New Jersey Family Health Group Develops and Disseminates Protocol to Screen Pregnant Women for Drug and Alcohol Use
Family Health Initiatives, a subsidiary of the Southern New Jersey Perinatal Cooperative, implemented a uniform statewide screening process to identify pregnant women who use alcohol and other drugs and then disseminated the results through a conference.
The goal of the project, known as A Window of Opportunity for Children, was to improve access to care for pregnant women who use alcohol and other drugs in order to mitigate the effects of prenatal exposure to these substances on their children.
- Using a protocol developed under the project, staff at perinatal clinics administered more than 34,000 screens to pregnant women for alcohol and/or other drug use during the duration of the project.
- Once identified as being at risk, pregnant women were assessed for treatment needs and, when necessary, referred for treatment. Staff made more than 5,200 such referrals during the course of the project.
- Family Health Initiatives held a statewide symposium to educate providers about the effectiveness of the 4P's Plus screening tool (see the Activities section) and share the results of A Window of Opportunity for Children. The dinner meeting and conference took place February 16–17, 2010.
RWJF provided a $325,243 solicited grant to support the project. An additional RWJF grant of $25,000 supported a conference in February 2010.
Participating providers in the state's six Maternal Child Health Consortia continue to use the 4P's screening protocol and tools developed during the project.
Some 6 to 11 percent of babies born in New Jersey each year are exposed to drugs and alcohol during pregnancy, according to Family Health Initiatives, a subsidiary of the Southern New Jersey Perinatal Cooperative, a state-licensed consortium of health care providers that offers health care oversight, support and training to perinatal clinics.
In 2000, nearly 15,000 infants were born in New Jersey after having been exposed to damaging substances in the womb. These trends match those of the rest of the country.
Prenatal exposure to alcohol may result in behavioral or cognitive deficits, as well as problems with the heart, kidneys, bones and hearing. In severe cases, it may lead to fetal alcohol syndrome, which is characterized by abnormal facial features, growth deficiency and central nervous system problems. See the Centers for Disease Control and Prevention (CDC) Web site for additional information.
According to the March of Dimes, illicit drug use during pregnancy can lead to a host of problems, depending on the drug, including:
- Cocaine: Increases the risk of miscarriage early in pregnancy and triggers preterm labor later, increasing the risk of a low-birthweight baby; may also increase the risk of urinary-tract and heart defects and may affect later mental development
- Marijuana: Can slow fetal growth and slightly decrease the length of pregnancy, increasing the likelihood of a low-birthweight baby
- Heroin: Increases the risk of miscarriage, poor fetal growth, premature delivery and low birthweight and may affect later mental development
- Methamphetamine: May increase the risk of cleft palate and heart and limb defects; also appears to contribute to high blood pressure in the mother, which can slow fetal growth and increase the risk of premature delivery
Despite the recognized dangers of drug and alcohol exposure in the womb, many public and private prenatal care providers do not consistently screen for substance use in pregnancy, leaving untold numbers of children at risk of alcohol- and drug-related problems.
This grant is part of the New Jersey Health Initiatives (NJHI), a statewide grantmaking program of RWJF that supports innovative approaches to resolve health and health care needs in New Jersey.
Since 1987, NJHI has supported a wide range of community-based service implementation projects that correspond to RWJF interest areas through competitive grants awarded annually. Projects focus on health services delivery, improvement in health and the expansion of leadership expertise through grantmaking.
In 1987, RWJF funded the $9 million Program to Improve Maternal and Infant Health in New Jersey, which ran through February 1993. It led to the development of seven New Jersey Maternal and Child Health Consortia. The consortia created referral systems for high-risk births with the goal of improving perinatal outcomes within a defined geographic area.
This statewide initiative for regional services used the Southern New Jersey Perinatal Cooperative's structure as a model. In 1992, New Jersey issued new perinatal regulations, which codified a statewide network of Maternal and Child Health Consortia (MCHC).
In 1996, RWJF awarded a grant to the University of Medicine and Dentistry of New Jersey (UMDNJ) (ID# 029553), which supported the startup activities of the Center for Perinatal Health Initiatives (CPHI). CPHI assesses changes in perinatal services and outcomes in New Jersey and is housed at the department of OB/GYN and reproductive sciences at UMDNJ-Robert Wood Johnson Medical School.
