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'Getting Our Priorities Right' & 'Hidden Harm' Pregnancy Protocol ABERDEEN CITY JOINT ALCOHOL AND DRUG ACTION TEAM ABERDEENSHIRE ALCOHOL AND DRUG ACTION TEAM MORAY DRUG AND ALCOHOL ACTION TEAM NORTH EAST OF SCOTLAND CHILD PROTECTION COMMITTEE 1 “Getting Our Priorities Right” and “Hidden Harm” Inter-Agency Guidelines Pregnancy Protocol (to be read as part of the above pack). This protocol applies to all those working or involved with: Pregnant women who have problematic substance use. The children of pregnant problematic substance users and their partners. Men whose partners are pregnant and where there are concerns in relation to problematic substance use. Overview There is growing public and professional awareness of the profound effects of parental drug and alcohol misuse on the wellbeing of children. Problematic substance use and good parenting are incompatible and increases the risks of harm to children. However, with the right kind of treatment and support problematic substance using parents are capable of caring for their children. A key factor in providing treatment and support thus preventing the detrimental effects of parental problematic substance use is early intervention, which focuses on the period of pregnancy and immediate postnatal period. Interventions need to start before a baby’s birth to enable parents to provide safe and appropriate parenting therefore reducing the physical and emotional harm caused by problematic substance use and lifestyle choices. (“Getting Our Priorities Right”, (2003)). Some pregnant women with problematic substance misuse issues do not seek antenatal services until late in pregnancy or when in labour. They may not realise they are pregnant because of the effects of some substances on the menstrual cycle. Their problematic substance use and associated life-style may make other more urgent demands on their time. They may fear their drug use or drinking will be detected through routine urine or blood tests, or that if they tell staff they will be treated differently or that child protection agencies will be contacted automatically. They may feel guilty about their drug or alcohol use and want, or feel they ought to stop but are worried that they will not succeed. They may be worried that their baby will be damaged or display withdrawal symptoms after birth. Many of these problems can be overcome by provision of accessible antenatal services that tackle these worries honestly and sympathetically. (“Getting it Right for Every Child: Proposals for Action”, (2005)). “Getting Our Priorities Right” (2003) established a baseline and the later document “A Framework for Maternity Services in Scotland” (2003) went on to set out broad principles for underpinning good practice in maternity care, recommending that; The woman should be the focus of maternity care, should be empowered and able to make informed decisions about her care. Staff should recognise and support the role of fathers and/or partners throughout the pregnancy and childbirth. Maternity services must be readily and easily accessible to all, sensitive to the needs of the local population and primarily community-based, with good continuity of care. Women should be involved in the planning of maternity services. A multi-disciplinary approach is essential in the management of pregnant alcohol or drug-using women. 2 Consideration must be given to the impact and harm continued problematic substance use has on an unborn child. Research shows that the immediate withdrawal of drugs or alcohol could result in premature birth or miscarriage, thus advice must be sought from midwifery or substance misuse services before giving any advice on cessation, or reduction of drug or alcohol misuse to a pregnant woman. Effects of Maternal Problematic Substance Use on the Pregnancy and the Unborn Baby “Parental problem drug use can and does cause serious harm to children at every age from conception to adulthood.” (Hidden Harm, (2003)). Pregnant women who use drugs or alcohol experience a range of medical problems, some specifically due to their drug or alcohol use, but many are due to their background of multiple social problems which are frequently exacerbated by problematic substance use. Many women attending maternity services are undernourished, have poor dental health and suffer from recurrent infections as a result of problematic substance use, particularly poor injecting practices. The unborn child of problematic substance using parents needs to be protected as soon as the mother’s pregnancy is confirmed. Maternal drug or alcohol use carries significant risk, which can affect foetal development. Drug injecting during pregnancy may also result in the transmission of HIV and viral hepatitis to the baby. (Siney, (2002)). Maternal