Knowledge From the Afrikan World, For the World

PMC Articles

Indigenous pregnancy: Agency and strength of Batwa women challenging colonialism and gender inequity

PMCID: PMC12851452

PMID: 41604382

Abstract

Pregnancy and birth can be times of joy, hope, ceremony, and connection for Indigenous women. However, Indigenous maternal health and wellbeing are adversely affected by colonialism and socioeconomic inequities, resulting in otherwise preventable maternal morbidity and mortality. These complex inequities (e.g., marginalization, economic barriers, gendered violence) are highly context specific, and understanding these contexts is essential to inform actions to improve Indigenous maternal health.This study examined the contexts shaping Batwa women’s maternal health in Kanungu District, Uganda, and explored how women engage with, challenge and define their own pregnancy and birth experiences. Using a community-based research approach, we partnered with Batwa women and their communities. We conducted 12 focus group discussions with 44 Batwa women and 16 men across three communities, 49 in-depth repeat interviews with 10 Indigenous Batwa women who had experienced pregnancy, and 17 interviews with 22 maternal healthcare providers. Data were analysed using a constant comparative method and thematic analysis. Four themes related to Indigenous pregnancy were identified: gendered pregnancy expectations; gender roles during pregnancy and birth; gender discrimination and violence during pregnancy and birth; and Indigenous resilience and resistance. Batwa women described pregnancy and childbirth as both joyous and an onerous expectation. Most women’s experiences were characterized by limited partner support, and many included instances of domestic and institutional violence. Women resisted challenges throughout their pregnancies and births finding comfort and strength in Indigenous knowledge and ceremony. These findings demonstrate that Indigenous Batwa women’s pregnancy and birth experiences are profoundly shaped by intersecting gender inequities and colonial structures that continue to undermine their safety, autonomy and access to care. Addressing these inequities requires more than improving service availability; it demands structural reforms that confront gendered violence, eliminate discriminatory practices in health facilities, and meaningfully include Indigenous leadership in maternal health policy and programming.

Full Text

Pregnancy and birth are often times of joy, hope, ceremony and connection for Indigenous women [1]. Colonialism through oppression, displacement, and violence has disrupted Indigenous maternal health knowledges and practices, including ways to support safe pregnancies and delivery [2]. For example, Indigenous maternal healthcare and midwifery have been criminalized or banned in some countries, while in other places, pregnant Indigenous women may not have access to Indigenous knowledge, medicines, and resources to ensure safe births within their communities due to the imposition of Western medicine and ongoing colonialism [2–4]. At the same time, Indigenous women’s interactions with biomedical health care systems are systematically poorer than that of other groups, whereby they receive lower-quality and/or abusive or inappropriate care [2,5]. Indigenous women have responded to these challenges by relying on family and communities for support, as well as reclaiming Indigenous birthing practices [1]. They also seek high-quality, culturally safe maternal health care that meets their needs, and may reject lower-quality care options, even if this means avoiding biomedical care altogether [2,6–8].
In Africa, when nation states regained independence many of the political and social institutions that transferred were built and rooted in colonial structures [9]. Colonialism in Africa is complex and is characterised by both the impacts of European colonialism and the ongoing marginalization of Indigenous Peoples by African nation states. For many Indigenous Peoples, this, in part, results in a lack of recognition and acknowledgement [9]; for instance, while Batwa are recognized as Indigenous Peoples by neighbouring populations and internationally by the United Nations [10], they have not been recognized as Indigenous in Ugandan law [11]. European colonial rule in Uganda intensified gender inequities by selectively expanding opportunities for men, especially in education and wage labour, while restricting women’s access to resources, mobility and decision making power [12]. These gendered exclusions shaped women’s health by undermining their autonomy, reducing access to biomedical and traditional care, and marginalizing Indigenous knowledge systems. As women navigated these constraints, many engaged in informal economic activities as acts of necessity, resilience and resistance to the narrow roles imposed on them [12]. These inequities did not disappear with independence. Instead, political and health systems continued to operate within colonial frameworks that reinforced social hierarchies, constrained women’s choices and failed to meaningfully center Indigenous women’s reproductive needs [13,14]. Like many Indigenous women across Africa, Batwa women now experience the intersecting effects of gender discrimination, colonial legacies, and ongoing systemic marginalization, conditions that profoundly shape their maternal health experiences today [5,9,15] (we provide additional history and current context of the Batwa in more detail in the methods section).
Examining the impact of colonialism and gender inequity on maternal health of Indigenous Batwa women is particularly relevant in light of their continued high burden of illness [16,17] and in the barriers they continue to face in accessing maternal health care [18–20]. While there is general agreement in the published literature on the drivers of maternal outcomes, there has been little consideration of how these may vary for Indigenous People(s) [5,16,21,22]. Further, global attempts to improve maternal health have largely focused on increasing access to maternal health services [23] without meaningfully addressing how women are treated once they arrive at health centers [24–27].
