Substance misuse during pregnancy

Screening and early intervention for substance use during pregnancy: A retrospective case note review of antenatal care records

INTRODUCTION

Screening for substance use during pregnancy is critical for enhancing maternal health and perinatal outcomes. However, disparities persist in screening and intervention rates within maternity services. This retrospective case note review explored contemporaneous practices around screening and interventions for substance use among pregnant women during routine antenatal care.

METHODS

A random sample of 100 sets of maternity records were reviewed. Eligible cases included any woman attending initial pregnancy assessments at one of two South Australian metropolitan Hospital-based antenatal clinics, from July 2019-September 2020. Screening rates for past and current alcohol, tobacco and other substance use were identified and compared with data from a subset of a nationally representative survey. Intervention details and referral pathways were also assessed.

RESULTS

The final sample of eligible cases (n = 93) demonstrated prioritisation of screening for current use, over past use, across all substances (p < 0.001). Screening was most likely for tobacco and least likely for e-cigarettes (p < 0.001). Significant underreporting of past use compared with the benchmark was identified for all substances (except tobacco, p = 0.224). Interventions typically involved written resources, which were usually declined by clients.

DISCUSSION AND CONCLUSIONS

Despite longstanding recommendations, screening and intervention practices for substance use appear inconsistent. With the recent emergence of vaping, no evidence of updated approaches to identifying e-cigarette consumption in pregnant women was found. Several opportunities for enhancing routine screening and intervention practices within antenatal clinics were identified, and will inform the development of policy directives, targeted training modules, and other resources for health professionals working in these services.

Improving the quality of antenatal screening and early intervention for alcohol and other drug use: protocol for a multi-stage approach to systems reform

BACKGROUND

Alcohol, tobacco and illicit drug use during pregnancy can cause significant harm to women and their developing fetuses. Despite recommendations for abstinence during pregnancy, some women continue to use, making screening for substance use during antenatal clinic attendances an important strategy for reducing risk. This study aims to improve the rates of screening and intervention for substance use among pregnant women, including appropriate referral for those who may be substance-dependent. The protocol outlined here focuses on a multi-stage implementation study.

METHODS

This study will occur in four phases. Phase 1 will identify a baseline rate of screening and subsequent care at the antenatal clinics of two, South Australian hospital-based maternity services, through a retrospective case note audit. Rates of self-reported substance use identified in the case notes will also be compared against representative data from Adelaide Primary Health Network to establish rates of over or underreporting. Phase 2 will involve an online Training Needs Analysis of midwifery staff working at those services, to assess their knowledge, attitudes, beliefs, and commitment to the care of women who use substances during pregnancy. Phase 3 will involve a training package for all midwifery staff at those services, focused on routine screening for substance use, and how to provide appropriate care. Outcome measures from phase 2 will be reassessed during phase 3 and any changes since training will be evaluated. Phase 4 will then repeat phase 1 to compare the changes in rates of both screening and any associated intervention before and after training.

DISCUSSION

From a public health perspective, this project has the potential to make a significant impact on reducing risk of harm from substance use disorders among pregnant women, and contribute to better health outcomes for their children.

TRIAL REGISTRATION

This trial has been pre-registered under the Open Science Framework.

REGISTRATION

https://doi.org/10.17605/OSF.IO/73FDZ .

Maternal opioid dose is associated with neonatal abstinence syndrome in children born to women with sickle cell disease

The objective of this study was to test the hypothesis that higher daily opioid dose is associated with the presence and severity of neonatal abstinence syndrome (NAS) in pregnant women with sickle cell disease (SCD). This was a retrospective study of pregnant women with SCD who required opioids. NAS was evaluated using the Finnegan scoring system and classified as none, mild, and severe. Severe NAS was defined as a Finnegan score ≥ 8 on 3 consecutive tests. Thirty-four pregnancies were examined in 30 women with SCD. Higher daily morphine dose was associated with a higher percentage of days in the hospital during pregnancy (P < 0.001). Hospital days contributed disproportionately to daily morphine dose as larger amounts of opioids were administered in the hospital compared to home (P = 0.002). Median maternal oral morphine dose was 416 mg for infants with severe NAS compared with 139 mg for those with mild NAS (P = 0.04). For infants with no NAS, median maternal morphine was 4 mg, significantly less than those with mild NAS (P < 0.001). Infants born to women who used on average >200 mg/day of oral morphine equivalent in the last month of pregnancy had a 13-fold increased risk of severe NAS compared with those who used <200 mg/day. These data demonstrate that higher median daily opioid dose is associated with progressively more severe NAS in pregnant women with SCD. Strategies to decrease pain and avoid hospitalizations are needed to reduce opioid use and NAS.

