CHILD GUARDIANSHIP IN A CANADIAN HOME VISITATION PROGRAM FOR WOMEN WHO USE SUBSTANCES IN THE PERINATAL PERIOD
Main Article Content
Keywords
Pregnancy, child welfare, substance-related disorders, prenatal exposure delayed effects
Abstract
Background
Retaining guardianship of one’s infant is often a priority for pregnant women who use substances, and may be beneficial to infants when they are safe in their mothers’ care. Previous studies from the United States have identified several maternal psychosocial characteristics associated with the ability to keep an infant free from abuse or neglect; however, little is known about the impact of multiple risk factors on guardianship, particularly in Canadian intervention programs.
Objective
To describe maternal characteristics associated with child guardianship among pregnant women at risk of an alcohol and/or substance exposed pregnancy who attended a Canadian home visitation program.
Methods
Guardianship status at 6 months post-enrolment was extracted from a provincial program’s records for all women enrolled between November 1999 and May 2005 (n=64). Bivariate analyses were performed to determine client characteristics most likely to have retained guardianship.
Results
At follow-up, 70% of participants were guardians of the index infant. Higher income, more prenatal care, no history of sexual abuse, better alcohol and psychiatric scores, and fewer risk factors on a cumulative risk index were significantly associated with retaining guardianship at 6 month follow-up (p<0.05).
Conclusions
Retaining child guardianship may be the greatest challenge and opportunity for women experiencing problems in multiple domains of their lives, including those associated with substance dependence. Programs targeted at women who use substances while pregnant may best assist mothers to retain guardianship of their infants by supporting clients to address the complex social and health problems often found in conjunction with addictions.
References
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9. Ernst CC, Grant TM, Streissguth AP, Sampson PD. Intervention with high-risk alcohol and drug-abusing mothers: II. Three-year findings from the Seattle model of paraprofessional advocacy. Journal of Community Psychology 1999; 27(1):19-38.
10. Daley M, Argeriou M, McCarty D, Callahan JJ, Jr., Shepard DS, Williams CN. The costs of crime and the benefits of substance abuse treatment for pregnant women. J Subst Abuse Treat 2000; 19(4):445-458.
11. Black MM, Nair P, Kight C, Wachtel R, Roby P, Schuler M. Parenting and early development among children of drug-abusing women: Effects of home intervention. Pediatrics 1994; 94(4):440-448.
12. Schuler ME, Nair P, Kettinger L. Drug-exposed infants and developmental outcome: Effects of a home intervention and ongoing maternal drug use. Arch Pediatr Adolesc Med 2003; 157(2):133-138.
13. Grant TM, Ernst CC, Streissguth A, Stark K. Preventing alcohol and drug exposed births in Washington State: Intervention findings from three Parent-Child Assistance Program sites. Am J Drug Alcohol Abuse 2005; 31(3):471-490.
14. Jansson LM, Svikis D, Lee J, Paluzzi P, Rutigliano P, Hackerman F. Pregnancy and addiction. A comprehensive care model. J Subst Abuse Treat 1996; 13(4):321-329.
15. Comfort M, Kaltenbach KA. Predictors of treatment outcomes for substance-abusing women: A retrospective study. Subst Abus 2000; 21(1):33-45.
16. Kissin WB, Svikis DS, Morgan GD, Haug NA. Characterizing pregnant drug-dependent women in treatment and their children. J Subst Abuse Treat 2001; 21(1):27-34.
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18. Bell K, Cramer-Benjamin D, Anastas J. Predicting length of stay of substance-using pregnant and postpartum women in day treatment. J Subst Abuse Treat 1997; 14(4):393- 400.
19. Badry DE. Becoming a Birth Mother of a Child with Fetal Alcohol Syndrome [Doctoral dissertation]. Calgary: University of Calgary; 2008.
20. Wolock I, Magura S. Parental substance abuse as a predictor of child maltreatment re-reports. Child Abuse Negl 1996; 20(12):1183-1193.
21. Leventhal JM, Forsyth BW, Qi K, Johnson L, Schroeder D, Votto N. Maltreatment of children born to women who used cocaine during pregnancy: A population-based study. Pediatrics 1997; 100(2):E7.
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25. Byrd RS, Neistadt AM, Howard CR, Brownstein-Evans C, Weitzman M. Why screen newborns for cocaine: Service patterns and social outcomes at age one year. Child Abuse Negl 1999; 23(6):523-530.
