Student Projects
Evidence Based Clinical Practice Guideline

Midwifery Care to Women in Recovery From Substance Abuse:
An Evidence-Based Clinical Practice Guideline


Laura Russell
Laura M. Russell, RN, BSN, BSEd, SNM
Midwifery Institute of Philadelphia University
Posted Fall Term 2003

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Abstract

Women recovering from substance abuse have traditionally been considered a high risk population due to the many negative health sequelae and behaviors related to substance abuse and are at high risk for many health problems, including sexually transmitted infections, HIV, cervical cancer, depression, psychiatric disorders, malnutrition and general lack of health care. Pregnant women in recovery from substance abuse are at additional risk for poor obstetrical and neonatal outcomes. Traditionally, substance abuse has been considered a "man's" problem but with the increase in the number of women substance abusers, recovery programs which focus on the special needs of substance abusing women have been developed. A review of the current literature explored several different areas related to this inquiry including, the effects of maternal substance abuse on the developing fetus and early childhood development, women's experiences in recovering from addiction, care models for treatment of recovering women substance abusers, and care provider effectiveness in treating women recovering from substance abuse. The conceptual framework chosen to guide this inquiry was Prochaska's Stages of Change Model because it offers support and guidance to care providers in their efforts to help the individual move toward change.

Midwives, because of their philosophy and scope of care, are prepared to take on the challenge of caring for women recovering from substance abuse. Holistic care, listening, and being "with woman" are hallmarks of midwifery care. These hallmarks of care have been shown by the literature to be very effective in providing for the primary health care needs of women recovering from substance abuse, influencing aspects of their care which are most effective in the support of change. Research has clearly indicated that midwifery care, in combination with a comprehensive care model and multidisciplinary team, is effective in providing for the emotional, physical, and health care needs of recovering substance abusing women and their families. The inclusion of women recovering from substance abuse into the scope of midwifery care will serve to increase access to health care, contraceptive services, cervical cancer screening, STI/HIV testing, and prenatal and obstetric care for this vulnerable population. An evidence-based clinical practice guideline for midwifery care to women in recovery from substance abuse was developed following a review of the current literature, and analysis of the data and significant findings of the research, and is presented here.


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Chapter 1
Introduction

Identification of The Phenomenon of Interest

Women in recovery from substance abuse present many health care challenges. Traditionally, substance abuse has been defined as a "man's" problem (Goldberg, 1995). Drug abuse and addiction research has focused primarily on men, as has most health research. Substance abuse and recovery present different challenges to women's health, may progress differently than in men and may require different treatment approaches (Mathias, 1995). Factors thought to be involved in the etiology of substance abuse among women include childhood and adolescent sexual abuse, partner violence, anxiety disorders, and depression, and the inappropriate treatment of these disorders (Mathias, 1995). Treatment facilities and in-patient recovery programs have been developed focusing on the needs of male substance abusers. Recently, the special needs of women substance abusers and women in recovery have begun to be identified as areas in need of research (Mathias, 1995).

Health services for women struggling with substance abuse must be broadened to include not only drug treatment but also primary health care and STD/AIDS treatment (National Institute on Drug Abuse [NIDA] Service Research Recommendations, 1995), as well as child care, counseling, mental health services, housing, nutrition, safety, and family planning. It has been demonstrated that women who were able to have their children in treatment with them remained in treatment for longer periods than women who were in treatment without their children (Connors, Donovan, & DiClemente, 2001). Pregnant substance abusing women want and need health care (NIDA Service Research Recommendations, 1995) but less than 25% will actually seek care prior to labor because of fears of ridicule and of having their child or children taken away (Huestis & Choo, 2002). When pregnant and nonpregnant women drug abusers seek health care, they often face barriers such as facilities with limited treatment capacity, long waiting lists, and lack of child care or women's health care services (Corse & Smith, 1998). Treatment programs and health care for these women must be readily available and designed specifically with these women's needs in mind (Hanson, Venturelli, & Fleckenstein, 2002).

Women recovering from substance abuse have traditionally been considered a high risk population due to the many negative health sequelae and behaviors related to substance abuse. These women often have dual diagnoses of substance abuse and mental health disorders. Depression is common and can often be linked with a history of childhood abuse, childhood exposure to a parent who is/was an alcoholic and/or drug addict, current abuse, low economic status, unemployment and low level of education (Snow & Anderson, 2000; Weaver, Turner, & O'Dell, 1999). Depression also influences the recovery process, being cited as a major factor in relapse (Snow & Anderson, 2000; Weaver et al., 1999). The physical and behavioral effects of substance abuse put these women at high risk for STIs, HIV, cervical cancer, psychiatric disorders, depression, malnutrition and general lack of health care (Windle, 1997). Pregnant substance abusing women and recovering women are at risk for compromised maternal and fetal outcomes such as miscarriage, pre-term delivery, intrauterine fetal death, placental insufficiency, eclampsia, septic thrombophlebitis, post partum hemorrhage, fetal distress, low birth weight and fetal malformations (Corse & Smith, 1998; Huestis & Choo, 2002). In 1988, an estimated 1.5 million women in the United States were in need of drug treatment, of these, an estimated 6% actually received treatment (Corse, McHugh, & Gordon, 1994). A National Association of State Alcohol and Drug Abuse Directors, Inc. study in 1990, found that an estimated 280,000 pregnant women nationwide were in need of drug treatment yet less than 11% actually received care (Jansson, Svikis, Paluzzi, Rutigliano, & Hackerman, 1996).

Healthy People 2010 (2001) has identified substance abuse as one of the top focus areas in our efforts to improve our nation's health and as one of the leading indicators which greatly affect the health of individuals and communities. The DSM - IV defines substance abuse as "that a person uses a psychoactive substance when expected to perform significant tasks at home, work, or school or when it is physically hazardous and that he or she continues to use a psychoactive substance despite awareness that such use is causing major problems in one or more aspects of life, such as financial, legal, psychological, or marital (APA, 1994). A 1988 study identified there were 4.6 million adults in need of treatment for regular or problematic drug use, 32% (1,472,000) were women (Corse & Smith, 1998). Figures from 1998 suggest that 24.5% of the United States female population use illicit drugs, of these women, 90% are of childbearing age (Hanson et al., 2002). Among all pregnant women, 5.5% reported taking an illicit substance at least once during pregnancy, this translates into an estimated 221,000 pregnant women with potential substance abuse problems (Smeriglio & Wilcox, 1999). In 1999, the Treatment Episode Data Set (TEDS) recorded more than 400,000 admissions of women of childbearing age (15-44) to substance abuse treatment facilities. Pregnancy status was reported by 43 states and the District of Columbia. Pregnant women represented 4% (16,000) of all TEDS admissions in those states that reported. This number does not include women who became pregnant or became aware of their pregnancies during treatment. Current statistics indicate that drug use/abuse by women is increasing. There has been an increase in the tendency of older women tend to abuse tranquilizers, sedatives, and antidepressants, and teenage girls are surpassing boys in the use of alcohol and tobacco (Hanson et al., 2002). Pregnant women are more likely than nonpregnant women to seek and enter treatment for cocaine abuse (Drug and Alcohol Services Information System [DASIS] Report, 2002). There have been more women seeking emergency treatment for heroin and marijuana, and the number of women seeking emergency treatment for substance abuse in general has risen (Hanson et al., 2002).

When discussing pregnant drug abusing or recovering women, it is important not to forget their babies. In utero drug exposure can have serious impact on the developing fetus and also during later stages of the child's life. Only 25% of substance abusing women receive prenatal care prior to labor, of this 25% who do seek care, most delay care until the third trimester of pregnancy (Huestis & Choo, 2002). More than 75% of infants exposed to drugs in utero have major medical problems and the cost of treating drug-affected infants is twice the cost of nonaffected infants (Huestis & Choo, 2002 ). Infants of mothers who are substance abusers are at high risk for prematurity. Seventeen percent of drug exposed babies are born prematurely, more than double that of babies not exposed. In addition to prematurity, drug exposed babies are at risk for many other complications including low birth weight, decreased length, small head circumference, impairment of brain development, intrauterine growth restriction, placental insufficiency, malformations, fetal distress and intrauterine fetal death. Drug exposed babies may also be at four times higher risk of dying from sudden infant death syndrome (SIDS) (Huestis & Choo, 2002). Pregnancy outcomes can be dramatically improved if women have access to substance abuse treatment programs that meet their needs and provide care that is non-punative, non-judgemental and nurturing (Goldberg, 1995; Huestis & Choo, 2002).

Drug dependent women are more likely to be unemployed than addicted men, because of this, they often feel that good drug treatment programs are unaffordable (Hanson et al., 2002). Forty two percent of pregnant women entering treatment had no health insurance, of those who did have health insurance 45% were covered by Medicaid/Medicare (DASIS Report, 2002). Women entering substance abuse treatment programs may have considerable heath needs which have been neglected for long periods of time due to lack of employment, health insurance, health care availability, and the woman's own lack of initiative at seeking out health care for herself. Treatment programs which address the woman's physical and psychological health care concerns early in her treatment may have positive effects on her general well-being and may increase her chances for full participation in the recovery process. Midwives, because of their philosophy and scope of care, are prepared to take on the challenge of caring for substance abusing and recovering women and their families.


Significance to Midwifery and Women's Health

Significance to Women's Health

Substance abuse and its sequela result in large human and financial costs incurred by women, their families and society in general (Healthy People 2010, 2001). Little research has been done to identify sex differences in psychosocial and behavioral drug treatment approaches for women. Research that has been done on drug abuse treatment and rehabilitation has been done using male populations with the results extrapolated to women. Women's responses to drugs may also be significantly different than men's responses, however, little research has been done in this area as well (Hanson et al., 2002). Studies that have been done so far indicate women have special needs for comprehensive programs which include child care, medical care, family planning/contraception services, STI/HIV screening and counseling, transportation, housing, education, lesbian issues, prenatal and obstetric care, and dealing with the effects of depression, violence and abuse (NIDA Service Research Recommendations, 1995; DASIS Report, 2002). Women drug abusers are at great risk for STIs, HIV/AIDS, tuberculosis, malnutrition, cervical cancer, oral and pharyngeal cancer, injury, physical and emotional abuse, depression and general lack of health care (Women's Health Statistical Information, 2003). It is estimated that more than one third of substance abusing women are involved in exchanging their bodies and sex for drugs or money (Windle, 1997) which puts them at increased risk. Pregnant substance abusers are at risk for a multitude of obstetric complications including placental insufficiency, intrauterine growth restriction, intrauterine fetal death, preterm birth, miscarriage, and post partum hemorrhage, among others. Their babies are at risk for low birth weight, poor brain development/growth, drug withdrawal, malformations and other serious medical problems (Huestis & Choo, 2002). Pregnant women who are recovering from substance abuse and not currently using drugs or alcohol remain at increased risk for poor perinatal outcomes because of pre-existing poor health related to their prior substance abuse (Hanson et al., 2002).

Families of addicted women also suffer. In our society, women are often the "glue" that holds families together. Despite addiction, depression, loneliness, abuse, and divorce, women are expected to work, to bear the burden of raising children, perform domestic chores, and keep the family together. Many women feel that they cannot postpone or delegate the care of their families for the time it would take to participate in drug treatment. Women suffering from drug addiction are often judged by a double standard and receive less support from family and friends (Hanson et al., 2002). Spouses/significant others, relatives, and friends will often deny that the woman has an addiction problem and may actively oppose her seeking treatment (Connors et al., 2001). Addicted women may be seen by family members, friends, and society as selfish, weak, spoiled, deviant, or immoral. These women are afraid of being condemned and are less likely to seek out help for their addiction problems (Hanson et al., 2002).

