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Introduction The non-medical use of prescription opioids has increased dramatically over the past two decades to 'epidemic' proportions with an estimated 10 million individuals [1-6]. Moreover, prescription opioids have been [...], A 2012 committee opinion from the American College of Obstetricians and Gynecologists highlights the considerable increase in opioid addiction in recent years, yet little is known about clinical correlates of prescribed opioids among pregnant women. This study examines clinical and demographic factors associated with the use of opioid analgesics in pregnancy. Data were derived from a prospective cohort study of pregnant women. Participants were administered the Composite International Diagnostic Interview to identify depressive and anxiety disorders and data on medication use were gathered at three assessment points and classified according to the Anatomical Therapeutic Chemical Code (ATC) classification system ATC group N02A. Participants included 2,748 English or Spanish speaking pregnant women. Six percent (n = 165) of women used opioid analgesics at any point in pregnancy. More pregnant women using opioids met diagnostic criteria for major depressive disorder (16 vs. 8% for non users), generalized anxiety disorder (18 vs. 9% for non users), post-traumatic stress disorder (11 vs. 4% for non users) and panic disorder (6 vs. 4% for non users). Women who reported opioid use were also significantly more likely than non users to report using illicit drugs and almost three times as likely to report smoking cigarettes in the second or third trimester of pregnancy (4 and 23%, respectively) as compared to non-opioid users (0.5 and 8%). The use of opioids in pregnancy was associated with higher levels of psychiatric comorbidity and use of other substances as compared to non-opioid users. Keywords Drug use * Pregnancy * Mental health

Introduction Antiviral medications are used to treat or prevent viral infections such as herpes simplex virus (HSV), influenza A and B, hepatitis B(HBV) and C(HCV), and antiretrovirals are used to [...], To evaluate the prevalence, trends, timing and duration of exposure to antiviral medications during pregnancy within a US cohort of pregnant women and to evaluate the proportion of deliveries with a viral infection diagnosis among women given antiviral medication during pregnancy. Live-born deliveries between 2001 and 2007, to women aged 15-45 years, were included from the Medication Exposure in Pregnancy Risk Evaluation Program, a collaborative research program between the U.S. Food and Drug Administration and eleven health plans. They were evaluated for prevalence, timing, duration, and temporal trends of exposure to antiviral medications during pregnancy. We also calculated the proportion of deliveries with a viral infection diagnosis among those exposed to antiviral medications. Among 664,297 live births, the overall prevalence of antiviral exposure during pregnancy was 4 % (n = 25,155). Between 2001 and 2007, antiviral medication exposure during pregnancy doubled from 2.5 to 5 %. The most commonly used antiviral medication was acyclovir, with 3 % of the deliveries being exposed and most of the exposure occurring after the 1st trimester. Most deliveries exposed to antiviral medications were exposed for less than 30 days (2 % of all live births). Forty percent of the women delivering an infant exposed to antiviral medications had a herpes diagnosis. Our findings highlight the increased prevalence of women delivering an infant exposed to antiviral medications over time. These findings support the need for large, well-designed studies to assess the safety and effectiveness of these medications during pregnancy. Keywords Antiviral medication * Exposure during pregnancy * Prevalence

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.forsciint.2009.12.034 Byline: Lisa O'Brien (a)(b), Carina Baumer (c), Detlef Thieme (c)(d), Hans Sachs (c)(d), Gideon Koren (a)(b)(e) Keywords: Pregnancy; Antidepressant metabolism; Hair; Segmental analysis Abstract: Depression and other psychiatric illnesses are common during pregnancy and are often treated with antidepressants. Physiological changes of pregnancy may alter the pharmacokinetics of medications and ultimately affect the dose required to maintain effective therapy. Human hair offers a safe, non-invasive way to monitor long term systemic exposures to medications. Author Affiliation: (a) Division of Clinical Pharmacology and Toxicology, Hospital for Sick Children, Toronto, Canada (b) Institute of Medical Science, University of Toronto, Canada (c) Forensic Toxicological Centre, Munich, Germany (d) Institute of Forensic Medicine, Munich, Germany (e) Department of Pediatrics, Hospital for Sick Children, Toronto, Canada Article History: Received 5 June 2009; Accepted 12 August 2009

