To explore pregnant women’s experiences of pregnancy

while on methadone maintenance treatment and any

associated concerns about the pregnancy or birth

Carol Murphy

September 2015

This thesis is submitted to the School of Social Work and Social Policy, Trinity College

Dublin, in partial fulfilment of the requirements for the degree of

Masters in Applied Social Research

Under the supervision of Dr Paula Mayock

i

Declaration

I declare that this thesis is entirely my own work. It has not been submitted to this or any

other institution for degree or publication.

I authorise the University of Dublin to lend this thesis to other institutes or individuals. I

further agree that this thesis may be copied at the request of other institutes or individuals

for the purpose of scholarly work.

Carol Murphy ______________________________

[Your Name, typed]

Date

ii

Acknowledgements

First and foremost, my sincere thanks to the participants in this study who generously gave

of their time and shared their experiences with me. Without their participation this research

project would not have been possible.

I would like to thank my supervisor, Dr. Paula Mayock, for her supervision and invaluable

feedback and guidance throughout the whole process.

I would also like to thank Prof Brian Cleary, Justin Gleeson and the DOVE team at the

Rotunda for their assistance, advice support and for facilitating this research.

I would also like to thank Dr. Fiona O’Reilly for her expert advice and guidance.

Finally, Thanks to Graham Barry and my family and friends for all of their encouragement

and support every single step of the way, my deepest gratitude.

iii

Abstract

While there is a large body of literature on the issue of substance misuse and methadone

maintenance treatment (MMT) in pregnancy, very little is known about the lived

experiences of these pregnant women and their fears about neonatal abstinence syndrome

(NAS).

Through a phenomenological approach, using semi-structured interviews with eight

pregnant women on methadone maintenance, this small-scale study aims to address this

gap in the literature. From the rich narratives produced from the interviews, the themes

that emerged were i) The lesser of two evils, ii) Fear and guilt, iii) Stigma and shame, iv)

Influence through support encouragement and control, and v) Pregnancy provides second

chances. The views of the participants on the services they received were also presented.

While methadone maintenance treatment is considered safe and effective in the

management of opiate addiction in pregnancy, these women reluctantly accepted their

need to be on MMT. They recognised the necessity of taking methadone during pregnancy

for the safety of their unborn babies. Profound fear, guilt and worry were experienced by

these women who were compelled to do the right thing for the benefit of their unborn

babies. Most understood they may need to increase their dose, but believed a lower dose

was safer for their babies. From a patient safety and health promotion perspective, it is

important to explore the views of pregnant women on methadone maintenance treatment

and their perceptions of the risks of NAS. More education is needed in this area to

reinforce that the incidence of NAS is not related to the dose. Stigma emerged as a

barrier when engaging with addiction services. These women attending antenatal

services were reliant on staff to have their identities as mothers endorsed.

Understanding the lived experiences of these women has provided a valuable insight into

the nature of the phenomenon. This study has highlighted how service provision and health

promotion approaches could be improved for pregnant women on methadone maintenance

treatment.

Keywords: Methadone Maintenance Treatment, Pregnancy, Opiate dependence, Opioid

dependence, Substance use, Drug use, Neonatal Abstinence Syndrome, Stigma.

iv

Table of Contents

Declaration ........................................................................................................................................ i

Acknowledgements .......................................................................................................................... ii

Abstract ............................................................................................................................................iii

Table of Contents ............................................................................................................................. iv

Introduction .................................................................................................................................... 1

Chapter 1: Literature Review ....................................................................................................... 2

Introduction .................................................................................................................................. 2

1.1 Drug Prescribing during Pregnancy ........................................................................................ 2

1.2 Methadone Maintenance Treatment ....................................................................................... 3

1.3 The Methadone Protocol ........................................................................................................ 4

1.4 Methadone and Pregnancy ..................................................................................................... 7

1.5 The Dose Argument ............................................................................................................... 9

1.6 Neonatal Abstinence Syndrome (NAS) ................................................................................ 10

1.7 Women and Drug Use .......................................................................................................... 11

1.8 Drug Use and Pregnancy ...................................................................................................... 13

1.9 Attitudes and Stigma ............................................................................................................ 16

1.10 Views of Services ............................................................................................................... 18

Conclusion ................................................................................................................................. 20

Chapter 2: Research Methodology ............................................................................................. 21

Introduction ................................................................................................................................ 21

2.1 Aim of the Study .................................................................................................................. 21

2.2 The Research Design ............................................................................................................ 22

2.2.1 Qualitative Research Approach ..................................................................................... 22

2.2.2 Phenomenology ................................................................................................................. 23

2.2.3 The Qualitative Interview .................................................................................................. 25

2.3 Data Collection ..................................................................................................................... 26

2.3.1 The Sample .................................................................................................................... 26

2.3.2 Access and Recruitment ................................................................................................ 27

2.3.3 The Semi-structured Interview ...................................................................................... 28

2.4 Data Management ................................................................................................................ 29

2.4.1 Storage and Confidentiality ........................................................................................... 29

2.4.2 Data Analysis ................................................................................................................ 29

v

2.5 Ethical Issues and Considerations ........................................................................................ 31

2.6 Limitations ........................................................................................................................... 32

Conclusion ................................................................................................................................. 33

Chapter 3: Findings ..................................................................................................................... 34

Introduction ................................................................................................................................ 34

3.1 Sample Profile ...................................................................................................................... 34

3.2 Background .......................................................................................................................... 36

3.2.1 The Women’s Childhood Experiences .......................................................................... 36

3.3 Drug Use History ................................................................................................................. 38

3.4 Experiences of Pregnancy on Methadone ............................................................................. 41

3.4.1 The Lesser of Two Evils ................................................................................................ 41

3.4.2 The Dose: Less is Better ................................................................................................ 42

3.4.3 Feelings of Fear and Guilt ............................................................................................. 46

3.4.4 Stigma and Shame ......................................................................................................... 49

3.4.5 Influences on Women’s Decision Making ..................................................................... 51

3.4.6 Pregnancy Provides Second Chances ............................................................................ 54

3.5 Women’s Views and Perspectives on Services..................................................................... 56

3.5.1 Maternity Services ......................................................................................................... 56

3.5.2 Addiction Services ........................................................................................................ 59

3.5.3 Social Services .............................................................................................................. 60

Conclusion ................................................................................................................................. 61

Chapter 4: Discussion and Conclusion ....................................................................................... 62

Introduction ................................................................................................................................ 62

4.1 Education ............................................................................................................................. 62

4.2 Desire to Detox .................................................................................................................... 63

4.3 Flexibility and Understanding .............................................................................................. 64

4.4 Focus on Family Planning .................................................................................................... 65

4.5 The Context of Stigma ......................................................................................................... 65

Conclusion ................................................................................................................................. 66

Bibliography ................................................................................................................................. 67

Appendices .................................................................................................................................... 75

1

Introduction

The first chapter in this study presents the literature relating to the topic under study, in

order to establish the context in which the research was carried out.

The second chapter describes the methodological approach employed, which includes the

research design, data collection methods, data analysis and the limitations of the study.

The third chapter presents the findings of this phenomenological study.

Finally, the fourth chapter discusses the findings and implications for practice, along with

recommendations for further research.

2

Chapter 1: Literature Review

Introduction

As stated, the aim of this study is to explore pregnant women’s views of methadone

maintenance treatment. In this chapter, drug prescribing in pregnancy, methadone

maintenance treatment, The Methadone Protocol in Ireland, and methadone maintenance

treatment in pregnancy will be discussed. Subsequently, women and drug use, drug use in

pregnancy, and pregnant women’s views and experiences of services will be addressed.

1.1 Drug Prescribing during Pregnancy

Prescribing drugs in pregnancy involves careful risk-benefit assessment (Webster &

Freeman, 2003), since drugs that are required for maternal health can pose a risk to the

fetus. The thalidomide scandal remains one of the most significant events in the study of

fetal anomalies (Webster & Freeman, 2003). This scandal involved the prescription of an

antiemetic drug to pregnant women from the late 1950s to 1962, leading to thousands of

viable healthy fetuses developing deformities while in utero. The drug was withdrawn

from pharmacies in the western world in 1962 (Webster & Freeman, 2003). However,

many fetuses had already been deformed as a result of its use and visible images of

affected babies are still evident and many adults are living with deformities and physical

disabilities as a result (Webster & Freeman, 2003). In recognition of the negative effects of

the use of this drug, Benegbi (2006) discussed the lessons for doctors arising from the

thalidomide tragedy and the responsibilities they must assume in order to curb any such

future occurrences. From a patient perspective, thalidomide changed how the public

viewed medication use in pregnancy. Birth defects in humans are known to be caused by

3

approximately 20 drugs or groups of drugs (Arunogiri, Foo, Frei & Lubman, 2013).

Webster et al. (2003) suggest the capability of one of these drugs to cause birth defects is

only possible under certain conditions. They further highlight that birth defects will only

occur following exposure to certain drugs during the critical stage of pregnancy with a

high enough dose and exposure for the appropriate duration of time. Webster and Freeman

indicate that, in most cases, regarding the known human teratogens (agents that cause

malformation of the embryo), babies without defects are born in more than 90% of

pregnancies that are exposed to certain drugs during the first trimester. Although many

drugs cause pharmacological effects in the second and third trimesters, they are normally

recognised and managed in most cases (Webster & Freeman, 2003). As Burns, Mattick &

Cooke (2006) advise, it is important to note that prescribing any medicine during

pregnancy needs to consider both the risks and benefits. A study examining patterns of

prescribing in almost 4,000 pregnant women’s medical notes by Irvine et al. (2010) in

Scotland found that safety data during pregnancy is unavailable for many drugs that are

commonly prescribed. According to Doering, Boothby & Cheok (2002) and Irvine et al.

(2010), the common use of prescription drugs during pregnancy highlights the importance

of conducting more research to identify evidence related to the risks and benefits of the use

of prescription drugs during pregnancy.

1.2 Methadone Maintenance Treatment

Methadone was first synthetized in Germany in 1939 but it did not become available for

general use until the drug manufacturers Eli-Lilly began production in the United States

(US) in 1947 (Joseph, Stancliff & Langrod, 2000). The use of decreasing doses of

methadone as a treatment for heroin addiction commenced in the late forties

(Isbell & Vogel, 1948). This detoxification protocol involved tapering the

4

methadone dose over a period of one to two weeks. High relapse rates with this

detoxification approach became apparent over the following years. In the mid-sixties,

Dole and colleagues developed methadone maintenance treatment in response to a heroin

epidemic in New York City (Joseph, Stancliff & Langrod, 2000). The methadone doses

used by Dole and his colleagues had the capability of achieving the ‘narcotic blockade’

required for opioid withdrawal. Patients were then maintained on a constant dose of 60-

120 milligrams (mgs) daily. This treatment was based on the hypothesis that opioid

addiction caused permanent physiological changes that could be alleviated by the regular

administration of methadone. One of the reasons, according to Schilling, Dornig &

Lungren (2006), for not including women in the early methadone treatment trials, which

were conducted shortly after the occurrence of the thalidomide disaster, centred on the

fear of fetal injury.

1.3 The Methadone Protocol

The extent to which heroin use has become endemic in Dublin, and the way in which

treatment policy has responded, may be illustrated through reference to the central

treatment list statistics, according to Butler (2002). In 1979, the Jervis Street clinic treated

55 heroin users; this figure rose to 213 in 1980. In 1990, the newly established Dublin

Drug Treatment Reporting System reported that 2,037 opiate users were being treated in

an expanding treatment system. By December 2000, there were 4,936 residents of the

Eastern Regional Health Authority registered for methadone treatment on the central

methadone treatment list (Butler, 2002). In July 2015, there were 10,037 people registered

for methadone maintenance treatment in Ireland and 3,072 were female (Central Treatment

List, 2015). More than 3,500 of these individuals have been on MMT for more than ten

years (Central Treatment List, 2015). Historically, methadone treatment services were

5

centralised in Ireland (O’Reilly & Reaper, 2005). Treatment for drug addiction began with

the establishment of a central treatment agency on Jervis Street in Dublin City in the late

seventies. This centre was established under the clinical direction of consultant

psychiatrists in response to the growing population of drugs addicts (particularly heroin) in

the Dublin area (O’Reilly & Reaper, 2005). In 1988, following the closure of Jervis Street

clinic, the National Treatment and Rehabilitation Board (NTRB), widely known as Trinity

Court, moved to Pearse Street, providing methadone maintenance to heroin users, with a

focus on abstinence (O’ Reilly & Reaper, 2005). GPs (General Practitioners) had no role in

the initial services, according to O’ Kelly et al. (1986), as the psychiatric services saw no

role for them, stating that they were ‘not in favour of the treatment by GPs of drug addicts’

and GPs were initially cautious of becoming involved in the care of drug users due to the

chaotic nature of addiction (O’ Kelly et al., 1986). However, a small group of inner city

GPs felt that they could not ignore the growing problem in the community and supported

the view that methadone maintenance at primary care level was necessary and viable

(Bury, 1989). Over time, this view became accepted and the Irish College of General

Practitioners (ICGP) in 1990 produced a policy statement on the management of problem

drug users in general practice. Over the next decade, addiction services and policy changed

from a service that was centralised and specialised, with an ideology focused on abstinence

models, to a regulated approach of methadone prescribing by general practitioners, with a

focus on harm reduction and stabilisation. (O’Reilly & Reaper, 2005). A formal

Methadone Treatment Protocol (MTP) was introduced in 1998, to ensure that treatment for

opiate misuse could be provided wherever the demand existed. New regulations pertaining

to the prescribing and dispensing of methadone were introduced, and a joint Health

Board/Irish College of General Practitioners (ICGP) committee was formed to provide

training, ongoing education and regular audit for general practitioners (GPs) taking part in

6

the programme (Butler, 1991; Langton et al., 1998). Under the Methadone Treatment

Programme, GPs were contracted to provide methadone treatment at one of two levels –

Level 1 or Level 2. Level 1 GPs were permitted to prescribe methadone treatment for

misusers who have already been stabilised on a methadone maintenance programme

(Latham, 2013). Each GP, qualified at this level, was permitted to treat up to 15 stabilised

misusers. Level 2 GPs were allowed to both initiate and maintain methadone treatment.

