Expand Steps to Minimize Substance Use During Pregnancy or Pregnancy During Substance Use

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Brief Description

Introductory Paragraph

Substance use in pregnant women is on the rise[1], compounded by the opioid crises and challenges resulting from the Coronavirus. People with substance use disorder can find it exceedingly challenging to moderate or stop addictive behaviors. Pregnancy adds significant obstacles to an already complex condition to overcome. Developing strategies to decrease substance use during pregnancy involves a multifaced approach to address complex, overlapping issues, and extenuating circumstances.

Pregnant women with substance abuse disorder face multiple social and situational challenges and obstacles, including social, mental health, legal, environmental, cultural, economic, and geographic. In addition, many pregnant substance abusers are victims of domestic abuse, are homeless, have unsafe/inadequate housing, lack reliable transportation and, do not possess health insurance or the means to pay for medical care. Lack of access to medical care, ineffective collaboration among social service systems, stigma, and fear of punishment further compound the issue.[2]

Current research suggests that a collaborative, integrated approach to managing SUD in pregnant women provides the best chance to counteract obstacles and minimize or eliminate substance use.  A wraparound, comprehensive approach based on evidential research including social, family, criminal justice, social service, medical, and mental health professionals. The risk for substance abuse and its consequences and optimal processes for treatment and recovery differ by gender, race, ethnicity, sexual orientation, education, economic status, geographic location, and other factors. Understanding group differences across segments of the population of women is critical to designing and implementing effective substance abuse treatment programs for women.[3]
 

 

Key Information

According to recent data, women are at their highest risk for developing SUDs during reproductive years. Polysubstance use is common among pregnant women with SUD, and the unintended pregnancy rate among women with SUD is ~80%. [4]

Studies [5]suggest that pregnancy provides a unique opportunity for women to embrace recovery options. 

Women, pregnant or not, have unique needs that should be addressed during substance use disorder treatment. Effective treatment should incorporate approaches that recognize sex and gender differences, understand the types of trauma women sometimes face, provide added support for women with child care needs, and use evidence-based approaches for the treatment of pregnant women. [6]

 Substance use during pregnancy is often intertwined with a host of issues including intimate partner violence, trauma and intergenerational trauma, unsafe/inadequate housing, poverty, food insecurity, mental health issues, mother-child separation, racism, and colonization.[7]

Prevalence

During 2015–2018, approximately half of all pregnant respondents who reported current drinking (drinking in the past 30 days) (9.8%) also reported binge drinking (4.5%). Among pregnant females who reported current drinking, 38.2% also reported current use of one or more other substances, including tobacco, marijuana, opioids, and other substances.[8]

In 2016, 91,800 births – or 24.3 per 1,000 hospital stays for birth – had a substance use disorder (SUD) diagnosis involving opioids, cocaine and other stimulants. [9]

Barriers to seeking treatment

It can be hard for any person with a substance use disorder to quit. But women in particular may be afraid to get help during or after pregnancy due to possible legal or social fears and lack of child care while in treatment. Women in treatment often need support for handling the burdens of work, home care, child care, and other family responsibilities. [10]

Stigma 

Stigma is a significant barrier to treatment and recovery. The societal stigma toward women who abuse substances tends to be greater than that toward men, and the stigma amplifies significantly for pregnant drug users. Ascribed roles and gender expectations across cultures affect societal attitudes toward women with substance abuse. Women who use alcohol and illicit drugs often have great feelings of shame and guilt, have low levels of self-esteem and self-efficacy. [11]

Culture

The complex interplay of culture and health—as well as the influence of differing attitudes toward, definitions of, and beliefs about health and substance use among cultural groups—affects the psychosocial development of women and their alcohol, drug, and tobacco use and abuse, resulting in further stigmatization of substance use.

Gender

Gender differences in use and treatment approach women and men sometimes use drugs for different reasons and respond to them differently. Additionally, substance use disorders can manifest differently in women than in men. [12]  In the past, women were not included in most clinical research.[13]

Discrimination

Women may experience varied levels of discrimination in both healthcare and criminal justice —based on gender, race, ethnicity, religion, language, culture, socioeconomic status, sexual orientation, age, HIV status and disability—that affect their substance use and may affect their recovery For some women, substance abuse may become a way of coping with the additional stresses of discrimination. Substance-using pregnant women, especially women of color and women in lower socioeconomic brackets, are subject to increased surveillance and may face arrest, prosecution, conviction and/or child removal.[14]

Woman also experience racial and ethnic disparities. 

