identity":"942ba2cf-a77a-46b8-8bd0-a442ba9d8c46","order_by":2,"name":"Willow Paul","email":"","orcid":"","institution":"University of Victoria","correspondingAuthor":false,"prefix":"","firstName":"Willow","middleName":"","lastName":"Paul","suffix":""},{"id":368979684,"identity":"8d72ce05-207e-423e-8a17-92ae40c1a600","order_by":3,"name":"Madison Wells","email":"","orcid":"","institution":"University of Victoria","correspondingAuthor":false,"prefix":"","firstName":"Madison","middleName":"","lastName":"Wells","suffix":""},{"id":368979685,"identity":"7d4fbf19-d752-4fbb-9bcd-b6c8820948d9","order_by":4,"name":"Emma Antoine-Allan","email":"","orcid":"","institution":"University of Victoria","correspondingAuthor":false,"prefix":"","firstName":"Emma","middleName":"","lastName":"Antoine-Allan","suffix":""},{"id":368979686,"identity":"398968e1-8bd8-4861-b826-921c67146980","order_by":5,"name":"Harlie Pruder","email":"","orcid":"","institution":"University of Victoria","correspondingAuthor":false,"prefix":"","firstName":"Harlie","middleName":"","lastName":"Pruder","suffix":""},{"id":368979687,"identity":"735c5655-f6fd-47b7-a0a9-09cc02862fe8","order_by":6,"name":"Piyêsiw Crane","email":"","orcid":"","institution":"University of Victoria","correspondingAuthor":false,"prefix":"","firstName":"Piyêsiw","middleName":"","lastName":"Crane","suffix":""},{"id":368979688,"identity":"293b4fed-1919-4210-bf95-83cddeca0a19","order_by":7,"name":"Créa Ferguson","email":"","orcid":"","institution":"University of Victoria","correspondingAuthor":false,"prefix":"","firstName":"Créa","middleName":"","lastName":"Ferguson","suffix":""},{"id":368979689,"identity":"1394e997-bcf2-4e64-814f-676c4388c42a","order_by":8,"name":"Danette Jubinville","email":"","orcid":"","institution":"Ekw’í7tl Indigenous Doula Collective","correspondingAuthor":false,"prefix":"","firstName":"Danette","middleName":"","lastName":"Jubinville","suffix":""},{"id":368979690,"identity":"236b519c-a48c-4da8-91ae-fb9dca42b638","order_by":9,"name":"Carmen H. 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Pérez","lastName":"Piñán","suffix":""}],"badges":[],"createdAt":"2024-10-16 21:08:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5278379/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5278379/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67925865,"identity":"7dc6e3b8-d337-49be-8c62-fcba6d99e21b","added_by":"auto","created_at":"2024-10-31 08:55:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":607101,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5278379/v1/f42e7a84-63d5-47d4-b240-d60bb0109d21.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Fireweed Project: Recommendations for Improving Abortion Access and Experiences by and for Indigenous Peoples in Canada","fulltext":[{"header":"Background","content":"\u003cp\u003eIndigenous communities in Canada hold intergenerational reproductive health knowledges that emphasize choice, holistic well-being, and community care (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Despite this, barriers to accessing abortion persist, rooted in historical and ongoing systemic inequities(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Colonial policies prohibiting Indigenous ceremonies and practices, coupled with geographic isolation, financial constraints, and the scarcity of healthcare providers in rural and remote areas, hinder access to reproductive health services, including abortion (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). These barriers are compounded by racism and discrimination within healthcare settings toward Indigenous peoples, highlighted by forced sterilizations and reproductive coercion, resulting in mistrust and avoidance of medical services (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e–\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). While addressing inequities in abortion access necessitates systemic reforms, Indigenous abortion seekers' voices are often missing from access solutions. Integrating Indigenous voices is vital for achieving equitable access and reproductive health outcomes (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Through a community-led approach, this paper centers the voices of Indigenous abortion seekers, highlighting their recommendations to improve access to and experiences with abortion services in Canada.\u003c/p\u003e\n\u003ch3\u003eThe Fireweed Project\u003c/h3\u003e\n\u003cp\u003eThe Fireweed project aims to investigate experiences of abortion access and support among Indigenous Women, Two-Spirit, and lesbian, gay, bisexual, transgender, queer, intersex, asexual and other sexually and gender diverse (LGBTQIA+) people in Canada. The project name was inspired by teachings of the fireweed plant, shared by a participant from the 'Global Goal Local Impact' study (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cem\u003eThere’s one plant called fire weed … I know that we traditionally used that as birth control, but also as a medicine to implement abortion… I kind of have a philosophy that … with the knowledge of herbal methods ending a pregnancy, Indigenous culture suggests a tradition of honoring pregnant people’s self-determination of their own bodies… (p.3)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThrough the application of an Indigenous feminist framework, which highlights the intersections of gender, colonialism, and Indigenous body sovereignty in health research (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), Fireweed centers the voices of Indigenous abortion seekers to identify and address systemic barriers within healthcare settings. It is led by four community partners, including Abortion Support Services Atlantic, ekw’í7tl Indigenous doula collective, Northern Reproductive Justice Network, and Northern Manitoba Abortion Support. It is guided by an Advisory Circle which encompasses a group of fourteen Indigenous and allied service providers working in the realm of abortion support and care in Canada.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Methods","content":"\u003ch2\u003eData collection\u003c/h2\u003e\u003cp\u003eUtilizing a conversational interview method informed by Ojibway scholar Kathy Absolon’s (2011) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Indigenous methodology, we collaboratively developed an open-ended conversational interview guide with our four partners. The guide encompassed eight open-ended questions centered around themes including abortion access experiences, stigma, support, Indigenous-specific services, community perceptions, traditional teachings, and how participants wished to see project results utilized.\u003c/p\u003e\u003cp\u003eRecruitment commenced September 2022, with the research team and partners sharing the recruitment poster through personal and organizational Instagram accounts and the Fireweed webpage. Our team allocated funding to conduct conversations with 40 individuals on a first-come, first-served basis, based on eligibility requirements. This number was determined based on the number of participants who had to be turned away from our Global Goal, Local Impact exploratory study due to funding constraints (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), while ensuring a diversity of experiences across geography. Once each potential participant was screened for eligibility, a date and time to meet over Zoom was arranged.\u003c/p\u003e\u003cp\u003eSelection criteria included participants who self-identified as First Nations, Inuit, and/or Métis; were 19 years old or older; and have accessed, or tried to access, an abortion in Canada. Participants received a \u003cspan\u003e$\u003c/span\u003e100 CAD honorarium via e-transfer at the beginning of their conversation and were each gifted a custom cotton throw blanket, made through a collaboration between the Fireweed team, Eighth Generation, and an artist from the W̱SÁNEĆ nation, on whose territories many of the researchers reside.\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eBeginning September 2023, our team employed the DEPICT model by Flicker and Nixon (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), a participatory approach to qualitative health research, to ensure a collaborative and inclusive data analysis process. The DEPICT model comprises six sequential steps: Dynamic Reading, Engaged Codebook Development, Participatory Coding, Inclusive Reviewing and Summarizing of Categories, Collaborative Analyzing, and Translating Findings.\u003c/p\u003e\u003cp\u003eOur analysis team was composed of nine Indigenous and allied team members from the Fireweed advisory circle, research team, and community partners, all with lived or front-line abortion support experience. This enriched the analysis by incorporating varied perspectives and expertise, ensuring that the findings were culturally relevant and grounded in real-world experiences.\u003c/p\u003e\u003cp\u003eThe process began with a (D)ynamic Reading, where team members immersed themselves in subsets of the data to identify key themes. (E)ngaged Codebook Development followed, involving a collaborative and comprehensive codebook. (P)articipatory Coding assigned each team member specific transcripts based on their area of interest and expertise, promoting a multifaceted examination of the data. (I)nclusive Reviewing and Summarizing involved team members working in pairs to distill coded data into summaries. During (C)ollaborative Analyzing, the team met to synthesize these summaries, interpreting the findings collectively. At the time of writing this paper, our team is focused on the (T)ranslating phase and developing a dissemination plan to share the results with relevant communities, policy makers, and abortion providers.