Substance Use In Pregnancy Research Articles

Screening for Alcohol Use in Pregnancy: a Review of Current Practices and Perspectives.

Global trends of increasing alcohol consumption among women of childbearing age, social acceptability of women’s alcohol use, as well as recent changes in alcohol use patterns due to the COVID-19 pandemic may put many pregnancies at higher risk for prenatal alcohol exposure (PAE), which can cause fetal alcohol spectrum disorder (FASD). Therefore, screening of pregnant women for alcohol use has become more important than ever and should be a public health priority. This narrative review presents the state of the science on various existing prenatal alcohol use screening strategies, including the clinical utility of validated alcohol use screening instruments. It also discusses barriers for alcohol use screening in pregnancy, such as practitioner constraints, unplanned pregnancies, delayed access to prenatal care, and stigma associated with substance use in pregnancy, providing recommendations to address these barriers. By implementing consistent alcohol use screening, prenatal care providers have the opportunity to facilitate access to counseling and brief interventions and thus, to prevent new cases of FASD and improve maternal and child health.

Racial differences in indications for obstetrical toxicology testing and relationship of indications to test results

Despite illicit substance use in pregnancy occurring across all demographic groups, minority pregnant and delivering patients with a low income tend to undergo testing at a higher rate than their counterparts. National guidelines for indications do not exist and ordering of toxicology testing may be applied inequitably. This study aimed to evaluate whether any documented indications in a large cohort of patients were associated with a positive toxicology test and whether indications for urine toxicology testing were applied consistently to different demographic groups. This was a retrospective cohort study reviewing pregnant and delivering patients who underwent toxicology testing on obstetrical units at 1 institution from May 30, 2015, to December 31, 2018. Age, race, marital status, median income of residential ZIP code, indications for testing, and test results were collected for each patient by individual chart review. Indications included preterm complications (preterm prelabor rupture of membranes or preterm labor), abruption or hypertension, reported substance use, fetal complications, maternal complications, and none. Multivariate logistic regression models were analyzed for the association between indication and test result and the likelihood of marijuana as the sole positive test result. Logistic regression was used to evaluate the relationship of indication for testing with maternal race. Among 20,274 births, 551 patients underwent toxicology testing during the study period. No indication for drug toxicology testing was associated with a positive result, except reported current or previous substance use. Compared with White patients, Black and Hispanic women were 4.26 times (95% confidence interval, 2.55-7.09) and 5.75 times (95% confidence interval, 2.89-11.43) more likely to have toxicology testing for an indication other than reported substance use, respectively. Of all patients with positive test results (n=194), 48% tested positive for marijuana only. Compared with their White counterparts, Black and Hispanic pregnant and delivering patients may be more frequently toxicology tested for indications less clearly associated with illicit substance use. The absence of evidence-based guidelines for toxicology testing on obstetrical units risks inequitable care and stigmatization of patient groups.

Pediatric surgery and future risk of cocaine, opioid, cannabis, and other substance use in women: longitudinal cohort study

BackgroundSubstance use is problematic in young women, particularly in pregnancy. We sought to determine whether pediatric surgery is associated with the subsequent risk of adolescent or pregnancy-related illicit drug use, including cocaine, opioids, cannabis, and other drugs. MethodsWe analyzed a cohort of 167,119 girls aged five years or less in Canada with 4,693,444 person-years of follow-up. We tracked the girls over time between 1989 and 2018. The main exposure measure was pediatric surgery before 20 years of age. The main outcome included subsequent hospitalizations for substance use disorders and substance use in pregnancy. We estimated hazard ratios and 95% confidence intervals (CI) for the association of pediatric surgery with the later risk of substance use, using Cox proportional hazards regression models adjusted for patient characteristics. ResultsPediatric surgery was associated with 2.08 times the risk of future hospitalization for substance use disorders (95% CI 1.96-2.22) and 1.48 times the risk of substance use in pregnancy (95% CI 1.35-1.62), compared with no surgery. Associations were stronger for girls who had surgery under general anesthesia and were present regardless of age at first surgery or total number of surgeries. Pediatric surgery was associated with the use of cocaine, opioids, cannabis, and other illicit substances later in life. ConclusionsThis study suggests that pediatric surgery may be associated with future substance use disorders in women, including substance use at pregnancy. Further study is needed to determine whether surgery may have a causal role in later drug abuse by women.

