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Substance Misuse In Pregnancy

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Jessica White

on 15 March 2014

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Transcript of Substance Misuse In Pregnancy

Women are advised to breastfeed immediately before an opiod dose to avoid peak concentrations of the drug in the breastmilk - NHS Evidence
Drug Misuse In Pregnancy
What do you perceive to be drug misuse?
Definition: Intoxication by consumption of and/or dependence on
– psychoactive substances, leading to social, psychological, physical or legal problems. It includes problematic use of both legal and illegal drugs (including alcohol when used in combination with other substances)

(NICE 2007)

Why is illicit drug use relevant to midwifery?
What can midwives and maternity services do?
Those responsible for the organisation of local antenatal services should work with local agencies, including social care and third-sector agencies that provide substance misuse services, to coordinate antenatal care.
This proportion has been similar over the past three years, with the average about 5%.
Long and short term benefits for the baby
Long and short term benefits for the woman
Long and short term benefits for the family
Much safer environment for the partner/ children
Partners of substance misuse users will feel more supported as a parent, have a stronger relationship with their partner
Partner may seek employment to support family now they are discontinuing substance misuse
Less risk of abuse within the family
Implications on the NHS
Legal drugs
General Sale (paracetamol)
Pharmacy only
(paracetamol and codeine)
Prescription only

Illegal drugs
Legal drugs that have been modified in some way which makes them illegal, eg.
Opiates - heroin
Stimulants - cocaine
Hallucinogenics - ectasy,
Out of these 914 - 72 were under 18 (1% of total number seeking treatment)
Neonatal abstinence syndrome

Benzodiazepine drugs
- valium
- Temazepam
Neonatal abstinence syndrome
914 pregnant women started drug treatment in 2011-12 (6% of all women starting for the year).
- Slows down fetal growth (interuterine growth retardation) Small baby for dates
- Premature birth

- Damages brain development
- Learning difficulties
Consequences of illicit drug use on the unborn baby

Women's Fears
Referral to social services
The damage her substance use is causing
Being blamed
Being perceived as unfit mother
Guilt/'to blame' for baby's withdrawal symptoms
Feeling inadequate - not possible to beastfeeding due to weaning process
All can lead to problems with maternal attachment
Women who use drugs are more likely to attend antenatal care late and/or conceal their drugs use from health professionals (Saving Mothers’ Lives; Hall & van Teijlingen).
Breastfeeding is encouraged for women who use illicit drugs. Parents should be informed that the benefits of breastfeeding usually outweigh the disadvantages even with substance use DOH 2007.
NHS Evidence: clinical knowledge summaries. Opioid dependence – management. Scenario: pregnant and breastfeeding
Pregnancy and complex social factors: NICE 2010 (CG110)
Joint care plans

Opiate replacement therapy in care plan

Information about the services provided by other agencies

Support with transportation to appointments
Referral to substance misuse programme - NMC Code 2008, Rule 28

Discuss potential effects of substance misuse on her unborn baby

Discuss what to expect when the baby is born

Pregnancy and complex social factors: NICE 2010 (CG110)
NICE recommends:
NICE recommends:
when a pregnant woman takes illicit or prescription drugs during her pregnancy.
The drug passes through the placenta to the baby
The baby becomes addicted
The baby is dependent on the drug at birth
Baby goes into withdrawal
The baby is less likely to develop NAS (Neonatal Abstinence Syndrome) which then means that they won't have to be treated/weaned off the drug and therefore will have a shorter stay in hospital.
There is less chance of the fetus developing any abnormalities or problems which could cause disabilities. Therefore if the fetus develops normally once the baby is born it will not be required to receive extra care or support unless any other complications occur.
Extending her social network may mean that not only does she have extra support, she might start new hobbies or activities/groups with other people which can benefit her socially and also mentally in the fact it gives her something else to focus on.
This means that:
- she might make new friends
- improve relationships with her family & friends
- find new ways to spend her time
- have less symptoms of mental health problems
She is more likely to bond well with the baby if she is able to do lots of skin to skin, breastfeeding and 'normal' motherly tasks.
Consequences of illicit drug use on the family
''Drug addiction goes hand in hand with poor health, homelessness, family breakdown and offending'' (NHS)
1,200,000 people affected by drug addiction in their family (NHS 2011)
Costs to the NHS
Annual cost of drug related crime: £13.9billion
In 2009, the cost of deaths related to drug misuse = £2.4 billion
Blood borne viruses and pregnancy
Effects on mother and baby
HIV, Hep B and Hep C are all BBV's
and can be passed from mother to

HIV causing AIDS - can be transmitted to baby intrauterine or through breastfeeding. Advice and treatment the risk of vertical transmission 2%, from 15-25%. 80% of transmission occurs during intrapartum period.
Hep B
80-90% transmission rate. No evidence risk increased through breastfeeding - can be promoted WHO 1996.
Babies can be chronic carriers and are at risk of developing liver conditions later in life.

