Alcohol and other drug use in pregnancy
- There are known negative effects of alcohol and other drug exposure on the developing fetus, pregnancy progression and maternal health.
- There is an increased risk of harm from bingeing, frequent and heavy consumption of alcohol, smoking and other drugs.
- The rate of alcohol consumption is decreasing among pregnant women in Australia and the majority of pregnant women reduce their alcohol consumption once they are aware of pregnancy.
- The majority of women that continue to drink alcohol in pregnancy drink at low levels.
- The proportion of women drinking at levels for high risk has remained stable over time.
- Women who have risky drinking patterns prior to conception are likely to continue drinking at high risk levels into their pregnancy.
- Being pregnant, or the possibility of being pregnant, may provide additional motivation to change alcohol or other drug use.
- Women with problematic substance use require additional support to cease or reduce their consumption during pregnancy.
- Support must be comprehensive and address the range of health, mental health and social factors that affect women’s wellbeing.
- Despite high rates of contraceptive use in the general population, up to 50% of pregnancies are unintended.
- Unintended pregnancy is a risk factor for exposure to alcohol or other drugs due to later pregnancy recognition, late access to antenatal care and higher likelihood of risky consumption patterns.
- Unintended pregnancies often arise from inconsistent contraceptive use, particularly of the oral contraceptive pill.
- Alternative forms of more effective contraception, such as long acting reversible contraceptives, are not widely used in Australia.
Identification of women at risk
- Strategies to identify and engage at risk women earlier into antenatal care are required.
- Ideally, all women of reproductive age should be asked about their alcohol and other drug use, contraceptive practices and pregnancy intentions by primary health care professionals.
- Although the evidence for universal screening is limited, routine screening of reproductive age women in primary health care settings can identify the risk of an alcohol or other drug exposed pregnancy prior to conception or during pregnancy.
- Embedding non-threatening discussion about alcohol or other drug use into routine health care may reduce stigma and facilitate disclosure.
- A broad range of primary health care providers and services can ask about alcohol, drugs and contraception, to ensure that women who are most at risk are identified and assisted This could include primary health care settings, emergency rooms, community health centres, child protection services, sexual health centres or family planning clinics and other community contexts including social work.
- Primary health care providers may require additional training and support to implement routine screening and intervention systems into practice.
- Primary health care professionals are best placed to routinely ask women about tobacco smoking. Pregnant women who smoke should be advised to quit as early in the pregnancy as possible and supportive smoking cessation interventions should be offered.
- A number of brief screening tools to assess alcohol consumption have been validated with pregnant women. The AUDIT-C is recommended in Australia.
- Currently there is not a sufficiently validated brief screening tool for other drug use by pregnant women in Australia. The ASSIST v3 has shown potential to identify alcohol and other drug use in pregnant women in Australia, but needs further investigation.
- Other health, mental health or behavioural indicators and more in-depth assessment tools can assist in the identification of other drug use by pregnant women.
Interventions for women at risk
- There is strong evidence for the effectiveness of screening, brief intervention and referral to treatment as a means of reducing risky alcohol use in the general population, although uptake in primary care settings is limited in Australia.
- Women who are alcohol or drug dependent, or are heavy or frequent alcohol or other drug users, are at the greatest risk of having a substance exposed pregnancy and of poor health and developmental outcomes for their babies. These risks are present across a continuum from preconception, pregnancy and post-birth.
- In Australia, there have been limited studies of screening and brief intervention for women who are pregnant and use alcohol or other drugs.
- Screening and brief intervention have been found to have good outcomes with pregnant women in international studies. Further research is needed in the Australian context.
- There is evidence from international trials to suggest that interventions prior to conception which combine contraceptive advice with motivational interviewing can reduce the rate of exposed pregnancies.
- Pregnant women who have problematic alcohol or drug use have different needs to the general population of pregnant women and require additional support so that harm is reduced.
