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Key principles 

From: Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers

Several principles can be integrated into clinical approaches to working with pregnant or breastfeeding women who use psychotropic medications or other substances. These principles will not necessarily apply equally to all women. Some women taking psychotropic medication may live in a stable environment that includes a support network, safe housing and secure employment. Some women may have substance use problems and endure violence and poverty. Some women may live with both substance use and mental health problems. Awareness of the key principles will allow providers to apply the most relevant principles to individual women in their care.

Consider the determinants of health

When assessing a woman’s health before, during and after pregnancy, practitioners need a holistic approach that—in addition to substance use and mental health problems—takes into consideration the determinants of health. These determinants include:1,2

  • access to health care
  • income and socio-economic status
  • social inclusion and exclusion
  • social support networks
  • early childhood care
  • education and literacy
  • working conditions
  • employment and job security
  • housing
  • food security and nutrition
  • physical environments (e.g., safe water, clean air, adequate transportation systems)
  • personal health practices and coping skills
  • biology and genetic endowment
  • gender
  • culture.

Women whose care takes into account their overall home environment, social support systems and other factors that affect their day-to-day living benefit more than those whose drug use alone is taken into account. For example, many women at risk of using substances during pregnancy face numerous social and economic stresses. Unemployment, violence, poverty and other issues may not only blur the importance of stopping substance use and seeking health care services, but may even create an environment where substance use serves as a benefit by numbing them to some of the realities of their lives. It is unreasonable to request that a woman stop using substances without addressing the multiple stressors that challenge a woman’s successful cessation.3

Provide women-centred care

Interventions with pregnant and breastfeeding women who use substances have traditionally focused on fetal health; women-centred care is an approach to clinical encounters that places value on a woman’s needs in the context of her life circumstances, such as whether she is experiencing violence or whether the pregnancy was wanted.3,4 This requires a holistic approach to health, including mental and physical health, as well as an awareness of the socio-economic context of a woman’s life. A women-centred approach focuses on a woman’s long-term health and intrinsic reasons for change—in this way it addresses longer-term motivation (i.e., beyond pregnancy and breastfeeding) for becoming and remaining abstinent from substances. Understanding how a woman’s unique situation impacts her substance use and mental health will allow practitioners to offer interventions tailored to individual women’s realities, priorities and needs. The British Columbia Centre of Excellence for Women’s Health proposes a women-centred model that encompasses a wide range of considerations (see Figure 1).

Figure 1: Providing women-centred care

Reprinted with permission from Poole, N. & Greaves, L. (Eds.) (2007). Highs & Lows: Canadian Perspectives on Women and Substance Use. Toronto: Centre for Addiction and Mental Health. Copyright © 2001 British Columbia Centre of Excellence for Women’s Health.

Fight stigma

The prejudice and discrimination at the heart of stigma affect the extent to which pregnant women with substance use and/or mental health problems receive both prenatal and postnatal care. A woman who is thought to be endangering the health of her fetus or baby (e.g., by not abstaining from substances or not following a doctor’s or midwife’s advice) has typically been considered a “bad” mother. This stigma can contribute to women with substance use and mental health problems keeping their symptoms and problems secret. As a result, they may avoid getting the help they need.

Statistics Canada reports that only 32 per cent of people with a mental health problem seek professional help;5 this means the majority receive no care at all. A pregnant woman who uses substances has the additional fear that disclosing information may lead to losing her child to child protection services (e.g., Children’s Aid Society or Children’s Services). As a result, she may minimize important issues that are fundamental to developing an effective treatment plan with her doctor.

In addition to compromized medical care, stigma can affect other areas of a woman’s life, including limiting her ability to secure employment; find safe and stable housing; be accepted by her family, friends and community; make friends or have other long-term relationships; and take part in social activities.

