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California Essentials for Childhood Initiative (CA)

The California Essentials for Childhood Initiative uses a public health and collective impact approach to align and enhance collaborative efforts to promote safe, stable, nurturing relationships and environments for children, youth and families through systems, policy and social norms change.

A community-based approach to supporting substance exposed newborns and their families

 

Massachusetts Essentials for Childhood (MA EfC) is excited to present "The Elements of an Effective Plan of Safe Care." This information brief highlights a community-based approach to supporting families and newborns affected by substance use. MA EfC developed this brief to address the profound intersection between the Massachusetts opioid crisis, Federal mandates for the development of Plans of Safe Care for substance exposed newborns, and, the MA EfC focus on increasing social connectedness as a means to reduce child maltreatment.Plan of Safe Care

This brief identifies key elements of an effective community-based approach to caring for substance exposed newborns and their families. It builds from the work of the Franklin County (MA) Perinatal Support Coalition and their EMPOWER Program, including their Pregnancy Plan tool.

pregnancy plan

The brief includes video footage of conversations among Coalition members about the EMPOWER Program. Listening in on these video-taped conversations provides insights into how a community can create a community-wide strategy to support the well-being and safety of substance exposed newborns, and how partnerships between diverse providers, including treatment providers, state agencies and hospitals can build linkages that meet families where they are. The elements are:

  1. Access to a continuum of care
  2. Collaboration across providers within the community
  3. Peer coaching

  4. Holistic support, and
  5. A priority on family unity whenever possible.

While federal law does not require a Plan of Safe Care until the child is born, the Massachusetts Essentials for Childhood Initiative believes EMPOWER is particularly effective because it gets a plan in place before the child is born. The work of the EMPOWER program demonstrates a well-conceived, well-run, community-supported plan. EMPOWER engages with pregnant and parenting women to support families with newborns affected by substance use and to keep as many newborns safely at home with their families as possible. Research indicates that, when possible, keeping children at home supports vital bonding between mothers, newborns and family members and reduces child maltreatment. Further, separating infants from their birth parent contributes to poor outcomes for both the parent and infant including relapse for women; and poor attachment and failure to thrive for infants. The elements outlined build social connectedness, particularly of the mother, through building formal and informal networks and reducing social isolation.

The MA EfC Initiative is funded by a grant from the Center for Disease Control and Prevention (CDC). The reduction of child maltreatment through increasing economic supports and community social connectedness is at the center of the work of the Initiative. Other recent work includes an information brief on the benefits to children of Paid Family and Medical Leave (in MA), and, a video on the importance of social connectedness for families. 

PFML
Current work focuses on increasing access to earned income tax credits (EITC) through supporting VITA sites in health care settings, monitoring access to and uptake of Massachusetts’ new paid family and medical leave benefit, as well as the development of a Tool-Kit for Municipalities to build social connectedness.

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Such a complex conversation...  

This is an area of passion for me - having worked with high-risk perinatal population for many years, conducted focus group interviews with women who were "clean" and in a treatment program - and heard first hand how and why they became pregnant while using - I was always surprised what they shared, and came to realize my assumptions were not accurate. 

I would urge the group to seek opportunities to work further upstream focusing on "preconception" or "interconception" care as an effective way to increase "wanted" pregnancies and to reduce substance exposed pregnancies and births. The attached ASTHO report describes our efforts in Sonoma County (CA) to reduce unintended pregnancies. 

Often the women in the focus groups shared that often pregnancy related services felt unsafe  (they may be safe, but not feel safe) women stay away.  Many women said they thought each time they gave a urine sample - it was a drug test, not realizing it was a routine urine test for proteins etc. So if they were using they really wanted to avoid prenatal care. A Nobel Prize winning economists demonstrates the earlier in pregnancy women get into care the greater ROI.  See attached Heckman Curve.

Locally (in Sonoma County CA), we had some one of the highest tox positive rates in the state (not what we expected) and highest binge drinking rates among women of reproductive age. With support from the CDC, WHO and others, we developed an integrated (substance use, mood disorder, IPV) screening tool to ensure would not miss opportunities to screen. *One of our unexpected findings (N=5K+) was how significantly the risk ratio increased for pregnant women who answered "yes" to the question regarding if their parents had substance use problems. See page 10 of the attached PSEP Report. And see the attached PPT deck. 

One additional note, we often look at prescription and illicit drugs when thinking about perinatal substance use. However, the impact of alcohol on the developing brain is devastating. See attached FASD brain for graphic. Living in "wine country" this was a significant consideration. 

At the state level, the California CDPH Preconception Health Council has done tremendous work to reduce mis-timed pregnancies (this doesn't mean they were not wanted, but the timing was not optimal). This is the website they developed: Every Woman California:

Every Woman California is an initiative working with individuals, health care providers and communities to improve the physical, emotional and social well-being of women during the years in which they can become pregnant, to ensure the health of current and future generations.

One tool that may be of interest is their Reproductive Life Planning tool in (English & Spanish) which patients and providers use to discuss the patient's life goals, including optimal pregnancy timing and contraception needs etc. 

In CA over 50% of pregnancies that are carried to term, were mis-timed. Even the most well meaning woman can have a substance exposed pregnancy, if she doesn't know she is pregnant. Please see the fetal development graphics that show how many weeks a women is pregnant, before she misses her period - if she is regular. Many women with complex lives, using etc, often have irregular periods - so this very high risk population often becomes aware of their they are pregnant much later. 

Below are a few more articles that may help inform your important work. Please let me know if you'd like further information. Many thanks for allowing me to weigh in, Karen Clemmer

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464612/  
for every increase in childhood adverse event endorsed, the risk of preterm birth increased by 18 %. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4849279/ 
Each additional ACE decreased birth weight by 16.33 g and decreased gestational age by 0.063.

UCSF FHOP pdf Maternal adverse childhood experiences confer vulnerability to prenatal, perinatal, and postnatal psychosocial health. 

https://pediatrics.aappublicat...tent/141/4/e20172495 Maternal health risk in pregnancy indirectly confers risk from maternal ACEs to child development outcomes at 12 months of age through infant health risk.

https://pediatrics.aappublicat...tent/141/4/e20180232 Maternal adversity, regardless of economic or educational attainment, needs to be asked about and addressed. The scars of adversity are carried from 1 generation to the next and have been shown to impact parenting and subsequent child development. These findings are not isolated.

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Last edited by Karen Clemmer (ACEs Connection Staff)
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