“Subutex is safe”: Perceptions of risk in using illicit drugs during pregnancy

International Journal of Drug Policy 23 (2012) 365–373

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Research paper

“Subutex is safe”: Perceptions of risk in using illicit drugs during pregnancy Anna Leppo Department of Social Studies, POB 16, 00014 University of Helsinki, Helsinki, Finland

a r t i c l e

i n f o

Article history: Received 13 May 2011 Received in revised form 23 November 2011 Accepted 18 January 2012 Keywords: Pregnancy Drug use Risk perception Subutex Finland

a b s t r a c t Background: The dominant biomedical discourse stresses the physiological risks to the foetus or newborn posed by the prenatal use of illicit drugs. There is also a strong moral incentive for pregnant women to abstain from drugs. Yet few researchers have explored how pregnant, drug-using women themselves perceive the risks involved. The present paper investigates the reasoning by women about risks involved in prenatal drug use. Theoretically, a socio-cultural approach to risk is taken. Methods: The paper is based on fourteen ethnographic interviews with women who had used illicit drugs during pregnancy (mainly buprenorphine), had recently given birth and had regularly used prenatal services during pregnancy. The interviews were informal, semi-structured and focused on the women’s experiences of pregnancy and service use. Each interview lasted about an hour. The interviews were transcribed and inductively analysed using thematic coding. Risk perceptions were identified in the interviewees’ expressions and understanding of fears, dangers, threats and worries. Results: The women were not primarily concerned about health risks: their greatest fears in connection with the prenatal use of illicit drugs were giving birth to a child with withdrawal symptoms, child protection interventions and child removal, encountering negative attitudes in seeking professional help as well as terminating drug use. The interviewees did not see abstaining from drugs as a risk-free option. On the contrary, the prospect of a drug-free life was filled with fears linked to physical and mental pain and disruptions in significant social bonds. The women made use of biomedical and nonprofessional understandings of risks. The women’s friends and acquaintances played a central role as providers of knowledge about risks. Conclusion: When providing health education to pregnant women with drug problems, professionals should take women’s perceptions of risk seriously, treat the women respectfully and engage them in dialogue about the risks involved. Further studies on pregnant women’s perceptions of risk in using illicit drugs would be highly valuable. © 2012 Elsevier B.V. All rights reserved.

Introduction There are numerous medical studies on the multiple risks of illicit drug use during pregnancy (see e.g. Hulse, Milne, English, & Holman, 1997; Jones et al., 2010; Kahila, Saisto, Kivitie-Kallio, Haukkamaa, & Halmesmäki, 2007; Lifschitz, Wilson, Smith, & Desmond, 1985; Winklbaur et al., 2008). However, very little research has been conducted on the perceptions of risk by pregnant women who use drugs. This paper investigates the reasoning about risk issues by Finnish women who have used illicit drugs during pregnancy. In the following encounter a health care professional talks to a young woman about the risks of prenatal drug use. Minna is 2 months pregnant and dependent on opioids: Professional: It is very important that you enroll in treatment as soon as possible in order to quit taking Subutex [a synthetic

E-mail address: anna.leppo@helsinki.fi 0955-3959/$ – see front matter © 2012 Elsevier B.V. All rights reserved. doi:10.1016/j.drugpo.2012.01.004

opioid], and I mean residential treatment. The nurse said you are interested in opioid substitution treatment, but you don’t fulfill the criteria: you have not been in treatment before, and you have used opioids only for a short time. Minna: If I enroll in treatment, it would be just for the sake of the child protection services. Professional: You don’t think about the baby? Minna: Well, that too, of course. Professional: It [the drug] goes into the baby and affects its development, the growth of its brain and its future.. . . This encounter, which I wrote down in my field notes whilst conducting ethnographic research, took place at a Finnish specialised maternity clinic that provides obstetric and psycho-social services to pregnant women who have alcohol and drug problems. The interviewees for the present study were recruited from the same clinic. Above, Minna responds to the professional’s advice to quit using drugs by saying that her fear of child protection services might prompt her to enroll in drug treatment. The professional takes a moral stand by suggesting that Minna does not care about

