1. Extrinsic Barriers to Substance Abuse Treatment Among Pregnant Drug Dependent Women Marty Jessup RN, PhD Institute for Health Policy Studies University of California, San Francisco American Public Health Association October 22, 2001

2. Acknowledgements National Research Service Award National Institute of Nursing Research, NIH No. 5F31 NRO7440-03 and National Institute on Drug Abuse San Francisco Treatment Research Traineeship No. P50 DA09253

3. Inclusion Criteria  in residential substance abuse treatment  pregnant (> 24 wks. GA) or parenting (0-12 mos.)  18 years of age

4. Recruitment flyers posted in 15 perinatal programs  flyers posted in 15 perinatal programs  phone screen  $25 retail gift certificate

5. Study Participants n = 36  12 pregnant 24 with an infant < 12 mos.  20 African-American 8 White 7 Latina 1 Native American

6. Participants (cont’d) MeanRange Age30.02 (± 5.8 S.D)19 - 43 Sober time 18.4 weeks (±20.1 S.D.) 1 - 88 GA @ entry tx 17.0 weeks (±14.3 S.D.) 1 - 40 GA @ entry pnc 15.2 weeks (± 9.3 S.D.) 1 - 32

7. Participants (cont’d) n = 36  Primary Drug n Cocaine16 Alcohol 6 Heroin 6 Methamphetamine 5 Cocaine/marijuana 2 Psychedelics 1

8. Participants cont ’ d n = 36 n % Homeless1336 Violence from partners 719 Incarcerations1131 Sudden/violent death exp. 925 Unplanned pregnancy3392 Past child relinquishment2466 Methadone maintenance 4 11

9.  Mode of Entry to Treatment n = 24 Moden Jail/court7 Child welfare6 Prenatal care6 Voluntary self-referrals5

10.  Mode of Entry to Prenatal Care n = 35 Moden Voluntary self-referral22 Jail medical services 8 Treatment contract 5

11. Data Collection  Demographic information sheet  Semi-structured life history: “ Tell me about the period of time before you went into treatment ”  Probes: How did you learn you were pregnant? How did you get to prenatal care? How did you get to treatment?

12. Analysis (Mandelbaum, 1973)  Dimensions  Turnings  Adaptation

13.  Trustworthiness CredibilityTransferabiltyDependabilityConfirmabilty

14.  Dimensions MandelbaumJessup BiologicalGender: pregnancy and childbirth Drug dependency Socio-culturalMaternal role stipulations Psycho-socialFear: arrest, incarceration, prosecution, loss of child

15.  Turnings Pregnancy

16. Adaptations  Adaptations Protecting custody Preserving the family Talking to God Doing the right thing

17.  Barriers Fear arrest and prosecution incarceration and loss of child Program-basedPartners Opiate dependency Pregnancy

18.  Turnings Pregnancy I love her. And I thank God for her. You know, I think He knows that I’m ready to have it…be a mom again and that’s good. He’s giving me another chance. Ivy, single mother, recovering crack addicted woman addicted woman

19.  Socio-cultural Dimension Criminality vs. disease model Socially stipulated roles Impact on : care-seeking child custody social relations

20.  Fear 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

21.  Fear 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

22.  Fear 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

23.  Adaptation Preserving the Family Compliance with child welfare Voluntary relinquishments

24. Discussion  Gendered impact of the War on Drugs  Transformation of the therapeutic alliance  Deterrent effects of fear  Collaborative harm from helpers

25. Discussion  Conflicts arise when help becomes harm  Delay re-conceptualized  Institutional readiness  Advocacy for therapeutic practice

26.  Implications Health Policy Renewed Public Dialogue Fetal Protection = Maternal Protection Systems Collaboration Advocacy Treatment Barrier Reduction Child Welfare System Evaluation Access is a Social Justice Issue

27.  Implications Clinical Practice Education Standards of Practice Disclosure Interdisciplinary Collaborations Legal Protections

28.  Limitations of the Study In-treatment sample MH status unknown In-residence setting Short time of sobriety

29.  Future Research Impact of punitive policy Influencing factors of tx entry Helping institutions and personnel Domestic violence Treatment utilization trend analysis

30. 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 ’l l have a place to rest, you and the baby... I think it sounds good...