On the path to reclaiming Indigenous midwifery: Co‐creating the Maternal Infant Support Worker pilot program

Abstract Objective The aim of the Maternal Infant Support Worker (MiSW) pilot program was to implement a virtual training program for lay maternal–infant health providers in remote First Nations communities in Northwestern Ontario, Canada. Methods The MiSW pilot program was administered jointly by a community college and a university and consisted of a 20‐week virtual course followed by a 9‐month mentored work placement in the community. Results The MiSW pilot program was delivered successfully; 11 of 13 participants received a certificate from a community college. MiSWs provided culturally and linguistically appropriate care to women, infants, and families in their respective communities. MiSWs provided doula support in their communities—a first for our region since the policy of forced evacuation for birth was implemented. MiSWs developed a community of practice for ongoing education, as well as to support each other in their work. Conclusion The MiSW pilot program demonstrated that it is possible to provide a virtual training program and then provide continued virtual mentorship as the participants work in their First Nations communities. By prioritizing Indigenous voices above those of the research team, we were able to gain the trust of the MiSWs and maintain engagement with communities.

by air from the 49 fly-in Indigenous communities or by ground transportation for the remaining road and rail access communities. Women evacuated for birth experience loneliness and disconnection during the 2-12 weeks they are away from their families and communities. 3 To exacerbate matters, Indigenous communities in the region began experiencing an epidemic of opioid misuse approximately 15 years ago. 4 Although community treatment for opioid misuse has improved access to care, 5 the 28% of First Nations women in remote and rural communities who use opioids during pregnancy continue to face a number of challenges, 6 including delays returning home while their infant receives care for neonatal abstinence syndrome and fragmented care as communication between the hospital and the community nursing station is poor. 7 The Maternal Infant Support Worker (MiSW) pilot program was a community-based intervention that aimed to increase the health system's capacity to provide integrated maternity, mental health, and addiction care to pregnant and parenting women affected by opioids, living in rural and remote First Nations communities in Northwestern Ontario, Canada. This article describes the implementation of the MiSW pilot program and the co-creation of the pilot program evaluation.

| Ethical space
The MiSW pilot program was carried out using the OCAP ®8 and the Tri-Council Policy Statement 2 9 principles, which govern research involving Indigenous peoples in Canada. This program also used the Truth and Reconciliation Conciliation Commission of Canada Calls to Action 10 and the Canadian Inquiry into Missing and Murdered Indigenous Women and Girls Calls to Justice 11 as a guiding framework ( Table 1). The MiSW pilot project training and mentored practice phases were approved by the research ethics boards at Confederation College and Lakehead University.

| Organizing framework
Indigenous grassroots theory and the sweetgrass story weaving methodology described by Wabie,12 an Algonquin researcher from Northern Ontario, formed the foundation for creating and evaluating the MiSW pilot program. This methodology centers Indigenous voices and focuses on the interconnectedness of mind, body, and spirit. The symbolism of sweetgrass was used as the organizing framework: surveying sweetgrasspreparation for the MiSW pilot program; gathering sweetgrass-MiSWs gathering information through their training; braiding sweetgrass-MiSWs consolidating their knowledge and skills through mentored practice; talking sweetgrass stories-community-level impact of the MiSW pilot program; and gifting sweetgrass-future goals of the MiSWs. This article encompasses the areas of surveying, gathering, and braiding sweetgrass.

| Program description
The MiSW pilot program was a facilitated online training program for lay maternal-infant health providers consisting of two phases: training and mentored practice. The training phase consisted of 18 weeks of facilitated online coursework shouldered by 2 weeks of in-person sessions, including a hospital placement in a prenatal clinic and on labor and delivery. The mentored practice phase consisted of 9 months of working in the community with the support of the course instructor and research team. Each participant received a tablet computer with pre-loaded curriculum that was also used to connect to virtual sessions. Participants were required to submit weekly self-reflections throughout the pilot.

