Addressing Substance Use in Pregnancy: One State’s Mission

Originally published in NeoTox, Winter/Spring 2016.
While the statistics were already alarming, those working with babies in West Virginia knew data greatly underreported the problem and aimed to provide a more accurate assessment of the prevalence of maternal substance use.

by Stefan Maxwell, MB.,BS., FAAP

There has been a recent focus, particularly in West Virginia, on the use of opioids during pregnancy and resulting neonatal abstinence syndrome (NAS) in infants, which has risen to alarming proportions. Substance use in pregnancy is a serious health concern for both the mother and their child. For the mother, episodes of drug withdrawal, perhaps coupled with inebriation and illnesses related to high risk behavior may occur, sometimes with near-fatal consequences or death. As the fetus is exposed to these substances, the effect on its development can vary depending on the concentration of drug, the frequency of exposure and the stage of development when the exposure occurs. The newborn is susceptible to neonatal abstinence syndrome or other neurobehavioral effects that present shortly after birth, potential congenital malformations, intrauterine growth restriction, prematurity and long-term adverse effects on growth and cognitive development.

Analyses from the Kid’s Inpatient Database reported increased maternal opiate use from 1.2 to 5.6 per 1000 hospital births from 2000 to 2009, and a rising incidence of NAS from 1.2 to 5.8 per 1000 hospital births per year from 2000 to 2012.^1,2 In addition, the admission rate to 299 neonatal intensive care units (NICU) in the United States rose from 7 to 27 cases per 1000 admissions from 2004 to 2013, with an increase in the median length of stay from 13 to 19 days.3 In each of the three Level III NICU hospitals in West Virginia, we are experiencing much higher rates of this epidemic. In 2013, Cabell-Huntington Hospital had greater than 100 cases of NAS per 1000 births.  According to the most recent report by the West Virginia Maternal and Infant Mortality review team, 27% of maternal mortality from 2007 to 2012 was a result of drug abuse. There has also been a 214% increase in the rates of prescription drug overdoses in West Virginia between 2001 and 2010. According to the Centers for Disease Control (CDC) the state continues to have the highest incidence of deaths from opioid overdose in the country with 35.5 deaths per 100,000, an increase of 10% from 2013.⁴  

Back in 2006, realizing that the state of West Virginia had some of the worst health outcomes in the country related to low birth weight, infant mortality, and teen pregnancy, the West Virginia Perinatal Partnership (WVPP) was formed. This partnership brought together a wide cross-section of providers, chairs and directors of perinatal health organizations, deans and representatives from the three medical schools in the state, and payers of health care in West Virginia. After almost two years of investigation, including surveys of providers, chart reviews and hospital discharge diagnoses, the inclusion of questions on our birth score data form (a form filled out on all births, with a compilation of data that comprises a “score” that identifies “high risk” infants) the incidence of substance use during pregnancy was estimated to be in 5% of births. Those of us taking care of babies in the state knew that the incidence was much higher, and felt the available data seriously underreported the extent of the problem.  

We believed that to obtain a more accurate assessment of the prevalence of substance use during pregnancy across the state we should conduct an anonymous sampling of umbilical tissue to screen for multiple drug metabolites and alcohol, rather than relying on medical records and self-report. With funding from the West Virginia Department of Health and Human Services we were able to collect 759 umbilical cord samples from eight birthing hospitals across the state in August 2009.⁵ Of the 759 samples collected, there were 115 (15%) cord specimens that were positive for drugs. Marijuana was the most prevalent drug detected, followed by opiates, benzodiazepines, and methadone. Many of these samples showed significant polysubstance usage, particularly among patients using benzodiazepines and methadone. There was also significant regional variation in drug use, ranging from 10% at Thomas Memorial (South Charleston) and City Hospital (Martinsburg) to 19% at Raleigh General (Beckley). With almost 1 in 6 babies being born with evidence of drug exposure, this study clearly demonstrated the significance of the problem of substance use during pregnancy in West Virginia. 

