Prevalence of alcohol use in pregnant women with substance use disorder

Academy of Breastfeeding Medicine Clinical Protocol #19: Breastfeeding Promotion in the Prenatal Period (Revised 2024)

Background: The Academy of Breastfeeding Medicine revised the 2015 version of this clinical protocol to review the evidence and provide recommendations related to breastfeeding promotion in the prenatal period. Key Information: Promoting and normalizing breastfeeding in the prenatal period can improve breastfeeding outcomes including initiation and duration of breastfeeding. Ideally, prenatal interventions should be a part of a comprehensive longitudinal breastfeeding support program. Recommendations: Clinicians or other health workers should discuss breastfeeding at each prenatal visit. Counseling topics should include the health benefits of breastfeeding versus not breastfeeding, the basics of breastfeeding (e.g., physiology, positioning), what to expect of hospital-based and immediate postpartum breastfeeding support (i.e., Baby-Friendly Ten Steps), and the risks of unnecessary supplementation. Medical, anatomical, and other risk factors for breastfeeding challenges should be identified, and targeted anticipatory guidance should be given. Prenatal counseling should include distribution of structured breastfeeding education at low literacy levels and in the parent's preferred language. Counseling should be culturally sensitive and patient-centered, including family members when appropriate. Prenatal support may integrate various health workers (e.g., medical doctors, midwives, community health workers, lactation consultants, among others) and include various modalities including telecommunication. Enhancing breastfeeding education for prenatal care providers is also imperative. Additional themes related to implementation of recommendations for specific populations are also reviewed.

Sex-specific Differences in Resting Oscillatory Dynamics in Children with Prenatal Alcohol Exposure

At rest children with prenatal alcohol exposure (PAE) exhibit impaired static and dynamic functional connectivity, along with decreased alpha oscillations. Sex-specific information regarding the impact of PAE on whole-brain resting-state gamma spectral power remains unknown. Eyes-closed and eyes-open MEG resting-state data were examined in 83 children, ages 6-13 years of age. Using a matched design, the sample consisted of 42 typically developing children (TDC) (22 males/20 females) and 41 children with PAE and/or a fetal alcohol spectrum disorders (FASD) diagnosis (21 males/20 females). Whole-brain source resting-state spectral power was examined to determine group and sex specific relationships. Within gamma, we found sex and group specific changes such that female participants with PAE/FASD had increased gamma power when compared to female TDC and male participants with PAE/FASD. These differences were detected in most source regions analyzed during both resting-states, and were observed across the age spectrum examined. Within delta, we found sex and group specific changes such that female participants with PAE/FASD had decreased delta power when compared to female TDC and male participants with PAE/FASD. The reduced delta oscillations in female participants with PAE/FASD were detected in several source regions during eyes-closed rest and were evident at younger ages. These results indicate PAE alters neural oscillations during rest in a sex-specific manner, with females with PAE/FASD showing the largest perturbations. These results further demonstrate PAE has global effects on resting-state spectral power and connectivity, creating long-term consequences by potentially disrupting the excitation/inhibition balance in the brain, interrupting normative neurodevelopment.

Prenatal Opioid Exposure and Risk for Adverse Brain and Motor Outcomes in Infants Born Premature

OBJECTIVE

To compare brain magnetic resonance imaging (MRI) biomarkers and neurodevelopmental test scores in infants born preterm with and without prenatal opioid exposure (POE).

STUDY DESIGN

We examined 395 preterm infants (≤32 weeks gestational age) who had term-equivalent brain MRIs, composite scores from the Bayley Scales of Infant and Toddler Development-III at 2 years corrected age, and POE data. MRI parameters included total/regional brain volumes and severe punctate white matter lesions (PWMLs). We conducted bivariable analysis and multivariable logistic regression analyses.

