ORIGINAL RESEARCH

Women crack users' perceptions of the drug's influence on pregnancy and childbirth

Daiani Modernel Xavier^I, Giovana Calcagno Gomes^II, Marta Regina Cezar-Vaz^III, Dóris Helena Ribeiro Farias^IV, Mauro Francisco Ferreira de Almeida^V, Cristiane Martins da Rocha^VI

^I PhD in Nursing. Federal University of Rio Grande. Rio Grande do Sul, Brazil. E-mail: daiamoder@gmail.com.br
^II PhD in Nursing. Adjunct Professor, Federal University of Rio Grande. Rio Grande do Sul, Brazil. E-mail: giovanacalcagno@furg.br
^III PhD in Nursing. Full Professor, Federal University of Rio Grande. Rio Grande do Sul, Brasil. E-mail: cezarvaz@vetorial.net
^IV PhD student in Nursing, Federal University of Rio Grande. Rio Grande do Sul, Brasil. E-mail: dorisenf@hotmail.com
^V Physician. Assistant Professor, Federal University of Rio Grande. Rio Grande do Sul, Brasil. E-mail: malmeida@yahoo.com
^VI Master student in Nursing, Federal University of Rio Grande. Rio Grande do Sul, Brasil. E-mail: enfecristiane@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.13697

ABSTRACT

Objective: to learn how women crack users perceive the drug's influence on pregnancy and childbirth. Method: in this quantiqualitative study, the participants were eighteen women crack users admitted to a maternity facility in southern Brazil in 2014. Data were collected by interview and then submitted to content analysis, with research ethics committee approval (Protocol Nº 135/2013 and CAAE No. 23116004845/2010-52). Results: the women were found to seek family support to overcome consumption of crack and prostitution. They mentioned losing weight, not producing milk, and failing to undergo antenatal care due to use of crack. They tried to rebuild a stable family relationship. Some gave birth normally, but others had complications, including premature labor and miscarriage. Conclusion: nurses need to equip themselves in order to assist women crack users to experience pregnancy and childbirth, by ensuring their safety and care for their newborn babies.

Keywords: Women; substance-related disorders; crack cocaine; nursing.

INTRODUCTION

The increasing consumption of crack has brought to society a series of troubles. In 2010, it was estimated that the number of crack users in Brazil was around 1.2 million¹. Women users are characterized as a group that presents sexual behavior of risk, due to multiple partners, prostitution and inconsistent use of condom as a means to obtain income to support the addiction².

A study reports that more than one-third of women infected with the Human Immunodeficiency Virus (HIV) report using crack³. Another study with crack-dependent women revealed their involvement with robbery, arrest, prostitution and home abandonment. Intervention programs are necessary to avoid the consequences of crack for both women and newborns⁴.

Crack consumption has been associated with a wide range of obstetric complications, including intrauterine growth retardation, preterm birth, placental abruption, intrauterine passage of meconium, neonatal abstinence syndrome, and fetal and neonatal death. These risks may be related to repeated exposure of the fetus to crack⁵. Another frequently associated factor is physical health complications, such as poor nutrition and lack of body hygiene on the part of women⁶.

Knowledge about how the influence of crack in gestation and childbirth is perceived by women users may contribute to a rethinking of the care practice, qualifying nursing care. Such reflections led to the guiding question: how do crack users perceive the influence of the drug in pregnancy and childbirth? Thus, the objective of the study was to know the perception of women users of crack on the influence of the drug in pregnancy and childbirth.

LITERATURE REVIEW

With the increase of crack consumption among the general population, there has been an increase in consumption among the female population, and, consequently, of pregnant women.

A study reports a limited number of prenatal consultations, search for treatment for substance abuse and resolution of health problems by these users^6,7. Contact with health professionals is limited as they fear losing custody of their children. In general, these women are single, unemployed, poor and have a low level of education^8,9.

During crack consumption, serum levels of the drug in the fetus reach levels close to those of the women. Researchers concluded that there is no safe amount of consumption during pregnancy. Newborns may present signs and symptoms of hyperactivity, restlessness, irritability and tremors⁸.

In view of the influence of crack on pregnancy and childbirth, it is necessary to identify these women and their children so that appropriate interventions may be carried out. The correct diagnosis helps the women and the newborns to receive appropriate treatment and care and can prevent these women from having other children exposed to the drug⁸.

Nursing professionals should seek alternatives to help these women to experience gestation and delivery in a safe way. To this end, they must establish with the women an educational space in which they are prepared to care for themselves and for the newborn. From this perspective, professionals should introduce in their care instruments a process to facilitate the adaption women to the new situation, promoting their qualification to care for their children¹⁰.

METHODOLOGY

This is a descriptive research with quantitative approach. Descriptive research addresses the description of the phenomenon investigated, allowing to know the problems experienced and to deepen their study within the limits of a specific reality. The quantitative approach associates numeric values ​​with the investigation of human relations¹¹.

