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Introduction of Midwifery Care to Women in a Residential Substance Abuse Recovery Center: Application to ACNM's 2001 Safe Motherhood Grant

Karen Carney

Please note: This grant was submitted to the ACNM Foundation on November 1, 2001. Chapter 3 represents the actual grant application. The grant was not awarded to us. It was a competitive grant with 5 applicants and one award.


Abstract

Women who abuse drugs and alcohol are at high risk for disruption of safe motherhood during pregnancy and beyond. National health goals target substance abuse as a serious health problem requiring a multidisciplinary approach to its prevention and treatment. Treatment programs developed specifically for substance abusing women have been shown to improve the overall health of these women, and in the case of pregnancy, both maternal and neonatal outcomes. Primary preventative and maternal health care services to these women in recovery, however, tends to be a goal that is secondary to the goal of treating their abuse. The introduction of full scope nurse-midwifery care to women at an all women's residential substance abuse treatment facility in August, 2001, offers an opportunity to explore the influence of midwifery care on selected variables linked to women's health and safe motherhood in this vulnerable population. This study will determine how the introduction of midwifery care to a residential population of recovering women in treatment for substance abuse will affect four areas of concern: 1) access to and use of preventative healthcare services; 2) initiation of prenatal care, 3) selected health outcomes, such as screening for cervical cancer and sexually transmitted infections and maternal and neonatal outcomes, and 4) patient satisfaction with midwifery care services, especially relative to their prior experiences with other providers.

Chapter one: Introduction to the problem

The problem of substance abuse by women is one of grave concern. Caring for the substance abusing pregnant woman can be very challenging. Substance abuse in affects women of all ages, races, education levels, and social positions. The DSM defines substance abuse as two parts " (1) 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 (2) 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). It has potential medical complications for the woman and that of her unborn baby. Some of the risks to the woman include medical complications, adverse lifestyle, and in the case of pregnancy, negative effects which may result in a premature birth (Cunningham, MacDonald, Gant, Leveno, Gilstrap, Hankins, &, Clark, 1997). Risks to the baby include congenital anomalies, complications related to preterm birth such as respiratory and feeding difficulties, delayed growth and development, low birth weight, intrauterine growth retardation , neonatal abstinence syndrome, fetal alcohol syndrome, and fetal/infant neurobehavioral deficits (Cunningham et al, 1997). As a result of these complications, there are social and financial costs incurred by the woman, neonate, and society in general. The substance abusing pregnant woman is considered high risk. This usually involves a greater number of procedures in the antepartum, intrapartum, and postpartum periods. Complications of the newborn also may result in a greater number of interventions and a longer hospital stay. All of these consequences result in a great financial burden.

Substance abuse has only recently been identified as an area in need of research in women's health (Snow & Anderson, 2000). Up until recently, most of the research available had been done on men. By reviewing the most recent research evidence, the best care practices for this vulnerable population will be identified. A successful plan of care specifically for women will result in better overall health and in the case of pregnancy better maternal and neonatal outcomes. Midwives would be effective obstetrical healthcare providers for these women. Midwives have long been providing care for women of vulnerable populations and achieving excellent outcomes (Greulich, Paine, McClain, Rabger, Edwards, & Paul, 1994). The philosophy of midwifery promotes care of the normal woman as well as addresses her substance abuse issue. The hope is that by developing a midwifery model of care for the substance abusing woman, those at risk can be identified, early interventions can be initiated, and women and their babies can be assisted to achieve optimal health.

Definitions of what constitutes substance abuse vary, however, the DSM-IV is a standard reference for diagnosticians. The criteria for substance abuse has been reviewed earlier in this paper. To be considered substance dependent, one must exhibit three of the following symptoms (1) that a person uses a psychoactive substance when expected to perform significant tasks at home, work, or school or (2) when it is physically hazardous or (3) 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 financially, legal, psychological, or marital, (4) loss of control of use, (5) inability to cut back, (6) substance use replacing important activities or taking up considerable time, (7) indications of marked physiological tolerance, (8) or withdrawal (APA, 1994). So for the purposes of substance abuse in pregnancy, a woman only needs to use the substance during their pregnancy to be considered abuse, she does not have to be dependent.

Substance abuse in pregnancy affects many women. The question of how many women is difficult to answer. In 1992, a study was conducted by the National Institute on Drug Abuse in an attempt to answer this question (NIDA, 1992). Information was gathered by questionnaires and urine toxicology screens at a number of sample hospitals. It was estimated 5.5% of all women used an illicit substance at some time during their pregnancy. Marijuana was used during pregnancy by 2.9% of the women, cocaine by 1.1%, and opiods by 0.1%. An estimated 18.6% of women used alcohol and another 20.2% used tobacco during their pregnancy. Rates of illicit drug use were 11.5% for black women, 4.4% for white women, and 4.5% for Hispanic women. Alcohol use was 22.7% for white women, 15.8% for black women, and 8.7% for Hispanic women. Cigarette use was 24.4% for white women, 19.8% for black women, and 4.8% for Hispanic women. Illicit drug use was found to be consistent despite the age of the client, 5.7% under 25, 5.1% for those between 25 and 29, and 5.5% for those over 30. Choice of drugs, however, did vary depending on age. Marijuana was more common among younger women and cocaine among older women. Socioeconomic status was also a contributing factor in drug choice. Marijuana, cocaine, and cigarette smoking were higher in women who were less likely to be married, unemployed, had less than a college education, and relied on public aid for payment of medical services. Alcohol use was more common among women who were working outside the home, had completed a college education, and paid for health with a private insurance (NIDA, 1992).

Many in the medical field feel these numbers greatly underestimate the problem. The manner in which data is gathered is not entirely reliable. Either women self report substance use or random toxicology screens are obtained. Not all women are honest as they fear embarrassment, punishment and possible loss of child custody. Random urine screens are usually targeted at a certain group of women and therefore do not reflect society as a whole. Another issue in collecting data is that it usually identifies that a drug has been used during pregnancy, but not the amount. When studies are done in an effort to analyze the problem of substance abuse it reflects the problem and needs of that specific community. So the controversy arises how reliable or helpful is the information from one community to another? Different communities have different needs (Smerigli & Wilcox, 1999). The medical community cannot decide how best to gather data on the substance abusing pregnant women or how to apply it to their care. What they do agree on is that is an area in need of investigation.

Another issue which has been identified is that there are a lack of treatment facilities available to these women. A study was done in 1990 by the National Association of State Alcohol and Drug Abuse Directors, Inc. that found an estimated 280,000 pregnant women nationwide were in need of drug treatment, yet less than 11% of them received care (Jansson, Svikis, Lee, Paluzzi, Rutigliano, & Hackerman, 1996).

It has also been identified that oppression appears to be a causal factor in creating and maintaining chemical abuse and dependency among women as well as a significant barrier to recovery. "Oppression is systematic harm that people with more power do to people with less power" (Goldberg, 1995, 790). Women in general are subjected to oppression of many kinds. Both childhood sexual abuse and domestic violence have been associated with a higher incidence of substance abuse (Goldberg, 1995).

The potential complications for both the mother and baby can be great. For these reasons, we need to address substance abuse in the pregnant client. This is a crisis in women's health care. "It is well documented that substance abusers may have extensive medical complications resulting either directly from the abuse (cellulitis, bacteremis, endocarditis, HIV/AIDS) or from the lifestyle of the abuser (poor nutrition, cigarette smoking, homelessness). Many of these complications can directly impact a pregnancy by increasing perinatal morbidity" (Jansson, 1996, 321). Perinatal morbidity includes congenital anomalies, medical complications such as respiratory and feeding difficulties, and fetal/infant neurobehavioral deficits. Also recognized problems are fetal alcohol syndrome, neonatal abstinence syndrome, consequences of a preterm birth, SIDS, and possible future child abuse (Jansson, 1996).

Based on our knowledge of the extreme detrimental consequences of substance abuse to the mother and the baby, it is imperative we develop a plan of care to decrease substance use during pregnancy. It has been shown intensive, multidisciplinary programs appear to be most effective in helping these women. Such a program was instituted at the Center for Addiction and Pregnancy (CAP) at Johns Hopkins Hospital in Baltimore, Maryland. The obstetrical healthcare providers were certified nurse midwives. Midwives were used based on the premise that they are cost-effective primary providers who generally function well in multidisciplinary setting, and offer care in a manner that would augment the work of recovery from substance dependency (Jansson, 1996).

As seen in the CAP program, midwives are effective care provider for the substance abusing woman. Midwives have always been strong advocates to women. Midwives also encourage women to participate in their care. As described earlier, many women who are substance abusers are victims of oppression. By encouraging women to participate in their care, it gives them a sense of control in some area of their life.

Midwives care for women of all ages, races, religions, education levels, and social positions. For this reason, midwives need to be educated on substance abuse in pregnancy and how to care for these women. Although caring for the substance abusing pregnant woman can be challenging and sometimes frustrating, when success occurs the rewards are great. By integrating a midwifery model of care to the substance abusing woman, the hypothesis is that the women will have a better health and for those who are pregnant, improved maternal and neonatal outcomes.


Chapter two: Review of the Literature and conceptual framework

Review of the Literature

Substance abuse by pregnant women has become a crisis. For this reason, research is being done in an effort to determine how severe the problem truly is, to better identify those women at risk, and to better understand characteristics that may place a woman at higher risk for substance abuse. One article reviews numerous studies in an attempt to investigate this crisis (Hans, 1999).