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.forsciint.2009.12.044 Byline: Xavier Joya (a)(b)(c), Mitona Pujadas (d)(e), Maria Falcon (f), Ester Civit (d), Oscar Garcia-Algar (a)(c)(g), Oriol Vall (a)(c)(g), Simona Pichini (h), Aurelio Luna (f), Rafael de la Torre (d)(e)(i) Keywords: Placenta; Prenatal exposure; Drugs of abuse; Interruption of pregnancy; Gas chromatography-mass spectrometry Abbreviations: MDMA, 3,4-methylenedioxymethamphetamine; AP, amphetamine; BEC, benzoylecgonine; BUP, buprenorphine; COC, cocaine; COT, cotinine; [DELTA]-9-THC-COOH, 11-nor-9-carboxy-delta-9-tetrahydrocannabinol; EI, electron-impact; FAEEs, fatty acid ethyl esters; GC/MS, gas chromatography-mass spectrometry; ISTDs, internal standards; LOD, limit of detection; LOQ, limit of quantification; LC/MS/MS, liquid chromatography-tandem mass spectrometry; MA, methamphetamine; MOR, morphine; NIC, nicotine; MSTFA, N-Methyl-N-(trimethylsilyl)tri-fluoroacetamide; NBUP-Gluc, norbuprenorphine glucuronide; QC, quality control; SIM, selected-ion-monitoring; SPE, solid phase extraction; SD, standard deviation Abstract: We describe the development and validation of a method for the quantification of drugs of abuse, using gas chromatography-mass spectrometry (GC/MS), in human placenta. Concentration ranges covered were 5-500ng/g for amphetamine, methamphetamine, MDMA, methadone, cocaine, benzoylecgonine, cocaethylene, morphine, 11-nor-9-carboxy-delta-9-tetrahydrocannabinol, nicotine, and cotinine. Intra-assay and inter-assay imprecisions were less than 15.7% for lower quality control samples and less than 14.9% for medium and high quality control samples. Recovery range was 36.2-83.7%. Placenta samples were kept at -80[degrees]C until analysis; analytes were stable after three freeze-thaw cycles (samples stored at -20[degrees]C). This accurate and precise assay has sufficient sensitivity and specificity for the analysis of specimens collected from women who voluntarily terminated their pregnancy at 12th week of gestation. The method has proven to be robust and accurate for the quantification of the principal recreational drugs of abuse in this period of the prenatal life. This is the first report that highlights the presence of drugs of abuse during the first trimester of gestation. Author Affiliation: (a) Unitat de Recerca Infancia i Entorn (URIE), Institut Municipal d'Investigacio Medica - Hospital del Mar, Barcelona, Spain (b) Departament de Bioquimica i Biologia Molecular, Universitat AutA[sup.2]noma de Barcelona, Barcelona, Spain (c) Red de Salut Materno-Infantil y del Desarrollo (SAMID), Instituto Carlos III, Spain (d) Grup de Recerca en Farmacologia Humana i Neurociencies, Institut Municipal d'Investigacio Medica-Hospital del Mar, Barcelona, Spain (e) CIBER Fisiopatologia de la Obesidad y Nutricion, Instituto Carlos III, Spain (f) Departamento de Medicina Forense, Universidad de Murcia, Murcia, Spain (g) Departament de Pediatria, Obstetricia i Ginecologia i Medicina Preventiva, Universitat AutA[sup.2]noma de Barcelona, Barcelona, Spain (h) Department of Therapeutic Research and Medicines Evaluation, Istituto Superiore di Sanita, Rome, Italy (i) Departament de Ciencies Experimentals i de la Salut, Universitat Pompeu Fabra, Barcelona, Spain Article History: Received 18 July 2009; Accepted 15 September 2009

