Lynda Winn, RGN, MSc, Advanced Diploma Applied Group Analytic Skills. Marian de Ruiter, MB, BS, MRCPsych, consultant psychiatrist, Windmill Drug and Alcohol Team, Surrey and Borders NHS Trust...
Abstract: Winn, L., de Ruiter, M. (2006) Evaluation of a pregnancy liaison service www.nursingtimes.net
This paper discusses the development and review of a pregnancy liaison service within a community drug and alcohol team over a four-year period. This is a small-scale study considering treatment for pregnant drug-using women and has been used to make appropriate changes in the care of this marginalised client group and their babies. The working practice of the multi-agency approach that the team uses continues to evolve.
The Windmill Drug and Alcohol Team is a multidisciplinary team providing a service to a population of 320,000 in north-west Surrey. The team is a statutory treatment service providing tier 3 and 4a interventions. It provides a wide range of services to clients requiring specialist interventions for drug and alcohol dependency. The team supplies both community and inpatient services - with a 10-bed unit - as well as liaison between the local psychiatric unit and general hospital.
The pregnancy liaison service was developed in January 2000 after a couple were referred to the team from a prescribing agency very late into the pregnancy. The baby was born at St Peter's Hospital, Chertsey, and was cared for in the neonatal intensive care unit (NICU).
The NICU has the capacity to care for 18 babies requiring differing levels of care. This case highlighted the necessity for an effective multi-agency approach to the needs of pregnant drug-using women.
The Windmill Drug and Alcohol Team developed a protocol for inter-agency working as a result of identifying the need to work with this population of clients, whose requirements for treatment are distinct during pregnancy. Attitudes towards pregnant drug-using women are often negative. This may deter them from coming forward and disclosing the pregnancy (Murphy, 1999).
Many factors contribute to non-disclosure, including judgemental attitudes, fear of stigma, breach of confidentiality (Plambeck, 2002) as well as fear of social service involvement - ranging from child protection proceedings to removal at birth.
Development of the Windmill Drug and Alcohol Team's pregnancy liaison service was informed by similar services across the country. The service was formulated according to the evidence base, local need and recognition that 'effective comprehensive care of drug addicted women has been shown to improve maternal and neonatal outcomes' (Jansson et al, 1996).
Between January 2000 and December 2004 there have been 40 pregnancies with various outcomes that will be discussed in this paper.
Data was collected from clients' clinical case notes using a pro-forma questionnaire. Statistical information was analysed using SPSS (Statistical Package for Social Sciences) - a Windows-based statistics package.
The data is discussed qualitatively in terms of the experience of working with the client group objectively and subjectively. In order to maintain client confidentiality, identifiable information will not be disclosed or discussed.
An extensive literature search into the area under discussion was carried out. There are many papers written covering themes including service development and management models (Hepburn, 2002; Wilbourne et al, 2001; Clarke and Formby, 2000; Daley et al, 1998; Lieberman, 1998; McGee, 1997; Jansson et al, 1996; Siney, 1995a; Thorp, 1995; Dawe et al, 1992).
Articles discussing medication options during pregnancy vary from methadone and buprenorphine (Subutex) treatment, detoxification and maintenance, as well as the effects on the neonate from opiates, cocaine and cannabis (Johnson et al, 2003; Schindler et al, 2003; Fergusson et al, 2002; Huestis and Choo, 2002; Johnson, 2001; Lejeune et al, 2001; Annitto, 2000; Fischer, 2000a; Fischer, 2000b; Arendt et al 1999; Coghlan et al, 1999; Doweiko, 1999; Fischer et al, 1999; Lawrence, 1999; Haywood et al, 1998; Fischer, 1998; Delaney-Black, 1998; Marquet, 1997; Siney et al, 1995b; Jarvis and Schnoll, 1994).
These papers are representative of the subject - there is a great deal of other literature available. Many of the papers, mainly from the US, express bias towards the medical model, and predominately discuss the health risks for the foetus. These are balanced with more recent literature concerning service development and delivery that are client-led and appear to be informed by leading services in the UK. Examples include models of care developed in Liverpool, Glasgow and Manchester (Klee et al, 2002).
Various papers discuss pregnancy liaison service development, and their models have helped influence good practice and shape local services (Clark and Formby, 2000; McGee, 1997; Dawe et al, 1992).
The Windmill Drug and Alcohol Team
The Windmill Drug and Alcohol Team has developed an effective shared care model of working. A multi-agency approach is effective due to the working relationships of those involved evolving as members learn together. Link professionals have been identified and regularly liaise during pregnancy. These include a consultant psychiatrist, associate specialist, nurse specialist for pregnancy liaison as well as consultant obstetrician, community midwife manager, antenatal clinic midwives and neonatal intensive care sisters.