Numerous studies have been done in an attempt to identify how many women were actually abusing substances during pregnancy and also to see if there is a target group of women at risk for substance abuse. Accurate information is difficult to obtain. There are biases in the methods used to identify substance abuse. Either women self report or random urine toxicology screens are obtained (Hans, 1999). Research was reviewed from numerous studies done on a state level and one national study. Results indicated there was a serious problem with substance abuse in pregnancy. It also showed substance abuse in pregnancy affected women of all ages, races, religions, education levels, and social positions.

One study (Chasnoff, Landress & Barrett, 1990) was done in one urban Florida county. It involved screening all pregnant women in 5 public and 12 private health offices. Fifteen percent of the samples were positive for alcohol, opiates, cocaine, or marijuana, 13% were positive for an illicit drug. Having a positive test was found to be unrelated to the mothers socioeconomic status or race. Black women were more likely to have used cocaine, 7.5%, versus white women, 1.8%. White women used marijuana 14.4% compared to black women at 6% (Chasnoff et al, 1990).

Another study (Mueller, Lavori & Keller, 1994) was done at a number of urban and rural hospitals in Illinois. It consisted of both private and public facilities. The results indicated 9% of the urine toxicology screens were positive for illicit drug use. Rates of positive screens were equal between the private and public hospitals (Mueller et al, 1994). Between 1991-1992 a study was done in South Carolina showing 25.8% of pregnant women had positive drug screens in either urine or meconium Hans, 1999 Lastly, in a 1989 study done in Rhode Island indicated that 7.5% of the pregnant women were found to have used cocaine, opiates, marijuana, or amphetamines (Mueller et al, 1994).

A study was conducted by the National Institute on Drug Abuse in an attempt to answer the question of how prevalent is substance abuse among pregnant women and who is at risk (NIDA, 1992). Information was gathered by questionnaires and urine toxicology screens at a number of sample hospitals. It was estimated 5.5% of all woman used an illicit substance at some time during their pregnancy. Marijuana was used during pregnancy by 2.9% of all women, cocaine by 1.1%, and opioids by 0.1%. An estimated 18.6% of women used alcohol and another 20.2% used tobacco. Rates of illicit drug use were 11.5% for black women, 4.4% for white women, and 4.5% for Hispanic women. Alcohol use was 22.7% for white women, 15.8% for black women, and 4.8% for Hispanic women. Cigarette smoking was 24.4% for white women, 19.8% for black women, and 4.8% for Hispanic women. Illicit drug use was found to be consistent despite the age of the client, 5.7% under 25, 5.1% for those between 25 and 29, and 5.5% for those over 30. Choice of drugs however did vary depending on age. Marijuana was more common among younger women and cocaine among older women. Socioeconomic status was also a contributing factor in drug choice. Marijuana, cocaine, and cigarette smoking were higher in women who were less likely to be married, unemployed, had less than a college education, and relied on public aid for payment of medical services. Alcohol abuse was more common among women who were working outside the home, had completed a college education, and paid for health with a private insurance (NIDA, 1992).

Research studies were also investigated in an effort to identify any underlying characteristics which may place a woman at increased risk for substance abuse. Information was obtained from women in substance abuse treatment programs. The substance abusing woman was found to report a higher incidence of having a close relative with a drinking problem, a history of sexual abuse, a history of domestic abuse, and a partner with a substance abuse problem (Corrigan, 1980).

The strength of this article are many. The article confirms substance abuse during pregnancy is a considerable problem with potential grave consequences. It also educates that substance abuse is nationwide and affects women of all ages, races, religions, education levels, and social positions. It also identifies characteristics that place a woman at higher risk for substance abuse, those include having a close relative with a history of substance abuse, a history of sexual abuse, a history of domestic violence, and a partner with a substance abuse problem. By identifying these risk factors, interventions can be done to assist the woman in dealing with these issues and hopefully decrease the substance abuse. This article also encourages looking beyond the substance abuse during the pregnancy and investigating the effects on the child and parenting. The weaknesses of this article is that most of the research was done in substance abuse treatment facilities which may not reflect with complete accuracy the general public. There were also few studies done comparing substance abusers and non substance abusers with the same characteristics.

This article aids further research by identifying areas which may need to be addressed in order to effectively care for the substance abusing pregnant woman and ensure continued sobriety. The care must be ongoing after the birth in order to maintain optimal health for both mother and baby.

A prospective quantitative study (Day, Cornelius, Goldschmidt, Richardson, Robles & Taylor, 1992) on the effects of cigarette and marijuana smoking on the weight and growth of babies at birth, 8, 18, and 36 months of age. The author felt due to the high incidence of smoking and marijuana use during pregnancy, this was an area that needed to be investigated.

The sample of women came from an outpatient clinic, were healthy, and generally of a lower social position. Seventy four percent had completed high school and 60% had less than $400 per month income. There was equal distribution between white and black women. The ages ranged from 18-42 years, the mean age was 23. Most of the subjects were single (67%) and 32% were primigravidas. The women were interviewed at 4 months and 7 months of pregnancy as well as at the babies birth, 8, 18, and 36 months. They were asked about quantity of cigarette and marijuana smoking. The babies were weighed and measured at birth, 8, 18, and 36 months. In an effort to control for confounding variables, the researchers controlled for the use of alcohol and illicit drugs other than marijuana.

Tobacco Use at Each Study Phase (% Reporting Use)
Tobacco First Second Third 8 months 18 months 36 months
Use Trimester
none45.747.347.437.437.838.4
<1/2ppd20.519.515.916.216.414.4
1/2-1ppd18.616.818.219.617.418.3
>1ppd15.216.518.526.928.429
sample#763692763591645662
(Day, Cornelius, Goldschmidt, Richardson, Robles, & Taylor, 1992)

Marijuana First Second Third 8 months 18 months 36 months
Use(joints per day) Trimesters
none59.778.382.260.762.964.9
>0-0.4/qd19.213.29.718.620.620.4
>.4-1/qd7.63.53.36.96.55.9
>1/qd13.55.14.813.79.98.8
any use40.321.717.839.337.135.1
sample# 761 692 763 591 645 661
(Day et al, 1992)

The results indicated at birth, there was a relationship between tobacco smoking and babies' measurements. Compared to nonsmokers, those women who smoked greater than 1ppd had babies that were on average 204 grams less, 10 mm shorter, and a head circumference 4 mm less (Day et al, 1992). The smokers were also at increased risk of having a small for gestational age baby. By 8 months of age, smoking did not appear to be a factor on growth. At birth, the only area affected by marijuana use was the babies were 1.5 mm shorter than non marijuana smokers, after 8 months there was no effect on growth. There appeared to be no effect either with smoking or marijuana use on minor or major physical anomalies or on gestational age. There were 10 deaths after 28 weeks, 8 of the women smoked tobacco throughout pregnancy, marijuana was used by 5 women in the first trimester and 2 in the third trimester, alcohol use was used by 6 women in the first trimester, and 2 in the third trimester. There were 3 deaths from sudden infant death syndrome. All 3 of these mothers smoked heavily, one used heavy alcohol use and light marijuana in the first trimester, one used light alcohol throughout pregnancy, and one did not use any alcohol or marijuana (Day et al, 1992).

The strength of this study is that it investigated cigarette smoking and marijuana use during pregnancy effects on infants' growth at birth and into childhood. The information gained from this study may be used to educate both providers and pregnant women. The weakness of this study is in the confounding variables. It was difficult to understand how the study accounted for alcohol and other illicit drug use. It was also difficult to rule out the problem of the women being exposed to second hand smoke. There was also the question that since these women were from a lower socioeconomic status, are there other factors that may have contributed to the results. This study does correlate prior studies that smoking does effect birth weight and growth. This information can be provided to women in education in an effort to deter smoking during and after pregnancy.

A research article reviewed quantitative research on the physiologic and psychological effects of drug use on the mother (Bishai & Koren, 1999). The authors felt that there were many papers investigating the potential teratogenic effects of substance abuse during pregnancy to the fetus, but very few addressed the effects of the drugs on the mother.

It was noted that women who abused substances during their pregnancy were at greater risk for poor prenatal care, poor nutrition, increased risk of STI's, smoking, and alcohol use (Silver, Wapner & Loriz-Vega, 1987). They were also at increased risk for preterm birth, abruption, premature rupture of membranes, antepartum hemorrhage, toxemia, anemia, breech presentations, and psychiatric disorders (Silver et al, 1987).

A study was done comparing 112 drug dependent women with 224 non drug abusing women in an effort to identify if the drug abusing woman had normal labor patterns and if routine intrapartum care was appropriate. It was found both groups had similar first, second, and third stages of labor. There was an increased incidence of premature delivery, abruption, breech presentation, and intrauterine growth retardation in the drug dependent group. There was no increase in complications with either vaginal or cesarean sections with the drug abusing group. There was a 40% increase in forceps births for the drug abusing group, this was believed to be as a result of the high incidence of epidural anesthesia. There was also a significantly greater use of analgesia and anesthesia with the drug abusing group. The results of this study support the use of a high level of maternal and fetal surveillance during pregnancy and birth care to ensure the best outcomes for drug abusing pregnant women (Silver et al, 1987).

