 Hi, everyone. Welcome. Welcome. I think we'll get started. Welcome to the Health Law Institute Seminar Series. I am so delighted to have my colleague here today. My name is Martha Painter. I am a registered nurse working clinically in abortion and reproductive health care. And I, with Megan, we are both Trudeau scholars. And my work is based out of the School of Nursing and I'm happy to be a research scholar at the Health Law Institute. I also chair Women's Wellness Within and Megan has kindly agreed to also do a talk tomorrow for Women's Wellness Within, our non-profit here in Nova Scotia that works for reproductive justice and prison abolition. So the Health Law Seminar Series is a platform for sharing research and ideas on issues of health law and policy. The Health Law Institute itself is a group of university faculty, policy analysts, and student fellows committed to the advancement of health law and policy and the improvement of health care systems and practice. And you can visit our website for more information. So now it's my pleasure to introduce Megan and to thank her for joining us today. A global health nurse and policymaker, Megan is a Trudeau scholar at the University of Oxford's Center for Evidence-Based Intervention, researching the impact of drug policy and child welfare systems on maternal mortality. For over a decade, Megan has provided technical assistance to international organizations such as the WHO, UNDP, UNAIDS, the World Bank, and the Global Fund to End AIDS, TB, and Malaria, supporting access to healthcare for sex workers, LGBTQ and people who use drugs in Central Asia, Latin America, the Caribbean, West and Central Africa, Middle East and North Africa. In Canada, she has served as the Chief of Staff to the Minister of Mental Health and Addiction in British Columbia as clinical coordinator of North America's first supervised injections facility in sight, and as a street nurse and senior practice leader at the BC Center for Disease Control. Megan's academic interests include health systems, gender equity, and access to healthcare for marginalized populations. She is an adjunct professor at UBC School of Nursing and holds clinical scientist affiliations with the BC Center for Disease Control and the Center for Gender and Sexual Health Equity. She holds a Master's of Science in Public Health from the London School of Hygiene and Tropical Medicine and is a registered nurse with advanced practice certification in sexual and reproductive health, HIV and addiction medicine. We are grateful, Megan will also present tomorrow at Women's Wellness within Annual Conference in Spritefield, confronting the carceral state, autonomy, community, and liberation. Over to you. That's amazing. Thank you so much for having me and I'm really honored to be here and thank you. I know we're on the traditional unceded land of the Mi'kmaq people and I come from Coast Salish territory. You can probably hear I don't have a British accent so again I'm from Vancouver traditionally and grew up there but really honored to be here and thank you for coming. It would be great to just know a little bit about the audience. So if we're a room primarily of lawyers or social work or where people work. So how many of you are joining from the law faculty and practicing lawyers? Amazing. And what about anybody here from nursing? Exciting. And medicine or any physicians? Oh hello. Social work? Okay. What about sort of outreach community workers? Awesome. Thanks for coming and peers included in that. Awesome. We'll really diverse groups so that's exciting and sorry if I speak a bit of epidemiological language sometimes so please feel free to ask me to raise my voice but also to define any terms that might be confusing because we're quite a mixed audience. Also want to declare that I don't have any conflicts, traditional and public health, to talk about whether or not we have pharmaceutical conflicts or others but this should also say my positionality. So this work that I do comes primarily from a critical theoretical framework informed by feminist and post-colonial perspectives and also might not recognize that woman because it's me 20 years ago but this is me with my son my oldest son Braden and so I was what would have probably been labeled as a teen mother. I was a young woman that used drugs and come very much from this work from the position that if I had had a urine drug screen when I was pregnant it probably would have been positive and I may very well have been one of the women that I'm talking to you about today that would have lost custody of their child and partly because of the privilege of being a settler and having a sort of white skin that didn't happen to me but that's certainly not the experience of many of the women that I work with and so I just want to sort of frame that before I speak and say thank you to my son Braden who I often like to say saved my life and is one of the reasons he's now in Montreal and studying at university and we've had a wonderful adventures together and he he's a really big part of why I do this work. So don't cry at the beginning of your talk. Epidemiology. I like to I've also over the years learned that numbers can be really powerful and influencing policy and so I like to think of epidemiology as a way to tell stories with numbers and why are we talking about this today? Substance use among women is really a big public health issue internationally. It's certainly a big issue in Canada and then so is the child welfare system. So Canada has one of the highest rates of children in care in the world upwards of 3% of children in care similar to our neighbours in the south in the US and so we tend to have a more risk averse system in contrast to the European system one where we apprehend quite a bit earlier than they do in European contexts and we're really focused primarily on the infant you know as as as child welfare system should be so it's not to say that abuse is acceptable we're not here to say that the child welfare system needs to be abolished certainly we need to protect vulnerable children but just that perhaps there's some fundamental issues of the system needing to be redesigned primarily this is because women who are marginalized by poverty, race, substance use, mental illness are really experiencing disproportionate burden of monitoring and so my colleagues that I work with like to say if there was a camera in any of our homes we would probably potentially have you know certain fights with our children where we might be people might judge us and what happens to my clients particularly Indigenous women that I work with they're just right away referred they're referred with birth alerts before their children are even born and they're just monitored to such a high degree and it causes so much stress that they're not really given a chance to parent. This is really bears out in the statistics and Dr. Blackstock Sydney Blackstock and a number of others have been talking about this for some time and it's finally starting to get some attention so I'm sure you're familiar that Indigenous families are really over represented in Canada these are quite shocking numbers so if you consider that Indigenous people are between four to seven percent of the population in most provinces in terms of a national average and then you see in my own province of British Columbia representing 68% of the children in care and in some other provinces upwards of a hundred in Nova Scotia it's 27% I don't know what your 4% of the population but 27% of kids in care so you can see it's it's quite a dramatic overrepresentation and Indigenous scholars talk about this the root of this being colonization experiences of residential school continuing until into the 60s scoop and then now more children being apprehended than were ever in residential school and so it's really this persistent racism in the system and this persistent insistent inequities around poverty and marginalization we also know that when children are apprehended mothers describe this in the qualitative literature as like a living death so the bereavement experience is quite intense because they often know that they're you know the child is there but they can't access them so it's some mothers have said who've also lost children have described it as being worse than than losing a child particularly for the mothers that I work