Difference between revisions of "Minimize Substance Use During Pregnancy"

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=Introductory Paragraph=
=Introductory Paragraph=


Substance use in pregnant women is on the rise<ref>https://www.recoveryanswers.org/resource/women-in-recovery/</ref>, compounded by the opioid crises and challenges resulting from the Coronavirus.  Pregnancy adds significant obstacles to an already complex condition of substance use disorder (SUD). Developing strategies to decrease substance use during pregnancy involves a multifaceted approach to address complex, overlapping issues, and extenuating circumstances.
The unintended pregnancy rate among women with SUD is approximately 80%. <ref>https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy#:~:text=Unintended%20pregnancy%20rates%20among%20women,than%20in%20the%20general%20population.</ref> 40% of pregnant women who drank alcohol during pregnancy reported co-using other substances, including tobacco, cannabis, cocaine, and heroin. <ref>England LJ, Bennett C, Denny CH, et al. (2020) Alcohol Use and Co-Use of Other Substances Among Pregnant Females Aged 12-44 Years - United States, 2015-2018. MMWR Morbidity and Mortality Weekly Report 69(31):1009-1014.</ref> Recently, the number of pregnant people using opioids has rapidly increased, in keeping with the increase observed in the general population. <ref>https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy</ref>  
 
Pregnant women with substance abuse disorder face multiple social and situational challenges and obstacles, including social, mental health, legal, environmental, cultural, economic, and geographic. In addition, many pregnant substance abusers are victims of domestic abuse, are homeless, have unsafe/inadequate housing, lack reliable transportation and, do not possess health insurance or the means to pay for medical care. Lack of access to medical care, ineffective collaboration among social service systems, stigma, and fear of punishment further compound the issue.<ref>https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf</ref>
 
Current research suggests that a collaborative, integrated approach to managing SUD in pregnant women provides the best chance to counteract obstacles and minimize or eliminate substance use.  A wraparound, comprehensive approach based on evidential research including social, family, criminal justice, social service, medical, and mental health professionals. The risk for substance abuse and its consequences and optimal processes for treatment and recovery differ by gender, race, ethnicity, sexual orientation, education, economic status, geographic location, and other factors. Understanding group differences across segments of the population of women is critical to designing and implementing effective substance abuse treatment programs for women.<ref>http://www.fasd-evaluation.ca/wp-content/uploads/2021/03/FINAL-CCE_Executive-Summary_Mar-10-for-web.pdf</ref>
 
 
Women who are misusing opioids or who have opioid use disorder (OUD) may have many obstacles to getting treatment, family planning, or prenatal care. A strategy to minimize unintentional pregnancies for these women should include plans to help them overcome obstacles to receiving these services. The obstacles include:
 
⦁ Transportation
 
⦁ Childcare
 
⦁ Employment conflicts
 
⦁ Unsupportive living environments
 
⦁ Unstable living environments
 
⦁ Homelessness
 
⦁ Partner with a substance use disorder
 
⦁ Stigma and/or guilt
 
⦁ Fear of losing the child
 
⦁ Fear of incarceration
 
⦁ Fear of being discovered about misusing substances (by family, employer, etc.)
 


Pregnant women with substance abuse disorder face multiple challenges and obstacles. Lack of access to medical care, ineffective collaboration among social service systems, stigma, and fear of punishment further compound their challenges. <ref>https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf</ref> Current research suggests that a collaborative, integrated approach to managing SUD in pregnant women provides the best chance to counteract obstacles and minimize or eliminate substance use. A wraparound approach is backed up by evidential research and provides comprehensive services by social, family, criminal justice, social service, medical, and mental health professionals. <ref>https://canfasd.ca/wp-content/uploads/publications/FINAL-CCE_Report_Mar-8-for-web.pdf</ref>


=Key Information=
=Key Information=


According to recent data, women are at their highest risk for developing SUDs during reproductive years.  Polysubstance use is common among pregnant women with SUD, and the unintended pregnancy rate among women with SUD is ~80%. <ref>https://www.ndsu.edu/fileadmin/centers/americanindianhealth/files/Maternal_Health_Learning_Collaborative_Session_2.pdf</ref>
Studies suggest that pregnancy provides a unique opportunity for women to embrace recovery options. <ref>https://www.cdc.gov/pregnancy/polysubstance-use-in-pregnancy.html</ref> However, there are significant barriers for pregnant women seeking treatment. Quitting substance use, especially when an individual has SUD, can be difficult. Pregnant women might find quitting complicated by the fear that asking for help could lead to potential social and even legal consequences. Reporting requirements and administrative policies of service agencies may lead to mandatory involvement with child protective services, loss of child custody, or other legal consequences. Limited child care options may deter mothers from seeking treatment. Likewise, women in treatment may need help with handling the burdens of work, home, and other family responsibilities. <ref>https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf</ref>
 
Studies suggest that pregnancy provides a unique opportunity for women to embrace recovery options.  <ref>https://www.cdc.gov/mmwr/volumes/69/wr/mm6931a1.htm?s_cid=mm6931a1_w</ref>
 
Women, pregnant or not, have unique needs that should be addressed during substance use disorder treatment.  Effective treatment should incorporate approaches that recognize sex and gender differences, understand the types of trauma women sometimes face, provide added support for women with child care needs, and use evidence-based approaches for the treatment of pregnant women. <ref> https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/summary</ref>
 
Substance use during pregnancy is frequently associated with a host of issues including intimate partner violence, trauma and intergenerational trauma, unsafe/inadequate housing, poverty, food insecurity, mental health issues, mother-child separation, racism, and colonization.<ref> http://www.fasd-evaluation.ca/wp-content/uploads/2021/03/FINAL-CCE_Report_Mar-8-for-web.pdf</ref>
 
'''Prevalence'''
 
Between 2015 to 2018, about half of all pregnant respondents that reported drinking in the past 30 days (9.8%) also reported binge drinking (4.5%).  Of the pregnant respondents who reported drinking in the past 30 days, 38.2% also stated they were currently using at least one other substance (tobacco, marijuana, opioids, etc.).<ref>https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6931a1-H.pdf</ref>
 
In 2016, 91,800 births – or 24.3 per 1,000 hospital stays for birth – had an SUD diagnosis involving opioids, cocaine and other stimulants. <ref>https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf</ref>
 
'''Barriers to Seeking Treatment'''
 
Quitting substance use, especially when an individual has SUD, can be difficult. Pregnant women might find quitting more difficult due to fears of potential legal and social consequences if they ask for help. Lacking child care when receiving treatment also may deter mothers from seeking help. Women in treatment may need help with handling the burdens of work, home and child care, and other family responsibilities.<ref>https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf</ref>
 
'''Stigma''' 
 
A large barrier to treatment and recovery is stigma.  The societal stigma toward women who abuse substances tends to be greater than that toward men, and the stigma amplifies significantly for pregnant drug users.  Women's ascribed role and the expectations placed on them influences societal perceptions and reactions towards women with SUDs.  Women who use alcohol and illicit drugs regularly feel shame and guilt, and they also often suffer from low levels of self-esteem and self-efficacy. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/</ref>
 
'''Culture'''
 
The intricate relationship between culture and health—and the influence of differing attitudes, definitions, and beliefs about health and substance use among cultural groups—affects the psychosocial development of women and their substance use and abuse, resulting in further stigmatization of substance use.
 
'''Gender'''
 
Gender differences in use and treatment approach women and men sometimes use drugs for different reasons and respond to them differently. Additionally, substance use disorders can manifest differently in women than in men. <ref>https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women</ref>  In the past, women were not included in most clinical research.<ref> https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/importance-including-women-in-research</ref>
 
'''Discrimination'''
 
Women may experience varying levels of discrimination in both healthcare and criminal justice —based on gender, race, ethnicity, religion, language, culture, socioeconomic status, sexual orientation, age, HIV status, and disability—that affect their substance use and may affect their recovery. Some women use substances to cope with the further stresses of discrimination. Pregnant women using substances, particularly women of color and women in lower socioeconomic brackets, deal with increased surveillance and may face consequences like but not limited to arrest and child removal.<ref>https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23</ref>
 
'''Environmental'''
 
Many women with SUDs have experienced trauma in the past that was perpetrated by someone close to them. This contributes to these women’s treatment needs.<ref>https://www.sciencedirect.com/science/article/abs/pii/S0091743520303273</ref>
 
'''Geography'''
 
Rural women are 9% more likely than urban women to face severe maternal morbidity mortality. They are also 59% more likely than urban women to have an SUD diagnosis at the time of birth.<ref> https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf</ref>    
 
Rates of substance use during pregnancy are typically higher in rural communities than in urban ones.  Rural communities often have limited resources for prevention and treatment and lack the resources needed to provide services to parents dealing with substance use.  For instance, more opioids are prescribed in rural communities than in urban ones. This has led to prescription opioids being the most common type of drug abused by rural pregnant women. Despite being vulnerable, a majority of the research on the prevalence, prevention, and treatment of substance abuse during pregnancy has focused on urban areas. 
 
