Mount Carmel Clinic
The Beginning of Caring: Pregnancy, Harm Reduction, and Substance Use. Margaret Bryans RN BN Program Manager Manito Ikwe Kagiikwe The Mothering Project Mount Carmel Clinic
Honouring of the land
Introductions
What am I going to talk about today? How culture impacts our notions and values around mothering and substance use. Harm reduction and trauma informed practice approaches to working with pregnant and/or parenting women who use substances. Manito Ikwe Kagiikwe and what we have learned so far.
Mothering: How the stories we tell about mothering impact our confidence in our own ability to parent
The Good Mom
The Bad Mom
Why does this matter for mothers who use substances?
Traditional Approaches to Substance Use as a Barrier to Care
How and why are traditional approaches to substance use problematic for pregnant and parenting women
Where do we get our knowledge about Drugs and Alcohol
Historically:
So, let s take a look at what our traditional approaches have been and what the realities that women face actually are.
Framing the issue Fear of Losing children Physical & Sexual Abuse Domestic Violence Don t drink/ use drugs message Social pressure Mental Illness Lack of Child care Treatment Barriers SHAME STIGMA Main Focus: child Part 2 What have we done and does it fit with what we know?
For example, take alcohol use in pregnancy.
Some of the campaigns marketed to the public (and picked up by healthcare providers)
Part 2 What have we done?
Part 2 What have we done?
Consider this Three groups of women: 1. Women and Teens with substance use problems who drink regularly and cannot quit on their own. 2. Women who binge drink university or young women who might be able to quit, but often don t know that they are pregnant until the end of the first trimester. 3. Women who drink very little and plan pregnancies.
Why this issue is so confusing Many countries recommend abstinence and many others recommend 1 drink per day and still others recommend light drinking???? No wonder people find this issue so difficult to figure out!
Our National Messaging There is no known safe amount of alcohol in pregnancy And if you can avoid alcohol all together, that is best.
The bottom line is drug and alcohol use in pregnancy is more complicated than some of our programs would have us believe. http://www.youtube.com/watch?v=3ftnm9cga6u
Part 3 What could we do differently? A new way
We have to create FASD interventions that address the needs that young women have around reproductive health, substance use, safety, and pregnancy.
The challenge at hand in practice and in integrating policies is to find a way to keep the woman, the fetus, and the child in mind simultaneously and with equal respect and value (Margaret Leslie, 2006).
Harm Reduction in Pregnancy
What is Harm Reduction?. It is a set of practical strategies that can be used to meet people where they are at to engage them in reducing the harms associated with risky behaviours. (Vancouver Area Network of Drug Users VANDU)
Harm Reduction strategies help minimize known harms associated with substance use and enable connections and supports to develop between women who use substances and available healing services.
Harm Reduction and Pregnancy How might we use a Harm Reduction approach in our work with young women who use substances in pregnancy?
Interventions that work (even when quitting doesn t) Accessing SAFE prenatal care! Making it okay for clients to disclose drug or alcohol use explain ahead of time. Access to safer drug use supplies 16 step groups Facilitate substance use treatment Pregnancy outreach services Nutrition Advocacy with other service providers Reducing amount of substance used Changing route of use Healthy baby benefit Building relationships Support in accessing housing Support in accessing financial assistance Discussions around birth control and family planning be clear that it is about choosing when to have children.
Trauma and Violence Informed: Trauma informed systems and services take into account the influence of trauma and violence on women s health, understand trauma related symptoms as attempts to cope, and integrate this knowledge into all aspects of service delivery. Trauma is the problem and substance use is the solution until it becomes the problem.
How can we be trauma informed in our practice? Principles and practices of TI Approaches 1. TRAUMA AWARENESS 2. EMPHASIS ON SAFETY AND TRUSTWORTHINESS 3. OPPORTUNITY FOR CHOICE, COLLABORATION, AND CONNECTION 4. STRENGTHS BASED AND SKILL BUILDING
Slow Down!
We need to tailor services to fit the needs of substance using families and Pregnant Women.
Kindness Support Services that are AVAILABLE meaningful to me Understand me as a mother AND a woman Respect my culture and my knowledge of my family A place to belong Help with being a good parent. Make me and my children feel welcomed Walk with me Believe me Support my need for connection and community Value my knowledge and expertise in what will work for me and my family.
