A Mustard Seed of Hope is a beautiful new booklet describing culturally grounded approaches within wraparound care for pregnant and parenting women who are dealing with substance use and trauma.
It describes the Indigenous cultural programming that is being offered in some wraparound programs, to honour this work and to inspire others who provide community-based services to take up/expand upon these approaches.
The title comes from one of the mothers who spoke of the caring, non-judgemental wraparound supports that allowed her to see hope in being able to keep her baby and be a good mom. All she needed was that “mustard seed of hope” to keep coming to the program for the supports and services.
The cultural programming of three wraparound programs – Sheway, the Healthy Empowered Resilient (H.E.R) Pregnancy Program and Manito Ikwe Kagiikwe (Mothering project) – are highlighted. Beautiful photos and descriptions of their culturally grounded approaches are offered as inspiration.
The booklet ends with a powerful description of how culturally safe approaches and Indigenous cultural programming make a difference for women. The quotes and images of those who have benefitted from this programming are well worth reading.
The booklet represents a thank you to the women who accessed, and the service providers who provided, wraparound programming in the Co-Creating Evidence project.
Thanks are also due to Marilyn Van Bibber for her commitment to this work and her conception of this booklet.
Funding for this booklet and the Co-Creating Evidence project has been received from the Public Health Agency of Canada, National FASD Strategic Project Fund. The views expressed here do not necessarily represent the views of the Public Health Agency of Canada.
The Co-Creating Evidence (CCE) Project has been a first-of-its-kind-in-Canada national evaluation involving 8 different programs serving women at high risk of having an infant with FASD or prenatal substance exposure.
The goals have been to:
Bring together many of Canada’s holistic FASD prevention programs to share promising approaches and practices;
Evaluate the effectiveness of multi-service programs serving women with substance use and complex issues;
Identify characteristics that make these programs successful.
Representatives of the eight programs and researchers from Note Bene Consulting Group and the Centre of Excellence for Women’s Health have collaborated since 2017 to achieve the following:
256 program participant interviews, 108 staff interviews, and 60 interviews with community partners of the services
A detailed report of all study findings (96 pages) for all audiences
12 info sheets on key components found to be helpful, to support the work of service providers
4 journal articles, to bring awareness of the findings to researchers and health system planners
A booklet on culturally grounded approaches within wraparound programs for all audiences (24 pages)
A digital handbook highlighting key components of wraparound programming found to be helpful, for service providers and peer mentors wishing to start a wraparound program or enhance the work they already offering
The 8 programs were guided by a similar set of theoretical approaches, including being trauma-informed, relationship-based, women-centred, culturally-grounded, and harm-reducing.
The range of services offered by wraparound services is key for women in finding what works for them, and in having the opportunity to choose the order and pace of services they will use.
The study has demonstrated that pregnant and early parenting women experiencing problematic substance use and other complex issues benefit from programs that include: Wraparound services – Knowledgeable and empathetic program staff – Indigenous (re)connection – Opportunities for community/peer support.
Further, the following elements are important characteristics that contributed to the programs’ success: Well conceptualized, evidence-based approaches – Strong partnership relationships – Flexible, multi-dimensional models – Keeping clients engaged over time.
The Digital Handbook on Wraparound Programs is a key legacy of the CCE Project. The handbook was developed with multiple audiences in mind, including program planners, managers and staff, service partners from a variety of health and social sectors, funders, researchers, community members, and families affected by perinatal substance use.
The Handbook is a remarkable, accessible collection of resources about:
Trauma- informed approaches
Culturally safe care
Harm reduction approaches
FASD informed approaches
Indigenous cultural programming
Attachment focused practice
Transitioning from wraparound services
Cross sectoral work
Wraparound programs as good investments
Data collection approaches and more
The Handbook supports one of the implications arising from the study:
“Ongoing learning opportunities, focusing on integrated, culturally grounded, trauma informed, relational practice, are important to practitioners in all fields and need to be actively supported.”
See the Executive Summary of the Co-Creating Evidence Evaluation Report for all the implications identified: 6 directed to practitioners, 5 for health system planners, and 6 government policy makers and funders.
Next month’s blog will feature, A Mustard Seed of Hope, a booklet created through the CCE Project about culturally grounded approaches within wraparound care for Indigenous pregnant and parenting women dealing with substance use and trauma.
