The effects of substance use during gestation on birth outcome, infant and maternal health

Ethnic disparities in accessing treatment for depression and substance use disorders in an integrated health plan

OBJECTIVE

This study examined ethnic differences in accessing treatment for depression and substance use disorders (SUDs) among men and women in a large integrated health plan, and explored factors potentially contributing to health care disparities.

METHODS

Participants were 22,543 members ages 20 to 65 who responded to health surveys in 2002 and 2005. Survey questions were linked to provider-assigned diagnoses, electronic medication, psychiatry, and chemical dependency program records.

RESULTS

Among women diagnosed with depression, Latinas (p < .01) and Asian-Americans (p < .001) were less likely than Whites to fill an antidepressant prescription. Among men diagnosed with depression, African Americans (p < .01) were less likely than Whites to do so. Among women diagnosed with an SUD, African Americans (p < .05) were less likely than Whites to have one or more chemical dependency program visits.

CONCLUSIONS

Results demonstrated ethnic differences in accessing depression and SUD treatment among patients diagnosed with these disorders, which persisted after controlling for education, income, having a regular health care provider and length of health plan enrollment. Findings highlight potential gender differences in ethnic disparities, lower antidepressant utilization among Asian Americans, and the effects of co-occurring disorders in accessing behavioral health care.

Factors associated with alcohol use, depression, and their co-occurrence during pregnancy

BACKGROUND

Alcohol use and depression each adversely affect birth outcomes, but the impact of their co-occurrence among pregnant women is not well understood. In this study, we examined factors associated with alcohol use, depression, and their co-occurrence during pregnancy.

METHODS

We analyzed datasets from 2 longitudinal studies conducted nearly 20 years apart in the same outpatient prenatal clinic of an urban women's hospital. Participants included 278 women recruited from 1982 to 1985 for the Maternal Health Practices and Child Development (MHPCD) Study and 209 women recruited from 2000 to 2002 for the Health Outcomes from Prenatal Education (HOPE) Study. Both studies selected women on the basis of their level of alcohol use early in pregnancy. We used multinomial logistic regression models to test multiclassification prediction of alcohol use, depression, and their co-occurrence during pregnancy.

RESULTS

In the second and third trimesters, more MHPCD participants than HOPE participants consumed alcohol (67% vs. 20%), experienced depression (85% vs. 34%), and had co-occurring drinking and depression (56% vs. 10%) (p < 0.001 for each). For the MHPCD cohort, smoking predicted alcohol use. There were no significant predictors for depression alone or the co-occurrence. For the HOPE cohort, older age and smoking were predictors of alcohol use, smoking and less education were predictors of depression, and illicit drug use was a predictor of the co-occurrence of alcohol use and depression (p < 0.05 for all relationships).

CONCLUSIONS

Smoking, older age, lower education, and illicit substance use predicted alcohol and/or probable depression in the second and third trimesters among women who drank in the first trimester.

Alcohol and drug use before and during pregnancy: an examination of use patterns and predictors of cessation

OBJECTIVES

This study examines alcohol and nonmedical drug use before and during pregnancy and identifies the predictors of use cessation before the first prenatal visit.

METHODS

Data analyses were based on the Prenatal Risk Overview (PRO), a structured interview that screens for psychosocial risk factors associated with poor birth outcomes. The study sample includes 1,492 consecutive prenatal care patients from four urban clinics between November 2005 and June 2007.

RESULTS

Reported alcohol and drug use pre-pregnancy was much higher among U.S.-born women than immigrants, and among unmarried women than married women. American Indians had the highest rates among racial/ethnic groups. Since learning of their pregnancy, 5.6% of patients reported alcohol use and 10.7% reported drug use, reflecting cessation rates of 87.0% for alcohol and 55.6% for drugs. In logistic regression analyses, older age, current smoking, and lack of transportation predicted both alcohol and drug use continuation. Alcohol use continuation was also predicted by pre-pregnancy alcohol use frequency, depression, and physical/sexual abuse by someone other than an intimate partner. Drug use continuation was also predicted by race (higher for American Indians and African Americans), and pre-pregnancy drug use frequency.

CONCLUSIONS

Women who continued to use alcohol or drugs after learning they were pregnant were more frequent users than spontaneous quitters, more likely to smoke cigarettes, and had more psychosocial stressors. Achieving higher rates of cessation may require approaches that simultaneously address substance use and impediments to quitting. Higher continuation rates among some cultural groups require further investigation.

Rural and Small-Town Attitudes About Alcohol Use During Pregnancy: A Community and Provider Sample

CONTEXT

While there has been considerable research on prenatal alcohol use, there have been limited studies focused on women in rural and small-town environments.