Environmental

A high proportion of women with substance use disorders, have histories of trauma, often perpetrated by persons they both knew and trusted. These traumas contribute to the treatment needs for women. live with other users. [15]

Geography

Rural women are 9% more likely than urban women to experience a composite measure of severe maternal morbidity and maternal mortality,63 and 59% more likely to have a substance use disorder diagnosis at the time of birth. [16]    

Rural communities often lack the resources to provide services to parents struggling with substance use issues. Rural economics, transportation and technological limitations exacerbate these challenges. Compared with urban areas, rates of substance use during pregnancy are frequently higher in rural areas, which often have limited resources for prevention and treatment.  For instance, rates of opioid prescriptions are higher in rural than in urban areas and prescription opioids are now the most common type of drug abused by rural pregnant women. Despite these statistics, most research on the prevalence, prevention, and treatment of substance abuse during pregnancy has been conducted in urban areas.[17]

Financial/socioeconomic 

Low income unstable housing, lack of access to transportation, medical care and poor nutrition Less access to health care and difficulty in funding treatment due to a lack of health insurance can result in later referral for substance abuse treatment.

Legal  

Pregnant women who misuse substances (alcohol, tobacco, and prescription and illicit drugs) are positioned at the nexus of public health and criminal justice intervention. The impact of their substance use on their personal health and the health of their fetuses is a public health concern, as professionals in this field are dedicated to improving maternal and infant health. In addition, the past three decades have seen prenatal substance use become a criminal justice issue as the fetal protectionism movement spurred the increasing use of criminal sanctions for “deviant” mothers.

In addition to being a public health concern, substance use during pregnancy presents legal challenges and the threat of punishment

Reporting requirements and administrative policies prevent additional obstacles, including mandatory involvement with child protective services, loss of child custody, or other legal consequences, fear of criminal prosecution, and legal requirements for medical professionals to report them.

For women seeking help, there is often a fear of judgment. Many are afraid they will be arrested, forced to have an abortion, asked to leave a prenatal care program, and reported to child protective services.

Several states have expanded their civil child-welfare requirements to include prenatal substance use, so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect.  A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child-welfare proceedings. And in order to receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance use. 

Public policy is catching up to this idea although there are many challenges with state legislature depending on geography and federal grants give states the power to decide how to implement key elements. Even though a number of States have adopted policies focused on the importance of treatment for pregnant women who are abusing drugs and of the accessibility of prenatal care, other States have approached this issue from a criminality standpoint (e.g., with child welfare and criminal laws) in the past few decades.

Women’s stories highlighted their strategies for managing their risk of detection by health or criminal justice authorities, including isolating themselves from others, skipping treatment appointments, or avoiding treatment altogether.  [18]

Co-occuring conditions

Further, women with substance abuse issues often have high levels of comorbid psychopathology and personality problems, mental health issues. The relationship between SUDs and mental disorders is known to be bidirectional. The presence of a mental disorder may contribute to the development or exacerbation of an SUD. Likewise, the presence of an SUD may contribute to the development or exacerbation of a mental disorder.[19]

Women are more prone to co-occurring disorders. In 2019, 34.3M adult women had a mental illness and/or SUD.[20]   There is also an increased risk for suicidality among women.[21]

 ~30% or pregnant women enrolled in SUD treatment screen positive for depression;

~40% report postpartum depression

Lack of adequate medical resources resources 

Women described multiple barriers to treatment and healthcare, including lack of access to medical care  lack of suitable treatment options and difficulty finding and enrolling in treatment. Residential treatment facilities are limited.In 2019[22], Pregnant or postpartum women 3,875 of facilities out of 15,961 had treatment programs tailored to pregnant women, accounting for only 24.3% including Private non-profit, Private for-profit, Local, county, or community government, State government, Tribal government. [23]

Relapse prevention/ Continuing treatment post partum

Although pregnancy may motivate women in initiating treatment, studies suggest that pregnant women do not stay in treatment as long and that retention may be significantly affected by stage of pregnancy and the presence of co-occurring psychiatric disorders.