Noteworthy characteristics that make rural living more challenging are the lack of economic opportunity, transportation, and technological limitations.<ref>https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf</ref>
 
'''Financial/socioeconomic''' 
 
Women dealing with SUD who struggle financially may have to deal with low-income unstable housing, lack of access to transportation and medical care, as well as poor nutrition. Less access to health care, and difficulty in funding treatment due to a lack of health insurance, can result in later referral for substance abuse treatment.
 
'''Legal'''  
 
Pregnant women who misuse substances are situated at the intersection of public health and criminal justice intervention. Their substance use affects their health and the health of their fetuses. Public health professionals are concerned about this since the field is committed to improving maternal and infant health. In the last 30 years, prenatal substance use has become a criminal justice issue since the fetal protectionism movement encouraged greater use of criminal sanctions for mothers who use substances.
 
In addition to being a public health concern, substance use during pregnancy presents legal challenges and the threat of punishment
 
Reporting requirements and administrative policies prevent additional obstacles, including mandatory involvement with child protective services, loss of child custody, or other legal consequences, fear of criminal prosecution, and legal requirements for medical professionals to report them.
 
For women seeking help, there is often a fear of judgment. Many are afraid they will be arrested, forced to have an abortion, asked to leave a prenatal care program, and reported to child protective services.
 
Some states have broadened their civil child-welfare requirements to add prenatal substance use so that prenatal drug exposure can lead to the termination of parental rights due to claims of child abuse or neglect. Several states demand healthcare providers test for prenatal drug exposure, and if necessary report it. These findings can serve as evidence in child-welfare proceedings. To be awarded federal child abuse prevention funds, states must make providers notify child protective services if they look after an infant affected by illegal substance use. 


Public policy is catching up to this idea although there are many challenges with state legislature depending on geography and federal grants give states the power to decide how to implement key elements. Even though a number of states have adopted policies focused on the importance of treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care, other States have approached this issue from a criminality standpoint (e.g., with child welfare and criminal laws) in the past few decades.
Stigma is a large barrier to treatment and recovery. The societal stigma toward women who abuse substances tends to be greater than that toward men, and the stigma amplifies significantly for pregnant drug users. Women's ascribed role and the expectations placed on them influences societal perceptions and reactions toward women with SUDs.  Women who use alcohol and illicit drugs regularly feel shame and guilt, and they also often suffer from low levels of self-esteem and self-efficacy. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/</ref> Women with substance use issues often have high levels of comorbid mental health disorders. In 2019, there were 34.3M adult women who had a mental illness and/or SUD. <ref>https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health</ref>


In one study, the pregnant participant’s stories demonstrated how they controlled the risk of health or criminal justice authorities detecting substance use, including isolating themselves from others, skipping treatment appointments, or avoiding treatment altogether. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/</ref>
Substance use disorders can manifest differently in women than in men. <ref>https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women</ref>  In the past, women were not included in most clinical research. <ref>https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/importance-including-women-in-research</ref> Women may experience varying levels of discrimination in both healthcare and criminal justice systems that affect their substance use and may affect their recovery. Pregnant women using substances, particularly women of color and women in lower socioeconomic brackets, deal with increased surveillance and may face consequences, such as arrest and child removal. <ref>https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23</ref> Some women use substances to cope with these stresses of discrimination. Women dealing with SUD who struggle financially may have to deal with low-income unstable housing, lack of access to transportation and medical care, as well as poor nutrition. Less access to health care, and difficulty in funding treatment due to a lack of health insurance, can result in later referral for substance use treatment. Since residential treatment facilities are limited, pregnant women have reported several barriers to treatment and healthcare, including insufficient treatment options and difficulty locating and entering treatment.


'''Co-occurring Conditions'''
Rural vs. urban geography also plays a role in substance use during pregnancy. Rates of substance use during pregnancy are typically higher in rural communities than in urban ones. However, most of the research on the prevalence, prevention, and treatment of substance abuse during pregnancy has focused on urban areas. Rural women are 9% more likely than urban women to face severe maternal morbidity mortality. They are also 59% more likely than urban women to have an SUD diagnosis at the time of birth. <ref> https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf</ref> More opioids are prescribed in rural communities than in urban ones. This has led to prescription opioids being the most common type of drug abused by rural pregnant women. Noteworthy characteristics that make rural living more challenging are the lack of economic opportunity, transportation, and technological limitations.<ref>https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf</ref>  Rural communities often have limited resources for prevention and treatment and lack the resources needed to provide services to parents dealing with substance use. 


Women with substance abuse issues often have high levels of comorbid psychopathology, personality problems, and mental health issues. SUDs and mental disorders have a bidirectional relationship. Having a mental disorder may contribute to the beginning or growth of an SUD. Correspondingly, the existence of an SUD may begin the beginning or growth of a mental disorder.<ref> https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-07-01-001-PDF.pdf</ref>
'''Best Practices in Treatment and Therapy'''


Women are more prone to co-occurring disorders. In 2019, 34.3M adult women had a mental illness and/or SUD.<ref>https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health</ref>   There is also an increased risk for suicidality among women.<ref>https://www.ndsu.edu/fileadmin/centers/americanindianhealth/files/Maternal_Health_Learning_Collaborative_Session_2.pdf</ref>
Despite the fact pregnancy motivates some women to begin treatment, several studies indicate that pregnant women do not remain in treatment as long. Researchers have also linked retention to the stage of pregnancy and if the individual has co-occurring psychiatric disorders. Transitional programs and aftercare services can offer educational programs, vocational training, relapse prevention programs, childcare services, and housing options for women and their newborns to support a sustained recovery as well.


 ~30% of pregnant women enrolled in SUD treatment screen positive for depression;
Offering holistic, integrated support for pregnant women with substance use concerns is an emerging best practice to support pregnant women with substance use concerns. These programs can be provided through various models including outreach, multi-service co-located agencies, or a network of community-based services. Research in this area has shown that integrated-support models can improve maternal and fetal outcomes and successfully support women to reduce alcohol use in pregnancy. <ref>https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf</ref> Best practices should take the following approaches into consideration:


~40% report postpartum depression
*'''Evidence-Based Practice (EBP)''' is increasingly becoming more popular in many health care disciplines. One of its main characteristics is its focus on the interaction between hard scientific evidence, clinical expertise, and patient needs and choices. There are many different EBPs that are effective, including traditional programs (which center around the pregnancy period), comprehensive treatment, and home visitation. Contemporary approaches include newer methods such as motivational interviewing and contingency management. They concentrate on the mother-infant relationship, collaboration among social service systems, including child protective services and family treatment drug court, and pharmacotherapy. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC226388/</ref>


Lack of Adequate Medical Resources 
*'''Mental Health.''' Mental health care is an integral aspect of addiction treatment. There is a need to increase identification of co-occurring substance use and mental disorders, such as mood, anxiety, and eating disorders. Integrated treatment for co-occurring disorders differs from traditional approaches. For example, this would mean that there are assessments provided that screen for both mental illness and substance use. <ref>https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf</ref> Behavioral therapies help to discover what may have prompted initial drug abuse, and they can teach participants new ways of thinking which will promote future healthy behaviors and habits. Another benefit for women is that counseling can help teach them how to manage childbirth and the pain and medical concerns which might occur during pregnancy and in childbirth. Creating a plan for these potential difficulties in combination with addiction treatment can be helpful. For example, after childbirth, pain medications may need to be monitored or switched for non-habit-forming ones. Such relational approaches take into consideration positive and negative familial and partner influences and relationships, and promote a safe and caring treatment environment.


In one study, the pregnant respondents reported several barriers to treatment and healthcare. Some of these were having insufficient treatment options and difficulty locating and entering treatment. Residential treatment facilities are limited.  In 2019[22]<ref>https://www.samhsa.gov/data/quick-statisticsresults?qs_type=nssats&state=United%20States&year=2019</ref>, only 3,875 out of 15,961 facilities had treatment programs tailored to pregnant women, accounting for only 24.3% including private non-profit, private for-profit, local, county, or community government, state government, tribal government.<ref>https://ncsacw.samhsa.gov/topics/pregnant-postpartum-women.aspx#sup-1-bottom</ref>
*'''Trauma-Informed Approaches''' include screening and assessing women for trauma history. Many women with SUDs have experienced trauma  which was perpetrated by someone close to them. This contributes to these women’s treatment needs.<ref>https://www.sciencedirect.com/science/article/abs/pii/S0091743520303273</ref>


'''Relapse Prevention/ Continuing Treatment Post-Partum'''
*'''Integrated Treatment and Coordinated Care''' works with the whole person, including their family and parenting responsibilities. Integrated treatment programs include on-site pregnancy services, parenting services, or child-related services with addiction services. These were developed to break the intergenerational cycle of addiction, potential child maltreatment, and poor outcomes for children. Collaborative care models offer a multidisciplinary approach to clinical care. Connection to psychosocial support services can improve the chances of treatment success for women with substance use disorders. Additionally, women can benefit from behavioral health referrals, connection with peer and community supports, services for addressing social determinants of health, such as housing or food insecurity.


