| A Study Of The Service Needs Of Pregnant Addicted Women In Manitoba
C. L. Tait as commissioned by Manitoba Health
Executive Summary and Key Recommendations
This study examines and describes the service needs and experiences of pregnant women in Manitoba who have problems with substance misuse. The goal of the project was to address the following research questions:
In Manitoba, substance misuse by pregnant women has been identified by service providers as a serious health concern. This is supported by medical research which has found that exposure to substances--particularly alcohol--in utero, can cause irreversible harm to the fetus. The Addiction Foundation of Manitoba reports that 4% of the women who entered AFM addiction programs between April 1999 and March 2000 identified as being pregnant. Given the influence of factors such as stigma and fear of child apprehension, other women may not be disclosing their pregnancies at the time of treatment. However, it can reasonably be assumed that the percentage of pregnant women accessing addiction treatment is higher, probably in the range of 5 to 8%.
Pregnant women who abuse substances heavily are at highest risk of causing harm to the health of their fetuses. These women are also at highest risk for substance abuse-related illnesses which are linked to poor quality of life and shortened lifespan. Therefore, it became a further goal of this project to draw attention to substance misuse as a serious health concern for women as well as their children.
Seventy-four women who had experienced problems with substance misuse during one or more of their pregnancies were interviewed in three geographical locations: Winnipeg, Thompson and The Pas. Eighty-five service providers who provide services to these women were also interviewed from Winnipeg, The Pas, Flin Flon, the Interlake region, Brandon, and Thompson. First Nation on-reserve services were not included in the study, nor were the experiences of First Nation women in accessing on-reserve services.
This study found that women in more advantaged socio-economic groups prefer accessing outpatient/day programs. However, they were under-represented in all areas of addiction services. Aboriginal women were over-represented in the majority of addiction treatment programs, as were women on income assistance. This is due partially to Aboriginal peoples generally being more accepting of addiction treatment for women, and Child and Family Service (CFS) agencies directing women on income assistance and with children in foster care into addiction treatment as a requirement to regain custody of their children.
This study found that the service needs of pregnant women who struggle with problems of substance misuse will not be fully addressed by any single service or program. In the view of women and service providers interviewed for this project, a collaborative effort among service providers is needed. Women reported overwhelmingly that the most valuable asset a service can offer is a supportive and non-judgmental environment where they feel free to work with service providers to address their needs.
This study also found that women were very pragmatic when accessing services. However, at times, their pragmatism was misread by some service providers as non-compliance or indifference when women did not choose to access available services. For women, pragmatic approaches to service provision stemmed from various responsibilities, demands, past experiences and compounding circumstances that made up the daily realities of their lives. When making decisions about what services to access, women based their decisions within this larger context. This was confirmed by many service providers who felt their service mandates were at times too narrowly defined and inflexible, given the fact that their clients did not access services as fragmented individuals, but were simultaneously dealing with various life issues.
Pregnancy for women is typically a time when they become increasingly visible to service providers and are able to access programs that will help to improve their health and well-being, and in turn, that of their fetuses. However, barriers do exist which prevent women--including pregnant women--from accessing service to help them with their substance misuse problems. Women and service providers in this study reported a number of barriers that prevent women from accessing addiction services. These were related to six areas: psychological barriers; barriers related to a woman's children; barriers related to social support networks; barriers related to socio-geographic factors; barriers related to stigma; and barriers related to treatment programs themselves.
Of the 66 women who reported trying to access addiction treatment, 59 (89%) reported experiencing one or more barriers that prevented them from accessing the treatment they sought. However, when reporting barriers to addiction treatment, women had differing views on what they considered to be factors preventing them from accessing treatment. As well, barriers identified by women were not always simultaneously identified by service providers, as many of the barriers reported by women were either not recognized as such by service providers, or were not interpreted as a barrier or as being less of an obstacle than the women reported. In other circumstances, both the women and service providers identified the same barrier, but were unable to find an immediate solution (i.e., long waiting list, lack of child care services).
