A Review of Recent Findings on Substance Abuse Treatment ... · crack cocaine epidemic, and its...
25
195 Journal of Substance Abuse Treatment, Vol. 16, No. 3, pp. 195–219, 1999 Published by Elsevier Science Inc. Printed in the USA. 0740-5472/99 $–see front matter PII S0740-5472(98)00032-4 ARTICLE A Review of Recent Findings on Substance Abuse Treatment for Pregnant Women Embry M. Howell, phd, Nancy Heiser, ma, and Mary Harrington, mpp Mathematica Policy Research, Inc, Washington, DC Abstract – Recent years have brought an increased interest in the treatment needs of pregnant substance abusers. This article reviews the literature on this subject, providing an overview of what is known about the prevalence of substance abuse during pregnancy; the factors in women’s lives, especially pregnant women, that lead to substance abuse and that facilitate and impede treatment success; and the compo- nents of successful treatment programs. The prevalence of prenatal illicit drug use is known to be about 5% of all pregnant women nationwide, with higher rates for selected subgroups. Local studies have shown much higher rates. Substance abuse is associated with poverty, with the substance abuse of significant others, and with family violence. Perinatal substance abusers experience poorer birth outcomes. The neg- ative consequences for babies do not stop at birth; home environments may be chaotic and often children are removed from their mother’s care if substance abuse continues after birth. While the literature on prevalence, correlates, and outcomes of perinatal substance abuse is plentiful, there continues to be sparse information on successful treatment approaches. Sample sizes are small and there are few studies with adequate comparison groups. The small number of outcome studies we review suggest that, as with the broader treatment literature for other populations, success (as measured by abstinence) is associated with retention. Retention is facilitated by the provision of support services, such as child care, parenting classes, and vocational training. There is no clear empirical basis for concluding that one type of treat- ment (for example, residential treatment) is more effective than another. Published by Elsevier Science Inc. Keywords – substance abuse; pregnancy; Medicaid substance abuse treatment. able to women, particularly mothers and pregnant women, and the corresponding lack of research on this topic (Finkelstein, 1990, 1993). Prior to the 1970s, few programs existed for women and few studies included or focused on women alone. In the 1970s, the National In- stitute on Drug Abuse (NIDA) began to sponsor some substance abuse treatment program development for women. Although NIDA funds initially supported pro- gram development and research, by the late 1970s few women-focused programs existed in the United States, and funds for these programs again began to shrink. Finkelstein (1993) cites several studies conducted in the 1980s that document the shortage of substance abuse treatment services available to women, specifically moth- ers and pregnant women, at that time. For example, one Received January 5, 1998; Accepted April 28, 1998. The authors acknowledge the helpful comments of Craig Thornton, PhD and Ira Chasnoff, MD on earlier versions of this work. Esther Alonzo, Sara Yang, and Miki Satake provided research assistance and Sharon Clark prepared the manuscript. This work was supported by U.S. Government Contract Number 500-92-0049 with the Health Care Financing Administration for the Evaluation of Demonstrations to Improve Access to Care for Pregnant Substance Abusers. The Project Officers were Ed Hutton and Suzanne Rotwein. Requests for reprints should be addressed to Embry M. Howell, PhD, Mathematica Policy Research, Inc., Suite 550, 600 Maryland Av- enue, SW, Washington, DC 20024-2512. INTRODUCTION Many researchers have documented the lack of sub- stance abuse treatment options designed for and avail-
Transcript of A Review of Recent Findings on Substance Abuse Treatment ... · crack cocaine epidemic, and its...
195
Journal of Substance Abuse Treatment, Vol. 16, No. 3, pp. 195–219, 1999Published by Elsevier Science Inc.
Printed in the USA.0740-5472/99 $–see front matter
PII S0740-5472(98)00032-4
ARTICLE
A Review of Recent Findings on Substance Abuse Treatment for Pregnant Women
Embry M. Howell, p
h
d, Nancy Heiser, ma, and Mary Harrington, mpp
Mathematica Policy Research, Inc, Washington, DC
Abstract –
Recent years have brought an increased interest in the treatment needs of pregnant substanceabusers. This article reviews the literature on this subject, providing an overview of what is known aboutthe prevalence of substance abuse during pregnancy; the factors in women’s lives, especially pregnantwomen, that lead to substance abuse and that facilitate and impede treatment success; and the compo-nents of successful treatment programs. The prevalence of prenatal illicit drug use is known to be about5% of all pregnant women nationwide, with higher rates for selected subgroups. Local studies have shownmuch higher rates. Substance abuse is associated with poverty, with the substance abuse of significantothers, and with family violence. Perinatal substance abusers experience poorer birth outcomes. The neg-ative consequences for babies do not stop at birth; home environments may be chaotic and often childrenare removed from their mother’s care if substance abuse continues after birth. While the literature onprevalence, correlates, and outcomes of perinatal substance abuse is plentiful, there continues to besparse information on successful treatment approaches. Sample sizes are small and there are few studieswith adequate comparison groups. The small number of outcome studies we review suggest that, as withthe broader treatment literature for other populations, success (as measured by abstinence) is associatedwith retention. Retention is facilitated by the provision of support services, such as child care, parentingclasses, and vocational training. There is no clear empirical basis for concluding that one type of treat-ment (for example, residential treatment) is more effective than another. Published by Elsevier Science Inc.
Keywords –
substance abuse; pregnancy; Medicaid substance abuse treatment.
able to women, particularly mothers and pregnantwomen, and the corresponding lack of research on thistopic (Finkelstein, 1990, 1993). Prior to the 1970s, fewprograms existed for women and few studies included orfocused on women alone. In the 1970s, the National In-stitute on Drug Abuse (NIDA) began to sponsor somesubstance abuse treatment program development forwomen. Although NIDA funds initially supported pro-gram development and research, by the late 1970s fewwomen-focused programs existed in the United States,and funds for these programs again began to shrink.
Finkelstein (1993) cites several studies conducted inthe 1980s that document the shortage of substance abusetreatment services available to women, specifically moth-ers and pregnant women, at that time. For example, one
Received January 5, 1998; Accepted April 28, 1998.
The authors acknowledge the helpful comments of Craig Thornton,PhD and Ira Chasnoff, MD on earlier versions of this work. EstherAlonzo, Sara Yang, and Miki Satake provided research assistance andSharon Clark prepared the manuscript.
This work was supported by U.S. Government Contract Number500-92-0049 with the Health Care Financing Administration for theEvaluation of Demonstrations to Improve Access to Care for PregnantSubstance Abusers. The Project Officers were Ed Hutton and SuzanneRotwein.
Requests for reprints should be addressed to Embry M. Howell,PhD, Mathematica Policy Research, Inc., Suite 550, 600 Maryland Av-enue, SW, Washington, DC 20024-2512.
INTRODUCTION
Many researchers have
documented the lack of sub-stance abuse treatment options designed for and avail-
196 E.M. Howell et al.
study in 1979 found only 25 programs nationally thatwere treating women (Beschner & Thompson, 1981). An-other study (House of Representatives Congressional Hear-ing, 1989) found that two thirds of the major hospitals infifteen cities had no place to refer pregnant women forsubstance abuse treatment.
By the late 1980s, the crack cocaine epidemic and itsapparent costly effects of prenatal cocaine exposure onthe newborn meant that new funding for treatment pro-grams for pregnant women became available. Breibart,Chavkin, and Wise (1994) recently conducted a study toassess availability of substance abuse treatment pro-grams to pregnant women in New York City and fourother U.S. cities. They found that 80% of the 294 resi-dential and outpatient programs surveyed in these fivecities accepted pregnant women. Many, however, did notaccept women on Medicaid or provide or arrange forchild care. The researchers concluded that barriers totreatment remain for many pregnant women, and thatmany programs still did not provide the wide range ofservices that many women need.
The history of substance abuse treatment programsfor women—especially mothers and pregnant women—is short and sparse. Research on this topic is similarlythin. Not until the NIDA began to fund the developmentof substance abuse treatment programs for women, didthese programs begin to emerge and be studied. Programdevelopment and research remains limited although thecrack cocaine epidemic, and its consequences for society,spurred new funding, treatment models, and research.
Medicaid Coverage for Pregnant Substance Abusers
The original Medicaid program design (late 1960s) didnot address coverage of substance abuse treatment as aseparate service since treatment services were not widelyavailable. The treatment that was available for low-incomepeople was provided by state or locally funded agencies,sometimes with federal support from the Alcohol, DrugAbuse and Mental Health Administration. As abuse ofillicit drugs continued to increase and treatment optionsexpanded, states began to cover some substance abusetreatment under existing Medicaid-mandated and optionalservices, such as inpatient hospital services (like detoxi-fication), outpatient department services, clinic services,other practitioner services (such as those offered by psy-chologists), rehabilitative services, and case management.
However, most forms of residential treatment not pro-vided in inpatient hospitals have been excluded from ei-ther mandatory or optional services. Services in institu-tions for mental disease (IMDs) are excluded for personsbetween 22 and 65 years of age. An IMD is any residen-tial facility of more than 16 beds that specializes in psy-chiatric care (including substance abuse treatment). Ser-vices in facilities with fewer than 17 beds can be coveredaccording to HCFA guidelines.
In addition to these exclusions, many states had notimplemented optional benefits that could be provided topregnant substance abusers. For example, according toHCFA data extracted from state Medicaid plans, onlyabout half the states covered services for pregnantwomen in alcohol and substance abuse clinics in March1992. While 28 states covered targeted case managementfor pregnant women, HCFA data do not indicate whichmanagement programs have a component (such asscreening and referral to treatment) targeted to pregnantsubstance abusers (Department of Health and Human Ser-vices, 1992b). Authors of a General Accounting Officereport that attempted to inventory Medicaid coverage forsubstance abuse treatment found it difficult to collectdata on these services because of the variety of optionsused and coverage limitations (General Accounting Of-fice, 1991).
In spite of the lack of well-developed literature on thistopic there has been an expansion in services for thispopulation. Also the implementation of welfare reformaround the country has highlighted the need for more ef-fective substance abuse treatment for young mothers,creating the need for a better understanding of the prob-lem of substance abuse during pregnancy and how totreat it.
We have provided some background on the problemof pregnant substance abuse and consequences—its preval-ence, correlates—followed by a summary of recent liter-ature on the types of treatment programs and their impact.
METHODS
We searched the formal literature for all citations of sub-stance abuse and pregnancy using the MEDLARS sys-tem of the National Library of Medicine. The articles re-viewed here were culled from a larger set of citations. Ingeneral, we included articles from the 1980s and 1990s.Virtually every published article on substance abusetreatment in pregnancy that addressed how to get preg-nant substance abusers into treatment and the outcomesof treatment was included in the review. On the otherhand, we chose selectively from the articles on preva-lence and correlates of substance abuse among pregnantwomen, since that literature is more abundant and morewidely known. We also obtained and reviewed severalmonographs including those that identify model treat-ment programs for pregnant women and a comprehen-sive monograph on issues surrounding treatment ofwomen. We contacted the evaluators of two major dem-onstration programs, the Pregnant and PostpartumWomen’s and Infants (PPWI) demonstrations of theCenter for Substance Abuse Prevention and the “Perina-tal 20” demonstrations of the NIDA (in the latter case wecontacted all 20 principal investigators). We obtained ei-ther monographs, conference presentations, or publishedarticles if they were available.
Literature Review: Treatment in Pregnancy 197
FINDINGS
Prevalence
Measuring the prevalence of substance abuse by preg-nant women has been difficult because women may use awide array of substances either singly or in combination.These substances include licit substances such as to-bacco, alcohol, and prescription medication, as well as il-licit substances such as marijuana, cocaine, heroin, orbarbiturates.
