What to Expect
When You’re Expecting Recovery

“Why do people like you have children?”

Ashley can still remember the shame she felt when confronted by this question in the hospital just hours after she gave birth to her son. The harsh judgment didn’t come from a fellow patient but from someone providing her care.
“This is exactly the kind of response that makes mothers hide their addiction,” she shares. “When women can’t even get support from medical professionals, but instead get shamed, getting high can feel like the only option. It’s a vicious cycle.”

Confrontations like the one Ashley describes are driven by the mistaken belief that addiction is a moral failing, rather than a disease process exacerbated by childhood trauma and family histories of addiction. This lack of understanding – even within the medical community – is exactly what Project CARA was designed to address.

Project CARA (Care that Advocates Respect/Resiliency/Recovery for All) is a substance use disorder clinic for pregnant women provided through Ob/Gyn Specialists at the Mountain Area Health Education Center (MAHEC). The Asheville-based clinic supports women with high-risk pregnancies from 16 counties in Western North Carolina. The innovative program, now in its second year, is a response in part to the national opioid epidemic that has hit WNC communities particularly hard. Our region ranks among the top in the state for fatal overdoses and has higher-than-average rates of opioid pills prescribed per resident.

“In 2016, we supported 200 pregnant women with substance use disorders,” shares Melinda Ramage, FNP, Project CARA’s clinical director. “We are on track to see twice as many women by this year’s end.”

What about the stigma that keeps addiction hidden, especially among pregnant women?

“We are very careful to make sure women feel safe and respected enough to share potential substance use issues,” Ramage shares. “We work hard to reduce the shame and blame around addiction.”

Establishing this trust is critical because it isn’t always obvious which patients are struggling with addiction, which cuts across all socioeconomic lines. Ramage saw this firsthand when she worked with impaired professionals at a residential treatment center in Mill Spring.

Women with substance use disorders are at the highest risk of relapse when they are pregnant.

Project CARA’s collaborative team includes MAHEC’s maternal-fetal medicine specialists, nurse practitioners, behavioral health specialists, and outside partners like the Women’s Recovery Center, Julian F. Keith Alcohol and Drug Abuse Treatment Center, and Mission’s Neonatal Abstinence Syndrome delivery preparation team, who all meet and assess patients during their prenatal visits.

“We know that women are more likely to get the recovery support they need when we combine it with prenatal visits,” shares Marie Gannon, LCAS, LPC, Project CARA co-founder and team member. “Pregnancy can be a positive experience, but it’s also stressful. It’s even more stressful for someone who has given up their primary coping mechanism, one they have literally become dependent on.”

Women with substance use disorders are at the highest risk of relapse when they are pregnant. This puts both moms and babies at risk. To help reduce this risk, Project CARA offers medication-assisted therapy (MAT), which involves the supervised replacement of opioids with buprenorphine. This approach is endorsed by both the American College of Obstetrics and Gynecology and the American Society of Addiction Medicine.

Women receiving opioid replacement therapy are much less likely to relapse than those using opioid blockers or abstinence-only approaches. MAT may also reduce the likelihood of alcohol use during pregnancy. Alcohol consumption is known to increase the risk for birth defects. Project CARA participants also have access to recovery education and group support provided by Denise Weegar, MA, LCAS, co-director of the Women’s Recovery Center, during their prenatal visits.

“Denise saved my life and my son’s life,” Ashley shares. “She held me accountable, but I always knew she really cared about me and believed in me.”

Women in MAHEC’s substance use disorder program also learn to set goals. For some, this may be the most important lesson of all.

“Your job is to go home with your baby after you deliver,” Weegar tells women when she meets with them for the first time.

“My job is to help you make sure you reach your goal.”

Mothers with a history of substance use have a lot of hurdles to overcome in meeting this goal, including Federal legislation that requires newborns to be referred to child protective services if it is determined they have been exposed to illegal substances.

Project CARA uses a harm-reduction approach, which means team members meet each woman wherever they are in relation to substance use. From here, providers work with expectant moms to create a plan that will help ensure the best outcome for them and their babies.

For some women, sticking to their plan may mean participating in recovery education during group prenatal visits. For others, it may mean going to the Women’s Recovery Center for counseling or more intensive outpatient support. For every mom, it means showing up regularly for prenatal visits to ensure they are getting the support they need.

For instance, while a patient is at an appointment with her obstetrician to refill her opioid replacement prescription, her history of depression emerges. Right then and there, Gannon is called in to consult with her and assess her need for additional mental health support.

Recovery support doesn’t end when the baby is born. MAHEC offers ongoing substance abuse and mental health recovery services across the parking lot at its family medicine practice where moms can continue MAT, if appropriate. This wraparound support is one reason Project CARA families are more likely to stay intact, reducing the trauma to the family and the burden on an overwhelmed foster care system.

“Our program’s success comes from being able to give women the support they need when they need it,” says Gannon. “We know this will have the greatest impact on the whole family. When people with addictions get well, they get really well. It can change the trajectory of their families’ lives for generations to come.”

Gannon should know, she’s been doing this for more than 15 years. Most of those on Project CARA’s team have extensive experience working with women who have substance abuse and mental health challenges.

Project CARA is a new incarnation of the Mountain Area Perinatal Substance Abuse Program, which MAHEC started more than 20 years ago, and its early impacts are still being realized today. Sitting in her office, Ramage reads through a letter she just received from a patient who went through the original MAPSAP program.

“MAHEC’s teen clinic provided my OB care when I was pregnant with my oldest son twenty years ago,” Anna writes. “I’m so glad to see that the mission of the program has continued. It was certainly one of the things in my life at the time that helped make sure I stayed on the right path. I’m now attending law school and working in government. I will always be grateful to MAHEC for the extraordinary support I received outside of the usual medical care.”

Melinda looks up with a smile on her face. The twinkle in her eyes tells you she is not surprised. Not one bit.

For more information about Project CARA, visit www.mahec.net or contact Melinda Ramage at melinda.ramage@mahec.net. For more information about the Women’s Recovery Center, visit www.insightnc.org/treatment/wrc.


Jennifer Maurer is the External Communications Manager at MAHEC, former director of a family mental health nonprofit, and a longtime advocate of mental health and substance abuse recovery programs. She can be reached at Jennifer.Maurer@mahec.net.

Written by Jennifer Maurer