This research study also investigated each drug's individual effects on the woman's body and what it placed her at risk for. The drugs researched were cocaine, amphetamines, opioids, alcohol, organic solvents, and cannabinoids. The effects of cocaine in pregnancy are greater than in nonpregnant women. There are enhanced cardiac and neurologic responses which place the woman at greater health risks. The placenta has been shown to be a target organ for cocaine (Chesnoff, Burns & Schnoll, 1985). Numerous studies were looked at which showed cocaine using women at increased risk for spontaneous abortions, premature rupture of membranes, premature delivery, abruption, hepatic rupture, pulmonary edema, seizures, cardiac problems, and possible death (Chesnoff et al, 1985).

The effects of amphetamine use is similar to that of cocaine. The placenta has also been shown to be a target organ. Amphetamine users are at increased risk for premature labor, fetal growth retardation, abruption, decreased uteroplacental bloodflow, and hypertension ( Eriksson, Larsson & Winbladh, 1978).

Complications that may develop as a result of opioid use during pregnancy include premature labor, premature rupture of membranes, breech presentation, antepartum hemorrhage, toxemia, anemia, and infections including HIV, hepatitis, or STI's (Stone, Salerno & Green, 1971). There were many studies done on the effects of heroin in pregnancy. A study was done of 382 heroin using women. The results showed only 25% received prenatal care and most began in the third trimester. The average number of prenatal visits was one per client. The length of labor was shorter for the heroin using mother versus a nonaddicted mother. Two hundred and ten women had labors less than 3 hours and more than 55% had a labor less than 7 hours. Most of the women delayed coming to the hospital for fear of withdrawal. For this reason, it was not uncommon to have home, ambulance, and stretcher deliveries. It was believed if these women had received proper counseling, these situations could have been avoided (Stone et al, 1971).

There has been no proven safe amount of alcohol use during pregnancy, therefore abstinence is the recommendation during pregnancy (Makarechian, Agro, & Devlin, 1998). Half of all pregnancies are unplanned and half of all women drink socially prior to knowing they are pregnant, therefore approximately 25% of all babies are exposed to some amount of alcohol in utero (Makarechian et al, 1998). Because of the high number of fetuses presumed to be exposed to alcohol in utero, a study was done on 12,000 pregnancies where less than 2 drinks were consumed per day. The results indicated there was increased risk of abruption, but no other increased risks (Makarechian et al, 1998). Heavy drinkers (which was not defined in this paper) have been associated with increased risk of spontaneous abortions, fetal alcohol syndrome, and abruption. The risk of fetal alcohol syndrome has also been found to increase with gravity secondary to the increased morbidity of long term alcohol abuse (Makarechian et al, 1998). Women with significant long term drinking histories are also at risk for hepatic, gastrointestinal, and neurologic problems (Makarechian et al, 1998).

The strength of this article is that it addresses an area that lacks research and understanding. By better understanding the way substances act on a woman's body and possible adverse effects to the pregnancy, better treatment plans can be developed, as well as patients better educated. The research also indicates and reinforces the need to care for the substance abusing pregnant woman as high risk in order to ensure the best possible outcomes. The weakness of this article is that by describing each drug individually, it leads one to believe we can screen and intervene based on one drug. The reality is that most substance abusers are polysubstance abusers and need to be evaluated appropriately.
This article has provided information with which a healthcare provider can educate the substance abusing pregnant woman on the way drugs act on the body and the possible negative consequences that can affect her baby.

In a study by the Alcohol, Drug Abuse, and Mental Health Administration (Goldberg, 1995) about 5% of American women abuse or depend on alcohol, and 1.5% abuse or depend on nonalcoholic illicit psychoactive drugs. Studies have shown equal substance abuse between women of all ages, races, religions, education levels, and social positions. Heavy drinking was found to be more common in white women compared to black or Hispanic women. American Indian women, however, do have an unusually high prevalence of drinking problems ( Goldberg, 1995). Some studies have indicated that there are more abstainers among lower class women than those of middle or higher class women. Those women of the lower class who do drink, however, have been found to usually be heavy drinkers (Goldberg, 1995). A study investigating urine toxicology screens in Pinellas County, Florida, found there were equal rates of positive screens for both white and black women, both in the public and private sector (Goldberg, 1995). The difference was the black women were more likely to be positive for cocaine and the white women more likely to be positive for marijuana or opoiods (Goldberg, 1995). Similar studies in California and Rhode Island found a slightly higher incidence of drug use amongst women who were not white and poorer (Goldberg, 1995).

A major risk factor identified for women being substance abusers are that they are at increased risk for oppression. They are at increased risk of being discriminated against in the workplace. They are also at increased risk of being indirectly discriminated against in the workplace by lack of support in assisting them with their families. These factors increase the number of single mothers who are poor and have increased difficulties (Goldberg, 1995). Women have been typically stereotyped in the public as unreliable, emotional, incapable of handling leadership or advanced roles at work Goldberg, 1995 This stereotype has been reinforced by the media. Because of this, women have difficulties advancing professionally (Goldberg, 1995).

Women are more likely to be victims of sexual abuse and domestic violence. Both sexual abuse and domestic violence have been shown to increase a woman's risk of being a substance abuser (Goldberg, 1995). Another risk factor is having a partner who is a substance abuser (Goldberg, 1995).

As a result of these risk factors, many women become poor, homeless, and single mothers. All of these can create barriers to care for the substance abusing woman. Many substance abuse treatment facilities are created for the male substance abuser (Goldberg, 1995). Many treatment facilities do not provide resources for childcare. Women fear financial loss and the potential loss of their children if they enter treatment (Goldberg, 1995).

Recent experimentation with programs designed for women suggest there are higher rates of recovery after receiving treatment designed specifically to meet the needs of women (Goldberg, 1995). In order for treatment programs to be successful, they need to be comprehensive. They need to provide care for substance abuse, housing, medical care, education, and counseling for all family members (Goldberg, 1995). Care of the substance abusing woman needs to be coordinated with other facilities, such as shelters. Women need to be cared for without fear of punishment (Goldberg, 1995).

The most effective way of addressing substance abuse is prevention (Goldberg, 1995). Prevention includes education programs on substance abuse, increased awareness of sexual abuse and domestic violence, providing opportunities for young girls to get out of these situations, as well as better treatment for the offenders (Goldberg, 1995). It is also essential substance abuse be presented to the public as a disease, not a moral issue (Goldberg, 1995). The stereotype of women frequently portrayed must also be dispelled (Goldberg, 1995).

The strengths of this article are many. The article stresses that all women are at risk for substance abuse. It identifies risk factors for substance abuse and barriers to care. It presents treatment options specifically designed for women and meeting their needs. It also addresses prevention and ways to decrease substance abuse before it becomes an issue. The weakness of this article for the purposes of researching pregnant substance abusing women is that it is not limited to pregnant women. This article provides direction for developing an effective treatment plan, as well as provides information on prevention of future substance abuse.

A study (Salmon, Joseph, Saylor & Mann, 2000) was done in an effort to identify the perceptions of the women on social and provider support during their treatment. The study also identified aspects of the treatment program which the women felt assisted them in successfully remaining sober. The authors of this study felt that substance abuse during pregnancy continues to be a significant problem, which lacks effective treatment programs. They also felt there are few studies available that investigate the woman's perceptions. By integrating the woman's perceptions into treatment options, there may be a higher success rate in decreasing substance abuse.

The conceptual model used for this research study was the Social Stress Model of Substance Abuse (Salmon, Joseph, Saylor, & Mann, 2000) . This model combines a variety of psychosocial theories and models. The theory is that the likelihood of a person using drugs is directly proportional to their level of stress and the stress modifiers available to them (Salmon et al, 2000).

The sample included 20 women, all over 18 years old, and volunteers. The majority of women were Hispanic (55%), white (20%), African American (10%), Filipino (5%), Vietnamese (5%), and American Indian (5%), single (70%), married (15%), and divorced (15%), unemployed (95%), employed (5%), the average age was 30, average number of children 3.3, and average number of pregnancies 4.9. 60% of the women were referred from the criminal justice system, 15% from social services, 15% self referred, and 5% from a family member (Salmon et al, 2000).

Data for this research study was obtained by interview and questionnaire. Initially, a one hour interview was done to obtain demographic and drug history. A second questionnaire was designed by the researchers to collect data on social support, provider support, and to identify aspects of the treatment program the women felt assisted them to maintain sobriety (Salmon et al, 2000).

The outpatient treatment program was a 9 month program that consisted of 4 levels. Most of the clients interviewed were in level 2, which meant greater than 2 months of sobriety (Salmon et al, 2000). The treatment program was comprehensive; it included child care, transportation, individual and group counseling, individual case managers, substance abuse education, introduction to the 12 steps of recovery, relapse prevention, health education, education on domestic violence, parenting and life skills, and individual needs, such as assistance with finances and housing. Weekly urine toxicology screens were obtained (Salmon et al, 2000).

The results were as follows: 1. Program support- The aspects of the program the women felt were most helpful were the educational classes, classes dealing with stress, and the staff roles in the classes. The educational classes identified as most helpful included 12 steps of recovery, relapse prevention, drug education, development of increased self esteem, and spiritualism. As a secondary benefit, the women felt they got social support from each other by participating in the classes. 2. Social support- Most of the women felt they did not get much support from their family and friends while they were using, but since entering treatment most of the women felt they were receiving enough support. Most of the support came from parents and siblings. Other support came from women in the group and counselors or sponsors. Some women made reference to God and church (Salmon, 2000). 3. Provider support- The providers consisted of perinatal educator, physician/nurse practitioner, and staff nurses. The perinatal educator was usually a registered nurse in the outpatient setting. In response to the perinatal educator, 50% felt supported, 50% felt she was trustworthy, and 64% felt they received adequate care. In terms of the MD/NP- 45% felt supported, 91% felt they were trustworthy, and 33% felt they received adequate care. The majority of women received little or no information regarding substance use and its effects on their health, the pregnancy, or the baby. Many of the women admitted they did not confide their substance abuse with their provider (Salmon et al, 2000).