PURPOSE

This 2-part study examines gender differences in attitudes and perceived barriers to intervention in large community sample of persons living in rural and small-town environments in Kentucky (n = 3,346). The study also examines rural/small-town prenatal service providers' perceptions of barriers to assessment and intervention with pregnant substance abusers (n = 138).

METHODS

Surveys were administered to a convenience sample of employees and customers from 16 rural and small-town community outlets. There were 1503 males (45%) and 1843 females (55%) ranging in age from under 18 years old to over 66 years old. Surveys also were mailed to prenatal providers in county health departments of the 13-county study area, with 138 of 149 responding.

FINDINGS

Overall results of the community sample suggest that neither males nor females were knowledgeable about the harmful effects of alcohol use during pregnancy. Results also indicate substantial gender differences in alcohol attitudes, knowledge, and perceived barriers. Further, prenatal care providers identified several barriers in assessment and treatment of pregnant women with alcohol use problems in rural and small-town communities, including lack of knowledge and comfort with assessment as well as a lack of available and accessible treatment for referrals.

Treatment compliance among prenatal care patients with substance abuse problems

There is an insufficient number of substance abuse treatment programs available to pregnant women; however, even when women do enroll in treatment, they often choose not to comply with particular components of their treatment. To better understand what factors are associated with a woman's likelihood of compliance with treatment, this study assesses 244 pregnant, substance-using women enrolled in a specialized substance abuse treatment program. Women who complied with treatment referrals are compared with those who did not comply with referrals on various factors including their sociodemographic characteristics, types of substance use before and during pregnancy, experiences of violence before and during pregnancy, and prior substance use treatment. Bivariate analysis found that outpatient treatment compliance was more likely among women who smoked cigarettes before pregnancy, women who had received previous substance abuse treatment, and women whose partner had received previous substance abuse treatment. Outpatient treatment compliance did not vary by sociodemographic characteristics, any other type of substance use, or the women's experiences of violence. Inpatient treatment compliance was more likely among women who received prior substance abuse treatment; however, no other characteristic was found to be associated with inpatient treatment compliance. Logistic regression analyses, which controlled for various factors, suggested that past experiences with substance abuse treatment by the woman or her partner were significantly associated with treatment referral compliance. These findings suggest that the previous treatment experiences of women and their partners are important factors in shaping a successful substance abuse treatment program for pregnant women.

The process of pregnancy smoking cessation: implications for interventions

OBJECTIVE

There is a growing body of knowledge about the pregnant smoker and what happens as she goes through the pregnancy and postpartum periods. This article reviews the process of smoking cessation in the context of pregnancy.

DATA SOURCES

Epidemiological data, extant reviews of the literature, and current original research reports are used to examine characteristics of the women and of the change process for those women smokers who quit, stop, or modify their smoking during pregnancy and the postpartum period.

DATA SYNTHESIS

An analysis of the interaction of the process of smoking cessation with pregnancy was conducted to gain insight into the unique problems faced by the pregnant smoker and discover directions for intervention.

CONCLUSIONS

Pregnancy and the postpartum period provide a window of opportunity to promote smoking cessation and smoke free families. Understanding obstacles and pathways for pregnancy and postpartum smoking cessation can guide implementation of effective existing programs and development of new ones. Recommendations include promoting cessation before and at the beginning of pregnancy, increasing delivery of treatment early in pregnancy, helping spontaneous and intervention assisted quitters to remain tobacco free postpartum, aiding late pregnancy smokers, and involving the partner of the woman smoker.

Physician response to prenatal substance exposure

OBJECTIVES

To examine physician responses to suspected prenatal substance exposure and the reasons underlying these responses.

METHODS

National mail survey of practicing obstetricians and pediatricians who see neonates. Response rate: 63%.

RESULTS

More than 70% of physicians reported having ever suspected prenatal substance exposure. Response rates did not vary by specialty. Twenty-seven percent reported that they had never suspected prenatal substance exposure. The most common lifetime pattern (60%) was some response whenever prenatal substance exposure was suspected; next most common was no suspicion (27%). Just over 10% had a discretionary response: acting in some cases of suspected prenatal substance exposure but ignoring others. Two percent consistently ignored their suspicions. Getting help for the patient and protecting the fetus were the most common reasons to act. Among those who had ignored their suspicions, lack of sufficient evidence of substance use was the most often cited reason. There were some important specialty differences in reasons for response and non-response and in specific responses likely to be taken. Obstetricians are far more likely to provide the patient with information and get a substance use history; pediatricians are more inclined to involve outsiders.

CONCLUSIONS

Obstetricians and pediatricians seem quite willing to act on their suspicions of prenatal substance exposure, and generally respond by taking positive actions. Specialty differences are few and reflect practice differences.