Orange County Grand Jury 2004-2005 — Substance Exposed Babies — Potentially, a Lifetime of Public Support

Summary The 2004-2005 Orange County Grand Jury studied county efforts to improve the birth Some Acronyms and outcomes of substance-exposed newborns. A Abbreviations in this woman who uses substances (alcohol, tobacco, Report and/or drugs) places her unborn child at risk for developmental, mental, behavioral, and HCA Orange County social handicaps. Therefore, an affected child Health Care Agency may require a lifetime of public support. OC Orange County During the past few decades, there has been an abundance of research, reports, and studies SEB Substance-Exposed regarding pregnant women who use Birth substances. In 1992, a California study was conducted to determine prevalence of SSA Orange County Social substance use during pregnancy. The study Services Agency estimated that 7.5% of Orange County pregnant Substances Tobacco, Alcohol, and women tested positive for alcohol and/or Drugs drugs. Toxicology tests for tobacco were not part of the study. However, the prevalence rate See Section 9, Appendix, for more of self-reported tobacco use in Orange County definitions. was 5.9%. Orange County agencies use this 13-year-old substance exposure data for planning and allocation of perinatal resources. There are two problems with using the old data: 1) the demographics of the county have changed, and 2) the drugs of choice have changed. Therefore, the applicability of the 1992 data is questionable. The current incidence of in- utero substance-exposed children is unknown. The grand jury observed: (cid:131) There is a need for better collaboration and coordination between private and public health care providers. (cid:131) There is a need for a new study in Orange County to better estimate the current prevalence of substance-exposed infants. (cid:131) The staffing for prenatal and perinatal services in county facilities is inadequate for the current estimate of substance using mothers. -2005 A mother can impair her child’s future by using substances during pregnancy. Fortunately, a pregnant woman has a natural and compelling concern for her child. This motivating concern offers an excellent opportunity to provide services that could improve the outcome of her child.

Introduction and Purpose of Study A mother who exposes her developing child to tobacco, alcohol, or drugs risks impairment that can result in a lifetime of public assistance. In 1991, the Model Needs In Orange County, Assessment Protocol was published by the State of about 45,000 babies California. The protocol was a framework for identifying risk are born annually. It to newborns and the corresponding level of intervention is estimated–using needed. (1) 13-year-old In Orange County, about 45,000 babies are born annually. prevalence rate The 10th Annual Report on the Conditions of Children in data–that 3,360 were Orange County, using 13 year old prevalence rate data, exposed, before estimated 3,360 newborns were exposed to alcohol and/or birth, to alcohol illegal drugs in 2002. One hundred twenty of these children and/or illegal drugs. required emergency response services. There is no reported information of newborns whose risk assessment was not high enough to warrant intervention. (2) The grand jury’s preliminary examination of the county’s existing perinatal resources revealed unmet needs for substance-using pregnant women. Therefore, the grand jury decided to launch a full study of the issue. The purpose of this report was to study county efforts to improve the birth outcome of substance-exposed newborns.

