Health consequences of child removal among Indigenous and non-Indigenous sex workers: Examining trajectories, mechanisms and resiliencies.

The child protection system can be a highly consequential institution for mothers who are sex workers, yet scant attention has been paid to the health consequences of its policies on this population. Drawing on 31 in-depth, semi-structured interviews with 19 Indigenous and 12 non-Indigenous sex workers in Vancouver, Canada, and using the stress process model and the concept of slow violence, this study proposes a typology of four trajectories through which child removal by this system shaped sex workers' health. Results suggest that child removal has health consequences beyond the conventionally thought of mechanism of mental distress and related health sequelae, to additionally alter women's social conditions, which also carried risks for health. Notably, while trajectories of Indigenous and non-Indigenous sex workers were similar, Indigenous participants, whose families are disproportionately impacted by long-standing colonial policies of child removal, were more severely jeopardized. Findings highlight how child removal can enact violence in the form of reverberating harms to sex workers' health, further reinforcing their marginalized statuses. This study calls for greater attention to how the child protection system (CPS) may influence the health of marginalized mothers, including how health inequities may be both causes and consequences of interventions by this system.

Family Separation and Maternal Self-rated Health: Evidence from a Prospective Cohort of Marginalized Mothers in a Canadian Setting.

OBJECTIVES: Involuntary child removal via the child protection system disproportionately affects marginalized women, yet the impacts on maternal health are under-investigated. This study prospectively examined the association of child removal with self-rated health of mothers who are sex workers. Given high levels of intergenerational family separation in this population, particularly among Indigenous sex workers, we also estimated joint effects of child removal spanning two generations. METHODS: Analyses drew on 2010-2015 data from AESHA (An Evaluation of Sex Workers' Health Access), a prospective cohort of sex workers (n = 950) in Vancouver, Canada. Using logistic regression with generalized estimating equations, we modeled the association of past child removal and current self-rated health in a sample of 466 sex workers who ever had a live birth. Joint effects of child removal and history of removal from own parents were also investigated. RESULTS: Of 466 sex workers, 180 (38.6%) reported child removal at baseline and 147 (31.6%) had a history of removal from own parents. In main effects model, child removal was associated with increased odds of poorer self-rated health [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.04, 2.16]. Joint effects model showed higher odds of poorer self-rated health (OR 2.04, 95% CI 1.27, 3.27) among women with intergenerational family separation. CONCLUSION FOR PRACTICE: Child removal was negatively associated with sex workers' health that was worsened when family separation spanned two generations. Findings underscore need to develop sex worker and Indigenous-led family support services, along with tailored interventions to address health needs of those separated from their children.

Integrated care for pregnant women on methadone maintenance treatment: Canadian primary care cohort study.

OBJECTIVE: To describe the characteristics of a national cohort of pregnant women on methadone maintenance treatment (MMT) and to provide treatment outcome data for integrated care programs. DESIGN: Retrospective chart review. SETTING: Three different integrated care programs in geographically distinct cities: the Toronto Centre for Substance Use in Pregnancy in Toronto, Ont; the Herzl Family Practice Centre in Montreal, Que; and the Sheway clinic in Vancouver, BC. PARTICIPANTS: Pregnant women meeting criteria for opioid dependence and attending an integrated care program between 1997 and 2009. Women were excluded if they were on MMT only for chronic pain. MAIN OUTCOME MEASURES: Patient demographic characteristics, concurrent medical and psychiatric disorders, and substance use outcome data. RESULTS: A total of 102 opioid-dependent pregnancies were included. The mean age was 29.7 years and 64% of women were white. Women in Montreal were more likely to have partners and had fewer children. Differences in living and housing situations among the sites tended to resolve by the time of delivery. Almost half of this cohort tested positive for hepatitis C. Women had a high prevalence of depression and anxiety across all sites. Half of this cohort was on MMT before conception and for the other half, MMT was initiated at a mean gestational age of 20.7 weeks, resulting in a mean dose of 82.4 mg at delivery. At the first visit, polysubstance use was common. Prescription opioid use was more frequent in Toronto and heroin use was more prevalent in Vancouver and Montreal. For the entire population, significant reductions were found by the time of delivery for illicit (P < .001) and prescription opioids (P = .001), cocaine (P < .001), marijuana (P = .009), and alcohol use (P < .001). CONCLUSION: Despite geographic differences, all 3 integrated care programs have been associated with significant decreases in substance use in pregnant opioid-dependent women.

