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By: Janet L. Stein, MD
From the Manual for Primary Care Providers: Effectively Caring for Active Substance Users. Reprinted with permission from Allan Clear and The Harm Reduction Coalition www.harmreduction.org
Introduction
The idea of a pregnant woman actively using illicit drugs, alcohol, and tobacco arouses emotional reactions from us. We think of the developing fetus and ask, “How can she do this? Doesn’t she care that she is harming her unborn child?” Even in our role as health care providers, we may find it difficult to hide our disdain and anger as we approach these women in the setting of their medical care. Some of our frustration may also stem from the feeling that we cannot elicit change in them, making us feel inadequate as providers.
Antagonistic and judgmental interactions only further alienate women from the system. In focus groups held with pregnant women in substance abuse treatment, women were asked what they would tell a friend who was pregnant and using drugs. Although they said that they would try to persuade the woman to stop, “…every one of them also would advise the woman not to admit to the doctor or social worker that she was using drugs.” These ingrained expectations and the judgmental reactions of health care providers can collide to create a powerful resistance to seizing the moment and, therefore, a lost opportunity. Entangling health care with the criminal and legal system has interfered with our credibility and ability to do our job.However formidable these obstacles to change may seem, pregnancy provides an opportunity for change because change (becoming a mother) is inherent in the process. Pregnancy also provides a unique opportunity for intervention by health care providers because women inevitably present to “the system,” even if it is only to deliver the baby. To have an opportunity for any meaningful impact, we, as providers, must be informed and prepared to engage these women whenever they present to us.Not only must we be prepared to engage the woman at any point; we must shift our focus. Viewing women as only vehicles for a fetus puts a primary focus on the baby instead of the woman, and neglects the context within which the baby exists. The woman is the primary patient and deserves careful, thoughtful intake assessment. For different women, at different times, particular issues will be more acute in a given situation and will guide the focus for initial efforts at treatment and referrals. Somehow, all of these problems need to be addressed while integrating prenatal care. It is a labor-intensive, time-consuming, and often emotionally draining process for the provider. The difficulties for the provider reflect merely a fraction of the difficulties the patient herself faces.With honest effort by the provider, some sense of the larger context, realistic expectations and goals, and a working partnership with the pregnant woman, the period of antenatal care, birth, and the postpartum period can be a rich time of opportunity and growth.
Background
Women of all demographic categories use different substances during pregnancy—for reasons far more complex than simple hedonism. The consequences they and their fetuses risk come not only from the effects of the drugs themselves, but also from the consequences of drug-seeking behavior.
The Extent Of Substance Use During Pregnancy
Studies that do blinded toxicology screens show similar rates of substance use during pregnancy across racial, class, and age categories. Demographic characteristics relate to the type of substance used: black and poor women are more likely to use cocaine; white and more educated women are more likely to use alcohol. An analysis of a 1993 National Institute on Drug Abuse (NIDA) survey revealed that “…the percent of adult women who ever used illicit drugs was positively correlated with income, while the percent who used illicit drugs at least monthly was inversely correlated with income.” However, demographics and racial features also relate to who is more likely to get tested for drugs and, therefore, reported to social agencies.
Reasons Contributing To Substance Use
Data show that women who were raised in homes with alcohol and substance abuse have a high rate of drug use during pregnancy. Very high proportions of these women have themselves experienced early sexual abuse during childhood. Concomitant/comorbid psychological/ psychiatric disorders, particularly depression and post-traumatic stress disorder, abound. Oftentimes, the mental disorder precedes the drug dependence, with drug use beginning as a form of self-medication.
Clearly, women must be viewed in the context of their lives as a whole. The underlying psychopathology of chronic substance use is complex. The initial reasons for drug use may be eclipsed, over time, by addiction and physical dependence. Patients may come to rely on drugs to “…protect against painful affect states” and, over time, “to produce not euphoria but, rather, relief from dysphoria.” That is, drug use becomes a coping mechanism rather than a hedonistic pursuit. This may also explain some of the appeal of one type of drug use over another. The misconception that illicit drug use is perpetrated solely by pleasure-seeking, irresponsible individuals is at the root of the judgmental and punitive views of society.
Harm Reduction As A Model Of Perinatal Ethics
Harm reduction seeks to establish long-term, realistic goals for pregnant substance users and to promote fetal well being through maternal well being. Harm reduction addresses the larger scope of a woman’s life by recognizing the context of the pregnancy and the obstacles substance use presents to quality care. By treating the woman as a whole, instead of merely a vehicle for the fetus, harm reduction seeks to eliminate “maternal-fetal conflict” and promote the long-term health of mother and child. As providers, we need to recognize pregnancy in its context, recognize obstacles to quality prenatal care, and identify harm reduction as a goal.
