Perceptions and practices of pregnant women attended in primary care using illicit drugs

Abstracts

Objective:

To identify perceptions and practices of pregnant women in primary care on the use of abuse drugs.

Methods:

A descriptive of qualitative approach research developed with 25 women drug users. The data were collected in July 2012 in Maringá - PR, through open interviews and subjected to content analysis.

Results:

The pregnant women reported difficulty in abandoning the use of drugs and the information about it during prenatal care is inadequate. It was observed that some of them feel fear and guilt from the possibility of harm to the fetus and others do not care about this possibility and also that illicit drug users feel judged and not supported by the professionals.

Conclusion:

It is necessary to sensitize the professionals who do prenatal about the importance of welcoming, enlightening, guiding and supporting pregnant drug users, in order to promote a qualified prenatal care and harm reduction.

Drug Users; Illicit Drugs; Primary Health Care; Pregnant Women; Nursing

Objetivo:

Identificar percepções e práticas de gestantes atendidas na atenção primária frente ao uso de drogas de abuso.

Métodos:

Pesquisa descritiva de abordagem qualitativa desenvolvida com 25 mulheres usuárias de drogas. Os dados foram coletados em julho de 2012 em Maringá - PR, por meio de entrevista aberta e submetidos à análise de conteúdo.

Resultados:

As gestantes relataram dificuldade em abandonar o uso de drogas e que as informações, sobre isto, durante a assistência pré-natal são insuficientes. Observou-se que algumas sentem medo e culpa decorrente da possibilidade de agravos ao feto e outras não se preocupam com esta possibilidade e ainda, que as usuárias de drogas ilícitas sentem-se julgadas e não apoiadas pelos profissionais.

Conclusão:

É necessário sensibilizar os profissionais que fazem o acompanhamento pré-natal sobre a importância de acolher, esclarecer, orientar e apoiar gestantes usuárias de drogas, com vistas a promover uma assistência pré-natal qualificada e a redução de danos.

Usuários de Drogas; Drogas Ilícitas; Atenção Primária à Saúde; Gestantes; Enfermagem

Objetivo:

Identificar percepciones y prácticas de gestantes asistidas en atención primaria frente al uso de drogas de abuso.

Métodos:

Enfoque cualitativo, descriptivo, desarrollado con 25 mujeres usuarias de drogas. Los datos fueron recolectados en Julio de 2012 en Maringá (PR), a través de entrevistas abiertas y sometidas al análisis de contenido.

Resultados:

Las mujeres reportaron dificultad para abandonar el vicio y que la información sobre el uso de drogas durante la atención prenatal es inadecuada. Se observó que algunas sienten miedo y culpa frente a la posibilidad de efectos adversos para el feto y otras no se preocupan. También que los consumidores de drogas ilícitas no se sienten apoyados y son juzgados por profesionales.

Conclusión:

Es necesario sensibilizar a los profesionales que hacen prenatal acerca de la importancia de apoyar las usuarias de drogas embarazadas, con el fin de promover una atención prenatal calificada y reducir los daños.

Consumidores de Drogas; Drogas Ilícitas; Atención Primaria de Salud; Mujeres Embarazadas; Enfermería

INTRODUCTION

The use of illicit drugs has increased by the feminine universe, as it had already occurred with the tobacco and alcohol. The number of women admitted for dependence has increased; previously the demand for assistance was more associated with the men, but these differences have diminished in recent years. Additionally, the addiction reaches all social classes, and some women who never sought medical help and/or the workgroup private rehabilitation clinics are hidden in this statistics¹.

In a study conducted in the State of Minas Gerais, for example, it was observed an increase of 79.5% in the number of women users of crack that sought treatment for dependence on this drug and 76% in the number of women admitted to the SUS units for consumption of psychotropic substances, such as cocaine and crack².

Drugs of abuse are classified, as licit and illicit to the legal status of substances, according to its marketing. The legal drugs have allowed the State to be sold and consumed, with or without a prescription, containing psychoactive substances whose production, sale and use are not criminalized. The legal drugs are represented mainly by alcohol, tobacco, caffeine, hallucinogenic plants and psychoactive drugs³.

