Addressing the Effects of the Inadequacy of Prenatal and Postnatal Care Among Unhoused Women in Canada

Submitted by Jada Samuels

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Addressing the Effects of the Inadequacy of Prenatal and Postnatal Care Among Unhoused Women in Canada

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Jada Samuels
Arthur Labatt Family School of Nursing, Western University N2220A

Health Promotion and Caring: Families and Communities Professor
Elizabeth Cowie Hayes

Around the world, homelessness has become an increasingly prevalent social issue. In Canada, homelessness reached record highs, following the defunding of social programs and services in the 1980s such as affordable housing. This has shifted the homeless demographic from primarily consisting of older single men to encompass a rapidly increasing number of young adults, women, and families (Berkum & Oudshoorn, 2019). According to Azarmehr et al. (2018), “individuals are considered homeless when their primary residence is not intended for residence, if they are in imminent danger of losing a residence, if they live with persistent housing instability, or if they are fleeing domestic violence” (p. 490). This statement holds true for many Canadians across the nation.

Identifying the Health Concern & Its Implications on Population Health

Although Canada is a well-off nation, many individuals still experience social, political, and economic inequities which untimely influences one’s access to resources and opportunities. While many literature reviews regarding homelessness tend to focus on the male experience, few explore the experience of women, who make up 36% of the Canadian homeless population (Andermann et al., 2021; Women's National Housing & Homeless Network, 2022), or attempt to address sex-specific issues and determine interventions to minimize inequities. Although all women face barriers to obtaining optimal health, unhoused mothers are particularly vulnerable and experience these barriers to a greater degree, due to inadequate access to prenatal and postnatal health services and inability to maintain the nutritional status needed to carry a healthy fetus to term. Adequate access to these services is integral in pregnancy as they reduce the likelihood of premature birth and low birth weight, which has been proven to be the leading cause of infant morbidity, mortality, and disability in Canada (Azarmehr et al., 2018).

According to United Way Canada, at least 235,000 Canadians experience homelessness each year, with 35,000 individuals experiencing homeless on any given night (2015). When partnering with marginalized populations, such as the homeless, it is essential to explore what might have happened to an individual that resulted in being unhoused. Homelessness is never the preferred choice for anyone; therefore, each person will have experienced complex circumstances that shaped their story. Particularly, Benbow et al. (2019) have explored the increasing prevalence of women within homeless communities and have identified that “intimate partner violence, lack of national housing policy, extreme poverty, food insecurity, and mental and physical illness are some of the compounding and contributing factors that shape mothers’ experiences of homelessness and health and relegate them to socially excluded positions in society” (p. 106). Amongst these factors, the lack of access to safe and affordable housing is the main cause of safety concerns for women. While there are services that can offer subsidized housing, the waitlists are extremely long, with many individuals waiting as many as ten years (Berkum & Oudshoorn, 2019). The issue that arises is that unhoused individuals often experience conflicting priorities and require frequent relocation; as a result, one may not have the ability to wait on social services. With this knowledge, it is important to understand that unhoused individuals are often victims of circumstance in one way or another. It is only by determining and addressing these circumstances that enables one to rise above homelessness and create a better life for themselves and their families.

While unhoused women are not often seen, this sub-demographic of homelessness continues to grow every day yet remains hidden from the naked eye. According to Andermann et al. (2021), “it has been shown that women have different pathways into homelessness, as well as different support needs than men. Women are more likely to experience homelessness due to domestic violence and a lack of social support” (para 4). As a result, these women are left with limited opportunities to make a ‘living’, often forcing them into human trafficking to ensure ‘safety’ and shelter, which they often receive from their traffickers. Therefore, unhoused women are often hidden behind closed doors and remain unaccounted for in the gathering of statistical evidence (Andermann et al., 2021). It has been estimated that 7% of women in Canada have or will experienced hidden homelessness at some point in their lives and this can often be attributed to a history of trauma, addiction and/or violence (Canada, 2021; Women's National Housing & Homeless Network, 2022). Once on the streets, many women continue to experience physical, emotional, and often sexual violence. While there a lack of statistical evidence linking sexual violence to increased pregnancies among unhoused women, it is estimated that these women are twice as likely to become pregnant than housed women (Azarmehr et al., 2018). Often, these women do not report violence in fear of being ignored or because they are dependent upon their abusers for money, food, safety, etcetera. Many women would rather be abused by a single person who supports them, than by multiple individuals on any given night. This is a sacrifice many women must make to survive. Unfortunately, compounding challenges faced by unhoused women are further exacerbated by the lack of contraception and sexual education, often resulting in increased rates of sexually transmitted infections (STIs) and decreased reproductive health.