with who themselves were raised in foster care which is quite common this intergenerational foster care if they experienced abuse in foster care which is also quite common say sexual abuse to then know that your child is completely removed from you and that you don't have access to them I think anyone who's a parent particularly when you felt like the removal was unfair and unjustified that that's really distressing and what I what I think is confusing sometimes to two colleagues working on social work side or law is that those women don't necessarily make their court appointments or they don't come back and make all of the steps to get their children back and what my my work's trying to demonstrate is because they're experiencing a profound grief response and a trauma they often sort of shut down to protect themselves and so what might look like indifference to the system is actually just that's all they can do to cope and and this has been described really well in the qualitative literature but not so well in the kind of quantitative public health literature with the exception probably of a couple colleagues Dr. Elizabeth Wallweiler out of Winnipeg did a really great paper that some of you in the health law seminar series or health class are reading now and that's she looked at mortality among sisters who had similar birth cohort experiences and compared sisters who had a child apprehended and sisters who didn't and found that the women who had had a child apprehended were 3.4 or almost 3.5 times more likely to die after controlling for kind of confounders that you would expect like substance use homelessness and poverty so pretty dramatic and aside from Elizabeth's work Dr. or Dr. Kenny, Kathleen Kenny's done some work in in Vancouver as well and then I'll talk to you about my research for anyone who works in this space you're probably familiar with the amount of stigma and judgment that women who use drugs face and this is primarily around illicit substances we don't have the same stigma for or judgment for women who are using substances that are illicit or legal and that's one of the greatest ironies in my you know social networks as I'm the first person in my family to go to university but now obviously have a lot of privilege being at Oxford and certainly meet families who you know middle class upper middle class white families who might use cocaine on the weekend and no one's taking their children away no one's making posters about how they don't deserve to parent but women who are women of color might have a totally different experience with their substance use being seen as totally unacceptable and if there's one you're in drug screen they're arrested or their and their children are removed and so there's just this really unjust way of framing substance use in different that's very classist and that we see in our work I don't know if folks are familiar with Lynn Paltrow from National Advocates for Pregnant Women so she's in the U.S. and in the U.S. context there women who are pregnant can be arrested at the at pregnancy and forced into treatment and she has this great slide I won't read it out to you but basically her her thesis is yet you know practice not losing your job don't be poor don't have poor parents don't be illiterate try not to be a part of a racially or socially marginalized group I mean it's obviously a joking jokie slide but her point is really these are not modifiable factors for many of these women and they really they're judged based on their circumstance as opposed to actually their ability to parent our work is framed much more in an equity lens where we look at different contexts people's access to you know resources education income the material circumstances of their life in child welfare I think one of the greatest tragedies is the is the intersection between the homelessness crisis and child welfare I don't know if you have this in Nova Scotia but in Vancouver where it's so expensive one of the most expensive cities in the in the country we routinely see children removed because of really poverty and the fact that the mother couldn't find a one bedroom apartment and often there's rules that if you have a child you have to have a bedroom for them and so women will might be sort of in a social housing unit for instance with bachelor's and they'll lose that unit because they're pregnant and when the baby delivers they'll deliver the child will be removed because they don't have a house to go back to and then now they're no longer eligible for a one bedroom apartment because they don't have a child anymore because the child's in care of the state and it's it's just mind-blowing but this happens regularly budgets are in different departments they're having worked in government and I've personally tried to intervene to try and have money moved from the foster care budget which is you know in a different different ministry to then this housing budget and it's like they don't they don't connect and so there's there's just so much injustice in this in this sector that's hidden in that our our aim of our research is really to try and surface this in a in a way that is evident in sort of the epidemiological data so I'm going to talk specifically about two papers today that are both in press one in the international journal for drug policy and another in an upcoming edition hopefully of the Lancet and that's our mortality paper but the the third that number three here of my thesis so before I delve into the overdose crisis I just want to or the overdose paper I just want to give a bit of background if you're not familiar with this area most of you are familiar I'm sure if you work in drug in the drug policy space but maybe not so the overdose crisis is now claimed more deaths than motor vehicle accidents and firearms in the US it's actually impacted life expectancy in Canada for the first time in four decades so massive crisis the research is primarily on cisgendered men so there's sort of an assumption often and this is true around the world that you know overdose prevention sites or supervised consumption sites are often geared towards men needle and syringe programs and women that use drugs are often have to be partly to protect their children more hidden and a bit and more underground in their drug use they face sort of a double stigma often of being a mother and being a drug user and we also know that there's just very little evidence about interventions that work specifically for women so with this we wanted to look at overdose within a cohort they had the privilege to work with which is run by Dr. Kate Shannon at the Center for Gender and Sexual Health Equity so she has two cohorts one's called Aisha of sex workers and the other Shauna women living with HIV and they're met that they have the same questionnaire so I merged the two data sets and we also have access to we do HIV and STI testing for the women and linkages to a population health data set using their PHN number so we can look at coroner's data as well as hospital data and community health data so within the context of this study it has a wonderful community advisory group of women with lived experience primarily still in active sex work women living with HIV women who use drugs and we were able to bring to them these research questions and have them sort of vet them there's also a qualitative arm and for this particular paper we looked at we used bivariate and multivariable logistic regression using GE or generalized estimating equations to examine the association between child removal and overdose and so not not surprising in some respects we found that of the of the almost 700 women who'd reported ever having a live birth almost 40 percent had had a child removed so quite a high underlying rate of child removal it was distressingly higher for the indigenous women so almost double that which was not surprising but but devastating for the women that were involved in the community advisory we also found quite a high rate of overdose so 35.1 reported ever having a non-fatal unintended overdose so in Canada generally we separate out suicide intentional overdose with unintentional so these are sort of what we'd probably in Vancouver context be fentanyl poisonings accidental poisonings and 19.4 percent almost 20 percent had had an overdose in the past six months at any point in our follow-up so also quite