Addiction, pregnancy and and a chance to engage
As the number of babies born with opioid addictions climbs, so do the services helping pregnant women — including everything from mobile midwives to methadone programs
A park bench. A Tim Hortons.
IF A WOMAN IS PREGNANT, at risk and in need of care, they will meet her wherever she is.
Across Hamilton, a team of midwives are ready to serve some of the most vulnerable moms-tobe. The Maternity Care Team is ready 24/7, awaiting calls from the Shelter Health Network or other social service agencies to meet homeless pregnant or postpartum women without a healthcare provider.
“We will be there within the hour, or whenever she wants,” says Lisa Nussey, one of eight midwives on the team.
And they will meet her anywhere — at a shelter or methadone clinic, wherever she is comfortable. They carry their equipment with them so that they are essentially a mobile prenatal unit.
The team, which operates on a volunteer basis, has received roughly four to six calls per month since its inception in 2013.
Not every woman they meet has drug or addiction issues — they also work with refugees or young women fleeing domestic violence, for example — but Nussey says drug use is “prevalent.”
But if a mom is struggling with substance use or abuse, they will refer her to the Maternity Centre at the David Braley Health Sciences Centre downtown, which is home to a specific program for pregnant women with addictions.
Their goal is not to be the mom’s primary care provider; they just want to ensure she gets basic care ahead of her delivery.
IT’S A HARM-REDUCTION approach, Nussey explains. Their goal is to reach women before they show up at the hospital “34 weeks pregnant and … bleeding.”
Nussey says it should come as no surprise that prenatal care might be low on a long list of priorities for a woman who doesn’t have access to shelter.
“As a sector, people just don’t appreciate how difficult it is to make it through the day,” she says.
Especially without a health card, for example, it can be difficult to access even basic health-care services like blood work.
The midwifery model, they believe, is a good fit for these cases.
“One of the things people really like about midwifery is that we can do home visits,” Nussey says, noting she came to the field from a social justice perspective.
She gives an example of a 15-year-old living in a shelter with her mother. She was 38 weeks pregnant when Nussey’s team connected with her. But in just two days, they were able to get all of her prenatal care done.
Their patients’ files are forwarded by the team to the local hospitals, so whenever and wherever a mom shows up to deliver, the information is there. Even having basic information like where the placenta is can make a big difference during the chaotic delivery process, she explains.
Four years in, they are trying to raise awareness about the program. Because there is a high turnover rate at social service agencies, she says it can be hard to keep people informed. They also have a longer-term goal of securing funding.
“We need to keep data, and we are trying to do that research on how many women aren’t accessing prenatal care and who they are,” she says.
And they are constantly trying to educate about the realities of addiction.
“It’s a choice to view the (opioid) epidemic as a law-and-order issue. That’s a decision. You can also view it as a public-health issue — and if you do, you view it very differently,” she said. “Especially given what we know about how hard it is to be destitute and poor.”
BUT IN THE MIDST of an opioid crisis — one that is claiming thousands of lives across Canada every year, and ruining so many more — not all who use or abuse drugs are destitute and poor.
When newborn baby Carter spent a month in hospital, his mom Adina told only close friends and family why he was there.
“I definitely didn’t want people to know that he was in withdrawal because I had a drug problem,” she says.
Because Adina, 27 — who asks that only her first name be used because of the stigma around addictions — was in a methadone treatment program when she got pregnant, her baby was born with neonatal abstinence syndrome (NAS), meaning he was born in opioid withdrawal.
When she discovered she was pregnant, she was afraid of going through with it. What would the methadone do to the baby? What would people think?
After all, she and her boyfriend were only recently clean after years of opioid abuse, stemming from doctor-prescribed painkillers, which had spiralled into street drug use before family and friends’ intervention.
At 21, while living and working in Toronto, Adina was diagnosed with interstitial cystitis (ulcers on the bladder) — a painful condition with no real cure. To manage the pain, she was prescribed Percocet and Dilaudid.
She has an addictive personality, she acknowledges now — in fact, it was partly recreational ketamine use, popular in the Toronto club scene, that led to her bladder issues. But the opioids were something new. Without them, she could barely leave the house without having to immediately run back inside to use the bathroom.
“I needed them,” she says. “I couldn’t have done anything without the opiates.”
Soon her prescription was not enough.
