I should begin by saying that in Bristol we are perhaps fortunate that well over 12 years ago it was recognised that substance misuse and alcohol consumption in the pregnant population was a growing problem that needed addressing.
The service began in Bristol when concerned practitioners saw babies regularly withdrawing from heroin, cocaine and, although not so regularly, alcohol as well.
The United Kingdom currently has approximately 40 Specialist Drug and Alcohol Midwives (Lakhani 2009). In the south west, geographically a diverse region, there are approximately 10 whole time posts, covering inner cities to the vast expanses of Dartmoor.
Drug use, and particularly alcohol, is not necessarily linked to poor quality of life and we appear to be now entering a culture where recreational drug use is on the increase, where statistics show that 10%-20% of all young women drink well over the recommended limit of 14 units per week and where as a consequence of such drinking and drug use unplanned pregnancy, especially in the under 19s, is problematic. So where do we start? A good way to start would be by asking the question about substance abuse including alcohol! (Winstone et al 2010, NOFAS 2012).
The specialist service offered at North Bristol NHS Trust is a benchmark service. Women are seen by a team of professionals including a consultant obstetrician, a neonatologist, a specialist drug worker and a specialist social worker. We run a one stop shop, but in addition to the routine antenatal care provided by the community midwife, we offer an enhanced service (NICE 2010). Our service, which has an accessible specialist midwife for as many hours of the day as is possible, sees on average between 170-200 women every year with significant and problematic addictions. These are vulnerable women who need continuity of care, time, empathy and compassion, and so this is where I come in – a midwife with the specialist knowledge to assist them through what for some can be a difficult phase in their lives, whilst reducing maternal and fetal morbidity and mortality.
The role of the specialist midwife varies around the country. My own personal ethos as a specialist midwife is to build trust and confidence and to encourage the women I care for, through joint working to take control of their addictions, their futures and the health and well-being of themselves and, most importantly, that of their unborn baby.
Part of my role involves explicitly tailored education for the women and their families, education for those professionals caring for them and setting goals and plans for the future through a coordinated, comprehensive and individual service. I aim to inspire women to take control, give up tobacco and alcohol, and eat healthily, and for the addicted mother to stop abusing herself by using illicit substances, to stabilise the pregnancy and so improve outcomes. This is not easy; even the most motivated of women will struggle. However, by encouraging early and continuing antenatal care and by being readily available to talk to, our figures here in Bristol make very positive reading.
For many women, telling a professional the real picture of their lives, how much substance they use, especially alcohol, which they often use as their crutch to just cope, is so very difficult. They already self-blame, carry guilt and reproach themselves for their need, so rationalising a woman’s fear about so many concerns is probably the best place to start (Economidoy et al 2012). Most drug and alcohol addicted women will explain or at least voice their concerns regarding their babies being affected by withdrawal. They often express anxiety over the possibility of losing their children or being forced into detox treatment, and they want to safeguard against these possibilities. The close communication that develops over time begins with open and honest discussion, and leads to direct access to the agencies involved.
In my years as a specialist midwife, it has become so apparent to me that many women don’t just come with one problem; their complicated lives can have multi-faceted problems from domestic abuse, sexual abuse, mental health issues, poor nutrition, poor housing/homelessness, poor access to primary health, including dentistry. So when planning care all these aspects need to be taken into consideration, most importantly though and central to all of this is the woman herself.
At the beginning I explained that giving control to the woman is a good place to start – this can only happen if, like specialist midwives, all professionals are prepared to put aside prejudice, and employ compassion and understanding when asking the question (NOFAS 2012) and engage with this vulnerable but complex woman.
- Economidoy E, Klimi A, Vivilaki VG (2012). Caring for substance abuse pregnant women: The role of the Midwife. Health Science Journal 6(1):161-9.
- Lakhani N, (2009). One in 500 babies now born drug dependent. The Independent 31st May.
- National Institute of Health and Clinical Excellence (NICE) (2010). Pregnancy and complex social factors: A model for service provision for pregnant women with complex social factors. London: NICE.
- National Organisation for Foetal Alcohol Syndrome UK (NOFAS) (2012). Alcohol and pregnancy information for midwives. London: NOFAS-UK.
- Winstone AM, Kesmodel V, Payne J et al (2010). 192 Fetal Alcohol Syndrome (FAS) cases: are we getting the message across?Pediatric Research 68:100-1. http://www.nature.com/pr/journal/v68/n5-2/full/pr2010401a.html
Contributor: Jayne Thomas, Specialist Midwife, Drugs and Alcohol Team, North Bristol NHS Trust.
Photo credit: © kentoh – Fotolia.com