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27. Neuspiel DR, Zingman TM, Templeton VH, DiStabile P, Drucker E. Custody of cocaineexposed newborns: Determinants of discharge decisions. Am J Public Health 1993; 83(12):1726-1729.
28. Tyler R, Howard J, Espinosa M, Doakes SS. Placement with substance-abusing mothers vs. placement with other relatives: Infant outcomes. Child Abuse Negl 1997; 21(4):337-349.
29. Nair P, Black MM, Schuler M, Keane V, Snow L, Rigney BA et al. Risk factors for disruption in primary caregiving among infants of substance abusing women. Child Abuse Negl 1997; 21(11):1039-1051.
30. Minnes S, Singer LT, Humphrey-Wall R, Satayathum S. Psychosocial and behavioral factors related to the post-partum placements of infants born to cocaine-using women. Child Abuse Negl 2008; 32(3):353-366.
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32. Marcellus L. Critical social and medical constructions of perinatal substance misuse: Truth in the making. Journal of Family Nursing 2003; 9(4):438.
33. Nishimoto RH, Roberts AC. Coercion and drug treatment for postpartum women. Am J Drug Alcohol Abuse 2001; 27(1):161-181.
34. Kearney MH. Damned if you do, damned if you don't: Crack cocaine users and prenatal care. Contemporary Drug Problems 1995; 22(4):639- 662.
35. Roberts LW, Dunn LB. Ethical considerations in caring for women with substance use disorders. Obstet Gynecol Clin North Am 2003; 30(3):559- 582.
36. Howell EM, Chasnoff IJ. Perinatal substance abuse treatment: Findings from focus groups with clients and providers. J Subst Abuse Treat 1999; 17(1-2):139-148.
37. Government of Alberta. Child, Youth and Family Enhancement Act. C-12, s2. 2004. http://www.qp.gov.ab.ca/documents/Acts/c12.cf m?frm_isbn=9780779726325 (June 25, 2008).
38. Baker PL, Carson A. "I take care of my kids": Mothering practices of substance-abusing women. Gender & Society 1999; 13:347-363.
39. Arlettaz R, Kashiwagi M, Das-Kundu S, Fauchere JC, Lang A, Bucher HU. Methadone maintenance program in pregnancy in a Swiss perinatal center (II): neonatal outcome and social resources. Acta Obstet Gynecol Scand 2005; 84(2):145-150.
40. Jaudes PK, Ekwo E, Van VJ. Association of drug abuse and child abuse. Child Abuse Negl 1995; 19(9):1065-1075.
41. Nair P, Schuler ME, Black MM, Kettinger L, Harrington D. Cumulative environmental risk in substance abusing women: Early intervention, parenting stress, child abuse potential and child development. Child Abuse Negl 2003; 27(9):997-1017.
42. Grant TM, Ernst CC, Streissguth AP. Intervention with high-risk alcohol and drugabusing mothers: I. Administrative strategies of the Seattle model of paraprofessional advocacy. Journal of Community Psychology 1999; 27(1):33-45.
43. Schuler ME, Nair P, Black MM, Kettinger L. Mother-infant interaction: Effects of a home intervention and ongoing maternal drug use. J Clin Child Psychol 2000; 29(3):424-431.
44. Grant TM, Ernst CC, Pagalilauan G, Streissguth AP. Postprogram follow-up: Effects of paraprofessional intervention with high-risk women who abused alcohol and drugs during pregnancy. Journal of Community Psychology 2003; 31(3):211-222.
45. Umlah C, Grant TM. Intervening to prevent prenatal alcohol and drug exposure: The Manitoban experience in replicating a paraprofessional model. Envision: The Manitoba Journal of Child Welfare 2003; 2(1):1-12.
46. Dakof GA, Quille TJ, Tejeda MJ, Alberga LR, Bandstra E, Szapocznik J. Enrolling and retaining mothers of substance-exposed infants in drug abuse treatment. J Consult Clin Psychol 2003; 71(4):764-772.
47. Olds DL, Robinson J, Pettitt L, Luckey DW, Holmberg J, Ng RK et al. Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics 2004; 114(6):1560-1568.
48. Tough SC, Johnston DW, Siever JE, Jorgenson G, Slocombe L, Lane C et al. Does supplementary prenatal nursing and home visitation support improve resource use in a universal health care system? A randomized controlled trial in Canada. Birth 2006; 33(3):183-194.
