GETTING OUR PRIORITIES RIGHT (GOPR)

Appendix 4

Pre-birth

Pre-birth in this context includes not only pregnancy but also family planning and reproductive health services. Adults using alcohol and/or drugs problem should be encouraged to think about family planning to assist them in making choices about contraception and avoiding an ill-timed pregnancy. Having a baby is a momentous time in a person's life and adults with problem alcohol/drug use should be supported in making choices in this respect that reflect their needs and circumstances and those of any potential baby.

Pregnancy is a crucial time for a woman who is using alcohol/drugs and her child. Alcohol or drug use can harm a fetus yet pregnancy can act as a strong incentive to make a positive change to substance using behaviour.

It is best to avoid alcohol completely during pregnancy as any alcohol you drink while pregnant will reach your baby and may cause harm. Women who are trying to conceive should also avoid drinking alcohol. There is no 'safe' time for drinking alcohol during your pregnancy and there is no 'safe' amount. We do know that the risk of damage increases the more you drink. Drinking no alcohol during your pregnancy is the best and safest choice.

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 contraction of the uterine muscle with miscarriage or preterm labour or to spasm of the placental blood vessels, 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 preterm delivery. Birth weight is an important factor in long term health but while methadone may have a small negative effect on birth weight this effect is much less than with other commonly used opiates. Methadone also causes neonatal withdrawal symptoms but there is no evidence these have a long term effect on the health of the baby. Effective opiate substitution therapy improves pregnancy outcome both directly (by reducing the risk of preterm labour and low birth weight) and indirectly by stabilising lifestyle, facilitating access to services and improving general health. As with other opiates, benzodiazepines, tobacco and alcohol (and poor housing as well as other poverty related factors) methadone is associated with an increased risk of cot death but due to the overall health and social benefits the risk from methadone use will be lower than that due to use of other opiates

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. However detoxification should always be the aim with brief (1 week) reducing cover by prescribed benzodiazepines to prevent maternal convulsions. Evidence suggests there is a slightly increased risk of cleft palate, but the absolute risk remains low and is not obstetrically significant.

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 consequently 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, and is often associated with longer term behavioural problems. It is not clear to what extent this is due directly to benzodiazepine use per se rather than to impaired parenting secondary to maternal 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 problem 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. Withdrawal symptoms due to tobacco are not sufficiently severe to require pharmacological treatment.

Alcohol

Fetal Alcohol Syndrome (FAS) is a lifelong medical condition that affects unborn babies caused by drinking alcohol during pregnancy. Individuals with FAS may have brain damage, may be small in size and have facial deformities. However it is important to note that alcohol per se does not increase the risk of prematurity although social problems associated with heavy alcohol use may do so.

Fetal Alcohol Spectrum Disorder (FASD) Fetal Alcohol Spectrum Disorder describes the range of effects associated with a baby exposed to alcohol in the womb. Some of these effects can cause lifelong mental, physical and behavioural problems. Because FASD can resemble other conditions, it is difficult to diagnose. Therefore the number of children in the UK with FASD is not accurately known.

Breast-feeding

Mothers who use drugs 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 breastfeeding is in itself a marker of adequate stability of drug use.

Assessing Pregnant Women With Problem Alcohol And/Or Drug Use

Most drug-using women are of child-bearing age. Problem alcohol and/or drug use 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. Alcohol and/or drug use during pregnancy increases the risk of:

• having a premature or low weight baby through social problems often associated with heavy drinking;
• 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; and
• pregnant women drinking to excess risk delivering babies with Foetal Alcohol Syndrome.

Some pregnant women who use alcohol and/or drugs typically do not seek ante-natal services until late in pregnancy or when in labour. 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. Women who are not pregnant but keen to become pregnant should in the first instance be encouraged to commence or continue LARC until their health and social circumstances have been fully assessed and optimised. For women who do not want to become pregnant provision of contraceptive follow up should be arranged. For all women family planning care should be provided in tandem with sexual health care including cervical cytology and screening for genital tract infections.

Pregnant women should be encouraged to register with a GP and seek maternity care. Access to maternity care in Scotland is via the GP. In exceptional cases where women are not registered with a GP options for accessing maternity care will vary geographically. Such women may be able to use a community midwife as a conduit into appropriate specialist care but the quickest and most effective route would be direct referral to the maternity hospital by any agency already in contact with the woman. …..specialist services for pregnant alcohol / drug using women and where these exist primary care teams and / or the referring agency should refer women directly to these as a matter of urgency.

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 alcohol and drug 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. 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 well-being of the new-born baby. In the multi agency assessment 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?

Where there are concerns about actual or potential significant harm to the unborn child, pre-birth child protection case conference should be held. The purpose of a pre-birth CPCC is to decide whether serious professional concerns exist about the likelihood of harm through abuse or neglect of an unborn child when they are born. The participants need to prepare an inter-agency plan in advance of the child's birth.

They will also need to consider actions that may be required at birth, including:

• whether it is safe for the child to go home at birth;
• whether there is a need to apply for a Child Protection Order at birth;
• whether the child's name should be placed on the Child Protection Register. It should be noted that as the Register is not regulated by statute, an unborn child can be placed on the Register. Where an unborn child is felt to require a Child Protection Plan, their name should be placed on the Register; and
• whether there should be a discharge meeting in the handover to community- based supports.

To enable effective breast-feeding and the development of appropriate attachment, babies should be cared for by their parents wherever possible. Unnecessarily prolonged 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, hospital and community services should recognise the need for increased support for the mothers and should provide full information about the child's care, progress and any prognosis to the parent(s) with sensitivity.