Significance

Child welfare involvement (CWI) in cases where the birth mother is a victim of violence has public health impacts. However, no research to date has explored child welfare involvement when the birth mother has experienced human trafficking. This qualitative study demonstrated positive (improved access to services) and negative (stress as well as trauma reactions) impacts of CWI upon trafficked mothers. Furthermore, it puts forth recommendations for change: mechanisms to support trafficked mothers, train hospital social workers, and systems change.

Introduction

Child welfare involvement (CWI) in cases where the birth mother is a victim of violence has public health impacts, affecting families across the United States (Langenderfer-Magruder et al., 2019; Mirick, 2014). Risk factors for involvement of child welfare (CW) services among Intimate Partner Violence (IPV) survivors include substance use, mental health issues, lower educational level, prior personal CWI, and criminal involvement (Hazen et al., 2004; Tutty & Nixon, 2020). CWI lies on a spectrum of engagement from merely investigating an allegation, to providing services, to child removal. Studies indicate that CWI is more likely to result in child removal when IPV is involved (Mirick, 2014). While intended as a means of protecting a child, CWI among IPV-mothers may be traumatic and destabilizing to the mother (Juby et al., 2014; McTavish et al., 2019; Sankaran, 2018). CWI can increase risk of abuse towards the child’s mother (Ogbonnava & Pohle, 2013; Devoe & Smith, 2003). CWI may reduce help-seeking from IPV survivor mothers (Wathen & MacMillan, 2013). IPV survivors of color and LGBTQ survivors may disproportionately face more undesirable consequences of CWI (Goodman et al., 2019).

The parallels in the experiences of exploitation and coercion inherent in IPV and human trafficking are well established in the literature (Bessell, 2018; Clark et al., 2014; Gavin & Thomson, 2017; Koegler et al., 2020; Menon et al., 2020; Verhoeven et al., 2015). A nascent body of literature is emerging to explore the needs of pregnant trafficked persons (Clark et al., 2014; Collins & Skarparis, 2020; Dovydaitis, 2010; Nightingale et al., 2018; Stoklosa et al., 2017; Tracy & Konstantopoulos, 2012). However, to date, there is no research which has explored child welfare involvement (CWI) in cases where the birth mother has experienced human trafficking.

The aim of this study was to explore human trafficking provider perceptions of the impact of CWI for the trafficked mother.

Methods

Study Design

Given the exploratory nature of our aim, a qualitative study was conducted using semi-structured interviews with care providers of the THRIVE clinic, designed to provide medical, social and behavioral health care services for survivors of human trafficking, including prenatal and perinatal care. (George et al., 2018). This study adheres to COREQ guidelines for qualitative research (O’Brien et al., 2014). Participants were selected among THRIVE clinic providers, all of whom who have cared for trafficked mothers, until saturation was achieved for major themes. Participants were recruited via email and after informed consent was obtained, interviews were conducted virtually using a HIPAA-compliant telemedicine technology without video (Archibald et al., 2019; Mealer & Jones, 2014). This study was conducted in accord with ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments and it was deemed IRB exempt after review by Partners Healthcare and University of Miami.

The semi-structured interview guide comprised two main areas of inquiry in relation to human trafficking survivor mothers (1) positive and negative impacts of CWI. (2) recommendations for improving CWI. The interview was conducted by a member of the study team external to the provider group, a female trainee physician without a formulated opinion on the child welfare system. The audio recordings of the interviews were transcribed for data analysis. Interviews lasted between 25 and 35 min. A unique identifier was assigned to participant interviews. All identifying information was redacted from transcripts to protect anonymity.

Analysis

The study used a directed content analysis approach (Hsieh & Shannon, 2005). A coding structure was developed by [redacted] and [redacted], guided by a review of relevant IPV literature. The transcripts were then independently coded by [redacted] and [redacted], compared for agreement and finalized. Each transcript was reviewed for accuracy against the recording and coded using NVivo software. Member checking was done by sharing the results with the interviewees and verified for accuracy.

Results

Four provider interviews were conducted. Providers had 3–8 years of experience working with trafficked persons. Data saturation was reached for major themes, as noted below.

Exemplar quotes for corresponding themes can be found in Table 1.

Table 1 Illustrative quotes of themes related to impacts of Child Welfare Involvementa on human trafficking survivor mothers and recommendations for improvement, [REDACTED] 2020
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Report to Child Welfare

Reports to child welfare (CW) were typically made by a hospital social worker after the mother gave birth. In one case a patient’s mother contacted CW, and in another case, a case manager at a shelter contacted CW. Respondents did not note any trends in the demographics of the reporter. Some cases involved CW prior to the birth of the infant. CWI prior to the birth only occurred when they were already involved in a case regarding another child of that mother, such as an ongoing open-custody hearing. Participants did not note any consistency in demographics among trafficked mothers with CWI.

