**Background:** The Indigenous Birth Support Worker (IBSW) Program was developed in response to an external review of tubal ligation procedures in the Saskatoon Health Region, which documented racism, coercion, and exclusion of Indigenous women from health decision-making. The program also honors Truth and Reconciliation Commission Call to Action #22, which calls for Indigenous patients to have access to Elders and cultural healing practices within Canadian healthcare institutions. Located in the Jim Pattison Children's Hospital (JPCH) Maternal Care Centre in Saskatoon, Saskatchewan, Canada, the program served 1023 clients between December 2019 and January 2021. IBSWs received training in Indigenous birth ceremony and cultural practices (facilitated by an Indigenous midwife) and doula training according to DONA International standards, with additional orientation from the Maternal Services unit and supervision by an Indigenous registered nurse.
**Methods:** The study aimed to explore the perspectives of IBSWs and program clients one year post-implementation. The research plan was developed collaboratively with the IBSW program director and manager, members of the Saskatchewan Health Authority's First Nations and Métis Health departments, Elders, IBSWs, and community and patient consultants. The study was approved by the SHA Research Ethics Board (REB 20–64). A qualitative research design was used with two parts. Part 1: A focus group with all four Indigenous IBSWs who provided services during the study period was conducted via Webex video conferencing over two 2-hour sessions. Topics explored included services, client needs, barriers to care, communication with healthcare professionals, lessons learned, and recommendations. Part 2: Between April-June 2021, ten clients who had delivered and were receiving IBSW program services were recruited for individual interviews. Due to COVID-19 protocols, interviews were conducted by telephone (n=4), in-person (n=3), or via handwritten responses in sealed envelopes (n=3). Questions covered program services received, experiences with IBSWs and other healthcare staff, and recommendations. Data were analyzed thematically using NVivo version 9. Initial coding of two detailed transcripts generated 48 base-level codes from client interviews and 98 categories from focus group data. These were harmonized into 16 intermediate themes, which were further consolidated into six primary themes.
**Key Results:** Thematic analysis revealed six primary themes: (1) Clients' needs, (2) Cultural support, (3) Experience with healthcare, (4) Communication, (5) Recommendations, and (6) IBSW program description. Clients greatly appreciated the IBSWs' cultural support and compassionate, nonjudgmental, and safe care. IBSWs identified clients' physical, emotional, cultural, and spiritual needs, noting insufficient access to prenatal care in communities and lack of understanding of how to navigate the urban healthcare system. Both IBSWs and clients expressed concerns about ineffective pain management, with one IBSW noting that clients were hesitant to report pain for fear of being viewed as "drug seeking." Clients frequently required financial assistance or connections to community resources for childcare, housing, or transportation. Cultural support included Elder connections, smudging, prayers, ceremonies, storytelling, beading, artwork, and traditional crafts. IBSWs acknowledged they lacked knowledge of the diverse Indigenous cultures and languages and respectfully deferred to community Elders and Knowledge Keepers. IBSWs reported that many healthcare providers were unaware of the IBSW role, sometimes mistaking them for nursing or social work staff. Clients reported instances where their pain was not addressed adequately, making them feel helpless and minimizing their concerns. IBSWs observed poor pain management or delays in treating health conditions that could result in more intensive procedures or become potentially life-threatening. All clients were very satisfied with the care from IBSWs, with one client stating, "They were the most help out of everyone." Recommendations included notifying clients about the program before hospital arrival, building relationships with communities and Elders, improving communication and training of healthcare providers about the program, and increasing access to Elders for spiritual support during perinatal loss.
**Clinical Implications:** The IBSW program aligns with the six principles proposed by BC Perinatal Services: cultural safety and humility, self-determination, trusting relationships, respect for traditional practices, anti-Indigenous racism, and strengths-based trauma-informed care. The study found that the program successfully provided culturally responsive services, but healthcare provider insensitivity toward Indigenous clients persists. The authors emphasize that the IBSW program must be viewed in the context of ongoing colonialism and the need for reconciliation and decolonization. They recommend cultural safety training for healthcare providers, increasing the number of Indigenous healthcare providers, addressing structural barriers to healthcare access (transportation, cost, availability in remote communities), integrating the IBSW program within the healthcare system, and providing trauma-informed training for both IBSWs and mainstream healthcare providers. The study limitations include selection bias (only hospitalized clients were included), potential inability of clients to fully express views while still receiving care, and no collection of demographic or delivery details due to clients' fragile physical and mental state.