Manito Ikwe Kagiikwe: The Mothering Project
Teaching Of Our Name
MIK Women s Advisory Council Compass of the program These women keep us on track with our program. Nothing about us without us.
How we came to be
What is Manito Ikwe Kagiikwe all about? single access site with multiple services under one roof including a drop-in, and infant and toddler early learning and child care centre
What is Manito Ikwe Kagiikwe? Providing in-reach AND out-reach services
What is Manito Ikwe Kagiikwe? Vision: to improve maternal and child outcomes in all 4 directions - related to Emotional, Spiritual, Physical, and Mental well being.
Support women s health and wellness
Support Healthy Pregnancies
Support Children s health and development
Keep Families Together
What makes this unique? Grounded in community and evidence based knowledge Strong inter-sectoral partnership model Peer Driven Low threshold access Rigorous integrated evaluation and research component Values that underpin this model are key in reaching this population
The things we care about
A Women s Health Determinants Perspective 10 Fundamental Components of FASD Prevention Http://www.canfasd.ca/files/PDF/ConsensusStatement.pdf 3 Key Components: Trauma Informed, Harm Reduction Approach, Culturally Grounded
Culturally Safe Women who seek help from service agencies need to feel respected, safe, and accepted for who they are, with regard to both their cultural identity and personal behaviours. Recognition of the influence of colonization and migration on a woman s identity is important. It is also important to recognize that people and communities that have been opressed are resiliant and that building on this resiliancy is crucial.
Trauma Informed Care
Harm Reduction Oriented
Community Based Programming
Food Security
Attachment-based Parenting and Relationship building
Equity Based Healthcare For All
Kindness
Who is this program for? Pregnant and early-parenting women and youth affected by systemic marginalization and substance use regardless of custody. Children affected by systemic marginalization and substance use. Family members (other than mothers) affected by systemic marginalization and substance use.
Why this program? Why now? Pregnancy outcomes in MB worsen as mothers become poorer or have less education or social support. (Heamon et al, 2012) Increasing social supports and improving caregiver/child attachment may lessen the need for Child Welfare involvement in substance using families. (2010, Lussier, Laventure, Bertrand) 20% of Children in MB are living in poverty (based on the LIM-AT Measure). (2012 Child Poverty Report Card, Social Planning Council of Winnipeg)
Why it is needed in MB Women who can most benefit from pre-natal care and ongoing social supports related to parenting are not being served by traditional models. (Heamon, 2012) Women who are street-involved and/or using drugs or alcohol are a population of women in our community who tend to not seek access to pre-natal care and other services due to fear of apprehension of their children. (Poole & Issac, 2001) Accessing Prenatal care is a protective factor for pregnant women who are using drugs and/or alcohol, their fetuses, and their babies. (Society of Obstetricians and Gynecologists of Canada, 2011)
This model of FASD prevention program, tailored specifically to this population can help support women through a time that can be extremely stressful and also a potential period of change and renewal. Additionally, these services have also shown that they work at keeping families together.
What we have now Pregnancy Outreach Team Program Manager Clinical Team Lead 2.6 EFT Outreach workers 0.6EFT Family Support Worker 30K Program budget *We will be able to serve 45 Families for up to three years*
What have we done so far?
MIK Current Status Since opening our doors on April 15 th 2013, we have had over 200 referrals. We have 49 active clients. We have started a weekly afternoon drop-in for our participants with a consistent participation rate. Weekly Cultural programming and Drum Group
So what about the families? Of the 49 women engaged in programing with MIK: 36% now state that they abstain from using drugs and alcohol 47% state that they have reduced their substance use 39 % have attended a treatment facility while in our program 92% are now receiving social assistance (EIA) 63% of families engaged with us are currently housed. 35% are housed in highly safe, clean, and affordable locations 100% of women who were pregnant upon intake, once in our program, were connected to and attended pre-natal appointments Of the 34 women who have given birth while engaged in our program 18 have taken their babies home from the hospital with them (53%). 37% of women in our program are parenting full-time. 32.6% of participants are working on a reunification plan with Child and Family Services to have their children returned home. 83% of women in our program with children in the care of CFS now attend regular scheduled CFS visits.