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the baby and lists some of the adverse effects of prenatal opioid use on the foetus. It appears that what Minna fears most is losing custody of her child, whilst the professional is concerned about the health risks, i.e. the foetus’s brain. The encounter aptly illustrates that professional experts and lay people may perceive or prioritise risks differently. Theoretically, this paper draws on a socio-cultural approach to risk. In contrast to the idea of risk as an objective phenomenon based on scientific probability calculations, sociocultural approaches emphasize that the perception of risk is embedded in social relations and culture, that is, in shared beliefs and values (Caplan, 2000; Douglas, 1992; Douglas & Wildavsky, 1982; Zinn & Taylor-Gooby, 2006). The pioneer of socio-cultural risk research, Douglas (1992), posited that it is impossible to be concerned about all potential risks; moreover, risks need to be ranked – which is hardly a value-free process, even if detailed information about the probability of the dangers is available. Whilst Douglas (1992) was interested in why some risks are selected as worthy of personal or public attention, she did not deny the reality of risk. In collaboration with Aaron Wildavsky, Douglas posited that “common values lead to common fears”, underlining the intertwined nature of moral values and the perception of risk (Douglas & Wildavsky, 1982, p. 8). Sociological studies on expert/lay controversies in the field of health and illness have shown that the biomedical risk rationales may differ from lay perceptions (for example, Armstrong, 2005; Bourne & Robson, 2009; Coxhead & Rhodes, 2006; Horlick-Jones & Prades, 2009; Rhodes & Quirk, 1995). It has been noted that lay perceptions of risk are usually less “rational” and individualistic than are the views of experts, which guide prevention responses (Rhodes, 1995). In a similar manner, previous studies that have shed light on risk perceptions by women who have used illicit drugs during pregnancy have noted that, whilst women are concerned about the well-being of the foetus, their risk perceptions may differ from those held by professionals (e.g. Murphy & Rosenbaum, 1999). Previous research has also established that many pregnant drug users engage in risk reduction behaviours such as reducing drug consumption and seeking treatment (see Flavin, 2002 for an overview of qualitative studies in this area). In some parts of the US drug-using pregnant women have suffered from stigmatisation when seeking help, and in using prenatal services, they have weighed up the benefits of increased foetal safety against the possibility of losing custody of the child (Kearney, 1995; Murphy & Rosenbaum, 1999). Moreover, women who used crack were terrified about adverse effects on the foetus; heroin users found heroin safe, whilst stimulant users were uncertain about the effects of drug use on the foetus (Irwin, 1995; Murphy & Rosenbaum, 1999). Murphy and Rosenbaum (1999) link these findings to punitive policies on drug-using pregnant women and the massive, negative media attention on “crack babies”, other studies in the US have also documented that fear of punitive actions (loss of infant custody, arrest, prosecution and incarceration) can become a barrier to seeking help (Jessup, Humphreys, Brindis, & Lee, 2003; Murphy, 2000; Oliva, Rienks, & McDermit, 1999; Roberts, 2011; Roberts & Nuru-Jeter, 2010). In the UK, however, pregnant women who use drugs have had less reason to fear punitive actions (Lewis, Klee, & Jackson, 1995). Finally, the lack of available drug treatment or prenatal care has been identified as a problem for pregnant drug users in the US (Flavin, 2002). In sum, previous research has established that women’s fears about the effect of prenatal drug use are linked to the physiology and social position of a particular drug as well as to the wider social context of prenatal substance use. In order to understand better the logic of how women who use drugs view the risks of illicit drug use during pregnancy, it is paramount to study the phenomenon in diverse cultural and social contexts with different drug use patterns and societal responses to drug use.

The present paper explores how Finnish women who have used illicit drugs during pregnancy retrospectively perceived and described the risks involved. Most interviewees had used buprenorphine (Subutex® ), which at the time had become the primary illicit drug for Finnish opioid users. In contrast to the US where criminal justice interventions targeting drug-using pregnant women take place in many states and prenatal care and drug treatment can be hard to gain access to (Flavin, 2002), Finland is a Nordic welfare state with universal and public social and health care services. Furthermore, in Finland prenatal drug use is not considered a criminal justice issue, but rather a treatment and child protection issue (Leppo, in press). The present paper explores the threats, dangers and concerns the Finnish women perceived or experienced in relation to the prenatal use of illicit drugs, whether they rejected or embraced the biomedical definitions of risk and, finally, whether they feared punitive actions. Context of the study Winklbaur et al. (2008) point out that, although opioid use has no teratogenic effects on the foetus, it is linked to other health risks. The authors summarise the effects of illicit opioid use during pregnancy as follows: fluctuating opioid concentrations in the maternal blood may lead to foetal withdrawal or overdose, the women are at high risk for malnourishment, often lacking adequate obstetric care and remaining in a violent environment and amongst those who continue intravenous opioid consumption, the risks of medical complications such as infectious diseases, endocarditis, abscesses and sexually transmitted diseases are increased (Winklbaur et al., 2008). Further, the incidence of neonatal abstinence syndrome (NAS) in opioid-dependent women is between 70% and 95% (Winklbaur et al., 2008) Apart from neonatal withdrawal, these health risks can in principle be avoided by the use of opioid substitution treatment (ST) and changes in the woman’s lifestyle such as an improved diet (Winklbaur et al., 2008; Jones et al., 2008; Kahila et al., 2007). Whilst methadone has long been used internationally in ST during pregnancy, in Finland buprenorphine has become the first choice in ST, including for pregnant women (Kahila et al., 2007). Buprenorphine seems to be well tolerated by the foetus, and neonatal withdrawal is reported to be shorter and less severe than with methadone (Jones et al., 2010). However, some authors have noted that subtle effects on the brain and on behaviour have been reported in animal studies on prenatal buprenorphine use (Kahila et al., 2007). ST during pregnancy aims at eliminating not only foetal exposure to illicit opioid use, but also exposure to other illicit drugs (Jones et al., 2008). Successful ST may enhance women’s involvement in prenatal care, which is significantly associated with positive pregnancy and neonatal outcomes (Jones, 2006). Compared with many other countries, the use of so-called hard drugs increased in Finland relatively late, in the late 1990s, and drug problems are still only a marginal phenomenon (Hakkarainen, Tigerstedt, & Tammi, 2007). Moreover, in Finland the recreational use of illicit drugs has not been “normalised” as in many other European countries (Partanen, 2002). The Finnish drug policy combines punitive criminal justice practises with extensive public drug-treatment services and, more recently with harm-reduction approaches (Tammi, 2007). There are, however, no harm-reduction programmes that specifically target pregnant drug-users. The purpose of ST is to replace illicit opioid use by the medicallycontrolled oral use of a synthetic opioid. In Finland methadone and buprenorphine (originally Subutex and, increasingly, Subuxone) are both used in ST (Forsell, Virtanen, Jääskeläinen, Alho, & Partanen, 2010). The medically-controlled use of buprenorphine in ST has resulted in a phenomenon known as pharmaceutical leakage in which the drug leaks onto the illicit market (Lovell, 2006). When