Indigenous maternal health and wellbeing are intricately linked to discrimination, as well as gender and economic inequities, leading to otherwise preventable illness and death [6,27–30]. These inequities are not only structural but also enacted in everyday interactions with health systems, where discrimination manifests through gender norms that devalue women’s health, economic barriers that restrict timely access to services, racism that positions Indigenous peoples as inferior, and cultural and linguistic differences that delegitimize Indigenous knowledge systems [31,32]. For example, research has documented how Indigenous women are shamed for using traditional medicines, denied care due to inability to pay, subjected to verbal and physical abuse during labour, or mistreated based on stereotypes of being “uneducated,” “weak,” or “non-compliant” [24,26,30]. Such experiences of obstetric violence and systemic exclusion not only erode trust in biomedical institutions but also drive Indigenous women to avoid or resist formal maternal health services, with significant consequences for maternal and newborn health outcomes [5,33]. Given the high prevalence of pregnancy loss among Indigenous Batwa women [17] and the challenges they face in accessing and using maternal healthcare [18–20,34], there is a need to better understand the contexts that shape Batwa maternal health and wellbeing [5,32,35]. Additionally, it is imperative to examine the ways in which Indigenous Batwa women challenge these realities and reclaim and define their own pregnancies and births. This aligns with global calls to document not only the risks, challenges and barriers of Indigenous Peoples, but also the ways they actively navigate, resist and transform oppressive structures [36,37]. Scholars have shown that focusing solely on risks and deficits can perpetuate stereotypes of passivity, whereas highlighting resistance and strength acknowledges women’s leadership in protecting both the health of their pregnancy and themselves [28,38–41].
The development, implementation, and interpretation of this research project were guided by six principles for meaningful community-based research: (1) acknowledging and addressing the imbalances of power between the research team and community partners; (2) focusing research on important community issues; (3) fostering empowerment; (4) developing community capacity and building from existing capacity and strengths; (5) working meaningfully with community members as partners; and (6) respecting established protocols for working with Indigenous Peoples [42]. The importance of researching maternal health and Batwa’s experiences was highlighted by the communities during work done by the research team on food insecurity that began in 2009. In 2016, when the research team was developing new grant proposals we met with community members to co-develop objectives, research questions and select methodologies to better understand Batwa maternal health. Recruitment for participants began 15/07/2017 and finished 20/12/2017. This manuscript adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines for reporting qualitative research (S1 COREQ Checklist in S1 File).
In this manuscript we use the term colonialism intentionally, rather than “neocolonialism” or “legacies of colonialism”. This reflects the position of Batwa partners and many Indigenous scholars globally, who emphasize that colonialism is not a past event but an ongoing structure that continues to shape Indigenous Peoples’ lives, lands and health [43,44]. To frame these realities as “legacies” risks implying that colonialism has ended, whereas Batwa women continue to experience direct impacts of displacement, non-recognition by the Ugandan state [11] and ongoing restrictions on access to their ancestral lands.
Indigenous Batwa have lived in forest environments for thousands of years. In Uganda, they were forcefully evicted from their lands when Bwindi Impenetrable Forest and Mgahinga Gorilla National Parks were established in 1991 [45]. The forest was, and continues to play, a key role in the health of Batwa, providing Indigenous medicines, foods, and spiritual connections. Continued barriers to accessing the forest for Batwa are deteriorating their knowledges, deeply felt connections, and ability to maintain harmony between the forest and their communities [15]. However, Batwa are resisting this dispossession by engaging in oral histories, advocating for access to the forest, and ensuring Indigenous knowledge is being passed on to Batwa youth [46].
Indigenous Batwa women experience inequities rooted in marginalization, discrimination, and settler colonialism [47]. Social, economic, and health inequities are well documented between non-Batwa and Batwa communities in Kanungu District [48,46]. Further, gender inequity impacts Batwa women through multiple avenues including domestic violence that has increased substantially with new sedentary livelihoods outside of the forest [15]. Research in the District has documented high prevalence of pregnancy loss [17], low-birth weight infants [18], malaria [49], acute gastrointestinal illness [50], food insecurity [51], and malnutrition [52] among the Batwa; all of these health outcomes are strongly embedded within social, economic, and environmental inequities. However, the focus on marginalization and vulnerability perpetuates stereotypes and can obscure the strength and agency of Batwa women. Herein, we aim not to minimize women’s experiences but to highlight their resilience and agency in spite of these challenges [53].
Batwa community members specified their preference for focus groups during early consultations. Women said they liked focus groups because they were fun, interesting to learn from others, and felt safe because there was no pressure to answer questions. A series of three focus group discussions were held in three Batwa communities (n = 9 focus group discussions) (Table 1), reflecting varying experiences of rurality and access to maternal health care services in the District. The focus groups would typically take place at the community Banda (a building or shelter). The research team in encouraged women to participate in other activities, like crafting, food sorting and preparation, during these sessions to increase comfort of participants, as tactile actions can be comforting, reassuring and offer a moment of intentional pauses and reflection [54]. Overall, the focus groups ranged in size from 5 to 15 participants with a total of 60 unique participants. Women above the age of 18, who were pregnant or had previously given birth were invited to attend the women’s focus groups by the community chair person, while we aimed to have 10 or less women, we welcomed anyone who wanted to participate. The topics of these sessions included pregnancy experiences, Indigenous knowledge and practices, and maternal healthcare use. In addition, we held one session in each of these communities with male spouses or partners aged 18 years and over to discuss their perspectives on pregnancy, knowledge, and engagement with maternal healthcare. The focus groups were conducted in English by Patterson and translated in the moment into Rukiga by Kesande and Twesigomwe. The total focus group time was 1320 minutes with an average duration of 110 minutes (range 92–131 minutes) per session. The focus groups were audio recorded with each participant’s informed consent.
