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Pregnant/Postpartum Women and Their Infants: Studies, Articles, & Reports September 1997

Table of Contents

• Primary Prevention

• Intervention

• Treatment

Primary Prevention

The ways alcohol can affect unborn children during pregnancy are outlined. The difference between full fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE) is discussed. The importance of aftercare resources that are knowledgeable about FAS/FAE is stressed. Ways to prevent FAS and FAE are described. A list of available resources is provided for people with FAS/FAE and their families.

This chapter defines the concept of prevention in a very broad manner--primary, secondary, and tertiary--and applies it to a public health model stressing both community norms and behaviors and public policies and the environment. Several factors that influence whether women use alcohol and take drugs, such as poor self-esteem, feelings of alienation, social isolation, anxiety, and depression. How women deal with social and family norms and attitudes are important in determining substance use. Women have long faced barriers in obtaining treatment for chemical dependency. They are now at higher risk than previously thought. Whether prevention works is considered in a series of program models, ending with California's State perinatal alcohol and drug use prevention effort. The recommendations of the select committee and their impact are reviewed. The chapter ends with a statement translating California's experience to other States.

Despite considerable public and media concern, attention has been devoted to prevention or early detection of substance use during pregnancy. A limited literature search suggests that this lack of attention stems from a lack of policies or procedures for systematically identifying substance-using pregnant women and substance-exposed neonates in health care institutions. This study was designed to generate exploratory data about health care provider response to prenatal substance exposure, and to examine current substance detection policies and practices in health care institutions. Based on interviews in local hospitals, study data reveal many disincentives to detecting substance exposure. For the most part, detection policies are not being developed or implemented, although hospitals serving poor communities are more likely to have such policies. Policy implications are discussed, including the appropriateness of mandated detection policies and whether such policies should be developed at the State or Federal level.

The problems associated with adolescent pregnancy are well documented and continue to challenge health care providers, community workers, social service personnel, educators, policymakers, and especially the young men and women and their families whose lives are so intimately affected. Problems such as poor educational achievement, poverty, family instability, homelessness, lack of prenatal care, low birthweight infants, and compromised child development persist for adolescent parents and their children. A resource guide provides information concerning adolescent pregnancy, prevention, and care. A substantial number of resources deal with the prevention of adolescent pregnancy because interventions that address the underlying issues and lower the incidence of pregnancy, especially among younger adolescents, are critical to improving the overall health of adolescents. Resources dealing with pregnancy care and parenting education to help assure optimal outcomes for both the adolescent and his or her child also are included. The resource listing is divided into three sections: (1) publications and resource materials; (2) organizations; and (3) commercial educational resources.

Current philosophies of perinatal addiction, prevention, early intervention, and treatment are examined. The key components of program planning and treatment strategies are described. The unique needs of women in prevention programs, early intervention, and treatment are outlined. The barriers to providing effective services are explored. Illustrations from current CSAP funded demonstration programs serving pregnant and postpartum users of alcohol and drugs have been included where appropriate. The field of chemical dependency treatment is analyzed, with an emphasis on the special needs of pregnant women who use alcohol and drugs. The major elements of medically based approaches for prenatal health care are compared with the traditional recovery service approaches for chemical dependency treatment. The relational model is presented as a distinctive paradigm that may help further the understanding of the psychological and lifespan factors in the development of women who become alcohol or drug dependent. Useful strategies are discussed for reaching out to and maintaining clients in perinatal addiction programs. The role of screening and assessment in programs serving alcohol/drug dependent pregnant and postpartum women and their families is discussed. Evaluation concepts and activities are explored.

Key issues in the prevention of perinatal abuse of alcohol, tobacco, and drugs are discussed, highlighting how various disciplines view the problem and its potential solutions. The frameworks and models used for defining problems, designing programs, and evaluating outcomes are described. An approach developed by the CSAP National Resource Center for the Prevention of Perinatal Abuse of Alcohol and Other Drugs, which is specifically focused on the prevention of the perinatal abuse of alcohol, tobacco, and drugs, is included. Ideas and activities that can be used in various combinations to address the issue of the perinatal abuse of alcohol, tobacco, and drugs are summarized. Strategies are presented in tables for each reference. Case studies illustrate how theoretical frameworks and models are translated into practice and show the various types of interventions that underlie a comprehensive prevention approach.

