A review of recent findings on substance abuse treatment for pregnant women

Availability of Services for Women in Outpatient Substance Abuse Treatment: 1995–2000

Women entering substance abuse treatment have more severe substance abuse problems and more medical and psychiatric comorbidities than men. Research shows that specialized women's services are associated with better retention and outcomes but relatively little is known about their availability nationwide. This study examined the adoption and implementation of reproductive and female-sensitive social services in a national sample of outpatient substance abuse treatment (OSAT) organizations in 1995 (N = 617) and 2000 (N = 571) by several organizational factors. Overall, reproductive and social services for women have not been widely adopted, although some services did increase over the study period, particularly social services. There was no evidence of large-scale decreases in service availability over the study period, although child care did decline. Nonprofit and public ownership (relative to for-profit) were associated with greater service provision. Managed care units had greater service adoption compared to nonmanaged care units, and this increased over time. Public units and hospital-affiliated units had greater service implementation than other units. However, OSAT units did not always implement the services they adopted, suggesting access to some services may be restricted.

Welfare reform and substance abuse

The 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) changed the nature, purpose, and financing of public aid. Researchers, administrators, and policymakers expressed special concern about the act's impact on low-income mothers with substance use disorders. Before PRWORA's passage, however, little was known about the true prevalence of these disorders among welfare recipients or about the likely effectiveness of substance abuse treatment interventions for welfare recipients. Subsequent research documented that substance abuse disorders are less widespread among welfare recipients than was originally thought and are less common than other serious barriers to self-sufficiency. This research also showed significant administrative barriers to the screening, assessment, and referral of drug-dependent welfare recipients. This article summarizes current research findings and examines implications for welfare reform reauthorization.

Changes in quality of life for pregnant women in substance user treatment: developing a quality of life index for the addictions

Using preference weights from a community sample, items from the Addiction Severity Index (ASI) were converted into a quality of life index (QOLI) and used to compare the cost-effectiveness of five addiction treatment modalities for pregnant women.

METHODS

Interviews using the time trade-off methodology were conducted with 143 members of Massachusetts local health planning boards to determine preference weights for different health states resulting from active addiction. A multi-attribute utility formula was used to convert these seven preference weighted scores into a single QOLI. To apply the QOLI, these preference weights were combined with the number of problem days reported in each ASI domain by a sample of 439 pregnant women in MA in five treatment modalities, 1992-1996.

RESULTS

Starting at 10 years with an addiction problem, board members indicated that they would give up between 0.83 and 3.96 years to avoid the problems in one domain caused by addiction. The average QOLI was 0.68 at intake but increased by 0.19 points by 6-month follow-up to 0.87. All five treatment groups showed notable improvement in their quality of life. Mean improvements ranged from a high of 0.23 QOLIs for clients who received both residential and outpatient treatment to a low of 0.16 for clients who received only detoxification. Treatment costs ranged from 10,187 dollars for residential and outpatient combined to 2535 dollars for detoxification only, with costs per QOLI ranging from 14,912 dollars to 44,291 dollars.

CONCLUSIONS

Although this QOLI could benefit from further refinement and development, it showed promise as a single outcome measure for CEAs in the chemical dependency field. This QOLI was sensitive enough to distinguish between the treatment groups, it correlated well with other outcome measures and can be easily converted from the ASI using spreadsheet software and a simple formula.

Substance abuse treatment for women: Changes in the settings where women received treatment and types of services provided, 1987–1998

Changes in social policies during the last 2 decades have had major implications for the provision of substance abuse treatment services to women. The goal of this analysis was to examine (a) changes in the proportion of women clients served within different types of treatment facilities and (b) the services provided in these facilities. Data were analyzed from national surveys of treatment providers for the period of 1987 to 1998. Overall, there were gradual increases in the proportion of women clients across treatment facilities and greater concentrations of women in more intensive treatment modalities. The provision of childcare increased over time, particularly in programs with only women clients. Treatment facilities in which there were higher proportions of women generally had higher rates of providing services related to pregnancy, parenting, and domestic violence. These findings can be used to assess the adequacy of service delivery to women in substance abuse treatment.

Psychopathology is associated with completion of residential treatment in drug dependent women

This study characterized drug dependent women based on current psychopathology (MCMI-III) and then examined the relationship between psychopathology and treatment retention. Participants included 97 pregnant (88%), African-American (78%), single (90%) 30-year old women enrolled in a 6-month residential drug treatment program for women and children. Clustering on personality test scores using Ward's technique identified three subgroups with mild (24%), moderate (59%) and severe (18%) psychopathology. Treatment completion rates varied by group (66%, 45% and 29%), with half of the high severity group leaving against medical advice (AMA) within 60 days. Although the majority of low severity women completed the program as scheduled, they may also have done well in a less intensive treatment modality. Conversely, it appears that women with severe psychopathology may require a more flexible, psychiatrically-oriented approach than is found in most residential settings including greater emphasis on psychiatric issues, individual psychotherapy, and pharmacotherapy.

Culturally appropriate substance abuse treatment for parenting African American women

Culturally appropriate strategies have been deemed necessary for the treatment of substance abuse among African American women. This qualitative study was conducted utilizing a grounded theory methodology within a womanist theoretical framework to explore the process by which parenting African American women participate in formal substance abuse treatment programs. Study findings yielded significant insights into this process and support the notion that culturally appropriate frameworks are necessary to help substance-abusing African American women enter into treatment programs and remain in recovery. In addition, specific interventions for treating substance-abusing African American women within a culturally relevant framework are discussed.

Substance use during pregnancy: time for policy to catch up with research

The phenomenon of substance abuse during pregnancy has fostered much controversy, specifically regarding treatment vs. punishment. Should the pregnant mother who engages in substance abuse be viewed as a criminal or as someone suffering from an illness requiring appropriate treatment? As it happens, there is a noticeably wide range of responses to this matter in the various states of the United States, ranging from a strictly criminal perspective to one that does emphasize the importance of the mother's treatment. This diversity of dramatically different responses illustrates the failure to establish a uniform policy for the management of this phenomenon. Just as there is lack of consensus among those who favor punishment, the same lack of consensus characterizes those states espousing treatment. Several general policy recommendations are offered here addressing the critical issues. It is hoped that by focusing on these fundamental issues and ultimately detailing statistics, policymakers throughout the United States will consider the course of action that views both pregnant mother and fetus/child as humanely as possible.

"New Choices" for women with addictions: perceptions of program participants

Background

Substance use in pregnancy is a major public health problem. It can have profound effects on pregnancy outcomes, and childhood health and development. Additionally, women who use substances have their own health-related issues. Although intervention is important, these women often have difficulty using traditional systems of care. The New Choices program is a centralized, multi-sector approach to service delivery that has attempted to overcome barriers to care by offering one-stop shopping in a supportive environment. As part of an evaluation of this program designed for women who are pregnant and/or parenting young children, interviews were conducted with participants to gain insight into their experiences in New Choices and perceptions of any changes attributed to program involvement.

Methods

A qualitative, exploratory design was used to guide data collection and analysis. Four women participated in a focus group interview and seven women agreed to individual interviews over the course of the program evaluation (N = 11). A semi-structured interview guide was used to explore women's experiences in New Choices and their perceptions of the program and its impact. The interview data were analyzed using NVivo software and an inductive approach to data analysis.

Results

The emergent themes captured women's motivations for attending New Choices, benefits of participation, and overall quality of the program. Children were the primary motivating factor for program enrollment. Perceived benefits included decreased substance use, improved maternal health, enhanced opportunity for employment, increased access to other resources, enhanced parenting skills, and improved child behaviour and development. Women highly valued the comprehensive and centralized approach to service delivery that provided a range of informal and formal supports.

Conclusions

Interview findings endorse the appropriateness and potential efficacy of a collaborative, centralized approach to service provision for women with substance use issues. Although the findings provide insight into an alternative model of service delivery for women with addictions, future research is needed to evaluate the effectiveness of the intervention. Research also is needed to determine which program components or constellation of components contribute to desired outcomes, and to learn more about processes that underlie changes in behaviour.

Behavioral responses of substance-exposed newborns: a retrospective study

This study assessed the behavior of infants whose mothers had a drug history by using the Neonatal Behavioral Assessment Scale. Data were collected via retrospective chart review (N = 103). Urine testing was only reported for 66 mothers during pregnancy and at birth. Infants performed within normally expected ranges for all items, except consolability and self-quieting. These findings support the use of NBAS in assessing newborn behavior because the information gained assists the parent in providing a supportive care giving environment that will not only help the infant recover but also enhance interaction between infant and parent.

Psychosocial treatments for women with substance use disorders

Research on psychosocial treatments for women generally has consisted of quasi-experimental studies, with few randomized controlled trials that specifically test the effectiveness of treatment for women. Review of the available research literature suggests the following: (1) women, compared with men, evidence poorer prognostic characteristics; (2) women generally do not differ significantly from men on treatment utilization or outcome, with the possible exception of employment outcomes, which have been found to be poorer for women; and (3) women may benefit significantly from enhanced treatment services. This article also discusses guidelines for treatment providers and researchers.

Family-Focused Substance Abuse Treatment: A Program Evaluation

Until recently, few programs were available for children whose mothers are in recovery. A refinement of the gender-specific model of substance abuse treatment, the "family-focused" approach, has placed increased emphasis on the needs of children and other family members. However, because these programs are relatively new, little is known about the effectiveness of this type of treatment for either the mother or her children. This article presents findings from a three-year evaluation of a family-focused residential treatment program for women and their children. Longitudinal assessment of the mothers indicated that their psychosocial status and parenting attitudes improved over time. Additionally, the mothers remained in treatment longer. At intake, as a group, the children who were birth to three years of age did not exhibit developmental delay. However, developmental concerns were identified for some children in the areas of motor and/or language development. The results reported here provide beginning evidence that family-focused treatment improves retention, psychosocial functioning, and parenting attitudes of pregnant and parenting women. It also provides a mechanism for early identification and intervention for children.

Ethical considerations in caring for women with substance use disorders

People living with addiction endure many hardships, and this may be especially true for women who face distinct clinical and significant psychologic and socioeconomic repercussions of addictive disorders and their companion stresses. Clinicians who work with women with addictions are confronted by many challenges, particularly in the care of pregnant and parenting women. The dilemmas faced by patients with addictions and their providers often arise directly from tensions among core ethical principles, from inconsistencies in the way these principles are applied, and from the pervasive effects of stigma. Although difficult issues are to be expected in the arena of substance abuse treatment, consideration of principles of voluntarism, beneficence, respect for persons and justice, confidentiality and truth-telling, and informed consent are invaluable in shaping clinical ethical decision making. Furthermore, proactive steps can be taken to enhance the ethical caliber of care. These steps involve policy-level and systemic actions, such as the development and expansion of programs serving women's unique needs, empiric research into the most effective treatments for women with various disorders, and reexamination of legal and societal stances toward pregnant and parenting women who have addictions. In addition, local and individual steps are needed, including addressing gaps or inherent biases in programs, training counselors and clinicians in effective strategies or counseling styles, and developing awareness of one's own attitudes when dealing with difficult patients and challenging disorders. Such efforts will help ensure that women who have addictions will be cared for in a manner that is respectful, beneficent, compassionate, honest, and just.

Effectiveness of substance abuse treatment programming for women: a review

Recent research has shown that women and men differ in substance abuse etiology, disease progression, and access to treatment for substance abuse. Substance abuse treatment specifically designed for women has been proposed as one way to meet women's distinctive needs and reduce barriers to their receiving and remaining in treatment. However, relatively few substance abuse treatment programs offer specialized services for women, and effectiveness has not been fully evaluated. This article reviews the literature on the extent and effectiveness of substance abuse treatment programming for women and provides an overview of what is known about the components of successful treatment programs for women. Thirty-eight studies of the effect on treatment outcomes of substance abuse treatment programming for women were reviewed. Seven were randomized, controlled trials, and 31 were nonrandomized studies. In our review, six components of substance abuse treatment programming for women were examined: child care, prenatal care, women-only programs, supplemental services and workshops that address women-focused topics, mental health programming, and comprehensive programming. The studies found positive associations between these six components and treatment completion, length of stay, decreased use of substances, reduced mental health symptoms, improved birth outcomes, employment, self-reported health status, and HIV risk reduction. These findings suggest that to improve the future health and well-being of women and their children, there is a continued need for well-designed studies of substance abuse treatment programming for women.

Pregnancy, drug testing, and the fourth amendment: legal and behavioral implications

In its efforts to protect the health of unborn children, the government is increasingly attempting to regulate pregnant women's conduct. As with other policies affecting pregnant women's autonomy, these policies have constitutional overtones. In Ferguson v. City of Charleston (2001), the Supreme Court struck down a South Carolina hospital's policy of testing pregnant women for cocaine and turning positive results over to law enforcement for prosecution. This article discusses the basis of the decision and its legal and behavioral implications. Although the decision came down on the side of pregnant women's rights, it left unresolved the issue of whether a similar policy could be constructed that would pass constitutional muster. The article concludes with a consideration of the likely effects of, and alternatives to, such a policy.

Victimization and Substance Abuse among Women: Contributing Factors, Interventions, and Implications

Although the literature indicates that there is an association of victimization with substance abuse, there has been limited research focused on understanding and synthesizing the factors that have been identified as contributing to victimization and substance abuse and on interventions designed to address these contributing factors. The purposes of this article are to (a) review the literature on factors related to victimization and substance abuse, (b) review interventions and outcomes, and (c) discuss clinical implications for interventions and research. Results suggest that there is a high rate of co-occurrence of victimization and substance abuse among women, that the factors contributing to victimization and substance abuse are complex, and that there is a lack of treatment models addressing victimization and substance abuse.

Psychopathology influences treatment retention among drug-dependent women

Three subgroups of drug dependent women (N = 78) were identified through cluster analysis on MCMI-II scores. Group 1 (26%) presented a relatively benign clinical picture. In contrast, Group 2 (37%) evidenced severe addiction, psychiatric (Axis I), and personality (Axis II) problems. Group 3 (37%) was characterized by fewer Axis I problems, prominent addiction and externalizing (Cluster B) personality deficits. Group membership was significantly associated with retention in a gender-specific day treatment program. Group 2 experienced rapid attrition, with only 36% completing treatment, compared to 57% for Group 1 and 76% for Group 3. Results indicate that drug-dependent women with externalizing psychopathology can be retained in treatment when environmental barriers are removed and an adequate "holding environment" is maintained. However, women with severe psychiatric problems, unstable mood, and interpersonal deficits are less likely to complete treatment. Early identification of women at risk for drop-out affords an opportunity to intervene to prevent its occurrence.

Severity of substance abuse and psychiatric problems among perinatal drug-dependent women

The present study assessed 108 women enrolled in a residential treatment program for perinatal substance abusers in order to examine possible subtypes based on current alcohol, other drug and psychiatric problem severity. Most participants were African-American (81%), unmarried (91%), unemployed (97%), high school graduates (63%) with a mean age of 30 years. The primary substances of abuse were cocaine/crack (87%) and opiates (9%). The majority (79%) of subjects were also nicotine dependent. Drug severity did not distinguish between these groups; however, when cluster analysis was applied to ASI alcohol and psychiatric composite scores, three clusters emerged: (1) high alcohol, drug, and psychiatric problem severity (57%); (2) high drug and psychiatric problem severity (20%); and (3) high drug severity only (23%). Neither current nor childhood demographic characteristics differed among the three groups. However, significant differences were found among selected childhood risk factors, including perceived quality of relationships with family, age of onset of substance use, childhood abuse history, and family history of mental illness. These results emphasize the need for careful assessment and treatment planning that addresses the unique needs of these women.

Mental health, drug use, and the transition from welfare to work

This study examines the effects of drug use and work requirements on psychological distress and employment among chronic drug-using and non-drug-using welfare recipients. Using a natural history design, 442 female Temporary Assistance for Needy Families (TANF) recipients (including 251 with chronic drug use problems) were interviewed every 4 months in order to assess changes in psychological functioning, employment status, and wages. Data from the first year (four waves) indicate that employment and wages increased substantially, though less so for drug users than non-drug users. Psychological distress decreased only slightly over the study period. Growth curve analyses show that drug use had no direct effect on wages; however, drug use did significantly increase psychological distress. Both the work mandate and psychological distress contributed to wages. The authors consider the implications of these trends for the mental health service needs of drug-using TANF recipients.

Antenatal depression, substance dependency and social support

BACKGROUND

The purpose of this study was to explore the prevalence of depression and factors associated with depressive mood among pregnant women.

METHOD

391 women who were 14-37 weeks pregnant were evaluated with the Edinburgh Postnatal Depression Screen (EPDS), which has also been validated for prenatal use. Four questionnaires were used in order to explore associated factors: a questionnaire on background and pregnancy data, the Substance Abuse Subtle Screening Inventory (SASSI) and two Social Support Questionnaires (SSQ1 and 2).

RESULTS

7.7% of the total sample screened positive on the EPDS with a cut-off point of 12/13 recommended. Substance dependency and experienced difficulties in social environment had an independently significant association with maternal depression.

LIMITATION

The caseness was defined with a self-report instrument.

CONCLUSION

Substance dependency and experienced difficulties, especially in relation to friends, partner and own mother, are associated with antenatal depression. It is important to be aware of this when developing interventions in maternity care primary units.

Treatment retention and birth outcomes of crack users enrolled in a substance abuse treatment program for pregnant women

This study examined characteristics of pregnant crack users that were associated with their retention in a residential treatment program and the outcomes of their pregnancies. The participant characteristics were assessed when the women were admitted to the program, and were related to their demographic status, physical health, psychological functioning, substance use, and pregnancy. In general, the findings point to the importance of early interventions with this population. Implications and limitations of this study, as well as suggestions for future research, are discussed.

Public hospitals and substance abuse services for pregnant women and mothers: implications for managed-care programs and Medicaid

Although an increasing proportion of the US population receives health services through managed care, pregnant women and mothers eligible for Medicaid who are involved with alcohol or other drugs are often excluded from these programs due in large part to lack of information on costs, service needs, and service use. To develop such information policy, service settings, and managed-care plans, the project conducted a national survey using a provider group with experience in caring for this population, the member universe of the National Association of Public Hospitals and Health Systems. The survey requested detailed information on hospital system information, current managed-care arrangements, outcome measurements, financing, service priorities, and service availability. The 81% response rate (n = 95) identified 35 hospital systems providing services to an average of 998 women in 1997. The majority of these systems (69%) reported coordinating care for these patients, but only 26% reported they computerize patient charts. Most use at least one indicator to measure effectiveness, and 50% use at least four. Counseling/education and transportation were seen as key support services, but many acknowledge they are not reimbursed for critical services such as nutrition education. The discussion highlights the need to provide formal support for core support services, to assist in care coordination and provide incentives for developing more sophisticated information, and to specify related services in the state Medicaid contract language.