Whereas it is of paramount importance to respond appropriately to this epidemic of opioid usage during pregnancy and the rising incidence of neonatal abstinence syndrome, it is also of urgent need to address the issue of alcohol use in pregnancy, which I believe is grossly under-recognized. Maternal alcohol use and prenatal alcohol exposure remain a serious public health problem worldwide. Alcohol freely crosses the placenta and is known to be teratogenic, interfering with normal prenatal development.⁶

In West Virginia, reported rates of alcohol use during pregnancy from birth certificate or birth score forms have been estimated at 1.2%. This rate is likely an underestimate of actual prevalence rates of alcohol use during pregnancy, based on the findings from the aforementioned pilot study that screened umbilical cord samples for drugs and alcohol. Using detection of PEth in the umbilical cord tissue as an indication of alcohol exposure, this study found an overall detection rate of alcohol use during pregnancy of 5.1% across all of West Virginia, with a range of 5 to 15% positivity among the different hospitals.⁵ At the Women and Children’s Hospital and the Women’s Medicine Center Clinic in Charleston, this umbilical cord tissue study revealed a rate of alcohol use of 8.3%, where rates from the birth certificate and birth score forms was 0.7%. The results of this study clearly demonstrated that alcohol use by pregnant women was being grossly under-reported and new methods for screening women during prenatal care was necessary to identify these women to improve early prevention and intervention.

To determine the most efficacious method of screening for alcohol use during prenatal care, we recently conducted a prospective observational study of women presenting for their first prenatal visit to the obstetric clinic at Women and Children’s hospital. Our hospital currently conducts universal screening for drugs and alcohol use using urine toxicology testing. The purpose of this study was to compare the detection rates of alcohol use during pregnancy between the clinic’s current practice of medical history assessment and a urine screen for ethanol with a method that would include medical history assessment and screening PEth from a blood spot collected by a finger stick. After testing a total of 314 patients, it was clear that screening with PEth identified significantly more patients than urine ethanol screening, with a detection rate of 7% versus 1.6%. This study also found that self-reporting of alcohol use during pregnancy was not as reliable as PEth screening, as only 1.9% of the study population reported alcohol use.

These initial prospective observational studies have indicated the need for further action with regards to the prevalence of substance use and alcohol consumption during pregnancy in West Virginia in order to address the potential maternal and neonatal consequences. It appears that there may be an alarming number of infants, at least in this population of clinic patients that have been exposed to drugs and/or alcohol during pregnancy which may have lasting consequences. These babies may not be diagnosed to have neurodevelopmental deficits until later in childhood or even in early adolescence, and then may be misdiagnosed or their diagnosis may be missed altogether.  

References

1. Patrick, SW, Schumacher, RE, et al. Neonatal abstinence syndrome and associated health care expenditures. United States, 2000-2009, JAMA. 2012; 307:1934.
2. Patrick, SW, Davis, MM, et al. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009-2012. J Perinatol. 2015; 35:650.
3. Tolia, VN, Patrick, SW, et al. Increasing incidence of the neonatal abstinence syndrome in US neonatal ICUs. N Engl J Med. 2015 372:2118.
4. Rudd, RA, Aleshire, N, Zibbell, JE, Gladden, RM. Increases in Drug and Opioid Overdose Deaths – United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378-82. Epub 2016/01/01. doi: 10.15585/mmwr.mm6450a3. PubMed PMID: 26720857.
5. Stitely, ML, Calhoun, B, Maxwell, S. et al. Prevalence of drug use in pregnant West Virginia patients. WV Med J. 2010; 106:48-52.
6. Jones, KL, Smith, DW, Ulleland, CN, Streissguth, P. Pattern of malformation in offspring of chronic alcoholic mothers. Lancet. 1973;1(7815):1267-71. Epub 1973/06/09. PubMed PMID: 4126070.

Dr. Stefan Maxwell has served the mothers and babies at CAMC Women and Children’s Hospital in Charleston, West Virginia, as Chief of Pediatrics and Medical Director of the NICU for over 25 years. He is a founding member of PEDIATRIX Medical Group and has served on the West Virginia Perinatal Partnership Central Advisory Council since 2006, providing leadership as Chair of the Central Advisory Council since 2013 and as Chair of the Committee on Substance Use During Pregnancy for over 9 years. In addition, Stefan is a Clinical Associate Professor of Pediatrics at West Virginia University School of Medicine.