Public Health Wales
Early years pathfinder project
Substance misuse (alcohol and drugs)
Early Years Pathfinder Project
Substance misuse
(alcohol and drugs)
Author: Dr Sarah J Jones, Consultant in Environmental Health Protection
Contributors:
Craig Jones, Senior Health Promotion Practitioner, Alcohol, Public Health
Wales
Josie Smith, Research Scientist, Health Protection, Public Health Wales
Chris Weaver, BCUHB, Substance misuse liaison midwife
Julie Evans, Cwm Taf HB, Senior Midwife
Rhys Sinnett, Principal Public Health Practitioner, Hywel Dda Public Health
Team
Jackie Williams, Senior Health Promotion Practitioner, Aneurin Bevan Public
Health Team
Sophia Bird, Principal Public Health Practitioner, Powys Public Health Team
Lynne Hockey, Clinical information analyst, ATTRACT
Jon Brassey, Support Manager, ATTRACT
Date: 8 May 2013
Version: 0d
Review Date:
Purpose and Summary of Document:
To outline the epidemiology of alcohol and substance misuse during
pregnancy and early years, to review the evidence of effectiveness for
interventions to reduce alcohol and substance misuse during pregnancy and
early years and to outline the current provision of services to reduce alcohol
and substance misuse during pregnancy and early years.
Work Plan reference:
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1
Summary
1.1
Background
Early years pathfinder project
Substance misuse (alcohol and drugs)
This document briefly reviews the evidence around the prevalence of
substance misuse during pregnancy and the implications of this during
pregnancy and early years (EY). It then examines the epidemiology of
substance misuse in Wales, as far as is possible using currently available
data, before reviewing the evidence for interventions to identify substance
misusing women who are pregnant and also to ‘treat’ their misuse. Finally,
detail is provided on current service provision in Wales.
The document uses the ‘catch all’ term substance misuse, but also uses
alcohol misuse and drug misuse to describe issues in relation to these
situations specifically. This review covers “[the] regular use of recreational
drugs, misuse of over-the-counter medications, misuse of prescription
medications, misuse of alcohol or misuse of volatile substances to an
extent whereby physical dependence or harm is a risk to the woman and /
or her unborn baby”. It does not cover tobacco or caffeine.
1.1.1
Alcohol
Alcohol is known to pass freely across the placenta from mother to child,
but the precise effects of this are not clear. As a result, clear guidance on
alcohol consumption during pregnancy is lacking both in the UK and
internationally.
There is little, if any, published data describing the prevalence of alcohol
consumption by pregnant women in the UK. Internationally, it has been
suggested that up to 60% of pregnant women consume alcohol, with up to
50% binge drinking at least once (Kalin et al, 2010; Kesmodal et al,
2003).
1.1.2
Drug misuse
Drug misuse covers prescription and recreational drugs, both legal and
illegal. While prescription drugs tend to carry guidance on use by pregnant
women, the general assumption about recreational drugs appears to be
that that any consumption is harmful.
UK data suggests that around 15% of pregnant women have used
cannabis or other illicit substances, with around 1-2% using heroin or
cocaine (Sherwood et al, 1999; Crome and Kumar, 2007; Williamson et al,
2007). Much of the international data on substance misuse is from the
USA and it is difficult to assess how applicable these data are outside of
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Substance misuse (alcohol and drugs)
the US. It is suggested that up to 27% of pregnant US women have used
cannabis, with 1.6 to 9.5% using cocaine or opiates.
1.1.3
Alcohol - outcomes
There is a link between alcohol consumption and complications or
problems during both pregnancy and EY. However, there is a lack of clear
data demonstrating the outcomes for any given level of consumption. On
this basis, the application of the precautionary principle and guidance not
to drink at all during pregnancy is only appropriate.
1.1.4
Drug misuse – outcomes
Based on the evidence available, mainly in relation to illegal drugs, there
are consistently poor outcomes associated with drug misuse during
pregnancy. Whilst the precise outcomes appear to vary with the substance
used intra-uterine growth retardation (IUGR), placental abruption and still
birth are common across multiple substances.
1.2
Epidemiology
There is a clear lack of data on the prevalence of substance misuse during
pregnancy and the incidence of harmful outcomes resulting from these
behaviours.
The Infant Feeding Survey (IFS) appears to offer more promise in terms of
understanding and addressing substance misuse issues, even given that
the data are likely to underestimate the prevalence of the problem and
suffer a number of biases. As long as these data are understood to be a
low estimate they can be used with appropriate caution. In addition, it is
difficult to see how else these data could be collected.
Without better data, adequately planning and managing services to tackle
these issues is almost impossible.
1.3
Evidence
In terms of screening, AUDIT-C appears able to identify problem drinking
amongst pregnant women, but TWEAK and T-ACE are also effective
screening tools. However, there is little or no evidence in relation to
effective interventions for addressing substance misuse during pregnancy
and EY.
1.4
Service provision
Service provision varies around Wales. The focus appears mainly to be on
drug misuse and safeguarding.
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1.5
Early years pathfinder project
Substance misuse (alcohol and drugs)
Conclusions
There are obviously significant problems associated with substance misuse
during pregnancy, but there are many difficulties with determining the
response needed to these problems, mainly because of a lack of
knowledge and understanding.
1. The dose: response relationship between alcohol and negative
outcomes is not clear.
2. The links between drug misuse and negative outcomes is not clear.
There is a particular lack of controlling for socio-economic
confounders in analysis.
3. The prevalence of substance misuse during pregnancy is not clear,
but given the prevalence of excess alcohol consumption in the
population, it is likely that many women are consuming harmful
amounts of alcohol pre-pregnancy and pre-pregnancy recognition.
4. There is some evidence of effectiveness for screening tools to detect
substance misuse in pregnant women, but no good evidence for
interventions to address the issue.
5. The services that are currently in place appear to focus on drug
misuse and the associated safeguarding issues.
1.6
Recommendations
1. All pregnant women should be given advice to moderate their
drinking, but older, professional women, in particular, should be
targeted.
2. To support this, all health care professionals who are in contact with
women who are either pregnant or thinking of becoming pregnant
should be trained to deliver alcohol brief interventions (ABI).
However, given the lack of good quality evidence in this area
generally, robust evaluation of such an approach would need to be
carried out to inform the evidence base.
3. In addition, advice is both easier to give and act upon when the
message is consistent. Constant changes to advice in relation to
alcohol are unhelpful, cause confusion and can also result in a lack
of trust and regard for future messages, not only in relation to
alcohol, but also for other health issues. Significant efforts are
therefore needed to establish an appropriate guideline, with a
regular time table for review.
4. Collection of more accurate data around substance misuse
prevalence and pregnancy outcomes is needed, but careful
consideration of how to collect these data accurately is also
essential.
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1.7
Early years pathfinder project
Substance misuse (alcohol and drugs)
Update on recommendations
To support the delivery of recommendation 2, the Public Health Wales
programme to reduce alcohol related harm has been delivering alcohol
brief intervention (ABI) training to midwives. Delivery is influenced by
Health Board priorities; to date, just 13.2% of Welsh midwives have been
trained to deliver ABI.
