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Principles for practice with substance-abusing pregnant women: a framework based on the five social work intervention roles.

Traditionally, substance abuse treatment programs are designed for men and are not readily available to women, particularly pregnant women (Blume, 1998; Finkelstein, 1994). Although more programs became available to substance-abusing pregnant women (SAPW) in the 1990s through federal funding policies, many do not provide pregnancy-specific treatment (Breitbart, Chavkin, & Wise, 1994). Cohen (2000) stated that although women-specific substance abuse treatment programs increased 53 percent during the past decade, some "do not facilitate them in a way that is supportive and positive for women" (p. 91). Using the five social work intervention roles (that is, teacher, broker, clinician, mediator, and advocate) (Compton & Galaway, 1994) as a framework and integrating relevant literature, I discuss components essential to a comprehensive pregnancy-specific treatment practice. [Compton and Galaway originally used the term "enabler." I changed "enabler" to "clinician" to avoid an association with "enabling" substance-abusing behavior, which has a negative connotation in the substance abuse treatment field.] Issues and elements related to substance abuse during pregnancy, although not exhaustive, are identified, and a systematic approach for working with SAPW is presented.

The Role of Teacher

Although specificity of perinatal substance-abuse knowledge varies with different audiences, all practitioners should understand drug effects on fetuses to effectively explain nonuse during pregnancy (Farkas, 1995). Sharing information with the SAPW is critical in prevention and rehabilitation and may help reduce their guilt and anxiety, thus increasing rapport and cooperation (Little & Gilstrap, 1998). Information should be explained nonjudgmentally (Siney, 1995) and in a way suitable to the woman's comprehension (Little & Gilstrap). Five areas may be shared with them.

Effect of Substance Abuse on Nutrition

Nutrition is emphasized for any pregnant woman, but it is particularly a concern for SAPW. Substance abuse can affect a pregnant woman's nutrition directly and indirectly. Directly, habitual alcohol and other drug (AOD) use may depress appetite, impair metabolism, and change nutrient activation and therefore may affect both maternal and fetal nutrition (Center for Substance Abuse Treatment [CSAT], 1995). Indirectly, the often chaotic lifestyle of the substance-using woman may lead to self-neglect, including poor diet (Sparey & Walkinshaw, 1995).

Effect of Substance Abuse on Medical Conditions

Drug Impact on Fetus. A fetus is much more vulnerable to drug effects because fetal tissue is more sensitive to drugs, and the fetus has not developed the enzyme systems to metabolize drugs (Geller, 1991). Prenatal AOD exposure may cause short- and long-term damage to the infant's physical, cognitive, and behavioral development (Little & Yonkers, 2001; Streissguth, 1997; Van Beveren, Little, & Spence, 2000). However, not all drug-exposed infants show significant medical complications or developmental problems, and it is difficult to predict outcomes for individual children. Depending on the type and combination of drugs used, reactions of the mother using the drugs, amount and frequency of use, the trimester in which the drug is used, and the fetus's genetic susceptibility to AOD, a baby may show severe, mild, or no symptoms (Kropenske & Howard, 1994; Little & Gilstrap, 1998; Streissguth). The concept of "critical periods" suggests that first-trimester drug exposure may cause congenital anomalies, whereas exposure during the second or third trimester may affect growth (Coles, 1994; Little & Gilstrap). The brain may be particularly susceptible because its development occurs throughout the pregnancy (personal communication with Colleen Morris, MD, University of Nevada School of Medicine, October 27, 2003).

The Neonatal Abstinence Syndrome (NAS). AOD-exposed fetuses, particularly those exposed to alcohol or heroin, may develop withdrawal symptoms at birth when the maternal drug supply stops. NAS usually appears within 72 hours of birth; the infant may die if the withdrawal is severe and untreated (CSAT, 1995). Although NAS depends on type of drug exposure and obstetric factors, it may involve the central nervous (for example, tremors, irritability, abnormal suck or poor feeding), autonomic (for example, sneezing or yawning), gastrointestinal (for example, diarrhea and vomiting), and pulmonary (for example, increased apnea) systems (CSAT, 1995; Walkinshaw, Shaw, & Siney, 2002). Teaching the mother about the effects of drugs may help her redefine her baby's behaviors. For example, the baby's nonresponsiveness or irritability are not signs of rejecting the mother, but medical withdrawal symptoms (Sameroff & Fiese, cited in Schutter & Brinker, 1992).