This report evaluates the impact of a television public awareness campaign on knowledge of the dangers of drinking alcohol during pregnancy. A survey with five questions on alcohol and pregnancy and five health questions unrelated to alcohol was administered before and after the campaign. The participants were 3,000 women, ages 15-45 years. A 30-second announcement with a message on alcohol and pregnancy was broadcast over 10 weeks by five television stations in Manitoba. More respondents thought that alcohol consumption in pregnancy would put the baby at risk. They attributed this information to television. There were no differences in the responses to the five health questions unrelated to alcohol. An increase in awareness of the risks of drinking alcohol during pregnancy was observed after a mass media campaign.

This article addresses the issue of maternal substance abuse and the consequences of our current punitive approach. The article initially presents information that defines the scope of the problem and then offers case illustrations of the court's attempt to deal with women who use drugs and alcohol when pregnant. The article then focuses on the characteristics of interventions that have the potential for bringing about a deterioration of the problem of maternal substance abuse.

Prenatal drug exposure of children is a national problem of alarming proportions. The problem of prenatal drug exposure is examined, addressing the prevalence and characteristics of substance abuse among women in their childbearing years; identifying the complications related to drug abuse during pregnancy, with specific focus on alcohol, tobacco, marijuana, and cocaine; reviewing cost estimates and treatment options for women with addictions; and describing a primary prevention model for this biopsychosocial problem. Comprehensive primary prevention efforts must be mounted that extend the current focus on secondary and tertiary prevention. Programs are needed that support and build upon one another within a seamless, holistic service delivery system that encompasses and promotes the continuity of primary, secondary, and tertiary prevention.

Substance abuse during pregnancy continues to be a serious health problem in the United States. Hazards associated with the use of alcohol, tobacco, and drugs by pregnant women have been documented. The extent to which prenatal drug education is included in school health education has not been addressed. This survey determined the nature and extent of prenatal drug education being conducted by Nebraska school teachers in health-related fields. Educators in public and private schools who teach health-related courses were surveyed. Respondents indicated prenatal drug education is being addressed in a variety of courses. Amount of time devoted to the topic was 2.68 hours overall. Problems associated with providing prenatal drug education included inadequate teacher knowledge and training, lack of appropriate materials, and time limitations in the curriculum. Implications for comprehensive school health education are identified.

Factors affecting the drinking patterns of 183 pregnant, African-American, Hispanic, and white adolescents were investigated, including the influence of peers, sexual partners, family members, and mentors. Among participants who drank alcohol prior to their pregnancies, 87 percent quit or cut back on their drinking behaviors. Those adolescents who lived in environments where their partners, peers, and relatives were drinking and using drugs were more likely to have consumed alcohol in the previous month, while adolescents who identified mentors and/or parents who provided high levels of support were less likely to have consumed alcohol. Finally, distinct patterns of both drinking and life circumstances among the African-American, Hispanic, and white adolescents were revealed. The implications of these findings for future research and intervention with pregnant adolescents are discussed.

In the late 1980's, many urban areas reported a serious illicit drug epidemic among pregnant women. Many of these women expressed a desire for treatment; however, there was a lack of programs providing services to pregnant women. The Parent and Child Enrichment (PACE) Project, located in Harlem, was born out of this need. The two primary goals of the PACE Project are to provide comprehensive drug treatment and health care services for pregnant women in one location through existing community providers, and to improve birth outcomes among children of substance abusing women through increased access to drug treatment, health services, parent education, and social support. The Health Department coordinated this effort, conducted the epidemiologic analyses for demonstrating need, prepared the grant proposal for funding, and serves in the role of coordinator as the recipient of a Federal grant. Staff provide drug treatment services including individual and group counseling, methadone treatment, acupuncture, 12-step programs, and urine toxicology screening. PACE Project clients pass through a series of treatment levels-orientation, therapy level one, and therapy level two-until they complete the program. Preliminary data indicate a significant reduction in low birthweight among infants born to women in the PACE Project, which opened in October 1990. The annual operating budget of the program is approximately $300,000. The PACE Project has improved the level and quality of services available to women and children in the Harlem community, enhancing their physical, mental, and emotional well-being.

