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Outcomes Improve When Pregnant Women Screened for Substance Use

Collaboration between obstetric and substance use health care clinicians creates a winning strategy to expand access and bring treatment to pregnant women.

By integrating routine screening and treatment for substance use, including alcohol and cigarette smoking, into the prenatal care system, the health outcomes of mothers and their babies can be significantly improved, according to a retrospective study conducted by the health care organization Kaiser Permanente.

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Pregnant women who visit outpatient obstetric clinics at Kaiser Permanente Northern California (KPNC) facilities are routinely given health screenings that include a questionnaire to identify potential alcohol, smoking, and other substance use problems. A urine toxicology test is performed if the woman gives her consent.

If the screening results suggest that a pregnant woman has substance use problems, including smoking or drinking, or has had the problem before and is at risk for relapse during pregnancy, she is referred to a licensed clinical social worker or therapist. This specialist will perform a thorough assessment for each woman referred to him or her and, if the person meets DSM-IV criteria for chemical dependence or substance use disorders, schedule follow-up appointments and provide counseling and treatment as needed.

This process of systematic screening and interventions, known as the Early Start program, has been in place at all obstetric clinics in KPNC since the 1990s.

In this study, Nancy Goler, M.D., and colleagues from KPNC examined the records of nearly 50,000 pregnant women who went through the prenatal substance use screening between 1999 and 2003. They found that women who were screened positive, assessed by the specialist, and treated for substance use had significantly better birth-related outcomes than those who screened positive but turned down assessments and/or treatment by the Early Start specialist.

The study was published online in the Journal of Perinatology on June 26. It was funded by a grant from Kaiser Foundation Research Institute.

The birth-related benefits were seen in both the mothers and the newborns. The risk of having a preterm delivery, placental abruption, and intrauterine fetal death (still birth) were all significantly reduced. The babies born to mothers who underwent the Early Start program had lower risks of requiring neonatal-assisted ventilation and having low birth weight.

Of the women included in the study, 2,073 were positive for alcohol, smoking, or substance use at screening and received an assessment and at least one follow-up appointment with a specialist; 1,203 were screened positive, assessed by the specialist, and declined follow-up appointment; and 156 were screened positive but received neither assessment nor follow-up. The other 46,000 women who had negative results at screening served as the control group.

"We saw a consistent pattern in essentially all the outcome indicators—those who were screened positive, assessed, and treated had the best outcomes, followed by the screened and assessed women, and women with positive screening without assessment or treatment did the worst," Goler, the medical director of the Early Start program throughout KPNC, told Psychiatric News. "It surprised us a little to see that the women who received treatment had outcomes similar or only slightly worse than the control group."

Women who were treated in the Early Start program had comparable or higher rates of smoking, drinking alcohol, and substance use at the time of screening to the groups that were screened positive and did not receive follow-up care. Yet they had substantially better birth-related outcomes.

Alcohol and substance abuse in pregnant women have been linked to a variety of adverse outcomes for both the mother and her newborn. Besides birth-related, short-term adverse effects, substance use during pregnancy also can lead to long-term developmental problems in the child. In a recent study published in the July Journal of the American Academy of Child and Adolescent Psychiatry, researchers found links between smoking by mothers during pregnancy and long-lasting internalizing and externalizing problems in their children.

In the study, Janka Ashford, M.Sc., and colleagues at the VU University Amsterdam analyzed data from longitudinal developmental surveys of 396 children who were assessed at the ages of 5, 10 to 11, and 18. They found that children whose mothers had smoked 10 cigarettes or more a day during pregnancy had significantly higher risks of developing internalizing and externalizing problems than children whose mothers had not smoked. This increased risk persisted from ages 5 through 18.

The key to the success of KPNC's Early Start program is removing most of the barriers to substance use treatment for pregnant women. "The licensed therapist is a part of the ob/gyn team in the department," Goler explained. "The substance use appointment is linked to a prenatal care appointment, and the patient can simply walk down the hall to see the specialist. She doesn't have to make an extra trip to the clinic."

Among the women who screened positive in the study, only 5 percent declined to see the specialist at all for an assessment. "If you bring the right provider to these patients, they will get the treatment," Goler noted. Because the substance use service is set up within the obstetric clinic, the patient is in a comfortable, private, and nonjudgmental environment and thus is more likely to accept the treatment.

"We knew it is the right thing to do. Now we have proof that it works," said Goler.

"Substance Abuse Treatment Linked With Prenatal Visits Improves Perinatal Outcomes: A New Standard" is posted at <www.nature.com/jp/journal/vaop/ncurrent/full/jp200870a.html>. An abstract of "Prenatal Smoking and Internalizing and Externalizing Problems in Children Studied From Childhood to Late Adolescence" is posted at <www.jaacap.com/pt/re/jaacap/abstract.00004583-200807000-00010.htm>.

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