A special type of 'hard-to-reach' patient: experiences of pregnant women on methadone

Abstract

INTRODUCTION: Opiate addicts in New Zealand are a heterogeneous, hard-to-reach group with illicit drug activity as their common characteristic. This project investigated the experience of a specific hardto-reach group: pregnant women with opiate dependency, focussing on their interactions with helping services and social networks. The aim was to explore the interactions of pregnant women on methadone with helping services and social support, with the objective to make recommendations to improve service to this ‘hard-to-reach’ group. METHOD: Questions for staff and client interview schedules were constructed, informed by a literature search. Seven methadone clinic staff were interviewed and a questionnaire was distributed to 10 antenatal clinic staff known to have previously managed pregnant women on methadone. Five methadone clients were interviewed at the clinic and interviews taped for transcription with consent. FINDINGS: High risk pregnancies warrant a multidisciplinary approach, but in the hard-to-reach this ideal can itself be out of reach. Although primary care is better placed than secondary care to coordinate maternity and community support services, few opiate-dependent people have a regular general practitioner and may have perceived or actual barriers to access to care. Perceived stigma deterred these women from engaging. Women also fear that services will judge and report them, worrying about the health of their child and the powers of child protection services. CONCLUSION: A fresh consideration of the functionality of services to the hard-to-reach may be beneficial. A nursing concept of ‘face-work’ throws some light on the misperception of well-intentioned services by the hard-to-reach. KEYWORDS: Pregnancy; methadone maintenance; addiction; hard-to-reach; face-work, resilience.

Methadone dosing and prescribed medication use in a prospective cohort of opioid‐dependent pregnant women

“…Other studies that assess quantitatively the determinants of methadone dose changes during pregnancy could not be identified. A recent qualitative study of health service staff and opioid‐dependent women on MMT reported that women expressed concerns about dose safety and neonatal withdrawal . The authors also noted that women resist recommended dose increases out of concerns for the neonate, and that family members may put women under pressure to lower their methadone dose during pregnancy.…”

“…A recent meta‐analysis reported that there was no consistent statistically significant difference in the incidence of NAS with differing doses of methadone . In spite of this, women frequently request detoxification or dose reductions during pregnancy, in the hope of avoiding NAS .…”

Health Care Encounters of Pregnant and Postpartum Women with Substance Use Disorders

“…Patients' trust that a health care provider cares about them and works in their best interest is considered foundational to the provider-patient relationship and is associated with positive health outcomes (Birkhauer et al, 2017). When pregnant and postpartum women and health care providers do not form trusting relationships, inadequate prenatal care and missed opportunities to improve health outcomes for women and their infants can result (Chan & Moriarty, 2010;Gilchrist et al, 2012;Leppo, 2012).…”

“…Pregnant and postpartum women with SUDs report fear of criminalization or punishment if their substance use is reported to authorities by health care providers (Chan & Moriarty, 2010;Gilchrist et al, 2012;Hall & van Teijlingen, 2006;Harvey et al, 2015;Howard, 2015;Jessup et al, 2003;Leppo, 2012;Stone, 2015). Fear of loss of infant custody, arrest, prosecution, or incarceration can thus impair the formation of trust in the provider-patient relationship, serve as a barrier to the utilization of prenatal care and addiction treatment services, and discourage disclosure of substance use to health care providers (Kruk & Banga, 2011;Phillips et al, 2007;Roberts & Nuru-Jeter, 2010;Roberts & Pies, 2011;Stengel, 2014;Stone, 2015;Van Scoyoc et al, 2016).…”

Editiorial: Relevant Research: Will this Confirm or Change my Practice?

“…The researchers conclude that a fresh look at services to the hard-to-reach may be beneficial. 9 While ear sunctioning or syringing is commonly performed in general practice to remove ear wax causing symptoms such as discomfort, tinnitus or hearing loss, a case review from the United Kingdom warns us that even the most common and benign of medical interventions can have serious or fatal adverse effects. 10 This issue's Charms and Harms deals with the herbal remedy black cohosh, which has inconclusive evidence of efficacy but real safety issues with regard to potential liver toxicity.…”