Recognize Pregnancy In Its Context
Providers working in an obstetrical setting realize that pregnancy itself is but a brief period of time in the larger context of the life of a woman and her child. True quality care ideally begins before the pregnancy in order to achieve optimal maternal well being. Whatever the concurrent medical problems, pregnancy outcomes are always better if chronic medical conditions are stable, medication regimens assessed for possible pregnancy-related concerns, and pregnancy is planned. Outcomes do not end at delivery: integration of the infant into the family unit— and the family unit into the community—is the long-term goal.
Recognize obstacles to quality prenatal Care
Patients with active substance use may be unwilling or unable to comply with our best efforts to provide prenatal care—they may not show for appointments, not follow through with referrals, and seem to ignore our advice to do such things as stop smoking. These behaviors may be construed as potentially harmful to their fetuses. This conflict may be seen as an ethical issue—”maternal-fetal conflict.”
Identify Harm Reduction As A Goal
Maternal goals during prenatal care should be viewed in the same way as any chronic medical illness; just as a diabetic will “cheat” on her diet, the nature of substance use is one of remissions and exacerbation. Perfection in the form of absolute abstinence should not be the short-term goal. Rather, harm reduction is a set of strategies recognizing that taking any steps toward reducing drug- and alcohol-related harm is moving in the right direction. For example, the use of illicit drugs while in methadone maintenance is tolerated, as it may reduce the incidence of drug overdose; needle exchange programs reduce the risks of HIV and other blood-borne infections. Harm reduction respects any positive change as defined by the individual and integrates this incrementally into a long-term treatment plan.
Lisa Harris, MD, puts forth an alternative model of perinatal ethics where “fetal well being is achieved when maternal well being is achieved.” If the particulars of a pregnant woman’s life are addressed along with the social and cultural contexts in which the ethical dilemma occurs, a clinician might not need to balance the relative moral weight of obligations owed to her against those owed to a fetus.”
Crucial Steps in Prenatal Care
Reproductive-aged women should always be viewed as “potentially pregnant.” Ideal prenatal care begins before a woman becomes pregnant, and recognizing the pregnancy as soon as possible is important to quality care. In order to lay the foundation for the long-term health of mother and child, prenatal care providers must
Assess The Likelihood Of Drug Use
To be able to offer services to women using drugs or alcohol, most professionals agree that a screening protocol is needed to identify women at risk and that, to be effective, all women should be screened. A recent study by Chasnoff classified women at low, average, or high risk for drug use in the current pregnancy and developed three easy, quick questions to ask.
Screening should be done at the first prenatal visit and subsequently as well. Patients may not discuss these issues at an initial visit, whereas, after some rapport and trust have been established, they may choose to disclose, particularly if the patient feels the purpose of the questions is to assess for help and medical care rather than to “catch.” Again, the doctor-patient relationship is crucial to successful steps toward meaningful care and treatment. It can provide structure to the patient in the form of scheduled appointments and supportive interactions that may not exist anywhere else in her life at the moment.
Treat Current Substance Use
Connecting the mother to drug treatment is essential; however, programs that are sensitive to the needs of women may be difficult to find. Retention in treatment is facilitated by the provision of support services, such as availability of childcare, parenting needs (education, skills), transportation, and social and mental health needs.
Opioid Addiction
Methadone maintenance is recommended for opioids such as heroin. Methadone has been used to treat women during pregnancy for more than 30 years, and has been shown to reduce maternal mortality and to lower rates of fetal morbidity and pregnancy-associated complications. Medical withdrawal from methadone during pregnancy has been described, but is generally not recommended. Motivation to withdraw rather than to remain on methadone maintenance is often based on the belief that it is better for the baby, but the overwhelming risk to the baby remains active maternal substance use. There is also the unfortunate reality that, rather than viewing methadone maintenance as a positive representation of a woman in treatment, stigma remains.
Cocaine Addiction
Treatment for cocaine addiction relies primarily on nonspecific measures common to all substance abuse treatment, such as removal of the woman from her environment, and an array of supportive services, such as twelve-step programs.
Alcohol Addiction
Alcohol treatment may require medication for severe symptoms of withdrawal, such as delirium, hallucinations, delusions, and seizures. Short-acting barbiturates or benzodiazepines are the drugs of choice for medicating.
