Women Crack Users , Pregnancy and Motherhood : Potential Periods for Health Care

This study aimed to understand how women report their behaviors concerning drug use during pregnancy and breastfeeding. This is a qualitative study, conducted in the metropolitan area of Santos. Twelve women who have used crack were interviewed through a semistructured interview. The interviews were analyzed from the perspective of content analysis. Our data indicate that pregnancy is a critical time to sensitize these women and try to lessen the damage and the risks associated with the use of crack among them.

Women who use crack cocaine have specific needs, such as the use pattern of crack cocaine, pregnancy, responsabilities of child care, prostitution and/or the exchange of sex for money or drugs, traumas and history of violence, mental health problems, low self-esteem and stigma for "being a woman" and a drug user.Therefore, it is important to identify and take into consideration their needs and characteristics when planning treatments (Cruz, Oliveira, Coimbra, Kantorski, Pinho, & Oliveira, 2014).
Although changes have slowly been introduced along with new social roles for women, they are still judged by moral beacons established in past times (Pinsky, 2012) and women drug users are still perceived through a gender bias.Women drug users are stigmatized by the general population and also by professionals when seeking health care.Professionals perceive them as irresponsible, criminals and sex workers (Cruz et al. 2014).
From the developmental perspective, the specialized literature shows some aspects of familial relationships associated with drug use.Parent-child relationships and parenting style have been consistently found as important factors.Pettenon et al (2014) found that women crack users had a different perception of the bond they had with their parents when compared to non-drug users; they were more likely to perceive their mothers as negligent and their fathers as affectionless and controlling.The authors also suggest that such findings might be associated with less resilience among children when facing stressful life events, what in turn increases their risk to use crack.
Systematic review of Brazilian women crack users shows that the use of crack by this group is related to a history of childhood maltreatment (neglect, physical and sexual abuse), lack of education, risky sexual behavior, prostitution and unplanned pregnancy; the study shows that the use of crack cocaine is high among them (Limberger et al, 2016).Additionally, a "binge" use pattern of crack has been identified among women (Cruz et al, 2014).
Risky sexual behavior and unplanned pregnancies have been associated with the use of crack cocaine (Bastos et al., 2013;Costa, Soibelman, Zanchet, Costa, & Salgado, 2012;Duff et al., 2013).The statistics of cocaine and crack cocaine use during pregnancy are difficult to estimate, given that pregnant women generally omit this information (Botelho, Rocha, & Melo, 2013).Nevertheless, it has been pointed out that the estimate is getting higher (Yamaguchi, Cardoso, Torres, & Andrade, 2008).Costa et al (2012) found among pregnant crack addicts admitted for detoxification in a psychiatric inpatient unit that the main reasons given for crack cocaine use were sadness or stress relief, the influence of a friend or a partner who uses crack and the easy access to/availability of the drug.
Moreover, fetal injuries can happen due to the use of crack cocaine.Injuries are especially likely during the perinatal period, ranging from the twenty-second week of gestation to the seventh day of birth.During this period, there is an increased risk of placental abruption, presence of meconium in the fetus, premature rupture of the amniotic sac, short stature, low birth weight, preterm birth (Araújo, 2012;Botelho, Rocha & Melo, 2013;Gouin, Murphy & Shah, 2011;Narcowicz et al., 2013), and genitourinary and abdominal abnormalities (Botelho, Rocha & Melo, 2013;Moreira, Mitsuhiro, & Ribeiro, 2012;Narcowicz et al., 2013).Furthermore, the regular use of cocaine during this period increases the likelihood that the child will develop hypertension later in life and will have difficulties both in concentration and in psychomotor movement throughout their development (Araújo, 2012;Botelho, Rocha, & Melo, 2013;Narcowicz et al., 2013).
Parental drug use has been consistently associated with drug use by the offspring (Basu & Ghosh, 2014;Biederman, Faraone, Monuteaux, & Feighner, 2000;Merikangas et al, 1998).Moreover, women who use drugs have been characterized by some faults in their motherhood which have been associated with a greater risk of drug use by the offspring, such as: negligence, practice of physical or emotional abuse, punishment to control child-like behavior, lack of emotional involvement and inconsistent discipline (Basu & Ghosh, 2014;Suchman & Luthar, 2000;Tucci, Kerr-Corrêa, & Souza-Formigoni, 2010).
A recent study has found that prenatal cocaine exposure alters responses to environmental stress and that it may increase sensitivity in relation to childhood maltreatment (CM).Moreover, prenatal exposure was associated with poorer coping strategies only among adolescents with CM (Min, 2017).Eventual consequences of addiction on the child, after birth or during infancy, such as prematurity, abstinence syndrome, breathing disorders, feeding disorders, sleep disorders, hyperactivity, malformations, make these women feel guilty, given that pregnancy and motherhood are experienced with a strong feeling of ambivalence between addiction and parenting (Silva et al., 2012).
In addition to that, it is desirable that mothers should be encouraged to breastfeed.It is believed that the promotion of this practice might even prevent or delay postpartum relapse (Forray, 2016).However, a research points out that crack cocaine use is absolutely contraindicated during lactation because the drug is present in the milk at high concentrations, causing irritability, vomiting, diarrhea and seizures in babies (Araújo, 2012).On the other hand, studies indicate that breastfeeding should be avoided by women with heavy drug use within the first 24 hours after the last use of cocaine or crack cocaine, while they are intoxicated.After 24 hours, the mother could technically breastfeed, except in cases in which she continues to use the drug.However, in any case, heavy use of any of the coca derivatives, if maintained after child-birth, contraindicates breastfeeding (Santa Catarina, 2015).
Given the complexity of crack cocaine use among women and its implications during pregnancy and breastfeeding, we sought to understand how women report their behaviors concerning crack cocaine use during pregnancy and breastfeeding, in order to foster the development of better care strategies for this population.

