In recent years, opiate abuse during pregnancy has shown a worrisome increase. Polysubstance abuse is common among women who are expecting, and this is frequently complicated by co-occurring psychiatric illnesses, pregnancy-related health concerns, and environmental stressors. Addiction during pregnancy is a grave concern because it puts two lives at risk.
Substance use disorders are most prevalent in adolescents and young adults. This puts women of childbearing age (15 to 44 years old) at greatest risk of developing an addiction. Based on this demographic, women who are pregnant or could soon become pregnant are at high risk of substance abuse. In fact, according to a nationwide survey on drug use in 2012, almost 16 percent of pregnant women smoked cigarettes, 8.5 percent drank alcoholic beverages, and nearly 6 percent used illicit drugs.
Every year nearly 2 million babies in America are exposed to tobacco, alcohol, and illicit drugs in utero.
Why Do Pregnant Women Use Cigarettes, Alcohol, and Drugs?
Most women, when they find out they are expecting a baby, do everything in their power to ensure a healthy birth. Yet, millions of babies continue to be exposed to harmful substances, including tobacco, alcohol, and drugs, while they are developing in their mother’s womb. What causes a mother to put her baby at risk? Why do pregnant women succumb to substance abuse? Here are some of the most common reasons for addiction during pregnancy.
Perhaps the biggest reason for substance abuse during pregnancy is that a woman’s reproductive years (age 15 to 44) coincide with a time in life when a person is most likely to seek out new experiences and begin abusing drugs. Adolescents and young adults are biologically wired to take risks and experiment with tobacco, alcohol, prescription pills, and illicit drugs. This puts women of childbearing age at an increased risk of addiction. Studies show that pregnant teens are more likely to abuse drugs compared to older women.
About 45 percent of pregnancies in the United States are unintended or mistimed, meaning either the pregnancy was not desired or it occurred earlier than desired. Unplanned pregnancies are a risk factor for exposure to drugs and alcohol due to a late recognition of pregnancy and delayed access to antenatal care. When a pregnancy is unplanned, the woman may continue risky consumption of alcohol and drugs without realizing she is carrying a baby.
Some of the drugs that may be prescribed during pregnancy, such as benzodiazepines (sleeping pills), are highly addictive. In addition, prenatal exposure to benzos such as diazepam is associated with birth defects including facial clefts and cardiac malformations. In pregnant women, treatment with any medication needs to be carefully monitored to ensure the mother does not become dependent and no harm is caused to the baby.
Most women want to do what’s best for their baby. They realize that quitting tobacco, alcohol, or drugs is an important step towards a healthy birth. Yet, changing behaviors is not easy. Not all women are able to stop smoking, drinking, or using drugs when they find out they are expecting. Women who are daily smokers, heavy drinkers, and long-term drug abusers find it the hardest to quit. In fact, studies show that only 1 in 3 women who smoked before pregnancy is able to quit in the prenatal period. Abstinence rates for alcohol and illicit drugs are slightly more encouraging, but relapse rates in the postpartum period remain high.
Any chemical that enters a pregnant woman’s body, whether it is prescribed by a physician or used illegally for recreational purposes, can harm the fetus. However, not every woman who is expecting understands the risks of tobacco, alcohol, and drug abuse for herself and her baby. Some women are under the false impression that light drinking is okay, believing that only binge drinking is harmful to the baby. According to the CDC, no type or amount of alcohol is safe for pregnant women.
It is mandatory for obstetricians to report substance abuse in pregnant women. Many expectant mothers are aware of the risks of drugs and alcohol but avoid seeking treatment for their addiction because they are afraid of the legal ramifications. Some women fear they will be judged and criticized by friends, family, and healthcare providers. Some women are afraid they may lose custody of their children or be evicted from their home if their addiction is discovered. The threat of institutionalization or incarceration keeps many pregnant women from seeking treatment for substance abuse.
Pregnancy and the birth of a child is associated with many biological and lifestyle changes for a woman. Many women struggle to cope with and adapt to the new phase of their lives and suffer from depression as a result. Postpartum depression, commonly known as baby blues, affects an estimated 15 percent of new mothers. Feelings of anxiety, sadness, and exhaustion make it difficult for the mother to care for herself and her baby. Studies show that women with postpartum depression are at a high risk of substance abuse. In fact, substance abuse and depression are risks for each other and both have a substantial negative impact on maternal and infant health.
