"There was no services that I could access so I just stayed on the street…using until I went into labour.": A qualitative study of accessibility and cultural safety of services for perinatal substance use in British Columbia, Canada.

Background: Perinatal substance use is a critical public health challenge, impacting both mother and fetus. Its prevalence has increased in British Columbia, Canada, disproportionately impacting First Nations people. For specialized perinatal substance use services to be effective, they must be accessible and safe. This study aimed to explore the accessibility and cultural safety of health services for perinatal substance use from the perspective of service users.

Methods: We conducted a qualitative study from six focus group discussions, consisting of five in-person sharing circles for people with lived/living experience of pregnancy and substance use and one virtual focus group with inreach workers, for a total of 55 participants including 48 people with lived experience and seven inreach workers across the five health delivery regions in British Columbia. We interpreted results using thematic analysis and narrative inquiry to explore inductively and deductively derived themes.

Results: Participants identified a lack of perinatal substance use specific services, particularly supportive housing facilities and wrap-around community centres in the province but highlighted that community-based services they were able to access made participants feel safe and respected. Thematic analysis identified six themes related to accessibility and cultural safety: geographic disparities in access to care, importance of Indigenous culture for Indigenous client's healing, transitions as critical moments in service accessibility, safe services protect the mother-infant dyad, inconsistent access to opioid agonist treatment, and relationality as a crucial element of safe service delivery.

Conclusion: This study suggests that services that preserve the mother-infant dyad, incorporate wholistic care including Indigenous culture, and are relationship-based are experienced as accessible and safe, and those that do not are often mistrusted and avoided. This study highlights needed improvements, particularly of acute care services, through supporting instead of reporting birthing parents with substance use, ensuring continuous access to opioid agonist treatment for pregnant people with opioid use disorder, and suffusing the client-provider relationship with empathy, respect, and connection.