high given that people generally perceive this as more of a male problem and in our bivariate analysis we found that child removal was associated with over 80 percent higher odds of unintentional non-fatal overdose and when we controlled for confounders so I'll just go right to that slide in our final multivariable model we use stepwise regression to include you know it's baseline substance use recent sex work looked at homelessness poverty a number of different kind of confounders and when what was left in the model was education and having indigenous ethnicity and even after controlling for all those confounders we found that women were 1.55 times more so that's the adjusted odds ratio likely to have an overdose when you compared women with really similar life circumstances that hadn't had a child removed so here we sort of see what I think we knew was happening clinically what I saw as a as a street nurse and at shiwei but I now here's this story with the numbers we also found just going back a bit women who'd been in jail and had experiences with corrections had also a higher overdose rate I think I have a slide on that 81 percent versus women who had all the women was 62 percent and so we know experiences of jail especially short-term frequent ones really increase people's risk of overdose because they come into jail have a period of abstinence then they might leave use the same amount that they had used previously and because they their tolerance has decreased they're much more likely to overdose so in bc certainly we've been arguing that these kind of short-term experiences when people have say even unpaid parking tickets people will get like this when they're poor and unable to pay they'll start to get these like oh well you'll spend a night in cells until we can get this organized that these are really dangerous and we're seeing people overdose much more likely after these periods of jail this is time yeah so g is a time point analysis so it's yeah that's a great question so it's a prospective longitudinal cohort so we have eight years of data and this up up until just you know we refresh the cohort every six months so they get questionnaires every six months and so we are able to sort of pinpoint so the child apprehensions primarily happened at baseline and then the overdoses are posts in mortality obviously the mortality is clearly temporalities established I'll show that paper next less we don't have enough new apprehensions in the cohort too so there's 39 new ones over the last eight years so we weren't able to say like here was a child apprehended and the overdose happened six months after that but we do these base these removals are all baseline and these overdoses are all in follow-up so there is some temporality but great question thank you if you're not in public health it's yeah they're quite a much more robust than just a cross-sectional sort of one-time analyses um going back to the indigenous issue because of the of what we described the overrepresentation of indigenous women we we did a joint effects model to look at um the specific issue comparing indigenous women to non-indigenous women so we used non-indigenous women who hadn't had a child removed as the reference population and just making sure you see what I see and found that indigenous women who did experience child removal if you look at the far right the 2.09 were more than double likely to experience an unintended non-fatal overdose than than the reference population so again even sort of more dramatic and distressing findings and this was adjusted for education food insecurity and sex work and I talked about that already in terms of criminalization just given the legal scholars in the room forgive me if this might not be totally up to date because I'm not a lawyer but what I understand from colleagues in the field is that um in Canada the question of whether a woman legally owes a duty of care to her fetus went before the supreme court um a case mischi I think a 24 year old in Winnipeg and the court concluded that they we do not have the right to force pregnant women into treatment programs and this is I think often misunderstood by clinicians and I would say social workers and others in the field who really when they have a woman that they feel is using and they really they really want to like just take her and put her somewhere and like get her force her into treatment and and I think the court upheld this finding that many of us have found which is the literature just doesn't support that there are so many forced treatment programs in the U.S. that have fairly robust um evaluations and the people don't stay abstinent so they might have a period of abstinence when they're forced in um one of the favorite things people and family members always come to me too is can't we kidnap our child can't we do secure care having sat and and reviewed that evidence with the minister for secured care in British Columbia versus Alberta we we just know it doesn't it doesn't work and the the people who experience that experience that as a trauma they lose trust with their family members they lose trust in the system and they just grow out and use on relapse that's not true of everyone certainly have colleagues in recovery who experienced um had a good experience that's anecdotal but the the literature just doesn't support that forced treatment works and we also know that um pregnant women who use substances and mothers generally are already hiding they're they're scared about losing their children and that sort of these forced coercive practices drive them further underground we know that from the U.S. context and that these forced treatment laws are always applied unfairly to women who are poor or racialized for many of the reasons we talked about earlier and that and then finally if fetuses were to be granted a legal right to care the court found that that power could be extended to control many of women of childbearing age um practices and that it just sort of wasn't wasn't worth it to have this and so we know it just it's it's not worth it um so that's kind of a little side note on what I know about the law currently in Canada it may be during the questions some of the lawyers can help clarify that um switching gears now to the second paper on maternal mortality so this was this is the beginning of this model so we haven't quite finished the second phase of second paper on the intersection with child removal but really just looking at mortality in the cohort we use the same um two cohorts shown on Asia that I described adding in now coroner and hospital data and we did a cost proportional hazards model we use the 2014 Canadian female population as our reference but we also did a sensitivity analysis because when we started this paper the overdose crisis had or this thesis the overdose crisis hadn't really hit uh and we wanted to make sure you know was that explaining all the mortality so we did a a sensitivity analysis for 2017 as well and then we look for predictors of mortality using time dependent cox proportional hazard regression and then the second paper which is just in process now we'll look at removal versus non-removal but I won't be presenting that today so among the 700 women um who are between 32 and 45 and these are the mothers in the cohort 39 had died between the eight years of follow-up which is almost 10 times more likely to die than women of the same age in the Canadian cohort so it's quite a dramatic standardized or mortality ratio which is distressing for us and also not surprising in that it's women who use drugs sex work and women living with HIV but keeping in mind that HIV is a treatable condition um among men of sex with men in the general Canadian population and that they are actually having the same life expectancy as the Canadian general population so at first when we found um we found one of the main predictors of death was HIV we we were going to take HIVO the model because we were like oh that's obvious but actually it was my British colleagues at Oxford who were like well no that shouldn't be obvious because HIV is a treatable condition so if you have good access to treatment and it's free which it is in British Columbia why do they have such high mortality rates so we ended up keeping keeping it into the model um what were the causes of death about half of them were injury and um those