Having a dependency on alcohol and other drugs (AOD) is linked to social stresses and physical and mental health.
Many women who use substances during their pregnancy fall into this category experience poverty, social disadvantage, unemployment, are a young parent, have poor health and inadequate antenatal care. Mental health issues are also common when there is AOD dependency, with depression and anxiety the most common diagnoses.
While pregnancy increases many women’s motivation to change their substance use, it is important to remember that dependence is an illness, not just a behaviour.
Some women may not be ready to change. If the pregnancy has been unplanned, they may find creating new patterns of behaviour or new ways to manage emotional and physical needs even more challenging. However, no matter where a woman is in the change cycle, her pregnancy is an opportunity. Pregnancy is often the first time a woman will appear before Health and Child Safety, which provides an opportunity to understand the support she needs, when she is ready. This is a crucial time for readying women for change.
In recent years, there has been an increase in the proportion of women who abstain from alcohol once they become aware of their pregnancy, but the proportion of women drinking at risky levels has remained stable. Women who find it difficult to stop drinking need extra support.
The National Drug and Alcohol Research Centre’s Supporting pregnant women who use alcohol or other drugs guide provides great strategies for reducing harm to women and their babies during pregnancy.
Effects of alcohol on an unborn baby
The use of AOD during pregnancy is linked to many potential risks for a baby. A baby who is affected by AOD crossing the placenta during pregnancy may:
- unexpectedly abort (miscarriage)
- be born early
- have low birth weight
- be stillborn
- be born with physical abnormalities or intellectual disabilities
- be born with foetal alcohol spectrum disorder
- be born with neonatal abstinence syndrome.
If a woman has been drinking heavily shortly before giving birth or has been withdrawing from alcohol during labour, her baby is at risk of acute alcohol withdrawal. The onset of withdrawal for a newborn may begin 24 to 48 hours after delivery, depending on the time of the mother’s last drink.
If a woman has been drinking alcohol regularly during her pregnancy, her baby will need to be monitored and assessed for foetal alcohol spectrum disorder by a paediatrician, who will guide the baby’s ongoing treatment needs.
Foetal alcohol spectrum disorder
The term ‘foetal alcohol spectrum disorder’ (FASD) is used to cover the full range of possible effects of foetal exposure to alcohol, while the term foetal alcohol syndrome is used to encompass the severe effects. Refer to Identifying and understanding common disabilities for more information on FASD.
Foetal alcohol syndrome
Foetal alcohol syndrome (FAS) is a continuum of permanent birth defects caused by alcohol crossing the placenta to an unborn baby. It typically includes deformities of the head and face, various defects in vital organs and appendages, and intellectual disability and behaviour problems. Partial FAS is where a child has some, but not all, features reported in FAS.
Alcohol-related neurodevelopmental disorders
Alcohol-related neurodevelopmental disorders refer to problems with learning and behaviour experienced by children as a result of alcohol exposure during their mother’s pregnancy.
Alcohol-related birth defects
Alcohol-related birth defects refer to abnormalities in organs (such as the heart or kidneys) related to alcohol exposure.
Watch the following video Foetal alcohol spectrum disorder impacts you, but you don’t know it.
Watch the following video about FASD in Australia.
Webinar: 'Supporting children and families affected by foetal alcohol spectrum disorder' (Australian Institute of Family Studies, 2014).
Opiate use during pregnancy
Studies have found that heroin use in pregnancy is associated with foetal harms such as intrauterine growth restriction (a condition in which a baby does not grow to normal weight during pregnancy), low birth weight and neonatal death. Injecting opioid use is also associated with harm such as blood-borne viruses, non-viral infections including cellulitis, endocarditis and septicaemia, and overdoses (fatal and non-fatal).
During pregnancy, other possible harmful effects of using opioids include:
- premature birth
For the child, other possible harmful effects of using opioids include:
- withdrawal in the newborn
- reduced growth
- death from sudden infant death syndrome (SIDS).
Keeping women and their babies safe when there is opiate use
A pregnant woman who is using opiate substances should be offered stabilisation by induction onto an opioid substitution treatment, combined with drug and alcohol counselling and psychosocial support.
Stabilisation (through methadone and buprenorphine maintenance programs) can result in improved foetal development, healthier infant birth weight and a reduction in neonatal mortality.
Research indicates that withdrawal from methadone or buprenorphine during pregnancy can put mothers at risk of returning to dependent illicit opioid use. Opioid withdrawal during pregnancy may also place unborn children at heightened risk.
As such, opiate withdrawal is not encouraged or recommended for women during pregnancy under the Queensland clinical guidelines – Perinatal substance use – Maternal.
The management of alcohol and drug use during and after pregnancy should be undertaken by suitable qualified medical professionals.
Neonatal abstinence syndrome
Neonatal abstinence syndrome (NAS) is a withdrawal symptom that occurs because infants are prenatally exposed to opioids, heroin, codeine, oxycodone, methadone or buprenorphine. Babies exposed before birth to these drugs can be become physically dependent on the drugs and be born with withdrawal symptoms.