Every individual experiences barriers to adequate healthcare, but this is especially true for unhoused mothers and other marginalized populations. Barriers to care are more prevalent among these populations because they are often placed at a social disadvantage and as a result experience increased levels of social exclusion and isolation leading to poor healthcare utilization (Benbow et al., 2018; Perrenoud et al., 2022). One may suggest that these women access healthcare services at hospitals or clinics, but this conclusion assumes that one has the necessary means to access care such as transportation, a health card, knowledge regarding the available services, financial resources and other resources needed to implement and adhere to plans of care once leaving the clinical setting. In addition to lack of access, social systems often stigmatize unhoused individuals when attempting to access goods and services. As a result, these women tend to delay seeking medical attention until it is desperately needed. In a study conducted by Benbow et al. (2019), unhoused women report “stigmas pushed on them by professionals, as well as society...[which] fueled discrimination, judgment, and monitoring, rendering no space truly safe” (p. 209). This stigma decreases women’s likelihood of accessing care because no human wants to expose themselves to judgment, instead one will avoid this situation at all costs, even when it may be detrimental to their health. In addition to the poor underutilization of health services, many women have reported a lack of understanding of how to navigate healthcare programs as a significant barrier to prenatal care. Lack of transportation is another barrier faced by unhoused mothers; in some cases, it is not the lack of knowledge of resources, but the physical inability to access them. Furthermore, the digitization of health service systems makes it difficult one to schedule and keep appointments. The most important takeaway is that the circumstances of unhoused mothers are highly dynamic, and they often experience competing priorities that take precedence over healthcare. Although access to health services is important, one’s basic needs must first be met before they can acquire greater goals because safety is a human right and is foundational for the maintenance of health and wellbeing (Azarmehr et al., 2018).

Health Promotion & Population Empowerment

Similar to the general homeless population, mothers experiencing homelessness face significant health consequences, such as increased morbidity and mortality and increased incidence of STIs and infections (Benbow et al., 2019). In addition to the various non-modifiable risk factors, one experiences due to their external environment, one is more likely to participate in risky lifestyle behaviours such as substance use and abuse. One may also experience higher rates of traumatic events and report increased chronic stress related to financial and housing instability, all of which are known to lead to negative fetal birth outcomes. Substance use and chronic stress experienced during pregnancy have been associated with underweight or overweight infants, higher rates of growth restriction in utero, fetal distress, and prematurity, all of which can lead to greater NICU admission rates, greater-than-average infant mortality rates, increased lengths of hospital stays, increased postpartum hemorrhaging and decreased maternal mental health (Azarmehr, 2018; Ake et al., 2018; Pantell et al., 2019). Maintaining a healthy pregnancy can be difficult for any woman because there are various physiological changes that need to be accounted for, and this often requires significant maternal education. Therefore, one can assume that coping with these changes can be especially difficult for unhoused mothers who do not have access to adequate goods and services, which negatively affects fetal and maternal health. Thus, it is important for HPCs to remember that each individual will experience a unique set of circumstances that have led them to where they are today; understanding these circumstances is essential to promoting health.

When one is in the ‘eye of the storm’ one tends to view themselves in a negative way. One may believe that they cannot see anything good in themselves or their situation, but this outlook fails to recognize one’s own strengths and resources. To combat this, it is important that HPCs, specifically community health and outreach nurses, identify and reinforce client and community strengths to empower others to adopt a ‘can-do’ attitude. In 1986, the Epp Report was published by the Government of Canada, which is a framework that focused on health promotion and the social determinants of health (SDoH), with the goal of achieving health for all Canadians. In this work, a self-care framework was proposed as one of the key mechanisms of health promotion. The framework involves supporting the individual, sharing of knowledge, facilitating learning and personal development, aiding the person build support networks, and providing a supportive environment (Health Canada, 1997).

As stated by Lathrop (2020) “although health care no doubt can have a positive influence on health, its influence is limited. Whether working with women to promote a healthy pregnancy or manage chronic conditions... nurses need an understanding of the social determinants contributing to women’s health and illness” (p. 37). Due to excessive exposure to poverty, unsafe living conditions, food insecurity, oppression, abuse, racism, and other determinants, unhoused women tend to experience chronic stress which puts the body into overdrive, which negatively affects its ability to function. With the aim of promoting greater health, nurses can better support unhoused mothers by building on their strengths, challenging their negative self-beliefs, and helping them push beyond barriers (Benbow et al., 2018). To achieve this, HCPs need to assess and separate their thoughts and beliefs from clinical interactions and focus on the client's needs and desires. Professionals must practice empathetic, respectful, trauma and violence-informed, and client-centered care to encourage clients to continue to seek medical attention before their health becomes an issue. Most importantly, one must foster a strong therapeutic relationship and meet clients where they are regarding their abilities, capacities, resources, and external circumstances.

