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Emily Paton

on 3 November 2015

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Transcript of Drugs

Drug & Alcohol
Abuse During

Why is this an issue?
Maternal drug and alcohol abuse during pregnancy is a significant
public health issue that affects not only the child, but also the family
and the community.

While illegal drug use is a concern, the prevalence of alcohol use is
an even greater threat to pregnant women and their fetus.

(Wallman, Bohling Smith, & Moore, 2011).
Statistical Evidence
More Alberta women are admitting they drank alcohol or took ilicit drugs during their pregnancies, while the smoking rate of mothers-to-be remains very high
The number of mothers-to-be conceding they were dependent on drugs increased to 661 in 2006, compared to 179 cases in 2000
Meanwhile, 1106 women (2.5%) who gave birth in 2006 said they drank daily or consumed three or more drinks at least one time during their pregnancy, in comparison to 179 women (0.5%) reported this in 2000
According to the Canadian Community Health Survey, 12% to 14% of women admitted they had used alcohol in their last pregnancy
Approximately 19% of women used alcohol during their first trimester, 7.8% in their second, and 6.2% in their third
The prevalence of FASD in some populations is as high as 9.8 in 1000 live births (Merritt et al., 2011)
Of women who used alcohol in their first trimester, 8% binge drank, 21.8% smoked cigarettes, and 4.6% used marijuana
It is estimated that 18% of mothers engaged with the child welfare system have alcohol problems, and 14% have other substance use problems
The Prevalence and incidence of illicit drug use during pregnancy is 5.5%, while the prevalence and incidence of alcohol consumption is 10% to 18.8%
The leading cause of disease burden worldwide is maternal depression, which is highly associated with alcohol, tobacco, and other drug use

(Wallman, Bohling Smith, Moore, 2011)
(March of Dimes, 2011)
(D'Aliesio, 2010)
(Connelly, Baker-Ericzen, Hazen, Landsverk, & Horwitz, 2010)
Socioeconomic Status
Maternal drug use is not equally distributed, and it is estimated that 15% to 30% of pregnant mothers abuse illegal and legal drugs in low income and/or urban populations. As a result, both maternal drug use and unwanted birth outcomes may occur in women from disadvantaged neighborhoods.

The use of illicit drugs is associated with multiple social, psychosocial, behavioral risk factors that include poverty, stress, depression, lack of social support, physical abuse, sexually transmitted infections, and poor nutrition.

(Schempf & Strobino, 2008).
Social Factors:
Older age
Lower levels of education
Poverty and level of SES
< half the time
> half the time
(cc) image by anemoneprojectors on Flickr
Money for necessities
Public Housing
Mothers are more likely to smoke throughout pregnancy if they have a household income three times below the poverty line (Page, Padilla, & Hamilton, 2011).

Social Support Systems
•Women may not be supported by their family and peers
•Women may be living with violent partners who do not want them to make changes to their substance use

In order for health care professionals to collaborate with women at risk, it is critical to provide supportive, respectful, and non-judgmental relationships.

Reorientation of health services must include support systems that are non-judgemental in their delivery of perinatal care

(British Columbia Centre of Excellence for Women's Health, 2010)
The Issue:
Alcohol Abuse:
It is a myth that low-income, minority women are the majority of those that abuse alcohol during pregnancy
Women with the highest income levels (>$75,000) reported the most alcohol use during pregnancy with a percentage of 16.3%; however, they consumed less per incident than lower income women
11.9% of women who's income was less than $20,000 per year reported alcohol use during pregnancy

(Wallman, Bohling Smith, & Moore, 2011)

There is a definite need for increased support for women at risk. The National Treatment Strategy offers recommendations with the intent to strengthen services and support through five tiers:

1. Community based outreach services
2. Brief support and referral by a wide range of professionals
3. Acute, proactive outreach and harm reduction services
4. Structured and specialized outpatient services
5. Intensive residential treatment

Programming which supports the 5-tier framework will allow health care providers to
successfully address the needs of pregnant women with substance abuse problems
(British Columbia Centre of Excellence for Women's Health, 2010)

Studies suggest that "pregnancy may be an optimal time to intervene in cases of substance use disorders due to a heightened maternal motivation for the well-being of the infant” (Anthony, 2010, p. 11).
Why is this important to nurses?
Pregnant women abusing substances are at a very high risk of pregnancy complications, putting themselves and their fetus at risk.
It is crucial for nurses to recognize risk factors and possible complications, and be able to collaborate with other healthcare professionals to identify appropriate resources.
Complications for the Mother:
Gestational diabetes
Placental insufficiency
Post-partum hemorrhage
Spontaneous abortion
Preterm birth
Lower gestational age

