COMPASSIONATE AND COMPREHENSIVE PERINATAL CARE:
A CRITICAL REVIEW OF PERINATAL SERVICES FOR WOMEN WITH
SUBSTANCE USE EXPERIENCES
By
Jenny Mantyka Ogden
BSW University of the Fraser Valley 2015

MAJOR PAPER SUBMITTED IN PARTIAL
FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE
OF MASTER OF SOCIAL WORK
in the
Department of Social Work and Human Services
© Jenny Ogden
UNIVERSITY OF THE FRASER VALLEY
Spring 2022

All rights reserved. This work may not be
reproduced in whole or in part, by photocopy
or other means, without permission of the author.

Approval
Name: Jenny Ogden
Degree: Master of Social Work
Title: Compassionate and Comprehensive Perinatal Care: A critical review of perinatal services for
women with substance use experiences
Examining Committee:1
Leah Douglas, MSW, Ph.D., RCSW
MSW Graduate Program Committee Chair, Associate Professor, School of Social Work & Human
Services, University of the Fraser Valley
Margaret Coombes, Ph.D., RCSW
Senior Supervisor, Associate Professor, School of Social Work and Human Services, University of the
Fraser Valley
Evan Taylor, BSW, MSW, RSW, PhD
Second Reader, Associate Professor, School of Social Work and Human Services, University of the
Fraser Valley

Date Approved: March 22, 2022

ii

Abstract
Early experiences during conception and pregnancy impact the developing baby. This
literature review reveals that maternal health during pregnancy is associated with infant health
outcomes and highlights that perinatal substance use negatively impacts maternal and child
health outcomes. Despite the awareness of maternal and infant risk, substance use in pregnancy
continues. On the one hand, the knowledge revealing the risks associated with perinatal
substance use is critical as it highlights the importance of effective intervention for perinatal
substance use. On the other hand, this knowledge reinforces dominant discourses villainizing
pregnant women with substance use experiences. The literature review considers how perinatal
substance use among marginalized women is conceptualized and provides a more contextualized
view on substance use. Furthermore, revealing that marginalized women with substance use
experiences are often isolated through extreme poverty levels and lack healthy natural or familial
support systems. (Heaman et al. 2014).
This review draws on feminist theoretical frameworks to examine dominant health and
social service systems. The research reveals that many current perinatal services support
ethnocentric and neoliberal ideologies which offer western medical approaches. Feminist
researchers argue western medical models undervalue the experience and gender-based
knowledge of traditional mothering practices and create dichotomies between the mental,
physical, and systemic aspects of women's experiences. These fragmented approaches produce
inadequate services and create barriers for women to access appropriate care. The findings from
this literature review suggest that when substance-using women are provided holistic, genderbased, and trauma-informed care, they experience the healing and support necessary for
improved maternal and infant health outcomes.

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Dedication
To my fellow motherless mothers; I see you, I honour you, and I fight with you.
Acknowledgements
First, I would like to thank my loving husband, Judd. His love and kindness have
reinforced my resilience, motivated me, and provided support throughout my learning journey. I
would also like to thank my amazing sons Payton and Kaylem, who give me the energy and
determination to be my best possible self. Without my family’s unwavering belief in me and
continuous support, I could not have completed this paper.
Second, I would like to express my appreciation to Dr. Margaret Coombes and Dr. Evan
Taylor as my primary and secondary readers, who provided feedback and supervision.
Finally, I would like to thank my colleagues, family, and friends who encouraged me along the
way.

iv

Table of Contents
Abstract .......................................................................................................................................... iii
Dedication...................................................................................................................................... iv
Acknowledgements ........................................................................................................................ iv
Table of Contents ........................................................................................................................... 1
Compassionate and Comprehensive Perinatal Care: A critical review of perinatal services for
women with substance use experiences......................................................................................... 3
Social Location ............................................................................................................................... 5
Methods .......................................................................................................................................... 5
Literature Review Findings ........................................................................................................... 6
Theoretical Frameworks .................................................................................................................6
Feminism.......................................................................................................................................................... 6

Perinatal substance use and risk factors .........................................................................................8
Prevalence and impact on maternal and infant health ................................................................................... 8
Environmental dangers and physical violence ................................................................................................ 9
Adverse childhood experiences (ACEs) ......................................................................................................... 11
Mental health ................................................................................................................................................ 11
Fear of criminalization ................................................................................................................................... 13
Child welfare involvement ............................................................................................................................. 15
Racism ............................................................................................................................................................ 18

Barriers and motivators to service utilization ................................................................................ 20
Stigmatization ................................................................................................................................................ 20
Systemic barriers and structural limitations of services................................................................................ 22
Motivators for engagement........................................................................................................................... 24
Relational approach ....................................................................................................................................... 24

Government ideology and Canadian social policy .......................................................................... 26
Birth Alerts ..................................................................................................................................................... 28

Practice Models ............................................................................................................................ 30
Integrated perinatal services ........................................................................................................ 30
Trauma-informed care ................................................................................................................. 32
Community-based program examples .......................................................................................... 33
Pregnancy outreach program ................................................................................................................... 34

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Single-access: Maxxine Wright ................................................................................................................. 35

Limitations...................................................................................................................................36

Implications for social work ........................................................................................................ 37
Conclusion .................................................................................................................................... 41
References .................................................................................................................................... 42

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Compassionate and Comprehensive Perinatal Care: A critical review of perinatal services
for women with substance use experiences.
Research affirms that good mental and physical health in the perinatal stages of
pregnancy is critical to creating optimal conditions for infants' healthy growth and development
(Hubberstey et al., 2019). This knowledge has influenced various health interventions in public
health and social services; it emphasizes the importance of women making lifestyle and dietary
changes to create the optimum growing conditions for their infants. Furthermore, perinatal health
literature provides significant evidence supporting the importance of maternal stress reduction
and avoidance of harmful substances (Hubberstey et al., 2019).
Research suggests perinatal substance use causes poor maternal and infant health
outcomes. Hubberstey et al. (2019) argue that women's prenatal substance use is a "gendered
issue" that is "often driven by a host of social determinants of health factors" (p. 2). Additionally,
high rates of maternal substance use, poor maternal mental health and low utilization of prenatal
health services are more common among women identifying as racialized, low income and
women with adverse childhood experiences (Hubberstey et al., 2019). Despite the importance of
support services and health intervention in the perinatal stages, research reveals many women
experience ongoing marginalization from structural and psychosocial barriers which prevent
them from accessing the support necessary for health and wellness (Heaman et al., 2014).
Women in the perinatal period with substance use experiences require comprehensive
and relevant care. Research reveals the importance of providing perinatal services that address
the social determinants of health; however, the studies also show that in practice, insufficient
consideration is given to the barriers that prevent marginalized women from utilizing universal

3

health services, creating dissonances between perinatal services and women's complex needs
(Hubberstey et al., 2019). Consequently, Heaman et al. (2014) illustrate low utilization of
prevention perinatal services among women experiencing intersecting oppressions. This study
also indicated that low utilization contributes to poor maternal and infant health outcomes and
increased child welfare involvement. Increased understanding of the barriers marginalized
women face when engaging and utilizing perinatal services will lead to developing traumainformed prevention and treatment programs that are safe, inclusive and relevant for pregnant
women and their families. Social work is uniquely positioned from a biopsychosocial framework
and could contribute to holistic responses.
Although there are various entry points into the diverse oppressions faced by women and
in the subject of motherhood, this paper will focus on women with substance use experiences
during pregnancy. This research utilizes an anti-oppressive feminist framework to analyze
perinatal services. The literature review focuses on perinatal intervention services rooted in
biomedical and trauma-informed practices. The paper critically examines how women engage in
the various perinatal health and support services and explores some of the best practices
recommended in the literature. The intention is to reveal possible implications for women with
substance use experiences in the perinatal period. The following questions will guide the
exploration:
How do women with experiences of intersecting oppressions utilize perinatal services?
What barriers do women with substance use experience encounter when accessing perinatal
services? How can social workers facilitate and improve perinatal services to provide enhanced
responses to women marginalized by the stigma associated with substance use?