Funding for this project was received from the Public Health Agency of Canada. The views expressed do not necessarily represent the views of the Public Health Agency of Canada.
In 2009 a group of women gathered in Victoria BC Canada to discuss how we would approach the development of a network on FASD prevention. We were researchers, policy advocates, service providers, community activists and those with Indigenous wisdom – all with a commitment to seeing and acting on how social determinants affect women’s health and substance use, and the ability for them influence the conditions of their lives.
Out of our discussion emerged a consensus on 10 fundamental components or principles for approaching FASD prevention from a women’s health determinants perspective. Now, in 2022, we have updated that consensus statement, so that those interested in FASD prevention are directed to new evidence and resources. The update is a testament to the soundness of the original principles and to the ever-growing expertise of the network participants and international partners. We hope this will empower those working on FASD prevention to continue to use and build upon this principle-based approach.
The principles foundational to approaching FASD prevention are:
Respectful – Grounding prevention initiatives in respectful relationships is vital to reduce stigma and discrimination.
Relational – It can be a transformative experience for women who use substances to experience care that aligns with their needs, views them as a whole person, and offers respect, understanding, and authentic collaboration.
Self-Determining– Health care and other support systems can facilitate self-determined care by supporting women’s autonomy, decision making, control of resources, and including exercise of their reproductive rights.
Women+ Centred– Women+ centered care moves beyond a fetus/child-centered approach, and focuses on fostering safety and empowerment when providing support to women and gender diverse individuals who are pregnant or parenting.
Harm Reduction Oriented– A harm reduction oriented approach focuses on safer substance use but also on reducing broader harms, including retaining or regaining custody of children, access to adequate and stable housing, and the challenges of poverty, food insecurity, and intimate partner violence.
Trauma- and Violence-Informed– Trauma- and violence-informed services integrate awareness of the impacts of trauma on health into all aspects of service delivery including wellness support and prevention of secondary trauma.
Health Promoting – Holistic, health promoting responses to the complex and interconnected influences on women’s health and substance use are vital to FASD prevention.
Culturally Safe – Respect for individuals’ values, worldviews, and preferences in any service encounter is important, as is respect for and accommodation of a woman’s desire for culturally-specific healing.
Supportive of Mothering – FASD prevention efforts must recognize women’s desire to be good mothers and the importance of supporting women’s choices and roles as mothers.
Uses a FASD-informed and Disability Lens – Uses strengths-based responses, makes person-centered accommodations, and ensures equity of access to health and social services.
We hope you will find the Consensus Statement with these principles and supporting sources – journal articles, reports and infographics – an inspiration for action.
There are many influences, stressors and life circumstances that affect pregnant women’s and new mothers’ alcohol use, yet few so challenging and heartbreaking as the experience of intimate partner violence (IPV) and other forms of abuse.
Holistic community-based programs that aim to engage pregnant women and gender diverse individuals with lived experience of violence are challenged to help everyone feel safe, and to access the services that they and their children need. In many ways the overall service approaches of these programs – being harm reduction oriented, non-judgemental, culturally safe and trauma informed – go a long way towards creating the needed safety and support.
The Breaking the Cycle (BTC) program in Toronto took on the role of assisting community based programs that work with families who may be living with IPV, to articulate and enhance their support approaches. BTC received a grant from the Public Health Agency of Canada to develop and share with over 800 programs across Canada, both a resource manual (Building Connections: Supporting Community-Based Programs to Address Interpersonal Violence and Child Maltreatment) and training that helped these programs build further awareness of IPV and their capacity to deliver trauma informed approaches. Connections is a manualized group intervention that supports increased understanding by mothers about positive relationships and their importance to healthy parenting and healthy child development. This work illustrates BTC’s ever growing understanding of the many impacts of trauma on mothers and their children, and the importance of embedding trauma-informed approaches in the delivery of addiction, mothering and early childhood intervention services.
The Breaking the Cycle program recently published the findings arising from the evaluation of this work in the document “What we Learned”. It documents the impact on: women who participated in the Connections groups, the group facilitators, other staff in the prenatal and child development organizations who engaged in the training and group delivery, and the organizations as a whole. Really compelling is the section on how women increased awareness of the impact of abuse, of children’s brain development, and of positive and mindful parenting; as well as their changes related to forgiveness and healing, self-care, self-esteem and empowerment. The facilitators also benefitted immensely in awareness, competency and overall through integrating and advocating for trauma-informed perspectives in their daily working relationships. The document is rich in detail about the impact of this important work to address intimate partner violence through relational and trauma informed approaches in community-based services, including Indigenous specific services.
