1. LANARKSHIRE’S ADDITIONAL MIDWIFERY SERVICE (LAMS)

2. Context Implementation of LAMS ‘one-stop-shop’ clinics throughout North Lanarkshire to improve pregnant women, with a history of substance misuse, engagement for antenatal care to improve:  stability of substance used  outcomes on 1) pregnancy 2) newborns wellbeing 3) service provision requirements.

3.  Improve pregnant women (with a history of substance misuse) in North Lanarkshire’s engagement for antenatal care to improve stability of substance of choice: 1.Implementation of ‘Pathway of care’ all localities 2.All women with a history of drug or alcohol use signposted for assessment & all care at LAMS clinics if applicable 3.Trained ‘Link’ community midwife to share care of clients at LAMS. 4.Addiction staff educated on ‘pathway of care’ & responsibilities 5.Multi-agency team approach of care. Improvements 1 - LAMS

4. Improvement 2 – ABI Screening  To accurately screen all pregnant women on their present and pre-pregnant alcohol consumption to identify where an alcohol brief intervention should be delivered and assist on future diagnosis of infants affected by Fetal alcohol Spectrum disorder (FASD).  collation number of women consuming alcohol in the 3 months prior to booking, identifying possible risk of alcohol damage 1 st trimester pregnancy.

5.  To evaluate the impact of the use of psycho-social interventions (via use of MYRAP diary) has on reduction/ abstinence of substances where clients are not open to or engaging with addiction staff but are attending LAMS clinics. Improvements 3 - MYRAP

6. Who is involved?  Pregnant women with a history of drug or alcohol misuse  Specialist Midwife substance misuse  Seconded substance misuse midwife (EYC)  ‘Link’ LAMS community midwife  Community midwives.  Integrated addiction nurse/worker  Seconded admin support (EYC)

7. Data! LAMS - referrals (1) REFERALS TO LAMS There have been 65 clients referred between April – Dec 2014’. 46 engaged assessment with 40 receiving all care LAMS. 71% Assessed LAMS 17% declined service 11% miscarriage 1% Unknown 87% of clients assessed received all care LAMS

8.  Impact implementation of LAMS clinics has had on engagement PDSA CYCLE Bellshill clinic: Data! LAMS - engagement (2)

9. Data! LAMS- engagement (3)

10.  Of the 46 clients who attended LAMS clinics for assessment the following graph shows the trend of substances used in North Lanarkshire: Data! LAMS- Stability (4) Stability substance use 3mths prior to LAMS assessment Stability substance use after 6mths LAMS support

11.  The following PDSA looked at accuracy of recording screening of alcohol use of pregnant women at booking. Particular focus on No. who advice no alcohol use prior to pregnancy. Data!- ABI Screening Prior to 1 st test of change. Audit 1 st test of change. Audit 2 nd test of change.

12. Data!- MyRap case study  Ms A –P1 14wks pregnant  Ref to LAMS assessed 14wks  History – Anxiety disorder & depression Using large amounts Cannabis treat MH Meds stopped by GP pregnancy External social pressures  Commenced MyRap 16wks  Seen fortnightly  Identified impact drug has on various aspects life  Motivation & confidence increased  Identified triggers use – work on relapse prevention.

13.  LAMS clinics:  Continue to record engagement at LAMS clinics.  Breakdown of the non-attendance by categories: rescheduled, 1 st appointment or no contact made (identify areas to work on).  The impact attendance has on the stabilising of their substance use will continue.  A focus on clients with ongoing illicit use to identify risk factors having an impact on ability to abstain.  Audit of LAMS input on 1) Pregnancy outcome (Gest / mode & type of delivery). 2) Newborns outcomes (weight, FASD/NAS, treatment & NNU admission). 3) Service requirements. Alcohol screening and recording : Ongoing audit of midwives recording within notes & changes to PDSA as required. Recording date of last alcohol use to assist in identifying alcohol use in 1 st trimester of pregnancy. MYRAP: Currently tested with one client linked to use of cannabis. For review on both stability and pregnancy outcomes. The test of change will be repeated with clients with different substance use & social factors. **Commenced Jan 15’, the specialist midwife will plan and introduce a PDSA to look at client’s experience of attending LAMS and will implement scope for client’s vision of a service to accommodate their needs. Next Steps

14. Next Steps…. Future thoughts??   Impact LAMS support has on the client and her partners knowledge of the impact drug &/or alcohol use has on her pregnancy, newborn and parenting capacity.  Support from smoking cessation to assist LAMS clients on abstaining from tobacco.  Impact use of SOLIHUL has on clients attending LAMS antenatal on their capacity to safely care for their child where previous social work involvement has been required.  The effect one-to-one breast feeding workshop has on women, who are on substitute prescribing, choosing to breast feed at birth, discharge from hospital and 6 weeks postnatal.  The impact new perinatal mental health centre (PMHS) has on women attending LAMS where significant mental health issues are identified.  Impact discussion of planned long term contraceptive device has during pregnancy at LAMS has on uptake of same following birth. Looking at methods used, numbers inserted prior to discharge from hospital and subsequent numbers of unplanned pregnancies with known drug or alcohol use.

15. “So What?”  Increase engagement for easily accessible specialised antenatal care.  Increase knowledge on the effects of substances on pregnancy and newborn.  Increase stability and/or reduction of drug use & identification and treatment of Neonatal Abstinence Syndrome.  Early identification of needs, multi agency support and sharing of information with holistic family centred care provision.  Improved parenting capacity by providing early specialised antenatal parenting programmes, knowledge and understanding of bonding and attachment and the effects substance misuse may have on parenting ability.  Increase breastfeeding rates within this client group.  Increase accuracy of ABI screening and recording resulting in improved identification of potential FASD.  Reduction in families affected by domestic abuse and gender based violence.  Increased understanding, early identification and appropriate support for women and families at risk of mental health issues.  Increased use of long term contraceptive devices to reduce unplanned pregnancies.  Reduce maternal and infant mortality and social gradient.  Improve maternal and infant mental, physical, social wellbeing and reduced social gradient, better housing and employment opportunities.  Provide person centred, safe and effective care to all women and families

16. Investment of Resources  What has been invested into this improvement work? The Specialist Midwife is currently funded through ADP & works with the existing community midwifery & addiction staff. Funding secured the secondment of a ‘substance use midwife- full time band 6’(incl training & equipment) which has allowed rollout of LAMS clinics & ability to collate data. In addition admin support of 6hrs week has aided data collation. What resources would you hope to reduce/stop in the future by implementing this change? The embedding of LAMS throughout Nth Lanarkshire has been successful in identifying the growing demands of specialist care for this vulnerable client groups. The need for ongoing secondment of substance use midwife is evident and would allow a vast amount of future tests/ data collation to be carried out.

17. For More Information  Insert Contact Details: Lorraine Farrow Specialist Midwife for Substance Misuse Bellshill IAS 95 Main Street Bellshill Tel: 01698 403798 Mob: 07827983933 Lorraine.farrow@lanarkshire.scot.nhs.uk