Association of Pregnancy-Specific Alcohol Policies With Infant Morbidities and Maltreatment

Championing reproductive and perinatal health with the recovery community: improving access to healthcare and health promotion resources to support recovery

Peer recovery support services are instrumental in the promotion of long-term recovery primarily by focusing on building the recovery capital of people with substance use disorders. Women may have specific health-related needs that are not generally part of recovery support staff training. Our team co-created a model by training people with lived experience as coaches to promote the health of women with SUD during the critical period of their reproductive years when mortality from overdose risk is high and can be compounded by issues surrounding pregnancy. We explored the outcomes of a small pilot test of this model to promote reproductive autonomy in a recovery community center (RCC). The RCC and the champion-trained peer recovery coach were able to increase their reach to women of reproductive age and facilitated linkage to healthcare and health-promoting resources. The model has the potential to improve the participants' abilities to access reproductive and perinatal health resources and healthcare that could lead to improvements in their recovery.

The Relationship Between Alcohol Availability and Drink-Driving Policies and Admissions to Substance Use Disorder Treatment During Pregnancy

OBJECTIVE

Pregnancy-specific alcohol policies are widely adopted yet have limited effectiveness and established risks. It is unknown whether general population alcohol policies are effective during pregnancy. This study investigated associations between general population policies and alcohol treatment admission rates for pregnant people specifically.

METHOD

Data are from the Treatment Episodes Data Set-Admissions and state-level policy data for 1992-2019 (n = 1,331 state-years). The primary outcome was treatment admissions where alcohol was the primary substance, and the secondary outcome included admissions where alcohol was any substance. There were five policy predictors: (a) government spirits monopoly, (b) ban on Sunday sales, (c) grocery store sales, (d) gas station sales, and (e) blood alcohol concentration (BAC) laws. Covariates included poverty, unemployment, per capita cigarette consumption, state and year fixed effects, and state-specific time trends.

RESULTS

In models with alcohol as the primary substance, prohibiting spirits sales in grocery stores (vs. allowing heavy beer [>3.2% alcohol by volume] and spirits) had lower treatment admission rates (incidence rate ratio [IRR] = 0.88, 95% CI [0.78, 0.99], p = .028). States with BAC laws at .10% (vs. no law) had higher treatment admission rates (IRR = 1.24, 95% CI [1.08, 1.43], p = .003). When alcohol was any substance, prohibiting spirits sales in grocery stores (vs. allowing heavy beer and spirits) was again associated with lower treatment admission rates (IRR = 0.89, 95% CI [0.80, 0.98], p = .021), but there was no association for BAC laws.

CONCLUSIONS

Restrictions on grocery store spirits sales and BAC laws were associated with lower and higher alcohol treatment admission rates among pregnant people, respectively, suggesting that general population alcohol policies are relevant for pregnant people's treatment utilization.

Understanding the effects of alcohol policies on treatment admissions and birth outcomes among young pregnant people

BACKGROUND

This study examines whether state-level alcohol policy types in the United States relate to substance use disorder treatment admissions and birth outcomes among young pregnant and birthing people.

METHODS

We used data from the Treatment Episode Data Set: Admissions (TEDS-A) and Vital Statistics birth data for 1992-2019. We examined 16 state-level policies, grouped into three types: youth-specific, general population, and pregnancy-specific alcohol policies. Using Poisson and logistic regression, we assessed policy effects for those under 21 (aged 15-20) and considered whether effects differed for those just over 21 (aged 21-24).

RESULTS

Youth-specific policies were not associated with treatment admissions or preterm birth. There were statistically significant associations between family exceptions to minimum legal drinking age (MLDA) policies and low birthweight, but findings were in opposite directions across possession-focused and consumption-focused (MLDA) policies and did not differentially apply to people 15-20 versus 21-24. Most pregnancy-specific policies were not associated with treatment admissions, and none were significantly associated with birth outcomes. A few general population policies were associated with improved birth outcomes and/or increased treatment admissions. Specifically, both government spirits monopolies and prohibitions of spirits and heavy beer sales in gas stations were associated with decreased low birthweight among people 15-20 and among people 21-24. Effects of Blood Alcohol Concentration (BAC) limits varied by age, with slight reductions in adverse birth outcomes among people 15-20, as BAC limits get stronger, but slight increases for those 21-24. Although treatment admissions rates across ages were similar when BAC limits were in place, treatment admissions were greater for pregnant people 21-24 than for 15-20 when there were no BAC limits.

CONCLUSIONS

General population policies also appear effective for reducing the adverse effects of drinking during pregnancy for young people, including those under 21. Policies that target people based on age or pregnancy status appear less effective.