Access to health care is also a problem for substance abusing women and recovering abusers due to lack of availability, lack of insurance and women's fears of prosecution and of having their children taken away. Women substance abusers, particularly those who are pregnant, want and need health care but they will end contact with health care providers who appear to judge, blame or humiliate them because of their drug use (NIDA Service Research Recommendations, 1995). Women substance abusers and women recovering from substance abuse are a vulnerable population in need of comprehensive services provided by non-judgemental, nurturing health care providers. The inclusion of women recovering from substance abuse into the scope of midwifery care will serve to increase access to health care, contraceptive services, cervical cancer screening, STI/HIV testing, and prenatal and obstetric care for this vulnerable population.

Significance to Midwifery

Hallmarks of midwifery practice include: empowerment of women as partners in health care, facilitation of healthy family and interpersonal relationships, promotion of continuity of care, health promotion, disease prevention and health education, skillful communication, guidance and counseling, therapeutic value of human presence, collaboration with other members of the health care team, and care to vulnerable populations (ACNM, 2003). All of these hallmarks of practice can be applied to providing safe, effective, satisfying care to women in recovery from substance abuse. It is the philosophy of the American College of Nurse-Midwives that midwives believe that every individual has the right to safe, satisfying health care with respect for human dignity and cultural variations. Midwives support each person's right to information and to active participation in all aspects of care (ACNM, 2003). The National Institute on Drug Abuse (NIDA) has put forth a plea to those involved in women's health care "to improve the situation for those women who are suffering from drug addiction" (Mathias, 1995). The March of Dimes similarly endeavors to encourage programs which provide prenatal and preconception health care to women less likely to seek care with the purpose of preventing prematurity and other birth defects. The American College of Nurse-Midwives assumes a leadership role in the development and promotion of high quality health care for women and infants both nationally and internationally (ACNM, 2003). Midwives, because of their education, philosophy and scope of care, are prepared to take on the challenge of caring for substance abusing and recovering women and their families. Midwifery care has already been shown to positively impact outcomes for pregnant substance abusing women and their babies (Corse & Smith, 1998). Evidence-based practice guidelines provide a map for midwives who provide care to substance abusing and recovering women. This inquiry will lay the groundwork for evidenced-based practice guidelines for full-scope midwifery care to women in recovery from substance abuse.

Gaps Between Current Practice and Evidence-Based Practice

Midwifery care has not been routinely provided to women in recovery from substance abuse because this population has traditionally been considered high risk and these women have been referred to physician care. Recent research has indicated that outcomes for selected populations of high-risk women who are cared for by midwives are the same as or better than national outcomes resulting from a more traditional medical model of care (Barkauskas, Low, & Pimlott, 2002; Davidson, 2002) and that the midwifery model of care has been shown to be effective when applied to the special needs of abusing and recovering women. Midwives have traditionally provided health care to vulnerable populations, offering non-judgemental, nurturing care (American College of Nurse-Midwives (ACNM, 2003). Women in recovery from drug and alcohol abuse represent one such population of women that can be effectively cared for by midwives.

After careful review of the current literature, evidence-based clinical practice guidelines (EBCPG) have been developed to guide the midwife practitioner in caring for women with substance abuse problems. Because of the health risks associated with substance abuse, midwifery care to these women must include primary health care, gynecological services, annual exams, PAP smears, STI/HIV testing and counseling, contraception and family planning services, pregnancy testing, and prenatal, intrapartum and post partum care. These services are most effectively provided within the context of a holistic midwifery model which focuses on the care of the whole woman, operating within or providing links to substance abuse treatment services, mental health services, domestic violence services, private and community services, housing, transportation, food, jobs, and child-care. The care of the substance abusing and recovering woman is best accomplished through a multidisciplinary system which is non-punitive and supports her readiness to change (Brown, Melchior, Panter, Slaughter, & Huba, 2000; Corse & Smith 1998; Jansson,et al., 1996).

Theoretical and Operational Definition of Terms

The definition of substance abuse used in this inquiry is that of the American Psychological Association (1994), "that a person uses a psychoactive substance when expected to perform significant tasks at home, work, or school or when it is physically hazardous and that he or she continues to use a psychoactive substance despite awareness that such use is causing major problems in one or more aspects of life, such as financial, legal, psychological, or marital."

The definition of midwife used in this inquiry includes Certified Nurse-Midwives (CNMs) and Certified Midwives (CMs) who are certified by the ACNM designated certifying agent, show evidence of continuing competency as required by the ACNM designated certifying agent, and are in compliance with the legal requirements of the jurisdiction where the midwifery practice occurs (ACNM, 2003). Midwifery practice is defined as: "Midwifery practice as conducted by certified nurse-midwives (CNMs) and certified midwives (CMs) is the independent management of women's health care, focusing particularly on pregnancy, childbirth, the post partum period, care of the newborn, and the family planning and gynecologic needs of women. The CNM and CM practice within a health care system that provides for consultation, collaborative management, or referral as indicated by the health status of the client. CNMs and CMs practice in accord with the Standards for the Practice of Midwifery, as defined by the American College of Nurse-Midwives" (ACNM, 2003).


Assumptions and Philosophical Approach

Substance abusing and recovering women want and need health care (NIDA Service Research Recommendations, 1995). They are at increased risk for a multitude of health problems related to their present and past substance abuse and the high risk behaviors associated with that abuse. The physical and behavioral effects of substance abuse put these women at high risk for STIs, HIV, cervical cancer, psychiatric disorders, depression, malnutrition and general lack of health care (Windle, 1997). Pregnant substance abusing women and recovering women are at risk for compromised maternal and fetal outcomes such as miscarriage, preterm delivery, intrauterine fetal death, placental insufficiency, eclampsia, septic thrombophlebitis, post partum hemorrhage, fetal distress, low birth weight and fetal malformations (Corse & Smith, 1998; Huestis & Choo, 2002).

Women substance abusers and women recovering from substance abuse are a vulnerable population in need of comprehensive services provided by non-judgemental, nurturing health care providers. Midwives have traditionally cared for vulnerable populations with extraordinary outcomes. Health care to women recovering from substance abuse must include primary health care, STI/HIV testing and counseling, gynecological care, pregnancy testing, prenatal, intrapartum, and post partum care, family planning, and contraception, in concert with a comprehensive treatment program which includes substance abuse treatment services, mental health services, domestic violence services, private and community services, housing, transportation, food, jobs, and child-care. These services may be best provided by midwives working in collaboration with Ob/Gyn physicians, pediatricians, perinatologists, neonatologists, counselors, therapists, educators, psychologists, social workers, facility staff, community workers, child-care workers, and transportation specialists.

Limitations of the State of Science in this Area

Traditionally, substance abuse has been defined as a "man's" problem (Goldberg, 1995). Drug abuse and addiction research has focused primarily on men, as has most health research. Women's responses to drugs may be significantly different than men's responses, however, little research has been done in this area (Hanson et al., 2002). Substance abuse and recovery present different challenges to women's health, may progress differently than in men and may require different treatment approaches (Mathias, 1995). Treatment facilities and in-patient recovery programs have been developed focusing on the needs of male substance abusers. Little research has been done to identify sex differences in psychosocial and behavioral drug treatment approaches for women. The majority of the research that has been done on drug abuse treatment and rehabilitation has been done using male populations with the results extrapolated to women (Hanson et al., 2002). Recently, the special needs of women substance abusers and recovering substance abusers have begun to be identified as areas in need of research (Mathias, 1995).


Chapter 2
Review of The Literature and Conceptual Framework
Review of the Literature

Methods

A literature search was done by accessing the Wright State University Libraries, Dayton, OH. The Academic Search Primer was used because of the availability of full-text articles and the large number of journals available at this site to search for articles relevant to this inquiry . The search engine was enlisted to search for articles published from January 1993 through August 2003, using the keywords: maternal drug abuse, substance abuse, prenatal, newborn, infant, fetal exposure and neonate in various combinations. Full-text articles in PDF and HTML format were down loaded and printed out on July 7, 2003 and August 8, 2003. Additional articles were obtained by searching the ACNM on-line database for the Journal of Midwifery & Women's Health and two articles used for this review were provide by the course instructor. Thirty six articles were obtained and ten were selected for review. Articles were chosen according to their relevance to this inquiry and quality of research.

Review

Infant Outcomes

Babies exposed to drugs, alcohol and/or cigarettes in-utero are at risk for prematurity and many other complications including low birth weight, decreased length, small head circumference, impairment of brain development, intrauterine growth restriction, placental insufficiency, malformations, fetal distress and intrauterine fetal death (Huestis & Choo, 2002). Despite these risks, recent studies by Cosden and Peerson (1997) and Nair and Rothblum (1994) suggest that many drug exposed infants may not have significant negative outcomes. However, after looking carefully at the data, the infants of substance-abusing women do seem to be at greater risk.

Cosden and Peerson (1997) studied the contribution of intra-uterine and extra-uterine maternal substance abuse factors on child outcomes. The purpose of the study was to assess the impact of maternal substance abuse on birth outcomes and cognitive and motor development for children whose mothers had entered into a substance abuse treatment program. Data were obtained on 80 infants in two residential substance-abuse treatment programs in Southern California. Sixteen infants were born while their mothers were in treatment and sixty-four mother-child pairs entered treatment postpartum. Half of the infants were girls and half were boys. Birth outcomes were coded from copies of medical records and sent to the investigators by local hospitals with maternal consent. The records were coded for the following information: Apgars at 1 and 5 minutes, gestational age, birthweight, length of hospitalization, birth problems including - central nervous system (CNS), behavioral, seizures, cardiological, gastrointestinal, respiratory, or other congenital problems, and maternal toxicology screen results at time of birth. Results reported that most infants were born full-term (N=77, Mean=38.79 weeks, Standard Deviation=2.28 with a Range of 33 to 43 weeks), were of normal weight (Mean=2933.48 grams, Standard Deviation=669.68 grams, Range=1320 to 5188 grams), with relatively high Apgar scores (1 min.- Mean=8.05, 5 min. - Mean=8.95). Differences in these findings were not significantly related to whether the mother entered the treatment program while pregnant or postpartum. The most common birth problem was respiratory difficulty including: apnea, respiratory distress syndrome, increased respiratory rate or decreased respiratory rate (N=18, 22.5%), followed by problems with CNS functioning: jittery, irritable, agitated, hypertonic, tremors, poor sleeping (N=16, 20%), and cardiac problems including irregular heartbeat, bradycardia, heart murmur and an atrial septal defect (N=9, 11.25%). Low Apgar scores were associated with lower birth weight, the presence of congenital problems and longer hospital stays. There were 21 (31.25%) positive maternal toxicology screens at birth, these were correlated with lower birth weight, behavior problems and congenital problems. Assessment of infant development was accomplished using the Bayley Scales of Infant Development, 1969 and the Bayley Scales of Infant Development II, 1993. The tests were administered to the children by an occupational therapist within 2 months of birth of mother's entry into treatment. Results indicated the majority of both groups of children (those born while their mother was in treatment and those whose mothers entered treatment postpartum) had scores in the normal range. A chi-square analysis found that children born in the program were less likely to have a low developmental score than children whose mothers entered the program postpartum.

