Substance Use in the Perinatal Period

Beyond a simple cause and effect relationship: Exploring the long-term outcomes of children prenatally exposed to opioids and other substances

The long-term outcomes of children exposed to opioids and other substances in utero, specifically those diagnosed with Neonatal Abstinence Syndrome (NAS), present a complex interaction of different factors. First, NAS and its clinical presentation will be defined, then summarized will be an overview of NAS prevalence, recent trends, and significance of NAS in the context of the rising synthetic opioid and polysubstance use. Highlighted will also be the identified risk factors for NAS, especially regarding the role of environmental and psychosocial stressors during pregnancy. Finally, reviewed will be the existing NAS literature, including its gaps and limitations, and suggested recommendations for future research and policy considerations for improving care for children and families impacted by NAS.

Pre-natal and post-natal screening and testing in neonatal abstinence syndrome

The way we enact screening for substance use during pregnancy within our healthcare systems can work by decreasing stigma, promoting engagement, and supporting people with reaching the end of their pregnancy in a manner where the newborn can be well supported. The way we enact biochemical specimen toxicology testing for substance use during pregnancy and in newborns contributes to increased stigma, disengagement from care, and potential continuation of uncontrolled substance use up until delivery such that the newborn may not be able to be well supported in the family environment. These effects are inequitably distributed, leading to worse outcomes for families of color and families living in poverty. Serial screening with a validated questionnaire starting at the first prenatal visit and continuing through the delivery hospitalization should occur and be followed up with service connections and substance use disorder diagnosis and treatment. Newborn toxicology testing as a diagnostic tool for risk of withdrawal or the etiology of potential withdrawal symptoms represents a failure in the effectiveness of compassionate communication by healthcare providers with the birthing person. Given the current level of evidence of clinical utility and the inequitable consequences specific to these tests, they are rarely needed.

Substance use disorder and severe maternal morbidity: is there a differential impact?

BACKGROUND

Substance use disorder (SUD) is a disease characterized by behavior patterns of substance use leading to dysfunction in cognition, mood, and quality of life. The prevalence of perinatal SUD in the United States continues to rise and has adverse effects on the maternal-infant dyad. Mirroring the rise in SUD is an increasing prevalence of severe maternal morbidity (SMM). However, this relationship needs further examination.

OBJECTIVE(S)

The primary objective of this study was to evaluate the association between perinatal SUD and SMM. We hypothesized that SUD would predict a significantly increased risk for SMM events, both as a composite and individually, in adjusted multivariable regression analyses.

STUDY DESIGN

We conducted a cross-sectional analysis of inpatient pregnancy hospitalizations from the Healthcare Cost and Utilization Project National Inpatient Sample from 2016 to 2020. ICD-10 codes were used to identify patients with an SUD and/or a SMM event. SUD was defined as a composite. Our primary outcome was rate of SMM as defined by the Centers for Disease Control and Prevention. Multivariable logistic regression analyses were performed to predict the likelihood of SMM among pregnancy hospitalizations with and without SUD as well as to predict the likelihood of SMM for each individual type of SUD in a subgroup of hospitalizations with SUD and SMM.

RESULTS

Of the 3672,932 inpatient pregnancy hospitalizations included in the analyses, 6.27% (230,110/3,672,932) had SUD diagnosis and 2.10% (77,021/3,672,932) had an SMM diagnosis. The prevalence of SMM was significantly higher among patients with SUD (7357/230,110%-3.20%) vs without SUD (69,664/3442,822-2.02%, P<.0001). Patients with SUD were 1.5 times more likely to have a SMM event as compared to those without SUD (aOR 1.52; 95% CI 1.48-1.56). In subgroup analyses based on SUD type-the likelihood of SMM was strongest for stimulants (aOR 3.86; 95% CI 3.61-4.13) and sedatives (aOR 3.82; 95% CI 3.08-4.75). In subgroup analyses based on SMM event, SUD was a strong positive predictor for acute myocardial infarction (aOR 3.63; 95% CI 2.78-4.74) and aneurysm (aOR 6.28; 95% CI 2.77-14.21).

CONCLUSION(S)

Pregnant patients with SUD carry significantly increased risk of experiencing an SMM event. These events occur more readily in patients with certain patterns of SUD use-most notably sedatives and stimulants. Patients with SUD were most likely to experience a cardiovascular-related SMM event, thus informing care.

Prenatal and postnatal cocaine exposure enhances the anxiety- and depressive-like behaviors in rats: An ontogenetic study

BACKGROUND

Prenatal and postnatal exposure to drugs such as cocaine is a public health problem that causes deficits in brain development and function in humans and animals. One of the main effects of prenatal and postnatal cocaine exposure is increased vulnerability to developing the substance use disorder at an early age. Furthermore, the negative emotional states associated with cocaine withdrawal increase the fragility of patients to relapse into drug abuse. In this sense, prenatal and postnatal cocaine exposure enhanced the cocaine- and nicotine-induced locomotor activity and locomotor sensitization, and rats exposed prenatally to cocaine displayed an increase in anxiety- and depressive-like behaviors in adulthood (PND 60-70).

OBJECTIVE

Therefore, the objective of this study was to determine the effect of prenatal and postnatal cocaine exposure on anxiety- and depressive-like behaviors at different ages (30, 60, 90, and 120 days of age) in rats.

METHODS

The study was divided into two stages: prenatal and postnatal. In the prenatal stage, a group of pregnant female Wistar rats was administered daily from GD0 to GD21 cocaine (cocaine pre-exposure group), and another group of pregnant female rats was administered daily saline (saline pre-exposure group). In the postnatal stage, during lactation (PND0 to PND21), pregnant rats received administration of cocaine or saline, respectively. Of the litters resulting from the cocaine pre-exposed and saline pre-exposed pregnant female groups, only the male rats were used for the recording of the anxiety- and depressive-like behaviors at different postnatal ages (30, 60, 90, and 120 days), representative of adolescence, adult, adulthood, and old age.

RESULTS

The study found that prenatal and postnatal cocaine exposure generated age-dependent enhancement in anxiety- and depressive-like behaviors, being greater in older adult (PND 120) rats than in adolescent (PND 30) or adults (PND 60-90) rats.

CONCLUSIONS

This suggests that prenatal and postnatal cocaine exposure increases anxiety- and depressive-like behaviors, which may increase the vulnerability of subjects to different types of drugs in young and adult age.

Prevention of postpartum methamphetamine use with micronized progesterone trial (PROMPT): A pilot randomized controlled trial protocol

Background

While most pregnant individuals with methamphetamine use disorder (MUD) achieve abstinence, the postpartum period remains a vulnerable time for return to methamphetamine use (MU). Promising data from human and animal models, including three randomized controlled trials, suggest that micronized progesterone may prevent postpartum return to cocaine and nicotine use by reducing cravings. The primary objective of this study is to assess feasibility of enrollment and randomization of postpartum individuals with MUD to micronized progesterone to prevent return to MU. The secondary objectives are to evaluate safety, establish a preliminary estimate of efficacy, and characterize the association between allopregnanolone levels and methamphetamine cravings.

Methods

This is a pilot double-blind placebo randomized controlled trial. We plan to enroll 40 postpartum individuals with MUD over 24-months. Individuals, stratified by opioid use disorder (OUD), are randomized 1:1-400 mg oral micronized progesterone daily or placebo and attend weekly study sessions for 12 weeks. Feasibility is measured by achieving 80 % of enrollment goal. Safety is evaluated by side effect frequency, mental health status changes, lactation and medical complications. Efficacy is assessed by comparing proportion of participants with return to MU and time to return to MU based on self-report or urine testing between treatment and control groups. Salivary allopregnanolone levels and methamphetamine cravings are compared between the groups.

Conclusion

Study results will provide a first critical step towards potential intervention for prevention of return to MU among postpartum individuals. Completion of this trial will set the stage for a large-scale efficacy trial.

Electronic-Screening, Brief Intervention and Referral to Treatment (e-SBIRT) for Addictive Disorders: Systematic Review and Meta-Analysis

BACKGROUND

Addictive disorders are significant global public health burdens. Treatment uptake with these disorders is low and outcomes can be mixed. Electronic screening, brief intervention, and referral to treatment (e-SBIRT) programs have potential to improve uptake and treatment outcomes. To date, however, no prior review of the literature has been conducted to gauge the effectiveness of e-SBIRT for addictive disorders.

