Problem: Drug overdose is the leading cause of maternal death in Texas. More than 60% of children in custody of Texas Child Protective Services (CPS) have substance use listed as a contributing factor in their CPS case, compared to the national rate of 34%. Pregnant and postpartum women and infants are a special population impacted by substance use and require a coordinated response from multiple sectors to ensure optimal outcomes for both the mother and her infant.

Purpose: In 2018, needs and readiness assessments were conducted in Houston, Texas, focused on improving care and service coordination for pregnant women with substance use disorder (SUD). The purpose of this paper is to briefly describe the results of the assessments and discuss how the Covid-19 pandemic has impacted implementation of the recommendations.

Methods: In late 2018, 59 stakeholders from 5 different sectors were interviewed to assess the current system of care and identify recommendations they felt would improve outcomes for pregnant women with SUD. These interviews were followed by 5 collaborative meetings with stakeholders to finalize the recommendations, and a readiness assessment (n=25) to determine the feasibility of implementing the recommendations. The goals of this survey were to determine which of these recommendations were most important, had organizational support for implementation, and would result in improvements within a year of being implemented. Interviews were conducted again in 2020 (n=9) to describe the progress that had been made on the recommendations and assess the impact the Covid-19 pandemic has had on implementing programs and initiatives that support peripartum women with SUDs.

Results/Discussion: The stakeholder interviews revealed substantial cross-sector misunderstanding about each sector’s roles and responsibilities. Further, several barriers to coordination were identified. Interviews and collaborative meetings led to the development of 25 recommendations that would improve cross-sector collaboration. There were 25 completed responses to the readiness survey focused on implementing these recommendations. Of the recommendations, 9 had above-average ratings on importance and had ratings indicating substantial short-term impact for pregnant women. Six additional recommendations had above-average ratings on importance, but it was determined that their benefits take longer to be seen. Progress made towards 8 of the recommendations and how the Covid-19 pandemic has impacted this progress are described.

Implications: The Covid-19 pandemic has created both opportunities and barriers to progress in the treatment and care of pregnant women with SUD. This analysis identifies resulting changes that must be considered for future planning and intervention implementation.

Author Biography

Bethanie Van Horne, DrPH, is an assistant professor of pediatrics at Baylor College of Medicine and the director of research for the Section of Public Health and Child Abuse Pediatrics at Texas Children’s Hospital. Dr. Van Horne has over fifteen years working in the maternal child health field, with experiences in both academic and community settings. Her research and programmatic work have been focused broadly around improving child and family well-being. Current projects and areas of interest include: early childhood caregiver support, postpartum depression, perinatal substance use, behavioral health, child abuse and neglect, and services and programs for foster and at-risk families. Dr. Dorothy Mandell received her PhD from the University of Washington, Seattle in Developmental Psychology and her BA from the University of Texas, Austin. She also served as a post-doctoral fellow at the Wake Forest School of Medicine and the University of Amsterdam. Her research has spanned multiple topics in maternal and child health including understanding the relations between early experiences and later developmental outcomes, especially neurocognitive outcomes. She has extensive direct public health experience through her work on a variety of public health topics including work that has supported the Maternal Mortality and Morbidity Task Force, Healthy Texas Babies, Child Fatality Review, and the strategic plan to align prevention resources between the Department of Family Protective Services and the Department of State Health Services in Texas. She is currently an Associate Professor at the University of Texas Health Science Center, Tyler and with Population Health, Office of Health Affairs at the University of Texas System Administration in Austin. She is the primary investigator for the Texas Safe Babies project and the Maltreatment Risk mapping project funded by Department of Family and Protective Services. Rachael J. Keefe, MD, MPH, FAAP is Assistant Professor of Pediatrics at Baylor College of Medicine/Texas Children’s Hospital in Houston. Dr. Keefe leads the Foster Care Clinic at Texas Children’s Hospital. She completed her training at Tulane University in New Orleans and earned her Master’s in Public Health from Johns Hopkins University in Baltimore. She serves on the American Academy of Pediatrics Foster Care, Adoption, and Kinship Care Executive Committee, which helps develop national care guidelines and policies for children in foster and kinship care. Dr. Keefe serves as an advocate for children in foster care and those at risk for going into care through her clinical, research, and policy work.


We would like to thank the University of Baltimore's Center for Drug Policy and Prevention for their support of the needs and readiness assessment. We would also like to thank and recognize the many people who gave us their time, expertise, and insights for this project. It is because of their tireless work and determination that Houston has continued to make great strides in improving the system of care for families impacted by substance use issues.