Best Practices : Fetal Alcohol Syndrome/Fetal Alcohol Effects and the Effects of Other Substance Use During Pregnancy
5. Tertiary Prevention
Tertiary prevention activities target those for whom FAS is already a concern. The aim of tertiary prevention is to minimize the damage to the fetus, reduce the likelihood of further affected pregnancies, and increase the capacity of the mother to care for her FAS children effectively (Astley et al., 2000b). Tertiary prevention involves intensive multi-component activities,including such strategies as substance abuse treatment, birth control, and parenting programs.
Those considered at high risk are women who drink heavily, and/or have mental health problems and/or histories of physical or sexual abuse and are of childbearing age. Also at high risk are women who have already given birth to an FAS child. Studies show that women who have given birth to one FAS child and who continue to drink, are at risk of having subsequent children that are progressively more severely affected (Jacobson et al., 1998; Astley et al., 2000a; Abel and Hannigan, 1995).
Compared with men, women with substance use and other serious health issues are less likely to access substance abuse treatment services, in part because they are more likely to describe their problems as being related to depression or anxiety and less likely to describe their problems as explicitly related to alcohol (Fillmore, 1984; Beckman and Amaro, 1986; Blume, 1982). Consequently, women are more likely than men to seek help from a physician or mental health service than from specialized substance abuse treatment services (Lex, 1990; Weisner and Schmidt, 1993; Weisner et al., 1995).
Pregnant women with substance use problems may be even less likely to access substance abuse treatment services; the difficulty in doing so is well documented (Howell and Chasnoff, 1999; Howell et al., 1999; Messer et al., 1996; Ernst et al., 1999). In the US, it has been estimated that only about 5% to 10% of pregnant women with substance use problems receive professional treatment (Messer et al., 1996). Many of the reasons presented by pregnant women for not accessing treatment arise from fear of loss of custody of their child, lack of child care, lack of access or priority for pregnant women, and lack of special services and other widely acknowledged systemic barriers (Blume, 1997). Virtually all of a sample of 80 women with substance use issues studied by Astley et al. (2000b) acknowledged a drinking problem. They offered a number of reasons for not wanting to reduce their use: because it helped them to cope (94%); because they were in an abusive relationship (72%); and because they were too depressed to do anything about it (79%).
Their most common reasons for not seeking substance abuse treatment were that: they did not want to give up alcohol (87%), they were afraid they would lose their children (42%), there was no one to take care of the children (40%), and their partner did not want them to go to treatment (39%).
For these and other reasons, a woman may be reluctant to seek help for substance use problems. Some women, on the other hand, may be motivated to enter and succeed at treatment to regain custody of their children who have been placed in foster care because of substance use (Howell et al., 1999). How this form of motivation affects the treatment experience of these women is not clear.
Reasons suggested for the low rate of treatment for pregnant women include the failure of clinicians to identify substance problems among their prenatal patients, and the lack of appropriate treatment and support services for this population (Messer et al., 1996). It has also been found that women who drink during a first pregnancy and have what they think to be a healthy outcome, report a decreased perception of risk (Testa and Reifman, 1996). This may contribute to a disinterest in treatment and to continued or increased drinking during subsequent pregnancies.
Murphy and Rosenbaum (1999) studied the perceptions of 120 particularly marginalized pregnant women with substance use and other serious health issues. All of the women reported that they were concerned about their fetus once they learned they were pregnant, but that the sense of the inevitability of harm to the baby (often arising from media reports) served as an obstacle to doing something about it. Yet most of these women did, in fact, try to reduce the harm to their fetus, such as switching to marijuana, not using on certain days or weeks, eating more, using prenatal vitamins, and sleeping more.
Few of the pregnant women with substance use problems studied by Klein and Zahnd (1997) in California desired or sought substance abuse treatment programs. Other needs such as housing, education, job training, and employment were ranked as greater needs than was substance abuse treatment. Most of these women reduced their substance use substantially on their own as the pregnancy progressed.
Zahnd and Klein (1997) reported on another survey of close to 300 urban and rural American Indian pregnant or parenting women in contact with community agencies. While close to 70% reported alcohol use problems, almost none were interested in treatment, indicating they “could cut down or quit on their own” and “could handle the alcohol and drugs”. These women gave much greater priority to economic concerns, such as education and vocational training, job placement, housing and transportation assistance, food and income support and help with health care.
