Understanding and supporting pregnant people facing homelessness

Homelessness among pregnant and parenting people in Canada is rising, with grave consequences for both parents and children. On this episode of the CMAJ Podcast, Dr. Mojola Omole and Dr. Blair Bigham explore the scope of the problem and the supports that can improve outcomes for parents and children.

Dr. Stéphanie Manoni-Millar, co-author of the CMAJ commentary Tackling the crisis of homelessness amongst pregnant and parenting people in Canada, explains who is most affected and what risks they face. She describes a predominantly young population, many of whom are homeless or experiencing precarious housing. She highlights the health consequences for children, including developmental delays, infections, and increased rates of anxiety and depression, and stresses the importance of affordable housing and integrated services to support families.

Nerina Chiodo, a social worker in Toronto with MotherCraft Breaking the Cycle, shares insights from more than two decades of supporting pregnant people who are homeless. She describes what stability can look like when housing, addiction treatment, mental health services, and social supports are coordinated, an approach often described as wraparound care. Chiodo also reflects on the stigma many of her clients face in medical settings and underscores the importance of small acts of validation and compassion from clinicians.

Both guests emphasized that people experiencing homelessness during pregnancy often want to parent and demonstrate resilience despite immense challenges. They urged clinicians to approach this population without stigma, to recognize the risks faced by children, and to understand how even brief, supportive interactions can influence whether patients return for care.

Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.

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Transcript

Dr. Mojola Omole

I'm Mojola Omole

Dr. Blair Bigham

I'm Blair Bigham. This is a CMAJ podcast.

Dr. Mojola Omole

So, Blair, the article that we are talking about today is looking at homelessness and pregnancy.

Dr. Blair Bigham

It kind of gave me shudders when I read the headline. I was like, oh, my goodness, this sounds like such a difficult topic to talk about. But homelessness is on the rise, not on the decline.

And so we have more homeless people and with it a comorbidity of substance use that can often make solving homelessness pretty challenging. And how devastating is it to think about a homeless child, let alone a homeless baby? And so today's episode is going to focus on not just homelessness, but the challenge of homelessness for people who are pregnant.

Dr. Mojola Omole

And what I enjoyed about the article is that it gave us some practical roadmaps of how we can help better address the situation of those who are homeless and who are pregnant.

Dr. Blair Bigham

Absolutely. So we're going to start by speaking with the author of the commentary in CMAJ titled “Tackling the crisis of homelessness amongst pregnant and parenting people in Canada.”

Dr. Mojola Omole

And our second guest is a social worker who has been involved for over 25 years in providing wraparound care for those who are experiencing homelessness and are pregnant.

Dr. Blair Bigham

She literally goes out in the streets looking for pregnant people and says, we need to talk. That's up next on the CMAJ podcast.

Dr. Mojola Omole

Dr. Stéphanie Manoni-Miller is a community researcher at the Center for Research on Education and Community Services at the University of Ottawa. Thank you so much for joining us today, Stéphanie.

Dr. Stéphanie Manoni-Millar

Thank you for having me.

Dr. Mojola Omole

So who are we talking about when we're talking about pregnant or parenting people experiencing homelessness?

Dr. Stéphanie Manoni-Millar

So these are individuals who are able to become pregnant. So it can include women, it could include non-binary, transgender individuals who just have the ability to to become pregnant and are experiencing homelessness. So by the Canadian definition of homelessness, this is insecure housing as well.

So it's people who are living in precarious housing. This can include hidden homelessness such as couch surfing. 

Dr. Mojola Omole

So what does that, I was going to ask you, what does hidden homelessness mean?

Dr. Stéphanie Manoni-Millar

So hidden homelessness means that it's not as we colloquially think about homelessness as rough sleeping. So that's sleeping on the streets. Hidden homelessness would be more couch surfing, sleeping over at friends' places and family places, but not having a secure and stable environment.

Dr. Mojola Omole

So what do we know about the people we're talking about, about their age, their background, that type of thing?