Hep C
Can only be transmitted if mother is chronically infected. Not through breastfeeding. The transmission rate is less than 6%.
Interventions and treatment
HIV: Antiretroviral drugs for mother and baby, obstetric management in labour, delivery of pre-labour caesarean when indicated,
avoidance of breastfeeding
- recommended by
The Royal College of Obstetricians and Gynaecologists 2010
- for women in the UK.

Psychological issues eg. coming to terms with diagnosis and how to manage infection.

Women refusing treatment - fear, denial, stigma = Pre-birth planning meeting with social services to discuss child welfare.

Hep B: Treatment to reduce transmission rate - oral antiviral tablets (during last trimester) -immunisations. If antenatal hep B surface antigen positive, vaccination programme started at birth for baby.

Hep C: If infant found to acquire infection it is referred to gastroenterology for liver disease management.
Parental drug use, along with poor parental mental health and domestic abuse, is a factor in around two-thirds of child protection cases and Serious Case Reviews. Parental involvement in the criminal justice system is also a risk factor (162,000 children have a parent in prison)

(Public Health England 2014)
Guidelines and Midwife's responsibility
Maternity Care
offers a range of resources for drug using women - information leaflets, care pathways, alcohol and drug diary for women to monitor progress/relapse, family support plans.

Barnard M. (2005) Drugs in the family. The impact on parents and siblings.http://www.jrf.org.uk/sites/files/jrf/1859353207.pdf
Crandal C, Crosby R, Carlson G. Journal of Substance Abuse TreatmenT. Volume 26, Issue 4, June 2004, Pages 295–303. Does pregnancy affect outcome of methadone maintenance treatment? Avaulable at http://www.sciencedirect.com.ueaezproxy.uea.ac.uk:2048/science/article/pii/S074054720400006
Hall H and Teijlingen E (2006) A qualitative study of an integrated maternity, drugs and social care service for drug-using women. BMC Pregnancy and Childbirth. BioMed Central Ltd. http://www.biomedcentral.com/1471-2393/6/19
o http://www.nta.nhs.uk/uploads/families2012vfinali.pdf
Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer – 2003-2005 Available at http://www.publichealth.hscni.net/sites/default/files/Saving%20Mothers'%20Lives%202003-05%20.pdf

NICE 2010 Pregnancy and Complex social factors
Training for healthcare staff:

-Healthcare professionals should be given training on the social and psychological needs of women who misuse substances.

-Healthcare staff and non-clinical staff such as receptionists should be given training on how to communicate sensitively with women who misuse substances.

Less likelihood of suffering from physical and emotional abuse and neglect, from inadequate parenting.
Reduces the possibility of separation of child and mother - involvement of social services.
More chance of receiving a good education - better attendance,
Less likely to be exposed to violent behaviour.
Improved social integration into society

Cost of a full-time midwife for women who substance misuse:
Band 6 Annual cost =£34,924. Per woman = £349
Band 7 Annual cost = £41,810 Per woman = £418

(Costing statement: Pregnancy and complex social factors 2010)

Family members involved with the drug user can be concerned about:
financial impact that the drug problem is having on the family
the women's state of physical and mental health
the reduction of social life for the family
negative impact of communication between the women and her family
the drug users behaviour
(Adult family members and carers of dependent drug users:
prevalence, social cost, resource savings and treatment
responses November 2009)
Long term social benefits can include:
Long and short term benefits of treatment/discontinuation
"More than 250,000 children have parents with drug problems in the UK, and three in ten children live with at least one binge drinking parent. These Children are at high risk of abuse or neglect, and often lead chaotic lives."

NSPCC. Family Environment: Drug Using Parents. 2014
Drug misuse can lead to physical or psychological addiction and can cause several health and well being issues
Drugs in the family
The impact on parents and siblings

Barnard M (2005) Drugs in the Family. The impact on parents and siblings. University of Glasgow. Joseph Roundtree Foundation.

The effort to maintain normality and manage situation themselves can bring family to breaking point. The stress inflicted upon other family members resulted in degradation of multiple relationships within family.
Element of protection, however this was challenged by behaviour from drug user - violence, stealing, running away.

Main themes of study:
Normal Relationships
- relationships of secondary importance.
Normal- not possible - no trust or time spent together. Family members viewed drug user as selfish, pre occupied by drugs and self absorbed by process.
Worry and Anxiety
- of drug user wellbeing, when they ran away, fear of overdose.
Family members believed anxiety affecting how they lived their normal lives.
Reluctance to accept
- for drug use to be publically acknowledged - embarrassment and shameful.

Symptoms of NAS
Sleep problems
Who do you perceive a drug misuser to be?
Drug Misuse In Pregnancy
The relevance to midwifery health improvement initiatives

The short and long term benefits of improving the health and well being of women and her significant family members

The implications of improving health and wellbeing in illicit drug use on the health care services

Opiate drugs:

- Heroin
Weight loss
Feeding problems
Excessive crying

- Speech and language development
- Congenital abnormalities
Consequences of illicit drug use on the mother
'Drug-misusing women are at high risk of antenatal and postnatal mental health problems.'