Noting that some women will choose not to enter treatment when it is offered, Messer et al. (1996) compared two groups of women, one of which accepted substance-related treatment services, the other declining the same services. Those who accepted treatment had more severe substance abuse problems, and were more likely to have undergone treatment in the past. These women were also more likely to have partners who used alcohol and were three times as likely to have experienced physical and/or sexual abuse during pregnancy.
Pregnant women dependent on illicit opioids are often marginalized and have a history of difficult relationships with health and social agencies (Ward et al., 1998). As a result, they are at-risk for a range of health and social problems related to the use of illicit drugs and injection drug use. The cycle of intoxication and withdrawal from opioids may stress the fetus and withdrawal during pregnancy can result in fetal death (Ward et al., 1998).
As well, the impurity of many drugs bought on the street and the possibility that such contaminants may be teratogenic, poor maternal nutrition, poverty, violence, homelessness, and use of other drugs may further put the health of the mother and fetus at-risk (Ward et al., 1998; Mitchell et al., 1995).
Engaging pregnant women who use substances is an ongoing process, but should begin as early as possible in their pregnancy. Engagement is most likely to occur within a supportive, culturally sensitive and non-judgmental environment and needs to lead to a full health and psychosocial assessment (Mitchell et al., 1995). For women whose substance use and personal circumstances (as determined by reproductive and substance use histories) place them at relatively less risk, a brief intervention may be sufficient to support change in use. Women whose circumstances place them at higher risk should receive a substance abuse assessment followed by referral to treatment and, if necessary, detoxification (although the availability of these services for pregnant women is limited in this country). When women visit a prenatal provider, they are unlikely to view substance use as an issue they are ready to work on. Consequently, the process of engagement, assessing the need for treatment and making a successful referral, requires sensitivity and patience (Corse et al., 1995).
The importance of providing both prenatal care and substance abuse counselling for the health of the mother and the baby is highlighted in a US study of cocaine-dependent women by Burkett et al. (1998) which found better outcomes for mother and child with the provision of both prenatal care and drug treatment when compared with prenatal care alone, or neither of these interventions. Though the study results are confounded by the fact that the groups were formed through self-selection, the study does highlight the importance of actively engaging pregnant substance using women in both prenatal care and treatment for cocaine dependence (Burkett et al., 1998).
Anisfeld et al. (1992) compared pregnant cocaine-using women attending a prenatal clinic who were provided with standard care with an intervention group provided with a more intensive and comprehensive range of services, including involvement with the same social worker, drug treatment referral, parenting group, close liaison with medical staff, home visiting and social support/counselling, whenever needed from the initial contact to two years after the birth of the child. Assignment to groups was based on time of enrolment at the clinic. In comparison with the standard care group, the intervention group reduced cocaine use, decreased length of stay for the newborn infant and increased compliance with post-birth nutritional and medical care. The authors of this study point out, however, that women who become drug-free before birth and whose infants are drug-free may still need support services to help them in longer-term recovery and parenting.
All women receiving substance abuse treatment also need to receive counselling on the full range of reproductive options. As women become sober they need to be warned that sobriety may result in a resumption of ovulation and an increased risk of unplanned pregnancy among some. The Centers for Disease Control and Prevention have initiated Project CHOICES to identify and help women at high risk for an alcohol-exposed pregnancy before they become pregnant. Recognizing a need for women who use substances to receive support to institute effective methods of contraception, program goals are to encourage these women to reduce their alcohol intake and to postpone pregnancy until they stop or limit their drinking. The results of this pilot project have not yet been reported (U.S. Department of Health and Human Services, 1999).
A Treatment Improvement Protocol (TIP) for pregnant substance-using women prepared by a consensus panel sponsored by the U.S. Center for Substance Abuse Treatment includes guidelines for detoxification (Mitchell et al., 1995). According to these guidelines, detoxification for a pregnant, alcohol-dependent woman must be undertaken in an inpatient setting under medical supervision that includes collaboration with an antenatal care provider. The 1995 Treatment Improvement Protocol notes that for pregnant women “there are no well documented studies on the safety or efficacy of using drugs to medically withdraw pregnant, cocaine-using women”. However, the TIP does provide guidelines for the use of a variety of medications to assist in cocaine withdrawal for pregnant women, including anxiolytics, antidepressants and barbiturates.