Methods to identify drug use differ in the type of usethey detect. For example, urine toxicology screening,which can detect use for a relatively short time periodprior to a test, may identify abusers who are more likelythan casual users to use drugs regularly. However, it mayunderidentify casual users. Another problem with toxi-cology screening is that such tests cannot measure fre-quency and intensity of use. Furthermore, health provid-ers may conduct these screening tests selectively, basingtheir decisions to do so on subjective assessments of risk(Chasnoff, Landress, & Barrett, 1990). Because of theseconcerns, physicians have been urged to rely on a stan-dard protocol for ordering these tests to avoid potentialbiases (Skolnick, 1990).
Surveys provide an opportunity to detect casual usersand users of substances over a long period of time (forexample, any time during the year prior to the survey).However, surveys may miss some abusers because of un-derreporting of recent or frequent use associated with guiltor reluctance to report illegal behavior. For example, re-searchers at RAND compared 1984 and 1988 responsesprovided through the National Longitudinal Survey YouthCohort and found that women who were pregnant be-tween the two survey waves were more likely than othersto respond to questions about past use of cocaine andmarijuana (Harrison, Haaga, & Richards, 1993) inconsis-tently from one survey to the next.
Because of the variations in the accuracy of differenttypes of measurement methods, estimates of the numberof pregnant women who use drugs also varies. Most ofthe national estimates are derived from surveys. Preva-lence data from the National Household Survey on DrugAbuse, which is conducted annually by the NIDA, areavailable by age and sex. These data can be used to esti-mate the number of women of childbearing age and preg-nant women who may be abusing substances of varioustypes. The 1995 National Household Survey found thatnationally 7.2% of women ages 15 to 44 years who werenot pregnant used an illicit drug at least once during thepast month, compared to 2.3% of pregnant women (De-partment of Health and Human Services, 1996a). Data onlifetime use do not show a difference in these twogroups, suggesting women reduce substantially their useof drugs during pregnancy. Estimates from the NationalPregnancy and Health Survey show 5.5% of pregnantwomen used an illicit substance some time during preg-
nancy and 18.8% used alcohol (Department of Healthand Human Services, 1996b).
Another trend that has been observed in the annualNIDA household surveys is a general decline in the useof illicit drugs in recent years, although prevalence of thedaily use of certain substances does not appear to havedeclined. For example, the rate of cocaine use declinedfrom its peak in 1985 of 2.7% of the population to 0.6%in 1994; however, the rate of weekly cocaine use re-mained the same—0.3% of the population. Also, the av-erage age of those using drugs, especially heavy users, isincreasing as the cohort of heavy users from the 1970sages. Consequently, drug-dependent pregnant womenmay be more likely to be older mothers (in their latetwenties and early thirties), who have other children anda relatively long history of chronic drug use.
A particularly disturbing trend is the increased use ofmarijuana among youth in the 1990s, which is causingconcern that a new cohort of regular drug users may beforming. In other words, a growing number of adolescentmothers may not yet be drug dependent but may be ex-perimenting with drugs. If prevention programs reachthese young mothers, it may be possible to prevent suchcasual use from becoming dependence.
Results from a very important one-time NIDA preva-lence study (The National Pregnancy and Health Survey)have recently become available (Department of Healthand Human Services, 1996b). The national survey, whichwas conducted in hospitals following delivery in 1992,showed that 5.5% of women used an illicit drug duringpregnancy. The majority of those women (2.9%) usedmarijuana, while 1.1% used cocaine. (Estimates for otherindividual drugs are unreliable because of small samplesizes.) The survey also examined the prevalence of alco-hol use (18.8%) and smoking cigarettes (20.4%) duringpregnancy; use of these substances is known to be poten-tially harmful.
The study found that the rate of use for all substancesdeclined starting the 3 months prior to pregnancy andthroughout the pregnancy. However, such declines wereless pronounced for cocaine (especially crack) and ciga-rettes than for alcohol and marijuana, indicating greaterdependence on those substances for pregnant women andless ability to quit substance use during pregnancy. An-other key result from the Pregnancy and Health Survey(which was consistent with the findings from the NIDAhousehold survey) is that the rate of use of cocainethroughout pregnancy was higher for older mothers (overage 25), while the rate of use of marijuana was higher foryounger mothers. The survey also found that the rates ofuse of cocaine and marijuana during pregnancy were sig-nificantly higher for women who were not married, cur-rently not employed, had less education, or relied onpublic aid for payment to the hospital.
Another recent prevalence study, the National Longi-tudinal Alcohol Epidemiologic Survey of 1992, did notspecifically examine the prevalence of substance use dur-
198 E.M. Howell et al.
ing pregnancy, but it did provide estimates of rates of usefor women enrolled in Medicaid, the publicly sponsoredhealth-care program for certain low-income people, includ-ing all poor pregnant women (Grant & Dawson, 1996). In1992, 4.3% of Medicaid women met the criteria for alco-hol abuse or dependence and 1.9% met the criteria fordrug abuse or dependence. The study noted that theseprevalence rates did not differ substantially from the gen-eral population.
Prevalence estimates are also available from severalone-time local studies. Table 1 summarizes the results ofthose studies. Findings from these studies performed inthe late 1980s and early 1990s show that from 1.3 to25.8% of pregnant women or their children were identi-fied as drug-exposed, based on self-reported data, urinetoxicology screening, or meconium testing. In these stud-ies, from 1.0 to 28% of pregnant women or their childrenwere exposed to marijuana, from 0.3 to 17% were ex-posed to cocaine, and from 0.2 to 6.7% were exposed toopiates. While these studies cannot be generalized to allpregnant women because they were confined to certain lo-cations, hospitals, or demographic groups, they suggestthat in certain high-risk groups the level of dependence onsubstances is much higher than the average use nationally.
A recent major review, “Substance Abuse and theAmerican Woman,” conducted by the National Centeron Addiction and Substance Abuse (1996) (CASA) atColumbia University, summarizes many of the demo-graphic and social factors that are associated withwomen’s substance use and abuse. Their analysis of the1993 NIDA household survey indicated that the percentof adult women who ever used illicit drugs was posi-tively correlated with income, while the percent whoused illicit drugs at least monthly was inversely corre-lated with income.
In terms of race/ethnicity, a higher percent of Whitewomen (36%) have used illicit drugs than African Amer-ican women (29.1%) or Latinos (25.0%), while the per-cent of women who were monthly users is highest forAfrican Americans (4.5%), followed by Latinos (3.4%)and Whites (3.0%). Argeriou and Daley (1997) observedvariations in the types of drugs used by different ethnicgroups in a sample of women admitted to detox facilitiesin Massachusetts. The drug of choice was more often co-caine for African American women, and heroin or alco-hol for Latino or White women.
The CASA study found a declining gender gap indrug use in recent years, with an equal proportion of ado-lescent females and males using illicit drugs. An equalpercentage of young men and young women drinkheavily, compared to older women drinkers who stilldrink less often and less heavily than older men (Quinby& Graham, 1993).
Numerous studies over the past decade have pointedto additional special factors in women’s lives that mayincrease their risk of substance abuse. Anglin, Hser, andBooth (1987) observed that women became addicted to
heroin over a shorter time period than men, and specu-lated that there may be biological and social reasons forthis. Many women in their study were living with orclosely connected to a man who was a heroin addict,which may have accelerated the women’s own increaseduse. Women appear to become addicted to alcohol morequickly than men with lower consumption of alcohol,and to have more health associated problems than theirmale counterparts (Quinby & Graham, 1993). One recentmajor review (Finkelstein, 1996) pointed to troubled re-lationships in both the family of origin and in currentrelationships as a major contributing factor to substanceabuse in women. These may lead to depression and poorself-esteem, both of which are strong risk factors for sub-stance abuse.
Studies (Boyd, 1993; Rohsenow, Corbett, & Devine,1988) have also shown a close association betweenchildhood sexual abuse and substance use, implying thatwomen often use drugs to soften the psychological painassociated with that abuse. From 61% to 75% of womenin substance abuse treatment reported experiencing sex-ual abuse some time in their lifetime. However, samplesizes were small (about 100 cases in each study). An-other study of 170 pregnant women in substance abusetreatment showed somewhat lower rates (15% had been“raped as a child,” 21% had been “raped as an adult,”and 28% had been “molested as a child”). However, dif-ferences could be affected by definitions of sexual abuseand methods of data collection (Regan, Ehrlich, & Finne-gan, 1987). This study also noted an even higher rate ofwomen reporting being “beaten as an adult” (70%) or“beaten as a child” (19%). Rates of these violent inci-dents were higher than rates for a comparison group ofwomen who were not in drug treatment. Another studyof violence showed a much closer relationship betweenbeing a victim of violence and rate of substance use thanbetween demographic characteristics and use (Martin,English, Clark, Cilenti, & Kupper, 1996).
Consequences of Perinatal Substance Abuse
Recent research has also provided greater understandingof the short- and long-term consequences of substanceabuse for mother and infants. A growing body of litera-ture has documented the relationship between smokingand poor birth outcomes (Kleinman, Pierre, Madans,Land, & Schramm, 1988; Lincoln, 1986; Oster, Delea, &Colditz, 1988; Shiono, Klebanoff, & Rhoads, 1986). Theheavy use of alcohol is known to be associated with fetalalcohol syndrome/fetal alcohol effect, which is associ-ated with mental retardation and behavioral problemsthat have been shown to last throughout childhood andearly adulthood (Streissguth, Barr, Kogan, & Bookstein,1996).
While findings regarding the impact of smoking onreduced birthweight have been consistent across many
Literature Review: Treatment in Pregnancy 199
studies, the literature on the impact of substance abuseon birthweight and prematurity is inconclusive. Somestudies show reduced birthweight or increased prematu-rity, and some show no effect. Table 2 summarizes theresults from 17 empirical studies and two comprehensiveliterature reviews of the impact of perinatal substanceabuse on birthweight or gestational age. Most studies fo-cused on cocaine or cocaine combined with other drugsor alcohol. While the majority of studies showed reducedbirthweight and shorter gestational age for infants of sub-stance abusers, not all studies showed these effects. Con-flicting results from human studies could be related to alack of control for the amount of drug use, the type ofdrug use, or the timing of drug use during pregnancy. Forexample, Chasnoff, Griffith, MacGregor, Dirkes, andBurns (1989) found poorer birth outcomes amongwomen who used cocaine throughout pregnancy com-pared with those who used only in the first trimester.Studies may also not have controlled sufficiently forother factors known to affect birthweight and gestationalage, such as social problems or environmental issues thatare often a part of a pregnant substance abuser’s life.
It is easier to introduce controls in animal studies.Behnke and Eyler’s review (1993) included 12 studies ofcontrolled experiments studying the effect of perinatalexposure to cocaine in pregnant rats. Three of these ani-mal studies showed a relationship between cocaine expo-sure and reduced birthweight, but none showed a rela-tionship with gestational age or postnatal growth.However, there was a relationship with higher mortalityfor both the offspring and mothers, suggesting that otherhealth problems other than prematurity or low birthweightwere caused by drug use and were related to the deaths.
There are few studies of the long-term consequencesof prenatal drug exposure. Some evidence suggests thatthe long-term physical and behavioral development ofdrug-exposed infants is impaired (Chasnoff, 1988; Chas-noff, Griffith, Freier, & Murray, 1992; Horgan, Rosen-bach, Ostby, & Butrica, 1991; Howard, 1993). Many ofthese effects are difficult to study because the home envi-ronments of affected infants have serious negative im-pacts on child development.