RESULTS

The mean ± SD gestational age was 29.3 ± 2.5 weeks; 35 (8.9%) had POE and 20 (5.1%) had severe PWML. Compared with unexposed infants, those with POE exhibited higher rates of severe PWML (17.1% vs 3.9%, respectively; P = .002); findings remained significant with an OR of 4.16 (95% CI, 1.26-13.68) after adjusting for confounders. On mediation analysis, the significant relationship between POE and severe PWML was not indirectly mediated through preterm birth/gestational age (OR, 0.93; 95% CI, 0.78-1.10), thus suggesting the association was largely driven by a direct adverse effect of POE on white matter. In multivariable analyses, POE was associated with a significantly lower score by -6.2 (95% CI, -11.8 to -0.6) points on the Bayley Scales of Infant and Toddler Development-III Motor subscale compared with unexposed infants.

CONCLUSIONS

POE was associated with severe PWML; this outcome may be a direct effect of POE rather than being mediated by premature birth. POE was also associated with worse motor development. Continued follow-up to understand the long-term effects of POE is warranted.

Impact of low-level prenatal alcohol exposure and maternal stress on autonomic regulation

BACKGROUND

Prenatal alcohol exposure (PAE) impacts the neurodevelopment of the fetus, including the infant's ability to self-regulate. Heart rate variability (HRV), that is, the beat-to-beat variability in heart rate, is a non-invasive measurement that can indicate autonomic nervous system (ANS) function/dysfunction.

METHODS

The study consisted of a subset of our ENRICH-2 cohort: 80 participants (32 PAE and 48 Controls) who had completed three visits during pregnancy. The participants completed a comprehensive assessment of PAE and other substances throughout pregnancy and assessments for stress, anxiety, and depression in the third trimester. At 24 h of age, infant HRV was assessed in the hospital during the clinically indicated heel lance; 3- to 5-min HRV epochs were obtained during baseline, heel lancing, and recovery episodes.

RESULTS

Parameters of HRV differed in infants with PAE compared to Controls during the recovery phase of the heel lance (respiratory sinus arrhythmia (RSA) and high-frequency (HF), p < 0.05). Increased maternal stress was also strongly associated with abnormalities in RSA, HF, and low-frequency / high-frequency (LF/HF, p's < 0.05).

CONCLUSIONS

Alterations in ANS regulation associated with PAE and maternal stress may reflect abnormal development of the hypothalamic-pituitary-adrenal axis and have long term implications for infant responsiveness and self-regulation.

IMPACT

Previous studies have focused on effects of moderate to heavy prenatal alcohol exposure (PAE) on autonomic dysregulation, but little is known about the effects of lower levels of PAE on infant self-regulation and heart rate variability (HRV). Prenatal stress is another risk factor for autonomic dysregulation. Mild PAE impacts infant self-regulation, which can be assessed using HRV. However, the effect of prenatal stress is stronger than that of mild PAE or other mental health variables on autonomic dysregulation.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

Effects of medications for opioid use disorder (MOUD) on fetal brain and cranial measurements

BACKGROUND

The use and misuse of opioids, as well as opioid use disorder (OUD) have increased remarkably among reproductive-aged and pregnant women. As many as 25% of pregnant women who report non-medical opioid use in the past month also report concurrent alcohol use. While teratogenic effects of alcohol are well established, there are limited studies evaluating fetal intracranial effects associated with medications for OUD (MOUD) and concurrent use of MOUD and alcohol during pregnancy. The objective of this study was to determine the effect of MOUD, with and without concomitant alcohol use, on fetal intracranial measurements. The type of maternal MOUD therapy (methadone vs. buprenorphine) was also examined.

METHODS

This study was a secondary analysis of a prospective cohort study among participants (n = 196) assigned into three groups (MOUD [n = 94], MOUD+Alcohol [n = 47], and unexposed controls [n = 55]). Co-exposure with either methamphetamines or cocaine were exclusionary criteria; other co-exposures were carefully characterized with prospective repeated self-report measures and biomarkers. Fetal ultrasound measurements at 18-22 weeks (2nd trimester) and 28-32 weeks (early 3rd trimester) were compared among study groups. In addition to standard morphometrics, we performed specialized intracranial measurements of caval-calvarial distance (CCD), frontal lobe width (FLW), frontal lobe length (FLL), and fronto-thalamic distance (FTD).