This study reported normal birth weights, gestational ages and 1 and 5 minute Apgar scores for 80 children born to women who entered a substance-abuse treatment program either prenatally or during the postpartum period (up to 30 months). The authors also state that the majority of these children did not show significant problems at birth. I do not agree with the authors conclusions, in fact I believe the results indicate that infants and children exposed in-utero to illicit substances, alcohol and cigarettes are at increased risk for problems at birth. The mean birth weight of infants in the study was 2933.48 grams which is approximately 6lbs 7.5 oz. The mean gestational age was 38.79 weeks, normal expected weight for a baby born at approximately 39 weeks is 3225 grams or 7lbs 2 oz. (Varney, 1997). The infants in the Cosden and Peerson (1997) study averaged more than one half pound below the expected birth weight for a baby of the same gestational age. Also, the study reports that 22.5% of the in-utero drug exposed infants at birth had respiratory problems and 20% had CNS problems. Beischer and Mackay (1986) present data on the incidence of respiratory distress syndrome in 41,057 consecutive live-births. Of these births, 3.3% (N=1,361) had respiratory distress problems, a much smaller proportion than the 22.5% reported by Cosden and Peerson as not significant. The percentage of CNS problems likewise seems disproportionately high considering the small study sample. The developmental scores reported in this study are confounded by the various timing of entry of women and their children into a drug treatment facility, also the motor and cognitive assessments do not address problems related to social behavior or exposure to abusive, chaotic or less-than-nurturing environments.

A study by Nair and Rothblum (1994) reports no significant difference between cocaine/opiate-exposed and drug-free infants in race, socioeconomic status, maternal age, birth weight, head circumference, length and Apgar scores. The study reports the neonatal outcome of infants with evidence of prenatal exposure to metabolites of cocaine, opiates, and marijuana by meconium analysis. Meconium was collected anonymously from 141 infants admitted to the term nursery over an 8-week period in February and March of 1991 at the University of Maryland Hospital, representing 60% of all infants delivered during that period. Maternal race, age, parity and type of insurance were representative of the population receiving care at this hospital. In this study, which was conducted using a sample of full-term, well newborns, 47.5% had evidence of exposure to one or more elicit drugs during fetal life. Of the 47.5% that tested positive for drug metabolites, metabolites of cocaine and/or opiates were detected in 39%, heroin in close to one fifth and marijuana in 17%. In the samples that were positive, more than one drug metabolite was detected in 49.1%. No drug metabolites were found in 52.5%. Infant outcome showed no difference in mean birth weight, gestational age, head circumference, length or Apgar scores between the two groups (those that tested positive for drug metabolites and those that tested negative). Clinically, some differences were noted. More of the exposed infants were worked up for sepsis and infection was confirmed in one third of these infants compared to none in the non-exposed group. Also, the exposed infants had an increased length of hospital stay due to a higher frequency of suspected sepsis, neonatal abstinence syndrome, birth asphyxia, and hyperbilirubinemia. The mothers of the exposed infants were significantly more likely (almost twice as likely) to have had a sexually transmitted infection during pregnancy.

This study indicates that most of the infants admitted to a term nursery with positive meconium drug screens indicating fetal drug exposure appeared normal and clinically indistinguishable from non-drug exposed infants. A population bias existed in this study as it looked at only full-term infants, excluding preterm and ill newborns. It is suspected a similar meconium sampling in a neonatal intensive care unit would reveal very different results. A significant finding however, is the strong correlation of sexually transmitted infections in the mother during pregnancy and positive meconium drug metabolites. Future studies must include preterm and sick infants as well as normal-appearing term infants. It is proposed by Nair and Rothblum (1994) that the effects of drug exposure on fetal growth may be related to severity of substance abuse and future studies need to attempt to quantify exposure.

Factors in Recovery and Relapse

Women substance-abusers and recovering substance-abusers face many challenges. They are at high risk for many health problems, especially sexually transmitted infections, HIV, cervical cancer, depression, psychiatric disorders, malnutrition and general lack of health care. They have frequently been abused, physically, emotionally and sexually as children, and most have been brought up in households where one or both parents, and often grandparents also, are chemically dependent (Snow & Anderson, 2000; Weaver et al., 1999). The process of recovering from addiction and the factors influencing relapse and recovery must be explored in order to understand the abusing and recovering woman. Several studies have given insight into what it takes for the substance-abusing woman to move into and maintain recovery and the factors which may cause her to relapse. This information is important when planning treatment programs and health care programs for substance abusing women and/or women in recovery.

Snow and Anderson (2000) proposed the following questions to guide their exploratory study: - How do alcohol and drug addicted women in relapse and recovery compare demographically and by history of substance abuse, past or current violence, and co-occuring addictions? - What factors are associated with relapse among alcohol and drug addicted women? - and, What factors are associated with abstinence among alcohol and drug addicted women in recovery? This descriptive, exploratory study used two independent convenience samples: women who had relapsed to drug or alcohol use and women who were continuing in recovery. Relapse was defined as the return to drug or alcohol abuse which resulted in being readmitted to a treatment program. Recovery was considered to be the abstinence from drug or alcohol use with participation in a support program or group, for two or more years. Fifty women who met criteria for inclusion were identified and obtained for each group, relapse and recovery. All subjects in both groups were over 18 and spoke English. The researchers developed their own tool specifically for this study because an instrument exploring factors associated with relapse and recovery was not available. The tool was developed based on literature review and the authors' personal clinical observations. Demographically, results indicated that compared to the recovery sample, relapse subjects were found to be: younger, less likely to be employed in either professional or semi-professional occupations, lacking college education, and unmarried as a result of divorce, separation, death of a spouse or never having been married. All of the women, those who had relapsed and those in recovery, were adult daughters or granddaughters of alcoholics or drug addicts and most had high rates of childhood abuse in their past. Depression was the most commonly reported stressor to influence relapse, followed by not attending a 12-step program, a personal crisis or life stressor, cravings, isolation, and no other known way to cope. Factors influencing recovery included attending a 12-step program, motivation to change, connection to family or friends, increased self-esteem, and nonreligious spiritual support. Women in recovery often traded their addictions for more socially acceptable addictions, such a work, nicotine and/or caffeine.

It is important to learn about influences and behaviors which impact women to either relapse or maintain sobriety when designing programs or services to meet their specific needs. This study provides insight into the factors which may influence maintenance of recovery or relapse in a population of women. The strength of this study is that it is a descriptive and exploratory study which seeks to identify differences between two groups of women who have relapsed into drug or alcohol abuse/addiction and women who had been able to maintain sobriety. Also, the sample size, 50 in each category, was adequate for the purposes of the study. Weaknesses include use of a nonstandardized tool and use of non-matched convenience samples. The authors suggest future research with demographically matched samples which may identify different triggers or stressors. They also suggest longitudinal studies which may follow women through recovery, relapse, and recovery, exploring factors which influence the recovery continuum.

Depression was reported by Snow and Anderson (2000) as the most commonly reported stressor to influence relapse. A study by Weaver et al. (1999) was done with the purpose of determining the level of depressive symptomatology experienced by women recovering from alcohol and other drug addictions, to identify the nature and extent of psychological stress and coping strategies experienced before and during recovery, and to examine differences in depressive symptomatology by demographic characteristics, psychosocial stress, and coping strategies. A purposive sampling procedure was used to recruit 102 participants who were identified and recruited by substance abuse counselors and educators, interviewers and study participants. They were residents of the Galviston-Houston area of Texas and had maintained continuous abstinence from drugs and alcohol for 1 to 5 years, were 18 years of age or older and were African-American or Anglo-American. Face-to-face interviews were conducted by recovering women in an attempt to decrease the likelihood of socially desirable responses. The variables investigated were: depressive symptoms (dependent variable), sources of stress, coping strategies, drug misuse and treatment history, and sociodemographic characteristics. The overall findings indicated that these women were functioning reasonably well in their recovery but need continued help in strengthening self-acceptance and coping skills. Many continued to use ineffective coping strategies such as procrastination, self criticism and poor eating habits. One third of the women were at risk for depression and more than three fourths cited emotional health as a stressor. Stressors that continued to be a problem during recovery included money, emotional health, physical health, close family friends, marital/intimate relationships, and parenting. Nearly three-fourths reported parental substance abuse, also, nearly three-fourths used more than one drug with alcohol and marijuana used as secondary drugs. Women who were married or cohabiting were at greater risk for depression and sited intimate relationships as a main source of stress.

This study gives insight into the sources of stress, coping skills and risks of depression for women recovering from substance abuse. When developing health care and recovery programs for women, special attention must be given to their specific needs in these areas. Implications include the need for health care which addresses the physical, psychological and emotional needs of women in recovery. Weaknesses of this study include a small sample size and that the sample was nonrandomized. Also, it included only African-American and Anglo-American women to the exclusion of other ethnicities. One must be cautious in the generalization of this study's findings to all recovering women.

A structural description of the experience of recovering from addiction through an analysis of the lived experiences of three subjects is described in a phenomenological study by Banonis (1989). Volunteers known by the researcher were invited to participate and were selected according to length of time from last addictive use, not less than 2 years but not more than 5 years, and ability to articulate personal experiences. The Giorgi modification of the phenomenological method was used in the study because it preserves the meaning of the phenomenon within the context of each subject's experience. The elaborate descriptions from each subject were studied intensely through the procedure of intuiting, analyzing, and describing. "Recovering from addiction emerged from the findings of this study as a lived experience of choosing the struggle to pull the self out of a well of darkness into the comfort of light." Each of the three subjects described becoming profoundly aware of pulling themselves out of the deepest darkness of despair.

This study reveals the perceived lived experiences of three women recovering from addiction. The strength of this study is that the meanings of the experiences of the three subjects were identified using their own words, not the words of the researcher. The primary weakness of this study was that the sample volunteers were previously known by the researcher. This may have influenced the results because the volunteers responses may have been biased toward known attitudes and opinions of the researcher. Implications for future phenomenological studies in this area would be that of obtaining a larger sample to validate the implications of this study and by use of subjects unknown to the researcher. The results, although obtained from a small sample, shed light into the thoughts and feelings of the drug addicted and recovering woman and can be used by health care providers in developing programs to provide sensitive, caring support.

Programs for Pregnant Women

Pregnant women recovering from substance abuse and pregnant substance abusing women present particular challenges to health care providers. Programs designed specifically for these women have begun to be developed. Attitudes of care providers, combining efforts of various disciplines, and enhanced efforts toward provision of prenatal care by midwives have been identified as possible effective strategies to provide care for substance abusing and recovering women. Research has begun to show the value and effectiveness of midwifery care to high risk, vulnerable populations. The American College of Nurse-Midwives (ACNM) estimates that 70% of women who receive care from CNMs can be considered vulnerable (ACNM, 1996). The art and science of midwifery is characterized by skillful communication, guidance and counseling, care which focuses on the woman and her family, and empowerment of women as partners in their own health care (ACNM, 2003). A component of basic midwifery care is that the midwife applies her knowledge and skills in the management of health risks which include domestic violence, sexually transmitted infections, and illicit drug, alcohol and tobacco use (ACNM, 2003).

Corse, McHugh, and Gordon (1994) looked at the impact of care provider attitudes on treatment. A group practice of Certified Nurse-Midwives at a prenatal office in a full-service nonprofit hospital near a suburb of a large metropolitan area began a 3-year demonstration program for the prevention and treatment of alcohol, tobacco, and other drug abuse among pregnant and postpartum women, funded by the federal Center for Substance Abuse Prevention. A model of care was developed to enhance care provider effectiveness in prevention and intervention. Substance abusing women were kept under the midwife's care rather than immediately referring them to the obstetrician, length and frequency of prenatal appointments was increased, on-site addiction services were offered, and multidisciplinary teamwork was initiated. Using this model, the nurse-midwife worked closely with each patient and with on-site counselors to provide comprehensive and integrated care which addressed medical, addiction, and psychosocial needs. This was a naturalistic study of the process of implementing this model of treatment for pregnant women with substance abuse problems in a prenatal setting and changes in caregiver attitudes and behaviors toward substance-abusing women during this process. Data were gathered on a continual basis through observation of the staff at meetings and ongoing training sessions over an 18 month period. Training sessions included interviewing skills, the nature of addictions, and addiction treatment. Interviews were conducted with each of the nurse-midwives nine months into the project. All staff were asked by interviewers, following an outline of questions, to describe how substance abuse issues had been handled in the past compared to the present and what changes they experienced in women's responses toward them. The interviews were then transcribed verbatim, checked for accuracy and analyzed using the method of constant comparison. The data were then broken down into units of information and sorted into categories that revealed recurring themes and ideas about the program through the eyes of the Nurse-Midwives. Results indicated that education, training and changes in the health care delivery model led to changes in the attitudes and behaviors, and increased effectiveness of the Nurse-Midwives toward substance abusing pregnant women.