were 18 deaths and 17 of the 18 were overdose deaths um which was also really distressing and uh second was um non-communicable diseases which were primarily cancers and then the last there was two deaths by communicable disease so actually not as many were uh HIV related as you would think it's just that I think the HIV in some ways is a is a surrogate marker for for poverty and marginalization because women who acquire HIV often is through the injection route in the British Columbia epidemic so they're sort of surrogates for all the inequities we're talking about um the predictors of mortality when we ran the Cox proportional hazard regression was HIV so HIV was explaining um so 2.54 times more likely to die if they were HIV positive at baseline and then having experience of tel-custi loss also held it was sort of marginally significant so you can see they were 1.6 times more likely but then the confidence intervals do cross one but that's also not unexpected with such a small number of deaths so that stayed in the model and then finally intimate partner violence as well so um all modifiable factors and then the next analysis we'll look at comparing mortality for women who'd experienced child removal or not but that one's just in process with the statistician now um so the strengths of this again are the prospective design thanks for that question where we found um we were able to look at uh eight years of follow-up using GE we also had biomarkers and population health data and then we also used time location sampling so that's a method so that we're not just taking a convenient sample of women that come into our drop-in center or our clinics we're actually going out into the street and doing outreach and that's that outreach is sort of randomized if you will so we're actually reaching women that are not not in care and not engaged with us as well as women who are and then uh some of the limitations are um under-reporting or respondent-driven bias so we're asking people really difficult questions about child welfare for all the reasons we discussed there's a lot of shame related to that so we try and minimize that by our interviewers are women from the community who are trained they themselves are often former sex workers or active sex workers they might be women living with HIV and then there's a nurse questionnaire so i've had the privilege to be a nurse on the study and was able to do the nursing component and we ask the child questions at the end of the interview after we've established rapport and we also follow-up so sometimes women denied having had any children in the first interview but at baseline actually get to know us you know we follow many of them for almost 10 years they might disclose their child as sort of the second or third interview and those are recoded back into this analysis so they're captured here and we talked about temporality already between the exposure and the outcome not not perfect but we think we have sort of a clear pathway that we're describing and then finally um there are confounders that we're you know if they're unknown to us we're not able to measure so after controlling for the confounders that we do know what what did we find what's our conclusion um we found that women have had a child removed experience higher odds of non-fatal overdose and that these odds are highest among indigenous women we also found that women in the cohort were almost 10 times more likely to die than women of the same age in the Canadian population and that the reasons most likely for death are HIV experiences of child removal and intimate partner violence um we know women who use substances do that often as a method of coping with trauma and that we have a really high prevalence of lifetime and recent overdose in the cohort which tells us that we really need to start thinking about women's needs in terms of overdose prevention and having specific overdose prevention responses for women we also would recommend that when children are removed from the care of their of their mothers as much as we hope that doesn't happen that when it does that enhance support plans are in place most of the focus is really often on the infant and people the women often kind of go up underground so clinically we found and they don't come back to see us again partly because they're embarrassed or just very grief-stricken and that's actually how we think how that pathway happens that these women are then no longer enrolled in HIV care because they might have been getting antiretrovirals from us they're maybe no longer enrolled in opioid agonist therapy like methadone or buprenorphine with us because they've lost to care so we really need to set up plans for these women when we know removal is going to happen and we need to aggressively outreach and support them and reassure them that we're going to help them navigate the court system um and that we think that we need training for health care workers and sorry that should say probably social workers and lawyers and everybody to recognize and refer women who might be experiencing grief post-child custody loss and for women that are at risk for overdose so that's kind of the conclusions from our study and I just want to wind up I'll take some questions but on a few more sort of more lessons from practice these photos from the Portland hotel societies projects with families as well as she-way this is one of our clients and just our our our sort of take-home message is that a urine drug screen is not an indicator of parenting ability this happens so often in clinical practice that someone will order a urine drug screen often it's women of color that get urine drug screens and then it's they find something it can in the before it was legalized it was often cannabis and that can just turn on this really massive response from child welfare that maybe as a clinician you weren't considering the impact of uh it all right is everyone familiar with the mother risk scandal a few of you yeah so this is a this was the lab that most of us sent our urine drug screens to in Toronto and um there was 1400 there was a massive audit of it and just essentially junk science they found that the people who were running the lab were not trained in pathology they had really poor practice a lot of false positives 1400 families were separated with inaccurate false positives that just shows you like the extent of how broken are I think our courts and child welfare systems are that these women actually hadn't even used drugs and they still lost their children and it was just devastating and this this pattern I described to you of women just giving up hope it it happened it can happen to anyone and so this this just happened I think two or three years ago some of you were reading a paper that um Dr. Susan Boyd wrote um sort of exposing a scandal and there there was a report you can find online but it's it's very very devastating uh this the headline is about a 10 year old girl who's just now being returned to her mother that's been in foster care for you know 10 years um what are some other solutions to this is a program that I worked at called She-Way which is a pregnancy and parenting program in British Columbia there's a number of sister programs now like Maxine Wright and others in the province and there we have sort of one-stop-shop models which are in the literature a lot where we can meet women where they're at one of our most effective programs is probably our hot lunch program um if you if you're familiar with the crack baby literature from the 1980s where we thought women who'd uh who's babies who'd been exposed to crack cocaine you know there was a lot of literature about how horrible their life trajectories would be that's recently been debunked by a number of scientists who re-ran the analyses finding they were never controlled for the effects of malnutrition or poverty and when you control for malnutrition and poverty you actually find that the so-called effects of crack cocaine use in pregnancy almost is essentially disappear it's not an advertisement for taking crack when you're pregnant but it's just to say we really there was a racialized lens applied where essentially it was mostly women of color in the US who were getting these drug screens and losing the custody of their children en masse as a sort of war on drugs approach and policing women's bodies and we now