Treatment of Substance Abuse During Pregnancy

Barry M Lester; Jean E Twomey


Women's Health. 2008;4(1):67-77. 

In This Article

Evidence-based Approaches

Treatment that starts during pregnancy is known to be effective. Prenatal clinics are prime settings for identifying substance users during pregnancy and for providing services.[15,16,17,18] The 4P's Plus screening tool administered in a prenatal clinic identified 9% of women as using illicit substances, which is higher than the 5.5% reported in national statistics.[15]

There is increasing evidence that length of time in treatment is critical and that this holds for both residential and outpatient treatment. An analysis of treatment outcomes of pregnant and parenting women in residential treatment programs found longer lengths of stay and treatment completion were the strongest predictors of abstinence following discharge.[19] Length of time in residential treatment was associated with abstinence, obtaining employment, fewer psychiatric symptoms, decreased involvement in the criminal justice system, and more positive parenting attitudes.[20] High rates of retention for pregnant and parenting women in residential treatment were associated with having their children live with them and being involved with child protective services (CPS) or criminal justice.[21]

Participation in treatment is affected by pragmatic concerns, such as child care and transportation.[18,22,23,24] Postpartum African-American women with CPS involvement were more likely to stay in a gender-specific day program than an intensive outpatient program. Women who did not complete treatment endorsed high internal barriers, including severity of the drug problem, not feeling like going to treatment, and negative staff attitudes, and resumed drug use.[102]

Determining the most appropriate level of treatment and tailoring treatment protocols to meet the specific client needs has shown to impact engagement and retention in treatment.[18,25] However, engaging pregnant substance abusers in treatment remains a challenge. Pregnant substance users with heavier substance use, more psychopathology and involvement in the legal system were more willing to engage in a comprehensive substance abuse day treatment than were women with fewer needs. A study examining the psychopathology of perinatal drug users participating in a comprehensive day program found most of the women (72%) had low psychopathology.[26] For the women in the study with low psychopathology, being in a program that was more intensive than their needs required may have contributed to high attrition rates, leading the authors to conclude that identification of the degree of psychopathology is necessary to best tailor interventions for drug-using women. In a study of pregnant drug users participating in methadone treatment, 73% had a mood or anxiety disorder, which was seen as an indication that mental health services need to be offered to improve treatment outcomes.[27]

The Engaging Moms Program was effective in promoting substance using mothers' enrollment in treatment through the use of supportive counselors who worked with the women and their families.[23] Unfortunately, few women remained in treatment after 90 days. In a comprehensive residential 7-day treatment program with intensive outpatient follow-up services, 19% of attrition occurred within the first 5 days.[28] Similarly, in other studies, severity of addiction and psychiatric problems were associated with early termination of treatment.[25] Compared with women who primarily used marijuana, had CPS involvement and were enrolled in a day treatment program, women who primarily used cocaine or crack sought, received and completed outpatient treatment, and were not involved in CPS had more positive treatment outcomes.[8] Although a high percentage (48%) of substance abusing mothers had been sexually abused, another study[29] reported no association between history of sexual abuse and retention, completion or abstinence after discharge when counseling for sexual abuse was offered as part of treatment.

There is widespread agreement that treatment for pregnant and parenting substance using women is more effective with comprehensive treatment. Earlier studies are summarized in Table 1 .[30] Recent work supports this approach.

A review of 38 studies of substance abuse treatment for women found more positive treatment outcomes associated with the provision of child care, prenatal care, mental health services, a focus on women's issues, women-only admissions and comprehensive treatment.[22] In another review, effective programs included improving parenting capabilities and family interventions, home visits during pregnancy to help prepare women for parenting responsibilities, parenting training and collaboration among multiple agencies.[31] Positive treatment outcomes in a study of clients in a long-term comprehensive residential treatment program included abstinence following treatment, no involvement with the criminal justice system, not living with a partner who abused substances, employment gains, improved mental health and obtaining child custody.[32] Increased self-esteem, decreased depressive symptoms and improved parenting attitudes were found in a program with comprehensive, gender-specific services to women with children aged under 3 years, who lived with them in the program.[33] Even though women had more mental health issues than men initially, they had a greater reduction in drug use than men when mental health and gender-specific services were provided.[34] Improvements in a 'one-stop shop' program included decreased substance abuse, increased social support, more positive parenting attitudes, less maternal depression, and improvements in child social development.[35,50]

Comprehensive treatment is effective in both long-term residential and outpatient treatment modalities.[37] Although analyses of data from national surveys on substance abuse treatment settings for women between 1987 and 1998 showed a slight increase in the proportion of women in all types of substance abuse treatment programs[38]:

"Less than half of the drug treatment providers whose clients were only women provided services for pregnant or postpartum women, prenatal and perinatal care, child care services, women's groups, or domestic violence services"

Another examination of 10 years of outpatient services for women between 1995 and 2005 found that specialized services were decreasing, with less availability of single-sex group therapy, fewer staff with specialized training and a trend towards less child care being provided.[39]

There is a history of home-based interventions.[40] Positive long-term outcomes were reported in a home-visitation program that used an advocacy approach and was staffed by women with backgrounds similar to the perinatal substance users with whom they worked.[41] Outcomes measured at the 3-year treatment completion and following treatment completion found women who participated in the program had high rates of abstinence and low rates of subsequent pregnancies. Another home-based intervention program for women who had used drugs during pregnancy provided home visits by paraprofessionals every week for the first 6 months following delivery and every other week until the babies were aged 12 months.[42] No significant differences were found in maternal competence, parenting attitudes, child responsiveness or substance use between the mothers who received the home-based intervention and a control group, which was attributed to continued substance use and negative parenting attitudes. In a subsample from this study, children in home-based intervention whose mothers had retained custody of them for at least 18 months showed positive results in cognitive and motor development.[43] The Reaching Families Early program found that the use of outreach and case-management services was highly effective in working with a group of perinatal substance users who were primarily poor, urban, single African-American women. More home case-management visits were associated with retaining custody of the child, less drug use and more drug-use treatment.[44]


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