In spite of the lack of empirical information, there is astrong societal belief that the children of substance abus-ers are at higher risk than other children. The adverse so-cial consequences for children of maternal substanceabuse may greatly outweigh the adverse physical conse-quences. For example, researchers have expressed con-cern about the parenting skills of substance abusers sincethey often lack role models for good parenting. The livesof many crack-addicted pregnant women have been de-scribed as chaotic (Kerson, 1988). Many of the mostprominent stories of child abuse and neglect, such as thedeath of Elisa Izquirdo in 1995 (Besharov, 1996a), havebeen associated with crack use. One small study sampleof 25 drug using women scored significantly higher onpotential for child abuse than did 88 nondrug using
women in the same clinic (Williams-Petersen et al.,1994).
Besharov (1996b) documented that the number ofchildren in foster care associated with the crack epidemicwent up from 280,000 in fiscal year 1986 to 445,000 infiscal year 1993. In New York City alone, the numbergrew from 20,000 in 1987 to 50,000 in 1991 (Sabol,1994). These increased case loads have placed greatstrains on the child welfare system (Curtis & Mc-Cullough, 1993) and have placed many pregnant sub-stance abusers in contact with the child protection systemduring pregnancy, at delivery (when most states requirethat child welfare be contacted if toxicology screensshow evidence of substance abuse), or afterward if chil-dren are placed in foster care.
This situation has created a major policy debate aboutwhen women should be screened and tested for sub-stance abuse, when such abuse should be reported, andwhen children should be removed from their parent’scare if there is continuing substance abuse at home. Thesystem does not seem to always work equitably, and Af-rican American and Latino women may be more fre-quently tested or have children removed more often(Neuspiel, Zingman, Templeton, DiStabile, & Drucker,1993). Furthermore, testing and child welfare involve-ment can be a deterrent to prenatal care and other ser-vices (Poland, Dombrowski, Ager, & Sokol, 1993).
However, there is widespread ambivalence about thisissue. Indeed, a substantial proportion of drug usingwomen (46.5%) in one study felt that pregnant chemi-cally dependent women should go to jail (Poland et al.,1993), and many child advocates feel strongly that theinterest of the child should predominate. New York’s At-torney General has recently advocated removing all new-borns from mothers who have tested positive for cocaineor opiates at delivery, even though current New Yorkpolicy only allows such a removal when there is otherevidence of “imminent danger” to the child (Hammond,1996). Policies in other states vary, as do policies withinhospitals regarding which mothers and newborns shouldbe screened for drug use.
In some cases, women may be motivated to enter andsucceed at treatment to get custody of children who havebeen placed in foster care because of their drug use. Evenwomen who are having their first child may end theirdrug use if they are concerned about losing custody oftheir babies. On the other hand, a woman may be reluc-tant to enter treatment if state laws indicate she couldlose custody of her children (Chavkin, 1990, 1991; Co-letti et al., 1992; Stevens, Arbiter, & Glider, 1989).
Women who are under the jurisdiction of the criminaljustice system may be motivated to enter treatment toavoid having to return to jail. Although mandatory treat-ment may increase some women’s participation in treat-ment and reduce their drug and alcohol use, there is alack of rigorous research on the effect of mandatorytreatment on long-term recovery (Chavkin, 1991).
200 E.M. Howell et al.
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licit
drug
s3%
cont
inue
d
Literature Review: Treatment in Pregnancy 201
TA
BL
E 1
Co
nti
nu
ed
Stu
dy C
itatio
nD
ate
of D
ata
Col
lect
ion
Loca
tion
Sam
ple
Siz
e/M
etho
d of
Sel
ectio
nS
ubst
ance
Pre
vale
nce
6. G
eorg
e, P
rice,
Hau
th,
Bar
nette
, & P
rest
on
(199
1)
Aug
ust 1
989
Ala
bam
aU
rine
scre
enin
g of
2,0
19 n
onpr
egna
nt
and
2,97
0 pr
egna
nt w
omen
en
rolle
d in
pub
lic h
ealth
mat
erni
ty
or fa
mily
pla
nnin
g cl
inic
s or
O
bste
tric
Com
plic
atio
ns C
linic
at
Uni
vers
ity o
f Ala
bam
a.
Mar
ijuan
aN
onpr
egna
nt14
.1%
Pre
gnan
t9.
3%C
ocai
neN
onpr
egna
ntP
regn
ant
1.4%
1.4%
Opi
ates
Non
preg
nant
0.7%
Pre
gnan
t0.
2%A
mph
etam
ines
Non
preg
nant
0.4%
Pre
gnan
t0.
2%.
Bar
bitu
rate
sN
onpr
egna
nt0.
5%P
regn
ant
0.7%
7. G
illog
ley
et a
l. (1
990)
Dec
embe
r 1,
19
87–
Nov
embe
r 30
, 19
88
Sac
ram
ento
, CA
Uni
vers
al u
rine
test
ing
perf
orm
ed o
n 1,
643
wom
en a
dmitt
ed to
obs
tetr
ic
serv
ice
for
1-ye
ar p
erio
d.
Coc
aine
, am
phet
amin
es,
or o
piat
es
20.5
%
8. H
abel
, Kay
e, &
Lee
(1
990)
1981
–198
7N
ew Y
ork,
NY
Link
ed fi
les
of N
ew Y
ork
City
birt
h an
d in
fant
dea
th c
ertif
icat
es u
sed
to
anal
yze
repo
rts
of in
fant
s bo
rn to
dr
ug-a
busi
ng m
othe
rs.
Any
dru
g (a
buse
of
coc
aine
ac
coun
ts fo
r m
ost o
f in
crea
se fr
om
1981
–198
7)
6.7/
1,00
0 liv
e bi
rths
(1
981)
; 20.
3/1,
000
live
birt
hs (
1987
)
9. M
arce
nko,
Spe
nce,
&
Roh
wed
er (
1994
)N
AN
A22
5 pr
egna
nt w
omen
inte
rvie
wed
at
inne
r-ci
ty h
ospi
tal o
utpa
tient
ob
stet
rics
clin
ic a
s pa
rt o
f ra
ndom
ized
clin
ical
tria
l. A
ddic
tion
Sev
erity
Inde
x us
ed to
det
erm
ine
subs
tanc
e ab
use.
Any
sub
stan
ce
abus
e 23
%
10. M
ater
a, W
arre
n,
Moo
mjy
, Fin
k, &
Fox
(1
990)
Nov
embe
r–D
ecem
ber
31,
1988
New
Yor
k, N
YU
rine
sam
ples
obt
aine
d fr
om 5
09
wom
en a
dmitt
ed to
del
iver
y su
ite a
t S
loan
e H
ospi
tal f
or w
omen
.
Coc
aine
10%
cont
inue
d
202 E.M. Howell et al.
TA
BL
E 1
Co
nti
nu
ed
Stu
dy C
itatio
nD
ate
of D
ata
Col
lect
ion
Loca
tion
Sam
ple
Siz
e/M
etho
d of
Sel
ectio
nS
ubst
ance
Pre
vale
nce
11. M
cCal
la e
t al.
(199
1)O
ctob
er 1
8, 1
988–
Mar
ch 1
, 198
9N
ew Y
ork,
NY
Urin
e sp
ecim
ens
from
1,1
11 p
regn
ant
wom
en te
sted
ano
nym
ousl
y at
m
unic
ipal
hos
pita
l.
Mar
ijuan
a1.
2%C
ocai
ne11
.5%
Opi
ates
1.1%
Met
hado
ne.3
%12
. Ney
et a
l. (1
990)
July
1, 1
988–
Dec
embe
r 15
, 19
88
Chi
cago
, IL
141
patie
nts
first
see
n at
N
orth
wes
tern
Mem
oria
l Hos
pita
l in
susp
ecte
d pr
eter
m la
bor
and
com
paris
on g
roup
of 1
08 p
atie
nts
with
full-
term
pre
gnan
cies
who
had
ur
ine
toxi
colo
gy s
cree
ning
pe
rfor
med
.
Any
dru
g17
% (
patie
nts
with
su
spec
ted
pret
erm
la
bor)
Coc
aine
2.8%
(co
mpa
rison
gr
oup)
10%
(pa
tient
s w
ith
susp
ecte
d pr
eter
m
labo
r
,
1% (
com
paris
on
grou
p)13
. Nal
ty e
t al.
(199
1)N
ovem
ber
1990
–A
pril
1991
Sou
th C
arol
ina
Ano
nym
ous
urin
e sp
ecim
ens
colle
cted
from
wom
en g
ivin
g bi
rth
in
24 h
ospi
tals
, as
wel
l as
anon
ymou
s m
econ
ium
spe
cim
ens
from
ne
wbo
rns
in 3
hos
pita
ls.
Alc
ohol
and
dr
ugs
12.1
%(u
rine)
22.4
% (
mec
oniu
m)
25.8
% (
both
test
ing
met
hods
)8.
3%M
ariju
ana
Coc
aine
5.8%
.O
piat
es6.
7%B
arbi
tura
tes
9.8%
14. G
ener
al A
ccou
ntin
g O
ffice
(19
90)
1986
–198
8B
osto
n, M
A;
Chi
cago
, IL;
Los
Ang
eles
, CA
;N
ew Y
ork,
NY
;S
an A
nton
io, T
X
Med
ical
rec
ords
rev
iew
ed in
two
hosp
itals
at e
ach
loca
tion.
10
hosp
itals
acc
ount
ed fo
r 44
,655
bi
rths
in 1
989.
Fou
r diff
eren
t crit
eria
us
ed to
iden
tify
drug
-exp
osed
in
fant
s in
clud
ing
posi
tive
urin
e to
xico
logy
res
ults
for
mot
her
or
infa
nt.
Dru
g-ex
pose
d in
fant
s
Coc
aine
-ex
pose
d in
fant
s
Ran
ge o
f 1.3
–18.
1%
(dep
endi
ng o
n ho
spita
l)R
ange
of .
3–11
.6%
(d
epen
ding
on
hosp
ital)
cont
inue
d
Literature Review: Treatment in Pregnancy 203
Costs
Some cost studies have focused on alcohol and drugabuse during pregnancy. Using California Medicaid data,Ellwood, Adams, Crown, & Dodds (1993) found that sub-stance-exposed infants cost 47.3% more than other infantsin the late 1980s. A related study of Maryland newborns(Norton, Zarkin, Calingaert, & Bradley, 1996) found aneven larger difference in the cost of drug-exposed andnonexposed infants and observed that the higher cost wasattributable to longer stays rather than higher charges perday. This study also found a much stronger relationshipto cost for drug exposure than for alcohol exposure. Astudy in one inner-city hospital found a difference of morethan $5,000 in newborn costs between cocaine-exposedand nonexposed infants (Phibbs, Bateman, & Schwartz,1991). Joyce, Racine, McCalla, and Wehbeh (1995), us-ing data on New York City newborns at one hospital in1991 and 1992, found that infants exposed to cocaineand other drugs were three times more costly than nonex-posed infants, while those exposed only to cocaine were44% more costly, and infants exposed to other drugs butnot cocaine were no more costly than nonexposed infants.
These studies point to the higher infant hospital costsof perinatal substance abuse. However, the studies relyon diagnosis codes from claims, discharge abstracts, ortoxicology results to identify pregnant substance abusers.If hospital personnel are more likely to include drugabuse codes for high-cost cases or to do urine tests onlyon mothers and infants already identified as problemcases, then cost results will be biased upward.
Model Programs
Many experts have recognized that more traditionaltreatment programs designed primarily for men may notbe appropriate for many women, especially pregnantwomen (Department of Health and Human Services,1992a; Finkelstein, 1996).