The study was carried out in the first semester of 2014 in a maternity hospital of a university hospital (UH) in the south of Brazil, a reference in high-risk pregnancy and in the care of drug users. The participants were 18 puerperal users of crack assisted in the sector and randomly selected. The inclusion criteria were: to be a crack user, to have had the child in the UH. We excluded the puerperal users of crack that were under 18 years old. All participants received explanations about the objectives and methodology of the study and they signed the Informed Consent Term.

Data were collected through individual semi-structured interviews. Clients were asked to talk about their perceptions of the influence of use of crack on gestation and delivery. The interviews took place in the waiting room of the sector, providing comfort and privacy.

The statements were submitted to content analysis, understood as a set of methodological instruments, constantly improved and applied to discourses, providing the researcher with the search for the latent, not apparent and hidden aspects in the analyzed discourses¹¹. This method is operationalized in three phases. The pre-analysis is the organizational phase, when an operational and systematized organization of the initial ideas is made, and a quick reading of the material, creating a corpus that is the set of documents to be analyzed. In the phase of material exploration, quotations are selected in the text for categorization of units for analysis and data coding. After this step, treatment results takes places, in which the coded material is now represented by the registration units, forming units and categories¹².

Ethical principles were respected in accordance with Resolution nº 466/12 on research involving human beings¹³. The research project was submitted to the Ethics Committee and approved under Opinion nº135/2013. The speeches of the participants were identified by the letter W, referring to woman crack user, followed by the number of the interview.

RESULTS

The characterization of study participants and the categories generated in the analysis of data are presented below.

Characterization of study participants

Eighteen female crack users who had their children in the UH maternity ward participated in the study. Their ages ranged from 24 to 36 years. All lived in the suburbs of the city of Rio Grande/RS. They live in houses of two to five pieces, four of masonry, eight of wood and six mixed (masonry and wood) with water and light; it is worth mentioning that five of the participants lived in houses without basic sanitation.

All participants had incomplete Elementary School. Eleven of them were single; three were married and four were common-law married. As for profession, seven considered themselves housewives; eight were unemployed and three were sex workers. As to the number of children, five reported having two children; six, three; five, four children; one, five; and another eight children.

It was found that 14 women had diseases associated with the use of crack. Three reported suffering from recurrent pyelonephritis; four had Human Immunodeficiency Virus (HIV); four had hepatitis; five had syphilis; one had gingivitis; and another one is hypertensive and suffers from tuberculosis and alcoholism. Only two participants used crack exclusively. The others used cocaine, marijuana, alcohol, merla (cocaine surplus) and tobacco besides crack. Only two had crack as their first drug.

Analysis of categories

Context in which the gestation occurred

Three study participants reported that the pregnancy had not been planned. They got pregnant under the effect of the drug. They reported:

Two participants reported not remembering how and where they became pregnant. They know that it was with their permanent partners and they discovered the pregnancy due to the interruption of the menstruation.

Because they use prostitution as a way to get money for buying the drug, in this study, two of the participants reported that pregnancy occurred as a result of unprotected sex with a client.

The discovery of pregnancy can cause the user to try to stop using crack for the health of the child. However, they need help to achieve this goal and to take care of the child after childbirth.

Perceptions about living during pregnancy

Instead of gaining weight during gestation, five users reported losing weight because they had not eaten properly. They attributed the non-production of breast milk to the fact that they were crack users and believed that their babies would therefore be malnourished and/or premature.

The gestation for them represented a motivator for the attempt to reduce the consumption of crack. However, abstinence crises caused them intense malaise and pain. They also said they could not do without the pleasure that the drug provides them.

Two participants reported that they had managed to avoid living days only in function of the drug, staying at home so that gestation occurred in a quiet way.

Four participants reported that they had not performed prenatal care during pregnancy. They believed that addiction to crack made them lose interest in pregnancy. They mentioned laziness as a reason for not attending the scheduled appointments. They were afraid that the doctor would find out that they were using crack and that they would report it to the police and the Guardianship Council and that they could be arrested or lose custody of their children. Furthermore, they were afraid to perform blood tests that detected illnesses in themselves or in the baby.

They perceived gestation as a motivator for the search of family structure and a stable marital relationship.

Perceptions about childbirth

Two of the study participants reported having had a normal, difficult birth. Here are the testimonials:

They believed that, because they had symptoms of abstinence of crack, they were not able to contribute to the progress of labor.

They reported having severe pain during labor and contractions without the necessary dilation for the birth of the baby due to the use of crack.

They consumed crack minutes before admission to the hospital to have the child and, therefore, they mentioned that were tranquil due to the effect of the drug.

Two women had preterm birth and had sexually transmitted infections. They attribute these facts to the use of crack during pregnancy.