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Substance misuse (alcohol and drugs)
Contents
1
SUMMARY ............................................................................... 2
1.1 Background.......................................................................... 2
1.1.1
Alcohol .......................................................................... 2
1.1.2
Drug misuse ................................................................... 2
1.1.3
Alcohol - outcomes .......................................................... 3
1.1.4
Drug misuse – outcomes.................................................. 3
1.2 Epidemiology ....................................................................... 3
1.3 Evidence .............................................................................. 3
1.4 Service provision .................................................................. 3
1.5 Conclusions .......................................................................... 4
1.6 Recommendations ................................................................ 4
2
BACKGROUND ......................................................................... 8
2.1 Terminology ......................................................................... 8
2.2 Alcohol consumption guidelines .............................................. 8
2.2.1
Policies from other countries ............................................ 9
2.2.2
Minimum legal drinking age ............................................ 10
2.2.3
Consumption during pregnancy and early years - Wales and
UK
12
2.2.4
Consumption during pregnancy in other countries ............. 12
2.3 Drug misuse........................................................................ 12
2.3.1
Drug misuse during pregnancy and early years - UK.......... 13
2.3.2
Drug misuse during pregnancy in other countries .............. 13
2.4 Outcomes of alcohol misuse during pregnancy and early years .. 14
2.4.1
Pre-pregnancy, pre-pregnancy recognition, pregnancy....... 14
2.4.2
Early years – ‘regular’ alcohol consumption ...................... 15
2.4.3
Early years – binge drinking ........................................... 15
2.4.4
Conclusions .................................................................. 16
2.5 Outcomes of substance misuse during pregnancy and early years
......................................................................................... 17
2.5.1
Pre-pregnancy, pre-pregnancy recognition, pregnancy....... 17
2.5.2
Early years ................................................................... 18
2.5.3
Conclusions .................................................................. 18
2.6 Policy context ...................................................................... 19
3
EPIDEMIOLOGY .................................................................... 20
3.1 Patient Episode Database Wales – PEDW ................................ 20
3.1.1
P04.3, P04.4, P04.9 ...................................................... 21
3.1.2
P96.1 – withdrawal from drugs of addiction ...................... 21
3.1.3
Q86 – foetal alcohol syndrome........................................ 22
3.2 Infant feeding surveys .......................................................... 23
3.3 Infant feeding survey - 2005 ................................................. 23
3.3.1
Wales .......................................................................... 23
3.3.2
UK .............................................................................. 24
3.4 Infant feeding survey – 2010 ................................................ 26
3.5 Summary comments ............................................................ 26
4
EVIDENCE OF EFFECTIVENESS .............................................. 28
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Substance misuse (alcohol and drugs)
4.1 Introduction ........................................................................ 28
4.2 Methods ............................................................................. 28
4.3 Screening for substance misuse ............................................. 29
4.4 Interventions for alcohol misuse ............................................ 30
4.5 Interventions for drug misuse during pregnancy ...................... 30
4.6 Interventions for substance misuse during pregnancy .............. 30
4.7 Interventions for FAS ........................................................... 31
5
CURRENT SERVICE PROVISION ............................................ 32
5.1 Antenatal care guidelines ...................................................... 32
5.2 Current service provision by Health Board ............................... 33
5.2.1
Aneurin Bevan Health Board / Gwent APB ........................ 33
5.2.2
Betsi Cadwaladr Health Board ......................................... 34
5.2.3
Powys Health Board ...................................................... 34
5.2.4
Cardiff and Vale Health Board ......................................... 34
5.2.5
Cwm Taf Health Board ................................................... 34
5.2.6
Hywel Dda Health Board ................................................ 35
5.2.7
Abertawe Bro Morgannwg Health Board ........................... 36
6
CONCLUSIONS AND RECOMMENDATIONS ............................. 39
6.1 Recommendations ..................... Error! Bookmark not defined.
7
REFERENCES ......................................................................... 40
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2
Background
2.1
Terminology
Early years pathfinder project
Substance misuse (alcohol and drugs)
The term ‘substance misuse’ can cover both alcohol and/or drugs and in
relation to pregnancy be defined as the “regular use of recreational drugs,
misuse of over-the-counter medications, misuse of prescription
medications, misuse of alcohol or misuse of volatile substances (such as
solvents or inhalants) to an extent whereby physical dependence or harm
is a risk to the woman and/or her unborn baby” (NICE, 2011).
However, ‘substance misuse’ is not always used to cover both of these
broad categories and much of the literature focuses on one or the other.
This may be due to the fact that alcohol is wholly ‘legal’, with government
issued guidelines on consumption which leads to inaccurate assumptions
about the safety of consumption, whilst drug misuse covers both legal and
illegal substances.
This document uses the terms ‘alcohol misuse’ and ‘drug misuse’ to
describe these issues separately and refers to ‘substance misuse’ as a
general catch-all. One of the key reasons for doing this is the need to
address alcohol related harm. There is a general lack of awareness, both
amongst the general public and health professionals, about the prevalence
of the harmful consumption of alcohol and the extent to which alcohol
related harm exists. This is reflected in the Welsh Government policy on
substance misuse “Working together to reduce harm” (WG, 2008), which
highlights the fact that the harmful use of alcohol is far more widespread
than that of drugs. It seems not unreasonable to suggest that the harmful
use of alcohol is almost universal and that approaches to managing the
problem should regard this as the start point.
Therefore, the terms are split to emphasise the need to address alcohol as
a misused substance, in the population as a whole, in the same way as is
necessary with drugs.
Caffeine is not included in this review, however, the use / misuse of
caffeine mainly in energy drinks, should be considered for future updates.
Tobacco is also excluded, but is covered elsewhere.
2.2
Alcohol consumption guidelines
Consumption of alcohol during pregnancy is a complex issue; alcohol
passes freely across the placenta from mother to foetus, but the precise
effects of it are not clear. Possible outcomes of excessive alcohol
consumption during pregnancy may include miscarriage, stillbirth, low
birth weight (LBW), learning disabilities and hyperactivity as well as foetal
alcohol spectrum disorder (FASD) (Nilsen, 2009; Botchway, 2012).
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However, definitive ‘dose-response’ evidence is lacking and not all women
who drink heavily during pregnancy give birth to babies with FASD.
This means that there is a lack of good quality evidence about how much
it is safe to drink. The House of Commons Science and Technology
Committee (2011) reviewed the available evidence and concluded that
there are no safe limits and that a great deal of uncertainty remains,
producing contrasting but equally probable concluding statements:1. There is no evidence for a level of risk free drinking during
pregnancy
2. Drinking one or two units once or twice per week has not been
shown to be harmful.
The Committee highlighted the lack of consideration of the available
evidence in relation to the production of guidelines by the Department of
Health (DH) (HCSTC, 2011). It then went on to conclude that advice
produced by the UK Chief Medical Officers (CMOs), encouraging
abstinence but providing advice for women who do wish to drink alcohol,
adequately balanced scientific uncertainty with a precautionary approach
and provided the most appropriate guidance in relation to drinking during
pregnancy (HCSTC, 2011).
Recently, the UK DH produced guidance based on the recommendations of
the UK CMOs and suggested that pregnant women should avoid drinking
alcohol, but that if they did choose to drink, they should not drink any
more than 1 or 2 units1 of alcohol once or twice per week and should not
get drunk. In addition, NICE (2010b) recommend not drinking at all during
the first three months of pregnancy because of the increased risk of
miscarriage.
It is also recommended that getting drunk or binge drinking (defined as
5+ standard drinks or 7.5 UK units on a single occasion), may be harmful
to the unborn baby (NICE, 2010b). However, it should also be noted that
the DH uses the Office for National Statistics (ONS) definition of heavy
drinking as a proxy for binge drinking, referring to 6+ units (for women)
over the course of an evening or similar time span (BMA, 2007).
2.2.1
Policies from other countries
Therefore the UK lacks clear guidance on safe levels of alcohol
consumption within the general population and for pregnant women.
However, review of guidance in place in other countries suggests that this
lack of clarity is not uncommon (Furtwaengler and De Visser, 2012).
1
In the UK, a standard drink, or unit of alcohol, refers to 8g ethanol (Furtwaengler and De Visser, 2012)
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Whilst ‘moderation’ is recommended consistently, what moderation is is
rarely defined; similarly a ‘standard drink’ lacks clear definition
(Furtwaengler and De Visser, 2012). The WHO Europe recommend a
maximum of two standard drinks (20g ethanol) per day, for both men and
women, and that pregnant women should be alcohol free (Furtwaengler
and De Visser, 2012).
In the UK, a standard drink (unit of alcohol) refers to 8g ethanol; in
Slovakia, it is 14g ethanol (Furtwaengler and De Visser, 2012;
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Table 1). Some countries produce daily guidelines, some daily and weekly,
some weekly only; the weekly guideline may be 7 times the daily
guideline, or it may allow for alcohol free days (Furtwaengler and De
Visser, 2012).
The list shown is based on an initial review of 57 countries, of which 27
were found to have low risk drinking guidelines that could be expressed in
grams of ethanol. Further review found that 145 countries have specified
limits on alcohol consumption whilst driving, but just 14 have published
guidelines on consumption during pregnancy, all of which recommend not
drinking at all (Furtwaengler and De Visser, 2012). In some countries,
women are also advised not to drink during the first few months of a
baby’s life nor if they are planning to become pregnant.
