Pregnant, Substance-Using Women - Treatment Improvement

Guideline on Continuum of Care
The pregnant, substance-using woman requires a continuum of care that includes a broad range of support services provided over an extended period of time. This continuum of care should reflect the complexity of her multiple roles as a person in recovery, parent, partner, and frequently, single head of a household. Ideally, support services should be provided as long as the woman and her family need and can benefit from them, potentially until her last child reaches adulthood. In reality, support services may be available for a period of a few months to several years.

The case management function is essential for the recovery and well-being of the substance-using woman and her family. Virtually any agency can provide case management services, although the lead agency typically assigns an appropriate staff person to this role, such as a social worker or nurse. The case manager assists the patient in accessing services, and monitors her participation and progress in using health care, alcohol and other drug treatment, and other social services.
The multiple services coordinated by the case manager are generally provided by a variety of agencies. Many of these services are initiated during or even prior to pregnancy and should continue after delivery for as long as they are appropriate. The consortium of service providers may change over time, depending on the family's individual circumstances and resources.

The case manager should be aware that differences in philosophies may exist between health and social service agencies and the alcohol and other drug treatment field. Behaviors that health and social service agencies view as helping and supportive are often viewed as codependent behaviors by the treatment field. As agencies work together on behalf of patients, they too must recognize and handle complex and legitimate differences in philosophies and practices.

Case Management
Case management is a vital function that helps to ensure that patients receive and appropriately utilize a variety of services necessary for their improved functioning. Case management should be initiated prenatally and continue throughout the postpartum period for all substance-using women. Services should be provided and maintained as appropriate for the individual woman and her family. The case manager should support and guide the patient to address issues concerning her recovery from alcohol and other drug abuse, develop psychosocial and parenting skills, and meet her survival needs. Key case management functions include:-

1. A review and assessment covering:

• Physical and mental health history
• Screening urine for alcohol and drugs of absue
• Psychosocial status, including family history, parenting skills and knowledge, and potential parenting problems (e.g., a history of sexual abuse)
• Alcohol and other drug use, treatment, and recovery status
• Support systems available to and used by the family, including sources of primary and emergency care
• Nutritional status of the mother and fetus
• Status of any unresolved legal issues, including outstanding warrants, domestic violence, child custody, adoption, foster care, and divorce
• Environmental circumstances, including financial status and needs, condition of housing, and availability of transportation
• Educational and vocational competencies
• Involvement with other social service agencies.

2. An individual care plan prepared in conjunction with the patient and other service providers.

• This plan should address, at a minimum, the areas listed above. It may also cover arrangements for infant case management, either directly or through referral.

3. Discussion of the plan with the patient and other members of her health care and service delivery team.

• After agreement is reached on the individual plan, the case manager should schedule the needed services.

4. Referrals to other agencies, groups, or institutions as needed.

• These referral linkages should be made in conjunction with plans for ongoing communication about the patient's status.

5. Monitoring of the patient's progress in the programs in which she is enrolled.

• Follow-up contacts should be made if she fails to participate as planned and scheduled.

6. Ongoing case management support at regularly scheduled intervals, with termination ideally agreed upon by the patient and the case manager.

• Standards of success should be determined on an individual basis, but should allow a period of time for the patient to become adjusted to her drug-free status, to achieve self-sufficiency, and to feel confident about her parenting skills.

7. A review of the patient's individual care plan with revisions as needed during the recovery process.

Comprehensive Service Delivery
The delivery of comprehensive services to substance-using women and their families should continue postpartum. The greatest success is achieved by and for these women when a continuum of care is available to address their special needs as women, mothers, spouses, and heads of households. The following services are often needed:

1. Health Care Services

• Comprehensive, high-risk obstetrical care
• HIV antibody counselling and testing
• Routine checkups and immunizations for all children through a well-baby clinic, care by a paediatrician or other physician for specific health concerns as long as needed, and referral to early intervention programs
• Postpartum medical and dental checkups for the mother as long as needed
• Family planning, including contraceptive counselling and contraceptives
• Counselling about the effects of prenatal drug use on the infant and ongoing mental health
• Health care for other family members.

2. Alcohol and Other Drug Treatment Services

• Medical withdrawal, as needed, in collaboration with prenatal care providers
• Ongoing alcohol and other drug treatment through a program of methadone maintenance (for opiate dependence), outpatient treatment, day treatment, or intensive outpatient care; or through intermediate or long-term residential care that provides services to a patient's children during the inpatient period
• Alcohol and other drug treatment in gender-specific programs that are ethnically and culturally sensitive, whenever possible
• Continuing support and relapse prevention through accessible community groups, including Alcoholics Anonymous (AA), Narcotics Anonymous (NA), , and community and church support groups, with the understanding that relapse should not exclude women from treatment
• Group and individual counselling, focusing on such areas as codependency, self-esteem, and issues of sexuality, parenting, and relapse prevention.

3. Survival-Related Services

• Housing assistance to find drug-free, affordable family housing, emergency shelters, safe homes
• Financial assistance through government departments.
• Vocational and job skills training with child care and/or transportation services
• Child care that is affordable and appropriate for the safety and well-being of the child. Programs should encourage the creation of and access to therapeutic and developmental child care centres onsite and in the community.
• Transportation for medical care, alcohol and other drug treatment, and for child care, and for vocational, parenting, homemaking, and recreational activities
• Home management training to develop nutrition, budgeting, time management, and food preparation skills
• Legal services for such issues as domestic violence, child custody, adoption, and divorce.

4. Psychosocial Services

• Training in stress management and reduction; assertiveness; issues of sexism, racism, and class bias; and anger management
• Group, individual, and family counselling concerning sexual and physical abuse and their prevention
• Relationship and interpersonal skill building
• Personal care, issues of sexuality, and image enhancement
• Psychiatric and other mental health services, as needed by the woman, her children, and other family members

5. Parenting and Family Services

• Planning and counselling for reunification with the patient's other children
• Counselling for women who wish to breastfeed regarding the risks to the infant of maternal drug use and from possible transmission of HIV; training in breastfeeding procedures, as appropriate
• Education about child and adult nutritional needs, food purchasing and preparation, and weight management
• Education about and training in child growth and development patterns
• Training in and support for non-punitive child-rearing practices
• Assistance with and counselling about maternal and child bonding; participation in parental support groups
• Counselling for couples or significant others in communication, money management, crisis management, and parenting
• Counselling and intervention concerning child abuse and neglect, as needed
• Education about family systems, including information about cultures, traditions, and heritage
• Family therapy, as needed