(Anthony, Austin, & Cormier, 2010)

Complications for the Baby:
Lower birth weight
Premature birth
Longer and more complicated hospital stays
Future developmental problems
Neonatal abstinence syndrome (NAS)
Fetal alcohol spectrum disorder (FASD)
(Anthony, Austin, & Cormier, 2010)
Ottawa Charter for Health Promotion
Creating Supportive Environments
•Reciprocal maintenance: taking care of each other, our communities, and our natural environment (World Health Organization [WHO], 1986, p. 2)
•Vulnerable women: less educated, unemployed, unmarried, and exposed to violence
•Persistent substance use during pregnancy associated with depression
•Persistent cigarette smoking associated with problematic relationships and maladaptive functioning
•Poor self-esteem associated with substance abuse

(Massey, Lieberman, Reiss, Leve, Shaw, & Neiderhiser, 2010)
Nurses can promote importance of families and communities supporting one another
Rapport is necessary to influence self-worth, depression, and anxiety; because of this, it is important to support relationships between family members, friends, and communities of people
Creating supportive environments is crucial as women are highly influenced by social pressure, perceived harm to fetus, stigma regarding various substances, and social condemnation
Work with not only the patient, but also their family, friends, and communities they belong to when enabling a safe social support network
Educate patient and their support networks on physiological implications of substance use – especially regarding the first trimester when women are least likely to discontinue the use of substances

(Massey, Lieberman, Reiss, Leve, Shaw, & Neiderhiser, 2010)

Nursing Considerations:
Reorient Health Services
•Maintain a system that “contributes to the pursuit of health” (WHO, 1986, p. 3)
•Focus on health promotion and not only curative services and utilize research, education, and training (WHO, 1986, p. 3)
•Less than one-third of women reported to Child Protection Services for abusing alcohol or drugs were identified in the hospital (Catlin, 2011, p. 257)
•Despite the implementation of screening tools into hospitals, substance abuse was rarely identified unless there were physical signs (Catlin, 2011, p. 257)
Nursing Considerations:
Educate all nurses on importance of screening, communication strategies, interdisciplinary approaches, and the importance of one-to-one training
Implement a universal screening tool for pregnant women
Emphasize patient’s strengths in discharge planning, along with providing information, resources, and education
Engage family and develop professional partnerships
Eliminate policy bias by implementing universal screening

(Caitlin, 2011), (Roberts & Nuru-Jeter, 2011)
Services & Resources
Primary Health
Care Principles
Increase Health Promotion &
Disease Prevention
Intersectoral Collaboration
•Emphasis should be placed on promoting health and implementing an upstream approach to preventing illness (AHS, 2005)
•Many psychosocial risk factors correlate with substance abuse: unstable housing, food insecurity, tobacco use, depression, and intimate partner violence
•Women may initially be identified as low-risk during the first screening and more risk factors may be identified during subsequent assessments
•Factors that influence an increase in risk identification: recall error, rapport with healthcare professional, social desirability, and changes in the mother’s living situation
•The earlier risk factors are identified, the more opportunity to integrate health promotion and teaching to mitigate health issues caused by substance abuse

(Harrison, Godecker, & Sidebottom, 2011)
• To improve primary healthcare, there needs to be an integration of various sectors into the provision of care (AHS, 2005)
• “Women who have substance abuse problems often first come into contact with the healthcare system when they are pregnant”
• Use professionals from private, public, inpatient, and community sectors
• Utilize justice system in a way that mitigates fear
• Utilize a variety of partners in healthcare and ensure effective communication amongst the entire team
- Obstetric services for physiological wellness
- Psychotherapists to address addiction – many mental comorbid illnesses
often arise
• Utilize a multicultural staff to reduce barriers to access

(Corrarino, Williams, Amrhein, LoPiano, & Kalachik, 2006)
Aventa Addiction
Treatment for Women
Parent Child Assistance Program
... small
Offers addiction treatment services exclusively for women
Phase 1 program offers priority access for pregnant women across Alberta who require immediate support and stabilization
Fees: subsidy, sliding scale, or financial support available
Service offers: individualized treatment and recovery goals, individual and group counselling, and support and case management
No referral required
Offers addiction treatment services exclusively for women who have a history of drug and alcohol abuse, and may be at risk of having a child with FASD
Services offers: support on a long term basis (3 years), advocacy and support accessing services, goal setting and review with mother every 3 months
Eligibility: pregnant or up to 6 months postpartum, have acknowledged drug/alcohol abuse during pregnancy
Requires referral

