Consent and Coercion in First Nations Contraception

Dr. Unjali Malhotra, CCFP Women’s Health NCMP Dip IPHC, is a Family Physician with extensive training and expertise in Women’s Health. She graduated from Family Medicine in Winnipeg, Manitoba, and went on to create and complete the Women’s Health fellowship program at the University of Manitoba, focusing on contraception, gynaecologic oncology, and general gynaecology. Dr. Malhotra and Dr. Alicia discuss the definitions of informed consent, establishing relationship, and creating safe spaces especially when it comes to Indigenous maternal health.

Resources:

• Aboriginal Pregnancy Passport: A book supporting the pregnant person in having a healthy pregnancy, and preparing for a traditional way of welcoming baby into the world
• Informed Consent for Contraception: A Shared Decision-Making Guide and Form
• Standing up Against Coerced Sterilization in the Health Care System

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Transcript

[00:00:00] Alicia: I'm really excited today, today we are chatting with Dr. Unjali Malhotra who is a family physician in Kelowna, and she's going to be talking to us around kind of coercion and consent in the First Nations perinatal journey. And Dr. Malhotra, why don't you start by telling us a little bit about yourself and what's brought you to the point in your career that you are doing all of this work. 

[00:00:22] Dr. Unjali: Thank you. So I started way back. I always focus all of my work on people's journeys. I like to share mine as well. So I'm a child of immigrants, but my parents' story started during the partition of India. They were essentially made refugees at that time where they walked the partition line. They subsequently became educated and my mother's family of three daughters all became educated, which was really something very special at that time in India, in the thirties. My mom and dad met and immigrated to England, [00:01:00] and then eventually landed in Northern Saskatchewan. On their journey, they faced object racism. They had a lot of issues surrounding both of them being employed, particularly my mother. My mother was the first female independent practitioner in Northern Saskatchewan, in our hometown. And started her own obstetrical practice. And that's the practice we were born into. And surrounded by this incredible love and acceptance, our own indigenous community of Northern Saskatchewan. So we were away from our own indigenous home, however we are embraced and made part of another family and community. And so in which I was raised and, it's been a pretty amazing journey since. 

[00:01:45] Work-wise I became a physician, and definitely to serve a similar or same community as home. And I've always had my mom and my ancestors guiding me through this [00:02:00] work. Particularly the hard work that we're doing right now on consenting. But I'm currently working and have been for the last five years with the First Nations Health Authority and it is a real honor, a real privilege, and I am incredibly grateful to be doing the work that I'm doing. Currently one of the main pieces of work that I'm doing is regarding people's rights, particularly surrounding maternal child health. And how does our system transform to ensure that these rights are met? So one large piece of work surrounds consent. 

Consent

[00:02:37] Dr. Unjali: Now when we consider what consent is this agreement between patient and provider. But because of the fiduciary responsibility between patient and provider, and the power imbalance, we as providers have a great responsibility when it comes to what that relationship looks like. And although our system hasn't always supported [00:03:00] with what that should look like, now as we enter our cultural humility journeys and try to reach a system that's culturally safe, which means one free of discrimination, bias, and racism, we need to look very hard on ourselves in the system that we look at for all provision of care. And I'm not talking to just physicians. I'm talking to social workers, nursing. medicine, everyone who's living in the hospital. When I talk about consent and rights, every point of contact that the patient makes within the healthcare system is one that's going to influence how they walk out of the system. So the person that's helping maintain clean rooms, the person that's taking in appointments, the person that does the surgery: all important, equally important to ensure that this person's wellness journey is respected and that when they leave care, they not only know what they are leaving as with having changed. But they know that they [00:04:00] felt safe and those are important pieces. 

