At-risk pregnant women: under surveillance, coerced, passively

At-risk pregnant women: under
surveillance, coerced, passively engaged
or actively engaged?
Rosa Flaherty
PhD Student
Australian Centre for Child Protection, Adelaide, Australia
Email: [email protected]
Overview
2
At-risk pregnant women –
who are they?
• Pregnant women living in circumstances where
there are serious health risk factors for example
violence, alcohol & other drug addiction,
unmanaged mental illness, disability,
homelessness & sex work (Australian Health
Minister’s Advisory Council, 2012; Duff et al., 2014; McConnell, et al., 2008)
• Apart from the direct physical effects of
exposure to these circumstances, these
issues can also contribute to a lack of
antenatal care
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Laws & processes enabling information
sharing about at-risk pregnant women
•
Child Protection legislation enabling reporting of, and
sharing information about, unborn children at risk e.g.
Australian legislation includes Children & Young Persons (Care and
Protection) Act, 1998; Children & Community Services Act, 2004;
Children Youth & Families Act, 2005; Children & Young Persons &
their Families Act, 1997; Child Protection Act, 1999; Children & Young
People Act, 2008
•
“Fetal protection” laws in other countries e.g. Texas Prenatal
Protection Act (2003)
•
Local Safeguarding Children Boards UK (National Collaborating
Centre for Women‘s and Children‘s Health, 2010)
•
Interagency Codes of Practice (e.g. Government of South
Australia, 2013)
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Goals of prenatal support to at-risk
pregnant women
Four goals:
1. Healthier birth outcomes for the
mother
2. Healthier birth outcomes for the
newborn
3. Mother more able to provide
adequate care for the newborn
4. Statutory agency can monitor
welfare of newborn
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How do we intervene?
Current international responses
•
•
•
•
Scotland: A pathway of care for vulnerable families (0- 3)
(2011)
England: Pre-birth child protection conferences/reviews
USA: Healthy Families initiatives, Nurse Home Visiting
NZ: Array of services e.g. CADS – Pregnancy & Parental
Service, women’s refuge, government policy e.g.
Ministry of Health (2010). Alcohol and Pregnancy: A
practical guide for health professionals.
•
•
•
•
AUS: non-government Brighter Futures
program
Compulsory treatment via applying law
Persistent international media interest in
the issue of prenatal harm
What is your country’s thinking on prenatal
harm?
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Unborn child “High Risk Birth Alert”
7
Literature review
A: Zero peer reviewed papers on the specific
form of intervention: “High Risk Birth Alert”.
This is despite its widespread use & the amount of resources
involved in activating & responding to such an alert.
• Literature was discovered on the related processes of prebirth assessment (Calder, 2000; Hart, 2010); legal action to separate
newborn babies from their parents – UK (Masson & Dickens, 2014);
and,
• Related discourses that could make a predictive
contribution to the at-risk woman’s journey through the
prenatal service delivery pathway.
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•
•
•
•
Literature review highlighted
4 dominant discourses related to at-risk
pregnant women
Bad mother
Fetus-centred
Risk
Woman-centred
Why it matters: the lens you look through may
strongly influence your practice
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Bad mother discourse
• Bad mothers are those that have chronic issues e.g.
substance abuse while pregnant and need intervention from
government (Reid et al., 2008)
•
Bad mother discourse promotes the rights
of the fetus above
the pregnant woman’s rights (Smith, 2006)
•
Bad mother discourse is further compounded by the judgment that
the woman is responsible for her circumstances i.e.