RESULTS

Brain and cranial measurements between MOUD, with or without alcohol co-exposure, and unexposed controls were generally not significantly different in multivariable analyses. Subjects in the MOUD groups had earlier gestational age at delivery and lower birth weight and birth weight percentile compared to unexposed controls with differences driven primarily by the methadone subgroup. Significant differences in standard and specialized intracranial indices at both second and third trimester as well as differences in the change of HC percentile over time were observed in the methadone subgroup compared to controls, while no differences between buprenorphine subgroup and controls were observed for any measures.

CONCLUSION

Patients receiving methadone therapy might require closer monitoring during pregnancy; however, detailed imaging of the fetal brain other than the standard measurements might not be warranted.

Disrupted dynamic functional network connectivity in fetal alcohol spectrum disorders

BACKGROUND

Prenatal alcohol exposure (PAE) can result in harmful and long-lasting neurodevelopmental changes. Children with PAE or a fetal alcohol spectrum disorder (FASD) have decreased white matter volume and resting-state spectral power compared to typically developing controls (TDC) and impaired resting-state static functional connectivity. The impact of PAE on resting-state dynamic functional network connectivity (dFNC) is unknown.

METHODS

Using eyes-closed and eyes-open magnetoencephalography (MEG) resting-state data, global dFNC statistics and meta-states were examined in 89 children aged 6-16 years (51 TDC, 38 with FASD). Source analyzed MEG data were used as input to group spatial independent component analysis to derive functional networks from which the dFNC was calculated.

RESULTS

During eyes-closed, relative to TDC, participants with FASD spent a significantly longer time in state 2, typified by anticorrelation (i.e., decreased connectivity) within and between default mode network (DMN) and visual network (VN), and state 4, typified by stronger internetwork correlation. The FASD group exhibited greater dynamic fluidity and dynamic range (i.e., entered more states, changed from one meta-state to another more often, and traveled greater distances) than TDC. During eyes-open, TDC spent significantly more time in state 1, typified by positive intra- and interdomain connectivity with modest correlation within the frontal network (FN), while participants with FASD spent a larger fraction of time in state 2, typified by anticorrelation within and between DMN and VN and strong correlation within and between FN, attention network, and sensorimotor network.

CONCLUSIONS

There are important resting-state dFNC differences between children with FASD and TDC. Participants with FASD exhibited greater dynamic fluidity and dynamic range and spent more time in states typified by anticorrelation within and between DMN and VN, and more time in a state typified by high internetwork connectivity. Taken together, these network aberrations indicate that prenatal alcohol exposure has a global effect on resting-state connectivity.

Implementation of State Laws Giving Pregnant People Priority Access to Drug Treatment Programs in the Context of Coexisting Punitive Laws

BACKGROUND

In response to increased prenatal drug use since the 2000s, states have adopted treatment-oriented laws giving pregnant and postpartum people priority access to public drug treatment programs as well as multiple punitive policy responses. No prior studies have systematically characterized these state statutes or examined implementation of state priority access laws in the context of co-existing punitive laws.

METHODS

We conducted legal mapping to examine state priority access laws and their overlap with state laws deeming prenatal drug use to be child maltreatment, mandating reporting of prenatal drug use to child protective services, or criminalizing prenatal drug use. We also conducted interviews with 51 state leaders with expertise on their states' prenatal drug use laws to understand how priority access laws were implemented.

RESULTS

Thirty-three states and the District of Columbia have a priority access law, and more than 80% of these jurisdictions also have one of the punitive prenatal drug use laws described. Leaders reported major barriers to implementing state priority access laws, including the lack of drug treatment programs, stigma, and conflicts with punitive prenatal drug use laws.

CONCLUSIONS

Our results suggest that state laws granting pregnant and postpartum people priority access to drug treatment programs are likely insufficient to significantly increase access to evidence-based drug treatment. Punitive state prenatal drug use laws may counteract priority access laws by impeding treatment seeking. Findings highlight the need to allocate additional resources to drug treatment for pregnant and postpartum people.

