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)
39
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).
40
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)
43
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)
44
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.
45
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.
46
‘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
47
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
48
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
52
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.
62
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
Carol Murphy
MSc Student Trinity College Dublin
01 8171700
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:
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?
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