3.2.1. Wanted Support in Relation to Problematic Substance Use and/or Trauma

The most frequently emerging theme—voiced by nearly half of the clients interviewed—was that women were seeking help in addressing their substance use. However, for many women, this was intertwined with wanting help in dealing with effects of trauma because of experiences of violence or abuse and with wanting help with housing and with child welfare issues. (Child protection/child welfare terms are used interchangeably. Provinces/territories within Canada hold the legislated mandate to protect children and if need be to remove them from their parent(s). Generally speaking child protection social workers investigate and will remove children if deemed necessary, whereas child welfare social workers are tasked with working with the family to mitigate the risk factors. Nevertheless, any involvement of child protection/child welfare authorities means that the parent(s)

is/are under scrutiny, that risk factors or concerns are present and that the parent(s) could lose their child if they are unable to satisfy the expectations of child welfare/child protection staff.)

I wanted to get sober. I wanted my children back, my family back. ... . I was using drugs and alcohol. I was going through a rough time—breaking up with my partner who was abusive mentally and emotionally.

[I wanted] better housing, support to keep me away from drugs and alcohol, and help with nutrition. [I wanted] to keep my baby.

[I wanted] connections with other mothers and knowing that there were groups I could do that would help me with being a mother with trauma and addiction.

3.2.2. Wanted Support with Child Welfare and/or Mother–Child Connection

Hand in hand with women's desire for support in relation to their substance use was their desire for support in relation to keeping or regaining their child(ren) in their care and/or in having a strong mother–child connection. Clients often sought participation in specific program activities (e.g., substance use/recovery groups or parenting groups) and/or sought connection with program staff who would be able to speak to their motivation and capacity to care for their child(ren); most often, the programs were already known to clients for their support and advocacy in relation to child welfare.

I wanted a different way of bonding with my child, a different community.

I wanted connections with other mothers and knowing that there were groups I could do that would help me with being a mother with trauma and addiction.

I wanted sobriety and to learn to parent my kids; I had lost custody.

I wanted to get support and bring my child home and parent in a healthy lifestyle for her and for me.

While wanting to demonstrate that they were capable of parenting may have been the initial impetus for attending their program, as women made gains, some realized that they wanted more, whether that was a better quality of life or a more stable foundation for building a life for their children.

To start with, I only wanted to get my children back. Now I want a better quality of life for me and my kids.

I also wanted to connect with a therapist. I wanted to have a stable foundation to work with. I knew [child protection] would be involved, so I wanted to create a healthy foundation for that involvement.

3.2.3. Wanted Support and Information Related to Pregnancy

Another strong theme and reason for engagement with their program was a desire for guidance and information in relation to their pregnancy as well as help with other issues such as finding safe and stable housing, child welfare, and substance use. Many women spoke of wanting this pregnancy to be different from their previous one(s).

I was pregnant and had addictions and I wanted to have support through my pregnancy.

Initially, I didn't know where or how I'd go with the pregnancy. I needed guidance and support. When I first found out I was pregnant, I cried for 48 hours straight. I also wanted information. I didn't know where to go and what my next step would be.

Support to keep moving forward. I wanted to make changes in my life.

#### 3.2.4. Wanted Help in Getting Housing

As noted previously, at intake over half of clients (ranging up to 85% at some program sites) had precarious and/or inadequate housing. Clients voiced their desire for program assistance in helping them access safe and stable housing, as they also recognized the inextricable connection between housing and child welfare authorities' safety concerns.

Support, because I have [child protection] involvement. I wanted support and stable housing and getting addictions out of the way. I want to go home with my baby.

I was in a really shitty situation. I was living with a friend; she was using drugs. I ended up in a shelter. I needed resources to help me with my pregnancy and with raising my baby, and I wanted help getting into different housing.

#### 3.2.5. Wanted Help in Getting Connected to Health Care or Prenatal Care

Approximately 20% of the clients interviewed stated that they were looking for health or prenatal care. Some women sought a health/prenatal care provider because they had recently moved to the community—often to flee an abusive ex-partner or to shed ties with people who used substances—while others may have been in the community for a while but sought a prenatal care provider in order to focus on having a healthy pregnancy. As well, some women emphasized that they wanted to connect with a health or perinatal care provider who would not judge or stigmatize them for their substance use.

My family doctor set me up with a maternity doctor who specialized in working with women with addictions. She suggested that I network with someone. I was afraid that the nurses at the hospital would see my medical history, see that I was on suboxone, and be judgmental and call child welfare.

I was looking for prenatal care. I was looking for programs and people to help support me to have a healthy pregnancy.

