Women in the shadows: prenatal care for street-involved women.

Mill, Judy ; Singh, Ameeta ; Taylor, Marliss 等

Abstract

Since 2003, Edmonton, Alberta, Canada has seen an alarming rise in infectious syphilis cases among mainly heterosexual persons. In response to this outbreak, a peer-based outreach program called Women in the Shadows (WIS) was designed and implemented in April 2008. In this manuscript, we highlight key findings from the qualitative evaluation of the WIS program, focusing primarily on the women's experiences of homelessness and with accessing the program. Twelve street-involved women who were pregnant, or believed they might be pregnant and seven program staff participated in in-depth, individual interviews. Participants experienced tremendous challenges in day-to-day survival and in their efforts to transition out of a street lifestyle. Both WIS staff and clients believed that obtaining appropriate housing was essential for any lifestyle change, yet posed one of the greatest challenges. The WIS program enabled the women to access non-medical support and services, in addition to providing pregnant street-involved women non-judgemental medical care.

Keywords: pregnant women, street-involved, program evaluation, qualitative

Resume

Depuis 2003, Edmonton, Alberta, le Canada a connu une augmentation alarmante des cas de syphilis infectieuse chez les personnes principalement heterosexuels. En reponse a cette epidemie, un programme base sur les pairs de sensibilisation intitule Women in the Shadows (WIS) a ete concu et mis en oeuvre en Avril 2008. Dans ce manuscrit, nous presentons les resultats principaux de l'evaluation qualitative du programme WIS, en se concentrant principalement sur les experiences des femmes sans-abris et de l'acces au programme. Douze femmes de la rue qui etaient enceintes ou croyaient etre enceintes et sept employees du programme ont participes dans des profondes entrevues individuelles. Les participants ont eprouve d'enormes defis de vie quotidienne et dans leurs efforts dans la transition de s'echapper d'une mode de vie de rue. Tant le personnel et les clients WIS croient que robtention d'un logement adequat est essentiel pour tout changement de style de vie, et a pose l'un des plus grands defis. Le programme WIS a permis aux femmes d'acceder le soutien et services non medicaux, en plus de fournir femmes enceintes de la rue des soins medicaux sans jugement.

Mots cles: Les femmes enceintes, de la rue, revaluation des programmes, qualitative

Introduction

Individuals who are street-involved have higher rates of infectious diseases, mental health problems, and mortality. Women who are street-involved are also often homeless or housed in temporary dwellings and are a "... particularly marginalized part of an already vulnerable population ..." (Cooper, Walsh & Smith, 2009, p. 122). In the current study, street-involved was defined as currently experiencing homelessness, substance use and/or sex work. Harm reduction is an approach to care and support for individuals who participate in high risk activities such as intravenous drug use, sharing or re-using needles, unprotected sex, and excessive alcohol use. Using a harm reduction approach the care-giver starts where the individual is at and provides care and support in a non-judgemental manner to assist the individual to reduce the harm associated with the high risk behaviour. The Women in the Shadows (WIS) project in inner-city Edmonton provides a compelling example of a harm reduction approach for street-involved pregnant women. In the current manuscript, we highlight key findings from in-depth, individual interviews with women who participated in the WIS program and health care providers who delivered the program.

Literature Review

Following a review of published research, Boivin and colleagues (2005) reported that street-involved youth have higher tares of hepatitis B, hepatitis C, HIV, pregnancy, mental health problems, violence and mortality compared to non-street-involved youth. Crawford and colleagues (2011) found that homeless, pregnant young women suffer from high rates of mental health problems and are the "... most at-risk young mothers in our society" (p. 181). Similarly, Frankish, Hwang and Quantz (2005) reported that homeless individuals are at increased risk for mental health disorders, substance abuse, tuberculosis, and HIV infection and have higher mortality rates, however the "... causal pathways linking homelessness and poor health are complex" (p.S23). Cheung and Hwang (2004) reported that homeless women in Toronto between 18 and 44 years had mortality rates 10 times higher than women in the general population. Higher rates of pregnancy have been reported in street-involved (48% versus 10%; Greene and Ringwalt 1998) and homeless (68% versus 12.6 %; Crawford et al. 2011) young women when compared to their counterparts who are not street-involved and adequately housed. Homelessness may in itself increase the vulnerability of pregnant women. In a recent American study, Brown and colleagues (2012) reported that pregnant women who had been recently homeless were almost 5 times more likely to have recently traded sex for economic survival than women who were not recently homeless. This in turn increased their risk of HIV and other infectious diseases.