Methadone, a long-acting opiate agonist, is the main pharmacological substitution

intervention for opiate users in Ireland (Latham, 2013). Taking methadone, as opposed to

daily drug-seeking, makes it easier for the individual to achieve ‘normal’ social behaviour

(Burns et al., 2006) and is less likely to suffer from the consequences of drug use, such as

ill- health, crime and relationship issues. According to Burns et al. (2006), the goal for

such patients is to quit drugs but the withdrawal symptoms are often too painful and they

end up using illicit drugs again to avoid the accompanying discomfort. Initially, a low

commencing dose (usually between 10-40 mgs) is prescribed, aimed at achieving a level of

stability, preventing opiate withdrawal and reducing the likelihood of overdose (Langton,

1998). Ideally, by the end of six weeks of treatment, the individual is usually stabilised on

an appropriate therapeutic dose (Delargy, 2008). Methadone maintenance is a long-term

treatment option of no fixed duration (Delargy, 2008). It often forms part of a wider

process, assisting the individual to reduce various forms of drug-related-harm, to address

social, legal and financial problems, until the person is ready and willing to withdraw from

the drug substitution therapy (Strang et al., 2005). Many individuals remain on a

maintenance dose for a number of years or as a permanent treatment (Delargy, 2008).

Research by O’Reilly& Reaper (2005) and Keane (2012) on drug users views of health

and addiction services in Dublin highlighted how the service users felt there were not

7

enough opportunities for detoxification or support to come down off methadone. Many

service users viewed their daily dependence on methadone as restricting their personal

freedoms, with some referring to methadone as ‘a ball and chain’, according to Keane

(2012). Keane (2012) further reported on an absence of clinical advice and support on

dosage reduction or detoxification in addiction services, stating how services users

perceived a detoxification from methadone as more difficult than coming off heroin itself

and perceived methadone as being more addictive than heroin. While many individuals on

methadone maintenance express a desire to detoxify, Lyons et al. (2008) highlight the

increased rick in overdose after a period of abstinence.

1.4 Methadone and Pregnancy

In Ireland, pregnant women are prescribed and dispensed methadone under supervision at

a local addiction clinic or by their own GP, as outlined above. Due to an increase in

pregnant drug dependant women, a specialist Drug Liaison Midwife (DLM) service was

created in March 1999 to liaise between the three Dublin Maternity hospitals and the Drug

Treatment Services (Scully et al., 2004). The aim of introducing this specialist role was to

assist with the ‘reduction of the stigma associated with the treatment of pregnant female

drug users, ease access to care for pregnant dependent women and help maintain care

pathways once established’ (Scully, Geoghegan, & Keenan, 2001).

MMT is considered safer compared to a pregnant woman that tries to stop her drug use

abruptly or reverts to the use of heroin. According to Jones et al. (2005) withdrawal may

lead to uterine contraction, which can cause a miscarriage (Jones et al., 2005). Mothers

using heroin or other opioids in pregnancy are at an increased risk of, “... premature birth

and low birth weight babies, babies with developmental delay, sudden infant death

8

syndrome, and neonatal abstinence syndrome (NAS) or ‘withdrawal” (Fischer et al., 2006:

275). With methadone, the pregnant mother can begin to improve her overall health, as

well as the health of her unborn child (Burns et al., 2006). Methadone maintenance

continues to be the safest and most effective treatment for opiate addiction during

pregnancy (Savage, Kirsh & Passik, 2008; Burns et al., 2006) and, with the appropriate

support and resources, mothering and methadone use can fit well together (Alexander,

2013). Methadone is recommended as the first line treatment option by the clinical

guidelines in various countries, including the UK, US and Australia, as the most effective

approach for the management of pregnant women affected by opioid-dependent

(Department of Health UK, 2007; New South Wales Department of Health, 2006; Batki et

al., 2005). In Ireland, its use is recommended by the Health Service Executive (HSE),

Clinical Practice Guideline on Methadone Prescribing, and Administration in Pregnancy

(Health Service Executive, 2013). Methadone is the most frequently used substitute drug

for pregnant women in Ireland and the UK, with buprenorphine (Subutex) also used in

both Ireland and the UK. Clinically, both methadone and buprenorphine are acceptable for

use in pregnancy (Johnson et al., 2003; Jones et al., 2005, 2008). Most pregnant opioid

using women whose social circumstances are complex are less likely to be keen on

antenatal care during the early stages of pregnancy or continue to use the maternity

services (Lewis, 2007). Substitute prescribing carries benefits; it can reduce the use of

illicit opioids, as well as provide regular and frequent contact between the client and a

health professional, ensuring a consistent and reliable dose of medication. According to

Stotts, Dodrill & Kosten (2009), methadone maintenance treatment (MMT) in pregnancy

can be expected to produce the same benefits as in the general opioid-dependent

population. These benefits include enhanced treatment retention, decreased abuse of illicit

drugs, reductions in blood borne virus risk behaviours, mortality rates and criminal activity

9

(Schilling, Dornig & Lungren, 2006). Compared to other pregnant women who use illicit

substances, pregnant women on methadone have better engagement with prenatal care,

counselling and family planning, as well as general health care (Arunogir, 2013).

Methadone, according to Alexander (2013), has proven efficient in reducing morbidity and

mortality. Early prenatal appointments, daily or weekly prescribing, coupled with close

and frequent contact with health care service, has proven to be effective in decreasing

infant mortality (Jones et al., 2010).

1.5 The Dose Argument

The methadone dose is the most important determinant of the therapeutic response in

methadone maintenance treatment, according to McCarthy et al. (2005), who highlighted

that high doses leads to better outcomes for opiate dependant patients that are not pregnant.

Methadone concentration levels are lessened during pregnancy due to physiological

changes such as ‘increased total body water, a larger tissue reservoir, enhanced hepatic,

placental and fetal clearance of methadone’, according to Cleary et al. (2012). This may

result in the mother experiencing withdrawal symptoms and requiring her methadone dose

be increased. There are conflicting views on whether methadone doses are related to the

incidence of Neonatal Abstinence Syndrome (NAS) Cleary et al. (2012).

Although methadone maintenance is a standard treatment for opioid dependence

in pregnancy, there appears to be little agreement in relation to the appropriate dosing in

pregnancy. McCarthy (2015) indicates that the most commonly applied dosage is the

single daily one but this may increase the severity of NAS by exposing mother and the

fetus to constant withdrawal experiences. According to Cleary et al. (2010), effective doses

lead to better outcomes for opiate dependant pregnant women. Previous studies in Ireland

10

and internationally indicate that women can be misinformed about the safety of

consuming methadone during pregnancy (Cleary et al. 2012, Chan and Moriarty, 2010, Jones

et al., 2012). For example, women may be advised to reduce their methadone dose during the

pregnancy in order to minimise neonatal abstinence syndrome (Jones et al., 2012; Cleary

et al., 2012). These women may also face pressure from partners, friends and family

members to keep the methadone dose low during pregnancy, according to Chan and

Moriarty (2010). Quantitative research by Cleary et al. (2012), in a Dublin maternity

hospital, found that a lower dose of methadone does not affect the incidence of NAS.

Recent research by Jones et al. (2013) found that no major difference in the incidence of

NAS associated with the varying doses of methadone. If craving is not controlled, women

may risk exposing the fetus to illicit drugs and this further highlights the importance of

adequate dosing.

1.6 Neonatal Abstinence Syndrome (NAS)

The most significant negative effect of the use of methadone in pregnancy is NAS.

Estimates of the incidence of NAS after exposure to methadone in utero vary between

13% and 94% (Cleary et al., 2010). NAS is a complex disorder resulting from the sudden

halt in fetal exposure to substances that were previously used by the mother during

pregnancy (Kocherlakota, 2014). NAS is, however, an expected and treatable condition

that follows prenatal exposure to opioids, most commonly heroin or methadone. NAS

occurs when the infant shows significant signs of withdrawal, characterised by high

pitched cry and other disturbances. Some form of withdrawal is noted in 50% of infants

born to methadone maintained mothers (Burns et al., 2006). While it is understandably

concerning, there is no evidence to indicate that NAS is life threatening or results in

permanent harm, particularly when effective treatment is provided (American Congress of

11

Obstetrics and Gynaecology, 2014). Unlike tobacco and alcohol use in pregnancy, there

are no reported long-term effects of maternal opioid use (ACOG, 2014). Longitudinal

studies have shown that babies who experience NAS as infants do not exhibit signs of

physical or cognitive impairment as they mature (ACOG, 2014). NAS does however

require medical treatment and long periods of hospitalisation for the newborn (Gaalema et

al., 2012). The initial treatment option for NAS, suggested by Jansson, Velez & Harrow

(2009), is non-pharmacological care. Pharmacological treatment is required in some cases

where there is no improvement observed following non-pharmacological measures or if

the infant is affected by severe withdrawal. Kocherlakota (2014) advises that the mother

continue breastfeeding, unless contraindicated by reasons such as continued use of illicit

drugs or HIV infection, as this may cause transmission to the neonate.

1.7 Women and Drug Use

Women and men may experience different issues when it comes to drug use, as a result of

both sex and gender. Sex differences according to Wizeman & Pardue (2001) refer to

biological and genetic difference, while gender differences refers to ‘culturally defined

roles’ and how males and females perceive themselves. Therefore, men and women use

drugs for different reasons, respond differently and, as a result, their substance use disorder

can manifest differently (Greenfield, Back, Lawson & Brady, 2010). Gender differences

are some of the reasons why individuals use drugs, with women being more likely than

men to consume drugs in response to stress and negative emotions. In contrast, men seem

more likely than women to consume drugs ‘to enhance positive emotions or to conform to

a group’ (Greenfield et al., 2010). Statistics on gender differences in drug use are well

documented in the literature and it has long been known that there are higher rates of use,

abuse and dependence in men than women (Greenfield et al., 2010). However, in recent

12

years, epidemiological studies have highlighted a narrowing in the gap between men and

women (Greenfield et al., 2010, 2012). According to Greenfield et al. (2010), the male-

female ratio of drug use disorders in the 1980’s was 5:1, whereas more recently it is

estimated to be 3:1. Research by Lawless (2003) found that a high proportion of female

drug users in Dublin began injecting before the age of twenty. Women tend to have shorter

histories of drug use and shorter injecting careers (Lawless, 2003). In spite of this, female

drug users are more likely than their male counterparts to report a range of physical and

mental health complaints (Lawless, 2003). Women’s biological make-up is considered

responsible for the negative effects on their health (Greenfield et al., 2010). Women have a

proportionally higher ratio of fat to water than men, thus, they are less able to dilute

alcohol or other substances within the body, and will therefore have a higher

concentrations in their blood than men after taking in the same amounts (Institute of

Alcohol Studies, 2008). Women’s hormones may affect drug absorption (Greenfield et al.,

2010. Women have been found to develop drug related health issues and progress to

problematic drug use and dependency more quickly than men (Lawless, 2003). Women

often have a shorter history of abusing certain substances and they typically enter

treatment with more severe medical, behavioural, psychological, and social problems (Cox

& Lawless, 2000). This is because women show a quicker progression from first using

substances to developing dependence. Women are more likely to have been diagnosed

with a psychiatric condition such as anxiety or mood disorders (Goldstein et al., 2012) and

have a history of traumatic childhood experiences such as sexual abuse (Khoury et al.,

2010). Recent ethno-epidemiology research in Ireland suggests women are more likely to

be involved in an intimate relationship at the time of heroin initiation (Mayock, Cronly &

Clatts, 2015). Most women who inject heroin point to social pressure and sexual partner

encouragement as factors, according to Bryant et al. (2010). Women have unique needs in

13

terms of substance use treatment. Many have traumatic childhood histories and/or

experiences of adult violent relationships. Often these intimate relationships pose great

risks for these women. Frequently, the male partner prepares and injects the female

partner, increasing the risk of blood borne virus transmission through sharing of drug

paraphernalia (Rhodes, 2009). Many women who have young children do not seek

treatment or drop out of treatment early because they are unable to take care of their

children. They may also fear that social services will remove their children from their care.

1.8 Drug Use and Pregnancy

Traditionally, mothers have always been portrayed as protectors of their children,

however, the notion that pregnant women consuming drugs during pregnancy, including

prescribed methadone, conflicts with this view, as is evident in the literature and media

coverage (Boyd, 1999; Livingston et al., 2013). At almost a primal level, there appears to

be a need to demonise the mother if she falls outside what society deems acceptable. In the

early 1980’s, the issue of drug use in pregnancy gained considerable media attention

within the United States (Gomez, 1997). This was fuelled by sensational and misleading

stories about ‘crack babies’ (Gomez, 1997) born to mothers using crack cocaine. In

response to this social problem in the eighties, legislators sought to criminalise the issue of

drug use in pregnancy and, to date, these women are at risk of imprisonment. Mothers in

the US are imprisoned for assault if their newborns test positive for substances (Gomez,

1997). Criminalisation of substance-using behaviours exacerbates stigma and deepens the

marginalisation of people who use illegal substances (Livingston et al., 2013). In Ireland,

however, the response to the ‘heroin epidemic’ in the eighties resulted in a harm reduction

approach (Butler, 2002) and pregnant women using drugs were prioritised for treatment, as

opposed to criminalised.

14

Women who misuse drugs in pregnancy are at increased risk of mortality and morbidity

(Varty, 2014), and are more likely to be socially excluded. Drug use in pregnancy is a

complex and contested area of social and moral debate, ‘where the competing individual

rights of both the pregnant woman and that of her unborn child take centre stage’,

according to Kennedy (1988: 364-384). The use of heroin and/or other drugs during

pregnancy poses a risk to the overall health of women and the unborn child (Riley,

Fuentes-Afflick, Jackson, Escobar, Brawarsky, Schreiber, & Haas, 2005). Heroin use is

associated with general self-neglect, poor nutritional habits, substandard living conditions

and exposure to high-risk behaviours such as smoking, prostitution, poor treatment

compliance and obstetric complications (Varty, 2014).

Historically, research has tended to focus on the biological or genetic determinants of the

health of these women. However, a focus on social risks and environmental factors are

now increasingly shaping research on substance use during pregnancy (Alexander, 2013).

