Substance Use Disorders in Pregnancy and Postpartum

Shimi Kang, MD, FRCPC

Web-only article from "Women" issue of Visions Journal, 2004, 2(4)

The use of mood altering substances has been an accepted feature of human society for thousands of years. However, the use of substances in pregnancy and lactation carries a higher risk and stigma, as can affect the health of both the mother and the child. The stigma can make it more difficult for women to ask for and receive help.

There is a common notion that women with substance use disorders are motivated to stop drinking and other substance use in pregnancy due to the potential harmful effects on the developing fetus. This unfortunately is not the case. In the Canadian Community Health Survey of 2000/2001,1 13.7% of Canadian women of child bearing years revealed that they had used alcohol at all during their last pregnancy. Binge drinking and heavy drinking are associated with increased risk of adverse fetal outcomes. Almost 10% of women who were pregnant at the time of the survey indicated that drank 5 or more drinks on one occasion in the past month, and about 2% in the past week. Approximately 7% of pregnant women said they regularly drank heavily (more than 12 drinks per week) in the past year, and less than one percent drank this much in the week before the survey.

Other drug use during pregnancy can also result adverse short and long term effects on offspring. It is difficult to know the level of illicit drug use during pregnancy due to the high stigma and consequences for mothering/custody. The BC Perinatal Database captures information on all births in the province. In the one year period from April 1 2000- March 31st 2001 ) 1.9% of births were flagged for drug use (8% of those 19 and under) and 13.2% were flagged as current smokers (38.5% of those 19 and under).2

According to the US National Institute of Drug Abuse (NIDA), the most commonly used drugs in pregnancy were as follows:3

  • Nicotine – 20%

  • Alcohol – 19%

  • Marijuana – 3%

  • Cocaine – 1%

NIDA also identified nicotine and alcohol use as risk factors for illicit drug use: Of those smoking and using alcohol, 20.4% also used marijuana and 9.5% cocaine compared to 0.2% and 0.1%, respectively, for those women not using tobacco or alcohol.

Concurrent mental health problems can make the clinical situation even more complex and dangerous, as well as other risks such as lack of prenatal care, poor nutrition, high stress. Other gender specific factors are seen in the entire range of issues related to problem substance use and addictive behaviors. Women differ from men in prevalence rates, drug of choice, and the influence of trauma. Mental illness, infectious disease, victimization, and issues such as child-care and the guilt, shame, and societal stigmatization of addicted mothers and pregnant women are all gender specific features.

There is certainly a window of opportunity in the prenatal period, as women are more likely to engage with the healthcare system and abstain or reduce their substance use, many for the first time ever. This is encouraging as almost 90% of individuals who remain abstinent for two years will be substance free at ten years.4 The US National Household Survey on Drug Abuse 2002 found that past month alcohol use was more likely during the first trimester of pregnancy than during the second or third trimesters.5

Without treatment, however, most will relapse.3 Accessing help for substance use disorders can be difficult at any time, but there are several specific additional barriers that women may face. These include:6,7

  • Stigma for women (guilt, shame, judgment)

  • Fear of losing custody of children if they identify as needing treatment

  • Experience of prejudice towards pregnant women and mothers with substance use problems, on the part service providers

  • Greater opposition to treatment from family and friends

  • Lower rates for identification and referral for women by doctors and social workers

  • Responsibility for dependent family

  • Lack of child care and transportation

Professionals working with women of child-bearing age need to be sensitive to these issues when screening, making referrals, and providing treatment. Often, the presenting signs for substance use in pregnancy and postpartum are subtle and can include:

  • Missed or inadequate prenatal care

  • Recurrent somatic complaints (chronic pain, nausea, sleep)

  • Psychiatric diagnosis or history and/or history of trauma

  • Failure to gain adequate weight

  • Intra-uterine growth delay/retardation

  • Withdrawal signs at delivery

Substance use disorders are common in the general population, and women of childbearing age are no exception. Numerous issues including the increased stigma for women who are pregnant or postpartum can certainly affect health-seeking behavior. For this reason, reproductive service providers such as physicians, nurses, midwives, and social workers, are vital for engagement of this population.

Substance use disorders can have a significant adverse impact on the mother, baby, and family unit. Certain therapies have proven useful for harm reduction and psychiatric symptoms in pregnancy and lactation. In addition, women specific services improve retention, substance use outcomes and psychosocial function. Thus, although substance use disorders carry a heavy burden in women who are pregnant and postpartum, specific treatments can be very effective in improving outcomes for the mother and baby.

 
About the author

Dr. Kang is an Addiction Psychiatrist with the Reproductive Mental Health Program, BC Women’s Hospital and Health Centre. This article is an online supplement to the Women's issue of Visions Journal.

Footnotes:
  1. Statistics Canada. (2002). Canadian Community Health Survey (CCHS), Cycle 1.1. See www.statcan.ca/english/concepts/health/index.htm

  2. British Columbia perinatal database registry 2000–2001 [Data file]. Vancouver, BC: British Columbia Reproductive Care Program.

  3. National Institute on Drug Abuse. (1996). 1992-93 National Pregnancy and Health Survey: Drug Use Among Women Delivering Livebirths. Rockville, MD: US Department of Health and Human Services. For summary, see www.drugabuse.gov/NIDA_Notes/NNVol10N1/NIDASurvey.html

  4. Valliant, G.E. (1988). What does long-term follow-up teach us about relapse and prevention of addiction? British Journal of Addiction, 83, 1147-1157.

  5. Substance Abuse and Mental Health Services Administration. (2002) Substance use among pregnant women during 1999 and 2000. Rockville, MD: Author. See www.oas.samhsa.gov/2k2/preg/preg.htm

  6. Beckman, L.J. & Amaro, H. (1986). Personal and social difficulties faced by males and females entering alcoholism treatment. Journal of Studies on Alcohol, 47, 135-145.

  7. Poole, N., & Isaac, B. (2001). Apprehensions: Barriers to Treatment for Substance-Using Mothers. Vancouver, BC: British Columbia Centre of Excellence for Women's Health. See www.bccewh.bc.ca/Pages/pubspdflist4.htm#addictions

 

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