This study found that pregnancy is a time when women can be motivated by service providers to seek addiction services. Data from this project suggest that centres that provide gender-sensitive outreach services are in key positions to offer frontline counselling and support to high-risk women. They also have the potential to house other services such as mentor programs, community clinics, and family support programs. Outreach centres are in a key position to work with other service providers, such as CFS, addiction services, and pregnancy programs to refer women to appropriate services which are meaningful to them. Added to this is their capacity to support and work with women while they are living in their home environments, and to provide addiction aftercare services and relapse prevention in communities where this is currently unavailable. Expanded outreach services also have the potential for building a sense of community for women who feel isolated and have limited healthy support networks. These services can also facilitate building community wellness by promoting, supporting and encouraging pregnant women to abstain from using substances.
Although barriers still exist for pregnant women, pregnant women in Manitoba are increasingly accessing addiction services, and efforts have been made to prioritize them. However, pregnant women who present while intoxicated are prevented from accessing services, including addiction treatment. Throughout the province, most services for women, such as shelters, are not equipped to deal with intoxicated clients. An emergency shelter does exist in Winnipeg that admits both men and women, but addiction services in the remainder of the province are unable to deal with this population within their current mandates.
Other barriers exist for pregnant women including women not being allowed to enter some treatment programs if they are due to give birth before completion of the program. Most addiction treatment programs do not allow women to bring their newborn babies to treatment, nor do they provide child care services for women who are in treatment or accessing aftercare services. In addition, the majority of service providers, including addictions services, have done little to address the stigma directed toward pregnant women who abuse substances, or the guilt and shame that many pregnant women feel because of their substance misuse.
This study found that pregnant women generally prefer to access treatment close to where they live, although issues of confidentiality and stigma were expressed by more women in smaller urban and rural communities. Pregnant women who do not have other children in their care prefer treatment programs that allow them to stay in treatment for the duration of their pregnancy. Pregnant women with other children in their care prefer outpatient/day programs, short-term residential programs, or residential programs that allow them to bring their children to treatment. For the majority of women, lack of safe, accessible child care services was a main barrier to accessing addiction treatment.
Where CFS is involved in a woman's life, it is the central service provider to which the woman responds, and therefore has the greatest influence on whether or not she will seek addiction treatment. A large percentage of women in this study entered addiction treatment because CFS required them to do so in order to regain custody of their children, or because CFS has placed an order for the apprehension of their babies at birth unless they entered addiction treatment. Several women reported frustration, anger, and feelings of hopelessness and defeat when discussing their relationship with CFS. As well, there was a great deal of mistrust of CFS by women--particularly Aboriginal women--because of past experiences of children not being returned to their care even though the women felt they had met all of CFS's requirements. Apprehension of children by CFS was also a risk factor for increased substance abuse by women, including pregnant women.
Women with extreme substance misuse problems are likelier to be motivated to address their addiction problems after the birth of their babies than when they are pregnant. However, once women give birth, they are not given admission priority by treatment programs and are placed on regular waiting lists. These women are more likely to have their babies apprehended at birth, increase their substance use after their baby is apprehended, have children in the permanent care of CFS, and not to use any form of birth control. The lack of immediate intervention services for women who have had their babies apprehended at birth is a serious gap in service provision.
Women who participated in this study viewed excessive substance misuse during pregnancy as placing the health of their fetuses at risk and as problematic behaviour. However, compounding factors, particularly mental health and relationship problems, poverty, lack of childcare options, stigma, and geographical location often prevented women from addressing their substance misuse problems. When given meaningful treatment options by service providers they trust and respect, women, including those who are pregnant, will participate in addiction treatment to improve their own health and that of their fetuses.
This study found that women had differing experiences in treatment programs, noting that treatment programs offering specialized gender-sensitive programming and individual counseling supported by group sessions, had the most positive impact. Differing experiences in accessing and participating in treatment suggests a need for individualized treatment and wellness strategies to be developed by women with the help of service providers whom they trust. Preparation to enter addiction treatment is a gap in current service delivery, with women most often choosing addiction programs based on factors unrelated to treatment philosophies and program delivery, such as child care availability, the waiting list of various programs, geographical location, etc.