49. Gomby DS. Promise and limitations of home visitation. JAMA 2000; 284(11):1430-1431.
50. Doggett C, Burrett S, Osborn DA. Home visits during pregnancy and after birth for women with an alcohol or drug problem. Cochrane Database Syst Rev 2005;(4):CD004456.
51. Mathews B, Kenny MC. Mandatory reporting legislation in the United States, Canada, and Australia: A cross-jurisdictional review of key features, differences, and issues. Child Maltreat 2008; 13(1):50-63.
52. Badry D, Trute B, Benzies K, Tough SC, Holmes E. The Addiction Severity Index: A Feasibility Study Examining the Scientific Quality and Research Utility of Data Gathered in Three Alberta Sites. Public Health Agency of Canada. 2006.
53. McLellan AT, Luborsky L, Woody GE, O'Brien CP. An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. J Nerv Ment Dis 1980; 168(1):26-33.
54. McLellan AT, Kushner H, Metzger D, Peters R, Smith I, Grissom G et al. The Fifth Edition of the Addiction Severity Index. J Subst Abuse Treat 1992; 9(3):199-213.
55. Treatment Research Institute. Addiction Severity Index: Composite scores manual (1986) http://www.tresearch.org/resources/compscores/ CompositeManual.pdf Washington, D.C. (June 25, 2008).
56. Parent-Child Assistance Program. Addiction Severity Index: University of Washington modification for pregnant & postpartum women. 2004. Seattle, Fetal Alcohol & Drug Unit.
57. Parent-Child Assistance Program. Biannual documentation of client progress. (2004) http://www.depts.washington.edu/pcapuw/ Seattle, Fetal Alcohol & Drug Unit (March 27, 2007).
58. SPSS 14.0. SPSS, Inc. Chicago, IL: 2005.
59. Bender R, Lange S. Adjusting for multiple testing--when and how? J Clin Epidemiol 2001; 54(4):343-349.
60. Rothman KJ. No adjustments are needed for multiple comparisons. Epidemiology 1990; 1(1):43-46.
61. STATA 10. StataCorp, LP. College Station, TX: 2008.
62. Motz M, Leslie M, Pepler DJ, Moore TE, Freeman PA. Breaking the Cycle: Measures of progress, 1996-2005. JFAS Int 2006;4(22).
63. Scannapieco M, Carrick KC. Families in poverty: Those who maltreat their infants and toddlers and those who do not. Journal of Family Social Work 2003; 7(3):49-70.
64. Shook K. Does the loss of welfare income increase the risk of involvement with the child welfare system? Children and Youth Services Review 1999; 21(9/10):782-814.
65. Éthier LS, Lacharite C, Couture G. Childhood adversity, parental stress, and depression of negligent mothers. Child Abuse Negl 1995; 19(5):619-632.
66. Morton N, Browne KD. Theory and observation of attachment and its relation to child maltreatment: A review. Child Abuse Negl 1998; 22(11):1093-1104.
67. Tough SC, Siever JE, Johnston DW, Clarke D. Resiliency in the midst of risk: Retention of women with limited resources in prenatal care. Expert Review in Obstetrics and Gyneocology 2007; 2(5):631-639.
68. Schuurmans N, Gagne G-P, Ezzat A, Colliton I, MacKinnon CJ, Bushinski B et al. Healthy Beginnings: Guidelines for Care During Pregnancy and Childbirth. Lalonde AB, Kinch RAH, editors. 71. 1998. Ottawa, ON, SOGC. SOGC Clinical Practice Guidelines.
69. Howard J, Beckwith L. Issues in subject recruitment and retention with pregnant and parenting substance-abusing women. In: Rahdert ER, editor. Treatment for Drug-Exposed Women and Children: Advances in Research Methods. Rockville MD: National Institute on Drug Abuse; 1996. 68-86.
2. Astley SJ, Bailey D, Talbot C, Clarren SK. Fetal alcohol syndrome (FAS) primary prevention through FAS diagnosis: I. Identification of highrisk birth mothers through the diagnosis of their children. Alcohol Alcohol 2000; 35(5):499-508.
3. Hankin J, McCaul ME, Heussner J. Pregnant, alcohol-abusing women. Alcohol Clin Exp Res 2000; 24(8):1276-1286.
4. Premji S, Serrett K, Benzies K, Hayden KA. Interventions for children and youth with a Fetal Alcohol Spectrum Disorder (FASD). 2004. Alberta Centre for Child, Family & Community Research.
