I’ve hesitated to weigh in on this current debate between obstetricians and midwives, over their respectives. Whenever I receive news or editorials about the ever growing chasm between physicians and midwives, it unnerves me because I feel like I’m being called on the carpet to declare allegiance-Are you for us or against us? I hate it. As an advocate for Mamas on Bedrest, can’t I be for both?
For me it’s always tough to choose. I am a Duke University trained physician assistant. (It doesn’t get much more “medically” (anally?) trained than that!) My training dictates that I only work under the direct supervision of a physician and strictly adhere to protocols established for the practice. I have often struggled with many of the established protocols and “norms” of this medical model and admittedly, it’s one reason that I am not currently practicing. But that aside, I worked hard to complete the program, learned a lot of good, solid medicine and am still proud to be a PA and use the skills I learned to serve and advocate for high risk pregnant women.
I have personal appreciation for obstetrical care. 10 years ago I married and (attempted) to start my own family. I had uterine fibroids which caused me significant problems. After miscarrying my first pregnancy and having a myomectomy, I became pregnant with my daughter and ushered in “the pregnancy from hell”. Although I had chosen a practice with midwives and had hoped for a water birth, all that went out the window after my uterine surgery. I spotted and cramped early on. Things then went from uncomfortable to grave. I hung in there-and so did the ever present nausea-9 months worth. My daughter put us both out of our misery by gracing us with her presence at 36 wks 6 days on my second wedding anniversary. I owe my life to my OB’s partner who performed my c-section. After delivery I bled profusely. Every time she tried to stitch, a small geyser of blood would sputter out from my uterus. She worked frantically to mend my “boggy” uterus and with each stitch, I’d hurl and my uterus would bleed. How she ever patched me up I’ll never know, but I’m here to tell you-she did a great job.
Then there is my midwifery heritage. My great Grandmother, Queen Elizabeth Perry Turner was a midwife in Inez, North Carolina from the late 1930′s through the 1940′s. As the story goes, she birthed a generation of “colored children” with no physician back up because black women weren’t allowed to attend or be attended to at the local hospital. With her lay midwife’s training (She also wasn’t allowed a formal education) and extensive knowledge of herbal therapies she provided the care and support to the colored women of Inez before, during and after childbirth. From what I have heard and as the stories go, she never lost a mama or a baby.
A History of Conflict
One can’t ignore the fact that midwives have existed since the beginning of time. In the bible in the book of Exodus (The second book of the old testament if you’re unfamiliar) the author recounts how the Hebrew midwives were instructed to kill the male babies at delivery while enslaved in Egypt (before the exodus with Moses, Exodus Chapter 1. ) Obstetrics on the other hand arose in the 15th and 16th centuries when men, traditionally barred from labor and delivery-began assisting with breech births and began writing about and teaching about various ways to perform such births in medical texts. The introduction of forceps in the 17th century increased male presence and intervention in labor and delivery. (But it’s interesting to note that the first successful Cesarean Section was performed by a woman, Mary Donally, in 1738) It also increased tension between female and male midwives. By the turn of the 20th century, maternal health was taught in medical school and the name midwife was replaced by obstetrician(1) and men replaced women as birth attendants, and have dominated maternal health care ever since.
The popularity and preference of midwife assisted birth re-surged in the 1970′s, and here we sit in 2010, arguing again over who is best to attend expectant mothers-obstetricians or midwives. Physicians, primarily men (although now there are a large number of women on this side of the fence) argue that obstetrics has saved the lives of innumerable mothers and infants and that the former practice of allowing women to labor at home in anyway that they please is absurd, archaic, barbaric and just down right dangerous. Many obstetricians feel that midwives are uneducated about the technical and academic aspects of obstetrics and are unprepared in the event of an untoward event. They cite the decrease in mortality since the onset of the obstetrical sub-specialty as the proof that their interventions are effective and the best treatments for mothers and babies.
Midwives argue that intervening in and forcing women who are experiencing uncomplicated pregnancies, labors and deliveries to submit to innumerable, unnecessary tests and invasive interventions puts both mother and baby at unnecessary risk. They base their argument not only on the sheer longevity of midwifery-without which none of us would even be present today to have this discussion-but also on recent evidence-based studies that show that the lower level of intervention at midwife assisted births is leading to a decrease in infant and maternal mortality worldwide, whereas in the United States, where invasive obstetrics dominates maternal and fetal health, there is actually higher maternal and infant mortality compared to the rest of the world. What is even more alarming (and saddening for me, a woman of color) is that among women who are unable to access obstetrical care-typically impoverished minority women, the maternal and infant mortality rates are higher the the average high rates in the United States.