Indeed, prior to the early 1990s, there was little con-sensus on the appropriate content of care during the pre-natal period for women with substance abuse problems.While health-care providers widely agreed on the impor-tance of prenatal care, substance abuse treatment serviceswere seldom included in the package of services offeredby or through prenatal care providers. Historically, sepa-rate service delivery systems and funding streams forprenatal care and drug treatment further interfered withlinks and coordination between health and substanceabuse treatment providers.
The federal Center for Substance Abuse Treatment(CSAT) helped to address this through the
Treatment Im-provement Protocol (TIP) for Pregnant, Substance-UsingWomen
(Mitchell, 1993). This was followed by two re-lated monographs:
Practical Approaches in the Treat-ment of Women Who Abuse Alcohol and Other Drugs
(Department of Health and Human Services, 1994) and
TA
BL
E 1
Co
nti
nu
ed
Stu
dy C
itatio
nD
ate
of D
ata
Col
lect
ion
Loca
tion
Sam
ple
Siz
e/M
etho
d of
Sel
ectio
nS
ubst
ance
Pre
vale
nce
15. V
alan
is, W
aage
, D
wor
kin,
& R
omig
(1
998)
NA
Por
tland
, OR
250
cons
ecut
ive
deliv
erie
s at
one
ho
spita
l. U
se o
f illi
cit d
rugs
id
entif
ied
thro
ugh
urin
e sp
ecim
ens,
m
edic
al r
ecor
ds, a
nd s
elf-
repo
rts
on a
que
stio
nnai
re.
Mar
ijuan
aC
ocai
neO
piat
esA
mph
etam
ines
Bar
bitu
rate
sB
enzo
diaz
epin
esP
CP
7% 1% 5%
,
1% 0% 0% 0%16
. Veg
a, K
olod
y,
Hw
ang,
& N
oble
(1
993)
Mar
ch–O
ctob
er
1992
Cal
iforn
iaU
rine
sam
ples
col
lect
ed fr
om 2
9,49
4 w
omen
at d
eliv
ery
in 2
02 h
ospi
tals
ac
cord
ing
to m
ultis
tage
pro
babi
lity
sam
plin
g de
sign
.
Mar
ijuan
aC
ocai
neO
piat
esA
mph
etam
ines
Alc
ohol
Any
dru
gs
1.9%
1.1%
1.5%
0.7%
6.7%
5.2%
204 E.M. Howell et al.
TA
BL
E 2
Rec
ent
Stu
die
s o
n t
he
Eff
ect
of
Su
bst
ance
Ab
use
on
Bir
thw
eig
ht
and
Ges
tati
on
al A
ge
Stu
dy C
itatio
nD
ate
of D
ata
Col
lect
ion
Loca
tion
Sam
ple
Siz
e/M
etho
d of
Sel
ectio
nS
ubst
ance
Impa
ct o
n B
irthw
eigh
t an
d/or
Ges
tatio
nal A
ge
1. C
hasn
off e
t al.
(199
2)2-
year
follo
w-u
pC
hica
go, I
LT
wo-
year
gro
wth
and
dev
elop
men
tal
outc
ome
stud
y on
thre
e in
fant
gr
oups
. Gro
up 1
exp
osed
to
coca
ine
and
mar
ijuan
a an
d/or
al
coho
l (
n
5
106
); G
roup
2
expo
sed
to m
ariju
ana
and/
or
alco
hol (
n
5
45)
; Gro
up 3
exp
osed
to
no
drug
dur
ing
preg
nanc
y.
Coc
aine
, mar
ijuan
a,an
d/or
alc
ohol
Sig
nific
ant d
ecre
ases
in
birt
hwei
ght i
nitia
lly; a
fter
1ye
ar, m
ean
wei
ght c
augh
tup
to th
at o
f con
trol
gro
up.
Mar
ijuan
a an
d/or
al
coho
lN
o di
ffere
nce
in b
irthw
eigh
t.
2. T
abor
, Sm
ith-W
alla
ce,
& Y
onek
ura
(199
0)Ja
nuar
y 1,
198
2–Ju
ne 3
0, 1
988
Tor
ranc
e, C
AR
etro
spec
tive
stud
y of
37
PC
P-
into
xica
ted
preg
nant
wom
en
mat
ched
with
37
coca
ine-
into
xica
ted
preg
nant
wom
en.
PC
P, c
ocai
neIn
fant
s ex
pose
d to
PC
P in
ut
ero
mor
e lik
ely
to h
ave
mec
oniu
m-s
tain
ed a
mni
otic
flu
id b
ut le
ss li
kely
to b
e bo
rn
prem
atur
ely
than
infa
nts
expo
sed
to c
ocai
ne.
3. M
acG
rego
r et
al.
(198
7)Ja
nuar
y 19
83–
Sep
tem
ber
1986
Chi
cago
, IL
Per
inat
al o
utco
me
data
for
70
wom
en re
ceiv
ing
care
at P
erin
atal
C
ente
r fo
r C
hem
ical
Dep
ende
nce
with
pre
gnan
cies
com
plic
ated
by
coca
ine
abus
e co
mpa
red
to th
ose
of m
atch
ed c
ontr
ol s
ubje
cts.
Coc
aine
Coc
aine
use
dur
ing
preg
nanc
y as
soci
ated
with
low
er
gest
atio
nal a
ge a
t del
iver
y,
low
er b
irthw
eigh
ts, a
nd
deliv
ery
of s
mal
l-for
-ge
stat
iona
l-age
infa
nts.
4. C
hasn
off,
Bur
ns,
Sch
noll,
& B
urns
(1
985)
Janu
ary
1983
–S
epte
mbe
r19
84
Chi
cago
, IL
23 c
ocai
ne-u
sing
wom
en e
nrol
led
in
perin
atal
add
ictio
n pr
ogra
m
divi
ded
into
two
grou
ps (
coca
ine
only
and
coc
aine
plu
s na
rcot
ics)
; co
mpa
red
to w
omen
who
use
d na
rcot
ics
in p
ast a
nd w
ere
mai
ntai
ned
on m
etha
done
dur
ing
preg
nanc
y an
d w
ith a
noth
er g
roup
of
dru
g-fr
ee w
omen
.
Coc
aine
, coc
aine
/m
etha
done
, m
etha
done
, or
cont
rol
No
stat
istic
ally
sig
nific
ant
diffe
renc
e in
birt
hwei
ghts
am
ong
infa
nts
in fo
ur g
roup
s.
cont
inue
d
Literature Review: Treatment in Pregnancy 205
TA
BL
E 2
Co
nti
nu
ed
Stu
dy C
itatio
nD
ate
of D
ata
Col
lect
ion
Loca
tion
Sam
ple
Siz
e/M
etho
d of
Sel
ectio
nS
ubst
ance
Impa
ct o
n B
irthw
eigh
t an
d/or
Ges
tatio
nal A
ge
5. P
etitt
i and
Col
eman
(1
990)
Janu
ary
1, 1
987–
Dec
embe
r 31
, 19
87
Ala
med
a C
ount
y, C
AP
opul
atio
n-ba
sed
case
-con
trol
stu
dy
of s
ingl
eton
infa
nts
born
in
Ala
med
a C
ount
y du
ring
stud
y pe
riod.
Infa
nts
iden
tifie
d us
ing
birt
h ce
rtifi
cate
s; s
elec
ted
thos
e w
eigh
ing
500
to 2
,499
g. C
ontr
ols
chos
en a
t ran
dom
from
infa
nts
wei
ghin
g 3,
000
or m
ore
g.
Coc
aine
Coc
aine
use
est
imat
ed to
ac
coun
t for
10%
of c
ases
of
low
-birt
hwei
ght b
abie
s bo
rn
to B
lack
wom
en in
Ala
med
a C
ount
y.
6. F
eldm
an, M
inko
ff,
McC
alla
, & S
alw
en
(199
2)
Oct
ober
18,
198
8–M
ay 1
, 198
9N
ew Y
ork,
NY
1,11
1 in
ner-
city
par
turie
nts
anon
ymou
sly
test
ed fo
r pe
rinat
al
illic
it dr
ug u
se.
Coc
aine
, mar
ijuan
a,
opia
tes,
or
met
hado
ne
Dru
g us
ers
wer
e at
3.3
tim
es
grea
ter
risk
of g
ivin
g bi
rth
to
child
wei
ghin
g le
ss th
an
2,50
0 g
inde
pend
ent o
f ot
her
fact
ors.
7. C
hasn
off e
t al.
(198
9)Ja
nuar
y 19
86 –
Feb
ruar
y 19
88C
hica
go, I
L75
coc
aine
-usi
ng w
omen
enr
olle
d in
pe
rinat
al c
are
prog
ram
div
ided
in
to tw
o gr
oups
: tho
se w
ho u
sed
coca
ine
only
in fi
rst t
rimes
ter
of
preg
nanc
y (
n
5
23)
and
thos
e w
ho
used
coc
aine
thro
ugho
ut
preg
nanc
y (
n
5
52)
. Out
com
es o
f th
ese
preg
nanc
ies
com
pare
d to
ou
tcom
es o
f mat
ched
gro
up o
f ob
stet
ric p
atie
nts
with
no
hist
ory
of
subs
tanc
e ab
use.
Urin
e sp
ecim
ens
obta
ined
at a
dmis
sion
an
d at
eac
h pr
enat
al o
bste
tric
vi
sit.
Coc
aine
Mea
n bi
rthw
eigh
t for
term
in
fant
s re
duce
d in
onl
y se
cond
gro
up o
f inf
ants
. G
roup
2 w
omen
had
in
crea
sed
rate
of p
rete
rm
deliv
ery
and
low
birt
hwei
ght
infa
nts.
Gro
up 1
wom
en h
ad
rate
s of
thes
e co
mpl
icat
ions
si
mila
r to
dru
g-fr
ee g
roup
.
cont
inue
d
206 E.M. Howell et al.
TA
BL
E 2
Co
nti
nu
ed
Stu
dy C
itatio
nD
ate
of D
ata
Col
lect
ion
Loca
tion
Sam
ple
Siz
e/M
etho
d of
Sel
ectio
nS
ubst
ance
Impa
ct o
n B
irthw
eigh
t an
d/or
Ges
tatio
nal A
ge
8. G
oldf
arb
et a
l. (1
991)
1988
Pen
nsyl
vani
a,
PA
Sam
ple
of 2
17 d
eliv
erie
s fo
r H
ealth
PA
SS
(a
Med
icai
d ca
se
man
agem
ent p
rogr
am) c
ompa
red
to m
atch
ed s
ampl
e of
del
iver
ies
at
sam
e ho
spita
l for
who
m p
ayor
w
as tr
aditi
onal
fee-
for-
serv
ice
Med
icai
d pr
ogra
m. D
ata
abst
ract
ed fr
om m
edic
al r
ecor
ds.
Coc
aine
Coc
aine
use
not
a s
igni
fican
t pr
edic
tor
of b
irthw
eigh
t.
9. B
urke
tt, Y
asin
& P
alow
(1
990)
Apr
il 19
85–
Sep
tem
ber
1986
Mia
mi,
FL
Obs
tetr
ic o
utco
mes
revi
ewed
for 1
39
wom
en w
ho v
olun
teer
ed
info
rmat
ion
on c
ocai
ne a
buse
du
ring
preg
nanc
y af
ter
20-w
eek
gest
atio
n.
Coc
aine
Mea
n bi
rthw
eigh
t of i
nfan
ts
sign
ifica
ntly
low
er th
an th
at o
f ge
nera
l hos
pita
l pop
ulat
ion.
Lo
w b
irthw
eigh
t occ
urre
d in
36
.2%
of c
ases
, and
sm
all
size
for
gest
atio
nal a
ge
occu
rred
in 3
2.4%
of c
ases
.10
. Zuk
erm
an e
t al.
