id 13697

ORIGINAL RESEARCH

 

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

 

Daiani Modernel XavierI, Giovana Calcagno GomesII, Marta Regina Cezar-VazIII, Dóris Helena Ribeiro FariasIV, Mauro Francisco Ferreira de AlmeidaV, Cristiane Martins da RochaVI

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 users6,7. 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 education8,9.

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:

I was not planning a kid now. I had sex with my boyfriend under the effect of crack without a condom and I got pregnant. I trusted my partner. I was in love. (W8)

It was at home with my partner. I had careless sex. Several times, it was under the effect of the drug and we did not use condoms. I did not want a son, but it happened. (W4)

I had sex and I got pregnant. It was at home. I was feeling the sensation of the drug and decided to have more pleasure with my husband. We used the drug and had sex. I did not think and I got pregnant. (W3)

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.

With the use of crack I cannot remember how or where I got pregnant. I know it was with my boyfriend. I think it was in a party. I discovered that I was pregnant when my period stopped. (W1)

It was with my husband, the father of my children. I don't remember when I got pregnant. (W9)

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.

I worked as a sex professional and had sex with some clients without a condom. (W15)

It was sex without condom, at the club where I work. (W18)

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.

It's been two months since I stopped using crack. I used it for most of the gestation. I could not help myself. I was depressed. (W9)

When I realize I'm already on the street and smoking crack again. I was able to stop for a while with the help of my partner. He was afraid I'd lose the baby. (W14)

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.

I lost weight during my gestation because I used to change food by crack. After using it, I would vomit a lot. My son was born premature because of that. (W3)

I lost too much weight because I did not eat. I only used crack and I lost a lot of weight. I lost 33 pounds from the beginning of gestation. Because of this my baby was born malnourished and premature. (W13)

I would smoke crack and then vomit. I got way too too thin, with small breasts and I did not produce milk due to the use of crack. My son was born undernourished. (W12)

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.

When I got pregnant I used to consume crack, but less than before. (W7)

I used crack during the gestation. I decreased the consumption, but I did not stop because I had horrible abstinence crises. [...] I felt bad. I had pains, I would scream out of pain in my body with no letup. I was going crazy. Even pregnant I had to smoke crack to get over my pain. (W18)

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.

During pregnancy I got about five months without abandoning my children, my mother, my husband and my house to live only for crack. Because of the pregnancy I tried to stay at home and not disappear after the drug. (W6)

Since the beginning of pregnancy I took care of my children, I assumed that commitment. (W5)

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.

I did not make prenatal care. Crack is so devastating that it made me lose interest in pregnancy and only go after crack stones. I was afraid the doctors would report me and get me arrested again or lose my daughter when she was born. (W18)

I did not perform prenatal care during pregnancy [...]. I was afraid that they would make tests and would find diseases in the baby. (W17)

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

After I got pregnant I promised to keep the promise I made him to stop using crack. I do not want the Guardianship Council to take my daughter away, nor does my partner discredit my promise. (W2)

I do not want to lose my husband. Now that I have had a child I do not want to undo my marriage. I intend to stop the crack. (W1)

Perceptions about childbirth

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

It was normal and fast. I waited, opened my legs, and I had the child. I had little pain. (W3)

I gave birth to my daughter, it was normal delivery. (W5)

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

I had a normal birth, but I little answered the questions they asked me. The lack of the crack made me nervous and depressed in the delivery room, besides the pain I felt. (W16)

When I went to the surgical room and looked at all those instruments, I started to get agitated, I screamed a lot and I became aggressive. They got mad at me and asked me to stop. As I did not stop, I was given a sedative in the vein. After some time I went to the room. My daughter was sent to the Neonatal ICU because she was born with a risk of death. (W8)

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.

My experience with childbirth was painful. There was no dilation. It was a pain that made me mad. (W1)

Lots of depression because of the drug. I could not keep lying down. [...] I was feeling contractions of childbirth, but I did not have dilation. I thought I couldn't handle it. [...] It was a cruel, very difficult birth. I almost died, I think. I lost my strength at the time of childbirth. (W6)

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.

I arrived at the hospital with contraction pains. The doctor told me that I would need a Caesarean section to have my daughter. I was calm because I was under the effect of crack. It gives me peace of mind. (W8)

I went to the hospital to have my daughter shortly after smoking crack. I felt better this way, less agitated. (W2)

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

Because of prematurity, my son was born with low weight. He does not have two pounds yet. He had respiratory insufficiency. And had low sugar, and always with low temperature. It was born before the time [...] (W1)

My daughter was born apathetic and with eye infection. They told me they think it's because of syphilis and gonorrhea. It was because I used crack that she was born with this problem. (W2)

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.

I did not know I had HIV. I learned after the quick test. I did not have prenatal care and I arrived at the hospital already with contractions to get the baby. I know I got this virus because I was using crack. (W4)

I found out when I went to the surgical room to have my baby that I had HIV. It was an exam I did there. It made me nervous to have my daughter. Yes, I used crack. I do not know how I got it, but when I'm under the effect of the drug I do not even know about myself. (W6)

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.

I started to go crazy on my own, only with my addiction partners. I smoked so many cracks that I felt a severe pain in the belly and bleeding. I arrived at the hospital and I had a miscarriage. I did not have the opportunity to take care of my son, because he died before he was born. (W11)

I hemorrhaged when I lost the baby. I had strong pains in my belly. The hemorrhage was such that I asked the neighbor for help and she called the ambulance, but I had already lost my son. They said it was an abortion caused by the use of crack. (W10)

 

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 unemployment16-18.

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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