METHODS

We conducted a systematic review and meta-analysis of the literature concerning e-SBIRT for addictive disorders by surveying the MEDLINE, PubMed, Web of Science, Scopus, Embase, and PsycInfo databases on January 17, 2023.

RESULTS

Ten articles were included at analysis reporting evaluation of e-SBIRT interventions for substance use disorders including alcohol use in a variety of settings. No articles were identified regarding treatment for behavioral addictions such as disordered/harmful gambling. Meta-analysis found e-SBIRT to be effective at reducing drinking frequency in the short term only. e-SBIRT was not found to be advantageous over control conditions for abstinence or other treatment outcomes. We identified and described common components of e-SBIRT programs and assessed the quality of available evidence, which was generally poor.

CONCLUSION

The present findings suggest that research regarding e-SBIRT is concentrated exclusively on higher-risk substance use. There is a lack of consensus regarding the effectiveness of e-SBIRT for addictive disorders. Although common features exist, e-SBIRT designs are variable, which complicates identification of the most effective components. Overall, the quality of outcome evidence is low, and furthermore, high-quality experimental treatment evaluation research is needed.

"He gets mad that I'm sober": Experiences of substance use coercion among postpartum women in recovery

PURPOSE

The number of women with substance use disorders (SUDs) is growing in the U.S. Many women with SUDs are of childbearing age, and studies show that women who abstain from substance use during pregnancy often relapse in the postpartum period. Given the high overlap between substance use and intimate partner violence, these women may be in relationships that make recovery more challenging. This study aimed to better understand how substance abuse coercion in intimate relationships may affect substance use and to identify and describe the presence of substance use coercion in postpartum women.

METHODS

The study conducted qualitative interviews with 30 women with substance use disorders who had given birth within the past six months. Researchers recruited women from a larger intervention study providing home visit support to postpartum women in substance use recovery. Thematic analysis was then identified overarching themes in the interview data.

RESULTS

Analysis of the impact of IPV on substance use revealed four themes: 1) sabotaging sobriety, 2) making substance use a condition of the relationship, 3) portraying her as a "bad mom," and 4) furthering social isolation.

CONCLUSIONS

Findings showed that women with SUDs have specific vulnerabilities that partners may exploit as a way of exerting control. Implications for practice with postpartum women who are working toward recovery are discussed.

Maternal Stress Mediates Association of Infant Socioemotional Development with Perinatal Mental Health in Socioeconomically Vulnerable Peruvian Settings

Increased maternal mental health during the perinatal period has been widely associated with a variety of positive outcomes for both mothers and infants. However, no studies in Peru have yet focused on studying maternal mental health and related psychological variables during this stage. Thus, the aim of this study was to test a model to associate a mother's parental stress with infant socioemotional difficulties and maternal mental health. The sample included 988 mothers of infants aged 6 to 18 months from Peru, all from socioeconomically vulnerable settings. The findings showed that infant socioemotional difficulties were associated with poorer maternal mental health through the mother's parental stress (χ2(7) = 28.89, p < 0.001, CFI = 0.98, RMSEA = 0.06, SRMR = 0.03). These results provide a better understanding of the key elements associated with maternal mental health during the perinatal period in Peru and offer valuable insights for developing interventions and support strategies for socioeconomically vulnerable mothers and their young children.

Perception of pregnant individuals, health providers and decision makers on interventions to cease substance consumption during pregnancy: a qualitative study

BACKGROUND

Despite multiple recommendations and strategies implemented at a national and international level, cigarette smoking, alcohol consumption, and cannabis use during pregnancy remains high in most countries. The objective of this study was to examine key stakeholders' perception of the treatment interventions adopted in Spain, to identify political, organizational and personal factors associated with successful implementation, and to propose strategies for improvement.

METHODS

A qualitative study with a phenomenological approach was conducted in 2022. The target groups were: (1) clinical decision makers in the field of addiction science, (2) health professionals who carry out treatment interventions, and (3) pregnant individuals who use tobacco, alcohol or cannabis. Two focus groups and eight in-depth interviews were conducted, recorded, and transcribed. Exploratory analysis and inductive open coding was performed, codes were merged into categories, and subcategories were identified.

RESULTS

The analysis resulted in 10 subcategories which were further merged into three main categories: (1) Degree of adoption and utility of treatment interventions implemented; (2) Needs and demands with respect to the organization of treatment interventions; and, (3) Personal barriers to and facilitators for treatment. Respondents reported that despite multiple national and regional cessation initiatives, treatment interventions were rarely adopted in clinical practice. Health care administrators demanded reliable records to quantify substance use for better planning of activities. Health care professionals advocated for additional time and training and both echoed the importance of integrating cessation interventions into routine prenatal care and creating in-house specialized units. The difficulty in quitting, lack of awareness of risk for foetus and child and the controversial advice were identified as barriers by pregnant individuals.

CONCLUSIONS

Consistent with previous work, this study found that cessation strategies implemented by the health authorities are not effective if they are not accompanied by organizational and behavioral changes. The current study identifies a set of factors that could be pivotal in ensuring the success of treatment interventions targeting tobacco, alcohol and cannabis use among pregnant individuals.

The Elephant in the Room: A Systematic Review of the Application and Effects of Psychological Treatments for Pregnant Women with Dual Pathology (Mental Health and Substance-Related Disorders)

PURPOSE

Maternal mental health and substance use, referred to as dual pathology, represent significant concerns associated with adverse pregnancy and birth outcomes, a prevalence higher than commonly anticipated. Nonetheless, a notable dearth exists ofevidence-based treatment protocols tailored for pregnant women with dual pathology.

METHODS

A systematic review, adhering to the PRISMA methodology, was conducted.

RESULTS

Out of the 57 identified papers deemed potentially relevant, only 2were ultimately included. Given the limited number of studies assessing the efficacy of psychological interventions utilizing randomized controlled trials (RCTs) for both mental health and substance misuse, and considering the diverse objectives and measures employed, definitive conclusions regarding the effectiveness of psychological interventions in this domain prove challenging.

CONCLUSIONS

Maternal mental health appears to be the proverbial "elephant in the room". The development of specialized and integrated interventions stands as an imperative to effectively address this pressing issue. As elucidated in the present review, these interventions ought to be grounded in empirical evidence. Furthermore, it is essential that such interventions undergo rigorous evaluation through RCTs to ascertain their efficacy levels. Ultimately, the provision of these interventions by psychology/psychiatric professionals, both within clinical practice and the RCTs themselves, is recommended to facilitate the generalizability of the results to specialized settings.

Behavioral Health Integration on Inpatient Obstetric Units: Program Development, Strategies for Implementation, and Lessons Learned

Perinatal mood and anxiety disorders and substance use disorders are the primary causes of maternal mortality in the postpartum period and represent major public health concerns. Despite this, these conditions remain undertreated. Behavioral health integration in outpatient obstetric settings is necessary but insufficient to meet the needs of all patients. Inpatient behavioral health integration represents a promising avenue for addressing gaps in care. Results from recent program development indicate that needs assessment, stakeholder backing, collaboration with existing programs, and adaptability are key factors in successful implementation.

Neural correlates of altered emotional responsivity to infant stimuli in mothers who use substances

Mothers who use substances during pregnancy and postpartum may have altered maternal behavior towards their infants, which can have negative consequences on infant social-emotional development. Since maternal substance use has been associated with difficulties in recognizing and responding to infant emotional expressions, investigating mothers' subjective responses to emotional infant stimuli may provide insight into the neural and psychological processes underlying these differences in maternal behavior. In this study, 39 mothers who used substances during the perinatal period and 42 mothers who did not underwent functional magnetic resonance imaging while viewing infant faces and hearing infant cries. Afterwards, they rated the emotional intensity they thought each infant felt ('think'-rating), and how intensely they felt in response to each infant stimulus ('feel'-rating). Mothers who used substances had lower 'feel'-ratings of infant stimuli compared to mothers who did not. Brain regions implicated in affective processing (e.g., insula, inferior frontal gyrus) were less active in response to infant stimuli, and activity in these brain regions statistically predicted maternal substance-use status. Interestingly, 'think'-ratings and activation in brain regions related to cognitive processing (e.g., medial prefrontal cortex) were comparable between the two groups of mothers. Taken together, these results suggest specific neural and psychological processes related to emotional responsivity to infant stimuli may reflect differences in maternal affective processing and may contribute to differences in maternal behavior in mothers who use substances compared to mothers who do not. The findings suggest potential neural targets for increasing maternal emotional responsivity and improving child outcomes.