(198
9)Ju
ly 1
984–
June
19
87B
osto
n, M
AP
rosp
ectiv
e st
udy
of 1
,226
mot
hers
re
crui
ted
from
gen
eral
pre
nata
l cl
inic
, and
thei
r inf
ants
. Int
ervi
ews
or u
rine
toxi
colo
gy te
sts
cond
ucte
d pr
enat
ally
or
post
part
um.
Mar
ijuan
a or
coc
aine
Mar
ijuan
a or
coc
aine
use
as
soci
ated
with
impa
ired
feta
l gr
owth
. Inf
ants
of m
othe
rs
with
pos
itive
urin
e as
says
for
mar
ijuan
a ha
d 79
gm
de
crea
se in
birt
hwei
ght.
11. H
atch
and
Bra
cken
(1
986)
1980
–198
2N
ew H
aven
, CT
Pro
spec
tive
stud
y of
3,8
57
preg
nanc
ies
endi
ng in
sin
glet
on
live
birt
hs a
t Yal
e-N
ew H
aven
H
ospi
tal.
Maj
ority
of i
nter
view
s co
nduc
ted
at 2
0th
wee
k of
ge
stat
ion.
Pre
gnan
cy o
utco
mes
ob
tain
ed fr
om m
edic
al r
ecor
ds.
Mar
ijuan
aE
leva
ted
risk
for
deliv
ery
of lo
w-
birt
hwei
ght,
pret
erm
, or s
mal
l-fo
r-ge
stat
iona
l-age
infa
nt
amon
g W
hite
wom
en
repo
rtin
g re
gula
r m
ariju
ana
use
but n
ot a
mon
g no
n-W
hite
us
ers.
cont
inue
d
Literature Review: Treatment in Pregnancy 207
TA
BL
E 2
Co
nti
nu
ed
Stu
dy C
itatio
nD
ate
of D
ata
Col
lect
ion
Loca
tion
Sam
ple
Siz
e/M
etho
d of
Sel
ectio
nS
ubst
ance
Impa
ct o
n B
irthw
eigh
t an
d/or
Ges
tatio
nal A
ge
12. S
penc
e et
al.
(199
1)N
AP
hila
delp
hia,
PA
Urin
e sc
reen
ing
for
coca
ine
met
abol
ite in
500
con
secu
tive
wom
en a
dmitt
ed to
labo
r an
d de
liver
y un
it at
Hah
nem
ann
Uni
vers
ity H
ospi
tal.
Coc
aine
Wom
en w
ith p
ositi
ve u
rine
sam
ples
four
tim
es a
s lik
ely
to
have
pre
term
labo
r an
d tw
ice
as li
kely
to h
ave
prem
atur
e de
liver
y or
1-m
inut
e A
PG
AR
sc
ore
of 6
or
low
er.
13. K
liegm
an, M
adur
a,
Kiw
i, E
isen
berg
, &
Yam
ashi
ta (
1994
)
Spr
ing
of 1
990–
1991
Cle
vela
nd, O
HA
nony
mou
s ur
ine
toxi
colo
gy
scre
enin
g of
425
wom
en e
nrol
led
at ti
me
of d
eliv
ery
in e
ither
del
iver
y su
ite o
r po
stpa
rtum
uni
t.
Coc
aine
and
m
ariju
ana
Coc
aine
use
det
ecte
d at
birt
h fo
und
to b
e si
gnifi
cant
pr
edic
tor
of p
rem
atur
e or
low
-w
eigh
t birt
h.14
. Shi
ono
et a
l. (1
995)
1984
–198
9O
klah
oma
City
, O
K; N
ew
Yor
k, N
Y;
New
Orle
ans,
LA
; San
A
nton
io, T
X;
Sea
ttle,
WA
7,47
0 w
omen
who
rece
ived
pre
nata
l ca
re fr
om o
ne o
f sev
en u
nive
rsity
-ba
sed
clin
ical
cen
ters
inte
rvie
wed
at
23
to 2
6 w
eeks
ges
tatio
n. D
ata
on d
rug
expo
sure
obt
aine
d fr
om
self-
repo
rt a
nd u
rine
toxi
colo
gies
.
Coc
aine
and
m
ariju
ana
Coc
aine
use
dur
ing
preg
nanc
y no
t ass
ocia
ted
with
low
bi
rthw
eigh
t or
pret
erm
birt
h bu
t str
ongl
y as
soci
ated
with
ab
rupt
io p
lace
ntae
. Mar
ijuan
a us
e du
ring
preg
nanc
y no
t as
soci
ated
with
low
bi
rthw
eigh
t, pr
eter
m b
irth,
or
abru
ptio
pla
cent
ae.
15. B
roek
huiz
en, U
trie
, &
Mul
lem
(19
92)
Jan.
1, 1
983–
Dec
. 31
, 199
0M
ilwau
kee,
WI
Com
pute
rized
dat
abas
e of
23,
926
deliv
erie
s at
Sin
ai-S
amar
itan
Med
ical
Cen
ter,
Uni
vers
ity o
f W
isco
nsin
. Dat
a co
nsis
ted
of
info
rmat
ion
used
for
birt
h ce
rtifi
cate
s, q
ualit
y as
sura
nce,
an
d cl
inic
al r
esea
rch
proj
ects
.
Coc
aine
, mar
ijuan
a,
opia
tes,
am
phet
amin
es,
and
PC
P
Wom
en w
ith d
rug
use
had
two-
to
-thr
ee-t
imes
hig
her
inci
denc
e of
low
birt
hwei
ght
and
perin
atal
dea
th. D
rug
use
with
inad
equa
te c
are
asso
ciat
ed w
ith th
ree
times
hi
gher
inci
denc
e of
low
bi
rthw
eigh
t and
per
inat
al
deat
h. D
rug
use
with
mor
e th
an fi
ve p
rena
tal v
isits
had
m
inim
al e
ffect
on
preg
nanc
y ou
tcom
es.
cont
inue
d
208 E.M. Howell et al.
TA
BL
E 2
Co
nti
nu
ed
Stu
dy C
itatio
nD
ate
of D
ata
Col
lect
ion
Loca
tion
Sam
ple
Siz
e/M
etho
d of
Sel
ectio
nS
ubst
ance
Impa
ct o
n B
irthw
eigh
t an
d/or
Ges
tatio
nal A
ge
16. R
acin
e, J
oyce
, &
And
erso
n (1
993)
1988
–199
0N
ew Y
ork,
NY
Pop
ulat
ion-
base
d re
tros
pect
ive
anal
ysis
of 7
,934
sin
gle
gest
atio
n liv
e bi
rths
to W
hite
non
-His
pani
c,
Bla
ck n
on- H
ispa
nic,
and
His
pani
c re
side
nts
with
pos
itive
indi
catio
n fo
r co
cain
e on
birt
h ce
rtifi
cate
s.
Coc
aine
Rec
eipt
of p
rena
tal c
are
amon
g co
cain
e us
ers
asso
ciat
ed w
ith
sign
ifica
nt im
prov
emen
ts in
bi
rthw
eigh
t. A
djus
ted
mea
n bi
rthw
eigh
t diff
eren
ces
betw
een
user
s w
ith fo
ur o
r m
ore
pren
atal
vis
its a
nd u
sers
w
ith n
one
wer
e 26
2 g
for
Bla
cks,
247
g fo
r W
hite
s, a
nd
317
g fo
r H
ispa
nics
.17
. Soe
patm
i (19
94)
1974
–198
3A
mst
erda
m,
Net
herla
nds
91 in
fant
s of
dru
g-de
pend
ent
mot
hers
del
iver
ed a
t Am
ster
dam
U
nive
rsity
Hos
pita
l.
Opi
ates
Mea
n ge
stat
iona
l age
5
38.
5 w
eeks
; mea
n bi
rthw
eigh
t
5
2,
858
g.18
. Fin
nega
n (1
994)
NA
NA
Lite
ratu
re r
evie
wC
ocai
neA
ssoc
iatio
n be
twee
n co
cain
e us
e an
d pr
emat
urity
.19
. Beh
nke
& E
yler
(19
93)
NA
NA
Lite
ratu
re r
evie
wA
lcoh
olA
ssoc
iatio
n be
twee
n hi
gh le
vels
of
alc
ohol
exp
osur
e an
d po
or
feta
l gro
wth
.M
ariju
ana
Inco
nsis
tent
find
ings
on
rela
tions
hip
betw
een
pren
atal
m
ariju
ana
use
and
poor
feta
l gr
owth
.O
piat
esP
rena
tal o
piat
e us
e as
soci
ated
w
ith p
oore
r pr
egna
ncy
outc
omes
incl
udin
g lo
w
birt
hwei
ght a
nd in
trau
terin
e gr
owth
ret
arda
tion.
Coc
aine
Incr
ease
in p
rete
rm d
eliv
ery
and
smal
l inf
ant s
ize
at b
irth
amon
g pr
egna
nt c
ocai
ne
user
s.
Literature Review: Treatment in Pregnancy 209
Treatment of the Pregnant Addict
(Center for ChemicalDependency Treatment, 1994). These documents—devel-oped by experts in medicine, substance abuse treatment,and social services—include guidelines for appropriateprenatal care and substance abuse treatment, as well asways to ensure that women receive necessary ancillaryand support services. Important legal and ethical issuesrelated to the reporting of information on drug use, in-cluding reports to child protective services, are also dis-cussed.
These materials on model programs emphasize thatprograms for pregnant, substance-abusing women mustbe family-centered, comprehensive, and staffed by an in-terdisciplinary team of professionals who provide servicesin a nonjudgmental, nonpunitive, nurturing, and culturallyand linguistically appropriate manner (Chavkin & Paone,1991; Department of Health and Human Services, 1992a;Kumpfer, 1991). Programs must address mental healthproblems and provide appropriate assistance and support,recognizing that the more confrontational techniques oftenused in treatment for men may not work as well withmany women. For mothers who do seek treatment, theunavailability of child care and transportation often posesbarriers to care. Treatment during pregnancy must there-fore be integrated and coordinated with child care andtransportation services.
Outreach and Screening
Most programs that have served pregnant substanceabusers have confronted the difficult problem of identi-fying their target population. Programs have discoveredthat implementing an effective outreach, screening, andreferral process in nontreatment settings requires sensi-tivity to the issues facing this population, as well as thecooperation of different individuals across the social ser-vice, prenatal care, and substance abuse treatment deliv-ery systems. Pregnant women may be especially hesitantto volunteer information about drug use because of fearsabout losing custody of their children, being prosecuted,or being alienated socially (Finkelstein, 1994). Thesefears are greatest in states that report suspected substanceabuse to child welfare or other authorities.
When women receive prenatal care, they have an op-portunity to work with support service providers to ad-dress substance abuse as part of the continuum of care.Several screening questionnaires have been developed ina variety of settings by persons with minimal substanceabuse training (Babor, Ritson, & Hodgson, 1986; De-partment of Health and Human Services, 1993; Smith etal., 1987; WHO Brief Intervention Study Group, 1996).For example, the Short Michigan Alcoholism ScreeningTest (SMAST) contains 13 questions to screen for lifetimedependence symptoms, alcohol-related problems, medicalconsequences, and previous treatment. The CAGE Ques-tionnaire identifies lifetime alcohol use through only fourquestions. The “Four Ps” is a similar four-question in-
strument oriented toward pregnant women (Departmentof Health and Human Services, 1993). Such brief screensfollowed by counseling have been shown to encouragepregnant women to reduce their drinking during preg-nancy (Reynolds, Coombs, Lowe, Peterson, & Gayoso,1995). While these were developed for alcohol screen-ing, they have been adapted for screening for drug use.