Providers of gynecologic and obstetrical services, either in private or public settings, have a special opportunity to deliver a smoking intervention in the context of targeted risks. There is little information on smoking cessation in the gynecologic setting. Researchers with extensive expertise in developing and implementing pregnancy-based interventions discuss issues such as the smoking status of the provider, the role of nurses in the intervention, counseling materials for clients and providers, and the reconciliation of staff time with patients' expectations. The experience gained from these trials will facilitate the development and implementation of further smoking interventions for women in a variety of practices and settings.

The author looks at the negative impact that legal and illegal drugs have on the development of the fetus. Alcohol can cause fetal alcohol syndrome, and illegal drugs can impair the development of the fetus, cause the infant to become addicted, and result in baby abandonment by the addicted mother. Several forces and issues in society that lead to increased involvement by the State in women's pregnancies are: protecting the developing fetus from harm, the abortion controversy, the drug epidemic, medical advances, and the responsibilities and costs our society has to bear in having so many drug babies. Some view the State's intervention as necessary to save children; others see the intervention as an unconstitutional intrusion into women's lives. The author presents the arguments advanced by each side, including two tables that summarize the issues. He also examines important related court cases and his own perceptions and conclusions. He says that we must carefully examine whether bringing the force of the law to bear on the issue will serve its intended objective or merely deter pregnant women from seeking prenatal care. Our society must increase the level, quality, and availability of prenatal care services and outreach efforts that educate women and men about the consequences of drug use during pregnancy.

Intervention

To analyze families living with drugs and HIV, a panel of local and national experts from a broad spectrum of agencies and disciplines was selected. The products of the efforts are threefold: an executive summary of important results; a videotape on drug-affected families; and this volume--a more comprehensive treatment of the salient topics discussed by the panel. This book includes four parts: an introduction to the problems of drugs and AIDS-affected infants and their families; prevention of substance abuse and approaches to prenatal care that can help drug-affected childhood; consideration of services to families already involved with drugs; and an overview of legal, ethical, and policy issues.

A comparison of high-risk pregnant (n = 55) and non-pregnant (n = 598) women from Harlem, New York City, on HIV-related drug and sexual risk behaviors was undertaken to identify appropriate prevention and intervention policy recommendations. Clients were recruited for an AIDS risk reduction research demonstration project and were either injecting drug users (IDU's) or sexual partners of IDU's. There was a higher percentage of IDU's among the non-pregnant women, and no significant differences were found between pregnant and non-pregnant IDU's in terms of needle risk behaviors. The two groups were also similar in non-injected drug use behaviors. Pregnant women were significantly less likely to use condoms. Recommendations focused on the need for increased HIV risk reduction among high-risk women in general, and increased education efforts among pregnant high-risk women regarding condom use as protection from HIV and the potential consequences of maternal substance use for their children.

The aim of the study was to ascertain whether there was a difference in developmental experiences between two groups of inner city postpartum patients; those who used cocaine during pregnancy and those who did not. A retrospective structured interview was administered to 80 postpartum women examining demographic characteristics, adaptive function, drug use patterns, and selected risk factors for adult substance abuse encountered before age 16. The sample was divided into 2 cohorts of women based on urine tests: 40 women identified as using cocaine shortly before delivery, and a comparison group of 40 women identified as not using cocaine. Comparisons between the two cohorts revealed that the cocaine identified women had significantly higher overall past and present use of a broad range of drugs, particularly crack and other forms of cocaine, as well as lower levels of general adaptive functioning despite the fact that they were demographically comparable. When compared to the nonusers, they displayed markedly elevated scores on measures of developmental risk factors for adult substance use. This study highlights the importance of early developmental risk factors on later drug use during pregnancy and general adult adaptive functioning. Further study and intervention targeted at persons with these risk factors are warranted.