People with substance use and mental health problems often internalize prejudice and discrimination. This self-stigma leads them to believe the external messages from others and the media. The guilt and shame that often result from stigma can lead to low self-esteem, social isolation, weaker support networks, increased poverty, depression, loss of hope for recovery, and even suicide. These outcomes can clearly affect a woman’s ability to cope with her own and her child’s care, both during pregnancy and afterward.
To help mitigate stigma’s effects as much as possible, providers can:

  • be aware of attitudes and behaviour. Prejudice and discrimination are passed on by society and reinforced by family, friends and the media. Challenging one’s own and others’ thinking can help to ensure that people are seen as unique human beings, not as labels or stereotypes.
  • be mindful about language. The way a person speaks can affect the way others think and speak. It is important to use accurate and sensitive words when talking to and about people with substance use and mental health problems. For example, using the phrase “a person with an addiction” instead of “a drug user” puts the person first and then identifies the issue she may have, rather than dehumanizing a person and defining her by the substance use.
  • provide outreach. Since many women with substance use and mental health problems are stigmatized and marginalized (e.g., by social exclusion, low socio-economic status, lack of formal education), it is important to ensure that women who do not present to health care providers are also reached. (See “An Example of Key Principles in Action” below for an inspiring illustration of an outreach program.)

Examine partner/social support

Few interventions focus on a woman’s partner or social environment, yet both cessation and relapse are affected by the presence of people who use substances in close proximity to the woman,3 as well as the amount of support a woman has. It is important to acknowledge the presence of others who use substances in a woman’s life and to determine the dynamics of those relationships. When exploring a partner’s behaviour, it is crucial to acknowledge potential power, control and abuse issues in a way that ensures the woman’s safety. Validate a woman’s entitlement to social support—because of stigma and the resulting shame, a woman may not feel that she deserves help. Encourage women to find appropriate support (e.g., confiding in a trusted friend, seeking a referral for additional services).

Integrate a harm reduction philosophy

Harm reduction—any program or policy that aims to reduce the harmful consequences of substance use without requiring the cessation, or even necessarily the reduction, of drug use—offers a practical approach to managing addiction.6 These strategies prioritize the goals of a person who uses substances, with an emphasis on immediate and realizable goals. Harm reduction initiatives are flexible, recognizing individual differences and the potential for a woman to re-evaluate her goals. They provide a maximum range of treatment options such as drug substitution, drug maintenance and interventions that adopt safer methods of use. A woman’s decision to use drugs is acknowledged as a personal choice, for which she takes responsibility. In this way, harm reduction strategies can help circumvent the stigma associated with substance use because they take a non-judgmental approach to people who use drugs.

Harm reduction can also mean helping women reduce or prevent the harm associated with other high-risk behaviours (e.g., unsafe sex) or environments (e.g., physical abuse, unsafe housing).3 By examining behaviours and environments, and offering information, providers encourage women to make healthier and safer choices for themselves, even if complete abstinence is not feasible, and support them in finding safer environments. Effective therapeutic intervention includes recognizing that some women may currently be ambivalent about their substance use or resistant to abstinence.

Examples of harm reduction choices include:

  • safer injection use and methadone maintenance treatment
  • nutritional improvements, which may moderate the effects of substance use
  • other health-enhancing practices, such as safer sex, more physical activity and using stress reduction techniques.

Identify concurrent disorders

Recent research7-11 has indicated a high prevalence of concurrent disorders—co-occurring substance-related and mental disorders. It is estimated that in Canada, between 40 and 60 per cent of people with severe mental illness will develop a substance use disorder in their lifetime.11 And opioid dependence is associated with almost every major mental illness (most commonly with mood and anxiety disorders, eating disorders and personality disorders). If concurrent disorders are not recognized and treated, negative effects can include:

  • the risk of harmful interactions between psychotropic medications and other substances
  • misinterpretation of symptoms (e.g., what seems to  be a sign of substance use or withdrawal may actually indicate a mental health problem)
  • a woman dropping out of treatment prematurely, thereby increasing the risk of harm to herself and her fetus or infant
  • a high risk of relapse.

