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Article Excerpt
I. INTRODUCTION
In the previous two articles that this author has written on the subject of drug and alcohol-exposed children, (1) she has argued that a key element to. preventing children from being exposed in utero to drugs or alcohol is the provision of efficacious, comprehensive substance abuse treatment programs for pregnant and mothering women. The purpose of this article is to explore this element in depth in order to provide further guidance to the states in their creation of such programs.
In order to provide an in-depth look at programs and legislation in the area of treatment for pregnant and parenting women, this article will discuss national trends, but will also focus more deeply on a few individual states, namely California, Oregon and Washington. The article will demonstrate that although progress has been made in creating greater access to comprehensive drug treatment programs for pregnant and mothering women, certain legislative action is needed to further improve this access. Additionally, in writing this article it became clear that, although the data collection in this area has improved over the past twenty years, more specific data is needed in order to have a clearer picture of the exact nature of the unmet need so that the states can better address it. Thus, although the authors were able to obtain enough information to provide some suggestions to the states for providing treatment programs for pregnant and mothering women, work in the area is severely limited by the lack of accessible data.
II. THE LEVEL OF NEED FOR COMPREHENSIVE DRUG TREATMENT PROGRAMS FOR PREGNANT AND PARENTING WOMEN
As this author explained in a previous article, (2) a woman's use of drugs or alcohol during pregnancy often causes serious, and in many cases severe, physical and behavioral problems for the exposed child. (3) In order to protect as many children as possible from such harm, the states need to put in place a system that involves collaboration between their respective healthcare (including drug and alcohol treatment programs), welfare, and criminal justice systems. (4) An essential element of this collaborative system is the provision of comprehensive treatment services. (5) Such services are essential because many of the women who prenatally expose their infants to alcohol or drugs are addicted and thus need assistance in overcoming this addiction. (6) Appropriate treatment programs can provide this assistance, as demonstrated by a large body of evidence indicating that if women can obtain effective substance abuse treatment services, a majority of them will be able to improve their circumstances in many different ways. (7) For example, in Oregon for the fiscal year 2005-06, the Oregon Addictions and Mental Health Division reported that by the end of treatment, 49% of children were returned to parents who received treatment; 66% of abusers were employed; 72% of abusers had reduced their use and 73% of the abusers who started treatment completed treatment. (8) Further, the 2006 National Outcomes Measure for Oregon reported a decreased homelessness rate for those receiving treatment. (9)
Thus, in order to protect as many children as possible from prenatal drug or alcohol exposure, the state must ensure that a sufficient number of appropriate treatment programs exist for all pregnant and mothering substance abusers. In addition, it must ensure that the women can expeditiously access those programs. However, in putting together a plan for the provision of efficacious treatment programs, one must first attempt to assess whether there is an unmet need for such services. This section will make that assessment by first explaining the types of programs that are needed and why they are needed. Data will then be presented to demonstrate that, although the past twenty years have seen an increase in necessary services, a significant number of pregnant and parenting women are not being served. Several factors contribute to this unmet need. First, there continues to be an inadequate supply of the necessary programs, and second, for a variety of reasons, many pregnant and parenting women encounter difficulties in accessing the needed services.
A. Types of Programs Needed
Fairly recent developments in the field of drug abuse treatment have provided increasing insight into the types of drug treatment programs that work most effectively for women in general, and for pregnant and parenting women in particular. The necessary components of such programs are outlined below. In examining these components we can better determine what legislative and regulatory scheme will best effectuate the desired treatment outcomes.
