Carol Couchie and Elvira Truglia: Sowing the Seeds of Healthy Relationships

(Access show transcript) Carol and Elvira are on a joint mission with the Canadian Association of Midwives to build capacity on addressing family violence in midwifery practice.

Show Summary

Midwives play a vital role in supporting patients through their pregnancy journey, establishing strong connections with both the expectant individuals and their families as they prepare for parenthood. This close relationship uniquely positions midwives to recognize and address instances of family violence that their patients may experience.

To support midwives in addressing family violence and abuse, Elvira Truglia, Knowledge Translation Lead at the Canadian Association of Midwives (CAM) and Carol Couchie, Indigenous Mentorship Lead at the National Aboriginal Council of Midwives (NCIM) have developed a comprehensive curriculum in their continuing education workshops and expert resources.

Tune into this episode of Healthcare Change Makers to learn more about how their innovative project empowers both current and future midwives in providing trauma-informed care, and how they work to collaborate with their essential partners at McMaster University’s Midwifery Education Program and the NCIM.

Mentioned in this Episode

• Canadian Association of Midwives (CAM)
• McMaster University Midwifery Education Program
• National Council of Indigenous Midwives
• Graphic Novel: Something Is Off
• CAM – Family Violence Resources
• Community Midwives of Ottawa
• Association of Ontario Midwives

Transcript 

Imagine you could step inside the minds of Canada's healthcare leaders, glimpse their greatest fears, strongest drivers, and what makes them tick. Welcome to Healthcare Changemakers, a podcast where we talk to leaders about the joys and challenges of driving change and working with partners to create the safest healthcare system.

Philip: Hey listeners, it's Philip here from HIROC. Before we get going today, I want to say thank you for listening to Healthcare Changemakers. Your engagement with our show keeps us super-motivated. Today's show is centered around midwives. We at HIROC have a long-standing relationship with midwives, one that is rooted in our shared values and vision. I was recently chatting with our good friend Tonia at the Canadian Association of Midwives, CAM, and she shared with me an initiative that has been on the go and that aims to support capacity building across the community of midwives, right across the country, actually. And so, today's guests, Elvira Truglia and Carol Cucci will offer up some valuable insight on a very important topic. So, let's get started. Welcome listeners. We're so lucky today to have Elvira and Carol join us. So, before we get going, welcome Elvira. Welcome, Carol.

Elvira: Hi. Thank you.

Carol: Thanks for having us.

Philip: Yeah, of course, of course. And so, Elvira, you go first. Why don't you tell our listeners a little bit about yourself. So, where do you work and what's your role there?

Elvira: So, for the last three years, I've been leading a project at the Canadian Association of Midwives to build the capacity of midwives to address family violence. And we're doing this by developing curriculum, continuing education workshops and resources to address intimate partner violence and also children's exposure to intimate partner violence.

I just wanted to note that I'm speaking to you, speaking with you from the unseated territories of the Kanien'kehá:ka Nation, also known as Montreal. And in terms of my background, I have a background in advocacy, strategic communications, community development and project management. And what that means is I've worked on programs and projects related to gender-based violence and social justice and human rights for several nonprofits and NGOs.

Maybe, I don't know, on something personal, when I have time, I'm also a writer and a journalist, and I love gardening, photography and getting involved in community projects. And of course hanging out with my teenage daughter who always keeps me on my toes.

Philip: That's fantastic. I feel like we could do a number of episodes with you, Elvira, and a variety of topics based on what you told us just now. Welcome. And Carol, welcome. Why don't you tell listeners a bit about yourself so we know where you work and what's your role?

Carol: My name's Carol Cucci, and I'm here. I'm a member of Nipissing First Nation, and I live in my community in a place called K'Tigaaning, which means in a garden. So, I also love gardening. I was a practicing clinical midwife for close to 25 years. I'm now, left clinical practice, and I won't say I'm retired because I'm far from that, even though I'm entering my 65th year.