Substance Use Disorders in Pregnancy: A Statistical Overview
Substance abuse in pregnancy is associated with a number of serious maternal and fetal health consequences. Nearly 90 percent of female drug abusers are of reproductive age. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 5.4 percent of pregnant women between ages 15 and 44 are current users of illicit drugs. In pregnant teens (age 15 to 17), the rate of drug abuse is much higher at almost 15 percent. More than 8 percent of women report current alcohol use and nearly 3 percent are binge drinkers. Tobacco use is also prevalent during pregnancy and 1 in 14 pregnant women smokes cigarettes. It is evident that substance use disorders are rampant during pregnancy. Let’s look at some facts and figures about addiction in pregnant women.
Data from the National Vital Statistics System in 2016 found that a little over 7 percent of women smoked cigarettes during their pregnancy. The study found that the prevalence of tobacco use is highest in the 20-24 years age group. American-Indians and Alaskan Natives have the highest incidence of tobacco abuse at almost 17 percent. Smoking during pregnancy is highest in West Virginia (more than 25 percent) and Kentucky (nearly 19 percent). Women with a master’s degree or higher are least likely to smoke while pregnant. Smoking during pregnancy is harmful to both mother and baby. For women who are trying to conceive, tobacco use makes it harder to become pregnant. Miscarriages are more likely in smokers and there is an increase in abortion rate by 33 percent. The risk of stillbirth increases by 23 percent in smokers. The risk of infections is higher in the unborn child if the mother is a smoker. Smoking is associated with placental problems such as early separation from the womb (the placenta is the source of oxygen and nutrition to the baby). Maternal tobacco abuse can lead to the baby being born prematurely or having a low birth weight and health problems, requiring a longer hospital stay. Maternal smoking is also a risk factor for SIDS (sudden infant death syndrome). Birth defects such as cleft lip and cleft palate are more likely in babies born to mothers who smoked while they were expecting.
Alcohol use during pregnancy is a widespread problem and is reported by 15 to 20 percent of women. More than 50 percent of women report drinking alcohol in the three months prior to conceiving. Nearly 7 percent of mothers report using alcohol during the last three months of their pregnancy. In women above the age of 30, the percentage of alcohol drinkers in the last trimester is higher at 10 percent. Interestingly, drinking during the last trimester is more common in mothers who are more highly educated. Women who are risky drinkers (more than 7 drinks per week or more than 3 drinks on one occasion) are less likely to achieve abstinence when they are pregnant. The good news is that alcohol consumption by pregnant women seems to be on the decline. Drinking alcoholic beverages during pregnancy has a number of harmful consequences including preterm labor. It is associated with a four times higher risk of spontaneous abortion. Fetal alcohol syndrome, a condition in which the baby suffers brain damage, malformations, and growth retardation, is a well-established consequence of maternal alcohol abuse and is present in 1 in 300 live births every year. An estimated 2.6 million babies suffer in utero exposure to alcohol each year.
Over the past decade or so, there has been a significant increase in prenatal marijuana use from 4.2 percent to over 7 percent. Interestingly, the jump is even more substantial in women under the age of 18, increasing from 12.5 percent to nearly 22 percent. The number of pregnant women seeking treatment for marijuana abuse has also increased. According to one study, about 20 percent of pregnant women under the age of 24 tested positive on drug testing for marijuana. Data from SAMHSA found that past-month marijuana use was reported by about 3.5 percent of pregnant females between the ages of 15 and 44. This would suggest that there is a considerable gap between self-reported marijuana use in pregnant women and marijuana use discovered on drug screening tests. Medical experts warn against using marijuana to treat pregnancy-related nausea. Although recreational marijuana is legal in some states, it should not be used during pregnancy as it can lead to a low birth weight baby and behavioral problems such as hyperactivity later in life. Long-term use of marijuana elevates the risk of premature birth. Women who use marijuana while pregnant have 2.3 times increased risk of stillbirth. Prenatal exposure to marijuana is associated with problems with neurological development manifesting as deficiencies in problem-solving skills, memory, attention, and social interactions. Babies born to women who abuse marijuana while pregnant are more likely to use marijuana as young adults.