Although physicians should screen routinely for alco-hol and other drug abuse problems, this practice is stillnot widespread (Clement, 1986; Kitchens, 1994; Wen-rich, Paauw, Carline, Curtis, & Ramsey, 1995). Studieshave documented negative attitudes toward pregnantsubstance abusers among prenatal care providers (Clem-ent, 1986) and substance abuse treatment providers(Finkelstein, 1993; Nurco et al., 1987). These negativeattitudes and feelings of anger toward pregnant substanceabusers may deter women from confiding about theirsubstance abuse.
A study by Li, Olsen, Kvigne, and Welty (1995) in-vestigated the barriers to implementing a prenatal sub-stance abuse screening program in the Aberdeen Area In-dian Health Service facilities in South Dakota. The studyidentified administrative and patient barriers. Major ad-ministrative barriers to implementing a screening pro-gram included the absence of staff training in screeningfor maternal substance abuse, failure to designate staff toadminister the screening instrument, insufficient staff toadminister the questionnaire, and an insufficient referralprotocol. Another qualitative study of a screening pro-gram among nurse midwives documented the trainingprocess that helped midwives feel more comfortable ask-ing questions about substance abuse (Corse, McHugh, &Gordon, 1995). In addition to the importance of ongoingtraining, this study and others have emphasized the ne-cessity of improving referral linkages to increase screen-ing effectiveness since providers do not want to identifysubstance abusers unless they can readily provide helpfor them (American College of Obstetrics and Gynecol-ogy Technical Bulletin, 1994).
Policies regarding urine testing in prenatal care set-tings or at delivery are not standardized around the coun-try. In a national survey of obstetric and pediatric trainingprograms conducted in 1990, physicians were questionedabout their opinions and formal policies regarding co-caine screening methods and protocols (Pelham & De-Jong, 1992). Routine universal urine screening of moth-ers or newborns was the policy in only 9% of obstetricprograms and 7% of pediatric programs, although 38%of the obstetricians and 33% of the pediatricians favoreduniversal screening.
It is not possible to identify all pregnant substanceabusers through screening programs in prenatal care orother service settings. Studies have shown that manypregnant substance abusers receive no prenatal care (Mc-Calla et al., 1991). To be successful, programs must use avariety of additional outreach and recruitment strategies(Laken & Hutchins, 1996). For example, community-
210 E.M. Howell et al.
based outreach in places outside service settings (such ashomes, schools, or streets) may be needed. However, re-search has also shown that these outreach strategies aredifficult to implement (Argeriou, Piedade, Finkelstein, &Shearer, 1996).
Treatment
The recent expansion in substance abuse treatment ser-vices for pregnant women has been accompanied bysome limited research on the outcomes of treatment forthis population. To date, few studies with rigorous re-search designs of these treatment programs have beenpublished in peer-reviewed journals, and much of the lit-erature is descriptive in nature.
1
Numerous studies, stillin preliminary stages, promise increased evidence abouttreatment effectiveness for pregnant substance abusers,but currently available evidence is still quite limited.
Table 3 highlights major design features and findingsfrom a small number of recent outcome studies of treat-ment for pregnant women. These studies show that find-ings are consistent with the broader treatment outcomeliterature (Gerstein & Harwood, 1990; Hubbard et al.,1989; McGlothlin & Anglin, 1981; Simpson, Joe, Leh-man, & Sells, 1986; Simpson & Sells, 1983; Wickizer etal., 1994; Woody et al., 1983). Women who completetreatment have a greater likelihood of reducing their sub-stance use than those who do not complete treatment.Retention is improved by more intensive treatment andby the provision of an enriched package of services, suchas child care. Studies that compare different types oftreatment (for example, residential versus outpatient) areinconclusive—most show little or no difference in out-comes by type of treatment. The lack of random assign-ment to treatment combined with small sample sizes lim-its the conclusions we can draw from these studies.
An evaluation of the Center for Substance Abuse Pre-vention’s Pregnant and Postpartum Women and their In-fants (PPWI) Demonstration Program (Macro Interna-tional, Inc., 1993) reviewed more than 130 treatment andprevention programs that received grants to introduceand enhance treatment options for pregnant women withalcohol and other drug problems. The evaluation find-ings, which are qualitative and descriptive, suggest thatthe PPWI program strengthened the capacity of the treat-ment system in providing appropriate services throughits funding of a large number of small, women-orientedtreatment programs around the country. Data from the 26programs that collected some person-level data showedthat about 40% of the participating women had negative
drug tests at delivery and that most PPWI women re-ceived intermediate (43.5%) or adequate (35.8%) levelsof prenatal care. The lack of any comparison group pre-cluded any conclusions about treatment effectivenessfrom the PPWI results.
Because methadone has been shown to be effectivefor opiate addiction generally, methadone has been usedto treat pregnant women. Many doctors consider it ap-propriate to continue a woman on her pre-pregnancydose of methadone (Jarvis & Schnoll, 1995). However,use of methadone during pregnancy remains controver-sial, and many providers are opposed to exposing the fe-tus to methadone. The outcomes of different methadoneprograms vary considerably and seem to depend on thedose of methadone and other factors.
Four small studies of pregnant women in methadonemaintenance programs found that those on methadoneremain in treatment longer than opiate-dependent womennot on methadone, consistent with findings from thebroader literature on methadone treatment. An enhancedmethadone maintenance program (incorporating relapseprevention and therapeutic child care) led to greater ab-stinence and improved birth outcomes in one small study(Chang, Carroll, Behr, & Kosten, 1992). Another smallstudy of pregnant women receiving methadone foundthat women in the program were more likely to receiveprenatal care and were less likely to use cocaine or alco-hol during pregnancy. However, a high percentage ofwomen continued to abuse drugs and there were no sig-nificant differences in the birth outcomes for methadone-maintained women and other polydrug using pregnantwomen not in a methadone maintenance program (Edelinet al., 1988).
These studies were limited by small sample sizes andpossible problems related to selection bias. Also, sinceopiate dependence is not the most prevalent form of sub-stance abuse among women of childbearing age, metha-done maintenance is appropriate for only a small propor-tion of pregnant substance abusers.
Studies of residential treatment suggest that tailoringprograms to the specific needs of women in order to im-prove retention can improve outcomes. One study (Stevens& Arbiter, 1995) of pregnant women in a residential pro-gram found that outcomes for women completing theprogram, including drug use, were better than those fornoncompleters. For example, measures of 6-month post-treatment outcomes showed that only 31% of com-pleters were again using drugs, compared to 64% of non-completers.
Several studies of enhancing residential programsalso report positive results. One study of a residentialtreatment for Alaskan Native pregnant substance abusersthat incorporated mental health treatment, as well asother support services such as parenting and vocationalplanning, experienced a 68% abstinence rate (Namyniuk,1995). Camp and Finkelstein (1995) investigated the im-plementation and effectiveness of a parenting component
1
The findings from 20 NIDA-funded demonstrations (known as the“Perinatal 20” studies), many of which had randomized designs, havenot been published by NIDA; however, some findings from these stud-ies have been published independently, presented in project reports, orreported at conferences. These are included in this review.
Literature Review: Treatment in Pregnancy 211
TA
BL
E 3
Rev
iew
of
Rec
ent
Stu
die
s o
n T
reat
men
t E
ffec
tive
nes
s fo
r P
reg
nan
t P
ost
par
tum
Su
bst
ance
Ab
use
rs
Stu
dy C
itatio
nS
ampl
e S
ize/
Des
crip
tion
Com
paris
ons
Fin
ding
s
PP
WI d
emon
stra
tion
prog
ram
sM
acro
Inte
rnat
iona
l, In
c. (
1993
)F
indi
ngs
from
26
CS
AT
PP
WI d
emon
stra
tion
gran
tees
, inc
ludi
ng 3
,641
wom
en r
evie
wed
. M
ost p
rogr
ams
incl
uded
sub
stan
ce a
buse
pr
even
tion
and
trea
tmen
t, ca
se m
anag
emen
t,pr
enat
al c
are,
out
reac
h, h
ome
visi
ting,
pa
rent
ing
clas
ses,
and
sup
port
ser
vice
s.
Sub
stan
ce a
buse
at d
eliv
ery
com
pare
d to
use
at p
rogr
amen
try.
37%
of w
omen
with
dru
g te
st a
t del
iver
y ha
d ne
gativ
e re
sults
for
illic
it dr
ugs.
Met
hado
ne M
aint
enan
ceA
nder
son
et a
l. (1
996)
Stu
dy o
f pre
gnan
t wom
en tr
eate
d un
der
two
diffe
rent
met
hado
ne p
roto
cols
. One
gro
up
rece
ived
3-d
ay m
etha
done
tape
r fo
llow
ed
by a
bstin
ence
-bas
ed tr
eatm
ent (
n
5
22)
; ot
her
grou
p pl
aced
on
met
hado
ne
mai
nten
ance
(
n
5
16)
.
Com
paris
on o
f pre
gnan
t wom
en in
m
etha
done
mai
nten
ance
pro
gram
and
thos
e in
abs
tinen
ce-b
ased
prog
ram
.
At 4
0 da
ys p
osta
dmis
sion
, a h
ighe
r pr
opor
tion
of
wom
en in
met
hado
ne m
aint
enan
ce p
rogr
am
(69%
) re
mai
ned
in tr
eatm
ent t
han
wom
en in
ab
stin
ence
-bas
ed p
rogr
am (
10%
).
Cha
ng e
t al.
(199
2)E
nhan
ced
trea
tmen
t pro
vide
d to
six
pre
gnan
t m
etha
done
-mai
ntai
ned
opia
te-d
epen
dent
pr
egna
nt w
omen
. Enh
ance
d tr
eatm
ent
cons
iste
d of
wee
kly
pren
atal
car
e, r
elap
se
prev
entio
n gr
oups
, thr
ice-
wee
kly
urin
e to
xico
logy
scr
eeni
ng w
ith p
ositi
ve c
ontin
genc
y aw
ards
for
abst
inen
ce, a
nd th
erap
eutic
chi
ld
care
dur
ing
trea
tmen
t vis
its.
Out
com
es fo
r si
x pr
egna
nt
met
hado
ne-m
aint
aine
d op
iate
-de
pend
ent w
omen
in e
nhan
ced
trea
tmen
t com
pare
d to
thos
e of
si
x w
omen
rece
ivin
g co
nven
tiona
l m
etha
done
mai
nten
ance
trea
tmen
t (da
ily m
etha
done
m
edic
atio
n, c
ouns
elin
g, a
nd
rand
om u
rine
toxi
colo
gysc
reen
ing)
.
Enh
ance
d tr
eatm
ent g
roup
had
few
er p
ositi
ve
urin
e to
xico
logy
scr
eens
, mor
e pr
enat
al v
isits
, an
d he
avie
r in
fant
s.
Out
com
es fo
r C
ompa
rison
/Enh
ance
d T
reat
men
t G
roup
s:
Out
com
eC
ompa
rison
Tre
atm
ent
Pos
itive
urin
e to
xico
logy
sc
reen
s
5
76%
59%
Pre
nata
l car
e vi
sits
5
2.7
visi
ts8.
8 vi
sits
Ges
tatio
nal
age
5
35.7
wks
38.2
wks
Birt
hwei
ght
5
2,34
4 g
2,95
9 g
cont
inue
d
212 E.M. Howell et al.
TA
BL
E 3
Co
nti
nu
ed
Stu
dy C
itatio
nS
ampl
e S
ize/
Des
crip
tion
Com
paris
ons
Fin
ding
s
Ede
lin e
t al.
(198
8)R
etro
spec
tive
anal
ysis
of p
regn
ancy
out
com
es fo
r 26
opi
ate-
depe
nden
t wom
en e
nrol
led
in
met
hado
ne m
aint
enan
ce p
rogr
am.
Pre
gnan
cy o
utco
mes
for
26 w
omen
in
met
hado
ne m
aint
enan
ce
prog
ram
com
pare
d w
ith o
utco
mes
fo
r 37
preg
nant
pol
ydru
g us
ers
not
in p
rogr
am b
ut w
ho d
eliv
ered
du
ring
sam
e 12
-mon
th p
erio
d (J
une
1985
–Jul
y 19
86)
and
com
paris
on g
roup
of a
ll pr
egna
nt
wom
en w
ho d
eliv
ered
in J
anua
ry–
May
198
6 (
n
5
716
).
88%
of w
omen
in m
etha
done
mai
nten
ance
pr
ogra
m c
ontin
ued
to u
se d
rugs
dur
ing
preg
nanc
y, 5
6% h
ad p
ositi
ve to
xico
logy
scr
een
at la
bor.
Com
pare
d to
oth
er p
regn
ant s
ubst
ance
ab
user
s, w
omen
enr
olle
d in
met
hado
ne
mai
nten
ance
pro
gram
had
mor
e pr
enat
al c
are
visi
ts, a
nd m
ore
adeq
uate
pre
nata
l car
e.
How
ever
, no
sign
ifica
nt d
iffer
ence
s in
bi
rthw
eigh
t or
AP
GA
R s
core
s be
twee
n th
ese
grou
ps w
ere
foun
d. S
igni
fican
t diff
eren
ces
in
birt
h ou
tcom
es w
ere
foun
d be
twee
n th
e tw
o pr
egna
nt s
ubst
ance
abu
ser
grou
ps a
nd
com
paris
on g
roup
, with
com
paris
on g
roup
ha
ving
bet
ter
outc
omes
.S
viki
s et
al.
(199
6)
a
Tre
atm
ent p
artic
ipat
ion
deci
sion
s an
d tr
eatm
ent
rete
ntio
n ex
amin
ed fo
r 22
4 pr
egna
nt p
rimar
y op
iate
or
coca
ine-
depe
nden
t wom
en s
eeki
ng
first
adm
issi
on to
inte
nsiv
e da
y-tr
eatm
ent
prog
ram
with
on-
site
chi
ld c
are
and
tran
spor
tatio
n be
twee
n N
ovem
ber
1992
and
O
ctob
er 1
993.
Tre
atm
ent r
eten
tion
com
pare
d fo
r op
iate
-dep
ende
nt w
omen
in
met
hado
ne m
aint
enan
ce, o
piat
e-de
pend
ent w
omen
not
in
met
hado
ne m
aint
enan
ce, a
nd
nono
piat
e-de
pend
ent w
omen
.
Wom
en in
met
hado
ne m
aint
enan
ce r
emai
ned
in
trea
tmen
t sig
nific
antly
long
er th
an o
ther
two
grou
ps.
Cam
p &
Fin
kels
tein
(1
995)
Stu
dy o
f 170
pre
gnan
t and
par
entin
g ch
emic
ally
de
pend
ent w
omen
at t
wo
urba
n re
side
ntia
l tr
eatm
ent p
rogr
ams
betw
een
Mar
ch 2
8, 1
990
and
Aug
ust 3
1, 1
993
in M
assa
chus
etts
that
ex
amin
ed e
ffect
iven
ess
of a
par
entin
g co
mpo
nent
and
afte
rcar
e se
rvic
es.
Mea
sure
s of
pro
gram
par
ticip
ants
’ pa
rent
ing
skill
s, s
elf-
este
em, a
nd
othe
r ou
tcom
es c
ompa
red
befo
re
and
afte
r pro
gram
. Birt
h ou
tcom
es
also
exa
min
ed. M
easu
res
of
rete
ntio
n fo
r pr
ogra
m p
artic
ipan
ts
com
pare
d to
thos
e of
no
npar
ticip
ants
.
Wom
en’s
out
com
es:
Wom
en im
prov
ed
cons
ider
ably
in p
aren
ting
know
ledg
e an
d at
titud
es a
ssoc
iate
d w
ith p
ositi
ve p
aren
ting
beha
vior
. The
y al
so e
xper
ienc
ed d
ram
atic
im
prov
emen
ts in
sel
f-es
teem
.
Birt
h ou
tcom
es:
Rel
ativ
ely
few
infa
nts
exhi
bite
d po
or b
irth
outc
omes
as
mea
sure
d by
birt
hwei
ght
(ave
rage
3,1
17 g
), g
esta
tiona
l age
(90
% fu
ll te
rm),
and
AP
GA
R s
core
s (8
9% w
ith 1
-min
ute
AP
GA
R’s
7–1
0).
Pro
gram
par
ticip
atio
n, p
rogr
am r
eten
tion,
and
re
laps
e:
Com
plet
ion
of p
aren
ting
prog
ram
po
sitiv
ely
rela
ted
to lo
nger
per
iods
of a
bstin
ence
w
ith a
vera
ge e
stim
ated
tim
e to
rel
apse
bei
ng
14.7
mon
ths
for
com
plet
ers
and
9.4
mon
ths
for
non-
com
plet
ers.
cont
inue
d
Literature Review: Treatment in Pregnancy 213
TA
BL
E 3
Co
nti
nu
ed
Stu
dy C
itatio
nS
ampl
e S
ize/
Des
crip
tion
Com
paris
ons
Fin
ding
s
Hug
hes
et a
l. (1
995)
a
Bet
wee
n A
pril
1990
and
Oct
ober
199
2, 5
3 w
omen
w
ith c
hild
ren
wer
e ra
ndom
ly a
ssig
ned
to
stan
dard
res
iden
tial t
reat
men
t (
n
5
22)
or
dem
onst
ratio
n re
side
ntia
l tre
atm
ent,
whi
ch
allo
wed
chi
ldre
n to
live
with
the
wom
en (
n
5
31)
.
Sta
ndar
d tr
eatm
ent c
ompa
red
with
de
mon
stra
tion
trea
tmen
t tha
t al
low
ed o
ne-t
o-tw
o ch
ildre
n to
live
w
ith c
lient
s.
Wom
en in
dem
onst
ratio
n gr
oup
rem
aine
d in
tr
eatm
ent s
igni
fican
tly lo
nger
than
wom
en w
ith
stan
dard
trea
tmen
t.M
ean
leng
th o
f sta
y:D
emon
stra
tion
grou
p:30
0.4
days
Sta
ndar
d tr
eatm
ent g
roup
: 10
1.9
days
Nam
yniu
k (1
995)
Stu
dy o
f res
iden
tial t
reat
men
t pro
gram
for
subs
tanc
e-ab
usin
g pr
egna
nt A
lask
an N
ativ
e w
omen
. Mod
el fo
cuse
d on
men
tal h
ealth
and
su
bsta
nce
abus
e tr
eatm
ent a
nd a
ddre
ssed
ba
rrie
rs to
ent
ry in
to tr
eatm
ent,
med
ical
car
e,
pare
ntin
g, fa
mily
and
rel
atio
nshi
p is
sues
, and
vo
catio
nal p
lann
ing.
Rel
apse
con
side
red
part
of
reco
very
pro
cess
; wom
en m
ay b
e re
-adm
itted
in
to p
rogr
am a
fter
rela
pse.
Ana
lysi
s of
abs
tinen
ce r
ates
and
dr
op-o
ut r
ates
com
pare
d w
ith
natio
nal r
ates
.
In fo
ur y
ears
of o
pera
tion,
pro
gram
sho
wed
68%
ab
stin
ence
rat
es a
nd 7
% d
rop-
out r
ate,
co
mpa
red
to n
atio
nal r
ates
of 5
0% a
nd 1
2%
resp
ectiv
ely.
50%
of w
omen
read
mitt
ed in
to th
e pr
ogra
m a
fter
a re
laps
e ep
isod
e gr
adua
ted.
Sch
inka
et a
l.(1
999)
a
46
coc
aine
-dep
ende
nt w
omen
trea
ted
at
ther
apeu
tic c
omm
unity
that
incl
uded
man
y fe
atur
es a
ddre
ssin
g w
omen
’s s
peci
al n
eeds
. W
omen
cou
ld k
eep
child
ren
with
them
whi
le in
tr
eatm
ent.
Com
paris
on o
f dep
ress
ion
mea
sure
s at
bas
elin
e an
d 12
m
onth
s af
ter
disc
harg
e.
Mea
n co
re o
n B
eck
Dep
ress
ion
Sca
le w
as 1
6.0
at
base
line
and
10.5
at f
ollo
w-u
p. S
core
of 1
6 or
gr
eate
r su
gges
ted
mod
erat
e to
-sev
ere
depr
essi
on.
Ste
vens
& A
rbite
r (1
995)
a
Out
com
es fo
r 57
sub
stan
ce-a
busi
ng p
regn
ant
wom
en w
ho e
nter
ed lo
ng-t
erm
res
iden
tial
prog
ram
bet
wee
n N
ovem
ber
1990
and
S
epte
mbe
r 19
94 e
xam
ined
. Pro
gram
allo
wed
ch
ildre
n to
live
with
clie
nts.
Wom
en w
ho c
ompl
eted
trea
tmen
t (
n
5
13)
com
pare
d to
thos
e w
ho
drop
ped
out o
f tre
atm
ent (
n
5
44)
ba
sed
on 6
- an
d 12
-m
onth
po
sttr
eatm
ent f
ollo
w-u
p in
terv
iew
s w
ith e
ach
grou
p.
Out
com
es (
e.g.
, dru
g us
e, c
rimin
al a
ctiv
ity,
empl
oym
ent)
bet
ter
for
com
plet
ers
than
no
ncom
plet
ers.
Alc
ohol
/dru
g us
e w
ithin
6 m
onth
s po
st-t
reat
men
t: C
ompl
eter
s:31
%N
onco
mpl
eter
s:64
%
cont
inue
d
214 E.M. Howell et al.
TA
BL
E 3
Co
nti
nu
ed
Stu
dy C
itatio
nS
ampl
e S
ize/
Des
crip
tion
Com
paris
ons
Fin
ding
s
Com
fort
, Kum
aras
wam
y,
& K
alte
nbac
h (1
997)
38 p
regn
ant a
nd p
aren
ting
wom
en e
nrol
led
at
leas
t 8 m
onth
s in
com
preh
ensi
ve o
utpa
tient
su
bsta
nce
abus
e tr
eatm
ent.
Com
paris
on o
f wom
en a
t bas
elin
e an
d af
ter
8 m
onth
s of
trea
tmen
t.S
igni
fican
t dec
lines
occ
urre
d in
sel
f-re
port
ed
30-d
ay s
ubst
ance
use
.
Laud
et, M
agur
a, &
W
hitn
ey (
1997
)18
4 w
omen
with
dru
g ex
pose
d ne
wbo
rns
in N
ew
Yor
k C
ity a
dmitt
ed to
out
patie
nt p
rogr
am w
ith
inte
nsiv
e ca
se m
anag
emen
t com
pone
nt.
Com
paris
ons
betw
een
thos
e co
mpl
etin
g tr
eatm
ent,
thos
e st
ill in
tr
eatm
ent,
and
drop
outs
.
