Substance use during pregnancy

The use of substances during pregnancy – ranging from cigarettes and alcohol to illicit drugs – is a sensitive problem that can be difficult for patients and practitioners to broach.
 
But it is often imperative for the health of mother and baby that the issue be faced, as sadly evidenced by the 2014 case of ‘Baby W’, who died not long after birth due to complications arising from her mother’s use of amphetamines during pregnancy.
 
While the baby’s mother admitted amphetamine use early in pregnancy, the Victorian Coroner’s Court report, which was released at the end of last year, found there was not enough effort to engage her with antenatal care and the framework she was referred to for assistance was ‘punitive rather than supportive’.
 
Dr Hester Wilson, Chair of the RACGP Addiction Medicine Specific Interests network, agrees a supportive attitude is vital in approaching women experiencing problems with substance use during pregnancy.
 
‘And if you’ve got someone who has got dependency or addiction, you need to put in more supports, not less,’ she told newsGP.
 
Dr Wilson believes pregnancy can be an incredibly positive motivator for women to address their issues with addiction and health.
 
‘It is a time where women often say, “I absolutely have to change this, because I don’t want to harm my child”,’ she said. ‘It’s when women give up smoking, change their drinking and their other drug use.
 
‘There is no one that I’ve seen that just says, “I don’t care about the baby, I’m just going to go on doing what I’m doing”. They all want to be a good mum, they all want good outcomes.’
 
As a starting point, Dr Wilson believes it is important to understand that substance use can affect people from all walks of life.
 
‘There is a bit of a tendency to go, “A person that uses drugs looks like this”, and that’s not always the case,’ she said.
 
‘Using drugs is a part of a person’s life, but it’s not who they are.’
 
Dr Wilson has found that one of the best ways to deal with this is to include questions about substance use into the screening of all pregnant patients.
 
‘If you don’t ask then you don’t know,’ she said.
 

Dr Wilson believes that questions about substance use should be included in the screening of all pregnant patients.

Dr Wilson feels that including this in screening, and treating it as an issue of health rather than morality, also helps to remove the sense of judgement from the question.
 
‘When I ask, it’s part of my medical assessment; it’s not because I’m making a judgement about you, I ask this of all of my patients because it’s really important,’ she explained. ‘So it sets it up in that safety-medical model.
 
‘I ask permission first, so, “Is it okay if I ask you?”. And then I will ask, “Do you smoke cigarettes? Do you smoke cannabis? Do you drink alcohol? Do you use any other drugs? Do you inject drugs?” And it’s all on that basis of what I need to know in terms of helping the woman to manage the risk.’
 
Removing judgement is very important, because stigma around substance use can often prevent women from being honest with their GPs, which can then lead to less positive outcomes.
 
‘Shame is such an important part of stigmatised conditions, including drugs and alcohol and smoking and being overweight and obese,’ Dr Wilson said. ‘That kind of shame doesn’t help people to engage in treatment and make healthy changes because they just feel so bad, that it’s very hard to make change.’
 
It is also important to be aware of the very real fears many women may feel around disclosing substance use during pregnancy.
 
‘One of the fears that comes up, particularly for more stigmatised pregnant women, so drinkers and drug users, is that the baby will be taken from them,’ Dr Wilson said.
 
‘This is a particular issue for Aboriginal and Torres Strait Islander communities, because their babies were taken away. We have a whole generation that was stolen, and we need to acknowledge the fear that is deeply built in as a result of that, and of anyone who was either taken away themselves as a child, or have had other children taken away, or has had in their community.’
 
However, Dr Wilson also believes it is very important to make it clear to the patient that as a GP, who has a duty to preserve the health of their baby, she has very strong boundaries.
 
‘I think you do need to be really overt that, although we want for mothers and their babies to be well, and we know that babies that do best are the ones that stay with their mums and their families – I will report if I am really concerned about the baby’s well-being,’ she said.
 
‘So I want to work together with [the patient]. Let’s get the supports in place, let’s get the substance use and pregnancy team from our local hospital involved, because they are really brilliant at this, to get the best outcome for everybody.’
 
Dr Wilson believes in a harm-reduction strategy to help produce the best outcomes for mothers and their babies, in which treatment can range from cessation of the substance use altogether to use of substitution therapies.
 
‘For example, one of the things I would do with women that are smoking is try and help them to give up, and if we can do that without using any medications that is brilliant,’ she said. ‘But if they can’t, I would use NRT [nicotine replacement therapy], because that is safer than having someone smoke during pregnancy.
 
‘For alcohol, we don’t know what the safe levels of alcohol are in pregnancy. So where I go with that is, it’s probably better not to drink at all.
 
‘In terms of the other drugs, for example, opioids, the big issue there is that if somebody is taking opioids and withdrawing, and then getting intoxicated, then that’s happening to the baby as well and that’s harmful. So if someone’s opioid-dependent, they’re much better off to be in opioid treatment, buprenorphine or methadone.
 
‘Certainly, while it would be great for the woman not to be dependent, the fact is that opioid dependence is a chronically lapsing condition and it does require treatment. It keeps the woman stable, so it keeps their baby stable.
 
‘That at the moment looks like the best outcome: to be on stable treatment, watch out for withdrawal in the baby with a high index of suspicion, and treat that as well.’
 
Dr Wilson is aware of the complexity of these issues, and stresses that there are support services available to which GPs can refer.
 
‘It is important to know where you can get help for people if it’s not something you feel confident with,’ she said. ‘The pregnancy and antenatal clinics at your local hospital will always have someone you can call and find out how you can get that support for women.’
 

Addiction medicine Harm reduction Maternity care Substance use in pregnancy