Preventing substance abuse in pregnancy: a successful program

Robin Wulffson MD's picture
substance abuse, alcohol, tobacco, drugs, morbidity, mortality, costs
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The use of alcohol, tobacco, and other drugs is currently a major problem in pregnancy; it impacts more than 400,000 pregnancies in the U.S. each year with preventable morbidity (health damage) and mortality (death). To address this issue, researchers affiliated with Kaiser Permanente Northern California, a large health maintenance organization (HMO), conducted a cost–benefit analysis of Early Start: an integrated prenatal intervention program for stopping substance use in pregnancy.

In 1990, Kaiser Permanente Northern California developed Early Start, an integrated prenatal intervention program for the prevention of alcohol, tobacco, and other drug use. The program created the Early Start specialist position, a licensed clinical social worker or marriage and family therapist with expertise in substance use and pregnancy who is located within the obstetrics and gynecology department. Appointments for substance use were linked to routine prenatal care visits. The combined appointments removed barriers that women face in obtaining substance use counseling, such as child care, fear of discrimination, and stigmatization.

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Previous research demonstrated that women who screened positive and participated fully in Early Start with at least one follow-up visit had perinatal outcomes similar to women in the control group, whereas those women who were only screened-assessed also had significantly improved outcomes as compared with the screened-positive-only group. The one-hour psychosocial assessment alone has a significant effect on behavior with a decrease in alcohol, tobacco, and other drug usage; improving outcomes; and decreasing subsequent utilization.

The researchers conducted a retrospective study of 49,261 women who had completed prenatal substance abuse screening questionnaires at obstetric clinics and who had undergone urine toxicology screening tests. The researchers concluded: “Early Start is a cost-beneficial intervention for substance use in pregnancy that improves maternal–infant outcomes and leads to lower overall costs by an amount significantly greater than the costs of the program.”

Four study groups were compared: (1) Women screened and assessed positive and followed by Early Start (screened-assessed-followed; 2,032 women); (2) Women screened and assessed positive without follow-up (screened-assessed; 1,181 women); (3) Women screened positive only (screened-positive-only; 149 women); and (4) Women in the control group who screened negative (control; 45,899 women). Costs associated with maternal healthcare (prenatal through one year postpartum), neonatal birth hospitalization care, and pediatric healthcare (through one year) were adjusted to 2009 dollars. Average costs were calculated and adjusted for age, race, education, income, marital status, and amount of prenatal care.

The screened-positive-only group adjusted average maternal total costs ($10,869) were significantly higher than screened-assessed-followed ($9,430), screened-assessed ($9,230), and control ($8,282). The screened-positive-only group adjusted mean infant total costs ($16,943) were significantly higher than screened-assessed-followed ($11,214), screened-assessed$11,304), and control ($10,416). The screened-positive-only group adjusted average overall total costs ($27,812) were significantly higher than screened-assessed-followed ($20,644), screened-assessed ($20,534), and control ($18,698). Early Start implementation costs were $670,600 annually. Cost–benefit analysis found that the net cost benefit averaged $5,946,741 per year.

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