Care for Substance Dependent Pregnant Women

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Care for Substance Dependent Pregnant Women
Parents of Neonates

• The Womens Alcohol Drug Service, The Royal
  Womens Hospital

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Pregnant substance using women

• Pregnancy at high risk of complications
• High risk environment
• Range of additional psychosocial stressors
• Increased likelihood of child abuse neglect

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Profile of WADS clients

• Age 18-44
• Self referral, AOD treatment
• Aboriginal 6
• North West metro, southern
• Not married
• Previous children

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Profile of the women

• Multiple drug use
• IV drug related issues Hepatitis, HIV
• Poor diet
• Poor oral health
• Financial disadvantage
• Housing instability
• Homelessness

• Past/ present violence
• Sexual assault
• Relationship issues
• Sole parenting
• Negative childhood experiences
• Subordinate position
• Legal issues

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Housing 05/06WADS Clients

• At time of initial assessment 33 homeless
• 56 remained in same postcode
• 44 moved postcode
• 34 moved region

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Mental health issues

• Dual diagnosis
• Depression/ anxiety
• Self-mutilation
• Suicide attempts
• Low self esteem
• Eating disorders
• Psychological distress
• Self medication

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Vulnerable women

• Drug saturated social environment
• Clients of child protection systems
• Perpetrators or victims of crime
• Educational disadvantage
• Poor employment opportunities
• Intergenerational substance use
• Separation from own family
• Inaccessible service systems

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Prevalence

• Prevalence of DA use in pregnancy unknown in
  Australia
• No reliable system of recording/data collection
  Privacy/ confidentiality issues
• Private obstetric care not included
• Undisclosed DA use

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Primary Drug use 05/06WADS clients

• Heroin
• Methadone
• Cannabis
• Alcohol
• Buprenorphine
• Amphetamines
• Benzodiazepines

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Sequelae of DA use in pregnancy

• Medical and social support availability
• Increased risk of SIDS
• Poor obstetric, fetal and neonatal outcomes
• Economic social cost
• Difficulties with mother-infant attachment
• Child behavioral developmental issues
• Parental coping ability

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Role of pregnancy care

• Established association between pregnancy care
  and improved birth outcomes
• Maternal neonatal outcomes compare favourably
  with non-exposed infants when specialist DA
  obstetric services provided
• Care based on principles of harm minimization

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window of opportunity

• Pregnancy is a time when substance using women
  become visible to service providers
• Imperative to engage women as early as possible
  in pregnancy care

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Early engagement

• All pregnant women screened for DA use
• Pregnancy advice and genetic counseling
• Options for care discussed with women
• Assessment of needs early and ongoing
• Pregnancy care discharge planning

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Early engagement

• Referrals for mental health issues
• Referrals for partner DA, mental health
  counseling
• Start to address DA and lifestyle issues
• Initiate pharmacotherapy
• Relapse prevention
• Limit reliance on advice from informal networks

15
Late initiation for care

• Substance using women are typically low users of
  obstetric services
• Many present at a late stage in pregnancy
• Unaware of pregnancy due to menstrual
  irregularity
• Pregnancy unplanned
• Ambivalence toward pregnancy
• Interventions often crisis driven

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Barriers to disclosure engaging in care

• Guilt and shame
• Past negative experiences
• Access issues
• Unsuitable appointment times
• Discouraging information from drug-using networks
• Mobile lifestyle

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Research 2005- Womens Voices

• Fear of child protection
• Fear of judgmental attitudes of health
  professionals
• Lack of stable housing
• Unaware of pregnancy
• Lost opportunity or lifeline?, MC Tobin

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Range of needs

• Not all substance using pregnant woman have
  complex DA and psychosocial needs.
• Provide less intensive pregnancy care
• Some are stable on pharmacotherapy, do not
  present as such high risk, however their DA
  status requires review throughout pregnancy and
  in the vulnerable early parenting period.

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Appropriate client information

• Additional to childbirth education and parenting
  information, women need to be prepared for
• longer postnatal hospital stays
• pharmacotherapy management
• infant withdrawal assessment and management
• breastfeeding safe infant sleeping

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Child protection issues

• Who is the client? Woman or fetus/baby
• Fear of CP a deterrent to attending for care
• Challenge of mandatory reporting vs therapeutic
  relationship
• CP involvement seen as punitive
• May also see ChildFIRST as CP
• Pre birth reporting

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Community referrals

• Communication gaps between pregnancy and
  community providers identified in infant death
  reviews
• Develop verbal and written communication
  processes
• Resource providers with contact details inc.
  phone numbers for feedback/emergencies

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Issues for providers

• Multidisciplinary care
• Non compliance with care referrals
• Capacity to provide assertive outreach
• Time required for communications
• Limited support services
• Workforce development issues
• Clients as patients in a maternity hospital
  setting

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Issues for women

• Access to specialist services, obstetric and DA
• Access to pharmacotherapy
• Fear of disclosure/stigma
• Guilt, especially if baby withdraws
• Attitudes of providers

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Issues for women

• Child protection issues
• Economic and lifestyle cost of pharmacotherapy
• Short term nature of many support services
• Multiple providers involved in care
• Special needs of indigenous women