Minimize Substance Use During Pregnancy

Introductory Paragraph

Drug, alcohol, and even tobacco use during pregnancy have lasting and sometimes detrimental effects on mothers and unborn babies. Prenatal use of substances cause the infant to be born with very serious health problems and can lead to stillbirths. In some cases, it can cause infant withdrawal symptoms, or dependency. Alcohol use during pregnancy can lead to what is known as Fetal Alcohol Syndrome (FAS), characterized by low birth weight, cognitive deficits, increased risk of birth defects, and behavioral problems later in life.

The unintended pregnancy rate among pregnant people with SUD is approximately 80%. 40% of pregnant people who drank alcohol during pregnancy reported co-using other substances, including tobacco, cannabis, cocaine, and heroin. Recently, the number of pregnant people using opioids has rapidly increased, in keeping with the increase observed in the general population.  Pregnant people with substance use disorder face multiple challenges and obstacles. Lack of access to medical care, ineffective collaboration among social service systems, stigma, and fear of punishment further compound their challenges.

Key Information

Studies suggest that pregnant people have a unique opportunity to embrace treatment and recovery options. However, they face significant barriers. Quitting substance use, especially when an individual has SUD, can be difficult, and they might find quitting complicated by the fear that asking for help could lead to potential social and even legal consequences. Reporting requirements and administrative policies of service agencies may lead to mandatory involvement with child protective services, loss of child custody, or other legal consequences. Limited child care options may deter mothers from seeking treatment. Likewise, pregnant people in treatment may need help with handling the burdens of work, home, and other family responsibilities.

Stigma is a large barrier to treatment and recovery. The societal stigma toward women who use substances tends to be greater than that toward men, and the stigma amplifies significantly for pregnant drug users. Women's ascribed role and the expectations placed on them influences societal perceptions and reactions toward women with SUDs. Women who use alcohol and illicit drugs feel shame and guilt regularly, and they often suffer from low levels of self-esteem and self-efficacy. Women with substance use issues often have high levels of comorbid mental health disorders. In 2019, there were 34.3M adult women who had a mental illness and/or SUD.

Substance use disorders can manifest differently in women than in men.   In the past, women were not included in most clinical research. Women may experience varying levels of discrimination in both healthcare and criminal justice systems that affect their substance use and may affect their recovery. Pregnant people using substances, particularly people of color and those in lower socioeconomic brackets, deal with increased surveillance and may face consequences, such as arrest and child removal. Some people use substances to cope with these stresses of discrimination. People dealing with SUD who struggle financially may have to deal with low-income unstable housing, lack of access to transportation and medical care, as well as poor nutrition. Less access to health care, and difficulty in funding treatment due to a lack of health insurance, can result in later referral for substance use treatment. Since residential treatment facilities are limited, pregnant people have reported several barriers to treatment and healthcare, including insufficient treatment options and difficulty locating and entering treatment.

Rural vs. urban geography also plays a role in substance use during pregnancy. Rates of substance use during pregnancy are typically higher in rural communities than in urban ones. However, most of the research on the prevalence, prevention, and treatment of substance abuse during pregnancy has focused on urban areas. Rural women are 9% more likely than urban women to face severe maternal morbidity mortality. They are also 59% more likely than urban women to have an SUD diagnosis at the time of birth. More opioids are prescribed in rural communities than in urban ones. This has led to prescription opioids being the most common type of drug abused by rural pregnant people. Noteworthy characteristics that make rural living more challenging are the lack of economic opportunity, transportation, and technological limitations.  Rural communities often have limited resources for prevention and treatment and lack the resources needed to provide services to parents dealing with substance use. 

Impacts

Prenatal habits are vital to the healthy development of the baby and the maintained health of the mother. Alcohol and drug use during pregnancy has many negative effects on both. Much of the research focuses on the physical effects of prenatal substance use on the fetus, but there are important impacts on the mother that must also be considered. One list of the potential negative consequences of substance use for mothers includes:

• psychosocial decline (stress, reduced social support, partner violence, isolation, financial/legal troubles, self harm),
• physical issues (vascular complications, infections, bodily trauma), and
• reduced frequency of prenatal care.