The nurse-midwives in this study received training on addiction, addiction recovery, and how people change addictive behavior. Their efforts were influenced by the 1992 work of Prochaska, DiClemente, and Norcross, incorporating the idea that change happens when the client is ready, not when the caregiver is ready. Nurse-Midwives described a shift from working on their own agenda to listening to the client and responding to what the client was saying. They also described a shift in their attitudes toward substance abusing women and a decrease in their anxiety through their understanding that the client must be ready to change and, until she is ready, the caregiver is powerless to effect change. Rather than working to change the attitudes of the clients, the Nurse-Midwives changed their own attitudes and subsequently described the interactions between themselves and their clients as more comfortable, open and empowered. A weakness of this study is that data were not collected from the clients describing their experience of the changes, if any, of the attitudes of the care providers. Another weakness is the small number of Nurse-Midwives who were interviewed for the study (N - not given). The study does, however, begin to give insight into ways to deal with the feelings of frustration and ineffectiveness care providers often experience when dealing with substance abusers and offers possible insight into ways to change perception of a client's attitude of withholding, dishonesty and noncommunication into communication which is seen as more comfortable, honest and empowered.

In another study, reported by Corse and Smith (1998), an enhanced prenatal care model was designed to reduce substance abuse among pregnant women and improve birth outcomes. The ANGELS Program was built upon the holistic nature of nurse-midwifery care to move the care of substance abusing women beyond the usual screening and referral practices generally employed by Certified Nurse-Midwives (CNMs) because of the 'high risk' label these clients receive. CNMs conducted ongoing prenatal care, assessment, education, intervention and referral, and focused on building trusting relationships with clients.. Intervention was targeted to patient readiness to change. Seventy-seven pregnant women seeking prenatal care in a suburban office were identified as abusers of alcohol or other drugs. Abuse was defined as heavy use of alcohol (use at least 3 times per week or a pattern of bingeing) and/or any use of illicit drugs or abuse of prescription drugs. Women in this setting identified as having alcohol or drug abuse problems tended to be Caucasian (69%), unmarried (84%), and without private insurance (94%), with an average age of 26 years and an average of two prior pregnancies. A computerized database stored data from all prenatal patients which included sociodemographic characteristics, previous medical and pregnancy history, current and past use of alcohol, cigarettes, and other drugs, course of pregnancy, labor and delivery, gestational age, birth weight, Apgar scores, complications, use of prenatal counseling services and a CNM assigned rating of either "no change", "somewhat reduced", or "largely abstinent" (dependent variables) for each substance used by the woman at the start of prenatal care. Discriminant analysis was used to determine the differentiating characteristics of women with substance abuse problems who were able to reduce their substance abuse to almost nothing, those who cut down somewhat, and those who made no change during their pregnancy. These dependent variables were specified in the study: alcohol use severity, cannabis use severity, and cocaine use severity. These were coded by the CNM at baseline as 0 = no use, 1 = occasional use, 2 = at least 3X per week or a pattern of bingeing, 3 = evidence of tolerance or loss of control. Additional dependent variables were: psychosocial problems, weeks gestation at the first prenatal visit, total number of prenatal visits, and number of visits with an addiction counselor. Results indicated that 87% of the 77 women identified as substance abusing at the start of prenatal care who participated in the ANGELS Program showed a reduction in drug and/or alcohol use, 51% of the 77 women were largely abstinent over the course of pregnancy, 35% reduced their use somewhat and 14% showed no change in their substance use by delivery. Discriminant analysis was conducted to determine the characteristics that differentiated those women who were largely abstinent from those women who showed no change. Women who showed no change in their substance use during the course of their pregnancy tended to use cannabis and cocaine more frequently, had greater psychosocial stress, and began prenatal care later than women who were able to reduce or largely eliminate substance use. These results of this study suggest that women who initiate prenatal care late in pregnancy, evidence frequent use of cannabis, cocaine or both (often in addition to alcohol), and have significant psychosocial problems are unlikely to reduce or stop their substance use during the course of their pregnancy.

This study gives the care provider pause to consider the likelihood of effectiveness of current intervention strategies during prenatal care aimed at reducing or eliminating substance use for the woman who abuses drugs and/or alcohol heavily. Programs that meet the needs of heavily abusing women, those who may need assistance beyond the strategies offered by typical substance abuse programs, may also be an important aspect of future research and program development. This study provides hope for care providers in that, in conjunction with a comprehensive, holistic care model, the majority of women identified as having substance abuse problems at the start of prenatal care can be largely abstinent by delivery. The study also provides evidence that midwives can provide effective care to women with pregnancies complicated by substance abuse. Weaknesses in this study were the small sample size and lack of a matched control. Future studies need to address the environment in which the child will be raised or likelihood the woman will return to previous patterns of substance abuse after the pregnancy. Comprehensive care models such as the ANGELS Program show promise in the treatment of pregnant women with substance abuse problems by midwives.

A study by Jansson et al. (1996) presents the results of a study conducted at The Center for Addiction and Pregnancy (CAP). The CAP Program provides a comprehensive care model which combines pediatrics, substance abuse treatment, obstetrics/gynecology and family planning, as well as offering transportation, nutritional support, and child care services, in a effort to reduce barriers to care for a population of pregnant drug addicted women and to improve both maternal and neonatal outcomes. The CAP model addresses the care needs of pregnant substance-abusing women using a multidisciplinary "one stop shopping" program housed in one wing of the Johns Hopkins Bayview Medical Center in Baltimore, Maryland. Obstetric, gynecologic and family planning care is provided by a team of Certified Nurse-Midwives and Ob/Gyn physicians, with the CNMs as the primary providers. Protocols include an enhanced model of care with more frequent prenatal visits (every 2 weeks until 28 weeks and then every week until delivery) and greater number of laboratory analyses (more frequent screens for gonorrhea, syphilis, hepatitis B and C, chlamydia, HIV, liver function tests, and group B strep for women not in residential programs or for those in residential programs returning from a leave of absence). The program was available to all women living in Maryland who satisfy DSM-IV criteria for alcohol and/or drug abuse/dependence regardless of race, age, ethnic origin, religious preferences, marital status, number of children, or ability to pay. The program is intensive (first 7 days are residential) and rigorous, including comprehensive physical and mental health assessments and required attendance at group programming every day. Women progress through the program in accordance with their recovery. This study examines data obtained regarding the first 100 women (N=100) who delivered while enrolled in the CAP Program. Demographically, 85% were African-American and 15% were White, the mean age was 27.7 years, 89% were single, 45% had less than a GED and 38% had a GED. The women abused heroin, cocaine, and/or alcohol alone or in combination. The mean gestational age at first prenatal visit was 26.5 weeks with 89% of the women registering for the program in the second or third trimesters. The spontaneous vaginal delivery rate was 82%, with a 7% primary cesarean section rate and a 10% repeat cesarean section rate. The mean gestational age at delivery was 38.6 weeks (range 33 - 42 weeks), thick meconium was present at 17% of the births. The mean gestational age by Ballard exam was 39.3 weeks. Mean birth weights and head circumferences fell within the 40 to 50th percentile. Eighty-eight percent of the infants were average weight for gestational age, 7% were small for gestational age and 5% were large for gestational age. There were no very low birth weight babies (<1000 grams) and the neonatal intensive care admission rate was 10% with a mean length stay of 6.6 days. Twenty seven percent of the infants had a urine toxicology positive for illicit substances at birth. Developmental tests (Bayley Scale of Infant Development) were given at 6, 12, and 24 months with results generally within normal range. Cost-effectiveness estimates translated into an approximate savings of $5000 per mother-infant pair.

This study indicates the value of a comprehensive prenatal program for pregnant drug addicted women. The outcomes were favorable and demonstrated effective care provided by Certified Nurse-Midwives (CNMs) to a vulnerable, high risk population. An analysis of cost effectiveness of the CAP Program was performed comparing a group of CAP participants with a group of matched controls. The authors state that infants in the control group were 2.5 times more likely to require neonatal intensive care admission with an average length of stay six times longer than the infants of mothers in the CAP Program. The size of the control group, demographics or other information was not included in the article. This study would be strengthened if a matched control were used to compare overall birth outcomes. Also, the study did not address obstetric outcomes for the women other than cesarean section rates. Difficulties of administering an intensive program such as the CAP Program were not addressed.

Davidson (2002) compared the outcomes of high-risk women cared for by Certified Nurse-Midwives (CNMs) over a ten year period with outcomes of all U.S. births in 1994. The study addressed the following research questions: 1. What is the incidence of specific high risk factors of the population cared for by CNMs? 2. What were the outcomes within the high-risk sample cared for by CNMs? and 3. How do these outcomes compare with a national sample of all women who delivered in the United States in 1994? The sample for this study was obtained from a total of 5,487 clinic patients who received care at a mid-Atlantic, inner city, nonprofit, hospital-based clinic during a ten year period from 1988 through 1998. Of this total, 803 clinic patients classified as high risk were identified by retrospective retrieval from the delivery log and were designated as the sample for this study. Percentages were calculated to identify and compare trends that were included in both groups, high risk variables that could be matched were compared. The most frequently occurring high-risk conditions in the sample were maternal drug use (19.6%), premature rupture of membranes (18.6%) and diabetes (11.6%). When compared to the Centers for Disease Control and Prevention final natality statistics for 1994, outcomes for this high-risk sample cared for by midwives showed a greater percentage of vaginal births, vaginal deliveries after cesarean section, and lower percentages of forceps and vacuum assisted deliveries and cesarean sections. Five minute Apgar scores were also higher in the midwifery group. There was a higher incidence of maternal fever and meconium staining in the midwifery sample, however, the author states that this finding needs further evaluation because these outcomes are often frequently underreported in national birth certificate data. Results indicate that CNMs can provide safe care to women with high-risk conditions.

This study compared the selected outcomes for a group of high-risk women under the care of CNMs with the outcomes of all women who delivered in the U.S. in 1994. Favorable results of midwifery care provided to high-risk women compared to the general population which includes high-risk as well as low-risk women indicate midwifery care may have a positive impact on high-risk outcomes. Limitations of the study include the use of a single site, lack of a paired control group and limitations in variables because of the retrospective approach. Replication of this study at other midwifery sites would strengthen the findings as well as performing a similar study with a matched sample. It would be interesting to look at the outcomes of similarly matched high-risk groups receiving midwifery care versus standard obstetric care.

Barkauskas et al. (2002) carried out a study comparing outcomes of a residential based prenatal care project for pregnant women incarcerated within a Midwestern state's correctional system with traditional prison obstetric services. The program used Nurse-Midwives as primary care providers with goals of reducing infant mortality and improving outcomes and the health of children of high-risk, chemically addicted mothers, prevention of the separation of mother and child through the provision of residential treatment services in the community as an alternative to incarceration, and empowerment of the women to make better lifestyle choices for themselves and their families. Women in the residential program were transported to a clinic for care which included prenatal care, family-planning services, and childbirth education all provided by the same midwife. Women in the regular prison program received care in the prison site. All the pregnant women in the study received care from the same team of health care providers, however, the women who received care in the prison were not offered as many and as varied services as the women in the residential program such as, prepared childbirth instruction, individual and family counseling, in-labor assistance by a staff member, and role modeling for parenting, among other services. Midwives from the same midwifery service provided labor and birth services. A cross-sectional, case control study design was used to determine if the residential program resulted in improved health outcomes compared with women who received traditional prison-based care.