[00:04:03] And one specific point that I'm hoping to talk about today is about coercion when it comes to contraception and sterilization. So do we think of that agreement between patient and provider, it's of the utmost importance when we're talking about anyone who has been discriminated against in the past. So our BIPOC and queer populations, our Indigenous families, our Métis First Nations, and Inuit families. We need to ensure that we have a heightened state of responsibility as providers to ensure again, as an entire circle of care, that people have cultural safety within the care that they are being provided. Traditionally our system has in that we, as providers, are taught to consent people, at certain periods of time. And a great example is postpartum to talk about contraception at that time. Say you're done having your baby this time, [00:05:00] let's have that conversation right now. However, story after story has come forward, saying that is not the time that it is most appropriate to have that conversation. I'm under dressed. I've just had a baby. I'm exhausted. And potentially even unfortunately, sedated or being threatened at a time when someone's very vulnerable. And so when I talk about how we need to change the system, we need to pass on to our learners and our teams and ourselves to ensure that these conversations are happening well in advance of that time period. And this is an easy tangential example because when you see a pregnant lady, you're going to see her for her entire pregnancy, or if you're having someone who's going to receive her as being someone expatriated from her clinic or from her home, you get to outreach because you know which communities are coming to you and have the conversation well in advance and these conversations can happen over [00:06:00] time then. They can be things that people have time to go home and think about what they'd like to do, potentially change their mind, potentially have other people involved in the conversation: kookums, aunties, uncles, children. Whoever they feel is important or maybe just themselves. But they're given the opportunity to have those conversations outside of the strain of the hospital confines and outside of that strain of duress, stress, fatigue. 

[00:06:29] Alicia: It's so true. We started doing a lot of this work in our clinic, in our community and starting to have these conversations in that like late second, early third trimester, when people are starting to think about birth and what's going to happen afterwards because you're a hundred percent right. Having it when they're sleep deprived at two weeks postpartum and not even thinking about being ready to have sex again. It just, it doesn't provide that useful ability for people to have those conversations and really make the right decision for them. And so having starting those conversations early, and involving all of the people [00:07:00] that need to be involved is challenging in our system, unfortunately, but it does such an important thing. So people can really make those decisions because some of the things that we can support people with, we can do immediately after delivery right now. And we know that, and some people want that, but if you haven't had those conversations, you can't give them that option anymore. 

[00:07:18] Dr. Unjali: Absolutely. And I think when we look at consent as a whole, it's important to know that it's not just reproductive health that these principles apply to. When we think of how consent can be coerced. It can be absolutely under duress, someone's sedated, someone's fatigued. But also it can be the language in which we use is something that is not understood by the person receiving it. And our system is built to protect the giver of the information, not the receiver of the information. And so it's important for us to remember that can be a big part of it. The forms in which we give, and I consider forms a living product here, they are part of that care circle. If someone can't understand [00:08:00] the forms that is not consent. If it's written in medical lingo, it's explained in medical lingo, or being translated potentially to me, that's still complex. We have to remember as providers, we speak a different language and we have to remember that not everyone speaks our language. And so we need to know that we need to effectively change the way in which we are looking at that consent. 

[00:08:22] But also if we don't give people that time, that can be coercive. That people don't have that separation of decision-making. Cause that power imbalance needs to be broken and challenged within our system. So absolutely. We're the harbors of information, but we are not the ones who should be making the decision for someone else. And then another big piece that comes into play surrounding bias. So cultural humility is us reflecting upon our own personal biases and advice, within our system. 

[00:08:52] Now, when that comes to consent, we can sway consent with our own biases. We can change how we talk [00:09:00] about risk and how we talk about benefit. That can happen. And that's the way our system was built, that we can sway the conversation and direction we feel that it should go in. Which is completely inappropriate and not consent. So we have to check our biases when we're consenting someone to how we are speaking to our patients and what that looks like. Cause it can't sway their decision-making, cause that's a big part of how consent can become coercive. So there's ways that we can change things, and another one would in fact be that space. So like I consider forms a living part of care, the space is as well. If someone walks into our space, and they don't feel safe in the space because nothing there represents them, there's no land acknowledgement, there is no art that they recognize, there's no safety net of any kind, of being asked to change too soon before meeting someone, anything along that line creates this unsafe environment [00:10:00] and that's again, the responsibility of the entire care team to try to work and facilitate to make people feel calm so that they can actually hear and receive the information, and then it's our responsibility on how we give the information.