Decreased resting-state alpha peak frequency in children and adolescents with fetal alcohol spectrum disorders or prenatal alcohol exposure

Prenatal alcohol exposure (PAE) can result in long-lasting changes to physical, behavioral, and cognitive functioning in children. PAE might result in decreased white matter integrity, corticothalamic tract integrity, and alpha cortical oscillations. Previous investigations of alpha oscillations in PAE/fetal alcohol spectrum disorder (FASD) have focused on average spectral power at specific ages; therefore, little is known about alpha peak frequency (APF) or its developmental trajectory making this research novel. Using resting-state MEG data, APF was determined from parietal/occipital regions in participants with PAE/FASD or typically developing controls (TDC). In total, MEG data from 157 infants, children, and adolescents ranging in age from 6 months to 17 years were used, including 17 individuals with PAE, 61 individuals with an FASD and 84 TDC. In line with our hypothesis, we found that individuals with PAE/FASD had significantly reduced APF relative to TDC. Both age and group were significantly related to APF with differences between TDC and PAE/FASD persisting throughout development. We did not find evidence that sex or socioeconomic status had additional impact on APF. Reduced APF in individuals with an FASD/PAE may represent a long-term deficit and demonstrates the detrimental impact prenatal alcohol exposure can have on neurophysiological processes.

Effects of prenatal opioid and alcohol exposures on immune and serotonin factors in human placenta

PURPOSE

Opioids and alcohol impact critical serotonin (5-HT) function in the developing placenta and fetus through the actions of immune proinflammatory factors. Yet, possible convergent effects of opioids and alcohol on human placental toll-like receptor 4 (TLR4) activation and subsequent 5-HT homeostasis remain entirely unknown. The purpose of this study was to examine the effect of prenatal exposure to opioids with or without prenatal alcohol exposure (PAE) on the expression of key placental immune and serotonin signaling factors in human placental tissue obtained from a well-characterized prospective cohort.

METHODS

Data were collected from a subset of participants enrolled in the prospective pre-birth Ethanol, Neurodevelopment, Infant, and Child Health (ENRICH-1) cohort. Women were recruited and classified into four study groups: 1) PAE (n = 20); 2) those taking medications for opioid use disorder (MOUD; n = 28), 3) concurrent PAE and MOUD (n = 20); and 4) controls (HC; n = 20) based on prospective, repeated self-report, and biomarker analysis. Placenta samples underwent tissue processing to identify mRNA for TLR4, nucleotide-binding oligomerization domain (NOD)-like receptor protein 3 (NLRP3), interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), serotonin transporter (SERT), tryptophan hydroxylase (TPH1), indoleamine 2,3-Dioxygenase 1 (IDO) as well as protein concentrations of TLR4, IL-1β, TNF-α, SERT. To consider the association between study group and mRNA/protein expression of our targets, multivariable regression models were developed with inclusion of a priori selected covariates.

RESULTS

There was a significant negative association between PAE and SERT mRNA (β = -0.01; p < 0.01) and a positive association with TPH1 mRNA expression (β = 0.78; p < 0.05). In addition, there was a negative association between MOUD and TNF-α protein expression (β = -0.12; p < 0.05).

CONCLUSIONS

This study provides the first evidence that PAE may inhibit SERT expression while simultaneously promoting increased TPH1 protein expression in human placenta. This may result in increased 5-HT in fetal circulation known to affect neurodevelopment. Our data suggest that opioids and alcohol may disturb the bidirectional, dynamic interaction between the placental immune and serotonin system. Given the implication for brain development and health across the life-span further investigation of these critical mechanisms in well-defined cohorts is required.

Prevalence of marijuana use in pregnant women with concurrent opioid use disorder or alcohol use in pregnancy

BACKGROUND

A quarter of pregnant women use alcohol, 6.5/1000 deliveries are affected by opioid use disorder (OUD), and the prevalence of cannabis use in pregnant women is increasing. However, marijuana co-exposure in polysubstance-using women is not well described.