All women entering the residential program between July 1, 1996 and December 1998 were included in the study (N=52), all of whom were drug dependent. Of these women, 39 delivered infants while in the program, 2 had miscarriages, 8 escaped before delivery and 3 were discharged from the program for rule violations. All of these women were drug/substance-dependent (cocaine, alcohol, and/or marijuana) when admitted to the residential program. Birth outcome data were gathered for 37 women and their infants. The comparison group was obtained from all pregnant women entering the prison between August 1997 and August 1998, from this group a sample of 40 women remained eligible. All 40 of these women were eligible for the residential program but for various reasons they did not to participate. All women were considered obstetrically high-risk. There were no significant differences in variables that might affect the health outcomes between the two groups and demographically the groups were similar but not matched. There was a high rate of cigarette smoking in both groups, 88% of the residential program women smoked and 84% of the comparison women smoked during their pregnancies. The researchers looked at selected information about the mother's pregnancies including: smoking, gestational diabetes, normal spontaneous delivery, cesarean section, no episiotomy, normal amount of amniotic fluid, clear amniotic fluid (no meconium), and estimated blood loss. Information about the infants included: meconium at birth, oxygen needed at birth, respiratory difficulty at delivery, birth weight, discharge weight, Apgar scores, gestational age, hemoglobin, hematocrit and whether the infant was breast-fed at discharge. Results of this study indicated there were no significant differences in birth or infant outcomes between the residential program and the comparison groups and outcomes were positive for both groups. Because the outcomes of both groups were similar, the researchers combined the results and began looking at outcomes reported in previous studies on birth and infant outcomes of incarcerated women. Results of the combined study samples compared very favorably to reported outcomes of pregnant incarcerated women.

An experimental design with random assignment may have yielded stronger data supporting the effectiveness of the residential program but ethical and legal constraints did not allow for random assignment. Additionally, larger sample sizes would be needed to clearly demonstrate significant differences in the selected areas of interest and for useful comparison and generalizability. In this study, matching of the groups would have been very difficult due to the many variables within the population. That the groups were similar, without any significant differences in variables that may have affected health outcomes, was sufficient for this study. The study findings support the effectiveness of Certified Nurse-Midwives in the care of drug/substance dependent incarcerated women. The midwifery model of care was able to meet the identified care needs of this study and, in this case, midwives became the providers of choice within this particular corrections department. It is becoming clear that midwives and the midwifery model of care offer safe, supportive, competent, comprehensive, comparable, and cost-effective care which is attentive to both the physical and emotional needs of women.

The Women's Steps of Change Model was developed by Brown, Melchior, Panter, Slaughter, and Huba (2000) based on Prochaska's Stages of Change model. The Steps of Change Model extends the original Stages of Change Model to describe the process of help seeking as it relates to entry into substance abuse treatment by women. The Steps of Change Model involves four areas in which women may seek to change their lives in order to enter into a more healthy and stable lifestyle. The four areas of readiness to change are: 1. readiness to change a domestic violence situation, 2. readiness to change sex risk behaviors, 3. readiness to change substance abuse behaviors and 4. readiness to deal with emotional problems. In this model, it was hypothesized that the most immediate problems, or the most threatening ones, will be those the woman will focus on first and therapeutic efforts to improve the overall quality of her life will need to start by addressing the problems she is most ready to change. The model allows a case manager to identify areas in which the woman may be more ready to change or take action. A key component is that the woman identifies the areas of her life she wants to change and when she is ready to make the necessary changes.

A study was done to examine the Steps of Change Model as it relates to entry into substance abuse treatment programs for women. A total of 451 women who were enrolled in a Los Angeles, California community-based outreach program which focused on preparing women for entry into substance abuse treatment participated in the study. All program participants who consented to data collection were included in the study, 99.3% were current substance abusers. Logistic regression analyses, in which the dependent variable was verified entry into each of the four substance abuse treatment modlalities, were performed on a sample of 423 women for whom complete data were available. In each regression analysis, a planned independent variable was entered that was thought to be a factor which affected entry into treatment, including demographic characteristics, ethnicity, whether the woman was an injection drug user, was a crack user, or engaged in sex work. In subsequent steps, indicators of readiness to seek help and services for domestic violence, HIV/sexual risk behaviors. substance abuse treatment and/or emotional counseling were operationalized as an 11-point single-item Likert-type scale ranging from 0 ("I do not plan to make the specific change in the next 6 months) to 10 ("For more than 6 months I have taken steps or have been involved in treatment/counseling). The first step analysis looked at the likelihood of a single common factor which may explain a woman's willingness to change in any of the four areas of domestic violence, sex risk behaviors, substance abuse or emotional problems. A second step of the analysis examined whether women were more ready to change behavior in one area as opposed to another. Results indicated that there was not a single common factor which indicated a woman's willingness to change in any of the four areas, and women were most likely to change problems which presented the greatest potential for immediate harm (for themselves or for their children). It is important to note, however, that the area the women saw as presenting the greatest immediate risk of harm was often not the what the counselor identified as the area of greatest potential harm. The results support Prochaska's Stages of Change Model when used for women substance abusers, however the Steps of Change Model may support explanations of why women move toward specific interventions when they do and why they may avoid other interventions that seem equally if not more important. Limitations of this study include the use of a newly developed, non-standardized instrument and the study's focus only upon entry into drug treatment. Future studies might include a longitudinal inquiry to look at the progression of steps women make toward recovery from substance abuse and how the Steps of Change Model may apply to other areas such as mental health issues and readiness to work. This study indicates that women have multiple needs and pressures and they may be ready to change in some areas but not in others.

This well executed study sheds light into the complex needs and pressures women substance abusers deal with every day. From an outsider's viewpoint, that of a counselor or health care provider, the solutions and choices often appear clear cut. However, from the woman's perspective, her choices are often ones of survival for herself and her children. This study begins to explore the complexities women substance abusers must deal with when contemplating seeking treatment or services and calls upon the care provider to seek to fully understand her dilemma and offer her support rather than judgement or criticism. Often what the counselor or health care provider sees as her "correct" or "best" choice may not be what the woman considers to be a viable alternative. Only the woman herself is able to choose the areas of her life in which she is willing to change. The health care professional cannot force commitment to change, nor can we choose her agenda. Some women in drug treatment are there because of commitment by the law enforcement system. Often they are given the choice between drug treatment and jail. These women have their agenda forced upon them. In choosing substance abuse treatment, they are forced into the action phase of change whether they are ready or not. Even within this "forced action", care providers and counselors must give these women opportunities to set their own agendas, and provide information and support toward their goals.

Summary

A review of the literature has revealed recurring themes indicating the need for programs for substance abusing women designed specifically to meet their needs. Holistic programs are needed to provide not only substance abuse treatment but also to address health care needs of women and their children, provide prenatal care, child care, counseling, mental health services, housing, nutrition, safety, and family planning. Care providers must be competent, caring, sensitive, non-judgemental and have a willingness to listen to the woman and what she defines as her needs. Poly-substance use and abuse is a common problem in women, and is often combined with mental health and emotional problems, abuse issues, whether past or current, and increased risk for sexually transmitted infections/HIV and risky sexual behavior. Depression appears to be the most pervasive and debilitating mental health problem, often cited as a key factor in relapse from recovery. Not surprisingly, most women substance abusers are the children or grandchildren of substance abusers. Pregnant substance abusing women are at risk for poor birth outcomes and their babies, who some studies have indicated may appear normal, are at increased risk both in-utero, at birth, and developmentally as children. Midwives and the midwifery model of care have been shown repeatedly to produce favorable outcomes for recovering substance addicted women and their babies. Although these women are considered to be high risk gynecologically and obstetrically, studies have indicated that care provided by midwives results in cost-effective and comparable if not optimal outcomes as compared to traditional high-risk medical treatment for this vulnerable group.

Even with the research that has been done, little is known about women and substance abuse. Continued research is needed to explore the many factors involved concerning substance abuse and addiction in women. In the past addiction has been seen primarily as a "man's" problem and research has focused primarily on studies with men (Connors et al., 2001). The unique needs of women who are involved in addictions are just beginning to be brought to the forefront. Studies utilizing larger, matched samples are needed as well as longitudinal studies which look at long term implications of recovery and relapse, contributing factors, and special strategies care providers can use to assist women in maintaining sobriety and improving their lives and the lives of their children and families. Also, effects of fetal exposure to illicit substances have yet to be quantified. Studies have indicated increased risks to the fetus but amount of exposure and the risks exposure incur on the fetus and newborn have yet to be identified. Part of the problem is ethics, and part of the problem lies within the designs of the studies themselves. In some studies, infants were considered drug-exposed if the mother admitted to substance use at any time in pregnancy, had a positive drug screen, had a history of bingeing or showed tolerance or any multitude of definitions. Nor did the studies specifically identify the substance of abuse. The substance identified as the drug or substance of abuse could be cocaine, crack cocaine, marijuana, alcohol and/or tobacco, or any combination. Few studies mentioned substances such as barbiturates, amphetamines, heroin, hallucinogens, or designer drugs such as ecstasy. It can be theorized that a fetus exposed to large amounts of substances over greater periods of time would be at increased risk for problems, however, this theory has not been studied in depth.

It is clear that women substance abusers and recovering abusers are at high risk for many health problems, especially sexually transmitted infections, HIV, cervical cancer, depression, psychiatric disorders, malnutrition and general lack of health care. Pregnant substance abusers and recovering abusers are at risk for poor obstetrical and neonatal outcomes. Drug exposed babies are at risk for prematurity and many other complications including low birth weight, decreased length, small head circumference, impairment of brain development, intrauterine growth restriction, placental insufficiency, malformations, fetal distress and intrauterine fetal death, and may also be at four times higher risk of dying from sudden infant death syndrome (SIDS) (Huestis & Choo, 2002). Midwives have traditionally provided health care to vulnerable populations, offering non-judgemental, nurturing care (ACNM, 2003). The inclusion of women recovering from substance abuse into the scope of midwifery care will serve to increase access to health care, contraceptive services, cervical cancer screening, STI/HIV testing, and prenatal and obstetric care for this vulnerable population. The identified needs of substance abusing and recovering women for holistic care mesh with the midwifery philosophy of being "with women". This inquiry will begin to lay the groundwork for evidenced-based guidelines for midwifery care to women in recovery from substance abuse.

Conceptual Framework

Theories and conceptual models provide frameworks upon which research may be guided. They help to clarify concepts and logically guide the researcher in making predictions about relationships being studied (Polit, Beck, & Hungler, 2001). The conceptual framework guiding this study is Prochaska's Stages of Change Model (Connors et al., 2001). The Stages of Change model, developed by Prochaska and DiClemente, has been continually refined over the past 16 years and has provided the basis for much of the research that has been done on issues of substance abuse and a person's willingness or readiness to change his or her patterns of behaviors. Connors et al. discuss the current model which describes five stages of change individuals use when moving toward behavior change and recovery. These stages flow from precontemplation, the beginning stage, through contemplation, preparation, action and maintenance, where the individual is able to continually carry out strategies necessary to prevent relapse into addictive behaviors. Persons suffering from addiction or entering into recovery are often seen by addictions counselors and care providers as difficult, uncooperative or out and out liars (Connors et al., 2001; Corse et al.,1994). The model offers care providers guidelines as to what types of therapeutic strategies might be more effective at various stages of an individual's recovery. This information allows the counselor or care provider to 'meet the individual where he or she is at' in his or her readiness to change and serves to support the counselor's efforts to help the individual move toward change.