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the data for this paper were collected in 2006, heroin had almost disappeared from the Finnish illicit drug market, and Subutex had emerged as the primary drug of opioid-dependent people. Between 2000 and 2005 the number of opioid users, who had taken advantage of substance abuse treatment services and reported heroin as their primary substance decreased from 20% to mere 2% (Forsell et al., 2010). During the same period the number of patients who reported buprenorphine as their primary substance increased from 7% to 29% (Forsell et al., 2010). In Finland maternity services in primary health care are free of charge and virtually all pregnant women attend regular checkups throughout pregnancy (Hakulinen-Viitanen et al., 2008). For instance, the interviewees for this study made regular visits to their local maternity clinic and to a specialised maternity clinic throughout their pregnancies. The specialised clinic was part of a large public maternity hospital and offered intensive medical and psycho-social services to pregnant women with substance abuse problems. In most cases the interviewees had been referred to the specialised maternity clinic by their local maternity clinic after the women had disclosed their drug use. The phrase “drug management system” is used here instead of drug treatment system because the former leaves open the nature of such practises, acknowledging that they can contain elements of treatment, control, surveillance and so on (Lovell, under review). In Finland the specialised drug management system provides residential services to opioid-dependent pregnant women in short-term detoxification units and long-term rehabilitation units, whilst the whole family can enroll in long-term residential drug treatment programmes in special family units. In addition pregnant women can use harm-reduction services and enroll in ST programmes. There are also outpatient services for pregnant women and their families (Tanhua, Virtanen, Knuuti, Leppo, & Kotovirta, 2011). Finnish municipalities are responsible for the practical implementation of statutory alcohol and drug treatment services, which are provided either by the local authorities or purchased by the municipality from the private sector (Tanhua et al., 2011). These services are free of charge or available at low cost to the users. At the maternity clinic attended by the interviewees during pregnancy the goal for amphetamine users was total abstinence. Amphetamine use during pregnancy was seen as particularly risky by the professionals, as it was understood to increase the risk of miscarriage and premature birth. Opioid users with a short history of drug use and no previous attempts at a detoxification programme were also encouraged to strive for total abstinence. Opioid users with a long history of opioid dependency and previous detoxification attempts were usually deemed by the clinic’s professionals to be unable to achieve total abstinence and were encouraged to enter ST. This practice was linked to the Finnish protocol on ST, in which opioid addicts qualify for ST only if they have previously been through detoxification treatment and either failed to complete it or relapsed at some later point. Also those pregnant women who qualified and opted for ST first had to undergo a two to three week detoxification treatment; starting ST typically involved withdrawal symptoms and considerable discomfort. In ST programmes the dose of medication was gradually lowered towards the end of the pregnancy, if possible, in order to avoid neonatal abstinence syndrome. (These observations are based on ethnographic fieldwork conducted at a specialised maternity clinic, and some of the findings have been published in Leppo (2008) and Leppo and Perälä (2009).)

Methods The data consist of 14 ethnographic interviews conducted with women who used illicit drugs during pregnancy or before becoming

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pregnant. The data were collected as part of a wider ethnographic study of a specialised maternity clinic that provided medical and psycho-social services for pregnant women with alcohol or drug problems; the majority of the interviewees (10) were recruited from this clinic. The clinic operates in a large town in southern Finland. Two interviewees were recruited from the family ward of a large drug treatment institution and two by the “snowball method”, i.e. asking interviewees if they had friends who could be interviewed. The inclusion criteria were that the woman was or had recently been pregnant and that she had been referred to the abovementioned specialised maternity clinic because of prenatal drug use (12) or a recent history of drug use before her pregnancy (2). The majority of the interviewees (12) were poly-substance users whose main illicit substance during pregnancy was Subutex. In addition to Subutex, the poly-substance users typically reported using cannabis, benzodiazepines and/or amphetamines. One interviewee had used illicit Subutex before pregnancy, but stopped before becoming pregnant. Another was in ST before she became pregnant, but had a relapse and used illicit drugs for a short period of time during the pregnancy. All but one of the women who used Subutex whilst pregnant injected the substance (11). The interviewees had given birth from 4 days to four months prior to the interviews with the exception of one who was pregnant and one who had given birth almost two years earlier. The interviews could be characterised as “ethnographic interviews”: the planning, conducting and analysis of the interviews were informed by knowledge acquired through ethnographic fieldwork conducted at the maternity clinic by the researcher. The interviews were semi-structured and exploratory in nature. The researcher endeavoured to create a friendly, respectful and informal atmosphere during the interview to allow the interviewees to bring up any issues they found relevant, ensuring rich data. The researcher had met most (12) of the interviewees at the maternity clinic prior to the interview whilst conducting ethnographic research. The interviewees were told that the interviews were strictly confidential and that the researcher was interested in their experiences of being pregnant, in particular their use of health and social services. It was also emphasized that the researcher was not in any way linked to the social services or the maternity clinic, but was an “outsider” who worked at the university and conducted independent research. Written informed consent was acquired from each interviewee. The interviews were conducted in 2006 and took place in locations chosen by the interviewee: in homes, in clinical settings as well as in cafés and at the researcher’s place of work. Each interview lasted about an hour, and all were recorded and transcribed. The interviewees were not promised anything in return for the interview, but afterwards they were given a gift-wrapped parcel containing clothing or a toy for the baby. The questions focused on the women’s use and experiences of health and social services during pregnancy and their views and experiences of prenatal drug use. Risk perception, the theme of the present paper, was not focused upon in the interviews, nor was the term “risk” used. The analysis was inspired by a theoretical interest in risk perception, yet at the same time the analysis was inductive and sensitive to the data; the point was to stay close to the interviewees’ experiences. The data were coded manually. Initial analysis involved the identification and coding of all episodes in which the interviewees expressed any worries, fears or anxieties during pregnancy in connection with illicit drug use. After careful reading and re-reading of all these episodes, three major risk themes were identified and coded. These themes were constructed in a more abstract and focused manner than the initial codes so that they could cover all the issues that initially came up in the data in connection with risks.

