Research Update

Alcohol Use and Pregnancy: An Important Canadian Public Health and Social Issue

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10 Policy and Legal Responses

What the Studies Say Although it has not been demonstrated empirically and would be difficult to do so, there is good reason to believe that social policy that aims to reduce inequity and poverty in Canada would contribute to reduced alcohol use problems among pregnant women. More specific to this issue, social and organizational policies that serve to increase access, reduce stigma and promote fetal protection through maternal protection in the form of therapeutic, non-punitive interventions have strong support in the literature.

As a population, women in their childbearing years, particularly younger women, are among the poorest in the country. In 2000, the National Council on Welfare estimated that young women between 18 and 24 years of age have a poverty rate of 24.9% (18.5% for women between 25 and 34 years of age). Overall, single mothers and their children fare the worst. The poverty rate for families led by a single mother under 25 years of age was an "abysmal" 85.4%.323 Women of all socio-economic groups use substances during pregnancy; however, poverty is an aggravating factor that greatly decreases a woman's likelihood of accessing adequate care. Government social policy that reduces the poverty rate among young, single mothers would undoubtedly serve to address substance use problems among pregnant women.³²⁴

Pregnant substance-using women have been more profoundly impacted by alcohol- and drug-related policies and sanctions than any other population group requiring substance abuse treatment. These policies include the historical emphasis on treatment models for men and co-educational treatment as the norm; lack of funding and other mechanisms to provide child care for those attending specialized substance abuse treatment; and civil and criminal sanctions for pregnant substance-using women.

A striking example of policy affecting women with substance use problems in Canada was the issue of mandatory treatment highlighted with the case of Ms. G.^xxxvi There are a host of arguments against mandatory treatment and/or the involvement of the criminal justice system as mechanisms to prevent substance use during pregnancy, and in favour of providing comprehensive care that addresses a range of health and social issues as most likely to lead to the best outcome for the mother and unborn child. The most obvious and serious consequence of a punitive approach is that it will deter women from accessing needed services or from being able to discuss their substance use with health care professionals, leading to poorer outcomes for mothers and children.^325,326

This review has found that being able to have children accompany a mother in treatment is one of the most important ways to help her complete the process. Fear of losing their children creates a substantial barrier to women in need of treatment. In Canada, apprehension of children due to parental substance use occurs in those situations in which parental substance use is assessed to have an impact on parenting and on the child's wellbeing. There is no question that the best outcome is for children to be parented by their mothers, but it is also clear that parental substance misuse can have an impact on parenting behaviours and ultimately on child development. There is also no question that systemic supports to support the mother and infant/child safely in all circumstances and levels of "risk" to the child are inadequate. This does not mean that these women are "bad mothers," but that because they did not experience relationships and environments that included safety, consistency, structure and responsiveness, they have adapted (or maladapted) in various ways (including substance use). They experience difficulties in parenting (not only because of their substance use, but also because of all the co-existing factors related to their substance use).

Clearly, the needs of women with significant substance use problems are multiple and complex. Increasingly, child welfare and substance abuse treatment providers in Canada are seeking a shared perspective on these issues; however, the capacity of systems to support these families remains woefully inadequate. Few programs exist where women can take their children to treatment, and women who wish to go to treatment without their children obtain little support for finding safe, temporary care for their children.³²⁷ In addition, child welfare agencies and related systems providers do not have the resources to adequately support the maintenance of children in their families with immediate access to the various services they may need (i.e. formal addiction treatment sector, with child care, for those who are using substances; women-centred services to address related trauma and mental health problems; safe and stable housing; and intensive supports for parenting and child development).³²⁸

Rutman et al., in a key Canadian policy discussion document, Substance Use and Pregnancy: Conceiving Women in the Policy-making Process, suggested that this complex issue calls for policy integration between those advocating for affected children and those advocating on behalf of women with substance use issues. The authors further called for policy approaches that recognize and address the complexities of the lives of many women who are pregnant and using substances. Based on broad consultation, they call for policy shifts in the following directions:

• from a moralizing medical model to a harm reduction/health promotion philosophy
• from a child welfare mandate as protection-focused to one that emphasizes supporting families
• from viewing child apprehension as the failure on the mother's part to failure of the system/community to provide what is needed³²⁹

A shift of policies in this direction can be argued from a human rights perspective and make sound economic sense as well.

10.1 Recommendations and Implications

Priorities for research and policy arising from this review of the evidence in relation to policy and legal issues are:

Evaluation Research

• Explore the links between socio-economic status and alcohol use during pregnancy in a Canadian context.
• Conduct Canadian research into the value of a policy and campaign to reduce drinking-during-pregnancy stigma among practitioners in the health care or social service fields.
• Conduct Canadian research into the extent to which substance abuse treatment and rehabilitation services in Canada that serve women have in place appropriate policies, program elements and linkages to other key sectors, such as prenatal care and child welfare services, in order to provide appropriate care for pregnant women using alcohol.

Policy and Program Implications

While awaiting the results of Canadian studies, priority should be given to these promising practices:

• Implement models of child welfare, through amendments to provincial/territorial child welfare legislation, which give preference to supporting mothers as the best means of protecting the child.
• Increase funding to child welfare agencies and related systems providers to support the maintenance of children in their families with adequate and immediate access to the formal addiction treatment sector (with child care) for those who are using substances, for immediate access to women-centred services to address related trauma and mental health problems, for access to safe and stable housing, and for intensive supports for parenting and child development.
• Increase resources available to service providers of high-risk pregnant women (beyond what is typically short-term funding) to increase access, level of care and evaluation research across Canada.
• Develop, disseminate and provide orientation on evidence-based model policies and protocols with organizations serving high-risk pregnant women.

xxxvi. In 1996, a landmark Canadian legal judgment was made in which a young, pregnant Aboriginal woman with a six-year history of solvent abuse was ordered by a Winnipeg judge to enter a mandatory treatment program; Canadian higher courts ultimately ruled against mandatory treatment of pregnant women.

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