Reasons for Report to Child Welfare

Data saturation was reached among reasons for reports to CW, including the trafficked mother’s history of human trafficking, housing instability, substance use, intimate partner violence, mental health issues, and prior CWI. Concern was expressed that CW was notified “automatically,” based on electronic health record review of a patient’s past, rather than an evaluation of the “whole picture” of the patient’s current state.

Impact of CWI

Figure 1 demonstrates the positive and negative impacts of CWI that were reported by interviewees. On the positive side, these included access to services, including housing and parenting skills training, that may not have been available otherwise. Depending on the patient’s readiness for change on their substance use journey, the requirements for substance use treatment could be transformative. One respondent defined success related to the child being able to stay with the mother. A success of CWI repeated by respondents was the safety of the child.

Fig. 1
figure 1

The impacts of child welfare involvement (CWI) on human trafficking survivor mothers

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On the negative side, data saturation was reached, with all participants noting trauma reactions and increased stress among survivor mothers with CWI. The trauma was particularly profound for those with prior CWI (as a child themselves, or with their other children). The stress of CWI was described as leading to “regression”, “self-destructive” behaviors, substance use relapse, more mistrust of the health care system and further decreased engagement with the health care system. Three respondents also stated the removal of the child was a negative outcome.

Interviewee Recommendations

Interviewee recommendations for future improvement included prenatal proactive approaches: discussing with the trafficked mother the possibility of CWI prior to the birth of child; enhancing prenatal communication between hospital social workers and longitudinal providers; and linking the trafficked mother to substance use treatment and housing. Training for hospital providers, including training delivered by people with lived experience such as survivor advocates was recommended. Interviewees also recommended refining post-partum communication strategies between hospital (obstetrics and pediatrics) and outpatient providers. Finally, respondents recommended structural and cultural changes within health systems to promote strength-based trauma-informed care and improved capacity and communication among perinatal providers and CW services in general.

Discussion

This study was single-centered with a limited convenience sample, so its findings are not generalizable. Moreover, data was collected via audio-recorded, non-in-person interview, possibly limiting rapport -building between the interviewee and the interviewer and therefore potentially decreasing the interviewee’s openness in sharing (Archibald et al., 2019; Mealer & Jones, 2014).

Despite the exploratory nature of our findings, our data do mirror what is reported in the public health literature. First, the fact that the reporter to CW lacks a long-term clinical relationship with the caretaker, in this case, the survivor mother, is consistent with the IPV literature. Those with a more holistic view of the entire family may be less likely to make a CW report (Carlson et al., 2019). Respondents also noted reflexive reports to CW based on a patient’s history in the medical record, rather than a global assessment of their current state. Stigma reinforced by the electronic medical record has been reported among other populations (Stablein et al., 2015). Stigma associated with a history of human trafficking, unfortunately, is not novel to this study (Richardson & Laurie, 2019). Reports of CWI for substance use are not uncommon (Alexander et al., 2020; O’Rourke-Suchoff et al., 2020). Finally, reports to CW because of housing instability, as we discovered in this study, has been described as a mechanism through which CWI may “criminalize poverty” (Chandler et al., 2020; Newberger, 1983). The types of positive impacts from CWI in our study were also present in the IPV literature (Lippy et al., 2020). Negative impacts, in particular, the trauma from CWI, are also well-described in the IPV literature (McTavish et al., 2019).

Recommendations from our exploratory findings, contextualized in the extant literature, include mechanisms to support trafficked mothers, train hospital social workers, and systems change. During the prenatal period, strategies to support the trafficked mother may include addressing gaps in social determinants of health, ensuring appropriate medical and mental health care, early screening and referral to substance use treatment services, promoting problem-solving and communication skills, providing parenting classes, implementing techniques to decrease parental stress, enhancing community support, and working to develop safety plans for survivors and their families (Alhusen et al., 2015; Clark et al., 2019; Ee & Anderson, 2018; Huebner et al., 2017; Terplan et al., 2015). The respondents also recommended enhanced prenatal communication between outpatient and hospital social workers. Furthermore, enhanced engagement of social workers and all providers to improve understanding of the unique complexity of trafficked mothers is needed (Wolfe & McIsaac, 2011). Education should include an understanding that judgement of a caretaker’s ability to parent should be current and holistic and not reflexive based on history in the electronic medical record (Hsieh & Shannon, 2005). An exploration of the child welfare system itself should also be undertaken to identify and modify discriminatory laws and policies (Wolfson et al., 2021). Finally, efforts to address social determinants of health in the community and enhance the trauma-informed nature of child welfare referrals could improve the lives of trafficked mothers.

To date, there are no prospective studies exploring whether mandatory reporting reduces recurrence of maltreatment or improves the well-being of children (McTavish et al., 2017). Future research related to this study’s exploratory findings could include interviews with trafficking survivor mothers, representing a diversity of experiences across the country. We recommend involving those with lived experience of trafficking and CWI in the study’s design, execution and publication. Effective responses and advocacy for pregnant trafficking survivors and their children requires comprehensive policies and procedures that involve multi-disciplinary community input including but not limited to trafficking survivor mothers, advocacy groups, healthcare providers, and child welfare services.