4

Social Location
It is essential to position myself and my privilege in this analysis. I benefit from many of
the privileges of fitting into the dominant discourse of the Eurocentric, white supremacist, and
patriarchal societal norms. I am a white, heterosexual, cisgender female. I am able-bodied and in
good health. I am a third-generation Scottish and Ukrainian Canadian. I am married with
children. I have post-secondary education and have stable employment with a good income and
various health benefits. I have lived experiences of multiple forms of oppression, including
adverse childhood experiences, foster care experiences and substance misuse. My social location
has created opportunities and barriers to doing anti-oppressive work with clients.
I have used my understanding of oppression to relate, build rapport, and provide system
navigation. I have also engaged in social justice activism as an insider and in solidarity as an
outsider, striving to develop allyship with clients with diverse and intersecting oppressions. I am
employed at a non-profit organization as a registered social worker managing perinatal and
parenting programs. This MSW program has inspired me to increase my knowledge in perinatal
substance use, orientate my practice through a feminist theoretical framework, develop capacity
and skills as a trauma-sensitive clinical social worker and improve the services delivered in my
agency.
Methods
The thematic analysis included the use of Academic Search Complete, CINAHL
Complete, MEDLINE, PsycARTICLES, PsycINFO, Social Sciences, SocINDEX, Social Work
databases and Google Scholar to conduct a comprehensive literature search. Key text was also
assessed to include relevant books and grey material. The reference lists of several of the journal
articles were reviewed to identify further resources. The keyword search terms used include

5

pregnancy, prenatal, perinatal, parenting, vulnerable, marginalized women, mothering, substance
use, alcohol use, postpartum, depression, mental health, prevention services, birth alerts, hospital
alerts, child welfare, apprehensions, high-risk, at-risk, pre-birth assessments, Indigenous,
maternity, single-access, integrated, hub-model, gender-specific.
The search parameters were unique to each database; however, to ensure the results
remained relevant and current, the search was limited to the English language peerreviewed/scholarly sources within the last 15-year period. The review sought knowledge in the
perinatal services to high-risk women in countries with similar health and child protection
systems as Canada. Therefore, search parameters were extended to other Anglophone countries
such as the United States of America (USA), Australia, and Wales.
The articles selected for the review include mixed qualitative and quantitative methods,
including peer-reviewed studies, commissioned government reports, and government press
releases. The empirical studies were primarily conducted in Canada and the USA and included
Australia and Wales. The research included data from sources such as population-based crosssectional cohort studies, interviews, and health record audits. The sources include birth mothers,
health care professionals, midwives and social workers. The majority of the studies examined
women's substance use and mental health experiences in the perinatal stages. Other studies
focused explicitly on pre-birth assessments and child welfare experiences. Additionally, a small
subset of studies focused more broadly on how intersecting oppressions affect mothering
experiences.
Literature Review Findings
Theoretical Frameworks
Feminism

6

Motherhood and childbirth have historically been considered a "woman's" experience.
Mothers have traditionally accessed ongoing support and care in homes by midwives or other
important women in their lives (Westergrena et al., 2019, p. 57). Western science has
pathologized female bodies and reproductive systems because they are deviant from male bodies.
As a result, midwifery has been professionalized (Westergrena et al., 2019). Birth experiences
have changed drastically from taking place primarily in the home, guided by women's
experience-based knowledge, to hospital births consisting of medicalized interventions
supervised and regulated by medical systems predominately created and practiced by men
(Westergrena et al., 2019). Westergrena et al. (2019) argue that " gender-based power
imbalances promote oppressive practices across various health care professionals and result in
disempowerment and loss of autonomy" (p. 57). Therefore, feminist research has argued that the
shift to the medical model and diminishing women's experience-based knowledge has
deteriorated holistic and gender-specific care (Westergrena et al., 2019).
The literature revealed that much of the current perinatal medical services do not
adequately respond to the complexity of women's experiences (Huuberstey et al., 2019).
Heteronormative and Eurocentric ideology supports the mandate of westernized medical services
(Westergrena et al., 2019). The services are primarily delivered by privileged professionals, who
expect women to develop motivation, be receptive to expert advice, and take individual
responsibility for their health. If women cannot make changes to benefit their own and their
child's health, they are viewed through a biomedical model lens, assessing women as diseased
and needing treatment (Baines, 2017). Lafrance & McKenzie-Mohr (2013) suggest "[t]hus,
hegemonic discourses of motherhood and biomedicine operate in tandem," which often make
women believe their experiences as the result of their failure or illness (p. 159). This stance

7

places the problem of perinatal substance use within the individual and ignores the structural and
politized contributions to women's oppression.
The feminist theories and practices challenge the ineffective approaches that villainize
women using substances in the perinatal stages and offer a way to engage in social justice efforts
for systemic change. Feminist researchers, such as Baines (2017), argue that social justice efforts
must unpack the dominant discourses on motherhood and incorporate anti-oppressive practices
within social work and health services. It is not enough to provide fragmented services that do
not meet substance-using women's needs. This perpetuates gender-based power imbalances,
reduces the issue to a problem with the individual, and ignores the intersecting levels of
oppression (Westergrena et al., 2019).
Feminism is centred on the belief that the personal is political, and therefore perinatal
substance use must be approached from a multidimensional analysis. Feminism and poststructuralism consider an intersectional analysis of multiple facets of oppression within women's
everyday lived experiences (Baines, 2017). Feminist frameworks align with many social work
frameworks as both consider the vast amount of different lived experiences by women, and
consider the systemic, structural and political barriers they may face. However, Salter &
Breckenridge (2014) confirm a lack of gender specific treatment programs for substance-using
women. Typical approaches to substance use disorder support services and treatment programs
do not attend to the diversity of women's current physical or emotional needs, nor is it responsive
to unresolved or ongoing experiences of abuse (Salter & Breckenridge, 2014).

Perinatal substance use and risk factors
Prevalence and impact on maternal and infant health

8

The consensus among current research on perinatal substance use suggests that despite
the recognized adverse maternal and infant health outcomes, perinatal substance use is an
ongoing social problem and is frequently identified as the main factor associated with perinatal
risk and child welfare involvement (Deutsch et al., 2020; Gartner et al., 2018; Grant et al., 2014;
Griffiths et al., 2020; Hubberstey et al., 2019; Le et al., 2019; O Connor et al., 2020; Ruthman et
al., 2020). Gartner et al. (2018) highlight that approximately 5% to 10% of pregnant women use
substances (p.3). According to a study conducted by Kar et al. (2021), "[t]he percentage of
participants who reported use during pregnancy was 6.7 % for alcohol, 4.3 % for cannabis, 4.9 %
for tobacco, and 0.3 % for illicit drugs; 2.6 % were using multiple substances" (p. 221).
A consensus throughout the literature is the notion that significant maternal and infant
health risks are associated with maternal substance use (Grant et al., 2014; Paris et al., 2020;)
Ruthman et al., 2020). Prenatal exposure to substances is associated with "placental abruption,
preterm birth, miscarriage, low birth weight" (Paris et al., 2020, p. 1397), and exposure may
negatively affect fetus growth and development, resulting in additional risk for "a range of physical
and neurodevelopmental problems that persist across the life span" (Grant et al., 2020, p. 1).
Further studies indicate adverse maternal health outcomes may include "drug-related medical
problems such as anemia, hepatitis, poor weight gain, and sexually transmitted diseases (STDs)
and maternal infection" (Lewis et al., 2017, p. 239).
Environmental dangers and physical violence
Many studies focus primarily on substance-using women's high-risk behaviour and
perpetuating cycles of harm (Deutsch et al., 2020; Grant et al., 2014; Griffiths et al., 2020).
O'Connor et al. (2019) offered insight into the daily experiences of women using
methamphetamines and the ongoing exposure to violence and maltreatment, "including

