Best Practices : Fetal Alcohol Syndrome/Fetal Alcohol Effects and the Effects of Other Substance Use During Pregnancy
A program that reflects these themes and has been subjected to strong evaluation is the Seattle Birth to Three Program (Ernst et al., 1999). The study is unique in this literature in that it randomly assigned women to experimental and control groups, matched groups by potentially intervening variables, assessed a range of maternal and child outcomes (not just substance use), and followed women and children for three years, with a low attrition or drop-out rate.
The Birth to Three Program is a comprehensive program for high-risk women in Seattle that employs intensive, long-term case management through paraprofessional advocates that provided emotional support and assisted with connection to community services. Advocates worked with a small caseload of 12 to 15 women at a time. The work of advocates was highly individualized, but reflected relational theory and was concerned with all of the issues facing these women. They did not provide direct services, such as substance abuse treatment or child care, but rather facilitated the women’s connection with these services in the community through regular and, as needed, home visits, and active contact with the extended family. This is one of the few programs to incorporate family planning as a form of prevention of FAS and other forms of teratogenic exposure. They encourage women to limit family size in order to cope with needs of the children already in their care.
Clients and their children were evaluated at 4, 12, 24, and 36 months into the program. All evaluations were done by raters who were unaware of the client’s status: control versus intervention. Outcome was assessed in five broad categories:
- Utilization of alcohol, drug treatments;
- Abstinence from alcohol and drugs;
- Family planning;
- Health and well being of the target child;
- Appropriate connection to the community.
At recruitment, there were no differences between the 65 intervention subjects and 31 control subjects. Maternal follow-up at 36 months included 92% of the intervention groups and 83% of the controls. Child follow-up was 92% for the intervention groups and 87% for the controls. This follow-up rate is higher than in the majority of studies involving high-risk women, who tend to be transient.
Clients receiving the services of the advocate scored higher than controls on all five aggregate outcome variables at 36 months. Clients with the best outcomes were those most closely connected to their advocates.
Almost half of the intervention group who had had no previous substance abuse treatment had completed inpatient treatment during the three years. Abstinence rates were higher in the intervention group, particularly for those closely attached to their advocates. By the end of the three-year period, 73% of clients reported using a reliable form of birth control and 43% had chosen a permanent form such as Depro-Vera injections or a tubal ligation, compared with 52% and 32% of control women, respectively.
The Seattle program provides tertiary prevention of future drug- and alcohol-affected births by encouraging women to seek treatment for their substance abuse and to use reliable family planning methods, and by connecting them with other health and social services. The connection of the at-risk woman with her advocate was a powerful intervening variable in outcome. Women were most likely to be well connected to their advocate when they shared cultural and linguistic values. The social support provided by the advocate appeared to have empowered the women to make and to sustain positive lifestyle changes (Ernst et al., 1999).
A treatment model that has been shown to be effective with a number of populations – contingency management – has also shown promise with pregnant cocaine-dependent women. Contingency management involves the use of incentives to systematically reinforce treatment retention and abstinence. Elk and colleagues (Elk et al., 1995; 1998) have used contingency management procedures in several studies in the treatment of cocaine-dependent pregnant women employing both pre-post comparison and random assignment. Though the samples were very small, the results indicated that monetary incentives resulted in decreased cocaine use and better compliance with prenatal care. Seracini et al. (1997) also found increased cocaine abstinence with the use of voucher incentives for pregnant cocaine users. Jones et al. (2000) did not find low magnitude incentives effective in increasing program attendance.
Methadone maintenance treatment (MMT) is recognized as the standard treatment for pregnant opioid-dependent women (Ward et al., 1998). Ward et al. (1998) notes that the research evidence has clearly shown that MMT produces better outcomes than not being in treatment for pregnant, substance-using women. Apart from providing a legally manufactured drug at a controlled dosage, MMT can retain women in treatment, reduce health risk behaviours associated with injecting drugs, provide women with access to prenatal care and other services, and reduce the likelihood they will have to engage in prostitution or other criminal activities to support their drug habit. Infants born to methadone-maintained women are also born later and larger for gestational age than those born to opioid-dependent women not in treatment (Ward et al., 1998). However, Jones et al. (1999) also note that many of the studies reporting better outcomes for mother and infant were done in settings that provided comprehensive care, and the conclusions that can be drawn about the role of methadone per se in improving birth outcomes are limited.
The importance of comprehensive services in support of MMT has been noted (Jones et al., 1999). Jarvis and Schnoll (1994) identified obstetrical and medical care, education about issues such as parenting, nutrition and addressing of a range of psychosocial issues through individual, group and family counselling. Ward et al. (1998) discuss the need for group therapy for women participating in MMT, as well as the need to consider the pros and cons of family oriented MMT.
Several studies have examined enhanced MMT in retaining women in treatment and in improving treatment outcome. For example, Carroll et al., 1995, in a randomized clinical trial and non-randomized pilot study respectively, compared women in a standard MMT program which, as well as methadone, included weekly group counselling and urine toxicology three times a week. This was compared with an enhanced program that provided weekly prenatal care, weekly relapse-prevention groups, monetary incentives for drug-free urine samples and child care. Though there were no differences in drug use between the enhanced and standard MMT groups, the enhanced group did have a higher rate of prenatal care visits, adequate gestation and high birthweight infants.