CPHI collaborated with a wide range of organizations and agencies, including representatives of the seven New Jersey Maternal and Child Health Consortia established in the 1980s to develop referral systems for high-risk births within defined geographic areas.
Initial meetings of CPHI participants raised concerns about the validity of the state's electronic birth certificate (EBC) data. As this was the primary data source for tracking trends in the quality of perinatal care, CPHI focused its first research projects on evaluating EBC data and developing strategies for improving the data's accuracy.
- Three of the state's seven consortia conducted data-validation projects, at least one of which resulted in decreasing error rates of EBC data during the validation period.
- CPHI developed a new model for analyzing an array of prenatal test procedures, including detection of Down syndrome, neural tube defects, trisomy 18 and cystic fibrosis. The model provides a method of judging how sensitive these obstetric test procedures need to be in order to be cost-effective.
- Innovative statistical methodologies were developed and applied to longitudinal data that will facilitate tracking of perinatal results over time. CPHI's research work has been enhanced through its extensive collaborations across disciplines at UMDNJ.
For more information on CHPI, see Grant Results on ID# 029553.
Family Health Initiatives implemented a uniform statewide screening process, known as A Window of Opportunity for Children, to identify pregnant women who use alcohol and other drugs.
The goal of the project was to improve access to care for pregnant women who screened positive for use of alcohol and other drugs in order to mitigate the effects of prenatal exposure to these substances on their babies and children.
Project funds primarily covered the salary of a project director, who worked to establish collaborations between the New Jersey Department of Health and Senior Services and seven (later, due to a merger, six) Maternal and Child Health Consortia (MCHC) in the state. Each of these consortia is licensed by the state to provide health care oversight, support and training to perinatal clinics.
Funding was also provided for a risk-reduction specialist in each of the MCHC sites. These substance abuse counselors helped implement—and standardize—the screening protocol developed under the grant.
During the grant term, project staff:
- Developed a screening protocol to improve the rate of identification of alcohol- and substance-using pregnant women. The protocol was based on the "4P's Plus Screening and Referral Tool" developed by Ira J. Chasnoff, M.D., of the National Training Institute.
The four "P's" are:
- Parents. Did either of your parents have any problems with drugs or alcohol?
- Partner. Does your partner have any problem with drugs or alcohol? Is your partner's temper ever a problem for you?
- Past. Have you ever drunk beer/wine/liquor?
- Pregnancy. In the month before you knew you were pregnant, how many cigarettes did you smoke? In the month before you knew you were pregnant, how much wine/beer/liquor did you drink?
- Devised a tracking system to gather data on the number of 4P's Plus screens received from each prenatal care provider in order to monitor regional and statewide progress.
- Created a statewide database to collect information on perinatal substance abuse and to analyze the outcome of screening, case management, assessment and treatment services. (See Afterward.)
- Created a statewide directory of substance abuse treatment programs serving pregnant women.
- Created a User's Guide for health care providers using the 4P's Plus form. (See the Bibliography for details.)
- Trained health care providers to ensure that the screening protocol would be uniformly implemented in public and private obstetric settings throughout the state.
- Educated childbearing families about the effects of alcohol and drugs on the unborn child.
- Disseminated information and data about substance-using pregnant women to stakeholders and policy-makers.
- Using a protocol developed under the project, staff at 100 public and 22 private perinatal clinics administered more than 34,000 screens for alcohol and/or other drug use to pregnant women from July 2004 to December 2005.
- Once identified as being at risk, pregnant women were assessed for treatment needs and referred for treatment when necessary.
- More than 5,200 such referrals were made during the course of the project.
- Implementation of the screening program has spurred several local jurisdictions to explore enhancing services. For example:
- The city of Trenton relied on data abstracted from the 4P's Plus Screening and Referral Tool to access new funding from the New Jersey Division of Addiction Services for four new case managers to work in the prenatal care clinics in Trenton.
- The Center for Healthcare Strategies, a New Jersey-based national nonprofit organization, established pilot projects in five Medicaid HMOs—in Camden, Trenton and New Brunswick—to implement the 4P's screening protocol. (HMOs were not included in the original A Window of Opportunity for Children project.)