The 1995 Treatment Improvement Protocol states that, although methadone maintenance therapy (MMT) is the treatment of choice for pregnant women dependent on opioids such as heroin, there are no specific guidelines established for methadone dosage levels for pregnant women. Rather, the trend is towards individualized dosages that are adequate to prevent withdrawal symptoms.
Acknowledging the need for clinical judgment concerning dosage, the publication, Guidelines for Perinatal Care of Substance Using Women and their Infants (Children’s and Women’s Health Centre of British Columbia, 1999) provides detailed protocols for physicians concerning dosage and related issues. It is likely that methadone maintenance therapy during pregnancy will result in abstinence or withdrawal syndrome in the newborn, the severity of which depends on a number of factors, including the mother’s dosage levels. Nevertheless, a comprehensive approach to MMT that allows for ongoing access to a range of supportive health and social services for the mother, along with medical management of withdrawal for the newborn, is generally considered preferable to terminating treatment and risking relapse to heroin use and a less healthy lifestyle (T. Oberlander, pers. com., 2000). Ward et al., (1998) and the 1995 TIP also discuss the issue of withdrawal from opioids, rather than maintaining a woman on methadone. Though this is not the treatment of choice, both Ward and the TIP provide guidelines for withdrawal, should this be necessary. The TIP also cautions about the dangers of prescribing any narcotic antagonist to a pregnant woman because it could result in spontaneous abortion, premature labour and/or stillbirth.
In relation to dosage levels, the literature on MMT for pregnant women has also addressed the issue of reduced methadone plasma levels and unexpected withdrawal symptoms among women in late pregnancy, leading to risk of relapse. For example, Jarvis and Schnoll (1994) note the need for higher doses to address the increased rate of methadone metabolism in the later stages of pregnancy, as well as the utilization of split daily doses. Jones et al. (1999) and Ward et al. (1998) also note that careful monitoring and adjustment of methadone dose and regimen is required throughout pregnancy, with the possible requirement for increased or split doses.
De Petrillo and Rice (1995) examined daily versus twice-daily methadone doses using a non-randomized control design. They found women on a split dose regime had better urine toxicology compliance rates and a lower percentage of urine screens positive for cocaine, but not opiate use in the last trimester. They found no differences in the first two trimesters. They also found that, overall, women admitted to the program in the first trimester did better than women admitted later, in terms of rates of opioid, cocaine use and compliance with urine testing.
Ward et al. (1998) point out that menstrual irregularities among heroin-dependent women have given rise to the myth that women on heroin are unlikely to become pregnant, and are partly responsible for the lack of emphasis on birth control against unwanted pregnancies. The early symptoms of pregnancy may be mistaken for heroin withdrawal or harmful contaminants that may further delay heroin-dependent women seeking prenatal care and substance abuse treatment.
Information providing guidance on effectiveness of women’s treatment that is based on strong empirical research continues to be lacking (Health Canada, in press 2000b). Many of the studies lack a randomized design and employ small sample sizes that limit analysis (Howell et al., 1999). To illustrate, Lightfoot et al. (1996) conducted a review of substance abuse treatment for women, with particular reference to the previous five years. The majority of the 211 studies were descriptive, with seven (2%) of the studies specifically examining treatment effects for women using randomized trials, and seven studies using non-random assignment or comparative treatments. Other reviews have found that most of the literature on women’s treatment comprises non-controlled clinical and descriptive studies (Institute of Medicine, 1990), discussions on barriers to treatment, and expert opinion on optimal treatment (Health Canada, in press 2000b).