Maternal Detoxification (Detox). Although drug use clearly negatively affects both mother and fetus, maternal detox must be considered with caution. Maternal detox may be harmful, "causing placental vasoconstriction with increased rates of abruption or placental insufficiency leading to death or poor growth of the fetus" (Hepburn, 1993, p. 54). Although opioid withdrawal symptoms are less likely life-threatening to the mother, they may cause spontaneous abortion or intrauterine death; in addition, acute withdrawal from alcohol and other sedative or hypnotic drugs may harm mother and fetus, but withdrawal from cocaine or other stimulants is less severe and medication is usually not required (CSAT, 1995; Siney, 1995). Three principles guide the maternal detox. Inpatient settings allow the mother and fetus to be monitored by a medical team, including an obstetrician (CSAT, 1995); tapering the dependent sedative/hypnotic drugs helps mother and fetus reach a drug-free state slowly, thereby experiencing no uncontrollable withdrawal (CSAT, 1995; Siney); and, although heroin treatment includes methadone maintenance or detox, pregnant women are usually advised to adopt methadone maintenance because of the possible lethal impact of detox on the fetus (Blume, 1998; CSAT, 1995; Hepburn). However, total abstinence and long-term maintenance should not be the only options--a pragmatic approach tailored to help each client achieve overall drug use reduction and a stable lifestyle is feasible (Hepburn).

Contraception and Prevention of Unwanted Pregnancy

Carten (1996) studied 20 AOD-using postpartum women, only two of whom had planned pregnancies. AOD-using women might be more likely than nonusing women to have unwanted pregnancies because of irregular menstruations resulting from drug use (Boyd, 1999). Pregnancy among these women is often detected only after the first trimester, when the mother feels fetal movement or other physical changes and abortion often is no longer a choice (Boyd; Siney, 1995).

Substance Abuse and Sexually Transmitted Diseases

AOD-using women may put themselves at risk of HIV/AIDS and other sexually transmitted diseases (STDs) in three ways: injecting drugs or having sexual partners who inject drugs; engaging in prostitution for drugs, thereby increasing unsafe sex; and using mind-altering drugs, which may lower inhibitions and put them at greater risk of unsafe sex (CSAT, 1994). STDs may lead to spontaneous abortion, premature birth, or intrapartum infections such as purulent conjunctivitis in the baby's eyes (Carey, 1995b). A baby can contract HIV from the mother while in utero, during childbirth, or through breast-feeding; women diagnosed with HIV must seek help from experts specializing in HIV and perinatal transmission (Carey, 1995a; Cohen, 2000).

Environment and Early Intervention for Drug-Exposed Children

Environment. Drug-exposed infants' developmental outcomes may be related not only to drug exposure in utero, but also to the quality of postnatal environment. Parker and colleagues (1988) called it "double jeopardy" when children were prenatally impaired and postnatally living in a poor environment. Postnatal environmental factors include family context (for example, parent-child interaction, parental mental stability, parental AOD use, and domestic violence) and the context of poverty (for example, nutrition, stable housing, access to health care, and community violence) (Carta et al., 1997; Harden, 1998).

Although methodological difficulties exist in comparing the effect of neonatal drug exposure with postnatal environment, most such studies emphasize the importance of both factors, if not just the environment (Carta et al., 1997; Harden, 1998). For example, Howard (1995) found that in utero drug-exposed toddlers with caring environments performed better than those without caring environments, although the former did not perform as well as nondrug-exposed, preterm toddlers. She inferred that both biological and environmental factors were important. Comparing children of untreated mothers using heroin, mothers receiving methadone, and a nonusing group, Lifschitz and colleagues (1985) found that maternal narcotic use did not predict a child's intellectual performance; rather, the "amount of prenatal care," "prenatal risk score," and "home environment" did (p. 269). Regardless of the debate of nature versus nurture, most people would agree that a child's developmental outcome is affected by the number of risk factors and their degree of persistence, be they biological, environmental, or mixed (Bernstein & Hans, 1994; U.S. Department of Health and Human Services [DHHS], 1999).