There is a need to focus on the social factors and the environment of expectant mothers

who are using drugs, according to Alexander (2013), instead of just focusing on their drug

abuse problem itself, since these could be major factors associated with their problems.

Significant risk factors such as intimate partner violence, mental health comorbidities,

racial differences, and the effect of place on pregnant substance users should all be taken

into account (Alexander, 2013). Echoing these views, Morris et al. (2012) argue that the

development and maintenance of drug use in pregnant women is encouraged by various

factors, including a family history of drug and/or alcohol abuse, family instability, sexual

abuse during childhood, having a dual diagnosis for both drug addiction and mental

illness, and having pressure from chemically dependent friends (Morris et al., 2012). Many

models have sought to explain substance abuse among pregnant mothers. Homelessness,

15

unemployment, involvement in prostitution, and co- morbidity are all aspects of the

mother’s functioning that affect parenting. In terms of societal support, Alexander argues

that mothers who are using drugs need to be seen in the context of their social risks and

environment (Alexander, 2013). Both the social and multiple complex needs are

significantly interwoven within the context of drug using pregnant women (Enkin et al.,

2000). The impact of such factors on a woman’s ability to maintain a healthy outlook for

both herself and her unborn cannot be ignored when addressing these issues. Context is

important because social policy in this area brings up many ethical dilemmas (Lester,

Andreozzi & Appiah, 2004). In reality, opioid dependant pregnant women are mostly poor

and from disadvantaged areas and child rearing is therefore affected by both context and

culture (Lester et al., 2004). These mothers may want the best for their children, but what

they mean by "best" is influenced by their context, experience and belief systems and may

differ from what the experts mean by "best" (Lester et al., 2004). Lester et al. (2004) states

that "best" needs to be weighed against the alternative, highlighting how placing a child in

care is not necessarily a better alternative for the child and there is a need to recognise the

challenges these mothers face. While methadone changes addictive behaviour patterns, the

underlying cause of addiction is not fully understood, according to Alexander (2013),

stating that ‘we are starting in the wrong place ... starting with a desire to find a cure

before determining why people use heroin will always fail to provide a

solution’(Alexander, 2013). It is therefore essential that we access and understand the

views, experiences of perspectives of women who use drugs in pregnancy.

16

1.9 Attitudes and Stigma

The traditional doctor-patient relationship is based on the assumption that the patient

presenting is unwell, attends the doctor with the intention of getting better, and will thus

comply with the advice of the physician (Langton et al., 1998). However, evidence shows

that opiate dependant patients may not conform to these expectations (Langton et al.,

1998) and it is recognised that a lack of motivation and/or resistance to medical advice on

the part of these patients can be challenging for medical professionals (Mohr et al., 2012).

Manipulative behaviour, chaotic attendance patterns and a perceived lack of motivation

can interfere with the normal doctor-patient relationship (McKeown et al., 2003). There is

a need for an awareness of what can be deemed suitable support services for people whose

behaviour is not consistent with the conventional expectations of health professionals

(Mohr et al., 2012). Procedures or treatments that are primarily rooted in medical

rationality and do not necessarily support the need of the ‘problematic drug abusing

patient’ (Mohr et al., 2012). The treatment of drug users often requires the health

professional to apply a more structured approach to manage prescribing (McKeown et al.,

2003) and a more patient-centred approach to the treatment of the overriding addiction

(Mohr et al., 2012). Hines & Douglas (2012) link drug use with stigma. In addition, this

stigma varies in terms of gender and is generally higher for women than men. According

to Finnegan and Kaltenbach (1992), women who continue to use drugs during pregnancy

are often seen as irresponsible and uncaring. Buckley, Razaghi & Haber (2013) echo this

view, highlighting that stigma is more pronounced for pregnant women. Women’s fear of

losing their baby to social workers and the negative effects of these drugs on the baby may

also cause increased anxiety and guilt on the part of mothers. This, according to Razaghi &

Haber (2013), exacerbates the stigma associated with the use of methadone. It is well

documented that stigma and judgemental attitudes are barriers for substance misusing

17

women accessing antenatal care (Radcliffe, 2011). Health-related stigma, according to

Livingston, Milne, Fang & Amari (2012), describes a socio-cultural process in which

social groups are devalued, rejected and excluded on the basis of a socially discredited

health condition. Livingston et al. (2012) suggest that stigma can manifest at self, social

and structural levels. Self-stigma, according to Livingston et al. (2012), is a process that is

characterised by negative feelings about self, resulting from an individual's experiences,

perceptions, or anticipation of negative social reactions on the basis of a stigmatised social

status or health condition. Social stigma, according to Livingston et al. (2012), involves

endorsing stereotypes about a stigmatised group, such as pregnant drug users. Structural

stigma refers to the rules, policies and procedures of institutions that restrict the rights and

opportunities of a stigmatised group (Livingston et al., 2012). Maternity staff can both

counter and perpetuate the stigma associated with drug use and motherhood, according to

Radcliffe (2011). In general, women of all ethnicities are reluctant to seek drug treatment

because of the social shame that substance use elicits (Greenfold and Gretta, 2009).

Radcliffe (2011) highlighted that so much is expected of mothers on methadone. They are

required to keep multiple appointments and, if one is missed, they are deemed unable to

cope by healthcare professionals. According to Greenfold and Gretta (2009: 881), ‘the

stigma attached to substance use among women which melds negative images of women’s

sexuality and their fitness as mothers, accompanied by social and familial ostracism’ is

often cited as a reason that women do not seek treatment. Alexander (2013) suggests that

sociological models, such as methadone maintenance treatment (MMT), are effective and

have the potential to eliminate the fear of social worker involvement and criminal

retribution and the accompanying alienation that drug users may feel. Social models have

the capability of decreasing stress and creating room for support. Understanding the

upstream factors that lead to the behaviour of abusing drugs can enhance the effectiveness

18

of health professionals who aim to affect change in their patient population (Greenfold and

Gretta, 2009). According to Radcliffe (2011), there is ‘intense disapproval evident in

popular discourse towards pregnant and postpartum women who may be harming or have

harmed their unborn child as a result of their drug use’. Stigma is well documented as a

barrier for these women in accessing care. It is essential that the ‘discourse involved in

caring for these women and how it is deployed by staff’ is taken seriously, according

Radcliffe (2011).

1.10 Views of Services

There is a dearth of research exploring opioid dependant pregnant women’s views and

experiences of maternity and addiction services. Much of the existing literature is

concerned with exploring the views of healthcare professionals caring for neonates and

their substance using mothers. Pregnant women receiving treatment for opioid

dependence have worthwhile and informative views which health professionals should

listen to, according to Varty (2014). Assumptions should not be made regarding these

women’s circumstances or needs. This recent qualitative study by Varty (2014) in

Scotland found that pregnant women on heroin substitute medication want to do the best

for their babies, and this can be a motivating factor in seeking treatment. However, feelings

of guilt, shame and embarrassment are prohibitive to seeking help and engaging with care,

and the supervised consumption of methadone whilst pregnant often causes embarrassment

and discomfort (Varty, 2014). Radcliffe (2011) highlights how these women

attending antenatal services are reliant on staff to have their identities as mothers

endorsed and it is essential that these women are viewed as ‘worthy of

motherhood’. Rosenbaum’s (1982) study involved interviewing 100 women using drugs

on the experience they undergo when trying to access the treatment for heroin-dependence.

19

The study is nearly 30 years old, but provides an interesting and informative view of drug

use from a woman’s perspective. This qualitative study highlighted how the areas of

importance to these women are parenting, health concerns, and the ‘chaos’ of their lives.

The findings of Cleveland & Bonugli’s (2014) study of NAS in an intensive care unit in

the United States of America also provides a clearer understanding of the experience of

mothers with addiction problems. This qualitative study, on mothers of babies with NAS

and their experiences of a neonatal intensive care unit, highlighted a lack of understanding

of addiction from the nurses and subsequently the mothers felt judged, which interfered

with their ability to trust the nurses (Cleveland & Bonugli, 2014). A UK report from the

National Collaborating Centre for women’s and children’s health stated that ‘women with

a substance misuse problem value staff consistency, non-judgemental attitudes,

reassurance about confidentiality in relation to child protection issues, a high level of

support in terms of visits and time given at appointments’ (2010: 56). Much is written

about the medical and clinical care for substance misuse in pregnancy, however, health

professionals should be trained to understand the emotional and social needs of these

women (Radcliffe, 2011).

Arunogir (2013) highlights how the pregnancy period can be an opportune time for

affecting behavioural change in women who use drugs. Addressing drug abuse during

pregnancy requires the input of an interdisciplinary health care team that is non-

judgmental and provides a comprehensive care package (Chan & Moriarty, 2010). The

problem of drug use in pregnancy is a health concern best addressed through education,

prevention and community-based treatments, according to ACOG (2014). Research shows

that whether or not pregnant women can stop their drug use, attending prenatal care,

staying connected to the healthcare system and being able to speak openly with their

20

physician about their addiction issues helps improve birth outcomes (ACOG, 2014).

Further and ongoing training is essential for healthcare professionals to increase their

awareness of the issues these mothers face both socially and medically.

Conclusion

Pregnancy can be an opportune time for effecting behavioural change in women who use

drugs (Arunogir, 2013). Methadone maintenance is the first line treatment for opioid

dependence in pregnancy. MMT is beneficial in promoting engagement with antenatal care

and achieving stability for the pregnant woman. The most significant negative effect of the

use of methadone is neonatal abstinence syndrome (NAS). NAS is an expected and

treatable condition that follows prenatal exposure to opioids, most commonly heroin or

methadone. Substance users are universally unpopular with the public and health

professionals. Pregnant women who use substances are even more unpopular. There is

substantial literature on the negative perceptions about women who are drug dependent

and, in particular, those who are dependent and pregnant. Stigma is a reality for many of

these women and impedes their care. Much is written about medical and clinical care for

substance misuse in pregnancy, however, health professionals should be trained to

understand the emotional and social needs of these women (Radcliffe, 2011). There is a

dearth of qualitative literature on the views and experiences of opioid dependant pregnant

women. Therefore, through exploring the experiences and views of pregnant women on

methadone maintenance, this study aims to address the gap in the literature. The following

chapter will discuss the research methodology of this study.

21

Chapter 2: Research Methodology

Introduction

As stated in the introduction, this thesis is concerned with exploring the views and

experiences of pregnant women on methadone maintenance treatment (MMT) and any

concerns they may have about the pregnancy or birth of their child. This chapter provides

an overview of the research design, methods of data collection and data analysis

procedures. The aims of the study are first outlined and then followed by a detailed

discussion of the phenomenological approach adopted. The ethical considerations that

arose during the design and conduct of the research are also discussed.

2.1 Aim of the Study

This research is qualitative and set out with the following aims:

To explore women’s experiences of pregnancy while on methadone maintenance

treatment and any associated concerns about the pregnancy or birth of their child.

To understand the factors and experiences that influence women’s decision making

about methadone maintenance treatment during pregnancy

To explore women’s understanding and perspectives on Neonatal Abstinence

Syndrome (NAS).

From a patient safety and health promotion perspective, it is important to explore the views

of pregnant women on methadone maintenance treatment and to understand their

perceptions of the risks of NAS. Methadone is the first-line treatment for the management

of opioid-dependent pregnant women, as recommended by the HSE Clinical Practice

22

Guideline on Methadone Prescribing and Administration in Pregnancy (2013). Withdrawal

from opioids can cause fetal death and preterm delivery (Jones et al., 2005; Cleary et al.,

2012). In spite of the evidence supporting the use of methadone during pregnancy, there is

evidence that women would rather reduce or detoxify from methadone during their

pregnancies (Chan and Moriarty, 2010; Jones et al., 2012). This study aimed to explore

pregnant women’s experiences of methadone maintenance treatment during pregnancy. It

is hoped that the findings will be used to help inform health promotion practices aimed at

reducing the risk of relapse among opiate-dependent pregnant women. The research will

also have the potential to inform the advice and information given to pregnant women who

are receiving methadone maintenance treatment.

2.2 The Research Design

2.2.1 Qualitative Research Approach

This qualitative study is informed by phenomenological approach. According to Bryman

(2008: 366), ‘[q]ualitative research is a research strategy that usually emphasises words

rather than quantification in the collection and analysis of data’. Research using a

phenomenological approach describes the meaning for individuals of their lived

experiences of an issue or concept (Denzin, 1989). As defined by Creswell (2009: 13),

‘phenomenology is a research strategy of inquiry in which the researcher identifies the

essence of human experiences about a phenomenon as described by participants’. This

methodological approach was deemed most appropriate, as the research sought to explore

the both the views and lived experiences of pregnant women on MMT in terms of

maternity and addiction services, daily life and social experiences. Alternative research

methods such as quantitative research could not adequately address the proposed research

questions since quantitative research is concerned more with testing theories and

23

relationships between variables (Creswell, 2014: 4). A qualitative approach was chosen,

as it had the ability to gain a clearer understanding of how opiate dependent women

experience pregnancy and what they do, and how they feel, about methadone maintenance

during pregnancy.

As described by Moustakas (1994: 58), ‘[p]henomenology seeks meanings from

appearances and arrives at essences through intuition and reflection on conscious acts of

experience, leading to ideas, concepts judgments, and understandings’. As such, this

phenomenological study sought to explore women’s experiences and perspectives on

MMT in pregnancy and to gain an understanding of any concerns about Neonatal

Abstinence Syndrome (NAS) that they may have experienced throughout their pregnancy.

The project also aimed to examine women’s decision-making regarding drug and

methadone use during pregnancy. The author utilised qualitative research in the form of

semi-structured interviews in order to gain an understanding of pregnant women’s

experiences of being on methadone while pregnant.

2.2.2 Phenomenology

A phenomenological research design provides an understanding of the themes and patterns

portrayed by the study’s participants. The participants in the study were asked open ended

interview questions so that their specific experiences could be identified and explored.

According to Moustakas (1994: 13), ‘[t]he empirical phenomenological approach involves

a return to experience in order to obtain comprehensive descriptions that provide the basis

for a reflective structural analysis that portrays the essences of the experience’. As

Groenewald (2004: 5) puts it,

[t]he operative word in phenomenological research is described. The aim

of the researcher is to describe as accurately as possible the phenomenon,

24

refraining from any pre-given framework, but remaining true to the facts.