5. Jacobson JL, Jacobson SW. Effects of prenatal alcohol exposure on child development. Alcohol Res Health 2002; 26(4):282-286.
6. Streissguth AP. Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: P.H. Brookes, 1997.
7. Hans SL. Studies of prenatal exposure to drugs: Focusing on parental care of children. Neurotoxicol Teratol 2002; 24(3):329-337.
8. Astley SJ, Bailey D, Talbot C, Clarren SK. Fetal Alcohol Syndrome (FAS) primary prevention through FAS diagnosis: II. A comprehensive profile of 80 birth mothers of children with FAS. Alcohol Alcohol 2000; 35(5):509-519.
9. Ernst CC, Grant TM, Streissguth AP, Sampson PD. Intervention with high-risk alcohol and drug-abusing mothers: II. Three-year findings from the Seattle model of paraprofessional advocacy. Journal of Community Psychology 1999; 27(1):19-38.
10. Daley M, Argeriou M, McCarty D, Callahan JJ, Jr., Shepard DS, Williams CN. The costs of crime and the benefits of substance abuse treatment for pregnant women. J Subst Abuse Treat 2000; 19(4):445-458.
11. Black MM, Nair P, Kight C, Wachtel R, Roby P, Schuler M. Parenting and early development among children of drug-abusing women: Effects of home intervention. Pediatrics 1994; 94(4):440-448.
12. Schuler ME, Nair P, Kettinger L. Drug-exposed infants and developmental outcome: Effects of a home intervention and ongoing maternal drug use. Arch Pediatr Adolesc Med 2003; 157(2):133-138.
13. Grant TM, Ernst CC, Streissguth A, Stark K. Preventing alcohol and drug exposed births in Washington State: Intervention findings from three Parent-Child Assistance Program sites. Am J Drug Alcohol Abuse 2005; 31(3):471-490.
14. Jansson LM, Svikis D, Lee J, Paluzzi P, Rutigliano P, Hackerman F. Pregnancy and addiction. A comprehensive care model. J Subst Abuse Treat 1996; 13(4):321-329.
15. Comfort M, Kaltenbach KA. Predictors of treatment outcomes for substance-abusing women: A retrospective study. Subst Abus 2000; 21(1):33-45.
16. Kissin WB, Svikis DS, Morgan GD, Haug NA. Characterizing pregnant drug-dependent women in treatment and their children. J Subst Abuse Treat 2001; 21(1):27-34.
17. Ingersoll KS, Knisely JS, Dawson KS, Schnoll SH. Psychopathology and treatment outcome of drug dependent women in a perinatal program. Addict Behav 2004; 29(4):731-741.
18. Bell K, Cramer-Benjamin D, Anastas J. Predicting length of stay of substance-using pregnant and postpartum women in day treatment. J Subst Abuse Treat 1997; 14(4):393- 400.
19. Badry DE. Becoming a Birth Mother of a Child with Fetal Alcohol Syndrome [Doctoral dissertation]. Calgary: University of Calgary; 2008.
20. Wolock I, Magura S. Parental substance abuse as a predictor of child maltreatment re-reports. Child Abuse Negl 1996; 20(12):1183-1193.
21. Leventhal JM, Forsyth BW, Qi K, Johnson L, Schroeder D, Votto N. Maltreatment of children born to women who used cocaine during pregnancy: A population-based study. Pediatrics 1997; 100(2):E7.
22. Smith DK, Johnson AB, Pears KC, Fisher PA, DeGarmo DS. Child maltreatment and foster care: Unpacking the effects of prenatal and postnatal parental substance use. Child Maltreat 2007; 12(2):150-160.
23. Walsh C, MacMillan HL, Jamieson E. The relationship between parental substance abuse and child maltreatment: Findings from the Ontario Health Supplement. Child Abuse Negl 2003; 27(12):1409-1425.
24. Bada HS, Langer J, Twomey J, Bursi C, Lagasse L, Bauer CR et al. Importance of stability of early living arrangements on behavior outcomes of children with and without prenatal drug exposure. J Dev Behav Pediatr 2008.
25. Byrd RS, Neistadt AM, Howard CR, Brownstein-Evans C, Weitzman M. Why screen newborns for cocaine: Service patterns and social outcomes at age one year. Child Abuse Negl 1999; 23(6):523-530.