Early Intervention. Human brain complexity relies on neurons and their interconnections; a baby has more neurons to mold networks at birth than at any other life stage. The brain at birth is not fully configured, tending to be formed by external stimuli, particularly during the first two years (Resnak, cited in Stump, 1992). Spinelli (cited in Stump) called this capacity "plastic" and "adaptive." Another capacity is "canalization," including the brain's self-correcting ability following deflections caused by external insults. Both the plastic and canalization capacities, however, may be bounded by "critical periods." Stump cited Wilson's definition of critical periods as: "Development includes coordinated pathways of change over time. Many of these pathways appear to depend upon the activity of timed gene-action systems that switch off and on according to a predetermined plan" (p. 15). The brain's plastic and canalization capacities offer an opportunity to mediate the damages caused prenatally, but limitations of critical periods suggest that timely intervention be provided. Early identification and intervention are critical to optimize drug-exposed children's development (Kropenske & Howard, 1994).

The Role of Broker

Explaining the significance of a healthy environment to a mother is no more important than helping her build one. AOD-using women are particularly in need of case management because of lower education, inadequate vocational training, lack of life skills and other resources, and child care needs (Yaffe, Jenson, & Howard, 1995). The negative effect of psychosocial risks is far-reaching for SAPW, and their meager pregnancy outcomes may be more the consequence of underlying socioeconomic deficiency than of drugs (Hepburn, 1993). Unhealthy environments further worsen development of drug-exposed children, who desperately need a functional postnatal environment for a second chance.

Contents of Case Management

Case management for SAPW may be extensive, including access to prenatal care; prevention of unwanted pregnancy; housing, nutrition, transportation, child care, and financial assistance; education and vocational training; emotional coping skills training; parenting education; AOD and psychiatric treatment; general health care; legal services for child abuse or other criminal behavior; and screening, assessment, and intervention services of early childhood development. Weisdorf and colleagues (1999) compared a pregnancy-specific program (that is, required obstetric care; parenting classes; content on pregnancy, nutrition, and AOD use; and child care services) with a traditional program and found that the former had significantly lower inpatient dropout and higher outpatient completion rates.

Case Management: Prevention Compared with Crisis Intervention

"Up-front" Case Management. Up-front case management is necessary to enhance women's treatment motivation and prolong treatment retention, because they may not enter treatment unless their basic needs (for example, child care, transportation, and housing) are met (Coletti, 1998; Howell & Chasnoff, 1999; Poland Laken & Ager, 1996). Hughes and colleagues (1995) found that the average length of stay of women admitted to a child live-in demonstration program (300.4 days) was significantly higher than the average length of stay of those admitted to a standard program (101.9 days).

Prevention and Outreach. Case management should not be limited to up-front services or crisis intervention, but should also be oriented toward prevention and rehabilitation. Emphasis should be on early involvement of community resources and long-term follow up, focusing on establishment of a healthy and stable family environment (Hepburn, 1993). Risks involving a SAPW are not necessarily reduced after delivery, and they do not disappear after the initial residential or outpatient treatment; aftercare is critical to help change the mother's lifestyle (Finkelstein, 1993; Howell & Chasnoff, 1999; Sparey & Walkinshaw, 1995).

Outreach is another key to prevention. Many SAPW, hesitant to reveal their AOD use, seldom volunteer for treatment. Fearing prosecution and child loss, many avoid prenatal care until a very late stage. Women often are referred because of positive urine-toxicology or drug-positive birth outcome. How to identify and reach SAPW early has been considered one of the most difficult challenges (Finkelstein, 1993; Howell & Chasnoff, 1999; Howell, Heiser, & Harrington, 1999). Howell and Chasnoff indicated four outreach routes: clinic-based (prenatal programs); indigenous outreach in nontraditional settings; enlisting aid of family members; and word-of-mouth from clients who completed the program. Coletti (1998) suggested that information on how state regulations may affect child custody be shared with the woman to help overcome her fears. Hennessey (2001) implemented in Illinois an outreach program to help AOD-using mothers in the child welfare system. Program workers identified and made daily contact with the families at risk; engaged and accompanied families, removing barriers to services; motivated, nurtured, and advocated for the families; and served as role models or surrogate family members and friends.