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The thematic analysis presented below is based on the three major risk themes and focuses on the frequent and characteristic ways in which the interviewees talked about the threats and dangers of illicit drug use during pregnancy. Owing to the limited number of interviewees, some attention will also be paid to individual variation and less frequent themes. The following interview quotations have been shortened and the missing sections are indicated by ellipses.

Findings The interviewees’ expressions of worries, fears and anxieties linked to prenatal drug use are divided into the following three subsections: risks to the foetus or child, risky encounters with professionals and risks related to abstaining from drug use.

Risks to the foetus and child The following excerpt illustrates how illicit Subutex use was typically described by the interviewees as undesirable during pregnancy: Viivi: Of course, I thought that would be the end of it. I thought I would definitely kick the habit because I’m pregnant; of course I would. I would never do that to the baby. But that’s not how it goes at the end of the day. You know you are pregnant, but the baby is not there; you cannot see it yet. It’s not there yet, even though you know it’s inside you. . . It’s really hard. It’s not that straightforward – that once you know you are pregnant you simply quit. . .. Above, Viivi accounts for her illicit intravenous use of Subutex during her pregnancy by underlining her intention to kick the habit – and her inability to do so. Viivi explained in the interview that she was worried about the baby and, for instance, tried to eat a lot despite her lack of appetite in order to give the baby enough nutrition. In addition, she tried to keep her daily intake of Subutex steady because of advice given by her friends. The interviewees’ perceptions of the risks of illicit Subutex use were ambivalent: despite the commonly shared view that one should not use Subutex during pregnancy, the interviewees seemed confident that Subutex use alone does not harm the foetus. Amongst others, Viivi was of the opinion that Subutex does not permanently damage the baby: Viivi: People I know who used [Subutex] during pregnancy have had babies that are fine. They are perfectly normal. . . Subutex should not have any negative effects apart from withdrawal symptoms, which are a disaster.. When you see these babies, they are fine. But they might have learning difficulties or that sort of thing later when they start school; you never know. Whilst medical experts viewed medically-supervised oral intake of Subutex as part of a controlled ST programme as safe, the interviewees also deemed illicit, intravenous use safe as long as the dose was low and steady and the needles were clean. The interviewees, including Viivi, trusted the advice and real-life examples from their peer group of other drug-users or ex-users who had had healthy offspring. Viivi did mention potential learning difficulties, but she did not seem concerned about this prospect. The possibility of learning difficulties or other effects on the functioning of the child’s brain was something the professionals at the maternity clinic talked about to the mothers in an attempt to motivate them to stop the drug use (Leppo, 2008), but the

interviewees themselves did not report any fears linked to this issue. Whilst the possible long-term effects of prenatal Subutex use on the foetus’s brain was not a cause for distress amongst the interviewees, a newborn’s withdrawal symptoms were viewed as a real danger, and avoiding them was paramount as the previous excerpt hinted. For instance, Viivi viewed the newborn’s withdrawal symptoms as the worst possible outcome of her Subutex use: Viivi: I wanted to quit, but I couldn’t. I kept postponing it. I thought I’ll quit a bit before the baby is about to be born, and then it won’t have withdrawal symptoms; the baby’s withdrawal symptoms would be the worst possible thing. But I kept postponing it, and suddenly there were only three weeks left, and it was only at that point that I finally enrolled in treatment. . .. Viivi entered a detoxification unit three weeks before the baby was due in order to stop using Subutex and thereby avoid withdrawal symptoms in the infant. Had the infant been born when expected, it would have had a good chance of going through withdrawal gradually before birth. However, for medical reasons, labour was induced soon after Viivi entered the detoxification unit, and the baby was born with severe withdrawal symptoms. What complicated matters was that the interviewees knew that women in ST programmes often gave birth to infants suffering from withdrawal symptoms. The fear of a newborn’s withdrawal symptoms in fact contributed to the apprehension amongst many mothers at the clinic about ST programmes; many preferred the idea of total abstinence, even though the professionals in many cases found ST a more realistic goal (Leppo, 2008). Some interviewees said that ST had a bad name amongst drug users. Poly-drug use and amphetamine use in particular concerned many interviewees: amphetamine, benzodiazepines and, according to one interviewee, heroin could be harmful to the foetus. One interviewee, Heta, was especially concerned about poly-substance use and described her desire to abstain from other drugs and take her illicit Subutex nasally instead of by injection. She explained that ideally she would have taken Subutex orally, but that would have been too expensive, as nasal or intravenous use requires a lower dose. At the time of the interview Heta was pregnant and had entered ST and enrolled in residential treatment. In the following quotation she contrasts the safety of Subutex use with the dangers of amphetamines and relies on both biomedical knowledge and an example drawn from her peer group: Heta: I’ve been told that there is no evidence of any specific harm [from Subutex use]. That’s why I felt quite safe using it. It would have been a different story if I had used amphetamines or large amounts of benzodiazepines. I have said no to amphetamines during the pregnancy and that’s been easy; I haven’t felt like using it. Using one drug less is a positive thing. AL: Why were you concerned about amphetamine use? Heta: Well, think about it. The foetus’s heart beats about twice as fast as mine,and it has usually been something like 140 or 160 beats per minute and amphetamine accelerates it, so it’s three to six hundred beats per minute. It increases premature delivery and miscarriages. A friend of mine was expecting twins, and she took speed and two days later her water broke. The babies have been in the hospital for over a month now; the first thing the doctor said was that it’s fifty-fifty. I’ve been told that Subutex is safe. Ada had used amphetamines, Subutex and benzodiazepines illicitly during her pregnancy and said in the interview that she had been very worried about the baby’s well-being. At the time of the interview she was in ST and living at home with her partner and

