Expand Perinatal Treatment and Support for People with SUDs

Introductory Paragraph

It is extremely important for infants to be well-nourished and well-cared for in so that 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 use disorder face great challenges in caring for their body and the baby they are carrying. Substance use at any time, but especially during pregnancy, is a highly stigmatized issue which has worsened over the decades. Substance use during pregnancy can have detrimental health effects on the baby and the mother, but the stigma may prevent the mother from seeking prenatal care or substance use treatment. .

Most doctors recommend that pregnant women with a substance use disorder undergo a long-term treatment plan called drug-assisted stabilization using Methadone. This harm reduction therapy remains financially sustainable for a woman after she has given birth, because it is covered under Medicaid. So new mothers can still access the treatment, even after their six-week Medicaid-provided postnatal care is done. In addition, the treatment does not subject a woman's mind and body to the stress of full withdrawal, allowing her to focus on caring for herself and her baby.

Key Information

Statistical Prevalence

The CDC reports that the most commonly substances used during pregnancy include tobacco, alcohol, marijuana, and opioids, each carrying its own risks. The prevalence of alcohol and substance use 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 vulnerable phase for the baby, making intervention during the first trimester a critical time frame to minimize potential harm.

Risk Factors

While substance abuse occurs within every demographic, there are certain factors which create higher risk of 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 young ages and women of color and low socioeconomic status. Most available data are taken from enacted policies, discussed below, which are meant to deter prenatal substance use but instead promote maternal prosecution. The following reflects non-prosecutorial risk factor data indicating 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 (childhood or adulthood sexual/domestic/interpersonal abuse)
• poly-substance use
• family history of substance use
• women of color and women on public health insurance had higher rates of prenatal substance use

Impacts

Prenatal habits are vital to the healthy development of the baby and the maintained health of the mother. Alcohol and drug use during pregnancy has 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. One list of the potential negative consequences of substance use for mothers includes:

• 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. 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 drug use and mental health complications, especially in Black and Indigenous women. Those who do retain custody of their infants and continue substance use are at risk of atypical maternal-infant bonding and attachment, which is linked to adverse child outcomes.

Barriers

There is a lot of debate among providers of various professions as to whether substance use screening should be universal in prenatal care. Early detection and treatment is critical to protecting the health of both the baby and the mother. However, the fact that many states make prenatal substance use a punitive offense can cause women to not seek prenatal care, which is detrimental in its own right. 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 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. It is vital to advocate and lobby for states to adopt impactful treatment policy, while also negating or varying the consequences of legal action taken against the mothers. See the Policies Section below for examples of states that have adopted successful legal policy that focus on pre-natal and post-natal SUD treatment to avoid infant removal and punitive action.

Relevant Research

• This website has a literature review in the form of an annotated bibliography on almost 50 topics on substance use during pregnancy. It highlights the main findings on a variety of topics, from prevalence and disparities to impacts and policy implications.

• This article identifies three dominant approaches to antenatal substance use -- contingency management, motivational interviewing, and cognitive-behavioral therapies. 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.

• This article provides support for use of pharmacotherapy as an effective treatment and lists its benefits. For pregnant women with opioid use, Methadone and Buprenorphine is the standard of pharmacotherapy.

Impactful Federal, State, and Local Policies

Federal. The Family First Prevention Services Act (FFPSA) permits states to use title IV-E foster care funding for children placed in foster care with their parent in a licensed residential family-based treatment facility for substance use. However, few states currently use this funding, due to barriers such as competing priorities and lack of facilities.

States. As noted above, half of the states plus D.C. have punitive policies that negatively impact mother and baby.

• 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 Guttmacher Institute provides a state-by-state index of policies on substance use during pregnancy and provides information on states that qualify prenatal substance use as child abuse, require reporting, have criminal commitment requirements, etc. This index currently reveals the following:

• 24 states and the District of Columbia consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and 3 states 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 those who are pregnant, and 17 states and the District of Columbia provide pregnant people with priority access to state-funded drug treatment programs.
• 10 states prohibit publicly funded drug treatment programs from discriminating against pregnant people.

Available Tools & Resources

• SAMHSA has published "A Collaborative Approach to the Treatment of Pregnant Women with Opioid Use Disorders." This manual offers best practices on collaborative treatment approaches for pregnant women living with opioid use disorders. It addresses the risks and benefits associated with medication-assisted treatment.

• 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.
  • "Addiction and Mental Health Resources for Women." It includes a series of resources for support during pregnancy.
  • See the wiki titled "Improve Care for Babies Born Drug Dependent" for more information on babies who are born with Neonatal Abstinence Syndrome and how they can better receive compassionate treatment/care.

• "Supporting Substance-Using Caregivers: Pregnancy, Birth, and Early Childhood" is a Harvard Kennedy School Government Performance Lab written report that explores ways to better support substance using caregivers and their families on the journey to recovery.

• The Northern New England Perinatal Quality Improvement Network provides 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.

• Drugabuse.com is a website that addresses the benefits of group therapy when led by a trained professional. It includes information on recovery education, social support, and motivation in recovery. It also provides observations on various issues and methods within recovery, such as peer empowerment and healthy coping skills to build a sense of optimism and connectedness.

Promising Practices

• Dartmouth Hitchcock Medical Center has a perinatal addiction treatment program based upon an integrated care model that includes maternity care, substance use treatment, behavioral health, and pediatrics. It has a participant-driven design that provides SBIRT screening and an 18-week parenting class. Outcome successes include an average gestational age of over 38 weeks, average birthweight in the normal range, and decreased NAS treatment rate. Two thirds 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.

• Colorado. The Special Connections Project provides gender-responsive treatment for pregnant and parenting women who are Medicaid-eligible to maximize the chance of a healthy birth. They provide postpartum treatment services in order to maintain gains made during pregnancy. Special Connections providers offer pregnancy risk assessments, care coordination services, group counseling sessions, individual counseling sessions, health education groups, and residential SUD treatment in a women-only setting.