PURPOSE:
Pregnant Indigenous Peoples living in remote, rural, and northern Indigenous communities in Canada are subjected to evacuation birth policies, whereby they are evacuated out of their community to large, urban hospitals to give birth. Evacuation for birth is assumed to decrease biomedical risk because people are birthing in hospitals. In Canadian health systems, evaluating and mitigating biomedical risk has become a standard in health decision-making but this framework disregards Indigenous ontologies and epistemologies that guide Indigenous people in their evaluation of health risk. Objectives: Describe how pregnant Indigenous people in Ontario conceptualise health and risk.

DISCUSSION:
Risks associated with evacuation for birth were conceptualised by participants in a wholistic manner based on principles of self-determination. Participants identified multiple risks that shaped their overall assessment of health risk when facing evacuation for birth including the risk of being separated from kin, confronting a lack of health services, and experiencing discrimination. As participants spoke, they reimagined perinatal care to mitigate health risks, which requires bringing birth back to Indigenous communities through Indigenous midwifery. We outline actions to limit the practice of evacuation for birth, support the return of birth to Indigenous communities, and expand understandings of risk within policy and clinical practice.

EVIDENCE WHERE RELEVANT:
We collected data through semi-structured interviews with 43 participants who have been evacuated for birth or are kin of an evacuee who live in Ontario, Canada.

KEY MESSAGE:
We call upon health systems to view risks associated with pregnancy wholistically, and address risks by including Indigenous midwives in healthcare planning. Place of birth - rural