What we are growing towards:
At any given time We will aim to comprehensively serve 100 active families
Social Support Team Clinical Team Lead Outreach Team Family Support Worker Social Worker Inclusion Specialists Infant and toddler early childhood educators
Primary Care Team Nurse Practitioner Substance Use and Perinatal Care Nurse Speech Language Pathologist Occupational Therapist
Cultural/Spiritual Care Team Elder Trauma Counselor Food and Nutrition Program Facilitator
Slow down and let go of that sense of urgency. And Remember
BEST RESOURCE FOR CURRENT EVIDENCE BASED INFORMATION ON SUBSTANCE USE AND DRUG USE IN PREGNANCY Motherisk Toronto Hospital for Sick Kids: http://www.motherisk.org/women/index.jsp Alcohol and Substance Use Helpline - 1-877-327-4636
Thank you Margaret Bryans RN BN Program Manager Manito Ikwe Kagiikwe Mothering Project Mount Carmel Clinic For more information call: (204)232-3303
References British Columbia Centre of Excellence for Women s Health (2003). Mother and child reunion: Preventing fetal alcohol spectrum disorder by promoting women s health. Accessed at: http://www.cewhcesf.ca/pdf/bccewh/fasbrief.pdf Boyd, S.; Marcellus, L. (2007). With Child. Fernwood Publishing, Halifax. Canada Northwest FASD Research Network. FASD Prevention Network Action Team. (2010). 10 Fundamental components of FASD Prevention from a Women s Health Determinants Perspective. Accessed at: http://www.canfasd.ca/files/pdf/consensusstatement.pdf Claren, S. (2009). Time for the development of effective approaches for the prevention of fetal alcohol spectrum disorder? Expert Review Obstetrics and Gynecology, 4(5). Dondertman, B. (2007). Exposure to Psychotropic Medications and other Substances during Pregnancy and Lactation: A handbook for health care providers. Centre for Addiction and Mental Health.
References Ernst, C.; Grant, T.M.; Streissguth, A.P.; Sampson, P.D. (1999). Intervention with High Risk Alcohol and Drug-Abusing Mothers: From the Seattle Model of Paraprofessional Advocacy. Journal of Community Psychology, Vol 27(1). P 19-38. Families First Screen, 2009. Healthy Child Manitoba Office. Heamon, M et. al. (2012). Perinatal Services and Outcomes in Manitoba. MCHP Deliverable. Lussier, K; Laventure, M; Bertrand, K. (2010) Parenting and Maternal Substance Addiction: Factors Affecting Utilization of Child Protective Services. Journal of Substance Use and Misuse, 45(10), 1572-1588. Mate, G. (2008). In the realm of hungry ghosts. Random House Canada, Toronto. Marcellus, L., Dr. Kerns, K. (2007). Outcomes for children with prenatal exposure to drugs and alcohol: a Social Determinants of Health Approach. In With Child (Eds. Boyd & Marcellus). P. 38-53.
References Midmer, D. (2005). Antenatal Psychosocial Health Assessment: Provider s Guide. 3 rd Edition. Family and Community Medicine: University of Toronto. Payne, S. (2007). Caring Not Curing; Caring for pregnant women with problematic substance use in an acute-care setting: a Multidisciplinary approach. In With Child (Eds. Boyd & Marcellus). P. 56-69. Poole, N. (2000). Evaluation Report of the Sheway Project for High-Risk Pregnant and Parenting Women. British Columbia Centre of Excellence for Women s Health. Accessed at: www.bccewh.bc.ca/publicationsresources/documents/shewayreport.pdf Poole, N. (2008). Fetal Alcohol Spectrum Disorder (FASD) Prevention: Canadian Perspectives. Public Health Agency of Canada. Poole, N., Greaves, L. (2007). Highs and Lows: Canadian Perspectives on women and substance use. British Columbia Centre of Excellence for Women s Health & Centre for Addiction and Mental Health. Toronto.
References Society of Obstetricians and Gynecologists of Canada; (2011) Clinical Practice Guideline-Substance use in Pregnancy. Rollnick, S., Miller, W., Butler, C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behaviour. New York: The Guilford Press. Rosengren. D. (2009). Building Motivational Interviewing Skills: a practitioner workbook. New York: The Guilford Press. Rutman, D.; Callahan, M., Lundquist, A., Jackson, and Field, B. (2000). Substance Use and Pregnancy: Conceiving Women in the Policy-Making Process. Ottawa: Status of Women Canada. Tait, C. (2000). A study of the service needs of pregnant addicted women in Manitoba. Prairie Women s Health Centre of Excellence. Accessed at: http://www.gov.mb.ca/health/documents/pwhce_june2000.pdf Weaver, S. (2007). Make it more welcome: Best Practice child welfare work with substance using mothers diminishing risks by promoting strengths. In With Child (Eds. Boyd & Marcellus). P. 76-90.