METHOD
This was an explorative, qualitative study in health research conducted in the metropolitan area of Santos/SP, Brazil, between March and December 2012.

Location
The metropolitan area of Santos consists of nine counties and has approximately 1.6 million permanent residents according to data from 2011 (Brazilian Institute of Geography and Statistics -IBGE).Migration to this region, the presence of the largest port in Latin America, and the fact that it is a coastal and tourist area have caused the metropolitan area of Santos to become one of the international drug routes in Brazil (Lacerda, Stall, Gravato, Tellini & Hudes, 1996).

Participants
The inclusion criteria were as follows: (1) women with a history of pregnancy and a history of crack cocaine use at least 25 times in their lifetime, to avoid the inclusion of beginners (Oliveira & Nappo, 2008); (2) a minimum age of 18 years old and (3) crack cocaine use in the metropolitan area of Santos.
Twelve women who used crack cocaine in the metropolitan area of Santos were interviewed.The interviews were conducted in places chosen by the participants and the researcher, in order to guarantee the secrecy of the information collected and the necessary ethical care.Interviews occurred in a non-governmental organization, in a feminine therapeutic community, and in public spaces (streets and squares) of the metropolitan area of Santos.Additionally, interviews were conducted individually in a single session and scheduled according to the participants' availability, each taking around 60 minutes.
The selection of women was facilitated by the assistance of leaders of collaborating institutions (non-governmental organizations and therapeutic communities for women) and of the users who participated in the first stage of the research, entitled "Mapping and Profile of Crack/Cocaine Users in Santos City" (Rodrigues, Silva, Oliveira, & Tucci, 2017).At that stage, we interviewed 292 crack cocaine users in Santos, with a predominance of men (86.4%).Previous study of this population has shown significant gender disparities in the following variables: age, marital status, participation in illegal activities, with whom they spend most of their free time and work status in the last three years (Rodrigues et al., 2017).

Measurements
The instrument for data collection was a semistructured interview, which included a script, both developed by the researchers themselves, that addressed the following topics: i) sociodemographic profile; ii) route of administration and use patterns; iii) reported effects; iv) association of crack cocaine and other drugs; v) activities motivated by the need for crack cocaine and; vi) consequences of drug use.Some questions had previously been standardized to allow comparison of responses between the participants, and other issues were further developed or added during the interview, as required by need and relevance (Oliveira & Nappo, 2008).

