The H.E.R. Pregnancy Program

What is the Program?

The H.E.R. (Healthy, Empowered, Resilient) Pregnancy Program operates out of Streetworks, located at the Boyle Street Community Services in Edmonton. The H.E.R. program aims to assist street-involved pregnant women to access healthcare and social resources – ultimately supporting women to shape and attain their pregnancy and parenting goals. The staff work to build trust with the women, empower them to believe in their own worth and vision for the future, and link them with the services and resources they need to achieve their goals. Staff provide health education nursing services including testing, systems navigation, referrals, and accompaniment to health and social services.

The H.E.R. Pregnancy Program has a team of two registered nurses, a social worker and four peer pregnancy support workers. The team works with women throughout their pregnancy and up to six months after they give birth. As part of the program, women are encouraged to get testing for sexually transmitted and bloodborne infections (STBBIs) either from the program nurse or from another healthcare provider. Women who are hepatitis C or HIV positive are linked with treatment and care. All of the women are offered preventive HIV and hepatitis C services, including education and access to harm reduction supplies.

Why Was the Program Developed?

In 2007–2008, Edmonton experienced a significant increase in rates of syphilis. A physician from the STD Centre (also known as the Sexually Transmitted Infections Clinic) in Edmonton approached the Streetworks program to explore how they might collaborate to address the syphilis outbreak and specifically work to help high-risk pregnant women to access prenatal care. The STD Centre accessed funding from 2008–2010 to implement this peer-based outreach program called Women in the Shadows.

The Alberta government started to fund the program in 2011, and it has evolved into the more comprehensive H.E.R. program. This funding allows the H.E.R. program to maintain a larger staff complement, provide a broader set of services for its clients and gain greater access to materials and supplies than the Women in the Shadows program was able to do.

How Does the Program Work?

The women in the H.E.R. program can face stigma and discrimination because of drug or alcohol use, engagement in survival sex, a history of incarceration, homelessness, poverty and racism when they access health and social services. This stigma and discrimination can prevent women from engaging with needed services. Women may also avoid accessing services out of fear that Child and Family Services will be alerted and apprehend their child(ren).

The H.E.R. Pregnancy Program works to decrease barriers to health and social services for street-involved pregnant women by firmly grounding their work in a harm reduction approach and by providing culturally safe and trauma-informed care.

The H.E.R. staff team work to:

• build trust with the women in the program;
• build on the women’s strengths and empower them to identify their goals;
• support women to access the health and social services they need based on their goals;
• advocate for the needs/rights of their clients;
• identify allied professionals and educate them on ways to support women in the program;
• build on the strengths of the women and empower them to access the health and social services they require to achieve their goals; and
• support the women if they choose to terminate their pregnancy.

The H.E.R. staff team

The H.E.R. staff team comprises two registered nurses, a social worker and four pregnancy support workers who are women with lived experience of pregnancy and street involvement.

Although team members have some specific role based tasks, roles within the team are kept relatively fluid so that women can receive services from the team members with whom they connect most easily. Team members provide a range of services to women including counselling, case management, safety planning, health education, systems navigation, accompaniment, outreach and group facilitation. All of the team members are also trained by the nurses to offer basic prenatal monitoring including measuring fetal heart rates and fundal heights and conducting kick counts.

The nurses on the team provide STBBI testing to women in the program. They also tend to take the lead on linkage to care and referral to other health service providers, including obstetricians. The nurses can also provide basic primary care to women in the program.

The social worker on the team has strong relationships with other social service agencies and has expertise in linking women with social services and other resources, including housing, welfare and food programs. The social worker also maintains a strong relationship with Child and Family Services and works to build allies/partners within Child and Family Services. The social worker educates women on their parenting options and supports women to advocate for their needs/rights within the Child and Family Services system.

The pregnancy support workers have expertise in system navigation including advocating for women and supporting women as they attend appointments with social and health services. Peer pregnancy support workers can be important mentors to women and demonstrate that it is possible to overcome challenges and achieve health, pregnancy and parenting goals.

Program engagement

In the early years of the program, peer outreach workers met with women on the streets and offered them basic prenatal services as a program engagement tool. Now, most women who engage with the H.E.R. program are referred by women who have been through the program and had a positive experience.

