Interconnections between unintended pregnancy, alcohol and other drug use, and pregnancy, birth, infant, childhood and socioeconomic outcomes: a scoping review.

BACKGROUND: Unintended pregnancy (UIP) and substance use disorder share underlying root causes with similar impacts for women and their offspring in pregnancy, birth and beyond. Furthermore, intoxication with alcohol and other drugs (AOD) increases the risk of UIP. OBJECTIVES: To assess the available evidence on associations between UIP and health, social and economic outcomes, in women who use AOD. SEARCH STRATEGY: The review utilised the Joanna Briggs Institute Methodology for Scoping Reviews and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting guidelines. The search was conducted across multiple databases, including Scopus and Medline, and limited to studies published between January 2000 to June 2023. SELECTION CRITERIA: Studies reporting on interactions between AOD use and UIP, and pregnancy, birth, infant, childhood, social or economic outcomes. All patterns and types of AOD use, except isolated use of tobacco, were included. Studies were available in English and conducted in high-income countries. DATA COLLECTION AND ANALYSIS: Selected articles were reviewed, and data collected by two independent reviewers using a standardised data extraction sheet. Findings were summarised and reported descriptively. MAIN RESULTS: A total of 2536 titles and abstracts were screened, 97 full texts were reviewed, and three studies were selected for inclusion in the scoping review. There was heterogeneity in types and patterns of AOD use, differences in study design and tools to assess pregnancy intention, and each focused on disparate outcomes. No study assessed or reported on birth outcomes. CONCLUSION: There is a paucity of data examining the intersection between AOD use and UIP and further research is needed.

First Trimester Use of Buprenorphine or Methadone and the Risk of Congenital Malformations.

Importance: Use of buprenorphine or methadone to treat opioid use disorder is recommended in pregnancy; however, their teratogenic potential is largely unknown. Objective: To compare the risk of congenital malformations following in utero exposure to buprenorphine vs methadone. Design, Setting, and Participants: This population-based cohort study used health care utilization data from publicly insured Medicaid beneficiaries in the US from 2000 to 2018. A total of 13 360 pregnancies with enrollment from 90 days prior to pregnancy start through 1 month after delivery and first trimester use of buprenorphine or methadone were included and linked to infants. Data were analyzed from July to December 2022. Exposure: A pharmacy dispensing of buprenorphine or a code for administration of methadone in the first trimester. Main Outcomes and Measures: Primary outcomes included major malformations overall and malformations previously associated with opioids (any cardiac malformations, ventricular septal defect, secundum atrial septal defect/nonprematurity-related patent foramen ovale, neural tube defects, clubfoot, and oral clefts). Secondary outcomes included other organ system-specific malformations. Risk differences and risk ratios (RRs) were estimated comparing buprenorphine with methadone, adjusting for confounders with propensity score overlap weights. Results: The cohort included 9514 pregnancies with first-trimester buprenorphine exposure (mean [SD] maternal age, 28.4 [4.6] years) and 3846 with methadone exposure (mean [SD] maternal age, 28.8 [4.7] years). The risk of malformations overall was 50.9 (95% CI, 46.5-55.3) per 1000 pregnancies for buprenorphine and 60.6 (95% CI, 53.0-68.1) per 1000 pregnancies for methadone. After confounding adjustment, buprenorphine was associated with a lower risk of malformations compared with methadone (RR, 0.82; 95% CI, 0.69-0.97). Risk was lower with buprenorphine for cardiac malformations (RR, 0.63; 95% CI, 0.47-0.85), including both ventricular septal defect (RR, 0.62; 95% CI, 0.39-0.98) and secundum atrial septal defect/nonprematurity-related patent foramen ovale (RR, 0.54; 95% CI, 0.30-0.97), oral clefts (RR, 0.65; 95% CI, 0.35-1.19), and clubfoot (RR, 0.55; 95% CI, 0.32-0.94). Results for neural tube defects were uncertain given low event counts. In secondary analyses, buprenorphine was associated with a decreased risk of central nervous system, urinary, and limb malformations but a greater risk of gastrointestinal malformations compared with methadone. These findings were consistent in sensitivity and bias analyses. Conclusions and Relevance: In this cohort study, the risk of most malformations previously associated with opioid exposure was lower in buprenorphine-exposed infants compared with methadone-exposed infants, independent of measured confounders. Malformation risk is one factor that informs the individualized patient decision regarding medications for opioid use disorder in pregnancy.