And it is this rally against unnecessary interventions, the high cost of care, the high US maternal and infant mortality rates compared to other nations-particularly nations with a nationalized health care systems necessarily concerned with high quality care at low costs-and the lower access to quality maternity care among low income and minority women that has prompted midwives to push, hard, with the backing of the World Health Organization, Amnesty International and other maternity and birth organizations for a midwifery model of care with evidence based medicine as the frame work.
The MOMS for the 21st Century Act
“The MOMS Act” amends the Public Health Service Act to require the Secretary of Health and Human Services (HHS) to add additional resources to the act to improve maternity services in the United States. In summary, the MOMS Act will :
- Establish the Interagency Coordinating Committee on the Promotion of Optimal Maternity Outcomes
- Develop and implement a consumer education campaign to inform women about the importance of making medical decisions based on “evidence”- born out of rigorous research and whose results have been replicated time and time again-and not out of fear, following directions or simply because “that’s the way it’s done”.
- Address the racial and ethnic disparities in health care by increasing recruitment of racially and ethnically diverse students into maternity health care programs, to establish maternity care shortage areas and student loan repayment programs under the National Health Services Corps to increase providers of maternity care in critically under served areas and to address workforce disparities for those who serve in these areas.
- Conduct research to improve maternity outcomes by creating a shared core maternity curriculum that is implemented across all disciplines (obstetricians, nurses, midwives, mid-level providers)
Tht ACOG Moms Initiative
On the heels of the bill’s introduction to the US House of Representatives, ACOG introduced its own initiative called, The American Congress of Obstetricians and Gynecologists’ Making Obstetrics and Maternity Safer (MOMS) Initiative or The ACOG Moms Initiative. ACOG proposes:
- Understand the Causes, Improve Interventions for, and Reduce the Prevalence of Premature Births.
- Focus on Obesity Research, Treatment, and Prevention.
- Improve Surveillance and Data Collection On Maternal and Infant Health.
- Support Maternal/Infant Health Programs at HRSA
- Research Disparities in Maternal/Fetal Outcomes, to Eliminate Disparities.
- Develop, Test and Implement Quality Improvement Measures and Initiatives.
- Test an Obstetric Medical Home Model
Now it doesn’t take a rocket scientist to see that the names of these proposals are confusingly close. However, the approach to patient care and lowering maternal and infant mortality in the United States is profoundly different. The Midwifery proposal is rooted in evidence-based medicine with many proposals tested in other countries throughout the world on maternal care during labor and deliery. The ACOG proposal is based more on theory and research. It doesn’t address the complaints and concerns birthing mothers have expressed nor does it give specifics on how it will lower its intervention rates (c-section rate in particular) or specifically what obstetricians will do to lower maternal and infant mortality. So should we follow an obstetrical model or midwifery model of maternity care? The answer is, we need both.
Each year about 6 million women become pregnant in the United States. While some will miscarry and some will elect to terminate their pregnancies, the vast majority of women will continue their pregnancies to term. That means that 6 million women will need care, support and assistance to safely gestate, labor and deliver their babies. Using the age old statistic that approximately 750, 000 women will be prescribed bed rest during their pregnancies, we can round up and say that about 1 million women will have high risk pregnancies requiring some medical intervention. Purely by extrapolation, that leaves about 5 million American women that will have uncomplicated pregnancies to attend.
According to (ACOG), there are approximately 53,000 members in the organization. Assuming that most practicing obstetricians are members, that means that there are approximately 53,000 practicing obstetricians in the United States. Now this number is inherently inaccurate because ACOG consists of retired physicians as well as OB/GYN’s who only practice gynecology and no longer deliver babies. But the number will suffice for our purposes.
According to the American college of Nurse Midwives (ACNM), there are approximately 11,546 CNM/CM. Again, we know that this number is inaccurate because it doesn’t seem to include Lay Midwives or Direct Entry Midwives. But let’s just take it as it is.