Maternal inulin supplementation ameliorates prenatal methamphetamine exposure-induced hepatotoxicity and restores gut microbiota in mouse offspring

Prenatal exposure to methamphetamine (METH) is an issue of global concern due to its adverse effects on offspring, particularly its impact on liver health, an area still not fully understood. Inulin, a recognized prebiotic, is thought to potentially ameliorate these developmental disorders and toxic injuries in progeny. To investigate the effects of prenatal METH exposure on the liver and the role of gut microbiota, we established a murine model, the subjects of which were exposed to METH prenatally and subsequently treated with inulin. Our findings indicate that prenatal METH exposure causes liver damage in offspring, as evidenced by a decreased liver index, histopathological changes, diminished glycogen synthesis, hepatic dysfunction, and alterations in mRNA profiles. Furthermore, it impairs the antioxidant system and induces oxidative stress, possibly due to changes in cecal microbiota and dysregulation of bile acid homeostasis. However, maternal inulin supplementation appears to restore the gut microbiota in offspring and mitigate the hepatotoxic effects induced by prenatal METH exposure. Our study provides definitive evidence of METH's transgenerational hepatotoxicity and suggests that maternal inulin supplementation could be an effective preventive strategy.

A novel approach to risk exposure and epigenetics-the use of multidimensional context to gain insights into the early origins of cardiometabolic and neurocognitive health

BACKGROUND

Each mother-child dyad represents a unique combination of genetic and environmental factors. This constellation of variables impacts the expression of countless genes. Numerous studies have uncovered changes in DNA methylation (DNAm), a form of epigenetic regulation, in offspring related to maternal risk factors. How these changes work together to link maternal-child risks to childhood cardiometabolic and neurocognitive traits remains unknown. This question is a key research priority as such traits predispose to future non-communicable diseases (NCDs). We propose viewing risk and the genome through a multidimensional lens to identify common DNAm patterns shared among diverse risk profiles.

METHODS

We identified multifactorial Maternal Risk Profiles (MRPs) generated from population-based data (n = 15,454, Avon Longitudinal Study of Parents and Children (ALSPAC)). Using cord blood HumanMethylation450 BeadChip data, we identified genome-wide patterns of DNAm that co-vary with these MRPs. We tested the prospective relation of these DNAm patterns (n = 914) to future outcomes using decision tree analysis. We then tested the reproducibility of these patterns in (1) DNAm data at age 7 and 17 years within the same cohort (n = 973 and 974, respectively) and (2) cord DNAm in an independent cohort, the Generation R Study (n = 686).

RESULTS

We identified twenty MRP-related DNAm patterns at birth in ALSPAC. Four were prospectively related to cardiometabolic and/or neurocognitive childhood outcomes. These patterns were replicated in DNAm data from blood collected at later ages. Three of these patterns were externally validated in cord DNAm data in Generation R. Compared to previous literature, DNAm patterns exhibited novel spatial distribution across the genome that intersects with chromatin functional and tissue-specific signatures.

CONCLUSIONS

To our knowledge, we are the first to leverage multifactorial population-wide data to detect patterns of variability in DNAm. This context-based approach decreases biases stemming from overreliance on specific samples or variables. We discovered molecular patterns demonstrating prospective and replicable relations to complex traits. Moreover, results suggest that patterns harbour a genome-wide organisation specific to chromatin regulation and target tissues. These preliminary findings warrant further investigation to better reflect the reality of human context in molecular studies of NCDs.

Factors associated with perinatal substance use among Ethiopian women: an institutional-based cross-sectional study

Introduction: Substance use during the perinatal period is a significant public health concern, as it can have potential adverse effects on maternal and neonatal health outcomes. Unexpectedly, no previous studies have been conducted to assess the prevalence of substance use during the perinatal period among Ethiopian women. Therefore, this study aimed to determine the magnitude of substance use and its determinant factors during the perinatal period. Method: We conducted a hospital-based descriptive cross-sectional study among a systematically selected sample of 418 women who attended perinatal care between May and July 2022. Data were collected using an interviewer-administered structured questionnaire. Multivariate logistic regression analysis, with a 95% confidence interval and p-values less than 0.05, was employed to identify factors associated with substance use behavior. Result: The prevalence of perinatal substance use was found to be 38.3% (95% CI: 33.5-43.5). Of the women who used substances, 109 (26.1%) reported using chat, 46 (11.0%) reported alcohol consumption, and 5 (1.20%) reported using shisha. Factors significantly associated with substance use behavior during the perinatal period included a history of obstetric complications (AOR = 1.722, 95% CI: 1.022-2.902), the presence of chronic medical conditions (AOR = 3.784, 95% CI: 2.164-6.615), experiencing physical abuse (AOR = 5.323, 95% CI: 2.171-13.050), depression (AOR = 1.963, 95% CI: 1.028-3.749), and experiencing sleep disturbances (AOR = 2.016, 95% CI: 0.975-4.168). Conversely, giving birth to a live baby was found to be a protective factor against substance use behavior (AOR = 0.389, 95% CI: 0.187-0.810). Discussion: This study highlights a high prevalence of substance abuse among women during the perinatal period. In light of these findings, a comprehensive approach is recommended to address perinatal substance use among Ethiopian women. This should include the integration of preventive educational programs into perinatal care.

Partnering for the future clinic: A multidisciplinary perinatal substance use program

OBJECTIVE

The current model of obstetric care does not integrate multiple subspecialty services for high-risk pregnancies with substance use disorder (SUD), resulting in fragmented care. We describe the framework of our multidisciplinary and integrated perinatal substance use clinic and provide recent clinical outcomes.

METHODS

We detail the Partnering for the Future (PFF) clinic, which integrates numerous subspecialty and support services for patients with SUDs and complex mental health needs. Additionally, a retrospective chart review of patients receiving care in the PFF clinic from 2017 to 2021 was completed.

RESULTS

Seven integrated services are detailed with a focus on reducing stigma, providing trauma-informed care and mitigating harm. During the study period, 182 patients received care in PFF clinic, with opioid use disorder the most common indication for care. Co-occurring mental illness was common (81%). NICU admissions and severe NOWS diagnosis declined after the implementation of Eat-Sleep-Console. Social services identified care coordination, transportation assistance and adjustment counseling as the most common needs. A novel virtual behavioral health consultation service was successfully launched.

CONCLUSIONS

Our integrated care model supports the holistic care of pregnant people with SUD and mental health disease. Patient-centered care and co-located services have improved perinatal outcomes, particularly for opioid-exposed pregnancies.

Prevalence and Predictors of Early Intervention Referral Among Substance-Exposed Newborns

OBJECTIVES

Substance-exposed newborns (SENs) are at risk for developmental delay(s). Early intervention (EI) access, key to addressing these risks, is inequitable. Objectives were to: 1. determine prevalence of EI referral in the Colorado Hospitals Substance-Exposed Newborn Quality Improvement Collaborative; and 2. evaluate predictors of referral.

METHODS

Within participating Colorado Hospitals Substance-Exposed Newborn hospitals, maternal-infant dyads with exposure to medications for opioid use disorder (MOUD), illicit/prescription opioids, and/or nonopioid substances were included on the basis of electronic medical record documentation. χ2, Fisher's exact, and analysis of variance tests evaluated differences in maternal/infant characteristics by referral. Multivariable Poisson regression models assessed the independent association of characteristics with referral.

RESULTS

Among 1222 dyads, 504 (41%) SENs received EI referral. Infants born to mothers with non-MOUD (adjusted risk ratio [aRR] 2.15, 95% confidence interval [CI] 1.67-2.76) and polysubstance (aRR 1.58, 95% CI 1.26-1.97) exposure were less likely to receive referral compared with infants born to mothers with MOUD exposure. Those with private (aRR 1.26, 95% CI 1.03-1.55) or self-pay/no insurance (aRR 12.32, 95% CI 10.87-13.96) were less likely to receive referral compared with infants with public insurance.