The strength of this study is that it investigated the perceptions of the women in the substance abuse treatment program and identified areas that the women felt assisted them in maintaining sobriety. It also reinforced the need for comprehensive treatment for women in order to maintain sobriety. It also showed a connection between support and continued sobriety. The results of the provider satisfaction were startling. This demonstrates an area for great improvement. It suggests that perhaps all women should be counseled equally whether or not they admit to substance abuse. We are missing alot of substance abusing women. It also encourages healthcare providers that educating women on substance abuse does in fact change the outcome of substance abuse on some level. There are some weaknesses in this study. The number of women involved in this study is few, only 20. It would have also been extremely helpful if this study had been done on a substance abuse treatment center that also integrated the women's obstetrical care. For the purposes of this research paper, it would have also been helpful if the care had been provided by CNM's. This study does guide the effective treatment approach of substance abusing pregnant women by providing suggestions that comprehensive treatment, education, and support improve success in abstaining from alcohol and drugs.

A quantitative research study (Degen, Myers, Williams-Petersen, Knisely & Schnoll, 1993) on the perceptions of social support and pregnancy anxiety of drug abusing and non-drug abusing pregnant women. The authors identified pregnancy as a time of stress and anxiety for most women. The study was conducted based on the theory the drug abusing pregnant woman has less resources and more anxiety than a non using pregnant woman.

The sample consisted of 80 women, 25 substance abusers and 55 non substance abusing pregnant women. All of the women were over 18 years old, greater than 20 weeks pregnant, and volunteered to be part of the study. They were seen at a public clinic in a large Southern city which was staffed by nurses, physicians, and nurse practioners trained in the detection of substance abuse. This decreased the risk that substance abusing women would be in the non-substance abusing group. The substance abusing women were identified either by self-admission, urine toxicology screen, or review of prior history of drug/alcohol use. There was no significant difference in the demographics for either group. Seventy-four percent of the women were African American, 26% white, 20% married, 64% single, 16% separated or divorced, 55% aged 18-24, 45% aged 25-39, 36% less than high school graduate, 29% partial college education, and 27% relied on public assistance. The only difference noted was that the substance abuser was less likely to have grown up in a two parent home. There was also no difference between gravity, OB history, number of children, or age of first birth (Degen et al, 1993).

The women participated in the research during their routine prenatal appointment. Consent was obtained, intake form complete, research measures administrated, and a urine sample obtained by a female experimenter, who did not know the status of the woman. Each woman received twenty dollars compensation for participating. Two evaluation tools were used. The Interpersonal Support Evaluation List (ISEL) consists of 40 statements assessing the woman's perception of her social support system. The other tool is Pregnancy Research Questionnaire (PRQ) which consists of 68 items that have 7 scales that evaluate pregnancy anxiety (Degen et al, 1993).

The results were as follows. There was no difference between the drug abusers and the nondrug abusers in terms of social support. They both indicated having a high level of support in their life. The one dimension that did differ was that the substance abusing women had less self esteem. Low self esteem has been identified in prior studies as a problem for substance abusers. The drug abusers and non drug users had equal desires for the pregnancy, maternal feelings, and anxiety during pregnancy. The drug abusing women did indicate having greater fears for themselves and for their baby. They were also had increased feelings of depression (Degen et al, 1993).

The strength of this research is that it compares drug abusing and non drug abusing pregnant women in analyzing their support and anxieties. The results indicate drug abusing pregnant women have normal maternal feelings and anxieties. This indicates they need to be cared for as a normal pregnant woman, as well as a woman who has a substance abuse issue. It also directs healthcare providers to assist these women in ways to improve their self esteem, treat them with respect and be aware of depression as a risk factor. The weakness of this research is that because the women were from completely similar backgrounds, this could explain how the results were so similar. It also may not reflect the typical substance abuser as these substance abusers were very compliant with prenatal care. It would have been helpful if this study had been done at a few different sites and in different areas. This research encourages a treatment program to be two-fold. It should encompass care of the normal pregnant woman and address the issue of substance abuse.

A quantitative research study ( Snow & Anderson, 2000) of women in recovery and relapse from alcohol and drug addiction contends that substance abuse in women is an area of grave concern. It is also an area which lacks research. Because of this, the author conducted a study of two groups of women. The first is a group of women who have relapsed and the second is a group of women who have remained in recovery. The study was done in hopes of identifying any consistent factors that may contribute to either relapse or recovery.

Two questionnaire tools were used to survey the women. The first was a questionnaire developed by the authors. It was based on literature review and the author's own clinical observations (Snow & Anderson, 2000). This survey collected demographic information, personal histories of drug and alcohol use, treatment information, and social supports. The second questionnaire was the PROMIS Addiction Questionnaire (PAQ). The PAQ has demonstrated validity and reliability as a tool for evaluating addictions (Snow & Anderson, 2000). The PAQ consists of 12 questionnaires each consisting of 30 questions. Scores are given from 0 to 30 for each question. The PAQ provides information on the type and severity of addictions. Two groups of women completed these tools. The first group consisted of 50 women who volunteered for the study. They were all between day 3 and 5 of admission to a treatment facility and had previously been in treatment. They received a five dollar compensation. Three treatment centers participated, two private and one public. The surveys were given out and collected by trained personnel at the facilities. The recovery group consisted of 50 women who had remained sober for at least two years, many had been sober for ten years or longer. The women had been found through Alcoholics Anonymous support groups, a states nurses peer assistance program, an addictions nursing list server, and through a "snowball" type of sampling method within local recovery organizations (Snow & Anderson, 2000). Tools were either hand or mail delivered. Questionnaires were returned through the mail.

The results of the study found there was alot in common between the two groups regarding their histories of substance abuse and personal experiences. Differences were also found. The women in the relapse group tended to be younger, less educated, less likely to be professionally or semiprofessionally employed, and less likely to be married. Other factors which contributed to relapse were depression, not attending a 12 step support group, and a personal crisis or stress. The recovery group had consistent themes which included attending a 12 step group, Alcoholics Anonymous, having a sponsor in A.A., having motivation to change, and having supportive family, friends, and coworkers.

The strength of this study is that it addresses substance abuse in women. This is an area which lacks research and knowledge. The information hoped to be found by this study would once identified be used to hopefully decrease the incidence of relapse. The weakness of this study is due to the small number of participants and the lack of randomness. For the purposes of this research, it would have been helpful to have studied pregnant women. This study has provided information which can improve healthcare practitioners care of the substance abusing woman.

A quantative research study ( Jansson, Svikis, Lee, Paluzzi, Rutigliano & Hackerman, 1996) on the outcomes of the first 100 participants in the Center for Addiction and Pregnancy (CAP) was conducted. Substance abuse in pregnancy continues to be an area of great concern. Comprehensive multidisciplinary programs have been shown to be an effective treatment program for women. This article researched such a program to see if the results supported the theory.

The Center for Addiction and Pregnancy (CAP) is a program at Johns Hopkins Bayview/Medical in Baltimore, Maryland was described. The program consisted of three levels of care. Initially, the woman resides for the first 7 days in a residential treatment program with intensive evaluation and counseling. She then advances to ambulatory care. The first 21 days the woman is required to receive treatment 6 hours/day for 7 days, then 6hrs/day for 5 days x 6 weeks, and then progress to 3, 2, and 1 x a week. The treatment program consists of the following groups- OB, Drug abuse education, individual and group therapy, occupational, Drug abuse education for family, parenting, family therapy, 12 step groups, relapse prevention, Lamaze, and lactation. The multidisciplinary team consisted of 1. Individual master's level therapist- individual and group therapy 1-3 x a week, also daily review. 2. BA level mental health worker- assumed individual case management. Assisted with housing and social services. 3. Ob careproviders- CNM's and MD's. The CNM was the main ob careprovider. Clinics were available 5 days a week and a CNM was on call on labor and delivery 24 hours a day. CNM's were used primarily because they were believed to be cost efficient providers who functioned well in a multidisciplinary setting, and they would offer care in a manner that would be well received by this client (Jansson, Svikis, Lee, Paluzzi, Rutigliano, & Hackerman, 1996).

The schedule of care included- An initial prenatal visit with history, physical, and labs. The patient returned in one week for results, they were then seen q 2 weeks until 28 weeks and then weekly. 28 week visit included labs and gtt. During the third trimester, the women were screened for STI's, had an ultrasound to check growth, at 32 weeks had weekly non stress tests, and at 36 weeks had weekly biophysical profiles. Postpartum care consisted of hospital visits, 2 week social visit, and a 6 week visit. Pediatrics was ongoing despite continued participation in program. Childcare and parenting programs continued postpartum (Jansson et al, 1996).