Despite pregnancy motivating some women to begin treatment, several studies indicate that pregnant women do not remain in treatment as long. Researchers have also linked retention to the stage of pregnancy and if the individual has co-occurring psychiatric disorders.
*'''Medication-Assisted Treatment (MAT)''' is clinically driven and focuses on individualized patient care. Medications used to treat opioid use disorders include Methadone and Buprenorphine. Both of these medications stop and prevent opioid withdrawal and reduce opioid cravings, allowing the person to focus on other aspects of recovery. Research shows that a combination of medication and behavioral therapies is most successful for substance use disorder treatment. MAT provides a whole-patient approach and is a recommended best practice for the care of pregnant women with opioid use disorders. <ref>https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy</ref> In considering the appropriate medications for pregnant women, Buprenorphine is safer than Naltrexone or Methadone to ensure better outcomes for newborn children.


Some components that inspire women to remain in treatment are supportive therapy, a collaborative therapeutic alliance, onsite child care and children services, and other integrated and comprehensive treatment services.<ref> https://store.samhsa.gov/product/TIP-51-Substance-Abuse-Treatment-Addressing-the-Specific-Needs-of-Women/SMA15-4426</ref>
*'''Group-Based Treatment & Peer Support.''' Comprehensive care includes individual or group therapy sessions. Group sessions may take place with other pregnant women and focus on specific issues for this population. Women can work together during group skills sessions to learn parenting techniques and healthy stress coping mechanisms. This serves to provide recognition of women’s cultural expectations and to help improve engagement and retention in treatment programs. In a study using online health communities, 58.5% of the pregnant women in the study expressed negative emotions, of whom only 10.2% wanted to address their emotional needs with the help of the online community. <ref>https://onlinelibrary.wiley.com/doi/epdf/10.1111/hsc.13335</ref> Five themes of self-management support needs were identified for online communities
 
**information regarding the potential adverse effects of gestational opioid use
Transitional programs and aftercare services can offer educational programs, vocational training, relapse prevention programs, childcare services, and housing options for women and their newborns to support a sustained recovery as well. Sociodemographics also play a role in treatment retention. Some studies have found that encouragement and engagement of significant others, being older, and having at least obtained a high school degree can improve retention. Women that have previously had positive experiences in other areas in life and are confident in the treatment process and result are also more likely to stay in treatment. Involvement in the criminal justice system or child protective services is linked to spending a long time in treatment.
**protocols for self-managed withdrawal
 
**pain management safety during pregnancy
'''Opioid Crisis'''
**hospital policies and legal procedures related to child protection
 
**strategies for navigating offline support systems.
Recently, the number of pregnant people using opioids has rapidly increased.  This population’s growth rate is similar to the increase observed in the general population. <ref>https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy</ref>
 
Looking at administrative data, researchers have estimated that 14%–22% of women filled an opioid prescription during pregnancy.  However, self-reported data on prescription opioid use during pregnancy are limited.<ref>https://www.cdc.gov/mmwr/volumes/69/wr/mm6928a1.htm</ref>
 
'''Treatments & Best Practices'''
 
Women’s risks for substance abuse are understood best in the social and historical context of where the influences of gender, race and ethnicity, education, economic status, age, geographic location, sexual orientation, and other factors converge. Understanding group differences across segments of the population of women is critical to designing and implementing effective substance abuse treatment programs for women. Treatment of pregnant substance users requires a multi-pronged approach involving integrated, comprehensive, evidence-based models that treat the entire individual. 
 
Offering holistic, integrated support for pregnant women with substance use concerns is an emerging best practice in how to support pregnant women with substance use concerns. These programs can be provided through various models including outreach, multi-service co-located agencies, or a network of community-based services. Research in this area has shown that integrated support models can improve maternal and fetal outcomes and successfully support women to reduce alcohol use in pregnancy.<ref> https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf</ref>
 
Over the last decade, researchers have increased the number of studies conducted on women with SUDs. Examples of topics that researchers have looked at are the effects of substance use on pregnancy in greater detail, best practices in SUD treatment for women, the impact of trauma and the need for trauma-informed services, and the significance of integrating a gender-responsive framework.  More recently, research is burgeoning in the area of outcome variables, relapse prevention, women and child services, and specific treatment approaches. The idea is to address the underlying contributing factors and work to eliminate/alleviate individual factors affecting women seeking to lower their substance abuse while pregnant.[28]<ref> https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-06-04-002.pdf</ref>
 
'''Approaches to SUD treatment for women should include:'''
 
● Relational approaches that take into consideration positive and negative familial and partner influences and relationships, and promote a safe and caring treatment environment.
 
● Treatment programs that integrate the whole person, including family and parenting responsibilities.
 
● Trauma-informed approaches that include screening and assessing women for trauma history.
 
● A focus on identifying and addressing co-occurring substance use and mental disorders, such as mood, anxiety, and eating disorders.
 
● Consideration of appropriate medications for pregnant women; buprenorphine is safer than naltrexone or methadone to ensure better outcomes for newborn children.
 
● Provider recognition of women’s cultural expectations to help improve engagement and retention in treatment programs
 
Medication-Assisted Treatment (MAT)
 
MAT is the combination of medications alongside counseling and behavioral therapies to provide a whole-patient approach when treating SUDs. The use of MAT during pregnancy is a recommended best practice for the care of pregnant women with opioid use disorders[29]<ref>https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy</ref>. Research shows that a combination of medication and behavioral therapies is most successful for substance use disorder treatment. 
 
MAT is clinically driven and focuses on individualized patient care. Medications used to treat opioid use disorders include methadone and buprenorphine. Both of these medications stop and prevent opioid withdrawal and reduce opioid cravings, allowing the person to focus on other aspects of recovery.
 
Comprehensive care management that includes medications for opioid use disorder (MOUD) is recommended for pregnant women with OUD. MOUD consists of opioid agonist pharmacological treatment options, such as buprenorphine (Subutex® and Suboxone®) or methadone, proven to be effective in reducing severe withdrawal symptoms, risk-taking behaviors, and improving adherence to treatment when combined with behavioral therapies, counseling, and prenatal care. MOUD is preferable to medically supervised withdrawal because of the high risk of relapse and adverse outcomes by 59–90% in pregnant women. [30]<ref>  https://aspe.hhs.gov/reports/models-medication-assisted-treatment-opioid-use-disorder-retention-continuity-care-0#implications</ref>
 
An overview of available drugs for management of opioid abuse during pregnancy. <ref>https://mhnpjournal.biomedcentral.com/articles/10.1186/s40748-017-0044-2</ref>
 
'''Integrated Treatment Program Integrated/Coordinated Care'''
 
Integrated treatment for co-occurring disorders differs from traditional approaches. Services are organized in an integrated fashion. For example, this would mean that there are assessments provided that screen for both mental illness and substance use.<ref>https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf</ref>
 
'''Integrated Programs for Mothers with Substance Abuse Issues'''
 
Integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, potential child maltreatment, and poor outcomes for children.
 
'''Care Collaboration and Support Services'''
 
A significant suggestion is that women would benefit from comprehensive care and professional advocacy.
 