The translated English portions of the focus group discussions, in-depth interviews, and maternal healthcare provider recordings were transcribed verbatim by Patterson and checked for accuracy against the audio recordings. To verify the accuracy of translations, an interpreter assessed 5 transcriptions for accuracy and found no major inconsistencies between the recordings and the transcriptions. All finalized transcripts were then prepared for NVivo version 12, for organization and code retrieval during thematic analysis (QSR International Pty LtD, 2018). This analysis involved several iterative steps. First, Patterson engaged in data familiarization and immersion by reading and re-reading transcripts and listening to the recordings. Preliminary codes were then generated inductively by Patterson, capturing both descriptive content (e.g., interactions with healthcare providers) and interpretive dimensions (e.g., resistance, discrimination). These initial codes were discussed collectively and refined into a codebook. Next coded segments were reviewed and organized into broader categories by identifying similarities, overlaps and patterns across women’s individual and group interviews and the men’s and healthcare provider narratives. We used the constant comparative method throughout this stage, iteratively comparing data within and across transcripts to refine codes, explore contrasts, and deepen conceptual coherence. Categories were then iteratively grouped into candidate themes that capture more conceptual patterns in the data. Themes were then refined and redefined through repeated comparison within and across transcripts and through regular peer debriefings (within research team) and community review. Our thematic analysis was guided by Braun and Clarke’s [55,56] six-phase approach and further informed by Vaismoradi et al.’s [57] description of moving codes to themes in qualitative content analysis. In addition, our community-based approach and Indigenous research principles [17] shaped interpretation by centering Batwa women’s voices, privileging Indigenous knowledge and incorporating community feedback into theme development.
Peer debriefing was conducted to improve the rigour and validity of data collection and interpretation [58]. After each interview or focus group discussion, Patterson, Kesande and Twesigomwe met for recorded debrief sessions (652 recorded minutes). These recordings provided context, and an Indigenous lens through which to understand the stories, experiences, and perspectives being shared with the research team. Finally, the presentation and interpretation of these narratives, experiences, and perspectives was done in partnership with, and the permission of all the Batwa women involved. In some circumstances, pseudonyms were used and identifying personal information and details were altered to keep their identity confidential at the participant’s request.
Along with Batwa community members, we co-developed a consent process, that included an initial consent to participate acknowledging that consent is a relationship and an ongoing decision [59,60]. Ethics approval was obtained from Ugandan and Canadian Institutions: University of Guelph Research Ethics Board, Makerere University School of Social Sciences Research Ethics Committee, and the Uganda National Council for Science and Technology. Preliminary results were shared in person with Batwa communities in Uganda in 2017. Summarized results and the manuscript were shared with Batwa community members via WhatsApp in 2020 and 2021, and in person results were shared with each community in 2022. Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S1 Checklist)
While there is variation in approaches and theories on compensation in research, it was important that we acknowledged and valued the time Indigenous women and their respective communities were spending with us and recognized the contributions they were making to the research [61]. As a result, we negotiated with each of the in-depth interview participants on fair compensation. We also worked with communities to identify an appropriate thank you for participants in the focus group discussions (most communities opted for meat, and household goods) [61]. Chair people were paid for their time reaching out to participants, time with the research team, and for organizing community spaces and gatherings. Finally, maternal health providers (where they were interviewed during work time were not paid) were given a token of appreciation.
For the Batwa, social determinants of maternal health are shaped by colonial structures. Their current socio-economic position is a direct result of their eviction from the forest [45,62]. The lack of resources in Batwa households kept women from being able to pay for maternal health services or transport and limited the amount of time they were able to seek care when providing for their families. Likewise, previous research has found that substantial disparities relative to other social determinants of health (e.g., education, housing, employment) in relation to non-Batwa women in the District impact Batwa women’s pregnancy outcomes and healthcare use [18–20].
Eviction from the forest has also had a direct impact on the ability of Batwa women to care for their pregnancies using Indigenous methods. Women’s narratives highlighted loss of access to medicinal foods herbs and plants traditionally used for strength, healing and safe labour. For Indigenous women access to Indigenous remedies and the ability to practice Indigenous medicine is critical to maternal wellbeing [2,31,63,64]. However, many healthcare institutions have demonized the use of Indigenous medicines in pregnancy by framing them as harmful and drawing a distinct line between biomedical and Indigenous practices [31,65]. Continued loss of access to the forest may exacerbate knowledge loss and potentially result in unsafe use of Indigenous medicines, as has been observed elsewhere [66].
Institutional maternal health service encounters underscored the intersection of colonialism, race, and gender inequality for Batwa women. Globally, Indigenous women who give birth at healthcare facilities report experiencing abuse, cultural disconnect, stress, isolation, and “feel dehumanized by the medical encounter” [67, p. 1859]. Likewise, Batwa women reported experiences of verbal and physical abuse and/or poor-quality care at health facilities, during their pregnancies. These encounters were often rationalized by healthcare, as necessary for safe delivery reflecting deeply engrained practices that providers do not realize are discriminatory or harmful [31,68]. Indeed, health providers in our study rationalized the use of physical violence against Batwa women to ensure the safe delivery of their babies, all the while affirming that their actions with the Batwa were not discriminatory. Existing research suggests that when mistreatment is normalized, women’s expectations of care are reduced to medical outcomes rather than quality of care, which reduces their ability to complain or advocate for change [33,68].
Documenting experiences of violence was not a primary objective of this study. However, violence emerged repeatedly in women’s narratives, in community discussions with Batwa women and men, and by maternal healthcare providers. Studies have found that intimate partner violence can cause unintended pregnancies, pregnancy loss, and negative maternal health outcomes including death, and women who experience this violence are less likely to access maternal health care services [69,70]. Colonialism has contributed to increased violence against Indigenous women through altered gender roles, normalized violence in colonial encounters, and the justification of violence as a way to maintain order [5]. In this study, many of the examples women provided when discussing intimate partner violence were linked to the expectation that they produce children and provide and prepare food, and, in other studies, these expectations are closely linked to the Batwa’s eviction from the forest [15]. Jackson [15] has described how the loss of complementary relationships in the forest – where Batwa men and women equally engaged in supporting the household – changed marital relationships, and how the higher mortality rate of children outside the forest has coincided with increased fertility rates among Batwa. Women described that while men often faced consequences for not meeting the expectations of their roles, women who fell short of household and reproductive expectations faced social ostracism, hunger, and increased risk of both institutional and intimate partner violence. These dynamics echo broader evidence linking normalized domestic violence to obstetric violence and mistreatment within health systems [68,71]. These patterns underscore the need for structural interventions that address gender norms, economic marginalization, and colonial inequities that limit Batwa women’s autonomy and wellbeing.