know those women really if they'd been offered hot meals and support instead of losing custody might have been able to successfully parent and so our hot we have birth weights of the babies of women who are extremely marginalized and many of them homeless but the birth weights and the baby's health are almost the same as population controls because they're getting fed they're getting good nutrition and as they're engaged with us ultimately getting into housing and so that housing first approaches really work and help stabilize families. Cindy Blackstock and other scholars have also written about the importance of reconciliation and rebuilding the child welfare systems this is a paper that they wrote looking at these four components so relating having sort of respectful co-design of child welfare reform the second component is truth telling so telling the story of how child welfare has really affected indigenous families the third is acknowledging and learning from the past and then finally the fourth is recommendation they have is to restore and having redressed the harms that we've caused by these racial injustices and there's a big movement in Canada now I think to reform the child welfare system or all still living through that kind of tension as it hasn't quite been informed yet. And just a plug for culture saves lives this is an amazing program in Vancouver that Patrick and other colleagues founded at the Portland and we they've really found that having indigenous culture and for families to be able to participate in powwows and things that were previously literally outlawed under the Indian Act is is so fundamental to women being able to reconnect to their culture and their family. And this is my final slide so I hope that today you've got the takeaway that really to make a difference for women and children and families that we need to focus on income support housing food security and safety rather than whether or not they took a drug or not that's not about the drugs. If for those of you who are clinicians in the room we also know that opioid agonist therapy really helps so replacing the what might be a dangerous toxic it could be poisoned street supply of drugs with something that's not poisoned so that could be methadone or buprenorphine if the women wants could also be we use S-ROMS low release oral morphine to great effect we're doing some pilots with fentanyl patches in BC as well where we know that fentanyl is actually what people are needing to be replaced and that's really where the real overdose risk comes from it's when people are having to turn to the street for a toxic supply. If you do have to involve child welfare agencies we have had some success in doing early referrals in partnership with the mother so at Chiwei for instance we have a social worker that works on our team that's not us doesn't have apprehension powers and she works with the mothers to introduce them to their social worker and to build safety plans and to sort of get child welfare involved this can help mitigate birth alerts happening at the last minute in BC we've recently stopped using birth alerts I understand does everyone know what birth alerts are so birth alerts are when women get flagged so it could be a nurse or a doctor or someone they work with at flags their electronic medical record or the medical record in the hospital and then what happens is those are then interpreted there's very little information in them and without a lot of context in the middle of the night when a when a baby's delivered and women can experience a removal minutes after birth when they're you know maybe breastfeeding a birth where it's been flagged child welfare will be called and then the child will be apprehended directly after the delivery it's very well documented in Blackstock's work and Minister Philpott when she was Minister of Indigenous Services came out and talked about the need to nationally sort of reform birth alerts it's still a very common practice my understanding is it happens here a lot certainly happens a lot in my province as well and for all the reasons we talked about it's a really dangerous practice and not not something that we're doing anymore in British Columbia so Minister Conroy recently placed a ban on it so we don't do it anymore they can they can put on a child welfare can put on a birth alert and they put it on the hospital file yeah so you become a birth alert on your file because you were in the foster right that yeah that used to happen to us or any other reason yeah your partner yeah that's previous involvement yeah but it often happens with previous involvement or a previous child or if you yourself were in the foster care system in our context you see yes that's another it also doesn't indicate immediate action but it gives an immediate notification to the child welfare system and then to give it sometimes exactly as you stated yeah sometimes very different things just so the audience comes to this means with absolute notification yeah top action by whoever is having birth it is important to note though with the changes to the Child and Family Services Act 2015 it would introduce that any suspicion of risk to the child now requires a child welfare investigation so that's a six-week intake period so any notification that child welfare receives they have to act on so that's a six-week period of involvement with the agency in your family's life and that's in the initial postcard period there's a very large trend in western nations for this birth alert and infant removals we see in the UK as well this sort of infant and I think what we're asking with with some of this research and other and what women who've been through the system are asking for is to really for clinicians to balance the risk-benefit ratio of that and there are workarounds I mean I don't know your system as well but in British Columbia the workarounds we found were trying to actually create that relationship earlier even though we were initially really afraid to work with child welfare even though of course they have the child's best interests at heart we found that having the women self-refer and start to build a relationship at pregnancy was useful even though there's this legal gray area because the fetus isn't a person but building especially if we knew they already had an alert in the file and they are they themselves were in foster care or they'd had previous children removed they're flagged already and so we found that was a good workaround and the other was helping women to ask for help themselves and so even as a clinician without if you're working in rural practice or a lawyer working with someone that's not you know in a place where there is wraparound service we found working with women to ask for help early was better than having a phone call because it's very hard to control the response like if you call from the hospital on a Saturday and you've got emergency services sometimes it's police who respond to the alert like it's really hard to control and so asking for help with the woman asking herself we found sometimes can work but but also just knowing that it's it's difficult to turn off once you've been intaked and that sometimes the response is a lot more dramatic than you would think and having been through so many cases of of babies that were removed that just really seemed profoundly unfair even with us you know making phone calls to ministers and using all of our advocacy powers it can be really shocking it can work beautifully and of course children shouldn't be abused and there needs to be you know pathways when children are being abused so it's it's such a difficult difficult issue but i hope you hope we've been able to tell a bit of the story of the numbers of the impact on women's lives and that the this system really does need reformed and even if a child is is removed surely we don't think that that woman deserves to die after the removal and so no matter how you feel about these issues there's there's gotta be a better way of supporting families than removing them because they're poor or because they had the misfortune to be homeless and so that's that's all closed with that and just acknowledge especially the community advisory committee who have very generously shared their stories and and worked with us on this analysis and in particular my mentor from the Trudeau Foundation Sophie