Method of Study The method of study adopted by the grand jury is as follows: (cid:131) Interviewed relevant hospital administration and staff, county agencies and departments, social workers, public nurses, non-profit health providers, judges, private physicians, recovering substance-using women, and state agencies. (cid:131) Visited relevant hospitals, perinatal clinics, county courts, jails, residential recovery homes, resource centers, and outpatient clinics. (cid:131) Attended relevant commission meetings, judicial proceedings, hearings, and conferences. (cid:131) Gathered and reviewed relevant articles from governmental, educational, and other authoritative sources. Report— Substance-Exposed Babies 4. Background This section discusses pertinent legislation, studies, data, and interviews while studying the current county programs for substance-exposed newborns in Orange County. 4.1 Proposition 10 In 1998, California voters passed The California Children and Families First Act (Proposition 10). Funding for the act is generated from a tax on tobacco products. The act, as stated in Section 130100 of the California Health and Safety Code, provides children— zero to five years—with a system of early childhood development services. The system is designed to help at-risk families with health care, child care, parent education, and effective intervention. The act is managed by a state commission that allocated nearly $40 million per year, for three years, for statewide media and community outreach programs. In addition, each county has a local commission (ours is the Children and Families Commission of Orange County) created by ordinance as a separate entity. County commissions receive 80% of the Proposition 10 revenue; Orange County’s allocation is about $50 million, annually. Proposition 10 requires that counties use their funds: (cid:131) to create new programs (cid:131) to supplement or expand, but not replace, existing services (cid:131) to use outcome-based accountability to determine future expenditures 4.2 Perinatal Studies Numerous studies have concluded that fetal development can be impaired by a mother who smokes, consumes alcohol, or uses drugs. This is not an isolated problem (see chart below). – Pregnant Women – Use of Drugs, Tobacco, and Alcohol Test Results Source Drugs Tobacco Alcohol 1992 National Institute on National 5% 20% 19% Drug Abuse 1992 School of Public Health 11.4% 8.82% See “drugs” State of at the University of California, used drugs column California Berkeley (29,494 women) and/or alcohol 1992 School of Public Health 7.5% 5.88% See “drugs” Orange County at the University of California, used drugs column Berkeley and/or alcohol A nation-wide survey (1992) (3) by the National Institute on Drug Abuse found that: (cid:131) 5% of pregnant women used illegal drugs; (cid:131) 20% smoked cigarettes, and (cid:131) 19% drank alcohol. a study (4) of the prevalence of substance use during pregnancy in the State of California was launched. This was a blind study (identity of donor unknown) conducted by the School of Public Health at the University of California, Berkeley. The study of 29,494 women who underwent anonymous urine toxicology screening in 202 birthing hospitals revealed: (cid:131) There was an 11.4% statewide prevalence of illegal drugs and/or alcohol, and 7.5% in Orange County. (cid:131) Additionally, self-reported tobacco use was at a rate of 8.82% statewide and at 5.88% in Orange County. When a mother uses substances she may be placing her child at risk for public dependency. Children exposed in-utero to the substances may be at increased risk for the following: (cid:131) low birth weight (cid:131) learning disabilities (cid:131) developmental disabilities (cid:131) mental retardation or low IQ (cid:131) poor reasoning and judgment skills (cid:131) stillbirths (cid:131) spontaneous abortions (cid:131) SIDS (sudden infant death syndrome) Multiple substance use is the rule rather than the exception. For example, most drug users drink alcohol and smoke cigarettes. Alcohol users often use tobacco, as well. Such behaviors serve to compound the deleterious affects to the fetus. Even though some of the abnormalities are not obvious at birth, the effects might not become apparent until the child has reached school age or adulthood. 