Appendix 5 - Pre-Birth
Pre-birth in this context includes not only pregnancy but also sexual and reproductive health and planning of pregnancies. Adults using alcohol and/or drugs should be encouraged to think about their plans to have children and to make choices about contraception and avoiding an ill-timed pregnancy. Having a baby is a momentous time in a person's life and adults using alcohol and/or drugs should be supported to make such plans to ensure the best possible medical and social outcomes.
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.
There are conflicting data on safe levels of alcohol consumption (if any) during pregnancy. While total abstinence is safe and heavy and/or binge drinking is hazardous the aim in this context is to help women identify clearly hazardous levels of consumption and to support women to reduce their intake as much as realistically possible.
Effects of drug use on pregnancy
While use of alcohol and drugs occurs throughout the social spectrum the use that is associated with significant ill health in mothers and babies is closely associated with poverty and inequality. Poverty increases the risk of maternal death 20 fold and as well as increasing the risk of stillbirth or subsequent death of the child at all ages, is associated with other risks including increased risks of premature birth, low birth weight, and Sudden Unexplained Infant Death ( SUIDS or cot death). These effects are increased by factors such as poor housing and stress as well as by lifestyles, in particular cigarette smoking. Use of alcohol and other drugs exacerbates these effects. It must be emphasised that ill health in the baby of a woman who uses alcohol or other drugs is not a direct consequence of her use (and certainly cannot be interpreted as a measure of the severity of her drug use). Instead it is important to recognise that care of sick babies is more demanding so women who use alcohol or other drugs will need a lot of support in caring for their babies.
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 pre-term 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 pre-term 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 pre-term 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 as discussed above) 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.
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 benzodiazepines 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 benzodiazepines 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. It is associated with an increased risk of SUIDS.
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 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 fetal death in utero. Adverse outcomes are more commonly associated with heavy and /or injecting use, although any level of use can harm the baby. Cocaine use during pregnancy does not cause withdrawal symptoms in the new-born baby.
Cannabis is frequently used together with tobacco, which may cause a reduction in birth weight and increases the risk of SUIDS. There is no scientifically robust evidence of other direct effects on pregnancy outcome.
Maternal use of tobacco can have significant direct harmful effects on pregnancy. Tobacco causes a reduction in birth weight greater than that from heroin, increases the risk of premature birth and is a major risk factor for cot deaths. Babies of women who smoke heavily during pregnancy may also exhibit signs of withdrawal, with 'jitteriness' in the neonatal period but withdrawal symptoms due to tobacco are not sufficiently severe to require pharmacological treatment.
Maternal consumption of alcohol during pregnancy can have a range of harmful effects on the fetus. At the most severe extreme is the constellation of effects (abnormalities of facial bones, reduced head size, reduced birth weight and various behavioural problems and learning disabilities) called Fetal Alcohol Syndrome ( FAS). More commonly however babies exhibit a less severe spectrum of problems known as Fetal Alcohol Spectrum Disorder. Low birth weight is a common outcome but maternal alcohol consumption per se does not increase the risk of premature delivery although it does increase the risk of SUIDS. There are conflicting data on the relationship between level of maternal consumption and outcome but the most severe outcomes are associated with heavy and/or binge drinking throughout pregnancy. Many women recreationally consume alcohol above recommended levels until their pregnancy is confirmed but most thereafter abstain from alcohol or very significantly reduce their consumption. This guidance is aimed at women who continue to drink well above safe levels throughout pregnancy and who need specialist support to address their use of alcohol. In this context abstinence may often be an unrealistic objective and the aim should be to engage with such women in supportive services and to recognise that any level of reduced consumption and stability of lifestyle will be of benefit for the health of both mother and baby.
Mothers who use drugs including those who are prescribed methadone or subutex should be encouraged to breastfeed 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 problematic alcohol and/or drug use
Most drug-using women are of child-bearing age. Problematic 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 birth through social problems and lifestyles associated with use of alcohol or drugs, as a direct consequence of smoking or, to a lesser degree, as a direct consequence of using heroin (but not as a direct consequence of drinking alcohol);
- having a low birth weight baby through social problems and lifestyles associated with use of alcohol or drugs as a direct consequence of smoking or, to a lesser degree, as a direct consequence of using heroin or alcohol;
- the baby suffering symptoms of withdrawal from drugs used by mother during pregnancy including opiates, benzodiazepines, nicotine and alcohol although only those due to opiates or benzodiazepines may need pharmacological treatment;
- the death of the baby before or shortly after birth;
- Sudden Unexplained Infant Death Syndrome;
- physical harm to the baby before birth if the mother is subjected to physical violence; and
- the baby exhibiting long term developmental and behavioural abnormalities due to a combination of health and social problems including heavy maternal consumption of alcohol during pregnancy.
Some pregnant women who use alcohol and/or drugs do not seek antenatal care until late in pregnancy or when in labour. Their alcohol or drug use 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 antenatal 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 contraception and follow up should be arranged. For all women contraception and information/advice on reproductive choices and planning of pregnancies 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 antenatal 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. Antenatal 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. Antenatal 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 postnatal care should be aware of the potential difficulties which could affect the safety and wellbeing 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 ( CPCC) 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 breastfeeding 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 fetal addiction may make the baby more difficult to care for in the postnatal 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.