Scottish Government

Good Practice Guidance for working with Children and Families affected by Substance Misuse

Appendix III: Substance Misuse in Pregnancy

Pregnancy is a crucial time for a woman who is misusing substances and her child. Substance misuse can harm a foetus yet pregnancy can act as a strong incentive to make a positive change to substance-misusing behaviour.

Effects of drug use on pregnancy

Opiates/Opioids

Heroin is short acting and many of the problems associated with its use result from the effects of withdrawal. Withdrawal causes contraction of smooth muscle; this can lead to spasm of the placental blood vessels, reduced placental blood flow and consequently reduced birth weight in babies.

Methadone, the opioid substitute, has a longer lasting effect, thus eliminating fluctuations in blood levels and creating more minor withdrawals. It does not increase the risk of pre-term labour, but can cause reduced birth weight and withdrawal symptoms in the new-born baby. While substitute prescribing has been reported to improve stability, there is no evidence that it benefits pregnancy.

Benzodiazapines

There is no good evidence of any benefit deriving from substitution therapy during pregnancy, although, in exceptional circumstances, substitution prescribing begun before pregnancy may be continued. Evidence suggests there is a slightly increased risk of cleft palate, so all pregnant women using benzodiazapines should be offered a detailed scan at 18-20 weeks.

There is no reliable evidence that use of benzodiazapines in itself affects pregnancy outcomes, but it is frequently associated with medical and social problems, and with poorer outcomes (especially low birth weight and premature birth). Use of benzodiazapines by the mother also causes withdrawal symptoms in the new-born baby, which can be particularly severe if there is 'poly' drug use.

Amphetamines and Ecstasy

There is no evidence that use of either amphetamines or ecstasy directly affects pregnancy outcomes, although there may be indirect effects due to associated problems. They do not cause withdrawal symptoms in the new-born baby.

Cocaine

Cocaine is a powerful constrictor of blood vessels. This effect is reported to increase the risk of adverse outcomes to pregnancy, e.g. placental separation, reduced brain growth, under-development of organs and/or limbs, and foetal death in utero. It would seem that adverse outcomes are largely associated with heavy problematic use, rather than with recreational use. Despite frequent reports to the contrary, cocaine use during pregnancy does not cause withdrawal symptoms in the new-born baby.

Cannabis

Cannabis is frequently used together with tobacco, which may cause a reduction in birth weight and increases the risk of Sudden Infant Death Syndrome (cot death). There is no evidence of a direct effect on pregnancy outcome from cannabis itself.

Tobacco

Maternal use of tobacco and alcohol can have significant harmful effects on pregnancy. Tobacco causes a reduction in birth weight greater than that from heroin, and is a major risk for cot deaths. Babies of women who smoke heavily during pregnancy may also exhibit signs of withdrawal, with 'jitteriness' in the neo-natal period.

Alcohol

Low levels of alcohol consumption during pregnancy may seem harmless, but safe levels cannot be precisely identified. At higher levels, alcohol causes reduction in birth weight, while amongst women who drink heavily in pregnancy (especially binge drinkers) a small number deliver babies with the combination of effects known as 'Foetal Alcohol Syndrome'. These features include low birth weight with reduction in all parameters of growth (including head circumference and consequently brain size), and central nervous dysfunction, including learning disabilities and characteristic facial abnormalities. The correlation with dosage is not exact, which suggests that other factors may contribute to the aetiology.

Breast-feeding

Mothers who are substance misusers and who are prescribed methadone should be encouraged to breast-feed in the same way as other mothers, providing their drug use is stable and the baby is weaned gradually. Successful establishment of breast-feeding is in itself a marker of adequate stability of drug use.

Assessing pregnant women with substance misuse

'A new approach is needed to address risks and needs. As a first step this should start with assessing the needs of all new-born babies born to drug or alcohol misusing parents.'

(Scottish Executive 2002) (c)

Most drug-using women are of child-bearing age. Substance misuse is often associated with poverty and other social problems, therefore pregnant drug using women may be in poor general health as well as having health problems related to drug use. Use of alcohol and tobacco is also potentially harmful to the baby. Substance misuse during pregnancy increases the risk of:

• having a premature or low weight baby
• the baby suffering symptoms of withdrawal from drugs used by mother during pregnancy
• the death of the baby before or shortly after birth
• Sudden Infant Death Syndrome
• physical and neurological damage to the baby before birth, particularly if violence accompanies parental use of drugs or alcohol
• pregnant women drinking to excess risk delivering babies with Foetal Alcohol Syndrome.

Some pregnant women who misuse substances do not seek ante-natal services until late in pregnancy or when in labour. They may not realise they are pregnant because of the effects of some substance use on the menstrual cycle. Their substance misuse and associated life-style may make other more urgent demands on their time. They may fear their drug use or drinking will be detected through routine urine or blood tests, or that if they tell staff they will be treated differently or that child protection agencies will be contacted automatically. They may feel guilty about their drug or alcohol use and want, or feel they ought, to stop but are worried they will not succeed. They may be worried that their baby will be damaged or display withdrawal symptoms after birth. Many of these problems can be overcome by provision of accessible ante-natal services that tackle these worries honestly and sympathetically.