The pregnancy liaison service developed by the Windmill Team is predominately linked with the Maternity Services based at St Peter's Hospital in Chertsey, the advantage being that both services are on the same site. Although our shared client group can choose to have their babies at two other local hospitals, the service provided differs greatly.
One of the most important team members is the health promotion outreach worker, who works with all agencies and in particular with the pregnant woman herself. All agencies work closely with social services in relation to child protection procedures.
Data analysis and results
The Windmill Drug and Alcohol Team pregnancy liaison service has been involved with 40 pregnancies with varying degrees of input from January 2000 to December 2004. At the time of writing, three women are awaiting delivery of their babies.
The ages of the women at the beginning of pregnancy varied from 17 to 44 years old ( n=28). The majority - 90% - are white British, and a small minority are categorised by ethnicity as 'other white' and 'mixed race'. This is indicative of the local population accessing Windmill Drug and Alcohol Team for treatment.
A total of 47.5% of the women accessing the pregnancy liaison service were current clients, 22.5% were referred by the maternity services and 22.5% were referred by drug treatment agencies outside the area, GPs and community mental health teams. The remaining 7.5% of women self-referred.
Prior to referral to the maternity services, pregnancy was confirmed usually by urine test and following this a dating scan was performed on 27.5% of women, facilitating early access to antenatal care.
In 2003, a bid was submitted to the drug action team requesting funding for pregnancy testing kits. A sum of £100 was allocated, which enabled 100 kits to be purchased. Early pregnancy testing is vital for drug-using women, because they are often a disadvantaged population both socially and economically. Testing as soon as possible has positive implications for maternal decision-making and if appropriate referral to maternity services for antenatal care (Siney, 1995a).
Some 37.5% of the women were unaware of how far into pregnancy they were due to amenorrhoea caused by drug use and lifestyle. Some women were not aware that they were ovulating and therefore could still conceive. A total of 72% of the pregnancies were confirmed before 14 weeks, which is comparable to the hospital average (Hepburn, 2002). There were five (17.5%) pregnancies confirmed between 17 and 25 weeks' gestation (Fig 1).
The main drug of choice was heroin and 50% of the pregnant women either smoked or injected it and did not use another illicit drug at the same time. Some 30% used more than two drugs in a variety of combinations and 5% used alcohol; the figures were low for crack cocaine, cocaine, cannabis, benzodiazepines and alcohol - 25% in total (Fig 2 ).
A total of 50% of women dependent on opiates were prescribed methadone. Three women had been prescribed buprenorphine and one was taking dihydrocodeine (DF118). As buprenorphine is not licensed in the UK for use in pregnancy, but these women were already taking it effectively when their pregnancies were confirmed. A clinical decision was taken to continue prescribing due to the medical risks involved in transferring to methadone.
Some 15% were prescribed a combination of medication, namely methadone and diazepam, and 22.5% did not require prescribed medication for various reasons including opiates not being their drug of choice, abstinence or reduction from cannabis/cocaine use (Fig 3). This sub-group accessed the service for support, psycho-education, harm minimisation and relapse prevention during their pregnancies.
Once pregnancy has been confirmed it is important that the treatment options are discussed. Literature suggests there is a better outcome if treatment is client-led.
The options include community and inpatient treatment, ranging from gradual reduction in the community to detoxification in the mid-trimester. The inpatient option also includes a primary six-week rehabilitation programme. There is also the opportunity to attend community groups as well as weekly individual sessions. Often the stated goal changed as the pregnancy developed, which is unsurprising given the difficulty associated with being a pregnant drug-using woman (Klee, 2002 et al; Siney et al, 1995b).
A total of 10% of women expressed a preference for stabilisation, hoping to stop illicit drug use and adhere to their prescribed medication without making any reduction. There were 37.5% who wanted admission for inpatient detoxification without the six-week primary rehabilitation programme and 7.5% requested admission for detoxification and the programme. A further 17.5% wanted to reduce their medication in the community and 7.5% wanted to continue their abstinence. There were 12.5% who decided to terminate the pregnancy (Fig 4).
Some 92% of the women were in relationships during the pregnancy, including 17.5% with partners in prison. A large proportion - 45.5% - of the women's partners were also in treatment.
A total of 13 women (32.5%) accepted admission into the inpatient unit and the remaining 67.5% opted for community-based treatment. There were 11 women who completed detoxification while only four chose to stay for the rehabilitation programme. Unfortunately the relapse rate was high, varying from 1 to 31 days of clean time post-admission.
The main medication used for detoxification during the pregnancies was methadone. One woman detoxified using dihydrocodeine and a small majority of women were prescribed a combination of methadone and oxazepam. A small number of women were prescribed Subutex before confirmation of pregnancy and chose to remain on it and reduce the dose throughout the pregnancy.
