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This program aims to provide trauma-aware reproductive care for pregnant individuals living with HIV and those living with increased risk, focusing on the intersectionality of trauma, substance use, exploitation, and homelessness. The program acknowledges the impact of trauma on care decisions and provides a safe and respectful environment for individuals to access necessary resources and support.
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Trauma-AwareReproductive Care for People Living with HIV and Those Living with Risk Jay MacGillivray, RM Mark H. Yudin, MD, MSc, FRCSC Positive Pregnancy Program (P3) Toronto, Canada
Positive Pregnancy Program • Premise of Model • A collaborative model providing medical care, health promotion and resources • Midwifery, Obstetrics, Nursing, Social Work, and robust community partnerships • Commitment to clients: respect, confidentiality, dignity, with highest standard of care using latest evidence • Normalizing care for HIV+ community
Positive Pregnancy Program • Preparation of Model • Out of hospital community consultation • Involved midwifery governing bodies and hospital medical directors in planning • Reviewed literature on care models
Positive Pregnancy Program • Community Partnerships • Culturally-based ASOs • Multiple front line agencies • Legal and Housing resources • Peer support services • Settlement services • Medical Partnerships • HIV, Pediatrics, Psychiatry, Pharmacy
Strength and Resiliency • Clients are not victims • They are survivors • They have remarkable resiliency and wisdom • We are not ‘helping’ them- they are truly partners in care
Gender-Based Violence in Conflict Zones • “Forced migration caused by conflict increases the vulnerability of women in every regard but especially to gender-based violence- rape, torture, abduction, forced marriage, slavery, trafficking, and forced pregnancies.” • Remarks by Judy A. Benjamin, Senior Technical Advisor, Women’s Commission for Refugee Women and Children. Presented at The World Bank, International Women’s Day, March 8, 2001
Positive Pregnancy Program • Demographics • Greater than 50% of women living in Canada less than 5 years • Over-representation of Racialized communities, including people of colour and Indigenous communities • Extreme marginalization, infrequent access to care, often lost to f/u
P3 Broad Demographics • people newly arriving from conflict zones • survivors of gender-based violence, migration • histories of incarceration • street-affected or homeless people • people in exploited sex work/survival sex • people with substance use, mental health issues • very few Anglo women of privilege and access • Strong theme of trauma, often unresolved, throughout
Trauma, Substance use, Exploited sex work, Street life and Pregnancy:Living with increased risk of HIV
Interconnected truths • Pregnancy isn’t always planned- sometimes it is • Substance use in pregnancy doesn’t just happen • Trauma isn’t self-inflicted • HIV is unintended • Harm reduction works • Respect is essential • Racism in health care and its affects are real
Street Realities Approximately 1,000 women of childbearing age will sleep in the streets of Toronto on any given night. Cheung 2004
Substance Use and Social Issues • Poverty 75% • Homelessness 85% • Police harassment 67% • Discrimination 50% • Addiction 81% Crack + Report Goodman, D. 2005 • Poor health 68% • Violence 64% • Sexual assault 44% • Isolation 56%
Exploited ‘Sex’ Whilst Pregnant • Often cant negotiate safer sex=violence, low self esteem, lack of power • People worth more on street when pregnant • Being run by someone else • May be someone else’s for-profit income
Harm Reduction: clients must lead • K.B.- 34 years old. G2p1. one previous term vaginal birth 10 months earlier=child apprehended. Brought into care by street team at 32 weeks. Blasting an H point 3x/day. • First appointment: =“do you have any screens?” • Keep harm reduction bags at work and in my car=Gave screen without comment. • Opened discussion of use pattern and related issues, strategies for harm reduction. • “I'm comin’ back here”.
Care Providers’ Judgements as Barriers to Care • Do clients have the autonomy to decide on appointments? • The great divide: I drove to clinic from the house I own; how did she get there and from where? Acknowledge my privilege. • Lack of awareness of true issues. Where is she going to get prenatal vitamins if she has no money, no bathroom to put them in, hasn’t eaten for a day and a half and she is drug sick? • Social determinants of health are real.
Trauma and Care Considerations • Often a time clients reflect on their history • Give consent too easily, be aware of power imbalance and gender-based fear. (watch for ‘trauma influenced consent’, Jay’s phrase) • Assume that any labour supports are unaware of status (eg. take charts out of room) • Sit down when talking, doing a vaginal exam or delivering the baby • Ask for permission before any touching
Trauma- What We Are Learning Has Informed Our Care • For Caesarean sections: • No pre-surgical identification routines with family/friends present • Foley prior to entering O.R.? • Don’t tie down her arms- just not necessary • “Just relax”=most triggering phrase, especially during spinal or epidural • Don’t turn spotlights on until cleaned and draped • Talk to her during CS to keep her grounded, not with colleagues about summer vacation plans. May further increase feeling of distance and disorientation.
Humility • No longer just about us being ‘experts’ on VL • Clinical humility; the expert is sitting in front of us • Cultural humility; we cannot presume to know the forces that shape her decisions nor her life • Trauma awareness for ALL clients • We have learned to stop talking and start listening
Our Starting Point for Care • Humility is essential. • Harm reduction works. • Women may not have the power to influence the actions of others, even if they harm her and her pregnancy. • People who use during pregnancy love their babies as much as we love our families. • Simple kindness and respect are fundamental.