[00:10:13] So we look at ways now within the system, how do we change that? What does that look like? One: forms should be in plain English. They should be translated. If any provider of any type of care has formed that are in medical language, you need another copy of them that represent the same things in a form that's easy to read. An example would be the postpartum contraception informed consent we have on the [to be confirmed] website that is in plain language. Absolutely, it's not going to give you the in depth details of a surgical consent form. It needs to be done alongside, and that needs to be translated. But for those conversations going in to a decision-making about what type and how you want to receive contraception care, we have a good example of that I can access on our site, that's public facing. We need to ensure [00:11:00] rooms have land acknowledgements. We need to ensure that they're safe spaces. When someone walks in, they feel that they have time to sit and get to know someone. And we often think, "wow, medicine's so busy and we just don't have that kind of time," I understand that. But there's always time to say, where did you come in from today? Where are you heading to after you leave here? Because I'll tell you our history taking is incomplete without knowing information like this. What's at home, what's supporting someone, what's happening at home. Because how can we offer any type of care other than emergent care without knowing those pieces of information. That's like an embed within our history taking. And what's amazing about it is you'll probably get everything you need anyway, from a lot of these questions. You'll probably know a lot more about your patient than you thought you would by not by asking these questions, so getting someone's information in place.

Establishing Relationships

[00:11:59] Dr. Unjali: [00:12:00] Another piece that you can do is of course ensuring that relationship is established before. So one thing that I encourage providers to do, particularly if they're receiving patients from out of their own home community, get to know the community. Start asking some questions, but on your own. Explore where are people coming in from to receive my care? And what does their community look like? Because I think the key point within all of this is that, when someone leaves our care, they should know exactly what their life is going to be like when they leave the care. And a good example of that would be if we're consenting someone for sterilization, they should know they can no longer have children. It should be open. It should outward and it should be in plain language. If you were giving someone an IUD, they should know exactly how to have it removed if they so wish. They should know who would do that? Who do they call, what does that look like? If they're getting an implant, same thing. So these are life altering pieces of someone's care that our [00:13:00] traditional system hasn't supported. And I totally understand the pressure of time as a clinician of 15 years. However, I will say these are the most important questions when someone walks in, they are vital pieces to ask anyone. 

[00:13:18] Alicia: I think also I was reading through you guys have some amazing documents on the www.fnha.ca website, and I was reading through one today, a couple of this morning, actually. And this is one of the, I'll just read a quote from it. "So prenatal delivery and postnatal care are among the most frequently cited locations of anti-indigenous racist, racism or discrimination, experienced within the BC health care system," Which, which on one hand blows my mind. But on the other hand, I can a hundred percent see that both from a historical context, but even the way that we're continuing to work now, especially over COVID, but looking at these very restrictive visitor policies when birth is such a celebration [00:14:00] in so many of our, so many of our cultures, but specifically first nations. And I'm going to tell a story that makes me look horrible, but it's a wonderful learning. Like I used to go into deliveries and there'd be so many people. And these tiny rooms, so many people celebrating this birthing person, like now looking back incredible. And I would be like, "why is, why are there so many people in here there's not enough space I need, like, how am I supposed to do this?" And everybody was respectful. They were not in the way they were just there to celebrate and this and looking back now, I can't believe that I ever had that thought. What a wonderful gift to surround yourself with the people who are the most important and who will help support you on your journey. If that's what you want to do. 