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daughter. In the following excerpt she describes her fears about the pregnancy: Ada: For one week I managed to use only Subutex, but I did not manage for any longer period. I thought I would have to have an abortion because I had used so many drugs. But I couldn’t make up my mind, and I didn’t manage to quit until I enrolled in treatment.. I had this fear that the baby would not be healthy. I used so much speed that the placenta was ruptured. Thank god, the virus count of my hepatitis C was low, and Anna [the baby] was not infected. Otherwise, she would have had it too. . .. When making sense of the risks of amphetamine use, Ada relied on her biomedical knowledge of risks.

Risky encounters with professionals Amongst the risks of prenatal drug use, losing custody of a child was a major fear for all of the interviewees. This threat was very real; the interviewees had friends or acquaintances who had temporarily or permanently been faced with child removal. These fears were linked to the protocol of the specialised maternity clinic in that the clinic’s social worker contacted the child protection services with the women’s consent during pregnancy – and without their consent after the child was born. The policy of the child protection services was that a newborn cannot go home from the hospital if the mother or her partner uses illicit drugs, in which case the mother was usually given the option to enroll first in detoxification alone and subsequently in residential drug treatment with the baby. The father or partner could also enroll in detoxification at this point and in some cases joined the mother and baby at a longerterm, residential drug treatment unit. If the mother successfully terminated drug use during pregnancy or enrolled in ST, then she could usually take the newborn home after which their lives would be monitored by child protection services, e.g. through urine tests and home visits. Based on my observations during seven months of ethnographic fieldwork in the years 2005–2006, a newborn was removed from its parents only if the mother’s drug use continued and she was first unwilling to enroll in treatment or failed to go through with treatment. In the following excerpt Pia, who had been in ST for years before becoming pregnant, but had a relapse early in the pregnancy, describes her fear of losing the custody of her child. Her newborn was hospitalised after birth because of withdrawal symptoms and medical problems owing to its premature birth: Pia: When I went to the hospital [to visit the baby], I really tried to prove myself. I was constantly panicking, thinking they will not let me take the baby home, although there was no reason for thinking that. I kept saying to my mum and friends, “Oh God! They are going to come up with something. I need to. . . and please them as best as I can!” And my mum and friends said, “You don’t need to do that, you can just be yourself; they can’t take the baby without a good reason.” They [the child protection services] have so much power over my life. . . but if things run smoothly as they do now, they can’t do anything; they can’t take a baby away for no reason. They need to have a good reason. The interviewees, including Pia, saw the health care staff as an extension of the child protection services, i.e. as part of the same control machinery that threatened to take their children into custody. Pia was still not quite convinced that her child would not be taken from her, even if she persisted in her ST programme, and took good care of the baby. Many interviewees described how the child protection services did not have a clearly defined protocol:

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usually the child is taken away from drug-using parents, although some cases were known in which the parents had the child at home even though their drug problems were known to the authorities. These unclear “rules” puzzled the interviewees and increased their feelings of insecurity. The interviewees felt threatened by difficult emotions induced by hurtful encounters with professionals. The negative experiences with professionals reported in the interviews induced feelings of guilt, shame, anxiety, anger and even despair. The core of the negative experiences was that something a professional had said or done made the mother feel that she was a bad person and a bad mother. Such emotions or the anticipation of them made the use of the services dangerous in the eyes of most interviewees. In the following excerpt Viivi describes both emotionally rewarding and difficult experiences with professionals: Viivi: It was good. The nurse was lovely; she was always encouraging me. She kept telling me that I would manage to kick the habit and she was really nice. It was easy to talk to her. AL: She was positive? Viivi: Yes, really encouraging. But I didn’t like the physician; he made me feel guilty about all sorts of things. AL: Could you give me an example? Viivi: Well, if the baby was not kicking when the physician was doing the ultra-sound examination, that was somehow my fault, even though I hadn’t necessarily taken anything [drugs]. He would say: “Why is the baby not kicking?” Well, he didn’t literally say that, but anyway. And he kept twisting my words; if I said that I was depressed, he twisted it to mean that I’m mentally ill and asked if I’d had suicidal thoughts. . . He was just too much. Viivi felt that the obstetrician blamed her for things she could do nothing about, categorised her as mentally very unstable and behaved in an overbearing manner. In a similar way Sanna described feelings of shame and defeat induced by encounters with a health-care professional: Sanna: There were a few of them, and one was really horrible; she talked to me as if I was a junkie. Whatever I had used, she should have been polite. Of course, they are allowed to ask how I’m doing and all that, but they shouldn’t start saying things like, “Do you have any idea how dangerous this is to the baby?” AL: How does that feel? Sanna: It feels very bad. Really bad. AL: Why is that? Sanna: It is hurtful. It would be okay to ask politely how things are going, but they shouldn’t talk to you in a way that makes you feel like a real shit, like you are a really bad person, like it’s all your own fault. Sanna did not want to be treated as “a junkie”: she did not identify with the derogatory and reduced identity that she felt the professional forcing on her. What is common to Sanna’s experience and many other interviewees’ is the feeling of lack of competence and moral worth in the eyes of the social welfare or health care professionals. Sanna did not see herself as a “junkie”, but as a worthy person who had a reason for her illicit use of benzodiazepines. Before becoming pregnant, Sanna had used illicit Subutex and her first child had been removed from her care because of her drug problems. Before becoming pregnant the second time, Sanna had stopped using Subutex and had been prescribed benzodiazepines to alleviate panic attacks and depression. The physician at her local health centre, however, decided to stop the prescription when Sanna became pregnant. Unable to cope with the abruptness of it and the subsequent withdrawal symptoms, Sanna started using

