This report presents a narrative literature review of treatments available to pregnant women who have alcohol use disorders and findings from interviews with key stakeholders regarding current treatment practices and areas requiring improvement.
Societal norms on alcohol use are contradictory and conflicting. Whilst for the most part widely available and accepted, alcohol consumption is regarded with disapproval and shame during pregnancy. This contradiction and associated stigma places unnecessary guilt on women and is in the large part responsible for women’s lack of disclosure of drinking during pregnancy.
Such is the stigma and guilt associated with alcohol use during pregnancy that only a minority of pregnant women with alcohol use disorders access treatment. There are also large barriers to treatment that include the fear of losing custody of children and practical barriers associated with the availability of services, access, transport, and childcare.
In addition women are more likely to attribute their problems to mental health issues rather than alcohol use and seek treatment through mental health services or primary care. Often these women are not referred to specialist drug and alcohol (D&A) services. Clinicians interviewed as part of this research reported there are areas where multidisciplinary teams are established and work well but it is clear that services for the treatment of substance use in pregnancy are sparse and, where available, are mainly located in metropolitan areas.
Unfortunately there is limited research on effective treatments available for pregnant women with alcohol use disorders. Trials focussing on at risk women have reported reduced alcohol consumption but treatment trials of pregnant women with alcohol use disorders are lacking. The evidence for the safety and effectiveness of pharmacological treatments is also limited. Although pregnant women are difficult to recruit into these studies, methodologically rigorous research into psychosocial and pharmacological treatments for this population is required.
This research reports on information gathered from 11 semi-structured qualitative interviews with clinicians that treat pregnant women with problematic alcohol use provided expert clinical advice on current treatment practices and the gold standard for treatment and factors that impinge on this approach. The clinician interviews supported evidence from the literature review reflecting that whilst the prevalence of alcohol use disorders in the population is higher than disorders related to illicit drugs the reverse is noted in specialist treatment services; problematic alcohol use in pregnant women is rarely seen. The interviews with the key stakeholders highlight that despite work aimed at improving the detection of alcohol use, screening and referral rates remain low.
Treatments need to be supportive, multidisciplinary and accommodate the woman and her children. A gold standard approach to treatment should incorporate community education about the chronic and relapsing nature of addiction
Overall, the evidence from the literature review and the expertise of the clinicians as part of research undertaken for this report suggests that there has been little progress in the treatment and recruitment of alcohol dependent pregnant women into treatment in the last decade.
This report puts forward the gold standards for the treatment of alcohol dependence in pregnancy. These standards should incorporate the following principles:
That standardised screening is undertaken of all pregnant women on their alcohol use. This screening should be undertaken by health professionals that see pregnant women and should accompanied by the provision of education, brief intervention, and continued monitoring where appropriate.
That all pregnant women who screen positively for alcohol-use disorders should be offered access to treatment and that this treatment should be matched to the severity of the disorder being experienced by the woman. Treatment should include inpatient admission for detoxification if necessary.
That all pregnant women who are alcohol dependent should be offered extended hospitalisation post-delivery and birth with help and support. The woman should also be offered assertive follow-up of the mother and child through the child’s formative years. This follow-up should assist to the woman in areas of healthcare, social services, housing and parenting support.
That treatment of pregnant women who are alcohol dependent should be undertaken by a multidisciplinary team. This would include alcohol and other drug services, obstetric care and the involvement of the woman’s general practitioner.
Lucy Burns, Courtney Breen