The psychiatrist or mental health worker is in a position to address women's substance use and provide intervention and education relating to a woman's potential pregnancy. Unplanned pregnancy is an increased risk for women with particular psychiatric illnesses. Women who seek treatment because of pregnancy are usually already at a severe level of addiction. The psychiatrist should explore her reasons for seeking treatment and consider the psychological experience of her pregnancy. Barriers to treatment exist for pregnant women due to pregnancy, lack of financial or health coverage, or her dual diagnosis of mental illness with substance use. Treatment may also not be available to women who already have children and who need residential care for them. Outpatient treatment schedules may not be a possibility for women with children. Lack of attention to the particular needs of women using alcohol or drugs, such as post traumatic stress disorder or domestic violence, may also prove to be barriers. Postpartum women may be at high risk for relapse to substance use, particularly after the birth of a first child, because of the physical and psychological stress of a new baby. Feelings of stress or guilt in postpartum women as well as physical demands upon her are often induced when a child is born prenatally exposed to alcohol and/or drugs. Some women will first enter treatment at this time.

Alcohol is a major cause of birth defects and mental retardation in the United States. The yearly cost to care for those affected has been estimated to be over $300 million. Prenatal education and counseling have been advocated as techniques to reduce alcohol use in pregnancy. The purpose of this study was to critically review investigations that used these methods in order to determine their effectiveness. Reports of relevant studies were found by searching Medline, the ETOH data base and bibliographies of primary sources. Only five studies were identified that met predetermined selection criteria. As judged by usual methodologic standards for intervention programs, only one was of acceptable quality. None employed a randomized design, and only two compared the treatment group to a control group. Both of these studies found no difference in alcohol use between control and intervention groups. An ethical argument was used by several authors to justify performing inadequately controlled studies. No intervention has proven superior to the usual care delivered to pregnant women. Despite the public health importance of prenatal alcohol use, alcohol prevention has not been rigorously evaluated and its benefits are unclear. Randomized trials are ethically justified and guidelines for undertaking such studies are proposed.

A pilot fetal alcohol syndrome (FAS) surveillance was carried out in four American Indian communities in the Northern Plains by the Aberdeen Area Indian Health Service to determine the incidence of FAS and to evaluate the feasibility of establishing continuing surveillance for FAS. Baseline data on the incidence of FAS would be used by the Indian Health Service to develop and evaluate preventive interventions, including treatment programs for pregnant women who drink alcohol. Four of the 1,022 children included in the project were found to have FAS, a rate of 3.9 per 1,000 live births. The rate is believed to underestimate the true rate of FAS because some low birthweight children were not screened, parents or guardians were reluctant to bring children suspected of FAS for evaluation, clinicians were hesitant to diagnose possible alcohol-damaged children for fear of labeling the child, and some children with FAS died before the diagnosis of FAS could be confirmed. If the rate of FAS is similar for the 39 percent of the infants not screened and for the 25 percent of suspected infants who were not evaluated, a rate of 8.5 cases of FAS per 1,000 live births may be postulated. The authors recommend routine screening of prenatal patients for substance abuse and establishing a tracking system for low birthweight infants suspected to have FAS or other alcohol-related developmental disorders in an effort to establish more accurate FAS rates. Such a surveillance system would identify women at risk of having alcohol-affected infants so that appropriate treatment and counseling could be provided, possibly reducing the severity of adverse effects of alcohol on their fetuses.

During a smoking intervention trial at Buskerud Central Hospital in Norway in 1988-1989, 79 out of 279 smoking pregnant women refused any form of intervention. Thirty-five of the women (44 percent) expressed a negative attitude to quitting smoking and insisted on continuing their smoking habits. Forty-four (56 percent) indicated a positive interest in quitting, but refused advice and assistance from the health service. The smoking pattern of the 79 women was followed during 12 months. In spite of their stated unwillingness to change their smoking habits or their refusal of advice, no difference was observed in their quitting or reduction rate during pregnancy compared to a control group of women with a positive interest in quitting. In addition, significantly more women in the latter group actually increased their smoking. The quitting rate of the negatively motivated women also proved similar to that obtained in a stop smoking intervention used among positively motivated women who also had received additional information. Hence, the negatively motivated do not appear to represent a graver risk group than other pregnant women.