AHS Addiction Services:
Adult Detoxification
Calgary Alpha House
24/7 service provides assisstance with the detoxification from alcohol and other drugs in a safe and controlled setting
Services: health stabilization, assessment, information sessions, self-help groups, addiction treatment planning, discharge planning, and referrals
Priority access is given to pregnant women

(AHS, 2012)
(cc) photo by medhead on Flickr
The alcohol and substance use helpline
Is a recognized leader for information about medications/drugs in pregnancy and breastfeeding
Offers information and counselling to pregnant and breastfeeding women, their families, and healthcare providers
Provides information regarding the possible effects of alcohol and other substances on baby, and referrals to services in the community
(Motherisk, 2012).
An excellent resource for women planning to become, or who already are, pregnant. The site provides information that promotes the overall health of the mother and child through the provision of relevant sources and information
Encourages women to speak with a healthcare professional before taking any prescription or non prescription medication or drugs

(SOGC, 2012)
The Society of Obstetricians & Gynaecologists of Canada
How Can Registered Nurses Inform & Influence Nursing Practice and Policies?
Hamilton & Bhatti. (1996). Population Health Promotion Model. Retrieved April 08, 2012, from http://www.tascc.ca/who
Promote Public Awareness & Knowledge
The Alberta Perinatal Health Program initiated a Preconception Framework in 2007 which mirrored BC’s National 5 Tier Treatment Strategy. Today this framework and consultants have been incorporated into Alberta Health Services. This is one program utilized within Alberta to influence perinatal health policies.

(Preconception Health Framework, 2007)
Develop a provincial preconception health communication campaign
Target education to youth in school and women and men in workplaces, and
Empower today’s woman to attain self help

Awareness strategies include mass media such as:
TV and Radio ads
Billboards on transit, and
Posters within health care, recreational, school and work environments

Men and their involvement
Women planning pregnancy
Women of younger age, offering behaviour modifying messages

(The Preconception Framework, 2007).
Build Capacity to Provide Preconception Health Promotion Services & Supportive Social Systems
Developing resources for health professionals
Developing post secondary curriculum to increase knowledge, skills and practices in preconception primary prevention
Utilize alternate care providers for preconception risk screening thereby increasing access to preconception health services
Integrate preconception into existing programs and services
Multidisciplinary collaboration to re-evaluate risks factors, and the Determinants of Health in order to address social and health policies, and
Work with other provincial initiatives

(The Preconception Framework, 2007)
What is Our Role as Nurses?
Pre-existing Programs
Alternate Care Providers
School Curriculum
Advocating for a Doanne & Varcoe Approach within the Alberta framework: applying the National 5-tier Health Strategy
Healthy Choices Act Now BC initiative mirrors the National 5-tier Health Strategy and promotes the Doanne & Varcoa Approach, through applying three competencies:
Mother/Women-Centred Care:

Media and Health care have taken a fetus-centred approach to substance use
Focus switched to mother-child centred care
Women are empowered with their own health pre, during, and post pregnancy
Internal motivation for behavioural and lifestyle change is supported based on the mothers needs, and
Service providers assist women in dealing with stigma, punishment, and blame

(Poole & Urquhart, 2010)
Harm reduction oriented:

Mother and fetus are first considered, Maslow’s Hierarchy - shelter and nutrition
Harm reduction incorporates the approach that not all mothers’ goals will include complete abstinence
Recognition of the determinants of health and their impacts on mother-fetus and coping mechanisms, and
Treatment begins with what is most important and possible for the woman

(Poole & Urquhart, 2010)
(McLeod, 2007)


Non-judgemental, respectful relationships are formed. Women are empowered to work with the health care system to achieve SMART goals, and
Motivational interviewing is an evidence-based communication style effective in guiding change while incorporating the ideals of empowerment and autonomy

(Poole & Urquhart, 2010)
Preconception Health Framework focuses on three competencies which reflect the Ottawa Charter Strategies within the Hamilton and Bhatti Model:
United Nations Millenium Development Goals:
Reduce the maternal mortality ratio by three quarters
Achieve universal access to reproductive health

(United Nations, 2012)
It is estimated that in Canada more than 3000 babies a year are born with FASD, and about 300,000 people are currently living with it. Research suggests that FASD is significantly greater in Aboriginal populations, and in rural, remote, and northern communities (Health Canada, 2009).
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