4.3 Study Results The “Parents” of PSASI/ACT The 1992 study of substance use during pregnancy in the State of California resulted in an assessment of the (cid:131) HCA - OC Health Care Agency needs for perinatal resources and treatment facilities in (cid:131) HCA’s Substance Abuse Orange County. In 1994, Orange County developed the Services Program Perinatal Substance Abuse Services Initiative (PSASI). A (cid:131) SSA - OC Social Services core element of PSASI is the Assessment and Agency Coordination Team (ACT). ACT is a team of public (cid:131) University of California, health nurses (within HCA) who case manage prenatal Irvine, Medical Center and perinatal substance abusers. All women under the (UCIMC), Department of care of ACT nurses are case-managed through Obstetrics & Gynecology six-twelve months after delivery. Currently, there are 10 (cid:131) Maternal Outreach full time nurses and one part time nurse employed to Management System care for substance-exposed babies and their mothers. (MOMS) PSASI was created to: 1) increase access of substance- Report— Substance-Exposed Babies using pregnant women to perinatal care, and 2) improve the clinical outcomes of their pregnancies. In 2004, 95% of ACT’s case-managed clients delivered drug-free babies. The table below illustrates findings from comparison studies of case-managed and non- case-managed pregnancies in Orange County in 1996. For pregnancies case-managed by ACT, only 11.8% of the SEB newborns tested positive for drugs (against 61.6% of the non- case-managed newborns). Further, the hospital cost for non-case-managed babies was significantly greater than for case-managed. Studies in Orange Babies Testing Approximate Cost of County and Positive for Care for Substance- Baltimore, Maryland, Drugs at time of Using Women and comparing case- Delivery (1996) their Newborns (1996) (5) (7) (7) managed versus non- case-managed Case-Managed 11.8% $22,928 Pregnancies indicated that significant cost Non-Case-Managed 61.6% $31,301 savings can occur. (8) Pregnancies See chart, at right. Grand Jury chart 2005 Across all social and economic strata of our society, there are, however, obstacles to treatment for substance- using pregnant women: (cid:131) low self-esteem (cid:131) fear of having baby taken after delivery (cid:131) dependence (physiological and psychological) on drugs (cid:131) family disapproval (cid:131) no health insurance (cid:131) societal stigma of being identified as a drug user (cid:131) reluctance of some physicians and nurses to report a patient’s substance dependence All the above can be barriers to obtaining perinatal assistance and treatment. The grand jury discovered there is insufficient information regarding the prevalence of substance use by pregnant and birthing mothers in Orange County. The jury gained insight as to the dissemination of information, the cooperative interplay between agencies, and how well the coordination of resources is managed. Data retrieved from the Orange County Social Services Agency (SSA) indicate that in 2004, the Child Abuse Registry (CAR) received 200 referrals involving newborns exposed to illegal substances. The breakdown is listed, below, : In view of the previous statistics, out of an estimated 3,400 substance-exposed children, 200 were referred to the Child Abuse Registry and about 3,200 were either not identified, were identified and referred to a perinatal service agency, or the prevalence has changed. Such an agency is the PSASI/ACT team, public health nurses with the OC Health Care , PSASI/ACT serviced 556 referrals. This leaves an estimated balance of 2,644 children who did not meet the protocol referral criteria or who were not identified. There are several programs that Newborns Referred provide perinatal assistance to Reporting Entity* to CAR* pregnant women: Orange County’s Western Medical Center 34 ACT program, MOMS, Mariposa, UCI Medical Center 24 St. Joseph Hospital 21 and Heritage House. The programs Anaheim Memorial Hospital 19 cater to pregnant women who are Fountain Valley Hospital 19 identified as substance users. The Garden Grove Hospital 11 Hoag Hospital 9 focus is on giving rehabilitation and Mission Hospital 9 parenting support to women so their Anaheim General Hospital 8 babies will not be adversely affected. St. Jude Hospital 7 Prevention, treatment, and La Palma Intercommunity Hospital 5 Saddleback Memorial Hospital 5 support—rather than punishment— Orange Coast Memorial Hospital 4 is the commitment of these Mandated Reporter 3 programs. Coastal Communities Hospital 3 Kaiser Hospital 3 In addition, there are a variety of County of Orange SSA 2 LA County DCFS 2 county and community programs Los Alamitos Medical Center 2 administered by OC’s Social Placentia Linda Hospital 2 Services Agency, Health Care CHOC 1 Irvine Regional Hospital 1 Agency, law enforcement, Child Norwalk Community Hospital 1 Welfare Services, community-based Riverside CPS 1 