Other possible effects of amphetamine-type substances for the child may include:
- reduced growth
- stroke or heart failure in newborn
- withdrawal in the newborn
- cognitive problems
- delays in motor development.
Heroin slows foetal growth, causing intrauterine growth retardation and premature birth. If mothers are injecting drugs, there is an increased risk of the transmission of HIV and viral hepatitis.
If women are stable on methadone and using no other substances, the baby will experience withdrawal due to the nature of the prescribed drug. Women will commonly need their dose increased while they are pregnant. Their current prescriber usually reviews this. Reducing the dose after giving birth is currently a common practice. The prescriber will also assess this.
Problematic drug use is associated with low birth weight, premature birth, stillbirth and sudden infant death syndrome (SIDS). But some women who use substances are also cigarette smokers, with poor nutrition and complex social circumstances. This means some of the symptoms may be due to tobacco exposure and other lifestyle factors such a malnutrition and parental anxiety or stress.
Symptoms of NAS in an infant may include:
- blotchy skin colouring (mottling)
- excessive crying or high-pitched crying
- excessive sucking
- hyperactive reflexes
- tight muscle tone
- tense arms, legs and back
- poor feeding due to sucking problems
- rapid breathing
- seizures (convulsions)
- sleep problems
- slow weight gain
- stuffy nose and/or sneezing
- trembling (tremors and jitters)
This syndrome usually begins within 72 hours after birth, but may appear up to two weeks after birth.
NAS can be detected when health professionals use the Finnegan Scoring System. Babies who score high on the system may need medical treatment, such as morphine or phenobarbitone, to help them withdraw safely.
What to do if a baby might have neonatal abstinence syndrome
Practitioners need to talk with health staff to understand the testing score and what treatment a newborn baby needs in order to withdraw safely. Ask about what this means for how parents may care for and look after her baby during this time, including settling, feeding and sleeping.
If a baby is discharged within the first two weeks, practitioners need to know the NAS signs to look for and talk with parents, carers and other professionals involved about this possibility.
Supporting parents who have a baby diagnosed with neonatal abstinence syndrome
Caring for a baby with NAS is difficult. Feeding and sleeping in particular are often difficult for the baby, which can make parenting more challenging. Parents may find it difficult to settle their baby, may experience more infrequent and shorter periods of sleep than other new parents, and will likely struggle to develop clear routines.
If AOD use has been a parent’s way of coping, the increase in stress may trigger a relapse or escalate their substance use. Carefully consider how to ensure how the needs of a baby with NAS will be met and who can help support the parents. Ensure a robust safety and support network is in place for the family.
Managing neonatal abstinence syndrome
The stress of caring for a baby with NAS may prevent early bonding between mother and baby. Babies may be in a great deal of distress, and this can be difficult for both parents and professionals.
A mother is already likely to feel guilty and ashamed for the impact her AOD use has had on her newborn baby, and negative attitudes from professionals are likely to make her feel worse. This can make a woman feel like withdrawing from services, drinking or using drugs as she tries to cope with her remorse. This can also affect the early bonding and attachment behaviours between a mother and her baby.
Babies experiencing withdrawal symptoms
Guilt, shame and stigma can get in the way of a mother bonding with her child. When a newborn baby is in the neonatal unit, as is often the case for a baby with NAS, a mother is able to visit to spend time and be a part of feeding, sleeping and care routines. But this is an unnatural setting, where babies are monitored and ultimately, where parents’ interactions are observed.
Some of the actions you can take to support parents when babies have withdrawal symptoms are:
- talking to mothers about what it is like seeing their baby distressed and in withdrawal:
- How do they feel when they see their baby in distress?
- What can you do to support them in connecting and bonding with their baby even if they feel guilt or sadness?
- talking to parents about who may be able to support them:
- Connect mothers to child protection social workers to talk about how they can be helped through this time.
- Ask if there are friends, family or community members who may be able to help parents cope with the challenges of their new baby and even provide short periods of respite.
- talking to mothers and fathers about the reaction they have when things are difficult:
- How do they feel when they hear their baby’s high-pitched cry or when it is very difficult settling the baby? Do they feel as if they have failed? Do they feel angry?
- How do they manage feeding problems?
- When the child is difficult to feed or settle, are they able to empathise?
- How do they feel and act towards the professionals working with them?
- talking to the nursing unit manager, or nurses, about what it is like for them:
- Check in with the nursing team about what it’s like for the mother, caring for her baby going through withdrawal and how this makes them feel about the mother.
- Talk about the impact negativity, blame and shame can have on a mother and how this can stop her from making positive changes and tending to her child’s needs.
- Let nursing staff know how important it is that they also support mothers by not being judgemental about their substance use.
In the following video, Deanna Murphy tells the story of Baby Emily and Mum Michelle and the impact of AOD use.
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