26. Mullins SM, Bard DE, Ondersma SJ. Comprehensive services for mothers of drugexposed infants: Relations between program participation and subsequent child protective services reports. Child Maltreat 2005; 10(1):72- 81.
27. Neuspiel DR, Zingman TM, Templeton VH, DiStabile P, Drucker E. Custody of cocaineexposed newborns: Determinants of discharge decisions. Am J Public Health 1993; 83(12):1726-1729.
28. Tyler R, Howard J, Espinosa M, Doakes SS. Placement with substance-abusing mothers vs. placement with other relatives: Infant outcomes. Child Abuse Negl 1997; 21(4):337-349.
29. Nair P, Black MM, Schuler M, Keane V, Snow L, Rigney BA et al. Risk factors for disruption in primary caregiving among infants of substance abusing women. Child Abuse Negl 1997; 21(11):1039-1051.
30. Minnes S, Singer LT, Humphrey-Wall R, Satayathum S. Psychosocial and behavioral factors related to the post-partum placements of infants born to cocaine-using women. Child Abuse Negl 2008; 32(3):353-366.
31. Badry D, Pelech W, Norman D. Fetal Alcohol Spectrum Disorder Practice Standards Evaluation Project. (October 31, 2005) http://www.fasdconnections.ca/id112.htm Calgary, Alberta Children's Services (June 25, 2008).
32. Marcellus L. Critical social and medical constructions of perinatal substance misuse: Truth in the making. Journal of Family Nursing 2003; 9(4):438.
33. Nishimoto RH, Roberts AC. Coercion and drug treatment for postpartum women. Am J Drug Alcohol Abuse 2001; 27(1):161-181.
34. Kearney MH. Damned if you do, damned if you don't: Crack cocaine users and prenatal care. Contemporary Drug Problems 1995; 22(4):639- 662.
35. Roberts LW, Dunn LB. Ethical considerations in caring for women with substance use disorders. Obstet Gynecol Clin North Am 2003; 30(3):559- 582.
36. Howell EM, Chasnoff IJ. Perinatal substance abuse treatment: Findings from focus groups with clients and providers. J Subst Abuse Treat 1999; 17(1-2):139-148.
37. Government of Alberta. Child, Youth and Family Enhancement Act. C-12, s2. 2004. http://www.qp.gov.ab.ca/documents/Acts/c12.cf m?frm_isbn=9780779726325 (June 25, 2008).
38. Baker PL, Carson A. "I take care of my kids": Mothering practices of substance-abusing women. Gender & Society 1999; 13:347-363.
39. Arlettaz R, Kashiwagi M, Das-Kundu S, Fauchere JC, Lang A, Bucher HU. Methadone maintenance program in pregnancy in a Swiss perinatal center (II): neonatal outcome and social resources. Acta Obstet Gynecol Scand 2005; 84(2):145-150.
40. Jaudes PK, Ekwo E, Van VJ. Association of drug abuse and child abuse. Child Abuse Negl 1995; 19(9):1065-1075.
41. Nair P, Schuler ME, Black MM, Kettinger L, Harrington D. Cumulative environmental risk in substance abusing women: Early intervention, parenting stress, child abuse potential and child development. Child Abuse Negl 2003; 27(9):997-1017.
42. Grant TM, Ernst CC, Streissguth AP. Intervention with high-risk alcohol and drugabusing mothers: I. Administrative strategies of the Seattle model of paraprofessional advocacy. Journal of Community Psychology 1999; 27(1):33-45.
43. Schuler ME, Nair P, Black MM, Kettinger L. Mother-infant interaction: Effects of a home intervention and ongoing maternal drug use. J Clin Child Psychol 2000; 29(3):424-431.
44. Grant TM, Ernst CC, Pagalilauan G, Streissguth AP. Postprogram follow-up: Effects of paraprofessional intervention with high-risk women who abused alcohol and drugs during pregnancy. Journal of Community Psychology 2003; 31(3):211-222.
45. Umlah C, Grant TM. Intervening to prevent prenatal alcohol and drug exposure: The Manitoban experience in replicating a paraprofessional model. Envision: The Manitoba Journal of Child Welfare 2003; 2(1):1-12.
46. Dakof GA, Quille TJ, Tejeda MJ, Alberga LR, Bandstra E, Szapocznik J. Enrolling and retaining mothers of substance-exposed infants in drug abuse treatment. J Consult Clin Psychol 2003; 71(4):764-772.
