Health-care utilization among mothers and infants following cocaine exposure

Stimulants: How big is the problem and what are the effects of prenatal exposure?

Globally, cocaine use increased by 7%-18.2 million people in 2016 or 0.4% of the world population aged 15-64. In 2016, over 34 million (0.7%) people aged 15-64 used amphetamines and a further 0.4% used MDMA (Ecstasy). Women of child bearing age worldwide are increasingly using and becoming dependent on stimulants; and are, in turn, more vulnerable to sexually transmitted diseases, sexual violence, unplanned pregnancies and mental health problems. Stimulant use during pregnancy increases obstetric complications for the mother, increases the rate of preterm birth and decreases birth weight, length and head circumference for the exposed infant. No consistent signs of neonatal abstinence syndrome requiring pharmacological treatment have been identified for cocaine or methamphetamine, however, infants exposed to one or both drugs exhibit disorganized neurobehaviour at birth. Increased efforts worldwide are needed to determine the extent of maternal stimulant use and to prevent or identify and treat substance use early during pregnancy.

Predictors of inadequate prenatal care in methamphetamine-using mothers in New Zealand and the United States

This study compared patterns of prenatal care among mothers who used methamphetamine (MA) during pregnancy and non-using mothers in the US and New Zealand (NZ), and evaluated associations among maternal drug use, child protective services (CPS) referral, and inadequate prenatal care in both countries. The sample consisted of 182 mothers in the MA-Exposed and 196 in the Comparison groups in the US, and 107 mothers in the MA-Exposed and 112 in the Comparison groups in NZ. Positive toxicology results and/or maternal report of MA use during pregnancy were used to identify MA use. Information about sociodemographics, prenatal care and prenatal substance use was collected by maternal interview. MA-use during pregnancy is associated with lower socioeconomic status, single marital status, and CPS referral in both NZ and the US. Compared to their non-using counterparts, MA-using mothers in the US had significantly higher rates of inadequate prenatal care. No association was found between inadequate care and MA-use in NZ. In the US, inadequate prenatal care was associated with CPS referral, but not in NZ. Referral to CPS for drug use only composed 40 % of all referrals in the US, but only 15 % of referrals in NZ. In our study population, prenatal MA-use and CPS referral eclipse maternal sociodemographics in explanatory power for inadequate prenatal care. The predominant effect of CPS referral in the US is especially interesting, and should encourage further research on whether the US policy of mandatory reporting discourages drug-using mothers from seeking antenatal care.

High lifetime pregnancy and low contraceptive usage among sex workers who use drugs- an unmet reproductive health need

Background

The objective of this study was to describe levels of pregnancy and contraceptive usage among a cohort of street-based female sex workers (FSWs) in Vancouver.

Methods

The study sample was obtained from a community-based prospective cohort study (2006-2008) of 211 women in street-based sex work who use drugs, 176 of whom had reported at least one prior pregnancy. Descriptive statistics were used to estimate lifetime pregnancy prevalence, pregnancy outcomes (miscarriage, abortion, adoption, child apprehension, child custody), and contraceptive usage. In secondary analyses, associations between contraceptive usage, individual and interpersonal risk factors and high number of lifetime pregnancies (defined as greater than the sample mean of 4) were examined.

Results

Among our sample, 84% reported a prior pregnancy, with a mean of 4 lifetime pregnancies (median = 3; IQR: 2-5). The median age of women reporting 5+ pregnancies was 38 years old [interquartile range (IQR): 25.0-39.0] compared to 34 years [IQR: 25.0-39.0] among women reporting 4 or fewer prior pregnancies. 45% were Caucasian and 47% were of Aboriginal ancestry. We observed high rates of previous abortion (median = 1;IQR:1-3), apprehension (median = 2; IQR:1-4) and adoption (median = 1; IQR:1-2) among FSWs who reported prior pregnancy. The use of hormonal and insertive contraceptives was limited. In bivariate analysis, tubal ligation (OR = 2.49; [95%CI = 1.14-5.45]), and permanent contraceptives (e.g., tubal ligation and hysterectomy) (OR = 2.76; [95%CI = 1.36-5.59]) were both significantly associated with having five or more pregnancies.

