Expand Perinatal Treatment and Support for People with SUDs

Introductory Paragraph

Most doctors recommend that pregnant women undergo a long-term treatment plan called drug-assisted stabilization using methadone, also known as harm reduction therapy. This treatment remains sustainable for a woman after she has given birth, because it's covered under Medicaid, so new mothers can still access the treatment, even after their six-week Medicaid-provided postnatal care is done. The treatment also doesn't subject a woman's mind and body through the stress of full withdrawal, allowing her to focus on caring for herself and her baby.

It is extremely important for infants to be well-nourished and well-cared for in order for the baby to thrive. While this is critically important to both mother and baby, making healthy choices isn’t so clear-cut for some pregnant women. Those who become pregnant while facing a substance abuse disorder face great challenges in caring for their body and the baby they’re carrying. Substance abuse at any time, but especially during pregnancy, is a highly stigmatized issue and one that has only gotten worse over the decades . Substance abuse during pregnancy can have detrimental health effects on the baby and the mother, but the stigma may prevent the mother from seeking prenatal and substance abuse treatment .

Key Information

Statistical Prevalence

A recent study conducted by the CDC shows the prevalence of alcohol and substance abuse amongst pregnant women is a growing problem, with 10% using alcohol and 4.5% reporting binge drinking during pregnancy . Of these women, 40% also reported using one or more substances, the highest of which is tobacco, and 5% reported use of illicit drugs., . The majority of use occurs during the first trimester, a critical and vulnerable phase for the baby. Use does significantly decline in the first and second trimesters (1.4%), making intervention during the first trimester a critical time frame to minimize potential harm to both baby and mother . The most common substances used during pregnancy reported by the CDC include opioids, alcohol, marijuana, and tobacco, each carrying its own risks .

Risk Factors

While substance abuse occurs within every demographic, there are certain risk factors that create vulnerability for use during pregnancy. It is important to note that demographic data collection is scarce, should be taken as a “minimum” amount, and is highly biased based on policies that disproportionately threaten women of color, low socioeconomic status, and of young ages. Most data available is taken from enacted policies, discussed below, that are meant to deter prenatal substance use but instead promote maternal prosecution ,. Cook, et al. has the most comprehensive, non-prosecutorial risk factor data indicating the following categories of being high risk to use substances while pregnant :

• ages 15-24
• education level high school or below
• at or below the poverty level
• concurrent psychiatric disorders (mood/anxiety & eating disorders most common)
• history of trauma (child- or adulthood sexual/domestic/interpersonal abuse)
• polysubstance use
• family history of substance use
• women of color and women on public health insurance had higher rates of prenatal substance use

Impacts

Prenatal health and habits are vital to the healthy development of the baby and the maintained health of the mother, and alcohol and drug use during pregnancy have many negative effects on both. Much of the research focuses on the physical effects of prenatal substance use on the fetus, but there are important impacts on the mother that must also be considered. Cook, et al. lists the potential negative consequences of substance use for mothers as psychosocial decline (stress, reduced social support, partner violence, isolation, financial/legal troubles, self-harm), physical issues (vascular complications, infections, bodily trauma), and reduced frequency of prenatal care . Impacts on the fetus are vast and vary by the specific substance it is subjected to. Consuming alcohol, however minor the amount increases the baby’s risk of Fetal Alcohol Syndrome, preterm birth, teratogenicity, neurodevelopmental disorders, miscarriage, and stillbirth . Fetal Alcohol Syndrome impacts the baby’s physical growth and appearance, along with its emotional, behavioral, and cognitive health . Exposure to illicit drugs may have the following consequences  :

• low birth weight and growth restriction
• preterm birth
• miscarriage
• stillbirth
• sudden infant death syndrome
• exaggerated startles and diminished crying response
• neonatal withdrawal or abstinence symptoms
• transient central and automatic nervous system symptoms
• congenital heart malformations
• abnormal physical developments

Postnatal impacts on the mother and baby extend beyond physio-social consequences. Mothers who use substances throughout pregnancy are at an increased risk of having the child removed from their care after birth . These child removals have been shown to lead to an increase in maternal drudge use and mental health complications, especially in Black and Indigenous women . Those who do retain custody of their infants and continue substance abuse are at risk of atypical maternal-infant bonding and attachment, which is linked to adverse child outcomes .