Factors that encourage a woman to stay in treatment include supportive therapy, a collaborative therapeutic alliance, onsite child care and children services, and other integrated and comprehensive treatment services.[24]

Transitional programs and aftercare services can offer educational programs, vocational training, relapse prevention programs, childcare services, and housing options for women and their newborns to support a sustained recovery as well. Sociodemographics also play a role in treatment retention. Studies suggest that support and participation of significant others, being older, and having at least a high school education are important factors that improve retention. Criminal justice system or child protective service involvement also is associated with longer lengths of treatment. Women are more likely to stay in treatment if they have had prior successful experiences in other life areas and possess confidence in the treatment process and outcome. 

Opioid Crisis

Opioid use in pregnancy has escalated dramatically in recent years, paralleling the epidemic observed in the general population.  [25]

Studies using administrative data have estimated that 14%–22% of women filled a prescription for opioids during pregnancy; however, data on self-reported prescription opioid use during pregnancy are limited.  [26]

Treatments & Best Practices

Women’s risks for substance abuse are understood best in the social and historical context of where the influences of gender, race and ethnicity, education, economic status, age, geographic location, sexual orientation, and other factors converge. Understanding group differences across segments of the population of women is critical to designing and implementing effective substance abuse treatment programs for women. Treatment of pregnant substance users requires a multi-pronged approach involving integrated, comprehensive, evidence-based models that treat the entire individual. 

Offering holistic, integrated support for pregnant women with substance use concerns is an emerging best practice in how to support pregnant women with substance use concerns. These programs can be provided through various models including outreach, multi-service co-located agencies, or a network of community-based services. Research in this area has shown that integrated support models can improve maternal and fetal outcomes and successfully support women to reduce alcohol use in pregnancy.[27]

Over the last decade, women with substance use disorders have increasingly been the subject of scientific study. Studies have explored the effects of alcohol and illicit drugs on pregnancy in greater detail, best practices in substance abuse treatment for women, the impact of trauma and the need for trauma-informed services, and the importance of incorporating a gender responsive framework. More recently, research is burgeoning in the area of outcome variables, relapse prevention, women and child services, and specific treatment approaches. The idea is to address the underlying contributing factors and work to eliminate/alleviate individual factors effecting women seeking to lower their substance abuse while pregnant.[28]

Approaches to SUD treatment for women should include:

● Relational approaches that take into consideration positive and negative familial and partner influences and relationships, and promote a safe and caring treatment environment.

● Treatment programs that integrate the whole person, including family and parenting responsibilities.

● Trauma-informed approaches that include screening and assessing women for trauma history.

● A focus on identifying and addressing co-occurring substance use and mental disorders, such as mood, anxiety, and eating disorders.

● Consideration of appropriate medications for pregnant women; buprenorphine is safer than naltrexone or methadone to ensure better outcomes for newborn children.

● Provider recognition of women’s cultural expectations to help improve engagement and retention in treatment programs

Medication-Assisted Treatment (MAT)

MAT is the use of medications in combination with counseling and behavioral therapies to provide a whole patient approach to the treatment of substance use disorders . The use of MAT during pregnancy is a recommended best practice for the care of pregnant women with opioid use disorders[29]. Research shows that a combination of medication and behavioral therapies is most successful for substance use disorder treatment. 

MAT is clinically driven and focuses on individualized patient care. Medications used to treat opioid use disorders include methadone and buprenorphine. Both of these medications stop and prevent opioid withdrawal and reduce opioid cravings, allowing the person to focus on other aspects of recovery.

Comprehensive care management that includes medications for opioid use disorder (MOUD) is recommended for pregnant women with OUD. MOUD consists of opioid agonist pharmacological treatment options, such as buprenorphine (Subutex® and Suboxone®) or methadone, proven to be effective in reducing severe withdrawal symptoms, risk-taking behaviors and improving adherence to treatment when combined with behavioral therapies, counseling, and prenatal care. MOUD is preferable to medically supervised withdrawal because of the high risk of relapse and adverse outcomes by 54–90% in pregnant women. [30]

An overview of available drugs for management of opioid abuse during pregnancy. [31]

Integrated, Evidence Based Treatment

Evidence-based programs suggest that a variety of approaches are effective, including traditional programs, which focus on the pregnancy period, length of treatment, comprehensive treatment and home visitation, and newer approaches, which include motivational interviewing and contingency management, a focus on the mother-infant relationship, collaboration among social service systems, including CPS and FTDC, and pharmacotherapy.