The review concluded that a standard drink should be 10g ethanol, that
women should drink no more than two standard drinks per day (12 per
week), men no more than 3 standard drinks per day (18 per week) and
that pregnant and breast feeding women should not consume any alcohol.
In addition, men and women should have at least one alcohol free day per
week (Furtwaengler and De Visser, 2012).
All of these issues highlight that making comparisons between countries,
generalising the findings of research carried out in different countries and
applying interventions that have good evidence of effect in other
countries, is very difficult.
2.2.2
Minimum legal drinking age
Minimum legal drinking age is also an important part of understanding
likelihood of alcohol consumption during pregnancy. In the UK, the
minimum is 18 years, as it is across most countries of the world. In the
USA it is up to 21 years, with state to state variations, whilst in a number
of countries, including Germany, Greece, Norway, Poland, Portugal, Spain
it is 16 years (Hanson, 2012). However, in many places, exemptions apply
that mean that consumption is permitted at younger ages under certain
conditions, for example, whilst drinking at home with parents.
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Table 1:- Summary of international guidelines on recommended daily alcohol consumption. Adapted
from Furtwaengler and De Visser (2012).
USA
g ethanol per
standard drink /
unit
14
Recommended daily consumption
Males
Females
g ethanol
units
g ethanol
units
56
4
42
3
Guidelines for
consumption during
pregnancy?
Yes
Mexico
--
48
--
36
--
Ireland
10
40
4
30
3
Estonia
10
40
4
20
2
Poland
10
40
4
20
2
Switzerland
10
40
4
20
2
Yes
Italy
12
36
3
24
2
Yes
South Africa
12
36
3
24
2
UK
8
32
4
24
3
Brazil
10
30
3
20
2
Bulgaria
10
30
3
20
2
France
10
30
3
20
2
Yes
Netherlands
10
30
3
20
2
Yes
New Zealand
10
30
3
20
2
Yes
Singapore
10
30
3
20
2
Spain
10
30
3
20
2
Slovakia
14
28
2
14
1
Canada
13.45
40.35
3
26.9
2
Austria
--
24
--
16
--
Czech Republic
--
24
--
16
--
Germany
12
24
2
12
1
Iceland
12
24
2
12
1
Australia
10
20
2
20
2
Portugal
10
20
2
20
2
Finland
12
20
1.7
10
0.8
Hong Kong
10
20
2
10
1
Slovenia
10
20
2
10
1
Denmark
12
--
--
--
--
Lithuania
10
--
--
--
--
Sweden
12
--
--
--
--
Yes
Kenya
--
--
--
--
--
Yes
Norway
--
--
--
--
--
Yes
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Yes
Yes
Yes
Yes
Yes
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2.2.3
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Substance misuse (alcohol and drugs)
Consumption during pregnancy and EY
Whilst many women reduce their alcohol consumption once they know
that they are pregnant, high consumption levels in the time between
becoming pregnant and recognising a pregnancy may be common.
2.2.4
Consumption during pregnancy and EY - Wales and UK
There is little available data describing the extent to which alcohol is
consumed by pregnant women in the UK. However, it has been suggested
that 64,000 Welsh children may be adversely affected by parental alcohol
problems (NPHS, 2006).
2.2.5
Consumption during pregnancy in other countries
International estimates of alcohol exposure range from 0.2% to 14.8%
depending on the stage of pregnancy, definition of exposure, diagnostic
classification and method of assessment (Crome and Kumar, 2007).
In Australia, it has been estimated that 47% of pregnant and / or breast
feeding women were using alcohol (Turner et al, 2003). However, more
recent data suggest that this had risen to 59% (Kalin et al, 2010). Risky
alcohol use during the first 6 weeks of pregnancy has been estimated at
15% in Sweden (Magnusson et al, 2005). In the USA, 9% to 15% of
pregnant 18 to 44 year olds use alcohol, with 2% to 4% binge drinking
(CDC, 2006; Shankaran et al, 2007; SAMHSA, 2003; Guerrini et al, 2009).
Alcohol consumption during pregnancy has also been estimated at 30% in
Sweden, 52% in France and 60% in Russia (Kalin et al, 2010).
A Danish study found that 10-25% of women were binge drinking and that
50% binged at least once in the pre-pregnancy recognition period
(Kesmodal, 2001; Kesmodal et al, 2003).
2.3
Drug misuse
Therefore, clear guidelines in relation to safe alcohol consumption during
pregnancy are difficult to establish. For over-the-counter (OTC) and
prescription drugs, there is often much clearer guidance available in
relation to the harms associated with use or misuse. The harm associated
with, e.g. thalidomide, in the past is well documented and appears to have
contributed to the development of more robust testing and guidance.
For recreational drugs however, evidence is again vague; the presumption
appears to be that any use of illegal drugs is harmful. However, recent
guidance from NICE, stated that the direct effects of cannabis on the
foetus are uncertain, but it may be harmful, not least because cannabis
use is associated with smoking and smoking is known to be harmful,
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therefore women should be discouraged from using cannabis while
pregnant (NICE, 2010b). Recreational drugs that are not illegal, with the
exception of tobacco and caffeine, also appear to fall under this general
heading.
2.3.1
Drug misuse during pregnancy and early years - UK
The Confidential Enquiry into Maternal Deaths in the UK 2000 to 2002
found that 8% of all deaths up to 1 year from delivery were caused by
drug misuse (Lewis, 2004), whilst a study in an inner-city clinic in the UK
in 1999 found that 16% of women had taken 1 or more illicit substances
(Sherwood et al, 1999).
Cannabis use amongst pregnant women has been estimated at 8.5% to
14.5% at 12 weeks gestation (Sherwood et al, 1999; Farkas et al, 1995).
In Glasgow, meconium analysis found that 15% of mothers had used
cannabis in the second or third trimester (Williamson et al, 2003). Opiate
use has been reported as 2% (Crome and Kumar, 2007). Use of cocaine is
reported to be less than 1.1% (Williamson et al, 2007, Sherwood et al,
1999, Farkas et al, 1995). Of a cohort of pregnant substance misusers in
Liverpool, 66.8% were using heroin, 33.2% cocaine and 11.3%
benzodiazepines (Pinto et al, 2010).
There is a lack of data on use of prescription or OTC medications during
pregnancy. Also lacking are data on volatile substance use.
In Wales, it has been estimated that 17,500 children and young people
live in families affected by parental drug misuse (Home Office, 2003).
Overall, it is estimated that one third of child care social work cases
involve parental substance misuse.
Although specific data on pregnant women are not available, it has also
been suggested that anabolic steroid use amongst females is increasing
(WG, 2008). Logically, therefore, this is likely to affect some women who
become pregnant.
2.3.2
Drug misuse during pregnancy in other countries
In the USA, 4.3% to 5.5% of pregnant women aged 15 to 44 were found
to have used illicit drugs during pregnancy (Slutsker et al, 1993;
Shankaran et al, 2007). However, amongst pregnant 15 to 17 year olds
only, this increased to 15.5% (SAMHSA, 2006). Illicit drug use in Australia
is reported as 6% (AIHW, 2004).
Cannabis use during pregnancy has been suggested to range from 1.8%
to 27% (Buchi et al, 2003; Williamson et al, 2003; Bell and Lau, 1995). In
the US, opiate use has been estimated at 1.6% to 7.2%, with cocaine use
ranging from 1.1% to 9.5% (Crome and Kumar, 2007, NIDA, 1996; Lester
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et al, 2001). Cocaine use has also be suggested to be 49 times more likely
to be associated with use of other drugs (Lester, 1996).
In a US study of pregnant trauma clinic patients (n=188), 37 tested
positive for intoxicants; 16 positive tests involved two or more intoxicants,
with four involving three or more. Alcohol accounted for just four cases,
with opiates (n=15), cannabis (n=12), cocaine (n=6) and benzodiazepines (n=6) also detected (Patteson et al, 2007).