Examining the Effectiveness of the FaCES Adolescent SBIRT Intervention.

PURPOSE: The Facilitating Change for Excellence in SBIRT (FaCES) is a service package for adolescent primary care that was developed based on best practices and evidence, but was empirically untested. The aim of this study is to compare the FaCES intervention to treatment as usual (TAU) for rural adolescent primary care patients. METHODS: In this modified cluster-randomized stepped wedge design, providers who completed at least 20 adolescent TAU visits received training in the FaCES package in random order. Adolescent patients (N = 1,226) waiting for appointments were continuously recruited into the study and completed a baseline assessment before their scheduled appointment and an on-line 3-month follow-up. Participants received either FaCES or TAU, depending on whether their provider had been trained in FaCES. Due to COVID-19 disruptions, only 14 of the 29 providers were trained before study recruitment activities ceased. RESULTS: More than 80% of the sample indicated no prior use of tobacco, alcohol, or marijuana at study entry. The Arm × Time interaction failed to reach significance for the substance use outcomes considered. In the FaCES condition, the group with no prior use had an increased probability of substance use at 3-month follow-up, while the group reporting prior use had a decreased probability of use at follow-up. Participants who reported no use at baseline had an increased probability of use at follow-up, whether they received the FaCES intervention or TAU. DISCUSSION: This study was unable to demonstrate the effectiveness of FaCES. Findings suggest some natural movement in substance use risk over time.

What Obstetrician-Gynecologists Should Know About Substance Use Disorders in the Perinatal Period.

Substance use in pregnancy is common; nearly one of five of pregnant individuals have past-month nicotine, alcohol, or illicit substance use, and more than one in 10 meet criteria for a substance use disorder (SUD). Substance use disorders are among the most stigmatized and poorly understood medical conditions, particularly in the perinatal period. The obstetrician-gynecologist (ob-gyn) is a critical member of the health care and social support team for pregnant and postpartum individuals with SUD. Yet, many do not feel knowledgeable in screening and treating SUD, hampering efforts to identify and treat this population. In this review, we focus on practices that ob-gyns can incorporate into daily care. We start with the unique vulnerabilities of the perinatal period and discuss overdose as a leading cause of maternal death in the United States. We then review the basic tenets of addiction medicine including person-centered language and current medical terminology as well as best practices for substance use screening. We provide a review of maternal, fetal, and child effects of the most common substances including tobacco, alcohol, cannabis, opioids, stimulants, and benzodiazepines and their respective treatment recommendations, so that ob-gyns can incorporate basic addiction management into their daily practice.

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

BACKGROUND: 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. OBJECTIVE: 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. STUDY DESIGN: 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. RESULTS: 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. CONCLUSION: 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.

Providing reproductive health services for women who inject drugs: a pilot program.

BACKGROUND: Needle syringe programs (NSPs), a proven harm reduction strategy for people who inject drugs, frequently offer limited healthcare services for their clients. Women who inject drugs face multiple barriers to accessing reproductive health care in traditional settings: personal histories of trauma, judgmental treatment from providers, and competing demands on their time. Our aim was to implement patient-centered reproductive healthcare services at a Seattle NSP. METHODS: We interviewed clients and staff of an NSP in Seattle and staff of other community-based organizations serving women who inject drugs, then used the Consolidated Framework for Implementation Research to code transcripts deductively. Based on our qualitative work, we implemented reproductive health care at the NSP program 1 day per week. We evaluated the implementation by surveying staff and clients and auditing charts over a 9-month period. RESULTS: Clients and staff (N = 15 for clients, N = 13 for staff) noted a high unmet need for trauma-informed, accessible reproductive health care. We successfully implemented reproductive health care services including short- and long-acting contraception, sexually transmitted disease testing, and cervical cancer screening. Survey data was limited but demonstrated client satisfaction with services. CONCLUSIONS: Integrating reproductive health care into an NSP's clinical services is feasible and can be a source of low-barrier preventive care for women unable to seek gynecologic care elsewhere.

Cannabis Use as Determined by Biologic Testing in Maternal and Newborn Urines during a Period of Drug Liberalization.