Address Prenatal Bonding Issues
Ultrasound is a widely available, non-invasive, and safe adjunct to prenatal care that can provide much useful information….The ultrasound examination itself can be an experience in maternal-fetal bonding. The woman can see the fetus, be reassured that she has not irrevocably damaged her baby, and be motivated to continue to try to work towards a good outcome. Knowing the sex of the baby, if she desires, can serve to facilitate making the pregnancy real and help the mother to project the future.
Antenatal consultation with pediatric providers can be useful. Preparing the mother for what to expect with her baby can allow her to be better prepared and, as a result, perhaps less emotionally vulnerable to relapse.
Crucial Steps in Intrapartum Care
The intrapartum period is a time for continued emotional support for the mother—preferably by the same staff—with an assessment of future support networks and decisions about pain management.
Achieve Continuity Of Staff
In many clinic settings, the inpatient staff differs from the outpatient staff. Once again, the women have to deal with new providers and the stigma of being identified as a “drug user.” Depending on the setting, and to some extent the degree of communication between in- and outpatient settings, the change of staff may undermine strides that have been made in the therapeutic relationship between patient and providers. The benefits of continuity, familiar faces, and limited provider turnover cannot be underestimated. These benefits hold true of medical staff, social work staff, and other support services.
Assess The Mother’s Support Network
The patient’s hospitalization may be a good time for staff to assess her support network. Who shows up to support her during labor and to visit may be telling.
Address Pain Management
Pain management may be an issue in labor. Providers may be tempted to under-medicate for pain if there is a bias about drug-seeking behavior and insensitivity to the reality of the pain. Involving the anesthesia providers early in the process may be most helpful. It is essential that anesthesiologists be knowledgable about and sensitive to the special needs of this population.
Crucial Steps in Postpartum Care
Quality postpartum care means showing that delivery is not the end of care, but the beginning of a new phase of care. Quality postpartum care includes continuity of staff, continued emotional support for the mother, support for bonding issues or questions, contraceptive advice, and watching for signs of postpartum depression.
Achieve Continuity Of Staff
Even when patients have had a relationship with obstetric staff, they must now deal with the pediatric staff that no longer has their interest in the forefront, but rather the baby’s. Keeping the obstetrical staff involved at this point can provide continued support for the mother.
Provide Emotional Support
The reality of neonatal problems is now apparent. Women who have had other children while using drugs may already be familiar with medical issues/complications at this time. When the newborn does have real problems, this is a time of tremendous shame and guilt that must be addressed.
Address Bonding Issues
Infants who are excessively irritable or non-reactive because of withdrawal or developmental problems contribute to the impairment of maternal-infant bonding, particularly in the first few days of life. Poor maternal-neonatal interaction can add to maternal frustration, guilt, depression, and further risk for relapse. Add concurrent medical problems necessitating prolonged neonatal hospitalization, with separation from the mother, and a cycle of events ensues that further impairs bonding. Breastfeeding can be a wonderful way to support bonding, but requires a level of involvement and commitment that may be difficult if the woman is wrapped up in her own issues. Breastfeeding is not contraindicated with methadone maintenance, but is contraindicated with active illicit substance use or HIV infection. Hepatitis B carrier status (HbsAg positive) is also not a contraindication to breastfeeding unless e antigen, highly correlated with infectivity, is also positive.
Address Contraceptive Issues
The postpartum period may, in fact, be the only opportunity to work with some women around family planning issues to prevent the next unexpected or unplanned pregnancy. Each attempt at pregnancy may represent a wish—consciously or unconsciously—to finally “get it right.” Contraceptive issues should be addressed before the woman is discharged from the hospital. Follow-up may need to be earlier than the traditional six weeks to engage the woman before she returns pregnant again.
Watch For Signs Of Postpartum Depression
Postpartum depression should be watched for, as it can lead to selfmedication. The possibility of postpartum depression can be discussed prior to the woman’s leaving the hospital, so that she is aware that it is a possibility and can seek help.
Practical Steps For Providers
Providing care for the pregnant woman who actively uses illicit drugs, alcohol, and tobacco presents great difficulties, but success can be achieved with a shift to the model of harm reduction. The following steps suggest attitudinal aspects of this shift:
In How Good Do We Have To Be?, Harold Kushner reminds us that “…being human can never mean being perfect, but it should always mean struggling to be as good as we can and never letting our failures be a reason for giving up the struggle…How good can we expect a person to be? As good as he or she is capable of being.” Both patients and providers would do well to remember this.