Heterogeneity in prenatal substance use screening despite universal screening recommendations: findings from the Pregnancy Risk Assessment Monitoring System, 2016–2018

The American College of Obstetricians and Gynecologists recommends universal screening for tobacco, alcohol, and drug use as a part of routine prenatal care. However, little is known about the prevalence of prenatal substance use screening or factors that may contribute to differential rates of screening during prenatal care. This study aimed to describe the prevalence of prenatal substance use screening by substance, year, state, and state-level prenatal substance use policies and to examine individual-level factors associated with receipt of screening. We analyzed 2016 to 2018 data from 103,608 women participating in the Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births. The Pregnancy Risk Assessment Monitoring System survey sampling weights were applied to all analyses. We described the percentage of individuals asked by a healthcare worker about substance use during a prenatal care appointment by substance, year, and state. Using chi-squared tests, we examined differences in the prevalence of screening by state-level prenatal substance use policies, including policies regarding classification of prenatal substance use as child abuse or neglect, mandatory testing or reporting of prenatal substance use, and targeted treatment funding and access for pregnant individuals with substance use disorders. Finally, we estimated the association between individual-level characteristics and receipt of prenatal substance use screening using logistic regression, controlling for year and state fixed effects and accounting for missingness using multiple imputation. In 2018, approximately 95% individuals reported being asked about cigarette or alcohol use during a prenatal care appointment, whereas only 80% reported being asked about drug use. The percentage of individuals who were asked about substance use during a prenatal care appointment increased overall between 2016 and 2018, with variability across states. For all substances, states with laws designating prenatal drug use as child abuse or neglect had lower prevalence of screening, whereas states with laws mandating providers to test for substance use in pregnancy had higher prevalence of screening. Several individual-level characteristics were associated with increased odds of reported prenatal substance use screening for one or more substances, including being younger, less educated, unmarried, Black (vs White), non-Hispanic, or publicly insured (vs privately insured), receiving adequate prenatal care, and having a history of prepregnancy cigarette use. Our study finds that despite recommendations for universal prenatal substance use screening, there are differences in who is actually asked about substance use during prenatal care appointments. This may be influenced by state-level prenatal substance use policies and selective screening approaches in which certain individuals are more likely to be asked about substance use during their prenatal care appointment. A better understanding of the repercussions of selective screening approaches on outcomes and the roles that policies, systems, and provider biases play in perpetuating these approaches is needed to advance guideline implementation efforts in prenatal care settings.

Alcohol and substance use in pregnancy during the COVID-19 pandemic

BackgroundThe impact of the COVID-19 pandemic on alcohol and substance use has been a topic of concern. Pregnant women are currently experiencing elevated anxiety and depression symptoms, which may increase risk of substance use, and potentially result in poor perinatal and neurodevelopmental outcomes for children. MethodsSurvey results were analyzed from an ongoing study of 7470 pregnant individuals in Canada: Pregnancy during the COVID-19 Pandemic. Participants were asked about current use of alcohol and substances, symptoms of depression and anxiety, and COVID-19 concerns: how much they worry about COVID-19 threatening their baby’s life, threatening their own life, care for themselves or the baby, feelings of social isolation, and financial difficulties. ResultsThe percentage of participants who reported use during pregnancy was 6.7 % for alcohol, 4.3 % for cannabis, 4.9 % for tobacco, and 0.3 % for illicit drugs; 2.6 % were using multiple substances. Higher depression symptoms and financial difficulties were associated with more cannabis and/or tobacco use as well as the co-use of substances. There were no associations between alcohol use and mental health or COVID-19 concerns. ConclusionsSelf-reported rates of use and co-use were lower or comparable to previous research, perhaps reflecting pandemic-related circumstances or the demographics of this sample. Depression symptoms and pandemic-related financial difficulties were associated with more tobacco use, cannabis use, and substance co-use. It remains important to maintain access to perinatal, mental health, and financial supports during the pandemic to mitigate prenatal alcohol and substance use and prevent poor perinatal and long-term neurodevelopmental outcomes for children.