Introduction: Cannabis use is common in pregnancy and prevalence of reported past month use have been increasing despite recommendations of abstinence. Our study aimed to evaluate the prevalence of cannabis use in pregnancy using urine drug screens obtained at the time of admission to Labor and Delivery. Methods: De-identified laboratory data from three birthing hospitals located in Maryland were used to determine the percentage of cannabis positive urine toxicology tests among women admitted to Labor and Delivery. Data were collected at each site starting the year that universal urine cannabis testing was instituted. One hospital also performed universal testing of newborns which was contrasted with maternal data there. Results: Overall, 5.7% of the 22,435 maternal and 3.4% of the 8,346 newborn urine toxicology tests and were positive for cannabis. Trends varied between institutions. When all three institutions were combined, the percent of positive urine toxicology tests was unchanged between 2016 and 2018. At Site 1 between 2014 and 2018, the percentage of cannabis positive urine toxicology tests increased from 5.7% to 9.9% and newborn tests increased from 1.7% to 3.4%. Only 27.7% of the neonates born to women with positive screens also had a positive screen at the time of birth. Conclusions: Prevalence of cannabis use until the time of delivery vary by location but were largely unchanged over a period of drug liberalization.

Sexual and Reproductive Health Characteristics of Women in Substance Use Treatment in Michigan.

OBJECTIVE: To evaluate the sexual and reproductive health characteristics of women in treatment for opioid use disorder in Michigan and explore services provided and desired. METHODS: We conducted a cross-sectional study of female patients aged 18-50 years who accessed opioid use disorder treatment at 22 randomly selected facilities in Michigan from December 2015 to May 2017. Computer-assisted self-interviews were completed using online survey management software to assess prior substance use and use disorder treatment, sexual and reproductive health history, and sexual and reproductive health services received in the previous 12 months through a treatment program, and desire for and barriers to sexual and reproductive health services within substance use disorder treatment. Descriptive statistics were calculated. RESULTS: The final sample consisted of 260 participants. About half (51.5%) had ever had an abnormal Pap test result, and 57.3% had ever tested positive for a sexually transmitted infection. Unintended pregnancy was common (61.2%), as was substance use during pregnancy (74.2%). Nearly half (46.5%) were not currently using a method of contraception, and only 28.5% were using a highly effective method. Common barriers to accessing reproductive health services included fear of being treated poorly or judged because of substance use, fear of child protective services, and structural barriers such as cost and lack of transportation. Most participants (80.4%) indicated interest in receiving sexual and reproductive health services on site or by referral from their substance use disorder treatment programs. CONCLUSION: Women in treatment for opioid use disorder in Michigan have high rates of adverse sexual and reproductive health experiences and face barriers to accessing care.

Obstetrician-gynecologists' practices and attitudes on substance use screening during pregnancy.

OBJECTIVE: To describe obstetrician-gynecologists' practices and attitudes related to substance use screening in pregnant patients. STUDY DESIGN: A 2017 cross-sectional survey assessed US obstetrician-gynecologists' (n = 462; response rate = 34%) practices (substance use screening frequency and methods) and attitudes (practice priority of screening, confidence in treating, and responsibility statements). Chi-squared tests and adjusted modified Poisson regression were used to estimate associations between practices and attitudes. RESULTS: Of 353 respondents with screening information, 79% frequently screen for substance use and 11% used a validated instrument. Confidence was the highest for treating pregnant patients using tobacco (81%). Respondents whose practices make it a high priority to screen for all substances were 1.2 times as likely to frequently screen as their counterparts (95% CI: 1.1-1.3). CONCLUSIONS: Four out of five obstetricians-gynecologists reported a high frequency of substance use screening in pregnant patients. Findings highlight the importance of increasing priority of substance use screening by obstetrician-gynecologists.

Co-occurring substance use disorder: The impact on treatment adherence in women with locally advanced cervical cancer.

The purpose of this study was to identify the prevalence of substance use disorder and its association with adherence to treatment and survival in locally advanced cervical cancer patients treated with primary radiation therapy. This is a retrospective case series of locally advanced cervical cancer patients with substance use disorder in a single academic institution treated with radiation therapy between 2005 and 2016. Substance use disorder was identified through chart review. Those with substance use disorder were compared to those without in regards to demographics, Charlson comorbidity index, treatment details and outcomes. Of the 129 patients with locally advanced cervical cancer, 16 (12.4%) were identified as having substance use disorder. Patients with substance use disorder were younger (42.1 years vs 51.5 years, p = .013) and more likely to be smokers (81.3% vs 42.5%, p = .004). The majority of patients with substance use disorder received concurrent chemotherapy (93.8%) and brachytherapy in addition to external beam radiation therapy (81.3%). There was no significant difference in days to completion of radiation therapy between patients with and without substance use disorder. Radiation dose received, toxicities and survival were similar between groups. Among cervical cancer patients receiving treatment with radiation therapy, substance use disorder was not associated with poorer adherence, longer radiation treatment times or a difference in total dose of radiation received. Our experience demonstrates that patients with substance use disorder are able to adhere to complex, multimodal treatment plans resulting in similar cancer specific outcomes compared to patients without substance use disorder.