Dr. Stéphanie Manoni-Millar

So it's a very young population. It is across the board. There is like older, more adult, above the age of 25 who are becoming pregnant.

But it does range from 16 to older.

Dr. Blair Bigham

But it's mostly teenagers, would you say?

Dr. Stéphanie Manoni-Millar

It's a higher percentage of teenagers, of youth. So I would classify it more as youth than teenagers because we're looking at the population of 16 to 24. So you are getting into young adulthood here, but we do classify it as youth.

Dr. Mojola Omole

Like in terms of their background, what are we thinking? What are their backgrounds? Is there something common that we see amongst these young people?

Dr. Stéphanie Manoni-Millar

So from what I've found, there's not a common like background other than the risky sexual behavior, the experiences potentially with sexual trafficking, the experiences of homelessness and poverty and low income status. So especially amongst the younger group, that would be individuals who have left home or have been kicked out of their home at quite a young age and they might not have the resources or education to properly care. And there's a lot who end up going into sexual trafficking or using sex for money as a way of survival.

Dr. Mojola Omole

Has the number of people in this situation changed in recent years?

Dr. Stéphanie Manoni-Millar

So as we see with the homeless population, it has grown since the pandemic, the COVID-19 pandemic. So it's increased for shelter use by children. It's increased by 8 to 13 percent in 2024.

And it's also increased by 20 percent from 2018 to 2022 for individuals experiencing homelessness who are pregnant or parenting.

Dr. Mojola Omole

What's the consequence of homelessness for people who are pregnant or in their early parenting journey?

Dr. Stéphanie Manoni-Millar

So I look at it as a lot of consequences on the child. So when we tackled this commentary, Dr. Racine and I, we were also thinking about the impact that it has on the child itself. It will have a developmental issues on the child.

It will have direct effect on their physical and mental health, an increase in infections and also cognitive and emotional development. So a lot of these children may grow to have more increased anxiety, depression and aggression. So when we're talking about pregnant and parenting people, the crisis of homelessness among this population, it's also a crisis of care for the child.

Dr. Mojola Omole

So in your article, you really emphasize the fact that many of these individuals want to parent. Why is it important for clinicians and policymakers to understand that?

Dr. Stéphanie Manoni-Millar

Well, I think there's an important aspect of keeping the dynamic of the mother and the child together. I think that has a lot of beneficial impacts on the child's upbringing as well as the parent. You see a lot of these individuals who are pregnant who are doing a lot of work in order to become fit, quote-unquote, as they would describe to parent their child, whether that's becoming sober, finding employment, doing a lot of care for themselves and taking care of their own environment.

So there's a big draw to it to try and keep the parent and the child together. But we also have to consider that it's really important to ensure that the child and the parent are in a secure environment.

So that's where the topic of coming back to the importance of housing and affordable housing comes in.

Dr. Mojola Omole

So what are some upstream solutions that would help to reduce homelessness in the first place?

Dr. Stéphanie Manoni-Millar

So there's a few programs that would help reduce homelessness. So first off, there's the need to ensure that people can find employment, can find support.

However, to be able to find employment, you need to have a constant address. You need to have a fixed address. So the step one is finding housing for everyone.

And well, when I say everyone, it's everyone who needs it and everyone who wants it. And that can be affordable housing. So we talked in the article about programs that are transitional housing programs of supportive housing where the sites of housing, that's not intended to be long term, but while the individual is pregnant or while they have a newborn or a young child, they have the services that are necessary, whether that's health services, daycare, mental health services directly on site. 

Another support service for housing that of an upstream service that could be talked about here is the Housing First model. The Housing First model is a very, it's not discussed in the paper, but it's a very well-established model.

And it's looking at ensuring that people are housed within a critical time period. So it's usually 30 days of experiencing homelessness or longer. They're housed and then the services follow after.

So once they're in a stable environment, then these services really support them in finding employment, getting back on their feet, building a community, and they're supported with a rent subsidy as well.

Dr. Mojola Omole

How well do existing services work together right now when we're talking about all these wraparound services?