The resilience of Indigenous women is underrepresented in research [37]. Through their discourse and actions, Batwa women demonstrated multiple forms of resistance and agency pertaining to their maternal health experiences. Despite experiences grounded in historical and ongoing oppression, Batwa women navigate these challenges through diverse forms of resistance and adaptation. For example, after leaving the forest women acquired new skills in agriculture and animal rearing, expanded support networks to protect themselves and their children. However, these acts of resilience occurred within significant constraints shaped by gender inequity and colonial histories.
Batwa women described covertly using family planning to protect their health and assert decision-making power, similar to patterns observed elsewhere in sub-Saharan Africa [72]. Women also emphasized self-reliance, including giving birth alone, both as a response to unreliable spousal support and as an expression of strength and independence [73]. Batwa women also emphasized the importance of trusted providers. The story of Agnes illustrates how resilience and trust shaped care-seeking. Finding a culturally safe and trusted healthcare provider is rare for the Batwa. Due to tight community networks among women, others now actively seek him out “the good doctor” when they need. Other studies have highlighted that building trust with both individual health providers and institutions is required to improve maternal healthcare for Indigenous women [74]. As demonstrated by Prossy’s experience, abusive interactions in facilities resulted in women refusing to seek even emergency care. Such resistance to harmful care represents an assertion of dignity and highlights how negative encounters damage trust in institutions and maternal health care services more broadly [67].
Emphasizing “strength” and “resilience” must be done with care. Black and African scholars caution that such narratives can justify structural neglect or normalize violence [75,76], (including in maternity care where women’s pain has been minimized by health care workers [77,78]. These forms of resourcefulness, whether relying on kin networks, reclaiming traditional practices, or refusing discriminatory care, should be recognized as acts of survival within contexts of dispossession, racism and gender-based violence. Resilience frameworks must therefore be balanced with attention to systematic justice to avoid placing the burden of survival on Indigenous women themselves [28,41].
Together, these findings point to critical intervention points to support Batwa women’s agency in maternal health. Increasing facility-based care alone will be insufficient; addressing colonial and gender inequities is essential to reducing gaps in maternal health outcomes [5]. Research on improving care for Indigenous Peoples through partnerships with healthcare institutions has shown that when power imbalances were addressed, trust was developed and fostered [79,80]. Key factors for success in Indigenous maternal health include: (1) incorporation of Indigenous knowledge and practices alongside medical maternal care, (2) the presence of Indigenous healthcare providers, (3) an acknowledgement of colonial trauma, (4) the building of trusting and long-term relationships between Indigenous women and their health provider, (5) institutional accountability, and (6) community level, wholistic interventions such as family counselling and education [5,23,31,56,63,64,80–82]. Without addressing structural inequities that constrain the agency of Indigenous women, preventable maternal mortality and morbidity is likely to continue [5].

Sections

"[{\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref001\", \"pgph.0005809.ref002\", \"pgph.0005809.ref002\", \"pgph.0005809.ref004\", \"pgph.0005809.ref002\", \"pgph.0005809.ref005\", \"pgph.0005809.ref001\", \"pgph.0005809.ref002\", \"pgph.0005809.ref006\", \"pgph.0005809.ref008\"], \"section\": \"1. Introduction\", \"text\": \"Pregnancy and birth are often times of joy, hope, ceremony and connection for Indigenous women [1]. Colonialism through oppression, displacement, and violence has disrupted Indigenous maternal health knowledges and practices, including ways to support safe pregnancies and delivery [2]. For example, Indigenous maternal healthcare and midwifery have been criminalized or banned in some countries, while in other places, pregnant Indigenous women may not have access to Indigenous knowledge, medicines, and resources to ensure safe births within their communities due to the imposition of Western medicine and ongoing colonialism [2\\u20134]. At the same time, Indigenous women\\u2019s interactions with biomedical health care systems are systematically poorer than that of other groups, whereby they receive lower-quality and/or abusive or inappropriate care [2,5]. Indigenous women have responded to these challenges by relying on family and communities for support, as well as reclaiming Indigenous birthing practices [1]. They also seek high-quality, culturally safe maternal health care that meets their needs, and may reject lower-quality care options, even if this means avoiding biomedical care altogether [2,6\\u20138].\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref009\", \"pgph.0005809.ref009\", \"pgph.0005809.ref010\", \"pgph.0005809.ref011\", \"pgph.0005809.ref012\", \"pgph.0005809.ref012\", \"pgph.0005809.ref013\", \"pgph.0005809.ref014\", \"pgph.0005809.ref005\", \"pgph.0005809.ref009\", \"pgph.0005809.ref015\"], \"section\": \"1. Introduction\", \"text\": \"In Africa, when nation states regained independence many of the political and social institutions that transferred were built and rooted in colonial structures [9]. Colonialism in Africa is complex and is characterised by both the impacts of European colonialism and the ongoing marginalization of Indigenous Peoples by African nation states. For many Indigenous Peoples, this, in part, results in a lack of recognition and acknowledgement [9]; for instance, while Batwa are recognized as Indigenous Peoples by neighbouring populations and internationally by the United Nations [10], they have not been recognized as Indigenous in Ugandan law [11]. European colonial rule in Uganda intensified gender inequities by selectively expanding opportunities for men, especially in education and wage labour, while restricting women\\u2019s access to resources, mobility and decision making power [12]. These gendered exclusions shaped women\\u2019s health by undermining their autonomy, reducing access to biomedical and traditional care, and marginalizing Indigenous knowledge systems. As women navigated these constraints, many engaged in informal economic activities as acts of necessity, resilience and resistance to the narrow roles imposed on them [12]. These inequities did not disappear with independence. Instead, political and health systems continued to operate within colonial frameworks that reinforced social hierarchies, constrained women\\u2019s choices and failed to meaningfully center Indigenous women\\u2019s reproductive needs [13,14]. Like many Indigenous women across Africa, Batwa women now experience the intersecting effects of gender discrimination, colonial legacies, and ongoing systemic marginalization, conditions that profoundly shape their maternal health experiences today [5,9,15] (we provide additional history and current context of the Batwa in more detail in the methods section).