The first 100 women to complete the program were evaluated. The women were primarily African American, in their late 20's, single, and had less than a high school education. Their drugs of choice were cocaine, heroin, and alcohol. The length and amount of treatment varied depending upon entry into care. The mean age at first prenatal visit was 26.5 weeks with 89% registering for care in the second and third trimester. The mean number of prenatal visits was 8.4 and the women attended 85% of their scheduled visits. Maternal complications included- 50% none, Urinary tract infections- 15%, Hepatitis B- 13%, pulmonary disorders/ primarily asthma- 10%, HIV- 8%, Psychiatric disorders- 4%, Gynecological history 38% negative, Gonorrhea- 37%, Chlamydia- 18%, Humanpapilloma Virus- 7%, Syphilis- 4%, and Herpes- 2%. Rates of STI's in this pregnancy- 61% neg., Chlamydia- 10%, Humanpapilloma Virus- 4%, Gonorrhea- 3%, Syphilis- 3%, and Herpes- 2%. Complications during this pregnancy- Intrauterine growth retardation- 16%, Preterm labor- 12%, Gestational Diabetes- 4%, Oligohydramnios- 4%, Pylonephritis- 3%, and 32% none.

Results- Normal spontaneous vaginal delivery- 82%, primary c/s- 7%, and repeat c/s- 10%.
Pitocin induction-18%
Epidural anesthesia- 57%
Mean gestation at delivery- 38.6 weeks
Birth weight, length, head circumference 40- 50 percentile
Small for gestation-7%, Average for gestation-88%, and Large-5%
no Very low for gestation
Thick meconium- 13%
Neonatal intensive care- 10%, average stay 6.6 days
Urine toxicology screens at birth-positive 27%
Mothers on methadone-22%
Family planning- bilateral tubal ligation-26%, norplant- 51%
Routine developmental testing at age 6, 12, and 24 months showed
no developmental delay.
Cost efficiency in a comparison control group showed that infants in
that group were 2.5 x more likely to require NICU admission than the
CAP babies and the stay 6 x longer this indicated a savings of
$5,0000 (Jansson et al, 1996).

The strength of this study is that is evaluates the effectiveness of a multidisciplinary program for the substance abusing pregnant woman. In demonstrating its effectiveness, it will hopefully inspire more programs like it, as women's treatment programs are lacking. The weakness of this study was in the small number of participants and their lack of diversity. It would have also been helpful to have known the patients' satisfaction with the program. It would have also been helpful to compare outcomes to a control group, not just financial. This treatment program provides an excellent example of combing prenatal care and substance abuse treatment as a template for a future program.

A quantitative research study (Corse & Smith, 1998) on the effectiveness of a substance abuse treatment program, ANGELS, for pregnant women which uses CNM's as the OB careproviders was done. The purpose of this program was to evaluate if substance use decreased or stopped based on this care.

The ANGELS program of care for the substance abusing pregnant woman was based on the midwifery model of care in an attempt to move beyond the routine care (Corse & Smith, 1998). ANGELS cares for both substance abusers and nonsubstance abusers. The midwives attempted to establish a trusting relationship and integrated substance abuse treatment into prenatal care. The routine care included- A CNM primary care coordinator for the patient, longer and more frequent visits, assessment of substance abuse and addressed at each visit, urine toxicology screen at initial visit, addictions counselors, education classes on drugs, and prenatal classes. Special interventions included- on site individual or group addictions counseling with a master's level counselor, referral to social services, intensive drug or alcohol treatment programs, homevisits for those women not compliant with prenatal care, childcare available, and vouchers for public transportation. There was a 6 month training program on substance abuse that all of the CNM's attended (Corse & Smith, 1998).

This study focused on 14% of the patients (77 women) in a 16 month period who were substance abusers in the care of ANGELS. Substance abuse was either self identified, CNM identified, or identified on a urine screen. The women tended to be white (69%), unmarried (84%), and had no private insurance (94%). The average age was 26, and have an average of 2 prior pregnancies (Corse & Smith, 1998).

The ANGELS program evaluated many outcomes from the treatment, but for the purposes of this paper the only outcome reviewed was the effectiveness of reducing substance abuse during pregnancy. The results showed of the 77 women 51% remained relatively abstinent over the pregnancy, 35% reduced their abuse somewhat, and 14 % showed no change in their use. The women who tended not to change their substance abuse tended to be heavier users, enter prenatal care later, and have more psychosocial issues (Corse & Smith, 1998).

The strength of this study is that it evaluated whether or not prenatal care combined with substance abuse treatment altered the woman's substance use during pregnancy. This is an area not evaluated in all studies. In this study it clearly did. It also evaluated a program which used CNM's. It also suggests that the OB careproviders need formal education in the care of the substance abusing pregnant woman. The weakness of this study is that it would have also been helpful to see the other outcomes of the pregnancy. The term relatively abstinent was not defined. It also would have been helpful to compare a similar program with different OB providers to see if the CNM's made any difference. This program suggests that in order to have a successful treatment program the providers must be first educated. It also suggests the prenatal providers need to be involved on all levels of the substance abuse treatment and work with treatment counselors.

A qualitative research study (Kennedy, 1995) discussed women's experiences with midwifery care. The philosophy of midwifery care as stated by the American College of Nurse-Midwives is that " the process of nurse-midwifery care is safe, satisfying, respectful of human dignity, and self determination, respectful of cultural and ethnic diversity, family centered, and health promoting" (ACNM, 2001). The purpose of this study was to evaluate if indeed this was the woman's perception of the care she received from her midwife.

The research method used was that of phenomenology. It is an inductive methodology that looks to understand the experience (Kennedy, 1995). In order for this method to be successful the researcher must set their own perceptions on the phenomenon aside.

Six women were included in this study. They were cared for in one of two settings. The first was a private practice that cared for women who mainly had private insurance, delivered at a level III hospital that had labor/delivery/recovery and a separate postpartum room. The second practice cared for women who were mainly on the Medicaid system and a few with private insurance. They received care at a health center and delivered at a level I hospital that had labor/delivery/recovery/postpartum rooms. Both practices were located in the Northeastern part of the United States. The women were over the age of 18, the mean age was 31, had most of their care and birth by a CNM, 3 were primiparas, 3 were multiparas, 4 white women, 1 African American, and 1 Native American. They all spoke English and were cared for by a total of 5 midwives (Kennedy, 1995).

Once a woman agreed to be part of the study, an interview took place, and consent was obtained. Each woman was asked to answer the question," Please describe what your experience was to be cared for by a nurse-midwife during your prenatal visits, birth, and postpartum contacts: describe all your thoughts, feelings, and perceptions about these experiences that you remember until you have no more to say" (Kennedy, 1995). The interviews were audiotaped and then transcribed. The data was then analyzed by the author and an independent judge, experienced in the phenomenological method. The women were then sent back the response and asked if this was indeed accurate. Five of the women responded yes and one women did not respond (Kennedy, 1995).

The results included 151 significant statements and 9 themes emerged. The themes were as follows- 1. The woman, as an individual determines and directs her care. 2. Development of a caring relationship built on mutual respect, trust, and alliance emerged. 3. The qualities and behaviors of the nurse-midwife laid the foundation for the richness of the women's experience. 4. The woman felt cared for within the domain of her family, the family's needs and potentials were always considered in relationship to her. 5. A sense of safety encompassed the woman's trust in the nurse-midwives knowledge and ability. 6. Time, the most valued commodity, was both given and respected by the nurse-midwife. 7. The health and normalcy of pregnancy were the presiding focus of care. 8. The woman ( and her family) felt guided in her decision making and actions based on the information provided by the nurse-midwife. 9. A continuos link with the nurse-midwife was repeatedly demonstrated to the woman throughout her care experience (Kennedy, 1995).

The strength of this research is that it asked the woman what was her perception of the care she received. The results in this study supported the women felt they were receiving the midwifery care midwives believe they provide. This study although small in sample size does have diversity in the demographics. The weakness in the study is the small number of participants. This is understandable given the time consuming nature of the study. This study supports it would be beneficial to incorporate midwifery care into the care of substance abusing pregnant women.

Theoretical/Conceptual Framework-

Every research study has within it a conceptual framework. It is the conceptual framework which provides the structure for the research. It identifies a relationship between two concepts. In attempting to explain this relationship new problems and hypotheses emerge for the researcher. This stimulates and guides further research. The research then tests the hypotheses. The presumed relationship and the actual outcomes of the research are then compared. This sometimes results in new theories and research (Polit, Tatano, & Hungler, 2001).

The conceptual framework of this paper is based on the theory that integrating the midwifery model of care to the substance abusing pregnant woman will result in improved health and in the case of a pregnancy improved maternal and neonatal outcomes. The conceptual map referred to is a conceptual representation of the midwifery model of care based on Rook's model.

The midwifery model of care focuses on the needs of the individual woman and her family. Care is provided on the belief that every individual is entitled to safe and satisfying health care with respect for human dignity and cultural diversity (ACNM, 2001). The midwifery philosophy is based on the belief that pregnancy, labor, and birth are normal processes. Midwives specialize in the care of normal pregnant women. In most countries, midwives are responsible for the majority of women who have uncomplicated pregnancies (Rooks, 1999). As a result of the midwifery philosophy, midwives are able to focus on all areas of a woman's life, as well as the pregnancy.

There are times when complications arise in pregnancy and require medical attention. For this reason, the American College of Nurse Midwives requires certified nurse midwives and certified midwives to practice within a healthcare system that provides for medical consultation, collaboration, and referral (Rook, 1999).

Midwifery care places special emphasis on the social, emotional, and cultural needs of each client. The midwife views each woman as an individual with a unique set of needs. The midwifery model of care identifies the woman, her family, and her life as the central focus of prenatal care. The pregnant woman is encouraged to be an active participant in her care and the ultimate decision maker. Most of the prenatal care is directed toward listening to the woman. The midwife wants to know her clients experiences and desires. She/he provides the woman with information and choices in her care.

