Prevalence of Substance Use Disorders in Pregnancy and the Postpartum Period

Substance use disorders (SUDs) have become increasingly prevalent among women of childbearing age over the past decade. Of concern is that we have also seen an increase in the number of individuals using cannaib and other illicit drugs during pregnancy.  This trend mirrors the broader epidemic of substance use observed in the general population. 

The prevalence of substance use varies depending on the specific substance and stage of pregnancy.   It is important to note that substance use often decreases during pregnancy compared to pre-pregnancy levels. Many women are able to quit or reduce their substance use as they plan for pregnancy or upon learning they are pregnant. However, those who continue to use substances during pregnancy are more likely to have a substance use disorder, which requires specialized treatment and support.

Racial and ethnic disparities exist in the prevalence and consequences of perinatal substance use. Studies have found that white women have the highest prevalence of drug use during the postpartum period, followed by Black and Hispanic women. However, Black women appear to be at greater risk for adverse consequences related to substance use during pregnancy and postpartum.

Screening for Perinatal Substance Use and Abuse

Early identification of substance use during pregnancy is crucial for improving maternal and infant outcomes. Universal screening for substance use is recommended as part of comprehensive obstetric care and should be conducted at the first prenatal visit. The American College of Obstetricians and Gynecologists (ACOG) emphasizes that screening should be done in partnership with the pregnant patient and should be universal, regardless of race, ethnicity, or socioeconomic status.

Several validated screening tools are available for identifying substance use during pregnancy:

1. NIDA Quick Screen/ASSIST: This tool combines a brief initial screen followed by a more comprehensive assessment for those who screen positive.  

2. 4 P’s Plus: A short screening tool specifically designed for use with pregnant women.

3. Substance Use Risk Profile-Pregnancy (SURP-P): A simple three-question scale that can differentiate between low-risk and high-risk populations of pregnant women.

These screening tools typically involve asking questions about past and current substance use, as well as assessing the impact of substance use on various life domains.  When conducting screening for substance use,  it is important to use non-judgmental, person-centered language to build trust and to encourage honest disclosure.

In addition to verbal screening, some healthcare providers may use biological testing methods, such as urine or blood toxicology screens. However, these should only be conducted with informed consent and should not be used punitively.

It’s crucial to note that punitive policies towards substance use in pregnancy have been shown to decrease prenatal care utilization and do not improve birth outcomes. Instead, a supportive, non-judgmental approach that focuses on the health of both the mother and baby is recommended.

Alcohol 

Alcohol consumption during pregnancy remains a significant concern due to its potential to cause serious harm to the developing fetus. Fetal Alcohol Spectrum Disorders (FASDs) are a group of conditions that can occur when a fetus is exposed to alcohol in utero.  These disorders can lead to lifelong physical, behavioral, and learning problems.

There is no known safe amount of alcohol use during pregnancy. The Centers for Disease Control and Prevention (CDC) and other health organizations recommend complete abstinence from alcohol during pregnancy. While heavy alcohol use and binging are associated with greater risk for FASDs, even light or moderate drinking can potentially affect the developing fetus.

For women who are struggling with alcohol use during pregnancy, several interventions may be helpful:

1. Brief interventions and counseling: These can be effective in helping some women reduce or stop alcohol use.

2. Referral to specialized treatment programs: For women with alcohol use disorders, more intensive treatment may be necessary.

3. Medication-assisted treatment: In some cases, medications may be used to manage alcohol withdrawal symptoms under close medical supervision.

It’s important to note that women who have been drinking alcohol during pregnancy should be encouraged to stop at any time – it’s never too late to benefit the baby’s health.

Cannabis

The prevalence of cannabis use among women of childbearing age (between the ages of 15 and 44) has increased in recent years, particularly in regions where cannabis has been legalized or decriminalized. According to data from the CDC and the National Survey on Drug Use and Health (NSDUH), approximately 17.3% of U.S. women in this age group reported cannabis use in the past year, and 11.1% reported past-month use as of 2021. Among pregnant women, about 7.0% reported using cannabis in the past month, with rates rising to 12–13% during the first trimester, often citing reasons such as nausea or anxiety.

Cannabis use during pregnancy has become increasingly prevalent as more states legalize its recreational use. However, the potential risks to fetal development are concerning. A recent study found that prenatal cannabis use was linked to adverse outcomes for both mother and baby.

The active compounds in cannabis, particularly THC, can cross the placenta and potentially interfere with fetal brain development. Prenatal cannabis exposure has been associated with the following adverse outcomes: 

• Lower birth weight
• Increased risk of preterm birth
• Higher rates of admission to neonatal intensive care units
• Potential long-term effects on child behavior and cognition

Healthcare providers should counsel pregnant women about these potential risks and encourage cessation of cannabis use before and during pregnancy. For women who use cannabis for medical reasons, alternative treatments should be explored under medical supervision.

Opioids

Recent data from the CDC and large national surveys indicate that approximately 6–7% of pregnant women report using prescription opioid pain relievers during pregnancy. The majority of opioid use in pregnancy is prescription-based: In 2019, 84% of women who used opioids during pregnancy obtained them from a healthcare provider.  Misuse—defined as using opioids not prescribed to them or for reasons other than pain—was reported by 1 in 5 women (about 20%) who used prescription opioids during pregnancy. 

