[Editor's note: For an introduction to this series, go here.]
Sun streams into the bright room painted in vibrant hues of green and blue. In a messy circle of soft sofas, baby strollers and rockers, six women sit watching infants crawl at their feet and toddlers play with scattered toys. Loud laughter fills the room, adding to the cheerful ambience. Looking in from the outside, it seems the typical sort of "mom meet-up" that happens in living rooms and community centres anywhere.
But this is more than just a coffee klatch. The gathering, held at Surrey's Maxxine Wright Community Health Centre, is part of an outreach program for pregnant women and mothers with histories of drug and alcohol addiction. On weekdays over the lunch hour, women arrive to see the doctor, eat a hot meal, and meet with the mental health, infant development, income assistance, and housing support workers who comprise the 15 staff members employed here.
At one end of a couch is Julie, feeding her six-week-old son, Elliott (names have been changed). A 31-year-old student and single mother of three boys, Julie has been a regular at Maxxine Wright since her middle son, Jonas, now four, was born. Remembering her early visits, Julie describes the centre's humble beginnings.
"Originally, it was just a little hut," she said. "There would be 20 to 30 women crammed in this very tiny space, all wanting to be at the drop-in or see the doctor. So it was very nice that they had this big building built."
In the eight years since it opened, in response to overwhelming demand for its services, the Maxxine Wright building has tripled in size. It's now a 6,000 square-foot multi-level complex, complete with floors dedicated to clinic care, childcare and housing.
Julie credits the services and community at Maxxine Wright for helping her stay clean and raise Jonas: "This is the only place I know in Surrey that has all the services: the daycare, the second stage [temporary rental housing] in the back -- it's like a one-stop shop. You've got the doctor, the dentist, the food and the support worker -- everything all in one go, everything you really need to get back on your feet."
Twenty years ago, before programs like Maxxine Wright existed, pregnant women living with addiction would arrive at hospital emergency rooms in labour, having received no prenatal care. A social worker would usually apprehend the baby immediately following birth.
But the popularity of such multidisciplinary community health programs has grown, and the reality is much different for such mothers today.
Vancouver's Sheway has offered these services for nearly two decades, and a similar program in Victoria, "HerWay Home," opened this past January. No longer seen as luxuries or experiments, such programs are increasingly viewed as core and essential service offerings, the key to bringing about the best outcomes for addicted women and their babies.
Outside cities, however, programs like these simply don't exist, meaning women living in smaller centres are forced to travel sometimes great distances to access the specialized health care they need.
'Every door is the right door'
Drugs feature prominently in the picture Julie paints of her life: born into a family of addicts, she fell prey to an abusive drug dealer at 13, she tells me.
"He burnt my arms and broke my jaw, so I would use in order to take the pain away -- and I tried killing myself many a time," she said. "I think I was 25 when I got into recovery for the first time; I managed to get nine months in there, and then I got pregnant with Jonas."
It's easy to suggest that women like Julie who use alcohol or illicit drugs while pregnant should not be bringing babies into the world, but of course the issue is complicated. Most health care providers and addiction specialists acknowledge that substance use often masks deeper issues of trauma, poverty, racism and social isolation.
For vulnerable women, substance use "provides a bit of temporary if problematic relief from the other, way more difficult, things that they're up against," notes Amy Salmon, formerly the coordinator of Sheway, a pregnancy outreach program based in Vancouver's rough Downtown Eastside. "It's the thing that these women have used to cope with otherwise really difficult life circumstances," she said.
A report published in 1993 (20 years out of date, but still the most recent available data for Vancouver) revealed that nearly half -- four in 10 -- infants born over a two-year period to mothers living in the Downtown Eastside were exposed to alcohol or other drugs in utero. That same year, Sheway opened to respond to the need for support for expectant women and mothers parenting in the area.