Philip: Oh, well, that's good. Don't retire.

Carol: Yeah, so I'm a grandmother, a mother of two. I've attended many, many births in our communities, lived in northern places and worked with largely northern rural and remote midwifery practices. And yeah, I've worked with Elvira over the last three years, but even prior to that was one of the consultants that helped develop the Vega or a curriculum that looked at helping health professionals be more attentive to families that were dealing with family violence and intimate partner violence and child abuse.

Philip: Very good. Very interesting. Thank you for that. We can't wait to dive deeper into this, but I'll start off with Elvira here. Elvira, when we chatted for the first time some time ago, you talked about your work bringing awareness to human trafficking. And so, before we dive deeper, tell us a bit about that and what you were setting out to solve.

Elvira: Thanks for asking, Philip, and I'm also going to try to connect it to the work at CAM. So, when we spoke, I mentioned to you my work. I was working for a national organization that advocates for refugee and migrant rights, and I oversaw the work to network build and raise awareness and advocate for policy change on forced labor and sex trafficking.

Both are gendered forms of violence and impact gender diverse folks. And really a lot of emphasis in our work was the role of policy in driving labor trafficking in particular, especially when it comes to migrant workers who come to Canada on temporary work permits and are tied to their employers. So, tied in the sense that they can't leave their job if they wanted to. So, often they have limited rights, and they work in really often dismal working and living conditions. And we saw how the pandemic really shone a light on this.

And so, these tied contracts create the conditions for exploitation. So, labor exploitation, but also sometimes that intersects with sexual exploitation, especially for women-identifying migrant workers. And so, in this work, our role was to try to bring this to the attention of the federal government and to push for policy change.

So, in other words, to change the nature of the temporary foreign worker program, among many other things. And so, the work is informed by a network of service providers and advocates who support refugee migrants at a grassroots level, but also human rights advocates.

And maybe sort of connecting that to the work at CAM, I mentioned that human trafficking is gendered, most survivors of human trafficking are women and girls, but it impacts some women and girls disproportionately. There was a report that I saw recently by the Center to End Human Trafficking, and it talked about how 51% of women and 50% of girls trafficked in Canada are indigenous.

The root causes of trafficking are poverty and inequality. And so, I think that this is the key link that connects the work to prevent human trafficking as well as other forms of gender-based violence and including CAM's work. CAM's work to mitigate the harm of violence to pregnant people and their families. So, in a nutshell, it's that connection to structural inequalities that create the conditions for exploitation and violence. So, that's a big, long-winded response to your question.

Philip: No, you gave some good background on that. I appreciate it. I know listeners as well. And so, now for both of you, Elvira and Carol, for our listeners who don't know, we were introduced to both of you by our good friend Tonia at CAM. And so, can you share with listeners the work you are currently doing with building capacity on addressing family violence? And I'll start off with the first thing is how would you define family violence and what does it encompass?

Carol: That's a very complicated question, but family violence can come in many, many forms. It's not just the sort of visual things where we think of violence as in hitting, punching, kicking, slapping. These are all forms of violence that can leave marks and scars and certainly are extremely traumatizing, but also control, control of money, movement, limiting of a person's family, isolation, verbal abuse. These are also things that really affect a person's self-esteem and their ability to function as a healthy, happy human being.

Philip: Of course.

Carol: So, those are the very direct kinds of things that we think about abuse and family violence, but there's also violence that comes from other places that impact on a family and on a person even before they... Like removing children from their family and community of origin, and placing them in a place that's vulnerable where their abuse in some ways is in a more horrific sense, that they now don't have anybody that they're connected to that love them in that unconditional love. And there's no cousins, there's no aunties, there's no uncles, there's no grandparents that are looking out for them. They're living among strangers.

And when they age out of that situation, out of that foster care, or they figure out that they can't handle the life of their adopted family, and that doesn't mean that there isn't some really nice adoptive parents. Not all of them are, and not all foster people are able to care for folks properly, but that's when things like human trafficking and vulnerability and the sort of repeat history happens where children become pregnant, women become pregnant very young. They don't have the supports they need. They end up having to lose that child to foster care, and it's a cyclical kind of abuse.