METHODS

The well-characterized ENRICH-1 cohort (n = 251), which focused on the effects of two primary exposures of interest-opioids and alcohol, was used to (1) estimate the prevalence/frequency of marijuana use in those with OUD and/or alcohol use, and (2) examined correlates of marijuana use. Participants were classified into an OUD group (n = 125), Alcohol group (n = 69), and concurrent OUD and Alcohol (OUD + Alcohol) group (n = 57). Self-report and biomarkers ascertained substance use. Multivariable logistic regression identified correlates of marijuana use.

RESULTS

The prevalence of any marijuana use in pregnancy was 43.2%, 52.6%, and 46.4% in the OUD, OUD + Alcohol, and Alcohol groups, respectively. Correspondingly, weekly or daily use was reported by 19.4%, 21.0%, and 24.6% of participants. In the OUD and OUD + Alcohol groups, the proportion of women using marijuana was significantly higher in those taking buprenorphine (45.8% and 58.3%, respectively) compared to women using methadone (37.5% and 42.9%, respectively). Mean maternal age was lower in women who used marijuana in all three groups compared to non-marijuana users. Independent correlates of marijuana use (controlling for group, race/ethnicity, education, and smoking) were maternal age (adjusted Odds Ratio (aOR) per 5-year increment 0.61; (95% CI 0.47, 0.79)), and polysubstance use (aOR 2.02; 95% CI 1.11, 3.67). There was a significant interaction between partnership status and group: among women who were not in a partnership, those in the OUD and OUD + Alcohol groups had lower odds of marijuana use relative to the Alcohol group. For women in the Alcohol group, partnered women had lower odds of marijuana use than un-partnered women (aOR 0.12; 95% CI: 0.02, 0.68).

CONCLUSIONS

Results indicate a relatively high prevalence and frequency of marijuana use in pregnant women being treated for OUD and/or women consuming alcohol while pregnant. These results highlight the need for ongoing risk reduction strategies addressing marijuana use for pregnant women receiving OUD treatment and those with alcohol exposure.

Prenatal opioid exposure is associated with smaller brain volumes in multiple regions

BACKGROUND

The impact of prenatal opioid exposure on brain development remains poorly understood.

METHODS

We conducted a prospective study of term-born infants with and without prenatal opioid exposure. Structural brain MRI was performed between 40 and 48 weeks postmenstrual age. T2-weighted images were processed using the Developing Human Connectome Project structural pipeline. We compared 63 relative regional brain volumes between groups.

RESULTS

Twenty-nine infants with prenatal opioid exposure and 42 unexposed controls were included. The groups had similar demographics, except exposed infants had lower birth weights, more maternal smoking and maternal Hepatitis C, fewer mothers with a college degree, and were more likely non-Hispanic White. After controlling for sex, postmenstrual age at scan, birth weight, and maternal education, exposed infants had significantly smaller relative volumes of the deep gray matter, bilateral thalamic ventrolateral nuclei, bilateral insular white matter, bilateral subthalamic nuclei, brainstem, and cerebrospinal fluid. Exposed infants had larger relative volumes of the right cingulate gyrus white matter and left occipital lobe white matter.

CONCLUSIONS

Infants with prenatal opioid exposure had smaller brain volumes in multiple regions compared to controls, with two regions larger in the opioid-exposed group. Further research should focus on the relative contributions of maternal opioids and other exposures.

IMPACT

Prenatal opioid exposure is associated with developmental and behavioral consequences, but the direct effects of opioids on the developing human brain are poorly understood. Prior small studies using MRI have shown smaller regional brain volumes in opioid-exposed infants and children. After controlling for covariates, infants with prenatal opioid exposure scanned at 40-48 weeks postmenstrual age had smaller brain volumes in multiple regions compared to controls, with two regions larger in the opioid-exposed group. This adds to the literature showing potential impact of prenatal opioid exposure on the developing brain.

You Didn't Drink During Pregnancy, Did You?