1. Overcoming Barriers
Effective programs must be able to address the unique characteristics of substance-abusing women in general and pregnant and parenting women in particular. Most women who abuse alcohol and illicit substances face enormous challenges in overcoming their addiction. These challenges include physical, social, and economic barriers to seeking treatment. They are pervasive and exist even as the women seek treatment. Further, the challenges encompass the more rapid progression of the women's disease from use to abuse and dependence as compared to their male counterparts. (10) Pregnant and parenting women encounter the same minefield of issues as non-pregnant and childless women, but must also face a heightened level of risk in terms of physical and sexual abuse, (11) extensive social stigma, (12) and of course the complexity of balancing their own often failing health, the health of their unborn child, and the well-being of their existing children. More specifically, the affected women face personal barriers to treatment such as fear of reprisal from significant others and family members, (13) fear of not being able to care for children, (14) a fear of losing custody of their children, (15) stigma associated both with using as a woman and, more particularly as a pregnant woman, (16) fear about confidentiality, (17) and finally, a fear of making life changes. (18) In addition, research suggests that women who struggle with substance disorders are more likely to come from "drug-abusing and disorganized families" (19) and they are often isolated from healthy support systems. (20) Also complicating this sense of isolation is the fear that their partners may become abusive either because of the women's use or because the partners do not want the women to expose their own use by seeking treatment. (21) Evidence also suggests that women experience a greater rate of co-occurring medical, psychiatric and psychosocial problems as compared with their male counterparts. (22) These factors serve as barriers to substance abuse services for pregnant and parenting women. Other barriers include intrapersonal issues such as guilt, shame, a lack of knowledge about addiction, (23) and a lack of knowledge regarding how to access health care.
2. Treatment Components
In addition to overcoming the personal barriers outlined above, a treatment program must provide treatment for the disease of addiction. There are a range of service modalities available for pregnant and parenting women including detox, outpatient, intensive outpatient, and residential treatment programs. (24) Within these settings there are a wide array of interventions including psychosocial interventions, medication assisted treatment, and wrap around services, which include parenting/family skills development, prenatal care, perinatal care, domestic violence services, and childcare services. (25) The question then is, out of all the possible components, which are most effective for pregnant and parenting women.
With regard to the most effective service modalities, the existing research indicates that while more research is needed, enhanced outpatient may be just as effective as residential treatment for most women. (26) Thus, although residential treatment may be required for severely dependant women, for other women enhanced outpatient "may be preferable and more cost effective." (27) However, as between enhanced outpatient and conventional outpatient, the enhanced outpatient treatment was found by at least one study to be more effective than conventional outpatient. (28) The enhanced portion for some of these programs include the following: intensive participation, i.e., four to five days per week; urine tests; individual counseling; family education; family therapy; couples counseling; relapse prevention and twelve-step groups. (29) Others include "parenting training, education about drug use, and personal development activities." (30)
In addition to choosing between modalities, choices have to be made as to the proper treatment methods. The use of opioids by pregnant women presents a special case because research has found that for pregnant women who are dependent upon opioids, most cannot remain drug-free throughout pregnancy. (31) Thus, to avoid the fetal distress caused by a cycle of intoxication and abstinence, (32) maintenance therapy with methadone or buprenorphine is the recommended treatment approach. (33)
A review of the critical, although somewhat scant, literature on the other key components for successful treatment of pregnant and parenting women finds a range of interventions. Within this range, however, it is generally recognized that certain components lead to better outcomes. Several of the components are related to the mandate that a program be sensitive to the unique needs of women. Thus, a women-only program is most often preferred because, overall, (1) women in women-only drug abuse treatment programs were more than twice as likely to complete treatment as women in mixed-gender programs, and (2) pregnant women in women-only drug abuse treatment programs averaged more days in treatment than did those in mixed-gender programs: 87.4 days vs. 74 days. (34) Successful treatment services for pregnant women must also be family-centered, comprehensive, and staffed by an interdisciplinary team of professionals who interact with the women in a nonjudgmental, nurturing way. (35) Research also confirms that a confrontational approach does not work well with women. (36) Further, providers must be sensitive to individual cultures, must focus on the importance of communication and how language is used, and must address mental health problems. (37)