Many of the women in the program avoid services altogether because they have had negative experiences with service providers including stigma, discrimination and punitive measures such as child apprehension. To make the program space welcoming to women, the program has set up specific visuals to signal some of the values of the program and alleviate specific fears. There is a large vision wall upon arrival that has photographs of women and their babies (with permission) who have been through the program. New clients sometimes recognize some of their friends on the vision wall. The vision wall also demonstrates to women that the program is designed to help them set and achieve their own goals – including becoming a healthy parent if they so choose.

Goal setting

At initial program engagement, a staff member will meet with a woman to understand her health, pregnancy and parenting goals. There is no formal intake process. Staff then work to build relationships with the women and empower them to develop and meet their own short- and long-term goals.

Health education

Health education is an important element of the H.E.R. program. All team members are equipped to provide health education, which is offered both one to one and in a group setting within a weekly pregnancy drop-in (the drop-in is described below).

Health education topics include prenatal health, postpartum realities, healthy parenting, HIV and hepatitis C prevention (including preventing transmission from mother to child) and parenting and pregnancy options, as well as broader health topics such as healthy eating, culture and spirituality, and healthy recreation activities.

System navigation, referrals and accompaniment

An essential component of the H.E.R. program are referrals and accompaniments to health and social services, both within and outside of the Boyle Street Community Services centre.

Boyle Street Community Services is a multiservice agency offering various programs/services on site, including mental health services, a housing program, a family support program, an Indian Residential School Survivors program, an employment program and an Inner City Child and Family Services office. Women in the H.E.R. program can access any of these programs and services.

The H.E.R. team works closely with the Boyle McCauley Health Centre, a nearby community health centre, which offers a range of primary care services. The H.E.R. staff also conduct hospital tours with women, accompany women to meet with the hospital social worker, accompany women to visits with welfare workers and support women in navigating other health and social systems, including Child and Family Services.

As part of the H.E.R. program’s system navigation services, H.E.R. staff engage in individual advocacy for their clients. For example, if a client is cut off from an agency for missing appointments, they will work to find solutions and help to advocate for their client’s needs and realities.

Prenatal care and STBBI testing

The H.E.R. staff offer basic prenatal monitoring, including measuring fetal heart rates and fundal heights and conducting kick counts. These basic prenatal services are offered on the street or wherever the woman is located.

More intensive prenatal care services are offered through referrals and accompaniment to allied professionals and health services outside of Boyle Street Community Services.

The two registered nurses can offer a range of STBBI tests to clients, including HIV and hepatitis C tests. If these tests come back positive, the clients are linked with appropriate clinics and accompanied, if they wish. Women can also access STBBI testing through an off-site obstetrician or external healthcare provider if they prefer.

Access to resources

The H.E.R. program collaborates with a variety of local community groups to make specific pregnancy- and parenting-related resources available to women in the program. Through the H.E.R. program, women are able to obtain baby clothing, diapers, coupons for baby food and other resources that are important for the health of the women and their children.

Pregnancy drop-in peer support and education

The H.E.R. program runs a weekly pregnancy drop-in for women in the program and women who are no longer in the program but still want to maintain a connection. This weekly drop-in space allows women to access peer support and advice. Peer support is an essential component of the H.E.R. program. The weekly pregnancy drop-in also provides women with a healthy meal, and the space is also used for group health education.

Harm reduction services

The H.E.R. program is closely connected with the Streetworks Needle Exchange program, which operates on site in the Boyle Street Community Services as well as in 14 other locations. Women in the H.E.R. program are able to access clean needles and other clean drug-use equipment through this program. Streetworks has a mobile van and an outreach team, so harm reduction supplies can be made available to women on the street or in other locations. Women are also offered education on safer drug use, including education on how to prevent HIV, hepatitis C and other infections. The H.E.R. staff work to educate women on safer substance use as well as other important ways to improve their health.

Support in working with Child and Family Services

Many women in the H.E.R. program have had negative experiences with the child protection system and have been traumatized from having had a child apprehended in the past and being excluded from any role in planning for their child or parenting. Many women avoid contact with any health or social services during their pregnancy out of fear that Child and Family Services might be alerted. Yet, avoiding Child and Family Services during pregnancy can lead to a situation where a child is more likely to be apprehended at birth and/or women are left with little ownership over their parenting experience.

