Negotiating the tensions of applying a perinatal harm reduction approach: Service providers' perspectives

BACKGROUND: Emerging research suggests that service providers experience dilemmas when implementing a harm reduction approach with pregnant or parenting people who use substances (PPPWUS). This study aims to (1) describe perinatal harm reduction practices (2) describe tensions that arise from applying a perinatal harm reduction framework and (3) examine how service providers negotiate these challenges. METHODS: This participatory qualitative study was co-developed with a perinatal substance use program in Montreal that operates from a harm reduction framework. We conducted 10 semi-structured interviews with interdisciplinary perinatal service providers and performed a reflexive thematic analysis informed by Dubet's sociology of experience framework. RESULTS: Providers experience tension due to divergent personal and professional values within themselves. Additionally, an important tension emerges between reporting to Child Protection Services and protecting the therapeutic alliance. These challenges are exacerbated by systemic injustices, social inequities, inefficiencies within health and social services, and collaborating with clinical partners who may have different commitments towards, or understandings of, harm reduction. Providers rely on team collaboration and re-ground themselves in the harm reduction ethic when confronted with opposing forces. CONCLUSIONS: Results highlight a need to strengthen academic formation and ongoing interdisciplinary/interagency development for professionals who might interface with PPPWUS to gain a shared understanding of the harm reduction philosophy. Further, results support the importance for health and social services system to prioritize greater capacity, accessibility, and collaboration between services to support PPPWUS, mobilize their strengths, and reduce harms for families.