Choices in Pregnancy

Needs Assesment 2005

‘Sometimes when you're on heroin or drinking they think you don't care'

A needs assessment with health care services for women with alcohol and drug problems in Aberdeenshire

Aberdeenshire ADAT

Executive Summary

1.1
In Spring 2003 the Children and Young People's Subgroup of Aberdeenshire Alcohol and Drug Action Team recognised that there was a need to take a closer look at the services available to pregnant women who have alcohol and/or drug problems. Further it was recognised that as support services in Grampian for this group had developed primarily in the city, it would be sensible to examine the issues around delivering a specialist service in a predominately rural area. The study aimed to improve the consistency of care for women in Aberdeenshire through providing evidence for the development of future services, structures and capabilities. This mapping of current services is in line with the Scottish Executive's drive to improve practice in this area. The study was conducted in parallel with work in NHS Grampian on a review of maternity services, and changes within the NHS structure as Grampian moved into Community Health Partnerships. This work was also contiguous with the development of a framework for Getting Our Priorities Right within Aberdeenshire.

1.2
We were keen in light of recent information about increased drinking levels in women in general, that the study did not solely focus on the extreme end of the spectrum in relation to either alcohol or drug use i.e. those women who have as a result of their substance use a highly chaotic lifestyle. We felt it was important to look at the topic across the spectrum of use and draw conclusions from there. The study highlights a number of recent changes in the nature and prevalence of drinking amongst women. Our philosophy for the study was that we were making an examination of a statistically normative behaviour within a normal population. Our focus was not just about small numbers of women living highly chaotic lifestyles therefore the majority of this study is not as relevant to drug use as to alcohol use. Given this approach we felt that our findings would not only be relevant to drinkers or drug users in contact with specialist treatment services, but also encompass the wider population, fathers, families and children.

1.3
Whilst the study was to focus on services available to pregnant women, it quickly became apparent that it had to be viewed and examined as an integral part of reproductive health, which encompasses a four – phase cycle of care.

Pre-conception – the planning for pregnancy with emphasis on good health and consistent support

Pregnancy & antenatal care – the 9-month period of pregnancy care involving women and their partner, with emphasis on quality and continuity of care

Childbirth – the achievement of a positive birth experience to meet the care needs and expectations of the woman and her partner; and the safe delivery of the baby

Postnatal and parenthood – the provision of postnatal care to baby and the woman and her partner to facilitate the transition to parenthood

[Source: Guide 8: Drug Misuse in Pregnancy and Reproductive Health, Scottish Executive]

The Scottish Executive's guidelines stress that reproductive health is a total package of care which encompasses all four phases. This model places the emphasis on the family as a whole (woman and partner) and on ‘parenting', which is an approach we were keen to adopt as opposed to focusing solely on what ‘a woman' should be doing.

1.4 Four factor model

Within the pregnancy phase we defined as a basis for measurement four key factors which influence the quality of care offered to pregnant women with alcohol or drug problems.

Confidence/competence
Services
Structure
Knowledge

By focusing on these four factors it was possible to audit the level of service available across the reproductive health cycle, to provide an overall audit of service provision.

1.5 Aims

The study aims to improve the consistency of care for pregnant women who use alcohol and/or drugs in Aberdeenshire through providing evidence for the development of future services, structures and capabilities. We also aim to increase awareness regarding the impact and prevalence of alcohol use in pregnancy and the potential impact in Aberdeenshire.

Recommendations are included regarding what needs to be done to achieve a functional system based on the four factor model within one particular phase of the reproductive cycle. It is an issue which needs to be acknowledged and accepted as part and parcel of life today – the challenge for the strategists in Aberdeenshire is to make this one of the first areas in Scotland in which the issue is addressed openly and effectively and does not remain a hidden problem.

The study benchmarks the services currently provided in Aberdeenshire, and also draws on international research and best practice.

1.6 Findings

71% of professionals who returned their questionnaire did not feel confident about discussing these issues with clients. This was confirmed in the interviews and focus groups.
77% of professionals who returned their questionnaire did not feel competent in discussing these issues.
Of the 60 completed questionnaires returned, 67% of respondents requested training.
The researchers noted little evidence of substantive specialist training in any of the professions surveyed (either at managerial or basic level) on dealing with alcohol or drug use in pregnancy.
The researchers also noted little evidence of awareness amongst the subjects of any form of commonly used protocol for working with the client group. The only exception to this being in Fraserburgh Maternity Unit where there is a specific service for this client group.
Wide variations are evident regarding the level and range of services available across Aberdeenshire. Whilst some local customisation is to be expected, there are specialist support services which cover the whole of Aberdeenshire yet who are often not involved in joint working or accessed by generic services for support.

1.7 In summary

there will be women in Aberdeenshire who continue to use alcohol or drugs when pregnant.
women are unwilling to disclose their alcohol and drug use but are often strongly motivated to do something during pregnancy
staff have indicated that they are also highly motivated to work effectively with this client group
staff are currently ill-equipped to enhance disclosure rates
women specific services are few and far between in Aberdeenshire

1.9 Recommendations

Recommendation: The chief recommendation we make is that the current structure requires more detailed strategic planning and leadership in this area. Responsible partners within the AADAT need to work together to identify the core values that underpin service delivery.

Recommendation: In other areas services exist, but often work in isolation. Work is required to develop referral routes between primary care and specialist services in all areas across Aberdeenshire.

Recommendation: If the decision is taken to find funding for a new specialist role, we recommend that the post be divided between education, awareness raising and research, and clinical support to midwives as they work in their local area.

Recommendation: Based on the data we have analysed and global responses to substance misuse in pregnancy, local management protocols and guidelines not only could be easily produced, but have been requested by primary care staff in this study, working in an area where they are expected to on the whole be generalists rather than specialists.

Recommendation: We recommend that action is taken to develop the Healthy Drinking Homework booklet and discreet support service .

Recommendation: Funding has been secured for this initial action from the Scottish Executive. Further work is required with midwifery training to increase the emphasis on substance misuse and related issues.

Recommendation: This study has several implications for further local research in:

Evaluating the existing specialist input that has informally developed in Fraserburgh
Developing, piloting and evaluating the Healthy Drinking homework booklet
Evaluating the provision of a discreet information and advice support service through the internet or help line

Project Team:
Anni Stonebridge, Aberdeenshire ADAT
Jane Livingston, Aberdeenshire ADAT

October 2005