\u003c/p\u003e\u003cp\u003eCongruent with our Indigenous feminist framework, our DEPICT analysis was informed by integrating an Indigenous Gender-Based Analysis Plus (IGBA+) (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The IGBA + framework, which considers intersecting factors such as gender, race, and socio-economic status, provided critical insights into the multiple dimensions of participants' experiences. This integration emphasized relationality, balance, and respect, while ensuring our analysis was methodologically rigorous, culturally sensitive and intersectional.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe conducted interviews with 40 participants that averaged one hour in length, between February and July 2023. One recording was lost and therefore not included in the analysis, resulting in a total of 39 interviews. The Indigenous identities represented among the participants include Salteaux, Cree, M\u0026eacute;tis, Michif, Dene, Algonquin, Mohawk, Ojibwe, Inuvialuit, Mi'kmaq, Coast Salish, Anishinaabe, and Haudenosaunee. Of the three federally recognized Indigenous groups in Canada represented in this study (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), twenty-five participants (n\u0026thinsp;=\u0026thinsp;25) identified as First Nations, six participants identified as M\u0026eacute;tis (n\u0026thinsp;=\u0026thinsp;6), three participants identified as both First Nations and M\u0026eacute;tis (n\u0026thinsp;=\u0026thinsp;3), one participant identified as Inuit (n\u0026thinsp;=\u0026thinsp;1), and four participants identified as Indigenous (n\u0026thinsp;=\u0026thinsp;4), not specifying a specific group.\u003c/p\u003e \u003cp\u003eInterviews took place between three months and nine years since the participants' abortions, with one outlier being sixteen years. The average age at the time of the interviews was 30 years old. The age range at time of abortion was between 16 to 35 years old. Out of the 39 participants, 36 had procedural abortions, 2 had medication abortions, and 1 experienced a miscarriage, resulting in them not needing their scheduled procedural abortion. Geographically, 28 participants were from urban areas, 6 from rural areas, and 5 from remote areas. The interviews represented participants from 11 provinces and territories, with every province and territory included except Prince Edward Island and Yukon.\u003c/p\u003e \u003cp\u003eBased on the first two steps of the DEPICT model, Dynamic Reading and Engaged Codebook Development, the analysis team chose six overarching themes to represent participant recommendations arising from the conversations. These themes included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Ongoing cultural safety training and establishing Indigenous-led or informed reproductive health clinics; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Enhancing mainstream abortion services through enhanced transparency, follow-up, and wraparound supports; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Informative resources and tailored support tools; (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Dismantling abortion stigma within Indigenous communities and enhancing culturally rooted community support systems; (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Integrating abortion education into public school curriculums; and (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Expand maternal-child health supports to be responsive to the needs of abortion seekers though policy change. These themes are interwoven and overlapping, reflecting the multifaceted nature of participant recommendations. The analysis team recognized that while these themes intersect, presenting them separately allows for more nuanced insights shared by participants, offering clear pathways for targeted actions and interventions.\u003c/p\u003e\n\u003ch3\u003eOngoing cultural safety training and establishing Indigenous-led or informed reproductive health clinics (n = 28)\u003c/h3\u003e\n\u003cp\u003eTwenty-eight participants emphasized ongoing Indigenous cultural safety training and Indigenous-led or informed reproductive health clinics to provide trauma-informed care. Participants shared how medical professionals often are unaware of the history of medical trauma among Indigenous peoples, and that effective care requires recognizing intersectional identities.\u003c/p\u003e \u003cp\u003e \u003cem\u003eMedical professionals I don\u0026rsquo;t think understand the impact of cultural safety which is interesting to me because it\u0026rsquo;s actually in the medical profession where \u0026hellip; this concept of cultural safety originated. Right in New Zealand, and yet, it\u0026rsquo;s still just so frustratingly not helpful for folks. Right? Because they don\u0026rsquo;t understand the trauma that\u0026rsquo;s involved there, they don\u0026rsquo;t understand the number of First Nations, Inuit and M\u0026eacute;tis people who were forced to be sterilized, who have all kind of trauma, trying to work through a colonial system\u0026hellip; If you don\u0026rsquo;t understand that, how can you possibly make sure that you\u0026rsquo;re providing good care to different people? This translates across\u0026hellip; Because there\u0026rsquo;s lots of intersectionality that needs to be included in that\u0026hellip; like are they Afro-Indigenous? Are they queer-Indigenous? \u0026hellip; Do they have disabilities? It\u0026rsquo;s the intersectionality, and using trauma informed approach is just so necessary, especially in this kind of a space. Because it is traumatic. It\u0026rsquo;s not something that you want to choose or ever think, \u0026lsquo;one day I\u0026rsquo;ll just have an abortion and I\u0026rsquo;ll be fine.\u0026rsquo; That is not how that happens. So \u0026hellip; if you don\u0026rsquo;t understand that, how can you possibly provide good care? (03)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eRecommendations for cultural safety included Indigenous-led or informed clinics that incorporate intergenerational, full-spectrum, family planning teachings, and \u0026ldquo;\u003cem\u003ecare for folks from womb to tomb in terms of reproductive health\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). As one participant shared, \u003cem\u003e\u0026ldquo;if there was an Indigenous-focused clinic I would have 100 percent accessed that because I feel like the cultural awareness, sensitivity, competence would have been there\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). In an Indigenous-led or informed space, participants shared that this may include having access to traditional medicines, \u003cem\u003e\u0026ldquo;having that open space where people can be culturally themselves.\u0026rdquo; (05)\u003c/em\u003e, and access to pro-choice Indigenous service providers, such as Elders, Grandmothers, Indigenous liaisons, doulas, and aunties. These providers were identified by participants to help with reducing abortion stigma, offering non-judgmental support, and sharing intergenerational knowledge around abortion to alleviate shame. As one participant shared, Indigenous abortion support providers may hold \u003cem\u003e\u0026ldquo;\u0026hellip; stories about how before colonization and before the women were removed of their power in the community, how we used plants to have abortions \u0026hellip; so you don\u0026rsquo;t feel like this is wrong.\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). One participant highlighted that they wish they had an Indigenous person who understands their unique experience,\u003c/p\u003e \u003cp\u003e \u003cem\u003eI wish I had an Elder, I wish I had a knowledge keeper, I wish I had another community member\u0026hellip; an Indigenous person\u0026hellip; Who understands what it\u0026rsquo;s like for me to exist in this world and to access this western medicine. This is the most sterile western thing I\u0026rsquo;ve ever done in my life [in] terms of medicine, and I wish I had somebody there with me, that could help me with the feelings that I was feeling\u0026hellip; through my own cultural values and my own teachings and my own understanding and my own world view.\u003c/em\u003e (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAnother participant shared that while a service provider may not be Indigenous, the space that provides abortions must have an Indigenous approach to care. This would incorporate elements of being trauma informed, culturally safe, low barrier, and accessible:\u003c/p\u003e \u003cp\u003e\u003cem\u003e In accessing \u0026hellip; sexual reproductive healthcare... if it\u0026rsquo;s not an Indigenous service provider or somebody with an Indigenous approach or understanding of care, and I mean I\u0026rsquo;m calling an Indigenous approach, but I think lots of people use words like trauma informed, or culturally safe, or low barrier, accessible\u0026hellip; When I think of Indigenous approaches to care, they include elements of all of those things, but they also just include a cultural understanding of what it means to actually engage in taking care of yourself and how revolutionary that is in the context of colonialism in history that we have... Any Indigenous person seeking any kind of care, that in a way that\u0026rsquo;s like deliberate or agreeing to care\u0026hellip; for their betterment, emotionally, mentally, physically, spiritually, that is totally an act of revolution and should be celebrated and supported. And I just don\u0026rsquo;t think that there\u0026rsquo;s \u0026hellip; capacity to do that within the regular healthcare system. I would have liked for somebody to recognise what a big deal it was that I was actively making a decision that was for the betterment of my life and my family\u0026rsquo;s life in a way that was like very rooted in a cultural context.