So, it's those things that we try to talk about, very complicated ways of looking at our society, and preparing our midwives to be able to handle situations and see past. Look at the bigger picture, not is she getting hit, but how do we make her feel comfortable and welcoming and see the sort of red flags that might be in front of us so that the person can establish trust?

Philip: I am happy you made that connection for our listeners. And so, Elvira, you can add on to that too, but for those who may not be aware, and I think you started it, Carol, thank you for that. And Elvira, you can add now, can you describe the connection between midwifery practice and families experiencing violence?

Elvira: Maybe I'll just take a step back just to build on something that Carol was mentioning earlier because I think she sort of nailed it in terms of the scope of this project, but also just to reinforce that one thing that's really important in the project is, as Carol said, to highlight that family violence can take many forms. It's not just about physical violence, and it could be psychological, emotional and even financial, and that it impacts children in the way that Carol described, but also children witness intimate partner violence. And in itself, that's a form of child maltreatment.

So, it is very complicated, and there's a lot of responsibility that comes with that for some of the reasons that Carol mentioned. So, if you get it wrong, you're breaking up families. So, I just wanted to reinforce that. And also I think that again, thinking about violence, it's that question of control that Carol talked about and that also connects with that, with human trafficking. Violence is about control over another person, and somebody exerting that control over another person, and that can happen in any family. There's also this assumption that it only happens in certain relationships or in certain cultures, but it can happen. It can happen to anyone.

Philip: Thanks for adding that. I'll mention my question again about the connection then, and I think you've both probably answered it, but just to make sure I cover it all, describing the connection between midwifery practice and then the families experiencing violence.

Carol: I think one of the main connections is the fact that childbirth is a stressful time. It can be a time of financial burden, and even happy stress is still stress. Emotions run high. There's change. And especially, I think for a lot of men in our society, they feel a lot of pressure about having to provide for family. There's still a lot of stereotypical feelings out there and pressures, and it is a common time where if there has been some abuse and control issues within a relationship, those often begin to escalate during pregnancy and childbirth.

So, midwives have a close relationship with a family during that time, probably more than most healthcare providers. We do home visits traditionally. We try to get to know our clients, try to connect with them in a way that's on an emotional level, and help them prepare for parenthood. We pride ourselves in sort of knowing what's going on in a woman's life. So, our expectation is that we're going to try to connect with them on an emotional level and sort of try to help them with their stress, and counsel them on that.

And so, we do have an idea of the kind of red flags that are seen in a couple's life. And just like Elvira said, there are many, many people that suffer from violent relationships. However, sometimes people are able to hide it easier than others. And that's why sometimes poverty is sort of looked at as, oh, well, there's going to be more problems there.

It's not necessarily the fact. It's usually it's because they're unable to hide it as good as other people.

Elvira: Yeah, that connection between midwifery practice and families experiencing violence, sure. What else I can add to that means sort of reinforcing what Carol said, but for sure in terms of the research, the research shows that for some people pregnancy is a time for decreased IPV, but for others it's a time when it escalates and it increases.

So, in terms of the role of midwives, as Carol described, and making it clear to say that I'm not a midwife, but I have been working with midwives over the last three years. And one thing that is really, has been communicated very clearly as being important is the idea of the continuity of care model, that midwifery is based on, that takes a holistic approach to wellness. So, in sort of thinking about this project when the rationale for it is that midwives are really well positioned to potentially address family violence because part of this model of care is about building relationships with clients, and building trust.

And so, that's why there's a conversation around midwifery and addressing family violence.

Philip: And I like how you brought up the word building because it's all about building capacity. And so, some of the outputs created to build capacity, training, course, resources, things that I learned about when we chatted last, Elvira, those things are there to help midwives build capacity. And so, what are you hoping to achieve in the short and long term with these outputs created?