Developing a model of care for substance use in pregnancy and parenting services, Sydney, Australia: Service provider perspectives

IntroductionThe absence of a clear model of care for services supporting pregnant women and mothers with substance use disorders has impeded opportunities to build an evidence base for the effectiveness of these services. Previous research has typically focused on the needs of pregnant women or mothers, as two distinct groups. This paper explores service providers' perceptions of key components of a model of care, extending from perinatal care to community-based support for up to 17 years post-delivery. A model of care is outlined and feasibility factors affecting implementation are highlighted. MethodsQualitative methods were adopted as a first step to informing development of the model of care. Semi-structured in-depth interviews were conducted with thirty-eight staff providing a range of substance use in pregnancy and parenting services (SUPPS) in hospital and community-based agencies, in a metropolitan health district in Sydney, Australia. Interview data was entered into NVivo and analysed using constant comparative methods. ResultsGuiding principles for the model of care included integrated care, harm reduction and person-centredness. Practice approaches integral to the model of care were promoting engagement with women, flexible service provision, trauma-informed care, and continuity of care. Feasibility factors influencing implementation of the model of care included fragmentation or siloing of the service network and workforce sustainability. ConclusionsA harm reduction approach was crucial for promoting engagement of women with SUPPS, particularly child protection services. A greater focus on providing ongoing community-based support for mothers also has the potential to achieve sustainable positive outcomes for women and children. Implementation of the SUPPS model of care could be undermined by threats to integration of service delivery and continuity of care. Further research is needed to explore consumer perspectives and inform the model of care as a framework for evaluation.

A qualitative assessment of structural barriers to prenatal care and congenital syphilis prevention in Kern County, California.

Congenital syphilis is the result of placental transmission from mother to fetus of Treponema pallidum. Although congenital syphilis is preventable through timely treatment, the rate of new infections in the United States (US) has increased each year since 2013, and is increasing at a noticeably greater pace in California (CA). Most research into congenital syphilis has focused on individual psychosocial and behavioral factors that contribute to maternal vulnerability for syphilis. The aim of this study was to evaluate structural barriers to prenatal care access and utilization and congenital syphilis prevention in Kern County, CA. Transcripts from 8 in-depth interviews with prenatal care providers and 5 focus group discussions with 42 pregnant and postpartum persons were examined using thematic analysis. Structural barriers experienced by pregnant and postpartum persons to prenatal care access and utilization included (1) burdens of poverty; (2) stigma around substance use in pregnancy; (3) citizenship status; (4) lack of healthcare coverage; (5) low sexual health literacy; and (6) gender inequality Structural barriers experienced by prenatal care providers in congenital syphilis prevention included (1) limited guidance on clinical management of syphilis in pregnancy; (2) decay in public health infrastructure; and (3) inadequate support for managing patients’ social comorbidities. The response to congenital syphilis prevention will require an examination of the complex context of social determinants of health in which persons diagnosed with syphilis live in.

Preschool Language Development of Children Born to Women with an Opioid Use Disorder.

Increasing evidence suggests that prenatal exposure to opioids may affect brain development, but limited data exist on the effects of opioid-exposure on preschool language development. Our study aimed to characterize the nature and prevalence of language problems in children prenatally exposed to opioids, and the factors that support or hinder language acquisition. A sample of 100 children born to pregnant women in methadone maintenance treatment and 110 randomly identified non-exposed children were studied from birth to age 4.5 years. At 4.5 years, 89 opioid-exposed and 103 non-exposed children completed the preschool version of the Clinical Evaluation of Language Fundamentals (CELF-P) as part of a comprehensive neurodevelopmental assessment. Children prenatally exposed to opioids had poorer receptive and expressive language outcomes at age 4.5 years compared to non-opioid exposed children. After adjustment for child sex, maternal education, other pregnancy substance use, maternal pregnancy nutrition and prenatal depression, opioid exposure remained a significant independent predictor of children’s total CELF-P language score. Examination of a range of potential intervening factors showed that a composite measure of the quality of parenting and home environment at age 18 months and early childhood education participation at 4.5 years were important positive mediators.

Assessing Stigma Towards Substance Use in Pregnancy: A Randomized Study Testing the Impact of Stigmatizing Language and Type of Opioid Use on Attitudes Toward Mothers With Opioid Use Disorder.