\u003c/em\u003e (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eWhile having access to Indigenous-led or informed clinics was identified as significant, participants also acknowledged abortion stigma within Indigenous focused health services and identified this as a barrier for Indigenous abortion seekers.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI mean we have a decent health center in my community, and they do offer good services but because of the stigma around abortion, I wouldn\u0026rsquo;t seek those services because this town is so small. Everyone would know in the next week what I\u0026rsquo;ve been talking about. (05)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEnhancing mainstream abortion services through enhanced transparency, follow-up, and wraparound supports (n\u0026thinsp;=\u0026thinsp;24)\u003c/h2\u003e \u003cp\u003eTwenty-four participants spoke to improving mainstream abortion services, including clinics and hospitals, by providing follow-up care, non-judgmental support, and comprehensive wraparound services like mental health referrals, transportation, and childcare. For follow-up services in mainstream settings, participants asked for clear communication on what to expect from providers to understand potential symptoms. Participants shared that this could involve receiving detailed instructions during intake, receiving an email, or a follow-up phone call. One participant highlights the need for support to handle the emotional and practical aspects of their abortion experience:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI think that that was never really explained to me and that it was always either the one, you\u0026rsquo;re fine. There\u0026rsquo;s nothing to be sad about. Or two, you\u0026rsquo;re a terrible person, you should feel like shit. There was no in between. So it\u0026rsquo;s like not even knowing where to find a resource, not a pamphlet, nothing. There\u0026rsquo;s nobody to call when you\u0026rsquo;re feeling sad or nobody to celebrate with even. Nobody fucking makes you a cake. You know what I mean? [\u0026hellip;] There\u0026rsquo;s no follow-up. There\u0026rsquo;s no anything. There\u0026rsquo;s not even a way to reach the doctor and say like hey, I\u0026rsquo;m bleeding a lot. What do I do? There was no number to follow up... It was just expected that I would know what to do if that happened, and as a teenager I didn\u0026rsquo;t know. I was like, do I just go to bed\u0026hellip; or do you call an ambulance? [\u0026hellip;]. Even if it\u0026rsquo;s just information about emotions and what to expect.\u003c/em\u003e (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eParticipants highlighted the need for non-judgemental service providers. Ultrasound technicians and receptionists within mainstream settings were described by participants as most likely to hold judgement around abortion, impacting Indigenous participants' experiences. After travelling hours by plane for an ultrasound, one participant shared,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThe ultrasound tech I remember them telling me \u0026hellip; they\u0026rsquo;re like \u0026lsquo;do you want to see?\u0026rsquo; and I said \u0026lsquo;no I don\u0026rsquo;t want to see\u0026rsquo; and she was just like \u0026lsquo;are you sure?\u0026rsquo; That to me wasn\u0026rsquo;t very supportive. I think she knew on paper what my decision was. And then I was sent back home to [remote community].\u003c/em\u003e (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother participant recalls the long wait, in addition to the lab technician and ultrasound technician making them feel as though they should be celebrating getting pregnant.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt was a very cold sterile place. Yeah, obviously that lab technician. I would change that\u0026hellip; I waited about four weeks for that appointment\u0026hellip; And that felt like an eternity for me. I had an alien inside me\u0026hellip; I had to go for an ultrasound too. And I remember them asking if I wanted to see it and I was like absolutely not. That\u0026rsquo;s the last thing I want to see right now. Between the ultrasound and the lab technician\u0026hellip; it was only them that made me feel like I should be celebrating something. But other than that, everyone was fine. Very supportive. Like the actual clinic staff and my family doctor were all lovely.\u003c/em\u003e (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis participant continues and recommends how lab and ultrasound technicians should avoid being congratulatory, acknowledging that everyone\u0026rsquo;s circumstances are different.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI told you about the lab technician, the ultrasound technician. I think that definitely should be taught because you don\u0026rsquo;t know anyone\u0026rsquo;s circumstance. You don\u0026rsquo;t know how they feel about it\u0026hellip; how they got into that circumstance, into the situation so \u0026hellip; the congratulatory or the warning of don\u0026rsquo;t do it because I regret it. Like no. That should never happen to anybody.\u003c/em\u003e (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eParticipants highlighted the need for mainstream services to offer wraparound supports, such as mental health care, transportation, or childcare to mitigate access barriers and complex emotions. As one participant shared, \u003cem\u003e\u0026ldquo;You\u0026rsquo;re not allowed to bring kids to the abortion \u0026hellip; how am I supposed to get an abortion if I don\u0026rsquo;t have anybody to help me?\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Another participant shared:\u003c/p\u003e \u003cp\u003e \u003cem\u003eDefinitely transportation, some kind of care plan. Even for that to be part of the process when you schedule your abortion, maybe there\u0026rsquo;s a follow up call from a community partner who talks to you about what\u0026rsquo;s your strategy, how can we support you on that day? Do you have a ride? Do you have childcare? You know, maybe that person is in crisis in other ways that can be you know, any form of intervention is good. Because with stress especially, you can get so much sicker, it just adds to the physical toll that the person experiences... And I would love to see little care kits, similar to what a sexual assault survivor in a hospital might receive. New clothing\u0026hellip; a voucher for a store. Something to help them meet their personal needs... A little care package just goes a long way\u0026hellip; giving people a little extra boost, I think is important in that process. And then, maybe some of the clinical pieces could be revised, that would be great. The whole clinical part is very much about assessing if you\u0026rsquo;re being coerced \u0026hellip; making sure that this person is fully consenting... But I feel like there\u0026rsquo;s a way to do that without judgement.\u003c/em\u003e (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInformative resources and tailored support tools (n = 22)\u003c/h3\u003e\n\u003cp\u003eTwenty-two participants highlighted the need for informative abortion resources, Indigenous-specific abortion support tools, and resources targeted at men. First, participants asked for accessible, clear, and informative materials about abortion procedures, processes, and symptoms. They expressed the need for more explanation and support, highlighting the lack of information provided about their options, procedures, and follow up. One participant recommended receiving information over email in advance of their abortion to describe the process,\u003c/p\u003e \u003cp\u003e \u003cem\u003eI feel like if I had like an email the day before or something like kind of like giving me the information of what\u0026rsquo;s going to happen and how they do it. Like to be well informed would have been really helpful.\u003c/em\u003e (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFollowing the abortion, this participant also described being sent home and \u003cem\u003e\u0026ldquo;\u0026hellip;not knowing how to find those supports\u0026hellip; [with providers] just sliding over a pamphlet [and saying] \u0026lsquo;call the number on the back\u0026rsquo;\u0026rdquo;.\u003c/em\u003e (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Participants often described how after their abortion, providers said \u003cem\u003e\u0026ldquo;you\u0026rsquo;re on your own.\u0026rdquo; (05)\u003c/em\u003e, being told, \u003cem\u003e\u0026ldquo;Good luck, safe travels on your way home. And that was it.