organizations, and the judicial Riverside Medical 1 system that make contact with, and San Diego County CPS 1 St. Bernardine’s Hospital 1 identify, substance-using pregnant Whittier Hospital Medical Center 1 women. These women may be 2004 TOTAL 200 identified as using illicit drugs but * CAR = Child Abuse Registry are not necessarily referred for Grand Jury chart of 2005information supplied by OC Social Services Agency services such as case management. The grand jury could not find a sufficiently coordinated effort to Substance Number of Mothers ensure that referrals are made and Methamphetamines 92 services are provided. Although the Amphetamines 50 aforementioned programs are Cocaine 20 directed toward the same goal, an Cannabinoids 15 organized, collaborative effort was Opiates 13 not evident. Benzodiazepines 4 Barbiturates 3 Supplementary information Methadone 3 gathered from OC’s Social Services 2004 TOTAL 200 Agency concerning the type of * Grand Jury chart, 2005, of information supplied by SSA substances found in the mothers’ systems is listed, at right: Report— Substance-Exposed Babies Note the absence of alcohol or tobacco as non-reportable substances identified in referrals to the Child Abuse Registry. And yet the grand jury was told by a medical professional, “For the outcome of a fetus, tobacco and alcohol are more damaging than heroine, cocaine, or methamphetamine.”(11) 4.3.1 Tobacco is Dangerous, Too! Tobacco exposure has been associated with fetal growth retardation and low birth weight. (6) Screening for tobacco use was never addressed by any interviewees. In the 1991 Model Needs Assessment Protocol (SB 2669), the incidence of tobacco use is self-reported by birthing mothers. The veracity of this self-reporting is in doubt. The effects of tobacco on a developing fetus are well known and documented. Carbon monoxide, nicotine, and other chemicals in tobacco smoke enter the motherʹs bloodstream and pass into the babyʹs body. This keeps the baby from getting nurturing amounts of food and oxygen. Therefore, a common effect of smoking during pregnancy is low birth weight of the infant. 4.3.2 Alcohol is Dangerous, Too! Alcohol exposure can cause permanent damage to a fetus. “Fetal alcohol syndrome (FAS) is almost certainly the most common known cause of mental retardation in the United States, but its actual prevalence is uncertain.”(10) There is a urine test for alcohol, but the substance traces disappear within 48 hours. The 1992 Berkeley study did test for the presence of alcohol. 4.4 Proposed Steering Committee The grand jury would like to see the county reinstate a steering committee, headed by the OC Health Care Agency and including those entities illustrated in the chart below ( ). The steering committee would: (cid:131) Provide ongoing collaboration, coordination, and feedback among all public and private providers of health care to pregnant women (cid:131) Initiate and support a new prevalence study (cid:131) Discuss proposing a change in the standard of care for pregnant women, to include substance testing and/or counseling At one time, Orange County had such a steering committee. It achieved its goals and was disbanded. The professionals interviewed believed a steering committee would keep caregivers focused on the needs of pregnant women and provide a central clearinghouse for information and standards of care. ) PSASI / ACT (Perinatal (cid:131) Children & Families Commission Substance Abuse Services Initiative and Assessment Coordination Team) Other Medical Providers Social Services Agency (SSA) (cid:131) P rotocol with hospitals (cid:131) OB Nurses, Private and University Hospitals (cid:131) Child Abuse Registry (CAR) (cid:131) Obstetricians (ACOG*) (cid:131) C hild Protective Services (cid:131) Pediatricians (AAP**) (CPS) Behavioral Health - – All OC Hospitals – Health Care Agency (HCA) (cid:131) Standards of Practice Protocols (cid:131) Perinatal Drug Treatment (cid:131) SSA (Social Services Agency) Programs (4 locations) protocols (cid:131) Methadone Clinic Maternal & Child Health Agencies (cid:131) Non-profit case management and outreach providers (cid:131) Residential alcohol and drug treatment centers (2 locations) (cid:131) Women’s and families counseling center * American College of Obstetricians and Gynecologists ** American Academy of Pediatricians Grand Jury Diagram, 2005 4.5 Finding Prenatal Care There are impediments to finding prenatal care in Orange County: Websites: The grand jury found deficiencies in HCA and SSA websites; it is difficult to find information related to agency assistance. Websites should be redesigned to make them friendly to clients who are seeking services, not organizations. Transportation: Once healthcare has been found, transportation to a clinic becomes a problem in Orange County. Report— Substance-Exposed Babies Lack of Resources: Orange County does not have sufficient county clinics, especially in south county. Lack of Awareness: Many private practice healthcare providers (doctors, nurses, hospitals) told the grand jury that they are not provided information by HCA and SSA about where to refer their substance-using patients. 