The Cedar Project: Using Indigenous-Specific Determinants of Health to Predict Substance use among Young Pregnant-Involved Indigenous Women In Canada

In Canada, Aboriginal^1,2 mothers have been hyper-visible in research, policy and intervention related to alcohol and drug use during pregnancy, while the social contexts underlying Aboriginal women’s substance use have often been ignored [17, 22] particularly as they relate to experiences with pregnancy. Due to imposed legislative and social conditions, beginning with colonization, many young Aboriginal mothers are located at the intersections of multiple dimensions of social inequality that shape their experiences with substance use and parenting in complex ways. However, there is a dearth of epidemiological data that explores these contextual factors related to substance use before, during and after pregnancy, and quantitative data which necessarily and explicitly attends to understanding these broader determinants of substance use is needed [22]. To understand these determinants across women’s lives in a more nuanced and contextualized way, the typical research focus on substance use only during pregnancy must be broadened to include pregnant-involved women’s life experiences with alcohol and drug use before, during and after pregnancy. For the purposes of this research project, pregnant-involved was defined as having ever experienced a pregnancy, regardless of pregnancy outcome or subsequent mothering role.

A secondary data analysis was conducted using data from a baseline questionnaire that was administered in a larger project, the Cedar Project, to all participants at enrollment [25]. A descriptive quantitative design was used, in addition to hierarchical logistic regression guided by mediation analysis principles, to test the ILCSD Model’s ability to predict heavy substance use among pregnant-involved female participants.

The sample for this secondary analysis included 291 pregnant-involved young Aboriginal women: 154 (52.9%) completed their baseline questionnaires in Vancouver, 111 (38.1%) completed their baseline questionnaires in Prince George, and 26 (9%) completed their baseline questionnaires in the Interior region of British Columbia. The median age of participants was 24 years old, and the majority of participants were single (64.4%), had not completed high school (79.5%), and were living in unstable housing situations (66.2%). Also, the majority of women had ever been homeless (65.9%), while 67.7% of women had ever been sexually abused and the median age of first sexual abuse was six years old (range 1–20 years old).

This study reports on empirical support for the importance of integrating socio-historical contexts into models of determinants of substance use and supports a counter-narrative to the current pathologizing discourse in Canada, where “Aboriginal Status” is often cited as a determinant of health on its own [16]. Instead, by using an Aboriginal-specific model, it was possible to explore how determinants that uniquely impact Aboriginal health in Canada (including residential school histories, racism, and intergenerational trauma) have differentially impacted the health status and experiences of Aboriginal women, in an appropriately nuanced and fluid manner. This is one of the first studies to evaluate an Aboriginal-specific social determinants model to identify predictors of substance use among pregnant-involved Aboriginal women. The inclusion of variables that measured the lifelong and future impacts of colonialism and cultural continuity provide a more complete picture of the social determinants of substance use, from an Aboriginal-specific perspective. Given the lack of previous research in this area that includes and explicitly acknowledges the important contexts of substance use among young pregnant-involved Indigenous women [22], this study is a timely and important contribution to the research landscape.

In testing the ILCSD Model, important independent risk and protective factors for heavy substance use were identified. Among participants who had ever been sexually abused, having reported sexual abuse to anyone was found to be associated with lower alcohol use. In their study, Draucker et al. [10] also found that disclosing abuse was the main way participants were able to make sense of their experiences and to heal.

Women’s substance use is often positively correlated to their partner’s use [20]. However, being in a relationship was associated with lower smoked drug use. Having spoken anecdotally with community workers and women who use injection drugs, they suggested that for many women, their partners initiate their first use of injection drugs, as well as continue to inject for them, and so there is the possibility that single women have higher use of smoked drugs because they have not progressed to injection drug use. Further research on this topic would be beneficial. The association between parental residential school attendance and increased use of smoked drugs is an indicator of the importance for understanding intergenerational trauma and the perpetuation of harms among young Aboriginal women as well as the impacts of foster care involvement, which is understood as directly linked with residential school histories.

Having participated in survival sex in the last 6 months was associated with daily or more injection drug use. This relationship could be bi-directional because women may be participating in survival sex to support their heavier use, or they may be using drugs more heavily to cope with survival sex. Also, having a higher number of pregnancies, having received sex abuse counselling and attending a support group in the last six months, were all protective against more than daily use of injection drugs. These results again suggest that attending to sexual abuse trauma can be protective, and that peer support is also a promising strategy for some women. The results also suggest that pregnancies can be protective, possibly because women reduce drug use for the pregnancies, and/or because of increased supports during pregnancy. Finally, having experienced barriers to any services (health and supportive) was also associated with lower injection drug use. This may be because those who are heavier users are less aware of or connected to services to perceive any barriers. Similarly, if those women are not accessing services as much as women who use less, then they would not have had an opportunity to encounter any barriers to services.

Women who participate in sex work in BC have reported that histories of injection drug use further compounded risks in women’s lives and added to barriers to parenting, while limited access to appropriate non-judgmental services to support their needs as women who participated in survival sex work and who used drug mitigated access to environments or services that support them as pregnant women/parents [11]. Survival sex work may therefore be confounding or contributing to the other associations with injection drug use.

Understanding Indigenous health in Canada within the context of colonial practices both past and present [12] is needed. Poverty, homelessness, housing instability, lack of education, involvement in the child welfare system, visits to the emergency room, survival sex work, and sexual abuse were all important predictors of substance use in the study sample. Given the relationship of all of these factors with historical and contemporary colonization practices (and that over 70% of the sample had a family history of residential school attendance and addiction), the intergenerational impacts of residential schooling, addiction, survival sex and trauma must foreground any deeper understanding of substance use among young Aboriginal women. Explicit attention to these factors has been decidedly absent from the literature examining substance use among Indigenous women [19], while a lack of meaningful data that captures the distinct sociopolitical, historical and geographical contexts of Indigenous women’s lives has limited discussions on these topics [2, 12].

Multiple perspectives and models, in addition to the ILCSD Model, including for example The Indigenist Stress-Coping Model (on which The Cedar Project is based) [26], will likely be needed to capture the complexity of young Indigenous women’s experiences with both pregnancy and substance use. As evidenced by this study, these contextual factors are paramount to creating a fuller understanding of substance use and pregnancy. Further, highlighting the structural and social determinants of substance use provides actionable targets for interventions that can support women and their children. Importantly, by including the variables in this analysis related to women’s socio-political-historical contexts, we were able to present a fuller depiction of women’s actual lives, in keeping with previous qualitative findings from work with this same population [23, 24]. Indeed, a common criticism of quantitative research is its inability to produce rich and contextualized data. By developing methods for capturing and measuring Indigenous-specific determinants of health, such as intergenerational trauma, foster care and racism experiences, it will be possible to provide richer and more useful empirical data to support and develop understandings in this area of research. Racism, while playing an important role in the health and well-being of Indigenous peoples in Canada [2], for example, can be particularly challenging for groups that have experienced marginalization throughout their lives (like women in this study) to even identify, let alone quantify. As more research stresses the importance of understanding the role of Indigenous-specific social determinants in the health and well-being of Indigenous people in Canada [12], however, this work is important, timely and necessary.

This analysis provided insight into the social contexts of women who have experiences with pregnancy as well as drug and/or alcohol use and highlighted the need to include Indigenous-specific determinants of health when examining young Aboriginal women’s social, political and historical contexts in relation to their experiences with pregnancy and substance use.