During the precontemplation stage, the individual has no intention of changing his or her behavior within the foreseeable future. The person may be unaware the behavior is a problem or may be aware but be unwilling to do anything about it. The individual is often defensive, will avoid steps to change the behavior, and often feels coerced or pressured to change by others. The problem behavior is often perceived to have more positives than negatives and the individual often judges the behavior as under control or manageable. Strategies for use by clinicians when dealing with a person in the precontemplation stage are to use motivational strategies, to acknowledge the problem but not focus on the behavior or on change, and to increase the individual's awareness of negatives of his or her behavior.

The contemplation stage is characterized by awareness that a need for change exists and thoughts by the individual of changing the behavior, but the individual has not yet made a commitment to take action. The person is more stressed by the problem behavior and has often begun to weigh the positives and negatives. The contemplation stage may last for years, the person may have made frequent past attempts, or may never progress beyond this stage. Strategies for clinicians are to enlist consciousness raising techniques, assisting the individual in evaluating his or her environment and identifying triggers which contribute to the behavior, and assisting the individual in engaging in preliminary action.

Preparation is the stage in which a plan exists and the individual intends on taking action to change attitudes and behavior in the very near future, often within the next month. The person may have even begun to change the problem behavior. He or she is engaged in the change process, has a plan, and is prepared to make firm commitments. Clinicians can assist an individual in the preparation stage by supporting the individual's commitment, assisting in setting goals and priorities and helping to further develop a plan for change.

In the action stage, the individual's behavior change has clearly begun. The person demonstrates motivation and effort to achieve his or her behavior change goals and is actively involved in the change process. Support for these individuals includes assistance with skills needed to continue implementation of their change strategies and helping them learn ways to prevent major setbacks or reversals that may work against their change efforts.

When the person has reached the maintenance stage, he or she works to prevent relapse and strengthen and sustain the changes he or she has made. These changes may take years to establish and the individual may put forth considerable effort to avoid relapse, temptations may still be present and the individual may express fears of "slipping" or making mistakes. The clinician must remain supportive and encouraging of the person's efforts.

Individuals progress through the Stages of Change at various rates and, as previously mentioned, may never progress fully through any of the stages. It is also common for individuals to slip back to a previous stage and then recycle forward again. This is known as a spiral model of change and is most often how a person will progress through the Stages of Change. This model of spiral change serves to give hope to individuals seeking to change their behavior and to clinicians alike. Even though a person experiences setbacks, he or she rarely falls back to the beginning precontemplation stage. The person may get discouraged but often learns from his or her mistakes and eventually will begin moving through the Stages of Change again, often more quickly than with the initial attempts.

The Stages of Change Model supports this inquiry in that it provides a framework for the development of evidence-based guidelines for midwifery care for women recovering from substance abuse. Discovering the specific needs of substance addicted and recovering women through continued research and understanding will assist in the development of programs designed to meet these women's specific needs. Midwives, because of their philosophy and scope of care, are prepared to take on the challenge of caring for substance addicted women and women recovering from substance abuse and their families. Research has clearly indicated that midwifery care, in combination with a comprehensive care model and multidisciplinary team, is effective in providing for the emotional, physical, and health care needs of substance abusing women and their families. As more research is done, it is felt that these conclusions will be further solidified and midwives will become valued contributors to the team of interdisciplinary experts working in concert on behalf of the health and welfare of substance abusing and recovering women.

Conceptual Map

Based on Prochaska's Stages of Change (Connors et al., 2001).






Chapter 3

Method of Development

Process Used

An extensive literature search was done by accessing the Wright State University Libraries, Dayton, OH. The Academic Search Primer was used because of the availability of full-text articles and the large number of journals available at this site to search for articles relevant to this inquiry. The search engine was enlisted to search for articles published from January 1993 through August 2003, using the keywords: maternal drug abuse, substance abuse, prenatal, newborn, infant, fetal exposure and neonate in various combinations. Full-text articles in PDF and HTML format were down loaded and printed out on July 7, 2003 and August 8, 2003. Additional articles were obtained by searching the ACNM on-line database for the Journal of Midwifery & Women's Health and two articles used for this review were provide by the course instructor. Thirty six articles were obtained and ten were selected for review. Articles were chosen according to their relevance to this inquiry and quality of research. The selected articles were reviewed and the information categorized and organized in an evidence table for grading research (see Evidence Considered). Criteria was established for effectiveness and components of an evidence-based clinical practice guideline were derived from analysis of the data and significant findings of the research. The findings from the research universally reveal that care for substance abusing and recovering women must be holistic, addressing physical, psychological, and emotional needs.


Evidence Considered

Evidence Table for Grading Research:
Study
authors
Grade of Evidence
A=true
experiment
B= quasi-
experiment
C= correlation
D= description
Study designSample size and descriptionResearch procedureMeasures used & their reliability & validityStatistics reported
(include type of statistic reported & p value/confidence intervals as indicated)
Study results & midwifery perspective
Snow & Anderson

“Exploring the Factors Influencing Relapse and Recovery Among Drug and Alcohol Addicted Women”
DDescriptive - ExploratoryUsed two independent convenience samples
N = 50 relapse
N= 50 recovery
Researcher developed questionnaire administered to both groupsResearcher developed questionnaires based on literature review and authors’ personal clinical observations which explored factors related to relapse and recovery, demographic info., and severity and type of addiction.
Unknown reliability and/or validity due to tool being researcher developed and not validated.
Statistics were reported as number and percentage of women in the sample who indicated a particular stressor as a factor in relapse, or a particular factor that influenced recovery.
Demographic info. was also obtained and compared.
Relapse subjects were found to be – younger, have nonprofessional jobs, lack college education, unmarried.
All were found to have history of parental alcohol and drug addiction, violence, co-occurring addictions. Stressors for relapse: depression, no 12-step program, personal crisis, cravings. Factors for recovery: 12-step program, motivation to change, connection to family/friends, increased self-esteem.
Knowledge of factors influencing recovery and relapse important for midwifery practice guideline development.
Weaver, Turner & O’Dell

“Depressive Symptoms, Stress, and Coping Among Women Recovering From Addiction”
BNon-randomized, cross-sectional surveyPurposive sample of 102 women abstinent from drugs/alcohol for 1-5 yrsSurvey administered using face-to-face interviews with a revised researcher developed questionnaireUnknown reliability and/or validity due to tool being researcher developed and not validated.Statistics were computed as frequencies, percentages, means and standard deviations to determine the distribution of depressive symptoms, stress sources, coping strategies, drug and treatment history, and background characteristics. Paired one sample t-tests examined the occurrence of significant changes in psychosocial stress and coping strategies between prerecovery and recovery periods. Chi-square, one-way analysis of variance (ANOVA), and paired one sample t-tests were performed to examine bivariate relationships among depressive symptoms, coping strategies, drug treatment history, and sociodemographic factors.The women in recovery were coping reasonably well but needed continued help in strengthening self-acceptance and coping skills. Many continued to use poor coping strategies such as procrastination, self-criticism and poor eating habits. 1/3 were at risk for depression, those who were married or cohabiting were at greater risk for depression and > cited emotional health as a stressor. reported parental substance abuse, used more than 1 drug.
Women recovering from substance abuse are at high risk for depression and other stressors. Midwives caring for this group of women must provide for continuing counseling and care that addresses physical, psychological and emotional needs.
Banonis

“The Lived Experience of Recovering From Addiction: A Phenomenological Study”
DStructural DescriptionN = 3
Volunteers experiencing recovery from addiction
Giorgi modification of the phenomenological methodThe methodology used preserves the meaning of the phenomenon within the context of each subject’s experience.
The subjects were asked to: Write a description of a situation in which you were aware of yourself as recovering from your addiction.
The descriptions provided by the subjects were studied intensely through the process of intuiting, analyzing, and describing. They were then analyzed for emerging themes and the situational structural descriptions were synthesized into a general structural description of the phenomenon.The phenomenon, recovering from addiction, emerged from the findings of this study as a lived experience of choosing the struggle to pull self out of the depths of darkest despair into the comfort of light. The limiting patterns of addiction change as new patterns are created.
These results shed light into the thoughts and feelings of recovering women and can be used by midwives in developing programs to provide sensitive, caring support
Corse, McHugh, & Gordon

“Enhancing Provider Effectiveness in Treating Pregnant Women With Addictions”
CQualitative,
naturalistic study of the process of implementing an innovative model of treatment for pregnant women with substance abuse disorders where CNMs keep substance abusing women (considered to be high risk) in their care, utilize a care-coordinator system, increase length and frequency of prenatal visits, and offer on-site addiction services.
N – not given
CNMs
Over an 18 month period, during which staff training sessions and meetings to enhance provider effectiveness were held on a continuous basis, staff were asked to describe how substance abuse issues had been handled in the past as compared to the present and what changes they experienced in women’s responses to them. Interviews were audiotaped, transcribed verbatim, checked for accuracy and analyzed.Interviews and observational data were analyzed using the method of constant comparison. The data were broken down into units of information which were then sorted into emergent categories which revealed recurring themes and unique ideas about the program as seen by the CNMs.Data were reported as themes which became clear as a result of staff interviews.
Impact of Training and Education:
-Improved interviewing skills.
-Shifts in attitudes.
-Increased knowledge of addiction.
-Reduced anxiety.
Impact of Structural Changes:
-Keeping “high risk” clients in CNM care.
-Availability of on-site addiction services.
Themes in Program Implementation:
-Client retention
-Increased openness in reporting substance abuse
-Incorporating “Addictions Treatment” into the nurse-midwife role
The overall goal of the study was to understand the program at an aggregate level and guide future implementation work. The CNMs described a shift from working on their own agenda to listening to and responding to the client. They also understood the powerlessness of a caregiver to effect change in an addicted client.
Education, training, and changes in the health care delivery model led to changes in the attitudes and behaviors, and increased effectiveness of CNMs toward substance abusing pregnant women.
Corse & Smith

“Reducing Substance Use During Pregnancy”
BMultivariate, QuantitativeN = 77 pregnant substance abusersEnhanced prenatal care model built on holistic nature of CNM practice. CNM care including prenatal care, assessment, education, intervention, referral, and focus on building trusting relationships. Intervention targeted at patient readiness to change. Data gathered included sociodemographics, previous medical and preg. History, current and past use of alcohol, cigarettes, and drugs, course of pregnancy, labor & delivery, gestational age, birth weight, Apgar, complications, and use of prenatal counseling services.Discriminant Analysis was conducted to determine the characteristics that differentiated those women who were largely abstinent, cut down somewhat, or showed no change in substance use.87% showed a reduction in substance use.
57% were largely abstinent
35% reduced use somewhat
14% showed no change
Women who showed no change tended to be heavier users of cannabis, cocaine (or both, often in combination with alcohol), had greater psychosocial stress, and started prenatal care later.