4.6 Interviews All personnel interviewed–social, medical, law enforcement, agency management and staff—supported the formation of a study to determine the number of substance-exposed babies born in Orange County. All agreed that the study should not be used to criminalize or to punish the mothers. Helping mothers have healthy babies is the goal. To reach the goal: (cid:131) First identify the extent of the problem. (cid:131) Second improve the quality of data available to physicians and other care providers. (cid:131) Third improve coordination and collaboration among providers of care for pregnant women. (cid:131) Fourth improve access to care. In fact, no one knows the prevalence rate for newborn substance exposure. All data and current predictions are based on a single 13-year-old study. This year, Monterey County launched its own study; Orange County should, also. (cid:131) The grand jury interviewed three former substance-using mothers. Each had a child under the auspices of ACT and, during the interview, described a life of drug abuse, incarceration, and despair. All of the women were grateful for the dogged effort by the ACT nurses, and all attributed their eventual break from drug dependence to the direct intervention of the nurses. Even so, the existing prenatal programs are woefully inadequate because of underfunding and understaffing. (cid:131) Residential treatment typically has a 2-3 week waiting list. While waiting for placement, a pregnant substance-user remains untreated. (cid:131) Public health nurses have large and rising caseloads (see table, below). Annual Rates 2002 2003 2004 Active caseloads – substance-using pregnant women 489 550 631 Referrals – substance-using pregnant women 359 435 556 Deliveries of babies 188 283 365 Average caseload per public healthcare nurse 49 55 63 Grand Jury chart, 2005, of information supplied by PSASI/ACT Although the current needs of the county are not met, the PSASI/ACT initiative has provided the core focus on the critical issue of substance-using mothers. The initiative has reported a positive cost/benefit ratio and should be expanded. (7) .13 states, in part, that a positive toxicology screen on a pregnant mother is not, of itself, a sufficient basis to report child abuse. The state is moving away from penalizing substance-using mothers and toward providing resources and referrals to assist the mother in becoming independent of substances. 4.7 Protocols The 1991 Model Needs Assessment Protocol (SB 2669) established by the state is a suggested protocol. Counties are free to either adopt this model or use it as an example for developing their own protocols. The protocol is a tool for assessing the need of pregnant and birthing women and/or infants for services related to substance exposure and/or substance abuse problems. (1) In 1992 and 1994, the Western Consortium for Public Health evaluated the effectiveness of the implementation of SB 2669. They found that almost all counties and hospitals develop their own protocols, but the majority reported that use of the protocols was inconsistent. Some of the reasons mentioned were lack of funds, liability concerns, and resistance from some private physicians. In 1994, hospital perinatal nurse managers and county social and health services personnel were surveyed. The findings confirmed earlier results of irregular application of protocols. Approximately two-thirds of the responding counties had protocols that would identify perinatal substance exposure; only one-third of the counties indicated their hospitals routinely followed the protocol guidelines. It also indicated that about half of the hospital nurse-managers believed that substance abuse treatment resources were not available for women giving birth in their communities. The study indicated that screening and assessment is more thorough in public hospitals than in private hospitals. (9) The 2004-2005 Grand Jury’s observations were consistent with the findings of the 1994 Western Consortium for Public Health (as indicated above). In other words, the inconsistent use of protocols still exists.

