Although women are highly motivated to abstain from tobacco, alcohol, and other substances during pregnancy, they may be hesitant to openly discuss substance use with obstetric providers. Given women’s concerns about negative appraisals from health care providers and fears that child protective services may be notified, it is likely that many women may not accurately report their usage of alcohol and other substances during pregnancy.
Most studies assessing substance use during pregnancy, such as the National Survey on Drug Use and Health (NSDUH), rely on self reports of substance use, and there has been concern that estimates from these studies may not accurately reflect the prevalence of substance use in pregnant women.
In a recent study which relied upon laboratory evidence of drug use in addition to self report (Ondersma et al, 2019), a sample of 1220 racially, ethnically and socioeconomically diverse pregnant women (18 years and older) were drawn from four prenatal care clinics in the United States.
The researchers assessed substance use in this sample using urine testing and self reports of use and found that 315 out of 1220 participants (26.3%) used alcohol or some type of substance during pregnancy. Rates varied across the four sites. Alcohol use was detected in up to 18.9% of pregnant women. At one site, tobacco use was identified in 27% of women during pregnancy; at the same site use of cannabis was seen in 29.4% of the women.
While there is considerable variation in the prevalence of substance use across the sites included in this report, these findings suggest that the use of substances in pregnant women may be 2 to 3 times higher than estimates from previous studies such as the NSDUH. Given the risks associated with the use of substances during pregnancy, this is a significant public health concern. Furthermore, as we are seeing higher rates of cannabis use among younger women, the number of cannabis-exposed pregnancies will likely continue to increase.
Taking care of pregnant women with substance use disorders presents many different challenges. In order to meet the complex needs of this patient population, MGH opened the HOPE Clinic (Harnessing support for Opioid and substance use disorders in Pregnancy and Early childhood). The HOPE Clinic provides care for pregnant women with substance use disorder and their infants from conception through early childhood.
The HOPE Clinic is a collaborative program bringing together the Departments of Obstetrics & Gynecology, Psychiatry and Medicine at MGH and the MGH Hospital for Children. In order to better support women and their families, obstetricians collaborate with a team which include specialists in substance use treatment, peer support specialists, social workers, and pediatricians.
In addition, women attending the HOPE Clinic will have access to a reproductive psychiatrist. Dr. Edwin Raffi, who is a member of the MGH Center for Women’s Mental Health, has expertise in the treatment of substance use disorders and perinatal psychiatric disorders. Given that a large proportion of women who develop substance use disorders also suffer from other psychiatric disorders, including PTSD, bipolar disorder, and anxiety disorders, optimizing substance use treatments requires stabilization of comorbid psychiatric illness.
Many women in this population rely upon treatment with a variety of medications, including antidepressants and mood stabilizers, to maintain their stability. While there may be concerns regarding the use of psychiatric medications during pregnancy, we have data to support the reproductive safety of many different types of medications and effectively managing psychiatric symptoms during pregnancy is of paramount importance. Women with untreated psychiatric illness are more likely to use alcohol and other substances during pregnancy, and those with histories of substance use disorders, while highly motivated to remain abstinent during pregnancy, may be more vulnerable to relapse in the setting of untreated psychiatric symptoms.
Read More:
Ondersma SJ, Chang G, Blake-Lamb T, Gilstad-Hayden K, Orav J, Beatty JR, Goyert GL, Yonkers KA. Accuracy of five self-report screening instruments for substance use in pregnancy. Addiction. 2019 Sep;114(9):1683-1693.
Edwin Raffi, MD MPH is a psychiatrist at the Massachusetts General Hospital’s Center for Women’s Mental Health and an Instructor in Psychiatry at Harvard Medical School. Dr. Raffi’s areas of interest include: Perinatal and Reproductive Psychiatry, Addiction and Substance Use Disorders, Geriatric Psychiatry, Trauma, Mind Body Medicine, Health and Technology.