\u0026rdquo; (05)\u003c/em\u003e\u003c/p\u003e \u003cp\u003eAnother participant expressed frustration over the lack of detailed information and explanations regarding their abortion procedure and options. They felt uninformed and wished for more clarity and opportunity to ask questions, comparing it to the thorough explanations provided during a dental exam.\u003c/p\u003e \u003cp\u003e \u003cem\u003eNobody ever at any point handed me a pamphlet about my options or what they looked like or what the actual procedure was\u0026hellip;No one ever really explained any of that. I just was like \u0026lsquo;oh, surgery.\u0026rsquo; \u0026hellip; I didn\u0026rsquo;t really understand what was happening and maybe that\u0026rsquo;s my fault for not asking but I feel like there should have been more explanation... Like now that I have the ultrasound, show me what I\u0026rsquo;m looking at. It\u0026rsquo;s still very much my body. I\u0026rsquo;d like to know what it was doing, if it was\u0026hellip; even a dental exam, they\u0026rsquo;ll show you on your x-ray, \u0026lsquo;Oh, we\u0026rsquo;re taking out this tooth. This is the cavity. This is what we\u0026rsquo;re doing.\u0026rsquo; Nobody showed you that... I just wish there was a little bit more explanation about everything, so I had the opportunity to ask questions.\u003c/em\u003e (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eParticipants recommended developing tools tailored to supporting Indigenous peoples\u0026rsquo; access abortion care in the form of an app, hotline, or website. One participant expressed the need for an Indigenous-specific hotline or app to provide support and guidance for Indigenous people needing to access an abortion.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSome kind of Indigenous hotline or something, an app that is advertised so that somebody who wouldn\u0026rsquo;t think to google would have that support \u0026hellip; it\u0026rsquo;s easier to figure out what to do for Indigenous girls because we\u0026rsquo;re lucky if we have a doctor in our community. Like we have a nurse practitioner. We don\u0026rsquo;t have a doctor. And you don\u0026rsquo;t know who\u0026rsquo;s going to talk and you don\u0026rsquo;t know who\u0026rsquo;s going to judge you if you were to ask for help\u0026hellip; I wish that there was an Indigenous-specific hotline or something that our young girls could access.\u003c/em\u003e (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e This participant continues and describes the benefit of having a national hotline and website to connect Indigenous abortion seekers with Indigenous abortion doulas and safe, non-judgemental support:\u003c/p\u003e \u003cp\u003e \u003cem\u003eI remember growing up, those frigging Kids Help phones stickers were everywhere. If there were a national hotline that could even direct you to somebody safe to speak with that\u0026rsquo;s Indigenous in your province that would be great. Even more great if that person were \u0026hellip; an abortion doula who is Indigenous. If there could be abortion doulas in every province and territory that would be beautiful. Having funds available via this hotline or via these doulas to make sure that all of those needs could be met so that somebody wouldn\u0026rsquo;t have to go through the awkwardness of going through their community health centre. I would really like to see \u0026hellip; a hotline, website, a list of services on the website like where people could call, directions as to how to access services.\u003c/em\u003e (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eLastly, participants called for resources targeted at men to destigmatize abortion. As one participant shared, \u0026ldquo;Is there a way to include more men in the conversation?... It\u0026rsquo;s good to have women and femmes obviously in the inner circle, but I feel like\u0026hellip; more awareness for the men too...\u0026rdquo; (09). Including men in conversations was shared by participants to foster support and understanding, helping to reduce shame. One participant describes the value of transferring this knowledge to include men of all ages:\u003c/p\u003e \u003cp\u003e \u003cem\u003eTransferring \u0026hellip; teachings about how our grandmothers and aunties and ancestors, what their teachings were surrounding abortion\u0026hellip; to the generations that have lost it, I think that\u0026rsquo;s really important\u0026hellip; And not just for women who are accessing abortions or people with uteruses that are accessing abortions but for all of us, like my son, my brother, my dad\u0026hellip; to help destigmatise the shame or just to remember these stories. Because they are so important and so vital and somehow getting them out there would be really valuable.\u003c/em\u003e (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eDismantling abortion stigma within Indigenous communities and enhancing culturally rooted community support systems (n = 21)\u003c/h3\u003e\n\u003cp\u003e Twenty-one participants emphasized the importance of addressing abortion stigma in Indigenous communities by fostering open dialogue to create a more accepting and supportive environment for those seeking abortion care. This included emphasizing choice and development of materials that share how abortion was practiced traditionally. As one participant shared,\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think it would be really great for the stigma in communities, because let\u0026rsquo;s be real, a lot of our communities do not accept this\u0026hellip; it\u0026rsquo;s not celebrated, it\u0026rsquo;s not really acknowledged at all. I think if we had more of these resources available to specifically us, it would cause communities to stop and think. It would put them in a position where they have to reflect.\u003c/em\u003e (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eBuilding on the above quote, another participant speaks to acknowledging resistance to the topic of abortion due to reproductive violence and coercion.\u003c/p\u003e \u003cp\u003e \u003cem\u003eJust normalising [abortion] more within community. Having campaigns in community. It\u0026rsquo;s so tough because\u0026hellip; birth control and abortion is something that is thrust onto our people because we\u0026rsquo;re told that society doesn\u0026rsquo;t want more of us. You have forced sterilization, and you have healthcare providers that are gung-ho to get an IUD in you as quick as possible. Indian Affairs, sometimes they\u0026rsquo;ll cover barely anything, but they\u0026rsquo;ll cover IUDs. Because they don\u0026rsquo;t want more of you. So, people are really resistant to hearing those narratives around \u0026lsquo;we want to see less of you in this world\u0026rsquo;. So, you\u0026rsquo;re up against that to normalise abortions. But thinking about what are culturally normative ways we can normalise abortions within community, looking more around choice...\u003c/em\u003e (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother participant further expressed that discussing abortion support within the community is challenging due to colonial trauma. Survivors are focused on ensuring the survival of the next generation.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI don\u0026rsquo;t know if that conversation is ready to happen yet in the community\u0026hellip; That\u0026rsquo;ll create more division because \u0026hellip; people who\u0026rsquo;ve gone through - like my family has \u0026hellip; residential school or 60s scoop, I was millennial scoop\u0026hellip; people who\u0026rsquo;ve gone through that, they survived, right? And they want to make sure their kids survive. So, they\u0026rsquo;re not ready for that discussion because their brain is still in the survival mode of making sure the next generation is allowed to exist. (08)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eAnother recommendation surrounded having respected community members act as advocates. One participant speaks about how abortion conflicts with their teachings, later emphasizing the importance of hearing from a respected community member that this is not the case.\u003c/p\u003e \u003cp\u003e \u003cem\u003eMy Anishinaabe teachings and in my Haudenosaunee teachings, abortion is very taboo in the sense of it conflicts with some of people\u0026rsquo;s main beliefs and teachings of the life span - where we come from. That\u0026rsquo;s concrete, that\u0026rsquo;s foundational to our stories and our creation stories.\u003c/em\u003e (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis participant continues,\u003c/p\u003e \u003cp\u003e \u003cem\u003eI wish\u0026hellip; I could have talked to an Elder with my family, maybe I could have had a better way of explaining that my choice wasn\u0026rsquo;t wrong, my choice isn\u0026rsquo;t in conflict with our teachings, it isn\u0026rsquo;t in conflict with our culture and our beliefs. Have them hear it from a \u0026hellip; highly respected community member. Like an Elder or a knowledge keeper, it would have been a lot easier for me and for them to hear it and understand. Even for myself\u0026hellip; I still have the same teachings that they do. I still live my life according to my beliefs and my cultural values. I do second guess myself\u0026hellip; did I do the right thing? Based off of what I\u0026rsquo;ve been taught and things that I still hold value to, just because I didn\u0026rsquo;t choose to keep a child that I didn\u0026rsquo;t want \u0026hellip; That\u0026rsquo;s the type of stuff that would have actually had an impact because at this point in my life\u0026hellip; I\u0026rsquo;m not going to change all of this intergenerational trauma that comes with a decision like this, I\u0026rsquo;m not going to change it in my lifetime, it\u0026rsquo;s not going to change in my parent\u0026rsquo;s lifetime. I might not have to hide this for the rest of my life\u0026hellip; But at this point, I feel like I will take this to the grave in terms of like telling my family. I simply can\u0026rsquo;t bear the consequence of what might happen because of the ongoing effects of what residential school did to my family and what systemic racism is continually doing. This is\u0026hellip; so much bigger than just abortions and accessing abortions. This is talking about way more than just that and the way it affects Indigenous people, especially Indigenous women, is way more complex than\u0026hellip; any white person could imagine.