CONCLUSIONS

Less than half of identified SENs received EI referral, with variation by substance exposure and maternal insurance status. Systems to ensure equitable access to services are crucial.

Quetiapine and other antipsychotic medications during pregnancy: a 15-year follow-up of a university hospital birth register

PURPOSE

To survey trends of antipsychotic use during pregnancy and examine the associations between the use of quetiapine or any antipsychotic and adverse obstetric and neonatal outcomes.

METHODS

Birth register study of 36,083 women who gave birth at Kuopio University Hospital, Finland, between 2002 and 2016. Obstetric and neonatal outcomes between women using quetiapine (N = 152) or any antipsychotic (N = 227) were compared to controls (N = 35,133).

RESULTS

Altogether 246 (0.7%) women used antipsychotic medications during pregnancy and 153 (62,2%) of these women used quetiapine. Antipsychotic usage increased from 0.4% to 1.0% during the 15-year follow-up. Women using antipsychotics were more likely to smoke, drink alcohol, use illicit drugs, use other psychotropic medications, and have higher pre-pregnancy body mass index. Quetiapine use was associated with higher risk of increased postpartum bleeding in vaginal delivery (aOR 1.65; 95%CI 1.13-2.42), prolonged neonatal hospitalization (≥5 days) (aOR 1.54; 95%CI 1.10-2.15), and higher placental to birth weight ratio (PBW ratio) (aB 0.009; 95%CI 0.002-0.016). Use of any antipsychotic was associated with a higher risk of gestational diabetes mellitus (aOR 1.64; 95%CI 1.19-2.27), increased postpartum bleeding in vaginal delivery (aOR 1.50; 95%CI 1.09-2.07), prolonged neonatal hospitalization (≥5 days) (aOR 2.07; 95%CI 1.57-2.73), and higher PBW ratio (aB 0.007; 95%CI 0.001-0.012).

CONCLUSION

The use of antipsychotic medications increased among Finnish pregnant women from 2002 to 2016. Pregnant women using antipsychotics appear to have a higher risk for some adverse pregnancy and birth outcomes and may benefit from more frequent maternity care follow-ups.

Polysubstance Use in Pregnancy: Surveillance, Interventions, and Next Steps

Substance use during pregnancy increases risk for a wide range of adverse maternal and neonatal health outcomes. Polysubstance use is common among people who use substances during pregnancy; however, the risks of combined substance exposures during pregnancy are poorly understood. In this report, we provide an overview of the activities of the Centers for Disease Control and Prevention (CDC) and partners and identified gaps related to (1) surveillance, (2) routine screening, and (3) prevention of polysubstance use during pregnancy. Efforts by CDC and other partners to reduce polysubstance use during pregnancy can improve the health of pregnant people and their infants and children.

Self-Identified Stage in Recovery and Substance-Use Behaviors among Pregnant and Postpartum Women and People with Opioid Use Disorder

Opioid use among pregnant and postpartum women and people (PPWP) has significant health repercussions. This study explores how substance-use behaviors may vary by stage in recovery among PPWP with opioid use disorder (OUD). We recruited 29 PPWP with OUD. "High-risk" participants self-identified as "not being engaged in treatment" or "new or early in their recovery" (n = 11); "low-risk" participants self-identified as being "well-established" or "in long-term recovery" (n = 18). Participants were queried regarding sociodemographic, mental health, and drug-misuse factors; urine drug screens were collected at baseline. Univariate group comparisons between high-risk and low-risk PPWP were conducted. High-risk PPWP were more likely to self-identify as non-Hispanic African American and more likely to report current opioid use, other illicit drugs, and tobacco. High-risk PPWP had higher opioid cravings versus low-risk PPWP. High-risk PPWP were more likely to screen positive on urine tests for non-opioid drugs and on concurrent use of both non-opioid drugs and opioids versus low-risk participants. PPWP earlier in recovery are at higher-risk for opioid and other illicit drug misuse but are willing to disclose aspects of their recent use. PPWP early in recovery are an ideal population for interventions that can help facilitate recovery during the perinatal period and beyond.

Mental health and substance use disorders at delivery hospitalization and readmissions after delivery discharge

BACKGROUND

The objective was to assess mental health and substance use disorders (MSUD) at delivery hospitalization and readmissions after delivery discharge.

METHODS

This is a population-based retrospective cohort study of persons who had a delivery hospitalization during January to September in the 2019 Nationwide Readmissions Database. We calculated 90-day readmission rates for MSUD and non-MSUD, overall and stratified by MSUD status at delivery. We used multivariable logistic regressions to assess the associations of MSUD type, patient, clinical, and hospital factors at delivery with 90-day MSUD readmissions.

RESULTS

An estimated 11.8% of the 2,697,605 weighted delivery hospitalizations recorded MSUD diagnoses. The 90-day MSUD and non-MSUD readmission rates were 0.41% and 2.9% among delivery discharges with MSUD diagnoses, compared to 0.047% and 1.9% among delivery discharges without MSUD diagnoses. In multivariable analysis, schizophrenia, bipolar disorder, stimulant-related disorders, depressive disorders, trauma- and stressor-related disorders, alcohol-related disorders, miscellaneous mental and behavioral disorders, and other specified substance-related disorders were significantly associated with increased odds of MSUD readmissions. Three or more co-occurring MSUDs (vs one MSUD), Medicare or Medicaid (vs private) as the primary expected payer, lowest (vs highest) quartile of median household income at residence zip code level, decreasing age, and longer length of stay at delivery were significantly associated with increased odds of MSUD readmissions.

CONCLUSION

Compared to persons without MSUD at delivery, those with MSUD had higher MSUD and non-MSUD 90-day readmission rates. Strategies to address MSUD readmissions can include improved postpartum MSUD follow-up management, expanded Medicaid postpartum coverage, and addressing social determinants of health.

The Association of Maternal Smoking and Drinking Changes During Pregnancy and Postpartum Breastfeeding Pattern and Duration

Objectives: To conduct a secondary data analysis of how changes in smoking and drinking during pregnancy impact status of any breastfeeding and breastfeeding duration in a national cohort. Materials and Methods: A cross-sectional study was conducted using Pregnancy Risk Assessment Monitoring System (PRAMS) data between 2009 and 2017 (n = 334,203). Univariate and multivariate analyses were conducted on the status of any breastfeeding and breastfeeding duration. Results: A dose-dependent inverse relationship was found in which women who smoked the same or more or resumed smoking during pregnancy showed the lowest likelihood and shortest duration of breastfeeding, followed by reduced smokers, quitters, and nonsmokers. Women with a history of alcohol use were significantly more likely to breastfeed compared with women without a history of alcohol use. Conclusions: The profile of smoking change during pregnancy impacts the likelihood and duration of breastfeeding in a dose-dependent and inverse manner. No such relationship was found with drinking change during pregnancy. Public Health Implications: Significant public health efforts should focus on implementing and sustaining evidence-based interventions for prenatal smoking cessation and educating providers and maternal populations on the adverse effect of postpartum alcohol exposure.

Initiation and Treatment Discontinuation of Medications for Opioid Use Disorder in Pregnant People Compared With Nonpregnant People

OBJECTIVE

To examine the association between pregnancy and medications for opioid use disorder (MOUD) initiation and discontinuation among reproductive-aged people receiving treatment for opioid use disorder (OUD) in the United States.

METHODS

We conducted a retrospective cohort study of people with gender recorded as female, aged 18-45 years, in the Merative TM MarketScan ® Commercial and Multi-State Medicaid Databases (2006-2016). Opioid use disorder and pregnancy status were identified based on inpatient or outpatient claims for established International Classification of Diseases, Ninth and Tenth Revision diagnosis and procedure codes. The main outcomes were buprenorphine and methadone initiation and discontinuation, determined by using pharmacy and outpatient procedure claims. Analyses were conducted at the treatment episode level. Adjusting for insurance status, age, and co-occurring psychiatric and substance use disorders, we used logistic regression to estimate MOUD initiation and used Cox regression to estimate MOUD discontinuation.