9

engagement in risky activities (ex. sex trade) and exposure to traumatic situations (ex. rape and
physical assault)" (p. 5). O'Connor et al. (2019) highlighted that many substance-using women face
highly unsafe and potentially life-threatening situations; therefore, it is paramount that service
providers understand the vast number of intersecting oppressions and lived experiences.
Substance-using women living in the downtown eastside of Vancouver, British Columbia.,
reported that they experience relentless fear and danger in their lives; for instance, "[t]wenty-seven
women (87.1%) indicated they had experienced emotional abuse, 23 (74.2%) reported physical
abuse, and 16 (51.6%) reported sexual abuse in adulthood, oftentimes by multiple perpetrators"
(Torchalla et al., 2015. p. 5).
A qualitative study identified that intimate partner violence is a common experience for
substance-using women and was noted as a significant barrier to accessing services (Torchalla et
al., 2015). Often, substance-using women reported that their partners had problematic substance
use issues and, therefore, could not provide them support in their mothering. Instead, of the 27
participants interviewed, "the majority experienced exploitation and repeated physical, sexual
and/or emotional abuse by their partners" (Torchalla et al., 2015 p. 5). The demands of surviving
daily life and abusive partners, in many cases, prevent substance-using women from complying
with ridged and time-consuming treatment plans and programs (McGrory et al., 2020).
The reason for using substances varies between each individual's lived experience. One
frequently reported reason was to reduce the emotional anguish of current or historical
maltreatment (Puurunen & Vis, 2019). Torchalla et al. (2015) described that "once regular
substance use was established, they entered a vicious cycle of engaging in high-risk behaviours and
situations to secure drug supply, resulting in more trauma exposure and a lifestyle that was
characterized by gendered risks, ongoing adversities and violence" (p. 8). The literature maintained

10

many of these women had long histories of exposure to substance use, including experiences of
parental substance use during childhood (Puurunen & Vis, 2019).
Adverse childhood experiences (ACEs)
The research consistently emphasized that women struggling with substance use often
experienced adverse childhood experiences (ACEs), relationship violence, poverty, racism,
homelessness, mental health, and social isolation (Deutsch et al., 2020; Gartner et al., 2018; Grant
et al., 2014; Griffiths et al., 2020; Hubberstey et al., 2019; Le et al. 2019; O'Connor et al., 2020;
Ruthman et al., 2020). The findings also reveal high rates of sexual violence and childhood sexual
abuse in the population (Puurunen & Vi, 2019). In one study, the women disclosed multiple ACEs,
including childhood abuse and/or neglect (Torchalla et al., 2015). Jasthi et al. (2021) argue that for
many women, ACEs relate to poor mental and physical health outcomes and behaviours; for
example, "cardiovascular disease, cancer, substance use, depression, adolescent pregnancy, and
sexually transmitted infections" (p. 1).
ACEs often result in complex trauma reactions such as Post Traumatic Stress Disorder and
Attachment Disorder, which contribute to women experiencing fear, mistrust, and avoidance of
health care systems (Puurunen & Vis. 2019).
Mental health
Furthermore, many pregnant women with ACEs have decreased social and structural
support resulting in an increased risk of mental health and substance use (Jasthi et al., 2021). There
is a strong understanding in addiction theory that substances are often used as a coping strategy for
individuals with historical trauma (Jasthi et al., 2021, p. 282). It is well documented that exposure
to trauma and childhood abuse experiences are predictors of poor physical health, mental illnesses,
and substance addiction (Keefe et al., 2018; Powers et al., 2020; Puurunen & Vis, 2019).

11

Given the risks and frequency of women experiencing trauma, it is vital to consider the
effect of maternal mental health on reproductive and infant health. The research indicates maternal
mental health is an indicator of prenatal vulnerability, substance use and child welfare involvement
(Grant et al., 2014; Griffiths et al., 2020; Le et al., 2019; Lewis et al., 2017; Keefe et al., 2018; O’
Connor et al., 2020; Powers et al., 2020; Puurunen, & Vis, 2019; Ruthman et al., 2020; WallWieler et al., 2018;). In a study of 1111 mothers involved with child welfare, Griffiths et al. 2020
revealed, "[h]alf (53.2% of the cohort, compared to 18.9% of the comparison group, self-reported
having a mental health condition at their initial assessment" (p. 6). Lewis et al. (2017) reported that
the Benningfield et al. (2010) study of 174 opioid-dependent pregnant women "found that
approximately one-third of the opiate-dependent pregnant women endorsed experiencing major
depressive disorder and major anxiety disorder and 12.6% endorsed current suicidal thinking" (p.
240). Furthermore, Lewis et al. (2017) found in their analysis of 141 women attending a high-risk
prenatal clinic that psychiatric diagnoses were noted in almost double the number of women in the
high-risk group compared to the group receiving services in the general Obstetrician (OB) clinic.
The findings reveal, "the disorders among the women in the high-risk prenatal group included
depression (30.9%), bipolar disorder (7.2%), anxiety (5.8%), PTSD (1.0%), schizophrenia (1.0%),
and other (1.4%;)" (Lewis et al., 2017, p. 246).
In the literature, it is recognized that compromised maternal mental health impacts both
mother and child. In a recent exploratory study of the effects of maternal mental health on child
outcomes, Klawetter et al. (2021) state, "[a]dverse maternal mental health affects children through
compromising bonding, impeding early childhood development, and increasing risks of child
maltreatment" (p. 1130). The author proposes that maternal depression and post-traumatic stress
disorder symptoms are associated with compromised infant health outcomes such as premature

12

birth and low birth weight. In addition, Klawetter et al. (2021) suggest that "[c]hildren of mothers
with depression experience increased risk for depression as adults compared to those whose
mothers did not have depression" (p. 1131). Finally, Power et al. (2020) conclude that early
detection and treatment for trauma in perinatal women may reduce the risk of adverse congenital
disabilities and provide protective factors against "the potential transmission of intergenerational
risk of trauma and related disorders from mothers to their children" (p. 139).
Research indicates that substance-using women may be self-medicating to treat untreated
mental health issues that would traditionally be treated with psychiatric medication and other
mental health interventions (Lewis et al., 2017). Lewis et al. (2017) also consider that women are
fearful of taking medications during pregnancy because of potential congenital disabilities and
argue that their fear may impact a physician's decision to prescribe medication. McGrory et al.
(2020) add that women with complex trauma and post-traumatic stress disorder symptoms may
avoid social and medical services because they perceive them as harmful.
Furthermore, Keefe et al. (2018) explored women's self-reported experience with
postpartum depression (PDD) and mothering. The studies offered an alternative understanding of
mental illness while discussing the contextual components of mothering within the intersecting
oppressions of race, gender, and class. The authors suggested that the mothers' lived experiences of
systemic discrimination and limited familial support contributed to PPD. In their writings, the
authors strayed away from pathologizing mothering with PDD; instead, they used an antioppressive approach to understand their experiences resulting from systemic and environmental
factors instead of individual deficits.
Fear of criminalization

13

The dominant discourse espouses the criminalization of women for using substances
during pregnancy and the consequent apprehension of their children. Feminist researchers suggest
public campaigns linked to the social construction of the perfect mother reinforce this view
(Salmon, 2011). The authors also emphasize "contemporary neoliberal public health messaging
recapitulates these obligations, emphasizing women's responsibilities to have a 'healthy pregnancy'
and a 'healthy baby' by avoiding alcohol, tobacco and other drugs" (p. 168). Furthermore, when
women are unsuccessful in meeting the ideal myth of motherhood they are villainized. Delker et
al. (2020) posit that this villainization is perpetuated by "media coverage and public discourse on
pregnant women who use drugs as "monstrous" mothers who willfully harm their children" (p.
106). According to Salmon (2011), this is problematic because the pervasive maternal health
messages are not combined with comprehensive services for women using substances while
pregnant. Therefore, women may feel discouraged to disclose their substance use and, as a result,
do not receive the care they need when they need it (Salmon, 2011).
Many USA states have laws to protect the health and safety of the unborn fetus, and
women can be criminally charged for using illicit drugs and alcohol during their pregnancy (Hui et
al., 2017). According to Goodwin (2014) “FPLs [Fetal Protectionism Laws] penalize pregnant
women for fetal outcomes incidental to maternal control, carving out punishable distinctions
between pregnant women's conduct and that of all other groups” (p. 794). Furthermore, Goodwin
(2014) argue that FPLs disproportionally impact marginalized women and contribute to the
stigmatization of pregnant women. Pregnant women using substances encounter significant
judgement from service providers and society. According to Delker et al. (2020), when the
public considered substance use a factor within an individual's control, then their attitudes
towards prenatal substance use endorsed "the belief that people with addiction should be

14

forbidden to take care of their children" (p. 103). This dominant discourse leads to punitive
rather than supportive attitudes towards women with substance use experiences (Delker et al.,
2020).
Child welfare involvement
The literature documented that maternal substance use has been identified as a critical
factor in child welfare involvement and a predictor of child abuse risk (Deutsch, 2020; Grant et al.,
2014). Grant et al. (2014) suggest "that parental alcohol or drug abuse may be a factor in 50 to 79%
of child welfare cases in which young children are removed from custody, and in approximately
25% of cases with substantiated maltreatment" (p. 11). Furthermore, Deutsch et al. (2020) examine
the relationship between the perinatal exposure to various types of substances and child risk.
According to Deutsch et al. (2020) "results support the hypothesis that use of any substance can put
children at risk for child abuse and neglect, as substance use generally has been associated with
risk-taking behaviors in the user that negatively impact child safety" (p. 38).
Wall-Wieler et al. (2018) assert research has thoroughly shown poor maternal mental
health coincides with child welfare apprehension, "and mothers with pre-existing mental illness are
more likely to experience postpartum depression and anxiety" (p. 1393). In their study, they
examine the mental health impacts of postnatal women with child welfare involvement, and the
findings suggest, "[s]eparation at birth due to involvement with child protection services has been
shown to increase maternal anger, guilt and depression" (p. 1393).
The literature further highlights the negative consequences of child apprehensions for
women with substance use experiences. According to Ritland et al. (2021), women reported:
"deteriorating mental health, symptoms of [posttraumatic stress disorder] PTSD and
psychological distress, and increased drugs and alcohol use to cope with loss and grief" (p. 3).

15

The risk for negative impact has been amplified due to the recent increase in opioid-related
overdose deaths. A recent study found that in Vancouver, British Columbia, marginalized
women, especially, were more likely to have an unintended overdose if their children were in the
custody of the child welfare system "after controlling for demographics, past and recent traumas,
substance use, and sexual vulnerabilities (Ritland et al., 2020, p. 7).
Punitive approaches have influenced the development of child welfare systems
responsible for child protection. Furthermore, child welfare legislation can reinforce fetal
protectism and maternal marginalization through the complexity of duty to report obligations.
When working with women that use substances and attempting to mitigate risk for infants,
service providers may experience dilemmas resulting from the dissonance between their personal
and professional values and the agency's practice procedures (Gregory et al., 2020). Delker et al.
(2020) revealed that service providers working with substance-using women feel conflicted
between acting in ways that support the mother's needs or protecting the fetus from harm.
Torchalla et al. (2015) added that women encountering child protection professionals often
perceived unfair treatment. When apprehensions happened, the women felt the child
apprehensions were unjust and simply the result of a "patronizing and paternalistic social and
child welfare system" (Torchalla et al., 2015, p. 8).
Canadian law recognizes an individual's human rights at birth. The government has no
legal power to facilitate control over a pregnant women's health behaviour, nor can government
enforce women's engagement with adequate prenatal care (Ministry of Children and Family
Development, 2020). However, the literature shows women still experience significant judgement
about substance use and receive societal pressure to abstain (McGrory et al., 2020). Further
research suggests that although no legal action can be exercised against the substance-using

16

mother, there is a long history of service providers using intimidation and fear in their child
protection practices. An example is a practice of apprehending infants in a hospital at the time of
birth. In these cases, social workers use surveillance methods through the mother's collaterals
(natural or professional supports) to collect information on the mother's risky health and lifestyle
behaviour; when the mother attends the hospital to deliver the baby, child protection services
intervene and apprehend the infant (British Columbia (2019); National Inquiry of Missing and
Murdered Indigenous Women & Girls (NIMMIWG), (2019).
Hospital apprehensions focus primarily on the fetus's exposure to substances and the
assumed potential future harm the infant may encounter due to being in the care of the substanceusing mother. However, Deutch (2020) points out that substance use alone is not a predictor of
child maltreatment. Deutch (2020) argues that:
Study results suggest that maternal and substance-exposure factors influence childwelfare involvement (screened-in status), but are not universally predictive of future risk
of harm to substance-exposed infants during the first year of life. Risk to infant safety is
likely multifactorial, and evaluation of maternal and substance exposure factors alone
may provide an inappropriate basis for decision-making around the level and type of
child-welfare interventions for substance-exposed infants. (p. 38).
Additional research confirmed that women with adverse experiences were at greater risk
of having their infant apprehended. According to Griffiths et al. (2020), "[v]ulnerabilities
identified, such as younger age at birth of the first child, mental health problems and patterns of
substance use have previously been found to be related to care proceedings and child
maltreatment" (p. 13). Tantawi-Basra & Pezaro (2020) argue that child apprehension is
associated with adverse maternal and infant outcomes, and child apprehensions are reduced

17

when vulnerable women and families are provided "evidence-based support and interventions"
(p. 377).
Service providers' inadequate understanding of the complexity of perinatal substance use
and concerns about duty to report have intensified negative responses towards women. The child
protection reporting responses often result in increased investigation and scrutiny. According to
McGrory et al. (2020), service providers feel increased pressure to monitor, assess and treat
substance-using pregnant women to reduce the potential harm to the infant. However, pregnant
women perceive the treatment as stigmatization related to drug use and the intensified
interventions are experienced as intrusive. This incongruence leads to women consenting to
services but resisting intervention.
Recent studies have documented increasing rates of the apprehension of infants into
government care and highlighted the importance of improving prenatal services (Griffiths et al.,
2020; Tantawi-Basra & Pezaro, 2020; Wall-Wieler et al., 2018). Furthermore, Griffiths et al.
(2020) argue that antenatal services for vulnerable women are not preventing child apprehension
and "there are concerns about the fit between how services as currently configured, and the
specific needs of mothers who lose infants from their care" (p. 2).
Racism
Research reveals that racialized women are disproportionately receiving inadequate
prenatal care (Heaman et al., 2014). Furthermore, common patterns in substance-using women's
lives emerged in the literature. For example, the studies reported that racialized women with
perinatal substance use experience often earned insufficient incomes, experienced time poverty,
lived in unsafe environments and lacked intimate partner support, which led to compromised
mental experiences void of adequate support and resources (Gartner et al., 2018; Heaman et al.,

18

2014; Keefe et al., 2018; Powers et al., 2020. Heaman et al. (2014) suggest that psychosocial
issues like pregnancy-related stress, emotional issues and depression predict the likelihood of
inadequate prenatal care, especially for poor, young, and racialized women, including Indigenous
women.
Intergenerational trauma and the ongoing effects of colonization increase instances of
trauma for Indigenous women. As a result, Indigenous women may use substances as a coping
mechanism for multiple forms of trauma (Puurunen & Vis, 2019). The research stressed that the
long history of colonization, cultural genocide against Indigenous peoples and racist health care
practice in Canada disproportionately harms pregnant women and contributes to the
overrepresentation of Indigenous children in the child welfare system (Heaman et al., 2014,
NIMMIWG, 2019). Heaman et al. (2014) discussed that historical and ongoing oppressive health
care practices contribute to indigenous women having lower engagement rates with prenatal
services. Additionally, the author highlighted the importance of cultural relevancy, "in
Aboriginal culture, pregnancy is considered a normal state of health, rather than an illness, with
some individuals viewing prenatal care as an unnecessary medical intervention" (p. 11).
In contrast to the dominant discourse on women of colour and mental health, Keefe et al.
(2018) highlight "how low-income mothers of color with histories of PPD conceptualize what it
means to be good mothers in hopes of providing a more contextualized view on PPD that has to
date been understudied" (p. 230). The author includes women's voices and their perspectives,
highlighting their strengths. The author recommends that utilizing a "feminist lens to the problem
of postpartum depression (PPD) can help facilitate mothers' self-evaluation of "good mothers"
and challenge medical and mental health perspectives on PPD" (Keefe et al., 2018, p. 231). The