Medications for Alcohol Use Disorder Among Birthing People With an Alcohol-related Diagnosis

OBJECTIVES

Although safety and effectiveness of medications for alcohol use disorder (AUD) are well established for adults, literature on these medications in pregnancy is limited. Given known adverse effects of untreated AUD during pregnancy, clinicians and researchers have recently begun to call for reconsidering use of medications for AUD in pregnancy. Thus, we sought to estimate the proportion of birthing people with an alcohol-related diagnosis who received a prescription for medication related to AUD treatment.

METHODS

Data were from Meritive MarketScan, a national private insurance claims database. The study cohort included birthing people aged 25-50 who gave birth to a singleton in the United States between 2006 and 2019 and were matched with an infant. Variables included an alcohol-related diagnosis within a year of birth and receiving a prescription for a medication related to AUD treatment. We calculated proportions with alcohol-related diagnoses who received any AUD medication and each medication type.

RESULTS

Of 1,432,979 birthing person-infant dyads, 2517 (0.18%) had an alcohol-related diagnosis. Of those with an alcohol-related diagnosis, 8.70% (n = 219) received any medication. The most common was gabapentin (4.69%, n = 118), with benzodiazepines for withdrawal as the second most common (2.19%, n = 55). Approximately 2% received naltrexone (1.91%, n = 48) and/or disulfiram (1.39%, n = 35); 0.56% (n = 14) received acamprosate. No one with an alcohol-related diagnosis received phenobarbital. Almost all medications were received postpartum.

CONCLUSIONS

Very few pregnant/postpartum people with alcohol-related diagnoses are prescribed medications related to AUD treatment. Research is needed to examine whether benefits of these medications during pregnancy outweigh harms.

Trends in U.S. State Alcohol and Other Drug Use During Pregnancy Policies from 2016 to 2020: Policymaking in the Comprehensive Addiction and Recovery Act Era

Background: Prior to the U.S. Comprehensive Addiction and Reovery Act of 2016 (CARA) , policymaking on alcohol and drug use during pregnancy was more concentrated on alcohol than drug use policy - although the overlap between the two types of policy was high. Further, the highest levels of legislative activity were requirements to report pregnant women who used alcohol or other drugs and child abuse/neglect policy.

Methods: This research brief uses rigorous legal epidemiology methodology to explore state policy activity on alcohol and other drug use during pregnancy after the U.S. Comprehensive Addiction and Recovery Act of 2016 (CARA) amended the 2010 Child Abuse Prevention and Treatment Act Reauthorization (CAPTA).

Results: Since CARA, policymaking has been more concentrated on drug policy than alcohol policy, although the overlap between the two is still high. Further, since CARA, states have concentrated policy activity on priority treatment for drugs and reporting requirements.

Conclusions: Even though CARA does not require reporting for the purposes of child welfare investigations, several states adopted such requirements during these years.

Dietary factors and risk for adverse pregnancy outcome: A Mendelian randomization analysis

This study aims to explore the link between dietary habits and adverse pregnancy outcomes (APOs), including preterm birth (PB), preeclampsia (PE), gestational diabetes mellitus (GDM), fetal growth restriction (FGR), and spontaneous abortion (SA) through two-sample Mendelian randomization (MR). We accessed publicly available genome-wide association studies' (GWAS) summary statistics for dietary habits and APOs, respectively. We used five MR methods to synthesize MR estimates across genetic instruments. To ensure the robustness of our results, we assessed heterogeneity, and horizontal pleiotropy, and conducted sensitivity analyses. The primary analysis showed that intake of dried fruit (odds ratio (OR), 0.522; 95% confidence interval (CI): 0.291-0.935) and fresh fruit (OR, 0.487; 95% CI: 0.247-0.960) was related to a decreased risk of PB. While intake of tea (OR, 1.602; 95% CI: 1.069-2.403) and poultry (OR, 6.314; 95% CI: 1.266-31.488) was linked to a heightened risk of PB. Cheese intake was a protective factor against PE (OR, 0.557; 95% CI: 0.337-0.920) and GDM (OR, 0.391; 95% CI: 0.270-0.565). Intake of lamb/mutton had a negative relationship with PE (OR, 0.372; 95%CI: 0.145-0.954), whereas oily fish consumption showed a positive relationship with FGR (OR, 2.005; 95% CI: 1.205-3.339). However, after correction using the false discovery rate (FDR) analysis, only the intake of cheese showed a significant causal relationship with GDM (p < .001). Our study preliminarily found that cheese intake was significantly associated with the lower risk of GDM, while others were suggestively associated with the risk of APOs. Well-designed prospective studies are still needed to confirm our findings in the future.

Training health professionals to reduce overreporting of birthing people who use drugs to child welfare

BACKGROUND

Health care providers are a key source of reports of infants to child welfare related to birthing people's substance use. Many of these reports are overreports, or reports that exceed what is legally mandated, and reflect racial bias. We developed and evaluated a webinar for health professionals to address overreporting related to birthing people's substance use.

