in Involuntary Hospitalisation of Drug and Alcohol Addicted Mothers During Their Pregnancies at Borgestadklinikken, Norway


This chapter deals with coercive measures in relation to pregnant substance abusers in Norway and experiences from Borgestadklinikken—Blue Cross South, where many of these women are treated. The legal basis is described and ethical problems to do with the women’s loss of liberty compared with the benefits for the child are discussed. In order to throw light on some of the problems, a hypothetical letter has been included in which summarizes what many of these women have said. The chapter ends with results from the author’s own study on the birth weight of the children. It has positive effects on children and mothers when involuntarily hospitalization is made as early as possible during pregnancy. Consequently this will reduce the risk of developing FASD and other negative consequences for the children. The reasons why, relatively speaking, so few women with alcohol problems are hospitalized involuntarily will be discussed.

It is however important for readers from other countries, such as those from North America, to understand that some European governments often have a different kind of relationship with its people than North American governments. The Norwegian government wants to help women to have healthy babies. In North America, governments want mothers to take personal responsibility for their actions. The Norwegian approach might perhaps seem like a form of punishment to a North American, when it is intended as assistance so a mother has a healthy baby.


Legal Basis


Proposing legislation that results in a loss of liberty for individual members of the population will always be a dilemma. In 1994–95, there was a great deal written in the Norwegian media about children born to women who use drugs and alcohol during pregnancy. In 1994, one of Norway’s biggest television channels broadcast a documentary about the severe postnatal symptoms suffered by infants when the mother had used heroin during pregnancy. The programme also looked at alcohol use in pregnancy and the knowledge available on this problem at the time, with one of Norway’s leading paediatricians appearing and shedding tears over the fate of these infants. Experts begged the politicians to do something. Although the Minister of Children at the time did not believe there to be any need for coercive legislation, the opposition was so strong that an addition to the existing Norwegian Social Services Act of 1993 was passed. Counterarguments that it was a backward step in the battle for women’s rights to deprive women of their rights, that women could go underground or that there was a risk that the frequency of abortions would increase had no effect. The interests of the child were perceived to be more important.

The first two subsections in section 10.3 of the Social Services Act read as follows:

It can be decided that a pregnant drug or alcohol user should be admitted to an institution designated by a regional health authority without her consent (…) and detained there throughout the pregnancy if the abuse is of such a nature that it is highly probable that the child will be born with defects, and if voluntary assistance is insufficient. The County Social Welfare Board shall also decide whether there are grounds for taking urine samples from the pregnant woman during her stay in the institution.

The purpose of admission is to prevent or limit the probability of the child being harmed. Importance shall be attached to the woman being offered during her stay in the institution satisfactory help with her drug or alcohol abuse and to enable her to care for the child.

Norway is the only country to have such a statutory provision, but similar legislative proposals are also being debated in some other countries. The original wording proposed by the health authorities was “…that the child will be born with severe defects…”, but the Norwegian Parliament omitted the word “severe” in order to strengthen legal protection for the foetus. The intention of the provision is to prevent negative consequences for the foetus, not to punish the woman. The provision also makes it a requirement that “voluntary measures are insufficient”. However, voluntary measures do not necessarily have to been tried before coercion is decided on. Social services also sometimes threaten the woman with coercion if she does not admit herself voluntarily, which is a form of passive coercion (Søvig 2007).

I have, on several occasions given lectures in other countries on our coercive treatment and found that the same counterarguments are put forward. Although the battle for women’s rights is important, of course, it seems strange in my opinion that there is not a greater understanding of the interests of the child being given priority. A Danish newspaper ran an article on our sheltered unit for these women in May 2014, and said that it perhaps took a paediatrician in tears for these infants to receive the protection of such a law. My impression is that in parts of the world where not as much progress has been made with regard to women’s and children’s rights there is considerable opposition to coercive measures against women.

Generally speaking, Norway does not stand out as a country with many statutory provisions that permit coercive measures over and above criminal measures (Søvig 2007). As a comparison, the mental health, child protection and communicable diseases legislation in many countries contains provisions permitting coercive measures if the person in question is a serious danger to himself or others. However, under section 10.2 of the Social Services Act, drug and alcohol users can also be hospitalised involuntarily if their life and health are at serious risks.