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.forsciint.2009.12.042 Byline: M. Falcon (a), F. Valero (a), M. Pellegrini (b), M.C. Rotolo (b), G. Scaravelli (b), J. Joya (c), O. Vall (c), O. Garcia Algar (c), A. Luna (a), S. Pichini (b) Keywords: Drug abuse; Pregnancy; Induced abortion Abstract: Drug abuse is a worldwide phenomenon with significant health and socioeconomic impact and it is of particular concern in women of reproductive age and in pregnant women. We aimed to investigate the prevalence of drug use by serum and hair testing in a cohort of pregnant women at 12th week gestation who decided voluntarily to interrupt their pregnancy and to investigate the relationship between drug exposure and induced abortions (IA), repeated IA and contraception. The study was conducted in an obstetrics clinic authorised to perform IA in Murcia, Spain during an 18 months period (2007-2009). Apart from serum and/or hair testing, the 142 women enrolled in the study completed a detailed questionnaire regarding drug, alcohol and tobacco use in the previous 3 months. Serum and hair samples were analyzed by gas chromatography mass spectrometry assays. Hair and serum samples showed a 30% overall positivity to drugs of abuse. Of these samples, 20.4, 14.1, 4.2 and 1.4% were positive for cannabinoids, cocaine, opiates, and MDMA, respectively, with polydrug use in 5.6% cases. In this cohort, a positive association was found between drug use and repeated IA. The results highlight the need for promoting pregnancy planning for young women in general, especially when consuming psychoactive substances as well as promote safe and accessible contraception in women of reproductive age. In women requesting IA, specific drug abuse counselling should be implemented. Author Affiliation: (a) Legal Medicine, University of Murcia, Spain (b) Istituto Superiore di Sanita, Rome, Italy (c) Paediatric Service, URIE, Hospital del Mar, and Universitat AutA[sup.2]noma, Barcelona, Spain Article History: Received 17 June 2009; Accepted 25 July 2009

Second generation studies of prenatal cocaine exposure failed to find gross deficits after controlling for confounders. Concern remained that exposure could cause subtle deficits. This prospective, cohort study evaluated effects of cocaine on development at 12, 18, 24, and 36 months. From 1991-1993, 361 mother-infant pairs were recruited from the Children's Hospital of New York, Presbyterian Medical Center's prenatal clinic or delivery room suite. Mothers were assigned to the cocaine group based on report of prenatal cocaine use or positive urine toxicology. Control mothers were enrolled from the same clinic and matched for age and socioeconomic status (SES). Women with serious medical problems were excluded from either group. Of the retained cohort, at 12 months, 147 infants were exposed and 89 were unexposed case controls. Both groups were raised in impoverished environments with few supports. Developmental evaluations were conducted blinded to group. Cross-sectional analysis revealed cocaine-related deficits in neurological exams and speech across all time periods, in spite of catch up in weight, length, and head circumference. Overall analysis of development was evaluated using Generalized Estimating Equations regression analysis. Bayley Mental [[B.sub.adj] = -6.5 (CI--9.4, -3.5, p [less than or equal to] 0.001)] and Psychomotor [[B.sub.adj] = -3.9 (CI--7.4,- 0.5, p = 0.02)] Developmental Indices showed deficits after controlling for confounders. Males were more vulnerable to cocaine exposure for height, motor development, and emotional regulation. Dose-response relationships existed for abnormal neurological exams ([p.sub.trend] < 0.08), Mental Development Index (MDI) ([p.sub.trend] < 0.001), and Psychomotor Development Index (PDI) ([p.sub.trend] < 0.001) deficits. Although nonexposed children performed poorly, cocaine-exposed children showed worse performance. Both groups showed declines at 18 months in mental and psychomotor development from which only nonexposed children rebounded. Overall, cocaine exposure adds an additional risk to disadvantaged children's development. Cocaine-exposed children are less resilient to effects of these multiple risks. Key Words: Prenatal cocaine exposure; Child development; Gender differences; Dose-related effects., INTRODUCTION Early reports of neurobehavioral and developmental outcomes of cocaine-exposed children were alarming (1,2) and were substantiated by reports of cocaine-related neurochemical (3) and behavioral (4,5) deficits among animals (6). [...]

Scientists were able to isolate children suffering from the result of cocaine, specifically, by testing for the presence of non-medically administered drugs of abuse and for alcohol in blood samples taken from the umbilical cord. Patients positive from any other drug use were excluded from the study. This allowed researchers to study the direct effects of cocaine on babies which included low birth weight and congenital anomalies.

Important advances have been made in defining the methodological issues that affect fetal drug exposure research. These issues include the application of complex statistical methods to improve scientific rigor, the assessment of examiner bias, the control of confounding variables, the adoption of the tetralogy model in neurotoxicity testing, and the use of multiple indicators of exposure. While some of these provocative issues may not be resolved soon, they do have serious repercussions and profound policy implications.