Integrated Treatment Program Integrated/coordinated care

Integrated Treatment for Co-Occurring Disorders differs from traditional approaches in several ways. First, services are organized in an integrated fashion. For example, assessments screen for both mental illness and substance use.[32] 

Integrated programs for mothers with substance abuse issues

Integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services) were developed to break the intergenerational cycle of addiction, potential child maltreatment, and poor outcomes for children.

Care collaboration and support services

A major implication is that women would benefit from some sort of wraparound or comprehensive care and professional advocacy. 

A multidisciplinary approach to clinical care and connection to psychosocial support services can improve the chances of treatment success for women with substance use disorders in general. Additionally, women can benefit from behavioral health referrals, services for addressing social determinants of health (eg, housing or food insecurity), and connection with peer and community supports. Integrated programs for mothers with substance abuse issues: A systematic review of studies reporting on parenting outcomes.https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-9-14

Given the barriers, risks, and outcome implications, researchers, clinicians, and policy makers recommend that substance abuse treatment programs address women's needs as well as their children's needs through comprehensive, integrated services in centralized settings for both women and children [14]. This recognition has resulted in the development of numerous integrated treatment programs (those that include on-site pregnancy-, parenting-, or child-related services with addiction services), both residential and outpatient. Integrated residential programs or "therapeutic communities" offer long-term (15-18 months) treatment services to women and their children. Both types of programs typically are comprehensive and include group and individual addiction treatment, maternal mental health services, trauma treatment, parenting education and counseling, life skills training, prenatal education, medical and nutrition services, education and employment assistance, child care, children's services, and aftercare. [33]

Evidence based

Evidence-based practice (EBP) is spreading in popularity in many health care disciplines. One of its main features is the reliance on the partnership among hard scientific evidence, clinical expertise, and individual patient needs and choices. EBP also involves integrating the best available evidence with clinical knowledge and expertise, while considering patients’ unique needs and personal preferences. Evidence-based programs suggest that a variety of approaches are effective, including traditional programs, which focus on the pregnancy period, length of treatment, comprehensive treatment and home visitation, and newer approaches, which include motivational interviewing and contingency management, a focus on the mother-infant relationship, collaboration among social service systems, including CPS and FTDC, and pharmacotherapy.[34]

There are a variety of behavioral treatments with established evidence for treating substance use disorders (SUDs).[35] These include cognitive behavioral therapy-based approaches, contingency management, motivational interventions, mindfulness-based treatments, and marital and family therapies. Additionally, self-help organizations/mutual help groups can play an integral role in a comprehensive recovery plan and can be a useful adjunct to evidence-based psychotherapies for SUDs. [36]

Treatment tenants and protocols for the following SUD interventions are discussed: (1) cognitive behavioral therapy-based approaches, (2) contingency management, (3) motivational interventions, (4) mindfulness-based treatments, (5) marital and family therapies, and (6) self-help organizations/mutual help groups.  [37]

Group/Peer Support

Mental healthcare is also an integral aspect during addiction treatment, and this includes both individual and group therapy sessions. Group sessions may take place with other pregnant women and focus on specific issues for this population. Women can work together during group skills sessions to learn parenting techniques and healthy stress coping mechanisms. 

Therapy

Behavioral therapies delve into what may have led to the abuse of drugs in the first place, and they can help women to learn new ways of thinking that will support healthy behaviors and habits going forward. Women may also benefit from counseling on how to handle childbirth, pain, and medical concerns that can arise both during pregnancy and in childbirth and set up a plan that will work in tandem with addiction treatment. For instance, pain medications may need to be closely monitored or substituted for non-habit-forming ones following childbirth.

Online Health Communities

In a recent study of online health communities.[38]

A total of 5 themes of self-management support needs were identified as women sought information about the potential adverse effects of gestational opioid use, protocols for self-managed withdrawal, pain management safety during pregnancy, hospital policies and legal procedures related to child protection, and strategies for navigating offline support systems. In addition, 58.5% of the pregnant women expressed negative emotions, of whom only 10.2% sought to address their emotional needs with the help of the OHC.[39]

 

Harm reduction should include[40]:

  • Public Health Strategies
  • Implementation of public health strategies (e.g., improving state prescription drug monitoring program use and enhancing provider training) can support delivery of evidence-based care for pregnant women.(7)
  • Group based treatment
  • Training of service professionals
  • Collaborative Care Models
  • Evidence based policy development