Our clinic, Borgestadklinikken, which specialises in the treatment of pregnant drug and alcohol users and families with young children, set up a small unit for pregnant women with drug and alcohol problems and mothers with young children in 1991. Since 1993 the clinic has had a larger family unit, which also admits fathers. Borgestadklinikken has had provision for pregnant women who are hospitalised involuntarily since the coercion legislation came into force in 1996. A separate sheltered unit for them was set up at the institution in 1998.

Between 1996 and 2013 there were 608 temporary coercion orders against pregnant drug and alcohol users, with 362 being upheld by an ordinary ruling of the County Social Welfare Boards. Borgestadklinikken has had more admissions than any other institution under this coercion provision and can document 197 admissions between 1996 and 2013. The age range was 16–45 with an average of 28, the same as for the rest of the country (Wiig and Myrholt 2012). The average age for women hospitalised involuntarily with alcohol as their primary diagnosis was 35 on a national basis. There were between three and five admissions to Borgestadklinikken annually in the first few years, but the number started increasing in 2001, and every year since 2003 between eight and 14 women hospitalised involuntarily have completed their pregnancy at Borgestadklinikken. In 2012 and 2013 there were 14 admissions each year.


Duty to Inform


Section 32 of the Norwegian Health Personnel Act contains another important statutory provision:

Notwithstanding the duty of confidentiality (…), the health personnel shall of their own accord provide information to the social welfare service, when there is reason to believe that a pregnant woman is abusing intoxicating substances in such a way that it is highly probable that the child will be born with defects, cf. the Social Services Act section 10.3.

When it comes to the duty of health personnel (doctors, psychologists, midwives, health visitors, nurses, etc.) to inform social services, issues can arise. On several occasions the author has provided training for fellow doctors and been told the following: “We would rather reach a preventive agreement with the woman than report her directly to social services. We could lose her trust and she might go underground. That would be worse.” But what the duty-to-inform provision says is indisputable. The number of reports of concern has increased in recent years as health personnel have gradually come to understand how important it is to speak out. There are few reports of women leaving the country or going underground, but isolated cases do occur. According to an evaluation report (Lundeberg et al. 2010), the figures from the County Social Welfare Boards also show that it was the woman herself who contacted social services in up to 41 % of cases.


Further Proceedings


Social services must obtain all the necessary information, after which coercive measures may become relevant if voluntary measures are insufficient. Social services can issue a temporary order (98 % of all cases), in which case the woman will be admitted to a suitable institution as soon as possible. Institutions that can take involuntary patients are specially designated by the health authorities (Søvig 2007).

An average of 55 days passed between social services receiving the report of concern and issuing the emergency order (Lundeberg et al. 2010). In terms of the safety of the foetus this seems too long, but timing has recently improved. Social services must submit the temporary order to the chairperson of the regional County Social Welfare Board within 48 hours. The woman can appeal against the emergency order and is entitled to a ruling within a week. Social services must then prepare and send the final case to the County Social Welfare Board within two weeks. If they exceed this deadline, the case is dropped. It then takes between four and seven weeks for the cases to be considered by the County Social Welfare Board (Søvig 2007). The women are still hospitalised during this period, which is a long time to wait for a final ruling. When social services and the County Social Welfare Boards assess the risk to the child, they base their decisions on expert knowledge, the observations and reports of concern they have received regarding the pregnant woman through social services, and statements by the woman and her lawyer. The County Social Welfare Board consists of a chairperson (who is a jurist), a specialist and a layperson. In difficult cases the County Social Welfare Board can be enlarged with two more members. It is also possible to use simplified proceedings if the woman and social services agree. The County Social Welfare Boards can rescind the order, but found in favour of social services in 92 % of cases. The woman can appeal the coercion order to the District Court.

Social services monitors the woman while she is hospitalised involuntarily and cooperates with the institution. Social services can rescind the order during the pregnancy, but rarely does so. Her case must be reviewed every 3 months. The institution’s medical director cannot rescind the order, but he can decide to release her if, for example, she is a risk to others or the institution is unsuitable for her. This must be done in consultation with social services.

Under the coercion provision the woman must be offered treatment for her drug or alcohol problem and she must receive help with taking care of her child. One complication is that some of the women do not want treatment and deny that they have a drug or alcohol problem. There is a strong emphasis on helping the woman to care for her child during the treatment phase and through cooperation with child protection while the woman is hospitalised. According to one of Borgestadklinikken’s reports (Wiig and Myrholt 2012), 51 % were allowed to care for their child after the birth (1996–2013).