A multidisciplinary approach to clinical care and connection to psychosocial support services can improve the chances of treatment success for women with substance use disorders in general. Additionally, women can benefit from behavioral health referrals, services for addressing social determinants of health (eg, housing or food insecurity), and connection with peer and community supports. For more information read, Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes.<ref>https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-9-14</ref>
 
Due to potential barriers, risks, and outcome implications, researchers, health care professionals, and policymakers suggest that substance abuse treatment programs confront both women and their children’s needs via comprehensive services.  Officials acknowledging the importance of this has led to the creation of many integrated treatment programs (these programs include pregnancy-, parenting-, or child-related services with addiction services), both residential and outpatient.  Integrated residential programs or "therapeutic communities" provide long-term (15-18 months) treatment services to women and their children.  Both types of programs often include group and individual addiction treatment, maternal mental health services, trauma treatment, parenting education and counseling, life skills training, prenatal education, medical and nutrition services, education and employment assistance, child care, children's services, and aftercare. <ref>https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-9-14</ref>
 
'''Evidence-Based'''
 
Evidence-based practice (EBP) is increasingly becoming more popular in many health care disciplines. One of its main characteristics is its focus on the interaction between hard scientific evidence, clinical expertise, and patient needs and choices. Evidence-based programs have discovered there are many different methods that are effective, including traditional programs (which center around the pregnancy period), comprehensive treatment and home visitation, and contemporary approaches. These newer methods include motivational interviewing and contingency management and they concentrate on the mother-infant relationship, collaboration among social service systems, including child protective services and family treatment drug court, and pharmacotherapy. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC226388/</ref>
 
There are many different behavioral treatments that are backed with evidence for treating SUDs.<ref>https://www.nationalpartnership.org/our-work/resources/health-care/maternity/evidence-based-maternity-care.pdf</ref> Some examples include cognitive-behavioral therapy-based approaches, contingency management, motivational interventions, mindfulness-based treatments, and marital and family therapies. Self-help organizations and mutual help groups can also be an important addition to a comprehensive recovery plan and can be a helpful complement to evidence-based psychotherapies. <ref>https://psycnet.apa.org/record/2018-18838-010</ref>
 
Treatment tenants and protocols for the following SUD interventions are discussed: (1) cognitive-behavioral therapy-based approaches, (2) contingency management, (3) motivational interventions, (4) mindfulness-based treatments, (5) marital and family therapies, and (6) self-help organizations/mutual help groups.  <ref>https://www.sciencedirect.com/science/article/pii/B9780323548564000109?via%3Dihub</ref>
 
'''Group/Peer Support'''
 
Mental healthcare is also an integral aspect of addiction treatment, and this includes both individual and group therapy sessions. Group sessions may take place with other pregnant women and focus on specific issues for this population. Women can work together during group skills sessions to learn parenting techniques and healthy stress coping mechanisms. 
 
'''Therapy'''
 
Behavioral therapies help to discover what may have prompted initial drug abuse, and they can teach participants new ways of thinking that will promote future healthy behaviors and habits. Another benefit for women is that counseling can help teach them how to manage childbirth and the pain and medical concerns that might occur during pregnancy and in childbirth. Creating a plan for these potential difficulties in combination with addiction treatment can be helpful. For example, after childbirth, pain medications may need to be monitored or switched for non-habit-forming ones.
 
'''Online Health Communities'''
 
In a study using online health communities (OHC), there were five themes of self-management support needs identified. In the online communities, women looked for information regarding the potential adverse effects of gestational opioid use, protocols for self-managed withdrawal, pain management safety during pregnancy, hospital policies and legal procedures related to child protection, and strategies for navigating offline support systems. 58.5% of the pregnant women in the study expressed negative emotions, of whom only 10.2% wanted to address their emotional needs with the help of the OHC.[39]<ref>https://onlinelibrary.wiley.com/doi/epdf/10.1111/hsc.13335</ref>
 
 
 
'''Harm reduction should include:'''<ref> https://www.nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf</ref>
 
● Public Health Strategies
● Implementation of public health strategies (e.g., improving state prescription drug monitoring program use and enhancing provider training) can support the delivery of evidence-based care for pregnant women.
● Group-based treatment
● Training of service professionals
● Collaborative Care Models
● Evidence-based policy development


=Relevant Research=
=Relevant Research=


'''CDC:'''<ref>https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6931a1-H.pdf</ref>Substance Use During Pregnancy Alcohol Use and Co-Use of Other Substances Among Pregnant Females Aged 12–44 Years — the United States, 2015–2018
*'''National Institute on Drug Abuse (NIDA)''' has published a research report on substance use by women. It includes sections associated with breastfeeding, as well as sex and gender differences in substance use. <ref>https://nida.nih.gov/publications/research-reports/substance-use-in-women/sex-gender-differences-in-substance-use</ref> 
 
'''Co-Creating Evidence Evaluation Report:''' Stories and Outcomes of Wraparound Programs Reaching Pregnant and Parenting Women at Risk.<ref> http://www.fasd-evaluation.ca/wp-content/uploads/2021/03/FINAL-CCE_Report_Mar-8-for-web.pdf</ref>
 
'''National Center for Biotechnology Information (NCBI)''' 


● Pregnant women and substance use: fear, stigma, and barriers to care<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/</ref>
*'''CDC''' Publishes MMWR (The Morbidity and Mortality Weekly Report). One of these is titled "Substance Use During Pregnancy Alcohol Use and Co-Use of Other Substances Among Pregnant Females Aged 12–44 Years — the United States, 2015–2018." It breaks down some of the findings in the National Survey on Drug Use and Health (NSDUH). For example, 38.2% of pregnant respondents who reported current drinking also reported current use of one or more other substances -- primarily tobacco and marijuana.
● Concurrent Opioid and Alcohol Use Among Women Who Become Pregnant: Historical, Current, and Future Perspectives<ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6545650/</ref>


'''Substance Abuse and Mental Health Services Administration (SAMHSA)''' 2019 National Survey on Drug Use and Health [45]<ref> https://www.samhsa.gov/data/sites/default/files/reports/rpt31102/2019NSDUH-Women/Women%202019%20NSDUH.pdf</ref>
*'''Public Health Agency of Canada''' funded a national evaluation of multi-service programs that reach pregnant women at risk. This report was completed by the Nota Bene Consulting Group  in partnership with the Centre of Excellence for Women’s Health. The evaluation was designed around a a theory of change developed that was collaboratively developed by organizations which were guided by a similar set of theoretical approaches, including being trauma-informed, relationship-based, women-centered, culturally-grounded, and harm-reducing. <ref>Rutman, D., Hubberstey, C., Van Bibber, M., Poole, N., & Schmidt, R.A. (2021). Stories and Outcomes of Wraparound Programs Reaching Pregnant and Parenting Women at Risk. Victoria, BC: Nota Bene Consulting Group. retrieved at https://canfasd.ca/wp-content/uploads/publications/FINAL-CCE_Report_Mar-8-for-web.pdf</ref>


'''Healthcare Cost And Utilization Project (H-CUP)''' Obstetric Delivery Inpatient Stays Involving Substance Use Disorders and Related Clinical Outcomes, 2016<ref> https://hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf</ref>
*'''This article''' is titled "Concurrent Opioid and Alcohol Use Among Women Who Become Pregnant: Historical, Current, and Future Perspectives." It highlights the historical context of opioid and alcohol use during pregnancy, summarizes the current knowledge of opioids and alcohol use during pregnancy, and details future directions in how health care providers could help. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6545650/</ref>


'''National Institute on Drug Abuse (NIH)'''
*'''This article''' is titled "Pregnant women and substance use: fear, stigma, and barriers to care." The research was based on interviews with 30 recently-pregnant women who had used alcohol or other drugs during their pregnancies. It highlights their strategies for managing their risk of detection by health or criminal justice authorities. It also documents multiple barriers to treatment and healthcare. The findings suggest that policies that substance-using women find threatening discourage them from seeking comprehensive medical treatment during their pregnancies. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/</ref>


● Substance Use in Women Research Report<ref>https://www.drugabuse.gov/download/18910/substance-use-in-women-research-report.pdf?v=b802679e27577e5e5365092466ac42e8</ref> 
*'''Healthcare Cost and Utilization Project (H-CUP)''' generated a brief that presents statistics from the National Inpatient Sample (NIS) on delivery-related inpatient stays involving SUDs, for select types of substances (opioids, cocaine, and other stimulants), and for both urban and rural areas. <ref>Obstetric Delivery Inpatient Stays Involving Substance Use Disorders and Related Clinical Outcomes, 2016. retrieved at https://hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf</ref>


● Treating Opioid Use Disorder During Pregnancy<ref>https://www.drugabuse.gov/publications/treating-opioid-use-disorder-during-pregnancy</ref> 
*'''Parenting Outcomes.''' This article provides a literature review on parenting skills and parenting needs of women with substance use issues. <ref> Niccols, A., Milligan, K., Sword, W. et al. Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes. Harm Reduct J 9, 14 (2012). retrieved at https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-9-14</ref>


● Substance Use While Pregnant and Breastfeeding[<ref> https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/substance-use-while-https://www.drugabuse.gov/publications/drugfacts/substance-use-in-womenpregnant-breastfeeding</ref>
*'''This study''' documents the increase in overdose deaths during pregnancy. <ref>https://www.statnews.com/2023/11/22/opioid-crisis-hits-maternal-health-pregnancy-overdoses-rise/</ref> 
 
● Sex and gender differences in substance use<ref>https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women</ref> 


=Impactful Federal, State, and Local Policies=
=Impactful Federal, State, and Local Policies=


'''Comprehensive Addiction and Recovery Act of 2016 (CARA)'''
Any advances in public policy and public health strategies support the delivery of evidence-based care for pregnant women. A major policy need is in enhancing the training of professionals to be more attuned to the needs of pregnant women. Advocacy for comprehensive care and professional services would benefit women.