There is a Child and Family Services office on site at the Boyle Street Community Services. The H.E.R. staff work to understand each client’s specific pregnancy and parenting goals and, where appropriate, encourage women to connect with the Child and Family Services office during their pregnancy, as this tends to improve the chance that a mother can have ownership over her parenting experience. Ultimately the decision to connect with Child and Family Services is left entirely with the woman, and the program respects each woman’s individual choice. The H.E.R. staff team work to ensure that women are heard and respected and that they develop effective relationships with the children’s service workers. They help to advocate for women’s rights and ensure that women are supported to achieve their parenting goals, whether this means being the primary caregiver, arranging a kinship care situation or making another arrangement.

Safety planning

Women who are on the street and pregnant face a variety of serious risks, such as violence, exposure to the elements, lack of sleep and isolation during a health crisis. H.E.R. staff work with clients to develop safety planning measures. For example, if a woman is in her final stages of pregnancy, H.E.R. staff work with her to develop a labour plan, if it happens on the streets and when the H.E.R. program is closed. H.E.R. staff will also work with women to develop a list of contacts or alternative safe spaces that women could go to in case of an emergency.

Partnerships and education

The H.E.R. staff work to develop partnerships with a range of health and social service providers who can help H.E.R. clients to achieve their goals. They provide training and education to these health and social service partners on substance use and pregnancy, cultural safety and trauma-informed work, and other information and skills that can help service providers to work in a positive manner with the H.E.R. clients. Education and skill building with partners reduce the stigma and discrimination faced by H.E.R. clients and promote the development of a health and social service system that supports healthy pregnancy, healthy mothers and healthy babies and breaks the cycle of apprehension, trauma and oppression in this community.

Required Resources

Accurate, unbiased information on pregnancy, substance use and healthy parenting

Women who use substances and experience poverty and/or mental health challenges can be healthy and loving parents. There is misinformation about pregnancy, substance use and healthy parenting and it is important to equip clients, staff and partners with accurate information.

Peer support workers and professional staff who embrace strengths-based and harm reduction approaches

Women come in to the H.E.R. program with a lot of guilt and self-blame. It is essential that staff empower and support women to see their own worth and achieve their short- and long-term goals.

Partnerships and skill building with a range of social service and health professionals

The H.E.R. program helps to link women with supports and services in the community. It is essential to build partnerships with other health and community services, including child protection services. It is also important to educate and develop the skills and abilities of these partners to work effectively with street-involved pregnant women.

Harm reduction supplies

Access to safer substance use equipment and resources is an important part of supporting pregnant women who may use substances.

Fetal heart monitor

Many women find it motivating and encouraging to hear their baby’s heart, especially when they are going through a challenging period. It is important to be able to offer prenatal supports such as fetal heart rate monitoring wherever women are at – on the street, in a detox or elsewhere – without the need to make an appointment.

Challenges

Lack of hope

One of the greatest barriers to supporting women to access health and social services is that women can lack the hope that they can be healthy and achieve their pregnancy and parenting goals. Women can experience internalized blame, shame and guilt and can accept messages of low self-worth and their inability to be healthy individuals or parents that they receive.

Stigma and discrimination by service providers

The stigma and discrimination that street-involved pregnant women can face from service providers often prevent them from seeking services and accessing care.

Misinformation about pregnancy, substance use and healthy parenting

There is misinformation about the impact of different substances on a fetus, as well as misinformation that mothers who use substances cannot be good parents. This misinformation can prevent women and service providers from exploring the range of health and parenting options available, making educated choices and pursuing positive goals.

Services and programs that do not take a harm reduction approach

Stopping all substance use is not always an option for women. However, women who use substances can still be supported to have a healthy pregnancy and be loving parents if they so choose. When service providers and programs take a punitive and abstinence-based approach, women can disengage from services.

Evaluation

In April 2012, the Alberta Centre for Child, Family and Community Research (ACCFCR) contracted an independent evaluator to conduct an impact evaluation of the H.E.R. Pregnancy Program. The evaluation included a photovoice project, staff focus groups, key informant interviews with stakeholders, analysis of program data and a social return on investment analysis.