The "Five Clocks" and Turf Issues

Case management often involves multiple agencies with conflicting treatment philosophies and timetables, resulting in service fragmentation for clients. Young and colleagues (1998) indicated the "four clocks" issue: child welfare systems require parents to be assessed at six months, a permanency plan at 12 months; AOD treatment expects client relapse and believes "one day at a time, for the rest of your life"; TANF obliges clients to find employment within 24 months; and the developmental timetable of the first 18 months is critical for the infant and mother to establish bonding. Young (2001) recently advocated for a "fifth clock," urging workers from different fields to collaborate to provide the most effective services.

Poland Laken and Hutchins (1995) indicated that interdisciplinary teams better meet women's complex needs; the challenge was interagency turf issues related to different values and policies. Feig (1998) offered directions at program planning and administration levels in bridging service systems: "joint training for social services and substance abuse treatment staff;" "team staffing" (for example, social services hires a part-time AOD counselor to conduct AOD assessment, and the AOD program has on-site CPS staff working with parents and children); "joint funding for services;" and "joint goal-setting for programs" (for example, systematically discuss varied treatment philosophies, not case-by-case) (pp. 84-86). At the individual level, workers should involve all agencies early and deal with turf issues when developing a team, making conflicts secondary to collaboration (Poland Laken & Hutchins). "One-stop shopping" may also reduce service fragmentation. It locates various professionals (for example, obstetrics professionals, AOD counselors, child development specialists, and social service workers) at a single site so that clients can obtain services in one place, rather than being sent to different locations. McMurtrie and colleagues (1999) found that babies of the one-stop shopping program had a significantly higher mean birthweight than control group babies. They concluded that not only did this model allow professionals to better coordinate services, but client motivation to consume a broader range of services was enhanced.

The Role of Clinician

The role of clinician can address the following four areas: dealing with shame and guilt, enhancing self-efficacy, strengthening nonusing social networks, and treating the dual diagnosis.

Dealing with Shame and Guilt

Finkelstein (1994) stated that sexuality and mothering underlie punitive attitudes toward AOD-using women; SAPW receive the most societal condemnation, resulting in low self-esteem, isolation, and guilt. Finkelstein and colleagues (1990) provided strategies to help the mother deal with guilt: to accentuate that both she and her child suffered from AOD, and her AOD-using behavior was not intentional; to help her express and disperse guilt feelings by listening to what she has to say about mistakes she feels she made; to state that parenting choices were often hampered when engaging in AOD use; and to convey hope that she can regain control over her life if she stays sober.

Enhancing Self-Efficacy

Literature suggests that traditional confrontational counseling is more effective with male AOD clients than with female clients who suffer from low self-esteem or psychological trauma (Yaffe et al., 1995). Sherman (1998) advocated the use of empowerment and self-efficacy to help SAPW. He defined self-efficacy as, "an individual's beliefs about her capability to mobilize the motivation, cognitive resources, and action needed to exercise control over task demands" (p. 49). Miller and Rollnick (1991) suggested that even when clients know they have problems, they can only deny the problems when they do not believe they can change. It is extremely important to instill hope in these clients regarding their capacity to change. Three areas may be emphasized.

Staff's Encouragement and Empowerment. Staffs positive attitudes toward women is critical in enhancing their self-efficacy. Carten (1996) found that the three responses most frequently given by clients as the most helpful aspect of their treatment program were "care and respect of staff," "the staff won't give up on you," and "individual relationships with staff" (p. 220). Sun (2000) quoted one interviewee, "My social worker has faith in me ... which, in turn, gives me confidence in myself."(p. 148). Involving the mother in developing a case plan also empowers her (Carten).

Peer Counseling and Culturally Sensitive Practice. Peer counseling increases client self-efficacy (Grant, Ernst, Streissguth, Phipps, & Gendler, 1996; Sherman, 1998). Paraprofessionals with life experiences similar to clients can be trained to help. These peer counselors can serve as inspirational models and convey hope to clients that recovery is possible (Sherman).