Values associated with a reduction in substance use:
Cannabis use severity
P value .000
Alcohol use severity
P value .277
Cocaine use severity
P value .002
Psychosocial index
P value .002
Weeks gest. At 1st prenatal visit
P value .023
Visits with care coor.
P value .000
Counselor visits
P value .001
Prenatal care offered in conjunction with a comprehensive, holistic care model can have positive impact on substance use. The majority of women identified as having substance abuse problems at the beginning of pregnancy can be largely abstinent by delivery.
Women who were heavier users, had greater psychosocial stress, and started prenatal care later, were less likely to change their substance use habits.
Provides evidence that CNMs can provide effective care to women with pregnancies complicated by drug abuse. Use of comprehensive care models are effective for women with substance abuse problems.
Jansson, Svikis, Lee, Paluzzi, Rutigliano, & Hacherman

“Pregnancy and Addiction – A Comprehensive Care Model”
BProspective outcomes researchN = First 100 women to complete the CAP (Center for Addiction in Pregnancy) ProgramReport of outcome dataData calculated as percentages and means of outcome data of study sample.

Cost effectiveness was calculated using a group of matched controls.
-Mean gestational age at delivery 38.6 weeks (range 33-42 weeks)
-Mean birth weights and head circumferences within 40-50th %ile
-88% of infants were average weight for gestational age.
-No very low birth weight babies.
-10% neonatal intensive care admission rate with mean length of stay 6.6 days.
-27% of infants had positive urine toxicology at birth
-Developmental tests given at 6,12,and 24 months generally within normal range.
-$5000 cost savings per infant/mother pair.
Favorable outcomes of an enhanced, comprehensive, intensive (inpatient and outpatient) prenatal program were demonstrated. Effective care was provided by CNMs and Ob/Gyns to a high risk, vulnerable population.
Provides evidence that CNMs can provide effective care to women with pregnancies complicated by drug abuse. Use of comprehensive care models are effective for women with substance abuse problems.
Davidson

“Outcomes of High-Risk Women Cared for by Nurse-Midwives”
BRetrospectiveN = 803 high risk pregnant women under CNM care
Most frequent high risk conditions:
Maternal drug use (19.6%), Premature rupture of membranes (18.6%),
Diabetes (11.6%)
Compared outcomes of high-risk women cared for by CNMs over a 10 year period with outcomes of all US births in 1994Data were reported as percentages and N numbersData were reported as percentages, N numbers, and National Averages in categories of: High-risk Conditions, Comparison of High-risk Factors, and Comparison of Maternal and Fetal Outcomes.
Out comes show a greater percentage of vaginal births and VBACs, lower percentage of forceps and vacuum deliveries, and higher 5 minute Apgar scores.
There was a higher incidence of maternal fever and meconium staining in the CNM group.
Favorable results of CNM care provided to high-risk women when compared to the general population which included high as well as low-risk women.
This study indicates favorable outcomes of high-risk women who receive CNM care and supports the role of midwives as a provider for this vulnerable population.
Barkauskas, Low, & Pimlott

“Health Outcomes of Incarcerated Pregnant Women and Their Infants in a Community-
Based Program”
BCross-Sectional Case ControlN = 37 women incarcerated drug-dependent women participating in a community-based residential program provided by CNMs.
Comparison group N = 35 women receiving traditional prison health care provided by the same group of CNMs.
Birth outcome data were gathered for 37 women and their infants in a residential program for incarcerated women, all of whom were drug dependent. The comparison group was a sample of 40 women entering the prison who received traditional prison care. All were considered obstetrically high-risk. There were no significant differences in variables that might affect health outcomes between the two groups, demographically the groups were similar but not matched. All prenatal care, delivery, postpartum, and family planning services were initiated and provided by CNMs. Outcome data were comparable in both groups.
Because of this, the data of both groups was combined and compared to outcomes of previous studies on birth and infant outcomes of incarcerated women.
P values indicated outcomes of both groups were statistically similar. The combined results were compared to outcomes of previous studies on birth and infant outcomes of incarcerated women. Outcomes of care provided by CNMs compared favorably with previous studies reported in the literature. These were reported as a comparison of rates.
-Low birth weight infants: 5.9% in study compared with 17-50% in literature and 25% small for gestational age.
-Cesarean rate: 12.5% in study compared with 16% in literature.
Study findings support a continued role for CNMs in the care of drug dependent incarcerated women. The midwifery model of care is attentive to both physical and emotional needs and is successful in motivating women to actively participate in their prenatal care.
This study indicates favorable outcomes of high-risk, drug dependent women who receive CNM care compared with incarcerated women receiving traditional prison care.
Brown, Melchior, Panter, Slaughter, & Huba

“Women’s Steps of Change and Entry into Drug Abuse Treatment-A Multidimensional Stages of Change Model”
BQuantitative MultivariateN = 423 women enrolled in a community-based program preparing them for entry into substance abuse treatmentAt the time of enrollment into the program demographic and risk behavior data were collected. A key component of the treatment model is the woman identifies the areas of her life she wants to change and the time she is ready to do so. She is then linked with the appropriate service within the services model. Women are provided with access to a full range of medical, social, housing, legal services from formal institutions, community organizations and neighborhood networks. They are referred to a variety of drug abuse treatment modalities and programs which include services which address domestic violence, sexual risk behaviors, and mental health issues.Logistic Regression Analysis was done to determine if there was any one common factor that indicated a woman’s willingness to change.
Logistic regressions were done to predict entry into a 12-step program, into a detoxification program, into an outpatient drug abuse treatment program, or a residential substance abuse treatment program, from background characteristics and readiness to change.
P values were >.05 in all comparisons of model summaries except predicting entry into a residential substance abuse treatment program where injection drug use readiness to seek help for physical violence and readiness to seek help for drug use were strong predictors on entry into a residential program (p < .001)Study results indicated that there was not a single common factor which indicated a woman’s willingness to change, and women were most likely to change in areas which presented the greatest risk for immediate harm. This was often not what the counselor identified as the area of greatest potential harm. Women have multiple needs and pressures and may be ready to change in some areas but not others.
This study indicates the need of health care professionals to recognize that only the woman herself is able to best identify areas in her life that she is ready to and willing to change, although it may not appear so to the professional. The study also supports the use of the Stages of change model with drug abusing women.



Criteria Established for Effectiveness

Health Care Services for Substance Abusing and Recovering Women

1. A holistic midwifery model of health care, with provision for collaboration, co-management, or referral (when needed), which focuses on support of the whole woman, operating within or providing links to substance abuse treatment services (12-step, inpatient, outpatient and community based), mental health services, domestic violence services, private and community services, housing, transportation, food, jobs, and child-care.

2. Midwife/program qualities to include:
-non-judgemental, non-punitive attitude and environment
-working within a Stages of Change Model care philosophy, with goals set by the woman and intervention targeted on client readiness to change.
-relationship development
-recognition of the frequency of depression in this population

3. Provide services and counseling that focus on the needs of the individual woman.
-Research has indicated that these needs are most often in the areas of stress, depression, self esteem issues, coping strategies, emotional support, and intimate partner issues. These are also the factors that most often contribute to relapse in a woman recovering from substance abuse.

4. Annual health exams and gynecological services available including PAP smears with HPV testing, breast exams, mammograms, STI testing and counseling, HIV testing and counseling, pregnancy testing, family planning and contraceptive services.

5. STI testing, HIV testing, pregnancy testing, family planning and contraceptive services available on an as needed basis.
-chlamydia, gonorrhea, syphilis, trichomoniasis, hepatitis B, hepatitis C, HIV, genital herpes.

6. Health education based on each woman's individual needs, geared to her education level and readiness to learn.

7. Programs available to all, those without a third party payor should be able to obtain help to acquire public or grant assistance.


Health Care Services for Pregnant Substance Abusing and Recovering Women

Same as above, but also including:

1. More frequently scheduled prenatal visits
-Every two weeks until 28 weeks and then weekly until delivery.
-Because substance abusing women often seek prenatal care late, increased frequency of visits allows for an adequate number of prenatal visits as well as time needed for education.

2. Increased length of time scheduled for prenatal visits.
-Suggested appointment times are at least one hour for an initial obstetric/prenatal visit and thirty minutes for subsequent obstetric/prenatal visits.
-Allows for increased time needed for relationship development and education.

3. Increased frequency of assessment and testing for STIs during pregnancy.
-chlamydia, gonorrhea, syphilis, trichomoniasis, hepatitis B, hepatitis C, HIV, genital herpes.
-Optimum frequency has not been established.
-Testing for STIs at the first visit and then repeated at the 32 week visit, and on an as needed basis has been suggested.

4. Urine toxicology screens and/or blood alcohol levels.
-Upon admission to an outpatient treatment program and at every prenatal visit.
-Upon admission to a residential unit and after any leave time away from the unit.
-Upon admission or for out-patient evaluation in Labor & Delivery.

5. Increased frequency of Non-Stress Tests (NSTs) and Biophysical Profiles.
-Optimum frequency has not been established.
-NSTs have been suggested at the first visit (if care is begun later in pregnancy), and every week from 32 weeks until delivery.
-A Biophysical Profile performed at the first visit, and then weekly beginning at 36 weeks.
-For women in a residential program who are abstinent or with continuing documentation of abstinence
-initial perinatology ultrasound and genetic counseling
-biophysical profiles and NSTs may be done as indicated.

6. Understanding by the midwife and other medical professionals that the research thus far indicates that the heavier the amount of substance abuse, the less likely the woman will be abstinent during pregnancy and for care to be planned accordingly.

7. Labor and delivery in a hospital that is equipped to handle potential intrapartum and postpartum complications as well as newborn complications.
-If the woman has been abstinent during her pregnancy and has obtained and remained within low-risk criteria, birth options available to low-risk women may be made available.

8. Post partum care provided which offers support for the woman's parenting and continued abstinence.

9. Provision of ongoing pediatric care for the infant and the woman's other children.


Clinical Perspectives Presented

Inter-disciplinary evidence is presented in the development of this EBCPG for midwifery care to women in recovery from substance abuse. The articles reviewed were obtained from a variety professional journals representing substance abuse treatment specialties, pediatrics, psychiatric nursing, nursing science, and midwifery. The care models represented in the literature that was reviewed in the development of this EBCPG included programs in which the primary providers of health care were Certified Nurse-Midwives. However, each of the care models included multidisciplinary teams comprised of various combinations of Ob/Gyn physicians, pediatricians, perinatologists, neonatologists, counselors, therapists, educators, psychologists, social workers, facility staff, community workers, child-care workers, and transportation specialists.


Population of Interest
Exceptions to the Guideline

The population of interest in the development and implementation of this EBCPG is substance abusing and recovering women, inclusive of age, race, and sexual orientation, pregnant or non-pregnant. Evidence in the literature reviewed supports that care provided by midwives is effective in outpatient treatment programs, community-based treatment programs, inpatient treatment programs, and health care programs for incarcerated women. For the pregnant woman, midwifery care provides benefits for both the woman and her baby. Outcomes for pregnant substance abusing and recovering women and their babies were found to be as good as or better than outcomes of women provided with a more medical model of care. In one study, outcomes of a group of 803 high risk women and their babies, cared for by midwives, were found to be better when compared to outcomes of all women in the United States in the year 1994 (Davidson, 2002).

Exceptions to the guideline would include women with pregnancies complicated by pre-existing medical conditions such as insulin dependent diabetes, primary hypertension, cancer, or other serious medical conditions. Serious medical conditions which occurred during pregnancy would require co-management with a physician or physician referral. Complications during labor, delivery, and postpartum which fall outside the scope of midwifery care would also be co-managed or referred to a collaborating physician. Other exceptions would be women who had health problems which fell outside the scope of midwifery care and women who did not want midwifery care.


Decision Support

Synthesis of Evidence and Conclusions

1. There is great need for cost-effective, safe, competent, nurturing health care for women substance abusers and women in recovery from substance abuse.

2. Women substance abusers and recovering abusers are at high risk for many health problems including sexually transmitted infections, HIV, cervical cancer, depression, psychiatric disorders, malnutrition and general lack of health care.