19

study reveals that the women studied demonstrate self-reliance, resourcefulness and resilience in
the face of various systemic and structural barriers.
Barriers and motivators to service utilization
Stigmatization
Women with substance-using experiences face several barriers in accessing and
engaging in perinatal services. Huuberstey et al. (2019) highlight that "stigmatization, lack of
mental health supports, negative attitudes of healthcare providers, and adversarial approach of
child welfare authorities" (p. 2) are all barriers that in traditional service models create barriers to
service utilization. The research highlights pervasive negative discourses underpinning public
opinion regarding women who use substances while pregnant. Consequently, the key messages
remain that women who use substances during their pregnancy cause harm to the baby.
The stigma of failed motherhood is described in the literature as the contradiction
between Canada's neo-liberal vs. paternalistic value systems. In Benoit et al.'s (2015) study of
women with substance use experiences, "participants employed a neoliberal view on raising
children that focused on the responsibilities of individual mothers, with little recognition of the
circumstances within which agency is enacted or even understood' (p. 6). On the one hand,
Canadian women have the freedom to choose their access to health care and are provided
protection to realize this universal human right. But on the other hand, "normative rhetoric
around abstinence during pregnancy and early parenthood is fundamentally moral with
motherhood framed as a corruptible bastion of purity and selflessness" (Benoit et al. 2015, p. 5).
The contradiction in values between freedom of choice and selfless nurturing places substance
use during pregnancy remains within the discourse of failed motherhood and perpetuates
stigmatization.

20

Society is provided public health announcements and messaging cautioning people about
the risks of perinatal substance use; this messaging is acquired over time and contributes to the
development of beliefs and biases supporting the villainization of substance-using pregnant
women (Paris et al., 2020). Women internalize these messages, and according to Paris et al.
(2020), women feel "horrible about themselves for misusing while pregnant and for possibly
harming their unborn child. While holding these self-critical beliefs, the anticipated judgement
by others also contributed to their silence about their substance misuse" (p. 1401). Furthermore,
it was often reported that women's negative beliefs and corresponding shame often "led
participants to hide the reality of their lives and forgo essential prenatal care and substance use
treatment" (ibid). Lewis et al. (2017) also found that the stigma associated with perinatal
substance use contributed to low utilization of prenatal care among "disadvantaged and
marginalized pregnant women with substance abuse problems" (p. 248). In conclusion, Benoit et
al. (2015) found women experienced more emotional distress from stigma and judgement
resulting from their substance use than the potential harm of the actual use itself.
The research argues that stigma regarding perinatal substance use contributes to increased
surveillance and discrimination from service providers. Lewis et al. (2017) revealed a "recurrent
and widespread barrier to adequate prenatal care was harsh treatment and disrespect by a
clinician," moreover the adverse experiences with service providers "predicted later initiation of
prenatal care, less adherence to doctor's advice, and increased failure to obtain preventive health
services, which resulted in worse health" (p. 241). Navigating these complex practice issues is
difficult and may contribute to dichotomies in service provision.
Renbarger et al. (2020) considered the stigma resulting from systemic challenges within
the health care profession and the inadequate responses to the complexity of perinatal substance

21

use. The authors suggested that inconsistencies exist among the range of prenatal and postnatal
services. Service providers face several practice complexities, including the requirement to fully
understand and manage biases around perinatal substance use, and identify and respond to the
needs of the women, all while preventing the risk of harm to the baby. Services tend to be
fragmented because service providers' knowledge is often limited to their role. They may not
have adequate information about other services related to women's addiction or health needs.
Systemic barriers and structural limitations of services
The literature highlighted several access barriers in perinatal services; in addition, the
research recognized both social and structural factors that create obstacles in perinatal service
utilization and treatment compliance. According to Tsantefski et al. (2011), when substanceusing women are grappling with adversities such as poverty and lack of support in their daily
lives, it adversely impacts their ability to meet the engagement criteria and services expectations.
The research reveals that substance-using women are often challenged to meet their basic needs
and consistently struggle to create safety in their physical environments and intimate
relationships (Staudt 2018). Staudt (2018) also reported "women with higher levels of burden,
including recent incarceration, homelessness, disability, and interpersonal violence, were more
likely to drop out during the first six weeks of treatment" (p. 57). Ultimately, substance-using
women experiencing adversities such as poverty and homelessness are forced to focus all of their
time and energy on accessing the necessities for survival, such as food and shelter for themselves
and, in many cases, their existing children leaving no time for professional interventions.
The literature noted that often women that use substances are isolated through extreme
poverty levels and lack healthy natural or familial support systems. Women that use substances
and experience poverty have unique barriers to services, including transporting themselves and

22

their children and insecure housing or homelessness (Heaman et al., 2014). Canada has a
universal health care system; however, many of the publicly funded resources are provided by
the government or non-profit agencies influenced by neoliberal policies which discourage social
program dependency. Insufficient funding is attached to these policies, which may contribute to
limited services and long waitlists. Accessing service often includes additional transportation,
parking, and childcare fees which may be unattainable for low-income individuals (Heaman et
al., 2014). More comprehensive services for women may be available through the private sector,
for example, for-profit wellness clinics and treatment centers; however, these services are out of
reach for low-income and substance-using women.
Many perinatal services require women to be open and receptive to various interventions,
including multiple appointments within complex and rigid systems. This includes complex
service delivery models and complicated referral criteria. Staudt (2018) noted that women
struggled to navigate from one service to another. Thus, women may repeat steps, for example,
obtaining multiple physician referrals or completing detox. Heaman et al. (2014) also argue that
barriers include a lack of understanding of where to receive treatment or long waitlists for
appointments.
Additionally, the care systems typically involve conflicting expectations or requirements
requiring intellectual capacity and resourcefulness to navigate. McGrory et al. (2020) suggested
that women actively using substances may struggle to remain organized and follow their
treatment schedules. Consequently, women are labelled non-compliant or resistant when they do
not meet the service expectations or complete tasks. As a result, the research suggested that the
inherent nature of treatment expectations and schedules simply set women up for failure

23

(McGrory et al., 2020); this contributes blame to the women and minimizes the contextual
restrictions, frustrating service providers, and discouraging women's engagement.
Motivators for engagement
Despite the focus on the prevalence of substance use among perinatal women and the
associated risks, many of the studies also noted an alternative discourse was highlighting that
pregnancy is seen by women and by many service providers as a time of opportunity for
recovery (Aparicio et al., 2015; Gartner et al., 2018; Hubberstey et al., 2019; Le et al., 2019;
O'Connor et al., 2020; Ruthman et al., 2020). Hubberstey et al. (2019) identify that "pregnancy is
a time of increased motivation to contemplate significant life changes, particularly promoted by
women's desire to keep their newborn in their care" (p. 2). Gartner et al. (2018), Heaman et al.
(2014), Hubberstey et al. (2019), Keefe et al. (2018), Le et al. (2019), O'Connor et al. (2020),
Tantawi-Basra & Pezaro (2020) and Ruthman et al. (2020) all recognize the need for perinatal
services to vulnerable women be responsive to diverse and unique structural, and psychosocial
needs of the women.
The literature points out that pregnancy often presents women with an opportunity to
engage in positive change (Hubberstey et al., 2019). McGrory et al. (2020) states that "pregnancy
can be viewed as a transition point which motivates changes and provides an opportunity for
intervention" (p. 86). Authors suggest that women feel a sense of hope for their pregnancy, and a
connection to their infants and therefore want to reduce harm related to substance use.
Additionally, women may feel more motivated during their pregnancy to consider significant life
changes to keep their newborn child out of the child welfare system (Hubberstey et al., 2019)
Relational approach

