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 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. In 2012, almost 6% of pregnant women used illicit substances, 15.9% endorsed using tobacco, and over 8% drank alcohol. 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. Pregnant women who use substances are highly stigmatized by medical professionals, family members, and society. Stigmatization often leads to women isolating and not getting proper prenatal care. Lack of prenatal care, or inconsistent care, can cause more health problems for the mother and unborn child. These facts call for increased interventions with women of childbearing age before they become pregnant in order to reduce the number of women who develop a substance use problem during pregnancy.

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. 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 facts for women when compared to men:

• 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 of substance use 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) Brief Screening consists of the provider asking a series of questions that can help to identify where patients fall along a continuum of substance use, not merely just “addicted” or “non-addicted.” SBIRT’s model of substance use has six categories:

• 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 to seek treatment if needed. If a patient is deemed “moderate” or “high risk” or having “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 to connect patients who need education and referral to treatment.

Relevant Research

Who is at Risk?

Women who were exposed to adverse childhood experiences (ACEs) and are socioeconomically vulnerable have a greater risk of using illicit substances, tobacco, and alcohol. White pregnant women are more likely to use tobacco when compared to black and Hispanic populations. Black women are more likely to use illicit substances when compared to Hispanics and white women during pregnancy. This data shows that 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. The study also found that environmental stressors and lack of consistent prenatal care were also correlated with worsening maternal and fetal outcomes. 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.

Parent Impact and Involvement in Prevention Parents play a vital role in preventing teen girls from unplanned pregnancies. Because teens are more likely to not notice they are pregnant and much more likely to engage in risky behaviors such as substance use and binge drinking, parents should aim to educate their teens early. Parents can begin to talk with their children about not only the risks of substance use, but the risks of becoming pregnant, and how to prevent unwanted pregnancy. Regarding substance use, SAMHSA reports that most pregnant teens used marijuana and drank alcohol more frequently than other substances before pregnancy. Experts believe that this trend exists because teens have a misconception that there are fewer risks involved when choosing to use these substances compared to other illicit drugs. It may be beneficial to increase prevention and intervention strategies for these particular substances among teens. Public health campaigns can begin to highlight the direct and indirect consequences of use such as criminal justice involvement, unwanted pregnancy, addiction, and greater risk of exposure to sexually transmitted diseases .

Impactful Federal, State, and Local Policies

SAFE Solutions is an ever-growing platform. Currently, limited information is readily available for this section. SAFE Project is dedicated to providing communities with the most relevant and innovative materials. We will continue to regularly monitor and make updates accordingly with community input and subject matter expert collaboration. Please check back soon.

Available Tools and Resources

SAMHSA National Prevention Week website has webinars for various topics relating to substance use. These webinars are from recent years and contain valuable information about prevention and education. https://www.samhsa.gov/prevention-week/webinars

Drugfree.Org has valuable information for parents about how establishing a relationship with open communication and a strong bond with teens can prevent future substance use. Since females of reproductive age can fall into this category (teens living at home), this would be a great resource for parents who want to strengthen their relationships with their teens in order to prevent substance use and other harmful behaviors. https://drugfree.org/article/connecting-with-your-teen/

Substance Use Risk Assessment for Teens - drugfree.org provides an online risk assessment for parents to help identify the risks associated with teen substance abuse. This is a great tool that provides important educational information as well as links to treatment resources. The risk assessment is not a diagnostic tool and can be found at this link: https://drugfree.org/substance-use-risk-assessment/

PowerToDecide.org has 10 tips to help parents engage in conversation about preventing teen pregnancy. The PDF document can be found at this website: https://powertodecide.org/sites/default/files/resources/primary-download/10tips_final.pdf

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. 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.

Colorado Department of Public Health developed an informational brief on the topic of substance use among women of reproductive age. The goal of the department is to identify women between the ages of 18 and 44 and provide interventions that prevent substance use, including prescription drugs and marijuana.

Substance Abuse and Mental Health Services Administration (SAMHSA) holds an event called National Prevention Week (NPW) that aims to raise awareness about substance use awareness and positive mental health . The purpose of NPW is to raise awareness of the importance of substance use prevention, showcase evidenced based intervention programs, improve partnerships and collaborations with different agencies and organizations, and promote quality prevention strategies and resources.