Homelessness impacts not only the health of pregnant women, but also health of the unborn fetus. In both Canada (Little et al. 2005) and the United States (Richards, Merrill and Baksh 2011), homeless pregnant women are more likely to have had less prenatal care, preterm birth, receive government financial assistance, and give birth to an infant with a lower birth weight than non-homeless women. The rate of pre-term birth doubles (38% versus 19%) when homeless women are also using substances (Little et al. 2005). Pregnant women who are homeless or use substances, or both, should therefore be considered high risk (Little et al. 2005).

Women are often street-involved or homeless in order to escape challenging home environments including substance use and physical, sexual and emotional abuse. Several studies have reported an association between street-involvement and childhood abuse (Mill 1997; Scappaticca and Blay 2009; Teruya et al. 2010), sexual victimization (Hathazi et al. 2009), and pregnancy (Haley et al. 2004). Haley and colleagues examined the characteristics of adolescent street-involved youth with a history of pregnancy and reported that these young women had frequently experienced severe sexual abuse and early injection use and that the rates were higher than in adolescents without a history of pregnancy. Substance use may be a coping strategy for women who have experienced trauma, and for Aboriginal women, a strategy to deal with the effects of historical trauma including residential schools and colonization (Nichols, Dell and Clarke 2010; Ruttan, LaBoucane-Benson and Munro 2008). Young women who are abused in their home environment often run away or 'hit the streets; (Haley et al. 2004; Little et al. 2007; Scappaticci and Blay 2009), perhaps as a strategy for survival (Mill 1997).

Housing instability impacts not only the health of the mother and fetus, but also access to health care services (Teruya et al. 2010). Individuals who are homeless or street-involved face a multitude of barriers to access health care. Homeless persons may not have a provincial health card, may have difficulty keeping appointments due to their transient lives and may be less able to practice effective birth control (Frankish, Hwang and Quantz 2005; Gelberg et al. 2008; Haley et al. 2004; Hathazi et al. 2009). Gelberg and colleagues (2008) reported that one third of the homeless women in their study rarely or never used birth control. The authors also suggested that "... contraceptive use is driven primarily by availability and by concerns about HIV and STIs, rather than concerns about pregnancy" (p. 58). Attitudes of health care providers have also been identified as a significant factor in homeless youth accessing care (Little et al. 2007).

In a study with pregnant, homeless women, Bloom and colleagues (2004) identified the following barriers to prenatal care: 1) site specific (e.g., wait time, distance and lack of transportation); 2) provider-client relationship; and 3) inconvenience (e.g., scheduling of appointments, parking and travel time). Transportation and scheduling were also identified as barriers to health care in a study with homeless women who blamed themselves for not prioritizing health (Gelberg et al. 2004). Homeless women may experience stigma (Gelberg et al. 2004; Sloss and Harper 2004) and as a result may hide their street work and become reticent to access care. Drug use may be a barrier to care for pregnant women through interactions with individual, interpersonal, systems, and policy factors (Roberts and Pies 2011); women may struggle emotionally to access care because they know that they are jeopardizing their baby's health when they are using drugs (Little et al. 2007; Roberts and Pie 2011). Accessing health care may differ depending on the population of homeless women. Teruya and colleagues (2010) recently examined the health and health care disparities among homeless African American, Latina and white women in the United States. Interestingly, they reported that white women were more likely to report unmet health care needs than African American or Latina homeless women.

Despite the very real challenges associated with being a mother while working on the street and/or being homeless, having children may be a motivator for women to make lifestyle changes in order to increase the likelihood that they will be able to keep their infant. Accessing prenatal care is part of a lifestyle change. This positive outcome of pregnancy in this population has been reported by researchers in Brazil (Scappaticci and Blay 2009), Canada (King et al. 2009; Ruttan, Laboucane-Benson and Munro 2012) and the United States (Gelberg et al. 2004; Hathazi et al. 2009; Jackson and Shannon 2012; Smid, Bourgois and Auerswald 2010). In a Canadian study with 75 street-involved young women (King et al. 2009) pregnancy and parenting represented a life turning point for participants. Ruttan and colleagues (2012) reported that pregnancy was a primary reason for leaving the streets; however, mothers reported increased stress levels when the babies became toddlers. The pregnancy narratives of 21 homeless youth in California (Smid, Bourgois and Auerswald 2010) revealed that most of the youth chose to continue their pregnancies and saw pregnancy as a catalyst to transform their personal lives and become good parents. Similarly, Gelberg and colleagues (2004) reported that some of the homeless women in their study believed that becoming pregnant would motivate them to care for themselves and get off the streets. For street-involved and/or homeless women, pregnancy was a primary motivator to change substance use behaviours or access treatment (Crawford et al. 2011; Jackson and Shannon 2012).