Elvira: I think big picture, we're hoping to sow the seeds of healthy relationships for families, for families that are experiencing violence. With this project, we're hoping that early intervention could mitigate the impact of family violence and physical, psychological and social health. So, that's sort of big picture. I can speak a little bit about what we have actually done in the project and what are some of our activities.

Carol: Yeah.

Elvira: Do you want to hear about that?

Philip: Please do.

Elvira: And also, Carol, please interrupt me and jump in at any time. But it's kind of three different pillars of work, and we're partnered with the Master University Midwifery Education Program. So, as part of this project, they developed an undergrad curriculum for midwifery students. And the aim there was to guide and educate students to address the needs of people impacted by family violence and perinatal care.

And also in collaboration with the National Council of Indigenous Midwives, we developed a series of workshops for midwives and a series of discussion circles for indigenous midwives, again to address family violence and health equity in culturally safe ways. And these courses and professional development trainings are really centered on three pillars. And the pillars are with the intention of avoiding harm or avoiding increased harm. So, social justice and health equity is a central part of the project, being client-centered, in particular, centering indigenous black and people of color communities.

And thirdly, working with clients in a trauma-informed way. And Carol can elaborate on what that means, and being trauma-informed means, it's something we've talked a lot about in the course of the project. To complement the trainings, we also developed a resource toolkit that includes, I won't name all of the tools, but there's 15 of them, tip sheets, backgrounders and resources. And they're designed for midwives to consult and to use as part of their clinical care. Everything from what are the signs of violence to checklists for supporting clients who may be experiencing violence.

Carol mentioned home visits. We have a tip sheet on how to prepare for home visit. So, they're really geared to individual learning and reference, but we're also hoping that within midwifery clinics they'll be socialized and become baseline practices within clinical settings, and hopefully even beyond midwifery settings, like in allied healthcare settings.

I just also want to put in a plug for a special resource be developed for midwives and their clients. And it's a graphic novel called Something is Off. And so, in the graphic novel, readers are introduced to two clients who go to a midwifery clinic in small town Ontario. As the weeks go by, midwives start to suspect that something is off in their clients' homes. And they create a space to have open conversations and to provide them with resources to make informed choices. It's a story-based resource. So, it's more about showing than telling, and that was an important part of the project.

Philip: Sounds very comprehensive. And where can people find these resources?

Elvira: So, on CAM'S website and the URL, so canadianmidwives.org/family-violence/, but if you go to canadianmidwives.org, it's in the section under resources and the family violence resources.

Philip: Perfect. That's all very helpful. I know our listeners will be heading over to those sites now, and so anything else you wanted to add to that, Carol?

Carol: One of the things that I would add is that we really try to talk to the midwives and to the students that you're never going to know all the answers. You're not necessarily going to become some kind of expert on how to handle families that are experiencing violence. But what we want you to do is find out what's out there, find out your resources, get your backup, and maybe have a visit to your local shelter if possible. Find out who does counseling, where there are second stage housing.

Find out who your community support people and champions are so that you have an idea of what to tell your clients when you suspect or you have an opportunity to help someone with that. And that trauma-informed care is about welcoming and making people feel comfortable, forgiving missed appointments, asking people if they would like a glass of water, thanking them for coming, and understanding how difficult it might have been for them to get there.

Families that are under stress or in distress often are the clients that miss their appointment, arrive late, have a lot going on, and that's where you need extra kindness and patience. And no shaming.

Philip: No, absolutely. Something that I've picked up, not just now but from this entire conversation, is how everything, the work you both and your team is doing, it sounds so supportive, and communications at the center. And when I mean communication, I don't just mean talking but listening, and I can feel it in how you both are talking about the work. And so, to build onto that, what have you learned along this journey? Were there any challenges? Or did you learn something new to build in capacity and sharing knowledge?

