Improve Identification of Pregnant People at Risk

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 can cause the infant to be born with very serious health problems, stillbirths, and in some cases can cause infant withdrawal symptoms, or dependency (1). 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 (1). In 2012, almost 6% of pregnant women used illicit substances, 15.9% endorsed using tobacco, and over 8% drank alcohol(2). This accounted for well over a quarter of a million infants exposed to illicit substances in utero, over half a million exposed to alcohol, and one million exposed to tobacco. The detrimental impact of prenatal substance use continues to be a public health concern.

Key Information

Primary Prevention The implementation of thorough screening and education in primary care settings for all females of reproductive age, not just those who are currently pregnant, could drastically impact the occurrence of prenatal substance use (5). Since about half of all pregnancies are unplanned, many women could be using alcohol or other substances without knowing they are pregnant. Physicians can provide broad education on the risks of using substances and the possibility of unknowingly becoming pregnant while continuing to use. Early detection and intervention for substance use in women of childbearing age can offer an opportunity for women to take necessary precautions such as contraception or abstaining from substance use if there is a chance of becoming pregnant. Medical providers and public health officials can increase education about the effects of substances and the associated risks. Women, in general, have unique risks pertaining to alcohol, tobacco, and illicit substance use when compared to males. For example, the National Center for Addiction and Substance Abuse (CASA) reports the following statistics for women when compared to men (5).

• Greater impairment after drinking the same amount of alcohol;
• Accelerated development of alcohol-related problems;
• Greater susceptibility to the development of alcohol-related medical disorders;
• Increased asthma attacks;
• Becoming addicted to nicotine at lower levels of use;
• Greater impairment of lung functioning;
• Greater difficulty quitting smoking;
• Greater susceptibility to brain damage from heavy use of Ecstasy;
• Greater likelihood of hospitalization from nonmedical use of pain medications;
• Moderate to heavy alcohol consumption increases risks for breast cancer;
• Increased risk of female infertility;

Along with all of these harmful impacts that substance use has on women in general, substance use also places women of reproductive age at a heightened risk for unplanned pregnancy. Medical provider training and improved local support for prevention in this area could potentially reduce the number of women who knowingly or unknowingly become pregnant and expose their unborn children to substances. Physicians can also screen and empower women who use substances to seek treatment or take precautions so as to not become pregnant through the use of contraceptives.

Screening, Brief Intervention, and Referral to Treatment (SBIRT)(6) Brief Screening consists of the provider asking a series of questions that can help to identify where patients fall under a continuum of substance use, not merely just “addicted” or “non-addicted”. SBIRT’s model of substance use has six categories that patients can fall under. The six categories are:

• abstinence
• experimental use
• social use
• binge use
• abuse
• substance use disorder.

The goal of SBIRT is to identify individuals who are unaware that their behaviors are putting them at risk for developing more serious issues. With feedback and support from medical providers, these individuals have the opportunity to make an informed decision and change their current behavior or seek treatment if needed. If a patient is deemed “moderate”, “high risk”, or “problematic use” the provider can provide a brief intervention and referral for treatment. SBIRT can be implemented with minimal time and effort on behalf of the provider. The impact SBIRT has on the patient is invaluable and helps connect patients who need education and referral to treatment.

Relevant Research

Who is at Risk? Women who have been exposed to adverse childhood experiences and are socioeconomically vulnerable have a greater risk of using illicit substances, tobacco, and alcohol (4). White pregnant women are more likely to use tobacco when compared to black and Hispanic populations (3). Black women are more likely to use illicit substances when compared to Hispanics and white women during pregnancy. This data that shows prenatal substance use is present among multiple races and ethnicities. Therefore, medical providers and public health professionals should intervene by identifying all mothers at risk for developing or continuing substance use during pregnancy.

Women with psychiatric comorbidities are at a higher risk of using multiple substances during pregnancy. A study from the National Survey of Drug Use and Health (NSDUH) results showed that women who experienced a major depressive episode within the last year were more likely to engage in alcohol and tobacco use during pregnancy when compared to pregnant women who abstained from substances (7). The study also found that environmental stressors and lack of consistent prenatal care were also correlated with worsening maternal and fetal outcomes(7). The World Health Organization (WHO) recommends engaging women in prevention efforts to improve mental health before becoming pregnant since mental health issues are a risk factor for developing a substance use disorder (7).

Impactful Federal, State, and Local Policies

Please list any federal, state, or local laws, policies, or regulations that support this topic or ones that could be a possible barrier. Are there laws or policies other states should know about and replicate for success?

Available Tools and Resources

Oftentimes, there are already great resources in the field that have been developed, but they are not housed in a single place. Please use this section to share information about those resources and drive the reader to that resource. It may be a worksheet, toolkit, fact sheet, framework/model, infographic, new technology, etc. I suggest no more than 5 really good links and a corresponding description for the reader. We also can use this section to highlight some of the great resources and programs at SAFE Project.

TR-Creating Improve Identification of a Women At Risk of having NAS Baby

Promising Practices

The Prevention of Substance-Exposed Pregnancies Collaborative is a group of organizations that work together with the common goal of reducing the number of women who use substances during pregnancy(5). Organizations from multiple states, including Oregon, California, Ohio, Colorado, Florida, and Maryland developed multiple strategies for medical and public health officials to implement in order to accomplish their mission of preventing substance exposure to women of reproductive age, pregnant women, and their unborn children.