Maternal mental health in primary care in five low- and middle-income countries: a situational analysis

BACKGROUND

The integration of maternal mental health into primary health care has been advocated to reduce the mental health treatment gap in low- and middle-income countries (LMICs). This study reports findings of a cross-country situation analysis on maternal mental health and services available in five LMICs, to inform the development of integrated maternal mental health services integrated into primary health care.

METHODS

The situation analysis was conducted in five districts in Ethiopia, India, Nepal, South Africa and Uganda, as part of the Programme for Improving Mental Health Care (PRIME). The analysis reports secondary data on the prevalence and impact of priority maternal mental disorders (perinatal depression, alcohol use disorders during pregnancy and puerperal psychosis), existing policies, plans and services for maternal mental health, and other relevant contextual factors, such as explanatory models for mental illness.

RESULTS

Limited data were available at the district level, although generalizable data from other sites was identified in most cases. Community and facility-based prevalences ranged widely across PRIME countries for perinatal depression (3-50 %) and alcohol consumption during pregnancy (5-51 %). Maternal mental health was included in mental health policies in South Africa, India and Ethiopia, and a mental health care plan was in the process of being implemented in South Africa. No district reported dedicated maternal mental health services, but referrals to specialised care in psychiatric units or general hospitals were possible. No information was available on coverage for maternal mental health care. Challenges to the provision of maternal mental health care included; limited evidence on feasible detection and treatment strategies for maternal mental disorders, lack of mental health specialists in the public health sector, lack of prescribing guidelines for pregnant and breastfeeding women, and stigmatising attitudes among primary health care staff and the community.

CONCLUSIONS

It is difficult to anticipate demand for mental health care at district level in the five countries, given the lack of evidence on the prevalence and treatment coverage of women with maternal mental disorders. Limited evidence on effective psychosocial interventions was also noted, and must be addressed for mental health programmes, such as PRIME, to implement feasible and effective services.

Behavioral effects of perinatal opioid exposure

Opioids are among the world's oldest known drugs used mostly for pain relief, but recreational use is also widespread. A particularly important problem is opioid exposure in females, as their offspring can also be affected. Adverse intrauterine and postnatal environments can affect offspring development and may lead to various disabilities later in life. It is clear that repetitive painful experiences, such as randomly occurring invasive procedures during neonatal intensive care, can permanently alter neuronal and synaptic organization and therefore later behavior. At the same time, analgesic drugs can also be harmful, inducing neuronal apoptosis or withdrawal symptoms in the neonate and behavioral alterations in adulthood. Hence, risk-benefit ratios should be taken into consideration when pain relief is required during pregnancy or in neonates. Recreational use of opioids can also alter many aspects of life. Intrauterine opioid exposure has many toxic effects, inducing poor pregnancy outcomes due to underdevelopment, but it is believed that later negative consequences are more related to environmental factors such as a chaotic lifestyle and inadequate prenatal care. One of the crucial components is maternal care, which changes profoundly in addicted mothers. In substance-dependent mothers, pre- and postnatal care has special importance, and controlled treatment with a synthetic opioid (e.g., methadone) could be beneficial. We aimed to summarize and compare human and rodent data, as it is important to close the gap between scientific knowledge and societal policies. Special emphasis is given to gender differences in the sensitivity of offspring to perinatal opioid exposure.

