Difference between revisions of "Minimize Substance Use During Pregnancy"

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=Introductory Paragraph=
=Introductory Paragraph=


The unintended pregnancy rate among pregnant people 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 people 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>
Drug, alcohol, and even tobacco use during pregnancy have lasting and sometimes detrimental effects on mothers and unborn babies. Prenatal use of substances cause the infant to be born with very serious health problems and can lead to stillbirths. In some cases, it can cause infant withdrawal symptoms, or dependency. Alcohol use during pregnancy can lead to what is known as Fetal Alcohol Syndrome (FAS), characterized by low birth weight, cognitive deficits, increased risk of birth defects, and behavioral problems later in life.  


Pregnant people with substance use 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 people 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>
The unintended pregnancy rate among pregnant people 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 people 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 people with substance use 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>


=Key Information=
=Key Information=

Revision as of 13:58, 6 December 2024

Introductory Paragraph

Drug, alcohol, and even tobacco use during pregnancy have lasting and sometimes detrimental effects on mothers and unborn babies. Prenatal use of substances cause the infant to be born with very serious health problems and can lead to stillbirths. In some cases, it can cause infant withdrawal symptoms, or dependency. Alcohol use during pregnancy can lead to what is known as Fetal Alcohol Syndrome (FAS), characterized by low birth weight, cognitive deficits, increased risk of birth defects, and behavioral problems later in life.

The unintended pregnancy rate among pregnant people with SUD is approximately 80%. [1] 40% of pregnant people 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 people with substance use 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]

Key Information

Studies suggest that pregnant people have a unique opportunity to embrace recovery options. [5] However, there are significant barriers for pregnant people seeking treatment. Quitting substance use, especially when an individual has SUD, can be difficult, and they 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, pregnant people in treatment may need help with handling the burdens of work, home, and other family responsibilities. [6]

Stigma is a large barrier to treatment and recovery. The societal stigma toward women who use 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. [7] 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. [8]

Substance use disorders can manifest differently in women than in men. [9]  In the past, women were not included in most clinical research. [10] 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 people using substances, particularly people of color and those in lower socioeconomic brackets, deal with increased surveillance and may face consequences, such as arrest and child removal. [11] Some people use substances to cope with these stresses of discrimination. People 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 people 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. [12] 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 people. Noteworthy characteristics that make rural living more challenging are the lack of economic opportunity, transportation, and technological limitations.[13]  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 people to begin treatment, several studies indicate that pregnant people 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 people and their newborns to support a sustained recovery as well.

Offering holistic, integrated support for pregnant people with substance use concerns is an emerging best practice to support pregnant people 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 people to reduce alcohol use in pregnancy. [14] 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. [15]
  • 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. [16] 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 pregnant people 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 people for trauma history. Many pregnant people with SUDs have experienced trauma which was perpetrated by someone close to them. This contributes to their treatment needs.[17]
  • 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 substance use services. These were developed to break the intergenerational cycle of substance use, 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 pregnant people with substance use disorders. Additionally, they 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 people with opioid use disorders. [18] In considering the appropriate medications for pregnant people, 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 people and focus on specific issues for this population. People can work together during group skills sessions to learn parenting techniques and healthy stress coping mechanisms. This serves to provide recognition of cultural expectations and to help improve engagement and retention in treatment programs. In a study using online health communities, 58.5% of the pregnant people in the study expressed negative emotions, of whom only 10.2% wanted to address their emotional needs with the help of the online community. [19] 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. [20] 
  • 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 people 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. [21]
  • 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. [22]
  • 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 people 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 people find threatening discourage them from seeking comprehensive medical treatment during their pregnancies. [23]
  • 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. [24]
  • Parenting Outcomes. This article provides a literature review on parenting skills and parenting needs of people with substance use issues. [25]
  • This study documents the increase in overdose deaths during pregnancy. [26] 

Impactful Federal, State, and Local Policies

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

  • 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 people 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. [27] 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. [28]
  • 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. [29]
    • 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 people 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. [30]
    • The National Academy for State Health Policy has an overview of state options for promoting recovery among pregnant and parenting people. [31]