24

Marsh et al. (2019) explore the importance of relational practices for women while
considering the impacts of living and working within fragmented service. The research reveals
that trauma-informed, culturally safe, and women-centred services are necessary. Hubberstey et
al (2019) reveal that responsive services that are attentive to women’s diverse and holistic needs
lead to safe environments that promoite health and healing.
Early intervention and prenatal care have been illustrated as strong predictors of
improved maternal and infant outcomes (Hubberstey et al., 2019; Lewis et al., 2017). The
research suggested that women demonstrate the desire to improve their health during pregnancy
and seek services to assist them in safer substance use or ending their use altogether (Hubberstey,
2019, p. 2). Arguably, when women encounter prenatal services that are women-centred and use
a harm reduction approach, the probability of engagement increases. Lewis et al. (2017) suggest
that women respond positively to nonjudgmental service providers who support the mother in
receiving prenatal care regardless of whether the mother is using substances or her motivation to
quit substances.
Identifying and challenging the stigma of substance use by recognizing women's
intersecting oppressions and resilience can further motivate engagement. Likewise, transparent
and supportive conversations about child welfare concerns can empower women. Lewis et al.
(2017) argue that social workers could support substance-using women's utilization of perinatal
services early in pregnancy by "[p]roviding accurate information about guidelines for mandating
reporting" (p. 247). Informative conversations provide opportunities to identify and dispel
misinformation and increase women's awareness of the benefits of prenatal care and the
effectiveness of harm reduction. Increasing women's access to accurate information may reduce

25

the stigma associated with the intolerant and discriminatory public health campaigns on alcohol
use during pregnancy.
As a result of their research study, Sperlich et al. (2021) revealed that gender-responsive
services provide the opportunity for women to develop a relationship of support and
understanding with peers. This parent education study highlighted the positive impact of genderspecific support groups therapy for women. They also discussed how the nonjudgmental
approach provides safety to share experiences with other women who relate and empathize with
their experiences of adversity. Providing women with choices for how their supports services are
delivered increases the effectiveness of the service (Sperlich et al., 2021). Safety and peer
support for women participating in group services has been documented to reduce stigma and
shame.
Finally, evidence shows positive maternal and infant outcomes when connected to
relational services that respond to the biopsychosocial complexities of women's experiences. The
research suggests that integrated and practical support minimizes the social stressors resulting
from social and structural barriers, and it facilitates the utilization of services. Furthermore,
Huuberstey et al. (2019) indicated integrated services that offer practical, gender-based and
culturally sensitive programs "may have an advantage in terms of engaging women who
otherwise have few reasons to trust the formal health care system" (p. 2)
Government ideology and Canadian social policy
Neoliberal societies, like Canada, idealize independence in parenthood preparation and
duties. However, this ideology is challenged by paternalism (Lightman & Lightman 2017). The
paternalistic discourse maintains that children require special and additional protection; this is
demonstrated by recognizing children’s' rights. Canada is a signatory to the United Nations

26

Convention on the Rights of the Child (UNCRC). Canada has a responsibility to ensure that all
Canadians under the age of eighteen realize their universal rights. As described in the UNCRC,
this is the "most comprehensive treaty for the protection and support of children in existence
today" (UNCRC, 2002, p. 4). A child, by definition, suggests an increase in vulnerability and
lack of capacity. Although parents have the primary responsibility for their children's care,
children sometimes require certain government protections, provisions, and increased
opportunities for participation for optimal growth and development (UNCRC, 1989, p. 9). This
commitment to the UNCRC (1989) confirms that protective and supportive services are
fundamental rights owned by all children in Canada. The federal government has a legal
obligation to uphold these rights and has historically delegated the jurisdictional responsibility of
child protection to the provincial and territorial governments. The Canadian government has
been entrusted by society to uphold and enforce rights that protect children from harm and create
optimal growth and development conditions.
In British Columbia, child protection policies fall under the Ministry of Children and
Family Development (MCFD) mandate. Simultaneously, the Child Family and Community
Service Act (CFCSA) governs child welfare services. Section 70 of the CFCSA declares
additional rights for children and youth in the care of MCFD. These rights ensure the provision
of comprehensive care that meets community standards of safety, health (physical and
emotional), and development while promoting healing from past trauma and meaningful
participation and connection to their culture (Government of British Columbia, 1996). The
Canadian government has developed a social policy focused on providing support and
intervention once the child is born. However, Lewis et al. (2017) argued that substance-using
women perceive this approach as reactive, intrusive, and ineffective.

27

Birth Alerts
For decades, health professionals and social workers flagged or labelled marginalized
pregnant women. Following the alert, a child protective social worker would arrive at the
hospital to pursue a child safety investigation, responding immediately with child apprehension
in cases where the child was considered at risk and needed protection. The information was
typically shared without the woman's knowledge or consent, violating privacy rights (Ritland et
al., 2021). Disproportionately, birth alerts have been used against Indigenous women in Canada
(Ritland et al., 2021). Studies confirm this practice resulted in traumatizing and preventable child
apprehensions, which excessively harmed indigenous women (NIMMWG, 2019).
Two significant social justice efforts have influenced the discontinuation of Birth Alerts
in British Columbia: The Truth and Reconciliation Commission of Canada (TRCC, 2012) and
the National Inquiry of Missing and Murder Indigenous Women and Girls (NIMMWG, 2019).
The TRCC (2012) aimed to document the factual history and the legacy of devastation and abuse
on the indigenous children and families caused by the Canadian Residential School system. The
TRCC (2012) found Canada guilty of cultural genocide and confirmed that indigenous children
continue to be overrepresented in child protection investigations and government care. The
TCRR's (2012) first call to action was to the Canadian government to reduce indigenous children
and youth in care (TRCC 2012). The Canadian government responded to the call to action by
introducing "Bill C-92 An Act respecting First Nations, Intuit and Metis children, youth and
families (the Act). The legislation was co-developed with Indigenous, provincial and territorial
partners to keep Indigenous children and youth connected to their families, communities, and
cultures" (Government of British Columbia, 2019, preamble).

28

The National Inquiry of Missing and Murder Indigenous Women and Girls Final Report
reveals the Canadian state committed acts of genocide and human rights violations against
"Indigenous women, girls and 2SLGBTQQIA people" that "have resulted in the denial of safety,
security and human dignity (v2, p. 167). The report calls for legal and social justice for
Indigenous communities across the country. For example, NIMMIWG (2019) calls for the end of
birth alerts targeting Indigenous mothers in Canada.
On September 16th, 2019, Katrine Conroy, Minister of Children and Family
Development, announced the discontinuation of birth alerts in British Columbia. The Minister's
statement on ending birth alerts highlighted that the ministry is working toward a more
collaborative model of child protection rather than depending on involuntary services
(Government of British Columbia, 2019, n.p.). Subsequently, amendments were made to the
Ministry of Children and Family Development: Family Support Services and Agreements. The
changes focused on creating a policy for expectant parents, which respects self-determination
and upholds the rights to confidentiality and informed consent to voluntary services.
The ideology of neo-liberalism and residual welfare policy theory inform the new policy
as it implies the requirement of government involvement only as a last resort. The policy for
expectant parents assumes that all individuals have the capacity, mobility, and resources to
access support independently and follow through with the intake social worker's
recommendations. It also assumes that adequate voluntary services are delegated from the
government to family, community, voluntary or NGO services. However, the policy does not
clarify client access to services if they refuse MCFD involvement. Nor does it address quality
standards; for example, it is unclear what services are available, if they are accessible, or if they
will be trauma-informed and culturally safe.