Data Analysis
This is a qualitative study which works with a universe of meanings, allowing greater depth of relationships, processes and phenomena (Pope & Mays, 2005) that cannot be translated through its reduction to variables in a quantitative analysis.
Each interview was given an alphanumeric code with the initials and the age of the interviewee, as follows in the results section: MP19, NN27, CD37, AF30, PS30 e PA31.
The reports were examined from the perspective of content analysis in the form of thematic analysis, which includes a set of communication analysis techniques that enable the inference of knowledge concerning collected messages (Bardin, 2011;Dahlgren, Emmelin, & Winkvist, 2004).
For the development of this technique, the data analysis consisted of the following procedures: i) exhaustive reading of each interview; ii) establishing thematic categories; iii) organizing and analyzing the material according to the thematic categories; and iv) re-reading the contents of the categories, comparing them with the existing literature and with the authors' theoretical framework (Bardin, 2011;Minayo, 2010).
The interviews were conducted by women researchers, which could be considered a facilitator in obtaining the information required, possibly for a question of gender parity that helped us introduce some thematics during the interviews and also facilitated empathy.

Ethical Aspects
The goals of this research were explained to the participants, and informed consent was obtained prior to the interview.Participants signed a written consent form that was previously approved by the Research and Ethics Committee (IRB) of the University of São Paulo.The Committee also approved the project as a whole.
This project is part of the study "Mapping and Profile of Crack/Cocaine Users in Santos City" (Rodrigues et al., 2017).

RESULTS
The mean age of the women interviewed was of 29.5 years and their mean age of first drug use was of 13.7 years.Most women were unemployed.Most (eight of them) were homeless and two were in a therapeutic community.They reported a long history of crack cocaine use (mean time was of 10 years).
The data have shown that pregnancy can trigger the exercise of self-control (abstinence or restricted use) with respect to crack cocaine use.Additionally, it was reported the weaning occurred due to crack cocaine craving.This could be understood as an instinctive measure of harm reduction.
She´s eight months old now.Eight?I think it's been a little more than a year since I´ve stopped, it's been over a year since I´ve stopped.(MP19) I think the longest time I didn't use was 6 months...It was, it was the pregnancy plus jail, it was one followed by the other, and now I'm without drugs for another month, thank God. (NN27) I was using right before I got pregnant.Since getting pregnant, I have not used drugs.(...) When he was eight months old, I weaned him (...).I began to feel the delay of the drug and felt afraid to use the drug and harm my son, so I gave him a baby bottle and continued using crack cocaine.(CD37) On the other hand, some reports showed that during pregnancy it was impossible to control the use of crack cocaine and, after the birth, maternal function was substantially impaired by the use of this drug, including also loss of custody of a child that can be observed in the following: If I was using crack cocaine and saw (the social worker) taking my son, (and if) I was high, I would end up (smoking) that crack cocaine real quick and go chasing after them.(AF30) (...) when I lost my children (...) [loss of custody], it hurt a lot.It was very painful.I went into that empty house, but the priority was the drug, the priority was the drug (...) (PS30) I discovered that I was pregnant.He (her spouse) did not want me to use crack cocaine while I was pregnant, but I did.I used my entire pregnancy.But I used too much, much, much, during the day and the night.(AF30) It is interesting to notice that pregnancy can be enough to trigger the self-control to stop the use of crack cocaine, as can breastfeeding.Self-control deficit may have contributed to the self-destructive behavior and difficulties encountered by these women to avoid the use of this drug during these periods.
The women interviewed also reported to be scared of passing on the drug addiction to their children.Some of them are aware that their drug use can increase the risk of drug use among their children.On the other hand, we also detected awareness about how a good family bond can be a factor in the safety of their children, as reported by PS30: "V is 2 years old today, he is a son of crack, I used crack the whole time of my pregnancy, he grew up with me smoking crack"; and PA31:

DISCUSSION
In Brazil, according to Bastos et al. (2013), crack cocaine users, both men and women, are mostly young adults with ages around 30, unemployed or on irregular jobs, single, with a significant number of them living on the streets (40%) or spending most of their time on it, which is similar to our findings.
It is important to note that most women interviewed in this study declared themselves to be homeless, spending a short time in social institutions or doing any kind of activity, which may be due to the lack of emotional or affective bonds among these women.The absence of a supportive relationship has been found as a risk factor for a problematic drug use (Marques, Ribeiro, Laranjeira, & Andrada, 2012;Marangoni & Oliveira, 2013), so social support needs to be the focus of any kind of intervention with this population.The social support can function as an important external mechanism of control for risky behavior as well as an emotional support for these women who are socially excluded.
Handlovsky, Bungay, Johnson and Philips (2013) indicated that the social relationships of women drug users are key elements in the process of safe use, mainly of crack cocaine use.According to these authors, healthy social relationships can help reduce physical, psychological and interpersonal harm associated with such use.These relationships -with family, friends and at work -would entail self-care and care for others and could be configured as a contingency management strategy for developing and maintaining healthy relationships as well as strategies for safe use and for reducing the damage caused by crack cocaine use or any other drug.
In the present study, women recognized that even if they are still using crack cocaine or had used during their pregnancy, a good family bond can protect their children from drug use later in life.This recognition follows the same direction of that found in the literature, which shows that a good parenting bond is a protective factor against drug use (Choquet, Hassler, Morin, Falissard, & Chau, 2008, Kopak, Chen, Haas, & Gillmore, 2012, Pettenon et al., 2014).However, literature also shows poor family relationships-specifically fragile parental bonds, permeated by violence, negligence, lack of support, control and authoritative parenting-among drug users (Brajević-Gizdić, Mulić, Pletikosa, & Kljajić, 2009, Choquet et al., 2008) which, in turn, have been associated with greater risk of drug use (Garcia, Pillon, & Santos, 2011, Huang et al., 2011, Seleghim & Oliveira, 2014, Shin, Miller, & Teicher, 2013;Tondowski, Noto, Pimenta, & Fonseca, 2011).In this direction, it is important to establish family-focused substance abuse prevention programs on high-risk groups to reduce the risk of later drug use in the offspring.There is some evidence of the effectiveness of such programs when they are long-term and involve the whole family.
These women can have a new understanding of harm reduction, services and resources through personal experience, informal and formal learning (Handlovsky et al., 2013), showing the importance of investment to bring information about crack use to the areas of use and of creating a link between drug users and health services.
Regarding the use of crack cocaine/cocaine during pregnancy, some women mentioned that getting pregnant encouraged controlled use or abstinence of crack cocaine.On the other hand, some female crack cocaine users consider pregnancy as a stressful period in life, suggesting that pregnancy may be a period of vulnerability to drug use.It is also common to find among women crack users insufficient prenatal care, with no visits to the doctor or a scarce number of visits.This behavior is related to the social isolation imposed to these women, which increases the discrimination and harm suffered by them (Botelho, Rocha, & Melo, 2013).Despite the changes in the social roles of women, they still suffer inequality of access to health care, to education and to the labor market (Piot & Cravero, 2011).
These findings suggest the importance of comprehending this period for women crack cocaine users and emphasize the implications of motherhood, which determines the amount of care and attention that women must devote to their child's well-being and healthy development (Pinsky, 2012, Silva et al., 2012, Fertig, 2016).
Although crack has been found as the most frequent illicit drug used during pregnancy, it is hard to establish all different drugs used during pregnancy because these women are poly drug users and use more than one drug at the same time, suggesting that female drug users constitute a specific group, with their own needs and characteristics.Moreover, this poly drug use is associated with social factor triggers, which should be the focus of drug treatments (Marangoni & Oliveira, 2013).
The relation that individuals have with drugs influences their choices and consequently their social and interpersonal contexts.Crack cocaine use is complex and the interpretation of life events influences the attitudes and motivations of such users.Thus, drug treatment should consider gender differences, and personal and social aspects related to drug use (Cruz et al., 2014).
Another finding was that some women chose early weaning to minimize the adverse effects of crack cocaine use on their child's development.Botelho, Rocha and Melo (2013) point that the use of crack cocaine among pregnant women increases health risk and harm for both mother and newborn.In this study, early weaning can be considered a harm reduction strategy developed by these women to protect their baby from adverse effects of crack cocaine during breastfeeding.Being aware of this behavior is an important aspect that should be considered in the guidance and treatment of women crack cocaine users.Although such a strategy can minimize the complications of crack cocaine use during breastfeeding, it could affect, in some cases, the development of the mother-child relationship during this period (Silva et al., 2012).In this sense, the benefits of continuing breastfeeding should be balanced against the risks of exposure of the baby to the drug through breastfeeding (Community Paediatrics Committee 2003-2004).
It is a consensus that mothers should be encouraged to breastfeed (Santa Catarina, 2015).To make breastfeeding possible, it is necessary to support and empower these women through an educative program -so that they can think critically about the issue -to ensure the health of these women/mothers and their children (Costa et al., 2012;Moreira, Mitsuhiro, & Ribeiro, 2012).Cocaine derivatives should be avoided during lactation, as the drug reaches high concentrations in milk, causing irritability, vomiting, diarrhea and seizures in babies (Araújo, 2012).If the mother starts weaning abruptly, it is important to provide guidance and care for both mother and child, concerning the mother's occasional discomfort caused by lactation and the introduction of the bottle and other foods to the child (Community Paediatrics Committee 2003-2004).
The findings of the present study show the importance of intervention programs to reach and change dysfunctional patterns of beliefs in order to minimize the harm among pregnant women who are drug users and their babies.It is also important to identify stressful life events and social and interpersonal contexts that trigger crack cocaine use during pregnancy.In this sense, drug treatments should take into consideration gender differences and personal and social aspects related to drug use.