To examine the extent to which colloquial phrases used to describe opioid-exposed mother-infant dyads affects attitudes toward mothers with opioid use disorder (OUD) to assess the role stigmatizing language may have on the care of mothers with OUD. We employed a randomized, cross-sectional, case vignette of an opioid-exposed dyad, varying on 2 factors: (1) language to describe newborn ("substance-exposed newborn" vs "addicted baby") and (2) type of maternal opioid use (injection heroin vs nonmedical use of prescription opioids). Participants were recruited using an online survey platform. Substance-related stigma, punitive-blaming, and supportive scales were constructed to assess attitudes. Two-way analyses of variance were conducted to determine mean scale differences by vignette. Posthoc analyses assessed individual item-level differences. Among 1227 respondents, we found a small statistical difference between language and opioid type factors for the supportive scale only (F = 4.31, η2 = .004, P = 0.038), with greater agreement with supportive statements when describing injection heroin use, compared to prescription opioid use, for the "substance-exposed newborn" vignette only. In posthoc analyses, greater than 85% of respondents agreed the mother was "responsible for her opioid use," her "addiction was caused by poor choices," and that she "put her baby in danger." We found no major differences in attitudes regardless of vignette received. Overall, respondents supported opportunities for maternal recovery yet blamed women, describing mothers as culpable for causing harm to their newborn, showcasing internally conflicting views. These views could contribute to ongoing stigma and avoidance of care among pregnant women with OUD.

Implementation of a Universal Screening Process for Substance Use in Pregnancy.

To implement a standardized universal substance use screening process in an outpatient prenatal clinic at an urban tertiary care hospital. Using a quality-improvement framework that involved process modeling, stakeholder analyses, and plan-do-study-act cycles, we implemented universal substance use screening for prenatal patients using a modified 5Ps screening tool (Parents, Peers, Partner, Past, Present). Implementation included an operational workflow based on the SBIRT (Screening, Brief Intervention, Referral to Treatment) model. The primary outcome measure was percentage of patients who were screened for substance use, with a goal of 90% screened. Secondary outcome measures were percentage who screened positive and percentage of the time a positive screen resulted in documentation of a brief intervention by a health care practitioner. Over a 19-month implementation period, 733 patient encounters were sampled. A substance use screen was completed in 618 (84%). We exceeded our goal of screening 90% of eligible patients for the final 6 months of data collection. Of the 618 completed screens, 124 (20%) screened positive. Health care practitioner documentation of brief interventions for patients with a positive screen reached 80% in the final phase of implementation, but then declined to 50% by the completion of the study period. A sustainable and generalizable process to carry out substance use screening within a large prenatal practice is feasible, and assisted with identification of patients not known to be at risk. Further efforts are needed to evaluate how to sustain health care practitioner documentation of intervention in response to positive screens.

Magnitude and associated factors of substance use among pregnant women attending antenatal care in public hospitals of eastern Ethiopia

BackgroundUse of substances like alcohol, tobacco and khat during pregnancy can bring miscarriage, prematurity, neurodevelopmental problems, sudden infant death syndrome and others. There are limited studies on the magnitude and associated factors of substance use among pregnant women in Eastern Ethiopia. Therefore, the aim of this study was to assess the magnitude and associated factors of substance use among pregnant women attending antenatal care in public hospitals of Easttern Ethiopia, 2019.MethodHospital based cross-sectional study was employed on 510 pregnant women attending ANC at public hospitals of Eastern Ethiopia (Jigjiga, Dire Dawa and Harar towns). Data were collected from the study participants that were selected using systematic sampling method from each public hospital. The data were collected through interviewer administered structured questionnaire. Binary logistic regressions with 95% confidence interval were used to determine the degree of association between covariates and outcome variable. Multicollinearity between independent variables by using the standard error was checked. The goodness of fit was tested by Hosmer-Lemeshow statistic and Omnibus tests.ResultsOut of 526 participants, a total of 510 study participants were involved in this study thereby making a response rate of 96.9%. In this study, the magnitude of substance use among pregnant women attending ANC was 26.5% (95% CI: 22.7, 30.6%). Among the overall pregnant mothers, 100 (19.6%) chewed khat, 48 (9.4%) drank alcohol, 12 (2.4%) used tobacco products and 28(20.7%) were dual substance users. Pre pregnancy substance use (AOR = 27.25, CI: 14.107–52.66), partner substance use (AOR = 3.704 CI: 1.839–7.464), family substance use (AOR = 3.447 CI: 1.69–7.031) and the amount of monthly household income (AOR = 3.397, 95% CI: 1.316–8.766) were found to be statistically significant and positively associated with substance use during pregnancy.ConclusionThe magnitude of antenatal substance use in the study area was 26.5%. Pre- pregnancy substance use, partner substance use, monthly house hold income and family substance use were found to be positively associated with substance use during pregnancy. Therefore, health education which is inclusive of child bearing age women with their partner and family may be helpful to decrease antenatal substance use during pregnancy.