Context for the Current Study

Since 2003, Edmonton, Alberta, Canada has seen an alarming rise in infectious syphilis cases, mainly among heterosexual persons (Gratix et al. 2007). For several decades, all pregnant women who access antenatal care in the province have been routinely tested for syphilis. In the early phase of this outbreak, the majority of infectious syphilis cases occurred in single males with a history of street involvement, such as substance use and/or sex work; among female cases infection rates were 20 times higher in Aboriginal women than their non-Aboriginal counterparts (Gratrix et al.). An escalation in the number of infants infected with congenital syphilis, passed from their mothers at the time of birth, accompanied this rise in syphilis rates (Singh et al. 2007). Of the nine mothers who delivered an infant with congenital syphilis between 2005 and 2006, six were First Nations, five reported working sex trade and four did not access antenatal care prior to delivery (Singh et al.).

In response to the outbreak, and the observation that many of the women were street-involved and accessed routine health services infrequently or not at all, a peer-based outreach program called Women in the Shadows (WIS) was designed and implemented in April 2008 (Mill, Singh and Taylor 2011). This initiative was a collaborative venture between the Edmonton Sexually Transmitted Infections (STIs) Clinic's Outreach Team (a team of registered nurses [RNs] and community health representatives providing STI care in Edmonton's inner city and Streetworks, the local needle exchange program) with funding from the Public Health Agency of Canada and in-kind support from the regional health authority. The goal of this program was to determine the feasibility and utility of using inner city community members to reach street-involved pregnant women and to examine the impact of the program on testing for sexually transmitted infections. The seven-member WIS team consisted of two Pregnancy Support Workers (PSWs), one Registered Nurse (RN), and an inner city outreach team (Mill, Singh and Taylor 2011). The team recruited street-involved women who were pregnant, or believed they might be pregnant, to participate in the project. Women were provided prenatal care and some physician services through the program.

The WIS project was designed using a harm reduction (Taylor & Caine, 2013) approach to the provision of pre-natal care for street-involved women. Harm reduction refers to a range of interventions, programs or policies with a primary goal to reduce drug-related harm among individuals who may not be willing or able to pursue a goal of abstinence; this approach does not preclude the use of abstinence-only strategies that are likely to result in a decrease in drug-related harm (Lenton & Single, 1998). Although this approach was initially used in relation to harms from drugs, the concept has broadened in meaning to include harm resulting from excessive drinking, nicotine, and other behaviours that put individuals at increased risk of harm (Logan & Marlatt, 2010). A practitioner using this approach "... meets the client where he or she is at in regards to motivation and ability to change ..." (Logan & Marlatt, p. 202) and endeavors to develop a greater understanding of the complex lives of individuals engaged in at-risk activities (Taylor & Caine). A harm reduction approach is based on a philosophy that care should be provided in a non-judgmental, non-stigmatizing manner in order to reduce barriers to health cate and promote access. Based on findings from a Canadian study, Pauly (2008a) reported that a harm reduction approach enabled nurses to develop respectful relationships, promote autonomy, and enhance decision-making among street-involved individuals with whom they worked. While acknowledging the benefits of this approach, Pauly (2008b) cautions that a harm reduction approach alone is insufficient to address the root causes of inequities in health and access to services for individuals who are street-involved.

A preliminary analysis was carried out after the first year of the program to evaluate its success: a detailed description of the quantitative findings is reported elsewhere (Singh et al. 2009). Seventy-five women accessed the services of the program between March 1, 2008 and March 31, 2009; the findings demonstrated that the program's objectives had been achieved and exceeded with regards to the number of women reached. In order to provide a more in-depth understanding of the factors that contributed to the program's success and what program elements required modification, in-depth, individual interviews were carried out with a sub-set of the participants in the WIS program. The purpose of the current paper is to highlight key findings from the interviews, focusing primarily on the women's experiences of homelessness and with the WIS program.

Method

A qualitative approach was used to guide the interview process; this approach was appropriate to provide an in-depth understanding of the WIS program. Ethics approval for this initiative was obtained from the University of Alberta Health Research Ethics Board. Streetworks staff provided a brief overview of the research study to potential participants and referred interested women to the research assistant to obtain informed consent and arrange an interview time. The research assistant was experienced conducting qualitative interviews; prior to carrying out the interviews, she spent time working as a volunteer at Streetworks to familiarize herself with the population. Interviews were conducted between June and August 2009 with 12 clients and seven health care providers associated with WIS. Audio recordings of the interviews were transcribed and subsequently reviewed by two members of the research team, the first author and the research assistant.