Pregnancy Intention, Risk Perception, and Contraceptive Use in Pregnant Women Who Use Drugs.

OBJECTIVES: The aim of the study was to evaluate pregnancy intention, risk perception, and contraceptive utilization among women reporting substance use during pregnancy. METHODS: Data were obtained from the 2009 to 2011 Tennessee Pregnancy Risk Assessment Monitoring System (PRAMS), an annual cross-sectional survey which assesses behaviors before, during and after pregnancy. Substance use during pregnancy and contraceptive use at the time of conception and after delivery were captured by self-report in the postpartum period. Pregnancy intention was categorized as intended (pregnancy desired then or earlier) or unintended (pregnancy desired later or not at all). Weighted descriptive and multivariable analyses were performed. RESULTS: A total of 3042 women completed the PRAMS survey, with 168 (5.4%) reporting substance use during pregnancy. Compared with women who did not report drug use, women who used drugs were more likely to have an unintended pregnancy (65.6% vs 48.4%, P = 0.003), were more ambivalent towards pregnancy planning or prevention (69.7% vs 46.2%, P < 0.001) and were less likely to report contraceptive use before pregnancy (31.3% vs 46.8%, P = 0.022) or in the postpartum period (79.6% vs 88.1%, P = 0.019). Finally, women reporting substance use in pregnancy had 2 times higher odds of reporting that they did not think they could get pregnant at the time of conception after adjusting for age, race, income, education, insurance, and smoking status (adjusted OR 2.18, 95% confidence interval 1.07-4.49, P = 0.033). CONCLUSIONS: Women who report substance use in pregnancy have unique reproductive health needs and would benefit from additional education and counseling concerning their pregnancy intention, contraceptive use, and ability to conceive.

Characteristics of Pregnant Women Reporting Cannabis Use Disorder at Substance Use Treatment Entry.

INTRODUCTION: The current study examined distinct characteristics of yearly trend, sociodemographic, and treatment-related variables of prenatal cannabis use as the primary drug of choice among pregnant women admitted to substance use treatment for the first time. METHODS: The Treatment Episode Data Set-Admission between 1992 and 2015 was used for a cross-sectional study focused on prenatal cannabis use reported at treatment admission. RESULTS: Among pregnant women admitted to substance use treatment for the first time (n = 489,796), 40.6% reported any level of cannabis use, and 40.8% reported cannabis use as the primary drug of choice at treatment admission. Adjusted for other characteristics, a statistically significant change in overall trends for any prenatal cannabis use, and also in cannabis use as the primary drug of choice over 20 years was detected. While pregnant women reporting cannabis use as the primary drug of choice were significantly less likely to co-use other substances, those involved in the criminal justice system were significantly more likely to co-use cocaine and opioids, but significantly less likely to co-use alcohol. DISCUSSION/CONCLUSION: Continued monitoring of prenatal cannabis use and patterns of other substance co-use is encouraged, given the perceived harm of cannabis use in young generations has lessened in recent years, coinciding with the legalization process. Targeted education materials and treatment options to treating prenatal cannabis use should be developed tailored to substance use characteristics and criminal justice involvement.

A Pilot Randomized Controlled Trial of a Phone-based Intervention for Smoking Cessation and Relapse Prevention in the Postpartum Period.