\u003c/em\u003e (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eParticipants highlighted the need for availability of culturally rooted community-based abortion supports. Participants spoke to sweats and healing circles and suggested these be offered in urban spaces such as Friendship Centres. One participant emphasizes the importance of having a communal healing space to feel less isolated.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI feel like that would have been really cool to just have that healing space circle in community to work through whatever it is that we\u0026rsquo;re healing from. Like collectively. Less lonely. I\u0026rsquo;m realizing that it was very lonely, I felt a lot of guilt and shame around it too. Like I don\u0026rsquo;t know if that\u0026rsquo;s societal or my own mind coming up with these ridiculous accusations, but it\u0026rsquo;s definitely a societal blame shame, especially as a young Indigenous woman.\u003c/em\u003e (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAnother participant reflected on their conflicted feelings because they couldn\u0026rsquo;t openly share their abortion with their community. They expressed a desire for community support, highlighting a lack of such services, especially in urban areas.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI felt very conflicted with my decision, not because it wasn\u0026rsquo;t the right one, more because I can\u0026rsquo;t tell my community this. At the same time was like, my community should support this. It would be nice to be able to go after the treatment be like okay, you\u0026rsquo;re all healed up. Everything\u0026rsquo;s good\u0026hellip; you\u0026rsquo;re not bleeding any more. We\u0026rsquo;re going to go out to the bush and we\u0026rsquo;re going to do cultural land-based teachings about how do you deal with the stress or how do you deal with guilt that you\u0026rsquo;re feeling\u0026hellip; I just feel like there\u0026rsquo;s no services like that. Especially now I\u0026rsquo;m in [an urban location], there\u0026rsquo;s services here but it\u0026rsquo;s a concrete fucking jungle. (08)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIntegrating abortion education into public school curriculums (n\u0026thinsp;=\u0026thinsp;18)\u003c/h2\u003e \u003cp\u003eEighteen participants highlighted the need for public school curriculums to incorporate comprehensive information about abortion into regular sex education. Participants highlighted the importance of teaching young people about making informed choices for their bodies and addressing societal pressures with accurate information. For example, one participant emphasizes incorporating detailed abortion care information into public school sex education to reduce stigma.\u003c/p\u003e \u003cp\u003e \u003cem\u003eMore information incorporated into regular sex education in public schools around abortion care. And not just that it terminates a pregnancy but what it is and other reasons why you might do it. \u0026hellip;. They should know about the process; they should know about what it is and how it works\u0026hellip; I think the younger we can target people so that they understand about the medically necessary decisions, I think will help remove some of that moral issue stigma around it. (03).\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Another participant advocates teaching school children about bodily autonomy, emphasizing that individuals have the right to make choices for their bodies, wellbeing, and families, and supporting people in their decisions.\u003c/p\u003e \u003cp\u003e \u003cem\u003eTeach \u0026hellip; school kiddos around what that is. And that choice that we, as humans, we are allowed to make choices for ourselves, for our bodies, for our wellbeing, for our families, all of those pieces. And just I think one of the last things is just to really hold folks where they\u0026rsquo;re at in the choices that they make.\u003c/em\u003e (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAnother participant stresses the need for better sex education, highlighting that information provided earlier could help counteract community pressures and improve contraceptive and abortion knowledge.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI just think better sex ed too. I feel like it comes down to a lot of more education\u0026hellip; especially just younger folks too. I just know that there\u0026rsquo;s so much pressure\u0026hellip; to carry on with a pregnancy from my community and my family experience. So \u0026hellip; more information earlier would have been just helpful combating some of the information that I was getting from family\u0026hellip; not combatting it but just something to compliment it or something to even just you saying that there were different contraceptive and abortion practices, like I didn\u0026rsquo;t ever know that. And that actually makes me feel so\u0026hellip; just better knowing that. [Crying] (09)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eExpand maternal-child health supports to be responsive to the needs of abortion seekers though policy change (n\u0026thinsp;=\u0026thinsp;13)\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThirteen participants recommended expanding maternal-child health supports to address abortion seekers' needs, emphasizing increased providers in underserved areas and policy changes to authorize midwives and improve abortion training. Participants also highlighted that policy must change to accommodate travel expense reimbursement. For example, one participant advocates for midwives to be recognized and incorporated into abortion provision:\u003c/p\u003e \u003cp\u003e \u003cem\u003eSometimes we think that midwives are only supportive of folks who are in pregnancy and labour and delivery. Same thing with doulas, but those folks who are taught in school around midwifery, they also talk about abortion. They also talk about miscarriage. They have that knowledge and those skills too from a different perspective, but we only hone into like \u0026lsquo;oh, well they birth babies and that\u0026rsquo;s all that they do, and it\u0026rsquo;s beautiful because they bring life into the world\u0026rsquo; and it\u0026rsquo;s like, \u0026lsquo;no, no, no. They support folks who are also birthing life into a different world. And they have that expertise, knowledge from a different perspective.\u0026rsquo; So also acknowledging those gifts\u0026hellip; They know the uterus - that\u0026rsquo;s their jam.\u003c/em\u003e (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the event that abortion seekers must travel for an abortion, participants suggested implementing a policy for reimbursement. One participant described a policy similar to Jordan\u0026rsquo;s Principle (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003eIf there\u0026rsquo;s travel involved, they should have resources, some kind of reimbursement. Something like Jordan\u0026rsquo;s Principle, maybe where there is a set fund. \u0026hellip; some kind of resources where folks can get a place to stay\u0026hellip; take at least an overnight to recover and follow up care.\u003c/em\u003e (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAnother participant described being denied travel reimbursement from the Non-Insured Health Benefits (NIHB) Program, offered to registered First Nation and Inuit members in Canada(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cem\u003eI had called the flight agency, and I was trying to figure out, I was like should I tell them that I miscarried, or should I tell them that I had an abortion as a thing that was covered under the policy. And I never got my money back for that because I had decided to tell them that I had an abortion because I was like\u0026hellip; fuck it. I don\u0026rsquo;t care. I\u0026rsquo;ll tell them the truth. Like I have nothing to hide. (01)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants recommended that reproductive leave policies be more comprehensive, including everything from abortion to menstruation, and include abortion aftercare support, such as funding for abortion doulas to provide wraparound support. Normalizing it as necessary support, one participant advocates for organizational leave policies to include abortion.\u003c/p\u003e \u003cp\u003e \u003cem\u003eI think Human Resources and organizational leave needs to have a space for abortion. It needs to be normalized as something women require, especially with how there is still workplace shame with pregnancy\u0026hellip; some people don\u0026rsquo;t want to have children.