This division, eminently legal, became cultural, and passes the idea that the drugs are safe and the illicit are dangerous. However, alcohol and tobacco are substances that cause most deaths likely to prevention in the world. Thus, it is not a matter of absolving, minimize or criminalize the substances, all bring prejudices that must be considered, regardless of the licit or illicit status³.

Currently, in various stages of prenatal care is the health care professional to detect consumption of these substances during pregnancy. Early diagnosis favors intervention and creates possibilities for access to specialized treatment services and coping alternatives to the use of drugs of abuse in pregnancy, avoiding maternal and neonatal complications⁴.

The habitual use of drugs and the advancement of addiction may lead users to develop illicit activities and including an unplanned pregnancy and undesirable, in addition to other health problems⁴.

In addition to all social issues involved, pregnant women drug users constitute a problem for health services, performing fewer prenatal appointments and have a higher incidence of complications and obstetric clinics⁵, creating new socio-medical challenges for the relationship drug use and maternal and child health.

When it is offered support to pregnant women who face this situation, they have lower level of stress, anxiety and depression, in addition to maintaining a positive perspective in relation to the use of drugs of abuse and visualize the situation more realistically⁵. However, in Maringá-PR a study found that there are deficiencies in reception drug users, and this is no different with the user expectant mother⁶.

Study conducted in Florida, USA, with 392 nurses who acted in 10 perinatal hospital units using a questionnaire entitled Attitudes About Drug Abuse in Pregnancy (AADAP), to assess attitudes against drug use in pregnancy, concluded that the nurses demonstrated limited knowledge about exposure to psychoactive substances, addition and its side effects, as well as, more punitive attitudes and negative demonstrated than positive or of support for women who abused substances during the perinatal period⁷.

However, by acknowledging the socio-cultural context in which the individual is inserted, it can identify the risk factors that permeate the dysfunctional drug use, fundamental step towards creating strategies of health teams together the families and people in vulnerable situation⁶.

Given this scenario and the fact there are few Brazilian studies reporting the contexts in which there is continuity of addictive behavior during pregnancy, it becomes relevant sensitizing nurses and other health professionals about the importance of a comprehensive healthcare, humanized and qualified to pregnant women, aiming at the promotion and protection of health, the prevention of diseases, the diagnosis and early treatment and social reintegration³.

Thus, the present study aimed to identify the perception and practice of pregnant women seen in primary care through the use of drugs of abuse.

METHODOLOGY

This is an exploratory descriptive study of qualitative approach. The descriptive study has as purpose to observe, describe, explore, classify and interpret aspects of facts or phenomenon⁸. The exploratory study has the purpose to clarify and provide an overview on dimensions more magnified about a particular fact, seeking to know how the phenomenon manifests itself, which interferes in it and/or how the variables interrelate⁸.

From the qualitative research attempts to understand a problem from the perspective of the subject that the experience in their daily life, their satisfaction, disappointments, surprises and other emotions, feelings and desires and also in the perspective of the researcher.

This study is part of a larger project entitled: "Mental Health in pregnancy and puerperal period", in which it was interviewed a representative sample of all the pregnant women assisted in the 25 primary health units of Maringá-PR. This sample has been constituted by 394 pregnant women, of which 72 reported using some type of drug of abuse. For the present study a pregnant woman at a primary health Unit (BHU) was contacted. In cases where there was more than a pregnant drug user in BHU, simple random drawing was held so that the informants are 25 pregnant women drug users, being one at BHU.

The contact with pregnant women took place by phone, at which point we ask again the participation in the study. After this contact, a visit home for the completion of data collection in July 2012 was scheduled, through open interview guided by the following guiding question: Tell me about the use of drugs of abuse during pregnancy. The interviews had duration of 26 to 63 minutes, and they were recorded and subsequently transcribed for greater reliability of the data.

The analysis of lines was based on content analysis technique of type theme, towards the understanding of communications, content or manifest latent, explicit or hidden events, according to the inferences of the researcher⁹. For the development of this technique their operational phases were followed, founded in the constitution of the corpus, floating, reading material exploitation, composition of the corresponding registration units, the unit of signification (clipping of lines) that were later classified to compose the categories. All these being formed by the semantic criterion, i.e. the contents with similar directions were grouped, which culminated with the thematic categories⁹. The data were analyzed giving rise to two thematic categories.

