This article describes the development of a service to support vulnerable women during pregnancy.
Leggate, J. (2008) Supporting vulnerable women during pregnancy. This is an extended version of the article published in Nursing Times; 104: 3, 30-31.
This article describes the development of a service to support vulnerable women during pregnancy. This service was developed after increased incidence of substance misuse during pregnancy was identified. The main aim of the project is to identify and offer multidisciplinary support to pregnant women who misuse drugs and alcohol, from early gestation until at least three months postnatal. The article outlines how supporting this group of women can improve the well-being of both mothers and babies.
AUTHOR Joyce Leggate, PGCert Addictions, BSc, RGN, SCM, is clinical coordinator, community and outpatient services, Forth Park Hospital, Kirkcaldy.
The vulnerable in pregnancy (VIP) project has been developed in Fife over the past eight years to help identify and support pregnant substance misusers presenting for care in Fife. Effective multiagency partnership working has been key to the success of this project.
In 1999, a model of care for substance misuse in pregnancy was developed by a community midwife in partnership with Fife NHS addiction services and Fife Council social services. This model has been reviewed, audited and adapted in response to an ever-changing environment. The purpose of the model was to identify early in pregnancy those women who misuse drugs and alcohol and to support them in treatment during and beyond pregnancy. It also aimed to identify and address child-protection issues before the birth of the baby in partnership with health visitors and social workers.
Developing the service
The VIP service is based at Forth Park Hospital in Kirkcaldy. At present, this service comprises the clinical coordinator for community and outpatient services and a 0.8 whole-time equivalent midwife funded initially through the Changing Children’s Services Fund (Scottish Executive, 2005). This funding was awarded in 2001, following an application to the Fife Drug and Alcohol Action Team. This outlined the initial improvement in pregnancy outcomes and the significant costs to the NHS and social services should babies be delivered needing treatment for neonatal abstinence syndrome (NAS). There is also a midwife employed by the contraception and sexual health service, who is allocated four hours per week to work with the VIP service. The midwife offers contraceptive advice and cervical cytology screening for clients within the VIP project.
The service is currently funded through SureStart and it is hoped that mainstream funding will be allocated in 2008 when SureStart funding is discontinued.
Fife is located in the east of Scotland and is a mix of rural and urban settings with areas of poverty and affluence throughout. It has three wards in the most deprived 5% in the whole of Scotland. The Scottish Index of Multiple Deprivation (Scottish Executive, 2006) indicates that Fife has greater levels of area deprivation than the Scottish average. Clients referred to the project are generally geographically located within the areas of greatest deprivation.
Heroin use in pregnancy was first identified in Fife in 1996 when babies were delivered who displayed signs of neonatal withdrawal symptoms. These infants were managed in the neonatal unit by the administration of neonatal chloral hydrate or morphine sulphate. The mothers were then discharged home from hospital and social services were contacted. The assessment required by social services regarding the mother’s parenting capacity was conducted in a crisis situation, during which the maternal bonding process was interrupted. Detoxification from opiates often lasted 6–8 weeks, during which time the baby remained in hospital.
The present service was developed after the need for more effective communication between professionals and these families was identified. Clients had also requested advice and help to manage their substance misuse in pregnancy. A literature search, identification of appropriate study days and visits to other areas working in this field informed the development of the service. However, determination, perseverance and focus were also required, as was the managerial support and encouragement to develop this service.
According to Crandall et al (2004), the lifestyles of substance misusers who are pregnant are often complicated by homelessness, poverty, illiteracy and an increased incidence of mental health problems. The authors also highlighted that, although some women are motivated to address their difficulties with substance misuse in pregnancy, it is important to provide a gender-specific care programme for them. Maternity services providing care to pregnant women therefore have the opportunity to offer individualised, gender-specific, longer-term care to their clients.
Clients within the project have both their medical and social needs assessed and appropriate referrals to partner agencies are made. Close cooperation with these agencies has been developed over the past few years and this is essential to the continuing success of the service, as it addresses the client’s holistic needs. The information obtained identified that, in 2006:
- Over half (58%) have injected drugs;
- Over half (52%) have never been employed;
- Nearly a fifth (18%) are homeless;
- Just over a fifth (21%) have previously been in prison;
- Nearly a third (30%) have outstanding court cases;
- Two-thirds (66%) live with a partner;
- Just under half (46%) live with other substance misusers;
- Nearly two-thirds (62%) live with dependent children;
- The majority (80%) of clients are abuse survivors.
The age at which clients in the VIP project first experimented with drugs or alcohol is given in Table 1. This indicates that 70% of clients were under the age of 20 when they were first exposed to illicit substances. The youngest reported use was seven years of age but most clients indicated that use usually began at around 12–13 years, which – in many instances – would coincide with puberty.