2.4
Outcomes of alcohol misuse during pregnancy and
EY
2.4.1
Pre-pregnancy, pre-pregnancy recognition, pregnancy
The primary outcome of alcohol misuse during pregnancy and EY may be
the pregnancy itself; binge drinking is commonly associated with
unprotected sex and unplanned pregnancy and often then continues until
the pregnancy is recognised (Nulman et al, 2004).
Miscarriage is often highlighted as a risk associated with alcohol
consumption during pregnancy; risk increased by 46% in women who
drink weekly (OR 1.46, 95%CI 1.16 to 1.85), by 64% in those who drink
more than 14 units per week (OR 1.64, 95%CI 1.09 to 2.47) and by 3.8
times in women who drink daily (OR 3.80, 95%CI 1.28 to 11.30;
Maconochie et al, 2007). However, a systematic review has also found no
conclusive evidence of effect (Henderson et al, 2006).
Brain and central nervous system (CNS) impairment and IUGR have also
been associated with alcohol consumption during pregnancy (BMA, 2007;
Shankaran et al, 2007).
Pre-term labour is associated with high levels of alcohol consumption in
early and late pregnancy and low to moderate levels associated with an
increased risk of still birth (BMA, 2007). Based on this information,
however, it is therefore logical to infer that it is preferable to drink more
alcohol than less.
These serious consequences of alcohol consumption during pregnancy are
complicated by the fact that women who misuse substances are known to
have poorer obstetric and neonatal outcomes, along with late booking and
poor attendance for antenatal care (NICE, 2011). However, clear, robust
interventions that can improve attendance and outcomes have not yet
been identified.
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2.4.2
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Substance misuse (alcohol and drugs)
Early Years – ‘regular’ alcohol consumption
FASD are a series of preventable mental and physical birth defects
resulting from maternal alcohol consumption during pregnancy (BMA,
2007). In the neonate, these may include facial deformities, physical and
emotional developmental problems, memory and attention deficits and a
variety of cognitive and behavioural problems (BMA, 2007). There is also
the potential for mental illness and alcohol and drug addiction (BMA,
2007).
The term FASD covers a range of disorders, from Fetal Alcohol Syndrome
(FAS) to Partial FAS (PFAS), Alcohol related birth defects (ARBD) and
Alcohol related neuro-developmental disorders (ARND). In the USA, FASD
is estimated to cost an additional $500,000 per case over a 20 year
period, with lifetime costs estimated at $2M (BMA, 2007).
FAS is regarded by some as the leading cause of non-genetic intellectual
disability in the Western World (BMA, 2007). However, the evidence in
relation to incidence in the UK is poor, England reported 128 cases in
2002/3, Scotland 2 cases, with no data available in either Wales or
Northern Ireland (BMA, 2007). Although data collection may have
improved since then, significant changes seem unlikely. Estimates suggest
that in Western countries up to 9 per 1000 live births will be affected by
FAS, PFAS or ARND (BMA, 2007), however, it has also been suggested
that the incidence in Europe is 0.4 per 1000 live births (Abel, 1998). In
the USA, FAS incidence has been estimated at 0.2 to 2.0 cases per 1000
live births (CDC, 2004).
In 2007, the BMA reported that the existence of FAS is still debated in the
UK (BMA, 2007) and there is no good reason to believe that this position
has changed significantly since then.
In Canada, the USA, New Zealand and Australia, FAS is a data item in the
National Paediatric Surveillance Units, but neither FAS, nor FASD are
currently included in the British Paediatric Surveillance Unit (BPSU). In
2007, the BMA called for FAS data to be routinely collected and extended
to the full range of FASD in order to accurately determine incidence.
There are other EY outcomes associated with alcohol consumption during
pregnancy; there is evidence to suggest that pre-natal alcohol exposure is
associated with increased risk of Sudden Infant Death Syndrome (SIDS)
and acute myeloid leukaemia (Kalin et al, 2010; BMA, 2007).
2.4.3
Early years – binge drinking
The effects of binge drinking have been suggested to include decreases in
birth weight and length (Shankaran et al, 2007), however, it has also
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been found that length, head circumference and weight, up to the age of
14, are not associated with binge drinking (Sampson et al, 1994).
Binge drinking (defined as 10 or more units on a single occasion) has been
associated with more birth abnormalities, especially where the mother also
smoked 10 or more cigarettes per day (Bell and Lumley, 1989).
One study of development found that at 18 and 36 months there were no
significant differences between children of mothers who binged and those
who did not (Olsen, 1994, Nulman et al, 2004). A much longer term
follow-up (14 years) by the Seattle Longitudinal Prospective Study on
Alcohol and Pregnancy (Streissguth et al, 1983, Streissguth et al, 1989,
Streissguth et al, 1990) found significantly more learning problems and
poorer performance, as assessed by both parents and teachers, in children
of binge drinking mothers.
Neonatal mortality in pregnancies complicated by heavy alcohol intake is
estimated as 18% (Kuczkowski, 2005).
2.4.4
Conclusions
There is a link between alcohol consumption and complications or
problems during both pregnancy and EY. However, there is a lack of clear
data on outcomes associated with a given level of consumption. On this
basis, the application of the precautionary principle and guidance not to
drink at all during pregnancy is only appropriate.
However, there are no consistent findings of adverse effects with low
consumption of alcohol or occasional binge drinking.
Lack of consistent guidelines, agreed standard drinks and poor
understanding throughout the population of consumption levels means
that obtaining a clear understanding of harmful consumption of alcohol
during pregnancy and actual consumption of alcohol during pregnancy is
very difficult. These issues make it not unrealistic to imagine that it will
never be possible to clearly define the dose:response relationship between
alcohol consumption and pregnancy outcomes.
In addition, international variations mean that identification of robust
interventions to tackle the problem is also likely to be very difficult.
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2.5
Outcomes of substance misuse during pregnancy
and early years
2.5.1
Pre-pregnancy, pre-pregnancy recognition, pregnancy
As stated previously, substance misuse generally is associated with fewer
pre-natal visits (Shankaran et al, 2007).
Cocaine users have been found to have a higher risk of complications such
as syphilis, gonorrhoea and hepatitis, as well as psychiatric, nervous and
emotional disorders, and placental abruption (Shankaran et al, 2007).
Miscarriage, prematurity, still birth and IUGR have also been linked to
cocaine use (Frost et al, 2011).
Amphetamine exposure during pregnancy has been associated with
cardiac anomalies, cleft lip and palate, biliary atresia, IUGR, fetal demise,
cerebral haemorrhage, fetal distress and placental abruption (Kuczkowski
and Benumof, 2003).
Opioid use has indirect effects linked to maternal malnutrition or infection
and direct effects on the fetus including transplacental opioid transfer,
IUGR and fetal distress (Kuczkowski, 2003; Kuczkowski, 2003b;
Fajemirokun-Odudeyi et al, 2006). Other complications include third
trimester bleeding, placental abruption, LBW and still birth (Frost et al,
2011).
The precise effects of cannabis on pregnancy are difficult to establish
because of the tendency for it to be used in combination with tobacco,
alcohol and cocaine (Kuczkowski, 2004). However, decreased uteroplacental perfusion and IUGR seem likely (Kuczkowski, 2007), there is
also a suggestion that it increases the risk of pre-term birth (Bada et al,
2005; Wright et al, 1998; Kliegman et al, 1994; Shiono et al, 1995; Burns
et al, 2006).
Perinatal substance abuse is also an important risk factor for trauma
during pregnancy and may complicate outcomes associated with other
causes of trauma (Patteson et al, 2007). A US study of 160 pregnant
women treated in an emergency department (ED) following a road traffic
crash (RTC) tested 82 for intoxicants (51%) and found that 37 (45% of
tested) were positive, including 27 who were driving. Seat belt use by the
intoxicated group was significantly lower (p=0.015) than the group who
were not intoxicated (Patteson et al, 2007). There were also 28 non-RTC
trauma patients, of which 11 were tested for intoxicants and 8 were
positive; these women had suffered falls (n=3), assault (n=2), gunshot
(n=1), bicycle crash (n=1) and pedestrian injury (n=1) (Patteson et al,
2007).
