“The Journey to Compassionate Care, One woman’s experience with early harm-reduction programs in BC”
by Susan C. Boyd
In 1991, I helped create one of the first woman-centred, harm-reduction programs for women from the Downtown Eastside of Vancouver (DTES). The grassroots program was named Drug and Alcohol Meeting Support for Women (DAMS) by women who met weekly (Margaret Michaud (DAMS’ director), Olive Phillips, the women who came to DAMS, and I were the founders of this unique program).
DAMS emerged as a response to concerns about harms associated with drug use, poverty, isolation, HIV/AIDS and parenting. DAMS was committed to working with those women who were deemed difficult to reach, “non-compliant” or “failures” by drug treatment workers and other professionals.
DAMS was a non-discriminatory group whose members met to offer support to one another: our door was open to all women, especially pregnant women and mothers. Outreach, healing circles, one-to-one counseling, drop-in and educational workshops, day care, yearly retreats, and meals were eventually provided. The format was an alternative to 12-step programs offered by Narcotics Anonymous and Alcoholics Anonymous.
DAMS was dedicated to harm reduction, stabilization and self-empowerment. Reunification of the family was also a central component of the program, because most of the women who participated in DAMS had at least one child apprehended by the state.
DAMS sought to meet the needs of women and their dependents. Needs were defined as whatever a woman prioritized (i.e., housing, social and economic support, medical care, prenatal services, reducing drug consumption – for example, smoking marijuana rather than crack-cocaine – methadone maintenance, detox, drug treatment, regaining or maintaining custody of children, getting one’s high school diploma, returning to college or university, etc.).
Abstinence from drugs was not required. Instead, support was diverse and women who used illegal and legal drugs were as welcome as those who sought to abstain. Our group was made up primarily of mothers, the majority of them First Nations women.
Because success was not based on abstinence, funding was quite difficult to obtain. In fact, in the beginning, everyone, including our coordinator, worked voluntarily.
Harm reduction and pre- and post-natal care
Harm reduction had not yet become a household phrase in Vancouver. In the early 1990s, pregnant women and mothers who used illegal drugs had few supports to turn to that were not abstinence-based, and most programs were punitive when they failed to, or could not, comply.
Pregnant women and mothers who used illegal drugs were often depicted by health, social service and criminal justice professionals as manipulative liars, immoral criminals, threats to both themselves and their infants, and more deviant than their male counterparts. Consequently, women suspected of illegal drug use were regulated by overlapping, and sometimes competing, professionals who sought to identify, manage and discipline them. It was believed they were incapable of parenting: drug use equaled poor parenting.
Permanent child apprehension was the norm rather than the exception for poor women suspected of illegal drug use in Vancouver. Thus, DAMS offered not only support but also advocated on women’s behalf.
A handful of individual social workers, doctors and drug treatment and outreach professionals worked with DAMS providing services and a non-judgmental approach. DAMS was intent on changing the attitudes of medical, social service and drug treatment professionals so that women and their children would have direct access to essential services, including culturally relevant, woman-centred, harm-reduction services.
In the early 1990s, there were no harm-reduction, prenatal or maternity programs for women in British Columbia hospitals. Those infants thought to be prenatally exposed to drugs were often separated from their mothers and sent to Sunny Hill Hospital for Children in Vancouver – which developed a neonatal abstinence syndrome program in 1983 – or to smaller centres throughout the province.
More often than not, these infants were apprehended by the state. Most of their mothers were poor, on social assistance, and First Nations, even though First Nations women’s narcotic use rates were no higher than those of non-Aboriginal women.
At that time (and still today), health-care professionals were taught little about addictions in their education programs.
Looking forward: Improving maternal outcomes through harm-reduction programs
DAMS sought to advocate for and provide harm-reduction services for women and their children and recognized the importance of providing ongoing education about harm reduction with a focus on pragmatic rather than moralistic interventions.
In our work with DAMS, and with support from the important work of others in the field, such as the pioneering work of Dr. Mary Hepburn and Dr. Ron Abrahams, we came to recognize that when pregnant women and mothers are provided with comprehensive continuity of care that is supportive, sympathetic, woman-centred, and non-judgmental, maternal outcomes improve and mothers have more positive birth experiences.
Rather than providing crisis intervention, successful maternity programs strive to normalize pregnancy and birth, providing multidisciplinary services, including midwifery care and early social worker involvement. Women are encouraged to freely disclose their drug use without fear of punishment. Stabilization rather than abstinence is the goal, so women can either stabilize on methadone or discontinue drug use during pregnancy.
The consequences of drug use are mediated by a woman’s social environment, as is her pregnancy. Consequently, woman-centred, harm-reduction programs seek to provide women and their children with medical, social and economic support that is welcoming and appropriate to their needs.
Today, there is much more acceptance of harm-reduction philosophy and practice in Canada than there was in the early 1990s. We have seen the slow emergence of more diverse programs, including harm-reduction services for pregnant women and mothers and programs such as Sheway, established in 1993 in the DTES. Sheway provided links and formal access to perinatal care at British Columbia Women’s Hospital for substance-using women in the DTES. Finally, in 2003, British Columbia Women’s Hospital opened Fir Square, the first combined care maternity unit in Canada for substance-using pregnant women and their infants, which takes a woman-centred, harm-reduction approach to care.
Canada had already implemented a number of other successful harm-reduction services such as needle exchange in the late 1980s, and later (to name just a few) drug user unions, Safer Crack Use Coalition in Toronto, a supervised injection facility in Vancouver, and the North American Opiate Medication Initiative in Montreal, Toronto and Vancouver.
By creating non-judgmental and practical services that speak to the needs of those most affected, health outcomes improve.
Harm reduction is not a panacea; it is unreasonable to believe that it will eradicate all social oppressions. Yet harm-reduction initiatives can provide a shift in policy and practice that bring social factors to the foreground. It can also pave the way for compassionate and health and human-rights models of care, and the rejection of drug policy based on punitive ideology.
Susan C. Boyd is an Associate Professor in Studies in Policy and Practice, University of Victoria, BC. She is the author of Mothers and Illicit drugs: Transcending the Myths (1999) and From Witches to Crack Moms: Women, Drug Law, and Policy (2004), among other books. She is also a community activist who works with harm reduction, drug-user unions and anti-drug war groups.
An earlier version of this article first appeared in (2007) “The Journey to Compassionate Care,” from Susan C. Boyd and Lenora Marcellus (eds) With Child: Substance Use During Pregnancy: A Woman-Centred Approach available from Fernwood Publishing, http://www.fernwoodpublishing.ca or (705) 743-8990. Modified and printed with permission by Fernwood Publishing.