Pierre who was the former chief of St. Mary's Indian Band and she really contributed a lot to the paper and she's um she parents so many children from her community that she helped save and she's lost many sisters and brothers to the sort of impact of the child welfare system so she was really crucial in informing this work so thank you Sophie as well and if you have any questions these are my contacts but we'll have to open it up the model of that work and but I think the essence of that work and the essence of the advocacy and the passion of women is the race that they're yes actually I'm so women centered and how women who are coming into that particular program and they're experiencing such trauma in their lives they're facing such inequities sometimes they're really they're powerful and they need allies and I think people part of that program is the fact that this effort and there are so passionate about being advocates and allies to women and really really working with the system to make sure that the voices are heard and respected and I don't know I think you actually reported upon like Rob Abrams and you know the founders of Shudei and his faculty themselves and who they're really rich to point them in using all their substances and nothing ever happened to those families and then coming into their scare and seeing when it's possible and seeing all these men who were from indigenous backgrounds mostly people from marginalized communities and that she has been able to so I think I just want to have like with that model a lot there's parts of that model I think that it ends early and the integration might be one of your last points around community along to the community or the non-community understanding the fact that you think about what's the difference between the children and the indigenous families and I'm just exactly so that there's a lot of power and we need to bridge back into the broader community program and look at the experiences on that second place in the government and be critical to the long-term success of those families but I just think we need to make a lot of that information here and it should be everywhere Thank you very much Yeah, yeah it was it was one of my if you're not familiar with it there's a companion hospital program called first square that Martha was able to visit so the comment if you couldn't hear was about about Shiwei and the community-based model but it also works really well which I didn't get a chance to speak about with first square which has a unit dedicated to mums who use substances and it's sort of a safe zone from apprehension and if you will and it's it is a semi-locked unit so it kind of allows everyone to take a breath and allow the mothers to be together and the social workers because again they're doing their best and they're working to prevent this headline of like I let that baby go home and something happened to the baby so I mean we all I have such empathy for the difficult spot there in as well and in because we have first square which is a protected unit we can sort of say they're here you know it's a safe place to be and it helps the system kind of calm down while they assess rather than just going right to this bedside removal but we still still do see these these removals and one of the reasons the birth alerts happened was was an indigenous family that you might have seen in the news who actually documented you know on video and posted I think it was on Facebook the child being removed that's right yeah the baby's age was yeah the baby was like hours old I think age baby age and that was what that family but that often these children aren't these cases aren't documented as much as you would think because once the children are removed they're in the care of child welfare and you can't speak to the media as even as a parent and so you know this family just kind of went ahead and did it with the advent of social media and that that baby age kind of really changed the practice of birth alerts just six six months three months ago in British Columbia yeah absolutely that's a great question about satellite programs so we we've just built a colleague Denise Bradshaw at BC women's hospital would be happy to share her resources so she's building a clinical pathway or has built I should say for women across the province so fur square is a provincial resource set of our provincial health services authority and she weighs a Vancouver coastal house for the partnership so we have many satellite she weighs there's one on Vancouver Island and one in Surrey which is called Maxine Wright they're not affiliated but we're sort of sister programs if you will and they all sort of use fur as a central resource so women can come in from across the province and deliver there which is problematic it would be nice if they could deliver closer to home so Denise is helping to build this pathway whereas the practices from fur square are sort of translated to other hospitals and so that we can have this sort of better understanding and training so there is a perinatal addictions coordinator whose job it is to do skills building in the rest of the province and then Dr. Abraham's and and his colleagues have been doing a lot of kind of training and skills building around the world really runs often in Central Asia and Eastern Europe and him and I have worked together there home on lots of different UNICEF projects and UN AIDS projects globally so there's a there's a number of resources that I'm happy to share or I think we I've already shared with Martha around just yet clinical practice guidelines we wrote an opioid vaginas therapy treatment guideline for pregnancy that BCCSU wrote and I was one of the authors BC Center for Substance Use in Collaboration with Sheaway that's available online now it's got a section on child welfare with some evidence of it's got Elizabeth's paper as I did it in it just to sort of say this is how we manage it here so hopefully that's a tool for others so I would say in some ways it's almost a hub and spoke model that we're starting to build out where there's this hub of fur square and the perinatal addictions unit and then there's spokes in different communities for very very rural women it really depends what we found works best is sometimes still coming out and doing skills building with the team and like getting a plan in place beforehand and helping reassure them that actually they can manage this at home addictions primarily up now you know chronic viewed as a chronic disease opioid agonist therapy you can do as a as a family physician so helping to do skills building on methadone and buprenorphine and buprenorphine is now emerging as the safest medication in pregnancy preferred in most systematic reviews above methadone now so that's again an oral medication that you can take if she's an she's using opioids so really kind of reassuring people in community that they can manage this and can keep the mother closer to home if there's a plan in place and if not I'd say our practice is generally to bring them to Vancouver which has its own risks it's not ideal to take people out of their support networks and bring them to a place in the middle of a fentanyl overdose crisis with lots of drugs in the downtown east side Sean I said I'm sorry to get my rim my minor you said the Miniature Fender student that the having been in the foster system is viewed as so potentially damaging that you would get in the work on your file such that a child of them. and just funneled into the fostering system. So what is the rationale for that? It's a really good question. I don't know if, maybe for the Nova Scotia context, if you want to answer, I can speak from the BC system, but. I think a lot of times it's stated. I know when I worked with the First Nations community here in Nova Scotia, a lot of us, because when the residential schools happened, a lot of those children, the children of the residential schools didn't really grow up with parenting. They didn't have the skills or the ability to do that. And then all of a sudden they are out in the system and the belief is that they can't parent or they lack parenting skills. So they would subsequently get a flight, not necessarily apprehended, but I also know from working in child protection that when they would get to me, you could take it into the computer and you would see generation after