The Comprehensive Addiction and Recovery Act (CARA) establishes a comprehensive, coordinated, balanced strategy through enhanced grant programs that would expand prevention and education efforts while also promoting treatment and recovery. 
*'''The Comprehensive Addiction and Recovery Act of 2016 (CARA)''' established a coordinated strategy through enhanced grant programs which expand prevention and education efforts while also promoting treatment and recovery. Section 501 (Improving Treatment for Pregnant and Postpartum Women) reauthorizes the Residential Treatment Program for Pregnant and Postpartum Women. It also authorizes the creation of grants within CSAT to enhance a state's services for women who are pregnant and postpartum while suffering from substance use disorder.


Applicable sections:
*'''SUPPORT Act.''' The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act is federal legislation which addresses tighter oversight of opioid production and distribution. It imposes additional reporting and safeguards to address fraud, and it limits coverage of prescription opioids, while expanding coverage of and access to opioid addiction treatment services. The bill also authorizes a number of programs that seek to expand consumer education on opioid use and train additional providers to treat individuals with opioid use disorders. <ref>https://fas.org/sgp/crs/misc/R45405.pdf</ref> Section 503 of the SUPPORT Act (Infant Plan of Safe Care) requires HHS to produce information concerning best practices on developing plans for the safe care of infants born with substance use disorders or showing withdrawal symptoms. This section also requires that state plans address the health and SUD treatment needs of the infant. <ref>https://www.acf.hhs.gov/sites/default/files/documents/cb/im1605.pdf</ref>
 
Title V:  Addiction and Treatment Services for Women, Families, and Veterans 
 
Sec. 501 – Improving Treatment for Pregnant and Postpartum Women:  This section reauthorizes the Residential Treatment Program for Pregnant and Postpartum Women. It also authorizes the creation of grants within CSAT for a pilot program to enhance a State's services for women who are pregnant and postpartum while suffering from substance use disorder.
 
Sec. 503 – Infant Plan of Safe Care: Requires HHS to produce information concerning best practices on developing plans for the safe care of infants born with substance use disorders or showing withdrawal symptoms. This section also requires that a State plan addresses the health and SUD treatment needs of the infant, among others.<ref>https://www.cadca.org/comprehensive-addiction-and-recovery-act-cara</ref>
 
'''Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) [Public Law 115–271]'''  
 
Broadly, the legislation imposes tighter oversight of opioid production and distribution; imposes additional reporting and safeguards to address fraud; and limits coverage of prescription opioids, while expanding coverage of and access to opioid addiction treatment services. The bill also authorizes a number of programs that seek to expand consumer education on opioid use and train additional providers to treat individuals with opioid use disorders.<ref>https://fas.org/sgp/crs/misc/R45405.pdf</ref>
 
'''State Child Welfare & Prenatal Substance Use'''
 
Several states have expanded their civil child-welfare requirements to include prenatal substance use so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect. Further, some states, under the rubric of protecting the fetus, authorize civil commitment (such as forced admission to an inpatient treatment program) of pregnant women who use drugs; these policies sometimes also apply to alcohol use or other behaviors. A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child-welfare proceedings. And in order to receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance use.<ref>https://fas.org/sgp/crs/misc/R45405.pdf</ref>
 
⦁ 23 states and the District of Columbia consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and 3 consider it grounds for civil commitment.
 
⦁ 25 states and the District of Columbia require health care professionals to report suspected prenatal drug use, and 8 states require them to test for prenatal drug exposure if they suspect drug use.
 
⦁ 19 states have either created or funded drug treatment programs specifically targeted to pregnant women, and 17 states and the District of Columbia provide pregnant women with priority access to state-funded drug treatment programs.
 
⦁ 10 states prohibit publicly funded drug treatment programs from discriminating against pregnant women.


*'''State Policy.''' Although federal public policy is advancing efforts to minimize substance use during pregnancy, there are many challenges with inconsistent efforts in state legislatures. This is driven by variations in geography, because federal grants give states the power to decide how to implement key elements of federal policies. <ref>https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/</ref>
**One area that is gaining public support is in the domain of child welfare and prenatal substance use. Several states have expanded their civil child-welfare requirements to include prenatal substance use, so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect. Further, some states, under the rubric of protecting the fetus, authorize civil commitment (such as forced admission to an inpatient treatment program) of pregnant women who use drugs. These policies sometimes also apply to alcohol use or other behaviors. A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child-welfare proceedings. And in order to receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance use. <ref>https://fas.org/sgp/crs/misc/R45405.pdf</ref>
**The National Academy for State Health Policy has an overview of state options for promoting recovery among pregnant and parenting women. <ref> https://www.nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf</ref>


=Available Tools and Resources=
=Available Tools and Resources=


"SAHMSA"
'''SAFE Project:'''
 
*'''"Have A Safety Plan"''' is a SAFE Project resource that instructs drug users on how to create a safety plan to prevent overdoses.<ref>https://www.safeproject.us/safety-plan/</ref>
● Pregnancy Planning for Women Being Treated for Opioid Use Disorder<ref>https://store.samhsa.gov/sites/default/files/d7/priv/pre_pregnancy_factsheet_041919_508.pdf</ref> 
*See the wiki titled "Expand Motivational Interviewing for Pregnant People" for more detailed information on the evidence-based practice of motivational interviewing and how it inspires change for those who are pregnant and struggle with substance use issues.<ref>https://www.yoursafesolutions.us/wiki/Expand_Motivational_Interviewing_for_Pregnant_People/</ref>
 
● Substance Abuse Treatment: Addressing the Specific Needs of Women A Treatment Improvement Protocol TIP 51<ref>https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf</ref>
 
● Tip 59 Improving Cultural Competence<ref> https://store.samhsa.gov/sites/default/files/d7/priv/sma14-4849.pdf</ref>
 
'''American Society of Addiction Medicine (ASAM)''' is a professional medical society representing over 6,600 physicians, clinicians, and associated professionals in the field of addiction medicine. ASAM is dedicated to increasing access and improving the quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of patients with addiction.<ref> https://www.asam.org/</ref>
 
Helpful guides and downloadable resources: 
 
● Covid 19 Guidance and Resource Update
 
● ASAM Physician Locator 
 
● Understanding Medication in Addiction Treatment for Drug Court Participants
 
'''National Harm Reduction Coalition''' National Harm Reduction Coalition works for the Harm Reduction movement built on a belief in and respect for the rights of people who use drugs. Our strategies include building leadership among people who use drugs and supporting communities in reducing the negative consequences associated with drug use.<ref>https://harmreduction.org/</ref>
 
● Downloadable pdf guide: Pregnancy and Substance Use: A Harm Reduction Guide 
 
'''National Advocates for Pregnant Women (NAPW)''' NAPW works to secure the human and civil rights, health, and welfare of all people, focusing particularly on pregnant and parenting women, and those who are most likely to be targeted for state control and punishment — low-income women, women of color, and drug-using women.<ref>https://www.nationaladvocatesforpregnantwomen.org/issues/pregnancy-and-drug-and-alcohol-use/</ref>
 
'''Birthrights (BRBA)'''


BRBA is a part of a growing global movement to ensure the human rights of people seeking reproductive health services, with special attention to childbirth, are respected and integrated into care provision.<ref>https://birthrightsbar.org/brba-resources</ref>
'''SAMHSA''' provides a fact sheet titled "Pregnancy Planning for Women Being Treated for Opioid Use Disorder." <ref>https://store.samhsa.gov/sites/default/files/d7/priv/pre_pregnancy_factsheet_041919_508.pdf</ref> 


'''American Addictions Centers  (AAC)'''<ref>https://www.apa.org/pi/women/resources/treatment-resources-pregnant-women.pdf</ref>  Treatment centers and resources for pregnant substance-using women and girls 
'''Pregnancy Justice,''' previously known as National Advocates for Pregnant Women (NAPW), works to secure the human and civil rights, health, and welfare of all people, focusing particularly on pregnant and parenting women, and those who are most likely to be targeted for state control and punishment — low-income women, women of color, and drug-using women. <ref>https://www.pregnancyjusticeus.org/</ref>


 '''Peer Support Resources'''
'''Her Way Home''' provides non-judgmental health care and social supports for pregnant and parenting women who have a history of substance use and who may also be affected by mental health issues, violence, and trauma. <ref>https://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf</ref>


    ●  '''Rovery Self-Management And Recovery Training (SMART)''''' is a global community of people and families working together to resolve addictive problems. In our free group discussion meetings, participants learn from one another using a self-empowering approach based on the most current science of recovery. <ref> https://www.smartrecovery.org/</ref>
'''Drug Treatment and Referral Services:'''


    ● '''Moderation Management (MM)''''' provides a non-judgmental, compassionate support community for anyone who wants to change their drinking in a positive way. MM provides support through face-to-face meetings, video and phone meetings, chats, and our private online support communities, the MM Forum, the MM Listserv, and the MM Private Facebook Group. <ref>https://moderation.org/</ref>
*The American Psychological Association''' <ref>https://www.apa.org/pi/women/resources/treatment-resources-pregnant-women.pdf</ref>


