Despite efforts over the last decade to increase awareness regarding the negative effects of alcohol and other drug use during pregnancy, substance abuse among pregnant women continues to be a significant problem in the United States.  The 2003 National Household Survey on Drug Use and Health indicated that 9.3% of pregnant women used alcohol and 4.3% percent of pregnant women used illicit drugs.  In other countries, the prevalence of substance use and abuse may be even higher.  For example, in a recent survey of pregnant women in Ireland, 54% admitted to drinking alcohol during pregnancy.

Various interventions and treatment programs have been designed to address the problem of substance abuse in pregnant populations. The Early Start program is an obstetric clinic-based substance abuse treatment program which has three key components.  First, a licensed substance abuse expert is placed within in the obstetric clinic; appointments for assessment and treatment are coordinated with the patients’ prenatal care visits.  Second, there is universal screening of all women for drug and alcohol use by questionnaire and, with consent, by urine toxicology testing.  Finally, all providers and patients are educated about the negative effects of drugs, alcohol and cigarette use in pregnancy.

A recent report published in the Journal of Perinataology suggests that the Early Start program may help to improve both maternal and neonatal outcomes among women substance abusers.  In this study, 49,985 women completed the Prenatal Substance Abuse Screening Questionnaires administered at a routine obstetric visit.  The subjects were drawn from 21 outpatient obstetric clinics within the Kaiser Permanente Northern California (KPNC) managed health care system.  Four groups were compared: women who screened positive for substance abuse (by questionnaire with or without positive urine toxicology) and were treated by Early Start (SAT, n=2073); women who screened positive but did not receive treatment (SA, n=1203); women who screened positive on a urine toxicology screen but did not receive any assessment or treatment (S, n=156); controls who screened negative (n=46,553). Ten neonatal and maternal outcomes were assessed, including intrauterine fetal demise (IUFD), low birth weight (<2500 g), preterm delivery (<37 completed weeks of gestation), and neonatal intensive care unit (NICU) admission.

The authors reported that the women who received no intervention (he S group) had significantly worse outcomes than the treatment (SAT) group, with higher rates of preterm delivery (odds ratio (OR)=2.1), low birth weight (OR=1.8), placental abruption (OR=6.8), and IUFD (OR=16.2).  The women who received treatment (the SAT group) were similar to the control women on most outcomes. Outcomes in the SA women generally fell somewhere between those of the SAT and S groups.

This study demonstrates that substance abuse assessment and treatment integrated with prenatal visits can improve both maternal and neonatal outcomes among women at high risk for substance abuse.  Although this type of program may seem costly, the authors comment that by reducing potentially costly negative outcomes, the Early Start program is cost-effective.  The American College of Obstetrics and Gynecology states that treatment is more effective and less expensive than restrictive policies.  The authors note that prior to Early Start, women identified with substance abuse problems were typically counseled to stop using and were referred to treaters outside the obstetrics department but generally did not follow up with substance abuse treatment.  The availability of an expert who specializes in the treatment of substance abuse during pregnancy within the obstetrics clinic helps to remove many of the barriers that can hamper substance abuse treatment.

Ruta Nonacs, MD PhD

Goler NC, Armstrong MA, Taillac CJ, Osejo VM. Substance abuse treatment linked with prenatal visits improves perinatal outcomes: a new standard. J Perinatol. 2008 Sep;28(9):597-603. Epub 2008 Jun 26.

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