Solutions and Implications for Nursing Practice

Due to the complexities of homelessness, services need to be coordinated to address the needs of this population in order to take the appropriate steps to optimize maternal, fetal, and neonatal health outcomes. To combat health inequities experienced due to homelessness, accessible programs must be curated to promote population well-being and fosters a greater sense of empowerment in a way that is meaningful to the client. CHNs are in a prime position to challenge and address systemic issues faced by unhoused mothers by “being aware of and sensitive to the complexity of social exclusion that shapes mothers’ lives, as well as their experiences of discrimination and stigma from health and social professionals... [in order] to unpack how such views can negatively impact care and detrimentally impact the health of those who most need support” (Benbow, 2019). There are a variety of programs that could be implemented to aid unhoused mothers in attaining optimal health. Curated programs must reflect the needs of, as defined by, the population. Through the analysis of resources, unhoused mothers have identified that they experience constant threats to safety. This includes physical threats as well as limitations in services such as shelter beds reserved for women, which in turn increased their exposure to harm. Limitations in service provision and strict criteria needed to access services were also highlighted. Many women noted that these limiting factors made them feel excluded from services that were implemented for their population, and as a result, they were further deterred from seeking care (Pantell et al., 2019).

Of all the identified needs, two stood out, the need for patient-centered care within heavily affected communities as well as increased maternal support and resources needed to empower individuals to rise above their circumstances. This can be done through the creation and implementation of programs that build on the population's existing strengths, which include, but are not limited to, resilience, problem-solving skills, resourcefulness, decisiveness, and an altruistic attitude, all of which have been developed through adversity. By building upon these strengths, CHNs can act in the best interest of the community to promote health and decrease the effects of experienced SDoH. This can include a mutually beneficial shelter-based patient- centered program that focuses on addressing the unmet needs of unhoused women related to maternal and infant health while providing a learning opportunity for medical students within the community context. This strategy would improve pregnancy and childcare education and encourage healthy behaviours during pregnancy through connected food services to prevent malnutrition as well as socially competent clinics that are aware of the needs of the unhoused population and actively work towards providing equitable care. Untimely, this would result in improved maternal health and thus decreased infant morbidity and mortality. CHNs can also increase the social support of unhoused mothers by facilitating and advocating for childcare services. CHNs would not be responsible for childcare itself, but they would use their power and access to resources to create inter-sectoral linkages to gather the resources needed to implement this program. This program would be based on the Canada-wide Early Learning and Child Care Plan, which was recently revised in 2021, and aims to invest in early education and childcare services to provide increased work opportunities, particularly for women; enable parents to attain their full economic potential; and prepare young minds for learning (Canada, 2021). As briefly described above, implementation of this program would enable mothers to seek work and access resources; this enables the family to have a source of income, which is the most integral SDoH. These suggestions will, in theory, allow unhoused women to access needed resources to face life’s challenges head-on while sustaining human dignity and individuality by empowering themselves to take back control over their health status and life trajectory.

Programs such as those described above are integral to health promotion and uphold the mission statement of CHN Standards of Practice (2002) by providing “a unified voice to represent and promote community health nursing and the health of communities” (p. 2). By addressing the health and safety concerns identified by members of the community, CHNs are better equipped with the knowledge and resources to implement a program that targets the root causes of health concerns and inequities. In doing so, CHNs address and fulfill the five core standards of practice which consist of promoting health, individual and community capacity building, build relationships, facilitating access and equity of care and demonstrating professional responsibility and accountability (Canadian Community Health Nursing. Standards of Practice, 2022). This can only be achieved by fostering an authentic therapeutic relationship with the client by “ensuring that all professional behaviours and actions meet the therapeutic needs of the client” (CNO, 2019) and this calls for CHNs to actively include the client as a member in the circle of care by identifying their goals, values, expectation and preferences as well as gain an understanding of the client’s abilities, limitations and needs. Advocating for the rights of underserved and vulnerable populations is not an easy task, but as CHNs it is their duty and responsibility to use their authoritative position and political power to empower others and to push for policy changes that support the health of individuals and the community at large. To put oneself in harm's way for those without a voice takes leadership, which as described by the CNO’s Standards of Practice (2002) “requires self-knowledge, respect, trust, integrity, shared vision, learning, participation, good communication techniques and the ability to be a change facilitator” (p.10).

Conclusion

While all individuals face barriers when accessing health, marginalized and vulnerable populations experience this to a greater degree. As discussed throughout this work, to obtain optimal health one must have the necessary resources and the ability to prioritize habits that promote better health outcomes. Particularly, many unhoused mothers are unable to gain adequate access to prenatal and postnatal services, which can be primarily attributed to a lack of safe and affordable housing, poverty and intimate partner violence. Inadequate access to maternal care has been proven to increase the likelihood of neonatal and maternal complications prior to, during and after birth. Although unhoused mothers experience various barriers to care, to address the population and those who function within it, it is essential that CHNs and associated HCPs understand that each client has experienced unique circumstances that have shaped their lives and self-perceptions. By addressing these circumstances, HCPs can address the root causes of inequity, provide clients with strategies to overcome adversity and foster a greater sense of empowerment, preventing more mothers from becoming victims of circumstance and unsupportive systems.

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