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2.5.2
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Substance misuse (alcohol and drugs)
Early years
Cocaine use has been associated with risk of premature birth, LBW and
smaller birth length and head circumference, but not with congenital
abnormalities (Shankaran et al, 2007). Heavy cocaine use has been found
to increase risk of subependymal haemorrhage by 3.89 times (95%CI
1.45 to 10.35; Frank et al, 1999). Other effects of cocaine use in the
neonate include CNS symptoms, autonomic nervous system (ANS)
symptoms and infections, as well as increased child protection referrals
and less breast feeding (Shankaran et al, 2007).
Opiates have been found to have a significant negative effect on birth
weight (Shankaran et al, 2007), along with problems for the neonate of
prematurity, opiate withdrawal, growth aberrations, microcephaly and
neurobehavioural abnormalities (Dattel, 1990).
The use of cannabis has not been found to be linked to teratogenicity, but
is associated with LBW and delayed cognitive development (Kuczkowski,
2007).
Maternal complications of cocaine use include placental abruption, uterine
rupture, cardiac dysrhythmias, hepatic rupture, cerebral ischemia /
infarction and death (Dombrowski et al, 1991; Kuczkowski, 2003c; Mishra
et al, 1995, Buehler, 1995, Iriye et al, 1994, Lampley et al, 1996, Moen et
al, 1993).
2.5.3
Conclusions
Much of the literature that is available around drug misuse relates only to
illegal recreational drugs and only a subset of those. The data that are
available tend to reflect drug problems and outcomes that are common in
the USA and it is difficult to determine the extent to which these are
relevant in Wales.
There is a lack of data on the outcomes associated with misuse of
prescription or OTC medications during pregnancy. There is also a lack of
information around volatile substance use and the implications for
pregnancy and EY.
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2.6
Early years pathfinder project
Substance misuse (alcohol and drugs)
Policy context
The key policy document relating to substance misuse in Wales is
“Working Together to Reduce Harm: The substance misuse strategy for
Wales 2008-2018.” (WG, 2008). This strategy has four key aims:1) Reducing the harm to individuals (particularly children and young
people), their families and wider communities from the misuse of
drugs and alcohol, whilst not stigmatising substance misuse.
2) Improving the availability and quality of education, prevention and
treatment services and related support, with greater priority given
than under the previous strategy to those related to alcohol.
3) Making better use of resources – supporting evidence based decision
making, improving treatment outcomes, developing the skills base
of partners and service providers by giving a greater focus to
workforce development and joining up agencies and services more
effectively in line with ‘Making the connections’.
4) Embedding the core Welsh Assembly Government values of
sustainability, equality and diversity, support for the Welsh language
and developing user focused services and a rights basis for children
and young people in both the development and delivery of the
strategy.
Emphasised in this document is the need to consider the distinct issues in
relation to alcohol misuse and the widespread consumption of harmful
amounts of alcohol by the population generally.
This is a general policy document, so makes little mention of issues
particular to pregnant women. The key item in relation to pregnant
women is the introduction of the All Wales Maternity Record, including
questions to help to identify expectant mothers with a substance misuse
problem. Based on the general position of the policy, it is expected that
this covers both alcohol and drugs, but from the information given it is not
explicitly clear that that is the case.
What this document does not cover are issues around alcohol advertising
and promotion, pricing and taxation, all of which are key policy issues that
are reserved to the UK Government at Westminster.
National Screening Committee (2011) has also examined the issue of
alcohol and concluded that it could not recommend screening in relation to
alcohol misuse. This position statement did not make any specific
consideration of pregnant women. This conclusion is due to be reviewed in
2014.
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3
Early years pathfinder project
Substance misuse (alcohol and drugs)
Epidemiology
Obtaining good quality information on the prevalence of substance misuse
during pregnancy amongst women, and on the incidence of harmful
outcomes, in Wales and the UK, is difficult. Data collection is difficult, with
a reluctance of staff to ask and women to provide information around
substance misuse. In addition, there are often problems with diagnosis of
disorders associated with substance misuse; FAS diagnosis at birth is rare
and usually occurs later in childhood (BMA, 2007). In terms of FAS, this
provides some explanation as to why the incidence, both in the UK and
internationally, is not clear.
The following section serves mainly to highlight the fact that the data that
are available are of questionable quality and that the incidence of
pregnancy and EY harm associated with substance misuse is not clear.
3.1
Patient Episode Database Wales – PEDW
PEDW collates information on in-patient (IP) admissions in Welsh hospitals
and by Welsh residents. These data include IP treatment for foetus’ and
newborn babies affected by maternal use of substances.
In relation to substance misuse and impact upon the foetus and newborn,
records relating to the following ICD 10 codes, listed as the primary
diagnosis, were extracted:P04.3
Foetus and newborn affected by maternal use of alcohol
P04.4
Foetus and newborn affected by maternal use of drugs
of addiction
P04.9
Foetus and newborn affected by maternal noxious
influence, unspecified
P96.1
Foetal withdrawal symptoms from maternal use of drugs
of addiction
Q86.0
Foetal alcohol syndrome
The data presented here relate to
conditions.
IP admissions associated with these
Data were available annually (April 1 to March 31) from 1999 onwards,
however, in 2005/06 a new ‘definition’ was applied to PEDW and the data
from this period onwards are subject to this change.
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3.1.1
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Substance misuse (alcohol and drugs)
P04.3, P04.4, P04.9
Reported admissions for foetal and newborns affected by maternal use of
substances suggest that the numbers of cases are very small (Table 2).
However, given the profile of alcohol related harm generally and during
pregnancy, and the issues of coding and diagnosis highlighted above, it
seems unlikely that this is a true reflection of incidence.
Table 2:- Admissions of Welsh residents with primary diagnoses P04.3, P04.4 and P04.9
ICD 10 code
P04.3
Time period
1999 to 2005
2005 to 2011
1999 to 2011
(Annual average)
1999 to 2011
P04.4
P04.9
n
6
<5
<5
Bed days
69
17 to 108
(annual 3 yr average range)
<5
However, analysis of P04.4 only, at any diagnostic position, suggests that,
although still small, there are considerably more cases than indicated by
primary diagnosis analysis alone (Table 3).
Table 3:- Admissions of Welsh residents with any diagnoses P04.4
2006
19
3.1.2
2007
16
2008
11
2009
14
2010
8
2011
13
P96.1 – withdrawal from drugs of addiction
Based on three year rolling average data there is a clear trend of
increasing admissions and numbers of bed days associated with foetal
withdrawal symptoms (Figure 1), rising from an annual average of 9
admissions and 136 bed days in 1999/02 to 57 admissions and 818 bed
days annually between 2008 and 2011. However, it seems reasonable to
suggest that these are a lower estimate of the true numbers of
admissions.
Figure 1:- Admissions associated with foetal withdrawal symptoms from maternal use of drugs of
addiction
Admissions
50
40
30
20
10
0
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900
800
700
600
500
400
Bed days
60
300
Admissions
Bed Days
200
100
0
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3.1.3
Early years pathfinder project
Substance misuse (alcohol and drugs)
Q86 – foetal alcohol syndrome
There were 7 IP admissions associated with FASD between 1999 and
2011. However, data available elsewhere in Wales suggest that the
number diagnosed in a single year was far higher (n=53, 2009; Botchway,
2012). This may be associated with delay in diagnosis and the 2009 figure
may reflect catch-up in diagnosis of FAS, particularly as awareness of the
condition increases.
As stated above, estimates suggest that the number of live births affected
by FAS ranges from 0.2 and 2.0 to 9.0 per 1000 live births (BMA, 2007;
CDC, 2004). Data from the Public Health Wales Observatory indicate that
in 2007, in a population of 579,100 women aged between 15 and 44,
there were 34,398 live births2. Based on these data, a range of estimates
of cases of FAS in Wales, per year, can be calculated. At an incidence of
0.2, there would be 7 cases of FAS in newborns each year in Wales; an
incidence of 2.0 would give 69 cases and an incidence of 9.0 would give
310 cases.
3.1.4
Combining P96.1 and Q86 – any diagnosis
Combining P96.1 and Q86 in any diagnostic position again increases the
numbers of cases detected, with numbers still lower than would be
expected based on estimates presented in section 3.1.3 (Figure 2).