[00:14:42] And through COVID. COVID robbed people from that experience, everybody. But especially those cultures that had this, this really celebratory community based birthing tradition, right? And so I think another thing that we need to make sure that we ask is, when we're going into the room, meeting [00:15:00] somebody in labor, you've never met them before. This is a very vulnerable time. Is there any traditions or beliefs that you want to incorporate into this? And that's one of the, one of the questions that I took away from that reading this morning that I'm going to start incorporating for everybody really. I asked that, but not in a very outright way. And so I think, I think that's hopefully a way that we can also understand each other a little bit better too.

Ceremony & Culture

[00:15:22] Dr. Unjali: Ceremony and culture are so important to so many people, and it's really important- perinatal services BC has also done a great deal of work on with Lucy Barney on bringing ceremony back to traditional pieces like birthing, and also loss of pregnancy. There's certain things that need to happen in certain cultures. And we have never had a system that has opened a space that says. What can we do? Let's create a ceremony space. Let's ensure that's occurring and that's that important part of your care and we will [00:16:00] respect. And that's vital cause that's where our biases have to be challenged to o. Birthing becomes one of the highest rates of racism and discrimination, there are a lot of reasons. And one is a lack of understanding of ceremony & tradition. And one is a lack of understanding of how culture deems birth, and what that looks like. Also on a personal level of, it's not a provider's right to make a decision about someone's birthing choice in the sense to say, I don't think that you should have more kids and it's not a medically induced decision. 

[00:16:41] When it becomes a social context, that's where we run into coercion and particularly core sterilization. But it's also how, when we take a step back, we're talking to patients. What kind of words and language are we using when someone comes in and they are pregnant? And they are in distress and maybe they have [00:17:00] more children than you think you should have, or that you feel like she should have. What are the steps that you're going to take to challenge bias? And what does that look like? Maybe her life doesn't look exactly like you think it should as a provider or you think it might look like in a different set of circumstances. That's where our cultural humanity has to come into play as providers. And that's a great example to say, it's not our decision to make how many people celebrate this beautiful baby being born. Our job is to step back and get out of the way and do our medical job and see why that is pretty incredible. His community has had this blessing that they are all celebrating and there are many cultures that have the same circumstance. And so I think, the sort of key messaging is to always be practicing that cultural humility, to always step back and look at, "am I reflecting them on my own biases here? [00:18:00] Or am I not, do I have a bias in this circumstance? Does the system have a bias? And how am I going to address that, going forward? Which you so eloquently and bravely, and kind of play in wonderfully. 

[00:18:14] Alicia: Well, I'm a true believer of learning from those who have gone before and how they've made mistakes, so that we don't all repeat the mistakes of the past because we, as a a society have made some horrific mistakes. And part of what I would love to have a quick chat about, and you've and you have mentioned some things is, is for those of us who are, we were chatting before how nervous I was to talk today because I'm on the beginning of my journey of learning around kind of cultural humility, and starting to look at my biases and hopefully recognize them. We all have biases. Some of them we don't see, but some of them with time, we have pointed out to us. How can we move on that kind of ally ship or how, what are the steps that we can start to take towards becoming useful allies or helping to improve the system for all [00:19:00] members, for everybody in our society. But for specifically these populations who have, who have been injured by us and have that memory. Very close at hand for many of them. How can we make safer spaces? What are some kind of concrete steps that we can do? 

Creating Safe Spaces

[00:19:15] Dr. Unjali: Absolutely. So when I look at allyship, I look at it as a stepwise piece. The first thing is cultural humility. The first thing is reflecting upon where and how we're working and what we have already experienced in one of those teachings and learnings that we've already come across. So that's that recognition piece. And within that, not asking people to retell their stories. So what we don't want is further victimization of those already been traumatized. So we want to ensure that, if you want to learn something about the residential school system, the Indian hospital system, forced sterilization, the information's been told. Seek it out. Learn it, hear it, and believe it. [00:20:00] Because too often, are we saying to Indigenous and other people of color to repeat their story. Particularly indigenous families and communities. To repeat their story about the atrocities that have occurred is not appropriate. And then it becomes this idea of how do we now challenge what's happening. And I always encourage people to start in their own life, their own circumstance. 

