Dana Cahill, peer recovery specialist for the Community Health Network’s CHOICE program, said she helps women feel human again.
It’s a voluntary 24-7 program that helps mothers detox from heroin, methamphetamine, and other addictive substances.
When she’s not giving out pastel-colored toys or maternity clothes, Cahill helps patients rebuild their lives. Sometimes that means getting a driver’s license or applying for jobs. Other times, Cahill helps mothers find an inpatient treatment center.
She went through the program herself and credits God with giving her a chance to give back.
“You're essentially picking yourself back up and starting all over,” Cahill said. “I try to help lighten that load.”
The CHOICE program is one of the few options available for Indiana mothers with an addiction, and its patient load has been growing.
“Pregnancy doesn't cure addiction,” said Ellie Turner, a nurse practitioner and lead provider with the program. “So, we have to meet people where they are and get them the help they need at that moment.”
State reports show substance use is the top cause of death among new Indiana mothers.
Overdoses contributed to about one-third of deaths in women during pregnancy and up to one year after giving birth, according to the Indiana Maternal Mortality Review Commission’s most recent report. Intentional overdoses are not included in that figure.
It’s hard to narrow down exact causes for overdose deaths among Indiana mothers, but there are some through lines. Providers say compounding issues of mental illness, trauma, and a lack of access to care contribute to those maternal deaths.
“I think it's a hard thing to easily fix, honest to goodness,” said Dr. Mary Abernathy, chair of the mortality review committee.
The multidisciplinary committee was formed in 2018 to address the state’s high maternal mortality rate, which typically ranks near the bottom 10 states in the country.
The committee’s report analyzed 367 deaths from 2018 to 2022 using death records, birth certificates, and other public resources.
Dr. Camila Arnaudo, a member of the committee, said many of Indiana’s overdose deaths occurred after a woman gave birth.
She said while the risk of overdose decreases during pregnancy, it drastically increases after the baby is delivered.
“In the postpartum period, the risk of having an overdose is higher than if you had never been pregnant,” Arnaudo said. “It's just such a deadly time for people.”
Mental health and addiction go hand-in-hand
Mental illnesses and addiction are tightly linked, and those issues don’t disappear during pregnancy.
“There are some estimates that between 80-90 percent of patients with substance use disorders have an additional behavioral health disorder or mental health disorder that has either been diagnosed or undiagnosed,” said Dr. Anthony Sanders, lead physician at the CHOICE program.
Sometimes women can stop using during pregnancy, Arnaudo said, but that doesn’t always translate to long-term sobriety.
“The reality about substance use disorder, it's a relapsing illness,” Arnaudo said.
The postpartum period is a particularly vulnerable and understudied time in women’s lives, Arnaudo said. Depression, anxiety and hormonal changes are common, and a history of addiction makes the period even more difficult.
While mothers typically have between six to 20 appointments before giving birth, Arnaudo said they usually have only one after.
“A lot of people who use drugs and who have psychiatric illness tend to not present for that six-week follow up,” Arnaudo said.
For patients who use drugs, those appointments could help with relapse prevention and connection to care, Arnaudo said.
She also pointed to research which shows patients skip appointments for practical reasons — such as trouble finding transportation and childcare — and because they don’t feel providers actually address their needs.
Women of color have an even harder time accessing appropriate healthcare during and after pregnancy.
“Black women are much more likely to die in childbirth and in the postpartum period,” Arnaudo said. “They also tend to be the least able to get access to, for example, medications for opioid use disorder, or even other medications for mental health and other forms of psychiatric care.”
Keeping up with frequent and attentive care is difficult for providers, too.
“We have a growing shortage of obstetrics providers, not just OB-GYNs but also nurse practitioners, and midwives and family medicine who all participate in this care,” Arnaudo said.
Child Services another pattern in maternal deaths
Cahill said she thought that she would never use drugs while pregnant, that she wasn’t that kind of person. But it wasn’t that easy. Her son was taken away from her, and for a moment, Cahill said she lost all motivation to get better.
“It's just . . . one of the hardest things I've ever been through,” Cahill said. “Your motivation is taken away.”
When she was pregnant with her youngest son, she said she knew she had to do something different.
“I'm two weeks away from losing my middle son,” Cahill said. “How can I parent this one when I don't have this one?”
After a family referral, she had a Sunday night call with the CHOICE program’s former director, Brooke Shaefer.
“She said, ‘When can you come in?’” Cahill said. “And I was like, ‘Well, I've got court for DCS this day. I have visits with my kids this day.’ And I had a million excuses. And she was like, ‘Or you could die tonight.’”
Cahill checked into CHOICE after that call.
Her story echoes data reported by the Maternal Mortality Review Commission. The commission found a clear pattern: the majority of mothers who died had some kind of interaction with the Department of Child Services.
“Two-out-of-three of our maternal deaths have had DCS involvement, whether it's as a child or as an adult,” Abernathy said. “Frequently, it's both.”
Abernathy said children who live through neglect or abuse often develop mental health illnesses. Studies show they’re also more likely to develop a substance use disorder.
“I don't think that's uncommon for us to resort to resources we have available at our fingertips,” Abernathy said. “It becomes almost intergenerational. ‘This is how my family copes with bad memories or PTSD, and so this is how I'm more than likely going to cope with that.’”
If a woman continues using during pregnancy and after giving birth, it’s possible she could lose custody.
An Indiana University analysis found that more than more than 7,100 Indiana children were removed from their homes in 2024, and about 57 percent were due to a parent abusing alcohol or drugs. In Monroe County, more than 74 percent of removals were due to drug or alcohol abuse.
For providers, Indiana has strict reporting guidelines for drug abuse — even for substances that are technically legal, such as Delta 9, Arnaudo said. If a pregnant mother is using drugs, and substances are found in a newborn’s system, it could trigger a report to the Department of Child Services.
“A lot of people really fear those reports and fear being separated from their babies,” Arnaudo said. “So, they tend to not always present to care.”
For Abernathy, the connection to Child Services could be an opportunity for the state to prevent deaths, especially if the state could flag mothers at the highest risk and intervene.
“If we can figure out how to capitalize on that association, I think that might help us,” Abernathy said. “It's going to require money. It's going to require resources.”
Despite improvements, the work isn’t done
After the COVID-19 pandemic, overdose deaths and maternal mortality rates improved. The Maternal Mortality Review Commission’s report lags a few years, because it takes time to study each person and the circumstances around their death, Abernathy said.
Advocates of harm reduction have already invested time and resources in Indiana to prevent overdose deaths. Naloxone, an overdose reversal medication also known as Narcan, is widely available for free.
Many users mix drugs. Testing strips, though not as common as naloxone, can detect fentanyl and other deadly substances to alert users of contamination.
At the CHOICE clinic, patients receive medication-assisted treatment that helps with withdrawal symptoms.
These practices, along with verbal screenings and education on substance use disorder, are recommended by the commission.
“Always try and engage the community's support, and make sure the community understands substance use disorder is a chronic, sometimes lifelong condition,” Abernathy said.
Despite progress, there’s still a demand for more recovery spaces dedicated to mothers. CHOICE providers are taking on more patients and seeing them longer after delivery.
“We're getting to a point where we may need multiple clinic days, because our census is high,” Turner said. “We're seeing so many patients in one day that we're kind of limited to what we can do, because our appointment times have to be shorter.”
The vast majority of patients will need some sort of inpatient rehabilitation to help with their substance use disorder, Sanders said. But it's difficult to find recovery programs that keep families together and specialize pregnancy care.
After going through the CHOICE program, Cahill found additional support through the Volunteers of America, which allows mothers in recovery to stay with their children. She recommends it to CHOICE patients today.
“We're a small team, and there should be a lot more people doing this work,” Cahill said. “There needs to be more places. When I hit the lottery, that's my goal, to make that possible for some more women.”