Findings from the program evaluation (April 2011 to July 2013) demonstrate that the program is successfully supporting women to feel empowered, linking women with social and health resources, and supporting women to achieve their health and parenting goals. The program is successfully supporting mothers who would like to become parents to keep their children.

The findings also show that the program is helping women to access health and social services and that women are experiencing a number of positive changes related to substance use and sexual practices. The evaluation also indicates that women in the H.E.R. program are feeling more empowered to stay safe and be involved in decisions about the care of their babies.

The social return on investment analysis revealed that every dollar invested in the program yields $8.24 in social value.

Key outcomes between 2011 and 2013:

• One hundred and thirty-four street-involved pregnant women received services/support from the H.E.R. Pregnancy Program over the evaluation period.
• Fifty-three percent of babies remained in the care of their mothers and 8% went into the care of family and friends. Children and Family Services estimates that 95–100% of these births would have resulted in apprehension without the intervention of the H.E.R. program.
• Of the women who were unable to parent because of homelessness or other factors, 70% were able to explore options for staying connected with their babies and involved in planning.
• Women in the H.E.R. program received the following health and social services: general support (100%), health education (94%), referral (75%), health services (74%) and advocacy support (74%).
• Client substance use was reported in 60% of the 139 pregnancies. While connected to the program, women reported elimination of use (40%), safer use (37%) and reduction of substance use (26%), at least once during their pregnancy with the program.

Lessons Learned

1. All women have the potential to be healthy, loving parents: If street-involved pregnant women are given hope and supported to access services, they can be healthy and loving parents. Most women in the program keep their children and go on to become healthy parents.
2. Advocacy work is critical to support women in navigating the child protection system: Many women have had traumatic experiences with child protection services and face discrimination within the system. It is critical to support women to be heard, advocating for their rights and accompanying women as they navigate the child protection system.
3. Healthy mothers lead to healthy babies, breaking cycles of intergenerational trauma: Separating mothers from children can be traumatizing and perpetuate cycles of oppression. It is essential to focus on the health and healing of mothers because this is deeply connected with the health of babies, families and communities in both the short and long terms.
4. It is critical to educate health and social service providers on how to work more supportively with pregnant women who use substances: Pregnant women who use substances face a great deal of stigma within health and social services, which can prevent them from engaging with services. Service providers may not be familiar with harm reduction and can take a punitive approach rather than supporting and empowering pregnant women to achieve their health goals. Education for service providers is critical so they can work more effectively with this population.
5. Street-involved pregnant women benefit from system navigation and accompaniment: Street-involved pregnant women have often experienced stigma and discrimination from service providers, which prevents them from engaging in care. Many women have had a traumatic life and experienced sexual and domestic abuse. Physical examinations and other health services can be triggering. System navigation and accompaniment services enable women to access services with a supportive advocate.
6. Pregnant women require specialized harm reduction services: Pregnant women who use drugs may not access harm reduction programs out of fear that child welfare services will be alerted and/or fear that they may face discrimination within these programs. Harm reduction services need to create specialized programs, policies and approaches to ensure they are accessible and supportive to pregnant women.
7. It is important to offer culturally safe health, family and parenting services: Health and parenting are culturally specific. Some Indigenous pregnant women may prefer culturally specific services. All women require health and parenting services that respect their culture.
8. Mobile prenatal monitoring is an important engagement tool: Mobile prenatal services can be an effective engagement tool for women who can then be linked with trauma-informed and harm reduction services.

Program Materials

• Impact Evaluation of the Healthy, Empowered and Resilient (H.E.R.) Pregnancy Program: Summary Final Report
• Impact Evaluation of the Healthy, Empowered and Resilient (H.E.R.) Pregnancy Program: Photovoice Final Report
• Oh Shit I’m Pregnant Booklet
• Supporting Pregnant and Parenting Women Who Use Substances: What Communities are Doing to Help

Contact Information

Morgan Chalifoux

Team lead/support worker
Streetworks
10116-105 Ave NW
Edmonton, AB, T5H 0K2
Tel: 780-239-2872
mchalifoux@boylestreet.org