In relation to the ethical question, the research is in accordance with resolution 196/96 of the National Health Council that dictates the rules and procedures for research involving humans and was approved by the Standing Committee on Ethics in Research with Human Beings at the State University of Maringá-PR (Opinion 448/2011). All respondents signed an informed consent in two ways.

To protect the anonymity of the participants, they are identified with the letter P of pregnant woman and two numbers, the first indicating the order of realization of interviews and the second the age from the informer, followed by their marital status, number of children and the drug of abuse used.

RESULTS AND DISCUSSION

The age of the pregnant women in the study ranged from 17 to 35 years old, but were between the ages of 16 to 24 years old (60.0%). The median age was 21.5 years old, but eight cases of them got pregnant as teenagers. Pregnancy in this phase can restrict the continuation of studies and even professional activities contributing to the maintenance of poor socioeconomic conditions. The teenagers who fail to complete their studies due to the use of drugs can lead to lives of economic depression, with increased risk of exposure to prostitution and marginalization as result of drug addiction⁴.

Among the markers and risk factors of pregnancy prior to pregnancy is the insecure marital status³, in which it can be observed in this study since more than half (56%) and only 20% were married, as found in other studies with pregnant women drug users^5,14-10.

About education it was realized that 76% had up to seven years of study, and they had delayed school according to the age. In relation to occupational situation 84% had no job. These data corroborate with other studies conducted with pregnant women drug users in a town in the southern of the country⁶ and in Rio de Janeiro¹⁰.

In relation to the number of children it was found that 11 of them had one or two children and nine no son. In this study the average was one pregnancy, differing from other studies conducted with pregnant women drug users in which the average were two pregnancies^6,10.

Finally the standard use of drugs of abuse, it was observed, according table 1, that the most consumed drug was tobacco (28.0%), followed by alcohol (20%) and cannabis (20%), multiple drug pattern also found in other studies^6,10-14.

Table 1
Distribution of pregnant women users of drugs of abuse, according to demographic and socioeconomic characteristics type of drug used

Variables n %
Age Group (years old)
16 to 19	8	32.0
20 to 24	7	28.0
25 to 29	7	28.0
≥ 30	3	12.0
Marital Status
Stable Union	6	24.0
Single	14	56.0
Married	5	20.0
Education (years of study)
None	1	4.0
1 to 3	7	28.0
4 to 7	11	44.0
8 to 11	5	20.0
12 and +	1	4.0
Occupational Situation
Housewife	13	52.0
Unemployed	8	32.0
Informal job	3	12.0
Student	1	4.0
Number of children
None	9	36.0
1-2	10	40.0
3-4	5	20.0
5 or +	1	4.0
Type de substance
Alcohol	5	20.0
Cocaine and derived	4	16.0
Cannabis	5	20.0
Tobacco	7	28.0
Multiple drugs	4	16.0

After characterization, there are followed the two thematic categories found: fear and guilt - Feelings that accompany pregnancy of users of drugs of abuse and differentiation in attending pregnant women drug users.

Fear and Guilt - Feelings that accompany pregnancy of users of drugs of abuse

Pregnant women have shown in their reports that know the harm that drug use may cause during pregnancy. However, they reveal difficulties in abandoning the habit just for the dependency that these cause. Thus, they experience a paradox in that at the same time, feel fear and guilt arising from the possibility of aggravations to the fetus, and this occurs in a more forceful manner in cases of addiction to illicit drugs.

I'm really scared of miscarrying again, because I've had three miscarriages and I know it was my fault. I tried to stop using cocaine, marijuana, alcohol and cigarettes, but it's hard, I couldn't put it down just the cigarette and tried to decrease the amount of cocaine and marijuana. But the will is greater sometimes. (P1, single, 20 years old, no children-marijuana, cocaine and alcohol).

[...] I've tried stopping when I had my first child, but I can't... it is just smell that I can't resist [...] (P10, single, 19 years old, a son-marijuana).

Every time I go to use it I think about what could happen to my son [...] but I can't [...] at most one day and I get uncontrollable [...] (P3, single, 17 years old, a son-marijuana).

