INTRODUCTION
In the late 1980s, as the use of crack cocaine became an epidemic in poor areas of the United States, there was virtually no experience caring for pregnant crack users and thus virtually no programs adept at working with this population (1). In response, in the face of the growing crack epidemic, the federal Office of Substance Abuse Prevention funded programs to understand the care of pregnant and postpartum women who used drugs, with special emphasis on cocaine users. Among these programs was the Parent and Child Enrichment (PACE) Project in Harlem.
PACE funding began in 1989 through a 5-year demonstration grant; it was a collaboration among the Bureau of Maternity Services and Family Planning (BMSFP) of the New York City Department of Health (NYCDOH), Harlem Hospital Center, and Reality House. Clients were recruited into the program from BMSFP outreach, Harlem Hospital's Special Prenatal Clinic (SPNC), self-referrals to Reality House, and some rather creative outreach.
Drug treatment at PACE included two phases: orientation (6 weeks) and therapy. Orientation allowed the stabilization of the client's life before she began to address her treatment issues and helped her feel comfortable trusting the staff and other clients in this new environment.
Drug treatment plans were tailored to the clients' needs and were coordinated by the obstetrician, the drug treatment counselor, and the nurse. Clients were also encouraged to participate in Narcotics Anonymous (NA) meetings at Reality House. Urine toxicologies were obtained three times a week (two scheduled and one unscheduled), but clients were not discharged from treatment for positive urine toxicologies. Rather, they were counseled and encouraged to stay in treatment and discontinue drug use.
On-site services included admission physical examinations; prenatal, postpartum, and pediatric care; group and individual counseling; nutritional assessments; on-site enrollment for Women, Infants, and Children (WIC) food supplementation services; psychosocial assessments; parenting education; high school equivalency classes; vocational preparation and counseling; and linkage to--as well as advocacy within--social services (including Medicaid, child welfare, legal services, emergency housing assistance, and BMSFP Home Visitation Program). Clients were referred to Harlem Hospital Center for delivery, as well as for specialty and inpatient care.
Project staff included a coordinator, an intake worker, two drug treatment counselors, a social worker, a parent educator, a part-time child care worker, and a nutritionist. Medical staff included a full-time nurse, a part-time pediatrician, and a part-time nurse midwife.
When PACE opened in October 1990, clients were expected to be present Monday through Friday from 9 A.M. to 5 P.M. Clients' other needs (pursuing social service referrals, securing housing, and obtaining child custody) soon led to the loosening of these rules. Eventually, women in PACE were permitted to come in 3 to 4 days a week. Such a flexible schedule improved retention in the program without encouraging relapses into drug use.
From October 1990 to March 1994, 192 women enrolled in PACE. Client age averaged 29 years (range 19-44 years); 80% were African-American, 13% Hispanic, and 5% white. The mean total length of stay (TLOS) was 100.0 days (median 55.5 days); mean pregnancy length of stay (PLOS) was 48 days, and mean postpartum length of stay (PPLOS) was 56 days. Of the 186 women for whom intake forms were available, 101 (54.3%) were still in PACE 42 days after intake. Most women (84%) entered while pregnant (60% after their first trimester); 16% entered postpartum. Most clients lived near PACE in northern Manhattan (63%) or the Bronx (23%).
PACE was set up to provide comprehensive, woman-centered, and family-oriented services, an approach that was, and still is, recommended by drug treatment proponents (2-5). Provision of comprehensive services for women and their families is cost effective compared to incarceration, foster care, and tertiary medical care (6, 7). Studies have documented an association between substance abuse and adverse birth outcomes, including decreased birth weight and shortened gestation (8-11).
It has been difficult for researchers to assess the impact of women's substance abuse treatment on birth outcomes due to confounding medical and sociodemographic factors, as well as inaccessibility of birth records. The collaboration with the NYCDOH in implementing and evaluating PACE facilitated access to birth certificate data. One study within a comprehensive program for pregnant substance-using women also found that treatment patients had better birth outcomes (higher birth weight and gestational age) compared to the nontreatment group (those who refused treatment) (7).
PACE's early years were described by La France et al. (12). This article describes qualitative and quantitative results of the final evaluation.
METHODS
Length of stay was determined using the intake form, discharge form, and activity logbook databases. Because of the 6-week orientation program, clients who stayed in the program for 42 days or more during pregnancy were categorized as long-stay clients; those who stayed for less than 42 days were categorized as short-stay clients.
Urine toxicology results were entered directly from a logbook into a database, enabling comparison of long-stay and short-stay clients. Clients were also dichotomized into high/low categories for service utilization in order to study the relationship between service utilization and positive urine drug tests (UDTs).
PACE was not set up with a comparison group. In retrospect, we created three comparison groups. The long-stay clients' live births were compared to (a) the PACE short-stay clients' live births (internal comparison), (b) 1991-1993 cocaine-positive live births in the Central Harlem Health District, and (c) 1991-1993 Harlem Hospital Center Special Prenatal Clinic live births.
We used the following data collection instruments: urine toxicology database, activity database, intake forms, discharge forms, Problem Oriented Perinatal Risk Assessment System (POPRAS) forms, PACE clinical charts, and PACE medical charts. Of the 192 clients, 130 had urine toxicology results entered into the urine database, and 163 had POPRAS data. The activity database was incomplete because about 9 months of activity sheets could not be located. The clinical and medical charts verified information in the intake, discharge, POPRAS, and activity databases and provided data not entered contemporaneously into databases.
SAS software (SAS Institute, Inc., Cary, NC) was used to do univariate analysis of demographic and birth outcome variables for PACE clients and comparison groups. To analyze and compare differences in the means of continuous variables from New York City birth certificate data, t tests were used. Proportional differences for variables associated with birth outcome were examined via chi-square tests. Also utilizing SAS software, frequencies, means, and medians were calculated for the drug use analyses. Yates corrected chi-square tests were used to test statistical significance. The qualitative methodology consisted mostly of interviews with participants and staff.
RESULTS
Qualitative: Lessons Learned
The following are some of the more important qualitative findings of this project.
1. Development of a female model of drug treatment. Drug treatment has evolved from authoritarian programs for male heroin users. Women (particularly pregnant women), however, often come to drug treatment for different reasons, have different reasons for staying in treatment, and have different needs than men (13).
PACE's clients often came to treatment so that they could be drug free at birth and retain custody of the infant after birth. They often stayed to regain custody of older children as their lives became less disorganized. Moreover, many women needed help dealing with their complex and powerful feelings about their roles as women, mothers, and partners. As other studies have found (14), many clients also had extremely low self-esteem, a condition often associated with having been abused during childhood. Being female, pregnant, and a substance user, then, made for a fragile population despite individuals' overt toughness.