- A comprehensive care framework is required to support women at risk of an exposed pregnancy or who are consuming alcohol or other drugs in pregnancy, after these women have been identified.
- Women at risk of an alcohol or other drug exposed pregnancy should be provided with comprehensive assessment and where appropriate, brief intervention, smoking cessation support, contraceptive advice, referral for mental health services and other social supports. They should be assertively referred for early antenatal care and provided with alcohol or drug treatment.
- Support should be tailored to each woman’s individual needs, the specific risk factors and the severity of harm.
- Pregnant women who use alcohol or other drugs should best receive specialist treatment services where these exist, in specialist antenatal settings or drug or alcohol clinics. Care and treatment should be provided as early as possible after pregnancy awareness.
- Optimally, there should be a clearly identified case coordinator and well-coordinated, multidisciplinary care from early in the pregnancy to postpartum.
- Integrated models of care in pregnancy and after birth are emerging as best practice to reduce barriers to access for health and support services for women with substance use issues.
- Comprehensive or integrated treatment programs which bring together antenatal care and alcohol or drug treatment have been shown to improve outcomes. Where integrated treatment programs are not available, care should be multidisciplinary and carefully coordinated, to ensure that women’s antenatal, drug and alcohol treatment, health, mental health and social support needs are met and treatment followed through.
- Effective interventions for pregnant women are holistic and women-centred. They address the specific needs of each pregnant woman who uses alcohol or other drugs.
- Holistic care should encompass a range of health and psychosocial domains and address practical barriers to treatment.
- Treatments can include withdrawal or pharmacotherapy as appropriate, psychosocial interventions and nutritional support.
- The NSW Clinical Guidelines for the Management of Substance Use during Pregnancy, Birth and the Postnatal Period (NSW Clinical Guidelines) give comprehensive advice about appropriate treatments. The NSW Clinical Guidelines are a revision of the previous National Clinical Guidelines for the Management of Drug Use During Pregnancy, Birth and the Early Development Years of the Newborn.
- The profile of pregnant women accessing specialist treatment is one of social disadvantage. Compared to population data, they are more likely to be younger, unemployed, Indigenous, have higher parity, report significant psychosocial issues and have involvement with child protection services. Comprehensive treatment needs to incorporate these issues.
- After delivery, assertive follow-up and coordination is particularly important, including ongoing alcohol and drug treatment, medical management, health and developmental assessment of the baby, parenting support, contraceptive advice, and referral for additional support services including child protection where indicated.
- Training and professional development has been shown to improve the implementation of clinical guidelines and processes for identification of pregnant women who use alcohol or other drugs.
- Professional skills which support engagement of women in management of the risks to their health, pregnancy, treatment and care include being non-judgemental, culturally safe and understanding the range of biological and psychosocial factors which influence alcohol and other drug use.
- To support women’s access to comprehensive and integrated treatment, health, drug and alcohol, community and government agencies need strong partnerships and clear referral pathways.
- Uptake of training and education needs to be supported locally and include the establishment and strengthening of collaborative, interagency partnerships to improve referral and coordination of care.
- Communication among health care providers, patients and carers is a critical dynamic in integrated care. Improvements to clinical records and IT resources for coordinated care are required across Australia.
- Pathways between primary care and specialist services needs to be strengthened with local pathways documented to facilitate better access.
Dissemination and evaluation of the resource
- This project has developed a resource, Supporting Pregnant Women who use Alcohol or other Drugs: A Guide for Primary Health Care Professionals, which will be available online.
- Online distribution of the resource is recommended with links to relevant training and resources.
- An implementation package, including online training with support materials and templates for local capacity building and service mapping would support dissemination and uptake of the resource, but requires development.
- Training could be supported with Continuing Professional Development points and engagement with state-wide training bodies and professional associations.
- The feasibility and acceptability of the resource should be trialled and evaluated. Ideally this would occur in a variety of locations and settings, such as General Practice, midwifery, in a sexual health clinic or in criminal justice setting.