Two women found out in the delivery room, through the rapid test, that they had HIV. This fact left them agitated and apprehensive at the time of childbirth. They attribute the contamination by the virus to the use of crack.

Abortion also represented a negative experience lived by women who used crack during pregnancy. They had severe vaginal bleeding and severe abdominal pain during pregnancy. They reported that the miscarriage occurred due to the abuse of crack during pregnancy.

DISCUSSION

As for the context in which the gestation occurred, the women attributed the unplanned pregnancy to the use of crack, resulting from unprotected sex. A US study found that 93% of crack-dependent pregnant women reported having sex with permanent partners. Of these, 73% did not use condoms. However, 43% were sex workers, and 21% reported having become pregnant with clients. As a result, the addicted person becomes a disturbed individual who, although trying to stop using the drug, feel the need for help to cope with chemical dependence¹⁴.

The use of crack by puerperal women during breastfeeding reduces the chances of proper nutrition of the newborn due to maternal malnutrition, low milk production and the risk of psychiatric comorbidities due to abstinence of crack, such as aggressiveness and lack of maternal affection for the baby. The changes in the life of these women result from psychological and physical changes influenced by the sentimental vulnerability in which they are¹⁵.

A study showed that the use of alcohol, marijuana and tobacco occur at higher rates among these women when they seek to reduce cocaine consumption during pregnancy and after childbirth.¹⁶ Pregnancy motivates women to stop or reduce the use of crack for the sake of the baby's health. The society and the family begin to demand from women responsibility for gestation, requiring their personal and family structure.

Some women performed prenatal care and sought to commit to a stable marital relationship. Others did not, because they feared that the Protective Services for Children could take their children away from them if they continued to use crack and/or other psychoactive substances ¹⁷.

The use of psychoactive substances is related to multiple social factors. Women who use psychoactive substances are less assisted by prenatal services and have a higher incidence of complications during pregnancy. The lack of follow-up by a healthcare team during pregnancy, with no right to qualified nursing care, adequate food, family support and the continuity of consumption during pregnancy are factors that can lead to the death of the children after birth, prematurity, low birth weight and congenital malformations¹⁸.

Studies have shown that women who use crack are vulnerable to HIV and other sexually transmitted infections due to risky sexual behavior, such as the exchange of sex for psychoactive substances, non-use of condoms, sex with multiple partners, history of physical and sexual victimization, problems with criminal justice, lack of stable housing and unemployment^16-18.

Regarding the perception about delivery, a study shows that the most appropriate conduct in these cases is vaginal delivery with analgesia. However, they perceived the peripartum period as critical, due to the abstinence of crack. Much of this risk is related to acute intoxication at the time of hospitalization¹⁹.

Stress related to the onset of regular contractions, sometimes without dilatation and the pattern of heavy use of the drug are factors that increase the chances of acute intoxication in the first moments of labor. Furthermore, crack users may present refractory hypotension to the use of ephedrine, drug-related thrombocytopenia, altered perception of pain with decreased efficacy of analgesia or anesthesia, and technical difficulties related to aggressive behavior¹⁹.

The use of crack during the gestational period can cause fetal malformations, miscarriage, premature birth, maternal mortality, stillbirth and neonatal mortality²⁰. Women who use crack found out to be HIV positive sometimes during the rapid test in the delivery room. Women who use crack are vulnerable to HIV infection and other sexually transmitted diseases due to inadequate prenatal care and sexual behaviors without the use of contraceptive methods¹⁷.

CONCLUSION

Considering the purpose of the study, it was found in the category Context in which the gestation occurred that the women had not planned the pregnancy, but rather resulted from unprotected sex. They tried to stop using crack and prostituting themselves and sought support from the family. In the category Perceptions about living during pregnancy, the women reported having lost weight, not having produced milk and not having undergone prenatal care due to the use of crack. They tried to reduce consumption and build a stable family relationship motivated by the pregnancy. Finally, in the category Perceptions about childbirth, some women reported having had a normal delivery, without difficulties. Others pointed out that they had not contributed to labor because of severe pain, vaginal bleeding, lack of contractions and dilatation; others had premature birth and miscarriage due to the use of crack. They used crack before giving birth, justifying this use by the fact that it had a calming effect on them.

The results of the study present the use of crack during pregnancy and childbirth as a complex problem, requiring health professionals/nurses to prepare for this confrontation. It is necessary to prevent pregnancy, when this is unwanted; and also to prevent sexually transmitted diseases. These women need to be referred for prenatal care, with adequate follow-up during this period. Health professionals/nurses should be prepared to perform the delivery of these clients, accompanying them in the puerperium. It is necessary to guide the women about the care with the babies and verify those at social risk to make the appropriate referrals, ensuring their safety and care.

As a limitation, the study was performed with participants linked to a single hospital. This configures findings of a specific reality and shows the understanding of the phenomenon under a given perspective, not allowing the generalization of the findings.

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