29

Lightman & Lightman (2017) argue that stigma is used by "service providers as a means
of rationing and deterring use" (p.153). Stigma is a common barrier for substance using women
accessing perinatal prevention services. Vulnerable and marginalized women are often treated
poorly and discriminated against by health care and child welfare professionals. Negative
experiences with helping professionals set the stage for mistrust and isolation, resulting in
women not engaging in prevention services. The policy changes also highlight the importance of
indigenous peoples receiving services through the Delegated Aboriginal Agencies, so
intervention is based on traditional teachings and indigenous cultural understanding. Substance
using Indigenous women can benefit from the collective responsibility and support of the
Indigenous community while avoiding racist and harmful treatment.
Practice Models
Integrated perinatal services
The research revealed that trauma-informed, culturally safe and women-centred services
could improve client experiences and maternal and infant health outcomes. Gartner et al. (2018),
Heaman et al. (2014), Hubberstey et al. (2019), Keefe et al. (2018), Le et al. (2019), O'Connor et
al. (2020), Ruthman et al. (2020) and Tantawi-Basra & Pezaro (2020), and all recognize the need
for perinatal services to vulnerable women be responsive to diverse and unique structural, and
psychosocial needs of the women. These services should be designed to respond to various
needs, including medical, mental health, parenting, housing, and childcare, and create safe
environments where women can experience health and healing (Hubberstey et al., 2019).
O'Connor et al. (2019) described a 29 –year old mother's positive experience with the traumainformed, integrated service support she received; the mother stated, "I can breathe for the first
time, and while I know I have a long way to go. I am in a good spot and I am very grateful for

30

the support I have received from the team" (p. 7). According to Gartner et al. (2018), women
receiving trauma-informed services felt safety and connection from the beginning of service
engagement; furthermore, the women developed meaningful and life-sustaining relationships
with other mothers.
Marcellus (2017) argues that research has supported the development and implementation
of integrated perinatal services for several years. The authors completed a study evaluating the
piloting of single-access service delivery models for vulnerable pregnant women, revealing
positive outcomes and lessons learned. The study recommends that perinatal services for
substance-using women address the structural and psychosocial factors in the women's lives.
Women with intersecting experiences of oppression require support to access and utilize
comprehensive services. The study shows evidence that women respond well to services that
support mother and baby togetherness when they also address "immediate health and substance
use concerns, but also longer-term intersecting socio-structural and resource concerns—
including poverty, discrimination, isolation, homelessness, and violence" (p. 343).
Furthermore, Hubberstey and Pool (2019) maintain that the leading Canadian
community-based FASD prevention programs "focus on problematic substance use more
broadly, within the context of social determinants of health context and women's lived
experiences as a way of engaging very vulnerable women without further stigmatizing them for
their choices" (p. 3). Rutman and Hubberstey (2019) completed a program evaluation of various
community-based perinatal prevention programs for women with substance use experiences and
revealed findings supporting the effectiveness of services. The authors define the services as "…
unique yet designed to address women's holistic needs through outreach and single access dropin services and by employing relational, trauma-informed approaches" (p.2). Their research

31

findings suggest that the women accessing community-based services experienced support,
gained parenting skills, established social networks, accessed better prenatal care earlier,
improved their and their children's health, decreased substance use, and had better child
protection experiences. Rutman and Hubberstey (2019) highlight the programs discussed in their
study were culturally informed and deeply centred around trauma-informed care and harm
reduction. Therefore, women reported developing trusting and supportive relationships with staff
and peers. Finally, the authors argue the benefit of having the various services available in one
place reduces several systemic and practical barriers (Rutman & Hubberstey, 2019).
Trauma-informed care
Trauma-informed care is a systemic approach focused on creating trauma-informed
environments that recognize the prevalence of trauma, reinforce healing, and reduce the risk of
further traumatization. The fundamental principles of trauma-informed care are "Understanding
trauma, and it impacts; promoting safety; ensuring cultural competence; supporting consumer
control, choice and autonomy; sharing power and governance; integrating care; healing happens
in relationships; recovery is possible" (Steele & Malchiodi, 2012, p.17). Trauma-informed care is
a strength-based, client-centred framework that creates trauma awareness, leading to safer
environments for healing and protection from re-traumatization (Knight, 2014). Protection from
re-traumatization is central to women dealing with the significant risks associated with substance
use.
Several research studies find that using trauma-informed practice with women with
perinatal substance use experience and diverse needs acquires positive results. Trauma-informed
care incorporates choice and safety by developing a deeper understanding of the structural and
systemic barriers for women with substance use experience (Quaile, 2020). Interventions

32

utilizing trauma-informed care approaches ensure that women's safety and mental health are
addressed in addition to addiction services (Sperlich et al., 2021).
According to Knight (2014), trauma-informed care focuses on helping the "survivors
understand how their past influences their present lives and on empowering them to manage their
present lives more effectively" (p. 3). Sperlich et al. (2021) also point to the importance of
creating a non-judgemental environment within services employing a trauma-informed approach.
The nonjudgmental environment contributes to safety for the women to express the range of
emotional and practical challenges they face without fear of judgement or negative consequences
such as child protection interventions. The study completed by Sperlich et al. (2021) revealed
that utilizing trauma-informed care was related to positive participant feedback. Rouland et al.
(2019) suggest that using a trauma-informed approach in all levels of service is paramount in
working with women with postpartum depression and should be considered for "all organizations
and providers" and that "social workers should follow its principles" (p. 231).
Community-based program examples
The research supports better outcomes with an integrated approach to perinatal services
(Hubberstey & Pool 2019). Integrated approaches to perinatal substance use provide low-barrier
access to trauma-informed and culturally safe clinical care, education and support. Through
integrated services, substance-using women are offered seamless access to services in perinatal
health, mental health, recovery, parenting, housing and income assistance.
This section of the paper will review two different community-based programs that offer
integrated perinatal services. The first approach is Pregnancy Outreach Programs (POPs), an
outreach model where women access various low-barrier services from a multidisciplinary team.
The team does not provide addiction or clinical services but facilitates access to perinatal

33

information, and resources and enables connection to health care providers (BC Association of
Pregnancy Outreach Programs (BCAPOP) Handbook 2017). The second approach is the singleaccess or hub model, where a mixture of gender-specific perinatal services is offered to
vulnerable women at a health centre. This paper will use the Maxxine Wright program as an
example to analyze the single access or hub model (Hubberstey & Pool 2019).
Pregnancy outreach program
According to the BCAPOP Handbook (2017), POPs are designed for vulnerable pregnant
women and respond to the social determinants of health. The mandate of POP is to provide
health and nutrition information and support to women with health and lifestyle vulnerabilities
(2017). Women are offered a range of low-barrier services from a multidisciplinary team of
public health nurses, registered social workers, pregnancy support workers, registered dietitians,
and early childhood educators (2017).
In the Pregnancy Outreach Program Handbook, the authors outline:
A set of six guiding principles have been set out by the Canadian Prenatal Nutrition
Program (CPNP) that can help unify the approach to program delivery. 1. Mothers and
babies first—the health and well-being of the mother and baby are most important in
planning, developing and carrying out the program. 2. Equity and accessibility—the
program must meet the social, cultural and language needs of the pregnant women in the
community and must be available in all parts of the country. 3. Community-based—
decision making and action in planning, designing, operating and evaluating the program
must be done as a community. 4. Strengthening and supporting families all parts of
society share the responsibility for children by supporting parents and families. 5.
Partnerships—partnerships and cooperative activities at the community level are key to

34

developing an effective program.6. Flexibility—the program must be flexible to respond
to the different needs in each community and to the changing needs and conditions of
women in these communities" (BCAPOP 2017 p. 4).
According to BCAPOP (2017), the program promotes safety through experiences of
choice and autonomy. Women are offered individual and group support, and staff will meet
women in their homes, in the community, and in program office spaces. Women are offered a
menu of services related to pregnancy, parenting, nutrition/food security, mental health, intimate
partner violence, substance use, immigration/settlement, housing, income assistance,
employment, education, childcare. Staff work in partnership with the women to create service
delivery plans that meet their unique needs. The program provides food and nutrition resources,
donations of baby items (breast pumps, clothes, car seats, cribs etc.), offers free childminding,
bus tickets and transportation to appointments. Women are supported in their connection to
community resources. They are also provided accompaniment and advocacy support with
medical and child welfare appointments (BCAPOP 2017).
Single-access: Maxxine Wright
The research revealed that having integrated services in one location reduced several
social and environmental barriers to service utilization (Hubberstey & Pool 2019). Maxxine
Wright (MW) is one of eight programs of its kind in Canada (Hubberstey & Pool 2019). MW
operates alongside Atira Women's Resource society; the agencies provide health and social
support for women in transition and second-stage housing. In partnership with local Ministries,
financial support are provided on site. Women can utilize these services until their child is
school-aged (Hubberstey & Pool 2019). Women are offered a range of health and social services
to meet their diversity of gender-specific and cultural needs, such as childcare, Mothers in