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.[32]
  • 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.[33]

SAMHSA provides a fact sheet titled "Pregnancy Planning for Women Being Treated for Opioid Use Disorder." [34] 

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 people, and those who are most likely to be targeted for state control and punishment because of gender, color, income, or and drug use. [35]

Her Way Home provides non-judgmental health care and social supports for pregnant and parenting people who have a history of substance use and who may also be affected by mental health issues, violence, and trauma. [36]

Drug Treatment and Referral Services:

  • The American Psychological Association [37]
  • National Partnership for Women and Families: Maternity Care in the United States: We Can – and Must – Do Better [38]
  • Maternal, Infant and Early Childhood Home Visiting Program Funding [39]
  • Healthy Safe Children [40]
  • Obstetric-Fetal Pharmacology Research Centers [41]
  • Alliance for Innovation on Maternal Health (AIM) [42]
  • Recovery Research Institute [43]

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. [44]

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 people and their newborns. [45] 

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. [46]

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. [47]

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://www.cdc.gov/pregnancy/polysubstance-use-in-pregnancy.html
  6. ↑ https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  7. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  8. ↑ https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health
  9. ↑ https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women
  10. ↑ https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/importance-including-women-in-research
  11. ↑ https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23
  12. ↑ https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf
  13. ↑ https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  14. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf
  15. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC226388/
  16. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf
  17. ↑ https://www.sciencedirect.com/science/article/abs/pii/S0091743520303273
  18. ↑ https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy
  19. ↑ https://onlinelibrary.wiley.com/doi/epdf/10.1111/hsc.13335
  20. ↑ https://nida.nih.gov/publications/research-reports/substance-use-in-women/sex-gender-differences-in-substance-use
  21. ↑ 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
  22. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6545650/
  23. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  24. ↑ 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
  25. ↑ 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
  26. ↑ https://www.statnews.com/2023/11/22/opioid-crisis-hits-maternal-health-pregnancy-overdoses-rise/
  27. ↑ https://fas.org/sgp/crs/misc/R45405.pdf
  28. ↑ https://www.acf.hhs.gov/sites/default/files/documents/cb/im1605.pdf
  29. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  30. ↑ https://fas.org/sgp/crs/misc/R45405.pdf
  31. ↑ https://www.nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf
  32. ↑ https://www.safeproject.us/safety-plan/
  33. ↑ https://www.yoursafesolutions.us/wiki/Expand_Motivational_Interviewing_for_Pregnant_People/
  34. ↑ https://store.samhsa.gov/sites/default/files/d7/priv/pre_pregnancy_factsheet_041919_508.pdf
  35. ↑ https://www.pregnancyjusticeus.org/
  36. ↑ https://www.samhsa.gov/sites/default/files/family_treatment_paper508v.pdf
  37. ↑ https://www.apa.org/pi/women/resources/treatment-resources-pregnant-women.pdf
  38. ↑ https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf
  39. ↑ https://mchb.hrsa.gov/maternal-child-health-initiatives/home-visiting-overview
  40. ↑ https://healthysafechildren.org/trending-topics
  41. ↑ https://www.utmb.edu/nichd-oprc/
  42. ↑ https://www.acog.org/practice-management/patient-safety-and-quality/partnerships/alliance-for-innovation-on-maternal-health-aim
  43. ↑ https://www.recoveryanswers.org/research-post/ob-gyns-say-opioid-use-disorders-pregnancy-provide-opportunities-life-changing-interventions/
  44. ↑ https://www.hopkinsmedicine.org/psychiatry/patient-information/bayview/substance-abuse/comprehensive-addiction-pregnancy
  45. ↑ https://www.bmc.org/obstetrics/pregnancy/addiction
  46. ↑ https://www.recoveryanswers.org/research-post/using-the-child-welfare-system-to-engage-parents-with-substance-use-disorders/
  47. ↑ https://mahec.net/patient-information/ob-gyn-care/project-cara-welcome
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