she should stop taking drugs while pregnant; she should not get
pregnant if she has an intellectual disability or mental illness; it is her
fault if she is homeless (Fordyce, 2014)
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Bad mother discourse – possible impact
on the prenatal journey
•
•
One of the objectives of the high risk birth alert is to monitor
the movements of the pregnant woman including
the baby’s birth
The conceptualisation of at-risk pregnant women as
‘bad mothers’ who engage in nonauthorised, immoral or unhealthy
behaviours can promote monitoring and surveillance of
their movements (Campbell, 2005; Fordyce 2014)
•
If the pregnant woman is conceptualised as a ‘bad mother’
who needs monitoring, her pathway through the
service system may amount to no more than (a)
being identified in the health system database
at the time the alert is issued and (b) the child’s
birth reported
GOALS
1.Healthier birth
outcomes for the
mother
2. Healthier birth
outcomes for the
newborn
3. Mother more
able to provide
adequate care for
the newborn
4. Statutory agency
can monitor
welfare of newborn
11
Fetus-centred discourse
• Fetus-centred discourse reflects the rights of
the fetus, outstripping the rights of the
pregnant woman (Epstein, 1995; Greaves et al., 2002)
• Fetus-centred discourse conceptualises the
fetus as a citizen, and the pregnant woman
primarily as the carrier of a fetus who must
have its rights protected (McCulloch, 2012)
• Fetus-centred discourse is reflected in fetal
protection laws (Cherry, 2007)
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Fetus-centred discourse - possible
impact on the prenatal journey
• Conceptualising the fetus as a citizen in
need of protection can result in the atrisk pregnant woman being offered a narrow
pregnancy service, where she is ‘directed’
to attend antenatal care in the best
interests of her fetus
• The high risk birth alert process is a system
that is aimed at fetus-protection – the
alert arises in response to a prenatal report, to
the statutory child protection agency, on the
welfare of the fetus
GOALS
1.Healthier birth
outcomes for the
mother
2. Healthier birth
outcomes for the
newborn
3. Mother more
able to provide
adequate care for
the newborn
4. Statutory agency
can monitor
welfare of newborn
13
Risk discourse
• Risk discourses as proposed by Lawless et al. (2014) & others, can
construct ‘risk’ in order to oversee and provide rationale for stateinitiated interventions
• Risk discourse includes key foci of risk: prevention,
management & reduction (Lupton, 2012;) & can be specifically
applied to at-risk pregnant women within
the emerging field of infant mental health
(Lawless et al., 2014; Salmon, 2011)
• Some risks to healthy pregnancies are seen as
‘preventable’ e.g. substance use
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Risk discourse - possible impact on
the prenatal journey
•
•
In the context of the unborn child protection high risk birth alert, the
risk discourse could explain the circumstance where both the
GOALS
pregnant woman and the service practitioner are
engaged in the process ‘passively’ – to reduce risk
1.Healthier birth
outcomes for the
mother
Provision of services to at-risk pregnant women & and
being seen
to be trying to reduce risk is steeped in risk
calculation, reduction and management of this
2. Healthier birth
outcomes for the
newborn
high-risk population
3. Mother more
able to provide
adequate care for
the newborn
• Risk to the pregnant woman & fetus is
presumably reduced by receiving antenatal care,
and risk to state authorities is presumably reduced
as authorities are perceived to be taking action to
4. Statutory agency
can monitor
welfare of newborn
protect the fetus
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Woman-centred discourse
• Woman-centred discourse reflects the ideology that the needs
of the woman are assessed & addressed (Hunting &
Browne, 2012)
• Woman-centred discourse emphasises the woman (rather than
the fetus) as the foremost recipient of services and
acknowledges the woman has capacity to change
(Marshall & Woollett, 2000)
• A woman-focussed approach may
help practitioners feel
more confident in their work & reduce some of
the barriers to seeking, engaging with and maintaining
engagement with health & social care (Gunn et al., 2006; Poole & Greaves,
2009; Racine et al., 2009)
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Woman-centred discourse - possible
impact on the prenatal journey
• The conceptualization of an at-risk
pregnant woman within a womancentred discourse may enable
better assessment of the
woman’s needs
• Women within the womancentred discourse are more
likely to be perceived and
construed as worthy and
needing help
GOALS
1.Healthier birth
outcomes for the
mother
2. Healthier birth
outcomes for the
newborn
3. Mother more
able to provide
adequate care for
the newborn
4. Statutory agency
can monitor
welfare of newborn
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Implications
•
Currently using a system (high risk birth alerts) that has no peer-reviewed
evidence base
•
Lack of evidence hopefully promotes enthusiasm to advocate
via research & policy responses including strong consideration
of the benefits of joined up services
• Joined up services – integrated service system, cooperative crossagency policy, community expectation that appropriate help will be
provided to this vulnerable group (Garrett, 2004; Winkworth & White, 2011)
•
While all pathways (surveillance, coercion, passive engagement & active
engagement) may all have a place in prenatal service delivery with at-risk
women, what can we do to optimise opportunities for facilitating
active engagement?
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Future Research
•
Mixed methods research is
underway in Australia via the
Australian Centre for Child
Protection at the University of
South Australia
•
Study design = interviews with
women who were at-risk while
pregnant + surveying staff across
health, statutory child protection
and the non-government sector
who provide services to, manage
staff who provide services to or
write policy for at-risk pregnant
women + developing and testing
a theory of change for the
prenatal service delivery model
of care
Thank you
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