Deliberations by the County Social Welfare Boards


The coercion order is dependent on the use of drugs or alcohol during pregnancy being such that it is highly probable that the child may have defects, i.e. the probability of defects occurring must be greater than 50 %. Defects in this context are considered to mean serious reactions and resulting conditions in the child such as teratogenic defects, withdrawal symptoms, growth retardation, risk of functional abnormalities, etc. When social services and the regional County Social Welfare Boards assess the risk to the child, they base their decisions on expert knowledge, the observations and reports of concern they have received regarding the pregnant woman through social services, statements by the woman and her lawyer, and witnesses. There is some debate as to whether the order is based on a ‘precautionary principle’, although there is no mention of this in the coercion provision. The experts and other advisers in these coercion cases provide details of the harmful effects that the individual substances can have on a foetus and the fact that using a variety of substances can amplify the negative effects of each. The use of alcohol at any stage of pregnancy is given great weight.

Stress factors, use of tobacco, nutritional state and other attendant health conditions also affect foetal development. However, smoking and snuff use are not taken into account in assessing coercive measures. The use of legally prescribed substitute preparations (methadone and buprenorphine) does not constitute grounds for coercive measures if the pregnant woman is not also using drugs and alcohol. On the other hand, illegal consumption of the same preparations would be significant in assessing the need for involuntary hospitalization, because it is considered to be more dangerous for the foetus when the mother has a variable consumption of opioids than a constant level of opioids during the pregnancy.


A Woman’s Own Description of Being Hospitalised Involuntarily


To throw more light on how the women fare during their involuntary hospitalisation, the following story is a description of a hypothetical woman’s ‘own experiences’ of being hospitalised involuntarily. In this hypothetical case, she writes a letter to a friend. The description is based on my own experience as a doctor to these women over a period of 18 years and represents my understanding of the reactions, thoughts and challenges often shared by them.

Hi Vicky!

Elisabeth here! What has happened to me in recent weeks has set off all sorts of thoughts and emotions that I just have to write about.

I still don’t understand how they could hospitalise me against my will four weeks ago. While Petter was in town, the drug and alcohol abuse counsellor from the municipal social services came to the house and read out an order they had written, saying that there was a strong suspicion that I used too much alcohol and pills, and that I’d twice tested positive for cannabis in my urine. I’d also phoned up and asked to postpone a check-up with the midwife because I was in Denmark. Surely you’re allowed to go to Denmark when you get a free ferry ticket. They also said they had received a report of concern from my midwife and GP, who said I smelled of alcohol and had been a bit of a mess when I went for a check-up. I’d only drunk some beer at a party the day before. I know I shouldn’t drink alcohol when I’m pregnant, so I didn’t do it again.

By the way, I’m already 18 weeks pregnant. I’m having a boy. Hooray! Cathrine, who is nearly 3, will have a baby brother. She’s so excited! I told her when I last visited her in the foster home. I think it’s shameful that she has a mother who has been hospitalised against her will.

I probably drank more when I was pregnant with Cathrine than I did this time. Of course I read in the leaflets the midwife gave me that alcohol can damage the baby in all sorts of ways, but I’m sure that’s just if the mother drinks a lot. But I cut down on my alcohol consumption a lot when I thought I was pregnant again. I was 11 or 12 weeks gone by then, I think. But you know yourself how bad you feel when you cut back. I got myself some pills, Valium and Rivotril, to help with the cravings. And then I smoked a bit of cannabis some evenings. I didn’t think it was as dangerous as alcohol. It’s not as if I’m a pill abuser or drug addict, and I’d virtually stopped drinking, so I think it was really unfair to hospitalise me against my will. But I’d had a couple of warnings about the possibility of coercion if my urine samples were positive or I didn’t attend check-ups. Maybe I should have gone to my auntie in Spain. They wouldn’t have found me there. It’s easy to buy pills there too.

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Feb 18, 2017 | Posted by in PSYCHOLOGY | Comments Off on in Involuntary Hospitalisation of Drug and Alcohol Addicted Mothers During Their Pregnancies at Borgestadklinikken, Norway

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