Introduction
Perinatal substance abuse (PSA) is associated with increased risk of prematurity, low birth weight, neonatal abstinence syndrome, behavioral issues and learning difficulties (Covington et al., Reference Covington, Nordstrom-Klee, Ager, Sokol and Delaney-Black2002, Eogan et al., Reference Eogan, Gleeson, Ferguson, Jackson, Lawless and Cleary2021). It is also a major risk factor for maternal suicide which has been identified as a leading cause of direct maternal death (Esscher et al., Reference Esscher, Essén, Innala, Papadopoulos, Skalkidou, Sundström-Poromaa and Högberg2015, Khalifeh et al., Reference Khalifeh, Hunt, Appleby and Howard2016, Knight et al., Reference Knight, Bunch, Patel, Shakespeare, Kotnis, Kenyon and Kurinczuk2022). It is imperative that robust care pathways are in place for these high-risk pregnancies and that staff and patient education are optimized (Eogan et al., Reference Eogan, Gleeson, Ferguson, Jackson, Lawless and Cleary2021). Ireland is ranked as one of the top five countries for prevalence of both alcohol use during pregnancy and fetal alcohol syndrome (Popova et al., Reference Popova, Lange, Probst, Gmel and Rehm2017). Stigmatising interactions, which decrease both quality and continuity of care as well as decreasing the likelihood of the patient disclosing substance use increase exponentially in pregnancy (Howard Reference Howard2015, Nichols et al., Reference Nichols, Welborn, Gringle and Lee2021). Both the National Maternity Strategy (HSE 2016) and the National Drugs Strategy have recommended that a Drug Liaison Midwife (DLM) be appointed to each maternity hospital and that PSA be managed with a multidisciplinary team approach. DLMs are currently only available in Dublin maternity hospitals with no hospital outside of Dublin having a dedicated clinic or DLM.
This study explored the knowledge and attitudes of healthcare professionals working in an Irish tertiary maternity unit toward PSA to identify knowledge gaps in the area to improve services and care available to pregnant and postnatal women with substance exposed pregnancies.
Methods
This is a cross-sectional study surveying health care professionals working in an Irish tertiary maternity hospital. Anonymous questionnaires were distributed consisting of three subsections: (1) demographic data (2) knowledge assessment and (3) an attitudinal scale. The attitudinal scale was adapted from the Attitudes About Drug Abuse in Pregnancy (AADAP) questionnaire (Coles et al., Reference Coles, Good and Strickland1992). Participants responded to knowledge items by answering true, false or not sure. A 5-point Likert-type scale was used for responses to the attitude items. The questionnaire was piloted on a sample of six people from the target population, and any issues or ambiguities were amended prior to distribution. We asked 84 healthcare professionals two further questions regarding alcohol use in pregnancy, namely, ‘there is evidence that 1–2 standard units of alcohol weekly are not associated with adverse neonatal/childhood outcomes’ and ‘fetal alcohol spectrum disorder only occurs when a pregnant woman drinks alcohol throughout her pregnancy’. Participants responded to the alcohol-specific questions by answering true, false or not sure. Questionnaires were distributed to all non-consultant hospital doctors (NCHDs), consultants, midwives, student midwifes, nurses and social workers working in University Maternity Hospital Limerick in August 2021. Descriptive statistics were conducted using the statistical software package SPSS (IBM v .27). We added the results of the attitudinal questions together to create an overall attitude score for each respondent. We then used the Kruskal–Wallis test to assess if differences existed between different groups, i.e., different roles, speciality or years of experience.
Results
Demographics
Participants (n = 172) included midwives, nurses, NCHDs, consultants, social workers, student midwives with varying experience (see Table 1).
Table 1. Demographics of participants
Knowledge
Among study participants, 21.5% (n = 37) answered correctly that Ireland is ranked as one of the top five countries in the world in terms of prevalence of alcohol use in pregnancy and fetal alcohol syndrome, whereas 57.6% (n = 99) answered that it ranked between 6 and 10th highest and 20.9% (n = 36) responded that it ranked between 11 and 50th highest. Among HCPs surveyed, 9.9% (n = 17) did not routinely inquire about substance abuse in booking and antenatal clinic, with 57% (n = 98) responding that they did routinely ask and 33.1% (n = 57) choosing non applicable. See Table 2 for further questions examining healthcare professionals’ knowledge of PSA.
Table 2. Healthcare professionals' knowledge of perinatal substance abuse
Key: SIDS = sudden infant death syndrome. PSA = perinatal substance abuse. IUGR = intrauterine growth restriction. FASD = fetal alcohol spectrum disorder.
The majority of respondents (75.6%, n = 130) were not confident in the antenatal management of PSA and 67.5% (n = 116) felt that they were not competent in the postnatal management. More than half of staff (53.5%, n = 92) did not know the referral pathway and 32% (n = 55) did not know when it is appropriate to make a TUSLA referral or who is responsible for making the referral. Among study participants, 61.6% (n = 106) did not know the indications for toxicology screens and when they should be repeated. Almost all respondents (96.5%, n = 166) felt that they would benefit from further training (see Table 2).