| Program administration
The training phase was administered by Confederation College and the mentored practice phase was administered by Lakehead University.
The course instructor submitted weekly notes on participation, pertinent themes, comments, and concerns from the participants, as well as documenting activities, programs, or training that the participants were involved with in their communities. This information was

| Inclusion criteria
Health directors from SLAAMB communities were invited to partici-

| Surveying sweetgrass-preparation for the MiSW pilot program
The first meeting for the MiSW pilot project was held on June 15, 2018. During this meeting, a course instructor was identified who had nursing experience and who had the respect of the First Nations communities in the region. The roles and responsibilities of each of the collaborating organizations were defined and a timeline for the pilot program was established (Table 3).
A review of the course objectives, which were structured across five dimensions (health system navigator, communicator, expert, health promoter, and professional) was undertaken ( Table 4).
The first course objective was to acknowledge that funding for maternal-infant workers may come from a single source or from multiple sources, and, as a result, the reporting structure, roles, responsibilities, and the work environment for each participant may be different. As a standardized job description does not exist, our goal was to support the participants in their role as defined by the community.
Prior to the initiation of the MiSW pilot program, the research Nations-based content (Table 5), at the discretion of the course instructor and research team.

| Gathering sweetgrass-the MiSW training phase
Two cohorts of six individuals participated in the pilot program ( Figure 1, Table 7). As the first cohort progressed through the vir- Health system navigator • Act within the role of the Maternal-infant Support Worker by following established policies and procedures, service plans in both institutional, and community-based settings • Apply a working knowledge of the healthcare system/function as a navigator through the system

| Braiding sweetgrass-MiSW mentored practice phase
Following graduation, the MiSWs continued to work in their respective communities and received mentorship for 9 months in the form of weekly virtual meetings that had two aims: developing case management skills and addressing the specific learning needs of the participant. Table 8 summarizes the topics that were generated by the participants. This phase of the pilot program was completed in full by the first cohort and only partially by the second cohort due to interruption from the COVID-19 pandemic.
Among the many activities during the mentored practice phase (Table 9), the MiSWs also provided doula support. Two MiSWs supported women during births at their respective nursing stations.
MiSWs also provided doula support to women who presented to the nursing station in labor prior to evacuation to a maternity hospital.
One urban MiSW provided doula support to Indigenous women in for themselves that continues to this day as a network for support, information, and sharing of professional development opportunities. Finally, despite our efforts to co-create evaluation materials for the mentored practice phase, the participants in both cohorts did not complete the logs or the weekly self-reflections. The research team wondered if the logs represented an additional documentation burden, but a clear response to this question was not obtained. In keeping with

| DISCUSS ION
Indigenous grass roots theory, the decision was made to abandon the log-based evaluation in favor of centering the stories of the MiSWs themselves. They had ongoing dialogue with the course instructor regarding the type of cases they were seeing, as well as their reflections on their management of clients. The course instructor, with the consent of the participants in both cohorts, kept notes of the encounters.

| CON CLUS ION
The overall aim of the MiSW pilot program-to implement a virtual training program for lay maternal-infant health providers in remote First Nations communities and to support them through the first 9 months following graduation-was achieved. By prioritizing Indigenous voices above those of the research team, we were able to gain the trust of the MiSWs and maintain engagement with communities. Our next steps will be to complete the overall pilot program evaluation to assess the impact of the MiSWs in their communities.

ACK N OWLED G M ENTS
The authors are grateful for the involvement and support of the communities that participated in this project, including the families of the MiSWs. We would also like to acknowledge the contributions of the staff at the Sioux Lookout Area Aboriginal Management Board, the PSI Foundation, Confederation College, and Lakehead University, who enabled the pilot project to continue despite significant adversity.

CO N FLI C T S O F I NTE R E S T
The authors have no conflicts of interest.

AUTH O R CO NTR I B UTI O N S
Under the lead of NJ, the authors LB, MT, AR, and CM contributed to the design of the study; LT and RT contributed to data collection and analysis. All authors contributed to manuscript writing and approved the final draft of the manuscript.