Ward et al. (1998) also discuss the need to consider the pros and cons of family-oriented MMT. If a pregnant woman is given priority access to MMT and her partner is not, this may produce conflict because their drug-dependent lifestyle is threatened by the woman’s entrance into MMT. Also, if her partner is continuing to use, this presents a high-risk situation for the pregnant woman. However, some clinicians are concerned about involving partners in the same MMT program because of high rates of violence experienced by women with substance use problems (Ward et al., 1998).
The report of the National Round Table on Aboriginal Health and Social Issues, The Path to Healing (Government of Canada, 1993), advocates a spiritual basis to treatment for Aboriginal peoples. Emphasizing a holistic approach reflected in the medicine wheel, central to the process is rediscovery of cultural and spiritual traditions. Treatment in this context often includes a community-wide approach to healing and recovery that sees other persons in the community, as well as organizations such as Native Friendship Centres, as part of an “extended” family (Van Bibber, 1997).
Treatment of substance abuse during pregnancy has been shown to be a cost-effective strategy (Svikis et al., 1997). This group from Johns Hopkins compared the cost of treating pregnant women’s drug abuse during pregnancy, and the subsequent cost of caring for their infant during the newborn period, with the cost of caring for the infants of a group of pregnant women who did not receive treatment. Infants born to women who received treatment during pregnancy were less likely to require neonatal intensive care and those who did require a stay in a neonatal intensive care unit (NICU) were admitted for shorter stays than those born to untreated mothers. The cost savings from reduced NICU time alone were greater than the cost of treating the women during pregnancy. The average cost of treating a woman ($6,639) as well as her infant ($900) was less than the average cost of an NICU stay for an affected infant born to an untreated mother ($12,183). These authors did not include later costs, such as those pertaining to special education needs of the affected children. Over a life-span, the actual cost savings from reduced costs of providing a panoply of services to the affected offspring alone would be much greater. The authors further noted that many of the women in their study were involved in prostitution and were HIV-positive. Reducing the health risks of these women would result in further cost savings, assuming that women in recovery from alcohol and drug addiction would be less likely to remain in the sex trade.
Pregnant substance-using women may have been more profoundly impacted by alcohol- and drug-related policies and sanctions than other population groups requiring substance abuse treatment. These policies and sanctions include the historical emphasis on treatment models for men, and co-educational treatment as the norm; lack of funding and other mechanisms to resource child care for those attending specialized substance abuse treatment; and civil and criminal sanctions for pregnant substance-using women. In addition, it is only very recently that those who advocate on behalf of women with substance use problems have come together with those who advocate on behalf of children affected prenatally by alcohol or other drugs. The recent Treatment Improvement Protocol on pregnant substance–using women eloquently summarizes the plight of pregnant, substance-using women:
“Most common, however, is the neglect they experience from health care and service delivery systems. The painful repercussions of the prosecution and neglect of pregnant, substance-using women and their children can be seen in shelters for battered women, among homeless populations, and in foster homes and child welfare institutions across the country” (Mitchell et al., 1995, p. 6).
Though enormous strides have been made in Canada in the last 25 years in recognizing the need for special programming for women, many women still enter a treatment system that may not have the resources to address their special needs. For pregnant substance-using women, the lack of appropriate services is even greater.
Both in Canada and the US, lack of child care presents a major barrier affecting access to treatment for women (Health Canada, in press 2000b; Blume 1996). Lack of child care is a major reason why women fail to seek treatment (Brown, 1992), while provision of services for children and child care attracts more women into treatment (Beckman and Amaro, 1986). Particularly given the high rates of historical and current physical and sexual abuse experienced by women with substance abuse problems, a pregnant woman who already has a child may find it difficult to find a suitable family member to provide child care. Even for those accessing non-residential treatment, the options for temporary child care may be limited and financially prohibitive. However, many women are very reluctant to turn to the child welfare system for temporary foster care because of fear of losing custody of their children (Blume, 1996; Health Canada, in press, 2000b).
In Canada, the Yukon has mandatory reporting requirements specifically related to substance use during pregnancy (1986), which is similar to a number of US jurisdictions. In some states, the definition of child abuse or neglect includes prenatal drug exposure, which has led to policies requiring reporting and automatic removal of children exposed to substances prenatally, regardless of whether the mother’s substance use impacts on her parenting ability (Blume, 1997; Paltrow, 1998). Poor and racial minority women have been disproportionately affected by such policies (Whiteford and Vitucci, 1997).
Some US jurisdictions have gone even further in requiring mandatory treatment for pregnant women using substances, charging women with a criminal offence related to their use of alcohol or other drugs during pregnancy (Blume, 1996; Whiteford and Vitucci, 1997). In Canada, the recent case of Ms. G. highlighted the issue of mandatory treatment for pregnant substance-using women. However, as in the US, Canadian higher courts have ruled against mandatory treatment of pregnant women.
