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, 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.

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. 
 

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%. 

Studies 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.

 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.

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.  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. 

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.

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.

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 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. In the past, women were not included in most clinical research.

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.

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. 

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.     

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.11,12 For instance, rates of opioid prescriptions are higher in rural than in urban areas13 and prescription opioids are now the most common type of drug abused by rural pregnant women.14 Despite these statistics, most research on the prevalence, prevention, and treatment of substance abuse during pregnancy has been conducted in urban areas.15

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. 

 

 

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. SAHMSA tip 57

 

Women are more prone to co-occurring disorders• In 2019, 34.3M adult women had a mental illness and/or SUD (NSDUH, 2020) • Increased risk for suicidality among women

• ~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, 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. 

https://ncsacw.samhsa.gov/topics/pregnant-postpartum-women.aspx#sup-1-bottom

 

https://www.samhsa.gov/data/quick-statisticsresults?qs_type=nssats&state=United%20States&year=2019

 

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. – Tip 51

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.

 

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.(7)

Relevant Research

In this section, please capture any recent findings, reports, or data on the topic. Please also highlight any gaps or existing disparities. Please include references and links to the information so that we may add a footnote for the reader to find further information. Do we have any available research about discriminatory practices? Is there information about the value of access to educational opportunities?

Impactful Federal, State, and Local Policies

Please list any federal, state, or local laws, policies, or regulations that support this topic or ones that could be a possible barrier. Are there laws or policies other states should know about and replicate for success?

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.