Drugs and having babies: An exploration of how a specialist clinic meets the needs of chemically dependent pregnant women

Abstract

Objectives

to explore the extent to which a specialist clinic meets the needs of chemically dependent women.

Design

a critical ethnography informed by theorists such as Habermas and feminists' interpretation of Foucault.

Setting

a specialist antenatal clinic for chemically dependent pregnant women at a major metropolitan women's hospital in Melbourne, Australia.

Participants

a purposive sample of twenty (20) chemically dependent pregnant women who attended the clinic.

Data collection and analysis included three taped interviews (two preceding the birth and one post birth), observation of the interactions between the women and the clinic staff over a 25-month period and chart audits.

Findings

similar to other studies there were multiple factors influencing development and maintenance of chemical dependency in this group of women, including family instability, family history of drug and alcohol abuse, childhood sexual abuse, having a chemically dependent partner and having a dual diagnosis of both drug addiction and mental illness. Initially there was considerable variation between the women and the clinic staff's expectations with regard to attending for antenatal care and conforming to a set regime as the women struggled with the contradictions inherent in their lifestyle and that of the ‘normal’ expectant mother. Aspects of that struggle included their belief that their opinions and knowledge of their lives was largely ignored, leading to episodes of resistance. Several women alleged the clinics staff's relationship with them was influenced by a belief that the women were ‘hopeless addicts in need of expert medical and midwifery care' and that the clinic staff exercised control in an authoritarian manner. However, as they explored possibilities for collaboration, they realised they could exercise power and work towards a more equal relationship with staff. The quality of relationships in most instances improved over time, and if not always strictly collaborative, was situated at various points along a continuum from minimal to full co-operation, with concomitant varying levels of success in terms of outcomes. It was often the attitude of individual staff members, particularly midwives, that was the key to the way in which the women responded to care.

Key conclusions and implications for practice

comprehensive history-taking and engaging women as early as possible in pregnancy; providing continuity of care – particularly midwife care – to assist in developing a collaborative approach to care; provision of an extended period of postnatal support to at least six months for those women able to parent their children was a key recommendation.

Introduction

Like hospitals in the U.K. (Siney, 1999, Klee et al., 2002), Victorian women's hospitals recognised the need in the 1980s to develop clinics which were specially designed to cater for the complex needs of this group of women. A Chemical Dependency Unit for pregnant women was established at the Royal Women's Hospital in Melbourne in 1985. In 1999 there was a move to decentralise the service because of the increase in the demand for it across the state and this led to a number of special services and clinics being established in several major maternity hospitals.

The Transitions Clinic (TC) at the Mercy Hospital for Women in East Melbourne was established in early 2000 and seeks to meet the needs of chemically dependent pregnant women, pregnant Koori (Aboriginal) women and young mothers-to-be. At the time of the study detailed below it had a multidisciplinary team of two obstetricians (Methadone prescribers), a paediatrician, a psychiatrist and psychologist, two social workers, two midwives (the first point of contact), one midwife/birth educator, a Koori liaison officer, a dietitian and a postgraduate research student. The Clinic provides a staged process of recovery through stabilisation on Methadone Maintenance Therapy (MMT) or buprenorphine, along with other treatment options with a focus on harm minimisation. Care includes antenatal and postnatal care, childbirth education, social, financial and psychological support and referral to community agencies. Harm minimisation assumes that risk behaviour persists despite education and legislation, and so aims to minimise adverse results by working with women to improve health outcomes ‘within an amoral framework’ (Rumbold and Hamilton, 1998, p. 135).

The purpose of the larger study was to evaluate the care provided to chemically dependent pregnant women (CDPW) by the Transitions Clinic. The related objectives were: to provide rich descriptions of the range of problems chemically dependent pregnant women face; to identify the extent to which chemically dependent pregnant women believe the services offered by the Transitions Clinic at the Mercy Hospital for Women met their needs, and to assess whether pregnancy is a time of transition or a turning point in the lives of some of the women. This paper reports predominantly on one aspect of a study, namely identifying the extent to which the TC met their needs.