Extrinsic Barriers to Extrinsic Barriers to Substance Abuse Treatment Substance Abuse Treatment

Among Pregnant Drug Among Pregnant Drug Dependent WomenDependent Women

Marty Jessup RN, PhD Marty Jessup RN, PhD

Institute for Health Policy StudiesInstitute for Health Policy Studies

University of California, San Francisco University of California, San Francisco

American Public Health Association American Public Health Association

October 22, 2001October 22, 2001

Acknowledgements

National Research Service AwardNational Research Service Award

National Institute of Nursing Research, NIHNational Institute of Nursing Research, NIH

No. 5F31 NRO7440-03No. 5F31 NRO7440-03

andand

National Institute on Drug AbuseNational Institute on Drug Abuse

San Francisco Treatment Research TraineeshipSan Francisco Treatment Research Traineeship

No.No. P50 DA09253P50 DA09253

Inclusion CriteriaInclusion Criteria

in residential substance abuse in residential substance abuse treatmenttreatment

pregnant (> 24 wks. GA) or pregnant (> 24 wks. GA) or

parenting parenting (0-12 mos.)(0-12 mos.)

18 years of age18 years of age

RecruitmentRecruitment

flyers posted in 15 perinatal flyers posted in 15 perinatal programsprograms

phone screenphone screen

$25 retail gift certificate$25 retail gift certificate

Study Participants Study Participants nn = 36 = 36

12 pregnant 12 pregnant

24 with an infant < 12 mos. 24 with an infant < 12 mos.

20 African-American20 African-American8 White8 White7 Latina7 Latina1 Native American1 Native American

Participants (cont’d)Participants (cont’d)

MeanMean RangeRange

AgeAge 30.02 (± 5.8 S.D)30.02 (± 5.8 S.D) 19 - 4319 - 43

Sober time Sober time 18.4 weeks (±20.1 S.D.)18.4 weeks (±20.1 S.D.) 1 - 1 - 8888

GA @ entry tx GA @ entry tx 17.0 weeks (±14.3 S.D.)17.0 weeks (±14.3 S.D.) 1 - 1 - 4040

GA @ entry pnc 15.2 weeks (± 9.3 S.D.)GA @ entry pnc 15.2 weeks (± 9.3 S.D.) 1 - 1 - 3232

Participants (cont’d)n = 36

Primary Drug nCocaine 16

Alcohol 6 Heroin 6 Methamphetamine 5 Cocaine/marijuana 2 Psychedelics 1

Participants cont’dn = 36

n %Homeless 13 36Violence from partners 7 19 Incarcerations 11 31Sudden/violent death exp. 9 25Unplanned pregnancy 33 92Past child relinquishment 24 66Methadone maintenance 4

11

Mode of Entry to Treatment

n = 24

Mode n

Jail/court 7Child welfare 6Prenatal care 6Voluntary self-referrals 5

Mode of Entry to Prenatal Caren = 35

Mode n

Voluntary self-referral 22

Jail medical services 8

Treatment contract 5

Data Collection Data Collection Demographic information sheetDemographic information sheet

Semi-structured Semi-structured life history:life history:

““Tell me about the period of time Tell me about the period of time before you went into treatmentbefore you went into treatment””

Probes: Probes: How did you learn you were How did you learn you were

pregnant?pregnant?How did you get to prenatal care?How did you get to prenatal care?How did you get to treatment?How did you get to treatment?

Analysis Analysis ((Mandelbaum, 1973)Mandelbaum, 1973)

DimensionsDimensions

TurningsTurnings

AdaptationAdaptation

TrustworthinessTrustworthiness

CredibilityCredibility

TransferabiltyTransferabilty

DependabilityDependability

ConfirmabiltyConfirmabilty

DimensionsDimensions

MandelbaumMandelbaum JessupJessupBiologicalBiological Gender: pregnancy and Gender: pregnancy and

childbirthchildbirthDrug dependencyDrug dependency

Socio-culturalSocio-cultural Maternal role stipulationsMaternal role stipulations

Psycho-socialPsycho-social Fear: arrest, incarceration, Fear: arrest, incarceration, prosecution, loss of prosecution, loss of childchild

TurningsTurnings

PregnancyPregnancy

AdaptationsAdaptations

Protecting custodyProtecting custody

Preserving the familyPreserving the family

Talking to GodTalking to God

Doing the right thingDoing the right thing

BarriersBarriers

Fear Fear arrest and prosecutionarrest and prosecutionincarceration and loss of incarceration and loss of

childchildProgram-basedProgram-basedPartnersPartnersOpiate dependencyOpiate dependencyPregnancyPregnancy

TurningsTurningsPregnancyPregnancy

I love her. And I thank God for her. You know, I I love her. And I thank God for her. You know, I think He knows that I’m ready to have it…be think He knows that I’m ready to have it…be a mom again and that’s good. He’s giving me a mom again and that’s good. He’s giving me another chance.another chance.

Ivy, single mother, recovering crack Ivy, single mother, recovering crack addicted womanaddicted woman

Socio-cultural Dimension

Criminality vs. disease model

Socially stipulated roles

Impact on : care-seeking child custody social relations

FearFear

I had heard so many horror stories about people coming up positive and not even seeing their baby ever, just having the baby taken straight from the hospital. And I thought that was what was going to happen to me…

Nina, 19 year old recovering heroin

dependent woman

FearFear

I didn’t tell him [physician] the full story…He might turn me in…to CPS.

Maisha, 29 year old mother of a 10 month old baby

FearFear

Knowing that they were gonna test me for drugs, that’s what scared me…they said if you don’t go into treatment, your baby will be taken away from you…That’s why I didn’t go to prenatal care…I didn’t want to lose my baby.

Emily, a 23 year old heroin dependent woman

Adaptation

Preserving the Family

Compliance with child welfare

Voluntary relinquishments

DiscussionDiscussion

Gendered impact of the War on DrugsGendered impact of the War on Drugs

Transformation of the therapeutic allianceTransformation of the therapeutic alliance

Deterrent effects of fear Deterrent effects of fear

Collaborative harm from helpersCollaborative harm from helpers

DiscussionDiscussion

Conflicts arise when help becomes Conflicts arise when help becomes harmharm

Delay re-conceptualized Delay re-conceptualized

Institutional readinessInstitutional readiness

Advocacy for therapeutic practiceAdvocacy for therapeutic practice

Implications

Health PolicyRenewed Public Dialogue Fetal Protection = Maternal

ProtectionSystems Collaboration AdvocacyTreatment Barrier ReductionChild Welfare System Evaluation Access is a Social Justice Issue

Implications

Clinical PracticeEducationStandards of PracticeDisclosureInterdisciplinary

CollaborationsLegal Protections

Limitations of the Study

In-treatment sample

MH status unknown

In-residence setting

Short time of sobriety

Future Research

Impact of punitive policy

Influencing factors of tx entry

Helping institutions and personnel

Domestic violence

Treatment utilization trend analysis

Epilogue

I: So . . . What would you say?

S: There’s a place you can go in with your pregnancy. You have room and board, you would eat , you’d be with community . . .You’ll have child care. . . You’ll have a place to rest, you and the baby . . . I think it sounds good . . .