Previous research has found an association between childhood and adult physical and sexual abuse and substance abuse, but has not examined or compared specific dimensions of the abuse experience. such as its age of onset or the type, severity, or frequency. Women receiving perinatal care (N = 1189) at an inner-city hospital clinic were systematically questioned about their lifetime and current cocaine use and experiences of abuse. We found an association between a history of abuse in childhood and lifetime and current cocaine use, as well as physical and sexual abuse during childhood and pregnancy. There was no difference in the rates of cocaine use between women whose onset of abuse was in childhood versus adulthood. Childhood sexual abuse (alone or in combination with physical abuse) was more associated with lifetime cocaine use than was physical abuse alone. Cocaine use was related to the severity, but not the frequency of abuse. Keywords - childhood abuse; cocaine; pregnancy; sexual abuse.

This study examined whether preterm infants are more vulnerable to the effects of prenatal drug exposure than are full-term infants. The sample of 235 low-income African American mothers and their infants included 119 cocaine-polydrug users, 19 alcohol-only users, and 97 nonusers; 148 infants were full term and 87 were preterm. Direct effects of exposure on birth weight, birth length, ponderal index, and irritability were moderated by length of gestation: Fetal growth deficits were more extreme in later-born infants, whereas increases in irritability were more extreme in earlier born infants. Effects of exposure on cardiorespiratory reactivity to a neonatal exam were not moderated by length of gestation. In general, effects of exposure occurred for both cocaine-polydrug and alcohol-only users and so could not be unambiguously attributed to either of these drugs alone.

This study investigated the effects of an intervention for polydrug-using adolescent mothers. The program included educational, vocational, and parenting classes; social and drug rehab; and day care for their infants while they attended school half-day. The drug-exposed infants were similar to the non-exposed infants on traditional birth measures, although they had inferior Brazelton Neonatal Behavioral Assessment Scale scores, including habituation, orientation, abnormal reflexes, general irritability, and regulatory capacity. The drug-exposed infants also spent less time in quiet sleep and more time crying and showing stress behaviors. Both the mothers and the infants in the drug groups demonstrated inferior interactions, and their dopamine and serotonin levels were significantly higher. As early as 3 months (following 3 months of intervention), the drug rehab mothers and their infants looked more like the nondrug group in their interactions; by 6 months, they looked similar on virtually every measure. At 12 months, the infants of drug rehab mothers (versus the drug control group) had superior Early Social Communication Scale scores and Bayley Mental scale scores, as well as significantly greater head circumference and fewer pediatric complications. The drug rehab mothers also improved on several lifestyle variables. They demonstrated a lower incidence of continued drug use and repeat pregnancy, and a greater number continued school, received a high school or general equivalency diploma, or were placed in a job. Thus, a relatively cost-effective high school based intervention had positive effects on both adolescent mothers who had used drugs and their infants., The incidence of cocaine use among pregnant women has been reported at about 10%, although in some areas it is as high as 28% (Singer, Garber, & Kliegman, 1991). Polydrug […]

A study of 96 pregnant women in a residential substance abuse treatment program establishes the correlation between trauma exposure, stress symptoms and program completion. These low-income women had a high rate of exposure to violent trauma with 72% having faced sexual assault, 67% having experienced physical assault and 68% having dealt with indirect violent trauma. 62% of women showed signs of posttraumatic stress disorder.

This paper presents evaluation results of a CSAP-funded case management project associated with an outpatient substance abuse treatment (SAT) program for women and their children. Key findings are: (a) case management and threat of child protective services encourage retention in SAT during pregnancy, (b) retention in SAT has a positive effect on reducing illicit substance use, (c) receiving methadone during pregnancy has a negative effect on reducing illicit substance use, and (d) reduction in illicit substance use has a positive effect on birth weight. These findings indicate retention in SAT and decreased illicit drug use are associated with improved infant birth weight, which is associated with other improvements, such as decreased infant mortality and morbidity. The finding of a relationship between methadone maintenance treatment (MMT) and illicit drug use creates' a dilemma for practice: to what extent should the dose of methadone be decreased during pregnancy, given the fact that women may then increase illicit use of drugs. Keywords - prenatal substance use: birth weight; case management; women and children's substance abuse programming; methadone maintenance.