Alcohol and Other Drug Use during Pregnancy among Women Attending Midwife Obstetric Units in the Cape Metropole, South Africa

Little is known about the nature and extent of alcohol and other drug (AOD) use among pregnant women in Cape Town, South Africa, despite the very high levels of AOD use in this part of the country. A cross-sectional survey was conducted among pregnant women attending 11 Midwife Obstetric Units (MOUs) in greater Cape Town. A two-stage cluster survey design was used. In total, 5231 pregnant women were screened to assess self-reported prevalence estimates. Of these, 684 (13.1%) were intentionally subsampled and completed an interviewer-administered questionnaire and provided a urine sample for biological screening. Urinalyses showed that 8.8% (95% CI: 6.7–10.9) of the subsample tested positive for at least one illicit drug. This is higher than the self-reported prevalence (3.6%). In addition, 19.6% (95% CI: 16.3–22.8) of the sub-sample tested positive for alcohol which is lower than the self-reported prevalence (36.9%). There are high levels of substance use among pregnant women attending public sector antenatal clinics. There is a need for routine screening for AOD use and appropriate responses depending on the women's level of risk.

Lessons learned from a comparison of evidence-based research in pregnant opioid-dependent women

OBJECTIVES

Lessons learned in research and treatment of opioid dependence demonstrate the need to include pregnant women in clinical trials.

METHODS

Two double-blind, double-dummy, randomized controlled trials (Pilot study, European sample(†) of MOTHER-trial) comparing buprenorphine and methadone in opioid-dependent pregnant women were conducted. In both studies, participants received voucher-based incentives for attendance and completion of study assessments. In the MOTHER trial, participants additionally received escalating voucher incentives for drug-free urine samples. Neonatal abstinence syndrome was treated with oral morphine solution based on standardized modified Finnegan scores.

RESULTS

After a mean treatment period of 13.79 weeks in the Pilot study (PS, n = 18) and 20.78 weeks in the MOTHER-trial (MT, n = 41), respectively (p < 0.001), PS patients delivered at mean doses of 14.00 mg buprenorphine/52.50 mg methadone and MT participants at 13.44 mg buprenorphine/63.68 mg methadone. Nonsignificant differences regarding dropout rates were found (22% in PS versus 10% in MT), but dropout was significantly earlier in the MT (p = 0.013). Significantly higher rates of concomitant consumption of opioids and benzodiazepines occurred in the PS compared with the MT (p < 0.001), however, with no significant differences in neonatal data between both settings.

CONCLUSIONS

Early treatment enrolment combined with contingency management contributes to reduced illicit drug use throughout pregnancy, surprisingly without influencing neonatal outcome parameters.

Neonatal abstinence syndrome: transitioning methadone-treated infants from an inpatient to an outpatient setting

OBJECTIVE

Each year in the US ∼50 000 neonates receive inpatient pharmacotherapy for the treatment of neonatal abstinence syndrome (NAS). The objective of this study is to compare the safety and efficacy of a traditional inpatient only approach with a combined inpatient and outpatient methadone treatment program.

STUDY DESIGN

Retrospective review (2007 to 2009). Infants were born to mothers maintained on methadone in an antenatal substance abuse program. All infants received methadone for NAS treatment as inpatient. Methadone weaning for the traditional group (75 patients) was inpatient, whereas the combined group (46 patients) was outpatient.

RESULT

Infants in the traditional and combined groups were similar in demographics, obstetrical risk factors, birth weight, gestational age (GA) and the incidence of prematurity (34 and 31%). Hospital stay was shorter in the combined than in the traditional group (13 vs 25 days; P<0.01). Although the duration of treatment was longer for infants in the combined group (37 vs 21 days, P<0.01), the cumulative methadone dose was similar (3.6 vs 3.1 mg kg(-1), P=0.42). Follow-up information (at least 3 months) was available for 80% of infants in the traditional and 100% of infants in the combined group. All infants in the combined group were seen ≤72 h from hospital discharge. Breastfeeding was more common among infants in the combined group (24 vs 8% P<0.05). Following discharge there were no differences between the two groups in hospital readmissions for NAS. Prematurity (34 to 36 weeks GA) was the only predictor for hospital readmission for NAS in both groups (P=0.02, OR 5). Average hospital cost for each infant in the combined group was $13 817 less than in the traditional group.