\u003c/em\u003e (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAddressing abortion access for Indigenous peoples in Canada requires tackling systemic barriers, stigma, and logistical hurdles. This study highlights the need for culturally safe healthcare, education, policy reform, and the integration of Indigenous knowledge. While rooted in Indigenous experiences, these recommendations align with broader public demands for equitable abortion care. Suggestions like wraparound support, culturally relevant care, improved service distribution, sex education, and reproductive leave reflect national concerns (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants highlighted the need for annual Indigenous cultural safety training, supported by studies showing its role in improving healthcare experiences (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Smylie and colleagues (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)found that healthcare providers who underwent cultural safety training were significantly more likely to be recommended by Indigenous patients. Despite the Truth and Reconciliation Commission's recommendations to implement such training, inappropriate care for Indigenous peoples accessing health services persists (\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants called for Indigenous-led clinics to provide stigma-free abortion services. Mainstream care often subjects Indigenous abortion seekers to discrimination and racism, increasing isolation (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Indigenous-informed care models are found to improve patient outcomes by fostering trust and creating supportive environments (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIntegrating wraparound abortion support was shared to enhance accessibility. Browne and colleagues (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) found that comprehensive support, like transportation and childcare, is essential for improving health outcomes for Indigenous populations by addressing broader social determinants of health. Literature further highlights the importance of accessible health services, as logistical and financial barriers are shown to significantly impact timely abortion care (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants highlighted the need for funding allocated towards travel reimbursement. Indigenous peoples in Canada face significant challenges in accessing healthcare due to travel barriers (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Travel is not always covered by the NIHB program, as highlighted by one of our participants. NIHB provides limited coverage and often excludes services related to abortion, reflecting broader systemic discrimination (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eComprehensive sex education was highlighted to reduce abortion stigma and promote informed choice. Sexual and reproductive health stigma in Indigenous communities stems from colonial legacies, including residential schools, which disrupted traditional knowledge transfer (\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). This fuels misinformation and shame around sexual health, worsening health disparities (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Accurate, culturally relevant sex education is essential for dismantling stigma and empowering Indigenous youth to make informed decisions (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEducational initiatives led by respected community leaders, such as Elders and Knowledge Keepers, as they are custodians of traditional knowledge (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), was further recommended. Participants shared that learning about reproductive and sexual health from these community members may help overcome abortion stigma. Elders have been shown to translate sexual health education that is culturally relevant, thus fostering a holistic approach that respects, normalizes, and integrates Indigenous values and knowledge systems (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants further recommended that abortion education resources target men. Engaging men in conversations about sexual and reproductive health has been found to help dismantle harmful stereotypes and promote a more inclusive understanding of abortion (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Such initiatives are shown to improve reproductive health knowledge and encourage supportive attitudes, thereby reducing stigma and fostering a more supportive environment (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants highlighted community-based strategies to reduce abortion stigma and promote cultural healing, fostering a supportive environment and reducing loneliness, guilt, and shame (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Integrating healing practices into urban settings, like Friendship Centres, nonprofit community organizations providing services to urban Indigenous people, can help bridge the gap for Indigenous individuals living in cities (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Friendship Centres facilitate the continuity of cultural teachings and practices, essential for the well-being and identity of Indigenous peoples (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eParticipants recommended increasing providers in rural and remote areas, where limited access to abortion services poses significant barriers, especially for Indigenous communities (\u003cspan additionalcitationids=\"CR44\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). While telehealth improved access to medication abortions during COVID-19, issues like limited broadband and specialized training remain (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Indigenous-specific tools, such as a hotline, were suggested to address judgment and confidentiality concerns, with lack of anonymity often discouraging service access in close-knit communities (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The Call Auntie Clinic, a hotline run by Seventh Generation Midwives Toronto, exemplifies culturally safe services, offering abortion counseling, birth control consultations, and harm reduction (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants noted authorizing midwives to provide abortions to improve access in rural and remote regions. Midwifery is provincially regulated, and abortion care is currently outside its scope in Canada (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Expanding this scope may enhance access and offer more holistic, culturally sensitive care (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Midwives are well-positioned to offer abortions due to their training in reproductive health and their ability to provide trauma-informed care, attributes crucial for supporting individuals through abortion experiences (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eLastly, participants recommended comprehensive reproductive leave policies with aftercare support, which are rare, especially for abortion services (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Funding for abortion doulas was also suggested, as they provide emotional, physical, and informational support, reducing stress and shame (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Indigenous doulas offer culturally relevant care that fosters holistic healing, crucial for Indigenous abortion seekers facing systemic barriers (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Funding these services ensures compassionate, comprehensive care that promotes well-being and positive health outcomes (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eDue to the limited sample size across provinces and territories, a limitation of this research is the inability to differentiate specific needs and experiences of urban versus rural Indigenous abortion seekers based on geographic location. Geographic disparities, known to affect abortion access due to fewer healthcare resources in rural areas, were not fully captured (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Another limitation is the underrepresentation of medication abortion experiences, which have become increasingly prevalent since the COVID-19 pandemic as telemedicine has expanded access to this form of care (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Finally, the study also lacks Inuit and M\u0026eacute;tis perspectives, limiting generalizability across Indigenous communities in Canada (Allan and Smylie 2015). Future research must target diverse Indigenous groups and geographic areas to better capture these nuances.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e This research emphasizes the need to center Indigenous voices in abortion access and care in Canada. Recommendations from Indigenous abortion seekers reveal gaps in culturally safe, accessible, and stigma-free services. Despite barriers like colonial legacies, geographic isolation, and limited culturally informed care, the proposed recommendations align with broader calls for systemic change across Canada\u0026rsquo;s healthcare system. Prioritizing the needs of Indigenous communities will enhance health equity nationwide.