Caffeine is a stimulant and is present in tea, coffee, sodas, energy drinks, and some headache medications, in varying amounts. The data on maternal caffeine consumption during pregnancy and fetal safety is conflicting. What we do know is that pregnant women metabolize caffeine slower than non-pregnant women and caffeine is transmitted across the placenta from the mother to the baby. Studies suggest that one to two cups of coffee a day are safe, but intake of more than 300 mg per day may be associated with adverse outcomes such as spontaneous abortion, growth restriction, congenital malformations, and stillbirth. A typical 8-ounce serving of coffee has about 135 mg of caffeine. Studies have found that a 100 mg dose of caffeine per day from all sources during pregnancy is associated with an elevated risk of miscarriage. Research shows that high caffeine intake is associated with impaired fetal growth and low birth weight. There is a linear increase in risk. For every additional 100 mg of caffeine (1 cup of coffee or 2 cups of tea) per day, there is a 3 percent increase in low birth weight. Pregnant women who drink more than 8 cups of coffee a day are at increased risk of stillbirth. Fetal exposure to moderate to high levels of caffeine has been linked to childhood obesity.
Hallucinogens, such as LSD, MDMA, and ecstasy, alter a person’s perception of reality by causing them to see, hear, and feel things that are not real. It is difficult to establish a link between hallucinogens and adverse fetal outcomes because pregnant drug abusers often simultaneously use other illicit substances. One study found nearly 9 percent of women in the age group of 20 to 29 years reported recent use of ecstasy. There is no doubt that illicit substance abuse is associated with poor obstetric outcomes such as stillbirth and eclampsia. Hallucinogen abuse during pregnancy may increase the risk of miscarriage, premature delivery, and withdrawal symptoms in the newborn. Babies born to mothers who abuse hallucinogens may have heart and brain abnormalities and be small in size. Studies show that spontaneous abortions occur significantly more frequently in mothers who abuse LSD. The drug can also lead to compromised fetal blood flow and ocular abnormalities in the baby. More research is needed to confirm whether LSD causes birth defects.
According to the National Institute on Drug Abuse (NIDA), 39 percent of women in the reproductive age group of 15-44 years enrolled in Medicaid have prescriptions written for narcotics, making opioid use during pregnancy a major concern in America. There has been a dramatic increase in maternal opioid abuse in recent years, paralleling the epidemic in the general population. The number of mothers dependent on opiates at the time of delivery increased fivefold from 2000 to 2009. In some states, more than 41 percent of women reported filling a prescription for opioids during pregnancy, with codeine and hydrocodone being the most commonly prescribed drugs. Population-based studies by the CDC have found a link between use of opioid painkillers by expectant mothers and birth defects in the baby. Misuse of opioids during pregnancy is also associated with serious complications such as placental abruption, fetal growth retardation, preterm labor, and stillbirth. Abnormalities such as spina bifida, hydrocephaly, gastroschisis, glaucoma, and congenital heart defects are reported due to opioid painkiller use by pregnant women. Opioid use by the mother in the first trimester increases the chances of a heart defect in the baby by two times. It is estimated that every 25 minutes a baby is born with neonatal abstinence syndrome (NAS), which is a type of drug withdrawal syndrome in newborns. In 2012, nearly 22,000 babies were born with NAS in the United States, representing a fivefold increase from the year 2000.
It is estimated that approximately 4 percent of pregnant women abuse illicit drugs. It is difficult to determine exactly how many expectant mothers use cocaine in the United States but studies show that cocaine accounts for 10 percent of illicit drug use in pregnant women. A 2015 National Survey on Drug Use and Health found that approximately 1,000 expectant mothers had used cocaine in the preceding month. Despite the well-known fact that cocaine use during pregnancy has long-lasting harmful effects on both mother and baby, there are an estimated 750,000 cocaine-exposed pregnancies each year in the United States. Prenatal cocaine exposure is associated with several long-term health consequences and neurodevelopmental issues in the baby, including impaired language development and behavioral problems. Other adverse outcomes of cocaine abuse during pregnancy include preterm birth, placental problems, impaired fetal growth, congenital malformations, stillbirth, and SIDS (sudden infant death syndrome). Methamphetamine abuse during pregnancy is associated with placental abruption (separation of the placenta from the wall of the uterus). Infants born to mothers who abuse meth or cocaine may be hyperactive and irritable with excessive sucking, tremors, and high-pitched crying.
