Barriers and facilitators in antenatal settings to screening and referral of pregnant women who use alcohol or other drugs: A qualitative study of midwives' experience.

BACKGROUND: Screening pregnant women for substance use is highly recommended in antenatal care settings. Although midwives provide routine screening for substance use and referral for treatment in pregnancy, little is known about the barriers and facilitators they experience. AIM: The study explored barriers and facilitators experienced by midwives in antenatal settings to screening and referral of pregnant women who use alcohol or other drugs. DESIGN/SETTING: A semi-structured interview was adopted to explore barriers and facilitators experienced by midwives in screening and referring pregnant women for alcohol or other drugs specialised services. Eighteen midwives were recruited from urban, regional and rural antenatal settings in Victoria. Interviews were tape recorded and transcribed verbatim. Themes were generated by thematic analysis, the process of identifying patterns within the data. FINDINGS: Of the seven themes identified under barriers, five could be categorised as "institution and provider-related", namely: (i) lack of validated screening tool, (ii) inadequate support and training, (iii) discomfort in screening, (iv) lack of multidisciplinary team and specialised treatment in regional and rural areas, and (v) workload and limited consultation time. Conversely, two themes could be classified as 'client-related', namely (i) non- or partial-disclosure of substance use, and (ii) reluctance and non-adherence to referrals. All five themes under facilitators were "institution and provider-related." They are (i) a woman-centred philosophy of care, (ii) evidence of harms from substance use on neonates, (iii) experience and training, (iv) continuity of care, and (v) availability of multidisciplinary team and funding. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: To the best of our knowledge, this is the first study of its kind conducted in Victoria. This study not only adds to the limited body of knowledge on barriers experienced by midwives but also identifies facilitators in antenatal settings that promote screening and referral of pregnant women who use substance. Most of the barriers and facilitators are interrelated. Despite midwives' willingness to screen all pregnant women for substance use and provision of referral, they often felt limited in their capacity. Availability and accessibility to validated screening tool(s), in addition to regular, ongoing training for all midwives to maintain clinical competence and provide effective communication are imperative. Availability of a multidisciplinary team, funds and specialised care facilities such as detoxification and mental health services, especially in regional and rural areas, are necessary to effectively support at-risk pregnant women.

Neonatal and maternal outcomes following maternal use of buprenorphine or methadone during pregnancy: findings of a retrospective audit.

BACKGROUND: Substance use in pregnancy is potentially harmful to both the fetus and pregnant woman. At the Royal Women's Hospital, the Women's Alcohol and Drug Service (WADS) provides pregnancy care and counseling for women who have complex drug and/or alcohol issues and psychosocial needs. Women who are stable on pharmacotherapy attend the general pregnancy clinics. RESEARCH QUESTION: What are the maternal characteristics, pregnancy and neonatal outcomes for a group of women attending for pregnancy care who were on pharmacotherapy substitution treatment, being prescribed buprenorphine or methadone? PARTICIPANTS AND METHODS: All women prescribed buprenorphine or methadone from September 2005 to December 2006 were identified by the hospital pharmacy department where prescribing permits are retained during the woman's pregnancy and postnatal period. Data were collected from medical records and a specific Drug and Alcohol Service database and analysed using descriptive statistics. RESULTS: Ninety-eight women were identified; 78 were prescribed methadone and 20 buprenorphine. Of these, 76 women also used other substances: tobacco (63%); cannabis (39%); and heroin (37%). Women who received no antenatal care had poorer outcomes overall. Twenty-four percent of live-born infants ≥33 weeks gestation (22/91) required medication for withdrawal. There was no difference in medication requirement where mothers were polysubstance users (18/70; 26%) compared with those who were not (2/21; 19%) (p=0.78), although these small numbers should be viewed with caution. The mean time until medication was required was 3.47 days. DISCUSSION: A significant proportion of infants whose mothers used buprenorphine or methadone in pregnancy displayed enough symptoms of withdrawal to require medication. This is therefore an important clinical issue of which care providers need to be aware. CONCLUSION: Further prospective research is required to explore whether factors such as specific substances are more likely to be associated with infant withdrawal.