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