Identifying Targets to Improve Antenatal Care for Substance Misuse in Pregnancy: An Observational Study

  

    
Child Outcome 
    
Substance Misuse Group n (%) 
    
Reference Group n (%) 
    
p-value
    
Odds Ratio (95% CI) 
    
Post Hoc Power (%) 
  
  

    
Social    Outcomes 
    

    

    

    

    

  
  

    
Social service    involvement 
    
33 
    
1 (2%) 
    

    

    

  
  

    
Child removed/out-of-home    care 
    
31a (39%) 
    
1 (2%) 
    

    

    

  
  

    
Health    Outcomes 
    

    

    

    

    

  
  

    
Full immunisation 
    
75b (86%) 
    
52 (100%) 
    

    

    

  
  

    
Mean number of GP    visits/5 year (range) 
    
28.7 ± 21.0 (0–126) 
    
30.6 ± 21.5 (1-130) 
    
0.6024 
    

    

  
  

    
Paediatric Assessment    Unit/A & E encounters 
    
0.8 ± 1.0 (0–4) 
    
0.6 ± 0.8 (0-3) 
    
0.2155 
    

    

  
  

    
Paediatric ward encounters/5    years 
    
1.0 ± 1.6 (0–8) 
    
0.6 ± 1.6 (0-10) 
    
0.1479 
    

    

  
  

    
Outpatient appointments/5    years 
    
2.6 ± 3.9 (0–17) 
    
2.4 ± 3.3 (0-16) 
    
0.7538 
    

    

  
  

    
Developmental delayc 
    
16d (23%) 
    
3 (6%) 
    
0.0206 
    
4.7 (1.3-17.0) 
    
66 
  
  

    
Assessed for ADHD, Autism 
    
4d (6%) 
    
1 (2%) 
    
0.2817 
    
3 (0.3-27.7) 
    
15 
  
  

    
Ophthalmology diagnosese 
    
19f (21%) 
    
2 (4%) 
    
0.0061 
    
6.6 (1.5-29.6) 
    
83 
  
  

    
Cardiac abnormalities-referred    to specialist cardiac unit 
    
2 
    
0 
    

    

    

  
  

    
Atrial septal defect due    to abilify (Aripriprazole) 
    
1 
    
0 
    

    

    

  
  

    
Hepatitis B positive 
    
1 
    
0 
    

    

    

  
  

    
a19    unknown. Population n=80.

      b10    unknown. Population n=89.

      cGlobal    delay and/or speech delay.

      d27    unknown. Population n=72.

      eDiagnoses    include: hypermetropia, esotropia, exotropia, amblyopia, astigmatism,    convergent strabismus, broad epicanthus, pseudosquint.

      f8 unknown. Population n=91. 
  

Table 5: Summary of child health and social outcomes of children born to substance-misuse and reference groups at five-year follow-up.

Discussion

Women who misuse substances during pregnancy are a high-risk group who are less likely to seek antenatal care [15]. Our maternal data and birth outcomes are consistent with other studies on substance misuse in pregnant women. Smaller average maternal BMI as well as illicit substance, alcohol and tobacco use have all been associated with increased likelihood of Small-for-Gestational-Age (SGA) infants [16-18]. Microcephaly [19], stillbirth18 19 and fetal alcohol spectrum disorders [22] are other reported negative outcomes.

Our study demonstrated good attendance to antenatal care in women with diagnosed mental health issues and taking psychiatric medication, indicating willingness by this sub-population to engage with the service throughout pregnancy. Attendance may therefore be motivated by continued access to established interventions such as Opiate Maintenance Treatment (OMT) [23] and psychiatric or analgesic medication such as tramadol.

However, expectant mothers who misuse alcohol throughout pregnancy demonstrated inadequate attendance and may represent an even higher risk category as the one least likely to access care. In our study, this risk was highlighted by a miscarriage and subsequent maternal death due to acute alcohol-induced liver injury. Given that fetal alcohol spectrum disorders are the most common yet preventable cause of intellectual disability in infants, motivating attendance and addressing the specific needs of this group is all the more necessary [22].