An early report on the mother-baby interactive capacity of substance-abusing mothers

OBJECTIVE

Examination of maternal interactive behavior and psychosocial situation of substance-abusing mothers in treatment.

METHOD

Twelve mothers with an alcohol or drug abuse problem and 12 control mothers were assessed in random order with the Parent-Child Early Relational Assessment, for the analysis of videotaped mother-infant interactions at 3 and 6 months' postpartum. Depressive symptoms were assessed with Edinburgh Postnatal Depression Scale and aspects of social support with two Social Support Questionnaires.

RESULTS

Substance-abusing mothers tended to have more problematic areas in their interactive behavior, a tendency which increased during the study period. As was expected, they were more often depressive, and experienced more social environment difficulties and less social support.

CONCLUSIONS

Mothers with alcohol and drug abuse problems need intensive professional support in early motherhood, and are seen to be particularly motivated to strive for abstinence and accept help at this stage of life.

The impact of women's family status on completion of substance abuse treatment

This study examines the role of family status and demographic characteristics in explaining the nearly 60% dropout rate for women in substance abuse treatment. Data from the administrative record files of the Illinois Office of Alcoholism and Substance Abuse (OASA) for the fiscal year 1996-97 were analyzed for women age 12 or older who completed intake for publicly funded substance abuse treatment and whose outpatient treatment records were closed at year-end. Multivariate logistic regression models found that the likelihood of not completing treatment was greatest for women who were African American, pregnant, had custody of minor children, or were younger than age 21. However, African American women who had children in foster care were more likely to complete treatment. Implications for treatment and research are discussed.

Program variation in treatment outcomes among women in residential drug treatment

Multilevel modeling was used to assess the program characteristics associated with treatment retention among 637 women in 16 residential drug treatment programs in the Drug Abuse Treatment Outcome Study. Women who were pregnant or had dependent children had higher rates of retention in programs in which there were higher percentages of other such women. Longer retention was associated with higher rates of posttreatment abstinence. Bivariate analyses showed that programs with higher proportions of pregnant and parenting women provided more services related to women's needs. The findings support the provision of specialized services and programs for women in order to improve outcomes of drug abuse treatment.

Identifying Pregnant Substance Abusers and Studying Their Treatment Using Birth Certificates, Medicaid Claims, and State Substance Abuse Treatment Data

A substantial body of recent research has focused on the prevalence of substance abuse among pregnant women, Its effects on maternal and infant health, ways to identify and effectively treat pregnant women, and the cost of care for pregnant women and their infants. However, this research has been hampered by a lack of data, particularly at the state and local levels. The potential benefits of such research for improving treatment and other services to this high-risk group make it important to continue to develop accurate and timely data sources. This study builds on previous work that investigated the quality of birth certificate and Medicaid data as well as previous efforts to merge these two data sources by augmenting the merged birth certificates and Medicaid data with data on a group of known substance abusers - those in substance abuse treatment. The purpose of merging these records is to improve the identification of pregnant substance abusers and, more importantly, to provide an enriched data source of variables from all three sources. Using merged data from two example states, we show that linked birth certificates, Medicaid claims, and state substance abuse treatment files provide a useful source of information for studying the birth outcomes and costs for pregnant women in substance abuse treatment. However, certain groups, such as women who do not obtain any health care or substance abuse treatment, will be underrepresented in such a database. Consequently, efforts at more complete surveillance of pregnant substance abusers should be undertaken, perhaps through increased efforts to improve reporting on the birth certificate, which is a universal document.

Fetal protection in Wisconsin's revised child abuse law: right goal, wrong remedy

Authors examine Wisconsin's recent revision of its child abuse and protection laws to address substance abuse by pregnant women. The new statute enables the state to take the fetus into protective custody. Authors argue that approaching fetal protection using a child abuse model creates a series of symbolic, conceptual, and practical problems of such severity as to undermine its justifiability as a public health measure.