Carol: I think what I learned is that, I know this sounds very cliche, but kindness and love and patience are really what is needed for the most vulnerable in our community. And I think it sounds so simple, but yet it is still very profound, because as we know, that doesn't always happen, right? We see that, even when we were going through COVID, some of the people that were affected the most were the elderly children, pregnant people, the sick. So, these people are the most vulnerable, and they need the most time and attention. And I think the more we remind people of that and get everybody paying attention to them, the better off we all will be.

Elvira: Yeah, there are so many learnings, things that I could say to add on to all the great things that Carol's already said, but I did want to also just mention that conversation, yes, is a central part of this project and the way that it was developed and all the resources and activities that were designed. But it's also sort of conversation, hoping that maybe through some of this work we're creating a conversation that starts to take away the taboo of talking about violence, because although it's very pervasive in society, and despite being pervasive, it still remains a taboo subject.

So, creating spaces to be able to talk about it is important. There have been lots of learnings in terms of what works, what doesn't work. If I put on my project manager hat, and I'll say a few things just really briefly, the importance of building on strengths and centering community knowledge, this was really important throughout the project. It was about hearing from people who do the work on the ground and reflecting that in the content itself, and making sure the right people are involved in the content development.

So, whether it's the design of the trainings to the design of the resources, a lot of people have been involved. Another thing is it's about learning. People learn in different ways, so we wanted to highlight learning through storytelling. And there's lots of learning scenarios in our workshops and our resources, and there's lots of knowledge sharing circles in the indigenous workshops. The focus is really peer learning and sharing.

And that was an important part of this work. And really, it sort of completely reflects, this discussion-based approach reflects that midwifery model of care that I spoke to earlier. And of course, again, on the theme of everyone learns differently, we had to learn how to tailor our resources and activities to different audiences, to different learners, and also to different learning styles. And so, that's one of the reasons why the graphic novel came out of this project as well.

It is a big project involving many different people, and that means we have to kind of reflect on process too and how we did and maybe what some of the challenges were along the way. And I think it's important to mention the importance of having value alignment when working with partners and stakeholders, and are you on the same page around shared values?

And sometimes you make assumptions that you are, but it's always good to check that assumption. And if you run into obstacles, to come up with creative solutions. And I know Carol and I had to think about several things at different points throughout this project, but really focusing on strengths and principles is a way to kind of move forward.

And maybe the last piece that I wanted to share is around trauma-informed. And the project is around building the capacity for healthcare providers to build their capacity to be trauma-informed in addressing family violence. But one thing that was really clear in this project is the need to be trauma-informed, not just in the delivery of the content, but also in the development of the project and its conception, and it's designed, and management, implementation, really across the board.

And again, why do that? Well, because trauma is something that is pervasive in all of our roles, whether we're midwives or not, we want to use approaches that don't re-traumatize people. So, this idea of having constant humility and self-reflection on the part of everyone involved is definitely something that I think I learned. And I think a lot of members, a lot of people that been on this project have said that they've learned as well.

Philip: I appreciate you bringing up the values point and how that can be a great anchor, a great foundation for the work. And so, I do want to just mention that. I know you mentioned you're a project manager, but I'm sure that helps that every project you do to ensure alignment and transparency and that everyone knows what they're working towards. So, I think that's very important. And I wanted to add Elvira, if you wanted to shout out any of the collaborators now, if you want to mention any of them who supported this initiative, feel free to.

Elvira: There's a long list. I'll share some names. I'll share some names, and then maybe Carol can fill in anyone that I've missed. I mean, McMaster University Midwifery Education Program. They're a partner in this project. Liz Darling is the assistant dean of the MEP, and she brought on wonderful staff and consultants like Carol and Amy McGee from Community Midwives of Ottawa to develop and deliver the undergrad course.

And then on the side of the continuing education side of things, the National Council of Indigenous Midwives. This project was conceived jointly with the NCIM, and I worked closely with Evelyn George at the beginning of the project. And of course, I've worked with Carol from the beginning. Jessica Danforth, Stephanie George, also members of NCIM, have been important contributors.

