One in five adults have a disability [1]. Historically, people with disabilities have been subject to discrimination and exclusion, including institutional segregation and involuntary sterilization [2]. In recent decades, pregnancy rates in women with disabilities have risen, with population-based studies reporting one in eight pregnancies are to women with a physical, sensory, or intellectual/developmental disability [3]. Many structural, social, and health-related barriers remain for mothers with disabilities [1, 4, 5]. Women with disabilities face negative societal attitudes about sexuality, pregnancy, and parenting [6]. Health and social service-providers consider an unborn baby to be more at risk if their mother has a disability [7]. Women with intellectual/developmental disabilities in particular are over-represented in child protection cases internationally [8–10], and are more likely to have their children placed in out-of-home care than other mothers [11]. Women with other types of disabilities, including physical and sensory disabilities, also describe being fearful of judgement by professionals in relation to their parenting [12], often without clear evidence or opportunity to demonstrate their abilities [13].

Whilst removing a child from their family is the option of last resort for social services, decisions to place children into care are happening more frequently and earlier in children’s lives [13, 14]. Newborn discharge to social services is of particular concern, as mother-infant separation has well-documented negative consequences for children’s emotional, social, and physical development [15], via impacts on attachment, bonding, and breastfeeding [16]. Such intervention is also traumatic for mothers and likely to worsen their own health and perceived parenting competency [17–19]. Without support, women are at risk of being caught in a cycle of recurrent involvement with children’s social services, and having more than one child removed from their care across their lifetime [20].

In our prior analyses of administrative health data in Ontario, Canada (2002–2012), women with intellectual/ developmental disabilities were eight times more likely than women without these disabilities to have their newborn discharged into social services, even after adjusting for other factors [21]. Yet, little is known about the rates at which women with other disabilities have newborns removed from their care and for how long they are separated, instances of multiple separations in families with more than one child, or predictors of these outcomes. Therefore, we extended our prior research and examined the risk of newborn discharge to social services among women with physical, sensory, intellectual/developmental, and multiple disabilities compared to women with no disability using an updated cohort (2008-2019). As secondary objectives, we (1) examined the risk of sustained separations at 12 months, (2) compared the risk of having multiple separations within one family, and (3) in each disability group, identified risk factors that predict newborn discharge to social services.

From 2008-2019, there were 114,685 births to women with physical, 38,268 to women with sensory, 2,094 to women with intellectual/developmental, 8,075 to women with multiple disabilities, and 1,221,765 to women without a disability. Women with sensory, intellectual/ developmental, and multiple disabilities were younger than those without disabilities. Women with intellectual/developmental disabilities were more likely to live in neighbourhoods in the two lowest quintiles, and all disability groups were more likely to receive social assistance. Women with physical and multiple disabilities were more likely to live in rural areas. Women with multiple disabilities were more likely to have stable chronic conditions; all disability groups were more likely to have unstable chronic conditions and mental illness; and those with physical, intellectual/developmental, and multiple disabilities were more likely to have a substance use disorder. Finally, women with multiple disabilities were more likely to experience severe maternal morbidity, and newborns of women with intellectual/developmental and multiple disabilities were more likely to be preterm and experience severe neonatal morbidity (Table 2).

Compared to newborns of women without disabilities (0.2%), newborns of women with physical (0.5%; aRR 1.53, 95% CI 1.39–1.69), sensory (0.4%; aRR 1.34, 95% CI 1.12–1.59), intellectual/developmental (5.6%; aRR 5.34, 95% CI 4.36–6.53), and multiple disabilities (1.7%; aRR 3.09, 95% CI 2.56–3.72) had elevated risks of discharge to social services after the birth hospital stay, after adjusting for maternal sociodemographic and health characteristics. Findings were similar after further adjusting for health care and pregnancy characteristics (Figure 1).

Among women with multiple livebirths during the study period, those with physical (aOR 2.00, 95% CI 1.51–2.64), intellectual/developmental (aOR 8.53, 95% CI 4.64–15.68), and multiple disabilities (aOR 4.47, 95% CI 2.68–7.45) had increased odds of having ≥2 newborns discharged to social services. Those with sensory disabilities did not (Table 3).

Newborns of women with physical, sensory, intellectual/ developmental, and multiple disabilities also had an increased risk of sustained maternal-newborn separation at 12 months (Table 4).

Finally, among newborns of women with physical (Supplementary Appendix 4), sensory (Supplementary Appendix 5), intellectual/developmental (Supplementary Appendix 6), and multiple disabilities (Supplementary Appendix 7), and newborns of women without disabilities (Supplementary Appendix 8), the strongest predictors of newborn discharge to social services were young maternal age, low neighbourhood income quintile, social assistance receipt, mental illness and substance use disorders; inadequate prenatal care; and severe neonatal morbidity.

In this population-based cohort study, we found higher rates of discharge to social services, including sustained and multiple separations, among newborns of women with disabilities, with particularly high rates in newborns of women with intellectual/developmental and multiple disabilities. Across all groups, the strongest predictors of newborn discharge to social services were indicators of young maternal age, poverty, maternal mental illness and substance use disorders, inadequate prenatal care, and neonatal complications. Our findings suggest that women with disabilities and their newborns could benefit from the development of tailored, family-centred services, and that these services should target social and mental health inequities as well as perinatal stressors such as newborn health issues. Many of these risk factors, such as living in poverty and experiencing poor health, might be mitigated by preconception and prenatal services, via comprehensive health and social care support, inclusive of family planning.

