Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions

Mishka Terplan; Shaalini Ramanadhan; Abigail Locke; Nyaradzo Longinaker; Steve Lui

doi:10.1002/14651858.CD006037.pub3

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Figure 1

Study flow diagram.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 4

Forest plot of comparison: 1 Neonatal outcomes any psychosocial intervention vs. control, outcome: 1.5 Mean days hospitalized after delivery.

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Figure 5

Forest plot of comparison: 2 CM vs. control, outcome: 3.1 Retention in treatment at the end of study.

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Analysis 1.1

Comparison 1 Any psychosocial intervention vs. control: neonatal outcomes, Outcome 1 Preterm birth (< 37 weeks gestation).

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Analysis 1.2

Comparison 1 Any psychosocial intervention vs. control: neonatal outcomes, Outcome 2 Positive neonatal toxicology at delivery (any drug).

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Analysis 1.3

Comparison 1 Any psychosocial intervention vs. control: neonatal outcomes, Outcome 3 Low birth weight (< 2500 g).

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Analysis 1.4

Comparison 1 Any psychosocial intervention vs. control: neonatal outcomes, Outcome 4 Days hospitalized after delivery.

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Analysis 2.1

Comparison 2 Any psychosocial intervention vs. control: maternal outcomes, Outcome 1 Positive urine drug test (end of treatment).

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Analysis 2.2

Comparison 2 Any psychosocial intervention vs. control: maternal outcomes, Outcome 2 Positive urine at 1 month+.

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Analysis 2.3

Comparison 2 Any psychosocial intervention vs. control: maternal outcomes, Outcome 3 Positive urine at delivery.

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Analysis 2.4

Comparison 2 Any psychosocial intervention vs. control: maternal outcomes, Outcome 4 Retention at treatment completion.

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Analysis 2.5

Comparison 2 Any psychosocial intervention vs. control: maternal outcomes, Outcome 5 Short term treatment retention.

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Analysis 2.6

Comparison 2 Any psychosocial intervention vs. control: maternal outcomes, Outcome 6 Retention in treatment at delivery.

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Analysis 3.1

Comparison 3 CM vs. control: maternal outcomes, Outcome 1 Positive urine drug test (end of treatment).

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Analysis 3.2

Comparison 3 CM vs. control: maternal outcomes, Outcome 2 Positive urine at delivery.

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Analysis 3.3

Comparison 3 CM vs. control: maternal outcomes, Outcome 3 Retention at treatment completion.

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Analysis 3.4

Comparison 3 CM vs. control: maternal outcomes, Outcome 4 Short term treatment retention.

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Analysis 3.5

Comparison 3 CM vs. control: maternal outcomes, Outcome 5 Retention at delivery.

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Analysis 4.1

Comparison 4 MIB vs. control: maternal outcomes, Outcome 1 Positive urine drug test (end of treatment).

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Analysis 4.2

Comparison 4 MIB vs. control: maternal outcomes, Outcome 2 Positive urine drug test at three months (follow‐up).

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Analysis 4.3

Comparison 4 MIB vs. control: maternal outcomes, Outcome 3 Positive urine at delivery.

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Analysis 4.4

Comparison 4 MIB vs. control: maternal outcomes, Outcome 4 Retention at treatment completion.

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Analysis 4.5

Comparison 4 MIB vs. control: maternal outcomes, Outcome 5 Short term treatment retention.

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Summary of findings for the main comparison. Summary of findings table 1

Outcomes	Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)
Patients: Pregnant women enrolled in illicit drug treatment programs for any treatment of substance abuse or dependence of any drug Settings: Outpatient treatment facilities Intervention: Psychosocial interventions of any kind (including Contingency Management methods and Motivational Interviewing based techniques) alone or given in addition to usual care Comparison: Comprehensive usual care such as methadone maintenance, counselling, prenatal care (PNC), STD counselling and testing, transportation, and/or childcare
Preterm birth (< 37 weeks gestation) (Any psychosocial intervention vs. control)	RR 0.71 (95% CI 0.34 to 1.51)	264 (3 studies)	⊕⊕⊕⊝ moderate 1
Low birth weight (< 2500 g) (Any psychosocial intervention vs. control)	RR 0.72 (95% CI 0.36 to 1.43)	160 (1 study)	⊕⊕⊕⊕ high
Days hospitalized after delivery (Any psychosocial intervention vs. control)	MD ‐1.27 (95% CI ‐2.52 to ‐0.03)	103 (2 studies)	⊕⊕⊕⊝ moderate 2
Retention at treatment completion (Any psychosocial intervention vs. control)	RR 0.99 (95% CI 0.93 to 1.06)	743 (9 studies)	⊕⊕⊝⊝ low 3
Short term treatment retention (Any psychosocial intervention vs. control)	RR 1.00 (95% CI 0.90 to 1.10)	514 (6 studies)	⊕⊕⊝⊝ low 4
Positive urine at delivery (Any psychosocial intervention vs. control)	RR 1.18 (95% CI 0.52 to 2.65)	217 (2 studies)	⊕⊕⊕⊕ high
Positive urine drug test (end of treatment) (Any psychosocial intervention vs. control)	RR 1.14 (95% CI 0.75 to 1.73)	367 (3 studies)	⊕⊕⊕⊝ moderate 5
Retention at treatment completion (CM vs. control)	RR 1.03 (95% CI 0.92 to 1.16)	388 (6 studies)	⊕⊕⊝⊝ low 6
Retention at treatment completion (MIB interventions vs. control)	RR 0.97 (95% CI 0.89 to 1.06)	355 (3 studies)	⊕⊕⊝⊝ low 7
CI: Confidence interval; RR: Risk ratio; MD: Mean difference; CM: contingency management; MIB: motivational interviewing based.
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
1 Downgraded by one due to possible selection bias in one of the three included studies. 2 Downgraded by one due to possible attrition bias associated with one of the two studies. 3 Downgraded by two due to possible selection bias, attrition bias, and detection bias in majority of the included studies (all but two). 4 Downgraded by two due to possible selection bias, attrition bias, and detection bias in majority of the included studies (all but two). 5 Downgraded by one due to possible selection bias associated with one of the three studies. 6 Downgraded by two due to possible selection bias associated with four of the included studies. 7 Downgraded by two due to possible selection bias associated with two of the included studies.