[00:20:26] So if you are working within a hospital system, you're working in a community clinic. You're. working within confines of a space within a larger space, look at what you can do within that space. Forms are a great one. Translate these forms, make sure that they're legible. Make sure they're understandable. Translate your room into one that is a culturally safe space. And have these conversations at the beginning of the conversations with the patient, that reflect that you are hoping to get to know them and you were hoping to know what their life will be like when they leave care. [00:21:00] So you have an idea and understanding of their life and share stories and that's okay. It's okay to put our medical guard down, which we all have every specialty of medicine. And healthcare. It's okay to let that down because we're asking people to do it, and that can be a two-way street to a degree, whatever you're comfortable with and whatever someone else is comfortable with. And then it becomes those larger steps of now, how do you challenge the system outright and make those changes? They start with those small steps and they turn into big steps. And there's never a harm in saying, you know what? I am a worker within a larger system. Who do I approach? And what does that look like to make those large changes? So you've changed your office and what it looks like, and you changed your forms, so now you go to your supervisor, you go to your manager. You go to the larger hospital network and you say, we need to make this change. And with enough [00:22:00] voices doing that, things will change. So it's starting with yourself and then growing it and it's, it can be this thought that we have to take it all on right away. Start there. And then it'll grow. So it's just this constant reflection. 

[00:22:17] Yeah, a lot of small changes end up making significant impact so I think that's awesome. Anything else that you wanted to chat about today? Get across to our audience? I know you've been doing a tremendous amount of work in this field and we, we'll post a bunch of resources, both in the show notes and and on the website just to make it easy for people to access, because there are some incredible resources that have already been developed and don't need to be redeveloped and we can all learn from. But are there any kind of final thoughts or words that you wanted to share? 

[00:22:46] I think some, as you've mentioned, there are a lot of resources that are available right now. The reading of them earnestly and understanding that most of our work at First Nations Health Authority [00:23:00] comes directly from community. So an example would be the consent that's available on the chief medical office website page, within the www.fnha.ca website. The questions and the form within that we've created, for example, it's by community. And so we're hearing, believing, challenging and making change. And so our allyship is represented in a lot of that. And just encourage everyone else that's listening or hearing this, to consider just what those small changes could be that could grow into much bigger ones, and what that might look like. And really reflect on some of the things that I've mentioned and you can actually find some summaries of some pieces as far as rights and coercion in my rights blog that comes out frequently, that you can search the website for. But also the college of physicians and surgeons has been a great ally to us, and we were able to collectively put out a joint statement on coercion. And we've been able [00:24:00] to contribute tremendously to their work on consent. And so the registrar statement of this month and the joint statement that came out within the last eight weeks, I think are important pieces to understand how coercion occurs and what healthcare providers can really do to change. When you look at, when we consider CMPA's sort of thoughts on this, there's a great manual on consent on the CMPA website, but it states very clearly that a lot of complaints come forward related to consent. And that consent is consent to being treated at all, being treated within our healthcare system. But it stems from how are we talking to our patients? Do we know our patients? You know where they're coming in from and do we know where they're going. And what does that look like? Have they been factored in to our forms, our thoughts, our processes. Has that voice been as important as that within the system, in which we have been operating. But I'm very grateful to [00:25:00] be here and I thank you very much. 

[00:25:02] Alicia: Thank you. We we have a patient focused site, She Found Health and we have a, we did a podcast on consent just to talk about all of the, everything that a patient should hear or should understand from any kind of conversation around medical issues. And it's such an important piece. And I think that's one of the biggest take away from the birth trauma is that lack of consent, to that lack of feeling heard, or that lack of knowing, understanding what's going on. 

[00:25:28] And so it's such an important piece in the perinatal world, but in all of our medical world. So thank you very much Dr. Unjali for coming and talking with me today. 

[00:25:37] Dr. Unjali: Thank you.