#### 3.2.6. Wanted Healthy Peer Connections or Peer Support

Finally, wrapped up in the notion of finding support was a desire by clients for healthy peer connections, partly born of a desire to be amongst women with similar backgrounds and with whom they could safely share their story.

I was looking for support and advocacy for my situation. I was needing a group for women like me who have been through years of trauma and abuse. I did not want to be the only woman in the room with that kind of lived experience.

[I wanted] to open up more; learn how to speak to others when they needed help; to share my story with others who were struggling; to help guide others on a positive path.

Some women wanted the sense of community that could come from being in a prenatal group and to have answers to their questions.

The sense of community here. Support group. I didn't know other pregnant women.

#### *3.3. Clients' Experiences of Utilizing Their Program's Services*/*Activities*

As part of the qualitative interviews, clients were asked to describe ways in which they used the various activities or services offered by programs. A sample of their comments, presented in Table 3, provides a more complete picture of the services listed in Table 2 and sheds light on women's perspectives on the value of a "one-stop" approach to health care, poverty, child protection issues, parenting, social connections, substance use, and culture.


**Table 3.** Examples of ways that clients utilized their program's services.

## *3.4. Most Significant Change(s) That Women Experienced (as a Result of Their Program)*

As a key component of the qualitative interview, clients were asked what had been the most significant change(s) that had taken place for them and their family since they started participating in their program. As was the case with other open-ended interview questions, women's responses often contained multiple themes, and the themes were clearly intertwined. The top themes were (reported in order of frequency):


#### 3.4.1. Quit or Reduced Substance Use

The most frequently emerging theme of the "most significant change," voiced by approximately 40% of the clients interviewed (*n* = 51), was that they had quit or reduced their substance use. Many attributed their program with helping them to quit using substances.

If I hadn't been at this program, it would have been harder to stay sober, and my baby would have gone to live with my mom.

Because the staff care so much about their clients, I've gotten clean. I've been in and out of addiction for 18 years, but because of them, my using time has reduced—it's down to two days. They've reached out to me. They've made a huge difference to me.

In keeping with these findings, on the client questionnaire, 79% (*n* = 93, 4% missing;) agreed or strongly agreed that the program had helped them quit, reduce or engage in safer substance use, and 70% (*n* = 83, 3% missing) agreed or strongly agreed that the program had helped them access substance use services or supports. Approximately 20% of women indicated on the client questionnaire that these items were not applicable to them, as they had not sought help from their program for substance use concerns.

#### 3.4.2. Strengthened Mother–Child Connection

The second theme, voiced by nearly the same number of clients (*n* = 49), pertained to the existence or strengthening of the connection between the woman and her child(ren). This important theme focused on the presence and preservation of the mother–child relationship rather than on whether women had retained or regained custody of their child(ren), and thus it was voiced both by women who did not have their child(ren) in their care as well as those who did. Similarly, most women (*n* = 93, 79%, 5% missing) agreed or strongly agreed on the questionnaire that the program had helped them improve their connection to their children. This theme also relates to the situation voiced by some women that, had they not had support from their program, they likely would not have continued with their pregnancy:

My baby and I have a home. We know we're not alone—both because I can call the [program] staff and because of other women. Without [program], I probably wouldn't have had my baby.

My stress level has gone down quite a bit. I know that no matter what, they'll be here. The program helps with everything: prenatal care, housing, [child protection] advocacy, baby stuff. Before coming into this program, I felt hopeless.

## 3.4.3. Kept/Regained Custody/Care of Child(ren)

In keeping with the previous point, the third strongest theme was that women had retained and/or regained their children in their care. As reflected in clients' comments, keeping their infant in their care and/or getting their child back from foster care nearly always occurred in tandem with other pivotal life events, such as reducing or ending their substance use, accessing stable housing, and breaking away from a high-risk "past lifestyle."

Getting my daughter back from foster care and having my baby come home from the hospital with me. Getting my kids back is the biggest thing. That showed me I'm done with my past lifestyle.

I've been clean and sober for 22 months. Getting clean changed my whole life. I got my son back, and I'm about to get the older two children back in September.

#### 3.4.4. Improved Wellness/Mental Health

The fourth top theme, voiced by about a third of the clients interviewed (*n* = 39), had to do with women's experience of improved wellness and well-being. Along these lines, clients described feeling happier, less stressed, more self-confident, self-aware and emotionally equipped to deal with personal triggers, as well as being more socially engaged.

Our household is more balanced. I know my triggers and deal with anger better. I am more balanced emotionally.

