Amphetamines are highly addictive, relatively low in cost and are easily procured (Pedersen et al, 2015). Amphetamines, and the issues associated with their use, have overtaken other classes of illicit drugs since the 1990s, with the majority of female users being of childbearing age (McDonnell-Dowling and Kelly, 2015). The UK, Australia and the USA have all recorded high rates of amphetamine use (Barratt et al, 2014). Degenhardt et al (2016) have estimated that between 2013 and 2014 there were 268 000 regular users of amphetamines in Australia aged between 15-54 years of age, and 160 000 had a high level of dependency. The sharp increase in the prevalence of amphetamine use globally will require particular consideration in the planning and allocation of future health care resources. This includes maternity services, as the majority of women who use amphetamines are of childbearing age. Pregnancies associated with amphetamine use are considered to be complex and pose an increased risk of complications occurring, which may have significant health implications for both the woman and fetus/newborn (Gorman et al, 2014). It is important to note that women using amphetamines often already have suboptimal health associated with substance abuse, including periodontal issues, poor nutrition and mental health issues (Baghaie et al, 2017), and are often members of marginalised groups with complex psychosocial issues, and a history of reduced rates of health care access and attendance (Whiteford et al, 2013).
Amphetamines act as a psychostimulant that affects the central nervous system and, depending on its form, has the potential to cross the blood-brain barrier and the placenta. Individuals under the acute or chronic influence of amphetamines may present with altered mood, agitation, hyperarousal, skin lesions, hypertension, tachycardia, insomnia and appetite suppression resulting in weight loss (Diaz et al, 2014).
The effect of amphetamines on perinatal and neonatal outcomes is difficult to predict and is heavily influenced by the amount used, frequency of exposure and variations in drug composition, as well as factors such as exposure to other substances, and other existing medical conditions (McDonnell-Dowling and Kelly, 2015). Documented maternal risks associated with amphetamine use during pregnancy include increased risk of placental abruption, premature rupture of membranes, preterm birth, hypertension in pregnancy including pre-eclampsia, cerebrovascular accident, anaemia, and maternal and subsequent fetal tachycardia (Gorman et al, 2014). Perinatal amphetamine use is also associated with placental pathology, and often results in larger sized placentas, but this increase in size does not translate to functional benefits (Carter et al, 2016).
Potential effects of amphetamine exposure on the fetus during pregnancy include intrauterine growth restriction (IUGR) due to placental insufficiency, fetal congenital abnormalities including cleft lip and/or palate, cardiac anomalies, limb malformation, smaller head circumference, and fetal death in utero (Behnke et al, 2013; Viteri et al, 2015). For neonates, there is an increased rate of admission to the neonatal unit (NNU) due to neonatal compromise resulting from obstetric emergency, traumatic birth or prematurity; low birth weight, and failure to thrive (Diaz et al, 2014). Neonates may also experience poor feeding, sleep disturbances and delays in meeting developmental milestones (Breen et al, 2014).
While there is a limited body of knowledge exploring the impacts of perinatal exposure to amphetamines on children beyond early childhood, Diaz et al (2014) found that children who had exposure to amphetamines in utero had increased rates of cognitive and behavioural issues compared to their peers at 7.5 years of age. Other research findings report that perinatally exposed children had altered brain morphology, and were consistently below average weight and height at birth, at 4 years old and at 8 years old (Abar et al, 2014).
Addressing psychosocial barriers to care
Globally, 80% of individuals who access treatment for substance abuse have a history of trauma (Mills, 2015). Consequently, for many women, their substance use is related to these past violent and traumatic experiences (Wingo et al, 2014). For many women with these backgrounds, accessing health care services is a source of anxiety and stress. Some women find the nature of questioning during assessments, or intimate procedures associated with perinatal care, a threat to their physical or emotional safety, and this has the potential to trigger negative associations, compound previous traumas or even cause women to re-live them (Kezelman, 2016). Complications during birth, or the impact of the neonate requiring an admission to the special care unit as a result of amphetamine exposure, may be additional sources of new trauma for the woman (Marcellus, 2014).
Women with substance abuse issues often face a barrage of social judgements and stereotyping, such as being seen as morally corrupt or deviants from the social expectations that have been historically placed on women (Pajulo et al, 2016). The experience of actual or perceived stigma when accessing health services in the past is another deterrent.
Fear surrounding potential legal consequences, or children being taken into care by authorities, is another reason for poor attendance or late presentation to services in pregnancy (Linden et al, 2013). Evidence suggests that services that provide non-judgemental care, sensitive to individual women's psychosocial contexts, result in increased antenatal care attendance and increased ability to monitor maternal and fetal health status, which has a direct correlation with positive health outcomes (Breen et al, 2014).
Maternal and fetal/neonatal considerations when planning care
During the antenatal period, in addition to the routine scheduled antenatal appointments, women using amphetamines should be encouraged to attend a booking visit as early as possible in pregnancy, and to attend additional midwifery/obstetric appointments, in order to assess both positive and negative changes to maternal and fetal health status (Geraghty, 2015). This may involve increased surveillance via serial ultrasound scans to monitor fetal growth and wellbeing, and referrals to other health professionals, such as dieticians and paediatricians, where required (Rausgaard et al, 2015).