According to the World Health Organization, amphetamine-type stimulants are some of the most widely abused illicit drugs in the world, making them highly likely to be abused by women of reproductive age. This is confirmed by the CDC finding that the percentage of American women in the reproductive age group who filled prescriptions for stimulant medications for ADHD treatment increased by 350 percent from 2003 to 2015. The hospitalization rate for amphetamine abuse during pregnancy doubled from 1998 to 2004. Unfortunately, there is not much research on the effects of amphetamine or bath salts use by pregnant women. What is known is that women abusing amphetamines and bath salts are at high risk of poor obstetric outcomes. Because the signs of amphetamine withdrawal are less pronounced than those of opiate withdrawal, this drug may remain undetected in some infants. The effects of bath salts during pregnancy are poorly understood but may include stillbirth, congenital malformations, and separation of the placenta. The systemic effects of prenatal amphetamine exposure include increased blood pressure, tremors, dilated pupils, and hyperactivity. Some of the risks of prenatal exposure to amphetamines include cleft lip, fetal growth retardation, and cardiac anomalies. Low body weight, premature labor, and stillbirth are also reported. One study found that 35 percent of children who were exposed to amphetamines during fetal life exhibited aggressive behavior at 4 years of age.
In the United States, a woman seeks emergency care every 3 minutes for prescription drug abuse. In 2014, SAMHSA reported that 4.6 million women above the age of 18 were misusing prescription drugs. The fast-growing abuse of prescription painkillers has not spared maternity wards. The number of babies born with prescription painkiller withdrawal symptoms has risen sharply over the past decade or so. Commonly abused prescription drugs include pain relievers such as Percocet, OxyContin, and Vicodin, CNS depressants such as Xanax, Valium, and Ativan, and stimulants such as Adderall and Ritalin. In the decade or so following the year 2000, there was a fivefold increase in opiate use during pregnancy. The risk of stillbirth is two to three times higher in women who take prescription pain relievers. About 13,500 babies are born with neonatal abstinence syndrome due to opiate withdrawal every year in the United States. Potential harm to the fetus includes low birth weight, preterm birth, and fetal death. Opiate exposure during fetal life can cause birth defects such as spina bifida and heart anomalies. Stimulants are known to increase the risk of brain and heart defects and cleft palate or cleft lip in the baby.
How Does Maternal Addiction Harm the Growing Baby?
It is well known that there are several serious health consequences for the developing fetus from maternal substance abuse. Some of the most common prenatal effects of various drugs include miscarriage, preterm labor, low birth weight, and a number of developmental problems and birth defects. Pregnant women with addictions is a high-risk group that requires intensive obstetric and neonatal care. Let’s look at some of the most common adverse prenatal effects of tobacco, alcohol, prescription drugs, and illicit substances.
Neonatal Abstinence Syndrome (NAS)
A baby who has been exposed to an illicit substance during fetal life because the mother was regularly using it can be born with a dependence on the substance. This is known as neonatal abstinence syndrome. Maternal abuse of drugs such as opioids (for example, oxycodone, codeine), heroin, and methadone can cause NAS in a newborn infant. It can also be caused by exposure to alcohol, benzodiazepines (sleeping pills), and antidepressants (SSRIs) in the womb. Babies who receive one or more of these drugs before delivery from their mothers are born with a dependence on the drugs. After birth, when they no longer get the drugs, it results in a postnatal withdrawal syndrome.
During the period 2000-2012, the incidence of NAS in the United States increased by 383 percent.