\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref016\", \"pgph.0005809.ref017\", \"pgph.0005809.ref018\", \"pgph.0005809.ref020\", \"pgph.0005809.ref005\", \"pgph.0005809.ref016\", \"pgph.0005809.ref021\", \"pgph.0005809.ref022\", \"pgph.0005809.ref023\", \"pgph.0005809.ref024\", \"pgph.0005809.ref027\"], \"section\": \"1. Introduction\", \"text\": \"Examining the impact of colonialism and gender inequity on maternal health of Indigenous Batwa women is particularly relevant in light of their continued high burden of illness [16,17] and in the barriers they continue to face in accessing maternal health care [18\\u201320]. While there is general agreement in the published literature on the drivers of maternal outcomes, there has been little consideration of how these may vary for Indigenous People(s) [5,16,21,22]. Further, global attempts to improve maternal health have largely focused on increasing access to maternal health services [23] without meaningfully addressing how women are treated once they arrive at health centers [24\\u201327].\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref006\", \"pgph.0005809.ref027\", \"pgph.0005809.ref030\", \"pgph.0005809.ref031\", \"pgph.0005809.ref032\", \"pgph.0005809.ref024\", \"pgph.0005809.ref026\", \"pgph.0005809.ref030\", \"pgph.0005809.ref005\", \"pgph.0005809.ref033\", \"pgph.0005809.ref017\", \"pgph.0005809.ref018\", \"pgph.0005809.ref020\", \"pgph.0005809.ref034\", \"pgph.0005809.ref005\", \"pgph.0005809.ref032\", \"pgph.0005809.ref035\", \"pgph.0005809.ref036\", \"pgph.0005809.ref037\", \"pgph.0005809.ref028\", \"pgph.0005809.ref038\", \"pgph.0005809.ref041\"], \"section\": \"1. Introduction\", \"text\": \"Indigenous maternal health and wellbeing are intricately linked to discrimination, as well as gender and economic inequities, leading to otherwise preventable illness and death [6,27\\u201330]. These inequities are not only structural but also enacted in everyday interactions with health systems, where discrimination manifests through gender norms that devalue women\\u2019s health, economic barriers that restrict timely access to services, racism that positions Indigenous peoples as inferior, and cultural and linguistic differences that delegitimize Indigenous knowledge systems [31,32]. For example, research has documented how Indigenous women are shamed for using traditional medicines, denied care due to inability to pay, subjected to verbal and physical abuse during labour, or mistreated based on stereotypes of being \\u201cuneducated,\\u201d \\u201cweak,\\u201d or \\u201cnon-compliant\\u201d [24,26,30]. Such experiences of obstetric violence and systemic exclusion not only erode trust in biomedical institutions but also drive Indigenous women to avoid or resist formal maternal health services, with significant consequences for maternal and newborn health outcomes [5,33]. Given the high prevalence of pregnancy loss among Indigenous Batwa women [17] and the challenges they face in accessing and using maternal healthcare [18\\u201320,34], there is a need to better understand the contexts that shape Batwa maternal health and wellbeing [5,32,35]. Additionally, it is imperative to examine the ways in which Indigenous Batwa women challenge these realities and reclaim and define their own pregnancies and births. This aligns with global calls to document not only the risks, challenges and barriers of Indigenous Peoples, but also the ways they actively navigate, resist and transform oppressive structures [36,37]. Scholars have shown that focusing solely on risks and deficits can perpetuate stereotypes of passivity, whereas highlighting resistance and strength acknowledges women\\u2019s leadership in protecting both the health of their pregnancy and themselves [28,38\\u201341].\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref042\", \"pgph.0005809.s002\"], \"section\": \"2. Methods\", \"text\": \"The development, implementation, and interpretation of this research project were guided by six principles for meaningful community-based research: (1) acknowledging and addressing the imbalances of power between the research team and community partners; (2) focusing research on important community issues; (3) fostering empowerment; (4) developing community capacity and building from existing capacity and strengths; (5) working meaningfully with community members as partners; and (6) respecting established protocols for working with Indigenous Peoples [42]. The importance of researching maternal health and Batwa\\u2019s experiences was highlighted by the communities during work done by the research team on food insecurity that began in 2009. In 2016, when the research team was developing new grant proposals we met with community members to co-develop objectives, research questions and select methodologies to better understand Batwa maternal health. Recruitment for participants began 15/07/2017 and finished 20/12/2017. This manuscript adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines for reporting qualitative research (S1 COREQ Checklist in S1 File).\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref043\", \"pgph.0005809.ref044\", \"pgph.0005809.ref011\"], \"section\": \"2.1 Positionality statement\", \"text\": \"In this manuscript we use the term colonialism intentionally, rather than \\u201cneocolonialism\\u201d or \\u201clegacies of colonialism\\u201d. This reflects the position of Batwa partners and many Indigenous scholars globally, who emphasize that colonialism is not a past event but an ongoing structure that continues to shape Indigenous Peoples\\u2019 lives, lands and health [43,44]. To frame these realities as \\u201clegacies\\u201d risks implying that colonialism has ended, whereas Batwa women continue to experience direct impacts of displacement, non-recognition by the Ugandan state [11] and ongoing restrictions on access to their ancestral lands.