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illicit benzodiazepines. The obstetrician at the maternity clinic organised gradual outpatient detoxification from benzodiazepines, and Sanna managed to stop. Sanna’s difficulties in coming off benzodiazepines serve as an introduction to the next theme, namely, the risks related to abstaining from drug use.

The risks of abstinence From the biomedical perspective, giving up illicit drugs completely is the only rational, risk-averse course of action during pregnancy. From the pregnant woman’s point of view, however, the prospect of abstaining from illicit drug use can entail huge risks. The opioid-dependent interviewees described physically and mentally painful withdrawal symptoms, which were extremely hard to endure. Despite their intention many women did not manage to go through with a residential detoxification programme. Some of them had made several attempts before they succeeded. Going through withdrawal during pregnancy is in fact harder than usual because detoxification units do not use benzodiazepines or certain other medications on pregnant women to ease the withdrawal symptoms because of the risk of adverse effects on the foetus. The urge to use Subutex was described by most interviewees as overwhelming. For instance, in Viivi’s words, she wanted to stop using Subutex, but the urge was so powerful “that one’s mind does not necessarily have a say in the matter”. When Subutex-dependent Kati unexpectedly became pregnant, the maternity clinic professionals suggested ST. She first refused because she wanted total abstinence in order to protect the newborn from withdrawal symptoms. After failed efforts at detoxification, however, Kati enrolled in ST shortly before the child was born. To Kati’s great relief, her baby did not suffer from severe withdrawal symptoms. In the excerpt below Kati first describes how she previously condemned drug use by pregnant women and why, paradoxically, she continued illicit Subutex use despite being pregnant. Kati: I can remind myself of how critical I used to be of pregnant women and mothers who do drugs, and I know how people generally feel about it. . . It [using illicit drugs during pregnancy] does not necessarily mean that you don’t care about your child or that you are irresponsible; there are other things involved. . . Addiction is an illness. In a way you’ve brought it on yourself, but once you have it, it’s an illness, and you can’t just pull yourself together. Several things have to work out simultaneously, and you need lots of support in order to succeed. People can’t usually stop on their own, and you need to have the experience that you’ve hit bottom or that you have no choices left. By emphasizing the power of addiction, Kati critically reflected on the general assumption that using drugs during pregnancy implies that the pregnant woman does not care about her child’s well-being. Most interviewees had been seriously concerned about their mental health in connection with detoxification. They described having felt very depressed, anxious or numb and exhausted and having gone through very difficult emotions. One interviewee linked a psychosis she had had previously to withdrawal from Subutex. In the following excerpt Kati explains why she finally decided that ST was a better option for her than total abstinence: Kati: It [ST] is much better for me. It’s not just the physical withdrawal symptoms, but the mental state after you have stopped using drugs: it’s absolutely terrible. That’s why I was unable to go through with the withdrawal at the detoxification unit. I felt so horrible that I just couldn’t take it.