Coming to [the program] is getting us out of our shells. My daughter and I, we really needed this. It's really made a difference in terms of our health, mental health and well-being

#### 3.4.5. Increased Support

Strongly connected to all themes was clients' sense that they had increased supports—both from program staff and from other program participants—and a support network that they could count on. As well, for some women, a significant change was their newfound capacity to reach out to others for support when needed.

I'm about to reach out for support. I couldn't do that before.

Paralleling these findings, on the client questionnaire, 93% (*n* = 111, 3% missing) agreed or strongly agreed with the statement "I feel supported and less isolated; I have social support."

#### 3.4.6. Safer, Improved Housing

Approximately 25% of the clients interviewed reported that, for them, a/the significant change since becoming involved with their program was accessing safe and adequate housing. As noted previously, clients often spoke of housing in essentially the same breath as they talked about keeping/regaining their child(ren) and/or quitting or reducing their substance use, as the inter-connections between these outcomes were evident. In one client's words:

Getting suitable housing and reuniting with my son. We were in the single room occupancy apartment when I had the baby. Then he went into a foster home. Then we got housing and the baby was returned to us.

#### 3.4.7. Additional "Significant Changes"/Outcomes

Three additional "most significant change" themes are important to mention, given that they emerged in the comments of quite a few clients (*n* = 20 or roughly 16% of those interviewed). These were:

• Increased self-confidence/self-esteem;


As these clients stated:

They've helped me open up more. I feel more self-confident and happier. I've opened up a lot more.

I got back into my culture. I'm teaching my daughter how to smudge and do drumming.

I'm happy, have lots of friends. I've connected again with family, and I'm sober.

It helped me—the therapy and the groups—to reflect on myself, and I wanted to do that for myself. I have a better understanding of myself. They give us the tools to help ourselves.

#### *3.5. Summary of Key Findings*

By way of summary, Table 4 presents the top themes and their interconnection in relation to what women hoped to get from participating in their program and their most significant change.

**Table 4.** Top themes in relation to what women hoped to get from participating in their program and their most significant change.


#### **4. Discussion**

The interim findings of the Co-creating Evidence multi-site evaluation make a valuable contribution to the literature by focusing on the perspectives of highly vulnerable, pregnant, and early parenting women with problematic substance use, and drawing an arc from their life circumstances prior to entering the program, to what it was they were hoping to gain by reaching out for help, and finally, to their views on the most significant changes in their lives as a result of their involvement with the program. In doing so, the preliminary findings support the already rich literature on the complexity of issues that this population of women face, including intimate partner violence, trauma/mental health, poverty, precarious housing, and child welfare involvement [1,5,6].

The study also contributes to a better understanding as to what prompts women to want to make a change in their life circumstances. In this vein, the study affirms the view that pregnancy can be a powerful catalyst for transformation for women who are marginalized from mainstream services by virtue of their circumstances and contributes to the literature that vulnerable pregnant and parenting women experiencing numerous personal and systemic barriers will seek help, ideally at a single point of access, when those services are non-judgmental and take into consideration and address their realities [2,19,37–39]. Additionally, from a gender perspective, women have also been found to respond to and benefit from programs that take into consideration their unique roles and responsibilities and that reduce obstacles to their participation, including those related to caring for children and family [18,19,40].

On that note, women's top priorities prior to joining their program and the areas of their lives in which they reported significant improvement were intertwined such that they rarely spoke of just one priority or benefit. In this regard, while obtaining support in relation to their problematic substance use was the most frequently cited theme, it was often entwined with issues of current or past trauma. Addressing these issues together was part of the programs' holistic, trauma-informed, and women-centered approach. Often closely associated with clients' desire for support in relation to their substance use was a yearning to retain and/or regain their children; a related goal was to create a better life for themselves and for their child(ren) including learning more about parenting and having opportunities for positive peer connections for themselves and their child(ren). This lends further weight to the tenet that when working with vulnerable women, the child is "undeniably part of the equation" [40]. At the same time, women who use substances pre and postnatally often experience parenting difficulties resulting in the further likelihood of child welfare involvement; hence, recommended best practices include not only being responsive to the mother–child dyad but also development of a collaborative working relationship between substance use services and child welfare agencies [12,23,41].

For almost one-quarter of clients, improved housing was reported as a, if not the, most significant change in their lives. As four of the co-creating evidence study programs offered housing to at least some clients either on-site (for example, through the program's own services or through co-location with a housing agency) and others achieved this through partnerships with local or provincial housing providers, clients were able to more readily access supported/social housing as a result of their association with their program. Safe and stable housing is fundamental to satisfying the safety concerns of child welfare authorities—i.e., enabling women to be able to go home with their infant after giving birth and/or to regain custody of older children—as well as to sustaining other positive life changes.