Uziel-Miller and Lyons (2000) indicated that only a few of the programs studied offered "culturally informed programming," even though clients in those programs were mainly African American women (p. 363). AOD-using white and African-American women may have different needs (Carroll, Malloy, Roscioli, & Godard, 1981). Jackson (1995) suggested an "Afrocentric treatment perspective" emphasizing community involvement. She believed that by learning one's heritage and being part of the community, a woman is more likely to develop productive roles other than substance abuser.

Vocational Training. Female AOD clients have lower education and fewer marketable job skills and work experiences than male counterparts (Nelson-Zlupko, Kauffman, & Dore, 1995). Fiorentine and colleagues (1997) found that men had a higher employment rate at posttreatment than women did (47.3 percent compared with 28.6 percent; p < .001). Kissin and colleagues' (2001) study indicated that more than 39 percent of SAPW were unskilled, and 68 percent had been unemployed in the past three years. Unemployment may impede women's long-term recovery because of many negative implications, especially for single mothers, such as a lack of financial re sources, relying on male AOD-using partners, no meaningful life goals, and low self-esteem (Yaffe et al., 1995). Gregoire and Snively's (2001) study showed a link between economic self-sufficiency and improvement in areas of AOD use, family, social function, and so forth. Marsh and Miller's (1985) review showed that "a strong work history" was associated with positive treatment outcomes and suggested including job training and counseling in women's AOD treatment.

Strengthening a Nonusing Social Network

Amaro and Hardy-Fanta's (1995) interviews with SAPW found "relationships" as the key theme. The authors found that women's self-esteem was heavily and negatively affected by "disconnected relationships" and by "the absence of positive, growth-enhancing relationships" (pp. 328-329). Relationships also may have a practical function--they are women's resources for emergency child care and other assistance (Tracy, 1994).

Substance-Abusing Partners. AOD use by male partners had predicted pregnant women's AOD use (Bresnahan, Zuckerman, & Cabral, 1992; Hutchins & Dipietro, 1997). Bresnahan and colleagues said that when counseled to stop using AOD, these women may face "the double loss" of a major coping device (AOD) and a major love relationship. Laudet and colleagues (1999) found five reasons why male partners might not support women's treatment: their own AOD-using behavior may send a powerful message to the women; they want to maintain the status quo, which might change if women recover; they might be working on their own recovery, unable to be bothered; they may have different views on treatment goals (for example, believing AOD using is acceptable if the woman fulfills household responsibilities); and they might want to disassociate with an AOD-using woman because of the stigma attached to her. Laudet and colleagues suggested that workers understand each client's partner situation, and that not all men should be engaged.

Facilitating Nonusing Support Systems. Studies consistently indicate that AOD-using women get less social support than other women. They may have a broken relationship with their original nonusing support systems because of drug abuse (Merseyside Drugs Council [MDC], 1995; Sun, 2000). Dodge and Potocky-Tripodi's (2001) study indicated that AOD-using women, compared with nonusers, are less likely to seek help from relatives and friends. Marcenko and colleagues (1994) found that pregnant women with AOD history received less family support than pregnant women without such histories (for example, 40 percent compared with 13 percent, respectively, did not know how their families felt about their pregnancy). MDC suggested that pregnancy is an opportunity to reconnect and may result in a "rallying round 'for the baby's sake'." However, intervention of family support groups may be necessary because of bitter, mistrustful relationships between the two parties.

To strengthen the new nonusing support system, practitioners can help women join the workforce or connect them with community resources (for example, churches, women's self-help groups or sponsors, schools, and neighborhood councils (Kissin, Svikis, Morgan, & Haug, 2001; Pape, 1992). Alcoholics Anonymous may be a second home for some AOD-using women, in that they seek and maintain nonusing friends and social support to replace their former using social circles (Kaskutas, 1994).