Pregnant and postpartum substance-using women are a special population whose needs do not reflect those of the general substance-using communities. This study examined length of stay in a federally funded day treatment demonstration program in order to identify predictor variables that may help identify pregnant and postpartum substance-using women at high risk for dropping out of treatment. Variables from intake and exit questionnaires on a sample of 163 women were analyzed using multiple regression on both days in treatment and the logarithmic transformation of days in treatment. Few predictor variables were identified, although findings suggest that if a woman is younger and self-referred, she may leave treatment sooner. As one of the first sets of published data on pregnant and postpartum women and retention in treatment, this study lays the groundwork for future research on the retention of pregnant and postpartum women in treatment, thereby facilitating the success of these women in overcoming their addiction. Keywords - retention; dropout; substance abuse; drug abuse; pregnant.

Many studies have focused on pregnant women who have used crack cocaine and other drugs during pregnancy, but few studies have conducted interviews with the women either during pregnancy or after delivery while undergoing residential care and the recovery process to determine what they feel their program needs are in an effort to ensure successful treatment. This exploratory study was undertaken specifically to consider not only drug-use patterns and sexual risk behaviors, but primarily to consider what characteristics the women felt would make drug treatment intervention strategies more effective for them and their families, including the significant other in their lives. Interviews were conducted at three residential treatment facilities for women as well as at home, after program discharge. Eighty-three women participated in this project, which was both quantitative and qualitative. There is discussion of the nurturing program that should be considered for use with this population.

An analysis of how violence affects the lives of pregnant, low-income women was undertaken, drawing from needs assessment data from two diverse California counties. Self-report screening was used to determine risk for heavier or problem substance use. Of 1,147 women, 401 met the screening threshold. The 401 at-risk respondents report significantly higher levels of substance-related violence when compared to the other 746 respondents. Among all respondents, neighborhood substance-related problems, being United States-born, meeting the screening threshold, and being a woman of color were associated with reported substance-related violence among acquaintances. Among the substance-involved sample, neighborhood drug problems, being a woman of color, and being hurt, beaten or taken advantage of due to drugs were associated with violence reports. The implications are that substance-related violence prevention strategies need to focus on the community as well as on the individual and the family.

This paper examines the relationship between the living arrangement of mother and baby in a residential treatment center and measures of self-esteem, depression and parenting sense of competence and a woman's length of stay and completion or non-completion of treatment. Scores on the Bayley Scales of Infant Development (Bayley 1969) are also examined by the amount of time the baby spent with mother, an arrangement that affords the opportunity for the child to participate in the facility's therapeutic child care center. Findings suggest that the earlier a mother's infant resides with her in the treatment setting, the longer her length of stay will be, with an increased opportunity for program completion. In addition, measures of depression were lower and measures of self-esteem were higher for women with their babies than for clients who did not have their infant in the treatment facility. Scores on the Bayley Scales of Infant Development were within normal limits for all infants living with their mothers in treatment.

The perceived magnitude of perinatal chemical dependency in California was the impetus for an interagency partnership within the California Health and Welfare Agency called Options for Recovery (OFR). It offered alcohol and drug treatment and recovery, case management, and recruitment and training of foster parents and relative caregivers to chemically dependent pregnant and parenting women. A 3-year, multi-method evaluation was conducted that included quantitative analyses of secondary data sources, semi-structured interviews with staff and clients, self-administered surveys of staff and clients, client focus groups, and child developmental assessments. Findings indicate that to achieve success, programs structured on the OFR model must recruit chemically dependent women early in their pregnancies, provide mechanisms for retention, offer a continuum of treatment modalities within the service system, make available a comprehensive array of ancillary services, and be responsive to the social, cultural, and familial context within which these women live.

The real problem is not teenage pregnancy alone, but the destructive combination of single motherhood, poverty, and drug abuse. The consequences of being a poor, inner-city, single mother with an expensive drug habit may include prostitution, drug dealing, dependency upon welfare and/or extra support from an already overwhelmed family system, and neglected children. Almost inevitably, the children exhibit cognitive deficits and behavioral problems, may turn to drugs at a young age, and may have an early involvement with the criminal justice system. To design effective prevention programs it is essential to understand the myriad complex risk factors that affect the lives of these vulnerable young women. As the first stage in a larger study of motivation and readiness for change and the development of self-protective health practices, interview data were collected from 30 participants. Sixteen were residents and staff who had graduated from a drug treatment program and 14 were undergraduate and graduate students, all of whom had been pregnant as teenagers. The results yielded a surprising commonality of experiences for both groups that included childhood physical and sexual abuse, coercive adolescent sexual relationships, early first sexual contact, early first pregnancies (often as a function of rape or incest), abortions, and chemical dependency, especially during pregnancy.

