This annual report - Taranaki District Health Board

Integrated care for pregnant women with alcohol and drug use problemsThe UK NICE guidelines for pregnant women who misuse substances (alcohol and/orother drugs) recommend that those responsible for the organisation of local antenatalservices should work with other agencies that provide substance misuse services(including social care and third-sector agencies), to coordinate antenatal care [139]. Colocationof services, and joint, cross-agency care plans which include information aboutopiate replacement therapy and other locally available services, are suggested. A numberof such integrated programmes, incorporating substance abuse treatment and pregnancy,parenting and child-related services, have been developed [267].In their systematic reviews Niccols et al. and Milligan et al. assessed the effectiveness ofsuch integrated programmes on parenting and child outcomes [267,268,269,270]. Milliganet al. examined the impact of integrated treatment programmes on maternal substance use[267]. Three RCTs (n=250 participants), nine quasi-experimental studies (n=2,105) andnine cohort studies (n=856) were included in the review. Compared to no treatment,integrated programmes were significantly more effective in terms of negative urinetoxicology screens and reduced alcohol and drug use (2 studies) and statisticallysignificant standardised mean differences in maternal substance use in the ten studiesexamining pre- and post-intervention data. However, comparison of integrated versus nonintegratedprogrammes showed no statistically significant differences in urine toxicology orself-reported abstinence (10 studies). Niccols et al. found that limited available evidencesupported the integrated programmes on parenting outcomes, although the effect size inthe three RCTs comparing integrated programmes to treatment-as-usual (419 participants)that examined parenting outcomes was small [269]. Outcomes did not include maternalcustody. Niccols et al. also examined the effectiveness of integrated programmes on childoutcomes [268]. Thirteen studies (2 randomised trials, 3 quasi-experimental studies, 8cohort studies; n=775 children) were included in the review. Most of the studies assessingpre-post effects on child development and emotional and behavioural functioning indicatedsmall to large improvements following the intervention. The one quasi-experimental studyand 2 RCTs that compared integrated programmes with non-integrated treatment foundfavourable effects for integrated treatment, although the effect sizes were small. A furthermeta-analysis examining the effect of integrated programmes on maternal mental healthidentified a small advantage in improvement in maternal mental health [270]. While theavailable evidence appears to support the use of integrated programmes, there is a lack ofhigh quality studies, limiting the conclusions that can be drawn, and highlighting the needfor high-quality randomised studies with larger sample sizes.Home visitingA recent Cochrane review found insufficient evidence to recommend the routine use ofhome visits for pregnant or postpartum women with a drug or alcohol problem [181]. SevenRCTs (reporting 803 mother-infant pairs) comparing home visits (mostly after birth), bycommunity health nurses, paediatric nurses, trained counsellors, paraprofessionaladvocates, midwives and lay African-American women, with no home visits, were includedin the review. Several studies had significant methodological limitations. Meta-analysisidentified no significant differences in a wide range of outcomes including: continued illicitdrug use (three studies, 384 women; RR 1.05, 95% CI 0.89 to 1.24); continued alcohol use(three studies, 379 women; RR 1.18, 95% CI 0.96 to 1.46); failure to enrol in a drugtreatment programme (two studies, 211 women; RR 0.45, 95% CI 0.10 to 1.94); notbreastfeeding at six months (two studies, 260 infants; RR 0.95, 95% CI 0.83 to 1.10);incomplete six-month infant vaccination schedule (two studies, 260 infants; RR 1.09, 95%CI 0.91 to 1.32); infants not in care of biological mother (two studies, 254 infants; RR 0.83,95% CI 0.50 to 1.39); and infant death (three studies, 288 infants; RR 0.70, 95% CI 0.12 to4.16). While individual studies identified some benefit, given the study limitations furtherhigh-quality research is required to establish whether routine home visiting should berecommended.Maintenance treatmentA draft protocol for methadone maintenance treatment published by the Ministry of Healthin 2001 identified pregnant women as a priority group for treatment [271]. At the time, NewIn-Depth Topic: Adversity in Pregnancy - 299