RESULTS

Our sample included 101,772 reproductive-aged people with OUD, encompassing 155,771 treatment episodes (mean age 30.8 years, 64.4% Medicaid insurance, 84.1% White), of whom 2,687 (3.2%, encompassing 3,325 episodes) were pregnant. In the pregnant group, 51.2% of treatment episodes (1,703/3,325) involved psychosocial treatment without MOUD, in comparison with 61.1% (93,156/152,446) in the nonpregnant comparator group. In adjusted analyses assessing likelihood of initiation for individual MOUD, pregnancy status was associated with an increase in buprenorphine (adjusted odds ratio [aOR] 1.57, 95% CI 1.44-1.70) and methadone initiation (aOR 2.04, 95% CI 1.82-2.27). Discontinuation rates of MOUD at 270 days were high for both buprenorphine (72.4% for nonpregnant episodes vs 59.9% for pregnant episodes) and methadone (65.7% for nonpregnant episodes vs 54.1% for pregnant episodes). Pregnancy was associated with a decreased likelihood of discontinuation at 270 days for both buprenorphine (adjusted hazard ratio [aHR] 0.71, 95% CI 0.67-0.76) and methadone (aHR 0.68, 95% CI 0.61-0.75), in comparison with nonpregnant status.

CONCLUSION

Although a minority of reproductive-aged people with OUD in the United States are initiated on MOUD, pregnancy is associated with a significant increase in treatment initiation and a reduced risk of medication discontinuation.

A Peer-to-Peer, Longitudinal Reproductive Psychiatry Educational Curriculum for Obstetrics/Gynecology Residents

OBJECTIVE

Pregnant patients with psychiatric diagnoses are commonly advised to stop their psychiatric medications. Few studies assess the knowledge of, attitude toward, or comfort levels of obstetrics and gynecology (OB/GYN) residents in managing psychiatric conditions, which carry adverse and potentially life-threatening risks to mother and fetus. A gap remains between evidence advocating for active psychopharmacological treatment during pregnancy and implementation of curricula targeting OB/GYN physicians in mental health. The authors' goals are to assess the knowledge, attitude, and comfort that OB/GYN residents have toward assessing and managing active psychiatric conditions in pregnant/postpartum women and to develop an educational, case-based intervention targeting these conditions in the perinatal/postpartum period.

METHODS

Eight perinatal/postpartum psychiatric topics were developed into interactive cases designed for OB/GYN residents. Two weeks before the curriculum administration, OB/GYN residents were surveyed on prior knowledge in, attitudes toward, and comfort levels in assessing and discussing psychiatric conditions in pregnant patients. The assessment was administered again after the intervention to assess its effectiveness.

RESULTS

Pre- (N = 19) and post-intervention (N = 15) surveys of residents were analyzed. Most residents (94%) felt it was both important and their responsibility to discuss mental health conditions with pregnant patients. Comfort levels with counseling psychiatric patients increased for all eight topics after the educational intervention was implemented, with statistically significant increases (p < 0.05) for five of the topics.

CONCLUSIONS

OB/GYN residents feel responsible for caring for pregnant patients with psychiatric illness, and case-based interventions offer an interactive, helpful tool for increasing residents' knowledge and comfort level in treating this patient population.

Development of an Electronic Screening and Brief Intervention to Address Perinatal Substance Use in Home Visiting: Qualitative User-Centered Approach

BACKGROUND

Perinatal substance use (SU) is prevalent during pregnancy and the postpartum period and may increase the risks to maternal and child health. Many pregnant and postpartum women do not seek treatment for SU because of fear of child removal. Home visiting (HV), a voluntary supportive program for high-risk families during the perinatal period, is a promising avenue for addressing unmet SU needs. Confidential delivery of screening and brief intervention (BI) for SU via computers has demonstrated high user satisfaction among pregnant and postpartum women as well as efficacy in reducing perinatal SU. This study describes the development of the electronic screening and BI for HV (e-SBI-HV), a digital screening and BI program that is adapted from an existing electronic screening and BI (e-SBI) for perinatal SU and tailored to the HV context.

OBJECTIVE

This study aimed to describe the user-centered intervention development process that informed the adaptation of the original e-SBI into the e-SBI-HV, present specific themes extracted from the user-centered design process that directly informed the e-SBI-HV prototype and describe the e-SBI-HV prototype.

METHODS

Adaptation of the original e-SBI into the e-SBI-HV followed a user-centered design process that included 2 phases of interviews with home visitors and clients. The first phase focused on adaptation and the second phase focused on refinement. Themes were extracted from the interviews using inductive coding methods and systematically used to inform e-SBI-HV adaptations. Participants included 17 home visitors and 7 clients across 3 Healthy Families America programs in New Jersey.

RESULTS

The e-SBI-HV is based on an existing e-SBI for perinatal SU that includes screening participants for SU followed by a brief motivational intervention. On the basis of the themes extracted from the user-centered design process, the original e-SBI was adapted to address population-specific motivating factors, address co-occurring problems, address concerns about confidentiality, acknowledge fear of child protective services, capitalize on the home visitor-client relationship, and provide information about SU treatment while acknowledging that many clients prefer not to access the formal treatment system. The full e-SBI-HV prototype included 2 digital intervention sessions and home visitor facilitation protocols.

CONCLUSIONS

This study describes a user-centered approach for adapting an existing e-SBI for SU for use in the HV context. Despite the described challenges, home visitors and clients generally reacted favorably to the e-SBI-HV, noting that it has the potential to fill a significant gap in HV services. If proven effective, the e-SBI-HV could provide a way for clients to receive help with SU within HV, while maintaining their privacy and avoiding the overburdening of home visitors. The next step in this study would be to test the feasibility and preliminary efficacy of the e-SBI-HV.

Supporting perinatal individuals with opioid use disorder and their newborns experiencing neonatal abstinence syndrome: impressions from patients and healthcare providers

Background: Facilitating maternal-newborn involvement and care is critical for improving outcomes for perinatal individuals receiving opioid agonist therapy (OAT) and newborns experiencing Neonatal Abstinence Syndrome (NAS). Comprehensive education strategies are needed to prepare pregnant individuals receiving OAT for navigating the perinatal period.Objectives: Identify facilitators to successful care of perinatal individuals receiving OAT and newborns experiencing NAS via interviews with perinatal individuals and healthcare providers. The goal of identifying this information is to inform a future educational tool development.Methods: Ten perinatal individuals receiving OAT and ten healthcare providers participated in interviews conducted via phone or video conference using semi-structured, open-ended questions. Data were analyzed separately for the two groups and later merged across samples using a qualitative descriptive content analysis approach to identify themes.Results: Under the overarching theme of empowerment to improve outcomes for perinatal women, four themes arose from perinatal and provider interviews: 1) Preparation for Child Protective Services (CPS) involvement, 2) Healthcare providers shape experience through stigma and support 3) Caring for newborns with NAS, and 4) Managing health and resources during postpartum.Conclusion: Perinatal participants emphasized the importance of self-advocacy while navigating healthcare and social systems. Providers highlighted the importance of communicating expectations to empower patients. Education is needed for pregnant individuals receiving OAT on what to expect during pregnancy and postpartum, as well as for providers to help them optimally support their perinatal patients receiving OAT.

"You have to take this medication, but then you get punished for taking it:" lack of agency, choice, and fear of medications to treat opioid use disorder across the perinatal period

INTRODUCTION

Medications to treat opioid use disorder (MOUD) during pregnancy and in the postpartum period remain underutilized. A need exists to enhance our understanding of modifiable factors, facilitators, and barriers to MOUD utilization and adherence in the perinatal period to improve maternal and child outcomes.

METHODS

The study conducted semi-structured qualitative interviews with recently pregnant people with opioid use disorder (OUD) to explore experiences as a pregnant and/or parenting person with OUD, perceptions of enabling factors and barriers to treatment utilization, incentivizing factors for maintaining adherence, and acceptability of ongoing supports to sustain treatment adherence. The study team used constant comparative methods to analyze transcripts and develop the codebook. The team double coded the transcripts, with an overall kappa coefficient of 0.88.