Key to what they learned, Breaking the Cycle identified 4 fundamental practice principles which are definitely relevant to all the work we do on FASD prevention and intimate partner violence:
Readiness is critical. There is background work that must be done first, before a group like Connections that addresses trauma can be implemented.
Safety is vital. Trauma-informed principles must be established and integrated into your organizational practices before women will feel safe enough to get involved with Connections.
Relationships are the building blocks of engagement. Women who experience IPV have limited experience of supportive relationships and find building safe and healthy relationships with others, including their children, difficult. It is imperative that service providers model supportive relationships during the implementation of Connections.
Research and evaluation are critical components of all programs, with co-occurring commitment to respect community wisdom. The commitment to research and evaluation needs to be accompanied by a flexible group approach for participating organizations who know the needs of their communities best.
These lessons are a tremendous gift to all service providers who take on this important work. Much appreciated Breaking the Cycle!
Over the past three years, the Co-Creating Evidence study (CCE) has been exploring best practices in the delivery of community-based wraparound programs that support pregnant and parenting women with substance use concerns in Canada. The CCE team recently published an article about how the partnerships fostered and maintained by community-based wraparound programs make a difference in their work and are in fact a best practice.
The CCE project team interviewed 60 partners and 108 staff of the eight programs involved in the CCE study. The interviews focused on the nature and benefits of interagency and cross-sectoral partnerships. The study found that these programs most commonly formed partnerships with child welfare and health services such as primary care, public health, mental health services and maternal addictions programmes, yet they also partnered to some degree with housing, income assistance, Indigenous cultural programming, infant development and legal services.
Key benefits of partnerships identified were:
improved access by clients to health and social care that addresses social determinants of health. This access includes expanded programming in the program sites, increased understanding of partners’ services, and greater ease of referral to other supports and programs as needed by clients.
increased knowledge on the part of both the interagency partners and the wraparound service providers about the experiences that women face, such as the significance of poverty and trauma to women’s substance use. In turn this positively promotes non-judgemental and trauma-informed approaches with pregnant women and new mothers, as well as provision of more multifaceted and paced supports to address their needs.
improved child welfare outcomes. The program level relationships with child welfare workers, and in some cases integration of a social worker onsite, results in increased planning for positive mother-child outcomes during the pregnancy, improved mother-child connections after birth and reduced likelihood of the infant being removed from the woman’s care at birth.
strengthened cultural safety within the programming and (re)connection to culture by women. Partnerships with Indigenous organizations enhances learning by program providers about how to work in a culturally safe way and increased opportunities for referral to Indigenous programming for those women interested in connecting to their culture as a part of their wellness/recovery.
The partnerships continue to evolve through dialogue, collaboration and communication. What the study has identified is how, through these partnerships, wraparound program providers are contributing to the reduction of fragmentation between the health, child welfare and addictions fields – and in turn to important benefits for clients in terms of access to care and enduring connections with their children. In the work on prevention of FASD, it has repeatedly been emphasized how important the role of “Level 3 and 4” programming is, particularly in how such programs attend to the range of determinants of women’s health and alcohol use. Clearly it is in part through partnership work that FASD prevention is achieved.
Harm reduction and health promotion for women and their partners before conception are key to FASD prevention . Providing health information and supports during the preconception period provides an opportunity for men and women to actively plan for a healthy pregnancy and learn strategies such as healthy nutrition, supplementation, and reducing alcohol and other substance use . Such education and support can contribute greatly to optimizing health and preventing FASD .
Around the world, there are examples of unique approaches to preventing alcohol exposed pregnancies. Some interventions are geared towards women and men separately, and others are gender synchronized, creating complimentary programs for men, women, boys, and girls. Interventions may also include both members of a couple and include training for healthcare professionals.