In 1986, the State health departments of Colorado, Maryland, and Missouri conducted a federally funded demonstration project to increase smoking cessation among pregnant women receiving prenatal care and services from the Women, Infants, and Children (WIC) program in public clinics. Low-intensity interventions were designed to be integrated into routine prenatal care. Clinics were randomly assigned to intervention or control status; pregnant smokers filled out questionnaires and gave urine specimens at enrollment, in the eighth month of pregnancy, and postpartum. Urine cotinine concentrations were determined at Centers for Disease Control and Prevention by enzyme-linked immunosorbent assay and were used to verify self-reported smoking status. At the eighth month of pregnancy, self-reported quitting was higher for intervention clinics than control clinics in all three States. However, the cotinine-verified quit rates were not significantly different. Biochemical verification of self-reported quitting is essential to the evaluation of smoking cessation interventions. Achieving changes in smoking behavior in pregnant women with low-intensity interventions is difficult.

This study tested a cognitive-behavioral intervention for reducing alcohol consumption among economically disadvantaged pregnant women. The intervention included a 10-minute educational session and a nine-step self-help manual. Women attending public health maternity clinics completed a screening questionnaire, a pretest questionnaire, were randomly assigned to receive the self-help intervention or usual clinic care, and completed a posttest questionnaire. A higher alcohol quit rate was observed among the intervention participants (88 percent) than controls (69 percent). The effect was strongest for "light" drinkers, African-Americans, and non-Protestants. This approach may be useful in clinics where staff time is limited.

Studies have demonstrated the effectiveness of smoking cessation interventions targeted at women who are smoking during pregnancy. In contrast, there is limited information about the experience of smokers who have stopped before entering prenatal care-"spontaneous quitters." These women constitute the majority of women who stopped smoking sometime during pregnancy, although evidence suggests that as many as one-third relapse prior to delivery. The authors report the results of a population-based, randomized clinical trial that tested the effectiveness of a relapse prevention program for spontaneous quitters. The intervention consisted predominantly of printed materials received through the mail. The population (n = 171) of spontaneous quitters was an ethnically diverse group of women enrolled in a large health maintenance organization. Biochemical confirmation of continuous abstinence through delivery revealed that 16 percent of the women in the experimental self-help program relapsed compared with 20 percent of usual care controls. Analysis confirmed that the program was equally ineffective among all subgroups including women at highest risk for relapse. Given the negative outcomes associated with self-help materials and clinic-based counseling reported in this and other trials, alternative intervention strategies need to be developed and tested for this significant group of prepregnancy smokers.

Treatment

Alcohol and drug treatment guidelines describe the comprehensive array of treatment and case management services needed by patients. Standard obstetrical procedures are presented for the care of substance using women. These guidelines identify additional medically relevant factors that may result from a woman's substance using lifestyle. Legal and ethical guidelines are presented for the care of women and their children. Issues concerning confidentiality, reporting, and child protection are addressed.

Through simulated calls to 294 drug treatment programs in 5 cities, this study investigated access for pregnant women and compared New York City's provision of services in 1989 to that in 1993. At all sites, the majority of programs accepted pregnant women. There was also a marked improvement in the availability of services in New York City, yet options were more limited for Medicaid recipients and women needing child care, and an appointment or referral for prenatal care was usually not offered. Although the door for treatment may be opening for pregnant women, institutional barriers still remain.

This preliminary study examined differences between cocaine-dependent pregnant women who received "baseline" drug treatment (n = 13) and those requiring additional "intensive" treatment (n = 9). Baseline drug treatment consisted of weekly individual counseling sessions. Intensive treatment, in the form of contingency management procedures, was added for patients who showed no reduction in cocaine use during the first 4 weeks of treatment. There were no differences between the two groups in terms of demographic and pregnancy characteristics or history of cocaine use. Significantly more patients in the baseline treatment group were cocaine-free at intake and had a higher rate of compliance with scheduled prenatal clinical visits. These findings may indicate a decision to cease cocaine use prior to entering treatment, and a high degree of motivation to remain drug-free. Despite the small sample size, the finding that a substantial proportion of cocaine-dependent pregnant women remain cocaine-free during treatment is encouraging.