It is noted that there is difficulty to identify the effects of marijuana use on the fetus. This occurs due to the high prevalence of patients who use concomitantly with other drugs, including alcohol and cigarettes¹¹. However, it was proven the increased risk of several malformations of fetuses as anencephaly and Gastroschisis in women who made use of marijuana during pregnancy, as well as cognitive disorders, changes in attention, learning difficulties and greater impulsivity¹¹.

In the case of cocaine, this may affect cardiac and vascular systems of the woman and the fetus, in addition to causing spontaneous miscarriages¹². In addition, it was identified that fetal exposure to cocaine is associated with cognitive dysfunction, including impairment of attention, executive function, and language learning¹².

The feelings of fear related to the health of the baby and early fault against the possibility of any complication can also be present in pregnant women that make use of legal drugs such as alcohol and cigarettes.

I tried to quit smoking when I found out I was pregnant, but I couldn't. I try smoking three cigarettes a day, because they said that the child is born with lightweight [...] I'm afraid of harming the health of my son [...] (P2, 35, married, three kids-tobacco).

I've tried to quit drinking... but I can't [...] I'm stuck at home [...] but I can't have anything [...] glass of alcohol, fuel and even perfume [...] because I already drank at the moment that I lose control [...] (P13, 26 years old, single, no kids, alcohol).

How hard it is to quit smoking [...] I'm very nervous, anxious and aggressive [...] I do everything to not smoke, I walk, I go in the shops, I don't take more coffee [...] but after spending a day or two I can't resist [...] even worrying about my son [...]I get a guilty conscience. (P6, single, 18 years, no children - tobacco).

The consumption of alcohol is a major global public health problem especially since its inception has occurred increasingly early and in addition, the number of women has grown dramatically. Alcohol intake in pregnancy can lead to the commitment of both the maternal and the fetus, characterized by abortion, placental abruption, uterine hypertonia, premature labor, and increased risk of infections¹³.

In relation to the fetus, for example, the consumption of alcoholic beverages has been associated with the pre and postnatal, growth deficiency developmental delay, microcephaly, neuro-psychomotor dysfunction and thin facial dimorphism, aside from cleft palate and cardiac anomalies¹³. The late effect is manifested by changes in intellectual ability, learning, attention and behavior¹³.

Smoking or exposure to tobacco smoke is associated with an increased risk of miscarriage, low birth weight, prematurity, perinatal death, sudden infant death syndrome, cognitive problems and growth and development¹⁴, childhood cancer, respiratory diseases and allergies with symptoms in the first few years of life^15,16.

In spite of all these possible harms women, as with users in general, she also has great difficulty in abandoning the use of drugs of abuse, whether licit or illicit, as already identified in other studies with pregnant women^6,10.

Moreover, the belief that the substance does not cause harm to the fetus often is enhanced by experience in previous pregnancies, which ends up interfering with drug withdrawal. For example, among women in the study, three of them reported that the use of drugs of abuse in gestation has not any problem to the fetus, which in a way they are disclaimed of fault. However, it is possible to observe that for lack of information or disbelief, they do not take into account the possibility of psychosocial and long-term consequences in the life of the child.

I've had alcohol in the last pregnancy [...] I have no problem [...] my son was born perfect [...] so I'm taking it now too [...] but the weekend huh?! This what they say drinking pregnant and the baby is born with a problem lis a ie huh? [...] (P8, 26 years old, married, five children-alcohol).

I smoked crack the entire previous pregnancy [...] the baby was born perfect [...] he had two legs, two arms [...] he was born before 9 months and weighing a litlle [...] but he's normal [...] at least they told me that [...] because he lives with my aunt and I keep using it [...] he will not have problems [...] (P9, 31 years old, married, one son-crack).

The entire pregnancy [...] I never had problems [...] so all children here with health. [...] so I keep smoking [...] I was in the Group of pregnant women [...] they told me to stop, but I told tjem that nothing happened with the other children [...] it would be with this one that it would happen right? [...] (P14, 24 years old, married, two kids-cigarette).

Look I'm not going to lie [...] I use marijuana yes, since my first child... I'm in the room [...] no one had mental problem, all are good [...] for me to be "pregnant" is not a disease, then I keep using about three cigarettes a day. (P11, 21 years old, single, three children-marijuana and alcohol).