At the time, pregnant women and mothers who used illegal drugs had few supports to turn to that did not demand abstinence, explains Salmon, and when they failed to, or could not, comply with that, most programs were punitive.
Some women were told their mental health issues must be treated before their addictions could be addressed, while other women would be turned down for mental health treatment because they were using, Salmon says. Women users seeking refuge from violent relationships would also often find themselves unwelcome at transition houses for the abused.
"It's getting better," Salmon says. "Systems are becoming much better integrated than they once were. For example, a lot of work has been done to try and move forward the idea that every door is the right door when it comes to accessing mental health or addiction services."
Today, Sheway features a team of 25 staff members, including doctors, community health nurses, family support workers, a housing outreach worker, infant development consultants, a nutritionist and a cook. The program currently sees 350 clients a year, helping them to access everything from primary health care to housing.
Typically referred by health professionals and other service providers in the Downtown Eastside, most clients visit Sheway for the first time during their pregnancy, and continue to visit after birth, until the child reaches 18 months.
Meeting women 'where they're at'
Heather Cameron first arrived in Vancouver from Kamloops, B.C., to go to make-up school. An off-and-on drug user for 10 years, Cameron quickly relapsed on arrival and turned to the sex trade to support her addiction. A year-and-a-half later she became pregnant and was referred to Sheway by a street nurse.
What she remembers most about Sheway were the efforts staff made to gain her trust during her daily visits.
"I went there every day for lunch because I was hungry, and I just remember they would say: 'Well, you have to see the doctor before you have lunch, Heather,'" she recalled. "That's how I would end up going upstairs and seeing the doctor first -- he would measure me and do all these things that weren't actually medically necessary. Looking back at it, I realize that he was trying to build a relationship with me."
Sheway's staff helped Cameron leave the Downtown Eastside and get into Fir Square Unit, a specialized 12-bed ward at B.C. Women's Hospital.
Like other multidisciplinary programs, Fir Square uses harm reduction as a guide in caring for pregnant women trying to stabilize or withdraw from substance use. That doesn't automatically mean a full detox.
"We would rather meet women where they're at," the unit's senior practice leader, Jill Mahy, explains. "If they're using every 15 minutes or every hour and they really want to come in and get recovered then, we need to go slowly. We wouldn't say to them, 'Okay, you're going to go cold turkey.'"
Started nine years ago, Fir Square was the first unit of its kind in Canada. In addition to its medical staff, it provides drug and alcohol counselling, access to legal aid and social workers, and housing assistance.
Its collaborative care model also allows mothers to "room in," meaning that if babies are born with drug withdrawal symptoms, their mothers stay in the same room for treatment. Such an arrangement isn't just convenient for mom: it leads to better medical (and by extension, economic) outcomes. Studies have shown that babies who stay with their moms during withdrawal need less treatment and are discharged sooner than those who don't.
Interestingly, those babies are also more likely to stay in their mother's custody afterwards.
Coming out of 'hell on Earth'
But trusted, holistic, and integrated service solutions are only as useful as they are accessible. When Cameron returned to Kamloops for her delivery in 2004, she discovered that local programs like Sheway and Fir Square were virtually non-existent for women living outside Vancouver.
"When I came to Kamloops, I just wasn't finding the proper services for me and wasn't making the connections. I was trying to find services to help counsel me getting out of the sex trade, and help counsel me to be a good parent and be in recovery," she said. But without supports in place, the troubling memories of her life in the Downtown Eastside plagued her, hindering progress.
"A lot of people thought I would be just fine and just go back to being the 'normal Heather,' but really I lived in what I call 'hell on Earth' coming out of Main and Hastings. It's still very haunting to me today."
When she couldn't access the services she needed for her and her newborn daughter, Cameron started to lay the groundwork herself. Through word of mouth she was able to get some seed money to start a drop-in program for recovering mothers in Kamloops.