Table 1. Age at which clients first used drugs or alcohol
|Age (years)||Clients (%)|
Assessment and care planning
The VIP midwives participate in the assessment and care planning in partnership with Fife NHS addiction services. The self-reported illicit drug misuse of clients referred to the project recognises that there is little psychostimulant use in Fife at present – heroin remains the most commonly used illicit drug locally. It appears to be plentiful in both supply and purity, resulting in a need for ever-increasing prescriptions for methadone hydrochloride.
Pregnant women in Fife may be tested for methadone tolerance within the antenatal ward area so that foetal well-being can be assessed and monitored during the procedure. Illicit opiate use is substituted by a methadone prescription under close supervision. Methadone is the only opiate substitute drug that is licensed for use in pregnancy (BMA and Royal Pharmaceutical Society of Great Britain, 2006). It is prescribed and administered under the guidance of the Misuse of Drugs Regulation (2001). It acts as a narcotic blockade to relieve the symptoms of withdrawal and craving from heroin. It is a long-acting drug that is administered in a single daily dose.
Berghella et al (2003) suggested that the risks of a baby exposed to methadone developing NAS are outweighed by the benefits that methadone stability brings. Throughout any antenatal admission, and during each antenatal encounter, women are educated on the risks and effects of methadone use and given advice on the benefits of breastfeeding, diet, kangaroo care (holding a baby so there is skin-to-skin contact) and general lifestyle strategies. Relapse rates for these clients appear to be low but it is recognised that pregnant women are motivated to remain in treatment through the fear of having their baby removed from their care.
Staff resistance to the antenatal admission of these clients has been overcome by the introduction of monthly drug workshops facilitated by the drug liaison midwives. Staff are able to attend these workshops, which are held during lunchtime when activity in the wards is reduced, and a rolling programme of training is delivered in an interactive setting. Other members of the multiagency team also attend, further breaking down barriers between agencies. The midwifery and nursing staff attend regularly for update sessions and medical staff are also invited. To date, over 800 workshops have been offered to staff in Fife with good attendance at each.
Breastfeeding is encouraged for all clients and few babies who have been breastfed require treatment for NAS. This then minimises the separation of mother and baby, thus improving bonding and encouraging positive parenting skills. Breast milk contains minimal amounts of methadone, which relieves symptoms in the baby over the first few days of life.
Breastfeeding rates have increased from a low of 7% to 56%. The advantages of breastfeeding for infants exposed to methadone are discussed at each contact throughout the pregnancy. The clients in the project initially needed a great deal of persuasion to consider breastfeeding, but the knowledge that so few babies who are breastfed require treatment has encouraged this choice. Women in the community of substance misusers now inform one another that breastfeeding is beneficial and midwives are often informed by women who are pregnant that they intend to breastfeed. Clients are encouraged to continue to breastfeed for at least six weeks postnatal and to introduce formula feeds gradually. Many clients continue to breastfeed for several months following the birth.
The outcome measures for these clients supported on a one-to-one basis throughout their pregnancy indicate a higher level of stability and improved health outcomes. Despite the increase in illicit drug use over the past eight years, the pregnancy outcome in terms of gestation, birth weight, neonatal abstinence and breastfeeding rates remain positive and have generally improved.
Breastfeeding has proven health benefits for mothers and infants but anecdotal reports have also indicated that clients find the act of breastfeeding a positive and empowering experience that improves self-efficacy. The ability to manage their own baby’s withdrawal by breastfeeding is described by clients as being the most important thing they have done in their life.
The challenges that social issues such as homelessness, criminality, past abuse and poverty bring have to be addressed by practitioners when developing a care plan for these clients.
The impact of abuse
Approximately 80% of women referred to the VIP project were exposed to childhood abuse. The DORIS Study (McKeganey et al, 2005) determined that a large percentage of substance misusers had experienced physical or sexual abuse in childhood. This cohort tends to then experiment with drugs at an earlier age. Females in the study were likely to have experienced abuse from a variety of sources both within and outside of the family. This results in an increase in episodes of repeat victimisation in women that may be associated with relapse. These women are extremely vulnerable to relapse – abuse survivors tend to do less well in treatment.
Sexual abuse is associated with reduced self-esteem, impaired social skills, suicidal tendencies and promiscuity, which persist throughout life with devastating effect. It increases vulnerability and re-victimisation, as also described by McKeganey et al (2005). Clients then indulge in maladaptive coping mechanisms that contribute to the subsequent addictive behaviour. Chiavaroli (1992) has evidenced the incidence of early relapse if clients have not disclosed or been encouraged to address past sexual abuse. Comprehensive assessment, including past sexual abuse, is essential if these clients are to progress through treatment successfully and cope with the trauma of their past. Gerwe (2000) suggested that early childhood influences are a contributing factor in relapse and they are seldom addressed. It is also suggested that childhood experiences and responses are deeply embedded in the developing brain and they can later resurface and disrupt the recovery process (Gerwe, 2000).
Clients referred to the VIP midwives are not actively encouraged to disclose past abuse but many women do disclose abuse for the first time as the therapeutic relationship between themselves and the midwife is established. Midwives are comfortable in discussing sexual health matters, body change and image and clients appear able to discus their past with them without fear or embarrassment.