When we look at the totals we see this: Every year in America 6 million women will give birth and need an attendant at that birth. For approximately 1 million of these births, an obstetrician is the attendant of choice because the pregnancy is complicated and will likely require intervention. For the remaining 5 million pregnancies, we can assume that-barring any complications- either an obstetrician or midwife will suffice. So why is there such a war between obstetricians and midwives about who should provide care? Using each professional society’s own statistics, there are some 65,000 providers (combining the two specialties) to care for 5 million women annually (not counting the high risk ladies who mostly sees obstetricians only).
However the numbers are not really the issue. The war between obstetricians and midwives really wages over practice philosophy and, at its core, whose philosophy should “predominate” in the world of maternity care. It’s a turf war, one that really is unnecessary. If a provider’s focus is on providing the most compassionate, supportive, most effective and most health enhancing maternity care to mothers and babies, who has time for these scruffles? If a provider is providing such care, there is be no need to worry about maintaining patients because the reputation of excellent care will bring him/her all the patients he/she could ever care for. And most importantly, if a provider is providing excellent care, surely all childbearing women are being served and maternal and infant morbidity and mortality will naturally go down.
I’m going out on a limb to speak for “the mamas”. For us the real issue isn’t whether a physician or midwife is a better birth attendant than the other, but will he/she listen to our concerns and address them as well as our medical needs. If we don’t want anesthesia, please don’t force us to have it. Same with an episiotomy. Yet, please allow us to have family or other supportive people like doulas present if we so desire. Please provide all women of childbearing age in the United States have access to safe, effective, up to date, supportive and humanistic maternity care. Please don’t make us worry if we have to move during our pregnancies that we will lose quality care. Please don’t create barriers to the births we want. If we do decide to birth with a midwife at home and complications arise, Please nearest hospital, don’t penalize us by delaying or withholding care. Obstetricians, please don’t chastise us like wayward teenagers because we “didn’t listen and do as we had been told.”
Both sides need to come together, pool their resources and provide the best maternity care to American women possible-a combination of midwifery care in uncomplicated pregnancies and deliveries and obstetrical intervention when necessary. Both groups must work together to reduce maternal and infant morbidity and mortality in the United States. Both sides need to give a little. Obstetricians must stop disparaging midwives saying that they are unskilled and uneducated. This simply isn’t the case and the evidence-based research bears this out.
Midwives must stop vilifying obstetricians. Like any other professions, there are good supportive obstetricians who care deeply about their patients and work diligently to support and care for them during their childbearing years (I know, I was cared for by a great group of them!). And then there are the others. It is the same with midwives. If each side could give just a bit and work together I am confident that we could create a maternity care system in this country that would be unparalleled anywhere else in the world. But it can only happen when the needs of mothers and babies come first.
So as a voice for mamas in general and mamas on bed rest in particular, I plead with you both asking, “Please, midwives and ob’s, come together; pool your resources and give mamas the care and support they need during childbearing.
1. The Start of Life: The History of Obstetrics by J. Drife. Postgraduate Medical Journal 2002:
Baggage Check By Angela Quinn
Wanna know a little secret? Not all homebirthers are free-spirit, hippie-types who run barefoot and bra-less through life without a care in the world. Some are (and I’m totally jealous) but a good many of us are really type-A, compulsive, control freaks. I wanted to have a homebirth for a number of reasons: lack of confidence in the non-evidence-based medical model of labor and delivery, lack of desire to fight policy and procedure during contractions, and mostly because I wanted to be in control of my own birth process. But I also wanted to be able let go at any time without feeling like someone was right there hovering over my shoulder waiting to take that control from me.
So there it was in a nutshell – why I chose homebirth. On July 29th, 2010, I had a “successful” HBAC and brought my beautiful little girl into the world to join our family. However, I’ve struggled for the past couple months with why I have felt cheated, dissatisfied and disappointed. After all, healthy mom, healthy baby – that’s all that matters, right?
Recently I realized that I am suffering from the loss of my expectations. I thought that I could control the whole process of birth. If asked, before the birth, I would have smiled serenely and said things like, “I don’t know what to expect, we’ll just wait and see,” or, “I’m just going to let things play out and see how they go,” or, “I’ll just go with the flow.”