\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref045\", \"pgph.0005809.ref015\", \"pgph.0005809.ref046\"], \"section\": \"2.2 Context: Batwa women of Kanungu district\", \"text\": \"Indigenous Batwa have lived in forest environments for thousands of years. In Uganda, they were forcefully evicted from their lands when Bwindi Impenetrable Forest and Mgahinga Gorilla National Parks were established in 1991 [45]. The forest was, and continues to play, a key role in the health of Batwa, providing Indigenous medicines, foods, and spiritual connections. Continued barriers to accessing the forest for Batwa are deteriorating their knowledges, deeply felt connections, and ability to maintain harmony between the forest and their communities [15]. However, Batwa are resisting this dispossession by engaging in oral histories, advocating for access to the forest, and ensuring Indigenous knowledge is being passed on to Batwa youth [46].\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref047\", \"pgph.0005809.ref048\", \"pgph.0005809.ref046\", \"pgph.0005809.ref015\", \"pgph.0005809.ref017\", \"pgph.0005809.ref018\", \"pgph.0005809.ref049\", \"pgph.0005809.ref050\", \"pgph.0005809.ref051\", \"pgph.0005809.ref052\", \"pgph.0005809.ref053\"], \"section\": \"2.2 Context: Batwa women of Kanungu district\", \"text\": \"Indigenous Batwa women experience inequities rooted in marginalization, discrimination, and settler colonialism [47]. Social, economic, and health inequities are well documented between non-Batwa and Batwa communities in Kanungu District [48,46]. Further, gender inequity impacts Batwa women through multiple avenues including domestic violence that has increased substantially with new sedentary livelihoods outside of the forest [15]. Research in the District has documented high prevalence of pregnancy loss [17], low-birth weight infants [18], malaria [49], acute gastrointestinal illness [50], food insecurity [51], and malnutrition [52] among the Batwa; all of these health outcomes are strongly embedded within social, economic, and environmental inequities. However, the focus on marginalization and vulnerability perpetuates stereotypes and can obscure the strength and agency of Batwa women. Herein, we aim not to minimize women\\u2019s experiences but to highlight their resilience and agency in spite of these challenges [53].\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.t001\", \"pgph.0005809.ref054\"], \"section\": \"2.3 Data collection\", \"text\": \"Batwa community members specified their preference for focus groups during early consultations. Women said they liked focus groups because they were fun, interesting to learn from others, and felt safe because there was no pressure to answer questions. A series of three focus group discussions were held in three Batwa communities (n\\u2009=\\u20099 focus group discussions) (Table 1), reflecting varying experiences of rurality and access to maternal health care services in the District. The focus groups would typically take place at the community Banda (a building or shelter). The research team in encouraged women to participate in other activities, like crafting, food sorting and preparation, during these sessions to increase comfort of participants, as tactile actions can be comforting, reassuring and offer a moment of intentional pauses and reflection [54]. Overall, the focus groups ranged in size from 5 to 15 participants with a total of 60 unique participants. Women above the age of 18, who were pregnant or had previously given birth were invited to attend the women\\u2019s focus groups by the community chair person, while we aimed to have 10 or less women, we welcomed anyone who wanted to participate. The topics of these sessions included pregnancy experiences, Indigenous knowledge and practices, and maternal healthcare use. In addition, we held one session in each of these communities with male spouses or partners aged 18 years and over to discuss their perspectives on pregnancy, knowledge, and engagement with maternal healthcare. The focus groups were conducted in English by Patterson and translated in the moment into Rukiga by Kesande and Twesigomwe. The total focus group time was 1320 minutes with an average duration of 110 minutes (range 92\\u2013131 minutes) per session. The focus groups were audio recorded with each participant\\u2019s informed consent.\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref055\", \"pgph.0005809.ref056\", \"pgph.0005809.ref057\", \"pgph.0005809.ref017\"], \"section\": \"2.4 Data analysis\", \"text\": \"The translated English portions of the focus group discussions, in-depth interviews, and maternal healthcare provider recordings were transcribed verbatim by Patterson and checked for accuracy against the audio recordings. To verify the accuracy of translations, an interpreter assessed 5 transcriptions for accuracy and found no major inconsistencies between the recordings and the transcriptions. All finalized transcripts were then prepared for NVivo version 12, for organization and code retrieval during thematic analysis (QSR International Pty LtD, 2018). This analysis involved several iterative steps. First, Patterson engaged in data familiarization and immersion by reading and re-reading transcripts and listening to the recordings. Preliminary codes were then generated inductively by Patterson, capturing both descriptive content (e.g., interactions with healthcare providers) and interpretive dimensions (e.g., resistance, discrimination). These initial codes were discussed collectively and refined into a codebook. Next coded segments were reviewed and organized into broader categories by identifying similarities, overlaps and patterns across women\\u2019s individual and group interviews and the men\\u2019s and healthcare provider narratives. We used the constant comparative method throughout this stage, iteratively comparing data within and across transcripts to refine codes, explore contrasts, and deepen conceptual coherence. Categories were then iteratively grouped into candidate themes that capture more conceptual patterns in the data. Themes were then refined and redefined through repeated comparison within and across transcripts and through regular peer debriefings (within research team) and community review. Our thematic analysis was guided by Braun and Clarke\\u2019s [55,56] six-phase approach and further informed by Vaismoradi et al.\\u2019s [57] description of moving codes to themes in qualitative content analysis. In addition, our community-based approach and Indigenous research principles [17] shaped interpretation by centering Batwa women\\u2019s voices, privileging Indigenous knowledge and incorporating community feedback into theme development.