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In recent years, there have been several outbreaks of syphilis among heterosexual women and men. This has led to a rise in cases of congenital syphilis. Many cases of congenital syphilis occur among babies born to women who do not have access to or face barriers to adequate prenatal care, which includes syphilis testing (and treatment if necessary). CATIE asked two service providers about how their programs help to engage women in prenatal care and how they support syphilis prevention, testing and treatment.

  • Catherine Astin is a nurse at Sheway. Sheway is a drop-in program for women who are pregnant and/or parenting young children, have substance use issues and live in Vancouver, British Columbia. Sheway provides wraparound care in a supportive environment that is trauma informed and provides healthcare and social supports to the women and children who attend the program.
  • Kelti Gore is a social worker and the supervisor of the H.E.R. Pregnancy Program and sexually transmitted infection (STI) outreach team at Boyle Street Community Services in Edmonton, Alberta. The H.E.R. program provides healthcare and social resources to street-involved women.

See more in the article: Combatting the rise in congenital syphilis: How service providers can support prevention, testing and treatment

Catherine Astin, nurse, Sheway

What are the barriers that prevent the people you work with from accessing healthcare generally and pregnancy care specifically?

Women who access the Sheway program are vulnerable and marginalized and they suffer stigma. As a result of the fentanyl poisoning and overdose public health emergency in BC for the last six years, the women have become even more marginalized. The majority of the pregnant women we see live in substandard housing or are homeless. They are often living on the street or in so-called tent cities. To survive extreme poverty, they often resort to prostitution* or become victims of gangs or pimps who prostitute the women for their own financial gain. Approximately 70% of the women Sheway serves identify as Indigenous. Many of the women are diagnosed with post-traumatic stress disorder or other mental health issues and have suffered trauma, grief and loss from a very young age. Substance use is seen by many as a way to minimize and survive their pain.

As a nurse working with this vulnerable population, I see many barriers to health/pregnancy care for our clients:

  • Women may have had negative experiences with the healthcare system in the past, having been judged and treated with disrespect when they have tried to access healthcare.
  • There is a lack of trauma-informed care at healthcare facilities.
  • Many facilities offer only appointment-based services; very few places outside the Downtown Eastside have drop-in services, which typically work better for this community.
  • Most primary care clinics have long wait lists, even in the Downtown Eastside.
  • There is a lack of women-centred services where women may feel it is safer to access care.
  • Many of the women grew up in foster care and have a strong distrust of the systems in place. They have a legitimate fear of losing their baby if they access healthcare during pregnancy.
  • Poverty forces the women to make lifestyle choices that may not be conducive to making healthcare a priority or possible. They do not have access to phones and are sometimes difficult to locate.
  • Homelessness increases the likelihood of poorer health outcomes and makes it difficult for women to access services, eat healthily and attend healthcare appointments and services.
  • They may lack transportation to healthcare services.
  • Women may not have family or partner support to assist them in accessing healthcare and support them during a healthcare visit.
  • They may not have ID.
  • They may have no healthcare coverage if they are coming from a different province or country.
  • A controlling and violent partner may limit a woman’s ability to access healthcare.

* While CATIE usually uses the word “sex work”, Catherine uses the term “prostitution” to describe the experience of clients at Sheway.

In your work, how do you help to support syphilis prevention, testing and treatment among women?

Sheway is run by an interdisciplinary team. We increase access to syphilis prevention, testing and treatment in the following ways:

  • We build a therapeutic relationship with the woman to build trust, which allows easier access to care.
  • We find out the best way to contact the woman, such as by phone or email, or learn where they hang out.
  • We provide easy access to birth control, which prevents unintended pregnancies (and potentially prevents vertical transmission of syphilis) in women who are vulnerable and marginalized. We also provide full access to all pregnancy options including abortion.
  • We run a drop-in medical clinic that provides testing, treatment, follow-up and information on syphilis and other STIs.
  • We offer routine syphilis blood work to women during clinic visits.
  • We offer outreach wherever they are, to provide syphilis testing and treatment if they are unable to attend the clinic. Non-medical team members will also reach out to women and bring them to Sheway for testing and treatment.
  • We give supportive care to women while they are being given a syphilis diagnosis, which can be scary and upsetting.
  • We allow partners to attend the clinic with women who have been diagnosed with syphilis so the partners can be tested and treated at the same time as the woman.
  • We handle contact tracing sensitively, so the woman is not at greater risk of harm. For example, if the woman has suffered violence at the hands of her partner and does not feel safe, Sheway can involve the BC Centre for Disease Control in contacting the partner for testing and treatment.
  • We offer follow-up for babies who may be exposed to syphilis in utero, so they can receive the appropriate care. If the child is in care, we ensure the social worker and/or foster family is aware of the need for blood work and/or healthcare follow-up and where they can access these services.
  • We liaise with other healthcare services to ensure continuity of care and treatment completion. For example, if the woman is admitted to hospital during syphilis treatment, the hospital will need to be informed so that treatment is continued and completed.