Attitudes
Among staff surveyed, 35.5% (n = 61) agree or strongly agree that women who abuse substances in pregnancy are more concerned with themselves than their babies. More than half of respondents (54.1%, n = 93) agree or strongly agree that PSA should be considered a form of child abuse. Among study participants, 40.7% (n = 70) agree or strongly agree that taking care of sick infants due to PSA places an unfair burden on society. 48.8% (n = 84) feel angry at mothers when they hear about the effects on infants. 58.7% (n = 101) believe that the mother is responsible for any damage done to her child. Most respondents (94.8%, n = 163) agreed or strongly agreed that the unit would benefit from a DLM. Role (p = 0.56), speciality (p = 0.61) or number of years of experience (p = 0.45) did not affect attitude score.
Discussion
Our study showed that healthcare professionals have a good knowledge of the risks of PSA on the fetus and infant. No risk-free level of alcohol exposure has been established in pregnancy, and there is no point during fetal development where prenatal alcohol exposure lacks consequences (O'Neil, Reference O'Neil2011). Even low to moderate levels of alcohol consumption during pregnancy are associated with adverse pregnancy and neonatal outcomes (Ikonomidou et al., Reference Ikonomidou, Bittigau, Ishimaru, Wozniak, Koch, Genz, Price, Stefovska, Hörster, Tenkova, Dikranian and Olney2000, Sood et al., Reference Sood, Delaney-Black, Covington, N.-K., Ager, Templin, Janisse, Martier and Sokol2001). Despite this, more than one-third of participants answered that 1–2 units of alcohol per week is not associated with adverse outcomes and a further 10.7% responded that they were not sure. 42.9% of participants responded that FASD only occurs with alcohol consumption throughout pregnancy and a further 16.7% responded that they were not sure. It is imperative that we improve staff education on gestational alcohol consumption to ensure that they can provide accurate preconception and antenatal advice to patients. Only 21.5% of participants answered correctly that Ireland is ranked between 1st and 5th highest in the world in terms of prevalence of alcohol use in pregnancy and fetal alcohol syndrome. It is important that staff are aware of the extent of the issue in Ireland so that they can be vigilant to alcohol use in pregnancy.
Over three-quarters of participating healthcare professionals reported that they were not confident in the antenatal management of PSA and more than two-thirds did not know how to care for these women and infants postnatally. More than half did not know the referral pathway for women with substance abuse issues and 61.6% did not know when to do a toxicology screen. Outside of the Dublin hospitals there are no appointed Drug Liaison Midwives. As mentioned previously, both the National Maternity Strategy (HSE 2016) and National Drug Strategy have endorsed the appointment of Drug Liaison Midwives in all maternity units and of dedicated multidisciplinary care in the management of women with substance abuse issues. This study highlights the urgent need for the same.
Our study shows high levels of negative attitudes amongst healthcare professionals towards substance abuse, which is similar among all roles, speciality and years of experience. Provider–patient interactions are critical in terms of engaging women with maternity services throughout pregnancy and the postpartum period (Harvey et al., Reference Harvey, Schmied, Nicholls and Dahlen2015, Howard Reference Howard2015). Stigma can create barriers for women to access services and to disclose substance use (Howard Reference Howard2015). Previous research affirmed that increased education is positively correlated with improved attitudes towards patients with addiction issues (Richmond and Foster Reference Richmond and Foster2003).
Maternal mental health is of the utmost importance. In recognition of the importance of maternal suicide and its direct link to pregnancy, the World Health Organization has recommended that maternal deaths due to suicide are classified as direct rather than indirect maternal deaths (World Health Organization 2012). MBRRACE-UK [Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries] and MDE [Maternal Death Inquiry] Ireland have adopted the changed classification (Maternal Death Enquiry Ireland 2019). Substance abuse has been identified as a major risk factor for maternal suicide (Esscher et al., Reference Esscher, Essén, Innala, Papadopoulos, Skalkidou, Sundström-Poromaa and Högberg2015, Khalifeh et al., Reference Khalifeh, Hunt, Appleby and Howard2016). Deaths from suicide and substance abuse account for nearly 40% of deaths occurring within a year after the end of pregnancy with maternal suicide remaining the leading cause of direct deaths in this period (Knight et al., Reference Knight, Bunch, Patel, Shakespeare, Kotnis, Kenyon and Kurinczuk2022, Maternal Death Enquiry Ireland 2019).
A limitation to this study is the potential for selection bias through the use of questionnaires. We sought to minimize this by distributing the questionnaires to all NCHDs, consultants, midwives, student midwifes, nurses and social workers working in the unit and have included a broad range of staff with different levels of experience and from different specialties.
This is a single centre study, and it is not fully clear how generalizable the findings are to other centers. However, the fact that this study was undertaken in a tertiary maternity unit and included a broad range of staff increase the likelihood that the findings are applicable throughout Irish maternity units who do not currently have a dedicated care pathway and DLM.
Our study highlights the urgent need for increased training in PSA in order to enhance care and reduce stigma. It is imperative that staff training, drug liaison midwives and dedicated clinics are introduced to all Irish hospitals as a matter of high priority.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Competing interests
The authors report no competing interests.
Ethical approval
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that ethical approval for publication of this cross-sectional study has been provided by their local Ethics Committee.