problematic substance use during pregnancy is reportedly associated with higher rates of perinatal mortality and morbidity, largely because of increased rates of delivery of babies who are preterm or of low birthweight or small for gestational age. There is also reported to be a higher incidence of sudden infant death syndrome among such babies. Many babies born to problematic substance using mothers will suffer from neonatal abstinence syndrome (NAS) otherwise called drug withdrawal. (Lloyd and Myerscough, (2006)). The Effects of Neonatal Abstinence Syndrome Almost every substance misused passes from the mother’s blood stream through the placenta to the unborn baby. Substances that cause dependence and addiction in the mother also cause the baby to become addicted. At birth the baby’s need for substance may continue. However, since the substance is no longer readily available the baby will experience withdrawal to a greater or lesser degree. The signs of drug withdrawal are collectively named neonatal abstinence syndrome (NAS). The following are the most common signs of NAS. However, each baby may experience symptoms differently. The signs include, high-pitched cry, fever, irritability, tremors, disruption of normal sleep pattern, sweating, diarrhoea, weight loss, fast breathing and skin excoriation from constant movements. In severe cases a baby may develop seizures. (Lloyd and Myerscough, (2006); Siney, (2002)). Foetal Alcohol Syndrome and Foetal Alcohol Spectrum Disorders. The importance of recognising women who are heavy alcohol consumers during pregnancy and providing support to reduce or discontinue their habit is clear. There 3 is an increasing body of evidence supporting the harmful effects to the unborn baby from alcohol consumption during pregnancy. (SAADAT, (2006)). These effects include pre and postnatal growth deficiency, central nervous system dysfunction and distinctive facial features. Babies may have difficulty feeding, be irritable and have difficulties establishing a regular sleeping pattern. Children exposed to alcohol in utero may suffer from serious cognitive effects and behavioural problems, which may present later in development. (Royal College of Obstetricians and Gynaecologists, (2006)). Many babies suffering from withdrawal will require admission to a neonatal unit for special care. NAS resolves slowly and many babies suffer NAS following discharge from hospital. These babies will require on-going care and may continue to require medication. Additionally babies may suffer from delayed onset NAS. These delayed signs are important because irritability, feeding difficulties and failure to sleep place additional burdens on parents or carers. “Window of Opportunity” A Multi-Agency Approach The impact of problematic substance use (particularly alcohol and illegal drugs) on children has been well documented. (Barnard and McKeganey, (2004)). Children of people with substance using problems will often be at risk from receiving poor and neglectful parenting, having poor physical and psychological health and relationship problems. (Harbin and Murphy, (2006)). A woman’s motivation for getting help for her substance problems is often increased because of pregnancy. This “window of opportunity” enables agencies to work closely together in order to minimise the harm to both the mother and her unborn baby’s health and to protect the welfare of any children in her or her partner’s care. Importantly, a problematic substance misusing partner can be fast tracked into treatment services. The welfare of the child must be paramount and all agencies are responsible for identifying pregnant women with substance misuse problems who may be in need of additional services and support. All agencies need to share their concerns with the appropriate agencies (social work.health, police). Concerns may come from indirect knowledge, such as those working with the father, partner, carer and any associated children, as well as from direct contact with the pregnant woman. When an agency identifies a pregnant woman experiencing substance misuse problems, then the NESCPC Guidelines should be followed (link to Section 5, page 52 on Pregnant Women Who Also Misuse Substances) An the Initial Referral Discussion Social Work, Health and Police will decide whether further protective action is necessary in relation to the unborn child and any other children in the family.