An inductive approach was used to analyze the data from the interviews. Morse's (1994) taxonomy guided the iterative approach to comprehending, synthesizing, theorizing, and re-contextualizing the data. A coding framework was developed by the research team using a small subset of interviews in order to comprehend the data. Once the coding framework was developed, the first author and the research assistant independently coded three of the interviews and then compared their coding to ensure that it was being done in the same manner. Any differences in coding were discussed until a consensus was reached. The coding framework was refined as new themes were identified during the analysis process. The qualitative software program NVivo 8 was used to assist with the coding of the transcripts and the management of the data.

Findings

Seven program staff and twelve clients were interviewed. In the following description of the findings, client responses are identified with a "C" and program staff responses are identified with an "S". The staff interviewed included five professional health care providers and two PSWs. Both PSWs were of Aboriginal descent and shared a history of being pregnant and street-involved at some point in their lives and lived in the inner city at the time of the interviews. A staff member described the need to earn trust and respect in the community before being able to do her job effectively. She described the importance of having "walked along beside you [the client] through some of your [the client's] journey" to support some of her clients:

Understanding that [WIS staff members] have kind of an innate "in" with the community because they have been, have come from the community. (S03)

The majority of the clients using WIS services were street-involved (see Table 1 for demographic details).

For many of the women, childhood was a tumultuous time that included frequent changes in living situations, movement between birth families and foster families, and parents who struggled with substance use. The sudden end of a relationship or a change in family situation often preceded homelessness. Beginning or accelerating drug use was frequently linked to traumatic life experiences, such as losing custody of a child. Most of the women interviewed had recently obtained stable housing or transitional housing. Those who were not housed lived on the streets, camped or used shelters.

Most of the participants had experiences with Child Protective Services. For some, their relationship with Child Protective Services had started when they themselves were children. Many of the clients had children under the care of Children's Services or had recently regained custody of their children. The women described losing custody of a child as a painful and devastating experience. Regaining custody of children or retaining custody of their baby involved significant commitment and change on their behalf:

So I went to different programs and completed them and I got my kids back, and I got my own place. I've been living there for seven months now, so ... it feels good. (chuckles) ... It means a lot to me to have my kids back, because it took me 8 months to get my kids back. (C06)

I've been in treatment two times already, and I'm hoping this time it works out, because I really want to get my children back ... and [common-law's name] is supporting me all the way, too, right, so ..., yeah, very big motivation. (C10)

Often regaining custody of one or more children was the motivation for quitting drug use and street-involvement. Women who were working to get their children back shared their frustrations with dealing with Children's Services and the lack of progress despite their efforts:

My youngest is 17 months, and, like, we went through everything, we cleaned up, we sobered up, and it still wasn't enough for the workers. So, like, now I'm going through court trying to get my son back, because I asked welfare to take him so I could get off the drugs. I'm off the drugs, I want my son (laughs), and it's ... it's a big run-around. (C09)

The Challenge of Housing: "One of the biggest drawbacks is housing"

Street-involved pregnant women experienced tremendous challenges in day-to-day survival and in their efforts to transition out of a street lifestyle. Both staff and clients believed that obtaining appropriate housing was essential for any lifestyle change, yet posed one of the greatest challenges. The barriers ranged from difficulties finding out about housing, discrimination, restrictions from landlords, and financial barriers. One of the WIS program staff shared her thoughts:

I think you're going to hear from all staff that the, one of the biggest drawbacks is housing for these women, trying to get them in, into a place, like. It's not even really the finances, because SH [Supports for Independence], Social Services, will pay their damage and that ... They're Aboriginal; a lot of landlords won't rent to Aboriginals 'cause they've had past histories with them on drinking, wrecking the place, or having cops or stuff. So they're pretty much discriminated upon quite often. So just finding them housing is hard. (S05)

A non-Aboriginal participant also described how challenging it was for her to find housing because of the restrictions imposed by landlords:

The rent is way too much ... and it's also because the landlords are putting "No Drugs, No Alcohol." Which is kind of understandable, because the thing is, when you're doing drugs and alcohol, sometimes you forget to pay the rent. So. or there's usually fights and violence and stuff like that. (C02)

Building Relationships: "They don't act like they care, they do care"

Staff members and clients provided insights about the philosophy of the WIS program and how staff approached the delivery of services. One staff member believed that it was:

All about being flexible and being able to communicate with the clients at their level, and to try and teach them, um ... trying to teach them how to access health care or, you know, to try and give them that confidence in order to ask the right questions. (S02)

Providing accessible services to the clients required a different approach than other agencies. A client recounted:

They made you feel comfortable, that's what they do. Like, I never felt like I didn't belong or anything when I was in here. It was just all friendly and fun to be around. They all have, they're all in good moods, none of them are bitchy or anything. (C05)

Staff were usually the first people clients were able to rely on for support. One of the women described how she felt after talking with a staff member:

Mostly I talk to [WIS staff], so she's, like, really good, good help. She keeps me positive when I'm down. Sometimes I'll just be having just the shittiest day, and I'll come here and talk to her, and that's when I'm just, like, really happy after that. So, I find, that's-, those are good support. (CO6)

While staff worked with clients who had lost hope of being mothers, they also worked with clients who wanted the opportunity to be mothers. Staff saw their role as being supportive in working toward this goal:

It's pretty awesome seeing, like, what they can do once they just focus, focus and we just keep reassuring them. Focusing, reassuring, and support. (S07)

The women reported that staff members were responsive to clients' needs; being non-judgmental was vital to building relationships with the women. The women valued this above all else:

You can ask questions about things and get a positive answer, not, you know, a rude remark or anything. (C06)

They listen awesome, they don't judge you. And that's the biggest thing ... Like, they don't act like they care; they do care.... that's what makes it easier for me to come to talk to, say, anybody in here, is they know my ups and downs, they know if I'm not doing good. (C09)

They were there to listen to me. They were just there for me, and many days, as a friend, as staff. (long pause) I would honestly have to say I wouldn't be this far if it wasn't for the staff here at [inner city agency]. I know that for a fact. Because I know no matter how many times I fell off, did everything, they were always there to pick me back up and make me try again. They've done a lot ... (C11)

The biggest thing I like about the staff here at [inner city agency], I'd have to say is they don't judge; they don't judge whether you're, you know, about to go into labour and you're standing in front of them smoking crack. They're not going to be, like, hating you or anything; well, they'll probably give you advice, but not to the point where it just makes you feel ... (C11)

The WIS program evolved to meet clients' needs and provided more than just health services for the women. Women in the Shadows staff members were significantly involved in helping their clients connect with outside services, such as temporary and permanent housing, social assistance, Children's Services and material resources such as clothing. Involvement in these supportive activities helped the staff members build relationships with the various agencies, which in turn assisted them to provide more comprehensive support for clients:

And so we started working with [Children's Services] well, and they did a lot in terms of teaching us about the rules of Children's Services, what does an apprehension order look like, and what's probably going to happen if the mom goes into hospital to deliver while she's still quite intoxicated or hasn't worked on addictions, and what can you prepare the mom to say to the Children's Services there when they come, when Crisis comes in. So, I mean, the social worker. So we started linking up with them and then trying really hard to bring the women downstairs [to where Childrens' Services office is]. (S03)

Another staff noted the importance of networking with others when trying to match a client with the best suited obstetrician:

We used a lot of the obstetricians at [physician clinic] and as well as the [primary health] Clinic and a few times, [community health] prenatal programs, we used quite a bit, so we built a relationship with all of those and were able to, connect them up with, with those services. (S06)

Experiences accessing the WIS program--"They care, they have heart"

Many of the women were motivated to seek out prenatal care when they became pregnant or suspected that they were pregnant. The majority were already familiar with Streetworks and learned about the program through word-of-mouth or from a WIS or Streetworks' staff member. One client was referred by an outside agency; another heard about the program through a family member. Clients described the WIS office as professional (i.e. similar to what they saw in other health facilities), welcoming, comfortable, and highly flexible. Women in the Shadows clients and staff described a wide variety of services that the women accessed, ranging from clinical services to non-medical support. Women in the Shadows clients repeatedly described the program as a nutrition access point, connecting them with milk coupons, vitamins, nutrition counselling, and food offered during drop-in sessions.

