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he pain of a pregnancy ending in a baby being removed into care
immediately after birth is one of the most distressing experiences
known to those involved in drug and alcohol treatment – yet it is all
too familiar to drug and alcohol service users, their families and
clinical staff. When it has happened once to an individual woman, it is
more likely to happen again when another pregnancy occurs – often very soon
after the first removal, and with no time to achieve stability before the mother is
once again traumatised and demoralised even further.
The
Hidden harm
report (2003) recommended that contraceptive services
should be provided through specialist drug agencies, but this has not happened
in practice. Staff at South London and Maudsley NHS Trust (SLaM) addiction
services approached colleagues in Guy’s and St Thomas’ NHS Foundation Trust
(GSTT) community sexual health and asked for help to make contraception
available to women with substance problems, while enabling them to retain their
fertility and have the best possible chance of successfully conceiving and keeping
their children when their recovery was secure. Two years later, we can evaluate
the success of this joint working and look at further ways to help marginalised
people gain access to sexual health services.
An audit in 2012 showed high levels of unmet need for contraception among
women using SLaM addiction services. Sexually active women said they were
worried about pregnancy, but were not using contraception. In April 2013, using
one-off start-up funding provided by Southwark drug and alcohol commissioners,
an agreement was reached that the consultant in community sexual health and
HIV from GSTT together with our already established BBV nurse would start
providing health care on drug service premises.
Due to administrative delays, direct work with patients did not start until June.
While waiting, links were made with a brand new, fully equipped, sexual health
clinic just ten minutes’ walk from the Southwark community drug and alcohol
team (SCDAT) base. Staff at SCDAT visited this clinic and actively informed
service users about it. Privileged access was provided so there would be no need
for appointments and no queuing, but even so, only one person per month used
this opportunity, demonstrating that an in-house service might be more effective.
In June 2013, the in-house clinic opened for four hours per week, backed up
by some additional visits outside clinic hours when SCDAT service users asked to
see the sexual health consultant. There have now been 52 clinic sessions and a
total of 184 consultations; 43 individual men and 74 women have received
services. Some people have come with a partner (both different sex and same
sex), many have come on their own, and often introductions have been made by
their key worker.
A total of 74 sexually transmitted infection (STI) screens have been carried
out and 67 BBV (including HIV) screens. Treatments for STIs have been started
and/or completed and the risk of transmission has been eliminated. Twenty-five
women have received (often long overdue) cervical smears. Investigations of
incontinence, sexual dysfunction, and prostate cancer have been carried out, and
concerns about sexual abuse, sexual assault, intimate partner violence, and
infertility have been raised and suitable referrals made.
Long acting reversible contraception (LARC) gives drug and alcohol dependent
women the opportunity to delay pregnancy while establishing their recovery. If the
woman chooses to stop the method it is removed and fertility is restored – she
doesn’t have to give a reason for asking for removal, this is done immediately, at
any time, on request without question. The hormonal contraceptive Depo-Provera
(depot medroxyprogesterone acetate, or DMPA) is an exception to this, as the 12-
week injection itself cannot be reversed and there can be a delay before fertility
resumes once the method is stopped; this is always explained before a woman
chooses this method. None of the LARC methods prevent STI transmission, and
none are prone to failure due to user error as is the case with oral contraceptive
pills and condoms.
Data shows that individuals using the clinic represent service users with the
most complex needs and the most severe poly-drug and alcohol dependency. This
demonstrates that the clinic is meeting the needs of drug and alcohol users who
would not otherwise attend any sexual health service, and is not just being used
as an alternative to mainstream services by people who have milder addiction
problems. Women were more heavily represented in the group using the service,
although they only make up one third of the CDAT population, so we are satisfied
that they are gaining more than fair access to the provision that they need.
The average number of consultations per clinic session is 3.5, leaving room
for more, and we have provided contingency management to increase uptake.
Small value shopping vouchers of £2 have been offered to people for having an
STI screen and £5 for those having a LARC method or a cervical screen. This
gained ethical approval and is in line with local policy for incentivising BBV
screening and vaccination. The sums were deliberately kept small in order not to
bring undue influence to bear on decision making.
We believe that the most important factor influencing attendance at the clinic
is accessibility and also providing additional training to drug service key workers
With family planning a sensitive and controversial subject,
the sexual health needs of service users can be overlooked.
Rosie Mundt-Leach
tells DDN how a south London drug
service has teamed up with commissioners and sexual health
experts to offer open in-house clinics, with promising results
12 |
drinkanddrugsnews
| August 2014
Practice exchange |
Family planning
www.drinkanddrugsnews.com
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