(see page 26,NESCPC Guidelines). The interests of the unborn child/children and the mother and her partner are inextricably linked. All services i.e. Maternity, Primary Care Health services, Social Work, Substance Misuse Services and other agencies must work closely together with parents to assist in tackling their problematic substance use. 4 If there is reluctance to engage with services designed to minimise harm to the unborn baby or children staff must consider whether the potential risk is significant enough to override the need for consent. Agencies must address this fear and use the opportunity afforded by pregnancy to develop best practice and provide effective assessment and support. (link to section on Information sharing and consent in NESCPC guidelines-pages 3-6 and information leaflet in GOPR pack) Best practice means: Identifying as early as possible in pregnancy the possible spectrum of risk to, and needs of both mother and baby, and alerting services before birth; Developing effective care plans and regular and realistic review of the plans; offering a range of multi-agency/multi-professional approaches to care, that are non-judgemental; and Ensuring that no pregnant woman with problematic substance usage arrives at a maternity unit to give birth without her situation being known and without support being available for her and her child. ("Hidden Harm – Next Steps, (2006)). The most effective assessment and support comes through good information sharing, joint assessments of need, joint planning, professional trust within the interagency network and joint action in partnership with families. Assessment of Risk When a woman is pregnant and she, and/or her partner, has problems with drugs or alcohol (or a newborn baby is found to be in this situation), then a multi-agency assessment of risk and need must be made in respect of both the unborn child (or baby), the parents or carers and any other children in the family. This is especially important where service awareness of earlier births may need to be clarified, for example, in the case of older or overseas children. The assessment should cover both consideration of the provision of appropriate services and whether or not to recommend a Pre-Birth Case Conference. A Pre-Birth Case Conference should be held by or before 28 weeks gestation and never later that 32 weeks, where assessment indicates risk of significant harm. 24 Weeks Gestation or Mid-Trimester Multi-Agency Review.(MTR). Whether or not a Pre-birth Case Conference has been convened, a multi-agency pre-birth case review must always take place at the 24 week stage. The pre-birth case discussion must include all those involved with the parents e.g., midwife, health visitor, GP, substance misuse service worker, social worker, support worker, Drugs Action and obstetrician, and where possible, parents should be invited. If parents are not present then their views must be taken into consideration. 5 The Review should; Consider all available information and make decisions about the level of interventions and support to be offered for the remaining pregnancy and the immediate postnatal period. Consider all actual or potential risk. Confirm and review the care plan for pregnancy. Identify / confirm the key worker. Decide whether to recommend a Pre-Birth Child Protection Case Conference, if one has not already been convened.. Formulate and agree a discharge plan and set out clearly in the mother’s and baby’s notes. Agreement should be made as to who has the responsibility for taking this task forward and involving the mother in the process. If no protection plan via a pre-birth case conference and no recommendation for a case conference, agree and record an action plan with actions allocated to relevant people. Inform the mother, where possible, of the outcome / decisions made. Ongoing risk assessment by all agencies must continue. There should be an Initial Referral Discussion between Social Work, Health and Police in relation to any baby, who is born with neonatal abstinence syndrome (NAS) and who has not been previously identified.. Local multi-disciplinary policies are recommended to improve communication and reduce risks to the unborn baby or children of substance misusing parents. Obstetric departments should develop good links with local substance misuse specialists and Primary Care health services and the local social work, children and families teams.. The key area of managing the care of pregnant problematic substance users, their partners and children is the co-ordination between the relevant agencies to assess risk, set goals and plan support networks. Agencies must consider referral for a Pre-Birth Case Conference as early as possible if there appears to be a risk of significant harm to the child when he or she is born. For further information on the Care Pathway and management of pregnant substance users please see attached flowchart. Please note that this is a guide and assessments must always be ongoing and decisions reviewed at all stages throughout the pregnancy. 