Impacts on the fetus are vast and vary by the specific substance. Consuming alcohol, however minor the amount, increases the baby’s risk of Fetal Alcohol Syndrome, preterm birth, teratogenicity, neurodevelopmental disorders, miscarriage, and stillbirth. Fetal Alcohol Syndrome impacts the baby’s physical growth and appearance, along with its emotional, behavioral, and cognitive health. Exposure to illicit drugs may have the following consequences:

• low birth weight and growth restriction
• preterm birth
• miscarriage
• stillbirth
• sudden infant death syndrome
• exaggerated startles and diminished crying response
• neonatal withdrawal or abstinence symptoms
• transient central and automatic nervous system symptoms
• congenital heart malformations
• abnormal physical developments

Postnatal impacts on the mother and baby extend beyond physio-social consequences. Mothers who use substances throughout pregnancy are at an increased risk of having the child removed from their care after birth. These child removals have been shown to lead to an increase in maternal drug use and mental health complications, especially in Black and Indigenous people. Those who do retain custody of their infants and continue substance use are at risk of atypical maternal-infant bonding and attachment, which is linked to adverse child outcomes.

Relevant Research

• National Institute on Drug Abuse (NIDA) has published a research report on substance use by women. It includes sections associated with breastfeeding, as well as sex and gender differences in substance use.  

• CDC Publishes MMWR (The Morbidity and Mortality Weekly Report). One of these is titled "Substance Use During Pregnancy Alcohol Use and Co-Use of Other Substances Among Pregnant Females Aged 12–44 Years — the United States, 2015–2018." It breaks down some of the findings in the National Survey on Drug Use and Health (NSDUH). For example, 38.2% of pregnant respondents who reported current drinking also reported current use of one or more other substances -- primarily tobacco and marijuana.

• Public Health Agency of Canada funded a national evaluation of multi-service programs that reach pregnant people at risk. This report was completed by the Nota Bene Consulting Group in partnership with the Centre of Excellence for Women’s Health. The evaluation was designed around a a theory of change developed that was collaboratively developed by organizations which were guided by a similar set of theoretical approaches, including being trauma-informed, relationship-based, women-centered, culturally-grounded, and harm-reducing.

• This article is titled "Concurrent Opioid and Alcohol Use Among Women Who Become Pregnant: Historical, Current, and Future Perspectives." It highlights the historical context of opioid and alcohol use during pregnancy, summarizes the current knowledge of opioids and alcohol use during pregnancy, and details future directions in how health care providers could help.

• This article is titled "Pregnant women and substance use: fear, stigma, and barriers to care." The research was based on interviews with 30 recently-pregnant people who had used alcohol or other drugs during their pregnancies. It highlights their strategies for managing their risk of detection by health or criminal justice authorities. It also documents multiple barriers to treatment and healthcare. The findings suggest that policies that substance-using people find threatening discourage them from seeking comprehensive medical treatment during their pregnancies. 

• Healthcare Cost and Utilization Project (H-CUP) generated a brief that presents statistics from the National Inpatient Sample (NIS) on delivery-related inpatient stays involving SUDs, for select types of substances (opioids, cocaine, and other stimulants), and for both urban and rural areas.

• Parenting Outcomes. This article provides a literature review on parenting skills and parenting needs of people with substance use issues.

• This study documents the increase in overdose deaths during pregnancy.  

Impactful Federal, State, and Local Policies

Any advances in public policy and public health strategies support the delivery of evidence-based care for pregnant people. A major policy need is in enhancing the training of professionals to be more attuned to the their needs. Advocacy for comprehensive care and professional services would benefit pregnant people.