Com
plet
ed
Pro
gram
Stil
lE
nrol
led
Dro
pped
O
utC
ocai
ne/c
rack
us
e at
follo
w-u
pS
elf-
repo
rt6%
17%
35%
Hai
r an
alys
is40
%60
%75
%
Kni
sely
et a
l. (1
995)
a
133
preg
nant
/pos
tpar
tum
wom
en r
ando
mly
as
sign
ed to
tim
e-lim
ited
(
n
5
78)
or
self-
pace
d (
n
5
55)
inte
nsiv
e ou
tpat
ient
pro
gram
s; 2
3 w
omen
not
inte
rest
ed in
par
ticip
atin
g re
crui
ted
as a
com
paris
on g
roup
. Dur
atio
n of
trea
tmen
t w
as 5
mon
ths
for
time-
limite
d gr
oup
and
5–18
m
onth
s fo
r se
lf-pa
ced
grou
p.
Com
paris
ons
wer
e m
ade
betw
een
time-
limite
d gr
oup
and
com
paris
on g
roup
. Cha
nges
in
prog
ram
des
ign
mea
nt o
utco
mes
fo
r se
lf-pa
ced
prog
ram
cou
ld n
ot
be e
xam
ined
due
to s
mal
l sam
ple
size
s. In
form
atio
n co
llect
ed a
t in
take
, dur
ing
trea
tmen
t, at
di
scha
rge,
and
at 6
-mon
th
inte
rval
s fo
r 2
year
s af
ter.
Wom
en in
tim
e-lim
ited
prog
ram
sho
wed
sig
nific
ant
redu
ctio
ns in
alc
ohol
and
dru
g us
e. W
omen
re
ceiv
ing
no tr
eatm
ent e
xper
ienc
ed n
o su
ch
impr
ovem
ents
.
Str
antz
& W
elch
(19
95)
a
Stu
dy o
f ret
entio
n/co
mpl
etio
n fo
r po
stpa
rtum
w
omen
in e
nhan
ced
day
trea
tmen
t (
n
5
151
) an
d tr
aditi
onal
inte
nsiv
e ou
tpat
ient
trea
tmen
t(
n
5
141
); w
omen
dis
char
ged
in J
anua
ry 1
995.
E
nhan
ced
day
trea
tmen
t con
sist
ed o
f int
ensi
ve
7-da
y-a-
wee
k pr
ogra
m.
Com
paris
on o
f wom
en in
enh
ance
d ou
tpat
ient
pro
gram
(in
clud
ing,
for
exam
ple,
par
entin
g ed
ucat
ion
and
pers
onal
dev
elop
men
t act
iviti
es)
with
thos
e in
trad
ition
al o
utpa
tient
pr
ogra
m.
Tre
atm
ent c
ompl
etio
n hi
gher
for
wom
en in
en
hanc
ed p
rogr
am (
45%
) co
mpa
red
to w
omen
in
trad
ition
al p
rogr
am (
21%
). P
rogr
am ty
pe,
infa
nt c
usto
dy, a
nd n
umbe
r of
chi
ldre
n in
hom
e w
ere
stro
nges
t pre
dict
ors
of tr
eatm
ent r
eten
tion/
com
plet
ion.
Com
fort
& K
alte
nbac
h (in
pre
ss)
a
Out
com
es s
tudy
of 6
4 co
cain
e-de
pend
ent
preg
nant
wom
en r
efer
red
to “
Fam
ily C
ente
r” in
P
hila
delp
hia,
PA
bet
wee
n F
ebru
ary
1991
and
D
ecem
ber
1993
.
Com
paris
ons
betw
een
wom
en in
re
side
ntia
l tre
atm
ent
(n
5
32)
and
w
omen
in o
utpa
tient
pro
gram
s(
n
5
32)
.
Com
paris
on o
f out
com
es fo
r w
omen
in r
esid
entia
l tr
eatm
ent a
nd th
ose
in o
utpa
tient
trea
tmen
t sh
owed
no
sign
ifica
nt d
iffer
ence
s in
birt
h ou
tcom
es (
birt
hwei
ght,
gest
atio
nal a
ge, h
ead
circ
umfe
renc
e, a
nd le
ngth
of f
ull-t
erm
infa
nts)
an
d to
tal m
onth
s of
sub
stan
ce a
buse
trea
tmen
t. M
arqu
es e
t al.
(199
5)
a
163
coca
ine-
depe
nden
t pos
tpar
tum
wom
en
rand
omly
ass
igne
d to
res
iden
tial t
reat
men
t be
fore
out
patie
nt, o
utpa
tient
trea
tmen
t onl
y, o
r no
trea
tmen
t.
Com
paris
ons
of w
omen
by
type
of
trea
tmen
t at 2
yea
rs
post
trea
tmen
t.
Tre
atm
ent c
ompl
ianc
e po
or—
few
er th
an 2
5%
com
plia
nt. R
esid
entia
l tre
atm
ent m
argi
nally
m
ore
effe
ctiv
e th
an o
ther
gro
ups
in r
educ
ing
aver
age
coca
ine
use
over
2-y
ear p
osttr
eatm
ent
perio
d. W
omen
with
bet
ter
base
line
char
acte
ristic
s an
d w
ho to
ok b
est a
dvan
tage
of
reso
urce
s ga
ined
the
mos
t.
cont
inue
d
Literature Review: Treatment in Pregnancy 215
TA
BL
E 3
Co
nti
nu
ed
Stu
dy C
itatio
nS
ampl
e S
ize/
Des
crip
tion
Com
paris
ons
Fin
ding
s
Sch
rage
r et
al.
(199
5)R
etro
spec
tive
stud
y of
pre
gnan
t and
pos
tpar
tum
su
bsta
nce
abus
ers
deliv
erin
g in
Was
hing
ton
stat
e fr
om J
uly
1, 1
991–
June
30,
199
2 an
d re
ceiv
ing
publ
icly
fund
ed s
ubst
ance
abu
se
trea
tmen
t ser
vice
s du
ring
pren
atal
per
iod
(
n
5
71
6). F
our
grou
ps d
efin
ed b
ased
on
type
of
subs
tanc
e ab
use
trea
tmen
t rec
eive
d: re
side
ntia
l an
d ou
tpat
ient
trea
tmen
t (
n
5
99)
, res
iden
tial
trea
tmen
t onl
y (
n
5
129
), o
utpa
tient
trea
tmen
t on
ly (
n
5
358
), a
nd m
inim
al tr
eatm
ent (
less
than
18
day
s of
out
patie
nt a
nd le
ss th
an 7
day
s of
re
side
ntia
l) (
n
5
130
).
Com
paris
ons
of o
utco
mes
for
(a)
subs
tanc
e ab
user
s an
d ot
her
wom
en d
eliv
erin
g in
sam
e tim
e pe
riod,
(b)
wom
en in
trea
tmen
t an
d th
ose
not i
n tr
eatm
ent,
and
(c)
wom
en in
trea
tmen
t by
type
of
trea
tmen
t.
Wom
en w
ho r
ecei
ved
only
res
iden
tial t
reat
men
tha
d po
orer
birt
h ou
tcom
es th
an w
omen
in o
ther
trea
tmen
t pro
gram
s.
Tre
atm
ent
Pre
term
Birt
hLo
wB
irthw
eigh
t
Res
iden
tial/
outp
atie
nt13
.4%
9.4%
Res
iden
tial/
only
20.5
%11
.0%
Out
patie
nt o
nly
14.8
%9.
5%M
inim
altr
eatm
ent
16.8
%9.
7%
CS
AT
5
Cen
ter
for
Sub
stan
ce A
buse
Tre
atm
ent;
NID
A
5
Nat
iona
l Ins
titut
e on
Dru
g A
buse
; PP
WI
5
Pre
gnan
t and
Pos
tpar
tum
Wom
en’s
and
Infa
nts.
a
NID
A P
erin
atal
20
stud
y.
for substance-abusing mothers and pregnant women thatwas added to the treatment protocol in two residentialtreatment facilities. Using pre- and posttest measures, theresults suggest that the parenting component contributedto increased self-esteem and parenting knowledge amongthe women. Completion of the program also resulted inlonger periods of abstinence.
The issue of the availability of child care is particu-larly important for women. Hughes et al. (1995) conducteda randomized controlled evaluation within one long-termresidential program that permitted cocaine-using womento live with their children in the treatment facility. Thestudy found that women who lived with their children re-mained in treatment significantly longer than women whodid not live with their children during treatment.
Two studies of outpatient programs suggest that out-patient treatment for pregnant women can also improveoutcomes. Knisely, Dawson, and Schnoll (1995) foundthat women in a 5-month intensive outpatient programhad greater abstinence than women with no treatment.Enhancing outpatient programs with other services, suchas parenting training, education about drug abuse, andpersonal development activities, may improve outcomes.Strantz and Welch (1995) found that women in an en-hanced outpatient treatment program were more likely tocomplete the program than women in a conventional out-patient program. Forty-five percent of women in the en-hanced program completed treatment, while only 21% inthe conventional program did so.
Three recent studies compare outcomes in residentialtreatment to those in outpatient settings. In general, thesestudies did not find significant difference in outcomes forwomen in different treatment programs. However, onestudy did find that residential treatment was marginallymore effective than other programs.
A randomized controlled study by Marques, Tippetts,and Branch (1995) tested the impact of three types oftreatment protocols for pregnant substance abusers: (a)residential before outpatient, (b) outpatient only, and (c)no active treatment. Although compliance was poor, res-idential treatment followed by outpatient treatment wasthe best predictor of decreased cocaine use. Schrager,Joyce, and Cawthon (1995), in a retrospective study, ob-served that women who received residential treatmentcombined with outpatient treatment had better birth out-comes and lower infant Medicaid expenditures thanwomen who received residential treatment only. A studyby Comfort and Kaltenbach (in press) found no signifi-cant differences between women in residential treatmentand those in outpatient treatment programs.
SUMMARY
This review has shown evidence of a substantial preva-lence of substance abuse during pregnancy. Estimates ofprevalence vary widely, but nationally about 5% of preg-nant women used an illicit drug during pregnancy. In ad-
216 E.M. Howell et al.
dition to the adverse consequences of such use for youngwomen, the literature shows poorer birth outcomes andhigher cost for drug exposed infants, although evidenceis mixed due to the lack of control for type of drug andamount of exposure in most of the studies. Still the litera-ture is convincing that there has been and continues to bea need for programs that effectively identify and treatpregnant substance abusers.
One of the most challenging tasks confronting thosedeveloping programs for pregnant substance abusers is toidentify them and persuade them to obtain treatment ser-vices. We have described some screening instrumentsthat have been used successfully in prenatal care settings,but these require cooperative providers who are willingto screen and refer women. Similarly, these programs re-quire effective, regular communication between prenatalcare and treatment providers to assure that a woman whois identified can be quickly counseled, assessed, and ad-mitted to treatment if she needs it and agrees.
A consensus has developed regarding the componentsof model treatment programs for pregnant substanceabusers, and a small body of research has generally sup-ported the recommendations that treatment programs forpregnant substance abusers should address the needs ofchildren (through parenting programs and child care),provide transportation, and address women’s social andmental health needs. As with the broader treatment liter-ature on effectiveness, retention is the major predictor ofsuccess (as measured by abstinence), and the programcomponents described above seem to lead to improvedsuccess through their effect on increased retention.
There is a lack of evidence that residential care is nec-essarily more effective than intensive outpatient care.However, there are few studies, and more work withlarger samples and random assignment to treatment alter-natives is needed before this important public policyquestion can be addressed. This is important becausemany of the programs that have been developed throughrecent federal demonstration programs have been resi-dential programs, and the residential programs are morecostly. New forms of reimbursement through Medicaidand managed care initiatives will demand evidence of ef-fectiveness before residential programs are covered. Weconclude that a larger number of well-designed studies isneeded to identify the most critical treatment programcomponents and their settings.
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