Observations 5.1 Healthcare providers are required to notify CPS of infants identified as substance exposed (Keeping Children and Families Safe Act of 2003). 5.2 The California Penal Code (11165.13) states, in part, that a positive toxicology screen on a pregnant mother is not, of itself, a sufficient basis to report child abuse. The state is moving away from penalizing substance-abusing mothers and toward Report— Substance-Exposed Babies providing resources and referrals to assist the mother in becoming independent of drugs, alcohol, and tobacco. 5.3 Studies that rely on one-time toxicological assessments reveal insufficient evidence about the overall pattern of substance use. Self-reports about such behavior lack reliability. 5.4 The grand jury has found that no one has an accurate assessment as to the current amount of substance-exposed births in Orange County. During the last assessment in 1992, many doctors were surprised to know that 7.5% of the mothers studied were found to have drugs or alcohol in their system. A clear assessment of the extent of the issue cannot be made until an accurate measurement is taken of the number of substance-exposed births there are in the county. 5.5 Many healthcare providers have expressed the belief that most substance-abusing mothers want to become “clean” in order to have a healthy baby. 5.6 There is a lack of county prenatal and perinatal resources for substance users in south Orange County (5th District). 5.7 In 2005, Monterey County’s Health Department is conducting a Perinatal Substance Abuse Prevalence Study of 1,672 pregnant women giving birth at that county’s hospitals. Blind urine samples will be taken from each pregnant woman as part of her hospital admittance protocol. Tests of each urine sample will reveal the level of substances (alcohol and illegal drugs) ingested by each pregnant woman. Monterey County is seeking to find the prevalence of SEB babies so they can develop programs for care and prevention. The funds for the urine tests were obtained through a grant application for Proposition 10 (Tobacco), “First Five” money. The grant application was written by Monterey County’s Health Department. Projected costs (considered to be at the high end of estimation) are: Cost: Study of 1,672 samples Service $14,000 Epidemiologist, Monterey County Health Department 13,000 Technical design, marketing, training of hospital personnel 15,300 Hospital stipends @ $9.15 per patient participant 7,500 @ $6 per specimen for screening and confirmatory testing 7,200 Travel and participation in Dr. Ira Chasnoff’s training academy 8,000 Data entry (costs will be lower if done in-house) $65,000 * Grand Jury chart, 2005, from Monterey Health Department 2005 information . Commendation The grand jury commends the ACT public nurses for their dedication and relentless efforts to assist expectant mothers to deliver healthy babies.

Findings Under California Penal Code Sections 933 and 933.05, responses are required to all Findings. The 2004-2005 Orange County Grand Jury has arrived at the following findings: 7.1 Coordinated Effort: The grand jury could not find an overall coordinated effort to ensure that referrals are made and services are provided to pregnant women. Although public and private programs are directed toward the same goal, an organized, collaborative effort was not evident. 7.2 13-Year-Old Data (1992): Orange County agencies use 13-year-old prevalence rate data (1992) for planning and allocation of prenatal and perinatal resources. The applicability of the prevalence data is now questionable because of changed prevalence rates, changed demographics, and changed substances of choice. 7.3 Staff and Resources for Substance Users Are Insufficient: The prenatal and perinatal staff and resources are insufficient for current caseloads and referrals. Therefore, many substance-using mothers go unattended. 7.4 South Orange County Healthcare: For its 18 communities, south Orange County has only one county healthcare facility serving substance abusing pregnant women. Compounding the problem, public transportation to north county healthcare providers is lengthy, inconvenient, and tiring. 7.5 Websites: The HCA and SSA websites are difficult to navigate. The sites are agency- oriented, not services-oriented. Responses to Findings 7.3 and 7.4 are required from the Orange County Board of Supervisors. Responses to Findings 7.1 through 7.4 are requested from the Orange County Health Care Agency. Responses to Findings 7.3 and 7.5 are requested from the Orange County Health Care Agency and the Orange County Social Services Agency. Report— Substance-Exposed Babies 8. Recommendations In accordance with California Penal Code Sections 933 and 933.05, each recommendation will be responded to by the government entity to which it is addressed. The responses are to be submitted to the presiding officer of the Superior Court. Based on the findings, the 2004-2005 Orange County Grand Jury makes the following recommendations: 8.1 Coordinated Effort: Recommend HCA initiate and support an ongoing steering committee to direct the focus and activities and promote collaboration of all agencies, departments, and contract firms to the same goal. See illustration of committee make-up in Section 4.6 (see Finding 7.1). 