But inside, I just knew. This birth, maybe my last baby, was going to be the most awe-inspiring-amazing-empowering-healing-example-setting-I-am-woman-hear-me-roar example of childbirth EVER. Here’s how it would go, I imagined. I would realize I was in labor, I mean, having surges, and I would immediately put on my Hypnobabies CD and go into hypnosis. I would recognize the surges for what they were, functional and opening my cervix like a flower. I would light some candles, send my husband out for Rita’s Italian Ice, read a book, and get into my nice warm birth tub where I would labor in stoic silence, a pillar of strength, telling my midwife and doula that they could rest and I’d let them know when the baby was born. I would push for a few minutes, because (this time) my baby would be in an optimal position since I’d done everything right during this pregnancy (I exercised, ate well, saw a chiropractor, sat on my birth ball for work, watched my posture, did pelvic tilts, visualized). I would have a waterbirth. The Hallelujah chorus would play as I reached down to feel the baby crowning and usher her into this world into calm, loving, peaceful surroundings. I would immediately place her on my chest. She would crawl up to my breast, just like the videos, and latch on by herself. And, cut! Fade to black with mother and baby happily bonding and music from a Summer’s Eve commercial playing in the background.
My mom says I’ve always been like that, expecting things to go the way I plan them. When I was 9 or 10 years old, I’d write these skits that my younger siblings and I would put on for my parents. Somehow I expected Broadway, and was always surprised and disappointed by the reality of 5 little kids who forgot their lines and had safety-pinned towels and paper hats for costumes. In preparing for this birth, I thought I was just visualizing and being positive, but what I had really done was written my birth story ahead of time. Well, guess what? It didn’t follow the script.
In reality, I went into labor in the morning and worked through the first 6 hours or so finishing up stuff for my boss and sending emails. Then I went to a scheduled appointment at my midwife’s office (an hour away), dropped off the kids at my mom’s, run some errands, and threw up in the car. The Hypnobabies stuff worked in the beginning, but once it got harder, damn, that woman’s voice got annoying. Surges, my ass! How about hot knives being shoved into my lower back. I had excruciating back labor (again!) because, despite my best efforts, I had another occiput posterior baby. I didn’t like the birth tub after a couple hours and got out. I whined and moaned…a lot. I considered transfer to a hospital since I really thought she wasn’t coming out at one point, but the only reason I didn’t transfer is because I was so wimpy that I knew I wouldn’t be able to handle my contractions (or the back pain in between) in the car. I never felt the urge to push since she was face up, but I pushed for over 2 hours, painfully, and she finally came out once my tailbone broke (again!). She didn’t crawl to my breast by herself, because she wasn’t breathing and didn’t breathe until after about 5 minutes of resuscitation attempts. It was the scariest few minutes of my life, and I’ll never be able to think about her birth without remembering that heart-stopping, throat-constricting fear. Fear that we would become a statistic, that this whole thing had gone horribly wrong. After this birth, I knew I didn’t want to have any more children.
This wasn’t how it was supposed to go. This birth was supposed to be healing. I was supposed to overcome the physical and mental obstacles of the birth process through sheer determination and feel so powerful afterwards. My education and knowledge was supposed to carry me through any tough times. I was supposed to have a wonderful, idyllic story to tell to those considering homebirth. I was going to be an example to others of how the female body is made to birth naturally and effortlessly. My birth was to be a statement about what’s broken in maternity care today. I don’t know about you, but I’m thinking that’s a pretty freakin’ huge burden to put on one vagina. That’s a hell of a lot of baggage to hang on the shoulders of one tiny little baby.
That’s not to say that I’m not allowed to be disappointed. Or grieve the loss of the perfect birth story that lived in my imagination. Or to feel betrayed by my body once again. I’m allowed to be sad about it sometimes. But I think I would have been less so if I had not decided ahead of time that my birth story would be defined by what it could DO for me. Assigning a value to the birth process based on a pre-determined “yes or no” outcome is exactly what frustrates us so much sometimes about the “quit whining you have a healthy baby” attitude of society. So why do we do that to ourselves with the other outcomes of a birth?
I wrote down my actual my birth story a couple days afterwards, and it had a lot of grief and anger and sadness in it. I could barely see to type it up because I was crying so much while I wrote it. It was only later, when I started looking through my camera to add pictures to the story, that I began to see the details that I had been missing because I had so many pre-conceived ideas that were clouding my perspective.
