Women who use cocaine or opiates during pregnancy are at elevated risk of a number of high-risk conditions and behaviors.1 Data collected at four clinical centers in the United States indicate that compared with women who were not exposed to these substances during pregnancy, those who used them were more likely to be infected with syphilis, gonorrhea, hepatitis or HIV; to have psychiatric or emotional disorders; and to have experienced pregnancy-related bleeding. These women also were significantly more likely than others to have used tobacco, alcohol or marijuana while pregnant.
As part of a large research study of the toxic effects of drug use during pregnancy on the health of the woman and the fetus, investigators collected data on women who gave birth between May 1993 and May 1995 at large medical facilities in Florida, Michigan, Rhode Island and Tennessee. Women were not eligible to participate if they were younger than 18, had evidence of psychosis or had been institutionalized because of emotional problems or mental retardation; if the newborn was unlikely to survive; or if there was a multiple gestation. In addition, potential participants were excluded at all centers if they refused to give consent and at some centers if they could not be interviewed in their preferred language.
Specially trained staff interviewed women about their social and demographic characteristics and their history of drug use, both prior to and during the pregnancy. To encourage the women to report honestly, each site had obtained a certificate of confidentiality from the National Institute on Drug Abuse exempting the research staff from requirements that they report prenatal drug exposure to state child protection services. The researchers defined drug use during pregnancy on the basis of the women's report during the interview or the detection of drug metabolites in the infant's meconium (the contents of the first bowel movements following birth).
The analyses are based on a cohort of 8,627 mother-infant pairs. Half of the participants (50%) were black, 35% were white and 15% were of some other race. Forty-nine percent were aged 18-25, 44% were 26-35 and the remaining 8% were 36-49. Unmarried women--either never-married (60%) or divorced (2%)--substantially outnumbered currently married women (38%), and the majority of participants had their delivery covered by Medicaid (64%). Sixty-seven percent had more than a high school education, and 51% had worked in the preceding year. Nearly all (95%) received prenatal care.
Thirteen percent of study participants had ever used cocaine, and 59% of these had used cocaine during their pregnancy. Additionally, 2% had ever used an opiate, and 58% of these had done so during the pregnancy.
Women who had used drugs while pregnant were substantially more likely to be black than were nonusers (76% vs. 48%) and were older, on average (30 vs. 26 years). Moreover, 93% of those who had used cocaine or opiates had also drunk alcohol or smoked cigarettes or marijuana while they were pregnant, compared with only 42% of nonusers.
In analyses controlling for the effects of differences by study site, the odds of a number of conditions or infections were significantly elevated among women exposed to cocaine or opiates during pregnancy: a positive HIV test (odds ratio, 8.2); syphilis (6.7); hepatitis (4.8); psychiatric, nervous or emotional illness (4.0); and gonorrhea (1.9).
Drug use during pregnancy also was associated with some delivery complications or treatments needed during pregnancy or labor. In particular, women who had used substances were substantially more likely than nonusers to have been hospitalized as a result of violence during pregnancy (odds ratio, 18.9). They also were significantly more likely than others to have been prescribed psychoactive drugs during pregnancy (2.8), to have experienced bleeding problems (2.3 for placental abruption and 1.9 for placenta previa) and to have had prolonged rupture of the membranes (1.8). Although the great majority (77%) of women who had used drugs received prenatal care, they were less likely than nonusers to have done so (odds ratio, 0.1). On the other hand, women exposed to cocaine or opiates were less likely than unexposed women to experience preeclampsia (odds ratio, 0.6) and to need anesthetics during their hospitalization (0.6).
Some of these findings differed by type of substance used. When the researchers restricted analyses to women who had used only cocaine (which does not usually involve injection with a needle), they found that odds ratios for most problems did not differ much from overall results. However, when they focused on women who had used opiates only (which usually involve needle use), they found that the odds of hepatitis were further elevated (odds ratio, 7.2), while the odds of HIV infection and syphilis were no longer significant. In addition, the odds of chronic hypertension became significantly elevated (3.0), as did the odds of needing medication for pain or sedation during delivery-related hospitalization (2.6). The odds of bleeding problems in this subgroup were nonsignificant.
The authors comment that their findings of an increased risk of hospitalization, particularly because of violence, "have far-reaching implications," and note that "physicians who are caring for women who admit to drug use, particularly cocaine use, should have a high index of suspicion for exposure to violence and abuse." They also observe that their findings support those of previous studies suggesting a link between drug use and bleeding complications such as hemorrhage before delivery, but they draw attention to the "relative rarity" of these complications, even in such a high-risk population, and attribute this to the women's greater-than-expected use of prenatal care. It is important, they conclude, to ensure the availability of "early, comprehensive prenatal care for [drug-]exposed women to prevent or treat the identified health hazards that accompany drug exposure."--M. Klitsch
1. Bauer CR et al., The Maternal Lifestyle Study: drug exposure during pregnancy and short-term maternal outcomes, American Journal of Obstetrics and Gynecology, 2002, 186(3):487-495.