8.2 13-Year-Old Data (1992): Recommend Orange County design, develop, and undertake a new prevalence study headed by HCA and supported by active participation from the recommended steering committee (see Finding 7.2). 8.3 Staff and Resources for Substance Users Are Insufficient: Recommend the county increase prenatal and perinatal staffing and resources for the Orange County Health Care Agency and the Orange County Social Services Agency (see Finding 7.3). 8.4 South Orange County Healthcare: Recommend the county consider providing healthcare facilities for substance-using pregnant women in south Orange County (see Finding 7.4). 8.5 Websites: Recommend HCA and SSA design websites that are client friendly by listing services, rather than organization (see Finding 7.5). Responses to Recommendations 8.3 and 8.4 are required from the Orange County Board of Supervisors. Responses to Recommendations 8.1 through 8.5 are requested from the Orange County Health Care Agency. Responses to Recommendations 8.3 and 8.5 are requested from the Orange County Social Services Agency. . Appendix Following are brief descriptions of agencies involved in prenatal and perinatal care and offerings for substance-abusing pregnant women. ACT — Assessment & Coordination Team. An HCA healthcare program offering free support to pregnant women who are HIV positive, have a history of drugs/alcohol use, or currently use drugs/alcohol. Services include: Home visits by public health nurses, prenatal teaching, referral and resources for socioeconomic needs, transportation, and case coordination with the involved programs and providers. See HCA, below. CalOptima — A case-managing agency authorized by state and federal law to administer MediCal (Medicaid) benefits in Orange County. CalOptima is funded by the State of California on a capitation plan. It manages caseloads and administers health care contracts with two HMOs and nine PHC-Physician/Hospital Consortia. There are 290,000 members enrolled in MediCal; 30,000 are children, managed by CalOptima. So they can receive medical care, CalOptima gives conditional waivers to undocumented women who are pregnant and needing health care. CalOptima refers all addicted mothers to MOMS. CAPTA — Child Abuse Prevention and Treatment Act, as amended by “The Keeping Children and Families Safe Act of 2003,” June 25, 2003 Child Abuse Registry — (714) 940-1000, (800) 207-4464 Community Clinics — There are 11 community clinics providing perinatal services. The clinics offer low cost health care to low-income patients. They are located in Anaheim, Costa Mesa, Fullerton, Garden Grove, Huntington Beach, Laguna Beach, La Habra, Orange and Westminster. HCA — The Orange County Health Care Agency, among its other county healthcare responsibilities, supports the four UCI prenatal clinics: Anaheim, Aliso Viejo, Santa Ana, and Westminster. See ACT, above. For a complete description of HCA functions, visit their website: http://www.ochealthinfo.com. Heritage House — A six-month residential alcohol and drug abuse recovery program for pregnant/parenting women and their small children. Services are provided on a sliding fee scale and are funded partially by the County of Orange. No one is turned away for lack of funds. (714) 687-0077 – North, (949) 646-2271 – South Mariposa — Mariposa Women’s & Family Counseling Center (714) 547-6494 Mariposa is an outpatient-counseling center offering a variety of programs and resource options for women, children, and families. Services include individual/group counseling, parenting and educational classes, child therapy, occupational therapy, and childcare. MOMS — Maternal Outreach Management System MOMS provides access to prenatal medical care and community-based case management of pregnancy through the infant’s first year of life. MOMS, under contract with Report— Substance-Exposed Babies CalOptima, interviews each CalOptima pregnant woman to assess her needs for care. No care is provided to the patient without the MOMS needs assessment. Therefore, if a woman wants the care but has no means of her own to get it, she must comply with the ground rules set down by MOMS. Such ground rules might include psychiatric counseling, scheduled prenatal medical attention, ACT monitoring, drug and alcohol addiction programs for rehabilitation, etc. Perinatal Drug Treatment Programs — An outpatient four-phase program for pregnant and parenting women that can be completed in approximately 9-12 months. In addition to weekly education and focus groups, a client will meet with a therapist individually on a monthly basis. Clients are required to submit random drug tests. Childcare is provided. See HCA, above. (714) 480-6660 – Santa Ana, (714) 934-4600 – Westminster, (714) 643-6930 – Aliso Viejo, (714) 517-6175 – Anaheim Presley Bill — SB 2669 (a/k/a Presley Bill), “Substance Abuse in Perinatal Services: A Model Needs-Assessment Protocol,” Health and Welfare Agency, State of California, July 1991. UCI Family Health Centers — The UCI Family Health Center operates four perinatal clinics in Anaheim, Irvine, Santa Ana, and Westminster.

Bibliography Following are sources studied by the grand jury and referenced within this report.