Treating the Dual Diagnosis

Female problem drug users living with children under age 18 were four times more likely to report a major depressive episode occurring in the past year, and 3.4 times more likely to report depression, anxiety, agoraphobia, of panic attack compared with female nonproblem drug users (DHHS, 1997). Compared with male addicts, female addicts showed a higher rate of comorbid psychiatric disorder, particularly depression and anxiety (Blume, 1998). Although Vaillant (1995) suggested that depression or anxiety is more the resulting behavior than the predisposing factor for alcoholism, his sample included only men. Such a connection is unclear among women because of the lack of studies (Blume). Blume's summary of various studies showed that about 66 percent of dual-diagnosed women had depression as their first disorder compared with 22 percent to 41 percent of men.

Studies consistently show high rates of childhood sexual abuse (CSA) and physical abuse (CPA) among AOD-using women, or that women with CSA/CPA history are more likely to use AOD (for example, McCauley et al., 1997; Wilsnack, Vogeltanz, Klassen, & Harris, 1997). Horrigan and colleagues (2000) indicated a triad relationship among AOD use, violence, and depression during pregnancy and suggested identification of one symptom indicative of the other. Although the causal link between CSA and CPA and the later development of AOD problems is debatable and research results are inconsistent regarding the association between CSA or CPA history and AOD treatment outcomes, recent studies suggest that women's AOD problems may relate to their response to a trauma (for example, posttraumatic stress disorder) rather than to the traumatic event per se (for example, CSA) (Epstein, Saunders, Kilpatrick, & Resnick, 1998; Simpson, 2003). Root (1989) said that women may use AOD to cope with psychiatric symptoms resulting from CSA or CPA--those issues, if untreated, may trigger relapse. Although AOD use and domestic violence (DV) can relate in either direction, many AOD programs may not screen for DV and vice versa (Miller, 1998). It is important to evaluate and treat or refer women about these issues, particularly when treatment plan noncompliance is frequent (Jessup, 1990). AOD treatment without addressing dual diagnosis may lower the chance of success (DHHS, 1999).

The Role of Mediator

A mediator helps parties negotiate conflicts by coaching them to handle conflict constructively (Barsky, 2000). Mediation in child protection emphasizes "facilitation," "problem solving," "developing a mediation alliance," and "maintaining fair neutrality" (Barsky & Trocme, 1998, p. 637). Barsky suggested two types: emergent mediation, in which the practitioner maintains a primary professional position (for example, as a social worker) but applies mediation techniques to help the client; and contractual mediation, in which a formal mediator is hired--possessing no dual roles to avoid real, or perceived, conflict of interest.

Emergent Mediation

Practitioners can adopt the emergent mediator role; for example, mediating between a woman and her nonusing original family to improve their fragile or conflict-laden interaction. The role of mediator, thereby, enhances the role of facilitator or clinician in strengthening nonusing social networks. Emergent mediation can also be applied to improve interorganizational communication in connecting clients with community resources. SAPW often encounter child protective services (CPS). CPS workers may also apply emergent mediation techniques (Barsky & Trocme, 1998). Although disputes between families and CPS are common, many CPS workers are not equipped with conflict resolution skills (Savoury, Beals, & Parks, 1995). Instead of an adversarial relationship or court hearings, mediation techniques may help CPS workers and clients achieve more mutually beneficial and productive communication (Barsky & Trocme).

Contractual Mediation

Mediation should receive greater attention in CPS because of its family empowerment and problem-solving orientation (Wilhelmus, 1998). A SAPW or family with an earlier negative experience with CPS may perceive any CPS worker as biased against them, regardless of repeated good intentions. In such cases, a contractual mediator--a neutral third party with mediation skills--may better earn the woman or family's trust and achieve more productive communication (Barsky & Trocme, 1998; Savoury et al., 1995). However, certain criteria should be considered before using mediation with CPS clients--for example, the child should not be in immediate danger, and the parties involved should not be severely impaired (Savoury et al.).

The Role of Advocate

Advocacy for Effective Policies and Laws on Substance Abuse during Pregnancy

Controversy over policies on AOD use during pregnancy stems from different philosophical beliefs. Pandya (1999) described three issues: (1) harm reduction versus use reduction: whether reducing the harm to the fetus or reducing mother's AOD use should guide the practice; (2) supply control versus impulse control: whether drug dealers or the woman should be punished; and (3) criminal versus victim: whether the mother is punishable for harming the fetus of is a victim of a poor socioeconomic environment. It is difficult to argue whether the philosophical positions are right of wrong; yet, most people would agree it is important to establish policies that effectively target the problem. Research strongly suggests that criminalizing AOD-using behavior does not deter women's drug use; instead, it prevents them from seeking prenatal care and AOD treatment for fear of being detected or prosecuted (Finfgeld, 2001; Jessup, Humphreys, Brindis, & Lee, 2003). It is imperative for social workers to educate society and policymakers about the implications of criminalizing SAPW and to advocate for policies less oriented toward punishment and more toward rehabilitation and harm reduction (Finfgeld).