Inspired by Sheway, the program now called Family Tree Family Centre is a peer-based program for pregnant women and early parenting mothers who live with addiction. Ten years on, Cameron, now a single mother of two daughters and a nursing student, passed the torch to former participant Susan Clarke, who now serves as the centre's executive director.
Family Tree now employs five staff and supports 75 women a year. Though no doctors are formally attached to the program as they are at Sheway and Maxxine Wright, Family Tree hosts a drop-in, recovery group and provides a space for women to meet with support workers, public health and street nurses who visit weekly.
Change from the MD up
Getting a multidisciplinary, community-health focused program underway is no small task. The considerable resources and broad range of collaborations needed to launch programs like Sheway, Maxxine Wright and HerWay Home, put such programs out of reach in most parts of the province.
Instead, a broader, system-wide approach to create awareness about substance use and pregnancy is needed, said Nancy Poole, director of research and knowledge translation at the British Columbia Centre of Excellence for Women's Health.
"It takes a fair bit of energy to get these kinds of one-stop programs going. To me, then, the other part of this work is really helping every single nurse, doctor, transition house worker, aboriginal service worker, sexual assault worker -- whomever sees the woman, for any reason -- to help them feel really confident to talk about alcohol and other substances," she said.
Poole wanted to help health providers feel more comfortable talking about how to care for women struggling with addiction, so in 2007 she started a resource website called "Coalescing on Women and Substance Abuse."
"I think as a society we've been so scared of substance use problems, that oftentimes some health providers feel that they don't have the skills to help," Poole said.
The effective treatment of substance abuse issues involves more than encouraging individuals to decrease their use, Poole said. It means also assisting them with the challenges they face in their lives -- often the real triggers behind addiction -- including mental health issues, housing, nutrition and trauma.
Substance abuse is not necessarily the first thing an expectant mother is ready to change when she enters the doctor's office, Poole points out. "Until she has housing and food and her stress levels are down a bit, it's unrealistic to expect a change in substance use," she said.
Lorna McRae, a midwife who regularly works with women from HerWay Home at her practice at Access Midwifery, says the specialized medical care she provides is often overshadowed by something as basic as providing some extra food, a temporary place to rest or a listening ear.
"I don't know if it's midwifery or a conscious effort as a health care provider," McRae said. "Anybody could do this. GPs could do it, midwives could do it -- a lot of people could do it. Do we do it? Not very often. There are lots of things we can still change about how we do practice."
'It keeps you coming back'
Still, specialized care for more complicated cases is lacking across the province. The same services for substance-using pregnant women available at Fir Square simply don't exist at most hospitals.
Outside of Vancouver, even in a larger hospital like Victoria General, McRae notes: "There's no actual addiction services once they're in the hospital, because they're pregnant. They are in the mother-babe unit or the antenatal unit up on the third floor. It's really hard on the nurse; it's really hard on the client."
"We've called up Fir Square a couple of times and said, 'Isn't there any way this woman can go to Fir Square? She really needs in-house kind of care.'"
Back at Surrey's Maxxine Wright, nurse and program coordinator Denise Penaloza said her own program serves all of the Fraser Health Authority, and women travel from as far as Mission, Port Moody, Langley, Delta and beyond to access its services.
"It's also not always feasible for them to get here, because it's a fair bit in change to get all this way here in transit and time-wise. It's not uncommon for a client to be on transit for two and half hours to get here," she said.
The program currently sees women until their children are four years old. Julie, whose son Jonas is now four, jokes that the reason she had her son Elliott was that she wanted to continue coming to Maxxine Wright.
Now clean four years, she's become an advocate for the centre, and stresses the need for other programs like it.
"There are still a lot of women who need that help every month or before cheque day, so it's those little things that are important," Julie said. Like knowing no matter what, your child is going to get fed or diapered. "You know they're not going to say no to you. It keeps you coming back."
Next Friday: A look at the lives of women in British Columbia who give birth without the benefit and assurances of health insurance.