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn accordance with the Declaration of Helsinki, this research has been approved by the University of Victoria Research Ethics Board #BC22-0581 and the UBC Behavioural Research Ethics Board #H22-02465.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to the sensitive nature of the information shared by participants and the ethical requirements to protect their confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSocial Sciences and Humanities Research Council of Canada (SSHRC) #\u003cem\u003e936-2021-\u003c/em\u003e\u003cem\u003e00728\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRM led the project conception, overall study design, manuscript writing and supported qualitative analysis. SH, WP, MW, EA, HP, PC, and CF contributed to data collection, qualitative analysis and manuscript editing. DJ provided methodological support and assisted with data interpretation. CL and SM contributed to the manuscript\u0026rsquo;s conceptualization and reviewed drafts. EP supported manuscript editing. APP provided project conception, overall study design, qualitative analysis, critical input on data interpretation and manuscript editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the participants who generously shared their experiences and to our community partners, including Abortion Support Services Atlantic, ekw\u0026rsquo;\u0026iacute;7tl Indigenous Doula Collective, Northern Reproductive Justice Network, and Northern Manitoba Abortion Support. We would like to extend our deepest gratitude to our Analysis Team, whose dedication, lived experience, and invaluable insights made this paper possible. Also, our heartfelt thanks goes out to the members of the Advisory Circle for their tireless commitment to centering Indigenous voices and advocating for reproductive justice. Your contributions, rooted in both professional expertise and personal experience, have profoundly shaped the analysis and outcomes of this work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAnderson K. Life Stages and Native Women: Memory, Teachings, and Story Medicine. University of Manitoba Press; 2011. \u003c/li\u003e\n\u003cli\u003eMonchalin R. Novel Coronavirus, Access to Abortion Services, and Bridging Western and Indigenous Knowledges in a Postpandemic World. Women\u0026rsquo;s Health Issues. 2020; \u003c/li\u003e\n\u003cli\u003eMonchalin R, P\u0026eacute;rez Pi\u0026ntilde;\u0026aacute;n A V., Wells M, Paul W, Jubinville D, Law K, et al. A qualitative study exploring access barriers to abortion services among Indigenous Peoples in Canada. Contraception. 2023 Aug;124:110056. \u003c/li\u003e\n\u003cli\u003eMonchalin R, Jubinville D, P\u0026eacute;rez Pi\u0026ntilde;\u0026aacute;n A V., Paul W, Wells M, Ross A, et al. \u0026ldquo;I would love for there not to be so many hoops\u0026thinsp;\u0026hellip;\u0026thinsp;\u0026rdquo;: recommendations to improve abortion service access and experiences made by Indigenous women and 2SLGTBQIA+\u0026thinsp;people in Canada. Sex Reprod Health Matters. 2023 Dec 31;31(1). \u003c/li\u003e\n\u003cli\u003eBurnett K. Different Histories: Reprodroduction, Colonialism, and Treaty 7 Communities in Southern Alberta, 1880-1940. In: Stettner S, Brunett K, Hay T, editors. Abortion: History, Politics, and Reproductive Justice after Morgentaler. Vancouver, BC: UBC Press; 2017. p. 35\u0026ndash;54. \u003c/li\u003e\n\u003cli\u003eShaw D, Norman W V. When there are no abortion laws: A case study of Canada. Best Pract Res Clin Obstet Gynaecol [Internet]. 2020;62:49\u0026ndash;62. Available from: https://doi.org/10.1016/j.bpobgyn.2019.05.010\u003c/li\u003e\n\u003cli\u003eAllan B, Smylie J. First Peoples, second class treatment: The role of racism in the health and well-being of Indigenous peoples in Canada. Toronto, ON: the Wellesley Institute. 2015. \u003c/li\u003e\n\u003cli\u003eStote K. From Eugenics to Family Planning: The Coerced Sterilization of Indigenous Women in Post-1970 Saskatchewan. Native American and Indigenous Studies. 2022;9(1):102\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eBoyer YLR. Forced Sterilization: A Malicious Determinant of Health. In: Margo Greenwood, Sarah de Leeuw, Roberta Stout, Roseann Larstone, Julie Sutherland, editors. Introduction to Determinants of First Nations, Inuit, and M\u0026eacute;tis Peoples\u0026rsquo; Health in Canada. Toronto, Ontario: Canadian Scholars Press; 2022. p. 37\u0026ndash;50. \u003c/li\u003e\n\u003cli\u003eGreen J. Chapter 1: Taking More Account of Indigenous Feminism: An Introduction. In: Green J, editor. Making Space for Indigenous Feminism. 2nd Editio. Fernwood Publishing; 2017. p. 1\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eAbsolon K. Kaandossiwin: How we come to know. Fernwood Publishing; 2011. \u003c/li\u003e\n\u003cli\u003eFlicker S, Nixon S. The DEPICT model for participatory qualitative health promotion research analysis piloted in Canada, Zambia and South Africa. Health Promot Int. 2014;30(3):616\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eClark N, Davis-Alphonse C. Indigenous Gender Based Analysis Plus (IGBA+) Toolkit. 2023 Mar. \u003c/li\u003e\n\u003cli\u003eSanchez-Pimienta CE, Masuda JR, Doucette MB, Lewis D, Rotz S, Neufeld HT, et al. Implementing indigenous gender-based analysis in research: Principles, practices and lessons learned. Int J Environ Res Public Health. 2021 Nov 1;18(21). \u003c/li\u003e\n\u003cli\u003eBlackstock C. Toward the full and proper implementation of Jordan\u0026rsquo;s Principle: An elusive goal to date. Paediatr Child Health [Internet]. 2016 Jun 1;21(5):245\u0026ndash;6. Available from: https://academic.oup.com/pch/article/21/5/245/2647378\u003c/li\u003e\n\u003cli\u003eCanadian Association of Midwives. CAM ACFF. 2019 [cited 2021 Feb 9]. Midwifery Across Canada. Available from: https://canadianmidwives.org/midwifery-across-canada/#1464901229059-08aa6afc-6b5c\u003c/li\u003e\n\u003cli\u003eBrowne AJ, Varcoe C, Lavoie J, Smye V, Wong ST, Krause M, et al. Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study. BMC Health Serv Res. 2016;16(1). \u003c/li\u003e\n\u003cli\u003eSmylie J, Rotondi MA, Filipenko S, Cox WTL, Smylie D, Ward C, et al. Randomized controlled trial demonstrates novel tools to assess patient outcomes of Indigenous cultural safety training. BMC Med. 2024 Jan 9;22(1):3. \u003c/li\u003e\n\u003cli\u003eChurchill M, Parent-Bergeron M, Smylie JK, Ward C, Fridkin A, Smylie D, et al. Evidence Brief: Wise Practices for Indigenous-specific Cultural Safety Training Programs [Internet]. Toronto, ON; 2017. Available from: https://www.iphcc.ca/wp-content/uploads/2020/02/CS_WisePractices_FINAL_11.02.17.pdf\u003c/li\u003e\n\u003cli\u003eWylie L, McConkey S, Corrado AM. It\u0026rsquo;s a Journey Not a Check Box: Indigenous Cultural Safety From Training to Transformation. Int J Indig Health. 2021;16(1):314\u0026ndash;32. \u003c/li\u003e\n\u003cli\u003eSmylie J, Kirst M, McShane K, Firestone M, Wolfe S, O\u0026rsquo;Campo P. Understanding the role of Indigenous community participation in Indigenous prenatal and infant-toddler health promotion programs in Canada: A realist review. Vol. 150, Social Science and Medicine. 2016. \u003c/li\u003e\n\u003cli\u003eMonchalin R, Smylie J, Bourgeois C, Firestone M. \u0026ldquo;I would prefer to have my health care provided over a cup of tea any day\u0026rdquo;: recommendations by urban M\u0026eacute;tis women to improve access to health and social services in Toronto for the M\u0026eacute;tis community. AlterNative. 2019 Sep 1;15(3):217\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eBrowne AJ, Varcoe C, Lavoie J, Smye V, Wong ST, Krause M, et al. Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study. BMC Health Serv Res. 2016 Dec 4;16(1):544. \u003c/li\u003e\n\u003cli\u003eMosley EA, Ayala S, Jah Z, Hailstorks T, Hairston I, Rice WS, et al. \u0026ldquo;I don\u0026rsquo;t regret it at all. It\u0026rsquo;s just I wish the process had a bit more humanity to it\u0026thinsp;\u0026hellip;\u0026thinsp;a bit more holistic\u0026rdquo;: A qualitative, community-led medication abortion study with Black and Latinx Women in Georgia, USA. Sex Reprod Health Matters. 2022 Dec 31;30(1). \u003c/li\u003e\n\u003cli\u003eBarr-Walker J, Jayaweera RT, Ramirez AM, Gerdts C. Experiences of women who travel for abortion: A mixed methods systematic review. PLoS One. 2019 Apr 9;14(4):e0209991. \u003c/li\u003e\n\u003cli\u003eNguyen NH, Subhan FB, Williams K, Chan CB. Barriers and Mitigating Strategies to Healthcare Access in Indigenous Communities of Canada: A Narrative Review. Healthcare. 2020 Apr 26;8(2):112. \u003c/li\u003e\n\u003cli\u003eDanielle Miller. Beyond Legal: A Feminist Intersectional Analysis of the Policy Landscape Shaping Indigenous Women\u0026rsquo;s Access to Abortion Services in Canada. [Victoria]: University of Victoria; 2023. \u003c/li\u003e\n\u003cli\u003eFlicker S, Wilson C, Monchalin R, Oliver V, Prentice T, Jackson R, et al. \u0026ldquo;Stay Strong, Stay Sexy, Stay Native\u0026rdquo;: Storying Indigenous youth HIV prevention activism. Action Research. 2019;17(3). \u003c/li\u003e\n\u003cli\u003eRoss A. \u0026ldquo;They couldn\u0026rsquo;t talk to anybody because there\u0026rsquo;s so much stigma\u0026rdquo;: A qualitative study exploring Indigenous Peoples\u0026rsquo; experience of abortion-related stigma in Canada. [Victoria]: University of Victoria; 2023. \u003c/li\u003e\n\u003cli\u003eNative Youth Sexual Health Network, Lesperance A, Kendrick CT, Flicker S. \u0026lsquo;This is what\u0026rsquo;s going to heal our kids\u0026rsquo;: bringing the Sexy Health Carnival into Indigenous cultural gatherings. Cult Health Sex. 2023 Jul 3;25(7):863\u0026ndash;78. \u003c/li\u003e\n\u003cli\u003eLoppie Reading C, Wien F. Health Inequalities and Social Determinants of Aboriginal Peoples \u0026rsquo; Health. 