\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref058\"], \"section\": \"2.4 Data analysis\", \"text\": \"Peer debriefing was conducted to improve the rigour and validity of data collection and interpretation [58]. After each interview or focus group discussion, Patterson, Kesande and Twesigomwe met for recorded debrief sessions (652 recorded minutes). These recordings provided context, and an Indigenous lens through which to understand the stories, experiences, and perspectives being shared with the research team. Finally, the presentation and interpretation of these narratives, experiences, and perspectives was done in partnership with, and the permission of all the Batwa women involved. In some circumstances, pseudonyms were used and identifying personal information and details were altered to keep their identity confidential at the participant\\u2019s request.\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref059\", \"pgph.0005809.ref060\", \"pgph.0005809.s001\"], \"section\": \"2.5 Ethics and inclusivity in global research\", \"text\": \"Along with Batwa community members, we co-developed a consent process, that included an initial consent to participate acknowledging that consent is a relationship and an ongoing decision [59,60]. Ethics approval was obtained from Ugandan and Canadian Institutions: University of Guelph Research Ethics Board, Makerere University School of Social Sciences Research Ethics Committee, and the Uganda National Council for Science and Technology. Preliminary results were shared in person with Batwa communities in Uganda in 2017. Summarized results and the manuscript were shared with Batwa community members via WhatsApp in 2020 and 2021, and in person results were shared with each community in 2022. Additional information regarding the ethical, cultural, and scientific considerations specific to inclusivity in global research is included in the Supporting Information (S1 Checklist)\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref061\", \"pgph.0005809.ref061\"], \"section\": \"2.5 Ethics and inclusivity in global research\", \"text\": \"While there is variation in approaches and theories on compensation in research, it was important that we acknowledged and valued the time Indigenous women and their respective communities were spending with us and recognized the contributions they were making to the research [61]. As a result, we negotiated with each of the in-depth interview participants on fair compensation. We also worked with communities to identify an appropriate thank you for participants in the focus group discussions (most communities opted for meat, and household goods) [61]. Chair people were paid for their time reaching out to participants, time with the research team, and for organizing community spaces and gatherings. Finally, maternal health providers (where they were interviewed during work time were not paid) were given a token of appreciation.\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref045\", \"pgph.0005809.ref062\", \"pgph.0005809.ref018\", \"pgph.0005809.ref020\"], \"section\": \"4. Discussion\", \"text\": \"For the Batwa, social determinants of maternal health are shaped by colonial structures. Their current socio-economic position is a direct result of their eviction from the forest [45,62]. The lack of resources in Batwa households kept women from being able to pay for maternal health services or transport and limited the amount of time they were able to seek care when providing for their families. Likewise, previous research has found that substantial disparities relative to other social determinants of health (e.g., education, housing, employment) in relation to non-Batwa women in the District impact Batwa women\\u2019s pregnancy outcomes and healthcare use [18\\u201320].\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref002\", \"pgph.0005809.ref031\", \"pgph.0005809.ref063\", \"pgph.0005809.ref064\", \"pgph.0005809.ref031\", \"pgph.0005809.ref065\", \"pgph.0005809.ref066\"], \"section\": \"4. Discussion\", \"text\": \"Eviction from the forest has also had a direct impact on the ability of Batwa women to care for their pregnancies using Indigenous methods. Women\\u2019s narratives highlighted loss of access to medicinal foods herbs and plants traditionally used for strength, healing and safe labour. For Indigenous women access to Indigenous remedies and the ability to practice Indigenous medicine is critical to maternal wellbeing [2,31,63,64]. However, many healthcare institutions have demonized the use of Indigenous medicines in pregnancy by framing them as harmful and drawing a distinct line between biomedical and Indigenous practices [31,65]. Continued loss of access to the forest may exacerbate knowledge loss and potentially result in unsafe use of Indigenous medicines, as has been observed elsewhere [66].\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref067\", \"pgph.0005809.ref031\", \"pgph.0005809.ref068\", \"pgph.0005809.ref033\", \"pgph.0005809.ref068\"], \"section\": \"4. Discussion\", \"text\": \"Institutional maternal health service encounters underscored the intersection of colonialism, race, and gender inequality for Batwa women. Globally, Indigenous women who give birth at healthcare facilities report experiencing abuse, cultural disconnect, stress, isolation, and \\u201cfeel dehumanized by the medical encounter\\u201d [67, p. 1859]. Likewise, Batwa women reported experiences of verbal and physical abuse and/or poor-quality care at health facilities, during their pregnancies. These encounters were often rationalized by healthcare, as necessary for safe delivery reflecting deeply engrained practices that providers do not realize are discriminatory or harmful [31,68]. Indeed, health providers in our study rationalized the use of physical violence against Batwa women to ensure the safe delivery of their babies, all the while affirming that their actions with the Batwa were not discriminatory. Existing research suggests that when mistreatment is normalized, women\\u2019s expectations of care are reduced to medical outcomes rather than quality of care, which reduces their ability to complain or advocate for change [33,68].