6 References / Further Reading. “A Matter of Substance? Alcohol or Drugs: Does it Make a Difference to the Child?” (Scottish Association of Alcohol and Drug Action Teams (SAADAT), 2006) “Alcohol Consumption and the Outcomes of Pregnancy” (Royal College of Obstetricians and Gynaecologists. RCOG Statement 5, March 2006) “Framework for Maternity Services in Scotland” (Scottish Executive, 2003). “Getting It Right for Every Child: Proposals for Action” (Scottish Executive, 2005). “Getting Our Priorities Right: Good Practice Guidance for Working with Children and Families Affected by Substance Misuse” (Scottish Executive, 2003). “Hidden Harm – Responding to the Needs of Children of Problem Drug Users. Report of an Inquiry by the Advisory Council on the Misuse of Drugs” (ACMD, 2003) “Hidden Harm Next Steps Supporting Children – Working with Parents” (Scottish Executive, 2006) “Neonatal Abstinence Syndrome. A New Intervention: A Community Based, Structured Health Visitor Assessment” (Lloyd, DJ; Myerscough, EJ. Scottish Executive Social Research Substance Misuse Research Programme, 2006) North East of Scotland Child Protection (NESCPC) Guidelines (www.nescpc.org.uk) “Pregnancy and Drug Misuse” (Siney, C. BfM. Books for Midwives. 2002 ed) “Secret Lives: Growing with Substance. Working with Children and Young People Affected by Familial Substance Misuse” (Harbin, F; Murphy, M. (Eds) Russell House Publishing. Lyme Regis, Dorset, 2006) “Sharing Information About Children At Risk: A Guide to Good Practice” (Scottish Executive, 2003) “Substance Misuse and Childcare” (Harbin, F; Murphy, M. (Eds) Russell House Publishing, Lyme Regis, Dorset, 2000). “The Impact of Parental Problem Drug Use on Children: What is the Problem and What Can be Done to Help?” (Barnard, M; McKeganey, N. Addiction. 99-5, 552-9, 2004) 7 MANAGEMENT OF PREGNANT SUBSTANCE USERS Booking Visit - Pregnancy Confirmed Woman declares herself to be pregnant The midwife will inform parent/s that under NESCPC guidelines the midwife must inform and share information with; Specialist Service eg. The Golden Square Pregnancy Team Social Work Substance Misuse Service Drugs Action Point of Contact: Community Midwife GP Social Worker Drug Worker Health Visitor CPNs (Substance Misuse Service) Other eg. Relative Service offered must be acceptable to the woman. May be with local midwife or specialist. Parent/s must be informed about the planned midtrimester review and reasons High-risk pregnancies are always referred to consultant clinic There must be an Initial Referral Discussion between Social Work, Police and Health. This discussion should decide whether or not to proceed to Pre-Birth Case Conference. Ongoing midwifery care as per NHS Guidelines. If unborn child to be placed on CP Register at birth, then ongoing core group meetings to progress Protection Plan. (Community Midwife or Specialist Clinic) 24 Weeks Gestation or Mid-Trimester multi-agency Review (MTR) The MTR must: Immediate Postnatal Period Mother and baby will undergo a 5-10 day assessment in a hospital setting. This time will be used to assess parenting and withdrawal in the newborn. Generic/specialist midwife will liaise with: Community Midwife Social Worker/key worker Health Visitor Share all available information and make decisions about the level of interventions and support to be offered for the remaining pregnancy and the immediate postnatal period Consider all actual or potential risk if no Pre-Birth Case Conference has taken place. Confirm and review the care plan for pregnancy Identify / confirm the key worker Decide whether to recommend a Pre-Birth Child Protection Case Conference if this has not taken place.. Formulate and agree a discharge plan with the mother and set out clearly in the mother’s and baby’s notes. Agreement should be made as to who has the responsibility for this task If no Pre-Birth Case Conference has taken place and decision not to recommend this, the Initial Referral Discussion process should enable agencies to continually share, review and evaluate information as it becomes known(NESCPC guidelines pg 26). Inform the mother, where possible, of the outcome / decisions made CPN/Substance Misuse Service Others where relevant to ensure ongoing support and risk assessment Ongoing care as per NHS Guidelines Late Presentation to Maternity Services An Initial Referral Discussion must take place if concerns about risk to unborn child. Baby identified as suffering from NAS (and not previously identified as “at risk”) Automatic Initial Referral Discussion between Social Work Health and Police.. Care Plan as per entry point to care. The child's needs are paramount. If at any point child protection concerns arise do not delay in sharing concerns with Social Work or Police as per NESCPC Guidelines. All professionals and services providers have a duty to take action to make sure that a child whose safety or welfare may be at risk is protected from harm, even if the child is not the client/patient. 8