 

Relevant Research

CDC:[41]Substance Use During Pregnancy Alcohol Use and Co-Use of Other Substances Among Pregnant Females Aged 12–44 Years — United States, 2015–2018

Co-Creating Evidence Evaluation Report: Stories and Outcomes of Wraparound Programs Reaching Pregnant and Parenting Women at Risk.[42]

National Center for Biotechnology Information (NCBI) 

  • Pregnant women and substance use: fear, stigma, and barriers to care[43]
  • Concurrent Opioid and Alcohol Use Among Women Who Become Pregnant: Historical, Current, and Future Perspectives[44]

Substance Abuse and Mental Health Services Administration (SAMHSA) 2019 National Survey on Drug Use and Health [45]

Healthcare Cost And Utilization Project (H-CUP) Obstetric Delivery Inpatient Stays Involving Substance Use Disorders and Related Clinical Outcomes, 2016[46] 

National Institute on Drug Abuse (NIH)

  • Substance Use in Women Research Report[47] 
  • Treating Opioid Use Disorder During Pregnancy[48] 
  • Substance Use While Pregnant and Breastfeeding[49]
  • Sex and gender differences in substance use[50] 

Impactful Federal, State, and Local Policies

Comprehensive Addiction and Recovery Act of 2016 (CARA)

The Comprehensive Addiction and Recovery Act (CARA) establishes a comprehensive, coordinated, balanced strategy through enhanced grant programs that would expand prevention and education efforts while also promoting treatment and recovery. 

Applicable sections:

Title V:  Addiction and Treatment Services for Women, Families, and Veterans 

Sec. 501 – Improving Treatment for Pregnant and Postpartum Women:  This section reauthorizes the Residential Treatment Program for Pregnant and Postpartum Women. It also authorizes the creation of grants within CSAT for a pilot program to enhance a State's services for women who are pregnant and postpartum while suffering from substance use disorder.

Sec. 503 – Infant Plan of Safe Care: Requires HHS to produce information concerning best practices on developing plans for the safe care of infants born with substance use disorders or showing withdrawal symptoms. This section also requires that a State plan addresses the health and SUD treatment needs of the infant, among others. [51]

Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) [Public Law 115–271]  

Broadly, the legislation imposes tighter oversight of opioid production and distribution; imposes additional reporting and safeguards to address fraud; and limits coverage of prescription opioids, while expanding coverage of and access to opioid addiction treatment services. The bill also authorizes a number of programs that seek to expand consumer education on opioid use and train additional providers to treat individuals with opioid use disorders.[52]

State Child Welfare & Prenatal Substance Use

Several states have expanded their civil child-welfare requirements to include prenatal substance use, so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect. Further, some states, under the rubric of protecting the fetus, authorize civil commitment (such as forced admission to an inpatient treatment program) of pregnant women who use drugs; these policies sometimes also apply to alcohol use or other behaviors. A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child-welfare proceedings. And in order to receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance use.[53]

⦁ 23 states and the District of Columbia consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and 3 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 pregnant women, and 17 states and the District of Columbia provide pregnant women with priority access to state-funded drug treatment programs.

⦁ 10 states prohibit publicly funded drug treatment programs from discriminating against pregnant women.

 

Available Tools and Resources

Oftentimes, there are already great resources in the field that have been developed, but they are not housed in a single place. Please use this section to share information about those resources and drive the reader to that resource. It may be a worksheet, toolkit, fact sheet, framework/model, infographic, new technology, etc. I suggest no more than 5 really good links and a corresponding description for the reader. We also can use this section to highlight some of the great resources and programs at SAFE Project.

Promising Practices

Please link to any best practice models or case studies that highlight creative/innovative or successful efforts in support of this strategy. Is there a community that does a really good job in this area that other communities should replicate? Please write a brief description and provide a link.