Prenatal Substance Exposure and Child Maltreatment: A Systematic Review.

State and federal policies regarding substance use in pregnancy, specifically whether a notification to child protective services is required, continue to evolve. To inform practice, policy, and future research, we sought to synthesize and critically evaluate the existing literature regarding the association of prenatal substance exposure with child maltreatment. We conducted a comprehensive electronic search of PubMed, Web of Science, PsycInfo, CHINAL, Social Work Abstracts, Sociological Abstracts, and Social Services Abstracts. We identified 30 studies that examined the association of exposure to any/multiple substances, cocaine, alcohol, opioids, marijuana, and amphetamine/methamphetamine with child maltreatment. Overall, results indicated that substance exposed infants have an increased likelihood of child protective services involvement, maternal self-reported risk of maltreatment behaviors, hospitalizations and clinic visits for suspected maltreatment, and adolescent retrospective self-report of maltreatment compared to unexposed infants. While study results suggest an association of prenatal substance exposure with child maltreatment, there are several methodological considerations that have implications for results and interpretation, including definitions of prenatal substance exposure and maltreatment, study populations used, and potential unmeasured confounding. As each may bias study results, careful interpretation and further research are warranted to appropriately inform programs and policy.

Pathways from Maternal Adverse Childhood Experiences to Substance Use in Pregnancy: Findings from the All Our Families Cohort.

Background: Exposure to adverse childhood experiences (ACEs) is a risk factor for maternal substance use in pregnancy, however, mechanisms by which maternal ACEs may influence substance use in pregnancy have not been fully explored. The current study examines the association between maternal ACEs and substance use in pregnancy (i.e., alcohol, smoking, and drug use) and explores mediating pathways. Methods: A community sample of 1,994 women as part of the All Our Families Cohort were recruited in pregnancy in Calgary, Canada, between 2008 and 2011. Women provided retrospective reports of ACE exposure before age 18 as well as reports of demographic information, substance use (i.e., moderate-to-high alcohol use, any smoking, or any drug use), a previous history of substance use difficulties, and depressive symptoms during pregnancy. Path analyses were used to examine maternal income, education, depression, and previous substance use as mediating variables. Results: There were significant indirect associations between maternal ACEs and maternal substance use in pregnancy via maternal education (β = 0.05, p < 0.001), previous substance use (β = 0.01, p = 0.001), and depression (β = 0.02, p = 0.02). The direct effect of maternal ACEs on maternal substance in pregnancy remained significant after accounting for the indirect effects (β = 0.22, 95% CI = 0.15-0.29, p < 0.001). Conclusions: Exposure to adversity in childhood can lead to socioeconomic and mental health difficulties that increase risk for substance use in pregnancy. Addressing these difficulties before pregnancy may help to reduce the potential for substance use in pregnancy.

Preterm Birth and Antiretroviral Exposure in Infants HIV-exposed Uninfected.

Infants HIV-exposed and uninfected (IHEU) who are born to women living with HIV are at an increased risk of preterm birth (PTB). Antenatal exposure to certain maternal antiretroviral therapy (ART) regimens has been associated with PTB, although existing studies in this domain are limited and report discordant findings. We determined odds of PTB among IHEU by antenatal ART regimens and timing of exposure, adjusting for maternal risk factors. We retrospectively studied IHEU born in British Columbia (BC), Canada between 1990 and 2012 utilizing provincial health administrative databases. We included data from a control group of infants HIV-unexposed and uninfected (IHUU) matched ~3:1 for each IHEU on age, sex and geocode. A total of 411 IHEU and 1224 IHUU were included in univariable analysis. PTB was more frequent among IHEU (20%) compared with IHUU (7%). IHEU were more often antenatally exposed to alcohol, tobacco, as well as prescription, nonprescription, and illicit drugs (IHEU: 36%, 8% and 35%; vs. IHUU: 3%, 1% and 9%, respectively). After adjusting for maternal substance use and smoking exposure, IHEU remained at increased odds of PTB [adjusted odds ratio (aOR) (95% CI): 2.66; (1.73, 4.08)] compared with matched IHUU controls. ART-exposed IHEU (excluding those with NRTIs only ART) had lower adjusted odds of PTB compared with IHEU with no maternal ART exposure, regardless of regimen [aOR range: 0.16-0.29 (0.02-0.95)]. Odds of PTB between IHEU exposed to ART from conception compared with IHEU exposed to ART postconception did not differ [aOR: 0.91 (0.47, 1.76)]; however, both groups experienced lower odds of PTB compared with IHEU with no maternal ART [preconception: aOR: 0.28 (0.08, 0.89); postconception: aOR 0.30 (0.11, 0.83)]. BC IHEU were over twice as likely to be born preterm compared with demographically matched controls. Maternal substance use in pregnancy modulated this risk; however, we found no adverse associations of PTB with exposure to antenatal ART.

Prenatal methadone exposure and child developmental outcomes in 2-year-old children.

To examine the developmental outcomes of children born to opioid-dependent females enrolled in methadone maintenance and identify pre- and postnatal factors that place these children at developmental risk. Ninety-nine methadone-maintained females and their 100 infants (42 females, 58 males, mean gestational age 38.8wks) were recruited during pregnancy/at birth and studied to age 2years alongside a regionally representative comparison group of 108 non-methadone-maintained females and their 110 infants (62 females, 48 males, mean gestational age 39.2wks). Information about perinatal exposure was collected from medical records, maternal urine and infant meconium toxicological analysis, maternal interviews (at birth and at 18mo), and a home visit (at 18mo). At age 2years, child neuromotor function, cognition, language, and emotional/behavioral dysregulation were assessed. Opioid-exposed children achieved lower motor, cognitive, and language scores and had poorer self, emotional, eating/feeding, and sensory processing regulation than unexposed children. After adjustment for maternal education and other substance use in pregnancy, between-group differences in child motor, cognitive, and overall dysregulation remained. Postnatal parental and family factors explained a further 40% to 52% of between-group differences in child outcomes. These children and families are extremely high-risk and need antenatal and postnatal support. Children exposed to opioids during pregnancy have pervasive developmental difficulties by age 2years. These challenges are largely explained by adverse pregnancy and socio-environmental exposures, emphasizing the importance of specialist prenatal care and postnatal intervention support. What this paper adds Children born to opioid-dependent females are at high risk of pervasive developmental problems. These problems span a range of functional domains, including motor, cognitive, language, and behavioral/emotional dysregulation. Contributing factors include other adverse pregnancy exposures, postnatal environmental factors, and the direct effects of prenatal opioid exposure.

Prenatal Care Outcomes in Women with Substance Use Disorders: A Retrospective Cohort Study.

This study sought to examine and compare the characteristics and prenatal care and pregnancy outcomes of women with and without substance use disorder (SUD). It also examined whether there were differences in prenatal care and pregnancy outcomes within the population of substance-using women based on the stability of their SUD during pregnancy. This retrospective cohort study involved pregnant women with and without SUD who accessed care through the Maternity Centre of Hamilton between 2015 and 2017. Cases and controls were matched 1:1 for gravidity, parity, ethnicity, smoking status, and postal code. Fifty-five pregnant women with SUD were identified and matched to 55 pregnant women without SUD. When analyzed by stability of substance use, women with stable SUD had similar outcomes to those of women without SUD. Women with unstable SUD received the poorest prenatal care and were more likely to have their infants removed from their care. There was significant movement towards stability of maternal substance use over the course of pregnancy in our integrated prenatal and addiction care model. Women with unstable SUD had poorer prenatal care and higher rates of custody loss than those with stable substance use disorders or those without substance use disorders. The disparate outcomes among women with unstable SUD may indicate a need to identify patients requiring greater support at entry into prenatal care and to target services accordingly. This integrated prenatal and addiction care model was effective in reducing maternal substance use in pregnancy.

Co-occurring Substance Use Disorders Identified Among Delivery Hospitalizations in the United States.

Substance use in pregnancy is increasing in the United States (US), although little is know about co-occurring substance use disorders in pregnancy. Our objective was to determine the prevalence and patterns of co-occurring substance use disorders identified at delivery hospitalizations among US women. Using data from the National Inpatient Sample, a nationally representative sample of hospitalizations in the US, we identified females ages 15 to 44 years with a delivery hospitalization from 2007 to 2016 (weighted N = 38 million). We identified diagnoses for use of any of the following substance use disorders: alcohol, amphetamines, cannabis, cocaine, opioids, sedatives, or tobacco. Using multivariable regression, we calculated the weighted adjusted prevalence of additional substances used within each specific substance use disorder category. Seven percent of women were diagnosed with any substance use disorder at delivery hospitalization (6.5% tobacco, 1% cannabis, 0.5% opioids, and <1% amphetamines, alcohol, cocaine, and sedatives). Among those with any substance use disorder diagnosis, the adjusted prevalence of any co-occurring use disorder was greatest for those who used alcohol (69%), cocaine (69%), amphetamines (63%), and opioids (62%). Among pregnant women who were diagnosed with cocaine, amphetamines, alcohol or opioid use disorder, tobacco (>45% in all groups), and cannabis (>10% in all groups) were the most common additional substances used. Tobacco and cannabis use disorders were commonly diagnosed together. Co-occurring substance use disorders are common among women with any substance use disorder in pregnancy. Findings support the need for public health efforts to monitor and address multiple, concurrent use of substances in pregnancy.

Maternal substance use in pregnancy: Differential prediction by childhood adversity subtypes

Substance use in pregnancy, including alcohol use, drug use, or smoking, is associated with poor health outcomes for both the mother and her unborn child. Building on previous research that has examined the cumulative impact of Adverse Childhood Experiences (ACEs) on maternal binge drinking and alcohol use in pregnancy, the current study sought to examine the association between maternal ACEs and substance use in pregnancy more broadly, including alcohol use, binge drinking, smoking, and drug use. Furthermore, we also examined how different adversity subtypes, including sexual abuse, family violence (physical abuse, emotional abuse), and household dysfunction, differentially predict maternal substance use behavior. A sample of 1994 women were recruited between 2008 and 2011 from a community-based pregnancy cohort in Calgary, Canada. Self-reported information on exposure to ACEs prior to the age of 18 years and maternal substance usewere collected. Examining ACE subtypes, medium effects were observed for the role of household-dysfunction on binge drinking, drug use, and smoking in pregnancy, while only small effects were observed for family violence on binge drinking, drug use, and smoking. There were no significant effects for sexual abuse after controlling for covariates. A dose-response association between the number of ACEs and substance use in pregnancy was also demonstrated. Increased support prior to, and in pregnancy, particularly for women with a history of childhood adversity, is needed to reduce substance use behaviors in pregnancy.

Self-regulation and emotional reactivity in infants with prenatal exposure to opioids and alcohol

BackgroundInfants with prenatal substance exposure are at increased risk for developmental problems, with self-regulatory challenges being some of the most pronounced. The current study aimed to investigate the extent to which prenatal substance exposure (alcohol, opioids) impacts infant self-regulation during a relational stressor and the association between self-regulation and infant affect. MethodsParticipants were 100 mother-child dyads recruited prenatally (Mean = 23.8 gestational weeks) and completed the Still Face Paradigm (SFP) when infants were 5 to 8 months of age (Mean = 6.9 months) as part of an ENRICH prospective birth cohort study. Based on prospective repeated assessment of maternal substance use in pregnancy, infants were grouped into: 1) Unexposed controls; 2) Alcohol-exposed; 3) Opioid-exposed due to maternal use of medications for opioid use disorder (MOUD) with or without other opioids; 4) MOUD and alcohol. Infant stress reactivity (negative affect) and self-regulation were assessed during the validated 5-episode SFP. Mixed effects linear models were used to analyze differences in the percent of self-regulation and percent of negative affect among the study groups across SFP episodes, as well as the group-by-self-regulation interaction with respect to infant negative affect. ResultsThe MOUD+Alcohol group demonstrated significantly lower self-regulation at baseline compared to controls (p < 0.05). There was a significant group-by-self-regulation interaction (p = 0.028). Higher self-regulation was associated with lower negative affect across SFP episodes in the MOUD+Alcohol group (p = 0.025) but not other groups. ConclusionSelf-regulation skills are particularly important for emotional modulation in infants with prenatal polysubstance exposure, highlighting the development of these skills as a promising intervention target.

Substance Use in Pregnancy Remains a Challenge

Back to table of contents Previous article Next article Clinical & ResearchFull AccessSubstance Use in Pregnancy Remains a ChallengeTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:17 Jun 2020https://doi.org/10.1176/appi.pn.2020.6b2AbstractCigarette smoking and opioid use disorder in pregnant women illustrate the need for more screening, education, and treatment.Psychiatrists should screen all of their pregnant patients for substance use, including cigarette smoking, says Kimberly Yonkers, M.D.Yale University/Robert A LisakFour in five women who decrease or stop hazardous alcohol, tobacco, or drug use during pregnancy return to using those substances after their babies are born, but there are concrete steps psychiatrists can take to treat women both before and throughout their pregnancies. Kimberly Yonkers, M.D., director of the Division of Psychological Medicine and the Center for Wellbeing of Women and Mothers at Yale School of Medicine, discussed different substances, their impact on maternal and infant health, and the importance of tailored treatment in a presentation at the virtual APA Spring Highlights Meeting in April.Pregnant women tend to stop using alcohol earlier in their pregnancies than they stop using tobacco, cocaine, or marijuana, and they are slowest to stop smoking cigarettes, with many women smoking throughout pregnancy or resuming smoking shortly after delivery, explained Yonkers, who is also editor of the APA journal Psychiatric Research and Clinical Practice.“Cigarette smoking in general has been decreasing, but still between 10% and 15% of women [smoke], and it’s very, very difficult to discontinue smoking, even in pregnancy,” Yonkers said.She noted that pharmacological treatments have not shown a benefit in treating pregnant women who smoke. For patients who use nicotine replacement products, intermittent treatments like gum or inhalers may provide benefit with less nicotine exposure than patches. She cautioned against the use of e-cigarettes.“E-cigarettes are no panacea. The solvents can be a hazard to women,” Yonkers said.Illicit drug use, notably illicit opioid use, also takes a tremendous toll on pregnant women and their infants.“The rates of opioid use disorder have gone up in the general population, and pregnant women are not immune to this,” Yonkers said. She added that although pregnancy-associated mortality rose 34% between 2007 and 2019, pregnancy deaths related to opioids doubled during that time. “We have to be careful that we’re not just taking care of kids and offspring. We have to take care of moms.”To that end, the first step is to screen all pregnant women for substance use disorders, Yonkers said. “If you are not universally screening, you are missing people. That doesn’t mean grabbing a urine test from them. It just means asking them and, ideally, engaging them in treatment.”Yonkers discussed the benefits of medication treatment for opioid use disorder (OUD), noting that maintenance treatment increases the use of prenatal care among pregnant women and decreases craving for other illicit drugs. She added that medication treatment may increase birthweight in infants born to women who receive it, compared with birthweight in infants born to women who do not receive medication treatment.Yonkers highlighted guidance by the Council on Patient Safety in Women’s Health Care, a group of women’s health organizations, on working with pregnant women who use substances. In addition to universal screening, other key steps the Council recommends include the following:Providing education about substance use disorders, including explaining that they are chronic medical conditions and that medication treatment works for OUD, and explaining the risks of neonatal abstinence syndrome.Matching treatment with the woman’s stage of recovery.Ensuring that all patients with substance use disorders are enrolled in a treatment program, coordinating care among health professionals, and engaging child welfare in safe care protocols. ■ ISSUES NewArchived