There are a host of arguments against mandatory treatment and/or the involvement of the criminal justice system as mechanisms to prevent substance use during pregnancy, and in favour of providing comprehensive care addressing a range of health and social issues as most likely to lead to the best outcome for mother and child. The most obvious and serious consequence of a punitive approach is that it will deter women from accessing needed services or from being able to discuss their substance use with health care professionals, leading to a poorer outcome for mother and child (Murphy and Rosenbaum, 1999; American Academy of Pediatrics, 1995; Paltrow, 1998; Whiteford and Vitucci, 1997). Punitive approaches also fail to recognize and address the complexities of the lives of many woman who are pregnant and using substances. These may include lack of a support system, unstable environments, homelessness, poor parenting, mental illness, partner substance abuse, family violence, poverty (Clarren, 1999; Mitchell et al., 1995; Murphy and Rosenbaum, 1999), as well as, of course, the lack of appropriate services.
Jails do not provide a substance-free environment or the appropriate prenatal care and substance abuse treatment that would seem to be the rationale for a criminal justice approach. As the American Academy of Pediatrics states in its 1995 policy statement on Drug-Exposed Infants (American Academy of Pediatrics, 1995), “There is no evidence that these latter sanctions (criminal penalties on women who use drugs during pregnancy) prevent in utero drug exposure or help drug-exposed children”. Finally, it has been pointed out that mandating treatment for pregnant women would introduce social control of women based only on the fact of pregnancy (Blume, 1996).
The earlier in the pregnancy a woman can access appropriate care, the greater the chance of a healthy pregnancy and outcome for the infant. It is not known to what extent provincial/territorial government policies give priority to pregnant women and link with other needed services such as prenatal care. However, 166 providers in the substance abuse treatment database of the Canadian Centre on Substance Abuse report that they provide priority access to pregnant women (Roberts and Ogborne, 1999b). For example, the Children’s and Women’s Health Centre of British Columbia has developed a protocol for admission of pregnant substance-using women that, along with concerted training, has improved access to care for this population (Children’s and Women’s Health Centre of British Columbia, 1999). The issue of priority access may be particularly crucial for women requiring MMT.
The requirement for training as different professions and systems come together to provide comprehensive care to pregnant substance-using women is crucial. The medical, child welfare and substance abuse treatment systems may have different agendas and understanding of issues, such as reporting requirements regarding suspected child abuse and child custody, confidentiality, expectations regarding recovery from a substance use problem, and the most effective methods for ensuring a healthy outcome for mother and child.
In conclusion, though much of the pregnant women’s treatment literature is qualitative in nature, a growing number of scientific studies is confirming expert clinical opinion in the following areas: the need to engage women prenatally, and to provide a comprehensive, coordinated and consistent range of prenatal and substance treatment services, including emphasis on promoting the mother-child bond and other important family relationships in a woman’s life. As well, there is some research and a consensus among experts that the provision of adjunctive services, such as child care, transportation, housing, and vocational rehabilitation, is of critical importance. Case management is an effective way of providing for the various health and social needs of pregnant women who use substances. In addition, there is some evidence that providing incentives, such as money, vouchers or gifts, may increase compliance with care and reduce cocaine use. Finally, there is no indication that punitive measures against pregnant substance-abusing women are effective.
There is moderate evidence and a consensus among experts that combining prenatal care with other services, including substance abuse treatment, shows positive outcomes for women with substance use problems and their newborn child.
There is moderate evidence and a consensus among experts that gender-specific substance abuse treatment is more effective for women than programs serving both men and women.
There is some evidence and a consensus among experts that treatment services employing a respectful, flexible, culturally appropriate and women-centred approach that is open to intermediary harm reduction goals, based on client circumstances, are effective in engaging and retaining women in supportive programming and in improving the quality of their lives.
There is some evidence and a consensus among experts that services with a single point of access addressing the range of social and health needs of pregnant women with substance use problems (e.g., assistance with transportation and child care, education, vocational training, job placement, housing, getting food, income support, and help in accessing health care and mental health services), through collaboration between relevant service providers, are effective in engaging and retaining women in treatment.
There is strong evidence that intensive case management or coordination services that advocate for women can be effective in promoting family planning, access to substance abuse treatment, retention in treatment, reduced consumption and connections to community services for high-risk pregnant women.
There is some evidence that a contingency management approach is effective in reducing cocaine use and increasing attention to prenatal care among cocaine-dependent women.
There is moderate evidence that providing Methadone Maintenance Therapy (MMT) in the context of comprehensive care has a positive impact on the health of mothers and birth outcomes for mothers who are opiate-dependent. Priority access to MMT for pregnant women and program components that address barriers to treatment should be considered in program design. Guidelines for methadone dosage and regimen should take into account changes in methadone metabolism that may occur in the later stages of pregnancy.
There is no evidence to support the use of punitive measures, such as mandated treatment, as being effective in improving maternal and fetal health. A consensus among experts suggests that such measures deter pregnant women from seeking needed services.
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