The scope of interventions into social problems is based on an accurate assessment of the nature of that problem. An accurate, biased or ambiguous analysis has serious consequences for the efficacy of social interventions. This may indeed be the case with studies on the prevalence of prenatal drug use. This paper examines 23 studies conducted since 1980 and finds that the data have a number of serious methodological issues that compromise their utility in determining the breadth and characteristics of the problem.

I. Introduction As the use of illicit drugs persists as a major social problem facing urban America, the clinical evidence linking prenatal exposure to illicit drugs, in particular cocaine, and [...]

Recent reports estimate that 5 million U.S. women of childbearing age use illicit substances [1]. The effects of maternal substance abuse to both mother and child have become a major […]

This paper discusses efforts to retain resistant subjects (N = 88) in a prospective research project which investigates the effects of prenatal substance use on pregnancy and infant outcome. Resistant subjects were women for whom we had valid addresses and/or phone numbers. They did not refuse to participate but were reluctant to schedule appointments and/or keep scheduled appointments. The persistent resistance we encountered led us to develop procedures which established and maintained rapport with resistant respondents and facilitated access to the 18-month assessment. No significant differences were found between the resistant participants and nonresistant subjects on six sociodemographic factors and on substance use. However, resistant subjects were significantly more depressed than nonresistant subjects. Anxiety and hostility did not differ at any time point. Resistant subjects who were finally interviewed, reported a significantly higher number of recent life events than nonresistant subjects at the 18-month postpartum interview. The follow-up rates for retaining the 88 resistant subjects were 44.3, 72.7, and 79.6% at Phases 4, 5, and 6, respectively., INTRODUCTION Longitudinal epidemiological studies require long-term contact with large numbers of subjects. As a result, a major effort of epidemiological studies is directed toward retention of large cohorts, especially when [...]

A rising number of children exposed to cocaine in utero are substantially vulnerable to mortality and morbidity expressed in a variety of physical, cognitive, emotional, motor, and social problems. Research on developmental outcomes in such children is reviewed and the interaction of prenatal and postnatal environmental factors, with a focus on the parent-child-environment transactional system, is discussed. Related societal and treatment issues are highlighted.

Medical literature concerning drug abuse during pregnancy provides conflicting information about the long-term effects of drug exposure to the fetus while in the womb. Several studies with different research angles are discussed. Researchers still do not have an estimate for the number of drug-exposed infants born each year in the US. The best estimates are from a few locations such as New York City and Rhode Island. The immediate and long-term effects of drug exposure have been difficult to analyze since addicted pregnant women typically do not obtain prenatal care. The effect of drug abuse on fetal development also is uncertain. Researchers are investigating the effect of drugs on animal fetal development. More in-depth research is needed to determine the overall effect of drug exposure on infant development and on strategies for the treatment of drug-exposed children.

This study examined both instrumental responses and facial expressions during learning and extinction in a group of cocaine-exposed infants ages 4 to 8 months. Of the 72 infants studied, half were exposed to cocaine in utero and half served as matched controls. The groups were matched on maternal demographic characteristics and maternal use of other substances. Findings indicated that (a) infants exposed to cocaine had a significant decrease in mean birth weight and birth length; (b) cocaine-exposed infants showed less overall arousal throughout the procedure; (c) cocaine-exposed infants expressed less interest and joy during learning and less anger and sadness during extinction; and (d) when control over the learning contingency was reinstated, cocaine-exposed infants did not show the expected increase in instrumental responding.

A comparison study was made between treated and untreated pregnant and postpartum cocaine-abusing women. The untreated women were less socially impaired with fewer symptoms of psychosocial distress. Thus, severity of psychosocial distress may be an important motivating factor in enrolling in a drug treatment program. However, the lack of childcare programs and social stigma attached to substance abuse in pregnancy may prevent pregnant and postpartum women from seeking drug treatment.