Late complications, such as cognitive and psychosocial issues arising out of the use of drugs may appear over the life of the child^10-14, which also may be more likely to develop mental disorders¹⁵.

As the women who claim that the use of drugs during pregnancy does not lead to problems because child did this usage in previous occasion and the son was not born with problems, there are those who claim that pregnancy is not a sickness and that consequently may use drugs of abuse during pregnancy.

Besides other people keep pointing to me [...] because I'm pregnant. [...] it is the story that pregnant woman can't drink anything [...] I do not agree with that [...] people say that pregnancy is not a disease [...] (P15, 29 years old, married, three children-alcohol).

Wow, anytime they speak for me to quit marijuana because I'm pregnant, I just turn around and say I'm not sick, I'm pregnant and marijuana is good for health [...] it is good for the sick [...] I saw on TV. (P4, 25, unmarried, no children-marijuana).

Look, I think pregnancy is just a normal state of the woman [...] making use of drugs will not cause the child to be born with a problem [...] so many people drink, smoke and have no disease [...] (P18, 18, unmarried, a son - alcohol and cigarette).

Differentiation in attending pregnant women drug users

Against what it has been presented so far, some pregnant women feel embarrassed to reveal their dependence to the primary care health professionals, which can help to ensure that they do not have access to further information concerning the possibility of obstetric complications and cognitive problems in children in the long time, as a result of drug use. It is noted in their reports that these women feel fear of being judged by professionals, depending on the use of drugs.

I'm afraid to tell to my family that I use marijuana and for the professionals of the clinic [...] because I'll have to come here to have the baby [...] if I say that, they're going to be talking about, everybody's going to know [...] and the people of the clinic don't like people drugged [...] (P7, 17 years, stable, no marijuana).

I never commented to anyone of the clinic [...] I'm not stupid [...] I think if I spoke, the people of the clinic wasn't going to take it further, I'm taking both lecture [...] (P15, 29 years old, married, three children-alcohol).

Look, at previous pregnancy I haven't talked to anyone in the clinic about the crack [...] and my son was born dead [...] this time I think, but I'm scared I won't help me and just listen what to do [...] (P20, 20 years, stable, a son - crack).

Precautions pregnant women addicted to alcohol and other drugs is complex and requires technical and psychosocial skills of health professionals. The main barrier in the accompaniment of women dependents is prejudice and when they are pregnant, this prejudice multiplies, so they tend not to report the use of drugs during pregnancy¹⁶.

However, it can be observed that in general, women who used legal drugs like the cigarette, they are not afraid to report this fact to health-care professionals.

I was supported when I told them that I smoke. It had a great smoking group that helped me to stop [...] It was very nice [...] (P23, 33 years old, married, two kids-cigarette).

By the time I was dependent on alcohol they advised me to continue going on and seek help in CAPS [...] they helped me a lot in the clinic [...] (P24, 26 years old, single, two sons-alcohol).

It was also evidenced the existence of differential treatment, depending on the type of drug used, and pregnant women users of legal drugs reported to feel supported and encouraged to pursue strategies to address addiction while users of illicit drugs, in addition to feel discriminated against, commented that they were not supported.

By the time I said I use cigarette nothing happened [...] the staff of the clinic put me in the group to quit smoking [...] they guided me to try to decrease the number of cigarettes [...] but when I used the cocaine [...] the people form the clinic changed [...] they were aggressive [...] they judged me telling me to stop or I was going to kill the baby [...] that I was clueless [...] I was very sad [...] I've heard of people talking about here she comes the pregnant junkie [...] I was trying to stop [...] (P16, 26 years, stable, no son - cigarette and cocaine).

[...] in the first query I told them I smoke and asked for help for the women from the clinic [...] so I went back to follow-up with them [...] and I was gradually decreasing the number of cigarettes smoked [...] 03 maximum per day [...] (P17, 21 years, stable, a cigarette).

It is observed in the four reports that the gestational period already constitutes encouragement for women trying to abandon the use of licit and illicit drugs, as identified in a study conducted with multiparous users of crack in south municipality region⁶ and with pregnant women that use of alcohol and tobacco in Rio Grande do Sul, Brazil¹⁷.

