Faye Macrory, a former outreach worker, is dedicated to helping pregnant drug addicts whose habits threaten their unborn babies. Until she took on the challenge, there was little support for addicts. Babies were automatically placed in special care, women were discouraged from breastfeeding and all families were referred to social services.

But since becoming one of the country's most senior midwives two years ago, Macrory has helped 400 mothers with drug or alcohol addictions to stay with their babies. Last night, her determination to make sure that the voices of such women were heard was recognised when she was named as one of the NHS's outstanding achievers.

As a consultant midwife in drug and alcohol dependence in Manchester, 48-year-old Macrory has built a career on working with individuals who are particularly vulnerable. Before taking up her current post, she was a drug liaison midwife for six years. Based in a community resource centre, she works closely with many agencies in the voluntary sector - her role covers a wide range of public health issues, including HIV in maternity services.

Outreach work and joint working is the key. By going where the women are, instead of waiting for them to approach maternity services themselves, help is focused on those she calls "the most socially excluded". This has meant, she admits, changing the attitudes "and prejudices" of colleagues.

"Initially, midwifery management was resistant to change and to recognising that drug-using women had particular complex needs," Macrory recalls. "A diabetic liaison midwife was appointed, but for those most socially excluded and vulnerable it appeared that care was based on staff's moral view of the perceived associated lifestyle - not on a respect for the individual person's health needs, not just physical but psychological."

An internal audit she carried out in 1994 confirmed that maternity services were failing drug-using women. Indeed, she found that for some women, drug use increased through fear that their wider family would find out about their habit because the baby was on special care. Determined to do something, she approached Drugs North West, a regional drug-misuse agency, which offered half a salary for a specialist drug-liaison midwife post - St Mary's hospital for women and children, Manchester meeting the other half. It was the first such jointly funded post in the country.

This marked the start of the specialist help offered to addicts and other pregnant women alienated from mainstream services. Macrory's work was recognised in 1997 when she was awarded an MBE. Since being appointed consultant midwife, she has recruited three midwives specialising in drugs and alcohol and HIV issues. Funding is being sought for a health visitor and counsellor.

Part of the job is ensuring that training is in place for all grades of staff: Macrory firmly believes that the needs of any client group cannot be met unless the educational needs of the staff have first been addressed. "Thinking across and outside traditional boundaries is the way forward," Macrory said in a recent interview in the Royal College of Midwives Journal. "Many of the women in our client group are in families with multiple problems and some do not want to approach mainstream services because they perceive them as unwelcoming and insensitive. However, there is a lot less stigma than there used to be."

The service now stretches across Manchester, with staff having links with three maternity hospitals, four drug service bases, a sexual health project for sex workers and the regional in-patient detoxification unit.

More than 200 women a year are referred to the service, which also offers support to HIV-positive women, many of them seeking asylum. The team can offer expert advice to other NHS staff who, according to Macrory, are now aware of the complexities of social exclusion and drug use and are confident to talk about difficult and taboo topics. Addicts now have fast-track access to drug treatment, maternity and other services and there is a recognition by staff that many users are doing very well, considering their traumatic pasts and present difficulties.

Babies are not separated from their mothers after delivery; there is an early discharge from hospital; and breastfeeding is promoted. Confidentiality is preserved and there is a decrease in anxiety levels about social services' involvement.

Collaborative working has been vital to the success of the service, says Macrory. "I have made it clear that I believe no one service should take total responsibility for clients who often are known to a wide range of agencies. As my vision for our service stretches far and beyond what many believe midwifery to be, I consider that joined-up thinking and working is the best way forward to ensure that those most socially excluded receive the care and opportunities that may enable them to make effective and sustained change."

This model of care is starting to become standard practice in many maternity services nationally. Macrory, who chairs a national forum of specialist midwives, is modest about her work, but admits to pride in the change in attitudes. "Women who use drugs are now treated by maternity services with the understanding and the compassion they deserve," she says. "Now women know that they will be treated the same as everyone else, they are keen to access maternity services.

"Staff at all levels no longer judge women by the myths and stereotypes associated with drug use, nor hold the view that it is incompatible with parenting. The information that both the staff and service users receive has resulted in a mutualrespect rather than previously, when misunderstandings and stressors led to conflict."