Therese Grant

Cocaine and the use of alcohol and other drugs during pregnancy

Recent reports of adverse pregnancy outcomes associated with prenatal cocaine exposure have raised questions about the actual numbers of infants who are exposed to cocaine in utero. Whereas toxicologic urine screens obtained at delivery can detect cocaine use in the preceding few days, they fail to yield a comprehensive picture of use during and immediately before pregnancy. According to postpartum self-report, 15% of a teaching hospital sample and 3% of a private hospital sample of mothers had used cocaine during pregnancy or in the previous month (total = 876). Rates at the teaching hospital reflect a fifteenfold increase over the past 12-year period, when compared with previously obtained data. Cocaine users were significantly more likely to report that they drank alcohol, smoked cigarettes, and took other illicit drugs during pregnancy than women who denied using cocaine. Mothers at highest risk for cocaine use were those who were black (20%), were single-separated-divorced (24% to 33%), and had less than a high school education (21%).

INTERVENTION WITH HIGH-RISK ALCOHOL AND DRUG-ABUSING MOTHERS: II. THREE-YEAR FINDINGS FROM THE SEATTLE MODEL OF PARAPROFESSIONAL ADVOCACY

!We examine the efficacy of a paraprofessional advocacy program for improving health and social outcomes of high-risk substance-abusing mothers and their children. This intervention included 3 years of home visitation, advocacy, and connection with appropriate community services. To assess the overall effectiveness of the model, clients were compared to concurrently enrolled controls on a composite variable comprised of indicators of alcohol/drug treatment, abstinence, family planning, child well-being, and connection to services. Clients obtained higher scores, on average, than controls on the composite variable—as well as on every indicator. Clients who spent more time with advocates had more positive outcomes. Results suggest that this paraprofessional advocacy model can help protect the safety of the children of substance-abusing mothers, while helping mothers take the steps they need to take in order to make fundamental changes in their lives.

Intervention with high‐risk alcohol and drug‐abusing mothers: I. Administrative strategies of the Seattle model of paraprofessional advocacy

Administrative components of an effective home visitation program for high-risk alcohol and drug-abusing mothers are described. In this program, the home visitors are paraprofessional advocates who have an historical and cultural background in common with clients, excellent problem-solving skills, and a strong belief in the promise of a difficult clientele. Paraprofessionals can be dynamic members of the community provider system when they build long-term relationships with families, firmly link clients with professionals in the community, and establish strong communication networks among service providers around individual clients. Components of the program important to job satisfaction and retention of paraprofessionals include comprehensive and ongoing training, individualized supervision and consistent feedback from evaluation and administrative staff, group support, encouragement of creativity, and community recognition.

Preventing Alcohol and Drug Exposed Births in Washington State: Intervention Findings from Three Parent-Child Assistance Program Sites

Home visitation interventions show promise for helping at-risk mothers, yet few programs have been developed and evaluated specifically for alcohol and drug-abusing pregnant women. This study examines outcomes among 216 women enrolled in the Washington State Parent-Child Assistance Program, a three-year intervention program for women who abuse alcohol and drugs during an index pregnancy. Pretest-posttest comparison was made across three sites: the original demonstration (1991–1995), and the Seattle and Tacoma replications (1996–2003). In the original demonstration, the client group performed significantly better than controls. Compared to the original demonstration, outcomes at replication sites were maintained (for regular use of contraception and use of reliable method; and number of subsequent deliveries), or improved (for alcohol/drug treatment completed; alcohol/drug abstinence; subsequent delivery unexposed to alcohol/drugs). Improved outcomes at replication sites are not attributable to enrolling lower-risk women. Public policies and programs initiated over the study period may have had a positive effect on outcomes. Study findings suggest that this community-based intervention model is effective over time and across venues.

A Pilot Community Intervention for Young Women with Fetal Alcohol Spectrum Disorders

Fetal Alcohol Syndrome, a permanent birth defect caused by maternal alcohol use during pregnancy, is a leading preventable cause of mental retardation. Neuropsychological deficits have been well documented, however interventions developed have not been evaluated. We describe a successful 12-month community pilot intervention with 19 young women with Fetal Alcohol Spectrum Disorders (FASD). Improved outcomes (including decreased alcohol and drug use, increased use of contraceptives and medical and mental health care services, and stable housing) were obtained by implementing a community intervention model of targeted education and collaboration with key service providers, and by using paraprofessional advocate case managers as facilitators.

Cocaine exposure during pregnancy: improving assessment with radioimmunoassay of maternal hair.

Objective: To compare radioimmunoassay of postpartum maternal hair samples with a structured maternal interview for the detection of cocaine use during pregnancy. Methods: Radioimmunoassay of hair samples obtained postpartum was compared with self‐report of cocaine use obtained by confidential, structured interviews of 405 postpartum women. Results: Cocaine or benzoylecgonine was detected in the hair samples of 129 of the 148 women (87%) who reported using cocaine at least once during pregnancy. Thirty‐six of 257 women (14%) who reported that they had used no cocaine during pregnancy had positive hair tests. Positive hair assay with negative self‐report was significantly more common among women who were unmarried (P = .001), African‐American (P < .001), and multiparous (P = .035). Conclusions: Hair analysis is a valuable complement to maternal self‐report by interview. The methods used together provide a useful clinical and research technique yielding a comprehensive estimate of gestational cocaine exposure. Either method alone may result in misclassification of gestational cocaine exposure. (Obstet Gynecol 1994;83:524‐31)

Prenatal alcohol exposure: An assessment strategy for the legal context.