\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref069\", \"pgph.0005809.ref070\", \"pgph.0005809.ref005\", \"pgph.0005809.ref015\", \"pgph.0005809.ref015\", \"pgph.0005809.ref068\", \"pgph.0005809.ref071\"], \"section\": \"4. Discussion\", \"text\": \"Documenting experiences of violence was not a primary objective of this study. However, violence emerged repeatedly in women\\u2019s narratives, in community discussions with Batwa women and men, and by maternal healthcare providers. Studies have found that intimate partner violence can cause unintended pregnancies, pregnancy loss, and negative maternal health outcomes including death, and women who experience this violence are less likely to access maternal health care services [69,70]. Colonialism has contributed to increased violence against Indigenous women through altered gender roles, normalized violence in colonial encounters, and the justification of violence as a way to maintain order [5]. In this study, many of the examples women provided when discussing intimate partner violence were linked to the expectation that they produce children and provide and prepare food, and, in other studies, these expectations are closely linked to the Batwa\\u2019s eviction from the forest [15]. Jackson [15] has described how the loss of complementary relationships in the forest \\u2013 where Batwa men and women equally engaged in supporting the household \\u2013 changed marital relationships, and how the higher mortality rate of children outside the forest has coincided with increased fertility rates among Batwa. Women described that while men often faced consequences for not meeting the expectations of their roles, women who fell short of household and reproductive expectations faced social ostracism, hunger, and increased risk of both institutional and intimate partner violence. These dynamics echo broader evidence linking normalized domestic violence to obstetric violence and mistreatment within health systems [68,71]. These patterns underscore the need for structural interventions that address gender norms, economic marginalization, and colonial inequities that limit Batwa women\\u2019s autonomy and wellbeing.\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref037\"], \"section\": \"4. Discussion\", \"text\": \"The resilience of Indigenous women is underrepresented in research [37]. Through their discourse and actions, Batwa women demonstrated multiple forms of resistance and agency pertaining to their maternal health experiences. Despite experiences grounded in historical and ongoing oppression, Batwa women navigate these challenges through diverse forms of resistance and adaptation. For example, after leaving the forest women acquired new skills in agriculture and animal rearing, expanded support networks to protect themselves and their children. However, these acts of resilience occurred within significant constraints shaped by gender inequity and colonial histories.\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref072\", \"pgph.0005809.ref073\", \"pgph.0005809.ref074\", \"pgph.0005809.ref067\"], \"section\": \"4. Discussion\", \"text\": \"Batwa women described covertly using family planning to protect their health and assert decision-making power, similar to patterns observed elsewhere in sub-Saharan Africa [72]. Women also emphasized self-reliance, including giving birth alone, both as a response to unreliable spousal support and as an expression of strength and independence [73]. Batwa women also emphasized the importance of trusted providers. The story of Agnes illustrates how resilience and trust shaped care-seeking. Finding a culturally safe and trusted healthcare provider is rare for the Batwa. Due to tight community networks among women, others now actively seek him out \\u201cthe good doctor\\u201d when they need. Other studies have highlighted that building trust with both individual health providers and institutions is required to improve maternal healthcare for Indigenous women [74]. As demonstrated by Prossy\\u2019s experience, abusive interactions in facilities resulted in women refusing to seek even emergency care. Such resistance to harmful care represents an assertion of dignity and highlights how negative encounters damage trust in institutions and maternal health care services more broadly [67].\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref075\", \"pgph.0005809.ref076\", \"pgph.0005809.ref077\", \"pgph.0005809.ref078\", \"pgph.0005809.ref028\", \"pgph.0005809.ref041\"], \"section\": \"4. Discussion\", \"text\": \"Emphasizing \\u201cstrength\\u201d and \\u201cresilience\\u201d must be done with care. Black and African scholars caution that such narratives can justify structural neglect or normalize violence [75,76], (including in maternity care where women\\u2019s pain has been minimized by health care workers [77,78]. These forms of resourcefulness, whether relying on kin networks, reclaiming traditional practices, or refusing discriminatory care, should be recognized as acts of survival within contexts of dispossession, racism and gender-based violence. Resilience frameworks must therefore be balanced with attention to systematic justice to avoid placing the burden of survival on Indigenous women themselves [28,41].\"}, {\"pmc\": \"PMC12851452\", \"pmid\": \"41604382\", \"reference_ids\": [\"pgph.0005809.ref005\", \"pgph.0005809.ref079\", \"pgph.0005809.ref080\", \"pgph.0005809.ref005\", \"pgph.0005809.ref023\", \"pgph.0005809.ref031\", \"pgph.0005809.ref056\", \"pgph.0005809.ref063\", \"pgph.0005809.ref064\", \"pgph.0005809.ref080\", \"pgph.0005809.ref082\", \"pgph.0005809.ref005\"], \"section\": \"4. Discussion\", \"text\": \"Together, these findings point to critical intervention points to support Batwa women\\u2019s agency in maternal health. Increasing facility-based care alone will be insufficient; addressing colonial and gender inequities is essential to reducing gaps in maternal health outcomes [5]. Research on improving care for Indigenous Peoples through partnerships with healthcare institutions has shown that when power imbalances were addressed, trust was developed and fostered [79,80]. Key factors for success in Indigenous maternal health include: (1) incorporation of Indigenous knowledge and practices alongside medical maternal care, (2) the presence of Indigenous healthcare providers, (3) an acknowledgement of colonial trauma, (4) the building of trusting and long-term relationships between Indigenous women and their health provider, (5) institutional accountability, and (6) community level, wholistic interventions such as family counselling and education [5,23,31,56,63,64,80\\u201382]. Without addressing structural inequities that constrain the agency of Indigenous women, preventable maternal mortality and morbidity is likely to continue [5].\"}]"

Metadata

"{\"Data Availability\": \"Quotations chosen by participants and community partners have been included in the manuscript text. However, there are ethical restrictions on sharing the rest of the qualitative data because interview transcripts and audio files cannot be completely de-identified. The data are available upon request to researchers qualified to manage confidential information. To request data access, researchers should contact the University of Alberta\\u2019s Climate Change and Global Health lab at \"}"