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Risk Management and Assessment
Risk Management and Assessment

Section 10
Addiction Risk: Barriers to Pregnant Women Seeking Substance-Abuse Treatment

Question 10 | Test | Table of Contents
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs

Policies that attempt to stop maternal drug use, through detection and punishment and its assumed deterrent effects, include surveillance-oriented drug testing, arrest, prosecution, incarceration, and temporary or permanent loss of child custody. These gender-specific policies, still currently in use in many regions of the United States, arose out of "fetal protection" initiatives in the late l980's and occurred concurrently to the upsurge in the use of smokeable cocaine among women of childbearing age (Jos. Marshall & Perlmutter, 1995; Roberts. 1997). Since 1987, prosecution of more than 200 pregnant drug users (Seigel, 1997) in the U.S. for "prenatal child abuse" has resulted in a contentious and continuing controversy about the status and treatment of pregnant drug dependent women.

Extrinsic Barriers To Treatment Punitive Policies And Fear
In the psychosocial dimension, the primary emotional state of participants was one of fear and worry about loss of infant custody, arrest, prosecution, and incarceration for use of drugs during pregnancy. Fear characterized the women's psychosocial response toward disclosure of their drug use during pregnancy and toward health care providers and child welfare personnel (personnel currently monitoring older children in the family and those whom participants believed could have custody of their newborn). The women were fearful of the process of seeking help in general and feared presenting for care as much as they feared not presenting for care. Jacqui (all names are pseudonyms), a mother of two children, described her reaction to her physician's anger al her drug use: "I stayed going to the doctor.. .cause 1 loved myself and I loved my baby, but I just have a problem with drugs. I didn't want to hurt my baby... I was fearful, but then I needed the prenatal, so I knew I did wrong, but I knew I had to go to the doctor, to see what was going on with my baby..."

The women believed that detection of their prenatal drug use would inevitably occur, even when in minimal contact with these helping institutions, and that detection would lead lo loss of custody of their newborn infant and concurrently, to arrest, incarceration, and prosecution. Vances, a 33-year-old woman on methadone maintenance, was fearful of interacting with police in the context of seeking care. She stated: "…with a dirty tox screen, it could have been a lot more severe. I
could have...been taken to court. I could have been arrested if they wanted to. Study participants described a cascade effect of fear: once their drug use was made known to a single representative of a health care or child welfare agency, any number of punitive consequences, arising out of multiple local and state agencies, could and would befall them: "Knowing that they were gonna test me for drugs, that's what scared me, ..That's why I didn't go to prenatal care.. .1 didn't want to lose my baby. (Emily. a 23-year-old heroin user).

As a result, the dilemma of voluntary disclosure vs. anticipation of inevitable drug testing later in pregnancy or at delivery was the subject to much solitary deliberation and anguish. Additionally, participants had a keen awareness of child welfare policies and legal actions regarding prosecution of pregnant women and removal of children, as well as other initiatives of fetal and child protection in drug affected families. Celia. a 32-year-old mother of five children, was warned about continued drug use and informed by four health and child welfare professionals that her name was on a list of high-risk pregnant women circulated to delivery rooms, clinics, and child welfare agencies in her geographic area. Though she was enrolled in methadone maintenance during her pregnancy, Celia described what she was told could still happen: "If you have another drug-exposed child within a three-year period, even if you're staying clean and sober, your child will be taken from you, and can be automatically be placed for adoption... it is a state policy...I wanted to come here to the treatment program and there wasn't an opening,.. I didn’t go to my doctor at that time in pregnancy I because of my name being on that list.. .I was really scared of that. . . that's what kept me from going to prenatal care."

Care Seeking
Most participants (n - 34) sought prenatal care. Many (n - 28) spoke of the importance of prenatal care for themselves and their infants, and 21 sought care independent of a mandate; from substance abuse treatment or jail. Although the women had heard from drug-using associates that positive tests could lead to loss of their infants, health care providers gave "official" affirmation as they threatened, cajoled, and predicted custody outcomes in light of positive drug tests: "...they told me if I come in three times dirty, that...when I had my baby, they was gonna take my baby. And then the second time I started in go to prenatal care I didn’t go back no more. (Ivy, 22- year-old mother of two).

Drug testing was rarely utilized in the context of a therapeutic recovery-oriented intervention, and threatening statements served to increase women's ambivalence and fear about participating in care. When referrals to substance abuse treatment were made by prenatal care providers, they also included threats regarding the loss of child custody if they did not stop using drugs. Unlike their attitudes about the necessity of prenatal care, participants viewed substance abuse treatment as a remote and unknown source of help and it was not identified as an immediate need during pregnancy. Treatment was seen primarily as a requirement in order to retain or regain custody of their children or for transitioning out of jail to a supportive environment. Although 24 of the participants had substance abuse treatment histories, treatment programs were not viewed as places that would have been of major assistance to them during pregnancy. In some cases, women construed "treatment"" to be a two or three day physical detoxification wherein no other services were provided.

