Illegal drugs are divided into classes according to the harm they cause and the criminal penalties attached:
- Class A: Ecstasy, LSD, heroin, cocaine, crack, magic mushrooms, crystal meth
- Class B: Cannabis, amphetamines, Methylphenidate (Ritalin), Pholcodine
- Class C: Tranquilisers, some painkillers, GHB, ketamine
8.6% of adults and 20% of young adults (16-24) have used illegal drugs in the last year (NHS Stats). 3.1% of adults and 7.3% of young adults have used a class A drug in the last year (NHS Stats).
Risk factors for drug use include: poverty, having been in care, having been homeless, having truanted or been excluded from school, involvement in crime (NHS Stats). 80% of women involved in street prostitution are problem drug users (Hester & Westmarland)
Substance misuse in pregnancy
- An estimated 1% of pregnant women are problem drug users and another 1% are problem drinkers (Hidden Harm)
- Heroin is the main drug of pregnant drug users but many use multiple drugs and alcohol. Cocaine (crack), amphetamines, benzodiazepines and cannabis are also common (Hall & van Teijlingen)
- During pregnancy, heroin dependence is usually managed by prescribing the safe substitute methadone on a dose that stabilises the condition and avoids injecting. Sudden detoxification (“cold turkey”) can be dangerous for the baby, especially in the third trimester when even mild maternal withdrawal is associated with fetal stress, fetal distress, and stillbirth. (NHS Evidence)
Substance misuse and parenting
- 2–3% of children in England and Wales have a parent with serious drug or alcohol problems. (Hidden Harm)
- Almost two-thirds of drug-using women entering treatment are parents, but only half live with their children. (Saving Mothers’ Lives)
Effects of drug and alcohol misuse on babies
- Babies exposed before birth to heroin, other opiates, cocaine and benzodiazepines can be become physically addicted to the drugs and be born with severe neonatal withdrawal symptoms (“neonatal abstinence syndrome” or “NAS”). (Hidden Harm)
- NAS can also develop in babies whose mothers have been prescribed the heroin substitute methadone (NHS Evidence)
- Cocaine damages brain development causing learning and behaviour problems (Hidden Harm)
- Heroin slows fetal growth, causing interuterine growth retardation (small for dates babies) and premature birth (NHS Evidence)
- Problem drug use is associated with low birthweight, premature birth, stillbirth and SIDS, but as most problem drug users are also heavy cigarette smokers, with poor nutrition and complex social circumstances, these outcomes may be due to tobacco exposure and other adverse circumstances (Hidden Harm; NHS Evidence)
- Heavy drinking can cause physical abnormalities, impaired growth and cognitive delay (“fetal alcohol syndrome”) (Hidden Harm)
- If drugs are injected there is an increased risk of the transmission of HIV and viral hepatitis (Hidden Harm)
- Babies born with NAS drug withdrawal symptoms can be very difficult to care for due to their feeding problems, irritability and poor sleep pattern and this may prevent early bonding between mother and baby (Potts)
- A mother’s feelings of inadequacy and guilt if her baby is born drug dependent or otherwise harmed by her drug use may also make it hard for her develop maternal attachment (Potts)
- Drug and alcohol addiction are important risk factors for maternal death through suicide, accidental overdose and medical complications (Saving Mothers’ Lives)
Effects of parents’ drug use on young children
Using drugs does not mean that an adult cannot be a caring and responsible parent (Potts). However, where there is problem drug use, often combined with mental health problems and poverty, children are at increased risk of:
- neglect and abuse
- dangerously inadequate supervision
- inadequate and unstable accommodation
- toxic substances in the home
- social isolation. (Hidden Harm)
Consequences for the children include:
- failure to thrive
- blood-borne virus infections
- inadequate health care and missed immunisations
- emotional, cognitive, behavioural and other
- psychological problems
- poor educational attainment. (Hidden Harm)
In families where the parents are problem drug users, other family members, especially maternal grandparents, may take on responsibility for the children to avoid them being taken into care. (Potts)
Drug users’ feelings about maternity services
Women who use drugs are more likely to attend antenatal care late and/or conceal their drugs use from health professionals (Saving Mothers’ Lives; Hall & van Teijlingen). As well as the pressures of a chaotic lifestyle, this may because of:
- Fear of professionals’ reactions – staff attitudes are more important to women in determining use of services than clinical care
- Anxiety & guilt about impact of drugs on baby
- Fear of the child being taken into care
- Denial – some women avoid facing the reality of pregnancy (Hall & van Teijlingen)
- The difficulty of dealing with multiple agencies (NICE)
On the other hand, pregnancy may be an important opportunity for change, when a woman is highly motivated to come off drugs or stabilise her drug use in order to have a healthy pregnancy and keep her baby. (Hall & van Teijlingen)
Caring for pregnant women who misuse substances (NICE)
NICE recommends that health professionals should:
- integrate care from different services by:
- jointly developing a co-ordinated care plan across agencies
- including information about opiate replacement therapy in care plans
- co-locating services
- offering women information about the services provided by other agencies.