A midwife attempts to assist the pregnant woman in identifying areas in her life that may negatively affect her and her pregnancy. Suggestions are made on ways she may improve on her health. Midwives identify problems or potential problems, provide information, and options, but stress that the final decision is to be made by the woman.

Prenatal care within the medical model focuses mainly on the fetus and pathology. It often fails to identify areas of the woman's life that could negatively impact the pregnancy. One example of this is in the area of smoking. Approximately 20% of low birth weight babies are a direct result of smoking. The National Ambulatory Medical Care Study identified that although 80% of physicians identified smoking as a risk factor for their patients only 22% counseled these women on the possible adverse effects of smoking and on smoking cessation options (Rook, 1999). A similar study was conducted in 1994 of members of the American College of Nurse Midwives. The results were that 93% of the midwives identified smoking as a risk factor for their clients and 86% of them provided the women with information for smoking cessation (Rooks, J. P., 1999). Another study of women who were cared for by MD's and CNM's found that the women believed the CNM's were focused more on health promotion than the MD's (Rooks, 1999).

As a result of midwives strong belief in the normalcy of pregnancy, labor, and birth, they try to use less interventions (Rooks, 1999). Midwives have a wider range of what they consider normal for labor, as long as the mother and baby are stable. By treating more labors as normal, it may help more labors to remain normal (Rooks, 1999). Midwives do use interventions when medically warranted. Midwives spend more time with the woman providing physical and emotional support.

Pregnancy and birth are viewed as a very powerful time in a woman's life. If the pregnancy and birth are a positive experience, it allows the woman to grow, have increased self respect, and be all around more confident. This confidence will enable her to be a healthier woman, mother, and family member. It will allow her to make healthier choices in all areas of her life.

Conceptual Model-

Midwifery Care + Substance Abusing Pregnant Woman -(+)-> Improved Perinatal Outcomes

The International definition of a midwife as described by the World Health Organization is "A midwife is a person who, having been regularly admitted to a midwifery educational program duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery" (Rooks, 1997, 6).

Substance abuse as defined by the DSM-IV includes two parts "(1) 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 (2) 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" (Goldberg, 1995).

Outcomes are defined as the effectiveness of the healthcare service and the end results of the patient care (Polit et all, 2001).

It has been shown that many substance abusing pregnant women have been victims of sexual abuse and domestic violence (Goldberg, M., 1995). As victims these woman have lost their voice and often feel they have no control in their life. The midwifery model of care encourages women to speak, participate in their care, and be the ultimate decision makers. They are given opportunities to make choices both prenatally and in childbirth. This model of care would give the substance abusing woman some sense of control in one area of her life.

It has been shown substance abusers lack self esteem. The midwifery model of care helps to increase a woman's self esteem and her confidence in her decision making. As a result of this process the woman will hopefully make better choices in the healthcare during her pregnancy and in her long term healthcare.

Midwifery care focuses on the normal pregnant woman, as well as her substance abuse issue. The midwife will first look at the woman and then address her issue of substance abuse. In a comparison study between substance abusing and non substance abusing pregnant women, it was shown they shared many of the same maternal feelings and anxieties during pregnancy (Degen, Myers, Williams-Petersen, Knisely, & Schnoll, 1993).

Midwifery care is time intensive, it includes educating and caring for the woman. The belief is that when women are educated and provided with emotional support and accurate information they may change their behaviors. In studies of substance abusing women, success has been directly linked to the support they received (Salmon, Joseph, Saylor, & Mann, 2000). Female substance abusers have also verbalized a change in their substance use as a result of education they received (Salmon et al, 2000).

If the midwifery model of care is successful the result will be improved maternal and neonatal outcomes. If the experience is positive the woman will bring confidence and skills to apply to all areas of her life. She will become a stronger woman, making healthier choices which will assist her to long-term sobriety and a fulfilling life.


Chapter Three: The grant application

Abstract

Women who abuse drugs and alcohol are at high risk for disruption of safe motherhood during pregnancy and beyond. National health goals target substance abuse as a serious health problem requiring a multidisciplinary approach to its prevention and treatment. Treatment programs developed specifically for substance abusing women have been shown to improve the overall health of these women, and in the case of pregnancy, both maternal and neonatal outcomes. Primary preventative and maternal health care services to these women in recovery, however, tends to be a goal that is secondary to the goal of treating their abuse. The introduction of full scope nurse-midwifery care to women at an all women's residential substance abuse treatment facility in August, 2001, offers an opportunity to explore the influence of midwifery care on selected variables linked to women's health and safe motherhood in this vulnerable population. This study will determine how the introduction of midwifery care to a residential population of recovering women in treatment for substance abuse will affect four areas of concern: 1) access to and use of preventative healthcare services; 2) initiation of prenatal care, 3) selected health outcomes, such as screening for cervical cancer and sexually transmitted infections and maternal and neonatal outcomes, and 4) patient satisfaction with midwifery care services, especially relative to their prior experiences with other providers.


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Significance for women's health/safe motherhood
Increasing the likelihood of safe motherhood among a population of substance abusing women is a challenge. It includes access to treatment for the substance abuse itself, supportive services to promote women's overall health, both during pregnancy and afterwards, and fostering healthy family/parenting dynamics. Substance abuse has only recently been identified as an area in need of research in women's health (Snow & Anderson, 2000). Until recently, substance abuse has been considered primarily a "men's disease." Recent thinking, however, posits that women respond better to treatment regimes that are both holistic in nature and target women's special needs (Goldberg, 1995). Treatment models tend to be based on experiences with male substance abusers. Gender specific concerns for women abusers, particularly those who are mothers or mothers-to-be, have largely been ignored in treatment regimes.
Substance abusing women, and especially those women with children, have unique concerns that need to be addressed if treatment is to be successful. Many substance abusing women have been victims of domestic violence and sexual abuse, resulting in negative psychological sequelae, such as low self-esteem, learned helplessness, suicidal ideation, and difficulty in establishing appropriate affective bonds with others (Goldberg, 1995). Women with children also have many barriers they need to overcome in order to access to treatment, such as transportation, shelter, and child care (Jansson, Svikis, Lee, Paluzzi, Rutigliano & Hackerman, 1996). Some of the health risks these women face include sexually transmitted infections, human immunodeficiency virus, cardiovascular complications, substandard lifestyle, and lack of medical care. Pregnant women who abuse drugs or alcohol may also experience direct negative effects on the pregnancy, such as premature birth and placental abruption (Cunningham, MacDonald, Gant, Leveno, Gilstrap, Hankins, & Clark, 1997). Risks to the fetus/neonate include congenital anomalies, complications related to preterm birth such as respiratory and feeding difficulties, and abnormal growth and development (Cunningham et al, 1997). Care focused specifically for these women and their families will allow them to gain access to treatment, healthcare, and supportive services essential to recovery and safe motherhood.
Definition and scope of the problem
The nation has identified substance abuse as a serious health problem requiring a multi-disciplinary approach to its prevention and treatment (Healthy People, 2001) The DSM-IV defines substance abuse as two parts "(1) 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 (2) 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). Substance use by nonpregnant women is estimated to be as high as 45% of women using alcohol, and 13% using illicit substances (Walton-Moss & Becker, 2000). For pregnant women, it is estimated that as high as 19% use alcohol, and 6% use illicit substances (NIDA, 1996). The stigma and denial associated with substance abuse means that many women do not define themselves as abusers and hence escape the attention of health care providers. Thus, the true number of women substance abusers is likely to be higher than the statistics suggest. Substance abuse and its sequela result in large human and financial costs incurred by the women, their families, and society in general (Healthy People, 2010).
Significance to midwifery
Midwives are healthcare professionals who can play a vital role in the promotion of safe motherhood in this population of women. Midwifery care is based on the premise that every woman is entitled to a safe and satisfying health care with respect for human dignity and cultural diversity (ACNM, 2001). Midwives have achieved excellent outcomes in providing care to selected vulnerable populations of women (Greulich, Paine, McClain, Rabger, Edwards, & Paul, 1994). Research evidence regarding midwifery care to women in treatment for substance abuse is limited to two studies (Corse & Smith, 1998; Jansson et al, 1995). These studies suggest two important conclusions. First, midwifery care can positively affect selected health problems among these women and their families. Second, midwives can be a positive influence in the recovery process of these substance abusing women.
Research questions
The following research questions will be addressed: Does the introduction of on site midwifery care at a residential drug and alcohol treatment center affect: 1) the use of preventative healthcare services by women residents? 2) initiation of prenatal care by pregnant women residents? and 3) patient satisfaction with midwifery care services? Additionally, selected health outcomes in the women experiencing midwifery care will be described, such as screening for cervical cancer and sexually transmitted infections and maternal and neonatal outcomes.
Facilities/Resources
The Women's Recovery Center (WRC) is a 32 bed, long-term residential treatment facility for women 18 years or older addicted to drugs and alcohol, which was established in 1987. Their mission is to provide and manage behavioral healthcare treatment services for women with a primary focus on alcohol and other drug addiction treatment. Additionally, they support mothers in recovery by allowing their children to reside with them during treatment. Midwifery care is provided by Greene Midwifery Care (GMC) to these women. GMC is a full scope midwifery practice that employs 1.5 FTE midwives and was established in August 2000. There is the potential for continuity of health care for these women with GMC after discharge from WRC. The midwives of this practice are committed to serving these special women and began seeing WRC clients in August, 2001.
Methodology
Design: A descriptive, comparative study will be done. The group of interest will be all women residents at the WRC during the first year of on site midwifery care. The comparison group will consist of all women who were residents at the WRC for one year prior to the introduction of on site midwifery care. Sample size: In 1999, 159 women were served by WRC and 16% of these women were pregnant. Estimates allowing for attrition and non-respondents are that each group will have 130 women, approximately 21 of these women will be pregnant, and the majority of these women are mothers. Ethical considerations: This study is under review at the Philadelphia University IRB committee. WRC, GMC and their respective staffs have reviewed this study proposal and are supportive of this project. Client participation is completely voluntary and will be obtained through verbal and written consent. Confidentiality will be respected at all stages of this project. Instruments: Please see the following appendices for data forms: 1) Demographic data form, 2) Survey of health care use of WRC current and former residents, 3) ACNM AP data form, 4) ACNM IP data form, 5) ACNM OB patient satisfaction form, and 6) GMC GYN chart review form. Data collection procedure: Data will be collected from WRC files and GMC records, and some information will be solicited directly from patients. Former patients will be contacted by phone and interviewed over the phone or by mail and sent data forms with return postage . Current residents will be recruited and interviewed through personal contact. Data management and analysis: Raw data will be entered into the Statistical Package for the Social Sciences for the personal computer [SPSS-PC]. Demographic data will be described and the groups will be compared for significant differences. Research questions will be answered through descriptive statistics, Chi-square analyses, and independent t-tests for comparative measures. Limitations: The number of participants from the comparison group may be smaller since they will lack personal contact with the midwives. Otherwise, there are no potential difficulties are anticipated in this study. Time frame: GMC already tracks ACNM AP and IP data on all their clients. The remainder of the data gathering will be initiated once funding to support the project has been received. The final data will be gathered by August, 2002. Data entry and cleaning will take approximately one month. Data analysis and a written report will be completed by December, 2002.
Dissemination of study results
The results of this study will be made available to the WRC, Greene Memorial Hospital, and the ACNM Foundation in the form of a report. A manuscript of this study will be developed and submitted to the Journal of Midwifery & Women's Health. The results from this study will be used as the basis for seeking a larger grant from foundations, such as the Dayton Foundation, to provide salary support for health care personnel at both WRC and GMC and to further develop the role and monitor the outcomes of midwifery care offered to this special population of women at WRC.