Figure 2:- Admissions associated with P96.1 and Q86 – any diagnostic position
Number of hospital admissions
160
140
120
100
Any mention
of
80
60
Primary
diagnosis
40
20
0
2006
2
2007
2008
2009
2010
2011
http://howis.wales.nhs.uk/sitesplus/922/page/36990. Accessed 24 July 2012.
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3.2
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Substance misuse (alcohol and drugs)
Infant feeding surveys
To date, eight national surveys of infant feeding practices have been
carried out, most recently in 2010. These surveys provide national
estimates of the incidence, prevalence and duration of breast feeding,
other feeding practices and the smoking and drinking behaviour of
mothers before, during and after pregnancy. Data collection is carried out
when babies are 6 to 10 weeks old, at 4-5 months old and at 8-9 months
old.
During the first stage of data collection, mothers are asked if they had
drunk alcohol during the previous two years and whilst they were
pregnant. Those who drank during pregnancy were asked how often they
drank different types of alcohol and how much they drank, allowing the
researchers to calculate the number of units consumed.
Given the limitations of recall and the tendency for people to
underestimate and under-report their alcohol consumption (BMA, 2007),
and response bias, it seems reasonable to suggest that these data provide
a lower estimate of the prevalence of drinking during pregnancy and EY. It
has been suggested that survey estimates represent only 55% to 60% of
the true alcohol consumption (Goddard, 2007; Catto, 2008)
3.3
Infant feeding survey - 2005
The 2005 survey3 was based on an initial sample of 19,848 mothers of
babies born between August and October 2005. Questionnaires were
returned by 12,290 mothers; a response rate of 62%, with 9,416 mothers
completing all three surveys.
The data provided in the report have been used to determine whether the
differences between Wales and the UK are important.
3.3.1
Wales
In Wales, in 2005, 88% of mothers reported drinking in the two years
prior to becoming pregnant, with 55% stating that they drank during
pregnancy. For the UK the figures were 83% (significantly fewer drinking
than in Wales, difference 5.0, (95%CI 3.4 to 6.5)) and 54% respectively.
Of those mothers who drank before pregnancy, 37% gave up drinking
during pregnancy (34% across the UK, Wales significantly more gave up
drinking, difference 3.0 (95%CI 0.7 to 5.4)), 58% cut down (61% UK,
Wales significantly fewer cut down, difference 3.0, 95%CI 0.6 to 5.4)) and
Infant Feeding Survey (2005). The Information Centre. NHS Health and Social Care.
http://www.ic.nhs.uk/pubs/ifs2005 Accessed 10 July 2012.
3
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4% did not change or drank more (4% UK, no significant difference to
Wales, 95%CI -1.0 to 1.0)).
Amongst mothers of 6 to 10 week olds in Wales 45% reported that they
did not drink (46% UK, no significant difference, (95%CI -1.3 to 3.3),
Figure 3). Almost half of mothers reported drinking up to two units per
week (47% v 46% UK, no significant difference4).
Figure 3:- Estimated weekly alcohol consumption by country, by mothers of 6 to 10 week olds.
100%
90%
80%
15+ units
70%
8-14 units
60%
50%
3-7 units
40%
1-2 units
30%
Less than 1 unit
20%
Did not drink
10%
0%
England
Wales Scotland
NI
UK
However, whilst significantly more women in Wales were drinking before
their pregnancy, 78% received advice on their drinking; this is compared
with 73% across the UK, a significant difference, (difference 5.0, 95%CI
2.9% to 7.0%). Almost all of these women (93%) reported that their
midwife was the source of this information (v 89% UK).
3.3.2
UK
More generally across the UK drinking behaviour varied with social class,
with managerial / professional and intermediate occupations more likely to
drink both before and during pregnancy than women who had never
worked (Figure 4).
4
Difference in proportions 1.0 (95%CI -1.3 to 3.3)
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Figure 4:- Drinking behaviour before and during pregnancy by mother’s socio-economic
classification (NS-SEC).
%
100
90
80
70
60
50
40
30
20
10
0
Drank during
pregnancy
All
Unclassified
Never worked
Routine and
manual
Intermediate
occupations
Managerial
and
professional
Drank before
pregnancy
The never worked not only reported drinking less before and during
pregnancy, but also were more likely to report giving up drinking (
Figure 5). However, this group were also most likely to report not
changing or increasing their consumption. Whether this difference is
statistically important is not clear, but it seems unlikely that it is.
Figure 5:- Changes in drinking behaviour before and during pregnancy by mother’s socio-economic
classification (NS-SEC).
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
No change /
drank more
Drank less
All
Unclassified
Never worked
Routine and
manual
Intermediate
occupations
Managerial
and
professional
Gave up
drinking
Alcohol consumption was generally linked to age, with older mothers,
aged 30+, being more likely to report drinking both before and during
pregnancy (Figure 6). Older mothers were also less likely to give up
drinking during pregnancy (Figure 7).
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Figure 6:- Drinking behaviour before and during pregnancy by mother’s age.
100
90
80
70
60
50
40
30
20
10
0
%
Drank before
pregnancy
All
35+
30-34
25-29
20-24
Under
20
Drank during
pregnancy
Figure 7:- Changes in drinking behaviour before and during pregnancy by mother’s age.
100%
80%
No change /
drank more
60%
Drank less
40%
20%
Gave up
drinking
All
35+
30-34
25-29
20-24
Under
20
0%
Overall, almost three quarters of women (73%) in the UK reported being
given advice on drinking during pregnancy, and the majority of these
(89%) reported receiving advice from their midwife. However, whether
women received advice or not, similar proportions (95% receiving advice v
94% not receiving advice) reported moderating their drinking habits.
3.4
Infant feeding survey – 2010
At the time of writing, only the early results for the IFS 2010 were
available. These do not include data on alcohol consumption by women
either before or during pregnancy or after giving birth.
3.5
Summary comments
There is a clear lack of data on the prevalence of substance misuse during
pregnancy and the incidence of harmful outcomes resulting from these
behaviours.
Currently available data on outcomes are at best inaccurate and at worst
misleading. PEDW is no exception; it suffers similar problems to other
datasets in terms of describing the outcomes associated with substance
misuse and it seems unlikely that these will be resolved in the near future.
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The IFS appears to offer more promise in terms of understanding and
addressing substance misuse issues, even given that the data are likely to
underestimate the prevalence of the problem and suffer a number of
biases. As long as these data are understood to be a low estimate then
they can be used with appropriate caution. In addition, it is difficult to see
how else these data could be collected.
It may also be possible to improve the quality of these data by trying to
refine the questions asked so that it is easier for people to provide more
accurate answers. Obviously, in the short term this may mean that trend
analysis becomes impossible, but the general data quality would be
improved. To understand age related profiles better it may also be useful
to aim to collect data on whether this is the first or a subsequent
pregnancy. It seems likely that the finding that older women are more
likely to drink during pregnancy is related to this being a second or third
pregnancy. This may also provide more useful data for targeting
interventions.
Given the quality of data currently available to the IFS, the biases and
difficulties in the collection of these data, and the apparent prevalence of
alcohol misuse compared with drug misuse, it would not seem appropriate
to extend the data collection beyond alcohol at the moment.
Finally, IFS ‘early results’ for both 2005 and 2010 do not include alcohol.
Although ‘early results’ report cannot cover all aspects of the survey it is
suggested that, in the future, consideration is given to including alcohol
alongside smoking as a key item for ‘early results’. This omission may,
unintentionally, have the effect of creating a perception that alcohol
consumption during pregnancy is less problematic than smoking during
pregnancy.
Without better data, adequately planning and managing services to tackle
these issues is almost impossible.
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4
Evidence of effectiveness
4.1
Introduction
This section brings together the evidence on the identification of substance
misuse through screening, and interventions available to reduce the harm
related to substance misuse during pregnancy and EY.
There are several screening tools that can be used with pregnant women
to establish their substance misuse.
A number of interventions have been reviewed for their effectiveness.
Some interventions are individual to the patient, while others incorporate
the whole family. Interventions may also be educational, psychosocial or
pharmacological interventions
4.2
Methods
Search strategy:
Title and text search using the search terms:
(substance or drug) (pregnancy or pregnant) alcohol
(substance or drug) paediatr* alcohol
Databases searched
Cochrane, NICE, TRIP database, NHS Evidence, Pubmed
Currency
Databases were searched from 2006 to 12/07/2012
Search date
12th July 2012
The scope of this review was to identify evidence in relation to screening
tools to identify substance misuse interventions to reduce substance
misuse related harm during pregnancy and EY.