CONCLUSION

A combined inpatient and outpatient methadone treatment in the management of NAS decreases hospital stay and substantially reduces cost. Additional studies are needed to evaluate the potential long-term benefits of the combined approach on infants and their families.

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.

Opioid detection in maternal and neonatal hair and meconium: characterization of an at-risk population and implications to fetal toxicology

Identification of maternal opioid abuse in pregnancy is often difficult to ascertain in the absence of a reliable self-report. We aimed to characterize an at-risk neonatal population for opioid exposures as well as other drugs of abuse and alcohol. From June 2007 to January 2009, 563 neonatal hair and 1318 meconium specimens were assessed for opioids and were positive in 11.4% and 17.0%, respectively. Neonates testing positive for opioids in hair or meconium analysis were also more likely to test positive for other licit and illicit substances (odds ratiohair, 1.75; 95% confidence interval, 1.03-2.97; odds ratiomeconium, 1.61; 95% confidence interval, 1.16-2.22). Specifically, a positive neonatal hair test for opioids also predicted a positive result for oxycodone. In addition, a positive meconium test result for opioids was associated with positive results for cocaine, oxycodone, methadone, benzodiazepines, and fatty acid ethyl esters (alcohol). Finally, there was a significant correlation between maternal and neonatal hair test results for opioids (Spearman rank rho = 0.657, P = 0.03). Understanding the addiction profiles of these women may lead to better clinical and social management and may largely benefit an at-risk population.

Neurodevelopmental and psychological assessment of adolescents born to drug-addicted parents: effects of SES and adoption

OBJECTIVES

Prenatal exposure to heroin may have long-term consequences for development during early and middle childhood. The present research studied the cognitive, social, and emotional functioning of adolescents exposed to drugs prenatally, and investigated the extent to which the early adoption of children exposed prenatally to drugs would alleviate the possible effects of exposure.

METHODS

The study included 191 adolescents (12-16 years of age) and their parents in Israel, who had or had not been exposed prenatally to drugs and differing in socio-economic status (SES), and in adoptive status. They were administered five subtests of the Wechsler Intelligence Scale for Children (WISC-III), and the Youth Self-Report Form for assessing behavior problems that measures problems associated with attention deficit, self-esteem and risk-taking. Parents were administered the Child Behavior Checklist (CBCL) for assessing behavior problems, the Conners Rating Scale (CRS) for assessing attention deficit problems in their children and the Wender Utah Rating Scale (WURS), a self-report measure of ADHD-related problems.

RESULTS

Adolescents exposed to at least one risk factor (exposure to drugs, low SES, or adoption) performed more poorly than those exposed to none of these risk factors on the WISC-III subtests, the CBCL and the CRS. The effects of risk factors did not cumulate. Contrary to our hypothesis, adoption did not mitigate the effects of prenatal exposure to drugs: for cognitive functioning exposure to drugs was associated with poorer performance among the exposed High SES Adopted versus non-exposed High SES non-adopted children on three of the WISC-III subtests. Exposed low SES children living with their parents performed at the same relatively low level as non-exposed low SES controls. Exposure to drugs was associated with adult ADHD-related problems assessed by the WURS. There were no direct or interaction effects of exposure on neurological functioning, self-competence, behavior problems on the CBCL or risk-taking.

CONCLUSIONS

Children exposed to drugs of abuse prenatally, including those adopted away, and children who grow up in low SES backgrounds, may be at risk of relatively reduced cognitive functioning (though still within the normal range) in adolescence. Children exposed to drugs, who are from low SES backgrounds, or who are adopted, may be at risk for lower cognitive or social functioning than children who have not experienced such risks.

PRACTICE IMPLICATIONS

There is a need for implementing early monitoring and long-term intervention programs featuring encouragement of cognitive and social skills for children prenatally exposed to drugs in order to alleviate the possible long-term effects of exposure to risk.

Pregnant heroin addict: what about the baby?