    ● '''HAMS''' is a peer-led and free-of-charge support and informational group for anyone who wants to change their drinking habits for the better. The acronym HAMS stands for Harm reduction, Abstinence, and Moderation Support. HAMS Harm Reduction strategies are defined in the 17 elements of HAMS. HAMS offers support via an online forum, a chat room, an email group, a Facebook group, and live meetings.<ref>https://hams.cc/</ref>
*National Partnership for Women and Families: Maternity Care in the United States: We Can – and Must – Do Better <ref>https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf</ref>


    ● "Women for Sobriety Women For Sobriety (WFS)''' is both an organization and a self-help program (also called the New Life Program) for women with Substance Use Disorders. Founded in 1975, it was the first national self-help program for addiction recovery developed to address the unique needs of women. <ref>https://womenforsobriety.org/</ref>
*Maternal, Infant and Early Childhood Home Visiting Program Funding <ref>https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview</ref>


'''Apps'''
*Healthy Safe Children <ref>https://healthysafechildren.org/trending-topics</ref>


    ● '''Be Safe App'''  BeSafe with people who use drugs. During the process, we learned safe(r) use isn’t as simple as calling 911; we needed to prioritize privacy, anonymity and autonomy of our callers. BYOGP has two components: the overall plan and the secret details. The overall game plan tells your supporter when they should worry<ref>https://www.thebraveapp.com/</ref> 
*Obstetric-Fetal Pharmacology Research Centers <ref>https://www.utmb.edu/nichd-oprc/</ref>


    ● '''Never use alone'''   To provide a life-saving point of contact for people who use drugs.<ref>https://neverusealone.com/</ref>
*Alliance for Innovation on Maternal Health (AIM) <ref> https://www.acog.org/practice-management/patient-safety-and-quality/partnerships/alliance-for-innovation-on-maternal-health-aim</ref>


* Recovery Research Institute <ref> https://www.recoveryanswers.org/research-post/ob-gyns-say-opioid-use-disorders-pregnancy-provide-opportunities-life-changing-interventions/</ref>


=Promising Practices=
=Promising Practices=


'''Center for Addiction and Pregnancy (CAP)''' - The Johns Hopkins Bayview Medical Center-CAP offers an innovative approach to help mothers and infants deal with the physical, emotional, and social problems caused by addiction. CAP, an outpatient program with an available overnight housing unit for patients requiring a recovery-oriented domicile, provides a comprehensive, coordinated, and multidisciplinary approach to one of our greatest problems today: drug-dependent mothers and their drug-affected babies.  <ref>https://www.hopkinsmedicine.org/psychiatry/patient_information/bayview/medical_services/substance_abuse/center_addiction_pregnancy.html</ref>
'''Center for Addiction and Pregnancy (CAP),''' at The Johns Hopkins Bayview Medical Center, offers an innovative approach to help mothers and infants deal with the physical, emotional, and social problems caused by addiction. CAP is an outpatient program with an available overnight housing unit for patients requiring a recovery-oriented domicile. It provides a comprehensive, coordinated, and multidisciplinary approach to drug-dependent mothers and their drug-affected babies. <ref>https://www.hopkinsmedicine.org/psychiatry/patient-information/bayview/substance-abuse/comprehensive-addiction-pregnancy</ref>
 
'''Her Way Home''' provides non-judgmental health care and social supports for pregnant and parenting women who have a history of substance use and may also be affected by mental health issues, violence, and trauma.<ref>https://www.islandhealth.ca/learn-about-health/pregnancy-birth-babies/herway-home</ref>
 
'''Project Nurture''' provides prenatal care, inpatient maternity care, and postpartum care for women who struggle with addictions, as well as pediatric care for their infants. Nurture integrates maternity care with substance use treatment and features coordination between the health care and human services sectors. The model provides pregnant women with peer support, clinical care, and links to social services with the goal of safe and healthy parenting in an environment that patients view as respectful and nonjudgmental.  Project Nurture Integrates Care And Services To Improve Outcomes For Opioid-Dependent Mothers And Their Children.<ref>https://www.healthshareoregon.org/health-equity/project-nurture</ref>
 
'''Project Respect'''  (Recovery, Empowerment, Social Services, Prenatal care, Education, Community and Treatment), is a high-risk obstetrical and addiction recovery medical home at Boston Medical Center and Boston University School of Medicine. Project RESPECT provides a unique service of comprehensive obstetric and substance use disorder treatment for pregnant women and their newborns in Massachusetts.<ref>https://www.bmc.org/obstetrics/pregnancy/addiction</ref> 
 
'''Project CARA''' 
 
Project CARA, housed at MAHEC Ob/Gyn Specialists, has supported over 800 women with substance use disorders since 2014. MAHEC first offered integrated substance use treatment services with obstetrical visits in the late 1990s. Our Project CARA team has built on this early foundation to provide comprehensive substance use care using current evidence-based practices.<ref>https://mahec.net/patient-information/ob-gyn-care/project-cara-welcome</ref>
 
'''Drug treatment services linkage and referral'''
 
● National Partnership for Women and Families: Maternity Care in the United States: We Can – and Must – Do Better<ref>https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf</ref>
 
● Maternal, Infant and Early Childhood Home Visiting Program Funding<ref>https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview</ref>
 
● Healthy Safe Children<ref>https://healthysafechildren.org/trending-topics</ref>
 
● Obstetric-Fetal Pharmacology Research Centers<ref>https://www.utmb.edu/nichd-oprc/</ref>


● Alliance for Innovation on Maternal Health (AIM)<ref> https://www.acog.org/practice-management/patient-safety-and-quality/partnerships/alliance-for-innovation-on-maternal-health-aim</ref>
'''Massachusetts.''' Project RESPECT (Recovery, Empowerment, Social Services, Prenatal care, Education, Community and Treatment) is a high-risk obstetrical and addiction recovery medical home at Boston Medical Center and the Boston University School of Medicine. Project RESPECT provides a unique service of comprehensive obstetric and substance use disorder treatment for pregnant women and their newborns. <ref>https://www.bmc.org/obstetrics/pregnancy/addiction</ref> 


● Recovery Research Institute[78]<ref> https://www.recoveryanswers.org/research-post/ob-gyns-say-opioid-use-disorders-pregnancy-provide-opportunities-life-changing-interventions/</ref>
'''New Jersey.''' The Child Protection Substance Abuse Initiative (CPSAI) is a program that targets parents engaged in the Division of Child Protection and Permanence. Although only 9% of the participants completed treatment, CPSAI is examining individual factors associated with successful treatment and  continuing to facilitate treatment engagement for parents being evaluated by the child welfare system. 
<ref>https://www.recoveryanswers.org/research-post/using-the-child-welfare-system-to-engage-parents-with-substance-use-disorders/</ref>


'''North Carolina.''' Project CARA is housed at MAHEC Ob/Gyn Specialists. It has supported over 800 women with substance use disorders since 2014. MAHEC first offered integrated substance use treatment services with obstetrical visits in the late 1990s. The Project CARA team has built on this early foundation to provide comprehensive substance use care using current evidence-based practices. <ref>https://mahec.net/patient-information/ob-gyn-care/project-cara-welcome</ref>


'''Child Welfare System''<ref>https://www.recoveryanswers.org/research-post/using-the-child-welfare-system-to-engage-parents-with-substance-use-disorders/</ref>
=Sources=

Latest revision as of 11:45, 23 October 2024

Introductory Paragraph

The unintended pregnancy rate among women with SUD is approximately 80%. [1] 40% of pregnant women who drank alcohol during pregnancy reported co-using other substances, including tobacco, cannabis, cocaine, and heroin. [2] Recently, the number of pregnant people using opioids has rapidly increased, in keeping with the increase observed in the general population. [3]

Pregnant women with substance abuse disorder face multiple challenges and obstacles. Lack of access to medical care, ineffective collaboration among social service systems, stigma, and fear of punishment further compound their challenges. [4] Current research suggests that a collaborative, integrated approach to managing SUD in pregnant women provides the best chance to counteract obstacles and minimize or eliminate substance use. A wraparound approach is backed up by evidential research and provides comprehensive services by social, family, criminal justice, social service, medical, and mental health professionals. [5]

Key Information

Studies suggest that pregnancy provides a unique opportunity for women to embrace recovery options. [6] However, there are significant barriers for pregnant women seeking treatment. Quitting substance use, especially when an individual has SUD, can be difficult. Pregnant women might find quitting complicated by the fear that asking for help could lead to potential social and even legal consequences. Reporting requirements and administrative policies of service agencies may lead to mandatory involvement with child protective services, loss of child custody, or other legal consequences. Limited child care options may deter mothers from seeking treatment. Likewise, women in treatment may need help with handling the burdens of work, home, and other family responsibilities. [7]