• The Comprehensive Addiction and Recovery Act of 2016 (CARA) established a coordinated strategy through enhanced grant programs which expand prevention and education efforts while also promoting treatment and recovery. Section 501 (Improving Treatment for Pregnant and Postpartum Women) reauthorizes the Residential Treatment Program for Pregnant and Postpartum Women. It also authorizes the creation of grants within CSAT to enhance a state's services for people who are pregnant and postpartum while suffering from substance use disorder.

• SUPPORT Act. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act is federal legislation which addresses tighter oversight of opioid production and distribution. It imposes additional reporting and safeguards to address fraud, and it limits coverage of prescription opioids, while expanding coverage of and access to opioid addiction treatment services. The bill also authorizes a number of programs that seek to expand consumer education on opioid use and train additional providers to treat individuals with opioid use disorders. Section 503 of the SUPPORT Act (Infant Plan of Safe Care) requires HHS to produce information concerning best practices on developing plans for the safe care of infants born with substance use disorders or showing withdrawal symptoms. This section also requires that state plans address the health and SUD treatment needs of the infant.

• State Policy. Although federal public policy is advancing efforts to minimize substance use during pregnancy, there are many challenges with inconsistent efforts in state legislatures. This is driven by variations in geography, because federal grants give states the power to decide how to implement key elements of federal policies.
  • One area that is gaining public support is in the domain of child welfare and prenatal substance use. Several states have expanded their civil child-welfare requirements to include prenatal substance use, so that prenatal drug exposure can provide grounds for terminating parental rights because of child abuse or neglect. Further, some states, under the rubric of protecting the fetus, authorize civil commitment (such as forced admission to an inpatient treatment program) of pregnant people who use drugs. These policies sometimes also apply to alcohol use or other behaviors. A number of states require health care professionals to report or test for prenatal drug exposure, which can be used as evidence in child-welfare proceedings. And in order to receive federal child abuse prevention funds, states must require health care providers to notify child protective services when the provider cares for an infant affected by illegal substance use.
  • The National Academy for State Health Policy has an overview of state options for promoting recovery among pregnant and parenting people.

Available Tools and Resources

SAMHSA provides a fact sheet titled "Pregnancy Planning for Women Being Treated for Opioid Use Disorder."  

SAFE Project offers "Addiction and Mental Health Resources for Women," which includes a series of resources for support during pregnancy.

Pregnancy Justice, previously known as National Advocates for Pregnant Women (NAPW), works to secure the human and civil rights, health, and welfare of all people, focusing particularly on pregnant and parenting people, and those who are most likely to be targeted for state control and punishment because of gender, color, income, or and drug use.

Her Way Home provides non-judgmental health care and social supports for pregnant and parenting people who have a history of substance use and who may also be affected by mental health issues, violence, and trauma.

Promising Practices

Center for Addiction and Pregnancy (CAP), at The Johns Hopkins Bayview Medical Center, offers an innovative approach to help mothers and infants deal with the physical, emotional, and social problems caused by addiction. CAP is an outpatient program with an available overnight housing unit for patients requiring a recovery-oriented domicile. It provides a comprehensive, coordinated, and multidisciplinary approach to drug-dependent mothers and their drug-affected babies. 

Massachusetts. Project RESPECT (Recovery, Empowerment, Social Services, Prenatal care, Education, Community and Treatment) is a high-risk obstetrical and addiction recovery medical home at Boston Medical Center and the Boston University School of Medicine. Project RESPECT provides a unique service of comprehensive obstetric and substance use disorder treatment for pregnant people and their newborns.  

New Jersey. The Child Protection Substance Abuse Initiative (CPSAI) is a program that targets parents engaged in the Division of Child Protection and Permanence. Although only 9% of the participants completed treatment, CPSAI is examining individual factors associated with successful treatment and continuing to facilitate treatment engagement for parents being evaluated by the child welfare system.

North Carolina. Project CARA is housed at MAHEC Ob/Gyn Specialists. It has supported over 800 women with substance use disorders since 2014. MAHEC first offered integrated substance use treatment services with obstetrical visits in the late 1990s. The Project CARA team has built on this early foundation to provide comprehensive substance use care using current evidence-based practices.