Research also indicates that increased attendance in treatment is critical to treatment success. (38) Thus, any mechanism that can improve length of stay is critical. In this regard, of overarching and critical import is the research that indicates that programs that allow the children to stay with their mother in residential treatment are more successful in retaining clients in care. (39) Similarly, for outpatient services the comprehensive review of the literature, as well as other investigations, have found that treatment for mothers is often more effective when coordinated with child care and transportation services, (40) as well as prenatal care, mental health services, and support services. (41) Further, other research on treatment strategies for pregnant and parenting women indicates that contingency management strategies are effective in improving retention rates and reducing illicit drug use of pregnant women in drug treatment. (42) Finally, motivational interviewing, educational videos, home visits and treatment as usual were all associated with greater engagement and retention. (43)
Regarding specifics, an excellent resource on the type of programs needed for pregnant and parenting women is an article by Barbara Wallace. (44) In this article, Wallace draws on her experience of working with pregnant crack cocaine smokers in an inpatient detoxification unit and a residential therapeutic community setting to present detailed recommendations that can be incorporated into existing treatment programs. (45) While a reader who wants detailed information is advised to read the article, a few highlights will be discussed. First, Wallace stresses that many addicts have a defensive stance characterized by arrogance and aloofness. Given that the stance generally is put in place to protect against feelings of pain, loss, shame, and guilt, the clinician must be careful to avoid reacting negatively to this stance, as such a reaction may cause the woman to close up, which will impede treatment. (46) Secondly, she cautions that there is no one-size-fits-all modality for pregnant substance abusers. Rather, clinicians must assess the client's needs and match that client to the proper modality. (47) Finally, for whatever modality is chosen, individual counseling is necessary to address the consequences of trauma such as child abuse, sexual abuse, domestic violence, rape and other types of violence. (48)
A final component of an effective treatment program is the provision of recovery services. As has been discussed elsewhere, such services are crucial to prevent addiction relapses. (49) As the Oregon Governor's Council stated in its 2009-2011 report, "[t]he recovery phase of treatment addresses [the] supports an individual needs to sustain sobriety: mentoring, housing, employment assistance, transportation, continued education, or socialization. Stable housing is an essential element for anyone recovering from alcohol or other drug addiction." (50)
B. Unmet Need
Many studies demonstrate that, compared with the number of women with substance use disorders, there are relatively low numbers of women in substance abuse treatment programs. (51) The reasons for this disparity are varied, but they center on the numerous barriers that women face when they seek treatment. Some barriers are systemic and some are personal. (52) The personal barriers "that women face were outlined above. (53) However, because this paper is focused on possible legislative means for expanding access to treatment services, it will primarily discuss the systemic barriers that pregnant and parenting women face. Such barriers are more amenable to legislative solutions than personal barriers. As discussed above, however, in creating effective treatment programs, the state needs to encourage the providers to be aware of and work to overcome the personal barriers. (54)
The systemic barriers that women face include insufficient programs with women or pregnant women-focused services, lack of money or insurance, unemployment, and homelessness. (55) In conjunction with these systematic and social barriers, associated logistical issues such as limited transportation, poor literacy, and a lack of child care also prevent women from seeking substance abuse treatment services. (56) In fact, some commentators contend that "little access to child care services is one of the most significant and frequently cited barriers among women who seek treatment." (57)
1. Dearth of Programs
Most commentators agree that there is an overall paucity of substance abuse treatment, reproductive, and social services tailored for women and their unique needs and lives. (58) However, very little detailed information is given as to what currently exists and what is needed. This section is designed to outline the information that currently exists on this topic. The section will examine this question in a general sense with regard to the national scene and then will focus on specific examples from Washington, California, and Oregon.
The evidence demonstrates that the past thirty years have seen a marked increase in the number of treatment programs available to pregnant and mothering women. Prior to the 1970s, there were very few treatment centers for women, let alone pregnant women. (59) In the 1970s the National Institute on Drug Abuse (NIDA) began to sponsor and develop substance abuse treatment programs for women. (60) However, in the late 1970s and early 1980s these funds began to shrink such that there was a shortage of treatment programs for women and specifically for mothers and pregnant women. (61) For example, a 1979 study found only twenty-five programs nationally for women. (62) In the late 1980s, funding became available for the creation of treatment programs for pregnant women, due largely to the perceived crack/cocaine epidemic and the effect of exposure to such drugs on a developing fetus. (63) A 1994 study found that, out of 294 facilities in five cities (including New York), 80% accepted pregnant women. (64) Unfortunately, most did not accept women on Medicaid or arrange for child care. (65) As of 1996-97, out of 2,395 treatment facilities nationwide, 562 offered special programs for pregnant women. (66)
Currently, as of 2007, out of 13,648 mental health and substance abuse facilities nationwide, 1,926 had programs specifically designed for pregnant and postpartum women. (67) This number represents 14.1% of the total treatment facilities in existence at the time. (68) However, there...
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