Despite decades of progress, individuals from all walks of life, in urban, suburban, and rural communities, continue to use and abuse legal and illegal drugs.
This report focuses on the drug treatment, medical care, and followup services needed by one special population -- pregnant, substance-using women.1
Because this Treatment Improvement Protocol is particularly designed to assist drug treatment programs that receive Block Grant funding through their State substance abuse agencies, the emphasis here is on women served in the publicly funded drug treatment system.
Such women are often poor and suffering from multiple socioeconomic problems.
This emphasis should in no way obscure the fact that many affluent women also experience alcohol and drug problems.
Those women who receive medical care through their private providers also need treatment for alcohol and other drug abuse.
These guidelines are relevant to these women as well.
Our knowledge has increased dramatically about the dangers for the fetus of maternal use of alcohol and other drugs during pregnancy.
These adverse effects are a source of mounting concern for many communities.
Evidence continues to accumulate that children exposed to drugs in utero are at risk for long-term developmental problems.2
Environmental risk factors may interact with substance abuse to impact women and their families.
For example, some women may suffer from poor nutrition and lack access to prenatal care.
Women and their families may experience unstable home environments and homelessness.3 Frequently, pregnant, substance-using women have experienced sexual, physical, and emotional abuse that has gone unnoticed and untreated.
Many women are victims of poor parenting.4
The pregnant, substance-using women who are targeted by these guidelines are often familiar with publicly funded medical, legal, and social service delivery systems.
These women may receive welfare support, hospital emergency room care, publicly supported housing, and food supplements.
They may involuntarily surface through the court system.
Other women may be prevented from seeking the help and care they need due to cultural prohibitions and earlier negative experiences.
Some communities prosecute and jail women who abuse alcohol and other drugs while pregnant.
These women may be legally separated from their children as well.
More common, however, is the neglect they experience from health care and service delivery systems.
The painful repercussions of the prosecution and neglect of pregnant, substance-using women and their children can be seen in shelters for battered women, among homeless populations, and in foster homes and child welfare institutions across the country.
Early intervention during the prenatal period is highly desirable for the health of the woman, the fetus, and her infant after birth and for the initiation of alcohol and other drug treatment for the mother.
The following guidelines emphasize a continuum of care, that is, long-term, perhaps indefinite, provision of services in support of the woman and her family.
The woman who is linked to appropriate resources can be effectively supported to recover and to manage her multiple roles.
This concept reflects the comprehensive approach to care that is needed and that is intended by these guidelines.
The Center for Substance Abusement Treatment (CSAT) has sponsored the development of this Treatment Improvement Protocol (TIP) to provide guidance for those who care for pregnant, substance-using women and their families.
The TIP development process was modeled on similar efforts undertaken by the Federal Government to address complex health and social service delivery issues.
The consensus model that was used to develop these guidelines drew on the experience and expertise of representative specialists from across the Nation.
The process began with CSAT's appointment of a Federal Resource Panel of medical personnel, alcohol and other drug treatment experts, social service providers, and representatives of national organizations (for Federal Panel members, see Appendix G).
The subsequent Consensus Panel of experts worked together in teams to prepare these treatment and service guidelines (for Consensus Panel members, see page vii).
The draft guidelines were reviewed by over 35 additional field specialists (for field reviewers, see Appendix H).
The final recommendations of the Consensus Panel reflect the diversity of experience and, most importantly, the agreement of many of the Nation's foremost experts regarding the basic principles and guidelines for programs to use to provide supportive, comprehensive care needed by pregnant, substance-using women.
The Consensus Panel strongly supports the view that the use of alcohol and other drugs by women during pregnancy is a public health issue, not a legal problem.
The guidelines are intended to offer direction for the many disciplines involved in caregiving, including physicians, nurses, social workers, psychologists, counselors, and others.
They are designed to be used in a variety of settings, such as hospitals, alcohol and other drug treatment programs, and clinics.
The Consensus Panel also supports these key recommendations:
The Panel does not support the criminal prosecution of pregnant, substance-using women.
Furthermore, there is no evidence that punitive approaches work.
Alcohol and other drug treatment programs must provide services to pregnant women and not deny these services based solely on the fact that a woman is pregnant.
Service providers need to be sensitive to the feelings and the cultural background of pregnant, substance-using women and offer care in an environment that is supportive, nurturing, and nonjudgmental.
Early intervention during the prenatal period is encouraged to improve the health of mothers and fetuses and to ensure that alcohol and other drug treatment is initiated.
Comprehensive medical care and treatment for alcohol and other drug addiction is essential to start substance-using women on the road to recovery.
This approach, it is hoped, will result in more productive adults, stronger families, and healthier children.
A continuum of care -- that is, the long-term provision of services -- is vital to the well-being of pregnant, substance-using women.
The continuum of care concept requires the collaboration and cooperation of many community-based services, ranging from agencies that offer safe housing to programs that stress parenting education and address the issues of domestic violence, abuse, and victimization.
Case management services are needed to ensure that a comprehensive and optimal level of care is available to and accessed by pregnant, substance-using women and their families.
The Consensus Panel encourages service providers to review these guidelines and to use them to identify and coordinate their roles in the care of pregnant women and their families.
The information in this TIP is intended to guide and instruct a broad spectrum of service providers who care for pregnant, substance-using women and their families.
Some of the guidelines provide information for specific disciplines, such as obstetricians.
Other guidelines, such as those on legal and ethical issues, are pertinent to all service providers caring for patients.
A review of the entire TIP will help providers create and maintain the continuum of care that is vital to the well-being and recovery of their patients.
This report is organized into three chapters.
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.
The charts are perforated for easy removal.
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