Health and non-health care agencies supporting women with alcohol or drugs-related problems should routinely ask about whether they have any plans to have a child in the near future, or whether they might be pregnant. Pregnant women should be encouraged to register with a GP and seek maternity care. Women not registered or unwilling to register with a local GP should be encouraged to attend ante-natal maternity services and register with community midwifery services to enable support to be provided in the community. Some urban areas provide specialist maternity services for pregnant substance misusers and primary care teams should consider involving these services early in pregnancy.

Staff providing ante-natal care for pregnant women should ask sensitively, but routinely, about all substance use, prescribed and non prescribed, legal and illegal, including tobacco and alcohol. If it emerges that a woman may have a problem with drugs or alcohol, she should be encouraged to attend addiction services, or specialist maternity services where available, and staff should offer to make the referral. Ante-natal services should arrange a multi-disciplinary assessment of the extent of the woman's substance use - including type of drugs, level, frequency, pattern, method of administration - and consider any potential risks to her unborn child from current or previous drug use. If the woman does not already have a social worker, the obstetrician, midwife or GP should ask for her consent to liaise with the local service to enable appropriate assessment of her social circumstances. If the woman does not agree to a referral to social work services, ante-natal staff should consider whether the extent of the woman's substance problem is likely to pose risk of significant harm to her unborn baby. If significant risk seems likely, this may override the need for the woman's consent to referral.

Professionals providing both ante- and post-natal care should be aware of the potential difficulties which could affect the safety and welfare of the new-born baby.

Consideration should be given to the following questions.

• Is the mother making adequate preparations for the baby's arrival? Is there sufficient material provision?
• What help may the mother need to provide good basic care?
• Is the environment into which the child will be discharged safe for a new-born baby? A chaotic, dirty or impoverished environment may not provide basic requirements for hygiene, stimulation or safety.
• Is there evidence of adequate support for the mother and child? Is the father supportive? Are extended family members available to help?
• Is there any evidence of domestic abuse?

If staff are worried that preparations for or the care of the new-born baby may be inadequate, or that other problems may pose risks, they should ask the local authority social work service to arrange a pre-birth case conference. This should include representation from ante-natal services, any alcohol or drugs-related services working with the pregnant woman, the social work service and the primary care team, such as the health visitor or GP, and the mother. This conference should consider whether an inter-agency child protection plan may be needed, and whether the child's name should be placed on the local Child Protection Register when s/he is born.

To enable effective breast-feeding and the development of appropriate attachment, babies should be cared for by their parents wherever possible. Unnecessarily prolonged hospitalisation or placement away from the parents should be avoided. Withdrawal symptoms at birth in a baby subject to foetal addiction may make the baby more difficult to care for in the post-natal period. If the baby experiences withdrawal symptoms or has other health problems, maternity services should provide full information about the child's care, progress and any prognosis to the parent(s) with sensitivity.

Vulnerable Infants Project (VIP)

The VIP was established in 2001 with short-term Scottish Executive Innovation Funding to meet the needs of pregnant women with social problems including addiction issues. The joint midwifery/social work service provides liaison between maternity, paediatric, primary care, social and addiction services. Women can be referred antenatally with more intensive input post delivery. The VIP provides vulnerable women with education, care and support for health and social child care issues and promotes good parenting. The main objective of the service is providing support when the woman and baby have been discharged home. The project is based in the Princess Royal Maternity Hospital. The project is led by a Clinical Midwife Specialist with two additional midwives, two social work services project workers and a pool of social work services sessional staff. Support is available up to 12 weeks postnatally.

In 2001/2002 the VIP worked with 85 women and 88 babies. 79% of women were aged between 21 and 35 years. 65% were referred following concerns around addiction issues. 92% had allocated social workers with 56% having allocated addiction workers, 54% had both. 7 out of 85 women had no contact with social work services including addiction services. 61% of women had VIP antenatal clinic contact. Of the 88 babies, 56% required admission at birth or during the post-natal period to the Neonatal Unit. 51 babies developed signs of withdrawals, with 30 requiring treatment. On discharge, 41 babies went home with both parents and 36 babies went home with mum only. 8 babies were accommodated by the local authority. 74 women received postnatal visits and support from VIP. It is hoped this services will be continued.

Good practice in maternity care

A Framework for Maternity Services in Scotland³⁶ sets out broad principles underpinning good practice in maternity care, recommending that:

• the woman should be the focus of maternity care, should be empowered and able to make informed decisions about her care
• staff should recognise and support the role of fathers and/or partners throughout pregnancy and childbirth
• maternity services must be readily and easily accessible to all, sensitive to the needs of the local population and primarily community-based, with good continuity of care
• women should be involved in the planning of maternity services
• a multi-disciplinary approach is essential in the management of pregnant alcohol or drug-using women.

These principles are being incorporated into maternity care throughout the country. Services may need to be modified for those with special needs or problems which may affect their pregnancy. Substance misuse is one such problem. The related medical and social problems increase the likelihood that drug-using women will have a high-risk pregnancy, which may restrict their choice of maternity care. Such pregnancies require multi-disciplinary assessment and care planning. With these provisos, women who use alcohol or drugs problematically should have access to the same range and quality of services as other women throughout their pregnancy and childbirth. Much maternity care will be delivered by the midwife and should be based in a health care setting, as far as possible in the community, and with input from other agencies as necessary. However, an obstetrician should supervise pregnancies considered medium or high risk.