RESULTS

The study team interviewed twenty-six women on average 10.1 months after delivery. All women had some prior experience using MOUD. Four unique themes emerged as barriers to medication utilization and adherence in the perinatal period: 1) Lack of agency and autonomy surrounding medication decisions because pregnancy or parenting status affected treatment adherence; 2) Hesitancy to use MOUD to minimize risk of newborn withdrawal; 3) Concern about increased scrutiny and potential loss of custody due to mandated child protective services reporting for opioid-exposure at delivery in Massachusetts; and 4) Perception that treatment environments, particularly methadone clinics, did not provide gender-responsive or equitable care, and standardized, inflexible visit regulations were particularly difficult to comply with in the early postpartum period.

CONCLUSIONS

Women with OUD experienced a double bind when making perinatal treatment decisions, describing pressure to use MOUD with negative consequences after delivery. Key areas for possible intervention emerged from interviews. These areas include improving uptake of shared decision-making to increase patient autonomy and agency, particularly among those in the earliest stages of recovery during pregnancy; ongoing education around perinatal MOUD safety and efficacy; detangling MOUD and neonatal withdrawal signs from mandated child protective services reporting; and improving gender-responsive and equitable care in substance use disorder treatment programs, including incorporating the utilization of home visiting services for dosing assessments and administration in the early postpartum period.

The Association of Psychological Stressors With Cannabis Use During Pregnancy: Findings From the National Survey on Drug Use and Health 2017-2019

ABSTRACT

Even though marijuana is illegal on the federal level, it is one of the most used drugs in the United States during pregnancy. Our study investigates the relationship between numerous socioeconomic, demographic, and mental health risk variables and substance use during pregnancy. We examined data from the National Survey on Drug Use and Health from 2017 to 2019. Compared with the no serious psychological distress (SPD) group, the odds of using cannabis were higher in pregnant women with past-month SPD. In this study, in comparison with unmarried pregnant women, married pregnant women had a 67% lower chance of currently using cannabis. Racially, Hispanic pregnant women had 3 to 4 times higher odds for current use of cannabis as compared with the other races. Preventing cannabis use and its adverse effects by screening pregnant women could be part of the current strategy for reducing cannabis use.

Substance-related diagnosis type predicts the likelihood and co-occurrence of preterm and cesarean delivery

This article aimed to evaluate whether a substance-related diagnosis (SRD; i.e., alcohol, opioids, cannabis, stimulants, nicotine) predicts the likelihood and co-occurrence of preterm (20-37 weeks' gestation) and cesarean delivery.

This study reviewed electronic health record data on women (aged 18-44 years) who delivered a single live or stillbirth at ≥ 20 weeks of gestation from 2012 to 2019. Women with and without an SRD were matched on key demographic characteristics at a 1:1 ratio. Adjusting for covariates, odds ratios and 95% confidence intervals were calculated.

Of the 19,346 deliveries, a matched cohort of 2,158 deliveries was identified. Of these, 1,079 (50%) had an SRD, 280 (13%) had a preterm delivery, 833 (39%) had a cesarean delivery, and 166 (8%) had a co-occurring preterm and cesarean delivery. An SRD was significantly associated with preterm and cesarean delivery (AOR = 1.84 [95% CI, 1.41-2.39], p-value= <0.0001; AOR = 1.51 [95% CI, 1.23-1.85], p-value= <0.0001). An alcohol-related diagnosis (AOR = 1.82 [95% CI, 1.01-3.28], p-value= 0.0471), opioid-related diagnosis (AOR = 1.94 [95% CI, 1.26-2.98], p-value= 0.0027), stimulant-related diagnosis (AOR = 1.65 [95% CI, 1.11-2.45], p-value= 0.0142), and nicotine-related diagnosis (AOR = 1.54 [95% CI, 1.05-2.26], p-value= 0.0278) were associated with co-occurring preterm and cesarean delivery.

Pregnant women with an SRD experienced disproportionally higher odds of preterm and cesarean delivery compared to pregnant women without an SRD. Substance-type predicts the type of delivery outcome. An SRD in pregnant women should be identified early to reduce potential harm through intervention and treatment.

Understanding the relationship between social determinants of health and maternal mortality: Scientific Impact Paper No. 67

Within this document we use the terms pregnant woman and women's health. However, it is important to acknowledge that it is not only people who identify as women for whom it is necessary to access care. Obstetric and gynaecology services and delivery of care must therefore be appropriate, inclusive and sensitive to the needs of those individuals whose gender identity does not align with the sex they were assigned at birth.

Validity and Reliability of the Modified Attitudes About Drug Use in Pregnancy Scale

OBJECTIVE

To contemporize the Attitudes About Drug Abuse in Pregnancy questionnaire, keep the length of the modified scale brief to promote use, and test the psychometric properties of the modified scale among perinatal nurses.

DESIGN

Cross-sectional survey.

SETTING

Four hospitals in the Midwestern United States.

PARTICIPANTS

Registered nurses who worked in perinatal units (N = 440).

METHODS

We collected data from participants using survey methods. Seven experts in perinatal substance use research and clinical care informed scale modifications. We used a split-sample design involving maternal-newborn units (labor, postpartum) and newborn-focused units (NICU, pediatrics). We evaluated construct validity using factor analysis and reliability using Cronbach's alpha. We tested for differences between units using analysis of variance and Tukey's post hoc honest significant difference test of pairwise differences.

RESULTS

The final modified scale included 13 items that loaded on one factor and showed internal consistency reliability in both samples (α = .88-.91). We found a statistically significant difference in mean score between NICU and pediatric units; however, the absolute difference was small and likely not clinically significant.

CONCLUSIONS

The Modified Attitudes About Drug Use in Pregnancy scale has initial evidence for validity and reliability, was updated to reflect current terminology in the field, and is a pragmatic tool for use in research.

Associations Between Adverse Childhood Experiences and Prenatal Mental Health and Substance Use Among Urban, Low-Income Women

This study examined associations between Adverse Childhood Experiences (ACEs) and perinatal mental health and substance use among 98 low-income women (mean age 25.4 years; 93% Black/African American) referred to a mental health care manager in an urban women's clinic. Self-report and retrospective chart review data were utilized. Chi-squared and Fisher's Exact tests were performed to assess bivariate relationships between ACEs and mental health and substance use outcomes. Multivariate logistic regressions were used to examine the impact of ACEs on mental health and substance use, adjusting for marital status, education, and age. Findings indicate high levels of childhood adversity, specifically childhood abuse, are associated with negative perinatal mental health and substance use outcomes, including suicidal thoughts, anxiety, mood dysregulation, and tobacco and marijuana use. Inquiring about ACEs during prenatal care and/or in community health clinics may help identify patients' overall risk and provide opportunities for intervention for mothers and their infants.

Nurturing families: One year pilot outcomes for a modified Parent Child Assistance Program in Australia

Alcohol and Other Drug (AOD) exposure during pregnancy is linked to serious adverse child outcomes, including Fetal Alcohol Spectrum Disorder (FASD). The Parent-Child Assistance Program (PCAP) supports women with problematic AOD use, who are pregnant or have young children, and are not effectively engaging with services. PCAP has been shown to reduce alcohol exposed pregnancies, promote AOD abstinence, increase employment and family planning and improve child outcomes. This manuscript reports the first pilot evaluation of the PCAP program delivered in Australia. A pre-post-intervention repeated measures design was used. Eleven women receiving PCAP from a not-for-profit organisation were invited to take part in the study, with eight providing complete pre-post data. Home visitation case management was provided by trained and experienced case-managers. Clients were assisted to engage with existing services effectively to meet their own goals via a combination of relational theory, motivational interviewing and harm reduction concepts. The PCAP Modified Addiction Severity Index 5th Edition was adapted for use in Australia and was used to measure domains of addiction severity related problems as the primary outcome. Secondary outcomes included client satisfaction and program fidelity. There were significant changes in composite addiction severity scores from baseline to one year. 80% of participants had periods of abstinence of longer than four months. All clients had better connection to services, no subsequent AOD exposed pregnancies, and were highly satisfied with the program. Four had children returned to their care. Implementation was similar to the original PCAP program with major differences including case-managers relying on training manuals only without undertaking in-person training; being more experienced; providing more direct AOD counselling; and having less supervision. The findings will inform future program delivery and methodology for a larger longitudinal study assessing outcomes at program exit.

Racial/ethnic variations in alcohol and cigarette use by pregnancy status among 20- to 44-year-old women, NHANES 2001-2018

OBJECTIVES

This study examines alcohol consumption and smoking behaviors by pregnancy status and race/ethnicity in order to inform improved interventions designed to assist women of all races to avoid alcohol and tobacco use during pregnancy for their health and to prevent potential fetal exposure.

