Supporting pregnant women who use alcohol and other drugs

June 2015
Dr Courtney Breen, Research Fellow at NDARC
A recent project conducted through NDARC developed a best practice guide to assist primary care health professionals to identify, support and treat pregnant women who use substances. The project involved a review of effective treatment approaches and input from professionals with expertise regarding substance use in pregnancy.

Research staff: Courtney Breen, Emilie Awbery, Lucinda Burns

Interventions to reduce the risks of an alcohol or other drug exposed pregnancy can take place across the continuum from preconception, pregnancy and after birth. A framework to prevent exposed pregnancies and to minimise harm during pregnancy was developed to address risks across this continuum. The primary focus of the project was to identify strategies to identify and assist pregnant women who use or are dependent on alcohol or other drugs.  In addition to assisting already pregnant women it is important to highlight that unintended pregnancy is associated with increased risk of exposure to alcohol or other drugs due to later pregnancy recognition, later access to antenatal care and higher likelihood of risky consumption patterns [1, 2]. Many unintended pregnancies occur due to inconsistent contraceptive use and therefore all women of reproductive age who use alcohol and other drugs should be provided with information and advice about effective contraception.

Substance use during pregnancy can be associated with significant harm to mother and baby. Health care professionals can make a substantial difference to the health of women and their babies by identifying and supporting women who use substances during pregnancy. It is important to remember that pregnant women who use substances are women who are dealing with all the complexities of substance use who become pregnant. Pregnancy may be a window of opportunity to motivate change and improve outcomes with the appropriate support and treatment. There is substantial stigma associated with substance use in pregnancy and this is a barrier for women accessing support [3].

Evidence suggests access to early antenatal care and access to specialist alcohol and drug treatment improves outcomes  and therefore it is important to identify women that may need additional support as soon as possible [4].  Alcohol and drugs are used by women across the population, from a wide range of backgrounds and ages. A safe and non-judgemental approach is required to encourage disclosure and enable assistance with psychosocial and pharmacological treatment as required. Although evidence for universal screening is limited, guidelines recommend asking pregnant woman about their substance use within a discussion of their health [5]. Disclosure may occur as rapport is built and patterns of use may change over time, so it is important to continue to have this discussion throughout the pregnancy.

Moving beyond a focus on alcohol or drug use alone towards comprehensively addressing a range of factors improves outcomes [6] [7]. These include addressing early access to antenatal care, poor nutrition, mental health, domestic violence and unstable housing. Central to successful treatment responses are recognition of women’s experiences, including potential trauma, and provision of a compassionate model of care [8].  

Best practice support of pregnant women who use substances:

  • Routinely ask women about their alcohol and other drug use throughout the pregnancy.
  • Avoid stigma and judgement. Engaging women in treatment requires sensitivity and provision of a culturally safe and accessible service.
  • Identify high-risk cases early and refer for specialist antenatal care and treatment, or consultation.
  • Address the range of needs including psychosocial factors, health and mental health issues and practical realities. 
  • Maintain up-to-date knowledge of treatment interventions.
  • Identify referral pathways to specialist antenatal services, consultation and community organisations.
  • Identify a case coordinator to coordinate a multidisciplinary or interagency team.
  • Organise paediatric assessment, assertive follow-up and support for mother and baby post birth.
  • Provide contraception and information to prevent future unintended pregnancy.

Women may require psychosocial and/or pharmacological treatment depending on their individual needs. The type of treatment required varies by drug type. Clinical information by drug type is available from recently updated NSW Clinical Guidelines for the Management of Substance Use during Pregnancy, Birth and the Postnatal Period [9]. 

Pharmacological treatment 

There is a lack of high quality research into pharmacological interventions with pregnant women who use alcohol and other drugs [10, 11]. Due to this lack of rigorous research, the safety and efficacy of many treatments that are available to the general population are not known for pregnant women.

Alcohol
The need for withdrawal management for alcohol may be an indication for inpatient admission and treatment. Pregnant women who are withdrawing from alcohol need to be monitored by appropriate health professionals and supported with medication (such as benzodiazepines), nutritional and vitamin supplementation. They should be provided with access to appropriate maternal and fetal monitoring [9, 11].

Benzodiazepines
Ideally benzodiazepines should be avoided in pregnancy but they may be used in the short term for the treatment of alcohol withdrawal or anxiety while awaiting onset of a safer drug. Long acting benzodiazepines should be avoided in pregnancy if possible.

Tobacco
Nicotine Replacement Therapy should be considered when a pregnant woman is otherwise unable to quit, and when the likelihood and benefits of cessation outweigh the risks of NRT and potential continued smoking. It is recommended that pregnant women who smoke use intermittent (gum, lozenge, inhaler, tablet) rather than continuous (patches) NRT preparations and use the lowest dose possible. NRT should be used in consultation with a health professional [9].

Opioids
Withdrawal from opioids is not routinely encouraged in pregnancy. Opioid Treatment Programs (methadone or buprenorphine maintenance) are recommended to stabilise and maintain opioid dependent pregnant women. Methadone and buprenorphine maintenance have been shown to reduce maternal illicit opiate use and fetal exposure, enhances compliance with obstetric care and are associated with improved neonatal outcomes such as increased birth weight [12-15]

Cannabis, Cocaine and Amphetamine Type Stimulants
There are no recommended pharmacological treatments for cannabis, cocaine, amphetamine type stimulant use in pregnancy.