- Cape Assist, a Cape May County drug treatment provider, has contributed support for a part-time drug counselor to work at the Burdette Tomlin Hospital prenatal clinic in Cape May County.
- Morris and Sussex counties explored whether to create a joint case management service for pregnant substance users using existing state funds available to all county alcohol and drug coordinators.
- To educate providers about the effectiveness of the 4P's Plus screening tool and share the results of A Window of Opportunity for Children, Family Health Initiatives held a dinner for physicians and a statewide symposium. The dinner meeting of physician stakeholders took place February 16, 2010. The conference was held the next day. The keynote speaker was Ira J. Chasnoff, M.D., the developer of the "4P's Plus Screening and Referral Tool."
The conference was delayed a number of times until a uniform Perinatal Risk Assessment (PRA) form, including the questions from the 4P 's Plus Screening and Referral Tool, was endorsed by five Medicaid Managed Care Plans in New Jersey and by the New Jersey Department of Human Services, Division of Medical Assistance and Health Services/Medicaid. The PRA form was revised four times by stakeholders during 2007–2009.
As a result of the dinner and conference, the Brooklyn Perinatal Network requested consultation services to assist them with the implementation of a perinatal risk assessment tool.
- Collaborations can be essential. The collaboration with NJDHSS and the regional Maternal and Child Health Consortia was an essential element in the accomplishments of this project. This partnership included monthly meetings between the NJHI project director and state staff and the creation of two brochures. (Project Director/Barbara May)
- Ongoing state regional- and county-based data dissemination, advocacy and program promotion are necessary in order to sustain provider awareness of the seriousness of drug and alcohol use by pregnant women. (Project Director/May)
- Access to treatment is still a huge obstacle for pregnant women identified as needing substance abuse/alcohol treatment. Pregnant women fear that being identified as a drug or alcohol user makes them vulnerable to government sanction, including loss of their children. (Project Director/May)
- Case management for the client throughout the multiple levels of both the maternal and child health care treatment system and the alcohol and drug treatment system will increase a women's success in accessing and sustaining services. (Project Director/May)
Participating providers in the state's six Maternal Child Health Consortia continue to use the 4P's Plus screening protocol and tools developed during the project.
GRANT DETAILS & CONTACT INFORMATION
Development of a Collaborative Statewide Approach to Improving Access to Care for Drug- and Alcohol-Affected Women and Children
Family Health Initiatives Inc. (Pennsauken, NJ)
- Development of a collaborative statewide approach to improving access to care for drug- and alcohol-affected women and children
Amount: $ 325,243
Dates: November 2002 to March 2006
- Conference to disseminate the results of a statewide approach to improving access to care for drug- and alcohol-affected women and children
Amount: $ 25,000
Dates: October 2006 to December 2009
Barbara May, R.N., B.S.N.
Maternal and Child Health Consortia
Maternal and Child Health Consortia agencies that participated in the A Window of Opportunity for Children project:
Central NJ MCH Consortium
2 King Arthur Court, Suite B
North Brunswick, NJ 08902
Gateway Northwest Maternal and Child Health Network
381 Woodside Avenue
Newark, NJ 07104
Hudson Perinatal Consortium, Inc.
242 10th Street
Jersey City, NJ 07302
Northern NJ MCH Consortium
17 Arcadian Avenue, Suite 204
Paramus, NJ 07652
Regional Perinatal Consortium of Monmouth & Ocean Counties, Inc.
1255 Route 70, Suite 31N
Lakewood, NJ 08701-5900
Southern NJ Perinatal Cooperative, Inc.
Kevon Office Center, Suite 250
2500 McClellan Avenue
Pennsauken, NJ 08109-4613
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
4P's Plus Perinatal Addictions Screening: A User's Guide. Family Health Initiatives, 2003.
The 4P's Plus Screening and Referral Tool, Family Health Initiatives, field-tested in several prenatal clinics in November and December 2003.
Report prepared by: Peter Meyer
Report prepared by: DiAnn Ohama
Reviewed by: Molly McKaughan
Program Officer: Pamela S. Dickson