BACKGROUND

Accurate characterization of prenatal alcohol exposure (PAE) is challenging due to inconsistent use of screening questionnaires in routine prenatal care and substantial underreporting due to stigma associated with alcohol use in pregnancy. The aim of this study was to identify self-report tools that are efficient in accurately characterizing PAE.

METHODS

Participants meeting eligibility criteria for mild-to-moderate PAE were recruited into the University of New Mexico Ethanol, Neurodevelopment, Infant and Child Health cohort (N = 121) and followed prospectively. Timeline follow-back (TLFB) interviews were administered at baseline to capture alcohol use in the periconceptional period and 30 days before enrollment; reported quantity was converted to oz absolute alcohol (AA), multiplied by frequency of use and averaged across 2 TLBF calendars. The interview also included questions about timing and number of drinks at the most recent drinking episode, maximum number of drinks in a 24-hour period since the last menstrual period, and number of drinks on "special occasions" (irrespective of whether these occurred within the TLFB reported period). Continuous measures of alcohol use were analyzed to yield the number of binge episodes by participants who consumed ≥4 drinks/occasion. The proportion of women with ≥1 binge episode was also tabulated for each type of assessment.

RESULTS

Average alcohol consumption was 0.6 ± 1.3 oz of AA/day (≈ 8.4 drinks/wk). Only 3.3% of participants reported ≥1 binge episode on the TLFB, 19.8% had ≥1 binge episode when asked about "special occasions," and 52.1% when asked about the number of drinks the last time they drank alcohol. An even higher prevalence (89.3%) of bingeing was obtained based on the maximum number of drinks consumed in a 24-hour period.

CONCLUSIONS

Self-reported quantity of alcohol use varies greatly based on type of questions asked. Brief targeted questions about maximum number of drinks in 24 hours and total number of drinks during the most recent drinking episode provide much higher estimates of alcohol use and thus might be less affected by self-reporting bias.

Fifty Years of Research on Prenatal Substances: Lessons Learned for the Opioid Epidemic

Current efforts to design research on developmental effects of prenatal opioid exposure can benefit from knowledge gained from 50 years of studies of fetal alcohol and prenatal drug exposures such as cocaine. Scientific advances in neurobiology, developmental psychopathology, infant assessments, genetics, and imaging support the principles of developmental neurotoxicology that guide research in prenatal exposures. Important to research design is accurate assessment of amount, frequency, and timing of exposure which benefits from accurate self-report and biomarkers of exposure. Identifying and control of pre- and postnatal factors that impact development are difficult and dependent on appropriate research design and selection of comparison groups and measurement of confounding, mediating, and moderating variables. Polysubstance exposure has increased due to the number of prescribed and nonprescribed substances used by pregnant women and varying combinations of drugs may have differential effects on the outcome. Multiple experimental and clinical assessments of infant behavior have been developed but predicting outcome before 18-24 months of age remains difficult. With some exceptions, prenatal substance exposure effect sizes have been small, and cognitive and behavioral effects tend to be specific rather than global. Studies require large sample sizes, adequate retention, and support for social services in at-risk samples. The ethical and legal contexts and stigma associated with drug/alcohol use disorder should be considered in order to prevent harm to families in research programs. Recognition of the pervasive use of addictive substances in this nation should lead to broad scientific efforts to understand how substances affect child outcomes and to initiate prevention and intervention where needed.

Alcohol Use Disorders and Increased Risk of Adverse Birth Complications and Outcomes: An 11-Year Nationwide Cohort Study