Psychosocial interventions

There is a lack of high-quality research into psychosocial interventions with pregnant women who use alcohol and other drugs.

Treatment should be trauma informed. Pregnant women with substance use disorders are a vulnerable population and many women may have a history of trauma.

Cognitive Behavioural Therapy may assist with identifying and challenging dysfunctional thoughts and developing better coping strategies around substance use.

There is some evidence for Motivational Interviewing reducing alcohol use in pregnant women.

Developing relapse prevention skills may be particularly important for use in the postpartum period.

There is some evidence for the use of contingency management in contributing to retention in treatment and reduction of drug use.

Best practice approach

It is time and resource-intensive to support pregnant women with problematic alcohol or drug use, however health professionals can make a substantial difference to the outcomes of women and their babies. The project resource developed provides components of best practice information on how individual health professionals can support pregnant women, including addressing stigma and practical barriers. The resource describes important skills individuals should have or acquire, steps to take and directs health professionals to existing resources.

Skills which can support women’s engagement in care include:

  • Understanding that alcohol or drug dependence is a health care issue and refraining from moral judgements.
  • Being aware that alcohol and other drug use occurs in context of other health, family, cultural and psychosocial factors.
  • Acknowledging that disclosing alcohol and other drug use during pregnancy can be difficult.
  • Reflecting on one’s personal values.
  • Building a trusting relationship over time.
  • Acknowledging women’s experiences and feelings.
  • Creating a safe, private and confidential environment.
  • Providing a culturally safe environment.
  • Understanding and addressing barriers to women accepting care.
  • Being committed to providing optimum care.

Practical barriers to providing care need to be addressed and some strategies to overcome these include;

  • Booking longer appointments or flexibility with appointment times.
  • Anticipate missed appointments and follow up appropriately.
  • Be opportunistic and arrange appointments with multiple disciplines for the same visit.
  • Refer for a range of services to address practical issues such as transport, or be prepared to see women in range of community settings.

In addition the guide provides suggestions for service providers such as documenting information on local resources, referral pathways and to consider auditing the use of resources and clinical guidelines and putting quality improvement processes in place. Clarification of pathways between services and disciplines may be useful. An Australian study evaluated the implementation of a clinical pathway which aimed to improve outcomes for infants in families affected by alcohol or other drug use [16]. The pathway was multidisciplinary, with shared responsibilities and clearly articulated roles and responsibilities. Interventions focused on harm minimisation for substance use, parent-infant relationship, community support, mental health, wellbeing and stress management. The pathway appeared to facilitate a better therapeutic alliance between staff and families, improved engagement of women who were more likely to have an assessment, discuss substance use and have a safety plan regarding domestic violence. The intervention group remained engaged with the service longer than the control group [16]. 

Strategies to address organisational issues include [16-20]:

  • Promoting education and training opportunities and educational resources
  • Providing comfortable, private and safe facilities
  • Sharing information about resources for screening, brief intervention, referral and management strategies. 
  • Sharing information among clinicians about referral pathways to specialist antenatal services and local drug and alcohol treatment services. 
  • Developing relationships with specialist antenatal clinics, drug and alcohol treatment services and other local community agencies to foster referrals, case involvement and multidisciplinary care.
  • Co-location of services
  • Mapping clinical or referral pathways to services and making this information available within the organisation or practice 
  • Protocols to ensure that first antenatal presentation maximises engagement of women in care and includes assessment and referral for treatment
  • Practice evaluation, audit of the use of clinical guidelines and implementation of quality improvement processes.

To ensure women get the appropriate support ongoing training of health professionals is required. There is lack of information and evaluation of the impact of education on practice. There is limited evaluation research of programs that treat pregnant women that use substances in Australia. Despite the availability of guidelines on screening and intervention for substance use in pregnancy, there is limited information on current practice or the extent to which guidelines are disseminated and implemented. Often funding is provided in stages and resource development occurs but the evaluation to determine the extent to which the guidelines and resources are used and their impact is not undertaken. This is an area that requires further attention to ensure that resources are being used effectively and women who use substances are supported throughout their pregnancy and beyond.

The project resources include:

  • a fully referenced report,
  • a practical guide for health professionals that contains information and links for resources including specialist antenatal clinics, guidelines, screening , assessment and intervention tools, domestic violence and contraception advice, Indigenous and youth specific resources.
  • and a two page reference sheet

The project resources are available at https://ndarc.med.unsw.edu.au/resources.

Acknowledgments

Consultation network: The members of the consultation network, a range of professionals with interest and expertise in substance use in pregnancy, for their valuable input. They provided information on services available in their state, clinical practice in the identification and treatment of pregnant women who use substances, and workforce development needs. They gave input into the development of the resource, including its content, formatting and dissemination strategies.

Funding:  The National Drug and Alcohol Research Centre, UNSW Australia, received funding for the Substance Misuse in Pregnancy Resource Development Project from the Australian Government

References

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