Opioid use during pregnancy presents significant challenges for both maternal and fetal health. The opioid epidemic has led to a sharp increase in the number of pregnant women with opioid use disorders. Untreated opioid use disorder during pregnancy is associated with poor fetal growth, preterm birth, stillbirth, and neonatal abstinence syndrome (NAS).

For pregnant women with opioid use disorder, medication-assisted treatment (MAT) with methadone or buprenorphine is the standard of care. These medications help to Improve prenatal care adherence, improve pregnancy outcomes, stabilize opioid levels,reduce withdrawal symptoms, and decrease risk of relapse.

Abrupt discontinuation of opioids during pregnancy can lead to withdrawal, which may be harmful to the fetus. Therefore, pregnant women should not attempt to stop opioid use without medical supervision.

Neonatal Abstinence Syndrome (NAS) is a group of conditions that can occur when newborns withdraw from certain substances, including opioids, that they were exposed to before birth. While NAS can be challenging, it is treatable, and long-term outcomes for infants can be positive with appropriate care and support.

Stimulants

Stimulants, including cocaine and methamphetamine, when abused during pregnancy can have serious consequences for both the mother and the developing fetus. These substances can cross the placenta and affect fetal development.

Other Potential risks associated with prenatal stimulant exposure include placental abruption, preterm labor, and intrauterine growth restriction.

Unlike opioids, there are no approved medication-assisted treatments for stimulant use disorders during pregnancy. Treatment typically involves behavioral interventions, such as cognitive-behavioral therapy and contingency management.

Pregnant women using stimulants should be encouraged to stop use and seek professional help. However, it’s important to approach this sensitively and without judgment, as fear of legal consequences can be a significant barrier to seeking prenatal care for women who use stimulants.

Postpartum Risks

The postpartum period presents unique challenges for women with substance use disorders. This time is characterized by significant physical, emotional, and social changes, which can increase vulnerability to substance use relapse.

Several factors contribute to increased risk during the postpartum period:

• Sleep deprivation and fatigue
• Postpartum depression and anxiety
• Pain from childbirth or cesarean section
• Decreased monitoring compared to the prenatal period
• Stress related to caring for a newborn

Alarmingly, drug-related deaths, including intentional and unintentional overdose, have become a leading cause of death among postpartum women, especially in the 6-12 months after birth. This highlights the critical need for continued support and treatment during the postpartum period.

Breastfeeding is another important consideration for postpartum women with substance use disorders. While breastfeeding is generally encouraged due to its numerous benefits for both mother and infant, the safety depends on multiple factors. Healthcare providers should discuss the risks and benefits of breastfeeding with each patient individually, taking into account the substance used, the potential for infant exposure, and the ability of the mother to appropriately care for her infant.

Support During Pregnancy and the Postpartum Period

Supporting mothers with substance use disorders requires a comprehensive, compassionate approach that addresses both the substance use and the unique needs of pregnant and parenting women. Several key elements are crucial for effective support:

1. Non-judgmental, person-centered care: It’s essential to approach these women with empathy and respect, recognizing substance use disorder as a medical condition rather than a moral failing.

2. Integrated care models: Programs that combine substance use treatment with prenatal care, mental health services, and parenting support have shown promising results.

3. Peer support: Recovery coaches and peer mentors who have lived experience with substance use and recovery can provide valuable emotional support and practical guidance.

4. Trauma-informed care: Many women with substance use disorders have histories of trauma. Care should be delivered in a way that recognizes and responds to the effects of trauma.

5. Addressing social determinants of health: Support should extend beyond medical care to include assistance with housing, transportation, childcare, and other social needs.

6. Continued postpartum support: Care should not end with delivery but should extend well into the postpartum period to support ongoing recovery and prevent relapse.

7. Family-centered approach: When possible, involving partners and other family members in treatment can improve outcomes and provide additional support for the mother.

8. Medication-assisted treatment: For opioid use disorders, MAT should be readily available and continued throughout pregnancy and postpartum.

9. Breastfeeding support: When appropriate, women should be supported in breastfeeding, as it can have benefits for both mother and infant, including potentially reducing the severity of neonatal abstinence syndrome.

10. Legal advocacy: Some programs offer support and advocacy for women involved with child protective services or the criminal justice system.

Focusing on Recovery and Wellness During the Perinatal Period

Programs like EMPOWER (Engaging Mothers for Positive Outcomes with Early Referrals) offer comprehensive support for pregnant and postpartum women with substance use disorders. These programs provide a range of services including peer support, doula services, assistance accessing treatment, and coordination with healthcare providers.

It’s crucial to recognize that recovery is a long-term process, and support should be ongoing. By providing comprehensive, compassionate care that addresses the complex needs of pregnant and parenting women with substance use disorders, we can improve outcomes for both mothers and their children.

In conclusion, perinatal substance use is a complex issue that requires a nuanced, evidence-based approach. By focusing on early identification through universal screening, providing appropriate treatment and support throughout pregnancy and the postpartum period, and addressing the multifaceted needs of these women, we can work towards better health outcomes for mothers and their children. It’s essential that healthcare providers, policymakers, and communities work together to create supportive environments that encourage women to seek help without fear of stigma or punishment.