One of the goals of the program was to ensure that mother and baby were as healthy as possible, thereby increasing the likelihood of a positive pregnancy outcome. The program allowed women to access non-judgemental medical care. One of the health services provided to the women was an assessment of the baby's health using a handheld Doppler to hear the fetal heart. The women could drop in at any time to hear their baby's heartbeat. For several women, hearing the fetal heart rate was a deep and emotional experience, providing the client with comfort regarding the baby's well-being. One of the women provided a powerful description of this experience:

The more I started coming here, the more I started hearing the heart beat, the more I started having ... the motherly thoughts that I should be having ... it started making me feel again, started making me ... aware that there was a baby and I was starting to love it. It took me a while. (C01)

Overwhelmingly, the clients described WIS staff members as sources of emotional support. Staff would listen, and provide counselling, encouragement, and reassurance. The majority of the women considered staff as more than just health care providers; they looked upon them as family members and friends who were there when the clients needed them most. Several of the clients felt motivated by the staff to make positive changes in their lives. The staff members were described as friendly, helpful, and non-judgemental. They were perceived as willing to go above and beyond what was expected of them as staff:

They care, they have heart. I absolutely love [WIS staff] and [WIS staff]. They're ... I consider them good friends now. I've, I've grown a bond with the people, even the doctor that runs here. (C01)

In addition to providing prenatal health care, staff engaged in a number of advocacy roles particularly pertaining to Children's Services. While not initially part of the program's mandate, staff quickly recognized the WIS clients' need for an advocate and guide for interactions with Children's Services.

The women who accessed the services experienced challenges navigating the traditional health care system. The instability in these women's lives introduced significant challenges that might not be readily apparent to professionals who did not normally work with this population. Both the clients and the staff members commented that something as simple as remembering to keep an appointment could prove to be difficult. Additionally, lack of transportation contributed to missed appointments. The flexibility of staff and the outreach approach helped to address some of these barriers. Overall, clients were satisfied with the care that they received through the program.

The caring approach, flexibility, and openness of the staff were seen as program strengths. The drop-in format, the willingness to accept women at any stage in their pregnancy, and the incorporation of a harm reduction approach were identified as positive aspects of the program. The program helped to alleviate shame and promote empowerment, allowing honesty in relationships, communication and learning. The willingness of staff to meet women "where they were at" (e.g. not requiring them to be sober and housed) and in the "place they were at" (e.g. through outreach) was appreciated. Through referrals from the different agencies, the number of women using WIS services increased significantly. The program was successful in engaging clients, as evidenced by the fact that some were returning for services during a second pregnancy.

The use of PSWs to engage in outreach was seen as instrumental to the success of the program. Women in the Shadows staff commented that having PSWs who were members of the community was integral to understanding the clients' backgrounds. In addition, the significant growth in capacity of the PSWs over the course of the project was noted. One PSW explained how she quickly established trust with clients:

A lot of them know I have a, a history, a past history on the streets, that, right away, they can tell that I used to be an addict; they can tell that right away. So ... they trust me more because they know I've been there, done that. (S05)

Another staff member believed that homeless pregnant women were more comfortable seeking advice from staff members who were connected to the community:

You're helping somebody make a difference in their life, and seeing where they come from and their background and knowing pretty much everything about them, just holding all that, you know, letting them know that this is strictly between you and them ... with that, they're able to, like, keep coming to us and making us, you know, feel super. (S07)

One staff member commented that PSWs were invaluable because they "have some lived experience, and [are] able to walk alongside the person making them feel supported" (S03)

Program Challenges--"It can be just too overwhelming"

The experiences of clients were overwhelmingly positive when accessing the WIS program; however, several challenges and recommendations were identified by staff members and clients. The chaotic lives of the women made it difficult for them to keep appointments. Women in the Shadows staff members were constantly rescheduling appointments, organizing transportation, and working the system in order to facilitate access. As one client recalled:

They pretty much helped me out with everything. They gave me a doctor and, um, they gave me rides to go see my doctor and stuff. And, uh (long pause) yeah, they pretty much did everything for me. (C08)

Transportation for women to get to their appointments was another very real challenge for staff members. The PSWs did not have drivers' licenses and so

relied on other staff members to assist with transportation:

If one outreach worker drove and had a vehicle; it'd make things so much easier. That's when we have to depend on the other co-workers, if one of our clients is too ill to travel by bus, or if they're late and they call in late and they're, like, have to get there in 20 minutes, you know, and it's just no way you're going to get there by bus in 20 minutes. That makes it hard, I think. (S05)

One PSW described the stress associated with working with this population:

You can't be over-sensitive in this position. And (long pause) uh, you got to really know how to handle problems that come up, and, and your own stress and that, otherwise it can be just too overwhelming, I think, for, for a lot of people. I don't think a lot of people could do this kind of work. I think it would get to them too much ..., sometimes that's how it feels when their baby's been taken away, you know? You feel that, that loss, too, and that disappointment that they lost their baby, and you know, that they're not going to get them back. (S05)

