Version One of study scope and parameters

I originally thought to select three different primigravida expectant mothers representing three different transport situations: staying in the village to deliver, transporting to Kotzebue from an outer-lying NANA village, and transporting to

Anchorage. Then, I would compare them to mothers who had stayed in Anchorage (from Anchorage), and Kotzebue (from Kotzebue) to deliver, for a total of five mothers and their respective networks. I present the original sampling design in Figure 2.3 to show the different transport possibilities involved. The networks depicted in the diagram are no

Figure 2.3 Transport Scenarios for Sampling of Maternal Networks, Study Version One Source: Author devised, 2/22/2012; Maniilaq and ANMC logo from websites.

Mom 2 Mom 1

Mom 3

Staying –in- Village Mom

TRANSPORT Maternal Care SERVICES

Mom 4 Staying in village Mom 5 Outer Lying Villages Mom 3 Kotzebue Anchorage

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longer under consideration in my current research strategy, but the different transport scenarios are the same for post-policy deliveries from northwest Alaska Native villages.

I had planned to trace the influences in a social network analysis of each of these case-study mothers. I would then identify the source of influence as either policy-based i.e. medical protocol or community/family-based, and compare the reported results to see which showed greater influence from their transport situation. I had also intended to capture the process of the mothers flying to their birthing destinations and planned on using the footage for coding and analyzing behavior streams later, at my leisure, without continually imposing on participants.

To identify first-time mothers, I had to have research liaison, lest I should look like a very strange stalker preying on young pregnant Alaska Native women. From 2008 to 2009, with the doctoral dissertation improvement grant, I instilled the assistance of key informants, but the process was slow and unproductive. I ran into issues making certain I dealt with adult-only mothers, dealing with medical privacy issues, and ultimately, lack of support from the ANTHC IRB (Schwarzburg 2012) and Maniilaq medical staff to assist with recruitment of participants. It was too difficult to track these specific first time mothers, scheduled to deliver within the study time period, without the assistance of medical personnel. Plus, there was no way for even the medical personnel to know who was going to end up staying in the village to deliver. Hence, after making adjustments to my research proposal with the approval of my funding agency and IRB, I proceeded with a different design.

2.2.1 Development of new study scope

Faced with the challenge of dealing with self-recruitment, I devised a new way to uncover the impact of the transport policy without the assistance of ANTHC or the medical staff. I had contacts in a few Maniilaq villages, so I reset my boundaries to include mothers from those villages: Buckland, Kotzebue, and Point Hope. I adjusted the scope of my study to include all mothers. I found I could uncover the impact of the policy by comparing mother's stories from differing communities and differing transport policy birth eras. Divided up this way, the criteria for participating in the study were simply: an

Alaska Native mother, 18 or older, who had given birth while living in, and presently residing in one of these villages. Another interesting feature of this new sample design was the fact that the most remote village, Point Hope, was also the only non-NANA village in the MSA. This fact adds dimension to the results when considering policy- influence and Iñupiat cultural-influence. I wanted to see if the village that mothers came from in addition to which birth era they delivered in effected the way the policy was applied or utilized for each group.

Since I designed the Arctic Passages study to question the impact of the maternal transport system operating within the Maniilaq area, these communities were obviously the ones on which I would concentrate my efforts. Inclusion of the situation in Selawik had become an option to begin with, but my contact ended up not going at the last minute, and Buckland surfaced as an outlying village comparison. Kotzebue, as the regional hub and site of the health care center and pre-maternal facility for the area medical center, was an obvious choice. Kotzebue mothers delivering in Kotzebue provided an interesting situation of birthing in community, yet somewhat within the biomedical model of birth—sans drugs and intervention strategies involving surgery. As previously mentioned, I had contacts in Point Hope, which led to its inclusion.

2.2.2 Development of new study design

With the communities and new comparisons in place, I focused on how to address the original research questions without the input of the medical community operating in these areas. Originally, the medical staff would recruit and become participants,

informing the questions at hand about the specifics of the protocol in certain situations. I was never planning to collect information with regard to an individual's treatment. I had planned to outline what happened when women in certain situations, presented as primigravidae from these communities. Having been cut off from this conversation with the lack of ANTHC support for the study at that stage in development, and loss of a filming element for data collection, I altered the design of collection and analysis. At this point, my data collection efforts excluded direct input from the Maniilaq medical

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community influence to family and village community influence in a social network analysis. I concentrated on a comparison among villages and birth eras; instead, to flesh out impact of the maternal transport policy as it operates in these northwest Alaska Native villages.

I also observed during this developmental phase of the study that certain features of a community were lining up with patterns of behavior among the participant mothers. This discovery led me to include features of the villages in respect to presence of cultural values. In recursive fashion, I incorporated this cultural value influence into the analytical framework, as presented earlier. This reorientation led to a new focus on how the policy, communities, and mothers were affected by changes in birth practices over time, and to uncover how cultural and political forces are operating in the process. To ask whether there were changes was not as relevant as uncovering how things had changed for expectant mothers over time and what community factors, if any, might be influencing these changes.

By devising a new methodology and adjusting the questions to reflect the new tact, I was able to look at how Western and Iñupait cultural influences of different areas affect how a mother experiences the protocol. In addition, I also explored how the mothers from areas with different aspects of Iñupiat cultural influences affect how the policy operates where they live. I present a breakdown of this picture of cultural features in each

community in the final chapter, in which I also cover the outcome of this analysis.