METHODS

This retrospective secondary data analysis utilized nationally representative National Health and Nutrition Examination Survey data between 2001 and 2018. Smoking and alcohol use were evaluated by race/ethnicity and pregnancy risk. Sexual behavior, reproductive health, and prescription drug use determined pregnancy risk, categorized as low pregnancy risk, at risk of becoming pregnant, and pregnant. Binary and multinomial multivariable logistic regression were used to examine associations.

RESULTS

The final sample consisted of 10,019 women of which 11.8% were Mexican American, 7.7% other Hispanic, 65.5% white, and 15% black (weighted percentages). White low pregnancy risk and pregnancy risk smoked most frequently in respective pregnancy risk groups (p < 0.001). Among pregnant women, smoking prevalence was highest among black women (14.0%, p < 0.01). Pregnancy risk women were more likely to smoke and pregnant women were less likely to smoke compared with low pregnancy risk. Low pregnancy risk and pregnancy risk Hispanics had a lower prevalence of binge drinking, but prevalence decreased less among pregnant Hispanics than other racial/ethnic groups. In adjusted analyses, pregnancy risk black women had more than 2 times the odds of combined smoking and alcohol consumption compared with low pregnancy risk black women.

CONCLUSION

Women who may become pregnant need interventions and improved policy to prevent alcohol use and smoking. Culturally appropriate alcohol and smoking cessation interventions before pregnancy and improved contraception access are needed.

Integrated vs nonintegrated treatment for perinatal opioid use disorder: retrospective cohort study

BACKGROUND

Pregnant women with opioid use disorder and their infants often experience worse perinatal outcomes than women without opioid use disorder, including longer hospitalizations after delivery and a higher risk for preterm delivery. Integrated treatment models, which combine addiction treatment and maternity care, represent an innovative approach that is widely endorsed, however, limited studies have compared the outcomes between integrated and standard, nonintegrated programs from real-world programs.

OBJECTIVE

This study aimed to evaluate the perinatal and substance use outcomes for pregnant women with opioid use disorder receiving coordinated, colocated obstetrical care and opioid use disorder treatment (integrated treatment) and to compare it with those of women receiving obstetrical care and opioid use disorder treatment in distinct programs of care (nonintegrated treatment).

STUDY DESIGN

In this observational, retrospective cohort study, we abstracted the perinatal and opioid use disorder treatment data from the records of pregnant women with opioid use disorder (n=225) who delivered at a rural, academic medical center from 2015 to 2017. The women either received integrated (n=92) or nonintegrated (n=133) opioid use disorder treatment and obstetrical care. Using inverse probability weighted regression models to adjust for a potential covariate imbalance, we evaluated the impact of the treatment model on the risk for preterm delivery and positive meconium or umbilical cord toxicology screens. We explored whether the number of obstetrical visits mediated this relationship by using a quasi-Bayesian Monte Carlo algorithm.

RESULTS

Women receiving integrated treatment were less likely to deliver prematurely (11.8% vs 26.6%; P<.001) and their infants had shorter hospitalizations (6.5±4.8 vs 10.7±16.2 days). Using a robust inverse probability weighted model showed that receiving integrated treatment was associated with a 74.7% decrease in the predicted probability of preterm delivery (average treatment effect, -0.19; standard error, 0.14; P<.001). There were no differences in the risk for a positive meconium or umbilical cord toxicology screen, a marker for second and third trimester substance use, between women receiving integrated treatment and those receiving coordinated treatment (29.4% vs 34.6%; P=.41), however, integrated treatment was associated with significantly lower rates of positive maternal urine toxicology screens at the time of delivery (35.9% vs 74.4%; P<.001).

CONCLUSION

Among a cohort of rural pregnant women with opioid use disorder, receiving integrated obstetrical care and opioid use disorder treatment was associated with a reduced risk for preterm birth, a lower risk for positive maternal urine toxicology screen at the time of delivery, and shorter infant hospitalization. This relationship was mediated by the number of obstetrical visits attended during pregnancy, suggesting that increased engagement with obstetrical care through integration of services may contribute to improved perinatal outcomes.

Factors associated with drug use during pregnancy and breastfeeding among females who use drugs (FWUDs) in Malaysia

Females who use drugs (FWUDs) are at risk of continuing illicit substance use during pregnancy and breastfeeding. We investigated the prevalence rates and factors associated with these practices in a sample of 200 FWUDs recruited from a publicly-run drug rehabilitation center. A semi-structured questionnaire was used to collect the data. The majority (86%) was Malay (n = 171/200), currently single (71%, n = 141/200), and 51% had nine years of education. The mean age of respondents was 32.2 years (SD = 8.61). Thirty-eight percent (n = 75/200) reported ever using illicit substances during pregnancy, while 15% (n = 30/200) had used them during breastfeeding. Higher odds of using drugs during pregnancy were associated with having an intimate male drug-using partner and with persons who reported abandoning an infant in the past. Lower odds were linked with women who used heroin with ATS (relative to those who used only ATS), and shorter-term ATS (≤3 years) relative to long term ATS users. At a lower level of significance (p = 0.054), being married also lowered the odds. Higher odds of drug use during breastfeeding were associated with having an intimate male drug-using partner, and previous methadone use history, while lower odds were associated with short-term ATS use and being employed. The findings highlight the need for timely and targeted interventions to inform, engage and promote the participation of FWUDs in pre- and post-natal care services.

Association between obsessive-compulsive disorder and obstetrical and neonatal outcomes in the USA: a population-based cohort study

Obsessive-compulsive disorder (OCD) is a mental disorder linked to functional impairments and adverse health outcomes. We sought to examine the association between pregnant women with OCD and obstetrical and neonatal outcomes in the USA. A retrospective population-based cohort study was conducted using data provided by pregnant women from the Nationwide Inpatient Sample, a nationally representative database of hospitalizations in the USA, from 1999 to 2015. Using diagnostic and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), we identified births and classified women by OCD status. Demographic and clinical characteristics were compared for women with and without OCD and multivariate logistic regressions were used to obtain odds ratios (OR) to compare obstetrical and neonatal outcomes between the two groups, adjusting for relevant demographic and clinical variables. Between 1999 and 2015, there were 3365 births to women with OCD, corresponding to an overall prevalence of 24.40 per 100,000 births. Women with OCD were more likely to be older than 25, Caucasian, of higher socioeconomic status, smokers or used drugs and alcohol, and have other comorbid psychiatric conditions. In adjusted models, OCD was associated with a higher risk of gestational hypertension, preeclampsia, premature rupture of membranes, caesarean and instrumental deliveries, venous thromboembolisms and preterm birth. Pregnancies in women with OCD are at high risk of adverse obstetrical and neonatal outcomes. A multidisciplinary approach should be used to identify high risk behaviours and ensure adequate prenatal follow-up and care be available for those with high risk pregnancies.

A Comprehensive Overview of the Physical Health of the Adolescent Brain Cognitive Development Study Cohort at Baseline

Physical health in childhood is crucial for neurobiological as well as overall development, and can shape long-term outcomes into adulthood. The landmark, longitudinal Adolescent Brain Cognitive Development StudySM (ABCD study®), was designed to investigate brain development and health in almost 12,000 youth who were recruited when they were 9-10 years old and will be followed through adolescence and early adulthood. The overall goal of this paper is to provide descriptive analyses of physical health measures in the ABCD study at baseline, including but not limited to sleep, physical activity and sports involvement, and body mass index. Further this summary will describe how physical health measures collected from the ABCD cohort compare with current normative data and clinical guidelines. We propose this data set has the potential to facilitate clinical recommendations and inform national standards of physical health in this age group. This manuscript will also provide important information for ABCD users and help guide analyses investigating physical health including new avenues for health disparity research as it pertains to adolescent and young adult development.

Methadone and buprenorphine discontinuation among postpartum women with opioid use disorder

BACKGROUND

The postpartum year is a vulnerable period for women with opioid use disorder, with increased rates of fatal and nonfatal overdose; however, data on the continuation of medications for opioid use disorder on a population level are limited.