Sources

  1. ^ https://www.recoveryanswers.org/resource/women-in-recovery/
  2. ^ https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf
  3. ^ http://www.fasd-evaluation.ca/wp-content/uploads/2021/03/FINAL-CCE_Executive-Summary_Mar-10-for-web.pdf
  4. ^ https://www.ndsu.edu/fileadmin/centers/americanindianhealth/files/Maternal_Health_Learning_Collaborative_Session_2.pdf
  5. ^ https://www.cdc.gov/mmwr/volumes/69/wr/mm6931a1.htm?s_cid=mm6931a1_w
  6. ^ https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/summary
  7. ^ http://www.fasd-evaluation.ca/wp-content/uploads/2021/03/FINAL-CCE_Report_Mar-8-for-web.pdf
  8. ^ https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6931a1-H.pdf
  9. ^ https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  10. ^ https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women
  11. ^ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  12. ^ https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women
  13. ^  https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/importance-including-women-in-research
  14. ^ https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23
  15. ^ https://www.sciencedirect.com/science/article/abs/pii/S0091743520303273
  16. ^ https://www.nationalpartnership.org/our-work/resources/health-care/maternity-care-in-the-united.pdf
  17. ^ https://www.hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  18. ^ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  19. ^ https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-07-01-001-PDF.pdf
  20. ^ https://www.samhsa.gov/data/data-we-collect/nsduh-national-survey-drug-use-and-health
  21. ^ https://www.ndsu.edu/fileadmin/centers/americanindianhealth/files/Maternal_Health_Learning_Collaborative_Session_2.pdf
  22. ^ https://www.samhsa.gov/data/quick-statisticsresults?qs_type=nssats&state=United%20States&year=2019
  23. ^ https://ncsacw.samhsa.gov/topics/pregnant-postpartum-women.aspx#sup-1-bottom
  24. ^ https://store.samhsa.gov/product/TIP-51-Substance-Abuse-Treatment-Addressing-the-Specific-Needs-of-Women/SMA15-4426
  25. ^ https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy
  26. ^ https://www.cdc.gov/mmwr/volumes/69/wr/mm6928a1.htm
  27. ^ https://store.samhsa.gov/sites/default/files/d7/priv/sma15-4426.pdf
  28. ^ https://store.samhsa.gov/sites/default/files/SAMHSA_Digital_Download/PEP20-06-04-002.pdf
  29. ^ https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy
  30. ^  https://aspe.hhs.gov/reports/models-medication-assisted-treatment-opioid-use-disorder-retention-continuity-care-0#implications
  31. ^ https://mhnpjournal.biomedcentral.com/articles/10.1186/s40748-017-0044-2
  32. ^ https://store.samhsa.gov/sites/default/files/d7/priv/ebp-kit-building-your-program-10112019.pdf
  33. ^ https://harmreductionjournal.biomedcentral.com/articles/10.1186/1477-7517-9-14
  34. ^ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC226388/
  35. ^ https://www.nationalpartnership.org/our-work/resources/health-care/maternity/evidence-based-maternity-care.pdf
  36. ^ https://psycnet.apa.org/record/2018-18838-010
  37. ^ https://www.sciencedirect.com/science/article/pii/B9780323548564000109?via%3Dihub
  38. ^ https://www.jmir.org/2021/2/e18296#ref8
  39. ^ https://onlinelibrary.wiley.com/doi/epdf/10.1111/hsc.13335
  40. ^ https://www.nashp.org/wp-content/uploads/2018/10/NOSLO-Opioids-and-Women-Final.pdf
  41. ^ https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6931a1-H.pdf
  42. ^ http://www.fasd-evaluation.ca/wp-content/uploads/2021/03/FINAL-CCE_Report_Mar-8-for-web.pdf
  43. ^ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5151516/
  44. ^ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6545650/
  45. ^ https://www.samhsa.gov/data/sites/default/files/reports/rpt31102/2019NSDUH-Women/Women%202019%20NSDUH.pdf
  46. ^ https://hcup-us.ahrq.gov/reports/statbriefs/sb254-Delivery-Hospitalizations-Substance-Use-Clinical-Outcomes-2016.pdf
  47. ^ https://www.drugabuse.gov/download/18910/substance-use-in-women-research-report.pdf?v=b802679e27577e5e5365092466ac42e8
  48. ^ https://www.drugabuse.gov/publications/treating-opioid-use-disorder-during-pregnancy
  49. ^ https://www.drugabuse.gov/publications/research-reports/substance-use-in-women/substance-use-while-https://www.drugabuse.gov/publications/drugfacts/substance-use-in-womenpregnant-breastfeeding
  50. ^ https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women
  51. ^ https://www.cadca.org/comprehensive-addiction-and-recovery-act-cara
  52. ^ https://fas.org/sgp/crs/misc/R45405.pdf
  53. ^ https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy