Treatment for cigarette, alcohol and drug use in pregnancy improves outcomes for mother and baby

Pregnant women who receive treatment for substance abuse early in their pregnancy can achieve the same health outcomes as pregnant women with no substance abuse, according to a Kaiser Permanente study published online in the Journal of Perinatology.

The study, which is the largest to date, examined 49,985 women in Kaiser Permanente's prenatal care program and found that integrating substance abuse screening and treatment into routine prenatal care helped pregnant women achieve similar health outcomes as women who were not using cigarettes, alcohol or other drugs. This is also the largest study to examine multiple substances: cigarettes, alcohol, marijuana, methamphetamines, cocaine and heroin.

"This program can happen everywhere and should become the gold standard for women who are pregnant and using cigarettes, alcohol or other drugs," said study lead author Nancy C. Goler, M.D., an OB/GYN and Kaiser Permanente regional medical director of the Early Start Program for the organization's Northern California operations. "The study's big finding was that study participants treated in the Early Start program had outcomes similar to our control group, women who had no evidence of substance abuse."

The study compared 2,073 pregnant women who were screened, assessed and received ongoing intervention during pregnancy through the Early Start program at 21 Kaiser Permanente Northern California outpatient obstetric clinics from 1999 to 2003 to women in three other groups: 156 women who were screened but did not accept assessment or treatment; 1,203 women were screened, assessed and received brief intervention only; and a control group of 46,553 women who showed no evidence of substance abuse.

The study found the risk of stillborn, placental abruption (when the placental lining separates from the mother's uterus), pre-term delivery, low birth weight and neonatal ventilation were dramatically higher for the 156 untreated substance abusers than the 2,073 women in the Early Start program:

• Risk of stillbirth was 16.2 times higher for women who were screened but did not accept assessment or treatment than those who received Early Start treatment

• Risk of placental abruption was 6.8 times higher for women who were screened but did not accept assessment or treatment than those who received treatment

• Risk of pre-term delivery was 2.1 times higher for women who were screened but did not accept assessment or treatment than those who received treatment

• Risk of low birth weight (under 5.5 pounds) was 1.8 times higher for women who were screened but did not accept assessment or treatment than those who received treatment

• Risk of neonatal ventilation was 2.2 times higher for women who were screened but did not accept assessment or treatment than those who received treatment.

The women who went through the Early Start program had the same statistical risks of stillborn, preterm delivery, placental abruption as the control group of women who did not use any cigarettes, alcohol or drugs during their pregnancy.

"The key message here to women who are currently smoking, drinking or using other drugs, or who recently tried to stop, is that it is not too late to seek help when you find out you are pregnant," said Dr. Goler. "The sooner women ask for help, the better the health outcomes will be for themselves, and their babies. My message to all pregnant women, as well as women who are trying to conceive, is to stop all alcohol, cigarette and drug use."

Launched in 1990, Kaiser Permanente's Early Start program integrates obstetric care with substance abuse treatment for pregnant women in three ways: all women are screened by questionnaire for drug, cigarette and alcohol use, and by urine toxicology testing with signed consent; a licensed substance abuse expert works in the OB/GYN department and sees the patients at the same time as their prenatal care appointments; and all providers and patients are educated about the effects of drugs, alcohol and cigarette use during pregnancy.

The program, which is in place in 40 Kaiser Permanente outpatient obstetric clinics in Northern California and being rolled out in other Kaiser Permanente facilities nationwide, screens nearly 40,000 women annually. By providing a licensed professional with expertise in substance abuse and pregnancy in the OB/GYN department – so women have barrier-free access to care in a safe, supportive environment – Early Start exceeds the American College of Obstetricians and Gynecologists Committee on Ethics Opinion recommendations to use universal screening questions, brief intervention, and referral to treatment programs for substance abuse

"This study is a superb example of how effective the Kaiser Permanente's Early Start approach and methodology is in treating chemical dependency and substance abuse in pregnant women," said Margaret Merritt, Executive Director of the American College of Obstetrics and Gynecology, District IX (California). "Early Start exceeds the guidelines set forth by ACOG and is a fantastic example of a program that can be incorporated in a variety of settings to reach this very important group of women."