Heroin misuse in pregnancy is a significant health and social problem, and it can have an adverse effect on the mother and the baby. Although heroin and methadone have no specific teratogenic potential, 48-94% of children exposed in utero will have neonatal abstinence syndrome (NAS). The primary aim of this case report is to raise awareness of NAS among clinicians and to remind them that although very common, it is not inevitable. The risk of NAS can be further minimised by offering comprehensive and co-ordinated antenatal care that addresses the various biopsychosocial needs of the pregnant woman. Further, a brief description of NAS and a review of evidence in the field of management of opioid misuse in pregnancy, as relevant to this case, are provided. We have also included the patient's own reflections on her pregnancy and treatment.

Maternal methadone use in pregnancy: factors associated with the development of neonatal abstinence syndrome and implications for healthcare resources

OBJECTIVES

The objectives of this study were to investigate factors associated with the development of neonatal abstinence syndrome (NAS) and to assess the implications for healthcare resources of infants born to drug-misusing women.

DESIGN

Retrospective cohort study from 1 January 2004 to 31 December 2006.

SETTING

Inner-city maternity hospital providing dedicated multidisciplinary care to drug-misusing women.

POPULATION

Four hundred and fifty singleton pregnancies of drug-misusing women prescribed substitute methadone in pregnancy.

METHODS

Case note review.

MAIN OUTCOME MEASURES

Development of NAS and duration of infant hospital stay.

RESULTS

45.5% of infants developed NAS requiring pharmacological treatment. The odds ratio of the infant developing NAS was independently related to prescribed maternal methadone dose rather than associated polydrug misuse. Breastfeeding was associated with reduced odds of requiring treatment for NAS (OR 0.55, 95% CI 0.34-0.88). Preterm birth did not influence the odds of the infant receiving treatment for NAS. 48.4% infants were admitted to the neonatal unit (NNU) 40% of these primarily for treatment of NAS. The median total hospital stay for all infants was 10 days (interquartile range 7-17 days). Infants born to methadone-prescribed drug-misusing mothers represented 2.9% of hospital births, but used 18.2% of NNU cot days.

CONCLUSIONS

Higher maternal methadone dose is associated with a higher incidence of NAS. Pregnant drug-misusing women should be encouraged and supported to breastfeed. Their infants are extremely vulnerable and draw heavily on healthcare resources.

Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: a knowledge synthesis for better treatment for women and neonates

AIMS

Through a novel synthesis of the literature and our own clinical experience, we have derived a set of evidence-based recommendations for consideration as guidance in the management of opioid-dependent pregnant women and infants.

METHODS

PubMed literature searches were carried out to identify recent key publications in the areas of pregnancy and opioid dependence, neonatal abstinence syndrome (NAS) prevention and treatment, multiple substance abuse and psychiatric comorbidity.

RESULTS

Pregnant women dependent on opioids require careful treatment to minimize harm to the fetus and neonate and improve maternal health. Applying multi-disciplinary treatment as early as possible, allowing medication maintenance and regular monitoring, benefits mother and child both in the short and the long term. However, there is a need for randomized clinical trials with sufficient sample sizes.

RECOMMENDATIONS

Opioid maintenance therapy is the recommended treatment approach during pregnancy. Treatment decisions must encompass the full clinical picture, with respect to frequent complications arising from psychiatric comorbidities and the concomitant consumption of other drugs. In addition to standardized approaches to pregnancy, equivalent attention must be given to the treatment of NAS, which occurs frequently after opioid medication.

CONCLUSION

Methodological flaws and inconsistencies confound interpretation of today's literature. Based on this synthesis of available evidence and our clinical experience, we propose recommendations for further discussion.

Opioid dependence and pregnancy

PURPOSE OF REVIEW

The management of opioid dependence during pregnancy has received considerable attention over the past three decades. Recent peer-reviewed literature in the fields of pregnancy and opioid dependence and neonatal abstinence syndrome has been evaluated and discussed.

RECENT FINDINGS

Pregnant opioid-dependent women must be carefully managed to minimize harm to the fetus; therefore, standardized care for maternal health is required. In a multidisciplinary care system opioid maintenance therapy is the recommended treatment approach during pregnancy. Equivalent attention must be given to the treatment of neonatal abstinence syndrome, which occurs in 55-94% of neonates after intrauterine opioid exposure with a 60% likelihood of requiring treatment; heterogeneous rating scales as well as heterogeneous treatment approaches are often responsible for extended hospital stays.