We suggest that current targeted interventions are limited in identifying and addressing polydrug misuse and high-risk groups that receive late or no antenatal care. Idealising abstinence and recovery in UK substance misuse policies could be an added deterrent by setting unrealistic goals [24]. Furthermore, the focus of these policies and research on separate individual drugs leads to failure in addressing polydrug use. Such a narrow approach can also overlook those women who do not qualify for interventions such as OMT [23].

The higher gravida in our results may also give credence to the hypothesis that young girls who misuse substances are more likely to engage in risky behaviour, are less likely to use contraceptives or use them unreliably, and may use sex to finance their habit [25,26]. A higher percentage of expectant mothers were separated from the child’s father. Where disclosed, a number of fathers were also recorded to misuse substances or had a history of domestic violence.

We recommend broader and more realistic policies and interventions to target polydrug and alcohol misuse, not just single substances. Booking and subsequent antenatal check-ups should systematically screen for polydrug use along with tobacco use and evaluate psychiatric history. Further consideration should be given to life circumstances through non-judgemental enquiries and appropriate documentation of domestic abuse or partner drug use [23].

Interventional programmes should involve a single location for combined services such as social services, midwifery, education and counselling, and coordination of care between primary care, psychiatry, obstetrics and gynecology, and mental health providers [6,17,24,27-29]. Scheduled appointments or community health visits with a specially trained staff member who can form a reciprocal and continuous working relationship could make a difference with the woman’s engagement with the service.

Improving access to sexual health and contraceptive services could limit the number of unwanted pregnancies in this population. This could be integrated into holistic assessments when these women present in primary care or to drug and alcohol misuse agencies. Increased use of Long Acting Reversible Contraceptives should be considered when appropriate because of their lower failure rates.

At the five-year follow-up, there was an increased incidence of global developmental and speech delay and a significantly higher number of ocular diagnoses in children of the substance-misuse group [30]. Evidence of abnormal visual development continuing into mid-infancy following perinatal drug misuse is increasing. Reported ocular manifestations include nystagmus, strabismus, delayed visual maturation, lack of binocularity and reduced visual acuity [31].

Longer-term improvements in child outcomes are associated with stable care provision and early promotion of resilience and protective factors [2]. Professionals thus need to identify children at risk from perinatal drug exposure through non-judgemental support and intervention as soon as possible. Targeted interventions to improve immunisation rates are recommended as well as ophthalmology assessment in all these children under the age of five years.

Limitations

Despite its many outcomes, our study had some limitations. This was a single-centre study with a small population sample. However, from current literature and our demographic, we believe our study is representative of the typical low-income, substance-misusing population where polydrug use is a common alongside tobacco and alcohol use. The study design accounted for concomitant affects such as economic, financial and educational level by matching the substance misuse and reference groups for postcode and deprivation score. However, as well as differences in average age and BMI, mental health, psychiatric and domestic issues are added risk factors for poor perinatal outcomes.

Heterogeneous polydrug and alcohol misuse are also noted in other studies and generate added difficulties in correlating the effects of individual substances with obstetric and infant outcomes [23,32]. In this case, the small population size did not lend itself for multivariate analysis. Post-hoc power analysis demonstrated that the study is underpowered, especially in demonstrating significant effects between good and poor attendees. However, the initial study was not designed to measure size effects post intervention. As a service evaluation, the sample size was sufficient in comparison with outcomes of other similar population studies to identify local trends and knowledge gaps as a means of improving antenatal care in substance misuse [12]. The outcomes may also be subject to selection bias, as the sample was composed of women who attended at least one scheduled antenatal clinic and therefore represent the most motivated subpopulation of women with a history of substance abuse. Finally, every effort was made to collect a complete data set but this retrospective study was subject to attrition bias as a number of children were lost to follow-up.

Conclusion

Current interventional programmes remain too focussed on single issues and need to consider polydrug misuse and a range of connected health, social and domestic issues. Our data further identifies high-risk groups, in particular those with high alcohol consumption, who require increased motivation to attend antenatal care. Long-term biopsychosocial outcomes of children of substancemisusing mothers suggest a need for earlier intervention and longerterm follow-up with screening for ocular and developmental delays.

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