References
` "ACNM Philosophy." ACNM online. 2001. http://www.ACNM.org. (August 2001).

American Psychiatric Association, (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington DC: Author.

Corse, S. J., & Smith, M., (1998). Reducing Substance Abuse During Pregnancy Discriminating Among Levels of Response in a Prenatal Setting. Journal of Substance Abuse Treatment, 15, 457-467.

Cunningham, MacDonald, Gant, Leveno, Gilstrap, Hankins, & Clark, (1997). Williams Obstetrics (20th ed.). Appleton and Lange.

Day, N. L., Cottreau, C. M., & Richardson, G. A. (1993). The epidemiology of alcohol, marijuana, and cocaine use among women of childbearing age and pregnant women. Clinical Obstetrics and Gynecology, 36, 232-245.

Goldberg, M., (1995). Substance-Abusing Women; False Stereotypes and Real Needs. Social Work, 40, 789-795.

Greulich, B., Paine, L., McClain, C., Rabger, M., Edwards, N. & Paul, R., (1994). Twelve Years and More Than 30,000 Nurse-Midwife-Attended Birth: The Los Angeles County and University of Southern California Women's Hospital Birth Center Experience. Journal of Nurse-Midwifery, 39, 185-196.

Healthy People 2010 online. 2001. http://www.washoe.k12.nv.us/wellness/2010/substance.shtml. (October 2001)..

Janusson, L.M., Svikis, D., Lee, J., Paluzzi, P., Patigliano, P., & Hackerman, F. (1995). Pregnancy and Addiction A Comprehensive Care Model. Journal of Substance Abuse Treatment, 13, 321-329.

National Institute on Drug Abuse: National Pregnancy and Health Survey: Drug Use Among Women Delivering Livebirths: 1992. Washington, DC, US Department of Health and Human Services, 1996.

Snow, D., & Anderson, C., (2000). Exploring the Factors Influencing Relapse and Recovery Among Drug and Alcohol Addicted Women. Journal of Psychosocial Nursing, 38, 8-19.

Walton-Moss, B., & Becker, K., (2000). Women and substance use disorders. Primary Care Practices, 4, 290-302.




Appendix A
Consent Form

Philadelphia University IRB. No.

Consent for participation in midwifery research.

I, , consent to participate in the research entitled,

Healthcare Services to Women in a Residential Substance Abuse Recovery Center: Introduction of Midwifery Care.

I understand the purpose of this study is to evaluate the influence of on site midwifery care at the WRC, a residential treatment facility for women in recovery from substance abuse. The study will determine if midwifery care results in improved access to healthcare, positive health outcomes, and increased patient satisfaction for women residents. I understand the results of the study will be made available to Women's Recovery Center , Greene Memorial Hospital, American College of Nurse-Midwives Foundation. A manuscript for publication may be developed from this study. I understand that my responses in this study are completely confidential and that no identifying information about me will be shared in any of these reports.

I understand the information will be obtained through Women's Recovery Center files, Greene Midwifery Care records and some information is obtained directly from me. I agree to release my Women's Recovery Center and Greene Midwifery Care records to be part of the study. I also agree to complete the questionnaire portion of this study, which is anticipated to take about 15-20 minutes of my time.

I understand that my participation in this study is completely voluntary and that I may choose to withdraw my participation in this study at any time without incurring any penalty. I also understand that my participation in the study will in no way affect the care I receive at Women's Recovery Center or at Greene Midwifery Care.



Date: Signature:
(Subject)
Signature: Signature:
(Primary Investigator) (Witness)


Appendix B

Demographic Data Form
ID ______
Please fill in the blanks or circle your answers as appropriate.

1. Today's date:2. Your age:3. Total years of education:
4. Marital status
1 single 4 separated
2 married 5 widowed
3 divorced 6 other
If “other”, please describe.
5. Race/ethnicity:
1 Caucasian 4 Asian
2 Hispanic 5 Native American
3 African American 6 other
If “other”, please describe.
6. Employment status:
1 not currently employed
2 not employed, full-time student
3 employed part time (<30 hours/week)
4 employed full time (30+ hours/week)
5 other
If “other”, please describe.
7. Annual family income:
1 <$15,000
2 $15,001 - $20,000
3 $20,001 - $30,000
4 $30,001 - $40,000
5 $40,001 - $50,000
6 $50,001 - $75,000

8. Religious affiliation:
1 Catholic
2 Protestant
3 Jewish
4 Muslim
5 none
6 other
If “other”, please describe.

Appendix C


Survey of health care use of
Women’s Recovery Center (WRC) current and former residents
Subject ID______
This form will be administered by the principal investigator or research assistant either in a face to face interview or over the phone.

1.Please state the month and year that you became a resident at WRC.___________________

2. Please state the month and year that you graduated from WRC._________________________
OR state if you are a current resident___________________________________________

3. How long have you been sober now?______________________________________________

4. For the year before you became a resident at WRC, did you have a complete medical history and physical exam?
If yes, please answer the following questions about that exam, Did the health care provider doing your exam (please answer yes or no):
do a breast exam?___________________________
complete a Pap smear on you?____________________________
explain how to perform a self breast exam?_________________________
offer to test you for sexually transmitted infections or vaginal infections?________________
discuss birth control options and safe sex, including the use of condoms?________________
discuss smoking with you and ways to stop?________________________
discuss substance abuse with you and ways to stop?______________________
discuss nutrition?_________________________
discuss the importance of injury prevention, such as wearing seat belts?________________
discuss your living situation, including questions about domestic violence?_______________

What kind of health care provider did this exam? (check one)
Doctor (type of doctor)_________________________ Nurse Practitioner______________
Midwife____________ Physician’s Assistant_______________ Other_______________________________
On a scale of one to ten, with 10 being most satisfied and 1 being least satisfied,
how satisfied were you with the care that you received from this health care provider?___________________________
During the time you lived at the WRC, did you have a complete medical history and physical exam?___________________________________

If yes, please answer the following questions about that exam: Did the health care provider doing your exam:
do a breast exam?___________________________________
complete a Pap smear done?____________________________
explain how to perform a self breast exam?__________________________
offer to test you for sexually transmitted infections or vaginal infections?_________________
discuss birth control options and safe sex, including the use of condoms?_________________
discuss smoking with you and ways to stop?_____________________
discuss substance abuse with you and ways to stop?_______________
discuss nutrition?______________
discuss the importance of injury prevention, such as wearing seat belts?_______________
discuss your living situation, including questions about domestic violence?_____________
What kind of health care provider did this exam?
Doctor (type of doctor)_________________________ Nurse Practitioner______________
Midwife_______________ Physician’s Assistant_______________ Other_______________________________

On a scale of one to ten, with 10 being most satisfied and 1 being least satisfied,
how satisfied were you with the care that you received from this health care provider?___________________________


Did you see one of the midwives while you were at WRC?__________________________

If yes, would you choose to receive your care again from a midwife?___________________
On a scale of one to ten, with 10 being most satisfied and 1 being least satisfied,
how satisfied were you with the care that you received from the midwives?___________________________