As I saw the pictures taken around my house, I remembered that there were times of peace during the process and that I was comfortable in my surroundings, allowing me to focus on what I needed to do. I can say without a doubt that had I not been at home I would have had another cesarean. The picture of my doula putting a wet washcloth on my forehead and pouring warm water on my back made me realize that I did need to rely on others around me and that it is OK to ask for help. Seeing how often my husband’s hands were in the pictures as I leaned on him for support made me realize how much he was there for me. Our relationship has been on the rocks for the past few years, and I even said to him that it didn’t matter to me if he was present for the birth. I didn’t need him or anyone else. I prided myself on my independence. But I did need him, surprising both of us just how much. He felt needed and I felt taken care of. It’s quite possibly the first time in 11 years of being together that I have ever relied on him to that extent, and it changed something subtle in the dynamic of our marriage, for the better. When I saw the picture of my husband cutting the cord and the one of her lying on my chest afterwards, I was grateful for the decisions I made leading up to and immediately after her birth. I remembered that I was smart enough to choose a competent, knowledgeable midwife who understood the benefits of natural birthing, delayed cord clamping, skin-to-skin contact and the power of the human body. My faith in my instincts as a mother returned as I looked at the picture of her nursing for the first time, strong, alert, and healthy. And when I looked at the pictures of myself laboring in different positions, my muscles straining, my face a mask of determination, I realized that I was not a wimp. I am strong. Not with the kind of strength that wills away the presence of obstacles altogether, but with the strength that allowed me to overcome and to persevere despite the unexpected difficulties and challenges I faced.
We can do our research; we can prepare our minds and bodies; we can make sure that we are healthy and ready. But we can’t define our birth story ahead of time. We can’t go into it assuming it will be healing or empowering or a message or a political statement. When we do that, we risk that we will not see our birth for what it is – a beautiful, amazing process that helps define us as women and mothers in ways we may not expect. It may not be pretty. It may not live up to our standards of perfection. Sometimes birth just….is.
And now, cheesy as it may seem, I have to close this post with this quote. Ask not what your birth can do for you…nah, just kidding. Worse, a Beatles song. It’s been going through my head since I started writing, so I guess it has to make it in here somewhere: “Let it be, let it be, let it be-ee, let it be. Whisper words of wisdom, let it be.” There, now it’s in your head too.
Thanks so much for that reminder, Angela!
Recently there has been a flurry of comments flying both in the news and the medical community. Two studies have published data stating that they found no link between low to moderate drinking during pregnancy and birth defects in infants and children.
The first study, Light Drinking During Pregnancy: Still No Increased Risk for Socioemotional Difficulties or Cognitive Deficits at 5 Years of Age? was published on October 5, 2010 in The Journal of Epidemiology and Community Health . British researchers found that by age 5 years, study members born to mothers who drank up to 1–2 drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioral difficulties or cognitive deficits compared with children of mothers in the non-drinking group.
The debate got even more heated when a study out of Australia found similar results. Colleen O’Leary, PhD, et. al. set out to evaluate if there is an association between how much alcohol a pregnant woman drinks, when in her pregnancy she drinks and the development of birth defects in the child. O’Leary and her colleagues found that
“A fourfold increased risk of birth defects classified as Alcohol Related Birth Defects (ARBD’s) was observed after heavy Prenatal Alcohol Exposure (PAE) in the first trimester. Many individual birth defects included in the Institute of Medicine classification for ARBDs either were not present in this cohort or were not associated with PAE.”
O’Leary and her colleagues went on to say that more large population studies are needed before any definitive conclusions or recommendations can be made.
Currently, the research conclusion is that since the evidence to date has shown that 1-2 drinks on occasion or weekly does not appear to be harmful to the fetus, infant or child, there is no scientific justification to make the statement that alcohol consumption should be completely avoided during pregnancy. However, physicians and researchers who treat pregnant alcoholics and their neonates, infants and children suffering from the effects of prenatal alcohol exposure advocate for absolutely no alcohol consumption during pregnancy and have railed against the studies. Currently, most countries, including the United States, Canada, France, and Italy, recommend that women planning to conceive or who are pregnant abstain from drinking alcohol. The American Congress of Obstetricians and Gynecologists (ACOG) continues with its long-standing position that no amount of alcohol consumption can be considered safe during pregnancy and they do not advocate alcohol consumption at all during pregnancy. They stand firm in their statement that,
“women should avoid alcohol entirely while pregnant or trying to conceive.”