Dr. Stéphanie Manoni-Millar

I think it depends on the community that you're exploring. There are areas where it's done quite well. We talk about the Maxine Health Center in the article, which is a center in Surrey, British Columbia, and it has the support from the community and it's run with health services, has beds for individuals experiencing homelessness who particularly women or women identifying individuals who need to have the support with them.

But one thing that I think about when you ask that question is the disjointed service between the federal, provincial and municipal governments. So there's also the issue of, within these services, usually health services, housing services, employment services, legal services are all separate and there's no discussion in between. So we really need to pull those services in and have them communicate, whether it's being within the same larger organization or whether it's just having more communication between the services.

Dr. Mojola Omole

What key shift in mindset or practice do you hope physicians take away when talking about individuals who are pregnant and experiencing homelessness?

Dr. Stéphanie Manoni-Millar

That's an excellent question. I think the biggest thing to think about is to work without stigmatization. These individuals are experiencing a variety of trauma and stressors, but they're also experiencing extreme resilience to their environment.

And I think that's something that we often forget or don't discuss is the resilience that they are displaying. They go through a lot of trauma and continue to move forward. And when you're talking about a group of individuals who may be pregnant or parenting, they're also doing a lot of resilience in ensuring the safety of their child.

So when talking with this population, I think it's important to talk about the amount that or it's important to consider and think about the resilience that they display and what they are going through and how they're adapting and coping with that. 

Dr. Mojola Omole

Amazing, thank you so much.

Dr. Blair Bigham

Thank you.

Dr. Stéphanie Manoni-Millar

Thank you for having me.

Dr. Mojola Omole

Dr. Stéphanie Manoni-Miller is a community researcher at the Center for Research on Education and Community Services at the University of Ottawa.

Dr. Blair Bigham

So we've heard about the research, but now we're going to explore what support actually looks like when someone is pregnant and experiencing homelessness. Nerina Chiodo is a social worker in Toronto with MotherCraft Breaking the Cycle. She spent nearly 25 years supporting pregnant people who are homeless.

Nerina, thank you so much for joining us today. 

Nerina Chiodo

Thank you for having me. 

Dr. Blair Bigham

I want to start with something aspirational. Describe what a strong support system looks like for someone who's pregnant and homeless.

Nerina Chiodo

Yeah, essentially, it's a wraparound type of situation. So we have a prenatal support person, a public health nurse, somebody like myself. Ideally, housing, which is very challenging.

Basic needs supports are met. There's addiction treatment that's available, mental health support. And if we can get all of those things in place, if the plan for the person is to parent their child, then that basically provides stability.

But nothing can start without housing. Housing is the most important beginning.

Dr. Blair Bigham

So you've got to have housing. You've got to have this huge multidisciplinary team. But how do you actually get people referred to that team if you're lucky enough to have access to it?

Nerina Chiodo

It's a little bit like a phone tree. So I often, well, I've been doing this job for long enough that I get referrals through phone calls and like community agencies where folks know me. But essentially, when I started the work, I was on the street looking for people, going into drop-ins and places where homeless folks were getting food, having a rest, that kind of thing. And basically, one of us, if it's me first meeting the client out in the community where they're at, then I may be the person to make a referral to a prenatal doctor and then to a public health nurse, filling out forms for housing, doing all of those pieces to try and get the person to have some stability in the pregnancy.

Then we bring on addiction workers and mental health support. And as much as we can get happening in the pregnancy, it really does impact the outcome once baby's born.

Dr. Blair Bigham

Once you've connected a homeless person to this network, to all of these specialists, how do you keep them engaged and connected longitudinally? What tricks have you found or what barriers have you had to overcome?

Nerina Chiodo

I mean, the long and short of it is it's about relationships. I think folks who feel listened to, validated, supported, if their plan is to parent and you're as transparent with them as possible about what that looks like, because the folks we work with also are substance users, that we talk about what does harm reduction look like in pregnancy? How is substance use and parenting, how are those two things impacting each other?

