Mothers with children taken into out-of-home care at risk of poor prenatal care in next pregnancies

Mothers whose first child was taken into care were found to have inadequate or no prenatal care during subsequent pregnancies, according to a study published in CMAJ (Canadian Medical Association Journal) https://bit.ly/2In4aS7.

The study was conducted in the province of Manitoba, which has one of the highest rates of children in out-of-home care in developed countries. About 3% of children live in homes without parental caregivers compared with a rate of 1% of children in most developed countries.

A total of 52 438 mothers were included in the study, of whom 1284 (2.4%) had their first child placed in out-of-home care before conceiving a second child. These mothers were more likely to have a substance use disorder, live in low-income and urban neighbourhoods, receive income assistance and have diabetes. They were also 46% more likely to receive inadequate prenatal care than women whose children had not been taken into care.

“Previous research has identified a fear of detection or involvement with child protection services as an important barrier for at-risk pregnant women, potentially leading to disengagement from, avoidance of or delayed presentation to prenatal care,” writes Dr. Elizabeth Wall-Wieler, Department of Pediatrics, Stanford University, Palo Alto, California, with coauthors. “We expect this fear to be intensified for pregnant women who had their first child taken into care by child protection services because they may fear this happening again.”

A harm reduction approach that provides easily accessible and nonjudgmental prenatal care could increase access to care for these women.

“Pregnancy presents an important opportunity to increase positive outcomes for vulnerable women and to enable children to have the best possible start in life,” write the authors. “This represents an obligation within the child rights principles and a crucial strategy for reducing population-level health disparities.”

In a related commentary http://www.cmaj.ca/lookup/doi/10.1503/cmaj.190183, Indigenous maternal-child health experts Dr. Janet Smylie and Wanda Phillips-Beck state that the exposed cohort in the linked study “was very likely to be largely Indigenous.” They describe the barriers that First Nations, Inuit and Métis women face in accessing prenatal care, which Dr. Smylie saw while providing obstetric care in an urban clinic in the late 1990s. “These barriers included but went beyond the basic material needs such as transportation and the need to prioritize housing, food security and safe child care over scheduled medical appointments. Women feared being misunderstood and incorrectly judged by culturally biased maternity care providers who, without reflection on how social stereotyping was driving their clinical interactions and decision-making, would deem them inadequate mothers-to-be and contact child protection agencies.”

The authors state that this situation is a consequence of colonialism. “These processes are also acknowledged to be ongoing, contributing to a situation where there are now more Indigenous children in Canada’s child welfare system than when residential schools were at their peak.”

To move past this, there must be support for Indigenous-led community solutions with First Nations, Inuit and Métis actively involved in the research and system transformation.

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Visual abstract: http://www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.181002/-/DC2

“Prenatal care and child protection services” is published February 25, 2019.