Key guidelines in this area did not include detail of specific interventions
appropriate to the scope of this review. Therefore the Cochrane library,
TRIP database, NHS Evidence and Pubmed were searched for systematic
reviews.
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The interventions identified were grouped into 7 main areas: (1) screening
(2) antenatal alcohol misuse, (3) antenatal drug misuse, (4) antenatal
substance/drug misuse and alcohol misuse, (5) effect of drug misuse on
children (6) FAS and (7) support for the families and carers.
Although more research has been carried out in this area over the past 20
years, evidence relating specifically to the UK is sparse. Generalising in
this area is difficult; much of the available evidence is from the USA where
patterns of substance misuse are very different and RCTs include only
small numbers of participants. In addition, confounding associated with
polysubstance misuse and nicotine creates further difficulties (BAP, 2012).
4.3
Screening for substance misuse
Screening tends to focus mainly on identification of alcohol misuse, but
there is no consensus on the approach to take during pregnancy and no
optimal screening tool available (SOGC, 2011). The SOGC approach
recommends using the ALPHA tool incorporating the CAGE questionnaire
to screen for maternal drug use. Toxicity testing is not recommended for
universal screening, only if indicated by ALPHA / CAGE (SOGC, 2011).
A systematic review of screening tools for alcohol consumption during
pregnancy included five studies of seven different instruments5 (Burns et
al, 2010). AUDIT-C had high sensitivity (95%) and specificity (85%) for
risk drinking, as well as alcohol dependence (100%, 71%) and alcohol use
disorder (96%, 71%). T_ACE (69 to 88%, 71-89%) and TWEAK (71-91%,
73-83%) also showed promise for identifying risky drinking however, their
performance as standalone tools is uncertain.
Raistrick et al (2006) also considered TWEAK and T-ACE, both of which
are derived from CAGE and take around one minute to administer. Both
tools were found to have high sensitivity and specificity and to be more
effective than CAGE. TWEAK was also found to be effective in a range of
socio-economically and ethnically diverse pregnant populations in the
USA, as well as men and non-pregnant women.
Therefore, AUDIT-C appears to have wider capacity to identify problem
drinking amongst pregnant women, but TWEAK and T-ACE are also
effective screening tools.
TWEAK (Tolerance, Worried, Eye-opener, Amnesia, Kut down), T-ACE [Take (number of drinks), Annoyed, Cut
down, Eye-opener], CAGE (Cut down, Annoyed, Guilt, Eye-opener], NET (Normal drinker, Eye-opener,
Tolerance), AUDIT (Alcohol Use Disorder Identification Test), AUDIT-C (AUDIT-consumption) and SMAST (Short
Michigan Alcohol Screening Test).
5
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4.4
Early years pathfinder project
Substance misuse (alcohol and drugs)
Interventions for alcohol misuse
Lui et al (2008) sought studies of psychological interventions for women
who were enrolled in alcohol treatment during pregnancy and found no
articles that met the inclusion criteria.
Smith et al (2009) carried out a similar review of pharmacological
interventions for pregnant women and found no articles that met the
inclusion criteria.
In terms of preventing, diagnosing and managing FASD, primary
prevention including warning labels on bottles, education and an alcohol
ban have been evaluated, but in a very small number of studies of poor to
fair quality (Elliot et al, 2008). A review of secondary prevention (one on
one, education based) yielded similar results, as did the review of tertiary
prevention (Elliot et al, 2008).
4.5
Interventions for drug misuse during pregnancy
In terms of managing pregnant drug misusers, psychosocial interventions
based on contingency management were found to have some effect on
reducing drug use, but, because of low numbers, no effect on obstetric or
neonatal outcomes could be detected (Terplan and Lui, 2008). There was
insufficient evidence available to support the use of motivational
interviewing (Terplan and Lui, 2008).
Pharmacological intervention (maintenance agonists) for opiate dependent
pregnant women showed no significant differences between the drugs
compared for both mother and child outcomes (Minozzi et al, 2009).
4.6
Interventions for substance misuse during
pregnancy
Milligan et al (2010) reviewed integrated programmes addressing a
woman’s physical, social and mental health needs, as well as children’s
needs and found moderate and statistically significant effect on maternal
substance use. However, integrated programmes were no more effective
than non-integrated programmes.
Home visits by a variety of professional and lay women were found to
have no effect on a whole variety of mother and child outcomes, including
illicit drug use (3 studies, n=384, risk ratio (RR) 1.05, (95%CI 0.89 to
1.24), continued alcohol use (3 studies, n=379; RR 1.18, 95% CI 0.96 to
1.46), enrolment in a drug treatment program (2 studies, n=211; RR
0.45, 95% CI 0.10 to 1.94), not breastfeeding at six months (2 studies,
n=260; RR 0.95, 95% CI 0.83 to 1.10), incomplete six-month infant
vaccination schedule (2 studies, n=260; RR 1.09, 95% CI 0.91 to 1.32;
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Turnbull et al, 2012). Therefore, there is insufficient evidence to
recommend the routine use of home visits for pregnant or postpartum
women with a drug or alcohol problem.
A review of antenatal care programme interventions including group
antenatal care, managed care, nurse home visits and telephone support
found no evidence relating to the effect of antenatal care interventions on
mortality from SIDS/SUDI and limited evidence relating to effect on
congenital anomalies (NPEU, 2009). There was insufficient evidence of
adequate quality to conclude that interventions involving alternative
models of organising or delivering antenatal care reduce infant mortality
or pre-term birth. There were some promising interventions in relation to
pre-term birth but further robust evaluation of these is needed (NPEU,
2009).
4.7
Interventions for FAS
FAS/D interventions include pharmacological, educational, social skills and
communication and behavioural, but there is limited evidence for these
interventions being effective in children with FAS/D (Peadon et al, 2009).
A wider review of interventions with children and youth with FAS/D,
including psychostimulant medications (methyphenidate, pemoline and
dextroamphetamine) and Cognitive Control Therapy found limited
evidence of effectiveness (Premji et al, 2006).
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5
Current service provision
5.1
Antenatal care guidelines
NICE (2010b) identify substance misusers as one of the four groups of
pregnant women with complex social factors and recommends appropriate
standards of care for this population.
These cover:








Recording and calculating the number of women presenting for
antenatal care with complex social factors.
Recording attendances for booking at 10, 12 and 20 weeks, along
with actual attendance and experiences of mother or baby of
significant morbidity or mortality.
Monitoring satisfaction with services to guide service development.
Co-ordinated care plans supported by multi-agency needs
assessment; health, social care and third sector agencies, and
including opiate replacement therapy information, co-location of
services and provision of information about services provided by
other agencies.
The need to be mindful of the right to confidentiality, but also to
raise with the woman that her information may need to be shared
with other agencies.
Providing support to obtaining a booking appointment and, if
necessary, the opportunity to discuss sensitive issues in a
confidential environment.
Providing training to health care professionals to understand the
social and psychological needs of women who misuse substances
and in how to communicate sensitively with these women.
Addressing fears that may exist in relation to the involvement of
children’s services and the potential removal of the child and
addressing feelings of guilt around substance misuse and the
potential effects on the baby.
Offering a ‘named’ midwife or doctor with specialised knowledge and
experience of the care of pregnant women who misuse substances,
and, where possible, provided with a direct dial number by which to
contact this person.
Once substance misuse has been disclosed, referral to an appropriate
programme should be offered, along with any additional services that may
be relevant. Reminders to attend clinic appointments should be sent by a
variety of methods, including sms, and offers to provide transport to
appointments made. Information should also be offered on the potential
effects of the substance on the unborn baby and what to expect once the
baby is born.
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National provision
Working Together to Reduce Harm has four areas for action, one of which
is to support families to reduce the risk of harm to children and adults as a
consequence of substance misuse by a family member. As a result of this,
five Early Parental Intervention Pilot projects have been set up in
Flintshire, Newport, Merthyr Tydfil, Blaenau Gwent and Bridgend. These
projects aim to
o Reduce the impact
o Enable substance
effective parenting
o Encourage parents
of substance misuse on parenting capacity;
misusing adults to develop positive and
skills; and
to develop greater self-determination.