Department of Health (2007) Drug misuse and dependence: UK guidelines on clinical management
Specialist Midwives
'There are 40 drug and alcohol specialist midwives in the UK who work closely with social workers and addiction services' (Lakhini, 2009).

Maternal health
& Well being
The Specialist Midwife will act as a point of contact for the woman and relevant agencies, to ensure inter-agency care planning.
Social circumstances
Poor social circumstances - poverty - associated with drug abuse - identified by Harkness S et al (2012) Poverty: The role of institutions, behaviours and culture.
Of those that are in receipt of out-of-work benefits estimated that just over
1⁄4 million
are problem drug users (2010) equating to 7 percent.
Lack of social support from family and friends
Poor support from partner - if they substance use also
Substance related crime and legal problems
Financial issues
Housing problems
History of sexual abuse/exploitation
Violence - drug related or domestic violence
Lack of education/employability

Physical Health
Respiratory depression
Lung problems - marijuana long term use
Poor dental hygiene
Complications from injecting
Liver disease
Overdose - maternal death
Poor sexual health
Urinary problems - ketamine

Mental health
Anxiety and paranoia - marijuana, stimulants
Depression - stimulants (cocaine/crack)
Psychosis - stimulants, hallucinogenics, ketamine


Women need to have discussion of risk factors: Injecting, psychostimulant drugs (insomia in baby) opiates (sedation in baby). Aswell as advice and education: bonding, skin to skin, reognising cues, timing of feeds in relation to substance use.
They promote early identification of women using illict drugs in order to increase birth outcomes for both mother and baby.
Reduces severity of Neonatal Abstinence Syndrome
These factors may contribute to women not accessing antenatal care
Fear and Denial – some women avoid
facing the reality of pregnancy
(Hall H & Teijlingen E)
How maternity services can help?
Associated with chaotic disorganised lifestyle - lacking routine and commitment obligations eg. antenatal appointments.
Late Booking
Poor attendance
Not registered at GP
Not engaging with parenthood education
Early discharge home after delivery
Failure to attend child health appointments
Reduced pressure on midwives - specialist not always available - normal appointment time no necessarily long enough, but difficult to build into regular clinics/home visits.
Midwives may have not felt trained to a high enough standard to effectively offer the care - back to focus on normality.

Reduced pressure on various agencies and resources from the multi-disciplinary care that is needed when working with vulnerable drug users.
Consistency in education of proffesionals
Supporting women to disclose
Hall H and Teijlingen E (2006) A qualitative study of an integrated maternity, drugs and social care service for drug-using women. BMC Pregnancy and Childbirth.
This study provides evidence of a drug use service for pregnant women in Aberdeen, and how maternity care and early intervention helped these ladies in overcoming their addiction. The study identified key areas that the women found especially helpful in their journey to recovery.
Attitude of staff
- "They didn't make you feel like it was something to be ashamed of. They made you feel worth something that you were here, at least you are trying you know..."
Continuity of carer
- "... having the same people because they know you and you know them...you don't have to keep repeating yourself, telling your story over and over again."
High level of support
- "I think it's important to drug users to go more often. I mean if you are going to relapse then there is somebody there to talk to."
- "They told you all about the drugs. I was quite far on and I didn't know that crack cocaine can kill the baby and I was a regular user. That's extremely important. They don't tell you that anywhere else"
Integrated care
- "They all interlink with each other, you know....that was really, really handy...it saves you having to travel....it's all in one building, so it was really good."
"... you don't want to have to keep telling people that you are a user, you only want to say it once for everybody to know."

"I blanked it out.... I didn't want to face up to it...then I got into more drugs to forget it."
"I think it was just so much easier to deny. It was just a bump in my tummy, you couldn't actually see the little person."
"I was just too frightened, too scared, thinking they were going to get me into trouble and take her off me the minute she was born."
Hall H and Teijlingen E (2006)
"I didn't really want to go along. I thought people would look at you and judge you because you were using heroin."
Hall H and Teijlingen E (2006) A qualitative study of an integrated maternity, drugs and social care service for drug-using women. BMC Pregnancy and Childbirth.
A qualitative study that aimed to gain an understanding of the experiences of women drug users, seeking and receiving prenatal care and drug services.

Provides evidence for the social and psychological issues women may face by being a drug user and pregnant, and evaluates why some women may not want to access maternity care.
"Every £100 invested in drug treatment services prevents a crime being committed, according to a study released. A report published by the NTA estimates that current drug treatment provision prevents 4.9 million crimes in England a year, with an estimated saving to society of £960 million in costs to the public, business, the criminal justice system and the NHS."

Crandall et al (2004) states 'the lifestyles of substance misusers who are pregnant are often complicated by homelessness, poverty, illiteracy and an increased incidence of mental health problems.'
Midwives need to be:
Woman and familiy centred
Good communication skills
Journal of Substance Abuse Treatment
Volume 26, Issue 4, June 2004, Pages 295–303
Does pregnancy affect outcome of methadone maintenance treatment?
Crandall, C. Crosby, R. Carlson, G
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