If no, why did you not see the one of the midwives while you were at WRC?
Circle one: They were not available when I was at WRC.
I did not know what midwives could do for me.
I did not need routine health care while I was at WRC.
Other, please explain:_______________________________________
Before coming to WRC, did you have one health care provider that you could go to for basic health care and screening?_________________________________
Who was that health care provider?___________________________________
Since your stay at WRC, do you have one health care provider that you could go to for basic health care and screening?_________________________________
Who is that health care provider?___________________________________
9. Have you ever been pregnant? Yes No

If yes, please answer the following questions:
How many living children do you have?_______________________________
What are their ages?___________________________________________________
How many of these children currently live with you?____________________________

10. Are you currently pregnant? Yes No

If yes, please answer the following questions:
What is your due date?
Are you currently seeing someone for prenatal care?
If yes, what type of provider are you seeing for this care?
Doctor (type of doctor)________________________ Nurse Practitioner_____________
Midwife____________ Physician’s Assistant_______________ Other_______________________________
How far along were you in your pregnancy when you started prenatal care?_____________________
On a scale of one to ten, with 10 being most satisfied and 1 being least satisfied,
how satisfied were you with the care that you received from this care provider?___________________________

10. Were you pregnant at the time of your stay at WRC? Yes No

If yes, please answer the following questions:
What was your due date?
Did you see someone for prenatal care during that pregnancy?
If yes, what type of provider did you see for that care?
Doctor (type of doctor)________________________ Nurse Practitioner_____________
Midwife____________ Physician’s Assistant_______________ Other_______________________________
On a scale of one to ten, with 10 being most satisfied and 1 being least satisfied,
how satisfied were you with the care that you received from this care provider?___________________________
How far along were you in your pregnancy when you started prenatal care?_____________________
Did you have any problems in your pregnancy? If yes, please describe_____________________________
Did you have any problems in your labor and birth? If yes, please describe_____________________________
Did you have any problems with your baby? If yes, please describe_____________________________

Thank you so much for participating in this study!


Appendix D

ACNM AP data form:

Appendix E

ACNM IP data form

Appendix F
GMC GYN chart review data form
Item
1. Complete annual physical exam done?1. Yes 2. No
2. Pap smear done?1. Yes 2. No Results:
3. STI screening done?1. Yes 2. No Results when applicable:
wet mount
RPR/VDRL
GC/CT cultures
HIV screen
others:
4. Method of birth control offered or reviewed?1. Yes 2. No Type used:
5. Health problems found?1. Yes 2. No List problems:



6. Health promotion teaching done?1. Yes 2. No Areas addressed:
diet
substance abuse
smoking
exercise
safe sex
self breast exam
injury prevention
domestic violence
other:





Appendix G
A.C.N.M. Foundation, Inc. Budget

Principal Investigator: Cindy Farley
Sample Budget
Cost Amount
Personnel

Graduate Research Assistant to perform data collection from WRC logs and files, GMC records, patient questionnaires, and some patient interviews. $8/hr x 125 hours

Graduate Research Assistant to perform data entry of collected information. $8/hr x 125 hours
$1,000




$1,000

Supplies

200 Solicit letters $100
200 Questionnaires $200
200 Business reply envelopes $20
200 Thank you postcards with postage $44
400 Stamps $136
$500
Equipment

None requested
$0
Travel

None requested
$0
Other

None requested
$0
Total $2,500



Total Projected Budget

A. What is the total amount needed to complete this project? $2,500.00

B. If the total amount exceeds the maximum amount of the award granted by A.C.N.M. Foundation, Inc., please list any additional sources and amount of funding already obtained for the project. None

C. If the total amount exceeds the maximum amount of the award granted by A.C.N.M. Foundation, Inc., please list any additional sources to which you plan to submit the proposal or to which you have submitted and notification is pending. Provide the date you expect to be notified of the outcome, the amount requested and the research expenses the budget will cover. None

D. Please explain how or what part of the proposed project will be conducted if funding from A.C.N.M. Foundation, Inc., is obtained, but funding from other sources is not obtained. Not applicable



Biographical Sketch

Name: Cynthia Lynne Farley, CNM, PhD

Contact Information: 1395 William & Mary Court
Yellow Springs, OH 45387
937-767-1990 or 1998
farleycnm@aol.com

Current Title and Place of Employment: Director, Greene Midwifery Care
850 E. Xenia Drive #200
Fairborn, OH 45324
937-878-2228

Faculty, Master's of Science in Midwifery Program
Philadelphia University
Home office, address as above (distance learning)


Education:

Institution/Location: Degree: Year Conferred Scientific Field

Ohio State University BSN 1978 Nursing
College of Nursing
Columbus, OH

Emory University CNM/MN 1981 Nurse-Midwifery
Atlanta, GA

Ohio State University PhD 1999 Nursing
College of Nursing
Columbus, OH



Major Research Interest/Area of Expertise:

My areas of research interest are midwifery care in all its many facets, psychophysiology of pregnancy, labor and birth, and innovative teaching methods in midwifery education.

Role in Proposed Project:

Principle Investigator

Briefly describe the role of this individual in this project:

Responsibilities include: As principle investigator, I will have primary oversight of this project. The midwives at GMC (of which I am one) will be assisting in data collection and the GMC secretarial staff will be assisting with some of the copying, mailing, and other necessary paperwork. I will also seek assistance from graduate midwifery students during the course of this study. One such student, Ms. Karen Carney, CNM, has assisted me in the development and submission of this grant as partial fulfillment of course requirements in the Critical Inquiry series, two required research courses in the Master's of Science in Midwifery degree completion program at Philadelphia University.

Research and Professional Experience: I have been active in clinical practice for 20 years, most recently establishing Greene Midwifery Care, a full scope midwifery practice in Fairborn, OH. I have been active in midwifery education for 11 years, and am now teaching in the Graduate Midwifery Program of the Philadelphia University. The courses I teach include a series of research courses with a focus on midwifery research. While I am an experienced midwife and teacher, I am somewhat of a neophyte researcher. I have completed an ambitious dissertation research project - a triangulated study examining the influence of the vicarious experience of witnessing a live birth on the self-efficacy and selected psychological measures and birth outcomes of pregnant nulliparous women. I am able to seek advice from several well-respected midwifery researchers and educators as I proceed with this project - Dr. Kathy Camacho Carr, CNM, Dr. Nancy K. Lowe, CNM, and Kate McHugh, CNM, MSN.

The following are some recent highlights of my professional experiences.

Clinical Practice

8/1/00 to present Half-time position to develop and maintain a full scope midwifery
practice with Greene Memorial Hospital. Introducing midwifery care
to a place that has never had it before.


1983-4 Staff CNM, Nurse-Midwives Center, (formerly Simpson Center for
(Full-time); Maternal Health), Springfield, Ohio. This practice served clients
1986-9 through prenatal care, birth services, and GYN care. Clinical faculty
(Full-time); for Case Western Reserve University, Frontier School of Midwifery
1993- and Family Nursing, and Institute of Midwifery, Women, and Health nurse
1999 midwifery students. Education Coordinator for student clinical
(Part-time) experiences.

Teaching

1998- Curriculum consultant and faculty for development of the Master’s of
present Science degree with a concentration in Midwifery at Philadelphia College,
using the Lotus Notes environment to deliver the curriculum for this
distance learning program. I am half-time faculty in the program. I teach
Critical Inquiry 1 & 2: An Introduction to Research Methods in midwifery
science, a required course series, and Introduction to Teaching Methods,
an elective.

Spring 2000 Adjunct associate professor at Wright State University, teaching Nursing
304-01, Foundations in Nursing Research at outreach site in Hillsboro, OH.

1996- Research preceptor for the Case Western Reserve University Master’s
1999 Completion Program. I have assisted 10 SNM/CNMs in mastering the
research skills required for their Inquiry 3 course through working with me
on my dissertation project.

1990- Antepartum Course Coordinator for Frontier School of
1997 Midwifery and Family Nursing, Community-Based Nurse- Midwifery Education Program, a distance education program.
Responsible for the supervision and updating of the antepartum care
course with an enrollment of approximately 320 students, 2 Course
Faculty, and 2 teaching associates.

Research

1999 Dissertation Research: “Vicarious Experience: A Source of Self-Efficacy for Labor and Birth.”

1981 Thesis Research: “A Comparison of Mothers' and Fathers' Role Expectations Toward the Father's Role.”

Grants
Funded ICEA Virginia Larsen research award of $1,000 for childbirth related research, 5/98.

Funded Sigma Theta Tau - Zeta Phi Chapter Clinical Research Award of
$1,400 for dissertation support, May 1998.


Publications

Farley, C. & Widmann, S. (2001). The value of birth stories. International Journal of Childbirth Education, 16(3), 22-25..

accepted for publication Sept - Oct 2001 Haninger, N. & Farley, C.L. The effects of routine screening for hypoglycemia on breastfeeding in healthy term neonates. Journal of Midwifery and Women’s Health.

under review Farley, C.L. & Carr, K. C. New directions in midwifery education: The Master’s of Science in Midwifery Degree. Submitted to Journal of Midwifery and Women’s Health, September, 2001.

under development Farley, C.L. Enhancing childbirth confidence as a facet of the art of midwifery: A review. For submission to Journal of Midwifery and Women’s Health.

Professional Activities

1984- Chairperson & Peer Review Chapter representative, The Ohio Nurse
present Midwives Peer Review Committee, a cooperative venture of all Ohio
Chapters of the American College of Nurse-Midwives.

1997- Committee member of the ACNM Division of Research.
2000

1996- Founding Board Member, Institute of Midwifery, Women, and
1999 Health, Philadelphia, PA.
. . . . . . .