Intergovernmental committee on Drugs working party on Fetal Alcohol Spectrum Disorders
Fetal Alcohol Spectrum Disorders in Australia: An Update
3.4 Alcohol treatment in Australia and barriers to care
Alcohol is the most commonly reported drug of concern among people seeking treatment in alcohol and drug services in every state of Australia except Tasmania (AIHW 2011). The most common source of referral in 2009-10 for alcohol treatment (37 percent of episodes) was self-referral. The most common main treatment for alcohol misuse was counselling (44 percent), and treatment was took place in a non-residential (61 percent of episodes) or a residential treatment facility (21 percent) (AIHW 2011). The type of treatment available and received differs by location. Counselling was the most common form of alcohol and drug treatment episode in very remote areas with two thirds (67 percent) of those seeking treatment receiving counselling, compared to major cities where 41 percent of episodes were counselled. Withdrawal management (detoxification) was lowest in very remote (0.7 percent) and remote areas (6 percent) compared to major cities (17.7 percent) (AIHW 2011).
For women seeking treatment, a number of issues have been identified that will affect the amount and type of treatment received (Roberts and Nanson 2000). Firstly, women are more likely to attribute their problems to mental health rather than alcohol use and will therefore be more likely to be seen in mental health or general practice rather than substance treatment centres (Weisner and Schmidt 1996; Greenfield et al. 2010). In addition to this discrepancy in women seeking treatment in specialised services, there are a limited number of specialist services that treat pregnant women in metropolitan areas and even fewer, if any, in many regional and rural areas.
Secondly, there are a number of barriers to treatment for substance use disorders for women that have been identified, including: a fear of losing of custody of their children; social stigma; lack of childcare; lack of transportation; and a lack of access or priority for pregnant women (Messer et al. 1996; Small et al. 2010). The most common reasons cited by women for not seeking treatment are: not wanting to give up alcohol; being afraid they would lose their children to care; being afraid there would be no-one there to look after the children if they went into treatment; and their partner did not want them to go into treatment. Messer et al. found that, compared to women who did not accept an offer of treatment, those who accepted treatment had more severe substance use problems, were more likely to have been in treatment previously, were more likely to have partners who also used alcohol and were much more likely to have experienced sexual or physical abuse during pregnancy (Messer et al. 1996). Factors that promote treatment seeking in women include support from someone significant and acknowledging that sharing the problem with others was a relief (Jakobsson et al. 2008). Feelings of shame and the perception that alcohol problems were incompatible with femininity were hindrances for treatment seeking. Awareness of these factors may be useful for health services providing treatment to women with alcohol problems.
Case study: Services for pregnant women who use alcohol in South Australia: A clinician’s perspectiveSpecialist alcohol and drug services exist in many large obstetric settings and referral follows identification of risky or harmful patterns of drinking. For example, at the Women’s and Children’s Hospital in Adelaide, protocols specify that if the clinician elicits a history of more than two standard drinks per day or a binge pattern of drinking (more than five standard drinks on a single occasion) at the booking visit, a referral to the Drug and Alcohol Service should be made. However, no further routine enquiries regarding alcohol use occur beyond the first visit.
Alcohol misuse is likely to be under-detected in pregnancy; nonetheless, women may be heeding the message regarding the risks of alcohol in pregnancy. In South Australia, there has been a prominent public health campaign regarding the risks of alcohol use in pregnancy and a recommendation that the safest choice for women is an alcohol-free pregnancy. (See www.wch.sa.gov.au/services/az/other/health_prom/programs/healthypregnancy.html (This website link was valid at the time of submission)).
It is worth noting less than five percent of referrals to the Drug and Alcohol Service are for alcohol misuse. Indeed, hospital data over the previous three years suggest low numbers (55 women with 47 of these recorded as polysubstance users) having alcohol abuse recorded as a diagnosis at birth.
The Drug and Alcohol Service at The Women’s and Children’s Hospital clinic includes a hospital midwife and obstetrician assigned to the clinic. Visiting clinicians from Drug and Alcohol Services South Australia (DASSA) include a clinical nurse and senior medical practitioner. Within the hospital, good working relationships exist between the clinic and social work and mental health services. Services include a comprehensive assessment regarding alcohol and other substance use; assessment of mental health and psychosocial stressors and provision of brief interventions and the use of motivational interviewing. Efforts are made to engage women’s partners in the process with emphasis on shared responsibility, to effect change in the home. Close review is provided in the clinic and referral for more intensive intervention is made when required. This may include inpatient withdrawal services, individual counselling, group work and residential support. The service also provides advocacy for the woman within the hospital and with other agencies.