Poor health or mental health were key issues at intake and were areas in which clients experienced positive change as a result of their involvement with the programs. For women, this "significant change" was characterized as an overall sense of wellness and social connections; a frequent theme was their experience of improved mental well-being, increased support, and self-confidence/self-esteem, reduced isolation, and increased self-compassion and self-determination. In describing the pathways that mothering women take toward quitting their substance use, Marcellus similarly found that restoring their sense of self—described as gaining and sustaining recovery, becoming more socially connected and less isolated, improving personal well-being, and regaining credibility in multiple domains—was a key trajectory for women [42]. In this regard the findings to date of the co-creating evidence study are consistent with client perceptions of integrated treatment programs in Ontario, in that those participating in integrated programs reported positive psycho-social outcomes, including improved self-confidence and greater sense of self [2].

Finally, it has also been noted in the literature that women respond differently to substance use services than do men, showing a preference for services and programs that engender an atmosphere of hope, acceptance, and support [43]. Earlier qualitative findings from the Co-creating Evidence study [29] described that what clients liked best about their program was the caring, non-judgmental, supportive, helpful approach of staff. This along with the availability of multiple services in one place was among the top themes, indicating that it is possible for vulnerable pregnant and parenting women with complex challenges including problematic substance use to achieve positive outcomes when presented with the right mix of services and approaches that adequately address their health and social support needs as women and mothers.

#### *Limitations*

Despite the strong congruence between this study's findings and the existing literature, the study's limitations should be noted. With regard to the on-site client-related data collection (i.e., interviews and questionnaires with clients), we understand that the voluntary sampling approach could have resulted in biases, in that clients with more positive views about their program would have been disproportionately inclined to take part in the evaluation study. As well, without the denominator in terms of potential participation in the evaluation, we cannot assess bias nor the representativeness of the sample. Further, with a circumscribed number of days for each site visit and on-site data collection, clients had a narrow window of opportunity to take part. As such, we cannot know for certain that we achieved "saturation," nor was the concept of saturation the means by which we determined the number of interviews to conduct at each site. Nonetheless, we have no reason to believe that clients who held fewer positive perspectives were disinclined to participate in the study nor were they prevented from doing so. The confidential, conversational approach to interviewing also facilitated participants sharing their diverse experiences and perspectives. Given that there will be a second round of on-site data collection with clients, there will be an opportunity to explore the issue of sampling bias and determine whether saturation was achieved.

#### **5. Conclusions**

Women's prenatal alcohol use and other substance use frequently occur within the context of inadequate housing, intimate partner violence, trauma, poverty, and social isolation. These burdens combined with systemic barriers affect their ability and willingness to engage with formal health care services. Often, women reveal the full extent of their substance use, including alcohol, only when they feel safe, accepted, not stigmatized, and when their program/service is meeting their practical needs.

With its focus on clients' perspectives, this paper makes a valuable contribution to the literature regarding multi-service programs aimed at vulnerable pregnant and parenting women who use alcohol and other substances. The article highlights the multiple, interconnected reasons why women seek help from these programs, most notably the twin desires to address their substance use and to regain and/or keep their baby/children in their care. Rounding this out are women's desires for help with housing, prenatal/health care, and peer support, suggesting that pregnancy can be an important catalyst for making significant life changes.

This study affirms how capably women can provide such guidance to service providers as to their service needs. It also affirms the value of a holistic approach that addresses both problematic substance use and the social determinants of health in accessible, women-centered, and integrated programming.

To ensure that this population of vulnerable pregnant/parenting women receive such holistic services, funders too will need to consider how to integrate funding streams, to include health, social and cultural services, housing, income support, child welfare, and public safety resources to these multi-service programs.

**Author Contributions:** Conceptualization, C.H. and D.R.; methodology, D.R., C.H., R.A.S., N.P., and M.V.B.; funding acquisition, C.H., D.R., N.P., and M.V.B.; investigation, D.R., C.H., M.V.B., R.A.S.; formal analysis, C.H., D.R., R.A.S., M.V.B., and N.P.; project administration, C.H. and D.R.; visualization, D.R. and C.H.; writing—original draft preparation, C.H., D.R. and R.A.S.; writing—review and editing, C.H., D.R., M.V.B., R.A.S., and N.P.

**Funding:** This research was funded by the Public Health Agency of Canada, FASD National Strategic Projects Fund, Project #1617-HQ-000070.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*