Prevent relapse

The risk of relapse is high for women who, while pregnant and breastfeeding, stop using substances.3 During pregnancy, the fetus provides daily motivation to abstain from or decrease substance use. Women who have quit or reduced use need to be re-motivated to deal with the postpartum pressures to return to substance use. Since relapse is often delayed while women are breastfeeding, support for breastfeeding not only provides obvious benefits to the infant, but also presents an opportunity to extend the woman’s experience of not using substances post-pregnancy. In this time, providers can help women explore their own intrinsic reasons for cessation.

An example of key principles in action

Sheway is an innovative outreach and drop-in program located in the Downtown Eastside of Vancouver. With a service philosophy that respects and supports women’s self-determination in the level and pace of change in their lives, Sheway provides holistic services to pregnant women with substance use problems, and support to mothers and families until their children are 18 months old.

Sheway was established in 1993 in response to a growing understanding of the high levels of substance use by pregnant and parenting women, the low birth weights of their infants and the very high rates of their children’s apprehension by child protection authorities. Sheway’s services are located in an accessible drop-in setting, and include such key features as:

  • practical supports (e.g., hot meals and vitamins, bus tickets, donated clothing and baby equipment, and advocacy on housing and other basic needs)
  • health-related and other support by a multidisciplinary team of professionals and paraprofessionals.

Sheway’s care providers take a woman-centred, harm reduction–based and culturally focused approach to providing these services.

A 2000 evaluation of Sheway’s work brought attention to the difficult lives of pregnant women and new mothers in the Downtown Eastside. It also highlighted the positive role that harm reduction approaches have had in the care of women who use substances and are at high risk, and of their families. The study looked at the outcomes for women who had accessed Sheway’s services in 1998, and found that the program had been successful in a number of ways:

  • Engaging women who use substances and are at high risk in prenatal and postnatal care on a range of health and social issues. At intake, 30 per cent of women had no medical or prenatal care, and by the time of their deliveries 91 per cent of women were connected to a physician or midwife (for the remaining nine per cent, the existence of prenatal and postnatal care was not known).
  • Supporting women as they improve their nutritional status. Of the women accessing services, 79 per cent had nutritional concerns at intake, whereas only four per cent had nutritional concerns at six months postnatal. (Nutritional concerns were defined as fewer than three meals a day, lack of money to buy adequate food, lack of knowledge of nutrition and food resources [e.g., food banks] or lack of kitchen facilities.) Women who use Sheway’s services are provided prenatal vitamins, hot lunches and information about food banks and community kitchens, as well as nutritional counselling—all of which may have contributed to this improvement in nutritional status.
  • Supporting women as they improve their housing. At intake, 27 per cent of the women had no fixed address, and 65 per cent in total had housing concerns. By six months after the birth of the child, only six per cent of the women had any housing concerns. (Housing concerns were defined as having no housing or having housing of an inadequate size; in a poor location; with overcrowding problems; or with safety, health or structural problems.)
  • Increasing the number of children with healthy birth weights. Eighty-six per cent of the babies whose mothers accessed care at Sheway were known to have a healthy birth weight (over 2,500 grams).
  • Helping women retain custody of their children. Over half (58 per cent) of mothers who used Sheway’s services were able to retain custody of their children (22 per cent had no involvement by the Ministry for Children and Families, and 36 per cent had ministry involvement for support only). The remaining 42 per cent of mothers did have their children apprehended; in these cases, 37 per cent were later returned to the care of the birth mother or her immediate family.

The evaluation also found that while using Sheway’s services, most women had not been able to completely stop using alcohol or other drugs, nor had they been able to participate in intensive substance use treatment. However, Sheway staff have found that stabilization and reduction in substance use are more possible when stability is established in basic life areas such as housing and food security.