Or they're competing interests, right? And so we just frame it that way. So people know exactly what's expected of them.

Child welfare will most times become involved. The Toronto CAS has a prenatal program where folks can work voluntarily, and that greatly impacts what happens at the birth, as opposed to, surprise, we're here to investigate you kind of thing. And then also just the pieces around, if this is your goal, then we're going to go with what your goal is, right?

So always reminding folks that it's not our expectations, it's their goal, and that we want to support them in reaching their goal. And that looks different for everybody, because using substances is also a relationship. It's not like a person to person, obviously, but it is a relationship.

And in almost all cases, it existed way longer than or way before pregnancy happened. And a vast number of our folks have childhood trauma or lifelong trauma. I don't know how else to say that, but like that they've had trauma in their life.

Also, possibly parents who are substance users, there's all kinds of variables around family dynamic and dysfunction.

Dr. Blair Bigham

Can you tell us a story about someone who had a great outcome or a really positive impact from your program?

Nerina Chiodo

For sure. There's a couple of folks that when I met them, they were homeless and using substances and first pregnancies. So really nervous, living with dealers, pimps, different people, sometimes boyfriends.

But they were really adamant about parenting. That was something that, and mostly because in their own experience, parenting was negative. And so there was an idea that they wanted to make, like change that, break the cycle, without sounding too cheesy.

But they wanted to do things differently and really worked on connecting to all the supports and being able to follow through with appointments and try their best to always be honest and say, you know, I messed up and like I just need to get back on track. And in both those cases, they also came into our postnatal services. So here at Breaking the Cycle, we also have postnatal services.

And so both those folks stayed in with their children for a couple of years in postnatal. And one of them went to university, became a social worker. Which was really, oh my gosh, I know.

Every time. It's wonderful. And then more recently, one of the folks is starting U of T in September.

Dr. Mojola Omole

Amazing. 

Dr. Blair Bigham

Wow. Of course, not everybody is going to be identified in the community or brought into a support network like yours.

For people who don't have the benefit of your program, where do they show up in the system? I mean, eventually they're going to end up in some sort of a system.

What happens when they don't have your program?

Nerina Chiodo

Yeah. So oftentimes the child welfare becomes involved, usually after there's a birth and babies are taken.

Dr. Blair Bigham

Oh, it gets that late, like it's postpartum where they get involved.

Nerina Chiodo

Yeah. So many years ago, we used to have a system called the birth alert system where any service provider, social worker could call child welfare and they would put a birth alert out to all hospitals. That has since stopped because there was a disproportionate amount of Black and Indigenous families being called on.

So then what happens now is if folks don't want to work with child welfare voluntarily in the pregnancy and someone is concerned at the hospital about their presentation or reads their chart or has concerns and they call child welfare, then child welfare will come to the hospital and have a conversation.

Dr. Mojola Omole

So anyone who is using substances, does that automatically trigger child welfare being involved, their kids being taken from them? Because I would sense that that would be the biggest fear of why I wouldn't want to get associated with anything to do with CAS, to be quite honest.

Nerina Chiodo

Yeah, that's a great question. And I think it really depends on presentation. So to be quite frank, if people present with a home and money and family and all of those factors that folks consider to be stable, even if the family is dysfunctional, usually, you know, people will look to the safety plan around family.

But for most of our folks, they don't have that. They don't have people and they don't and they're homeless in lots of cases. And so it is like showing up and asking at the time of birth about what the person wants to do in terms of parenting.

And then at that point, they're going to start the work that I would do with our community colleagues prenatal. Right. It's not just an apprehension and then you never see your baby again.

It's more like we're going to set up visits, but we need you to go to treatment. We need you to find a place to live. But it starts then when there's already a baby.

And oftentimes folks give up because it's, oh, they just took my baby anyway. Right. And sometimes we do get referrals from child welfare here postnatal where people will come while their baby's in care to access service.

And sometimes that works out really well, because the thing about addiction, too, is that for some people, it takes a little bit longer to get to that point of making change than it does for others. And it really depends on lots of different things.