OBJECTIVE

This study aimed to examine the effect of discontinuing methadone and buprenorphine in women with opioid use disorder in the year following delivery and determine the extent to which maternal and infant characteristics are associated with time to discontinuation of medications for opioid use disorder.

STUDY DESIGN

This population-based retrospective cohort study used linked administrative data of 211,096 deliveries in Massachusetts between 2011 and 2014 to examine the adherence to medications for opioid use disorder. Individuals receiving medications for opioid use disorder after delivery were included in the study. Here, demographic, psychosocial, prenatal, and delivery characteristics are described. Kaplan-Meier survival analysis and Cox regression modeling were used to examine factors associated with medication discontinuation.

RESULTS

A total of 2314 women who received medications for opioid use disorder at delivery were included in our study. Overall, 1484 women (64.1%) continued receiving medications for opioid use disorder for a full 12 months following delivery. The rate of continued medication use varied from 34% if women started on medications for opioid use disorder the month before delivery to 80% if the medications were used throughout pregnancy. Kaplan-Meier survival curves differed by maternal race and ethnicity (the 12-month continuation probability was .65 for White non-Hispanic women and .51 for non-White women; P<.001) and duration of use of prenatal medications for opioid use disorder (12-month continuation probability was .78 for women with full prenatal engagement and .60 and .44 for those receiving medications for opioid use disorder ≥5 months [but not throughout pregnancy] and ≤4 months prenatally, respectively; P<.001). In all multivariable models, duration of receipt of prenatal medications for opioid use disorder (≤4 months vs throughout pregnancy: adjusted hazard ratio, 3.26; 95% confidence interval, 2.72-3.91) and incarceration (incarceration during pregnancy or after delivery vs none: adjusted hazard ratio, 1.79; 95% confidence interval, 1.52-2.12) were most strongly associated with the discontinuation of medications for opioid use disorder.

CONCLUSION

Almost two-thirds of women with opioid use disorder continued using medications for opioid use disorder for a full year after delivery; however, the rates of medication continuation varied significantly by race and ethnicity, degree of use of prenatal medications for opioid use disorder, and incarceration status. Prioritizing medication continuation across the perinatal continuum, enhancing sex-specific and family-friendly recovery supports, and expanding access to medications for opioid use disorder despite being incarcerated can help improve postpartum medication adherence.

Neonatal Outcomes after Combined Opioid and Nicotine Exposure in Utero: A Scoping Review

BACKGROUND

The majority of women who are pregnant with opioid use disorder (OUD) also smoke tobacco but are rarely offered tobacco cessation counseling. While the effects of exposure to opioids and nicotine in utero are well-understood separately, understanding the impact of the combined exposure to these substances on neonatal outcomes is lacking.

METHODS

A scoping review was conducted using PubMed and Scopus databases for studies addressing the combined exposure to opioids and nicotine during pregnancy published between 1 January 1980 and 9 July 2019. A total of 29 papers met the eligibility criteria for inclusion, with nine being identified as clinical trials (three from the MOTHER study) and two as secondary data analysis of clinical trial data.

RESULTS

Neonatal outcomes for infants who had a combined exposure to opioids and nicotine in utero indicated a reduction in birth weight and birth length. Findings in infants exposed to both nicotine and opioids were mixed with regard to the duration of neonatal abstinence syndrome (NAS), the likelihood of treatment for NAS, doses of medicine used to treat NAS, and NAS scores when compared with infants who had opioid exposure without nicotine.

CONCLUSIONS

The combined exposure to nicotine and opioids during pregnancy may lead to a reduction in neonatal birth weight and birth length and more severe NAS signs, compared with opioid use alone, but more research is necessary to identify the minimum dosage and length of nicotine exposure to accurately predict these outcomes.

Nurses' Descriptions of Interactions When Caring for Women With Perinatal Substance Use Disorders and Their Infants

The purpose of this review is to describe health care interactions between nurses and women with perinatal substance use disorders, including interactions with their infants from the perspective of the nurses. Findings from 11 qualitative inclusion articles were synthesized using a metasummary approach. The majority of articles showed that nurses experience problematic interactions when providing care to women with perinatal substance use disorders and their infants, although some results indicated that some nurses engage in interactions that are assuring. Six types of conflictual interactions were identified: inadequate care, distressing, condemning, deficient knowledge, rejecting, and dissatisfying. Two types of therapeutic interactions were identified: compassionate and supportive. The findings underscore the importance of managing stigma, enhancing knowledge of the science of addiction processes, and promoting best practices when caring for this population.

Addiction treatment in the postpartum period: an opportunity for evidence-based personalized medicine

Substance use disorders (SUD) are becoming rapidly more prevalent in women and a leading cause of pregnancy associated deaths, with most deaths occurring during the 12 months after pregnancy. The postpartum period can be quite intense, especially for women seeking addiction recovery. There is a call to reconceptualize the obstetrical postpartum care model into one that extends specialised care and is tailored to an individual's specific needs. Although SUD treatment improves maternal and infant outcomes as well as decreases overdose risk, many women do not receive consistent SUD treatment during the postpartum period. Thus, SUD treatments should consider following the same guidance as obstetrics to reconceptualize how SUD treatment is delivered postpartum. Clinically, this translates into substantially modifying traditional siloed SUD treatment structures to meet the unique needs of this vulnerable patient population. At the same time, more research is urgently needed to inform these advancements in clinical care to ensure they are evidence-based and effective. In this article, we review the existing evidence as well as highlight opportunities for both clinicians and researchers to advance the integration of tailored approaches for postpartum women into personalised SUD medical and behavioural treatments.

Alcohol and illicit and non-medical prescription drug use before and during pregnancy in Stockholm, Sweden: A cross-sectional study

OBJECTIVES

To provide current estimates of alcohol and drug use among pregnant women attending antenatal care lectures in preparation for childbirth in Stockholm, Sweden.

STUDY DESIGN

A cross-sectional study. Data was collected anonymously among women attending lectures in preparation for childbirth.

MAIN OUTCOME MEASURES

The prevalence of alcohol and illicit and non-medical prescription drug use among pregnant women attending antenatal care lectures in preparation for childbirth.

RESULTS

Nine hundred and thirty-six pregnant women attending lectures in preparation for childbirth participated. Among those answering all questions about alcohol use during pregnancy, 4.2 percent reported use (95% confidence interval (CI), 3.0-5.7%) and among those answering all questions about illicit or non-medical prescription drug use during pregnancy, 0.5 percent reported such use (95% CI, 0.1-1.3%). The prevalences of binge drinking during pregnancy and alcohol and drug use before pregnancy are presented. Comparisons of anonymously and non-anonymously collected data are included.

CONCLUSIONS

Approximately one in 25 women reported using alcohol and approximately one in 200 reported using illicit or non-medical prescription drugs while pregnant. Alcohol use during pregnancy may have decreased in Stockholm, Sweden.

Nurses' Approaches to Pain Management for Women With Opioid Use Disorder in the Perinatal Period

OBJECTIVE

To identify how nurses approach pain management for women with opioid use disorder (OUD) in the perinatal period from the perspectives of nurses and women.

DESIGN

A secondary analysis of data from a qualitative descriptive study on the development of trust between nurses and women who use substances during the perinatal period.

SETTING

We interviewed the woman participants in a private conference room at a residential treatment center, and we interviewed the nurse participants over the phone.

PARTICIPANTS

Four women from a residential treatment center in the rural U.S. Midwest and nine nurses who were members of a local Midwestern Chapter of the Association of Women's Health, Obstetric and Neonatal Nurses.

METHODS

We used semistructured individual interviews, and participants were asked to describe positive, negative, and typical interactions they had with the other group to identify factors that helped or hindered the formation of trust. In the course of the interviews, four of the women and nine of the nurses described interactions centered on pain management. This information, which we summarized using content analysis, provided data related to the approaches to pain management that nurses use for women with opioid use disorder in the perinatal period.

RESULTS

Analysis showed that nurse participants used five approaches to pain management: Promoting Nonopioid Pain Management Strategies; Trying to Give Pain Medications on Time; Doubting or Judging Women; Withholding, Delaying, or Resisting Giving Pain Medications; and Responding to Women's Hostility.

CONCLUSION

Nurses should confront biases related to opioid use during pregnancy and receive training on how to manage aggressive behavior during the provision of maternity care.