2009. \u003c/li\u003e\n\u003cli\u003eAnderson K. Vital Signs: Reading Colonialism in Contemporary Adolescent Family Planning. In: Anderson K, Lawrence B, editors. Strong Women Stories: Native Vision and Community Survival [Internet]. Sumach Press; 2003. p. 174\u0026ndash;91. Available from: https://books-scholarsportal-info.subzero.lib.uoguelph.ca/en/read?id=/ebooks/ebooks0/gibson_crkn/2009-12-01/5/412084#page=191\u003c/li\u003e\n\u003cli\u003eFlicker S, O\u0026rsquo;Campo P, Monchalin R, Thistle J, Worthington C, Masching R, et al. Research Done in \u0026ldquo;A Good Way\u0026rdquo;: The Importance of Indigenous Elder Involvement in HIV Community-Based Research. Am J Public Health. 2015;105(6):1149\u0026ndash;1154. \u003c/li\u003e\n\u003cli\u003eFlicker S, Danforth J, Konsmo E, Wilson C, Oliver V, Jackson R, et al. \u0026ldquo;Because we are Natives and we stand strong to our pride\u0026rdquo;: Decolonizing HIV Prevention with Aboriginal Youth in Canada Using the Arts. Canadi J Aborig Community Based HIV/AIDS Res. 2013;5:4\u0026ndash;24. \u003c/li\u003e\n\u003cli\u003eStrong J. Men\u0026rsquo;s involvement in women\u0026rsquo;s abortion-related care: a scoping review of evidence from low- and middle-income countries. Sex Reprod Health Matters. 2022 Dec 31;30(1). \u003c/li\u003e\n\u003cli\u003eShand T, Marcell A V. Engaging Men in Sexual and Reproductive Health. In: Oxford Research Encyclopedia of Global Public Health. Oxford University Press; 2021. \u003c/li\u003e\n\u003cli\u003eRuane-McAteer E, Amin A, Hanratty J, Lynn F, Corbijn van Willenswaard K, Reid E, et al. Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews. BMJ Glob Health. 2019 Sep 11;4(5):e001634. \u003c/li\u003e\n\u003cli\u003eAmbtman-Smith VN, Crawford A, D\u0026rsquo;Hondt J, Lindstone W, Linklater R, Longboat D, et al. Incorporating First Nations, Inuit and M\u0026eacute;tis Traditional Healing Spaces within a Hospital Context: A Place-Based Study of Three Unique Spaces within Canada\u0026rsquo;s Oldest and Largest Mental Health Hospital. Int J Environ Res Public Health. 2024 Feb 28;21(3):282. \u003c/li\u003e\n\u003cli\u003eBurnett C, Purkey E, Davison CM, Watson A, Kehoe J, Traviss S, et al. Spirituality, Community Belonging, and Mental Health Outcomes of Indigenous Peoples during the COVID-19 Pandemic. Int J Environ Res Public Health. 2022 Feb 21;19(4):2472. \u003c/li\u003e\n\u003cli\u003eHatala AR, Njeze C, Morton D, Pearl T, Bird-Naytowhow K. Land and nature as sources of health and resilience among Indigenous youth in an urban Canadian context: a photovoice exploration. BMC Public Health. 2020 Dec 20;20(1):538. \u003c/li\u003e\n\u003cli\u003ePitts E. A House of Healing: The Importance of Friendship Centres to A House of Healing: The Importance of Friendship Centres to Urban Aboriginal Populations Urban Aboriginal Populations. [London]: The University of Western Ontario; 2018. \u003c/li\u003e\n\u003cli\u003eSimpson A. Siem Qulmuhw Mustimuxw Tze Tzu Wut Tu Mamu\u0026rsquo;na\u0026rsquo;tzt: Honoured Indigenous People Helping Our Children: The co-creation of a culturally grounded family wellness curriculum with Tillicum Lelum Aboriginal Friendship Centre and urban-Indigenous families. [Victoria]: University of Victoria; 2022. \u003c/li\u003e\n\u003cli\u003eDressler J, Maughn N, Soon JA, Norman W V. The Perspective of Rural Physicians Providing Abortion in Canada: Qualitative Findings of the BC Abortion Providers Survey (BCAPS). PLoS One. 2013;8(6):6\u0026ndash;10. \u003c/li\u003e\n\u003cli\u003eNorman W V., Soon JA, Maughn N, Dressler J. Barriers to Rural Induced Abortion Services in Canada: Findings of the British Columbia Abortion Providers Survey (BCAPS). PLoS One. 2013 Jun 28;8(6):e67023. \u003c/li\u003e\n\u003cli\u003eNorman W V, Munro S, Brooks M, Devane C, Guilbert E, Renner R, et al. Could implementation of mifepristone address Canada\u0026rsquo;s urban\u0026ndash;rural abortion access disparity: a mixed-methods implementation study protocol. BMJ Open. 2019 Apr 20;9(4):e028443. \u003c/li\u003e\n\u003cli\u003eJong M, Mendez I, Jong R. Enhancing access to care in northern rural communities via telehealth. Int J Circumpolar Health. 2019 Jan 28;78(2):1554174. \u003c/li\u003e\n\u003cli\u003eCall Auntie Clinic. Call Auntie Clinic. 2022. Our Story. \u003c/li\u003e\n\u003cli\u003eCarla Ciccone. Chatelaine. 2022. Midwives Can Do More\u0026mdash;Why Won\u0026rsquo;t We Let Them? \u003c/li\u003e\n\u003cli\u003eKoert E, Malling GMH, Sylvest R, Krog MC, Kolte AM, Schmidt L, et al. Recurrent pregnancy loss: couples\u0026rsquo; perspectives on their need for treatment, support and follow up. Human Reproduction. 2019 Feb 1;34(2):291\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eMcGinn T, Casey SE. Why don\u0026rsquo;t humanitarian organizations provide safe abortion services? Confl Health. 2016 Dec 24;10(1):8. \u003c/li\u003e\n\u003cli\u003eChor J, Hill B, Martins S, Mistretta S, Patel A, Gilliam M. Doula support during first-trimester surgical abortion: A randomized controlled trial. Am J Obstet Gynecol. 2015 Jan 1;212(1):45.e1-45.e6. \u003c/li\u003e\n\u003cli\u003eLee S. Hold my Hand: How Abortion Doulas Improve Abortion Care. Voices in Bioethics. 2022;8. \u003c/li\u003e\n\u003cli\u003eCidro J, Doenmez C, Sinclair S, Nychuk A, Wodtke L, Hayward A. Putting them on a strong spiritual path: Indigenous doulas responding to the needs of Indigenous mothers and communities. Int J Equity Health. 2021 Dec 1;20(1). \u003c/li\u003e\n\u003cli\u003eDoenmez C, Cidro J, Sinclair S, Hayward A, Wodtke L, Nychuk A. Heart work: Indigenous doulas responding to challenges of western systems and revitalizing Indigenous birthing care in Canada. BMC Pregnancy Childbirth. 2022;22(41). \u003c/li\u003e\n\u003cli\u003eWodtke L, Hayward A, Nychuk A, Doenmez C, Sinclair S, Cidro J. The need for sustainable funding for Indigenous doula services in Canada. Women\u0026rsquo;s Health. 2022 Apr 1;18. \u003c/li\u003e\n\u003cli\u003eDemont C, Doctoroff J, Neron B, Foster AM. Seeking support for abortion care from national hotlines in Canada: Caller characteristics and call outcomes, 2019\u0026ndash;2021. Perspect Sex Reprod Health. 2023 Sep;55(3):192\u0026ndash;9. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5278379/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5278379/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eIndigenous Peoples in Canada face significant barriers to accessing abortion services, attributed to colonial policies, systemic racism, and geographic isolation. Despite the presence of intergenerational reproductive knowledge, barriers persist. The Fireweed Project seeks to address barriers by gathering recommendations from Indigenous abortion seekers to improve access and experiences.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eForty-one-on-one conversations were conducted with Indigenous abortion seekers across Canada. Data was analyzed using the DEPICT participatory qualitative analysis model, ensuring that the voices of Indigenous communities were central to the process. The Indigenous Gender-Based Analysis Plus (IGBA+) framework further informed analysis, considering intersections of race, gender, and socio-economic status.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSix key themes emerged from the data, including the need for Indigenous-led reproductive health services, ongoing cultural safety training for healthcare providers, enhanced follow-up and support services, and dismantling abortion stigma within Indigenous communities. Participants also recommended expanding abortion education in schools and improving maternal-child health supports through policy change.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study highlights the importance of centering Indigenous voices in the improvement of abortion services. Implementing the recommendations from Indigenous abortion seekers can help dismantle systemic barriers and improve cultural safety and accessibility of care. These findings contribute to ongoing efforts to ensure equitable reproductive health services for Indigenous communities in Canada.\u003c/p\u003e","manuscriptTitle":"The Fireweed Project: Recommendations for Improving Abortion Access and Experiences by and for Indigenous Peoples in Canada","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-31 08:47:14","doi":"10.21203/rs.3.rs-5278379/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-22T09:35:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-21T04:22:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-21T04:21:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-10-16T20:56:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d0b47759-cbb2-4dc2-b709-78273b079f98","owner":[],"postedDate":"October 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-05T15:38:28+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-31 08:47:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5278379","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5278379","identity":"rs-5278379","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}