References British Columbia Centre of Excellence for Women s Health (2003). Mother and child reunion: Preventing fetal alcohol spectrum disorder by promoting women s health. Accessed at: http://www.cewhcesf.ca/pdf/bccewh/fasbrief.pdf Boyd, S.; Marcellus, L. (2007). With Child. Fernwood Publishing, Halifax. Boyd, S. (2007). Hooked: Drug War Films in Britain, Canada, and the U.S. New York: Routledge Canada Northwest FASD Research Network. FASD Prevention Network Action Team. (2010). 10 Fundamental components of FASD Prevention from a Women s Health Determinants Perspective. Accessed at: http://www.canfasd.ca/files/pdf/consensusstatement.pdf Canada Northwest FASD Research Network. FASD Prevention Network Action Team. (2010). Taking a Relational Approach: The importance of Timely and Supportive Connections for Women. Accessed at: http://www.canfasd.ca/files/pdf/relationalapproach_march_2010-1 Claren, S. (2009). Time for the development of effective approaches for the prevention of fetal alcohol spectrum disorder? Expert Review Obstetrics and Gynecology, 4(5).
References Cohen, S. (1972) Folk Devils and Moral Panics, London: MacGibbon and Kee. Dondertman, B. (2007). Exposure to Psychotropic Medications and other Substances during Pregnancy and Lactation: A handbook for health care providers. Centre for Addiction and Mental Health. Ernst, C.; Grant, T.M.; Streissguth, A.P.; Sampson, P.D. (1999). Intervention with High Risk Alcohol and Drug-Abusing Mothers: From the Seattle Model of Paraprofessional Advocacy. Journal of Community Psychology, Vol 27(1). P 19-38. Families First Screen, 2009. Healthy Child Manitoba Office. Mate, G. (2008). In the realm of hungry ghosts. Random House Canada, Toronto.
References Marcellus, L., Dr. Kerns, K. (2007). Outcomes for children with prenatal exposure to drugs and alcohol: a Social Determinants of Health Approach. In With Child (Eds. Boyd & Marcellus). P. 38-53. Midmer, D. (2005). Antenatal Psychosocial Health Assessment: Provider s Guide. 3 rd Edition. Family and Community Medicine: University of Toronto. Payne, S. (2007). Caring Not Curing; Caring for pregnant women with problematic substance use in an acute-care setting: a Multidisciplinary approach. In With Child (Eds. Boyd & Marcellus). P. 56-69. Poole, N. (2000). Evaluation Report of the Sheway Project for High-Risk Pregnant and Parenting Women. British Columbia Centre of Excellence for Women s Health. Accessed at: www.bccewh.bc.ca/publicationsresources/documents/shewayreport.pdf Poole, N. (2008). Fetal Alcohol Spectrum Disorder (FASD) Prevention: Canadian Perspectives. Public Health Agency of Canada.
References Poole, N., Greaves, L. (2007). Highs and Lows: Canadian Perspectives on women and substance use. British Columbia Centre of Excellence for Women s Health & Centre for Addiction and Mental Health. Toronto. Rollnick, S., Miller, W., Butler, C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behaviour. New York: The Guilford Press. Rosengren. D. (2009). Building Motivational Interviewing Skills: a practitioner workbook. New York: The Guilford Press. Rutman, D.; Callahan, M., Lundquist, A., Jackson, and Field, B. (2000). Substance Use and Pregnancy: Conceiving Women in the Policy-Making Process. Ottawa: Status of Women Canada. Tait, C. (2000). A study of the service needs of pregnant addicted women in Manitoba. Prairie Women s Health Centre of Excellence. Accessed at: http://www.gov.mb.ca/health/documents/pwhce_june2000.pdf
References Vancouver Area Network of Drug Users. http://www.vandu.org/ Weaver, S. (2007). Make it more welcome: Best Practice child welfare work with substance using mothers diminishing risks by promoting strengths. In With Child (Eds. Boyd & Marcellus). P. 76-90.