An Honest Exploration of Harm Reduction in Reproductive Work
There are no guidelines for harm reduction work for doulas. We’re still writing the map and creating new systems together with Drug Users and folks in recovery. Drug use is still criminalized, and bodies are still controlled. We have a lot of work to do in dismantling systems of oppression and changing public opinion around substance use. Thus, this work requires a willingness to hold visions for the future, while working with folks on the day to day.
When you center harm reduction, you may play many roles: doula, birth worker, supplier, driver, social worker, legal assistant, witness, advocate, chef, friend - all in one day. Boundary-setting is a dynamic process and is not straightforward, law and language are flexible, liability and scope are difficult to clarify. This is why we must do this work in community.
My Journey into Harm Reduction
I came to harm reduction work when I was volunteering at a shelter. Houseless people and Drug Users are some of the most highly stigmatized populations. During my time at the shelter, I had several doula clients who were in active use or in recovery.
I was struggling with the definition of “scope” in the many doula trainings I had attended. My clients’ needs seemed to exist far beyond the boundaries of what traditional doula “scope” entailed. I was feeling isolated and empty handed when it came to resources and community, especially in supporting pregnant people who used drugs. The mainstream doula industry is more concerned with business creation, and profit over people. In this model, doulas are a luxury, something my houseless clients couldn’t afford. And, yet, they had very real needs, worthy of companionship and care.
I started reaching out, asking questions, trying to find resources – programs, people, anything to help support my clients. Additionally, I asked my clients their opinions on providers, what they did or didn’t like about a program or treatment center, and what they’d like to see. As I gathered resources, I also started dreaming of a website, a collective, and a continuing conversation around reproductive care in harm reduction.
Each client has taught me many new things. Where to get free diapers, who to call for a phone, where to get emergency housing, how to get a housing voucher, who to call for legal support, the good/bad treatment programs, what to expect from CPS, and most importantly, that people who use drugs LOVE their children.
What It Means to Do Harm Reduction Reproductive Work
Many harm reduction trainings are fantastic but rarely dive deeper into what it looks like to provide reproductive support to people using drugs. Because drug use is just one symptom of system harm, not a cause. Mental health and crisis response, racism and privilege, de-escalation and intervention, trauma-informed care, working with survivors and sex workers, bereavement and loss, QTBIPOC experiences, are just a few prerequisites for starting work in harm reduction.
The over used and misunderstood phrase “meet them where they’re at” requires a deeper look at ourselves, identities, social and institutional structures. It means accepting that you may not relate to someone’s experience or fully understand their situation, and being comfortable in discomfort. We cannot make assumptions, or impose our wants, or coerce our clients into making choices. This work requires being present in the moment, and asking questions that we may not like the answers to. This is not a space for saviorism, ego, or pride.
There are legitimate risks to those who work under oppressive systems. In witnessing our clients, we, too, may face or interact with carceral systems such as law enforcement, CPS, or hospital security. As a person in recovery, I also struggle sometimes with watching a client in active use. We have to understand how vicarious trauma and triggers impact the ways we show up for someone. What is your capacity? Who are your supports? Who can help you process? Are you willing to unlearn biases?
Drug use during pregnancy is not the determinate for adverse outcomes, though frequently it takes the blame. This is another stigma to dismantle. Instead of staying stuck in these assumptions, start asking: What is this person's access to nourishing cultural foods? Are race and ethnicity a factor in equitable health care access? What violence has occurred (poverty, sexual, criminal, carceral, etc)? So many factors come into play when we look at a whole person and not just their drug use.
How to Practice Harm Reduction as a Doula
As doulas, there are so many ways we can practice harm reduction. First and foremost, treat your client who uses drugs the same way you would treat any other client. They are powerful and capable of making the best decisions for their body. Echo their voice. They are the best at understanding their circumstances and lived experiences - trust them in their decision making process and always be honest. Never promise something you can't personally deliver - or overcommit. Always ask permission, whether it's to have a conversation or to touch their body.
Be prepared for grief. Miscarriage, stillbirth, and pregnancy release (abortion) are socially accepted to varying degrees. The loss of a child due to a hospital hold/dependency/or placement into kinship care or the foster care system is highly stigmatized - and can be just as heartbreaking. Other losses that may arise include the loss of a friend, partner, or even the client due to an overdose.
What can you do for clients?
Encourage clients to always use with a friend and to track their use
Carry and be trained in using naloxone (Narcan)
Offer snorting or smoking as a safer alternative for those who inject
Slowly reducing the amount used is safer than quitting suddenly
Connect them with a trusted provider who specializes in addiction medicine and follows a harm reduction framework can help keep the client safe if abstinence or recovery goal. This is a good first step in making sure your client has the resources they need for perinatal care.
What can you do in community with others?
Most community based syringe service programs are underfunded and rely on public donations and volunteer support. You can help make supply kits to hand out, volunteer for direct service, or create a reproductive care resource list for them (vet your sources).
Find the addiction and recovery teams at your local clinics or hospitals and start up a dialogue with providers. Street medics or mobile medical vans are also a good place to make an introduction.
Support your state’s Medicaid reimbursement for doulas by signing up for legislative updates, community planning meetings, or voting.
Network with other doulas who share the same goals and that you would trust to support your client.
Fight the stigma around pregnant and parenting people using drugs. There are many great resources and articles. Start having those conversations with family and friends. Understand person-first language, and how to use non-stigmatizing terms when addressing the public or health care providers. Remember only your client can define and use the language they choose when talking about themselves.
Build a local resources list for pregnancy/baby supplies, shelters, counselors, social workers, medical clinics, low barrier addiction treatment centers, HIV/HCV testing centers, crisis lines, transportation options, etc. Contact these places and speak to their directors. Find out who they serve, their opinions, procedures, and goals.
Talk to your client and their community. Word of mouth and personal experience go a long way and can help save someone's life, as well as keep families together.
Encourage perinatal service providers to offer community care hours (pro bono or sliding scale) in their practice
Find those doing the work and build community. Nothing is more energizing to a movement than knowing you have shared goals, struggles, and are not alone.
Most importantly, witness your client’s agency and power. Release expectations and projections, and show up every day with compassion and empathy.
Ash Woods (they/them) is a trans full spectrum doula living on Coast Salish land in so-called Seattle, Washington. They view doula work as community work, and are dedicated to dismantling the stigmas associated with perinatal drug use. They helped form the Harm Reduction Doula Collective to meet the needs of pregnant people using drugs.