5.3
Current service provision by Health Board
5.3.1
Aneurin Bevan Health Board / Gwent Area Planning Board
Gwent Substance Misuse Area Planning Board (APB) has established an
Alcohol and Pregnancy Task and Finish Group. The purpose of this group is
to make recommendations for a regional approach to promoting and
addressing harms from drinking alcohol during pregnancy, because of
concern over a lack of clear national guidance around safe drinking levels
and the confusion that this may cause and the lack of awareness of FAS /
FASD. Once developed, the regional guidelines will be circulated and
midwives trained to deliver ABI and to improve recognition and reporting
of alcohol use and related conditions affecting pregnancy and the
newborn.
The APB has also developed a Prevention Advisory Group, with alcohol and
pregnancy one of the four priority areas, and a proposal for action
currently under development.
A regional alcohol conference is planned for October, with a key aim being
to promote evidence of effectiveness, including in terms of services for
pregnant women and young children.
The Director of Public Health’s annual report highlights the need to
address alcohol use during pregnancy.
There are also a number of substance misuse services in place across the
region, with specialist or complex issue support from the Gwent Substance
Misuse Specialist Service. A lead midwife for substance misuse is also in
post and all midwives will be trained to deliver ABI in September 2012.
In addition, Barnardo’s offer an Integrated Family Support Service,
currently in Newport only, but due to be extended, to provide a ‘whole
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family’ response to families with complex needs through a multi agency
team of practitioners.
5.3.2
Betsi Cadwaladr Health Board
In the Betsi Cadwaladr Health Board area a specialist midwifery liaison
service has been developed to support pregnant women who misuse
substances. This service provides both education and guidance for those
who may be treating pregnant substance misusers, as well direct clinical
care.
The delivery of ABI training in the area specifically includes health visitors
with a view to targeting the mothers of young children, although there is a
lack of evidence in relation to the effect of ABI in this area. Strengthening
Families and Families First programmes are also active in the area.
In North Wales, sexual health and substance misuse services are closely
linked and a substance misuse midwife is in post, working closely with the
harm reduction team.
5.3.3
Powys Health Board
Powys Health Board area has no specific services in place to address this
issue, but all midwives work with and refer to the substance misuse team
Kaleidoscope.
5.3.4
Cardiff and Vale Health Board
Cardiff and Vale also has a specialist substance misuse midwife, as well as
the Cardiff Young Persons Substance Misuse Task Group; a multi agency
group taking forward children and young people’s (CYP) actions from the
CYP plan and Substance Misuse Action Team (SMAT) Plan.
Both Cardiff and the Vale offer family support interventions in cases where
there is parental substance misuse and Integrated Family Support
Services are offered where there are safeguarding risks. Cardiff Drug and
Alcohol Team also offer guidance, counselling and care for substance
misusers and their families. Strengthening Families is also delivered in
Cardiff to prevent substance misuse.
5.3.5
Cwm Taf Health Board
In Cwm Taf HB are due to upgrade to version 2 of the All Wales maternity
record in September 2012. This will include Cwm Taf specific additions
that cover detailed drug misuse information of both mother and father.
This information is then recorded in the maternity hand held records and
the in-house maternity database. These data can be updated throughout
pregnancy and post delivery.
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Disclosure of substance misuse during booking or at any other time during
pregnancy is followed up with requests for information on any other
agencies involved and key worker details. If no agencies are involved
relevant referrals are offered.
Disclosure also triggers use of the substance misuse pathway which
includes 22 week risk assessment for mother and / or partner to inform
the safeguarding assessment. The risk assessment tool assesses risks and
protective factors, identifies key agencies already involved and highlights
appropriate referrals and was developed by a multi agency collaboration
following serious case review health recommendations. It is a generic tool
used by all relevant agencies within the Health Board (e.g. Families First,
Taff Ely Drug Support, Drugaid). A copy of the completed risk assessment
is sent to each key worker in each agency involved in parent’s care.
The pathway is followed through to the post-natal period and includes
consultant led care, named midwife as care co-ordinator, and close liaison
with other appropriate services.
Pre-birth plans are completed for every case, detailing care plans following
delivery and discharge arrangements. Post natal care is in the community
with the community midwife co-ordinating care for up to 28 days.
Each local authority area in Cwm Taf also has its own substance misuse
action plan, as well as Integrated Family Support Services. Strengthening
Families is also available in Merthyr Tydfil.
A project to map substance misuse education in school settings is also
underway, linking to sexual health.
5.3.6
Hywel Dda Health Board
Hywel Dda has a specialist midwife to work with pregnant women
identified as substance misusers. The primary aim of this role is to ensure
that all safeguarding issues are fully considered.
This post has been in place for 18 months and currently covers
Carmarthenshire and Pembrokeshire. Activity data is available, but no
proper evaluation has been carried out.
There are no other evaluated maternal and early years schemes in the
area.
Both Pembrokeshire and Ceredigion have Substance Misuse Prevention
Plans.
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5.3.7
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Substance misuse (alcohol and drugs)
Abertawe Bro Morgannwg Health Board
Healthy Schools programmes in the Abertawe Bro Morgannwg area work
with the substance misuse team and Strengthening Families is also
available.
A pilot project, Children and Adults Together (CATS), is also underway to
involve parents in substance misuse work with children.
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Conclusions
There are obviously significant problems associated with substance misuse
during pregnancy, but there are many difficulties with determining the
response needed to these problems, mainly because of a lack of
knowledge and understanding.
1. The dose: response relationship between alcohol and negative
outcomes is not clear.
2. The links between drug misuse and negative outcomes is not
clear. There is a particular lack of controlling for socio-economic
confounders in analysis.
3. The prevalence of substance misuse during pregnancy is not
clear, but given the prevalence of excess alcohol consumption in
the population, it is likely that many women are consuming
harmful amounts of alcohol pre-pregnancy and pre-pregnancy
recognition.
4. There is some evidence of effectiveness for screening tools to
detect substance misuse in pregnant women, but no good
evidence for interventions to address the issue.
5. The services that are currently in place appear to focus on drug
misuse and the associated safeguarding issues.
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Recommendations
1. All pregnant women should be given advice to moderate their
drinking, but older, professional women, in particular, should be
targeted.
2. To support this, all health care professionals who are in contact with
women who are either pregnant or thinking of becoming pregnant
should be trained to deliver alcohol brief interventions (ABI).
However, given the lack of good quality evidence in this area
generally, robust evaluation of such an approach would need to be
carried out to inform the evidence base.
3. In addition, advice is both easier to give and act upon when the
message is consistent. Constant changes to advice in relation to
alcohol are unhelpful, cause confusion and can also result in a lack
of trust and regard for future messages, not only in relation to
alcohol, but also for other health issues. Significant efforts are
therefore needed to establish an appropriate guideline, with a
regular time table for review.
4. Collection of more accurate data around substance misuse
prevalence and pregnancy outcomes is needed, but careful
consideration of how to collect these data accurately is also
essential.
7.1
Update on recommendations
To support the delivery of recommendation 2, the Public Health Wales
programme to reduce alcohol related harm has been delivering alcohol
brief intervention (ABI) training to midwives. Delivery is influenced by
Health Board priorities; to date, just 13.2% of Welsh midwives have been
trained to deliver ABI (table 4). Cardiff and the Vale UHB (32.0%) and
Hywel Dda HB (25.4%) have trained more midwives than any other HB,
but significant efforts are now needed to improve coverage.
Table 4:- Training of midwives to deliver ABI.
Total Midwives
Total
Trained
Midwives
Hywel Dda
50
197
Betsi
22
282
Aneurin
39
285
ABMU
2
285
Cardiff and Vale
87
272
Powys
0
48
Cwm Taf
0
150
WALES
200
1519
Note: All Powys midwives to be trained in September 2013
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%
trained
25.4%
7.8%
13.7%
0.7%
32.0%
0.0%
0.0%
13.2%
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To support this, the PHW alcohol related harm team are also aiming to
train staff in fertility clinics to deliver ABI.
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