Stigma is a large barrier to treatment and recovery. The societal stigma toward women who abuse substances tends to be greater than that toward men, and the stigma amplifies significantly for pregnant drug users. Women's ascribed role and the expectations placed on them influences societal perceptions and reactions toward women with SUDs.  Women who use alcohol and illicit drugs regularly feel shame and guilt, and they also often suffer from low levels of self-esteem and self-efficacy. [8] Women with substance use issues often have high levels of comorbid mental health disorders. In 2019, there were 34.3M adult women who had a mental illness and/or SUD. [9]

Substance use disorders can manifest differently in women than in men. [10]  In the past, women were not included in most clinical research. [11] Women may experience varying levels of discrimination in both healthcare and criminal justice systems that affect their substance use and may affect their recovery. Pregnant women using substances, particularly women of color and women in lower socioeconomic brackets, deal with increased surveillance and may face consequences, such as arrest and child removal. [12] Some women use substances to cope with these stresses of discrimination. Women dealing with SUD who struggle financially may have to deal with low-income unstable housing, lack of access to transportation and medical care, as well as poor nutrition. Less access to health care, and difficulty in funding treatment due to a lack of health insurance, can result in later referral for substance use treatment. Since residential treatment facilities are limited, pregnant women have reported several barriers to treatment and healthcare, including insufficient treatment options and difficulty locating and entering treatment.

Rural vs. urban geography also plays a role in substance use during pregnancy. Rates of substance use during pregnancy are typically higher in rural communities than in urban ones. However, most of the research on the prevalence, prevention, and treatment of substance abuse during pregnancy has focused on urban areas. Rural women are 9% more likely than urban women to face severe maternal morbidity mortality. They are also 59% more likely than urban women to have an SUD diagnosis at the time of birth. [13] More opioids are prescribed in rural communities than in urban ones. This has led to prescription opioids being the most common type of drug abused by rural pregnant women. Noteworthy characteristics that make rural living more challenging are the lack of economic opportunity, transportation, and technological limitations.[14]  Rural communities often have limited resources for prevention and treatment and lack the resources needed to provide services to parents dealing with substance use. 

Best Practices in Treatment and Therapy

Despite the fact pregnancy motivates some women to begin treatment, several studies indicate that pregnant women do not remain in treatment as long. Researchers have also linked retention to the stage of pregnancy and if the individual has co-occurring psychiatric disorders. Transitional programs and aftercare services can offer educational programs, vocational training, relapse prevention programs, childcare services, and housing options for women and their newborns to support a sustained recovery as well.

Offering holistic, integrated support for pregnant women with substance use concerns is an emerging best practice to support pregnant women with substance use concerns. These programs can be provided through various models including outreach, multi-service co-located agencies, or a network of community-based services. Research in this area has shown that integrated-support models can improve maternal and fetal outcomes and successfully support women to reduce alcohol use in pregnancy. [15] Best practices should take the following approaches into consideration:

  • Evidence-Based Practice (EBP) is increasingly becoming more popular in many health care disciplines. One of its main characteristics is its focus on the interaction between hard scientific evidence, clinical expertise, and patient needs and choices. There are many different EBPs that are effective, including traditional programs (which center around the pregnancy period), comprehensive treatment, and home visitation. Contemporary approaches include newer methods such as motivational interviewing and contingency management. They concentrate on the mother-infant relationship, collaboration among social service systems, including child protective services and family treatment drug court, and pharmacotherapy. [16]
  • Mental Health. Mental health care is an integral aspect of addiction treatment. There is a need to increase identification of co-occurring substance use and mental disorders, such as mood, anxiety, and eating disorders. Integrated treatment for co-occurring disorders differs from traditional approaches. For example, this would mean that there are assessments provided that screen for both mental illness and substance use. [17] Behavioral therapies help to discover what may have prompted initial drug abuse, and they can teach participants new ways of thinking which will promote future healthy behaviors and habits. Another benefit for women is that counseling can help teach them how to manage childbirth and the pain and medical concerns which might occur during pregnancy and in childbirth. Creating a plan for these potential difficulties in combination with addiction treatment can be helpful. For example, after childbirth, pain medications may need to be monitored or switched for non-habit-forming ones. Such relational approaches take into consideration positive and negative familial and partner influences and relationships, and promote a safe and caring treatment environment.
  • Trauma-Informed Approaches include screening and assessing women for trauma history. Many women with SUDs have experienced trauma which was perpetrated by someone close to them. This contributes to these women’s treatment needs.[18]
  • Integrated Treatment and Coordinated Care works with the whole person, including their family and parenting responsibilities. Integrated treatment programs include on-site pregnancy services, parenting services, or child-related services with addiction services. These were developed to break the intergenerational cycle of addiction, potential child maltreatment, and poor outcomes for children. Collaborative care models offer a multidisciplinary approach to clinical care. Connection to psychosocial support services can improve the chances of treatment success for women with substance use disorders. Additionally, women can benefit from behavioral health referrals, connection with peer and community supports, services for addressing social determinants of health, such as housing or food insecurity.
  • Medication-Assisted Treatment (MAT) is clinically driven and focuses on individualized patient care. Medications used to treat opioid use disorders include Methadone and Buprenorphine. Both of these medications stop and prevent opioid withdrawal and reduce opioid cravings, allowing the person to focus on other aspects of recovery. Research shows that a combination of medication and behavioral therapies is most successful for substance use disorder treatment. MAT provides a whole-patient approach and is a recommended best practice for the care of pregnant women with opioid use disorders. [19] In considering the appropriate medications for pregnant women, Buprenorphine is safer than Naltrexone or Methadone to ensure better outcomes for newborn children.
  • Group-Based Treatment & Peer Support. Comprehensive care includes individual or group therapy sessions. Group sessions may take place with other pregnant women and focus on specific issues for this population. Women can work together during group skills sessions to learn parenting techniques and healthy stress coping mechanisms. This serves to provide recognition of women’s cultural expectations and to help improve engagement and retention in treatment programs. In a study using online health communities, 58.5% of the pregnant women in the study expressed negative emotions, of whom only 10.2% wanted to address their emotional needs with the help of the online community. [20] Five themes of self-management support needs were identified for online communities
    • information regarding the potential adverse effects of gestational opioid use
    • protocols for self-managed withdrawal
    • pain management safety during pregnancy
    • hospital policies and legal procedures related to child protection
    • strategies for navigating offline support systems.

Relevant Research

  • National Institute on Drug Abuse (NIDA) has published a research report on substance use by women. It includes sections associated with breastfeeding, as well as sex and gender differences in substance use. [21] 
  • CDC Publishes MMWR (The Morbidity and Mortality Weekly Report). One of these is titled "Substance Use During Pregnancy Alcohol Use and Co-Use of Other Substances Among Pregnant Females Aged 12–44 Years — the United States, 2015–2018." It breaks down some of the findings in the National Survey on Drug Use and Health (NSDUH). For example, 38.2% of pregnant respondents who reported current drinking also reported current use of one or more other substances -- primarily tobacco and marijuana.
  • Public Health Agency of Canada funded a national evaluation of multi-service programs that reach pregnant women at risk. This report was completed by the Nota Bene Consulting Group in partnership with the Centre of Excellence for Women’s Health. The evaluation was designed around a a theory of change developed that was collaboratively developed by organizations which were guided by a similar set of theoretical approaches, including being trauma-informed, relationship-based, women-centered, culturally-grounded, and harm-reducing. [22]
  • This article is titled "Concurrent Opioid and Alcohol Use Among Women Who Become Pregnant: Historical, Current, and Future Perspectives." It highlights the historical context of opioid and alcohol use during pregnancy, summarizes the current knowledge of opioids and alcohol use during pregnancy, and details future directions in how health care providers could help. [23]
  • This article is titled "Pregnant women and substance use: fear, stigma, and barriers to care." The research was based on interviews with 30 recently-pregnant women who had used alcohol or other drugs during their pregnancies. It highlights their strategies for managing their risk of detection by health or criminal justice authorities. It also documents multiple barriers to treatment and healthcare. The findings suggest that policies that substance-using women find threatening discourage them from seeking comprehensive medical treatment during their pregnancies. [24]
  • Healthcare Cost and Utilization Project (H-CUP) generated a brief that presents statistics from the National Inpatient Sample (NIS) on delivery-related inpatient stays involving SUDs, for select types of substances (opioids, cocaine, and other stimulants), and for both urban and rural areas. [25]
  • Parenting Outcomes. This article provides a literature review on parenting skills and parenting needs of women with substance use issues. [26]
  • This study documents the increase in overdose deaths during pregnancy. [27] 

Impactful Federal, State, and Local Policies

Any advances in public policy and public health strategies support the delivery of evidence-based care for pregnant women. A major policy need is in enhancing the training of professionals to be more attuned to the needs of pregnant women. Advocacy for comprehensive care and professional services would benefit women.