generation was involved in the system, which I'll take the question from my part, is what are we doing? Because we're obviously not helping if we're continuing to include families. So it can be a number of reasons. It could be because that, maybe somebody in that family has a sexual perpetrator designation that they're still involved in the family. I know for a game, a lot of visible minorities is because of the fact that there's the beliefs that they weren't able to parent or... I think to one of the things that people, if you're not in the system, you think you're referring to this like amazing family that's gonna take this child and that's not the reality. Like in BC, I can't speak to the Nova Scotia context, but especially youth are placed in hotels and we've had, I mean, Alex, just this young, beautiful young man who, you know, grew up in a school, and who, you know, completed suicide, jumped off a balcony bridge. I mean, he was, someone was being paid $4,000 a month to check in on him and hadn't checked in on him in months and weren't answering his texts in distress. And he was living in a hotel who's 15 with 10 other foster children in like a horrific situation in a suburb of Vancouver. And like, this is what you're referring to. Like you're not referring to a grandmother's breaking cookies. So you're taking people out of this, they're a family of origin because the mother's homeless and you'll pay $4,000 for like this private for-profit company to check in on them in hotels instead of just giving that money to house the family and keep them together. The number one reason for child removals in Canada is neglect. And then the subcategory of it is poverty. And so it's not actually physical and sexual abuse and the drama that we think it is. And clearly sexual, though they're not acceptable. And I've certainly also seen neglect with women who have untreated substance use disorder that again, they need support. But it doesn't mean they're not capable of treating their substance use and regaining family. A lot of the children too, that's when I worked at Self-Defection and then I explained it to them some odd years ago. The majority of the children that weren't apprehended at birth, so the children that were laid out since early teens probably had to vote I think about one of the theater non-homes that they would be put in over the span of that being involved. So you've got a youth that's involved at 14 by the time they're named out of the system at 16, they might be in eight separate homes. So. The system's not addressing the poverty or the neglect. Yeah, and I think to be, when I said earlier that we know a lot about the impact of foster care on children and adolescents is there is quite a bit of literature on children who've grown up in the foster care system are more likely to be homeless, have mental health issues, substance use disorder. So again, you can sort of see from the child welfare standpoint that child becomes pregnant. You know they've been through this distressing period. That's one of the reasons for the flags because you know that they themselves have, they're living in a hotel. I think Dan, you had a point and then, sorry. So question, so with the, I'll give it over to us, crisis that's been opening up with policy innovation around drug policy. I'm curious how much of this, which is so affected by that essentially, has been uploaded at the federal level, like there's any kind of drug policy reform that's happening in Canada that addresses this. I haven't seen any time, I'm really curious, why hasn't, yeah. I think it's a great point, I mean I'm hoping, this is kind of actually one of the first times I've presented this, or this is probably the, aside from in my department and the publications in press. So we haven't done a lot other than Elizabeth's paper, which did make some headlines. So two years, I think two years ago, Elizabeth's paper on mortality in Winnipeg. But other than that, there's not a lot of people doing, you know as part of my, I did a systematic review and only found seven papers on the outcomes of child custody loss for women. So it's definitely a sort of under-researched area. It's one of those that, especially if people are parents, are like, oh yeah, I can understand the grief of having my child removed, but it's just not, it's not documented, so it hasn't been, there hasn't been policy responses to this thing that's just out there that people think is obvious. But at the same time, people have such profound stigma towards mothers who use drugs, and until you've worked at places like She-Way and seen these women's lives, it's really hard to explain. And even among drug users, there's often a lot of self-stigma within those groups that I myself have been part of. And so people, it's a very difficult thing to wrap your mind around. And even on my different thesis examination committees and things people have been like, but surely you're not, I've heard the comment, surely you're not suggesting that women that use drugs can have their children. And it's like, oh, that's a nice glass of wine in your hand. And I happen to know that you're someone that goes to Burning Man and uses recreational drugs, but you're not saying that that's okay for other women. It's those women. And so it's just a very, and the overdose, I don't think anyone's written about the overdose link that I know of. The irony there is that stigma is one of the central points of the new drug policy. It's like de-stigmatizing substance abuse. This seems like the most intense form of that. Yeah, thanks. Hopefully, get it out there. I think you had a question and then go to you as well. Yeah, this week I was really happy to hear that in Ontario, they had talked with the control welfare system and received 5 million dollars. I saw that. 5 million dollars. So that they could change the variation of the representation to keep the children in the home. With an American government in support of this sad part, of course, that they need private money to do that. And so obviously, it's hard for government to move from this to a lot of government work that's reactive and market-oriented and far more. So I'm just wondering, moving forward, and for you as a researcher, I think it's great that you've done this. How do we build an evidence base to look at whether these changes actually work and how it works? Is that how it's supposed to be? So the reason I think it goes about, we must do this because it makes sense. Look at this. Yeah, I think it's crucial to have both. I mean, having been in government and worked, I know the Treasury Board folks well, and having tried to make a case, they actually really do need data. So I think as much as I'm more of naturally a storyteller and someone that wants to just go out and be an implementer as a nurse clinician, I've come to see you having been on the inside of government that you also need data. You need both. But data doesn't change hearts and minds either. So I think you need strong advocates from women who've been through the system and children because children are often some of the strongest advocates about the distress they have and their own experiences in foster care. I think you need both. One of the gaps in research, I would say, is quantifying the cost of the current system. I'm not a health economist, but if anybody is, or economist generally, I mean, the idea that it would be expensive to make a change, I would sort of refute that, because I think actually the current system is extremely expensive. Most of these infants get coded as having neonatal abstinence syndrome, which is an extremely problematic area of clinical practice without a solid evidence base. And the babies then go to like extra expensive foster cares, run often by nurses or people who are clinicians. And so there are thousands of dollars a month and actually what we've found, and that's what Dr. Abraham's has written about and there's a great paper in Canadian Journal of Family Practice about is if you keep the children together in what's called rooming in and you let the mother breastfeed, especially if she has methadone, which is a safe, clean substitute for heropioids, the baby gets a bit of methadone in the breast milk and they don't cry and they're not anxious and they don't have what we would call NAS, Neonatal Abstinence Syndrome. So there's just stigma just throughout the