Studies over the last two decades have shown that people with fetal alcohol spectrum disorders (FASD) have the kind of brain damage that increases risk of criminal behavior. Thus, it is generally accepted that FASD is likely to affect a sizable minority of individuals involved in the justice system. Most of these defendants have never been diagnosed because they lack the facial abnormalities and severe intellectual deficiency that would have improved identification and diagnosis in childhood. Despite the fact that an FASD diagnosis and associated cognitive deficits may be directly relevant to offense conduct and post-arrest capacities, screening for prenatal alcohol exposure (PAE) by legal teams remains relatively rare. This article addresses the relatively straightforward screening process with strategies that may be used singly or in combination to produce information that can establish PAE and provide a foundation for diagnostic assessment by medical and mental health experts.

Alcohol use before and during pregnancy in western Washington, 1989-2004: implications for the prevention of fetal alcohol spectrum disorders

OBJECTIVE We examined trends in rates of self-reported pregnancy alcohol use among women in western Washington. STUDY DESIGN Between 1989 and 2004, we conducted 3 studies in western Washington State on problems that are associated with maternal prenatal alcohol or drug abuse (n = 12,526). To determine study eligibility, we screened hospitalized postpartum women for alcohol and drug use in the month before and during pregnancy. We examined trends in alcohol use rates and identified characteristics that were associated with any drinking and binge drinking (> or = 5 drinks on any occasion). RESULTS We found a substantial decrease in pregnancy alcohol use between 1989 and 2004 (from 30-12%) across almost all demographic categories. Binge drinking in the month before pregnancy increased significantly among all race categories, except Native American. CONCLUSION Increased prepregnancy binge drinking rates may estimate alcohol use during very early gestation and warrant clinical attention because of the potential for fetal alcohol spectrum disorders.

Three-Year Developmental Outcomes in Children with Prenatal Alcohol and Drug Exposure

Purpose: The purpose of this study was to describe the performance of children whose mothers abused alcohol and drugs heavily during pregnancy, using the Bayley Scales of Infant Development Second Edition (BSID‐II) at three years, and to examine the effects of study group, prenatal binge alcohol exposure, and prematurity on developmental outcome. Methods: Children were born to mothers recruited from two large hospitals or through community referral. Hospital recruits were randomly assigned to either a three‐year paraprofessional home visitation intervention program (n = 30) or a control group (n = 31). Community recruits were enrolled in the intervention program (n = 35). Results: Among all children the mean BSID‐II Mental Developmental Index (MDI) was 84.4 (SD = 14.4) and mean Psychomotor Developmental Index (PDI) was 84.1 (SD = 16.9). Box plots of the MDI and PDI scores by study group, maternal prenatal binge alcohol status, and a binary indicator of prematurity suggested an effect of maternal binge drinking on MDI and PDI scores: children of mothers with a history of binge alcohol consumption have, on average, slightly lower scores. We saw no evidence of a systematic effect of the maternal intervention. Conclusions: Developmental performance of preschool children exposed to alcohol and drugs prenatally was, on average, substantially lower than expected for age regardless of study group. Although this home visitation intervention has been shown to be effective in helping mothers address a wide spectrum of needs, it is unlikely sufficient to overcome complex developmental risks of children exposed to alcohol and drugs prenatally. The effect of more comprehensive, multidimensional services specifically designed for the children should be investigated within this context. (Pediatr Phys Ther 2002;14:145‐153)

Does Rural Residence Affect Access to Prenatal Care in Oregon

CONTEXT Identifying how maternal residential location affects late initiation of prenatal care is important for policy planning and allocation of resources for intervention. PURPOSE To determine how rural residence and other social and demographic characteristics affect late initiation of prenatal care, and how residence status is associated with self-reported barriers to accessing early prenatal care. METHODS This observational study used data from the 2003 Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) (N = 1,508), with late initiation of prenatal care (after the first trimester) as the primary outcome. We used Rural-Urban Commuting Area (RUCA) codes to categorize maternal residence as urban, large rural, or small/isolated rural. Multivariate logistic regression was used to evaluate whether category of residence was associated with late initiation of prenatal care after adjusting for other maternal factors. Association between categories of barriers to prenatal care and maternal category of residence were determined using the Cochran-Mantel-Haenszel test of association. FINDINGS We found no significant association between residence category and late initiation of prenatal care, or residence category and barriers to prenatal care initiation. Urban women tended to be over age 34 or nonwhite. Women from large rural areas were more likely to be younger than 18 years, unmarried, and have an unintended pregnancy. Women from small rural areas were more likely to use tobacco during pregnancy. CONCLUSIONS Maternal residence category is not associated with late initiation of prenatal care or with barriers to initiation of prenatal care. Differences in maternal risk profiles by location suggest possible new foci for programs, such as tobacco education in small rural areas.