Several studies have described the over-representation of women with intellectual/ developmental disabilities in child protection cases, with most studies examining children of any age and showing a prevalence of 26% to 87% across studies [33, 34, 35]. Only two studies have examined newborn discharge to social services in this population. In a study of 53,565 women in Manitoba, Canada, maternal intellectual/developmental disability was associated with a seven times greater odds of newborn discharge to social services [36]. Likewise, we previously found newborns of women with intellectual/developmental disabilities had an eight times greater risk of discharge to social services [21]. To our knowledge, no studies have examined this outcome across diverse disability groups, thus showing the novelty of our study. Our study also suggests that sustained and multiple separations are more likely to occur.

We know from previous research that a myriad of factors can increase the risk of children’s social services involvement for families, including young maternal age, living in poverty, and maternal mental illness or substance use [9, 36]. In our study, as in previous research [37–39], we found that women with disabilities have higher rates of such concerns when compared to women with no disabilities. Our findings could therefore indicate that intersectional disadvantages and social vulnerability, of which disability status plays a role, increase the risk of children’s social service involvement.

Additionally, professionals may have concerns around how maternal disabilities impact on safe parenting practices, for example, challenges with cognitive processes, such as memory or organisational skills, or physical capabilities, such as the mobility needed to lift a baby [40, 41]. From qualitative literature, we know women with disabilities fear judgement and assumptions around their parenting abilities [12], with women describing their needs as being largely unmet by services, with little or no access to interventions specific to parenting and child rearing with a disability [41]. These issues are important because studies show that up to 50% of disparities in developmental outcomes of children of women with intellectual/developmental disabilities, for example, could be explained by other factors such as poverty and lack of social support – which are amenable to intervention [42, 43]. Our findings could therefore illustrate more systemic and cultural barriers to parenthood for women with disabilities, including a lack of appropriate services to address the specific needs of parents with disabilities and those of their newborns. Our findings draw particular attention to the prompt involvement of children’s social services at the point of birth, giving families a narrow window of opportunity to engage meaningfully with support and evidence their parenting capabilities [21].

Research suggests many mother-infant separations may be preventable through targeted and timely intervention that can improve outcomes associated with child abuse or neglect, including maternal health, family functioning, and the home environment [44–46]. Approaches to supporting parents at risk of children’s social service involvement include home visiting programs [47], parenting interventions [48], and family-focused casework. Effective interventions have been developed on principles of being strengths-based and flexible in supporting the needs of each family [44]. For example, a home-based intervention supporting parents with intellectual/developmental disabilities reported improvements in caregiving skills and knowledge associated with child safety [48]. Similarly, women with physical disabilities have described the usefulness of adaptations which enabled safer parenting practices, including furniture modifications, specialist equipment, and caregiving support from extended family [49]. Utilising wider social networks of support can be characteristic of child rearing practises within many families [50]. Yet, there is an assumption within child protection that parents must be able to evidence their parenting competency unsupported [51]. Supported and tailored services and resources for women with disabilities could enable them to care effectively for their children. Providing targeted support for women most at risk, including those with comorbid conditions and living in poverty, might reduce the risk of newborn removal for those families [36].

Analysis of administrative health records enables a large-scale examination of the population in Ontario, Canada, but there are limitations to this approach. We were not able to capture health needs that are not known to services or not captured within administrative records. We had no information on social services involvement after birth hospitalization discharge, and used a proxy of discordant maternal-infant postal codes at 12 months to examine whether newborn discharges to social services were sustained, which may not fully capture all cases of foster care and other longer-term separations. We also had no information on other supports around the time of pregnancy that might have impacted the risk of newborn discharge to social services, such as disability support programs, home visiting programs, or parenting skills classes. We also had no information on women’s own history of social service involvement. This limitation highlights the importance of population-based health and social services data linkages to fully understand such experiences. Although we had information on a range of important sociodemographic, health, health care, and pregnancy characteristics, we were unable to examine some of these in detail (e.g., specific type of mental illness or substance use disorder). We were also unable to measure important equity-related variables such as race/ethnicity in these data. Indigenous and Black children are disproportionately represented in the care system across Canada [52, 53], and future research should aim to understand intersectional discrimination for families with children’s social service involvement. Finally, while administrative health data provide a population-based, quantitative picture of important disparities, they do not provide information on individuals’ experiences. Listening to the voices of women with disabilities with children’s social service involvement would be an important next step in understanding needs and experiences of this population.

Women with disabilities may face more systemic challenges and assumptions about their parenting than other mothers. While children’s social services play a crucial role in protecting at-risk children from harm, such as abuse or neglect, there are instances where families may be supported to stay together safely. Our population-based study is the first to evidence the increased risk of newborn entry into social services among women with different types of disabilities. Targeted supports for women with disabilities at heightened risk of children’s social service involvement are needed to prevent mother-newborn separation where possible. Comprehensive interventions should address disability-specific needs, as well as factors associated with increased risk of newborn separation, such as poverty, mental illness, substance use disorders, and perinatal complications.