Conclusion

These findings demonstrate high levels of unwanted pregnancy in the context of low utilization of effective contraceptives and suggest a need to improve the accessibility and utilization of reproductive health services, including family planning, which are appropriately targeted and tailored for FSWs in Vancouver.

Impact of maternal substance use during pregnancy on childhood outcome

The impact of maternal substance abuse is reflected in the 2002-2003 National Survey on Drug Use and Health. Among pregnant women in the 15-44 age group, 4.3%, 18% and 9.8% used illicit drugs, tobacco and alcohol, respectively. Maternal pregnancy complications following substance use include increases in sexually transmitted disorders, placental abruption and HIV-positive status. Effects on the neonate include a decrease in growth parameters and increases in central nervous system and autonomic nervous system signs and in referrals to child protective agencies. In childhood, behavioral and cognitive effects are seen after prenatal cocaine exposure; tobacco and alcohol have separate and specific effects. The ongoing use of alcohol and tobacco by the caretaker affects childhood behavior. Therefore, efforts should be made to prevent and treat behavioral problems as well as to limit the onset of drug use by adolescent children born to women who use drugs during pregnancy.

The effect of race on provider decisions to test for illicit drug use in the peripartum setting

BACKGROUND

Testing for illicit drugs may expose women who test positive to severe legal and social consequences. It is unknown whether racial disparities in drug testing practices underlie observed disparities in legal and social consequences of positive tests.

METHODS

Using administrative hospital and birth certificate data, we analyzed factors associated with both receipt and results of illicit drug testing among women with live births during 2002-2003. We assessed the independent association of race and other sociodemographic factors with both receipt of a drug test by the mother or her newborn infant and positive maternal or neonatal toxicology results, after controlling for obstetrical conditions and birth outcomes associated with maternal substance abuse.

RESULTS

Of the 8487 women with live births, 244 mother-newborn pairs (3%) were tested for illicit drug use. Black women and their newborns were 1.5 times more likely to be tested for illicit drugs as nonblack women in multivariable analysis. However, race was not independently associated with a positive result.

CONCLUSIONS

We identified racial differences in rates of testing for illicit drug use between black and nonblack women. We found equivalent positivity rates among tested black and nonblack women. The prevalence of drug use among untested women is unknown, however, so although tested women had equivalent rates of substance use detected, whether black and nonblack substance users are equally likely to be identified in the course of peripartum care remains uncertain.

Mortality risk associated with perinatal drug and alcohol use in California

OBJECTIVE

To analyze the relationship between perinatal drug/alcohol use and maternal, fetal, neonatal, and postneonatal mortality.

STUDY DESIGN

Linked California discharge, birth and death certificate data from 1991-1998 were used to identify drug/alcohol-diagnosed births. Mortality relative risk (RR) ratios were calculated and logistic models were generated for mortality outcomes.

RESULTS

Among 4,536,701 birth records, 1.20% contained drug/alcohol discharge diagnostic codes (n=54,290). The unadjusted RRs for maternal (RR=2.7), fetal (RR=1.3), neonatal (RR=2.4), and postneonatal (RR=4.3) mortality were increased for drug/alcohol-diagnosed births. After controlling for potential confounding, the odds of maternal death for cocaine use (OR=2.15) remained significant as did amphetamine (OR=1.77), cocaine (OR=1.43), polydrug (OR=2.01) and other drug/alcohol use (OR=1.79) for postneonatal mortality.

CONCLUSIONS

The association of cocaine use with maternal mortality and any drug/alcohol use with postneonatal mortality supports screening and identifying women using illicit drugs and alcohol during pregnancy. Increased collaboration with drug treatment programs and closer follow-up for drug-using women and their children may improve mortality outcomes.