whole pathway for these families because what they do now in most hospitals is they take the baby, they say this baby has NAS, it has to go into a, it's so crazy, a room by itself in a cubicle because it can't have stimulation and the lights have to be down. This happens all over the world. And then, oh, the baby cries and the baby's sweating because the baby's wanna be held. But someone wrote about this practice like 30 years ago and it's really hard if you know about how to change hospital practice. It's really hard. So they just take the, and then they go, look at this poor baby's been exposed to drugs. Oh, it needs a foster home that, with a nurse that can treat its abstinence syndrome. They're like, it's just this crazy making. Whereas if they just let the baby cuddle with his mother or hold anybody, which we know works for everything else. Yeah, oh it, so at first square, this has been the first square, so we do, we don't use the Finnegan score, which is this problematic score that reinforces stigma. We use Eat Sleep console where we just, if a baby's crying, pick it up, you feed it, you let it sleep, you let it be with the mother. And so there's, I don't know what you do here in your hospital. We continue to have a type traded morphine. You do type traded morphine, yeah. We do use rooming in those. That's great. For that model, so they are packed with their parents. Yeah. They are currently using Finnegan. We've actually been working really close in BC to try and get an evidence-based work of their medicine colleague to shift. So I think we're like, kind of really, really, really hard. Close, that's great. So you're using rooming in, which I thought you were, which many Canadian hospitals are using rooming in now, I would say. It's more typical that we see this response in the U.S. context and internationally, it's still very much used. Quite a strong intervention. Yeah. Yeah. Yeah. Yeah, you guys are some of the, I think most major Canadian hospital centers now use rooming in. So it's sort of a bit of a comment on international models, but it took quite a long time to build up that evidence. I mean, Ron couldn't publish that paper for years. People would just reject it and go, oh, it's biased and like the stigma of, you know, pediatrics and others to read this. It was really difficult to explain why there was no solid evidence base for this putting a baby in a dark room. There's still a really fetishized response to those kind of articles that come out, saying like, oh, music therapy helps the NAS baby or volunteer cutlers help the NAS baby as opposed to the most, the actual intuitive response of being with your mom and presently these, yeah. Yeah, that's quite interesting. Rooming in, sorry, okay. Rooming can really only work with the mom of the lab near the baby. Yeah. Right? And that's not really the hospital's legal ability to provide, right? So there's this other important point. You can have rooming in, but if parents are not allowed near their children, then it's a vote. That is a major barrier to rooming in. Thank you. Sorry that we had a question there. Two questions. Sure. Is anybody actually done and not, like in economics, not thinking, thinking, but very generic economics for how much this costs so we can see how we could better spend that money. The society's already spending the other one and they're going to cost the whole spectrum, not just through healthcare pieces, but social services, jail, justice, all of those things. Because you don't have to do it in a piggy-picky, you can do it the other way and see how much we're really spending because let's spend it better. And the second one is what do the mothers themselves actually say could make a difference? Thank you. So on the first question, I'm not aware of a major analysis and Dan might actually want to comment from the Center for Evidence and Drug Policy. Certainly there's been some work that I think you've been doing on costing, like or describing the current state and how much criminalization kind of costs us, not necessarily for women and this issue, but generally, so maybe I'll let Dan speak to that after. I'm not aware of that, but I do know there was a major policy response to this when Minister Philpott was Minister of Health and we had Carolyn Bennett as Minister of Indigenous Services and there was some meetings that I went to and others were reforming child welfare. Certainly she's made a number of responses and really acknowledged that Canada's role in this, particularly for Indigenous children and so I think that's sort of starting to work its way through the system and the Toronto piece, I read the Gilpin Mail piece that probably you read as well. They're doing some big innovative pilots as well, but I would say we still have a ways to go to actually change the system. So if there's researchers in the room, I think this is definitely a space for collaboration and absolutely by you to get in touch. On the second question, what do mothers say? I think, I mean, mothers say in qualitative work, but also in the clinical practice, like give us the things we need, like give us diapers and clothes and give us safe places to sleep and give us respect and treat us like other mothers and don't judge us. Probably housing is one of the number one things women say they need and want and to not just be stuck in this sort of cycle of short term housing issues and then food security. I think that's kind of often the biggest thing people need and whether that's if they need infant replacement. Another big area that I think is under spoken about is just when you grew up in the foster care system and you don't have a network of grandparents and a network of aunties and uncles, like how do you build that community? So myself as a young drug using mother was really beneficial partly like my current husband. We're still together 20 years later and we have a 10 year old, but his family was really stable and they were very much our support network and we could still go out on the weekends with our friends and have our son with grandparents, which is a safe place. A lot of my clients don't have that. So like they just wanna do what anybody wants to do. You wanna go out and have a date night with your husband or your wife or whatever and you wanna go and have some wine. Like you have someone you can call to do that or you have the money to pay a babysitter. These women don't have that. And that's when sort of we have instances where people get called, it's like, oh, they left the baby. Like well, just any young parent needs some backup. I mean, anyone who has children can kind of relate to that. So how do we build those backups? So it's just she way part of the work is fostering babysitting networks within. We actually have a child care center and emergency daycare on the third floor that people can come last minute because we all know daycare wait lists are huge. So if you don't have a she way, how can you build those backups organically in a community advocacy role here? How can you make sure that women have even thought about that and talked about, facilitating dialogue in prenatal classes about that is one strategy we've used in the rural communities. Dan, do you want to comment on that? Absolutely. I know again, on the issue of institutionalization, there's incredible cost-effectiveness that institutionalization people who are using substances. Or, you know, that are institutionalized because of substance use, always less cost-effectiveness than other non-institutionalization options. I think the really good question that your work raises is that if you want to do cost-effectiveness analysis of the institutionalization of children, you really have to take into account the impact of child loss on the mother and the mother's use of services accidentally, right? So what is the cost of non-fail or even a failed overdose on the system? And I think that's where your work is super novel and can open up a whole new area of truly quantifying the cost-effectiveness here. And yeah, on the side of the cost of child-institutionalization is going to be astronomical, but if you also take into account the potential preventive impacts on the mother's trajectory for her life, I think it's an order of magnitude higher. So it's really exciting. Thank you. A lot of work to you, Dan. Thank you so much. Thank you so much, everybody. Thank you.