A rooming-in program to mitigate the need to treat for opiate withdrawal in the newborn.

OBJECTIVE: The purpose of this study was to explore the effect of our rooming-in protocol on the need to treat withdrawal in the opiate-exposed newborn. METHODS: We reviewed the medical records of mother-infant dyads born between October 1, 2003, and December 31, 2006, who received care in our rooming-in program. Data on the type of drug used by the mother, maternal methadone dose at delivery, morphine treatment of the baby, and perinatal outcome were considered. RESULTS: We found a significant positive relationship between maternal methadone dose at delivery, "other opiate" use, and breastfeeding and the need to treat the neonate for withdrawal. We also found the maternal methadone dose at delivery to be related to the duration of pharmacological treatment of the neonate. CONCLUSION: Our findings suggest a role for our rooming-in program in mitigating the relationship between maternal methadone dosage and the need to treat opiate withdrawal in the newborn. Consideration of the role played by the mother-infant dyad model of care needs to be considered in future studies.

An evaluation of rooming-in among substance-exposed newborns in British Columbia.

OBJECTIVE: Rooming-in, the practice of caring for mother and newborn together in the same room immediately from birth, is preferred for the general postpartum population but is not yet standard practice of care for newborns of substance-using women. Such newborns are usually separated from their mothers and admitted to a neonatal intensive care unit and treated for substance withdrawal if necessary. We compared clinical and psychosocial outcomes associated with traditional standard care models versus an interdisciplinary rooming-in model of care for substance-exposed newborns. METHODS: We conducted a retrospective comparative review of a cohort of substance-exposed newborns. Data were extracted from the British Columbia Perinatal Health Program database to populate the standard care and rooming-in groups. The main study outcomes were neonatal admission to NICU, breastfeeding, presence of neonatal withdrawal, length of stay, and custody status at discharge. RESULTS: Rooming-in was associated with a significant decrease in admissions to NICU and a shorter NICU length of stay for term infants, increased likelihood of breastfeeding (either exclusively or in combination with formula) during the hospital stay, and increased odds of the baby being discharged home with the mother. There were no significant differences between groups with respect to the presence of neonatal substance withdrawal or breastfeeding status at discharge. CONCLUSION: Rooming-in may facilitate a smooth transition to extrauterine life for substance-exposed newborns by decreasing NICU admissions and NICU length of stay for term infants, encouraging breastfeeding, and increasing maternal custody of infants at discharge. This review supports the finding that rooming-in is both safe and beneficial for substance-exposed babies.

Rooming-in compared with standard care for newborns of mothers using methadone or heroin.

OBJECTIVE: To evaluate the effect of rooming-in (rather than standard nursery care) on the incidence and severity of neonatal abstinence syndrome among opioid-exposed newborns and on the proportion of mothers who retain custody of their babies at hospital discharge. DESIGN: Retrospective cohort study. SETTING: Lower mainland in southwestern British Columbia. PARTICIPANTS: We selected 32 women in the city of Vancouver known to have used heroin or methadone during pregnancy between October 2001 and December 2002. Comparison groups were a historical cohort of 38 women in Vancouver and a concurrent cohort of 36 women cared for in a neighbouring community hospital. MAIN OUTCOME MEASURES: Need for treatment with morphine, number of days of treatment with morphine, and whether babies were discharged in the custody of their mothers. RESULTS: Rooming-in was associated with a significant decrease in need for treatment of neonatal abstinence syndrome compared with the historical cohort (adjusted relative risk [RR] 0.40, 95% confidence interval [CI] 0.20 to 0.78) and the concurrent cohort (adjusted RR 0.39, 95% CI 0.20 to 0.75). Rooming-in was also associated with shorter newborn length of stay in hospital compared with both comparison groups. Newborns who roomed in at BC Women's Hospital were significantly more likely to be discharged in the custody of their mothers than babies in the historical cohort (RR 2.23, 95% CI 1.43 to 3.98) or the concurrent cohort (RR 1.52, 95% CI 1.15 to 2.53) were. CONCLUSION: Rooming-in might ease opioid-exposed newborns' transition to extrauterine life and promote more effective mothering.