What approaches have been effective at helping to engage women in prenatal care? What advice do you have for other service providers who work with pregnant women who face barriers to accessing prenatal care?

Sheway is run by an interdisciplinary team and all members of the team are involved with engaging the women in prenatal care in a non-judgmental manner. It is difficult for women who are poor, hungry and homeless to access healthcare. Assisting with the social determinants of health allows women time and space to be able to attend to their healthcare needs.

The members of the Sheway team provide the following:

  • We offer woman-centred, trauma-informed care.
  • We provide care that is based on the recognition that the health of women and their children is linked to the conditions of their lives and their ability to influence these conditions.
  • We build relationships by doing outreach, meeting the woman where she is at.
  • We consistently reach out to the woman in a low-key way, knowing when to back off and when to step up with supports.
  • We provide care that is non-judgmental regarding substance use, lifestyle and other elements of womens lives.
  • Women have the ability to call or text the clinic or particular Sheway workers and receive a prompt response.
  • Care is given on a drop-in basis; there are no appointments to keep.
  • Wraparound care is provided in the drop-in area; assistance is given for housing referrals, welfare applications, disability applications, obtaining ID, etc.
  • We offer a nutrition program, daily lunch for women and a support person of her choosing, including all her children. We provide weekly food bags including eggs, milk, cheese and prenatal vitamins.
  • On outreach, staff take food such as snacks and treats with them as a way to engage the women. We accept that interactions may be limited until a trusting relationship has been formed. This can be a lengthy process and requires patience.
  • Women can receive services via self-referral. Women do not need to be referred by another agency; they can walk in to Sheway and request services.
  • We offer transport and accompaniment to medical appointments and hospital admissions.
  • We offer women kindness and respect.

Kelti Gore, social worker and supervisor, H.E.R. Pregnancy Program and STI outreach team, Boyle Street Community Services

What are the barriers that prevent the people you work with from accessing healthcare generally and pregnancy care specifically?

Healthcare generally is difficult to access because of issues such as racism, classism and sexism. For people who use drugs this is exacerbated by fear of discrimination by service providers. When someone discloses they use drugs, more often than not, service providers (especially in the healthcare field) blame their mental health issues on their substance use. Substance use is one of the only health concerns for which people can get their children taken away if they disclose to healthcare providers.

In terms of pregnancy care, people are afraid to disclose houselessness or substance use because they fear that they will not get accurate information and fair treatment from service providers. Determinants of health like racism and history of incarceration make accessing prenatal care difficult. Also, the current climate of increasing inflation exacerbates houselessness as prices for necessities like rent, food and bus fare increase.

In your work, how do you help to support syphilis prevention, testing and treatment among women?

To support syphilis prevention, testing and treatment, we connect clients to doctors and nurse practitioners as early as possible in the prenatal process. We also have an STI outreach team comprised of a registered nurse and an outreach worker with lived experience. Our outreach workers on the H.E.R. team are all Indigenous women with lived experience of substance use. They are familiar with the community members we serve, so we are able to create relationships of trust with community members to help them access reliable and safe STI treatment and testing that they can trust. We also provide STI testing requisitions and treatment here at our office. Women who test positive for syphilis when they are more than 20 weeks pregnant are too far along to receive treatment at our clinic. For these cases, we have an existing working relationship with the Royal Alexandra Hospital, which is located in the inner city. Clients receive syphilis treatment at the hospital’s case room, which is dedicated to providing care for people experiencing pregnancy complications. In terms of services to prevent STIs and unwanted pregnancy, we offer condoms, education and access to birth control as well as the Plan B pill.

What approaches have been effective at helping to engage women in prenatal care? What advice do you have for other service providers who work with pregnant women who face barriers to accessing prenatal care?

It is very helpful to have staff who are outreach workers with lived experience engaging clients. When we need to make referrals outside of our clinic, having nurse practitioners and doctors at offices we trust makes it easier to bridge service provision. We meet clients where they are at. Sometimes clients are really focused on basic needs like eating or how to get to their appointments, so we like to make those things easier by offering snacks and/or rides to appointments. Dealing with the immediate needs of clients (as defined by them) instead of dealing with all the things you want to deal with is a way to build trust so that clients will come back. For example, if a client comes in just needing some food, you can provide what she needs and she will most likely come back as she felt heard and supported. Having access to nurses who dress in plain clothes, who are approachable and who do not use jargon and are able to explain things in plain language has also helped us.

Related resources

The H.E.R. Pregnancy Program – case study