Infant risk and safety in the context of maternal substance use

• We conduct a prospective case study of 20 substance-dependent mothers.
• We report risk assessment and management from perinatal period to infant age 12 months.
• Our study identifies a sub-group of infants at increased risk.
• We argue for a differential response to management of risk in infancy.

Substance-exposed infants are extremely vulnerable due to biological, environmental and systemic risk factors that commence in pregnancy and are compounded by the postnatal caregiving environment. Substance-dependent mothers face unique challenges in caring for an infant while managing drug use or pharmacotherapy. The vulnerability of infancy therefore requires thorough assessment of risk and a prompt response from service providers. Drawing upon a prospective case-study of twenty women accessing a specialist alcohol and other drug obstetric service, this article explores the factors which contributed to infant risk or safety from the perinatal period to the end of the infant's first year. Data sources included structured interviews with counsellors and child protection workers and semi-structured interviews with mothers. The findings demonstrate continuing exposure to risk identified in pregnancy, including substance use and domestic violence, and inadequate follow-up of infants after discharge from hospital. The ability of an obstetric provider to conduct accurate risk assessment was evident. In addition, a sub-group of infants at higher risk of removal from maternal care was identified. The argument is made for a differential response by the service system to ensure women in greatest need are provided with extensive support when infants are most vulnerable and mothers most open to help.