IT WAS AROUND THIS TIME she met her boyfriend, Chris. He had been homeless before Adina met him, having long struggled with addictions himself that stemmed similarly from doctor-prescribed pain medication after a car accident at 19 years old.
“That’s when it kind of got to another level … when there are two people, you’re kind of feeding off each other,” she says.
Her injection use lasted just a few months before friends — worried about this seemingly bizarre turn in her previously “normal” life — called Adina’s mom. This wasn’t like her.
“They were sick,” her mom says. She begged her daughter to come home to Burlington. And with her lease about to expire, Adina eventually agreed — on the condition that Chris came, too.
In the spring of 2015, they moved into her dad’s place in Burlington. Her mom got the two family doctors and into the Wellbeings pain clinic where, for the first time, they started on a methadone program. Things were looking up.
One month later, Adina got pregnant.
TODAY, CARTER is 17 months old and a healthy, happy baby. On a Wednesday morning in March, he is happily running around, banging toy trucks on the hardwood floor of his grandmother’s suburban Burlington home. He says basic words like mama and dada but otherwise communicates through gurgles and shrieks.
Adina watches him with a smile. Sipping tea at her mom’s dining room table, she acknowledges she does not fit most people’s stereotypical image of a mom struggling with addictions.
“Before I was pregnant, I’d be at the (methadone) clinic and see pregnant women and be like, ‘Is that even possible? What are you doing right now?’” she admits. “You think it’s trashy. But now I wonder if people think that of me when I’m at the clinic with him … but what are you supposed to do?”
Adina’s story is part of a growing narrative across Hamilton, Ontario and Canada. As opioid prescriptions rise, and overdose rates rise, so do the rates of babies being born in opioid withdrawal each year.
For every 1,000 babies born across the province between April 2015 and March 2016, 5.9 were diagnosed with NAS. The national rate was 4.2 births per 1,000 — a stark increase from a decade earlier, when the provincial and national NAS birth rates were both 1.8 per 1,000.
In Hamilton, there were roughly 45 NAS births in 2015 — a number that rose to roughly 62 last year.
It’s an alarming increase. But health-care providers point out there is another trend: a growing number of moms, like Adina, who are getting onto stable methadone programs before or during their pregnancies. And that, doctors say, is a very good thing. According to a 2015 study on neonatal withdrawal by the Institute for Clinical Evaluative Studies (ICES), doctors noted that as delivery approached, more and more women were switching to methadone from other opioids — from 29 per cent of the women having been prescribed methadone one to two years before delivery, to 53 per cent in the 100 days before delivery.
The number of women prescribed non-methadone opioids also dropped from 23 per cent one to two years before delivery to 11 per cent in the 100 days before delivery.
This is important because women who misuse opioids are more likely to have premature and underweight babies. But women who switch to methadone, the study says, are more likely to have their babies at term and with full birth weights.
“NAS is a treatable condition. It doesn’t have any long lasting sequelae for the baby,” says Dr. Suzanne Turner, a family physician at St. Michael’s Hospital and the study’s lead author.
“I mean, as someone who treats women with addictions and particularly in pregnancy, I am happy that these women are getting evidencebased treatment,” Turner says.
“In many ways, if someone (with addictions) wants to parent on methadone … it is the best thing they can do. They are treatments that we know work to avoid the constant cycle of addiction.”
What would the methadone do to the baby? What would people think?
ADINA ACKNOWLEDGES she was lucky. She had her mom, who shuttled her to every appointment.
And she credits the Wellbeings clinic with connecting her with the resources she needed.
“They were so amazing. Very professional and not the least bit judgmental,” she says. “A lot of methadone clinics are a bit rough around the edges and not the happiest of places … but Wellbeings is very clean, and a very positive environment to have to go to every week.”
It was Wellbeings staff who connected her with the Maternity Centre and the NAS program at St. Joe’s. She remembers how nervous she was during her first orientation meeting at the hospital, where she met social worker Sarah Simpson.
“And Sarah Simpson was so good to you,” her mom says to her. “She really understood that you felt (embarrassed), and she said, ‘It’s not what it’s about. This is about protecting babies, and we have to watch (out for them).’ And you were fine.”
They made her feel proud of being on methadone and getting the treatment she needed — rather than shaming her for taking something bad for her baby.
