Misconceiving mothers: Women-centred care key to FASD prevention

CrossCurrents

By Astrid Van Den Broek

It was a landmark case in Canada that ultimately began to change our approach to assisting pregnant women and mothers with substance use problems. In 1996, a Winnipeg, Manitoba judge ordered a young pregnant woman with a history of solvent abuse to enter treatment against her will. Reportedly, the woman’s three other children had been affected by her addiction and were no longer in her care, and she had repeatedly been unsuccessful in accessing treatment. The case was appealed to the Supreme Court of Canada, where the coercive ruling was overturned.

The court’s ruling in what is now known as the “Ms. G” case, had “a very positive influence on prevention programs because it fit in with what the research says we should do in preventing fetal alcohol spectrum disorder (FASD) – that we have to keep the interests of the mother and the developing baby connected and treated as one,” says Michelle Dubik, FAS community program co-ordinator with the Healthy Child Manitoba program based in Winnipeg.

Traditionally, prevention programs focused largely on the child at risk. “With this focus, usually there wasn’t much understanding of the context of women’s substance use or what would be helpful to the woman in terms of changing her substance use,” says Nancy Poole of B.C. Women’s Hospital and the British Columbia Centre of Excellence for Women’s Health in Vancouver. “There wasn’t much thinking about how we need to support the woman’s own changes, so that her health and the health of her fetus are enhanced.”

Poole also notes that in prevention programs of the past, efforts were very much focused on alcohol rather than on the full range of the health, social and economic concerns that may be connected to alcohol and other substance use in pregnancy. “We took a very narrow, simplistic alcohol focus, saying that if the woman stopped using alcohol, that was it, that was what we needed to focus on,” says Poole. “But we now understand that women’s alcohol use, especially for women who aren’t immediately able to stop drinking, is connected to other factors like their stress levels, use of other substances, exposure to violence, personal resilience and many other factors related to their health and long-term outcomes.”

Part of that deeper understanding of women’s needs comes through the work of people such as Caroline Tait, a Saskatoon-based anthropologist who has studied the service needs of pregnant women with substance use issues in Manitoba. She found that women could not be helped effectively by one single service or program and were sometimes perceived as non-compliant with programs. Many of the 74 women interviewed had, like Ms. G, tried to access addiction treatment programs but had come up against barriers.

Tait feels that a multi-pronged, holistic approach to FASD prevention works best, particularly one that includes a focused understanding of the highest-risk group of women. “We shouldn’t give up on primary prevention, but we really need to look at the circumstances of this high-risk group, for instance, women we know have given birth to a child who is alcohol affected, but who remain alcohol dependent,” says Tait. “There are two groups of women – women who are alcohol-dependent and women who use alcohol. We need to look at certain interventions for those women who may differ or overlap to a certain degree.”

Poole agrees that a comprehensive prevention strategy is necessary and describes three levels of prevention. The first level is about increasing public awareness of FASD, for example, through community health campaigns that inform the public of the risks of using alcohol during pregnancy and where to turn for more information and support. “This serves as the foundation of prevention where people are prompted to see that that there is an issue,” says Poole. Part of the primary prevention groundwork is also to involve the community in reducing barriers to care for women and creating co-ordinated solutions for care.

The second level of prevention aims at helping service providers be comfortable and non-judgmental when discussing alcohol and other drug use with women. “When women turn up, they don’t necessarily find someone knowledgeable about substance use and how to help women explore their use and connected health and social issues,” says Poole. Informing women of the risks and helping them access respectful and collaborative care is key to this second level of prevention.

Third-level prevention involves specialized, multi-faceted support for women at highest risk of having a child affected by alcohol exposure. Services with multiple components that include nutrition counselling, addiction counselling, housing support and prenatal/postnatal services are responsive to the needs of women at highest risk. In Canada, several programs are leading the way in providing holistic and respectful care to women at the highest risk.

Breaking the Cycle, Toronto

“We are an early identification/intervention program for women and their children – pregnant women with substance use problems and mothers who have substance use problems with children under age six,” says program manager Margaret Leslie. Breaking the Cycle, which serves parents and children together, offers services such as addiction counselling, parenting programs, child development services, medical services and an FASD clinic to the women who come to the clinic, largely through street outreach programs. “We offer services in an integrated way because we think that for women who are mothers, those areas are related,” says Leslie. Along with numerous addiction programs, Breaking the Cycle offers postnatal parenting-related programs, such as learning through play, new mom support group, a meal preparation program and parent-child counselling.

Fir Square Combined Care Unit, Vancouver

This unique program offers various services, including obstetrical care, alcohol and other drug counselling, parenting groups and assistance with finding housing. The program’s hallmark is its “rooming-in” program, where new moms who have had substance use issues share a room with their newborn in order to boost the bonding process between the two. “We have had incredible results,” says Sarah Payne, senior practice leader with the program. “We see a 40 per cent decrease in the need to treat withdrawal from opiates in newborns.” The rooming-in component gives mothers the support they need and builds their confidence as parents. These women are much more motivated to go home with their babies. Women can self-refer the program.

Sheway, Vancouver

The goal of this program is to improve the overall health of expectant mothers, and by extension, that of their children. Women can access multiple services through Sheway, including nutrition counselling, basic healthcare services, prenatal care, substance abuse counselling and community education through a staff of 22 people. “It’s engaging women in a program that looks at their basic needs in order to help them have healthier pregnancies and children,” says Dana Clifford, one of Sheway’s substance abuse counsellors. Two social workers from the Ministry of Children and Family are also on staff. They are not authorized to apprehend children; rather, they work with clients on an advocacy level. Sheway also offers a weekly food bank service and daily drop-ins. Admission is voluntary and women come to it through outreach efforts and word of mouth.

Stop FASD Program, Winnipeg

This three-year intensive home visit program is designed for high-risk women to access support on their own turf, so to speak. “It’s intensive,” says Dubik with the Healthy Child Manitoba program. “In the beginning, women could see home visitors daily, and never at any point see her less than monthly. The program is designed to reach out to those who don’t have the skills or don’t have a history of establishing positive relationships with the support system.” The home visitors use theoretical approaches and tools such as goal setting to support women in making changes in their lives, whether they be around addiction issues or other areas. Women come to the program after being identified at the hospitals (some giving birth intoxicated), or from community services such as soup kitchens. “These women need intensive support in the context of a trusting, non-judgmental relationship to make a change,” Dubik says. “The mentoring relationship starts to look like what a trusting relationship looks like.”

The thread  that clearly ties these programs together is women-centred support - services that go beyond merely providing support around substance use during pregnancy. Barriers to assistance in all life areas - from food to housing to mental health issues to parenting issues - are reduced in these programs for high-risk women. "The real goal for a successful FASD prevention strategy, what we really need to achieve, is to allow these three levels of prevention to mutually reinforce one another," says Poole. "We need to recognize that each level is a very important piece in the prevention spectrum."

 

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