Websites, such as Healthy Families BC and the Society of Obstetricians and Gynaecologists of Canada have pages offer information about alcohol use during pregnancy and clear and concise steps to consider before becoming pregnant. The recent ThinkFASD website sponsored by the CanFASD Research Network offers advice both for couples who are consciously planning a pregnancy, and those who are drinking and having unprotected sex. Other websites are interactive, such as Alberta Health Services’ Ready or Not, which allows a woman to click through different resources and prompts based on whether or not she feels ready to become pregnant. Don’t Know? Don’t Drink is a creative campaign in New Zealand, which posts fun, engaging graphics and videos to their social media platforms with messages about using contraception and supporting friends to not drink if there’s a chance they might be pregnant. The campaign caters to younger girls and encourages finding a “Pretestie Bestie”, a friend who supports you and your decision making before getting a pregnancy test, as a strategy of FASD prevention.
Interventions in the preconception period are not limited to women. Paternal drinking can impact men’s safety, sperm health, fetal/infant health, and women’s ability to reduce their alcohol use . Various programs have been geared towards men’s education about contraception options, reproductive health, and how to support partners in their efforts to reduce drinking before and during pregnancy. Project Alpha is an American collaboration aimed at educating boys age 12 to 15 about fatherhood, contraception, healthy relationships, and sexuality.
MenCare+ empowers men to be active and positive participants in their own health as well as the health of their partners and children. It has been implemented in Brazil, Indonesia, Rwanda, and South Africa and has been shown to reduce intimate partner violence in its participants, which is an important contributing factor to women’s substance use during pregnancy . In addition to programming for men, MenCare also offers workshops and training for healthcare professionals on engaging men in maternal and child health.
The internet has been a preferred source of information when it comes to preconception  and for couples who know they want to have children, web-based interventions are helpful tools. The UK’s Smarter Pregnancy program helps couples build a profile through an online health assessment and then offers evidence-based recommendations based on their profile. A similar approach is taken by HealthyMoms and HealthyDads complimentary websites, which were created after asking expectant moms and dads what information and supports they need to prepare for parenthood.
Culturally safe and non-judgemental interventions have been shown to be effective in reducing the risk of alcohol exposed pregnancies . In the US, CHOICES and Amor Y Salud are interventions geared towards Indigenous and Latinx communities. CHOICES educates non-pregnant at-risk women about contraceptive options and uses motivational interviewing to support women to reduce drinking. Amor Y Salud, available through the Oregon Health Authority Website, offers a radionovela that follows a young couple as they learn how to optimize their health and prepare for future children. In Canada, Best Start’s website has a page for Indigenous prenatal health with information and resources that integrates Indigenous knowledge with Western health information. They also provide resources, such as Planning for Change, to support healthcare providers in educating their patients about FASD and supporting them in making meaningful changes.
The variety of preconception education and support approaches illustrates opportunities for incorporating these initiatives across the various levels of reproductive health. Childbearing years span four decades for women and are longer for men, and interventions have and can continue to focus on those that are planning or not yet planning a pregnancy, as well as for those in the period before a pregnancy is confirmed. When such preconception and early pregnancy supports are well incorporated throughout the healthcare system, this key component of FASD prevention can be realized.
1. Network Action Team on FASD Prevention. (2010). Consensus on 10 fundamental components of FASD prevention from a women’s health determinants perspective. Canada Northwest FASD Research Network.
3. Webb, Shelby, and Diane Foley. “An Introduction to the Optimal Health Model for Family Planning Clinicians.” National Clinical Training Center for Family Planning, 17 Feb. 2020, http://www.ctcfp.org/optimal-health-podcast/.
4. McBride, N. and S. Johnson, Fathers’ role in alcohol-exposed pregnancies: Systematic review of human studies. American Journal of Preventive Medicine, 2016
5. Alhusen JL, Ray E, Sharps P, Bullock L. Intimate partner violence during pregnancy: maternal and neonatal outcomes. J Womens Health (Larchmt). 2015 Jan;24(1):100-6. doi: 10.1089/jwh.2014.4872. Epub 2014 Sep 29. PMID: 25265285; PMCID: PMC4361157.
6. Da Costa D, Zelkowitz P, Bailey K, Cruz R, Bernard JC, Dasgupta K, Lowensteyn I, Khalifé S. Results of a Needs Assessment to Guide the Development of a Website to Enhance Emotional Wellness and Healthy Behaviors During Pregnancy. J Perinat Educ. 2015;24(4):213-24. doi: 10.1891/1058-1243.24.4.213. PMID: 26834443; PMCID: PMC4718007.