Summary of findings for the main comparison. Summary of findings table 1

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Comparison 1. Any psychosocial intervention vs. control: neonatal outcomes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Preterm birth (< 37 weeks gestation) Show forest plot	3	264	Risk Ratio (M‐H, Random, 95% CI)	0.71 [0.34, 1.51]

2 Positive neonatal toxicology at delivery (any drug) Show forest plot	1	89	Risk Ratio (M‐H, Random, 95% CI)	1.91 [0.86, 4.24]

3 Low birth weight (< 2500 g) Show forest plot	1	160	Risk Ratio (M‐H, Random, 95% CI)	0.72 [0.36, 1.43]

4 Days hospitalized after delivery Show forest plot	2	103	Mean Difference (IV, Random, 95% CI)	‐1.27 [‐2.52, ‐0.03]

Comparison 1. Any psychosocial intervention vs. control: neonatal outcomes

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Comparison 2. Any psychosocial intervention vs. control: maternal outcomes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Positive urine drug test (end of treatment) Show forest plot	3	367	Risk Ratio (M‐H, Random, 95% CI)	1.14 [0.75, 1.73]

2 Positive urine at 1 month+ Show forest plot	1	159	Risk Ratio (M‐H, Random, 95% CI)	1.13 [0.55, 2.31]

3 Positive urine at delivery Show forest plot	2	217	Risk Ratio (M‐H, Random, 95% CI)	1.18 [0.52, 2.65]

4 Retention at treatment completion Show forest plot	9	743	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.93, 1.06]

5 Short term treatment retention Show forest plot	6	514	Risk Ratio (M‐H, Random, 95% CI)	1.00 [0.90, 1.10]

6 Retention in treatment at delivery Show forest plot	1	89	Risk Ratio (M‐H, Random, 95% CI)	0.97 [0.50, 1.88]

Comparison 2. Any psychosocial intervention vs. control: maternal outcomes

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Comparison 3. CM vs. control: maternal outcomes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Positive urine drug test (end of treatment) Show forest plot	1	89	Risk Ratio (M‐H, Random, 95% CI)	1.91 [0.86, 4.24]

2 Positive urine at delivery Show forest plot	1	89	Risk Ratio (M‐H, Random, 95% CI)	1.91 [0.86, 4.24]

3 Retention at treatment completion Show forest plot	6	388	Risk Ratio (M‐H, Random, 95% CI)	1.03 [0.92, 1.16]

4 Short term treatment retention Show forest plot	2	88	Risk Ratio (M‐H, Random, 95% CI)	1.10 [0.70, 1.73]

5 Retention at delivery Show forest plot	1	89	Risk Ratio (M‐H, Random, 95% CI)	0.97 [0.50, 1.88]

Comparison 3. CM vs. control: maternal outcomes

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Comparison 4. MIB vs. control: maternal outcomes

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Positive urine drug test (end of treatment) Show forest plot	2	278	Risk Ratio (M‐H, Random, 95% CI)	0.96 [0.63, 1.48]

2 Positive urine drug test at three months (follow‐up) Show forest plot	1	159	Risk Ratio (M‐H, Random, 95% CI)	1.13 [0.55, 2.31]

3 Positive urine at delivery Show forest plot	1	128	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.57, 1.24]

4 Retention at treatment completion Show forest plot	3	355	Risk Ratio (M‐H, Random, 95% CI)	0.97 [0.89, 1.06]

5 Short term treatment retention Show forest plot	3	334	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.88, 1.12]

Comparison 4. MIB vs. control: maternal outcomes

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