35

Recovery groups and connection to Indigenous elders. The programs are offered in a group or
1:1 setting and are trauma and culturally informed while focusing on relationships (Hubberstey
& Pool, 2019). The services are low barrier and take a harm reduction approach; women can
self-refer and drop-in to the health centre to access holistic support. The program website lists
the following services:
Daily hot lunch program; Nonjudgmental emotional and practical support; Medical and
nursing care; Dental hygienist; Alcohol and drug counselling; Donations of clothing,
household, food, and baby items; Assistance with housing, income assistance, forms;
Access to a social worker; ReDiscover Parenting Program; Information and resource
referral;16 Step Empowerment Group (open to all women in the community); Outreach;
Advocacy; Safe, welcoming drop-in space and opportunity to socialize with other women
and kids; Various other groups may be offered throughout the year (Atira Resource
Society 2021).
The POP and Maxxine Wright community-based programs incorporate several elements
of integrated perinatal services and effective practice for working with women with substance
use experiences.
Limitations
This review provides evidence of a breadth of literature on the prevalence and impacts of
perinatal substance use. However, there are limited findings concerning the implementation and
outcomes of integrated perinatal intervention services for vulnerable women with substance use
experiences. The bulk of existing evidence is based on quantitative administrative reviews
derived from traditional medical services. Social workers' voices are not adequately captured or
considered in the research. A limited number of qualitative studies focused on women's

36

experiences in the perinatal stages with experiences accessing prevention services. When studies
included women's voices, they were small samples primarily derived from focus groups,
questionnaires, and interviews with professionals. Furthermore, most of the studies focused on
the barriers to service utilization, while limited studies revealed comprehensive information
about the integrated services proven to produce positive maternal and infant outcomes. The
qualitative work tended to focus on the systemic and psychosocial vulnerabilities of the women,
with limited attention to their strengths and resiliencies.
A significant gap in the research was the sparsity of literature on the role of the father in
perinatal substance use. The data collected and reported throughout the literature identified the
mother as the focus of study and service intervention. When fathers were discussed, it was
primarily from the perspective of the substance-using women's support or lack of support.
Implications for social work
The literature recommends that perinatal services for substance-using women address the
structural and psychosocial factors in the women's lives through trauma-informed and womencentred practice. Social workers who work directly with vulnerable women in various capacities
are integral in researching, developing, and implementing strategies that effectively reduce
perinatal substance use. Understanding and responding to the contributing factors such as early
childhood trauma, poverty, racism, and gender inequality is the starting point to stopping the
perpetuating cycles of pain and harm. The social work profession is rooted in the intrinsic values
required to provide this critical work. According to the Canadian Association of Social Workers
(CASW) (2005) Code of Ethics:
"Social workers promote social fairness and the equitable distribution of resources, and
act to reduce barriers and expand choice for all persons, with special regard for those who

37

are marginalized, disadvantaged, vulnerable, and/or have exceptional needs. Social
workers oppose prejudice and discrimination against any person or group of persons, on
any grounds, and specifically challenge views and actions that stereotype particular
persons or groups" (p. 5).
The research identifies that although progress has been made in some areas, trauma
informed and gender-specific services are needed because women continue to be victimized and
traumatized by services intended to support them. The literature recognizes the psychological
impact of trauma, and untreated mental health needs of substance-using women is a contributing
barrier to seeking and utilizing health and social services (Marcellus 2017). Heaman et al. (2014)
emphasize that stress, depression, family issues, and fear of a child protection apprehension were
all contexts that contributed to accessibility issues and avoidance of health and social services for
pregnant women that use substances. Furthermore, for services to be relevant to the needs of the
women, safer environments that facilitate disclosure of health and social challenges are required.
The emotional difficulties related to women's intersecting oppressions have been proven to
diminish women's capacity and agency and lead to premature termination of services. Therefore,
social workers in this field must be aware of the current limitations of services and work towards
altering services to better support women through trauma-informed practice and low-barrier
services.
There is a need for social justice efforts to change the dominant discourse of perinatal
substance use that perpetuates gender-based oppression and stigma. Social workers can create
counter stories that challenge the villainization of perinatal substance use. Social workers can
create awareness and reinforce discourses that demonstrate the realities of women, which include

38

the adversities and resiliencies, but most importantly, revealing the powerful systems supporting
the status quo.
Salter & Breckenridge (2014) maintain that women report feeling supported and
empowered when gender-responsive approaches are utilized for perinatal services. According to
Eyal-Lubling and Krumer-Nevop (2016), a feminist practice also addresses power dynamics
between service providers and women. By naming and addressing power dynamics, women
receive more collaborative services which promote women's empowerment and agency. A
feminist framework works to challenge the concept of gender by challenging traditional
understandings of what it means to be a "woman"; as a result, more experiences of gender can be
included within services and support that employ a feminist framework. The above concepts can
be applied to services on macro and micro levels allowing for more comprehensive services for
pregnant women (Eyal-Lubling & Krumer-Nevop, 2016).
Furthermore, the CASW code of ethics states, "social workers analyze the nature of
social needs and problems, and encourage innovative, effective strategies and techniques to meet
both new and existing needs and, where possible, contribute to the knowledge base of the
profession" (p. 8); thus, it is the responsibility of social workers to align their practice with this
principle by utilizing evidence-based research, best practices, and reflexivity.
Social workers have a unique role and professional responsibility supporting women with
intersecting experiences of oppression which may require support to access and utilize services,
including removing systemic barriers. Anti-oppressive practice should be the foundation of all
interventions for vulnerable pregnant women and respond to the social detriments of health. The
end to birth alerts and the subsequent MCFD policy for expectant parents is an example of antioppressive practice. (MCFD 2020). It demonstrates progress towards ending the paternalistic

39

and discriminatory treatment of families requiring support services. The updated policy respects
the rights to privacy and informed consent; in theory, it recognizes the mother as an expert in her
life and follows the CASW (2005) Code of Ethics and self-determination principles (MCFD
2020). However, the social worker's role is also to represent the state concerning UNCRC and
Section 70 rights violations; therefore, the social worker must intervene in cases of child risk.
The contradictions of these competing rights create ethical issues for the social work profession
and create the opportunity for advocacy and social justice.
From a micro perspective, a social worker's role in supporting an expectant parent for
parenting is complicated. According to the Ministry of Children and Family Development:
Family Support Services and Agreements (2020), social workers are to engage parents in "prebirth planning and voluntary services; however, if expectant parents make clear that they do not
want preventive or support services, take no further action" (p. 11). This standard requires every
effort to assist an expectant parent before giving birth to develop the parent's capacity, skills,
support, and resources. However, the expectant parents have the right to exercise selfdetermination and informed consent (MCFD 2020). However, according to Turpel (2014), social
workers are not afforded the resources to meet this expectation; funding cuts to resources and
increased caseloads make it nearly impossible to provide the intense and time-consuming support
needed. From a macro perspective, social workers must advocate for more resources and
integrated service delivery models aligned with best practices for substance-using women.
According to sections 10 & 11 in the BC. Association Social Workers (BCASW) Code of Ethics,
"social worker shall promote excellence in her or his profession & A social worker shall
advocate change in the best interest of the client, and for the overall benefit of society "(BCASW
2003). It is imperative that social workers advocate for change that contributes to the

40

development and implementation of trauma-informed, responsive and relational care that has
been proven to reduce perinatal substance use.
Conclusion
Women continue to experience inequality and harmful treatment in society and, as a
result, experience oppression and detrimental health outcomes. Perinatal substance use is a direct
result of the suffering experienced by women in unique and complex contexts. Women cannot
continue to take personal responsibility for systemic problems. Instead, women's intersecting
oppressions of ACEs, racism, poverty, gender inequality, and mental health must be understood.
Perinatal support services must be responsive and effective. Social workers have a role in
creating this change and advocating for social justice. Social workers need to contribute to this
greater understanding through critical social research that includes women's voices within the
margins. Social workers also need to advocate for adequate services that are holistic, integrated,
and inclusive. Finally, social workers need to integrate the enhanced understandings of women's
identities and experiences into practice that is responsive to diverse needs, demonstrates cultural
humility, and creates welcoming and safe environments for pregnant women using substances.

41

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