The phenomenologist is concerned with understanding social and

psychological phenomena from the perspectives of people involved.

Phenomenology was standardised as a phenomenological research methodology by

Moustakas (1994), and then modified by van Kaam (1995), as a method that involves

understanding the essence, meaning, and structure of an individual’s lived experiences.

This methodology is used to search for patterns and trends by identifying shared beliefs

that have yet to be addressed by existing literature (Lin, 2013). This study, as stated earlier,

focuses on the lived experiences of pregnant women who are on methadone maintenance

treatment in order to understand the factors and experiences that influence women’s

decision making about methadone maintenance treatment during pregnancy. There is a

dearth of research exploring pregnant women’s views and experiences of maternity and

addiction services.

Phenomenology is a recommended methodology when the study goals are to understand

the meanings of human experiences or to explore concepts from new and fresh

perspectives (Lin, 2013: 469). Phenomenology is a reflective analysis of life-world

experiences (Moustakas, 1994). Phenomenological methodologies allows researchers to

reveal the “essence of things” and provides insights into social phenomenon. As a

philosophy, phenomenology concerns the phenomenon of human consciousness

(Moustakas, 1994). As a scientific research methodology, phenomenological research

focuses on the meanings of human experiences in situations as they spontaneously occur in

the course of daily life such as the experience of being on methadone maintenance

treatment while pregnant. A phenomenon can be an emotion, relationship or an entity.

Phenomenology seeks to expose the implicit structure and meaning of such experiences; it

is the search for ‘the essence of things’ that cannot be revealed by ordinary observation

25

(Moustakas, 1994: 5). Phenomenology research that aims to reveal “what it means to be

human” and also helps professionals to develop sensitivity and empathy, to understand

what it is like for these women to be on methadone maintenance while pregnant and their

experiences of addiction and maternity services.

2.2.3 The Qualitative Interview

Interviews are one of the main methods of data collection in qualitative research and can

be unstructured or structured (Creswell, 2003). The interviews in this study are semi-

structured and follow an interview schedule of fairly specific topics and questions (see

Appendix 3). Semi-structured interviews allow flexibility so that questions do not have to

be asked in the same way or order, thereby providing interviewees with the freedom to

answer the questions in their own time and (Creswell, 2003). Interviewing is utilisied when

we want to know something about what another person has to say about her or his

experience of a defining event, person, idea, or thing.

We choose the interview because we know that the best way to get into the

lived experience of a person who has experienced an important health-

related issue is to enable the person to narrate that experience. We are

interested in the person’s cognition, emotion, and behavior as a unifying

whole rather than as independent parts to be researched separately

(Nunkoosing, 2005: 699).

The interview invites and persuades individuals to think and to talk, that is, to discourse

their needs, wants, expectations, experiences, and understandings at both the conscious and

unconscious levels (Nunkoosing, 2005: 699). At the root of phenomenology, ‘the intent is

to understand the phenomena in their own terms to provide a description of human

experience as it is experienced by the person allowing the essence to emerge’ (Cameron,

Schaffer & Hyeon-Ae, 2001: 34). This research method fits well with the intent of the

current study, which is to understand the current and previous experiences of pregnancy

26

and birth while on methadone, their understanding, experience and concerns about NAS,

and the factors and consideration that influence women’s decision-making regarding drug

and methadone use during pregnancy.

2.3 Data Collection

2.3.1 The Sample

In phenomenology, samples sizes typically range between three and ten (Creswell, 2014).

In the case of this study, eight individuals were interviewed. This is the recommended

sample size for in-depth qualitative studies using a phenomenological approach (DeVaus,

2013). Purposive sampling was used to recruit women for participation in the research.

Purposive sampling is a non-probability form of sampling, according to Bryman (2008).

The researcher does not seek to sample research participants on a random basis. The goal

of purposive sampling is to sample participants in a strategic way, so that those sampled

are relevant to the research questions that are being posed, according to (Bryman, 2008:

415). This study recruited women from a specialised antenatal clinic (DOVE clinic)1 that

cares for opiate-dependent pregnant women and women at risk of viral exposure in the

Rotunda Hospital, which is located in Dublin’s city centre. After written informed consent

was obtained, in-depth interviews were conducted with eight pregnant women attending

The DOVE Clinic at the Rotunda Hospital, who were at different stages of pregnancy

(1st,2

nd and 3

rd trimesters).

The eligibility criteria for this study included:

Pregnant and on methadone maintenance treatment;

Attending the DOVE clinic;

1 DOVE stands for Danger of Viral Exposure

27

Over the age of 18 years; and

Have a good understanding of spoken English

As stated above, efforts were made to include women who were at different stages in

their pregnancies.

Exclusion criteria for research participants included:

Pregnant women under 18.

Pregnant women deemed unable to provide informed consent.

Pregnant women deemed unsuitable to participate by the Drug Liaison

Midwife or Consultant Obstetrician.

Women were deemed unsuitable to participate if they presented under the influence of

substances or had ongoing social, emotional or health issues.

2.3.2 Access and Recruitment

As stated, this study recruited women from a specialised antenatal clinic (DOVE Clinic)

that cares for opiate-dependent pregnant women in the Rotunda Hospital. Women

attending this clinic were informed about the study by the drug liaison midwife (DLM) or

clinic staff on the day of their ante-natal appointment and they were provided with a

patient information leaflet (see Appendix 1). The aims of the study were verbally

explained to women who might be interested in participating by the researcher. If

interested and willing to consider participating, women were asked by DLM if they could

take part in the interview on the day of their next appointment date or at a time convenient

to them. Women were given a period of approximately two weeks to make a decision

about participation. In other words, prospective participants were not required to make a

28

decision during the first meeting with the researcher. It was made clear that a decision not

to participate would not adversely affect their health care treatment in any sense. Once

they confirmed that they understood the purpose of the research, and agreed to participate,

all participating women were asked to sign a consent form. After written informed consent

was obtained, the interviews were conducted. The interviews were conducted in a

consultation room in the DOVE clinic and lasted between 45 minutes and one hour. The

interviews took place during clinic times, therefore, the midwives and consultant were

onsite at the time of every interview. The researcher encountered no recruitment issues. All

women that were approached agreed to participate, which gives a strong indication that

they wanted their voices heard on the topic under study.

2.3.3 The Semi-structured Interview

The interviews in this study were semi-structured which followed an interview schedule

of fairly specific topics and questions (See Appendix 2). Semi-structured interviewing

allowed flexibility so that questions did not have to be asked in the same way or order,

thereby providing interviewees with the freedom to answer the questions how they so

wished (Creswell, 2003). Care was taken to ensure that the interviews were conducted in

a non-judgmental manner and with respect for all individuals, their privacy and welfare.

Participants reserved the right to terminate the interview at any time or to decline to

respond to specific questions. This was made explicit by the researcher prior to the

interview commencing and again when they gave formal written consent to participate.

They were also made aware that the interviews were recorded. Based on the aims and

objectives of the study, the main topics chosen were childhood and significant

relationships, drug history, methadone maintenance treatment, previous and current

pregnancies and their views of services. Most of the women spoke honestly and openly.

29

Some participants spoke at ease about their childhood, while others were more closed and

eager to move on to the next question. One participant was quite closed with her

responses and reluctant to talk about her addiction history. Two women had previous

babies that were stillborn. This was obviously very upsetting for them to talk about. The

researcher offered to stop the interviews but both participants insisted on continuing.

2.4 Data Management

2.4.1 Storage and Confidentiality

Assurances of anonymity and confidentiality were given to participants. To ensure

confidentiality, the recordings were stored securely in a locked cabinet at The Rotunda

Hospital. All transcribing took place in the hospital. To ensure anonymity, all identifying

information such as place names, children’s names and clinic names were removed from

the transcripts. Participants were assigned pseudonyms for use in writing up the findings.

No personal information appeared on any research instruments. The signed consent forms

were stored separately. The recordings will be destroyed after the dissertation is examined.

The transcripts will be stored for two years.

2.4.2 Data Analysis

The philosophy and theory underpinning a phenomenological approach were discussed in

the previous section 2.2.2. The practical application of the method used during the data

analysis will now be described according to the procedures outlined by Kleiman (2004).

Data analysis process is a way to discover ‘patterns, coherent themes, meaningful

categories, and new ideas and in general uncovers better understanding of a phenomenon

or process’ (Suter, 2006: 327). Neuman (2003) described the process of data analysis as a

30

means of looking for patterns to explain the goal of the studied phenomena. In

phenomenology, existing methodological guidance is often conceptual and abstract. There

are few procedural instructions on how to code and interpret the data. Therefore, according

to Lin (2013), novice researchers are often required to use other qualitative methodologies

to guide their decision making. The phenomenological analysis involved such processes as

coding, categorising and making sense of the essential meanings of the phenomenon

(Kleiman, 2004). As the researcher worked with the rich descriptive data, common themes

or essences began to emerge. The initial stage of analysis involved total immersion for as

long as was needed in order to ensure both a pure and a thorough description of the

phenomenon (Kleiman, 2004).

A code in qualitative inquiry is a word or short phrase that symbolically assigns a

summative, salient, essence-capturing, and/or evocative attribute for a portion of language-

based data. The structure of phenomena is the major finding of any descriptive

phenomenological inquiry. This structure is based upon the essential meanings that are

present in the descriptions of the participants and is determined both by analysis (as

detailed below), and also by the researcher’s (intuitive) insights (Kleiman, 2004). An

overview of how the analysis was conducted is outlined below, as described by Kleiman

(2004).

The transcripts were read in their entirety in order to get a global sense of the

whole.

The transcripts were read a second time in order to divide the data into meaningful

sections or categories.

The categories that were identified as having a similar focus or content, were

integrated to make sense of them.

31

Descriptions of essential meanings were discovered from these categories. This

process is known as ‘free imaginative variation’, according to Kleiman (2004).

The raw data was revisited in order to justify the researcher’s interpretations of

both the essential meanings and the general structure. This process was essential to

substantiate the accuracy of all the findings by reference to the raw data (Kleiman,

2004).

In the final description of pregnant women’s experience of methadone maintenance

treatment and the health services they attended, all of the phenomenological themes

from each interview were combined and, from these, general and unique themes

were extracted.

The advantage of this approach was that it provided strong themes. The next chapter

describes these themes in detail.

2.5 Ethical Issues and Considerations

Before commencing this study, ethical approval was sought from The Rotunda Hospital’s

Ethics Committee and the Department of Social Work and Social Policy Research Ethics

Committee. Approval was granted from both ethics committees in May 2015 and

fieldwork was completed between June 10th

and June 30th

2015.

Conducting the study during clinic times meant that if a participant became upset or

distressed, the Drug Liaison Midwife or Consultant Obstetrician could be informed and the

participant would be seen immediately.

All participants were given a detailed Patient Information Leaflet (see Appendix 3), with a

written and verbal account of the nature and aims of the study.

The conduct of research on any form of licit or illict drug use during pregnancy is

32

highly sensitive (Alexander, 2014). Women who are receiving methadone treatment

during pregancy might be said to be a particularly stigmatised group and many can

experience feelings of guilt and shame related to their drug use and about potential

harms to their unborn baby (Radcliffe, 2011). There was no physical risk to any

participant in this study. However, due to the sensitive nature of the research topic, there

was a risk that some participants may experience emotional stress. If the participant

disclosed any information that could potentially harm the fetus, herself, or another

person, the researcher informed the appropriate clinical staff, in line with The Rotunda

Hospital’s Child Protection Policy and Children First guidelines (Department of

Children and Youth Affairs, 2011) .This was made explicit by the researcher prior to the

interview and again when they gave formal written consent to participate. One

participant disclosed an incident of sexual abuse when she was a child. This disclosure

was reported to the Drug Liaison Midwife who confirmed that the clinical team and

social workers were aware of this incident, in line with child protection policies.

2.6 Limitations

As this research was a small-scale study, the findings are not generalisable to all pregnant

women on methadone maintenance treatment. However, the research did ensure that the

sample was varied in terms of age, pregnancy trimester and length of time on methadone.

The fieldwork took place in The DOVE clinic at Rotunda Hospital, where all participants

are cared for. There is a possibility that they may have been less open or less inclined to

provide information that they felt would meet disapproval from the clinic staff. However,

as stated previously the women were very open during the interviews.

33

Conclusion

This chapter provided a detailed account of the study’s methodological approach and has

outlined the processes associated with the recruitment of participants and the conduct of

the interviews. It has also discussed the ethical considerations and limitations of the study.

34

Chapter 3: Findings

Introduction

As outlined in the previous chapter, this study aimed to explore pregnant women’s

experiences of methadone treatment during pregnancy. The in-depth interviews produced

rich narrative data on the nature of the phenomena under study. This chapter presents the

research findings. First, a profile of the eight women who participated in the research is

presented. The focus then turns to the women’s accounts of their childhood experiences

and their drug using histories. Following this, findings detailing participants’ experience of

being on methadone during pregnancy will be described according to the themes that

emerged from the data, including:

i) the lesser of two evils;

ii) fear and guilt;

iii) Stigma and shame;

iv) influence through support, encouragement and control; and

v) pregnancy provides second chances.

Lastly, the views of the participants on the services they received are presented.

3.1 Sample Profile

As stated in the previous chapter, eight women were interviewed for the purpose of the

study. Participants ranged in age from 28 to 39 years (average age 32 years). One woman

was in the first trimester of her pregnancy at the time of interview, while two were in the

second, with five in the third trimester of pregnancy.

35

Six of the women had grown up (and currently lived) in an inner-city or disadvantaged

area of Dublin city (in localities known historically for concentrated drug use problems).

One woman was from an affluent Dublin suburb and one was from the travelling

community and lived outside of Dublin.

Seven of the eight women reported previous pregnancies and all were in a relationship

with the father from their current pregnancy at the time of interview. Of those who had

previous pregnancies, five had children from different relationships. Two of the eight

women reported previous stillbirths, which they described as unrelated to their drug use

and three had experienced miscarriage in the past.

Five of the mothers had children that were in care at time of interview. For those mothers

who had children in care, three stated that their children were being cared for by family

members. Two stated their children were in state care. The women that stated their

children were in state care had weekly supervised visits. These visits were supervised by a

social worker. All stated drug use as a reason why their children were not in their care.