The gestation at time of admission varied between 13 and 37 weeks. Some women were admitted for stabilisation as opposed to detoxification. A total of 5% of admissions were at 17 weeks and a further 5% at 19 weeks. There were 33% of women who remained clean for up to one month post-admission while 66% relapsed back to daily drug use. At the point of relapse the gestational age was between 18 and 35 weeks.
There were67% of women who returned to heroin use. The remainder used cannabis, cocaine and one woman returned to a combination of heroin and diazepam. Interestingly, there was a reduction in the amount of injecting heroin users indicating that the harm reduction approach may have had some influence as the women smoked rather than injected.
Despite the range of community interventions available, the numbers of women who actually used the services were minimal. A total of 13% attended groups such as the women's group, relapse prevention and auricular acupuncture. Some 87% chose to attend their individual sessions only. In addition 58% used the services provided by the outreach worker from the health promotion outreach team.
All clients used the maternity services for antenatal care. However, some women engaged more effectively than others. The health promotion outreach worker facilitated both women and midwives in managing appointments by visiting, encouraging attendance and providing emotional and practical support when and where it was required, in a non-threatening manner.
The women who continued to require prescribed medication and those who continued to use illicit drugs were offered a visit to the NICU if there was any possibility that the baby would be looked after there following delivery. This was planned around 32 weeks into the pregnancy, and 15.5% of women accepted the offer of a tour to meet the nursing sisters who would be caring for their babies. The parents were familiarised with the surroundings and the equipment that they might see their baby using. Parents were also encouraged to ask questions and to book another visit if they wished.
A total of 27.5% of women and their partners refused to visit the NICU. This was for a variety of reasons, which often included their fear that it all seemed too real - feelings of anxiety and guilt are often high at this stage. A further 27.5% did not attend an orientation visit - either because they had previous experience of the NICU from prior pregnancies, or they arranged to visit and did not arrive, or cancelled and did not rearrange, or the baby arrived before they could visit. Some women were referred to services on delivery of the baby or had disengaged up to the point of delivery.
Planning meetings at 32 weeks took place for 13% of the women on a formal basis. However, there was regular inter-agency liaison for the other women. This was because maternity services made referrals to social services at the point of booking in as standard practice. In some cases social services did not commence with child protection procedures until the baby was born. In other cases, where the family was already known to them, or the risk was perceived to be very high, pre-birth child protection conferences took place.
A total of 52.5% of new referrals were made by the maternity services with 5% being made by the Windmill Drug and Alcohol Team. There were 38% of women who were already known to social services and therefore were not a new referral, while a small minority - 22% - were not referred.
Gestation at time of referral varied from 12 to 42 weeks. There were various outcomes following referral:
- Assessment - no further action: 3%
- Child protection register at birth: 45%
- Local authority care orders: 15%
- Await decision on birth: 3%
- No social services involvement: 18% (9% later removed with care orders)
- Allocated social worker as a family in need: 6%
- Unknown - disengaged: 9%
- Child protection registration pre-birth: 3%
Gestation at time of delivery varied between 36 and 42 weeks, which is unusual given the client group and its known risks for early delivery and smaller babies. Unfortunately information relating to the babies details is not widely available in the case notes - 22.5% of babies were born weighing between 3lb and 7lb 8oz. This is representative of the birth weights reported anecdotally by the women.
A total of 81% of the babies born needed to be treated in the NICU: all were treated for neonatal abstinence withdrawal syndrome, and a small minority of babies had other medical complaints. Two babies were looked after in transitional care as both mothers had recently completed detoxification and the paediatricians were happy to monitor the babies outside the NICU. A further two babies were observed on the postnatal ward. Anecdotally, the babies born to mothers who were taking various doses of buprenorphine spent less time in hospital and required less medication than those babies born to mothers using opiates; two out of the three babies were managed outside the NICU (Schindler et al, 2003).
The length of stay for babies in hospital varied from five days being monitored on the postnatal ward to 56 days (Johnson et al, 2003). Some data is missing as the length of stay was not recorded in the clinical notes and some women disengaged from services.
Four miscarriages were reported at various stages of pregnancy between eight and 22 weeks. A total of 7.5% of the womenhad various degrees of postnatal depression that required intervention from both GP and psychiatrist. One referral was made to the postnatal nurse specialist.
Operationally, the Windmill Team's Pregnancy Liaison Service offers weekly appointments, prescribing, fast-track inpatient admission for detoxification or stabilisation with the opportunity for attending the six-week primary rehabilitation programme. Partners are also offered treatment where necessary.
The inpatient unit is located on the same site as the maternity unit, therefore access to antenatal care is immediate if there are any clinical problems. The community midwives also offer to visit the client on the unit if required.