OBJECTIVES: To pilot-test a Phone-based Postpartum Continuing Care (PPCC) protocol developed from existing evidence-based approaches to address both postpartum smoking relapse among low-income women who quit smoking during pregnancy and postpartum smoking increase among those who had cut down. METHODS: One hundred thirty low-income pregnant women who were current or recently quit tobacco smokers were recruited at their first prenatal appointment and randomized to either a Control (standard care) or Experimental (standard care + PPCC) group. An intent-to-treat analysis was conducted on biochemically verified data from 6 in-person interviews during pregnancy and postpartum. Feasibility with regard to recruitment, randomization, assessment, and implementation of PPCC were assessed, along with acceptability among the target population. RESULTS: PPCC was found to be feasible and acceptable to some participants, but not all. There were no significant differences in tobacco products per day at 6 months postpartum between groups; however, effect sizes differed at 6 weeks compared with 6 months postpartum. Similarly, there were no significant differences between groups in cessation rate (24% in each group) and past 90-day tobacco use (59 vs 55 days, for Control and Experimental groups, respectively). CONCLUSIONS: The PPCC intervention did not differentially reduce tobacco use postpartum compared with a controlled comparison group, though it was found to be acceptable among a subpopulation of low-income pregnant women and feasible with regard to recruitment, randomization, assessment procedures, and implementation. Further research is needed to identify an intervention that significantly improves smoking relapse rates postpartum.

Risk of complication during surgical abortion in obese women.

BACKGROUND: Surgical abortion is a generally safe procedure. Obesity is a known risk factor for complications in other surgical procedures, but insufficient information exists to determine the effects of increasing body mass index on the risk of surgical abortions. OBJECTIVE: The purpose of this study was to determine whether obesity is a risk factor for major complications in surgical abortions. METHODS: A quality control database from a single outpatient center was analyzed to determine rates of major complications during surgical abortions in relation to obesity class. Complications included hemorrhage, need for repeat evacuation, uterine perforation, cervical laceration, medication reaction, unexpected surgery, or unplanned admission to the hospital. Chi-squared and analysis of variance were used for analysis. RESULTS: We included 2468 procedures: 1475 procedures (59.8%) in the first trimester and 993 procedures (40.2%) in the second trimester. The overall complications rate was 2.2%. Second-trimester procedures were more likely than those in the first trimester to have complications (3.1% vs 1.6%; P=.009). Overall, 39.6% of the women were obese, and 9.6% of them met criteria for class 3 obesity (body mass index, >40 kg/m2). Women who underwent second-trimester abortions with class 3 obesity had a rate of complication of 8.7%, which was significantly more than normal weight women (odds ratio, 5.90; 95% confidence interval, 1.93-8.07; P<.001). COMMENT: Surgical abortions are overall safe procedures, but class 3 obesity increases the rate of complication in second-trimester procedures.

Cannabis and pregnancy: Maternal child health implications during a period of drug policy liberalization.

Cannabis use is common and increasing among women in the United States. State policies are changing with a movement towards decriminalization and legalization. We explore the implications of cannabis liberalization for maternal and child health. Most women who use cannabis quit or cut back during pregnancy. Although women are concerned about the possible health effects of cannabis, providers do a poor job of counseling. There is a theoretical potential for cannabis to interfere with neurodevelopment, however human data have not identified any long-term or long lasting meaningful differences between children exposed in utero to cannabis and those not. Scientifically accurate dissemination of cannabis outcomes data is necessary. Risks should be neither overstated nor minimized, and the legal status of a substance should not be equated with safety. Decreasing or stopping use of all recreational drugs should be encouraged during pregnancy. Providers must recognize that even in environments where cannabis is legal, pregnant women may end up involved with Child Protective Services. In states where substance use is considered child abuse this may be especially catastrophic. Above all, care for pregnant women who use cannabis should be non-punitive and grounded in respect for patient autonomy.

The role of screening, brief intervention, and referral to treatment in the perinatal period.

Substance use during pregnancy is at least as common as many of the medical conditions screened for and managed during pregnancy. While harmful and costly, it is often ignored or managed poorly. Screening, brief intervention, and referral to treatment is an evidence-based approach to manage substance use. In September 2012, the US Centers for Disease Control and Prevention convened an Expert Meeting on Perinatal Illicit Drug Abuse to help address key issues around drug use in pregnancy in the United States. This article reflects the formal conclusions of the expert panel that discussed the use of screening, brief intervention, and referral to treatment during pregnancy. Screening for substance use during pregnancy should be universal. It allows stratification of women into zones of risk given their pattern of use. Low-risk women should receive brief advice, those classified as moderate risk should receive a brief intervention, whereas those who are high risk need referral to specialty care. A brief intervention is a patient-centered form of counseling using the principles of motivational interviewing. Screening, brief intervention, and referral to treatment has the potential to reduce the burden of substance use in pregnancy and should be integrated into prenatal care.