Six of the women currently lived in local authority housing; one woman had been living in

homeless B&B accommodation for eight months at the time of interview and the final

participant was living in private rented accommodation. Seven of the respondents were

unemployed and in receipt of social welfare payments and one was working fulltime. All

eight of the women described this pregnancy as ‘unplanned’ and two stated that they

thought that they could not become pregnant because of their drug using histories.

I actually thought that, that I was after doing that many drugs over the years, I

thought that I couldn’t have any more kids until now (Lily).

36

The duration of the women’s methadone use ranged from five months to twenty years and

amount of methadone each woman was taking ranged from 26-120 mgs daily. Two of the

women had no history of heroin use: one had commenced methadone maintenance

treatment (MMT) for a codeine addiction and, the other, because they were methadone

dependent. Seven of eight respondents had been on MMT prior to becoming pregnant,

while one commenced MMT after she became pregnant and had experienced some

difficulty in accessing treatment. This woman reported that she had been told by a Doctor

in the hospital outside Dublin that they could not help her. She then travelled to Dublin for

treatment. Six received methadone from an addiction clinic and two from their GPs. Three

were in receipt of take home doses which meant they were not required to attend a clinic or

pharmacy daily to consume their methadone dose under supervision.

3.2 Background

In order to provide a fuller context for a detailed exploration of the women’s experiences

of MMT, this section examines their childhood experiences and drug use histories.

3.2.1 The Women’s Childhood Experiences

Five of the women stated that they had experienced one or more of the following

adversities during childhood: parental alcohol abuse, child sexual abuse, early childhood

bereavement and/or the relationship breakdown of their parents. Practically all of these

women attributed their drug use initiation and progression to ‘heavy’ or dependent drug

use to these difficult or traumatic childhood experiences.

‘When me da died it was like me whole world ended. Then I ended up on

drugs’ (Lily)

‘…I’d be put to bed by my grandmother cause my mother would be in the

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pub, most nights (Joan)

‘Eh, I was abused for a while. Well for years actually at home ... My

mother was good, and so was my father …he was a good father but a dirty

man. He done a lot of wrong and there was a lot of conflict because my

mother didn’t want to accept that’ (Serena)

Others described ‘happy’ and ‘normal’ childhoods, stating that they ‘never wanted for

anything’ in terms of material possessions, and some suggesting they were ‘spoiled’. Three

of the participants were the only child in their family.

‘So, it would have been normal in the sense that I never needed anything’

(Tina, aged 28)

‘I am an only child, I had a great, very good upbringing… actually I was

spoiled an awful lot’ (Joan)

Three respondents had completed their Leaving Certificate, two left school after

completing their Junior Certificate examinations and two respondents left school without

completing any formal state examinations. While almost all reported liking school and

doing well, there was a sense that they wanted to grow up fast, start working, and earning

money.

And then secondary school although I loved it and wanted to stay in I had

relatives and friends going to work and they were passing every Friday…

with their shopping clothes bags waving or whatever, they were getting 30

something pound at the time, and they were making me jealous so I

dropped out (Serena )

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3.3 Drug Use History

Almost all of the women began using drugs during their early teenage years and the most

common drugs of initiation were cannabis and ecstasy. All had also started to consume

alcohol during their early teens, usually prior to experimenting with a drug for the first

time. Many of the women also described themselves as ‘curious’ and ‘rebellious’ as

teenagers and they frequently stated that older peers had influenced their early

experimentation with drugs.

‘… it’s a lot to do with the company you keep as well in school growing up

like you know you have different types of friends and acquaintances... I

would do what they were doing, which was smoke hash, cannabis or you

know, take tablets whatever’ (Shauna).

Four of the women first used heroin during their teens and two were in their early twenties

when they were introduced to the drug (as stated previously, two of the women were not

heroin users). There was a strong sense of naivety and innocence from the women’s

accounts of first heroin use, with two respondents stating they thought heroin was ‘liquid

cannabis’ when they tried it first. Some explained that it was ‘too late’ when they realised

the seriousness of their heroin use dependency. When describing heroin use initiation,

almost all stated that they had been influenced negatively by a romantic partner and some

explained that they first used heroin because they wanted to understand their partner’s

addiction.

‘So I tried it, but I didn’t like it, but it was half to understand him, but I

didn’t like it’ (Serena)

‘He was upstairs with tinfoil and like smoking heroin, and I wanted to

know what was the big buzz he was getting out of this’ (Denise)

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Denise was unusual in that she had first used heroin after the birth of her first baby to help

her lose weight.

‘So when I got these jeans out when I had the baby I got very depressed

cause obviously I couldn’t fit into them, so I thought he’s still using, I’ll

use a bit of that and I’ll lose a bit of weight and I’ll be grand like, but it

didn’t work like that’ (Denise)

A considerable number of the women told that their drug use had escalated after they first

attended a drug treatment setting. They described meeting other drug users in these

settings and being introduced to other substances, including benzodiazepines and crack

cocaine.

‘They [community workers] sent me into town, to [clinic name] and I

ended up meeting all sorts of people and then if heroin turned into crack

and then, awh, I was on everything, I was on tablets’ (Lily).

‘I started on [Clinic name] and when I started on [clinic name], things

actually got worse. Because I never was a city centre girl, I never went into

the city. Because I had to go in every day, I seen different people and like

that again, the company I kept in the town going for a cup of tea, and stuff

like that, after you get your methadone, out popped the pills. So I’d to try

a couple and it went from there’ (Shauna)

Fiona, whose primary substance of misuse was methadone, told that she had smoked

heroin just to get into treatment as she was required to provide opiate positive urine

samples to be eligible for a place on a methadone treatment programme

‘I did smoke it twice, to actually help me go to a methadone programme, I

had to kinda, ye know’ (Fiona).

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Joan explained that she had developed an addiction to codeine that was prescribed to her

on a long-term basis for back pain and she subsequently needed methadone as a

substitution treatment.

‘What happened was- even though I’m on methadone I never had a heroin

addiction- I had a codeine and morphine addiction- cause after [first

child] I had back pain and the muscles in my back were very weak and I

was prescribed distalgesic and df118’s-strong pain killers and oromorph-

and I got addicted and the substitute for them is methadone’ (Joan).

As stated earlier, six of the women attended a methadone clinic to consume their

methadone under supervision, while others (two in total) were prescribed methadone by

their own G.P and had it dispensed from a local pharmacy. Two respondents were in

receipt of ‘takeaway’ prescriptions, which meant they were only required to attend twice

weekly for their methadone prescriptions. Six were required to attend a treatment clinics

either daily or three times per week to consume their methadone under the supervision of

the clinic staff.

To summarise, although many of the women interviewed were keen to point out that they

had happy or ‘normal’ childhoods, accounts of experiences of trauma, neglect or abuse, as

well as a family history of addiction, were present in most of their narratives of childhood.

The influence of peers, and particularly of romantic partners, was strong in many accounts

of early drug use and heroin use initiation. Interestingly, for some, opioids as treatment or

accessing treatment appeared to exacerbate their drug use dependence, at least initially.

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3.4 Experiences of Pregnancy on Methadone

Women were asked about experience on methadone during pregnancy, about the dose and

what they felt about the dose they were on. During the interview, they were asked about

their drug use during pregnancy, their concerns about taking methadone while pregnant

and about their supports and influences.

3.4.1 The Lesser of Two Evils

In the main, respondents indicated that they did not like taking methadone during

pregnancy. Most had experienced nausea, vomiting and constipation and those women on

higher doses of methadone complained about the difficulties consuming it. A number

described methadone as something they ‘have to take’ or as ‘poison’ and many expressed

concern about the potential effects on their unborn babies. Methadone use during

pregnancy was not their only concern; most stated that they believed that methadone had a

long-term negative effect on their own bodies, that it damaged ‘their bones’.

Most of the women appeared to resent the control they felt methadone exerted over their

lives, often because they could not feel ‘normal’ without it. These women were very aware

of the effects of withdrawal and did not want to risk their babies to experience these

symptoms. The maternal instinct to protect ones unborn meant they were had to accept

taking the drug during pregnancy. A sense of remorse was strong in a number of the

interviews; the loss of ‘what would have been’, as described by Joan, who stated that she

would do things differently if she could turn back time. Joan described feeling ‘terrified’

about what might happen to her baby as a result of her taking methadone during

pregnancy.

‘It (methadone) controls your life, you have to attend every day like, and if

you don’t take it you’re not normal. Emm, the withdrawals from it are

horrible and that’s the terrifying part, your baby is going to feel that way,

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you know … and I don’t want her to go through anything like that. If I feel

like she’s sick in any way, I’ll be the first one to put me hand up and say, ‘I

don’t want her to feel anything’, cause it’s not nice, it’s horrible’ (Joan)

While the women did not like having to take methadone, they also recognized the benefits.

For example, most stated that methadone had helped them achieve stability, improved their

personal and family relationships and, most importantly, it vastly improved the possibility

of keeping their babies in their care. There was in fact a sense of a reluctant acceptance to

being on methadone maintenance on the part of all of the women interviewed. Methadone

was viewed by them as a necessity, and preferable to the alternative, which the women

accepted would be illicit drug use. For the sake of their unborn children, they felt they had

no choice. It was the lesser of two evils.

‘Well I suppose it’s the lesser of two evils, I don’t know’ (Tina)

‘Well like, at the moment, it’s a thing that I have to take, I have to take it, I

really wish I didn’t have to’ (Joan)

3.4.2 The Dose: Less is Better

There appeared to be a conflicting relationship between the women’s understanding of

their need for an increase in their methadone dose and their desire to keep the dose as low

as possible. This conflict paralleled the ‘lesser of two evils’ theme described above. Again,

their desire and instinct to do what would be best for the baby prompted a desire keep the

dose as low as possible among some.

‘Well I’ve had the option of going up (referring to the dose) when I got

pregnant, but I chose not to, I didn’t wanna, ye know … make the situation

worse for me or the baby so … I just stuck at the ninety mls’ (Fiona)

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This conflict between understanding and instinct regarding dose was also apparent with

regard to NAS. Most appeared to understand that their baby may or may not have NAS

when born, irrespective of dose. Joan misunderstood that the risk of NAS was related to

how ‘controlled’ or stable she was.

‘And this time now, I’m on 80mls and I’m being good. I realise it’s not the

amount of methadone you are on, it’s how controlled you are, it’s maybe

your baby will be sick, maybe not’ (Joan)

Nevertheless, some expressed a desire to lower their dose of methadone in order to

decrease the likelihood of NAS.

‘Emm, I worry that the effects it might have when he’s born, I would like to

come down a bit. I’m on 35mls, and I feel like for me to come down now, I

feel my body would be able to come down, but they’re eh, they don’t want

to in case it puts the baby in any sort of, you know, position. Now that’s not

saying the baby will be you know, sick. I’m told, the likelihood is 50-50’

(Serena)

Although most of the women appeared to understand the need to increase methadone

intake during pregnancy, in the main, they expressed discomfort about this ‘reality’. Detox

and dose reduction were seen as desirable, while increases in dose and being on MMT

were reluctantly seen as necessary but also as undesirable. Women simultaneously

described “having” to “up” the dose and “hoping” or ‘wanting’ to reduce their methadone

intake.

‘When I had my third child I detoxed myself down to 20mls. And I got

pregnant again fairly quickly, and I was fine like- I had a baby 9 months

ago like I said, I had to go up 10mls, 5 and 5 … I was hoping to reduce

after he was born , like he wasn’t sick…. Emm, I had to go up 10mls, like

that too, he was four months and I was pregnant again, so I didn’t have a

chance. Only last week I had to go up another 5mls, so now I’m up to

35mls’ (Denise)

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Those who had previously been on a low dose, or who were in the process of detoxing

prior to pregnancy, viewed the increase in their methadone intake during pregnancy as a

setback, since it would mean having to be on methadone longer because it would take

more time to achieve a reduction from this higher dose. Some women were keen to point

out that they had previously been progressing towards “coming off” methadone and were

therefore being good mothers by increasing the dose for the baby’s sake.

‘So the only thing I take at the moment is methadone. I was doing a detox

but then I fell pregnant, so obviously for the sake of the baby I decided I’d

stick with it and I can finish the detox when I have the baby, just to keep

him safe’ (Tina)

The need to increase their dose during pregnancy was seen by women as reducing the

likelihood of withdrawals for both mother and child, which increased during pregnancy.

Respondents described the withdrawal effects during pregnancy as more severe than those

they experienced when they were not pregnant. In one woman’s words, ‘the sickness was

double’. Another woman described needing to go to the clinic as early as possible each day

to avoid withdrawal symptoms.

‘When you’re pregnant and when you’re on methadone, you just feel twice

as sick, ya know. It’s like the sickness is double, double the amount, like, I

don’t know what it does. When you’re pregnant it takes a certain amount

of it, you know that way. When I wake up in the morning if I was to go miss

me clinic and wait till two I’d say I’d probably be all sweaty feeling all, a

bit, cause I was after leaving myself for the couple of extra hours. But

when I wake up in the morning, I don’t, I feel like I got the morning

sickness and all. Yeah I do, like I wouldn’t be able to go until 2 without me

Phy2, I needed to get it in the morning’ (Lily)

2 ‘Phy’ refers to physeptone, a methadone preparation that was prescribed in the eighties.

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Tina spoke of having to have her dose increased because the amount prescribed pre-

pregnancy did not appear to be adequate during pregnancy without experiencing

withdrawal symptoms.

‘Well, that’s what I’m saying, I got down to a very low dose, at one stage I

was only on 25mls- and then your body goes through changes and it’s not

holding you or whatever, you’re putting on weight, it’s a horrible drug to

be on- methadone’ (Tina)

Although they reluctantly accepted MMT, all of the women were keen to point out that

this was temporary. Almost all stated an intention to reduce the dose or detox from

methadone after the birth of their babies. This desire to reduce or stop taking methadone

completely once their baby was born appeared to help women to accept MMT during

pregnancy.