The rationale for this level of surveillance is to identify complications or situations in which a risk of maternal or fetal compromise would indicate medical intervention, for example birthing the baby in the case of severe IUGR or in the event of placental malfunction. Serial ultrasounds may also have a positive effect on amphetamine-using pregnant women by promoting maternal attachment, and motivating lifestyle changes to improve their health for the benefit of the developing fetus (Pajulo et al, 2016). Due to the increased risk of IUGR and abruption due to placental insufficiency related to amphetamine use (McLaurin and Geraghty, 2013), birth plans are usually discussed and scheduled with the woman, including plans made for induction of labour usually at or before 39 weeks gestation to avoid pregnancies continuing post dates (Taylor et al, 2012).
Formal observations for withdrawal should be initiated both intrapartum and postnatally. In addition to routine care during the postnatal period, an increased length of stay is often recommended and allows for follow-up from all those involved with the woman's care before discharge (Gopman, 2014). Advice regarding contraceptives and avoiding unintended pregnancies in the immediate period following birth should be provided and discussed with the woman, and contraceptive methods should be provided and/or applied, with the woman's consent, before discharge (Olsen et al, 2014).
Education regarding safety strategies for women and neonates should be reinforced, including safe sleeping, breastfeeding, and using support networks or people who can care for the newborn if the woman decides to use amphetamines, or any other substances, once discharged from hospital (Gopman, 2014).
During the postnatal period, neonates who have had perinatal exposure to amphetamines should be reviewed by a paediatrician before being discharged from hospital. In cases of congenital abnormalities diagnosed before birth, a paediatric consultation should have been initiated during the antenatal period, but an additional follow up consultation with the parents should also occur postnatally regarding relevant plans of care, such as future surgeries and subsequent check-ups (Taylor et al, 2012). Due to the short-acting nature of amphetamines, neonates do not typically suffer from withdrawal, but this can occur as a result of fetal toxicity during the third trimester (Breen et al, 2014). Observations for Neonatal Abstinence Syndrome (NAS) should also be applied, to ensure that neonates are not withdrawing from any additional or previously undisclosed substances. Neonates are at risk of continued exposure in the postnatal period as amphetamines are transferred to breastmilk (Chomchai et al, 2016).
The role of midwifery
The midwife's role, when caring for amphetamine-using women, is to facilitate strategies and assess the effectiveness of interventions that aim to minimise harm to the woman and fetus/neonate (Wright et al, 2012; Geraghty, 2015). Midwives in these settings should work closely with other members of the multidisciplinary team. Collaboration is essential in implementing a plan for care that facilitates the woman to be an informed and active participant in her care, and promotes her capacity to make decisions that contribute to positive outcomes for herself, her baby, and her family (Ebert et al, 2014). Midwives should be non-judgemental in their interactions, but should also clearly communicate to the woman the impact of her amphetamine use on her pregnancy and fetal wellbeing, and discuss the potential complications that may be precipitated by amphetamine use.
Education is an essential element of midwifery care, particularly for women continuing to use substances while pregnant and postnatally. The midwife can educate women on signs and symptoms of obstetric complications that require her to seek immediate advice (McLaurin and Geraghty, 2013), and can assist women in formulating plans to have supporters who can supervise the woman's wellbeing during pregnancy, assume care of the baby if the women uses amphetamines postnatally, and can be relied upon to seek urgent medical attention in the event of an emergency (McLaurin and Geraghty, 2013).
Midwives are also involved with promoting women's confidence and their capacity for parenting through parent education (Wright et al, 2012). Advice regarding amphetamines and newborn feeding is also part of the midwifery role. If the woman is planning to breastfeed, she should be advised that she should not breastfeed within 24 hours of using amphetamines, and should continue to express breast milk and discard it during this time frame (Davanzo et al, 2016). In addition to this, an alternative form of feeding should be provided, such as surplus pre-expressed breast milk or formula. Education surrounding safe sleeping is also essential for newborns being discharged to homes with caregivers who may be under the influence of substances (Cohen et al, 2015).
Conclusion
Amphetamine use in pregnancy is a complex care issue and continues to be a social and public health concern. The priority of care planning is to minimise harm and to implement strategies that reduce risks, including acute and long term adverse effects on the woman and newborn. Complications associated with amphetamine exposure during pregnancy are significant, but difficult to predict, both for the woman and the fetus or neonate. Perinatal care and outcomes are further enhanced by plans of care that are holistic, woman-centred, and which involve health care services and practitioners who are well versed in the complexity of women's psychosocial, medical and obstetric presentations related to substance use. Best practice promotes collaboration between the woman and the members of the multidisciplinary team in the formulation of individualised plans of care. Midwives have an important role and contribute to this team approach to care by providing routine aspects of care, assessing and evaluating the care provided, supporting and facilitating behavioural change, and educating. In regards to the management for women of childbearing age who use amphetamines, further review and research with a strong design needs to be conducted in order to address existing gaps in research and to validate the quality of evidence it contributes.