Illicit Drug Use in Pregnancy: An Appropriate Response

A Position Paper from the Women and Harm Reduction International Network and the International Network of Women who use Drugs.

“Women who use drugs are reported to experience disproportionate levels of stigma and discrimination, often compounded during pregnancy, and also as mothers” (p.3) .

In some countries, such as Russia and Ukraine, pregnant women who use illicit drugs have been coerced by health providers to either terminate their pregnancies or relinquish their children to the State, and are denied information about, and access to, appropriate interventions. In Norway, a unique law gives social workers the right to incarcerate pregnant women who use drugs to protect the health of the foetus. , 

In other countries, pregnant illicit drug users face criminal sanctions if they continue to use prohibited drugs.  For example, in the United States of America, cocaine users have been convicted on a number of charges including foetal abuse, delivering drugs to a minor, and even murder. This is despite evidence showing that heroin and cocaine use are less harmful to the foetus than alcohol use during pregnancy.  ,

Contrary to current research in this area, misinformation, stigma and discrimination contribute to the promotion of ideas that any type of drug use during pregnancy will result in harm to the foetus. Criminalisation, stigma and discrimination associated with illicit drug use during pregnancy also results in many women keeping their pregnancy concealed and prevents them from accessing a range of services, such as antenatal care, harm reduction services including voluntary drug treatment programs, and interventions to prevent vertical transmission of HIV. International guidelines oppose forced withdrawal, while significant evidence shows that treatments, such as methadone or buprenorphine, are safe for use during pregnancy and are recommended.  ,  Such antenatal care and drug-specific support protects both the woman and the foetus from potential harms caused by an unregulated drug market, drug withdrawal and poor nutrition. However, some nations make no provision for opioid substitution therapy (OST) at all, much less for pregnant women. Where drug treatment is available, it may exclude women living with HIV, or may not be provided in women-friendly facilities. Strict regulation or a lack of formalised systems may make it difficult for women who use drugs to receive treatment in maternity hospitals or other health care settings.

Additionally, a recent study from the USA showed a comprehensive harm reduction service provided to women who used methamphetamines led to better health outcomes for mothers and foetuses when compared to an abstinence-based program.

Comprehensive harm reduction for pregnant women includes access to evidence-based information on how to manage drug use during pregnancy and antenatal care, support during labour and birth, advice on breastfeeding and postnatal support. Programs which also include elements of psychosocial support, counselling and partner/family engagement work best.

Women who continue to use drugs throughout pregnancy can be exposed to many risks during their pregnancy, including violence, pressure to terminate their pregnancy, increased risk of sexually transmitted infections due to changes in partner’s sexual behaviour, changing drug use patterns, changing body mass and consequently variability in the effects of drugs. Health care providers in some regions are inadequately educated about the effects of drug use on women in general and during pregnancy in particular. This often leads them to deny services or provide appropriate care, increasing distress and harm to the mother and foetus.

Inadequate access to information, education and counselling can also cause women who use opiates or cocaine (both of which can impact on the menstrual cycle) to be unaware of the continued possibility of pregnancy and the need for contraception and/or may delay accessing antenatal care if pregnancy occurs. 

The prevention of vertical transmission of HIV is also of upmost importance for women who use drugs.  This area requires significant emphasis during pregnancy as the literature shows that women can be more susceptible to HIV infection during pregnancy, and infection at this time results in a high rate of transmission to the foetus.   It is also well-documented that access to non-judgemental and targeted services at this time can prevent vertical HIV transmission.  
It is therefore critical that all women are able to access appropriate, evidence-based, non-judgemental health services, including sexual and reproductive health, antenatal care and harm reduction services.

Recommendations

Policy recommendations for governments

Policies that punish, stigmatize and discriminate against women who use drugs whilst pregnant create a significant barrier to women accessing antenatal care and harm reduction, including HIV-related services. In order to provide best practice care to these women, such policies must give way to evidence-informed frameworks that support health and human rights. To this end, national governments should:

  • Enforce the protection of women’s confidentiality, including the review and reform or removal of any existing compulsory drug registration systems;
  • Remove any legislation that makes drug use an adequate justification for the removal of children from their parents’ custody;
  • Develop specific guidelines and targets to address the sexual and reproductive needs of women who use drugs;
  • Support research endeavours to improve understanding of the needs of women who use drugs and support evidence-informed service provision, as well as research into HIV, including co-infection with hepatitis C, women’s sexual and reproductive health, and drug interactions;
  • Support the provision of antenatal care, including harm reduction, HIV and drug treatment services in women’s prisons and other closed settings.
  • Explore options to reform drug policy so as to better protect the human rights of women who use drugs.

Recommendations for service providers

Services providers, including both mainstream antenatal and drug-use specific services should be encouraged to adapt their practices in order to meet the needs of pregnant women who use drugs, and improved health and well-being of their foetuses and later, infants.  The following is recommended:

  • Obstetric services should provide non-punitive, evidence-informed education and care to pregnant women and nursing mothers to protect their health and that of their foetuses and infants.
  • Staff of harm reduction and HIV services, as well as mainstream services, should be trained and supported to recognise the sexual and reproductive health needs of women who use drugs and to improve service relevance and accessibility.
  • In order to reduce the risk of exposure to HIV during pregnancy, pregnant women who inject drugs should have priority access to OST.
  • Sexual and reproductive health services that are appropriate and sensitive to the needs of women who use drugs should be incorporated into harm reduction services and vice-versa.
  • Ensure the meaningful involvement of women who use drugs in the design, implementation, monitoring and evaluation of services as their expertise contributes to an informed approach to service provision, resulting in improved effectiveness and efficiency.
  • Be aware of, and enhance, gender-sensitivity of services to improve access by women.
  • Enhance awareness of services to issues which may increase the vulnerability of women, such as being homeless, young, disabled, ethnic minority or active in sex work.
  • Given that violence creates a significant obstacle to women accessing harm reduction services, and correlates with an increased risk of acquiring HIV, harm reduction and HIV-related services should connect with domestic violence and violence prevention programmes or offer such services onsite themselves.

Services for women who use drugs are limited in a majority of countries. Governments and services providers are encouraged to work with the International Network of Women who use Drugs, the Women and Harm Reduction International Network, and other such networks at national and regional levels to advocate for, and share information pertaining to, the development of appropriate models of service delivery targeting women who use drugs.