Reaching out to the homeless and pregnant
More than 300 homeless women give birth in Toronto each year amid huge risks. A unique Toronto program reaches out to pregnant women on the street. The nurses who run it push compassion to the limit to help a few tiny lives
Renee lifts up her baggy grey sweatshirt and jabs a finger at her bare belly. Underneath the taut skin, her unborn baby girl kicks and squirms. She says the constant jabs keep her up at night and make her lower back ache.
The 22-year-old is six months pregnant and homeless. She and her partner, Cliff, live in an east-end city shelter with scant belongings and $150 in savings. Little else keeps them from the streets.
The young couple have four other children. All were taken away at birth because the pair were deemed unfit to parent.
Renee, whose pale, lined skin and mouth full of rotting teeth make her look worn down and older than her years, doesn't much care what happens with this new baby.
"I'd prefer her to come home with us," she says with a shrug. "But I'm okay with whatever happens."
More than 300 homeless women give birth in Toronto each year. Drug abuse, violence, poor nutrition and the chronic misery that comes from scraping by on the street put their lives – and the lives of their unborn babies – at risk.
A team of five nurses from Toronto Public Health are charged with treating this precarious population. The program, the only one of its kind in North America, was launched in 2007 after a string of tragedies involving homeless pregnant women shook the city – most notably the 1997 death of a 5-week-old baby in a city shelter and the abandonment of a newborn girl on a winter street six years later. Toronto could no longer fail its most vulnerable citizens.
Nurses with the Homeless At-Risk Prenatal Program, or HARP, work to get homeless pregnant women off the street and into apartments, and teach them how to mother their babies.
When that's not possible – many women can't fully leave the street and the pull of addiction – the nurses settle for smaller successes: a woman coming into the shelter system long enough to finish her pregnancy; a baby delivered in a hospital and not in a cold, wet alley; an addict getting her fix not from alcohol but crack cocaine, a less harmful substance to a fetus.
The nurses are compassionate realists who know that some people find what they do abhorrent – that there are those who believe crack-addled women who sell their bodies on street corners to pay for their next high should never have children, let alone a chance to bring home a baby.
But more than anyone else, HARP nurses see the bleak truth play out in Toronto's lowest, most desperate corners: Babies will be born to homeless women. It's the nurses' job to help make sure those babies are born as healthy as possible.
Cheryl Dillon has met with Renee once a week since the beginning of the young woman's pregnancy. Today, the public health nurse has come to see Renee and Cliff at Family Residence, the east-end shelter where the two live with some 50 other homeless families.
Renee, who was recently diagnosed with placenta previa, a potentially dangerous complication that can cause excessive vaginal bleeding before or during delivery, resists getting anything but the most basic of care. She needs many of her teeth pulled to prevent infection, but refuses to see a dentist.
Cliff is no better. Even though he likely broke his hand in a fight the previous night, the 23-year-old told Dillon he won't go to a doctor.
At the end of the meeting, Dillon shakes her head and sighs. Parents have less chance of keeping their baby if they ignore their own health. "If you don't find health care important for yourself," says Dillon, "how do you find it important for your kids?"
Dillon usually has some 15 patients on her roster. Many, like Renee, are initially reluctant to accept care; they have learned to rely on no one but themselves. Her job is to gain their trust and help them to make better choices. It sometimes doesn't happen on the first pregnancy.
"The biggest intervention is just your relationship with them," Dillon says. "They're looking for support. They're just surprised it's out there."
In this sprawling metropolis, homelessness can be anything from couch surfing at a friend's apartment to sleeping in the back room of a crack house to shelter-hopping to seeking respite from the wind in a downtown doorway.
In her three years with the program, Dillon says she has learned that women with no fixed address share a common hard-luck narrative. While their individual traumas are different, the story arc is the same.
Almost all have suffered horrendous physical or sexual abuse. Many have undiagnosed or untreated mental illnesses, including post-traumatic stress disorder, bipolar disorder and major depression. Drugs and alcohol become the balm to soothe their pain. They need money to use, and so they sell their bodies to pay for drugs. Or, they use sex to gain allies who will protect them on the streets. The cycle of abuse, sex and drugs quickly becomes all-consuming.
Roughly 50 per cent of homeless women get pregnant, many within the first 12 months of becoming homeless. Women with a history of sexual abuse or with a developmental delay may not be aware of the need for constant contraception, something that is usually in short supply on the streets. And stress, poor nutrition and substance abuse can halt menses, which means some women don't realize they are pregnant for months.
The HARP nurses take on homeless women at any point in a pregnancy, whether at three weeks or 33 weeks. Shelter workers, street nurses and health-care staff at walk-in clinics and hospitals who know about HARP alert the team to potential clients. There is never a wait list.The nurses follow individual clients throughout a pregnancy and meet with them weekly at a place where the women are most comfortable, whether a coffee shop, city shelter or street corner. In cases where clients keep their babies, HARP team members often continue to see them for months.
Since the program's inception the nurses have helped more than 360 patients and averaged about 1,500 visits each year. Doctors at St. Michael's Hospital, shelter workers and the homeless women themselves say the HARP nurses have had successes where other agencies have failed.
"Many clients still believe that no one in the world is going to care for them," says Holly Kensey, a supervisor at Robertson House, a city shelter for homeless women and their children near Gerrard and Sherbourne Sts. "Then they meet their nurse, who shows up and makes a huge impact. Most clients I see love their nurse."
Each nurse has dozens of heartrending stories about the women they help. A few agreed to share their stories. (Some were willing to have their last names used, but the Star decided to omit them to protect the privacy of their children.)
First, Hannah, whose family kicked her out of their house; she had nowhere to go but a city shelter. Then, Tara, a former crack addict and drug dealer who is pregnant for the eighth time; she has never yet been allowed to keep a baby. And finally Ruby, a former sex worker and crack addict who kicked her habit and kept her baby.
Saturday March 13th 2010
By Megan Ogilvie
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