One particular detoxification unit was mentioned by many interviewees as a terrible place. According to the interviewees, this unit treated a large number of psychotic drug users, which made it a grim and restless environment, and the interviewees found the staff unfriendly. Apart from feeling physically and mentally bad, many interviewees described the emptiness and dullness that stopping drug use leaves in one’s life. The emptiness relates to everyday routines and activities, social relations and the sense of self. Ada’s account illustrates the difficulty of imagining herself as “a normal mother” after long-term drug use: Ada: Before Anna was born and also afterwards, it was hard for me to imagine myself as a normal mother who works and has an ordinary life without drugs. I felt that it just wasn’t really for me or that it wouldn’t work out and I wouldn’t be able to cope. It was all so new to me because I started doing drugs very young; I was thirteen. Reetta had tried to stop the use of Subutex and other drugs for several years, and when I asked her what was the hardest thing about stopping, she described the power of a deeply-rooted habit and a feeling of absolute dullness in the face of life without drugs: Reetta: I don’t know. Maybe it’s the fact that you are used to it. It’s a way of life, and you’ve got this idea that so called normal life is so boring; nothing ever happens. . .. In addition to the suffering linked to withdrawal and the boredom linked to life without drugs, there was another significant risk linked to abstaining from drugs, namely, what abstinence would do to relationships and significant social bonds. During pregnancy, the majority (10) of the interviewees lived with a partner who was a drug-dependent, poly-substance user. According to the interviewees, most of the drug-using partners had planned or tried to stop drug use during the pregnancy. Some couples had managed to enter a detoxification unit at the same time, but this was not always possible, owing to the bureaucracy or the partner’s unwillingness to enroll in residential treatment. At the time of the interview, two couples were in long-term residential rehabilitation programmes together with their child. In many cases a partner’s continued drug use caused a great deal of grief to the interviewee who worried about his wellbeing; she found it hard to go through treatment programmes and withdrawal alone and to start a new life with a baby without her loved one. Kati’s and Matti’s baby was six weeks old at the time of the interview; Kati had started in ST before giving birth and was then in a residential rehabilitation programme with the baby. When Kati entered the detoxification unit, Matti could have enrolled at the same time, but according to Kati, Matti’s fear of closed facilities stopped him from joining her. At the time of the interview Matti was at home and still trying to stop using Subutex and other drugs; according to the rules of Kati’s drug treatment unit, active drug users could not visit the unit, and therefore the couple was not able to meet. Kati tried to remain optimistic, but she found the situation very distressing. She felt that Matti had not been given enough support during the pregnancy because the professionals focused on Kati. In the following excerpt Tuuli talks about the time when she enrolled in residential treatment against her wishes with her newborn in order to avoid losing her child. The child protection services were unwilling to let the child go home, as the mother had a history of amphetamine use, had tested positive for benzodiazepines at the time of the birth, and had refused to give urine samples for drug

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testing during the pregnancy, whilst the father’s situation regarding drug use was unknown to the authorities. Tuuli: It was a big shock to me that they [the child protection services] wanted me in residential treatment. There wasn’t a place for Heikki, and I don’t think that he would have been willing to come anyway. It was hard to go there without him. I had to be there for two months. At first he wasn’t allowed to visit; it was only after his urine tests were negative that he could visit us. I missed him and I felt so sad because we were not allowed to start our life together as a family. The way he was shut out – it just felt terrible. In most cases the majority of the interviewees’ friends were also drug users. When trying to discontinue drug use, the women were leaving behind a number of significant social bonds, perhaps their entire social life as they knew it, causing feelings of fear, emptiness and loss.

Discussion In sum, the biomedical discourse on prenatal risk factors focuses on health risks to the foetus and child. From this perspective stopping illicit drug use during pregnancy is the only risk-averse and thereby safe and rational course of action. Interviews with pregnant drug users, however, demonstrated that whilst women may fear adverse effects of illicit drug use on the child’s physical health, questions of safety and risk were much more complicated for them than the simple notion that abstaining from illicit drug use equals safety. The interviewees did not believe that illicit Subutex use would harm the foetus if the doses were steady and the injecting equipment clean. This conclusion was drawn from the observation that their friends and acquaintances had had healthy babies, despite the mother’s prenatal Subutex use. The fact that pregnant opioiddependent women are provided with Subutex in ST programmes may have boosted the interviewees’ confidence about the safety of the substance in prenatal use, although this observation did not come up in the interviews. The interviewees’ views of illicit prenatal Subutex use as being safe for the foetus was in some respects similar to the medical understanding of risks: the women were aware of the importance of steady dosages and hygienic injection practises. To make it more complicated, however, the women regarded Subutex withdrawal symptoms as riskier for the newborn than the experts seemed to do. Paradoxically, enrolling in ST, which professionals saw as a safe solution, was feared by many women, because ST was known to lead often to neonatal withdrawal symptoms. Perhaps the mothers identified strongly with the newborn’s withdrawal symptoms and feared them because the threat loomed in the near future; secondly, they had personal experience of the hardships of withdrawal. In line with professional risk conceptions the interviewees were concerned about the risks of amphetamine use, especially miscarriage and premature labour. The interviewees navigated between biomedical views of risk and lay views, the latter being rooted in their everyday lives and social circles. These findings differ somewhat from those of Murphy and Rosenbaum in the US (1999); they showed perceptions of risk amongst crack-using pregnant women were largely shaped by media accounts. Murphy and Rosenbaum (1999) concluded that, given the media-led moral panic around crack at that time, it was not surprising that crack users were convinced that their babies would inevitably and irreversibly suffer from drug-related harm (Murphy and Rosenbaum, 1999, pp. 73, 75). In contrast to the reputation crack had in the US for being a dangerous drug