‘… and when I have this baby, obviously I’ll … I’m hoping this is my last

child, and I have to come off it like’ (Denise)

‘So this is my kinda opportunity where, if I had the opportunity, I would go

into treatment and come off the methadone but I was told while you’re

pregnant it’s kinda a bad thing to do. But I would like that when I do have

the baby to start detoxing, do ya know down off it’ (Lily)

While some expressed a desire to detoxify, others who were on methadone long term felt

that their long histories of methadone use meant that it was unlikely that they could easily,

if ever, get off the drug completely. Factored into this view, was that they felt doctors

would be unlikely to agree to detox them. Again, there was a strong sense from the

narratives that power rested primarily in others or in the drug: in the “addiction” and the

“doctor”. Shauna imagined that she would continue to take methadone for the remainder of

her life.

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‘I’m on it so long. I actually imagine I’m going to die on it so it’s going to

be with me all life. I can’t see them (doctors) taking me off methadone now.

Not at going on thirty nine, I’m thirty nine next month. The best part of my

life has been on methadone’ (Shauna).

In general, the women reluctantly accepted the need to be on methadone during pregnancy,

often viewing it as “the lesser of two evils”. Although they were aware of the

physiological need to increase the methadone dose during pregnancy in order to reduce the

risk of withdrawal symptoms, practically all expressed a desire to be on the lowest possible

dose. Plans to detoxify after pregnancy appeared to parallel this reluctant acceptance and

also appeared to give women some sense of personal agency whilst having to accept

something – methadone treatment – that was essentially counter intuitive to them during

pregnancy. Most experienced debilitating side effects such as nausea and constipation and,

although some of the benefits of MMT as an aid to achieving stability were recognized by

the women, being on methadone was perceived as undesirable, particularly so during

pregnancy, but perhaps paradoxically, something that they had to do for the benefit of their

babies.

3.4.3 Feelings of Fear and Guilt

Strong among the range of feelings expressed by the women were anxiety and worry, and

fear and guilt. Above all else, women expressed anxiety about the impact of methadone on

their babies. All were acutely aware of how taking and not taking methadone made them

feel and did not want their baby to go through those experiences. Much anxiety stemmed

from women’s fear about the potential distress that the baby may experience by going into

withdrawal if the mother did not take an adequate dose; correspondingly, by taking

methadone the baby could also experience withdrawal symptoms after birth when the

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supply of methadone was removed. This paradoxical situation appeared to diminish the

control that women felt over their situations. Most expressed feelings of guilt, fearing that

they were causing harm or distress to their babies as unborns. Joan did not want her baby

to feel the way she felt when she went through withdrawals. Her choice of language is

perhaps significant in that she will readily “put her hand up”, or accept blame, if her child

is “sick in any way”.

‘… the withdrawals from it (methadone) are horrible and that’s the

terrifying part; your baby is going to feel that way, you know ... and I don’t

want her to go through anything like that. If I feel like she’s sick in any

way, I’ll be the first one to put me hand up and say, ‘I don’t want her to

feel anything’, cause it’s not nice, it’s horrible … I’m after bringing her

into the world and I’m after making her sick’ (Joan)

Fear of causing harm was associated strongly with the sense of guilt and shame anticipated

if the baby was “sick”, an outcome for which women would hold themselves responsible.

‘It’s something that I’m dreading to be honest [if the baby is sick]. I don’t

want to be responsible for, you know, before he can take a breath he’s

taking drugs, so emm, it shames me’ (Tina)

With no choice but to take their methadone and little control over their dose, some women

tended to employ strategies common to all individuals who find themselves in situations

beyond their control; to alleviate anxiety and fear, they prayed.

‘I prayed every night that he’d (baby) be ok and nothing would go wrong

like. At the time, I didn’t know I was having a boy, I prayed and cried

every night that he’d be ok, and he was thank god’ (Serena).

It seemed that older age and previous experience of methadone during pregnancy did not

reduce the anxiety that women experienced about the pregnancy. Although these women

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had been taking methadone maintenance for many years, they nevertheless experienced

high levels of anxiety which was exacerbated by the fact that they had the added stresses

of caring for other children.

‘Because the last baby I had I thought was going to be me last child, so I

was hoping to come off it. And I didn’t get a chance to reduce or anything

before I found out I was pregnant again, do you know what I mean? And

now I’ve had to go up another 5mls, do you know, and when I started I was

on 20mls and now I’m on 35mls, and I know that over the course of 4 years

but like for me, that fear in the back of my head, just does not leave me and

it’s not going to until I have my baby in my arms’ (Denise)

However, Mary, a multigravida woman, while stating that she was ‘more nervous’ than

during her first pregnancy, appeared to have let go of some of her previous fears and

focused to a greater extent on the more routine and normalised stresses associated with

child birth. This woman felt confident in the care she would receive in hospital and her

main concerns centered on having to stay in the hospital for five days after the birth

because of the challenges this posed for her ability to care for her other children.

‘Well the eldest is going to [school], the youngest is in [ class] and I’m due the

[date], so I’ve schools overlapping the five days I’m going to have to stay in here

(hospital), that’s assuming I last until the date. So that’s what my worries are, it’s

not about the methadone, it’s worried about the kids getting to school, having

uniforms sorted, their books and everything like that,’ cause I know they look after

you in here with everything ... and it’s just outside stresses, kind of just worried,

getting them to school, making sure everything is sorted’ (Mary).

Every aspect of taking methadone daily was of great concern to these women. Those on

higher doses expressed fear and guilt about the effect such high doses could potentially

have on their baby.

‘awh yeah it’s a lot of methadone to be on having a baby, 90mls like, it’s

emm even when I look at it in the cup ya know every morning… where I’m

like god then jaysus is it really this much like. But I just please god I just

pray’ (Lily).

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The internal conflict between the reality of their addiction and the strength of their

maternal instincts placed women in a kind of limbo, where assertive action to deal with

their addiction was not possible and, therefore, their maternal instinct to protect was

challenged. Women’s agency over their addiction was surrendered in favour of ‘doing the

right thing’ for their babies in accordance with the advice of ‘the experts’. Thus, being a

good mother in these circumstances meant that they had to reject their maternal instincts,

at least to some extent. Understandably, this was a challenging predicament which

produced the undesirable effects of worry, fear and guilt.

‘I do feel bad, I kinda feel, eh, like I hope that the baby is alright, you know

that type of way, but just it’s so hard. If I thought that it wouldn’t harm the

baby I would try to come off it (methadone)’ (Lily)

3.4.4 Stigma and Shame

The women frequently described experiences of stigma, often associated with the attitudes

of family members, peers, and healthcare professionals, that led to them feeling

stigmatised. As the pregnancy became more visible, most felt more self-conscious and

feared that others would judge them for taking methadone while pregnant. Tina explained

that fear and paranoia about the views of others prevented her from engaging with people.

She imagined what others might be thinking and admitted that these imagined thoughts are

not dissimilar to her own, suggesting self-stigma.

‘I hated going into the clinic, the stigma attached to it, some people on the

clinic wouldn’t bat an eyelid, but others, the hypocritical personalities

would look at you like, ‘How could you do that your baby is going to be

sick’. For me, I never was happy that I was on methadone, I would have

been paranoid of those kind of feelings and the bigger I got the more self-

conscious I got and I was very closed off, I wouldn’t really talk about my

pregnancy, yeah, it had a huge effect on me’ (Tina)

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Fiona felt she was treated differently and excluded by her peers because she was a

pregnant woman on methadone.

‘Like you can tell by certain people, that they don’t want be around you

and you kind of emm … kind of see a you different, it’s just kind of

discrimination sort of, you know’ (Fiona)

Respondents also described the shame they felt, as well as a perceived need to hide the fact

that they were on methadone from their family members. They worried about what family

members would think and worried that they might judge them or treat them differently. In

general, women felt that their families lacked an understanding about their addiction and

their need to be on methadone maintenance. One respondent worried about how her family

might react if her baby had NAS.

‘They didn’t understand, they did not understand why I was on methadone

… and I was so worried if he was kept in (hospital) what they would say,

how I would I be looked upon’ (Joan).

‘What’s hard for me, eh oh, telling his family about me being on

methadone. Well I don’t have to do, I know. .. And then I feel like then

they’ll be looking at me different and, ya know, cause for the past two and

a half years they never knew’ (Lily).

A perceived lack of understanding about heroin addiction on the part of family members

was strongly apparent. Serena explained that her mother wanted her to ‘get off’ drugs,

without methadone substitution treatment and was of the view that taking methadone

meant she remained in the ‘addiction scene’.

‘My mam she would never have wanted it, she would always say do it

yourself-fight it. Because in the long run, you’re out of the addiction scene

like’ (Serena)

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The shame described by another respondent, Tina, was coupled with a sense that she

should have known better than to become drug dependent. She came from a more

privileged background than other respondents and told that she had wanted more from life.

For her, the shame associated with her past drug use was more pronounced because of

current ‘status’ as a pregnant woman on methadone.

‘It shames me, I was raised better, I should know better. A lot of people on

the streets don’t know any better but because I did, I think that’s why it

hurts me kind of more to see what I’ve become. I always wanted to be a

social worker, I wanted to help the people that I was turning into and it

does, it sickens me. When you know you’re better, it’s a lot harder, to keep

doing the wrong thing as opposed to not really feeling like you deserve any

better, kind of thing’ (Tina)

One respondent referred the DOVE clinic as a ‘methadone clinic’ and not an antenatal

clinic, demonstrating the strong association she had with the clinic and ‘addiction’ as

opposed to with child birth. She expressed concern about other pregnant women knowing

that she was on methadone when she attended antenatal appointments. She was not happy

to have to attend the same clinic as other drug users, who presented under the influence of

drugs and felt that she may be viewed in the same negative light. There was a sense of her

wanting to disassociate herself from others who were ‘addicted’ and to be viewed the same

as any other expectant mother attending the clinic.

‘I don’t like that I’m coming into a methadone clinic (referring to Dove

Clinic in the Rotunda), you know, there’s other girls that come in here

and there, they don’t be in a fit state some of them and , now I can’t judge

anybody, but if other people see me going into the same room as them,

I’d be thinking they know I’m on methadone’ (Denise).

3.4.5 Influences on Women’s Decision Making

During interview, respondents were asked about whom and what influenced their decision

making about methadone treatment during their pregnancy. These women were influenced

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to care for themselves and their unborn baby through three mechanisms: support,

motivation and control.

Most of the women interviewed stated that they were supported by their partners and

families, and health care professionals. One woman was particularly appreciative of her

mother’s support and encouragement and described how she seemed accepting of her need

to be on methadone. Another respondent was positive about the support she received from

the DOVE clinic in terms of information and advice and the manner in which many of her

fears had been alleviated.

To be honest I feel the service here, like if I had any concerns or questions,

I feel confident that I’d get them answered to the best possible, you know, I

leave here, you know, content (Serena).

… she [respondents mother] sees im doing really well and looks past the

methadone end of it for that reason (Lily)

Me husband, and the clinic has been great they have, and here the

hospital, me dad, mam and me aunt is very supportive…I’ve lots of support

(Joan).

By their own admission, many of the women had low self–esteem and lacked confidence

in their abilities to be ‘good’ mothers. For some, the encouragement they received from

peers and family members provided them with the affirmation that they were capable of

being good mothers.

…at first I was like, ‘I can’t do this, a baby are ya mad, no way’. I won’t

be able to look after it, I can hardly look after me self never mind look

after a baby. And they [family members] were like, ‘Come on [name], like,

ya look after, ya do look yourself’, and I’m like ‘No, I don’t, I don’t be up

there. They’re like [NAME] think about it, like ya have nobody and like

yeah you get up in the morning, you go out, you’re never stuck. Like not

that I always have money, not eh that type of way. They’re saying,

‘[name], you don’t really need help, you’re strong enough to do it on your

own. And when I kinda sat down and thought about it I was like jaysus

maybe they’re right, maybe I’m just over thinking things as usual.

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Women who had other children in the care of social services appeared to be motivated to

remain stable in the hope of having their children back in their care and by the desire to

ensure the baby from their current pregnancy remained in their care.

My children, definitely, my kids are my world and the baby. They’re what I

live for, my children are my life and this baby is going to make me the

person I know I am. (Serena).

The narratives revealed a stark lack of agency. The women did not perceive that they had

any right or ability to question their Doctor’s decisions because they risked having their

babies taken from them. These women did not, however, resist this control because it was

for the benefit of their babies.

No I wouldn’t have been afraid to approach a doctor or get my point

across (before her pregnancy) but the fact that I was pregnant made me

feel like they had some kind of hold over me, and I would never have had a

reason to feel like that until I got the kind of ‘you’ll do what we say, and if

you don’t this is how it will be’ you know (Tina).

The control exercised by healthcare professionals appeared to act as a positive influence

for some of the women, who expressed a strong desire to do the right thing and to protect

their unborn babies. The priority of protecting their unborn child was evident in the advice

they received from healthcare professionals. There was a necessity to exercise such

control, according to the women, to ensure they remained stable in their drug use, attended

the clinics daily, did not reduce their methadone dose whilst pregnant or consume illicit

substances. The Drug Liaison Midwife provided advice that was motivating for the women

to remain stable.

54

The first time I met [DLM], he went through with me why it was so

important, number one to keep on a stable dose while I was on

methadone, and kind of the effects of other drug , to encourage me, if I

had been using or lying to him like, not to be taking any drugs and so,

when he told me the way you take methadone, the way he described it

was when we take heroin we go up on a high and go down your levels go

up and down and up and down , so you need an even keel for the baby. So

the way he described it was the baby is in my tummy, he’s going up and

down cause I’m not stable, he says I don’t like this anymore and sends a

hormone to my brain and I miscarry or I’m premature. So, as soon as he

put it like that to me I decided it’s not about me anymore, it’s about the

baby, so I made a decision then and there to stay on the methadone and

stay stable on it. And I never swayed off it for the whole nine months

(Tina.)

These women felt compelled to do the right thing or they risked harming their baby or

losing their baby to social services. There was a stark lack of agency. There was a conflict

of exposing their baby to what they viewed as a highly undesirable substance (methadone)

in their desire to be good mothers. It was necessary for these women to abdicate some of

the responsibility, as they felt they had little or no choice and, therefore, must trust and

follow the advice of their health care professionals.

…I’m hoping that it all goes well like. As I was told its depending [baby

having NAS] and surely they know what they’re doing. If it does come to

that and he is sick, hopefully he’s not but if he is, surely they’ll know how

to deal with it I think…(Serena, aged 31..)