Dr. Mojola Omole

So it seems as if the best course of action is actually to be involved with you guys prior to a birth, because then you have the plan in place that would mitigate your biggest fear of why you wouldn't want to be in the system in the first place. For us and our listeners, what do your clients describe as their experience when they encounter the medical system? 

Nerina Chiodo

Oh, that's a great question.

So a big piece of the work that I do and my community colleagues do is actually supporting folks to connect to the medical system. Oftentimes, unless they're in a program that's specific to, which is only one in Toronto at St. Mike's, which is like specific for folks who are pregnant and using substances and homeless, but often they're met with judgment and criticism or like even just little subtle things like people not making eye contact or kind of turning their back to them, or they often feel judged. And it's a long time of that.

It's not just when they're pregnant. Also, if they're showing up in emerg and they're looking rough and they've been using and they're not well, they just often describe being treated poorly and being judged and sometimes being talked to like they're stupid or like no good or that kind of thing. And I think it's the sensitivity around pregnancy is even higher because there is a societal image of what a pregnant person looks like and is.

And so even I'll be walking with my client down the street and she might be having a cigarette and the stares are like they can just go right through you. So imagine seeing somebody who is pregnant and looks like they're high or they're out of it or there's so much judgment and emergency rooms right now at an alarming rate are seeing folks who are OD-ing on fentanyl and other opiates. And sometimes those people are pregnant people.

And so there is very much like people have, I guess, their own moral compass around that and feel the need to express that, which is sometimes not good.

Dr. Blair Bigham

I want to ask a question about sort of the biases that you've encountered or the misconceptions that people have about the population that you work with. I mean, when we were in our story meeting and this idea of homeless pregnant people came up, we were like, oh, we have to do that story. And I think I think we probably had our own sort of bias or preconceived idea of what those people struggle with or are like.

And tell us some of the misconceptions out there. 

Nerina Chiodo

Oh, Blair.

Dr. Blair Bigham

OK, maybe just one or two.

Nerina Chiodo

No, no. Just even on a personal note, if I go to an event and somebody says, oh, what do you do for a living?

And I'll say I'm a social worker, social service worker, and they'll say, oh, what kind of, you know, do you do? And then I explain and people will literally hold their hearts like they're about to have a heart attack. And I'm like, OK, just hold on there.

Dr. Mojola Omole

Why do you think they have that reaction?

Nerina Chiodo

Because what they're thinking about is the fetus, right? They're not necessarily thinking about the person, but what they're thinking about is the fetus being impacted by drugs and homelessness and sex work and STIs and all these things. They're just thinking about the fetus.

And then it's a blame situation. And oftentimes it's like, why can't she stop? Why can't she just do this?

Why is she so weak? Why is this? Why is that?

And then my like answer to that all the time is she was that child. Right. Let's think about it this way.

So she was that child who didn't get any support and is now in her child’s in a similar situation, but she's actually looking to get support. And there's how we think about, again, breaking the cycle. Right.

But folks have very strong opinions about pregnant people and, you know, using substances and being homeless. Like, how can that happen? We live in Canada.

How can there be homeless pregnant people? And it's like, well, because we don't have enough housing for all our citizens and our citizens get pregnant. It happens.

So it's just I think it's like, you know, again, it goes back to like people's moral feelings about things, if they have religious affiliations about things as well. And then I've also had people say they should just terminate. And I said, well, it's really their decision, not yours.

Dr. Blair Bigham

Oh, wow. 

Nerina Chiodo

So it's there's lots of varied reaction, for sure.

Dr. Blair Bigham

Do you have a closing thought for what our audience should keep in mind or maybe really commit to improving upon, especially those who work in settings where they may come across this group, people in the emergency department, obstetricians, midwives, people who work in the field?

Nerina Chiodo

For sure. Like I can say with a lot of confidence that our clients will always tell us when they've had a positive interaction with a medical professional, always, because it doesn't happen that often. And sometimes folks will say to me, medical professionals will say, well, they're only in the hospital for two hours or they're only in the hospital for two days.