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for pregnant women, the findings of the present study demonstrate that in the Finnish context pregnant drug users viewed illicit prenatal Subutex use as a fairly safe practice. Murphy and Rosenbaum found that heroin users were fairly confident that prenatal heroin use at low levels was not a risk to the foetus and that much of the knowledge they considered valuable regarding prenatal drug use came from the drug-using community (Murphy and Rosenbaum, 1999). These findings resemble those of the present study: prenatal Subutex use was deemed safe by pregnant women, and friends and acquaintances from drug-using backgrounds played an important role as providers of knowledge of the risks. In contrast to previous studies conducted in the US, the Finnish interviewees did not fear criminal justice intervention, as such measures were not directed at pregnant drug-using women. Using social and health services, however, was a risky prospect because of the threat of child removal by the child protection services and because of a fear of hurtful encounters in which the woman felt she was being morally condemned by the professionals. These findings support previous research findings, which have underlined drug-using pregnant women’s and mothers’ fear of child protection services and posited that this group of women is very sensitive to professionals’ negative attitudes, which can even become a barrier to treatment (Jessup et al., 2003; Lewis et al., 1995; Murphy & Rosenbaum, 1999; Roberts, 2011; Roberts & NuruJeter, 2010; Vironkannas, in press). A common denominator in negative experiences and fears about professionals was the experience of being treated as a “bad person”, as one interviewee put it. Finally, for the interviewees abstaining from drugs was not a magic-bullet solution to all of their problems. On the contrary, abstaining from drugs was perceived as a major risk: the interviewees feared the physical and mental pain of withdrawal and the suffering and bleakness of life without drugs. Further, most interviewees’ partners had drug problems, and when the women made the decision to enroll in drug treatment programmes their partners were sometimes unwilling and other times not given the opportunity to enroll in treatment with the woman. Stopping drug use and enrolling in treatment could thus cause major disruptions to the interviewees’ social bonds: leaving behind a drug-related lifestyle often meant leaving behind one’s partner and friends – a hard choice. The interview situation influenced the way the interviewees represent their experiences; interviews about substance abuse “easily evolve into a discussion of guilt and exoneration from guilt”, because such a topic puts the interviewee at risk of condemnation (Järvinen, 2000; Järvinen & Ravn, 2011). This is, of course, even more the case with interviewees who were pregnant at the time of the substance abuse. For example, the fact that the interviewees talked a lot about the difficulties or impossibility of quitting Subutex (because the addiction was so powerful) should not be understood only as a direct reflection of their experiences, but also as a means to explain and justify to the interviewer why they had used drugs during pregnancy. It has been noted in previous research that the core narrative in interviews with mothers who suffer from drug problems is a moral tale in which women represent themselves as good mothers (Banwell & Bammer, 2006). The present paper started with a scene in a specialised maternity clinic: a health care professional talks to a Subutex-dependent, pregnant woman about giving up drugs. How should this encounter be understood in the light of the findings presented in the present paper? The professional takes Minna’s Subutex use as a sign of her indifference towards her child. There is no dialogue about risks. Had Minna been asked to elaborate on her fears, she might have explained that she thinks that Subutex does not harm the child

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and that she knows many women who have had healthy Subutexexposed babies. In the encounter only one interpretation of risk is valid, namely, the expert conception of risk. Had Minna been asked why she is unwilling to consider quitting, she might have opened up about the various reasons why she finds terminating drug use difficult, and these fears could perhaps have been discussed. Instead, Minna is labelled as an indifferent mother. This encounter is a good illustration of how values are entwined with risk-assessment and how easily communication about risks becomes permeated with morality and blame. According to the socio-cultural approach to risk, debates about risk link a real danger and disapproved behaviour that threatens a valued institution (Douglas, 1992). Pregnant women’s use of illicit drugs is strongly condemned in society, not only because of the biomedical risks involved, but also because it is seen as a threat to the highly valued institution of motherhood. Further studies on pregnant women’s risk perceptions of drug use would be highly valuable. For instance, the interplay and negotiations between biomedical expert knowledge and lay knowledge requires further attention. Do pregnant women, for example, adhere to expert advice mainly when it is in line with information that comes from their peer group? What kinds of advice do pregnant, drug-using women get from their peer group regarding harm reduction? In addition further studies related to welfare policy are needed in order to examine possible problems or unintended consequences of current policy and practice, which appears to presume that drug use is sufficient rationale for removing of a child from the care of its mother. The present study has several policy implications. In the context of service delivery the perspectives of pregnant women who use drugs perspectives should be taken seriously because it could make the communication of the risks of prenatal drug use in health care settings more effective. Firstly, the adoption of non-judgemental responses in face-to-face encounters seems to be a challenge to many professionals. Secondly, if professionals took seriously perceptions of risk by pregnant women, they could enter into a more open dialogue with the women about those risks, which might offer a better starting point for getting the message across. Finally, fear of the authorities and of losing a child to them was strong amongst the interviewees, indicating that clearer policies on child removal and more information about the protocol of child protection services should be provided to pregnant women with drug problems as early in the pregnancy as possible. Acknowledgements The author wishes to thank Lars Fynbø for his valuable comments on an earlier version of the manuscript and the three anonymous referees for their helpful and comprehensive comments. The study was funded by the Academy of Finland, the Finnish Foundation for Alcohol Studies and the Kone Foundation. References Armstrong, N. (2005). Resistance through risk: Women and cervical cancer screening. Health, Risk and Society, 7, 161–176. Banwell, C., & Bammer, G. (2006). Maternal habits: Narratives of mothering, social position and drug use. International Journal of Drug Policy, 17, 504–513. Bourne, A. H., & Robson, M. (2009). Perceiving risk and (re)constructing safety: The lived experience of having ‘safe’ sex. Health, Risk and Society, 11, 283–295. Caplan, P. (Ed.). (2000). Risk revisited. London: Pluto Press. Coxhead, L., & Rhodes, T. (2006). Accounting for risk and responsibility associated with smoking among mothers of children with respiratory illness. Sociology of Health and Illness, 28(1), 98–121. Douglas, M. (1992). Risk and blame: Essays in cultural theory. London/New York: Routledge. Douglas, M., & Wildavsky, A. (1982). Risk and culture: An essay on the selection of environmental and technological dangers. Berkeley: University of California Press. Flavin, J. (2002). A glass half full? Harm reduction among pregnant women who use cocaine. The Journal of Drug Issues, 973–998.

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