3. Pregnant substance abusers and recovering abusers are at risk for poor obstetrical and neonatal outcomes.

4. Midwifery care has been demonstrated to be very effective in providing for the primary health care needs of substance abusing and recovering women, influencing aspects of their care which are most effective in the support of change.

5. The more trusting the environment and the greater emphasis that is placed on relationship development, the more likely the woman is to admit her substance abuse problem.

6. Midwifery care to women in recovery from substance abuse includes primary health care, gynecological services, annual exams, PAP smears, STI testing and counseling, HIV testing/counseling, contraception and family planning services, pregnancy testing, and prenatal, intrapartum and postpartum care.

7. Health care services for women substance abusers and recovering abusers have been shown to be most effective when provided within the context of a holistic midwifery model which focuses on the care of the whole woman, operating within or providing links to substance abuse treatment services, mental health services, domestic violence services, private and community services, housing, transportation, food, jobs, and child-care.

8. Outcomes for pregnant substance abusing and recovering women and their babies, who were cared for by midwives, were found to be as good as or better than outcomes of women provided with a more medical model of care.


Summary Statement of Findings

For the millions of women in the United States who have problems with substance abuse or are recovering, the need for safe, competent, nurturing and cost effective health care has never been greater. Midwifery care is a logical answer to these needs. The hallmarks of midwifery care provide the very essence of what the research has identified as the needs of substance abusing and recovering women - care that is holistic and nurturing, and focuses on the woman and her perceived needs. Midwifery care to select high risk populations, including substance abusing and recovering women, has been repeatedly shown in the research to result in outcomes that are the same as, or better than, national outcomes resulting from a more traditional medical model of care (Barkauskas et al. 2002; Davidson, 2002). Midwifery care to women in recovery from substance abuse includes primary health care, gynecological services, annual exams, PAP smears, STI testing and counseling, HIV testing/counseling, contraception and family planning services, pregnancy testing, and prenatal, intrapartum and postpartum care. Ideally these services should be available regardless of ability to pay and should operate within or be linked with substance abuse treatment services, mental health services, domestic violence services, private and community services, housing, transportation, food, jobs, and child-care. It had been suggested by the research that the midwife could act as not only health care provider, but also as the point of contact or case-manager, enlisting the members of a multidisciplinary team according to the needs of each woman (Corse & Smith, 1998; Jansson et al.,1996).

Because pregnant substance abusing women and recovering abusers are at risk for poor obstetrical and neonatal outcomes, enhanced prenatal care guidelines have been suggested in the literature (Barkauskas et al. 2002; Corse & Smith, 1998; Davidson, 2002; Jansson et al.,1996). Suggestions include increased frequency of scheduled prenatal visits, increased length of prenatal visits, increased testing for STIs/HIV during pregnancy, urine toxicology screens as indicated, and increased frequency of non-stress tests and biophysical profiles to assess fetal well-being and aid in the management of the pregnancy. Research has also indicated that the attitudes of the midwives and other members of the health care team affect the outcomes of care. Non-punitive, non-judgemental, nurturing and supportive care were found to be most effective in relationship building efforts with substance abusing and recovering women. The women receiving this type of care were more likely to voluntarily admit to substance use/abuse or relapse, thereby facilitating the midwife to provide appropriate care (Corse & Smith, 1998). With effective care, most pregnant women are able to remain largely abstinent during pregnancy. However, it is important for health care providers to be aware that research has also indicated that the heavier the amount of substance abuse/use prior to pregnancy and the more significant the woman's psychosocial problems, the less likely she will be to reduce or stop her substance use during pregnancy (Corse & Smith, 1998).

Programs which utilize a Stages of Change Model in working with substance abusing and recovering women have been found to have increased effectiveness (Brown et al., 2000; Connors et al., 2001). It is also important that those who are caring for substance abusing and recovering women be acutely aware of the prevalence of depression in this population. Depression, stress, poor self esteem, ineffective coping strategies, lack of emotional support, and intimate partner issues were found to be the areas where counseling most needs to be focused. Interestingly, these were also found to be the factors which most often contribute to relapse (Snow & Anderson, 2000; Weaver et al. 2000).

It is clear that women substance abusers and women in recovery from substance abuse present many health care challenges and are acutely in need of comprehensive health care services. Research has strongly indicated that the inclusion of substance abusing women and recovering women into the scope of midwifery care will serve to increase access to health care, including contraceptive services, cervical cancer screening, STI/HIV testing, and prenatal and obstetric care for this vulnerable population. The literature indicates that this care should ideally be provided in a non-punitive, non-judgemental, nurturing and supportive atmosphere. These hallmarks of midwifery care have been shown by the literature to be very effective in providing for the primary health care needs of substance abusing and recovering women, influencing aspects of their care which are most effective in the support of change. Midwives have traditionally provided health care to vulnerable populations, with extraordinary outcomes. This evidence-based clinical practice guideline for midwifery care to substance abusing women and women in recovery from substance abuse will serve as a first step in the inclusion of this vulnerable group of women into the scope of midwifery practice.

Outline of EB-CPG Clinical Algorithm

Substance Abusing/Recovering Woman presents for health care -->

*When offering and providing care for any substance abusing or recovering woman, nonpregnant or pregnant, it is important for the midwife to incorporate therapeutic use of self. It is also important to treat the woman with respect, and with a non-judgemental, non-punitive attitude. A relationship built on trust has been found to be most effective when providing health care and other services to this population.

Not pregnant -->

1. Information given to woman about services available to her -->

2. Complete assessment of the woman's health care needs as perceived by the woman -->

3. Complete medical and obstetric history (as much as woman will disclose) -->

4. Complete sexual history (as much as woman will disclose) -->

5. Complete psychosocial history (as much as woman will disclose) -->

6. Initial assessment of substance use/abuse (as much as woman will disclose, including:
- substance(s)
- amount
- frequency
- tolerance
- effects (blackouts,etc)
- how she feels about her substance use -->

*NOTE: the initial assessment may have gaps in the information provided by the woman due to the lack of an established trusting relationship. Additional assessment at every visit is recommended.

7. Assessment by midwife of available services which may be appropriate for the woman (health care services, testing, family planning, contraception, mental health services, substance abuse treatment services (12-step, inpatient, outpatient and community based), domestic violence services, private and community services, housing, transportation, food, jobs, and/or child-care services) -->

8. Utilizing a Stages of Change approach, discussion/teaching with woman to choose her plan of care and services she chooses to utilize -->

9. Referral/Initiation of services -->

10. Performance of agreed upon physical exams and testing (PAP, STI testing, HIV testing, mammogram) -->

11. Results of testing received -->

12. Treatment or referral as indicated -->

13. Plan for return visits and follow-up care as indicated.


Pregnant -->

*Substance abusing pregnant women often seek prenatal care late in pregnancy. They may not divulge complete information on their substance use/abuse because of fears of legal repercussions and/or of having their children or baby taken away.

1. Initial visit - Complete medical, obstetric, sexual, psychosocial, substance use/abuse history -->
*NOTE: the initial assessment may have gaps in the information provided by the woman due to the lack of an established trusting relationship, ongoing assessment must be done as the trusting relationship develops.

2. Physical exam, pelvic exam.
- PAP, STI testing, HIV testing with patient consent, Prenatal blood work (consider a liver profile), consider blood alcohol level, urine drug screen, urinalysis, urine culture.
- Ultrasound for fetal assessment, confirm dates
- Biophysical Profile for assessment of fetal well-being -->

3. Utilizing a Stages of Change Model, assess where woman is in her readiness to abstain from or reduce her substance use/abuse
- Precontemplation - "I don't have a problem", denial
- Contemplation - "I might have a problem", not willing to make changes
- Preparation - "I have a problem", willing to accept help
- Action - "I know I have a problem and I want to change", motivated to change and to take action
- Maintenance - "I have made changes and it is important for me to continue" -->

4.Utilizing a Stages of Change approach, assessment of what woman feels are her most urgent needs -->

5. Assessment by midwife of available services which may be appropriate for the woman (health care services, testing, family planning, contraception, mental health services, substance abuse treatment services (12-step, inpatient, outpatient and community based), domestic violence services, private and community services, housing, transportation, food, jobs, and/or child-care services) -->

6. Utilizing a Stages of Change approach, discussion/teaching with woman to choose her plan of care and services she chooses to utilize -->

7. Plan with woman for prenatal care, to include:
- more frequent prenatal visits
-Every two weeks until 28 weeks and then weekly until delivery. (Because substance abusing women often seek prenatal care late, increased frequency of visits allows for an adequate number of prenatal visits as well as time needed for education.)
- increased length of time scheduled for prenatal visits (Allows for increased time needed for relationship development and education)
-Suggested appointment times are at least one hour for an initial obstetric/prenatal visit and thirty minutes for subsequent obstetric/prenatal visits.
- repeat of STI cultures as indicated and at 32 weeks
-chlamydia, gonorrhea, syphilis, trichomoniasis, hepatitis B, hepatitis C, HIV, genital herpes.
- urine toxicology/blood alcohol as indicated
- for women with documented abstinence
-initial perinatology ultrasound and genetic counseling
-biophysical profiles and NSTs may be done as indicated.
- for women who have continued substance abuse or without documented abstinence
- repeat of Non-stress testing - at 32 weeks and then weekly until delivery
- repeat of Biophysical profile - at 36 weeks and then weekly until delivery -->

8. Referrals to substance abuse treatment services (12-step, inpatient, outpatient and community based), mental health services, domestic violence services, private and community services, housing, transportation, food, jobs, and/or child-care services based on woman's perceived needs -->

9. Continued reassessment at each prenatal visit of woman's substance use and her psychosocial needs. As a more trusting relationship develops, the woman may divulge additional information about her substance use and her psychosocial needs. Offer continued support for her efforts to reduce or eliminate her substance use. Remain aware that stress, depression, self esteem issues, coping strategies, emotional support, and intimate partner issues are often the main reasons for relapse and that the research thus far has indicated that the heavier the amount of substance abuse, the less likely the woman will be to reduce her substance use or remain abstinent during pregnancy, and for care to be planned accordingly -->

10. Plan for labor and delivery in a hospital that is equipped to handle any potential intrapartum and/or postpartum complications as well as newborn complications.
-If the woman has been abstinent during her pregnancy and has remained within low-risk criteria, birth options available to low-risk women may be made available -->

11. Post partum care provided which offers support for the woman's parenting and continued abstinence -->

12. Provision of ongoing pediatric care for the infant and the woman's other children.

Evaluation - Measurement Strategy and Re-evaluation Plan

Evaluation of this Evidence Based Clinical Practice Guideline is best accomplished through outcomes measurement of implemented programs which are based on a midwifery model of care with midwife providers and an annual review of the literature. A holistic midwifery model which provides for collaboration, co-management, or referral (when needed), which focuses on support of the whole woman, and operates within, or provides links to, substance abuse treatment services, mental health services, domestic violence services, private and community services, housing, transportation, food, jobs, and child-care, is a model which has been demonstrated by research thus far to be effective in providing for the health care needs of substance abusing and recovering women. Suggestions have been made, based on models presented in the literature, regarding enhancing prenatal care provided to this vulnerable population. It has been demonstrated thus far and reported in the literature that outcomes for pregnant substance abusing and recovering women and their babies, who were cared for by midwives, were found to be as good as or better than outcomes of women provided with a more medical model of care. Midwifery care provides the very essence of what the research has identified as the needs of substance abusing and recovering women - care that is holistic, non-judgemental, and nurturing, and focuses on the woman and her perceived needs. Additional and ongoing research must be carried out to address all aspects of midwifery care for substance abusing and recovering women especially in the area of providing optimal prenatal care.


References

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