FINAL CONSIDERATIONS
Studies about the use of crack cocaine among women are still a recent practice.Notwithstanding, the structural, social and cultural barriers faced by these women in their search for treatment and health care are a well-known problem, especially with regard to gender issues.The complexity of such issues also indicates the need for an interdisciplinary approach in tackling this phenomenon (Sugarman, 2016), in order to minimize situations of vulnerability and health hazards.
Pregnancy was perceived as a motivator for controlled use or for abstinence of crack cocaine but, on the other hand, it was also considered a stressful period in life, suggesting that pregnancy may be a period of vulnerability to drug use.The findings highlight that pregnant women using drugs require early intervention (Minnes et al., 2012), community support, and inter/multidisciplinary treatments that address their clinical and social problems individually, since in order to change their behaviors, it is necessary to strengthen their emotional and affective bonds and minimize their vulnerabilities and self-control barriers.
Women using drugs face a social stigma, making their access to treatment more difficult (Botelho, Rocha, & Melo, 2013;Pinto et al., 2010, Simpson & McNulty, 2008) as well as their adherence to the practices of the prenatal period (Silva et al., 2012, Simpson & McNulty, 2008).Despite this, pregnancy may be an opportunity for a woman to start a relationship with the health care system and to engage in prenatal and postnatal self-care practices (Botelho, Rocha & Melo, 2013).The follow-up of these women should be systematic and periodic, with a more human stance and integral care for the health of the mother and the baby.It is necessary to create a soothing and warm atmosphere to get the attention of this population and facilitate their access and adherence to prenatal and postnatal care, since the findings show that women crack users understand the harm that crack cocaine can cause in their offspring yet need more information about how to protect their children from such harm.One possible way to prevent more harmful effects of crack cocaine to their offspring is to develop a strong family bond through long-term, family-oriented substance abuse prevention programs focused on high-risk groups, and with parenting and family skills training.
The use of crack cocaine during pregnancy can increase risks to the health and harm of mother and newborn.In this study, some women crack users chose early weaning to minimize the adverse effects of crack cocaine use on their child's development, suggesting a harm reduction strategy developed by these women to protect their baby.However, such strategy could affect the development of the mother-child relationship.Thus, the benefits of continuing breastfeeding must be put in the balance, as well as the risks of exposure to the drug through breastfeeding.These are important aspects that should be considered in the guidance and treatment of women crack cocaine users.
The findings also highlight the need to provide information and care for these women who are marginalized and socially excluded during pregnancy, with emphasis on the implications of motherhood.Pregnancy can be a critical time to sensitize them and attempt to lessen the harm and risks associated with the use of crack cocaine or any other drug.This study still suggests that harm reduction education could be the most indicated intervention to avoid further negative effects related to drug use among pregnant women.