“They would reassure her, ‘It’s OK, you’re doing the right thing. You’re getting treatment and it’s going to be all right,’” her mom recalls.
DURING THE MONTH that Carter spent in the neonatal intensive care unit (NICU) at St. Joe’s for morphine treatment, Adina and Chris were able to stay in a bunk room (or “care by parent” room, as they call them) on the maternity floor, to be nearby and feed and care for Carter.
If mom used non-opioid drugs during her pregnancy, like cocaine, babies will be under observation for an extra two or three days after birth. But because the withdrawal from opioids — whether it’s prescribed drugs, methadone or illicit opioids — is more intense, those babies stay for at least five days. If they need medication, like morphine, they could be there for six weeks until their tiny bodies are fully weaned off.
It’s hard to gauge ahead of time whether a baby will need morphine or not. The severity of the withdrawal is not necessarily related to the level or dose of a mom’s drug use, pediatrician Dr. Sandi Seigel says. There are too many other factors to consider — like body weight, metabolism, etc.
One Friday this past March, there were more babies in opioid withdrawal in the St. Joe’s NICU than there were rooms to keep them in. Nurses and even the desk clerk take turns rocking the tiny swaddled bundles.
For the days or weeks they are there, the babies need to be held almost constantly. It is not hightech care, but it is hands-on care. They are irritable, sensitive to light. This is why bunk rooms — “care by parent” rooms, they call them — are provided to parents during the withdrawal period — so they can be there to hold their babies, and provide skin to skin contact and breastfeeding.
Even those who stay offsite — and even those who will not be taking their babies home with them — are encouraged to come in each day for as much as that care as they can handle.
When the parents are unavailable — if they leave to get food, for example, or to go to a methadone appointment — the staff takes over. Nurses take turns holding babies until they are calm enough to put in the bassinettes, back in the sparsely decorated quiet rooms.
But today there are five babies, and only four rooms.
“When I started (20 years ago), we’d maybe have one every six months,” registered nurse Ann Patton says, rocking one of the babies in her arms.
When she has to put him down to tend to another patient, the desk clerk shuffles in to take over. Volunteer ‘cuddlers’ come in to help hold babies when the staff are overwhelmed.
IN CASES where an apprehension plan is in place, foster parents have a more involved role than ever before. In the past, if a baby was going to be taken away, the family would never cross paths with the foster parents.
“Before, they’d come in one door and out the other,” Patton says. It was secretive. Taboo. “But now they work together.” After a baby with NAS goes home, the St. Joe’s clinic follows up closely. There are 63 babies they are still following. Because longer-term effects of opioids on babies aren’t totally clear, they return for growth and development checks by a pediatrician at regular intervals: two months, four months, six months, eight months, 12 months and 18 months.
If an issue is detected in a baby — a speech delay or a motor skill delay, for example — the clinic helps get the appropriate services looped in as soon as possible, whether they know if it’s connected to the NAS or not.
“Partly just being pragmatists, we may not be able to say why (this issue exists as a result of NAS), but we know there’s an issue so it’s important to identify so they can get follow up,” Dr. Seigel says.
“We have some babies who are doing quite well. And even those ones with delays, it doesn’t mean it’s permanent,” she says. “It’s possible to have a baby (with NAS) and have it be perfectly fine.”
In total, 30 babies have “graduated” from the St. Joe’s checkup program since it launched three years ago. Another 15 babies stopped coming in. None of this is mandatory, of course. They can’t force people to come in for appointments. But most are enthusiastic about it — and it offers the doctors a chance to check in on mom and how she is doing as well.
NEXT MONTH, Carter and Adina will go for their final 18-month checkup.
Adina has now been sober for two years and her bladder issues have subsided. She is thinking about going back to work and is working on getting her driver’s licence. She and Chris hope to get their own place. Eventually, she’d like to get off methadone entirely. She wants to have more children and doesn’t want them to go through withdrawal.
Life is better now than she could have ever imagined even three years ago. She is proud, because she knows people thought she was going to “screw up” and she didn’t. “I’m just so happy having a clear head,” she says.
As a family, they are thriving. Even Chris, the guy she says friends saw as a bad influence and who nobody ever had faith in. “But he actually saved my life,” she says. “And I saved his.”
The Maternity Centre made her feel proud of being on methadone, and getting the treatment she needed Women who switch to methadone are more likely to have their babies at term and with full birth weights