The relatively few studies that have investigated treatment outcomes by gender tend to show no difference in outcomes between female and male alcohol-dependent persons in traditional treatment programs (Lex, 1990; Walitzer and Connors, 1997). Walitzer and Connors (1997) speculate, however, that those who overcome the various barriers facing women, (i.e., the stigma, family and child care responsibilities, lack of identification and referral by gatekeepers, predominantly male treatment programs, and lack of support from those close) may be more distressed or have greater alcohol dependence that motivates them and differentiates them from women who do not receive treatment. Whether this is so or not, there is a commonly held contention that male and female alcohol-dependent persons differ on important dimensions regarding symptoms and treatment needs. Many client satisfaction studies and discussions by experts call for separate treatment facilities or groups for women, as many women in treatment programs are victims of physical and sexual abuse, and need supportive environments where these issues can be explored (Finkelstein, 1993; 1994). Dahlgren and Willander (1989) compared 100 women attending a specialized clinic for women with 100 women in a regular program, and found the clinic group showing fewer social and alcohol problems at follow-up.
While empirical support for the view that women-only treatment facilities are more effective is limited, there is a consensus that has led to the development of female-specific treatment programs (Walitzer and Connors, 1997). An important issue in determining treatment effectiveness is identifying the outcomes that are worthwhile and can be measured. Several investigators suggest that discussion of effectiveness in women’s treatment be reframed to give greater prominence to intermediary measures, such as self-efficacy, stress management, and decision-making, rather than simply abstinence measures (Health Canada, in press 2000b; Lieberman, 1998a).
The Center for Substance Abuse Prevention supported a number of programs under the Pregnant and Postpartum Women and Infants (PPWI) granting program that together concluded that programs showing effect on these intermediary measures have a greater and longer lasting impact on the quality of women’s lives than programs that demonstrate only a short-term period of abstinence (Lieberman, 1998b).
In their review of this literature, Howell et al. (1999) noted that research on treatment efficacy for pregnant women is sparse and shares the same design weaknesses as women’s treatment research generally. There is no clear evidence of any treatment setting being superior to others. Schrager et al. (1995) compared the birth outcomes of over 700 women who had used one of four publicly funded services (either residential treatment only, outpatient treatment only, residential and outpatient, or minimal treatment) and found that women who received only residential treatment had poorer birth outcomes than women in the other programs. Kaltenbach and Finnegan (1998), in a discussion of prevention and treatment issues for pregnant cocaine-dependent women, note that women who lack stable housing and/or are living in adverse conditions may require residential treatment or the provision of safe housing to accomplish and maintain abstinence during pregnancy. Apparent from the literature is that non-traditional settings need to be considered, given that many women have less interest in “formal” substance abuse treatment. Klein and Zahnd (1997) note the role that public health, social services and criminal justice agencies can play in ameliorating substance abuse in ways that may not be referred to as “drug treatment”.
Because women with substance use and other serious health issues are typically challenging to engage and retain in treatment, much of this literature focuses on factors affecting program completion. This line of investigation has also been spurred by the finding that women who complete treatment have a greater likelihood of reducing their substance use than those who do not complete treatment (Howell et al., 1999). However, many of the associations being made in this literature between program enhancements, retention and positive outcomes cannot be confirmed without further studies that control for client characteristics, because it may be that clients who remain in treatment differ on other dimensions (for example, are more motivated) (Roberts and Ogborne, 1999a).
In a randomized clinical trial using a small sample of cocaine-abusing women, participants who had their children living with them remained in a long-term care therapeutic community longer than those women who did not (Hughes et al., 1995). In another controlled study, Strantz and Welch (1995) found that new mothers were significantly more likely to remain in an intensive day treatment program (similar to residential, but returning home each evening) than in a standard outpatient program.
There is increasing evidence from demonstration projects of the US Pregnant and Postpartum Women and Infants (PPWI) granting program that perinatal substance abuse treatment for high-risk women can have a positive impact (Eisen et al., 2000). Eisen et al. (2000) reported on the impact of nine community-based PPWI programs using a quasi-experimental design and a sample of 658 women. Participating women received either case management and referral to services or day treatment; these women showed significantly reduced substance use between intake and delivery, whereas comparison women did not. It appeared that, after controlling for other possibilities, the amount of substance abuse programming (i.e., the number of contact hours with the program) received prior to delivery was the major factor in the reduction of substance use among participating women.
As a result of these and other findings from PPWI projects and other US government granting programs, a strong consensus among experts is emerging concerning important elements of substance abuse treatment in the perinatal period. The following themes arose in evaluations of these programs as contributing to successfully reaching pregnant substance users and retaining them in care.
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