The midwive’s role
It has been necessary to identify a source for clinical supervision for midwives due to the complexity of the cases they manage and the child protection nurse adviser has undertaken this role. She has an excellent understanding of the drug liaison midwife’s role. Clinical supervision is also available within Fife NHS addiction services.
The midwives within the project act as an effective liaison between agencies and as an advocate for clients. Clients perceive the midwives as being ‘there for them’, rather than for their addiction or the unborn baby, which other agencies such as addiction services or social services appear to be. Clients develop a positive relationship with the midwives and tend to remain compliant with treatment and attend most – if not all – of their appointments.
The VIP midwife’s primary goal is to support clients throughout pregnancy in order that they remain stable and safe. This, in turn, minimises the risk of infants developing neonatal abstinence symptoms that need treatment.
Planned and structured involvement of social services allows a full assessment of risks and needs to be completed before the birth and a supportive care plan needs to be discussed and agreed with clients during the antenatal period. More babies have had their name placed on the child protection register with most of them remaining in their mother’s care with support from the multi-agency team. However, there are occasions where, for the infant’s safety, a decision is made to remove the infant into care at birth. In all cases encountered recently, a full assessment of risk had been made and it was agreed at a child protection case conference that it was in the infant’s best interests to be placed in foster care at birth. Only one infant removed at birth in 2006 was reunited with its mother, the remainder remain looked after.
The incidence of NAS remains steady despite increasing numbers of referrals and an increase in the level of substance and alcohol misuse over the past few years – this is largely due to the high breastfeeding rates. Clients appear willing to engage at an early stage of gestation and this enables midwives to undertake early pregnancy screening tests and to fully assess and support clients’ needs. Postnatal support is extended until around 12 weeks. This ensures that clients have developed a positive relationship with other professionals such as health visitors and voluntary groups like Home-Start (a charity that supports families with young children). The midwife from the contraception and sexual health service is introduced to clients during pregnancy, if possible, and she then visits them both in the postnatal ward and at home to discuss their sexual-health needs. Many of the clients within the service have declined cervical cytology screening in the past, probably as a consequence of previous sexual abuse. They are able to gain confidence in the midwife who will perform their cervical smear and most attend for this procedure. Contraceptive needs are discussed and clients are encouraged to consider long-term methods of contraception to enable them to consider a reduction in their substance misuse before another pregnancy.
Clients are proud to be known as VIPs and tell their friends and family about the service. These women overcome tremendous adversity during their lives and the period of stability that pregnancy brings is often the starting point for their recovery from addiction.
The drug liaison midwives have been willing to extend their role and to challenge others to view this client group in a more positive light. The rewards that are yielded by working with these women are immense – to receive a handwritten note of thanks from a woman who is barely literate is both humbling and moving. A ‘beautiful baby gallery’ of photographs adorns the office wall and is proudly added to on a regular basis. Professional acknowledgement from organisations such as Nursing Times, the Scottish Executive and research funding from the Jennifer Brown Research Fund have been welcomed. However, this in no way matches the acknowledgement from a young girl, stable on methadone, nursing her baby, who states that she feels positive about her future for the first time in her life.
Implications for practice
- This was a ‘needs-led’ service development following the identification of a previously unknown group of patients;
- Funding was sourced in collaboration with other agencies including the local Drug Alcohol Action Team;
- To set up a similar service, training needs for staff should be identified and addressed;
- Close multi-agency working practices have been developed with both the statutory and voluntary sectors;
- The service can improve the well-being of both mothers and babies, as pregnancy outcomes have generally improved since the start of the project
Berghella, V. et al(2003) Maternal methadone dose and neonatal withdrawal. American Journal Obstetrics and Gynecology; 189: 2, 312–317.
BMA, Royal Pharmaceutical Society of Great Britain (2006) British National Formulary. London: BMJ Publishing Group, RPS Publishing.
Chiavaroli, T.(1992) Rehabilitation from substance abuse in individuals with a history of sexual abuse. Journal of Substance Abuse Treatment; 9: 349–354.
Crandall, C. et al(2004) Does pregnancy affect outcome of methadone maintenance treatment. Journal of Substance Abuse Treatment; 26: 295–303.
Gerwe, C.F. (2000) Chronic addiction relapse treatment: a study of the effectiveness of the high risk identification and prediction treatment model Part 1. Journal of Substance Abuse Treatment: 19: 415–427.
McKeganey, N. et al(2005) Physical and sexual abuse among drug users contacting drug treatment services in Scotland. Drugs: Education, Prevention and Policy; 12: 3, 223–232.
Misuse of Drugs Regulation (2001) www.opsi.gov.uk/si/si2001/20013998.htm
Scottish Executive(2006) Scottish Index of Multiple Deprivation 2006: General Report. Edinburgh: SE.
Scottish Executive(2005) Changing Children’s Services Fund. Edinburgh: SE.