With Child: Substance Use During Pregnancy: A Woman-Centered Approach

This short and easy-to-read book presents the editors’ strong feminist perspective concerning the care, treatment, and perceptions of women who use drugs while pregnant. The book is divided into three major sections, including content on theory, innovative practices, and directions for the future. Although the majority of contributors are nurses, there is also content from social work and other medical fields. All contributors are Canadian and appropriately qualified to share their points of view. Interviews with drug-using women are also included. Throughout the book, there is a strong belief that adverse outcomes for both mother and baby can occur as a result of maternal drug use, but that the majority of such outcomes are related to pervasive conditions of economic poverty and social deprivation.

 Using this belief, social determinants of health are defined, and it is suggested that they be used as a foundation to examine maternal and infant outcomes and also to critique related research literature. Of particular interest is the brief, straightforward, and well-founded biologic overview of frequently used substances and their effects during pregnancy, especially on the developing fetus and child. It is pointed out that research in the field is rapidly changing and that ongoing studies are needed that allow for the overlapping of biologic effects of substances and longitudinal effects of environment when studying maternal-infant outcomes. Although a few references concerning the concept are mentioned, additional citations would be of value. The suggestion that selective research is not easy to interpret and that researcher’s recommendations be more medically objective and less moralistic are interesting areas for readers’ consideration.

 The evolution of the first designated unit in Canada to care for substance-using pregnant women is described in some detail. Fir Square at British Columbia’s Women’s Hospital was developed by a multidisciplinary team that believed in a harm-reduction, woman-centered approach that included no referrals without the woman’s consent (Canada does not have legal obligations to report issues related to unborn children as in the Unites States). The unit was used as an example for models of practice in other parts of Canada. However, the inclusion of specific concepts to be considered and actions to be undertaken by communities interested in such programs would be valuable.

 An extensive discussion from a variety of child protection social workers demonstrates some frustration with the standards of training and practice. Several claimed that they were not well prepared to assess and provide support imperative for positive mother-child relationships under circumstances involving substance use. Case studies are included and a few mechanisms for change are mentioned, but additional interpretations and suggestions for action are recommended.

 Several areas of the book make reference to the lack of proof regarding the cause and effect relationship between the use of substances and selected abnormalities in the offspring. It is true that birth defects may be a result of multiple factors, but it is still important for contributors to encourage reduction or elimination of known or suspected deleterious substances, which is not the case in all of the material presented.

 On the whole, With Child urges vigilance in maintaining women’s rights and reproductive autonomy and providing non-judgmental care to all women, particularly those with problems of substance use. It recognizes that women who use drugs or alcohol during pregnancy are sometimes treated in a non-caring criminal manner and stresses that the effects of poverty and social marginalization are often mistaken for the effects of drugs. The establishment of programs that provide all women access to appropriate harm-reduction care are encouraged. It would be quite helpful if more specific suggestions were enumerated to assist in accomplishing this goal.

 Portions of the book are somewhat repetitive, and a few of the interviews could have been eliminated. This could have been handled with some very strong editing, which would have allowed the stellar quality of several contributors to shine through more easily. Overall, the book raises the level of awareness for professionals in the field regarding the manner in which substance-using pregnant women are treated. It challenges the accepted models of service and highlights a few emerging practices that could be beneficial for mother, baby, and society. At first glance, it appears to counter generally accepted knowledge and application, but if readers persevere, they are provided with sufficient stimulation to think about value of changes in the delivery of care. - Barbara P. Sinclair, MN, RNP, FAAN 

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