In 2013, there were 6 cases of NAS reported per 1,000 births, up from 1.5 in 1999. Treatment for NAS often requires pharmacological intervention with medications such as methadone and morphine in up to 70 percent of infants. The treatment protocol can extend for several weeks, depending on the severity of the withdrawal, which in turn depends on the duration of in utero drug exposure.
Fetal Alcohol Spectrum Disorders (FASD)
Fetal alcohol spectrum disorders are a set of conditions that occur in babies that were exposed to alcohol during their mother’s pregnancy. FASD is characterized by growth problems and irreversible brain damage. The severity of fetal alcohol syndrome varies from child to child and depends on the duration and amount of maternal alcohol abuse. According to the National Organization on Fetal Alcohol Syndrome (NOFAS), alcohol and pregnancy don’t mix. Expectant mothers who drink even small quantities of alcoholic beverages are putting their baby at risk of fetal alcohol syndrome.
The CDC fact sheet on alcohol and pregnancy states that 3.3 million women in the United States are at risk of exposing their baby to alcohol. Factors that increase the risk of FAS include maternal age, poor socioeconomic status, heavy and frequent drinking, and a family history of alcoholism. In the 1980s and 1990s, the prevalence of FAS in America was estimated at 2 cases per 1,000 births. The CDC reports that assessment of school-going children has revealed a prevalence of 6 to 9 cases of FAS per 1,000 children. A recent study conducted on more than 13,000 children in four U.S. communities found that fetal alcohol spectrum disorders are present in up to 5 percent of first graders.
Miscarriage and Stillbirth
Miscarriage is the death of a baby in the womb before 20 weeks of pregnancy. Stillbirth is the death of a baby in the womb after 20 weeks of pregnancy. There is a strong link between illicit drug use and stillbirth. According to the National Institutes of Health (NIH), smoking tobacco or marijuana, using illicit drugs, or misusing prescription painkillers during pregnancy increases the risk of stillbirth by two to threefold. Heavy alcohol use (more than three alcoholic drinks daily) during pregnancy increases the risk of spontaneous abortion by more than threefold.
Women who consume any amount of alcohol while pregnant have a 40 percent increased risk of stillbirth compared to women who do not drink at all.
As more and more states legalize recreational marijuana, the effects of this drug on the fetus are an increasing public health concern. The CDC estimates that 1 in 20 women in America uses marijuana while pregnant. Studies reveal that reducing the use of illicit substances substantially reduces the risk of abortion.
Premature Labor and Birth
Any infant born before the 37th week of pregnancy (about three weeks before the due date) is considered premature. Premature infants have a number of problems, including low weight, breathing troubles, and difficulties with eating and drinking.
Prescription drug abuse in pregnant women may result in premature rupture of membranes. Babies born to mothers who abuse illicit drugs such as cocaine during pregnancy have a higher rate of prematurity.
Women who consume seven or more alcoholic drinks per week while pregnant are more than 3 times likely to deliver prematurely.
Tobacco use during pregnancy raises the risk of premature birth. Besides active tobacco use, exposure to second-hand smoke during pregnancy is associated with a significantly higher rate of preterm delivery. Opium use is associated with an increased risk of premature birth, with the risk being double in women who use both tobacco and opium.
Developmental and Behavioral Problems
A large number of women who use alcohol or drugs during pregnancy are poly-substance abusers. Maternal substance abuse is closely linked to child development. Many different physical, behavioral, developmental, cognitive, social, academic, and vocational problems are noted in the children of women who abuse drugs and alcohol while pregnant.
According to one study, more than 30 percent of women who abused methamphetamines during their pregnancy reported having a child with a physical or mental disability.
Prenatal marijuana use is associated with a significant increase in impulsiveness, hyperactivity, inattention, and delinquency in children aged 10. Prenatal exposure to MDMA and other recreational drugs is associated with poor mental and motor development in infants at 1 year of age, with the severity of the disorder being heavily dose-dependent.
Fetal alcohol exposure is associated with a number of problems later in life. The umbrella term of fetal alcohol spectrum disorders includes lifelong difficulties with coordination, emotion control, school work, social skills, and employment.