In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) currently recommends that women avoid alcohol during the first trimester because it may be associated with an increased risk for miscarriage.
How is one to make any sense of all of the news reports and the scientific data? How are we to interpret what is being reported by researchers and sensationalized by the news media?
Dr. Ira Chasnoff* is one of the nation’s leading researchers in the field of maternal drug use during pregnancy and the effects on the newborn, infant and child. He has written an excellent editorial about these studies, the British study in particular. He examined how the studies were carried out, how the data has been interpreted and what his findings have been in his research on the effects of drugs and alcohol on a developing fetus. Here we present a summary of the major points in Dr. Chasnoff’s editorial, but you can read the full text here.
- Although the authors presented their findings in an evenhanded manner, the translation of the study findings in the national and international media has been anything but responsible. Headlines in newspapers and newscasts scream the message that light drinking of alcohol during pregnancy is not only perfectly safe, but actually results in higher developmental scores in children at five years of age. Such conclusions are not supported by the research and are reckless and misleading.
- Mothers were asked to recall their pattern of alcohol use during pregnancy nine months after having delivered. Multiple studies have shown that such recall is fraught with error when it comes to estimating the amount and frequency of alcohol use. The authors of the study recognized and stated that the study “was prone to recall bias.” (This is seldom if ever reported in media reports.)
- There is the significant demographic differences between the “light drinking” mothers and the other cohorts.
- Women who reported light drinking during pregnancy were less likely than any of the other groups to smoke suggesting the possibility that lack of prenatal or postnatal exposure to tobacco smoke might be a source for the differences seen between the children.
- Another limitation of the study is that the authors examined only the more global aspects of child development: behavioral and emotional functioning and cognitive ability.
- As the authors of the study pointed out, prenatal exposure to alcohol may have “sleeper” effects resulting in the emergence of developmental issues as children enter the school years. Because this study only evaluated children until age five, before they entered school, these potential developmental problems could not be captured. In this study the children have not yet been developmentally challenged in problem areas that typically begin to develop within a school environment, such as peer problems, hyperactivity and conduct.
- The methods of evaluation of the children are screening tools and not full assessment tools.
- Only 3 of a possible 14 assessments were carried out on the children. These specific three sub tests together have no validity for assessing overall cognitive functioning.
- While some reporters in the public media have presented thoughtful evaluations of the implications of the article in question, others have taken the information out of context and presented conclusions that the authors did not intend and that are not supported by the facts. In fact, the authors place a question mark at the end of their article’s title (Light drinking during pregnancy: still no increased risk for socioemotional difficulties
or cognitive deficits at 5 years of age?), indicating their inability to draw any firm and lasting conclusions about the effects of light drinking during pregnancy; instead, they state that “causal inference based on observational data is limited, and further work to tease out etiological relationships is needed.”
Which brings us to the public health response to the question,
“How much alcohol can a woman safely drink during pregnancy?” The answer is, “We don’t know.”
Multiple factors play into a child’s risk for developmental and behavioral difficulties, including genetics, the family environment in which the child is raised, and the intrauterine environment in which the fetus develops.
Importantly, we must realize that the U.S. population, with its wide range of races and ethnicities, is far more diverse than the all white population that was included in this study. The pregnant woman’s ability to metabolize alcohol varies greatly across race and ethnicity, so applying data developed on an all-white British population to the U.S. population with a broad mix of metabolic capabilities, is hazardous. Prenatal exposure to alcohol is known to impact the development of the fetal brain, and nothing in the recently published study from Great Britain concludes otherwise. Until we know more, we must advise people, in the best interest of unborn children, that no amount of alcohol is safe to drink during pregnancy.
*Ira Chasnoff, MD, serves as the president of the Children’s Research Triangle, a non-profit organization dedicated to the healthy development of children and their families. He is a Professor of Pediatrics at the University of Illinois College of Medicine in Chicago and is one of the nation’s leading researchers in the field of maternal drug use during pregnancy and the effects on the newborn infant and child. The Mystery of Risk: Drugs, Alcohol, Pregnancy and the Vulnerable Child.