7. Hanson, J., & Pourier, S. (2015). The Oglala Sioux Tribe CHOICES Program: Modifying an Existing Alcohol-Exposed Pregnancy Intervention for Use in an American Indian Community. International Journal of Environmental Research and Public Health, 13(1), 1. doi:10.3390/ijerph13010001
Building trusting and supportive relationships is foundational to women feeling safe and confident enough to take on the challenges of reducing substance use, addressing trauma, and parenting. As such, the relational approach addresses a core aspect of women’s health, stimulating a ripple effect that can enact change and growth in the lives of women at risk of having children with FASD.
Breaking the Cycle (BTC) has been delivering services using a relational lens since 1997 and have found that relationships facilitate healing and change for mothers, children, and the mother-child dyad through improving self-efficacy, instilling purpose, and increasing engagement in services2. The program emphasizes relationships of many types, including those among staff, between women and their children, staff and women, and the organization and service partners.
Breaking the Cycle Compendium Volume 2 – Healing Through Relationships compiles research conducted between 2008 and 2018, and the evidence shows that the relational approach offers opportunities to model relationships based on equality, empowerment, and respect, and that having strong relationships with service providers can have more impact on women’s health than the services themselves. Additionally, emphasizing interagency and intra-agency relationships and collaborations better positions a program to meet the needs of the women and children receiving services3. Through this approach, the BTC program has been successful in preventing FASD and has also positively increased confidence in parenting and mother-child bonds.
In focusing interventions and preventative efforts on building belonging and connection, existing and future programs can better address root causes of women’s substance use. It is from here that we can stimulate a ripple effect to make positive changes in the psychological, emotional, and physical health of mothers and their children.
Developing specialized, culturally safe, and holistic support for pregnant women is an important strategy in preventing FASD . In Labrador, Thea Penashue and June Fry of the Innu Roundtable Secretariat are bringing Innu midwifery and parenting back to Sheshatshiu and Mushuau Innu First Nations through two initiatives.
Centering Pregnancy was introduced in Sheshatshiu in 2018 to increase access to and use of primary prenatal care. The project was born from dialogues between the Innu Round Table Secretariat, Innu Health Directors, the Regional Health Board, physicians, and public health nurses. Centering Pregnancy is a group pregnancy outreach program where women can access prenatal group education, health assessments, and social support. The program promotes relationship-building by allowing participants to bring supports with them to the group sessions and encouraging discussion and bonding between women within the program. Expectant mothers have autonomy and control in their care in addition to support from a health care worker .
The Innu Midwifery Project aims to reintroduce traditional midwifery to Sheshatshiu and Natuashish, drawing on Innu Elders’ knowledge of Innu birthing practices. The project is being done in collaboration with Gisela Becker, the Chief Midwife for Newfoundland and Labrador, to support the training Innu midwives using a culturally-specific, hands-on, individually paced learning approach. Reintroducing midwifery to the Innu First Nations will result in Innu children being born on Innu lands, fostering a greater connection to the land and culture, continuation of cultural practices and culturally safe care, and empowering women in the context of their pregnancy.
These initiatives create a safer environment for Innu women to discuss their health. Based in and driven by the communities and culture, these programs are centered around women, their families, and the communities .
Thea Penashue, the Community Wellness Systems Navigator at the Innu Round Table Secretariat, delivered her second child in a tshuap, a traditional Innu tent, in September. She hopes that, through the Midwifery project and Centering Pregnancy program, more Innu women will be able to give birth in a tshuap, connecting to their land, culture, and sense of self as Innu people, in the company of their loved ones .
As we continue to connect our work in Canada on FASD prevention, via the Prevention Network Action Team on FASD Prevention from a Women’s Health Determinants Perspective (pNAT), new priorities for action emerge. These are five priorities that this virtual community identified for the coming year.
Collaboration across fields provides an important opportunity to support mothers, children, and women who may be at risk of using substances during pregnancy. Resources, such as Mothering and Opioids: Addressing Stigma – Acting Collaboratively, highlight opportunities for collaboration across fields to foster advocacy, streamline service delivery and referrals, and offer systems navigation.