Keeping Baby Safe: Addiction Treatment During Pregnancy
Addiction in pregnant women is a rapidly growing problem in America. Without drug rehab during pregnancy, the health consequences for mother and child can be devastating. Here are some of the facts, figures, and challenges of addiction treatment in pregnancy.
Drug Rehab During Pregnancy: Facts and Figures
According to a report by the Substance Abuse and Mental Health Services Administration (SAMHSA), about 4 to 5 percent of women between the ages of 15 and 44 who enter substance abuse treatment are pregnant at the time of admission. Among pregnant women seeking treatment at drug rehab centers, the number of women addicted to alcohol saw a decline from 2000 to 2010, but the number of pregnant women addicted to drugs increased from about 51 percent to nearly 64 percent, indicating that the substance of abuse reported at the time of rehab admission has changed over the years.
In the past couple of decades, prescription opioid overdose deaths in the United States increased dramatically by more than 500 percent. Mirroring this increase, the number of pregnant women admitted for treatment of prescription opioids as the primary substance of abuse increased from 2 percent in 1992 to 28 percent in 2012 despite the percentage of pregnant women seeking addiction treatment remaining more or less stable.
Drug Rehab in the First Trimester: Better Outcomes for Mother and Child
Substance use during pregnancy is associated with poor outcomes for both mother and child. Women who are addicted to drugs or alcohol require specialized care, including prenatal care and addiction treatment, to address their complex medical and psychosocial needs. Studies have found that a comprehensive prenatal and addiction treatment program for women with a history of alcohol or drug abuse is associated with positive health outcomes. Women who present for treatment early in their pregnancy have the best outcome with a higher rate of breastfeeding and discharge home with the mother following delivery (as opposed to protective child custody or adoption). More than 90 percent of women who start addiction treatment in the first trimester have custody of their baby at discharge.
Research shows that infants with only first-trimester exposure to methamphetamines fare better than infants with continuous exposure until the third trimester.
Studies have found that medication-assisted treatment with methadone therapy for opioid-addicted pregnant women is associated with reduced fetal morbidity, improved maternal health, and better utilization of prenatal care.
Avoiding alcohol is recommended to all women who are pregnant or planning to become pregnant. Alcohol is most harmful to the developing fetus for the first 12 weeks of the pregnancy, but stopping drinking at any time, even during the second and third trimester can help reduce risks. According to the CDC, brain development occurs throughout the pregnancy and the sooner a pregnant woman stops drinking the better it is for her and her baby.
Treatment for Substance Use Disorder and Legal Issues
Many women are aware of the risks of alcohol and drugs during pregnancy and want to quit but are unable to do so on their own. Some pregnant drug and alcohol abusers avoid seeking addiction treatment for fear of legal issues. Expectant mothers fear there will be consequences regarding custody of other children or other legal ramifications. Social stigma and the fear of being criticized and judged by healthcare providers, friends, and family also prevents some pregnant women from going to drug rehab.
According to the American College of Obstetrics and Gynecology (ACOG), the threat of incarceration prevents many women from seeking prenatal care and this is ineffective in reducing drug and alcohol abuse in expectant mothers. There is no specific criminal law for drug abuse during pregnancy, but in some states, substance use during pregnancy is equivalent to child abuse. Laws mandate obstetricians report substance abuse in their patients. Pregnant drug abusers may be persecuted for child neglect, endangerment, mistreatment, and abuse. Legally mandated drug testing and reporting and fear of legal consequences, such as incarceration, commitment, loss of child custody, and loss of housing, leads many pregnant drug abusers to disengage from even routine prenatal care, putting themselves and their babies at considerable risk.
Addiction Treatment In Pregnancy: Making the Best Chioce
Getting help for addiction as early as possible in the pregnancy is of benefit to both mother and child. A comprehensive drug rehab program reduces the risk of miscarriage, preterm delivery, birth defects, and neonatal abstinence syndrome. It also restores the mother’s physical and psychological health to enable her to care for her baby during the pregnancy and after birth.
According to a study published in the Journal of Substance Abuse, treatment outcomes are significantly improved for those enrolled in comprehensive residential substance abuse treatment programs for pregnant women and new mothers. Addiction in pregnancy is not the end of the road. It is possible to get help at drug rehab and save two lives in the process.