While the involvement of PSWs from the community was undoubtedly seen as a strength of the program, some staff expressed concerns about this approach. These staff questioned whether the PSWs background in the community might jeopardize patient confidentiality. Recognizing this as an issue, confidentiality training was conducted shortly after the program started and no incidences of confidentiality violation were reported. In addition, the PSWs stated that there were some aspects of care in which they felt they lacked experience and that certain messages were more effective when delivered by a health care professional. One of the professional staff commented on these issues:

Because, you know, nurses and physicians, in order to keep our license, we have to have certain rules that we follow around confidentiality, so that's entrenched in us from, through our training and through years and years of training and through years and years of work, and it's reinforced. But for individuals who don't come from that kind of training, it's a difficult thing to expect them to learn in a very short time, so there is a bit of a challenge around that. (S06)

The staff started the program by establishing connections and working with agencies serving the street-involved population. Women in the Shadows staff wanted to work collaboratively to avoid working in isolation, but it was not a smooth transition in the early stages of the program. They also suggested that this was not caused by geographic barriers, but rather because other agencies did not know what to expect of the WIS program:

I think we were always looked at as "the bad guys," because we're from [government health agency] and we've got all this funding behind, you know what I mean? So communication could have been better. It was never adversarial, but it was more like, well, "We'll only tell you what we really need to tell you." (S04)

Staff members commented that strategic actions could be taken to improve interactions and coordination with other agencies. This, in turn, could produce more positive outcomes for clients. Despite this realization, three of the staff mentioned that "territoriality" was a concern both within the program and between programs. One of the staff members expressed her sensitivity to this issue:

I'm more than willing to refer them to WIS because we do have a rapport with them, and, um, you know, like I said, I'd really love to have my hands on there and, you know, but it's really hard not to step on other people's toes and make them feel, you know, like, that, you know, that I've sort of taken over their territory and, um ... (S02)

As the program evolved, these issues were discussed and dealt with when staff became aware of them.

Discussion

Overwhelmingly, clients described the WIS staff members as sources of emotional support. Staff would listen, and provide counselling, encouragement, and reassurance. The caring approach, flexibility, and openness of staff were seen as program strengths. Similar to previously reported research (Hathazi et al. 2009; Smid, Bourgois and Auerswald 2012) many of the women in the current study were motivated to access prenatal care when they became pregnant or suspected that they were pregnant. Access to prenatal care is critical to the health of street-involved mothers and their babies. Hathazi and colleagues (2009) reported that street-involved women who received prenatal care were less likely to report a miscarriage than those who did not have prenatal care. Several of the clients felt motivated by the staff to make positive changes in their lives. In a study with American street-involved women (Sloss and Harper 2004), participants often decreased or stopped their street work while pregnant. Participants were stressed that they would be separated from their children, they would be unable to find child care to accommodate their work hours, their children could be harmed by their work, and by the reality that their work was very financially unstable. In addition to services to address pregnancy-related health needs, street-involved pregnant women must develop parenting skills, despite often having poor parenting role models in their own childhood (Ruttan, Laboucane-Benson and Munro 2012).

The issue of child custody is a critical and often stressful issue for homeless and street-involved women. The participants in the current study described the experience of losing custody of a child as a painful and devastating one. Homeless and street-involved pregnant women, including those in the current study, are often involved with Child Protective Services in relation to the custody of their older children. Bloom and colleagues (2004) reported that although 83% of the homeless pregnant women in their study had been pregnant at least once previously, only 38% of the women had children living with them. Similar findings were reported by Smid and colleagues (2010); among 21 California homeless youth, 15 pregnancies were carried to term, and of these only three babies remained in the custody of their parents. The participants in this study were fearful of mainstream institutions and sometimes delayed seeking health care because they were concerned that care providers would report them to Child Protective Services. Crawford and colleagues (2011) explored pregnancy and mental health in 90 young homeless women and found that just over half (55%) of the women had constant custody of their children and almost 20% had never had custody of their children. Sloss and Harper (2004) also argue that street-involved mothers may delay or avoid accessing services for themselves and their children due to a fear that they will be deemed unfit and separated from their children.

