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Substance Misuse in Pregnancy



Contents

  1. Introduction
  2. What are the Risks?
  3. Initial Response
  4. Communication and Confidentiality
  5. Early Identification of Vulnerability
  6. Taking Fathers into Account
  7. Targeted Early Help and Support
  8. Multi Agency (SUAT) Meetings
  9. Non-Attendance for Antenatal Care
  10. Where there are Child Protection Concerns
  11. Record Keeping
  12. Safer Sleeping Advice

    Appendix 1: Known Risks of Specific Substances


1. Introduction

This guidance is for all professionals who may come into contact with parents who are expecting a child and are using substances aims to provide information and good practice advice with regard to substance use during pregnancy.

Maternal substance misuse in pregnancy can have serious effects on the health and development of the child both before and after birth. It needs to be recognised by all practitioners that the effective treatment of the parent can and does have major benefits for the child at any stage of development.

Substance misuse (alcohol and/or drugs) can be defined as the regular use of recreational drugs, misuse of over-the-counter medication, misuse of prescription medications, misuse of alcohol or misuse of volatile substances (such as solvents or inhalants) to an extent whereby physical dependence or harm is a risk to the woman and/or her unborn baby.

Many factors affect pregnancy outcomes, including poverty, poor housing, poor maternal health and nutrition, domestic abuse and mental health. Assessing the impact of parental substance misuse must take account of these other factors.

The effect of maternal mental health also needs to be considered especially when there are other risk factors such as domestic abuse.

Pregnant women (and their partners) must be encouraged to seek early ante natal care and treatment to minimise the risks to themselves and their unborn child.

Although much of this guidance is focussed on maternal substance use in pregnancy, consideration must be taken of the support needs and impact of the substance use of the partner / father and wider family.

For information about the impact of parental substance use post birth please see Children of Parents or Carers who Misuse Substances Safeguarding Practice Guidance.


2. What are the Risks?

The effect of drinking or drug use on the developing foetus is dependent on 3 inter related factors: the pharmacological make up of the drug, the gestation of the pregnancy and the route/amount/duration of the drug use. Gauging the impact of maternal drug use on the unborn child is further complicated when mothers take a combination of substances.

Women living in disadvantaged or minority groups and communities are less likely to access services early or maintain contact throughout their pregnancies. They are also less likely to breastfeed. In consequence, the outcomes for their own and their baby’s health and well being are worse than for the population as a whole. It is important that services are designed to meet their needs.

Structural damage of the foetus is most likely during 4 – 12 weeks of gestation; drugs taken later can affect growth or cause intoxication or abstinence syndromes. Some of the problems associated with maternal problem drug misuse can be ameliorated by good ante natal care.

For pregnant drug users in general, irrespective of the substance used, especially where poor social conditions prevail, there is an increased risk of low birth weight, premature delivery, peri-natal mortality and cot death.

Unfortunately, some pregnant problem drug users do not seek ante-natal care, either because the drugs affect menstruation and leave women uncertain of dates, or because they fear that revealing their drug use to health professionals will result in judgemental attitudes, the involvement of children’s social care services and the possible loss of the baby once it is born.

While there is general agreement that substance use while pregnant can increase the risk of impairment to the unborn child’s development, it is also probable that most women who misuse drugs will give birth to healthy children who suffer from no long term effects.

For more information about the known risks of specific substances please see Appendix 1: Known Risks of Specific Substances.


3. Initial Response

Every opportunity should be taken to provide the woman and her partner or other relevant family members with the information and support they need.

At the initial contact with any professional if the woman does not have a booking appointment arranged:

  • Discuss the need for and importance of antenatal care;
  • If she wishes to continue the pregnancy offer a booking appointment in the first trimester, ideally before 10 weeks, or if she is considering termination offer referral to Sexual Health Services.

It is recommended in the National institute for Clinical Excellence (NICE) Ante-natal Care Guidelines that women have access to maternity services at 8 – 10 weeks of pregnancy to give them time to plan their pregnancy effectively and consider early screening options. All professionals who become aware that a women is pregnant and may be experiencing problems with substance misuse must encourage contact with direct access midwifery services as early as possible.

Approachable and supportive ante-natal services in convenient and accessible settings encourage and enable women to engage with maternity services early in their pregnancy and maintain contact throughout the pregnancy, the birth and the early post-birth period.


4. Communication and Confidentiality

Respect the woman’s right to confidentiality and sensitively discuss her fears in a non-judgemental manner. Tell her why and when information may need to be shared with other agencies and how this will be shared. For more information about good practice with regard to information sharing see Effective Communication, Consent and Information Sharing Procedure.

At the First Contact with Midwifery Services, each woman should be provided with a one to one consultation, where possible without partners, family members or legal guardians present, on at least one occasion.