The ways society judge drug users brings out feelings, which sometimes prevents pregnant women users to admit the problem, being the consequence of not looking for help or seek health services late^6,7,10-14. Thus, a systematic follow-up and integral during the gestational period is indispensable, because it may help women shed their doubts about their pregnancy, identify early complications of pregnancy and including the need for a differentiated intervention to cases of drug use.

Finally, another serious problem highlighted was the fact of women reveal that health professionals generally do not address issues related to the use of drugs - licit or illicit during prenatal follow-up.

They don't even ask for us if we use drugs, what medicine we take [...] they just look at the stomach and told to take vitamin [...] (P7, 17 years, stable, no marijuana).

Nobody ever asked me if I used drugs [...] they asked of food [...] to prepare the breasts for breastfeed [...] if I had contraction [...] (P5, 19 years old, unmarried, no children - crack).

So they look my pressure, they look if I'm bloated and asks if I had a problem, hence step for the nurse to make an appointment next month, I don't even know what the cigarette does during pregnancy [...] (P12, 18 years old, single, no kids-tobacco).

However, there are women who reported that they address these issues related to drug use, but very simple and superficial claiming that the guidelines about what can happen to the pregnant woman and the fetus are insufficient.

They just told me that I cannot use anything during pregnancy, no drugs, no medicine, no plants [...] because it interferes in me and the kid, I was told to cut the cigarette but I don't even know what makes cigarettes in me and my son [...]. (P21, 17 years old, unmarried, a son-tobacco).

In addition, another flaw in prenatal follow-up pointed to it was the lack of continuity in care or a misdirection to another health service after reported that they used drugs.

Well after I revealed who used crack... people from the clinic didn't know where to send me [...] they talked to us to go to drug users anonymous or find some guy named CAPSON [...] I was not [...] they do not report things right, I don't understand anything. (P22, 21 years, stable, 3 kids - crack).

I was sent there in CAPS alcohol [...] after I came back to check on the clinic and asked if they knew if these homes help women right... they didn't know [...] I just heard from people on the street [...] (P25, 24 years old, single, 4 sons-alcohol).

This kind of behavior leads us to infer that the health team is not properly equipped to deal with the situation or even the existence of neglect with this problem characterized by not valuing its effects to the pregnant woman and the fetus. It is important that all pregnancies of drug users are considered high risk and that all possible measures to try to keep women of this practice be adopted, including with the support of multidisciplinary^10-18 and intersectoral team.

The nurse, as a member of the health team and as coordinator of the nursing staff, is qualified to perform the greeting of the pregnant women users of drugs of abuse and must prepare the nursing staff and community health workers to deal with this phenomenon in the community, aimed at the promotion of assistance to health and harm reduction⁵.

FINAL CONSIDERATIONS

In view of the objectives of the study, it was noticed under the optics of pregnant women, that information on drugs of abuse offered by primary care health professionals during prenatal care are inadequate. Still, according to reports from users of illicit drugs in addition to feel judged, they did not receive support or appropriate follow-up to the confrontation of the problem.

Thus, it is necessary to sensitize health professionals, including those of nursing which do prenatal consultations about the importance of clarifying and guide pregnant women about the use of drugs of abuse, in order to sensitize them on the importance of interrupting the use during pregnancy and at the same time help them in this endeavor.

However, for this it is necessary that the professionals are adequately prepared for this approach. In addition, government investments are also needed to encourage the development of research in this area in order to better subsidize the activities of health professionals among pregnant women drug users.

It is believed that early detection of this event by primary care health professionals, will allow women to be admitted early and this may encourage the adherence and treatment of chemical dependency, minimizing complications and obstetric clinics, in addition to promoting harm reduction and better quality of life for mother and son.

Finally, it is important to note that during the study may have been scouting bias, since the use of interview as a tool for data collection is subject to memory lapses, confusion or even embarrassment on the part of women interviewed in reporting aspects of her life.