Sheway staff, allied service providers and the women themselves see Sheway’s service philosophy as critical for women to feel safe and to access the help they need. The positive findings of this 2000 evaluation continue to inform harm reduction–based and woman-centred approaches to work with pregnant women and mothers who use substances and face a range of other health and social problems. In the face of known risks to the health of both mothers and children from substance use and exposure to the dangers of life in Vancouver’s Downtown Eastside, Sheway staff continue to expand their practice and understanding of how best to encourage pregnant women with substance use problems  to engage in prenatal and postnatal care, and to take realistic, small steps toward change.

Poole, N. (2007). Improving outcomes for women and their children: Evaluation of the Sheway Program. In N. Poole & L. Greaves (Eds.), Highs & Lows: Canadian Perspectives on Women and Substance Use. Toronto: Centre for Addiction and Mental Health. Adapted with permission from the Evaluation Report of the Sheway Project for High-Risk Pregnant and Parenting Women, authored by Nancy Poole and published in Vancouver by the British Columbia Centre of Excellence for Women’s Health in 2000. The full study is available from the centre’s website at www.bccewh.bc.ca/publications-resources/documents/shewayreport.pdf.

References

  1. Public Health Agency of Canada. (2004). The Social Determinants of Health: An Overview of the Implications for Policy and the Role of the Health Sector. Ottawa: Author. Available: www.phac-aspc.gc.ca/ph-sp/phdd/overview_implications/01_overview.html. Accessed July 13, 2007.
  2. Wilkinson, R. & Marmot, M. (2003). Social Determinants of Health: The Solid Facts (2nd ed.). Denmark: World Health Organization. Available: www.euro.who.int/document/e81384.pdf. Accessed July 13, 2007.
  3. Greaves, L., Cormier, R., Devries, K., Bottorff, J., Johnson, J., Kirkland, S. et al. (2003). Expecting to Quit: A Best Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women. Vancouver: British Columbia Centre of Excellence for Women’s Health. Available: www.hc-sc.gc.ca/hl-vs/pubs/tobac-tabac/expecting-grossesse/index_e.html. Accessed July 9, 2007.
  4. The “Expecting to Quit” Research Team. (2007). Better practices for smoking cessation with pregnant and postpartum women. In N. Poole & L. Greaves (Eds.), Highs & Lows: Canadian Perspectives on Women and Substance Use. Toronto: Centre for Addiction and Mental Health.
  5. Statistics Canada. (2003). Canadian Community Health Survey: Mental health and well-being. The Daily, September 3. Available: www.statcan.ca/Daily/English/030903/d030903a.htm. Accessed October 5, 2007.
  6. Centre for Addiction and Mental Health. (2002). CAMH Position on Harm Reduction: Its Meaning and Applications For Substance Use Issues. Toronto: Author. Available: www.camh.net/Public_policy/ Public_policy_papers/publicpolicy_harmreduc2002.html. Accessed July 11, 2007.
  7. Adlaf, E.M., Paglia, A. & Beitchman, J.H. (2004). The Mental Health and Well-Being of Ontario Students: Findings from the OSDUS 1991–2003. Toronto: Centre for Addiction and Mental Health.
  8. Centre for Addiction and Mental Health. (2006). Navigating Screening Options for Concurrent Disorders. Toronto: Author.
  9. U.S. Department of Health and Human Services. (2002). A Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration.
  10. Wise, B.K., Cuffe, S.P. & Fischer, T. (2001). Dual diagnosis and successful participation of adolescents in substance abuse treatment. Journal of Substance Abuse Treatment, 21 (3), 161–165.
  11. Health Canada. (2002). Best Practices: Concurrent Mental Health and Substance Use Disorders. Ottawa: Author. Available: www.hc-sc.gc.ca/ahc-asc/pubs/drugs-drogues/index_e.html. Accessed November 1, 2007.

Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers

General issues and background

Psychotropic medications and other substances: Properties, effects and recommendations

Resources

Index of drugs

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