Addiction and Pregnancy

consisting of reading and taking a post-test on
Pregnant, Substance-Using Women
Treatment Improvement Protocol (TIP) Series 2

Overview
Traditionally, alcohol and other drug treatment programs served adult males, and few women received the treatment they needed. The scarcity of treatment services for women continues today. It is imperative that programs include services designed specifically for women, particularly pregnant women. Many alcohol and other drug treatment programs do not accept pregnant women because of liability issues or a lack of knowledge about pregnancy. Furthermore, programs have not had access to standardized guidelines for treatment, case management, and followup services. The information that follows offers such guidance and is intended to
encourage programs to broaden and strengthen their services to pregnant, substance-using women.

Profile of the Women Being Served
Reliable national estimates of the prevalence of alcohol and other drug use by pregnant women are not available. Several factors limit the accuracy and usefulness of current estimates, including differences in the populations studied, the lack of representativeness of samples used, and differences in the methods employed to determine drug use.

To meet the need for estimates of the prevalence of alcohol and other drug use by pregnant women that are generalizable to the Nation, the National Institute on Drug Abuse has recently sponsored a national, hospital-based study known as the National Pregnancy and Health Survey. Until these and other data become available, service providers should be alert to patterns of alcohol and other drug use occurring locally among women of all socioeconomic and ethnic groups. Those with clinical experience in treating substance-using women have found that the therapeutic needs of women, especially those with children, are markedly different from the needs of men. Substance-using women come from every ethnic and socioeconomic group and have a multitude of needs. Moreover, a substantial portion of the women who seek publicly supported treatment for their addictions share a core group of problems that reflect problems of the communities in which they live. Unless these core problems are addressed, women will be unable to take full advantage of the therapeutic process.

Many women who seek treatment for their alcohol and other drug problems through publicly funded programs share the following characteristics:

* Function as single parents and receive little or no financial support from the birth fathers
* Lack employment skills and education and are unemployed or underemployed
* Live in unstable or unsafe environments, including households where others use alcohol and other drugs.
* Many women are at risk of being homeless and some are homeless.
* Lack transportation and face extreme difficulty getting to and from a variety of appointments, including treatment
* Lack child care and baby-sitting options and are unable to enroll in treatment
* Experience special therapeutic needs, including problems with codependency, incest, abuse, victimization, sexuality, and relationships involving significant others
* Experience special medical needs, including gynecological problems

Gender-Specific Alcohol and Other Drug Treatment

Alcohol and other drug treatment providers need to understand and address the specific problems pregnant, substance-using women face in accessing and participating in treatment. Treatment programs may lack linkages to medical services, especially prenatal care. Similarly, providers of prenatal care have a poor understanding of addiction and treatment issues and may not have appropriate linkages with alcohol and other drug treatment providers. Both prenatal and drug treatment providers have a poor understanding of treatment issues specific to women.

It is recommended that treatment programs serving pregnant, substance-using women include the following services, or support active outreach to and linkage with appropriate service resources already available in the community:

Comprehensive inpatient and outpatient treatment on demand
Comprehensive medical services
Gender-specific services that are also ethnically and culturally sensitive. These services must respond to women's needs regarding reproductive health, sexuality, relationships, and all forms of victimization. Services should be offered in a nonjudgmental manner and in a supportive environment.
Transportation services, including cab vouchers, bus tokens, and alternatives for women who live in communities where public transportation is cumbersome, unreliable, or unsafe
Child care, baby-sitting, and therapeutic day care services for children
Counseling services, including individual, group, and family therapy
Vocational and educational services leading to training for meaningful employment, the General Equivalency Diploma (GED), and higher education
Drug-free, safe housing
Financial support services
Case management services
Pediatric followup and early intervention services
Services that recognize the unique needs of pregnant, adolescent substance-users

In addition to the delivery of direct services, there is a need for continuing collaborative efforts by maternal and child health programs, primary health care agencies, mental health agencies, and alcohol and other drug programs. Such collaboration can be useful in conducting needs assessments, designing interdisciplinary strategies, and establishing linkages through memoranda of understanding and interagency agreements.
Ongoing technical assistance and training is recommended for all health care, alcohol and other drug treatment, and other social service providers. Such efforts must involve administrative staff as well as direct service personnel to ensure that supportive, appropriate, and comprehensive care is offered to pregnant, substance-using women.

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Addiction and Pregnancy
In this 8 unit course, Learning Objectives are:

1. Clinicians will understand the goals and components of substance abuse treatment with pregnant women.

2. Clinicians will learn that early intervention
efforts during the prenatal period increase the likelihood that a pregnant woman will successfully recover from alcohol and other drug abuse.

3. Clinicians will understand dangers to the fetus of substance abuse during pregnancy, including intrauterine growth retardation, prematurity and low birth weight, central nervous system damage, and congenital physical malformations.

4. Clinicians will review the need for gender specific substance abuse treatment to meet the needs of pregnant women.

5. Clinicians will become familiar with the impact of the legal system as it impacts on substance abusing pregnant women

Table of Contents

Chapter 1 provides alcohol and other drug treatment guidelines. These guidelines describe the comprehensive array of treatment and case management services needed by patients. The guidelines also make it clear that women function as part of larger family groups and must not be treated in a vacuum.

Chapter 2 presents standard obstetrical procedures for the care of substance-using women. Equally important, these guidelines identify additional medically relevant factors that may result from a woman's substance-using lifestyle.

Chapter 3 presents legal and ethical guidelines for the care of women and their children. Issues concerning confidentiality, reporting, and child protection are addressed.

This report also includes endnotes and several appendixes.
The endnotes provide references for specific statements of fact made in the TIP. The vast majority of information presented in this report is not referenced, however, since it was developed through a consensus process and is the unique product of the experience and expertise of panel members.

Appendix A consists of guidelines for training staff.
Appendix B presents information about a selected group of standard instruments; some are examples of instruments that have been adapted to the special needs of particular programs. These instruments are used by professionals to assess a patient's alcohol and other drug use, and psychosocial and mental health functioning.
Appendix C contains a model program, sample budget, and list of Medicaid reimbursement rates for selected medical procedures.
Appendix D provides a discussion of quality assurance.
Appendix E offers a glossary of terms used in the TIP.
Appendix F consists of a bibliography and a resource list of selected national organizations that can provide information and assistance to service providers.
Appendix G lists the members of the Federal Resource Panel on Pregnant, Substance-Using Women.
Appendix H lists other contributors to the TIP, including programs from which relevant materials were obtained, and the names and affiliations of experts from the field who reviewed the document.
Appendix I provides two comprehensive care flow charts for pregnant, substance-using women, depending on whether the point of entry to treatment is through alcohol and other drug treatment or through prenatal care.

This course consists of reading and taking a post-test on:

Pregnant, Substance-Using Women
Treatment Improvement Protocol (TIP) Series 2
Janet L. Mitchell, M.D., M.P.H., Consensus Panel Chair
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
Rockwall II, 5600 Fishers Lane
Rockville, MD 20857
DHHS Publication No. (SMA) 95-3056

All material appearing in this volume except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT) or the authors. Citation of the source is appreciated.

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