While addiction treatment services in Manitoba are incorporating specialized programming for women, according to women and service providers interviewed for this project there is a need to ensure that gender-sensitive treatment is made available to women in all parts of the province, and that these programs are more than just the absence of men from treatment programs or groups. As well, treatment strategies for women should be developed within a framework that is sensitive to issues of gender, and inter-related factors such as culture, age, and geographical location.
Mentor programs for women who are at highest risk of using large amounts of alcohol while pregnant have recently begun to operate in Winnipeg. According to women participating in the programs, as well as service providers, these initiatives have had very positive short-term results. However, similar services for women who are at high risk of abusing other substances, particularly inhalants, or for women living in other parts of Manitoba, do not exist.
Effective aftercare services for women, particularly pregnant women who have completed a treatment program while still pregnant, have also been identified as serious gap in service delivery. For a large number of women in this study, lack of aftercare services and support meant that it was extremely difficult for them not to use substances, particularly if they were surrounded by friends and family members who were using, were in abusive relationships, did not have their children in their care, were unemployed, and/or lived in impoverished circumstances. While many service providers believed that pregnancy should be a strong motivation for women to stop using substances, this study found that pregnant women were often reacting and responding to other relationships in their lives, such as relationships with partners, family members, and CFS workers, and that their "relationship" with their fetus or "unborn child" tended to be less immediate and more abstract. Furthermore, being substance-free for the length of their pregnancies was extremely difficult for women who had serious addiction problems and few positive supports in their lives.
Of the seventy-four women interviewed for this project, the majority (77%) were of Aboriginal descent. The over-representation of Aboriginal women suggests that this is a serious health concern for Aboriginal women. This study found that for Aboriginal women, substance misuse during pregnancy is related to being the most impoverished group of people in Manitoba, historical events (such as residential schools and mass adoption of Aboriginal children that undermined Aboriginal families and communities), and low levels of education and chronic unemployment found generally among Aboriginal peoples living off-reserve. It is also related to Aboriginal children being removed from the care of their mothers at higher rates than non-Aboriginal children, resulting in Aboriginal children spending longer periods of time in foster care, and being placed in multiple foster homes over the course of their childhoods.
This study found that in general, Aboriginal women preferred treatment programs that addressed their cultural beliefs and the historical realities of Aboriginal peoples. They also reported that they preferred to access services from Aboriginal organizations, specifically those that were associated with their own Nation. Aboriginal women said that they often did not identify with service providers, such as CFS workers, because their workers were usually non-Aboriginal and had a more privileged socio-economic status. Aboriginal women also reported a greater distrust of CFS agencies, and were likelier not to access support services for fear that their request for support would be understood as an inability to parent their children which could result in their children being apprehended.
This study found that pregnant women who are at risk of misusing substances do not do so because they are unaware of the public health message, or because they are indifferent to the potential harm to their fetuses. Rather, the contributing factors to substance misuse by pregnant women are complex and varied, and therefore call for services and programs which reflect this reality. Currently in Manitoba, a great deal of creativity and thoughtfulness has been directed toward these issues. However, service providers in this study agreed that for high-risk women, positive long-term outcomes are still difficult to achieve.
Service providers in this study agreed that increased communication and flexibility among various service agencies is needed, particularly with regard to addiction service providers and CFS agencies. From their point of view, all services providers must work toward a stronger continuity of care for women in general, and avenues to facilitate this should be financially and ideologically supported by policy-makers and programming.
Given a strong commitment from Manitoba Health and other government ministries, significant gains can be made to address this health issue for women and their children. By tapping into the willingness of women at risk to work toward improving the quality of life for themselves and their children, and by utilizing the positive momentum that service providers across the province have created around this issue, Manitoba Health can make meaningful improvements to outcomes of high-risk pregnancies and the health status of women with substance abuse problems.
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