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

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.