Pregnant, Substance-Using Women
Treatment Improvement Protocol (TIP) Series 2

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. Results of specific studies, such as those reported below, illustrate to some degree the nature and extent of the problem.

• Data from one study of 36 hospitals, mainly in urban areas, were extrapolated to arrive at an estimate of 375,000 infants exposed in utero to illegal drugs each year, or 11 percent of all births.⁵
• A study conducted in Pinellas County, Florida, of urine samples from more than 700 women enrolling in prenatal care during a 1-month period in 1989 found little difference in the prevalence of drug and alcohol use between women seen at public clinics (16.3 percent) and those seen at private offices (13.1 percent), as well as similar rates of substance abuse among white women (15.4 percent) and black women (14.1 percent).⁶
• A study based on a review of medical records in eight hospitals in Philadelphia in 1989 found that 16.3 percent of women had used cocaine while pregnant.⁷
• A study that assessed drug use, utilizing urine samples obtained at admission for delivery in all seven hospitals in Rhode Island, showed that 3 percent of women used marijuana.⁸
• Fifty-nine percent of the women in a Boston City Hospital study acknowledged that they had consumed alcohol during their pregnancies.⁹

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.

Preconception Counseling

All women who receive alcohol and other drug treatment services should receive counseling on the full range of reproductive options, including preconception counseling. Issues that should be thoroughly discussed include

• The various methods of contraception and the attitudes of the woman, her significant others, and her community regarding their use
• The impact on the woman and the fetus of alcohol and other drug use during pregnancy
• The teratogenic impact of prescribed medications, such as Antabuse and various anticonvulsants
• Alternative medications with reduced or no teratogenic potential for such common problems as seizure disorder. An obstetrician or geneticist can recommend such medications.

For patients who temporarily require medications such as Antabuse, or for those who choose to postpone childbearing, an effective, reversible form of contraception should be recommended. Substance-using women who have a history of irregular menses and involuntary infertility should be warned that sobriety or the successful initiation of a recovery program may result in a resumption of ovulation and an increased risk for unplanned pregnancy.

Access to Services

Pregnant, substance-using women may access health care services from a variety of sites, including emergency rooms, pregnancy testing sites, clinics treating sexually transmitted diseases, community health centers, and clinics of the Special Supplemental Food Program for Women, Infants, and Children (WIC). Occasionally, alcohol and other drug treatment program staff are the first to notice that a woman is pregnant. Regardless of where she accesses care, appropriate referrals for prenatal care should be provided, and she should be assisted to follow through on these referrals. The two perforated charts that accompany this TIP as Appendix I illustrate the components of comprehensive health care, depending on whether the woman's point of entry into the treatment system is alcohol and other drug treatment or prenatal care.

Access to care must be simplified for a woman when she enters the system. She should receive whatever support is needed -- whether it is financial assistance, help in setting up appointments, or transportation and child care services. Whenever possible, a case manager should schedule a specific prenatal appointment for the woman and initiate other needed services. In addition, a psychiatric assessment should be done to identify cases of alcohol and other drug use and psychiatric illness.