Advocacy for Pregnancy-Specific Treatment Programs

Although SAPW is a top priority for federal funding, establishing a pregnancy-specific program is a challenge. The trend of lee for service based on the number served makes it tough on a new program, which may not quickly bring in sufficient clients. As noted earlier, it is not easy to recruit SAPW for treatment. Obtaining a program license and hiring qualified staff are two more tough, funding-related tasks. In light of constraints resulting from the issue of fee-for-service policies, program administrators may request staffing grants (personal communication with Larry Ashley, addiction specialist, University of Nevada, Las Vegas, March 29, 2002). Multiple funds should be sought--the federal block fund (managed by the SAMHSA) considers SAPW a top priority and is a major funding source; TANF pays for AOD treatment if a pregnancy is over six months; the state or county can play an important role in funding; although minimal, a sliding scale fee from clients may help; and other community funds may be available. It can take up to 30 grants to run a program (personal communication with Diane Thorkildson, acting director, Light House Sierra, April 1, 2002). Although Medicaid is supposed to serve poor AOD-using women with children, states and providers are daunted by multifarious federal regulations (Darnell, 1997). In some states, AOD treatment is not paid by Medicaid unless offered in a hospital. Creatively recruiting funding and coordinating suitable plans are critical for program survival.

Advocacy for Nonjudgmental Attitudes in the Obstetric and Other Communities

Double standards and stigma regarding AOD-abusing women are well documented (Blume, 1998). The stigma is more severe when the drug abuser is pregnant (Finkelstein, 1994). The obstetric community may be biased against these women, holding them responsible for birth outcomes (Boyd, 1999). Nelson-Zlupko and colleagues (1995) said that women's distrust of service systems is a major obstacle to their treatment--service providers often hold negative views of women clients. For humanistic and practical reasons, social workers must advocate for a nonjudgmental attitude toward SAPW at all leyels, particularly in the obstetric, substance abuse treatment, and child welfare communities.

Conclusion

Pregnancy specificity is critical in engaging and retaining SAPW; retention is associated with positive treatment outcomes (Howell et al., 1999). This article offers a conceptual framework for practice with SAPW. The concepts and approaches can be applied by social workers in AOD treatment programs; prenatal, labor, and delivery facilities; child welfare systems; public health clinics, or family services centers. Although pregnancy specificity is important, it is just as important to maintain balance between treating pregnancy and treating substance abuse. Uziel-Miller and Lyons (2000) found that some programs place too much emphasis on pregnancy and too little on AOD use. These authors suggested that those programs may improve birth outcomes, but are less likely to improve mothers' long-term AOD problems. More funding has been allocated for pregnancy-specific treatment, but few guidelines are available about building effective treatments. More evaluation and research should be conducted to improve these programs' effectiveness and efficiency.

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An-Pyng Sun, PhD, is associate professor, School of Social Work, Greenspun College of Urban Affairs, University of Nevada, Las Vegas, 4505 Maryland Parkway, Box 455032, Las Vegas, NV 89154-5032; e-mail: apsun@ccmail.nevada.edu. An earlier version of this article was presented at the 44th International Council on Alcohol and Addictions Conference, September 5, 2001, Heidelberg, Germany. The author thanks Dr. Colleen A. Morris professor of pediatrics and chief, Genetics Division, University of Nevada School of Medicine; Larry Ashley, addiction specialist, Department of Counseling, University of Nevada, Las Vegas; and Diane Thorkildson, acting director, Nevada Step 2/Light House Sierra, for their helpful comments.

Original manuscript received July 5, 2001 Final revision received April 15, 2002 Accepted August 6, 2002
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Date:Jul 1, 2004
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