But those two hours, if there's a little bit of validation, a little bit of kindness can make a huge difference. And behaviour is communication, right? Because I think oftentimes if our clients behave in a way that feels maybe scary, but also just feels like non-control, people will do things like get security, kick them out.

And that's the kind of thing where they might just need somebody to say, hey, do you need a glass of water and let's just sit down and have a conversation? And I know that our medical system is strapped. So I don't even want to like just I don't want to say that has to happen every single time.

But even just making eye contact, being kind, saying I understand that it's hard to wait or just validating, because I think that those little, you know, those little kinds of interactions then will create a positive feeling about going to the hospital when people need medical care. So I mean, maybe I sound a bit idealist, but a little bit of kindness goes a long way, a little bit of compassion goes a long way for sure.

Dr. Blair Bigham

Thank you so much. I really appreciate you taking time to chat with us.

Nerina Chiodo

Thanks for having me.

Dr. Blair Bigham

Nerina Chiodo is a social worker in Toronto with MotherCraft Breaking the Cycle. OK, Jola, let's start with you. What are your thoughts?

Dr. Mojola Omole

So to me, this was actually quite emotional as someone who is a parent and who loves being a parent. It really breaks my heart that there are, you know, these young people who want to parent, but because of their circumstances, because of homelessness, don't get to parent. And having a solution that allows them to parent, to me, is really impactful.

Dr. Blair Bigham

And it's quite, it's quite the tension, right, of this like this prerogative for a human being to parent their own child versus this societal thought that we need to keep children safe and that someone might not be capable of doing so. The tension is so thick.

Dr. Mojola Omole

And I think I could be honest and say that I would assume that this is my bias and my assumption before this was that, well, if you have a substance use issue, well, you wouldn't be caring about parenting. Like, not that you wouldn't care, but that it's not necessarily a priority for you. But to hear both Stéphanie and Nerina speak, it's like it is still a priority for them.

So I think for me, that was actually a big mind shift that I needed to understand that substance use, homelessness doesn't take away from that innate desire, if you have it, to be a parent, which I have it. And so there's tons of other young people out there who, no fault of their own, are in this situation that makes it precarious for them to parent.

Dr. Blair Bigham

And I think separating the pregnancy and the effects on the developing fetus from what comes after the birth and the parenting is sort of a helpful way for me to open my mind to just how consequential some of these conversations are. Because, you know, I go to this biological place of development, right? But there is all of the psychological benefit of being raised by somebody who loves you that a lot of children who end up, say, in the foster system, I don't know that that's any better than having a bit of an unstable circumstance.

And I think that's what, yeah, exactly. I think that's what, you know, this research and certainly the social workers who live in this environment might come to the realization of before the rest of us.

Dr. Mojola Omole

Yeah. Yeah. And, you know, I hope that I'm sure parts of this is integrated into different medical education for the learners, because I remember when I was at U of T a long time ago, we had to do, ours was called determinants of community health.

So we had to go into the community to learn. But as our communities are getting larger and having more diversity, whether it's about like precarious housing, whether it's about LGBT issues, whether it's about, you know, Indigenous and Black and, you know, other racialized groups, we as physicians, whether it's new and like just baby doctors or it's, you know, us fully developed doctors, we need to be in our community, like we need to understand what our patients' daily life looks like. And I think part of that is finding a way to get us to be face to face with our patients, not as our patients, but just as like our fellow citizens, our fellow people in our community.

Dr. Blair Bigham

And that is why this wraparound care works, is because social workers go out into the community and they see what these people face and they build rapport. That's it for this episode of the CMAJ podcast. Thanks for joining us for that difficult conversation.

If you can, please like or share our podcast, spread the word so that we can get the message out. The CMAJ podcast is produced by PodCraft Productions. Our producer is Neil Morrison.

Our senior editor at CMAJ is Catherine Varner. I'm Blair Bigham.

Dr. Mojola Omole

I'm Mojola Omole. Until next time, be well.