5. Early Identification of Vulnerability

Any system of early identification has to be able to:

  • Identify risk factors that make some children more likely to experience poorer outcomes;
  • Include protective factors as well as risks;
  • Be acceptable to both parents;
  • Promote engagement in services and be none stigmatising;
  • Be linked to effective interventions;
  • Capture the changes that take place in the lives of children and families; and
  • Identify safeguarding risks for the child.


6. Taking Fathers into Account

Planning and delivery of health and social care during pregnancy should focus on the needs and safety of the woman and baby. However, a wider supportive family-centred approach will encourage the best possible outcomes. It is particularly important to engage fathers in the assessment and care process:

  • Include an assessment of the father’s needs as well as the mother, as these will have a direct impact on both the mother and child;
  • Include an assessment of the fathers health behaviours (e.g. diet, smoking, drug or alcohol use), asking him directly wherever possible. These behaviours have a direct impact on both the mother and the child, and specifically on the mothers own health behaviours;
  • Refer fathers to all the relevant services.


7. Targeted Early Help and Support

Some women, particularly those from more vulnerable and disadvantaged groups, may require more support and access to a range of services, e.g. Children’s Centres, housing, advice on benefits, relationship support.

A system of clear referral pathways should be locally established so that pregnant women who require additional support are managed and treated by the appropriate specialist teams when problems are identified.

Agreed protocols between agencies help to ensure that partners share accountability for improving the outcomes of families at risk. These can clarify professional roles and responsibilities when working with multiple agencies and give professionals the confidence to work together around the needs of families at risk.

(Think Family: Improving the life chances of families at risk – Social Exclusion Task Force (2008), Archived).


8. Multi Agency (SUAT) Meetings

The Substance Use Assessment Tool (SUAT) is a framework to help co-ordinate the support needs of pregnant women who have been identified as vulnerable as a result of substance use. It is the responsibility of all professionals involved in the care of the pregnant woman to provide information to the SUAT to be able to assess the level of concern / risk regarding the safety and protection of the unborn baby.

In order that this information is brought together regular multi agency planning meetings will be held to review the management of individual cases through this process. Meetings will include, as a minimum, the involvement of Substance Misuse Services, Midwifery and Children’s Social Care.

N.B. Consent should always be obtained before a woman’s details are brought to the SUAT meeting.

Key Points

  • There should be a co-ordinated care plan;
  • Progress should be tracked through the relevant agencies involved in care;
  • Offer women information about the services provided by other agencies;
  • Jointly develop care plans across agencies;
  • Offer women a named midwife or doctor who has specialist knowledge of and experience of working with women who use substances;
  • Provide a direct line telephone number for this; and
  • Ensure that hand held maternity notes contain a full record of care received and the results of all ante natal tests.


9. Non-Attendance for Antenatal Care

Evidence has shown that the provision of antenatal care can greatly improve outcomes for both mother and baby, especially in high risk cases.

It is essential that there are robust mechanisms for capturing women who miss their appointments:

  • One missed appointment – Community Midwife will contact the woman directly by phone and arrange appointment for the following week or sooner if clinically indicated;
  • Two missed appointments – Community Midwife will contact directly and arrange appointment or home visit if required;
  • Three missed appointments – a letter is automatically generated, which is sent to the woman and her GP. The Consultant Obstetrician is informed. A referral is made to Children’s Social Care.


10. Where there are Child Protection Concerns

Where any professional has concerns that there may be risk to an unborn through maternal substance use they should make a referral to Children’s Social Care (see Contacts and Referrals with Children’s Social Care Procedure).

Three missed ante natal appointments will automatically generate a referral to Children’s Social Care – this would be in writing and the woman and her GP also informed.

Where a newly born child is found to need treatment to withdraw from substances at birth, an assessment and a pre-discharge discussion should take place and consideration should be given to making a referral to Children’s Social Care.

Parents/carers may not agree to information being shared, but this should not prevent communication with Children’s Social Care where child protection concerns persist. Reasons for dispensing with consent by the family should be clearly recorded (see Effective Communication, Consent and Information Sharing Procedure).

Any on-going assessment by the Midwife, Substance Misuse Agency or other involved service will contribute to any assessment undertaken by Children’s Social Care in line with the Children’s Social Care Assessment.

Where a Children’s Social Care Assessment under Section 47 of the Children Act 1989 gives rise to concerns that an unborn child is likely to suffer Significant Harm, Children’s Social Care may decide to convene an Initial Child Protection conference prior to the child’s birth. The involvement of midwifery services is vital in such cases. Such a conference will have the same status, and proceed in the same way, as other Initial Child Protection Conferences, including decisions about a Child Protection Plan.


11. Record Keeping

There should be clear and accurate records for each child to ensure that there is a documented account of an agency’s or professional’s involvement with the child and / or their family or caregiver. These records help with continuity when individual workers are unavailable or change and they provide an essential tool for managers to monitor work or for peer review.

Records relating to work with the child and their family should use clear, straightforward language, be concise and accurate, not only in fact, but also in differentiating between opinion, judgement and hypothesis.

