However, not all drugs cause problems and some cause problems only if used in large amounts.  Drug use is also functional and it is helpful to understand these functions if considering reducing or stopping drug use.  In some cases, withdrawal (particularly rapid withdrawal) may lead to miscarriage.  Minor effects of drugs in breast milk may be outweighed by the benefits of breastfeeding.

The World Health Organisation estimates that 90% of pregnant women take prescription, over-the-counter, social or illicit drugs during pregnancy. Drug use during pregnancy is estimated to account for 2 - 3 percent of all birth defects.

There is a great deal of shame and stigma attached to the use of substances by pregnant women.  In some, this acts as a positive motivation to reducing or ceasing their drug use. In others, it may become a barrier for accessing support. Some may even increase their drug use to cope with shame and guilt.  Respectful and supportive case management procedures are required to overcome shame and perceived fear by mothers of negative governmental interventions. Pro-active case finding and Initial, Positive Intervention  Strategies which offer attractive and well-packaged support options may enhance overall therapeutic outcomes.

Currently, legislation in NSW (under review) does not allow for reporting of an unborn child where there are safety concerns.  It is therefore important that there are good communication structures between DoCS, the Department of Health and associated agencies.  

This page and associated links provides some tips on working with pregnancy and drug use as well as providing on-line reference guides to the possible effects of substances on children used during pregnancy as well as during breastfeeding.

Nature of harm
Case finding and initial contact
Assessment
Interventions

Drug use by women during pregnancy indicate potential harm in a variety of ways:

1. Harm to the foetus
   Substances may cause harm to foetal development in utero
   Sudden withdrawal may lead to miscarriage or premature labour
   
2. Harm to the mother
   Substances may impair the health of the mother and her ability to nourish the child
   
3. Accidents and violence
   Drug use can be associated with accidents and violence which may harm mother and/or child
   
4. Infectious diseases
   Drug use may lead to infectious diseases which may be transmitted to the foetus
   
5. Fear of professional support
   Drug use may increase isolation and fear of professional support. This can reduce antenatal care
   
6. Block feelings and resolution of issues
   - Drug use may block feelings and issues which may need to be resolved prior to the birth of the child
   - Mental illness may be exacerbated by unprescribed drug use
   
7. Reduced commitment and care
   Drug use during pregnancy may indicate reduced commitment or ability to care for and protect the child
   
8. Relationship problems
   Drug use during pregnancy may lead to relationship problems with partner, family and friends and reduce parental supports
   
9. Money and resources reduced
   Money spent on drugs may be at the expense of stable accommodation and preparation for the new born child
   
10. Legal consequences
    Crime and/or prostitution to raise money for drugs may put mother in prison
    
11. Baby withdrawal symptoms & bonding
    Withdrawal symptoms of babies born addicted to substances can make them hard to manage and reduce bonding
    
12. More serious physical problems such as foetal alcohol syndrome require more intensive care which is associated with higher rates of child abuse and neglect
    
13. Sudden Infant Death Syndrome
    Some drugs such as nicotine and cocaine in utero have been associated a with higher risk of Sudden Infant Death Syndrome (SIDS)
    
14. Drug use which continues after the child is born may seriously interfere with effective parenting and put the new born child at risk in a range of ways
    - Inability to care for child when intoxicated and hangover
    - May role on child while intoxicated, particularly if child is sleeping with parent
    _ Legal, social, and lifestyle issues associated with drug use are likely to negatively impact on child development

In summary, because of the many areas of potential harm to children and to the parent, drug use by pregnant women is represent very high risk, Protective Services Investigation, risk assessment and possibly ongoing statutory interventions.

Because women who are pregnant and using substances tend not to access professional services, they are less likely to be noticed.  Options to identify and engage with these women and their family include:

1. Education and training of community support services, particularly local GPs and health services, of screening procedures which may help identify pregnant women with drug use problems.
2. Public health advertising which appeals to partners, parents and friends of pregnant women with drug problems to contact health and welfare service to enable assessment and support to be offered.  This can occur on a local level through radio interviews, fliers and posters being distributed in local health and welfare waiting areas, advertising in community newspaper, etc.
3. Development of support packs for pregnant women which targets:
   - pregnant women in low socio-economic groups
   - pregnant women with mental health issues - particularly anxiety disorders and depression
   - pregnant women who feel isolated and possibly ashamed

One program (ESCAPP) in the USA has formed close links with the local maternity hospital.  Midwives who suspect drug use by pregnant women or women who have just given birth contact ESCAPP staff who initially come with a basket of practical gifts and a the offer to take a series of photographs of pregnant mother, and/or new born child and information on a range of local services.  The photographs allow for a second visit to discuss which one will be framed along with the support options.

Assessment

More formal assessment is required to determine:

1. Drug factors (how much, what type, pattern of use, history of use including former drug treatment or attempts at controlling drug use)?

2. Any drug related problems (health, relationship, lifestyle and legal issues)?

3. Stage of change regarding reducing or stopping drug use?
   NB Drug specialists should be contacted prior to sudden cessation of drug use - it may cause miscarriage or premature labour

4. Is mother aware of possible effects of drug use on foetus (click here for

5. Access and use of anti-natal medical checks and preparation for child birth?

6. Relationship of the mother to the unborn child - is this pregnancy and child wanted?

7. Mother's mental health and self-image?

8. Parent's ability to look after new born child (particularly if strong possibility of low birth weight, withdrawal symptoms, or any other neo-natal complication?

9. Partner drug use behaviour and ability (and willingness) to be actively involved in child rearing and support of the mother

10. Any associated violence or abuse in the home?

11. Any other children and how are they cared for?

12. Type of accommodation and financial stability

13. Families social support (note that there is a high incidence of mothers who use substances were themselves physically and/or sexually abused by their own parent(s).

14. Types of friends (drug using, non-drug using, supportive, not supportive)?

15. Other agencies involved?

16. Confirmatory reports from other sources?

This assessment procedure aims to identify level of risk and safety as well as build a working relationship to enable support and monitoring of child development and safety.

1. Link with community service agencies as required and indicated, particularly health, accommodation and drug services (gender sensitive if available)
   
2. Coordinate inter-agency case management as required
   
3. Provide practical assistance
   
4. Use motivational techniques to
   - shift towards decreasing drug use
   - increase knowledge of possible effects of drug use on foetus and family
   - shift towards safer drug using practices if drug use continues
   - improve cooperation with community and health services
   - set realistic and achievable goals which are meaningful to the mother
   - strengthen resolution to change via clear decision making and problem solving
   - improve self efficacy through identification of parents achievements and successes
   - remove obstacles for achieving goals
   
5. Identify functions of drug use
   - determine if mother has achieved these functions in other ways
   - can these alternative methods of meeting needs be increased
   
6. Help parent prepare for the possibility of relapse
   
7. Maintain active and regular follow-up
   
8. Link with family and other social supports as appropriate
   
9. Support parenting ability of both parents where possible
   
10. Initiate statutory proceedings where indicated

The use of supervised methadone in pregnant women has been associated with decreases in the incidence of neonatal complications and deaths.  While it is associated with neonatal withdrawal symptoms and low birth weight, these factors are viewed as acceptable as compared to other risk factors.  Methadone has also been shown to allow people to reorganise their lives away from drug using subcultures.