Indigenous approaches to FASD prevention
There are an increasing number of wholistic FASD prevention and wellness programs that are incorporating culture and language, traditional knowledge, and land-based programming, while responding to the needs of families and communities. Programs such as Circle of Life in Terrace, Xyólhmettsel Syémyem (Family Empowerment Team) in Chilliwack and others highlighted in the recent booklet, Revitalizing Culture and Healing: Indigenous Approaches to FASD Prevention, bring attention to the importance of community-led, community-driven FASD prevention and wellness programs.
Trauma-informed practice and policy development are essential components in responding to each level of the four-part prevention model. Trauma-informed services recognize the interconnections of trauma, mental health, and substance use and the role that substance use may have in coping with past or current violence or trauma. When discussing alcohol and other substance use, trauma-informed approaches will promote building relationships, building upon individuals’ strengths, and offering choice and collaboration in service provision.
There has been an increasing focus on reducing stigma that mothers and women who use substances during pregnancy experience. By reducing stigma, pregnant women and mothers will be able to better access necessary supports and servicces that support stigma reduction. The recent issue paper from the Canada FASD Research Network on mothers’ experience of stigma through a multi-level model offers recommendations and recommended resources for service providers, health systems planners, and policymakers.
Keeping families together
More attention is being brought to service delivery models that have the goal of keeping families together. These programs, which range from co-located multi-service programming to mentor and peer support models increase women’s access to prenatal care, health care, social support, advocacy, and childcare. PNAT members from programs such as the Parent-Child Assistance Program, Sheway in Vancouver, HerWayHome in Victoria, H.E.R. Pregnancy Program in Edmonton, Manito Ikwe Kagiikwe (the Mothering Project) in Winnipeg, and Mothercraft (Breaking the Cycle) in Toronto are helping us understand how this goal can be achieved in community contexts.
Key challenges in FASD prevention are the stigma directed to pregnant women and new mothers who use alcohol and other substances, and the fear of having children removed from mothers’ care if they report their use and/or seek help. A new resource, in toolkit format, Mothering and Opioids: Addressing Stigma – Acting Collaborativelyaddresses these long standing dilemmas for women and for service providers.
This toolkit provides tools, worksheets, and factsheets to aid substance use and child welfare workers in building capacity to offer mother-child centred, trauma informed, culturally safe, and harm reduction-oriented services and policies. The toolkit’s four sections each address a specific area or need in service delivery and provision:
Addressing Stigma in Practice
The first section examines how women who use opioids experience stigma and includes tools for assessing potentially stigmatizing practices. This section also includes a script for responding constructively to coworkers’ stigmatizing behaviour arising from the work of Lenora Marcellus and Betty Poag, as well as a factsheet entitled “10 Things Pregnant and Parenting Women Who Use Substances Would Like Practitioners to Know” created by women with lived experience accessing services at HerWay Home in Victoria BC.
Improving Programming and Services
The second section describes how stigma relates to the barriers that women face. It identifies promising practice and policy responses that address stigma and health, substance use, and child protection concerns. Tools are provided to facilitate integrating promising approaches into our responses, and to identify ways in which barriers can be overcome. It honours and advances the differing roles of substance use services and child welfare services in supporting women and children, as well as evidence informed shared approaches (See diagram from page 21)
Cross System Collaboration and Joint Action
The third section includes information and tools to facilitate cross-system collaboration. Collaboration between the child welfare and substance use fields provides an opportunity to improve child safety and support the recovery of parents. Cohesive working relationships between these sectors can foster advocacy, consultation, system navigation, safety planning, and streamlined referrals. In this, as in all sections there are resources that focus on Indigenous approaches to child welfare and substance use.
The final section discusses policy matters, and how defining and affirming policy values can clarify our work in both systems of care. This section emphasizes viewing mothers and children as a unit when developing policy and programming to facilitate the goal of keeping mothers and children together.
Researchers at the Centre of Excellence for Women’s Health worked with other researchers, service providers and women with lived experience to create a practical and forward looking resource designed to inspire self-reflection and action, to promote an immediate impact on current policy and practice. The tools are designed to help us continue to build on our capabilities to make mothers’ needs and voices central in our work, and to offer mother-child centred, trauma informed, culturally safe and harm reduction-oriented services and policies related to women’s use of alcohol, opioids and all other substances.