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Bringing programs together improves results

Integrating substance abuse treatment with prenatal visits brings positive results to maternal and newborn health, according to a study published June 26 on the online Journal of Perinatology. The study, “Substance Abuse Treatment Linked with Prenatal Visits Improves Prenatal Outcomes: A New Standard,” reviewed Kaiser Permanente’s Early Start program—an obstetric clinic–based prenatal substance abuse treatment program that tests all expectant mothers for drug use.

Nancy C. Goler, MD, regional medical director of the Early Start program for Northern California at Kaiser Permanente Medical Group in Vallejo, CA, and coauthor of the study, says testing for drug use should be as routine as treating diabetes. “[Testing] needs to be universal and as nonjudgmental and nonpunitive as possible,” says Goler.

The study authors tracked nearly 50,000 women who completed prenatal substance abuse screening questionnaires, had urine toxicology screening tests, and live births or intrauterine fetal demises (IUFD).

The women were separated into the following four groups:

SAT—Women who screened/assessed positive and were treated by Early Start

SA—Women who screened/assessed positive without treatment

S—Women who screened positive

The control group—Women who screened negative

The results showed that:

SAT women had similar or slightly higher rates than the control group for most outcomes, but significantly lower rates than S women

SA women generally had intermediate rates to the SAT and S groups

The S group had significantly worse outcomes than the SAT group, including preterm delivery, placental abruption, and IUFD

(For more information about the results, see “Adjusted odds ratios for neonatal and maternal outcomes by study group” below.)

“The women and babies served by Early Start are healthier; therefore, the impact of the program reaches beyond them to also positively influence the health and well-being of the community at large and, consequently, must also be considered from a public health perspective. The results of this study reflect the importance of widespread implementation of this model of care as a national standard,” the authors wrote.

Cigarette, alcohol, and drug use by mothers have long-lasting health effects on a child’s health and development and create more health-related costs in the long run. The Centers for Disease Control and Prevention (CDC) reports that smoking before and during pregnancy is the most preventable cause of illness and death among mothers and infants.

In fact, babies born to women who smoke during pregnancy have an approximately 30% higher chance of being premature, are more likely to be born with low birth weight, which increases their risk for illness or death, and are more likely to die of sudden infant death syndrome.

Women who smoke during pregnancy are nearly twice as likely to experience premature rupture of membranes, placental abruption, and placenta previa during pregnancy, according to the CDC.

Use of drugs during pregnancy, such as marijuana, cocaine, and amphetamines, can cause low birth weight, premature birth, birth defects, and learning and behavioral problems. Mothers who drink alcohol during pregnancy can cause physical and mental birth defects, according to the March of Dimes, a national agency that looks to improve the health of babies. And there are many women who partake in risky behavior when pregnant. The American Pregnancy Association reported that each year:

820,000 women smoke cigarettes while pregnant

221,000 women use illicit drugs during pregnancy

757,000 women drink alcohol while pregnant

“It is time for our nation to look at the issue of substance abuse in pregnancy with a nonjudgmental, coordinated, effective intervention that all pregnant women can easily access,” wrote the authors.

Early Start

Kaiser Permanente’s Early Start program is part of its prenatal care program. Piloted in 1990, the program is used in all 40 outpatient obstetric clinics at Kaiser Permanente and screens nearly 40,000 women annually.

The program has three components: an Early Start specialist, who is a licensed substance abuse expert in the OB/GYN department; universal screening of all women for drugs and alcohol by questionnaire and, with signed consent, by urine toxicology testing; and education of all providers and patients about the effects of drugs, alcohol, and cigarette use in pregnancy.

Goler says the universal screening eliminates potential biases and stigmas. In regard to drug and alcohol use screening, she says, “I think you need to make it universal more than anything else. It needs to be universal so all women are screened equally.”

Potential Early Start patients are found through the questionnaire, clinical referral, self-referral, and positive urine toxicology screen results.

Those who are identified as being at risk of using alcohol, tobacco, or other drugs during pregnancy are referred to the on-site specialist, who is a licensed clinical social worker or marriage and family therapist. The specialist conducts a psychosocial assessment of the patient. The counselors use motivational therapy, cognitive/behavioral therapy, and psychodynamic therapy as techniques to reach out to patients at risk of using substances.

Goler says having the specialists on-site allows a physician to simply walk down the hall to talk to the behavioral expert if there is a potential issue with a patient.

“The ready availability of the Early Start Specialist, who specializes in both pregnancy as well as substance abuse treatment and maintains a practice in the Women’s Health Clinic, affords women easy access to the program by removing both the physical and emotional barriers that can be overwhelming during pregnancy. The coordination of care between mental health and obstetric professionals enhances the service delivery model for addressing substance abuse in pregnancy,” the study authors wrote.

Goler says Kaiser Permanente’s prenatal model is cost-effective and significantly decreases negative birth outcomes as well as maternal morbidity.

ROI wasn’t part of the study, but the authors wrote that an internal business care cost analysis for Early Start resulted in a 30% ROI.

Few pregnancy programs tackle drug/alcohol use

Premature birth rates continue to rise, and one reason is drug and alcohol abuse. Yet there are still few treatment programs for expectant mothers with addictions.

Rose Bemis-Heys, executive vice president of strategic development at The Assist Group in Irvine, CA, says there is simply a lot of ignorance regarding the problem, and pregnant women using drugs fear discovery and repercussions.

Bemis-Heys says she would like to see programs that help drug-addicted new mothers get treatment so they may keep their baby and have a better opportunity to raise a healthy child.

Drug abuse is now viewed as less of a lifestyle choice and more of a medical problem due partially to research showing chronic damage in the brain caused by drug use. There are currently few treatments (except methadone for opioid withdrawal) to help expectant mothers handle these mental issues and drug withdrawal.

For those looking to create programs tackling this problem, Nancy C. Goler, MD, regional medical director of the Early Start program for Northern California at Kaiser Permanente Medical Group in Vallejo, CA, says, “I think when you are creating a program such as this, one thing to keep in mind is that this is a very sensitive topic, and you need to have the education up front to your staff and your providers, and you really need the education around the fact that substance abuse and pregnancy crosses across all ages and ethnicities.”

Bemis-Heys says care providers and companies looking to reach out to expectant mothers with drug and/or alcohol problems need to use “readiness to change” and “motivational interviewing” motivational models. A healthcare provider should not preach to the women or try to make them feel guilty.

Bemis-Heys says the women know they are not doing the right thing, and making them feel guilty won’t resolve the issue.

“The best model seems to be to involve and engage the woman and her decision-making process, and ask her what her goals are, and if she is ready to quit, provide her with treatment options” Bemis-Heys says. “It’s not about education; it’s about motivation and individualized care based on each woman’s needs.”