REFERÊNCIAS

• ¹
  Zilberman ML, Hochgraf PB, Andrade AG. Gender differences in treatment-seeking Brazilian drug-dependent individuals. Subst Abus. 2003 mar; 24(1): 17-25.
• ²
  Uso de crack aumenta entre mulheres de Minas Gerais. Jornal Hoje em Dia (Belo Horizonte) 2010 [citado 2013 jan 10]. Disponível em: http://noticias.r7.com/saude/noticias/uso-de-crack-aumenta-entre-mulheres-de-minas-gerais-20100314.html
  » http://noticias.r7.com/saude/noticias/uso-de-crack-aumenta-entre-mulheres-de-minas-gerais-20100314.html
• ³
  Centro Brasileiro de Informações sobre Drogas Psicotrópicas - Cebrid. Livreto informativo sobre drogas psicotrópicas. 5ª ed. Brasília (DF); 2010.
• ⁴
  Nappo S, Sanchez ZDM, Ribeiro LA. Troca de sexo por crack. Porto Alegre (RS): Artmed; 2012. p. 566-75.
• ⁵
  Marangoni SR. Contextos de exclusão social e de vulnerabilidade de mulheres usuárias de drogas no ciclo gravídico puerperal [dissertação]. Maringá (PR): Programa de Pós-graduação em Enfermagem, Universidade Estadual de Maringá; 2011.
• ⁶
  Marangoni SR, Oliveira MLF. Uso de crack por multípara em vulnerabilidade social: história de vida. Cienc. cuid. saude. 2012 jan/mar; 11(1): 166-72.
• ⁷
  Taylor P, Zaichkin J, Bailey D. Screening for Substance Abuse during Pregnancy. Washington (USA): Ed 1; 2009.
• ⁸
  Dyniewicz AM. Metodologia da pesquisa em saúde para iniciantes. São Caetano do Sul (SP): Difusão; 2007.
• ⁹
  Bardin L. Análise de conteúdo. Lisboa (POR): Ed 70; 2008.
• ¹⁰
  Freire K, Padilha PC, Saunders C. Fatores associados ao uso de álcool e cigarro na gestação. Rev. bras. ginecol. obstet. 2009; 31(7): 335-41.
• ¹¹
  van Gelder MM, Reefhuis J, Caton AR, Werler MM, Druschel CM, Roeleveld N; National Birth Defects Prevention Study. Maternal periconceptional illicit drug use and the risk of congenital malformations. Epidemiology. 2009 jan; 20(1):60-6.
• ¹²
  McCarthy DM, Sadri-Vakili G, Zhang X, Darnell SB, Sangrey GR, Yanagawa Y, Bhide PG. Cocaine alters BDNF expression and neuronal migration in the embryonic mouse forebin. J Neurosci. 2011 sep; 31(38):13400-11.
• ¹³
  Ornoy A, Ergaz Z. Alcohol abuse in pregnant women: effects on the fetus and newborn, mode of action and maternal treatment. Int. J. Environ. Res. Public Health. 2010 feb; 7(2):364-79.
• ¹⁴
  Ortega JA, Martin M, Lopez MT, Fuster JL, Donat J, Lopez B, et al. Transgenerational tobacco smoke exposure and childhood cancer: an observational study. J. Pediatr. Child. Health. 2010 jun; 46(6):291-5.
• ¹⁵
  Massachuts General Hospital (MGH) Center for Women's Health. Reproductive Psychiatry Resource and Information Center. 2012 [citado 2012 out 05]. Disponível em: http://www.womensmentalhealth.org.
  » http://www.womensmentalhealth.org
• ¹⁶
  Yamaguchi ET; Cardoso MMSC; Torres MLA; Andrade AG. Drogas de abuso e gravidez. Rev. psiquiatr. clin. 2008; 35(Supll 1):44-7.
• ¹⁷
  Sanfelice C. Tem que se cuidar: saberes e práticas de gestantes atendidas em uma unidade básica de saúde de Santa Maria/RS [dissertação]. Santa Maria (RS): Programa de Pós-graduação de Enfermagem, Universidade Federal de Santa Maria; 2011.
• ¹⁸
  Duarte SJH, Andrade SM. Assistência pré-natal no Programa Saúde da Família. Esc Anna Nery. 2006 jan/mar; 10(1):121-5.

Publication Dates

• Publication in this collection
  Jul-Sep 2014

History

• Received
  29 Jan 2013
• Reviewed
  24 Aug 2013
• Accepted
  31 Aug 2013