Barriers

There are substantial barriers to prenatal substance abuse treatment that have lasting consequences for the mother and baby. Since 2000, the number of states that criminalize prenatal substance use has more than doubled, with 25 states plus D.C. classifying it as child abuse, and the same amount has medical reporting requirements , . These laws had the intention of deterring prenatal substance use, but have instead had severe adverse effects. With so few states offering pre-or postnatal drug treatment programs as an alternative to prosecution due to liability issues, many mothers have instead reported self-isolation and avoidance of both prenatal medical appointments and substance use treatments ,. Substance-using pregnant women who, “do receive prenatal care experience more positive birth outcomes and have greater opportunities for other health-promoting interventions than women who do not receive care,” . However, the majority of pregnant substance-using women who receive appropriate care and intervention are older, white women with private health insurance that are less likely to be reported, creating significant disparities. Women who use substances while pregnant have a great fear and mistrust of medical and treatment providers because of the risk of reporting, prosecution, and infant displacement. Those who are marginalized and do seek out treatment have little success, as their honesty often leads to criminal reporting or they are unable to find available and affordable treatment programs . This lack of medical care and intervention of untreated prenatal substance use can lead to a greater likelihood of fetal substance dependency and ensuing fetal medical complications.

Relevant Research

See section: "Key Information".

Impactful Federal, State, and Local Policies

As noted above, half of the states plus D.C. have punitive policies that negatively impact mother and baby. Below is a link for state-by-state policies and another for their impacts. Kentucky and Arizona, while having punitive laws, have also implemented an alternative to immediate criminal punishment, giving mothers 90 days to enroll in a treatment program while also giving them priority access to these programs , . This shows promise in preventing continued drug use and infant removal from care. Texas offers prenatal and postnatal health support to women with substance use disorder and access to residential treatment centers for both mothers and their new infants . Montana has allowed women to seek treatment to avoid prosecution, as long as they maintain active treatment, but it isn’t clear if they provide available pathways . The Children’s Bureau enacted the Title IV-E Prevention Program that provides funding for many issues, including prenatal substance use intervention, however, very few states are implementing its use .

Available Tools & Resources

There are gaps in demographic reporting of prenatal substance abuse and any reports should be considered a minimum and non-comprehensive reflection. As stated above, Cook, et al. has the most comprehensive demographic data with available references to review (6). Drug Policy Facts.org has a literature review covering topics from prevalence and disparities to impacts and policy implications, highlighting the main findings of each and including quick links . Below are some tools that providers may find helpful in aiding women with prenatal substance use:

https://www.nnepqin.org/a-toolkit-for-the-perinatal-care-of-women-with-opioid-use-disorders/

• The Northern New England Perinatal Quality Improvement Network has put out a comprehensive toolkit that includes: best practices recommendations, treatment facilitation, screening tools, specific substance information, breastfeeding support, mental health access, social needs assessment, and implementation tools.

https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy

• This site has the most current state-by-state policies relating to prenatal substance use,

including those that qualify it as child abuse, require reporting, has criminal commitment requirements, etc.

A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders: https://ncsacw.acf.hhs.gov/files/Collaborative_Approach_508.pdf

• This pdf has a comprehensive medical and child welfare collaborative approach to caring for

women with prenatal substance use during pregnancy and postnatal.

https://www.tnjustice.org/punitive-policies-pregnant-women/

• This website has a great, comprehensive fact sheet for providers that covers the scope of the problem, punitive policies, and their impacts.

Promising Practices

Perinatal Addiction Treatment Program

Perinatal Addiction Treatment Program- Dartmouth Hitchcock Medical Center
Program Highlights

• Integrated Care Model: Includes maternity care, substance use treatment, behavioral health/psychiatry, pediatrics
• Participant Drive Design
• Private setting 10 minutes from hospital campus
• Tablet-based SBIRT screening
• 18 week parenting class

Outcome Successes

• Perinatal: Average gestational age is over 38 weeks; Average birthweight in the normal range
• Decreased NAS treatment rate
• Decreased neonatal LOS
• Effective use of technology for screening
• 2/3 of participants remain in treatment postpartum

Centering Pregnancy

While not specifically focusing on issues of addiction or substance misuse among pregnant women, the Centering Pregnancy approach has the potential to cost-effectively improve prenatal and perinatal care among women who may be using or be addicted to opioids or other substances. It is a group approach to prenatal and perinatal care. 

Additional Resources

https://www.nursingcenter.com/ce_articleprint?an=00005237-201407000-00006

• This resource identifies contingency management, motivational interviewing, and cognitive-behavioral therapies as the three dominating approaches to antenatal substance use. It notes that there is little research done on perinatal psychological interventions, but suggests that these practices may have similar benefits in perinatal treatment for substance use. It gives in-depth descriptions and benefits of each modality.

https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/what-treatment-available-pregnant-mothers-their-babies

• For pregnant women with opioid use, methadone and buprenorphine is the standard of

pharmacotherapy. This article provides support for use of pharmacotherapy as an effective treatment and lists its benefits.

https://drugabuse.com/treatment/therapy/group/

• This site addresses the benefits of group therapy when led by a trained professional, including,

but not limited to recovery education, social support, and motivation in recovery, observe various issues and methods within recovery, peer empowerment, and feedback learned healthy coping skills, and build a sense of optimism, self, and connectedness.