47. Olds DL, Robinson J, Pettitt L, Luckey DW, Holmberg J, Ng RK et al. Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics 2004; 114(6):1560-1568.
48. Tough SC, Johnston DW, Siever JE, Jorgenson G, Slocombe L, Lane C et al. Does supplementary prenatal nursing and home visitation support improve resource use in a universal health care system? A randomized controlled trial in Canada. Birth 2006; 33(3):183-194.
49. Gomby DS. Promise and limitations of home visitation. JAMA 2000; 284(11):1430-1431.
50. Doggett C, Burrett S, Osborn DA. Home visits during pregnancy and after birth for women with an alcohol or drug problem. Cochrane Database Syst Rev 2005;(4):CD004456.
51. Mathews B, Kenny MC. Mandatory reporting legislation in the United States, Canada, and Australia: A cross-jurisdictional review of key features, differences, and issues. Child Maltreat 2008; 13(1):50-63.
52. Badry D, Trute B, Benzies K, Tough SC, Holmes E. The Addiction Severity Index: A Feasibility Study Examining the Scientific Quality and Research Utility of Data Gathered in Three Alberta Sites. Public Health Agency of Canada. 2006.
53. McLellan AT, Luborsky L, Woody GE, O'Brien CP. An improved diagnostic evaluation instrument for substance abuse patients: The Addiction Severity Index. J Nerv Ment Dis 1980; 168(1):26-33.
54. McLellan AT, Kushner H, Metzger D, Peters R, Smith I, Grissom G et al. The Fifth Edition of the Addiction Severity Index. J Subst Abuse Treat 1992; 9(3):199-213.
55. Treatment Research Institute. Addiction Severity Index: Composite scores manual (1986) http://www.tresearch.org/resources/compscores/ CompositeManual.pdf Washington, D.C. (June 25, 2008).
56. Parent-Child Assistance Program. Addiction Severity Index: University of Washington modification for pregnant & postpartum women. 2004. Seattle, Fetal Alcohol & Drug Unit.
57. Parent-Child Assistance Program. Biannual documentation of client progress. (2004) http://www.depts.washington.edu/pcapuw/ Seattle, Fetal Alcohol & Drug Unit (March 27, 2007).
58. SPSS 14.0. SPSS, Inc. Chicago, IL: 2005.
59. Bender R, Lange S. Adjusting for multiple testing--when and how? J Clin Epidemiol 2001; 54(4):343-349.
60. Rothman KJ. No adjustments are needed for multiple comparisons. Epidemiology 1990; 1(1):43-46.
61. STATA 10. StataCorp, LP. College Station, TX: 2008.
62. Motz M, Leslie M, Pepler DJ, Moore TE, Freeman PA. Breaking the Cycle: Measures of progress, 1996-2005. JFAS Int 2006;4(22).
63. Scannapieco M, Carrick KC. Families in poverty: Those who maltreat their infants and toddlers and those who do not. Journal of Family Social Work 2003; 7(3):49-70.
64. Shook K. Does the loss of welfare income increase the risk of involvement with the child welfare system? Children and Youth Services Review 1999; 21(9/10):782-814.
65. Éthier LS, Lacharite C, Couture G. Childhood adversity, parental stress, and depression of negligent mothers. Child Abuse Negl 1995; 19(5):619-632.
66. Morton N, Browne KD. Theory and observation of attachment and its relation to child maltreatment: A review. Child Abuse Negl 1998; 22(11):1093-1104.
67. Tough SC, Siever JE, Johnston DW, Clarke D. Resiliency in the midst of risk: Retention of women with limited resources in prenatal care. Expert Review in Obstetrics and Gyneocology 2007; 2(5):631-639.
68. Schuurmans N, Gagne G-P, Ezzat A, Colliton I, MacKinnon CJ, Bushinski B et al. Healthy Beginnings: Guidelines for Care During Pregnancy and Childbirth. Lalonde AB, Kinch RAH, editors. 71. 1998. Ottawa, ON, SOGC. SOGC Clinical Practice Guidelines.
69. Howard J, Beckwith L. Issues in subject recruitment and retention with pregnant and parenting substance-abusing women. In: Rahdert ER, editor. Treatment for Drug-Exposed Women and Children: Advances in Research Methods. Rockville MD: National Institute on Drug Abuse; 1996. 68-86.