  • The Comprehensive Addiction and Recovery Act of 2016 (CARA) established a coordinated strategy through enhanced grant programs which expand prevention and education efforts while also promoting treatment and recovery. Section 501 (Improving Treatment for Pregnant and Postpartum Women) reauthorizes the Residential Treatment Program for Pregnant and Postpartum Women. It also authorizes the creation of grants within CSAT to enhance a state's services for women who are pregnant and postpartum while suffering from substance use disorder.
  • SUPPORT Act. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act is federal legislation which addresses tighter oversight of opioid production and distribution. It imposes additional reporting and safeguards to address fraud, and it limits coverage of prescription opioids, while expanding coverage of and access to opioid addiction treatment services. The bill also authorizes a number of programs that seek to expand consumer education on opioid use and train additional providers to treat individuals with opioid use disorders. [28] Section 503 of the SUPPORT Act (Infant Plan of Safe Care) requires HHS to produce information concerning best practices on developing plans for the safe care of infants born with substance use disorders or showing withdrawal symptoms. This section also requires that state plans address the health and SUD treatment needs of the infant. [29]
  • State Policy. Although federal public policy is advancing efforts to minimize substance use during pregnancy, there are many challenges with inconsistent efforts in state legislatures. This is driven by variations in geography, because federal grants give states the power to decide how to implement key elements of federal policies. [30]
    • One area that is gaining public support is in the domain of child welfare and prenatal substance use. Several states have expanded their civil child-welfare requirements to include prenatal substance use, so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect. Further, some states, under the rubric of protecting the fetus, authorize civil commitment (such as forced admission to an inpatient treatment program) of pregnant women who use drugs. These policies sometimes also apply to alcohol use or other behaviors. A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child-welfare proceedings. And in order to receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance use. [31]
    • The National Academy for State Health Policy has an overview of state options for promoting recovery among pregnant and parenting women. [32]

Available Tools and Resources

SAFE Project:

  • "Have A Safety Plan" is a SAFE Project resource that instructs drug users on how to create a safety plan to prevent overdoses.[33]
  • See the wiki titled "Expand Motivational Interviewing for Pregnant People" for more detailed information on the evidence-based practice of motivational interviewing and how it inspires change for those who are pregnant and struggle with substance use issues.[34]

SAMHSA provides a fact sheet titled "Pregnancy Planning for Women Being Treated for Opioid Use Disorder." [35] 

Pregnancy Justice, previously known as National Advocates for Pregnant Women (NAPW), works to secure the human and civil rights, health, and welfare of all people, focusing particularly on pregnant and parenting women, and those who are most likely to be targeted for state control and punishment — low-income women, women of color, and drug-using women. [36]

Her Way Home provides non-judgmental health care and social supports for pregnant and parenting women who have a history of substance use and who may also be affected by mental health issues, violence, and trauma. [37]

Drug Treatment and Referral Services:

  • The American Psychological Association [38]
  • National Partnership for Women and Families: Maternity Care in the United States: We Can – and Must – Do Better [39]
  • Maternal, Infant and Early Childhood Home Visiting Program Funding [40]
  • Healthy Safe Children [41]
  • Obstetric-Fetal Pharmacology Research Centers [42]
  • Alliance for Innovation on Maternal Health (AIM) [43]
  • Recovery Research Institute [44]

Promising Practices

Center for Addiction and Pregnancy (CAP), at The Johns Hopkins Bayview Medical Center, offers an innovative approach to help mothers and infants deal with the physical, emotional, and social problems caused by addiction. CAP is an outpatient program with an available overnight housing unit for patients requiring a recovery-oriented domicile. It provides a comprehensive, coordinated, and multidisciplinary approach to drug-dependent mothers and their drug-affected babies. [45]

Massachusetts. Project RESPECT (Recovery, Empowerment, Social Services, Prenatal care, Education, Community and Treatment) is a high-risk obstetrical and addiction recovery medical home at Boston Medical Center and the Boston University School of Medicine. Project RESPECT provides a unique service of comprehensive obstetric and substance use disorder treatment for pregnant women and their newborns. [46] 

New Jersey. The Child Protection Substance Abuse Initiative (CPSAI) is a program that targets parents engaged in the Division of Child Protection and Permanence. Although only 9% of the participants completed treatment, CPSAI is examining individual factors associated with successful treatment and continuing to facilitate treatment engagement for parents being evaluated by the child welfare system. [47]

North Carolina. Project CARA is housed at MAHEC Ob/Gyn Specialists. It has supported over 800 women with substance use disorders since 2014. MAHEC first offered integrated substance use treatment services with obstetrical visits in the late 1990s. The Project CARA team has built on this early foundation to provide comprehensive substance use care using current evidence-based practices. [48]

Sources

  1. ↑ https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy#:~:text=Unintended%20pregnancy%20rates%20among%20women,than%20in%20the%20general%20population.
  2. ↑ England LJ, Bennett C, Denny CH, et al. (2020) Alcohol Use and Co-Use of Other Substances Among Pregnant Females Aged 12-44 Years - United States, 2015-2018. MMWR Morbidity and Mortality Weekly Report 69(31):1009-1014.
  3. ↑ https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy
  4. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf
  5. ↑ https://canfasd.ca/wp-content/uploads/publications/FINAL-CCE_Report_Mar-8-for-web.pdf
  6. ↑ https://www.cdc.gov/pregnancy/polysubstance-use-in-pregnancy.html
  7. ↑ https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  8. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  9. ↑ https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health
  10. ↑ https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women
  11. ↑ https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/importance-including-women-in-research
  12. ↑ https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23
  13. ↑ https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf
  14. ↑ https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  15. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf
  16. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC226388/
  17. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf
  18. ↑ https://www.sciencedirect.com/science/article/abs/pii/S0091743520303273
  19. ↑ https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy
  20. ↑ https://onlinelibrary.wiley.com/doi/epdf/10.1111/hsc.13335
  21. ↑ https://nida.nih.gov/publications/research-reports/substance-use-in-women/sex-gender-differences-in-substance-use
  22. ↑ Rutman, D., Hubberstey, C., Van Bibber, M., Poole, N., & Schmidt, R.A. (2021). Stories and Outcomes of Wraparound Programs Reaching Pregnant and Parenting Women at Risk. Victoria, BC: Nota Bene Consulting Group. retrieved at https://canfasd.ca/wp-content/uploads/publications/FINAL-CCE_Report_Mar-8-for-web.pdf
  23. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6545650/
  24. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  25. ↑ Obstetric Delivery Inpatient Stays Involving Substance Use Disorders and Related Clinical Outcomes, 2016. retrieved at https://hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  26. ↑ Niccols, A., Milligan, K., Sword, W. et al. Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes. Harm Reduct J 9, 14 (2012). retrieved at https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-9-14
  27. ↑ https://www.statnews.com/2023/11/22/opioid-crisis-hits-maternal-health-pregnancy-overdoses-rise/
  28. ↑ https://fas.org/sgp/crs/misc/R45405.pdf
  29. ↑ https://www.acf.hhs.gov/sites/default/files/documents/cb/im1605.pdf
  30. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  31. ↑ https://fas.org/sgp/crs/misc/R45405.pdf
  32. ↑ https://www.nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf
  33. ↑ https://www.safeproject.us/safety-plan/
  34. ↑ https://www.yoursafesolutions.us/wiki/Expand_Motivational_Interviewing_for_Pregnant_People/
  35. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/pre_pregnancy_factsheet_041919_508.pdf
  36. ↑ https://www.pregnancyjusticeus.org/
  37. ↑ https://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf
  38. ↑ https://www.apa.org/pi/women/resources/treatment-resources-pregnant-women.pdf
  39. ↑ https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf
  40. ↑ https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview
  41. ↑ https://healthysafechildren.org/trending-topics
  42. ↑ https://www.utmb.edu/nichd-oprc/
  43. ↑ https://www.acog.org/practice-management/patient-safety-and-quality/partnerships/alliance-for-innovation-on-maternal-health-aim
  44. ↑ https://www.recoveryanswers.org/research-post/ob-gyns-say-opioid-use-disorders-pregnancy-provide-opportunities-life-changing-interventions/
  45. ↑ https://www.hopkinsmedicine.org/psychiatry/patient-information/bayview/substance-abuse/comprehensive-addiction-pregnancy
  46. ↑ https://www.bmc.org/obstetrics/pregnancy/addiction
  47. ↑ https://www.recoveryanswers.org/research-post/using-the-child-welfare-system-to-engage-parents-with-substance-use-disorders/
  48. ↑ https://mahec.net/patient-information/ob-gyn-care/project-cara-welcome
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