For women who suffer from Alcohol Use Disorders (AUDs), the use of alcohol before and/or during pregnancy may result in various birth complications, including miscarriage, stillbirth, or preterm delivery. Thus, this study aimed to explore whether Alcohol Use Disorders (AUDs) are associated with increased risk of adverse birth complications and outcomes. A total of 76,799 deliveries between 2003 and 2013 in the Korean National Health Insurance Service National Sample Cohort (NHIS-NSC) were analyzed. Women with an AUD diagnosis preceding delivery were identified as individuals with alcohol dependence. A multivariate Cox proportional hazards model was used to estimate the hazard ratio of adverse birth complications and outcomes associated with alcohol dependence. Diagnosis of an AUD was associated with increased risk of adverse birth complications (Hazard Ratio [HR]: 1.15, 95% CI: 1.01–1.31, p = 0.0302). This was especially the case for women whose AUD diagnosis was in the same year as their delivery (HR: 1.53, 95% CI: 1.24–1.88, p < 0.0001). AUDs were associated with increased risk of adverse birth outcomes, especially when prevalent in the same year as a woman’s delivery. Our study confirms that the monitoring of expecting women with a diagnosis of alcohol-related problems may be useful in preventing adverse birth complications.

Applying Ethical Principles When Discussing Alcohol Use During Pregnancy

Over the past 2 decades, more women in the United States are engaging in excessive alcohol use, including women of reproductive age. Consuming alcohol in amounts greater than recommended limits is associated with an increased risk for adverse health effects, such as breast cancer, hypertension stroke, spontaneous abortion, and infertility. No safe time, safe amount, or safe type of alcohol to consume during pregnancy has been identified. Contradictory beliefs about alcohol use, fear of stigmatization, and potential legal consequences can provide challenges for health care providers who communicate these risks to clients. Health care providers can help to prevent alcohol-related health issues, including alcohol-exposed pregnancies, by providing their clients with factual information about alcohol and health and client-centered options for reducing their health risks. Clinicians can use alcohol screening and brief intervention as a framework for applying the ethical principles of autonomy, veracity, beneficence, and nonmaleficence when talking with women in ways that are nonstigmatizing and supportive to help reduce their health risks and prevent alcohol-exposed pregnancies.

Treatment for substance use disorders in pregnant women: Motivators and barriers

BACKGROUND

Pregnancy is a unique opportunity to provide broad and necessary medical care for women- including treatment for Substance Use Disorders (SUD). The standard of care for SUD in pregnant women is treatment at a comprehensive care facility. There is little existing qualitative research exploring what brings pregnant women with SUD to treatment and what barriers to treatment exist for this population. This study explored women's self-reported reasons for pursuing treatment or hesitating to do so.

METHODS

This qualitative study used interviews to explore common factors that motivate pregnant women with SUD to seek comprehensive care during pregnancy and common hesitations/ barriers to treatment. The study population included 20 women in treatment at a comprehensive care facility for pregnant and parenting women at Johns Hopkins. Participants volunteered to do interviews which were recorded and transcribed for analysis.

RESULTS

Interviews revealed several major themes in motivators to seek treatment: readiness to stop using, concern for the baby's health, concern about custody of the baby or other children, wanting to escape violent environments or homelessness, and seeking structure. Barriers to treatment included fear of loss of custody, not wanting to be away from children/partner, concern about stigma or privacy, and lack of childcare and transportation.

CONCLUSIONS

This study revealed common motivators to seek treatment and barriers to treatment for pregnant women with SUD. These themes may help direct future studies and guide efforts to increase access to crucial care in this vulnerable population.

Concurrent Opioid and Alcohol Use Among Women Who Become Pregnant: Historical, Current, and Future Perspectives

The numbers of women using opioids who become pregnant have captured the attention of media, research, policy, and community. At the same time, there is an ever-growing use of alcohol among women who continue drinking during pregnancy that has received less focus. Although both untreated opioid use disorder and alcohol misuse pose risks for maternal, fetal, and child morbidities, alcohol is the substance with the most significant documentation of harms. As we focus on the opioid epidemic in the United States, it is critical that we do not overlook alcohol use during pregnancy. Both opioid use and alcohol use during pregnancy are important public health challenges and often happen concurrently. Thus, this commentary aims to (1) highlight the historical and current context of opioid and alcohol use during pregnancy; (2) summarize the current knowledge of opioids and alcohol use during pregnancy; and (3) detail future directions in how health care providers can help identify and therapeutically respond to women with concurrent opioid and alcohol use disorder.