Case study: SallySally presented to the antenatal clinic aged 25 years old. She had a four-year-old daughter who was not in her care (residing with paternal grandparents). She was in a relatively new relationship of six months. She presented for a booking visit at nine weeks. At this visit she denied substance use including alcohol, cannabis, and stimulants; she smoked 15 cigarettes daily. She admitted to past intravenous drug use (amphetamines and opiates). Sally attended the women’s emergency service after-hours at 16 weeks gestation and disclosed domestic violence; following this, a social work referral was made (no patterns of substance use were recorded). Sally presented again for routine care at 21 weeks. At 26 weeks Sally disclosed alcohol, cannabis and amphetamine use. She was not seen in the Drug and Alcohol Clinic until 29 weeks. At this visit she reported daily alcohol use at dependent levels (up to 250g alcohol or 25 standard drinks per day). She agreed to hospital admission for withdrawal management; however, during negotiations with the senior obstetrician, Sally received distressing family news and left in crisis. She returned the following week and stated that she had managed to reduce substantially her intake, reporting that the stressor of the previous week was her aunt’s admission to hospital with alcohol related liver failure. She denied significant withdrawal symptoms and she agreed attend the clinic weekly for review.
Sally continued to binge drink at progressively lower levels. A case conference was arranged antenatally to consider supports and child protection issues. At this meeting the paternal grandparents agreed to care for the baby. It became clear Sally had long-term significant psychosocial stressors including homelessness, domestic violence and significant alcohol and opiate use by her partner. Sally reported longstanding substance use since early adolescence and was noted to be impulsive and emotionally labile. With a strong family history of alcohol dependence, including by her mother, the question was raised as to whether Sally herself had undiagnosed Fetal Alcohol Spectrum Disorder.
Crises continued to occur for Sally during the antenatal period and after an increase in alcohol consumption (a high level binge) in addition to reports of ongoing violence, Sally accepted admission to hospital at 37 weeks. Sally improved both physically and emotionally during her hospitalization. She was reviewed by social work and mental health whilst an inpatient. She remained abstinent from alcohol and other substances and reported feeling ready for the birth. Sally had a normal delivery of a baby boy at 38/40 weeks. The baby was a healthy weight (3050g) and had Apgars of 5/5. During the postnatal period Sally was noted to have good parenting skills and was comfortable with the care arrangements in place. Sally was discharged one week after delivery. It was concerning to note that, despite the clear documentation of alcohol use complicating this pregnancy and the lengthy hospitalisation, alcohol abuse was not recorded as a discharge diagnosis.
Sally attended for follow up in the early postnatal period. However, multiple address changes and difficulties with phone contact made it difficult to continue working with her.
What can we learn from Sally’s experience?
Sally’s case illustrates missed opportunities for intervention at an earlier stage in the pregnancy. Sally had a significant past history, including losing custody of a child and previous polysubstance use, which could have offered an earlier opportunity for further exploration of her circumstances. She presented mid-pregnancy with issues of domestic violence and the correlation between violence and alcohol misuse is well established. Once she disclosed these issues, there was a significant delay before she accessed specialist services. Following this, further barriers existed to her gaining admission to hospital to give birth. Sally’s case also raises questions of missed diagnoses for adults in our health system. Importantly, alcohol dependence was not recorded in her medical records. Also, loss to follow-up of the mother suggests that her infant was denied appropriate referral to paediatrician services for assessment for fetal alcohol spectrum disorders.
It is clear that opportunities exist to improve health services’ responses to alcohol use in pregnancy. A more proactive approach is required, with clinicians appropriately assessing women, providing information and referral at the earliest opportunity, and improving the health system to enable provision of a more coordinated and responsive approach to this very significant health issue.
- There is an urgent need to improve availability and access to services for women who drink during pregnancy, particularly those who drink at risky levels.
- The evidence to support pharmacotherapies and psychosocial interventions and treatments is limited; however, a holistic approach is important for program success. High quality intervention research is crucial.
- A multidisciplinary, supportive and culturally appropriate approach is required to address the complex needs of alcohol-dependent mothers and their families.
- The key objective is early identification and treatment of women with alcohol misuse to maximise the chance of FASD prevention.