…so I have to go by what they say. They’re the ones that’s experienced,

d’you know what I mean. They see this every day, you know so I just have

to take it (Shauna, aged 39).

3.4.6 Pregnancy Provides Second Chances

Pregnancy was viewed positively by most of the women interviewed: it provided a chance

to stabilise their drug use and/or to become drug free. One respondent described pregnancy

as having ‘saved [her] life’. Pregnancy was also viewed as having had a positive impact on

their relationships with partners and family members.

55

‘In a way it’s a good thing, I never once thought about using or taking

tablets, people say your life changes when you have a baby, but my baby

saved my life as far as im concerned. I’ll never look back, there’s no way

I’ll ever go back to it again’ (Tina)

‘So please God, when [partner] gets out, this will be the making of the two

of us, the baby ya know, like’ (Lily).

Pregnancy was perceived by many of the women as a chance to put their lives of drug

dependency behind them and to move on. It was an opportunity to be “normal”.

‘No, I live in a nice apartment, my husband works, I don’t have concerns

about looking after the baby, I know I’m well able, I had three children, I

know they’re not with me but, I know I’m well able to look after a baby …

really looking forward to get into the swing of things’ (Joan).

Those women who had other children in state or relative care viewed the current

pregnancy as a chance to ‘get it right’ and be a good mother. There was a sense of looking

to the future positively. The desire to get it right this time was in a sense a coping

mechanism for these women.

‘I feel like every day is an achievement, I look forward to this baby, and

being a mother, I missed out so much with my other two kids, I just don’t

want to miss a minute with this baby. I understand there’s good days and

bad days with motherhood, I get that, but I’m just going to embrace it, I

really am’ (Serena)

‘You know, I’m near the end of my pregnancy now and the outcome is

hopeful, and positive and I’m in a good place’ (Serena)

Being on MMT during pregnancy appeared to provide an impetus for these women to

achieve stability, and in a way that they found more challenging when not pregnant. Joan

spoke more positively than others about her progress in terms of stopping drug and alcohol

use and the subsequent advantages of providing ‘clean’ urines. However, her experience

differed from that of other respondents in that she was given ‘takeaway’ doses and was not

56

required to attend a treatment clinic daily. She also described being monitored closely

because of her addiction history and ill-health.

‘I was attending daily (clinic) now I’m blowing zero (alcoholmeter

reading) so I’m on takeaways, only in clinic twice a week now, all my

urines are spotless; clean from alcohol, and they put me on a benzo

maintenance, just up until I have the baby because they didn’t want me to

go through withdrawal cause I do have a history of benzo fits. So they kept

me on it to be sure’ (Joan)

Serena felt that commencing MMT when she became pregnant had helped her achieve

stability as she could not and would not risk experiencing withdrawal symptoms and she

did not want her unborn baby to experience withdrawals.

‘… it’s[methadone] actually been the best thing for me. I really would

have found it harder to get clean myself this time, more so than any other

time(attempts to stop drug use), because it’s probably because I had it in

my mind, if I’m feeling sick, then is my baby feeling sick? You know, if I go

through withdrawals is my baby feeling this as well? There was concerns,

so basically this has been the best way for me dealing with it’ (Serena)

3.5 Women’s Views and Perspectives on Services

During interview, respondents were asked about their views and experiences of the

services they attended, specifically maternity, addiction and social services. The women’s

accounts were revealing and provided interesting data that was critical to understanding

the women’s perspectives on the services they attended.

3.5.1 Maternity Services

The women were generally quite positive about the maternity service they attended and

expressed confidence in the information and advice they received. Some, however, did

57

express a lack of confidence in other services such as treatment clinics and their G.Ps. The

midwives at the clinic the women attended, and especially the Drug Liaison Midwives,

appeared to have the capacity to reassure the women and allay their considerable worries

and fears. They had certainly successfully convinced the women that staying on MMT

throughout their pregnancy was best for their baby. Women frequently spoke about the

midwives as people with whom they had a relationship and in whom they trusted. They

addressed them by their first name and some mentioned being able to call them and having

access to the service between appointment where much of the reassurance and trust was

developed. Women generally perceived the health care professionals at the maternity

service as ‘experts’.

‘So, as soon as he put it like that to me I decided it’s not about me

anymore, it’s about the baby, so I made a decision then and there to stay

on the methadone and stay stable on it. And I never swayed off it for the

whole nine months. So I was happy with the information’

(Tina).

‘To be honest I feel the service here, like if I had any concerns or

questions, I feel confident that I’d get them answered to the best possible,

you know, I leave here, you know, content’

(Serena)

‘Emm, just worried in case anything happened, but they give you all the

information that you need and they tell you about the %’s of studies, the

withdrawal effects, you know, and what can happen, and that’( Lily )

A number of the women explained that the information they received through the

maternity service sometimes differed from what they had been told previously by other

health care professionals.

‘Yes, breast feeding is a big thing. I was told you can’t before, now I’m

told [by the Dove clinic] that you can on methadone. I can wean the baby

off it (methadone) breastfeeding’ (Joan)

‘No, well my GP would [advise her to reduce her dose]… if I told him I

wanted to reduce he’d say, ‘Yeah’. He’s often asked me to and I’d have to

58

say, ‘Look, not at the minute … But in here [DOVE Clinic] no, no one

would (Denise ).

Although the women appreciated the supports offered by the maternity service and relied

on the advice of midwives, in particular, a small number felt that they were treated

differently and that the focus was solely on their drug use to the exclusion of other issues.

‘Like, you’ve got them [other mothers]… for instance you’re sitting out

there and you’re sitting beside the next person. You don’t know who the

next person is, you don’t know their story. They’re sitting there with their

chart in their hands. Why amn’t I given my chart? It was only when

another person on methadone actually brought it up and said it to me. She

said, ‘Do you get your chart’? And I never thought about it once, why

start to think about it ... but it just went through me head’ (Shauna).

This respondent also spoke about not been advised to take iron and it was her perception

that all non-drug using women were prescribed iron supplements. She was of the view that

staff tended to only focus on her drug use.

‘They’ve never told me to take iron. Now, granted, I can’t take it because

I’d puke me guts up, I hate the thing. But they never encouraged me to take

it. I found they have more interest in my urines. It’s like, oh, she’s on

methadone so just put her in a corner with all the say, labelled people

that’s on methadone. You know, where you’re not……you’re treated so

different to a normal human being. We are, in all fairness, we’re treated

so different’ (Shauna)

Being treated as a ‘normal’ mother-to-be was important rather than being treated like a

drug addict. Shauna (above) did not want the iron but wanted to be offered it as this was

normal and what she expected as a pregnant woman.3

3 Patients attending the DOVE clinic are not given their medical chart for reasons of confidentiality. For

example, in some instances the partner may not know about the woman’s drug use or viral status and

therefore the medical team decided that the woman’s chart should be stored in the Doctor’s office to prevent

any breach in confidentiality.

59

3.5.2 Addiction Services

Women’s views on addiction services varied to a far greater extent. Some had quite

positive experiences, while others viewed the addiction clinics negatively. The clinics

appeared to contribute to the stigma and shame experienced by these mothers. For

example, there was a perception that clinic staff lacked compassion and understanding.

Women frequently found their prescribers did not trust them, with one respondent stating

her prescribing doctor from the addiction clinic expected her to use drugs.

‘I wanted to leave my clinic, I still do. The Doctor I had there seemed to be

very, hostile I suppose, it was like, because I was an addict and because I

was pregnant she expected me to be using she expected me to be doing

these things [using drugs]… I have given a urine every single week, and

they’ve all been clean and I’m still only on three takeaways’ (Tina).

Respondents who were heavily pregnant at the time of interview found it extremely

difficult to attend their clinics as frequently as required. Some felt that they were entitled

to more ‘takeaways’ because they were providing opiate negative urines, which was proof

of not using illicit substances. The strict requirements that go hand in hand with being on

methadone, such as daily attendance at the addiction clinic was, for Fiona, part of the

reason she did not want to be on MMT.

‘Every single day, yeah…It was actually wearing me out, yeah, like and

being pregnant as well, like I was dreading the journey every single

morning, you know. That’s why, that’s one of the main reasons why I

really want to come off it as well, you know’ (Fiona)

Some respondents found it difficult to consume large amounts of methadone they were

prescribed due to the nausea they experienced and felt that more flexibility and

understanding was required from the clinic staff. One respondent also felt that the clinic

should provide more advice and information.

60

‘I go down and I’m really really sick and I know I’m not going to keep it

down, they should be able to give me the takeaway for that day. I’d still

have attended and given a urine, even an extra urine, to be given the bottle

and allowed to take it that night when I’m not sick, I do think that should

happen, you’re still taking the same dose, giving the urines, you still

attending the clinic and they’re the three rules as far as my doctor tell me

have to be abided by. So I just think there could have been more of a give,

instead of expecting all of this from you all the time, with no information

being given’ (Tina).

‘… when I look at it in the cup ya know every morning, and I’m like oh god

like I even, it’s getting to the stage it’s taking me, I used to drink it in like

one or two goes, now it’s taking me about four’ (Lily)

Others, however, viewed addiction services more positively. One respondent described

having an addiction outreach worker as a “great support”, while another appreciated her

doctor’s strict but caring approach and felt it was what she needed to remain stable.

‘You know he (doctor) listens, he’s kind, he’s you know, he’s strict and

that’s what you need. You need a strict doctor that you have a bit of fear.

I feared {Doctor’s name} when I met him. It was like this doctor, you

know he’s like, he’s like really the king of the kids that are after turning to

drugs’ (Shauna)

3.5.3 Social Services

Many women described negative past experiences of social work services, in particular. A

number explained that their asking for help in the past had resulted in their child being

taken into care and these women expressed resentment towards the service and the service

staff they encountered. These negative past experiences meant some were now reluctant to

ask for help. Both Serena and Lily painted a picture of feeling wronged in a context where

the acknowledged their need for and sought support.

‘And then, when my son was almost two, the social workers got involved,

there was a lot of lies told, I was working and I everything, and I was

depressed and I told them I was suffering bad and I asked for support but

instead of support they took my kids’ (Serena)

‘But eh like I ended up going to social workers then for a bit of help and eh

61

it turned out they were saying to me, kind of like, well like…well ‘’we’re

gonna put the child into care’ (Lily)

The negative past experiences of one mother meant that she was now more cautious about

seeking advice from social workers. If she was having a ‘bad day’, she felt social workers

would think that she could not cope. She explained that she knew ‘what to say and what

not to say’ to social workers during this pregnancy. She also described an awareness of the

possible challenges of being a parent to a newborn baby and felt that any initial struggles

could be misinterpreted as an inability to cope. Her account demonstrates a profound

distrust in social work services based on her prior experience of having her child taken into

care.

‘.. I don’t tend to talk a lot like it’s like cause it’s like what I done with

[child’s name, who was taken into care]. I talked too much and that’s

when social workers came in and got involved. And they were just when I

was having bad days, it wasn’t like that all the time, ya know. But they just

got it into their heads, ya know, she can’t cope, ya know that type of way,

take that child off her. So I’m kinda like I like, I’d be more I know what to

say to them now. But now I won’t be afraid to say like, well yeah, like put

my hands up, ‘Yeah, I need a bit [of help]’ (Lily)

Conclusion

This chapter has detailed a thematic analysis of pregnant women’s views and experiences

of methadone maintenance treatment. The narratives produced a rich and complex set of

sometimes contradictory experiences and emotions, associated with the dual position of

‘pregnant woman’ and ‘methadone patient’. The next chapter will discuss these findings in

the context of the literature.

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Chapter 4: Discussion and Conclusion

Introduction

This research project sought to explore pregnant women’s experiences and views of

methadone maintenance treatment. It has drawn on the narratives of eight pregnant women

on methadone maintenance treatment, of different ages, at different trimesters in their

pregnancy and all on methadone maintenance treatment for varied lengths of time.

Drawing on the data gathered during the interviews with eight women, the themes that

emerged were i) the lesser of two evils, ii) fear and guilt, iii) Stigma and shame, iv)

influence through support encouragement and control and v) pregnancy provides second

chances. The views of the participants on the services they received were also presented.

This chapter will discuss these findings in the context of the literature and provide

recommendations for future research, health promotion and service provision.

4.1 Education

Methadone is recommended as the first line treatment option in Ireland (Health Service

Executive (HSE) Clinical Practice Guideline on Methadone Prescribing and

Administration in Pregnancy (2013). Methadone concentration levels are lessened during

pregnancy due to physiological changes such as ‘increased total body water, a larger tissue

reservoir, enhanced hepatic, placental and fetal clearance of methadone’, according to

Cleary et al. (2012). This may result in the mother experiencing withdrawal symptoms and

requiring her methadone dose to be increased. This was the case for some of the women in

this study. These women were dissatisfied with needing to increase their dose and it

caused concerns for them, as they worried about the effects on their unborn baby.

63

Methadone dose is not related to the incidence of NAS (Cleary et al., 2012), however,

many of these women were of the view that a lower dose was better for the baby. From a

patient safety and health promotion perspective, it is important to understand the views of

pregnant women on methadone maintenance treatment and their perceptions of the risks of

NAS. There is a need for increased education in this area for both these women and the

healthcare professionals who provide care for them. It is essential that healthcare staff and

methadone prescribers are providing consistent information and advice to pregnant women

on methadone. Further research is required in this area of methadone prescribing practices

and the advice women are receiving.