- ensure that the attitudes of staff do not prevent women from using services
- address women’s fears about the involvement of children’s services and potential removal of their child, by providing information tailored to their needs
- address women’s feelings of guilt about their misuse of substances and the potential effects on their baby
- offer the woman a named midwife or doctor who has specialised knowledge of, and experience in, the care of women who misuse substances, and provide a direct-line telephone number for the named midwife or doctor.
NICE further recommends that women who use drugs should have the following advice and support:
- The first time a woman who misuses substances discloses that she is pregnant, offer her referral to an appropriate substance misuse programme.
- Use a variety of methods, for example text messages, to remind women of upcoming and missed appointments.
- The named midwife or doctor should tell the woman about relevant additional services (such as drug and alcohol misuse support services) and encourage her to use them according to her individual needs.
- Offer the woman information about the potential effects of substance misuse on her unborn baby, and what to expect when the baby is born, for example what medical care the baby may need, where he or she will be cared for and any potential involvement of social services.
- Offer information about help with transportation to appointments if needed to support the woman’s attendance.
Breastfeeding and drug and alcohol misuse (NHS Evidence)
- Most women who use heroin or other opiod drugs or substitution therapy (methadone) should be encouraged to breastfeed, but not if they use cocaine/crack or high-dose benzodiazepines.
- Mothers should breastfeed immediately before an opioid dose is taken (to avoid peak concentrations of the drug in breast milk).
- Some methadone passes into breast milk, and where a mother continues to use methadone after birth, her fully breastfed baby is likely to develop fewer withdrawal symptoms.
- Seek specialist advice if the woman is HIV positive or hepatitis C positive
- Alcohol passes into breastmilk at approximately maternal concentrations, and a baby’s growth and development may be affected where the breastfeeding mother regularly drinks more than two units a day (Jones)
Key organisations for women
Tel: 0800 77 66 00
Babycentre information on illegal drugs in pregnancy
Hall J & van Teijlingen E. A qualitative study of an integrated maternity, drugs and social care service for drug-using women. BMC Pregnancy and Childbirth 2006, 6:19 http://www.biomedcentral.com/1471-2393/6/19
Hester M & Westmarland N (2004) Tackling Street Prostitution: Towards a Holistic Approach. Home Office Research Study No. 279. London: Home Office. http://www.mesmac.co.uk/blast/research/pdfs/Tackling_street_prostitution.pdf
Hidden Harm – Responding to the needs of children of problem drug users. The report of an Inquiry by the Advisory Council on the Misuse of Drugs (2003) http://www.homeoffice.gov.uk/publications/agencies-public-bodies/acmd1/hidden-harm-full?view=Binary
Jones W & The Breastfeeding Network. Alcohol and breastfeeding 2009 http://www.breastfeedingnetwork.org.uk/pdfs/Alcohol_and_Breastfeeding_March_2009.pdf
NHS Evidence: clinical knowledge summaries. Opioid dependence – management. Scenario: pregnant and breastfeeding. http://www.cks.nhs.uk/opioid_dependence#-482510
“NHS Stats”: NHS Health and Social Care Information Centre. Statistics on Drug Misuse: England, 2010 http://www.ic.nhs.uk/webfiles/publications/003_Health_Lifestyles/Statistics_on_Drug_Misuse%20_England_2010.pdf
NICE guidance 2011 Pregnancy and complex social factors (CG110) A model for service provision for pregnant women with complex social factors http://guidance.nice.org.uk/CG110
Potts N. Problem drug use and child protection: Interagency working and policies in Scotland. Infant 1(6):189-193. http://www.infantgrapevine.co.uk/pdf/inf_006_dto.pdf
“Saving Mothers’ Lives”: Centre for Child and Maternal Enquiries. Saving Mothers Lives. Reviewing maternal deaths to make motherhood safer. BJOG vol 18 supplement 1 2011 http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2010.02847.x/abstract