Appointments can be made on the same day as an antenatal appointment therefore allowing good communication between services as necessary. There is a very strong professional working alliance and relationship between the various departments involved in caring for the pregnant drug-using women, which enables good practice. In 2002 the midwife manager at the time submitted the 'guide for inter-agency working' to the national inquiry on the children of problem drug users as an example of good practice.
When the baby arrives Windmill team staff liaise with the postnatal ward, midwives and medical team regularly, also maintaining contact with the woman at this time to support her. This can be particularly useful as many women struggle emotionally. There is often considerable guilt and anxiety experienced at this time that is often heightened with coping with birth and the associated physical issues.
Home visits are offered on discharge for a short period of time. However, it is envisaged that more home visits, both antenatal and postnatal, will be carried out, particularly in those cases where there may be some reluctance to engage in services or where there are other issues, such as transport or other children (Doggett et al, 2004).
For many women pregnancy, planned or unplanned, with a stable lifestyle, partner and supportive family - that is, in 'ordinary' circumstances - can be difficult. The pregnancy of a drug-using woman is complicated by her dependency, lifestyle, and health. The focus of treatment is not always on the maternal needs: a balance needs to be achieved where she is able to meet her own and her baby's requirements.
Women can frequently feel pressure from professionals, who are ofteninsensitive or judgemental and may negatively discriminate, often underpinned by stereotypical preconceived ideas (Klee et al, 2002; Daley, 1998; Siney, 1995b).
The concept of motherhood is complicated with the stigma associated with this client group, often reinforcing their fears and anxieties. Drug dependence is a chronically relapsing condition; the figures from the Windmill inpatient unit are indicative of how difficult it can be to maintain abstinence. Some women require more than one admission during the pregnancy and still remain unsuccessful in terms of detoxification and stabilisation (Klee et al, 2002; Andersen et al, 2001; Daley et al, 1998). This was true for a small percentage of our clients.
Many women feel discriminated against and misunderstood by services, there are often high levels of expectation that they will 'perform'.
It is understandable that parents need to be seen to put the needs of their child before their own. The high percentage of social service involvement with the families involved with the Windmill team is indicative of the levels of support required before a mother can be seen as 'good enough'. Lewis (2002) suggests that there is an imbalance between what is expected of a mother and what she can deliver. From a psychoanalytic perspective she says ambivalence can be managed and that society should encourage this and help mothers find ways that 'fit with their own capacities and circumstances'.
Substance misuse teams are often asked to comment on their clients' parenting skills and the perceived impact of drug use on the ability to parent and meet the needs of the child. There is a vast amount of literature based on research and evidence that discusses the longer-term effects of parental substance misuse on the child (Meschke et al, 2003; Ornoy, 2002; Olson, 2001; McNamara et al, 1995).
Pregnancy is often seen as a great motivator for change in maternal drug use. However, the figures this review indicates, particularly in relation to babies needing the NICU, are suggestive of the chronic nature of dependency. From a harm-minimisation perspective, many of the women were able to stabilise on their prescribed medication and stop illicit use. This was not always enough to avoid the babies needing detoxification; however, the proactive working relationship that has developed between local services has had a positive impact on the neonatal outcomes for this and other areas (Day et al, 2003).
In June 2003, the Advisory Council on the Misuse of Drugs published its report Hidden Harm. Responding to the Needs of Children of Problem Drug Users. This both highlights and acknowledges the harm and damage parental drug use has on children from conception to adulthood, physically and psychologically. It recommends: 'Drug misuse services, maternity services and children's health and social care services in each area should forge links that will enable them to respond in a coordinated way to the needs of the children of problem drug users.'
The Windmill team's pregnancy liaison service is proactive in multi-agency working and, while the numbers of women using this service are small, it has evolved and developed over time and will continue to do so.
It will be useful to develop a child and family nurse specialist post within the Windmill team, as currently there is no dedicated time. The work can be time-consuming on top of core responsibilities. The remit of such a post would not only include pregnancy liaison but contraception services - as recommended in the hidden harm report.
Teaching sessions have taken place for midwives and health visitors, facilitated by a nurse specialist and outreach worker. It would be useful for these sessions to be delivered to midwives, health visitors and student nurses in training. At this time this is not part of the formal curriculum. In line with the recommendations in the Hidden Harmreport, this training could be offered to our colleagues with the social services.
Further research would be interesting relating to the study of NICU admissions, maternal drug doses and length of stay for babies born to our client group.
In the interest of clinical governance, good practice, the results of a national inquiry as well as service development in line with National Treatment Agency and Drug Action Team policy, it will be beneficial and necessary for the work of the pregnancy liaison service to continue to develop and grow for the benefit of the women who need consistent support during an extremely important life stage.
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