4.2 Desire to Detox

While MMT is the standard treatment offered both in Ireland and internationally, these

mothers displayed a reluctant acceptance about their need to continue taking it during

pregnancy. Findings from the study showed a general consensus among the women that

methadone was necessary for the safety of the baby but all expressed a desire to complete

detoxification after the birth. The findings highlight how individuals on methadone are

motivated to detoxify. Research by O’Reilly & Reaper (2005) and Keane (2012) on drug

users views of health and addiction services in Dublin highlighted how the service users

felt there were not enough opportunities for detoxification or support to come down off

methadone. Many service users view their daily dependence on methadone as restricting

their personal freedoms, with some referring to methadone as ‘a ball and chain’, according

to Keane (2012). Keane (2012) further reported an absence of clinical advice and support

on dosage reduction or detoxification in addiction services. This is important and relevant

to the findings as all of the respondents in this study described plans to detoxify after the

birth of their babies. The views and wishes of individuals taking methadone should be

64

taken into account and they should be given opportunities to detoxify with the right

supports in place. However, this requires a cautious approach due to the cyclical nature of

addiction. The complex environment these women are in, may provide a different reality,

where detoxification is unachievable. Many of these women come from extremely

difficult social situations with long histories of addiction, childhood abuse and neglect

(Alexander, 2014), therefore, while detoxification and abstinence after pregnancy would

be an ideal outcome, over emphasis on achieving abstinence could have detrimental

effects, placing the mother under considerable stress. People who detoxify are at an

increased risk of overdose mortality (Cleary et al., 2012) and these women in particular,

are extremely vulnerable with the added stress of having a newborn baby to care for. There

is a need for relapse prevention interventions and education on the risks of overdose after

periods of abstinence or detoxification in this cohort. Further research is required in the

area of women detoxing after pregnancy.

4.3 Flexibility and Understanding

The findings highlighted how pregnant women on methadone experience debilitating side

effects such as nausea, vomiting and constipation, making it difficult for them to tolerate

consuming their dosage, especially those on larger doses. They experience shame and

stigma, especially attending their methadone clinic when heavily pregnant. These findings

concur with research by Varty (2014) that highlighted feelings of guilt, shame and

embarrassment are prohibitive factors in seeking help and engaging with care. The

supervised consumption of methadone while pregnant causes embarrassment and

discomfort (Varty, 2014). More flexibility and understanding is required from addiction

clinics. Pregnant women on methadone maintenance should be offered split dosing and

65

increased ‘takeaways’ when it is a viable option clinically, for example, if the woman is

providing opiate negative urines and displaying abstinence in terms of their drug use.

4.4 Focus on Family Planning

While pregnancy was viewed positively and seen as an opportune time to achieve stability

(Arunogiri, 2013) it is important to recognise the external stressors and complex

environments of these women (Alexander, 2013). As stated in the findings of this study,

all of these pregnancies were unplanned, with some women stating that they did not think

they could become pregnant because of their drug use histories. There should be an

increased focus on family planning and education in this area. Addiction services should

offer contraception and advice on safer sex to women attending the service.

4.5 The Context of Stigma

It is well documented that stigma prevents drug users from engaging effectively with

services (Radcliffe, 2011). There was the perception for some that the healthcare staff

lacked compassion and understanding. The addiction clinics appeared to contribute to the

stigmatization and shame experienced by these mothers. It is important to recognise the

context of stigma. These women experience self, social and structural stigma according to

Livingston et al. (2012). Self-stigma, according to Livingston et al. (2012), involves

negative feelings about self, resulting from an individual's experiences of negative social

reactions on the basis of a stigmatised social status or health condition. Social stigma,

according to Livingston et al. (2012) involves endorsing stereotypes about a stigmatised

group, such as pregnant drug users. Structural stigma refers to the rules, policies and

procedures of institutions that restrict the rights and opportunities of a stigmatised group

66

(Livingston et al., 2012). Radcliffe (2011) highlights how pregnant women on

methadone attending antenatal services are reliant on staff to have their identities as

mothers endorsed and it is essential that these women are viewed as ‘worthy of

motherhood’. For these women, much is expected of them in terms of proving their

ability to be good mothers. As Radcliffe highlighted, they are required to attend multiple

appointments to confirm their abstinence from drug use. The narratives revealed a stark

lack of agency. These women feel that they have no control over their dose and are in a

sense forced to abide by the rules of the healthcare system. The women did not perceive

that they had the right or ability to question this system. The control exercised by the

services, whose priority is child protection, is not resisted by these women. They are

compelled to do the right thing for the benefit of their babies. The narratives produced a

rich and complex set of sometimes contradictory experiences and emotions, associated

with the dual position of ‘pregnant woman’ and ‘methadone patient’. This study has

highlighted areas of complexities where further research is required. A large scale

qualitative study of women’s experiences of methadone maintenance would address this.

Conclusion

This was a small scale qualitative study using a phenomenological approach. While the

findings are not generalizable, this study highlights the importance of understanding the

lived experiences of pregnant women who are on methadone maintenance treatment, in

order to attempt to understand the phenomenon. This study has provided an insight into the

lives of these women and the issues they face. It has also provided suggestions for what

steps might be taken to address the issues raised by the individuals who have first-hand

experience of these issues and recommendations for future research in this area.

67

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Appendices

Appendix 1 – Patient Information Sheet

Patient information sheet

Dear Patient,

You are being invited to take part in a research study. This research is being

undertaken by Ms Carol Murphy as part of a MSc course at Trinity College Dublin However, before you decide whether or not to take part, it is important that you fully

understand what the research is about and what you will be asked to do. It is important

that you read the following information in order to make an informed decision and if you

have any questions about any aspects of the study that are not clear to you, do not hesitate

to ask me. Please make sure that you are satisfied before you decide to take part or not.

You may stop the interview at any time. Thank you for your time and consideration of this

invitation

1. Research Study Title

To explore pregnant women’s experiences of pregnancy while on methadone maintenance

treatment and any associated concerns about the pregnancy or birth.

2. What is the purpose of the research study?

The purpose of this research is to understand women’s experience of being on methadone

during pregnancy and any related concerns about the pregnancy or birth.

3. Why have I been chosen?

You were chosen because you are currently on methadone maintenance treatment and

attending the DOVE clinic for antenatal care.

4. Who is organising the research study?

The researchers for the study will be Brian Cleary at the Rotunda and Carol Murphy, Trinity College Student. The study will commence in June 2015.

5. What will happen to me if I take part?

You will be asked to take part in an interview that will take about one hour. The interview

will take place in the DOVE clinic.

There will be no change to you and your care should you decide to be included in the

study.

6. Are there any disadvantages in taking part in this research study?

From a medical point of view there are no disadvantages in taking part in this study.

7. What are the possible risks of taking part?

All your information will be kept secure and confidential therefore there are no risks.

76

8. What are the possible benefits of taking part?

You will not directly benefit from participating in this study, however it is hoped that this

study will provide a greater understanding of the views of pregnant women on methadone

maintenance about drug treatment and their fears and opinions about withdrawal

symptoms the baby may experience. This information will be used to influence the advice

and information given to pregnant women on methadone maintenance treatment.

9. Confidentiality – who will know I am taking part in the research study?

All information, which is collected about you during the course of this research will be

kept strictly confidential. Your consultant/team will be aware of your participation but they

will not have access to the information you share. The researchers are under an ethical and

legal duty of disclosure. If in the course of the research you disclose information that indicates

that a child is at risk of harm or that you are at risk of harm to yourself or another person.

10. Hospital Research Ethics Committee Approval

The name of the Research Ethics Committee who approved the research study is the

Rotunda Hospital Ethics Committee.

11. What will happen to the results of the research study?

The information will be collected, analysed and a research paper will be written up by the

researcher. A copy of the results will be available to you on request.

12. Voluntary Participation

It is up to you to decide whether to take part or not. If you do decide to take part you will

be given an information leaflet and consent form. Even if you do decide to take part, you

are free to withdraw at any time and without giving a reason. This will not affect the

standard of care you will receive.

Contact Detail:

If you have any questions about the study please contact:

Brian Cleary

The Rotunda Hospital

Dublin 1

01 8171700

bcleary@rotunda.ie

Carol Murphy

MSc Student Trinity College Dublin

01 8171700

Murphc95@tcd.ie

77

Appendix 2 – Consent Form

CONSENT FORM

Research title: To explore pregnant women’s experiences of pregnancy while on

methadone maintenance treatment and any associated concerns about the pregnancy or

birth.

Researchers: Brian Cleary and Carol Murphy Tel: 01 8171700

E-mail:

bcleary@rotunda.ie

Murphc95@tcd.ie

78

Appendix 3 – Patient Information Leaflet

DECLARATION by participant: Please tick () and provide your initials

1

.

I have read the information leaflet for this

research study and I understand the contents.

Yes [ ] No [ ] initials [ ]

2

.

I have had the opportunity to ask questions and all

my questions have been answered to my

satisfaction.

Yes [ ] No [ ] initials [ ]

3

.

I fully understand that my participation is

completely voluntary and that I am free to

withdraw from the study at any time (prior to

anonymisation/publication) without giving a

reason and that this will not affect my care in any

way.

Yes [ ] No [ ] initials [ ]

4

.

I understand that I have been requested to

participate in an interview on the topic covered by

this research and I consent to this.

Yes [ ] No [ ] initials [ ]

5

.

I understand that I will be given an opportunity to

review the transcript of such an interview to

confirm accuracy.

Yes [ ] No [ ] initials [ ]

6

.

I understand that the transcript will not identify

me by name but will use the study code and that

the original digital recording will be erased once

the accuracy of the transcript has been confirmed.

Yes [ ] No [ ] initials [ ]

7

.

I understand that information from this research

will be published but that I will not be identified

as a participant in this research in any publication

Yes [ ] No [ ] initials [ ]

8

.

I understand that I will not be identified as a

participant in this study and that the researchers

may hold my personal information for ten years

after the study has been completed.

Yes [ ] No [ ] initials [ ]

9

.

I agree that information obtained from me in this

research which has been coded so as not to Yes [ ] No [ ] initials [ ]

79

identify me may be stored and used for the

purpose of future research which will have

obtained Research Ethics Committee approval

without the need for further consent from myself.

1

0

.

I understand that my personal details (name and

address and other identifying information that

links my identity to the study data) will be

destroyed when this study is complete.

Yes [ ] No [ ] initials [ ]

1

1

.

I consent to my personal details being retained for

a further period of ten years after this study has

been completed.

Yes [ ] No [ ] initials [ ]

1

2

.

1

3

.

I understand that the researchers undertaking this

research will hold in confidence and securely all

collected data and other relevant information.

I freely and voluntarily consent to participating in

this research study

Yes [ ] No [ ] initials [ ]

Yes [ ] No [ ] initials [ ]

80

Appendix 3 Patient Information Leaflet

PARTICIPANT'S NAME

……………………………………………………………………………………………………

…………

Contact

Address…………………………………………………………………………………………

……………………………

…………………………………………………………………………………..

………………………….

Phone number:…….……………………………………………………

Email:…………………..………………..

Participant’s signature: …………………………………………………..…………

Date: ……………………………

Name of person taking consent: ……………….……… Signature: …………..……………

Date:………….…………………

Researcher: ………………………….………………Signature: ………………………..…

Date:…….………………………

81

Appendix 4 - Interview Schedule

Interview schedule with pregnant women in DOVE clinic to explore pregnant women’s

experiences of pregnancy while on methadone maintenance treatment and any associated

concerns about the pregnancy or birth.

Introduction

The research participant will be made comfortable and her understanding about her

participation will be checked to ensure she has understood the information given and has

provided informed consent.

The following topics will be discussed with each participant. Open questions and a

flexible approach will be used so that questions may not be asked in the order or exact

articulation outlined below so that the participant can lead the conversation around these

issues.

Some demographic data and data about the women’s previous pregnancies and social

situation will be collected at the end of each interview as follows:

1) Age

2) No. previous pregnancies

3) Number of live births:

4) Current relationship status _____________

5) Housing situation at present? (Homeless accommodation/ couch surfing/ council /

private owned

Other __________________________

6) Who are you living with at present?

_________________________________________________

7) Length of time on methadone

8) Dispensing arrangements

9) income (social welfare; part-time employment; full-time employment)

82

Background

First, if its ok with you, I would like to ask you to tell me a bit about growing up ..’.

Next could you tell me a bit about your family and the place where you grew up’

Tell me about your family, parents, brothers and sisters etc. work, school

Significant Relationships? Are you in a relationship at present?

Do you have children? If yes, can you tell me about them?

Drug use

Can you tell me a bit about your drug use and how it started?What was going on for you,

that you started using drugs? What drugs?

Any drug use in your family? Does your partner use drugs?

When did you first use heroin? Can you tell me about how your heroin use went from

there?

When would you say that you recognised that your use of heroin was a problem?

And when did you start on methadone?

Have you accessed other forms of treatment? If yes, what happened? How did you find

that?

Now I would like to discuss your pregnancy. (For those who have had previous

pregnancies explain we will first discuss the previous pregnancies before coming to this

current pregnancy). This is a conversation style interview (rather than question and

answer) so please speak openly and freely.

Can you tell me about your previous pregnancies?

Probes:

Were you on MMT at the time?

Can you tell me about any changes to your methadone dose during previous

pregnancies?

Who or what influenced what you did or took (including MMT) during past

pregnancies? (prompt - peers/ past experience/ partner/parents/clinic/gp )

83

What influenced your decision making around how much methadone you took?

How was your other drug use during this pregnancy? (Did this change since you

became pregnant?)

Thinking back to those previous pregnancies: were you worried about your baby

going into withdrawal?

Can you talk me through any other concerns you had about you or your health or

your baby’s health during or after pregnancy?

Can you tell me how these concerns influenced you in relation to drug use & MMT

in pregnancy?

Who did you consider your most important support during past pregnancies and

why?

Can you tell me about this pregnancy?

How do you feel about being pregnant?

Probes –

When did you commence on MMT (most recent episode)?

Can you tell me about your methadone dose and how you feel about this?

Do you feel you have control over your dose and decisions about your treatment?

Can you tell me about any changes to methadone dose during this pregnancy?

(Include intentions to change dose)

How do you feel about being on methadone now that you are pregnant?

Who or what influences what you do or take (including MMT) during this

pregnancy? (prompt - peers/ past experience/ partner/parents/clinic/gp )

How is your other drug use during this pregnancy? (Has this changed since you

became pregnant?)

Thinking about this pregnancy can you talk me through any concerns you have

about you or your baby’s health during pregnancy or after birth. (probe- NAS).

Can you tell me if or how these concerns influence what you do in relation to drug

use and methadone?

Who do you consider your most important support during this pregnancy and why?

84

What is your experience health care generally (e.g. about GP care, their midwife,

individuals at their treatment centre).

Closing question Have any questions been raised for you during this interview that you

would like to speak to the midwife about now?

Yes No Refer to midwife as appropriate.