And at CAM, worked with several midwives on the project advisory committee. They've all informed the work and kept it grounded in practice. Maybe just a special shout-out to Bounmy Inthavong, who's the Vice President of the Association of Ontario Midwives, but there's so many other midwives across Canada who are on the committee, and I've worked on the project in several capacities. So, yeah, that's my shout-out to everyone.

Philip: Wow.

Elvira: Carol, did I miss anyone?

Carol: Well, ones that worked in the original development of some of the curriculum that happened even three years before we started was Darlene Birch. Of course, Amy again was with us there. Karen Lawford that started with us. Just all the people that came, all the indigenous midwives that came on my side of the project with the National Council of Indigenous Midwives. A lot of the Inuit midwives from Pauktuutit. And yeah, there's just so many.

Philip: Wow.

Carol: A lot of people worked on this.

Philip: It's amazing to hear how many people have supported this fantastic initiative. And as we close out, I want to ask both of you, because I can hear the passion in your voices. So, where do you both personally draw inspiration and motivation from? Because I can just hear the passion in your voice to make a difference, to drive change, to make an impact, and also aligning to HIROC's vision of partnering to create the safest healthcare system, but also even further to how Elvira spoke about values. It's all about sharing knowledge so that everyone has that information, has that valuable knowledge to scale across the country. So, yeah, where do you both draw inspiration and motivation from?

Elvira: I'm going to speak to, in connection to this work where I draw inspiration, motivation. I mean, I've personally experienced the impact of violence and have witnessed the impact on many people in my life and in many communities. And I know that violence has long term impacts on physical and social and psychological health. And really, like I said earlier, that early intervention could mitigate some of these impacts. So, really what keeps me going is that I think that we do have a role to play or we can have a role to play in preventing it or mitigating, making it sort of less harmful. And as I said earlier, and taking the shame away about talking about it.

So, in a nutshell, that's kind why I'm involved in this project. But sort of maybe big picture, and this might sound kind of like a cliche. I think what motivates me is the belief that we're really part of a shared humanity, and that we all seek to be seen and heard and feel a sense of belonging. And I personally think that life is a constant journey of learning of how to understand and connect with one another. So, I think that's hope that motivates me.

Carol: I think to just even share what Elvira said about the shared humanity. As midwives, we really have this beautiful opportunity to greet brand new human beings that come onto the planet and see that change happening. And I want to greet those babies in a way that's the least violent as possible, giving them as much comfort and their parents an opportunity to nurture that moment.

Of course, you want every baby to arrive safely and to live, but we want them to live well, to arrive gently, and to make space for those parents and that family to bond and to greet and to establish the seeds of the mental health that are sown at a delivery in that moment.

And it's not that my colleagues can't offer that, but they don't have the time that we do as midwives. And that's really unfortunate. And I want to foster a society that recognizes that that time is important and that it needs to be acknowledged.

Philip: Everything you both said has definitely inspired me, so if I inspired me, everyone listening right now, I can feel they're likely inspired as well. And it all comes back to, Carol, I know you mentioned it earlier, kindness, love, and patience. And I think that's a great way to end off.

So, I really appreciate you both being here today and sharing this important information. And like Elvira mentioned, listeners, please do head to the Canadian Midwives. We'll share that link as well in all of our other comms and socials to get more information on the toolkit, the resources, even the novel. That's such a innovative way to share knowledge. And so, thank you both. Thank you, Elvira. Thank you, Carol.

Elvira: Thank you, Philip.

Carol: Thank you.

Thank you for listening. You can hear more episodes of Healthcare Changemakers on our website, hiroc.com, and on your favorite podcasting apps. If you like what you hear, please rate us or post a review. Healthcare Changemakers is recorded by HIROC's communications and marketing team and produced by Podfly Productions. Follow us on Twitter at @hirocgroup or email us at [email protected]. We'd love to hear from you.