SUMMARY

Interpretation of available literature is confounded by several methodological flaws. In general, there is still a lack of evidence-based study designs for pharmacological treatment of these patients as well as neonatal abstinence syndrome.

Midwives' descriptions of the postnatal experiences of women who use illicit substances: a descriptive study

OBJECTIVES

to describe midwives' perceptions of the early mothering experiences of 20 Australian illicit-drug-using mothers.

DESIGN

a qualitative retrospective study using an explorative descriptive design. Twenty client records, completed by research midwives over 6 months (with follow-up visits at 12 and 18 months), formed the data set. Thematic analysis and the techniques associated with constant comparison were used to analyse the data.

SETTING

Perth, Western Australia.

PARTICIPANTS

twenty postpartum women with a history of using illicit drugs.

FINDINGS

seven major themes were identified that described how childbearing women with drug problems strive to be 'normal mums' although living on the fringe of society. The first three major themes were labelled; Baby as the priority; Hating the body: and Life sucks. Theme four represents the level of family and community support available, which had the potential to facilitate and/or hinder the experience. The analysis suggested that women who had good support, particularly at 4 months postpartum and beyond, were more likely to move towards the fifth theme Hanging in there: striving to be a normal mum. Women with minimal support, living in hostile and often abusive environments, gravitated towards the theme of Beyond caring with the eventual consequence being chaos and a return to heavy drug use, labelled Emotional fibrillation.

CONCLUSION

very few women were using drugs early in the postnatal period. These new mothers made every effort to prioritise the needs of their newborns, often within a context of abusive relationships, poor emotional well-being and financial hardship. High levels of physical and psychological morbidity were related to psychosocial factors as opposed to drug use alone. By 4 months postpartum, there was evidence that women were becoming increasingly vulnerable to the challenges of their lives. Family and community support played a role in how this group of women moved through their mothering experience.

IMPLICATIONS FOR PRACTICE

the range of health, social and support services required by new mothers when they are using illicit drugs is substantial. Collaboration and coordination between agencies is crucial for quality outcomes. Fostering positive relationships with drug-using pregnant women and maintaining these links into the extended postnatal period may be one strategy that would improve the integration of services and ensure that women stay engaged with the system.

Methadone-exposed newborn infants: outcome after alterations to a service for mothers and infants

OBJECTIVE

To evaluate the impact of a shared care approach in clinical management with a drug liaison midwife (DLM) service for mothers and infants established in 1995-1996 in an inner city area and to address the problem of congenital abnormality and microcephaly with fetal drug exposure.

METHODS

Descriptive analysis of data in live births of women enrolled in a methadone maintenance programme in 1991-1994 (n = 78) and 1997-2001 (n = 98), including time spent in hospital, treatment for neonatal abstinence syndrome (NAS), admission to the neonatal medical unit (NMU) and follow-up for child health checks.

RESULTS

In 1997-2001 compared with 1991-1994, the mothers used more methadone in the last week of pregnancy (median 40.0 mg/day vs. 21.5 mg/day, P = 0.0006) and there were more preterm deliveries (36% vs. 21%, P = 0.03). The infants spent less time in hospital (median 5 days vs. 28 days, P < 0.0001), a smaller proportion had treatment for NAS (14% vs. 79%, P < 0.0001), and NMU admission was reduced (median 14 days vs. 26 days, P < 0.0003). Neonatal convulsions (P = 0.0001) and jaundice (P < 0.001) occurred less frequently, and more infants were breastfed (P = 0.001). One infant in each study group had a cleft palate and none had microcephaly. Child health checks for 18-24 months showed a favourable outcome in 1997-2001.

CONCLUSIONS

We altered antenatal care and modified neonatal management, subsequently infants spent less time in hospital and NMU admissions were reduced with less NAS treatment. Congenital abnormalities and microcephaly were not common and as regular child health checks were possible, the impact of the DLM service in shared management merits further investigation, for mother-infant bonding and developmental outcome.