The article by Johnson et al (Reference Johnson, Gerada and Greenough2003) was disappointing as they failed to present a balanced view of this topic. It is, of course, important to discuss possible effects of drug misuse on pregnancy, but to emphasise them without due and thorough consideration of the many confounding factors in this area is misleading. These include smoking, alcohol use, social deprivation, poor nutrition, quality of antenatal care and drug treatment, as well as accessibility of services. Clearly, these are additional factors that drug-misusing women will have to contend with. Well-designed, unconfounded studies in this area are rare, which means that findings on the specific effects of illicit drugs are inconsistent and contradictory (Reference Ford, Hepburn and BeaumontFord & Hepburn, 1997).

The article failed to reflect that much of the recent work in this area has looked at flexibility of treatment services and equity of access. Women drug users are deterred from engaging with health and social care providers because of judgmental attitudes (Reference Klee, Jackson and LewisKlee et al, 2002). We felt that the article had an unsympathetic tone, and had missed the point that the onus is on treatment services to make themselves accessible to women who may have chaotic lives. Our approach to care is crucial if we are to retain these women in treatment throughout pregnancy, and this support needs to flow seamlessly into the postnatal period.

There is a relationship between maternal methadone dose and severity of neonatal abstinence syndrome, but this is not a close one (Reference Johnstone and RobertsonJohnstone, 1998). The onset, duration and severity of neonatal abstinence syndrome is multi-factorial and related to the infant's metabolism, gestational age and central nervous system maturity. It is essential to work with parents to prepare them for the possibility of neonatal abstinence syndrome and to try to involve them in the management of this condition.

Johnson et al (Reference Johnson, Gerada and Greenough2003) have provided us with a comprehensive list of possible unfavourable outcomes, but a more measured picture of the many difficulties that face both clients and health care professionals in this area would have better informed the Journal's readership.