Safeguarding and promoting the welfare of children requires information to be brought together from a number of sources and careful professional judgements to be made on the basis of this information.

(See Record Keeping Guidance for more information.)

Hand-held maternity notes should be up to date. Women in Hull always keep their handheld records until they go into hospital in labour. Hand-held maternity notes should contain a full record of care and the Results of all antenatal tests.


12. Safer Sleeping Advice

It is best practice that all those working with parents and cares are able to give advice and information about ‘Safer Sleeping’.

Key risk factors associated with co-sleeping include, if the parent or carer:

  • Is a smoker, even if they never smoke in bed or in the home;
  • Has been drinking alcohol;
  • Has taken medication or drugs that make them drowsy; or
  • Feels very tired.

Or if the baby:

  • Was low birth weight (less than 2.5kgs or 5 ½ lbs); or
  • Was premature (born before 37 weeks gestation).

N.B. Co-sleeping describes a baby sharing their parent’s bed, or sleeping with a parent on a sofa or chair. A parent represents anyone caring for the baby.

The Lullaby Trust advises that parents and carers should never sleep with a baby on a sofa or in an armchair, and they should be reminded that accidents can happen: parents might roll over in their sleep and suffocate their baby, or the baby could get caught between the wall and the bed, or could roll out of the bed and be injured.

Sudden infant death syndrome associated with co-sleeping is recognised as one of the risk factors that puts babies at increased risk of harm when there is parental substance misuse.

See also Safer Sleeping for Babies and Infants – Factsheet (Hull Safeguarding Children Board)

Further resources for safer sleeping information can be found on the Lullaby Trust website.


Appendix 1: Known Risks of Specific Substances

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.

Breast-feeding and methadone - Mothers who misuse substance 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.

Benzodiazepines

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 benzodiazepines should be offered a detailed scan at 18-20 weeks.

There is no reliable evidence that use of benzodiazepines 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 benzodiazepines 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.

(Taken from Good Practice Guidance for working with Children and Families affected by Substance Misuse Effective Interventions Unit Integrated Care Pathways Guide 8: Drug misuse in Pregnancy and Reproductive Health.)

Mephadrone (MCAT)

With a lack of available research about the impact of substances such a MCAT, (sometimes referred to as ‘legal highs’), the safest approach is to approximate using drugs with similar reported effects/profiles so using MDMA and crack as reasonable proxies, key risks concerns:

  • Significant hypertension during use, so if BP is already elevated during pregnancy this could be a significant cause of concern;
  • Significant basic instruction - concern that during use this vasoconstriction will reduce flow of oxygenated blood to foetus. With crack this has been associated with reduced brain development, limb development and possible death in uterus;
  • As with other stimulants premature birth, low birth weight;
  • Association with stimulant use and learning and concentration deficit in early years;
  • MCAT associated with serious depression/craving post heavy use so likely to be significant risk factor when PND is also an issue;
  • General diet issues as per other stimulants including anaemia, low levels of folic acid etc;
  • Risk of spasms convulsions during use bringing risk of miscarriage;
  • No reported physical withdrawal syndrome but use alongside benzodiazepines fairly common so need to screen for benzodiazepines dependency too.

Alcohol

Low levels of alcohol consumption during pregnancy may seem harmless. However a safe level of alcohol consumption during pregnancy has not been established (Gray and Henderson 2006, BMA, 2007). The Chief Medical Officer and NICE both advise pregnant women or women trying to conceive to avoid drinking alcohol, especially during the first 3 months of pregnancy as this is associated with an increased rate of miscarriage and is the key time for organ and nervous system development National Institute for Health and Clinical Excellence (2008).

Foetal Alcohol Spectrum Disorder / Foetal Alcohol Syndrome

The Foetus is completely unprotected from alcohol circulating in the blood system during pregnancy which can result in foetal damage. (BMA 2007)

Foetal Alcohol Spectrum Disorder (FASD) is an umbrella term for a set of disorders caused by the consumption of alcohol by a mother while pregnant (Mukherjee et al 2006). These include Foetal Alcohol Syndrome (FAS), Alcohol Related Neurodevelopmental Disorders (ARND), Alcohol related Birth Defects (ARBD) and Foetal Alcohol Effects (FAE).

The effects can be sever to mild, ranging from loss of IQ points, to Attention Deficit Disorder, to heart defects and death. Many children experience serious behaviour and social difficulties that last a lifetime. (NOFAS UK 2011)

Heavy drinking can cause FAS, whose features include growth deficiency for height and weight, a distinct pattern of facial features and physical characteristics and central nervous system dysfunction.

Many of the problems associated with problem alcohol use during pregnancy could be ameliorated to some extent by good ante-natal care. However, pregnant women with alcohol problems may not attend ante-natal care until late in pregnancy because they fear professionals will judge them.

N.B. NOFAS-UK (National Organisation for Foetal Alcohol Syndrome – UK) has produced a 20 minute educational film and is available on the website.

End.