Research was conducted on programs targeting drug-involved pregnant and parenting women and their children. Programs selected for study share an association with an urban public hospital with a predominantly poor and disproportionately minority clientele. As a result, these programs are faced with clients who often have significant social needs in addition to drug treatment needs, both of which must be addressed for an effective intervention. The programs are similar in that most offer prenatal, postnatal, and aftercare, either directly or through referrals. Also, most programs have at least formal interagency or community advisory boards and endorse the goal of supporting drug-involved women as parents. The study began as a study of programs developed in response to the cocaine epidemic of the mid- to late-1980's and concern over the impact of cocaine and crack cocaine exposure of newborns. In fact, polydrug use was found to be common as was a high incidence of alcohol and tobacco use. The core of the study includes site visits to 17 programs and 15 cities associated with 16 public hospitals. Case studies are included from the participating programs, as well as an analysis of some of the components and challenges faced, and a series of recommendations for policymakers.

A retrospective, inception cohort, nonrandomized control design was employed to evaluate the effects of daily vs. twice daily dosing of methadone on opiate/cocaine use, and noncompliance with urine toxicology requests in methadone-maintained pregnant women, (n=45). Earlier program entry was associated with decreased opiate and cocaine use and increased compliance with urinalysis requests. The single dose and split-dose groups differed in urine toxicology compliance rates, 23.8 vs. 0.5 percent, as well as percentages of urines positive for cocaine, 15.3 vs. 0.3 percent, only in Trimester III.

The fact that women of childbearing age make up a large proportion of the alcohol and drug using population has gained national attention. Since treatment for addicted pregnant women and women with children has become a Federal priority, treatment programs of various modalities have opened their doors to this population. One promising treatment modality is the therapeutic community (TC). This article briefly describes Amity, a long-term residential TC for addicted pregnant women and women with children. Amity currently has 65 women and 50 children living together on a 23-acre ranch. Descriptive data including demographic information and data on violence are presented. Preliminary outcome data are detailed, comparing dropout and treatment completion on such variables as alcohol and drug use, re-arrest, employment, child custody, and involvement in support groups. A pattern of behavior involving experiences in violent episodes and alcohol and drug use is illuminated and discussed. Ideas for further research are suggested.

Medications are under development for the treatment of pregnant addicts and their infants. The effects of drugs on pregnancy and offspring are reviewed. The clinical management of drug dependency in pregnancy is discussed. Methadone use during pregnancy is explored. Treatment options are outlined for drug-exposed infants. Opioid receptor approaches are detailed for the development of medications for pregnant women. Pharmacokinetic and pharmacodynamic considerations involved in the design and screening of potential medications are discussed. Principles of toxicology and teratology are applied in the evaluation of risks of new drugs for the treatment of drug addiction in women of reproductive age. Possible applications of drug delivery systems in the treatment of drug addiction are described. Clinical trials are conducted of pharmacologic treatments in pregnant women. Legal and ethical issues in medications development are also outlined. Medications are tested for the treatment of addiction in pregnancy.

Health-compromised drug-dependent patients require specialized treatment that addresses both drug use and health risks. This preliminary study examines the efficacy of a contingency management procedure (shaping) on decreasing cocaine use and increasing compliance with the prescribed treatment regimens in two health-compromised cocaine-dependent populations: (1) tuberculin (TB) exposed patients (n = 5), and (2) pregnant women (n = 7). A multiple-baseline, across-subjects design was used. There were no contingencies on cocaine use during baseline. During the contingent phase, patients received a monetary reinforcer for (a) or (b). During the contingent phase, there was a significant decrease in cocaine metabolite levels and an increase in cocaine-free samples in both populations, with a more robust effect in the TB-exposed group. There was an increase in compliance with prenatal visits among the pregnant women during the contingent phase. Implications for health care are discussed.

Confronted with a high rate of infant mortality caused by inadequate prenatal care and compounded by substance abuse among pregnant women, New Haven's Hospital of Saint Raphael embarked on "Project MotherCare." The initiative aimed to reduce the access barriers to prenatal care regardless of insurance status or ability to pay. The mission was twofold: (1) to bring prenatal care to underserved neighborhoods of New Haven, and (2) to identify substance-abusing pregnant women and deliver a continuum of services including prenatal care, counseling, social services, and referral to a drug treatment program. Community need caused the program to expand beyond prenatal services and provide additional primary care services to other residents of these neighborhoods.