Participants’ adaptations, which arose out of coping with punitive responses to the problem of drug use during pregnancy, were actions taken lo have a drug-free baby and maintain child custody. Because of their experience and knowledge of these punitive threats to family cohesion, participants engaged in multiple forms of "creative coping" (Becker, 1974) focused on this reality. From the data, these adaptations can be conceptualized as: preserving the family, managing fear, and manifesting faith. These adaptive behaviors occupied a large part of participants' out-of-care time during pregnancy and in these behaviors, Mandelbaum's (1973) concept of the "active doer"' was illuminated. The adaptations served to keep faith in a positive outcome, to fulfill socially prescribed roles as good mothers, to avoid child welfare actions, to preserve their families, to get out and/or stay out of jail and to maintain spiritual survival. Anita, a 33-year-old mother of five children, described her actions during her pregnancy when told by child welfare authorities that she had to place her older children in foster care primarily due to her drug-using brother's presence in the home: "...that was the hardest thing for me to do, was to dress my kids and have them ready at the door. And they came and they took them...my kids is my life. Without them I feel I have no need to exist...I'm gonna do whatever I have to do to get my kids back." Another participant, Alicia. a 20-year-old mother, described how she made the choice to enter treatment after being evicted from her apartment: "There was an opening for here the treatment program. But the only hardest part was I had to choose one kid...(crying) So. ..they (child welfare) came and got my ten-month-old, and my two-year-old came here...It's not fair...(crying) Because he's only a baby, he didn't deserve all this. I had to do it by myself...just what I thought would be best."

Other Barriers
Other barriers to care included partners (n = 14). program-based barriers (n -7), the status of opiate dependency (n = 5). and the status of pregnancy (n = 2). Regarding partner-based barriers to care, domestic violence and partners’ substance abuse made disengagement threatening for the women due to physical and financial dominance by male partners and the women’s responsibility for their children. Among the women subjected to intimate partner abuse (n - 7), findings suggest that safety for the women and their children and relief from the abuse was part of the motivation for treatment. Program-based barriers, cited by participants, included limits on the number and ages of children who could accompany their mothers to treatment and other burdensome pre-admission requirements. While some women were able to place children with a family caregiver, placement of children in foster care in order to enter treatment was commonly experienced. Other pre-admission requirements, purportedly imposed to evaluate treatment willingness and motivation, were highly risk-laden and included daily call-ins for 7-14 days and admonitions by program staff to get detoxification (program- or self-managed) prior to admission.

Participants' status as opiate-dependent pregnant women created barriers that disrupted and delayed residential treatment entry. Opiate dependent women enrolled in narcotic treatment programs (NTP) (methadone maintenance) described being viewed by residential programs as "too complex," and program admissions were therefore delayed or refused. Misdirected child welfare mandates required that one opiate-dependent woman stop MM treatment in order for family reunification to proceed. Loss of maternal drug treatment Medicaid coverage as a result of an infant's placement In foster care was also a barrier to continued NTP treatment. Pregnancy itself was a barrier to drug treatment, as it conferred stigma and resulted in additional health care needs. Participants described treatment programs that excluded pregnant women by their claim of inappropriate services and milieu and other programs, purported to serve pregnant women, that had difficulty accepting and keeping a woman on medically indicated bedrest, providing transportation to prenatal care and serving nutritious meals.

Findings from this study suggest that threats and warnings were demotivating as they instilled distrust and therapeutic ambivalence that eroded alliances with helping professionals. Though this sample of women ultimately entered substance abuse treatment, entry in the first trimester of their pregnancies in concert with consistent prenatal care, could have prevented medical and social complications for the women and their children. In such a climate of fear and instructional approaches by providers, ethical conflicts arise when the role and clinical practice of the helping professional shifts from beneficence to harm. This model of life during pregnancy stands in stark contrast to traditional maternal role acquisition and anticipatory activities of motherhood among pregnant women who do not use drugs. Women's negative care-seeking experiences also influence actions in future pregnancies. Retelling of these experiences by members of the drug-using community also wields influence on the help-seeking behaviors of other pregnant drug-dependent women. In a study of readiness to change. Brown, Melchoir, Panter, Slaughter. & Huba (2001) described a gender-specific "hierarchy of readiness'" among drug-dependent women seeking help for a variety of complex problems. In that study, women participants (n - 451) were shown to seek help based on the immediacy of their needs. Findings from this study support the perspective of Brown and colleagues, as participants prioritized seeking prenatal care and safety from intimate partner
- Jessup , Martha A. et al; Extrinsic Barriers To Substance Abuse Treatment Among Pregnant Drug Dependent Women; Journal Of Drug Issues; Spring 2003, Vol 33 Issue 2, p. 285.

Pregnant women and substance use: fear, stigma, and barriers to care

- Stone R. (2015). Pregnant women and substance use: fear, stigma, and barriers to care. Health & Justice, 3, 2. doi:10.1186/s40352-015-0015-5.

Personal Reflection Exercise #2
The preceding section contained information about barriers that prevent pregnant women from seeking substance abuse treatment. Write three case study examples regarding how you might use the content of this section in your practice.

Peer-Reviewed Journal Article References:
Preis, H., Inman, E. M., & Lobel, M. (2020). Contributions of psychology to research, treatment, and care of pregnant women with opioid use disorder. American Psychologist, 75(6), 853–865.

Reising, V. A., Bergren, M. D., & Bennett, A. (2019). Care and treatment recommendations for pregnant women with opioid use disorder. MCN: The American Journal of Maternal/Child Nursing, 44(4), 212–218.

Sanjuan, P. M., Pearson, M. R., Fokas, K., & Leeman, L. M. (2020). A mother’s bond: An ecological momentary assessment study of posttraumatic stress disorder symptoms and substance craving during pregnancy. Psychology of Addictive Behaviors, 34(2), 269–280.

According to Jessup, what are the extrinsic barriers to seeking substance abuse treatment among pregnant addicts?
To select and enter your answer go to Test.

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