Program design is critical to ensure that street-involved and/or homeless pregnant women are able to access prenatal care. The drop-in format, the willingness to accept women at any stage in their pregnancy, and the incorporation of a harm reduction approach were identified as positive aspects of the program. The program approach helped to alleviate shame and promote empowerment, allowing honesty in relationships, communication and learning. The willingness of WIS staff to meet women "where they were at" (e.g., not requiring them to be sober and housed) and in the "place they were at" (e.g., through outreach) was appreciated. In a recent study with substance using pregnant women, Wright and colleagues (2012) found that the use of a comprehensive, harm reduction approach to prenatal care was successful in preventing some of the effects of drug use, such as pre-term birth. Several authors (Benoit et al. 2003; Niccols, Dell and Clarke 2010) have argued that an integrated model of care that provides culturally appropriate services is required to address Aboriginal women's health concerns. Integrated programs typically incorporate services to address both the health and social needs of clients. Marshall and colleagues (2005) evaluated the Sheway program for substance using pregnant and parenting women over a 9 year period and found that the program served an increasing proportion of Aboriginal women with increasing health and social challenges. Despite these challenges, indicators of infant health stayed the same or improved over the evaluation period. The Sheway program offers a comprehensive, flexible, harm reduction approach to care that is client driven. The availability of older, supportive mentors has also been advocated as a critical aspect of prenatal care for homeless pregnant women (Crawford et al. 2011).

Housing was viewed by participants as one of the most challenging issues they faced and was fundamental to making changes to transitioning out of a life on the streets. Securing safe, affordable housing has been identified as a critical resource for street-involved or homeless parents who are hoping to maintain custody of their infants (Crawford et al. 2011; Ruttan, Laboucane-Benson and Munro 2012; Smid, Bourgois and Auerswald 2010). In a recent study with 41 homeless young injection drug users, Hathazi and colleagues (2009) reported that pregnancy motivated some participants to seek housing, however presented challenges for those who were already housed. Cooper and colleagues (2009) interviewed 12 homeless, pregnant Toronto women to explore the ideal shelter design. The women recommended that shelters be purposively designed to: provide secure, accessible space that feels like home; include a range of services; provide opportunities to foster empowerment and build self-confidence among residents; and enable residents to engage with the community.

A limitation of the current study is that we were only able to interview 12 out of the total 75 women who accessed the WIS program. This subset of 12 women were still accessing services at WIS and/or Streetworks at the time of recruitment and therefore may have represented the more stable, motivated women within the larger group. Additionally, the sample was drawn from one urban area so the experiences of homeless, pregnant women in rural settings and other urban areas may be different. In a recent study, Parker and colleagues (2012) reported that rural intravenous drug users in Atlantic Canada had challenges accessing harm reduction information and services, and were more likely to re-use or share syringes when clean equipment was not available. The WIS program was itself very challenging to deliver. It was important to provide structure to the program to ensure that services were provided in a consistent, fair manner, while at the same time building in some degree flexibility to meet the unique needs of each woman. Working with an extremely vulnerable population, and in this instance, women who may have several layers of vulnerability, may be very challenging for staff: the emotional energy required, and potential for burnout considered, must be considered in planning support for staff.

The use of PSWs represented a shift from the more traditional way of delivering care and services to street involved pregnant women and provides a compelling example of a harm reduction approach. This approach was highly valued by the women and was successful in facilitating the women's access to services for themselves and their unborn children. Despite the challenges highlighted, our study highlighted the benefits of using women who have had direct experience with being pregnant and giving birth while living in unstable social situations. This study supports the need for specialized services and initiatives to be delivered in an innovative way and with the use of peers to successfully reach street-involved women who are either pregnant or might become pregnant. It is hoped that the strengths and challenges flora this study will be used to continue and further enhance future services to this population.

Acknowledgments

The authors would like to acknowledge funding received from the Public Health Agency of Canada and Alberta Health Services. In addition, we would like to acknowledge the following partner organizations and their staff, without whom this work would not have been possible: Streetworks and Alberta Health Services Edmonton STI Clinic/Boyle McCauley Public Health Outreach. We also acknowledge the contributions of Amanda Jones, a research assistant for the project for her assistance with the data collection and management.

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Judy Mill

Faculty of Nursing

University of Alberta

Ameeta Singh

Medical Director, Alberta Health Services-Edmonton STI Clinic, Clinical Professor, Division of Infectious Diseases, University of Alberta

Marliss Taylor

Program Manager Streetworks

Edmonton, Alberta

Table 1: Demographic Profile of Women in the Shadows Participants
(n = 12)

Ethnicity Age Number of Housing Drug/alcohol
 children during last use during
 pregnancy pregnancy

Aboriginal: 9 Mean: 25.5 Mean: 3.4 Homeless/on Drug/alcohol
 years street: 5 use during
 pregnancy: 10

Non-Aboriginal: Range: 17-39 Range: 1-7 Shelters/ Unknown:2
3 years temporary
 housing: 4

 Housed: 3