METHODS

This evaluation study collected data from health professionals registering to participate in a professional education webinar about pregnancy, substance use, and child welfare reporting. It collected baseline data upon webinar registration, immediate post-webinar data, and 6 month follow-up data. Differences in both pre-post-and 6 month follow-up data were used to examine changes from before to after the webinars in beliefs, attitudes, and practices related to pregnant and birthing people who use drugs and child welfare reporting.

RESULTS

592 nurses, social workers, physicians, public health professionals, and other health professionals completed the baseline survey. More than half of those completing the baseline survey (n = 307, 52%) completed one or both follow-up surveys. We observed statistically significant changes in five of the eleven opioid attitudes/beliefs and in four of the nine child welfare attitudes/beliefs from baseline to follow-ups, and few changes in "control statements," i.e. beliefs we did not expect to change based on webinar participation. All of the changes were in the direction of less support for child welfare reporting. In particular, the proportion agreeing with the main evaluation outcome of "I would rather err on the side of overreporting to child welfare than underreporting to child welfare" decreased from 41% at baseline to 28% and 31% post-webinar and at 6-month follow up (p = 0.001). In addition, fewer participants endorsed reporting everyone at the 6 month follow-up than at baseline (12% to 22%) and more participants endorsed reporting no one at the 6-month follow-up than at baseline (28% to 18%), p = 0.013.

CONCLUSIONS

Webinars on the legal, scientific, and ethical aspects of reporting that are co-developed with people with lived experience may be a path to reducing health professional overreporting to child welfare related to birthing people's substance use.

Associations between alcohol taxes and varied health outcomes among women of reproductive age and infants

OBJECTIVE

No studies have examined whether alcohol taxes may be relevant for reducing harms related to pregnant people's drinking.

METHOD

We examined how beverage-specific ad valorem, volume-based, and sales taxes are associated with outcomes across three data sets. Drinking outcomes came from women of reproductive age in the 1990-2020 US National Alcohol Surveys (N = 11 659 women $\le$ 44 years); treatment admissions data came from the 1992-2019 Treatment Episode Data Set: Admissions (N = 1331 state-years; 582 436 pregnant women admitted to treatment); and infant and maternal outcomes came from the 2005-19 Merative Marketscan® database (1 432 979 birthing person-infant dyads). Adjusted analyses for all data sets included year fixed effects, state-year unemployment and poverty, and accounted for clustering by state.

RESULTS

Models yield no robust significant associations between taxes and drinking. Increased spirits ad valorem taxes were robustly associated with lower rates of treatment admissions [adjusted IRR = 0.95, 95% CI: 0.91, 0.99]. Increased wine and spirits volume-based taxes were both robustly associated with lower odds of infant morbidities [wine aOR = 0.98, 95% CI: 0.96, 0.99; spirits aOR = 0.99, 95% CI: 0.98, 1.00] and lower odds of severe maternal morbidities [wine aOR = 0.91, 95% CI: 0.86, 0.97; spirits aOR = 0.95, 95% CI: 0.92, 0.97]. Having an off-premise spirits sales tax was also robustly related to lower odds of severe maternal morbidities [aOR = 0.78, 95% CI: 0.64, 0.96].

CONCLUSIONS

Results show protective associations between increased wine and spirits volume-based and sales taxes with infant and maternal morbidities. Policies that index tax rates to inflation might yield more public health benefits, including for pregnant people and infants.

Clinician views on reporting pregnant and birthing patients who use alcohol and/or drugs to child welfare

BACKGROUND

Multiple health professional associations have expressed concern with policies that require clinician reporting of pregnant people's substance use to child welfare, including that reporting negatively affects patient outcomes and the patient-provider relationship. However, research has shown that clinicians continue to report pregnant and birthing patients at high rates.

OBJECTIVE

This study aimed to explore clinician views on reporting pregnant and birthing patients who use alcohol or drugs during pregnancy to child welfare and whether there are patterns in the types of decisions that clinicians agree with, disagree with, or feel conflicted about.

STUDY DESIGN

In-depth interviews were conducted with 37 hospital-based clinicians (13 obstetrics and gynecology physicians, 12 emergency medicine physicians, 10 family medicine physicians, and 2 advance practice registered nurses) in the United States. The participants discussed one or more patient cases where they or someone else on the care team had to decide whether to report that patient to child welfare related to their use of alcohol or drugs during pregnancy. Cases were categorized on the basis of whether the participant agreed, disagreed, or was conflicted by the reporting decision in that case. Patterns were explored by patient-level factors, provider specialty, and whether the participant perceived that the decision was influenced by a state or hospital policy.

RESULTS

A total of 53 patient cases (average 2 per interview) were identified. The participants typically described cases where they agreed with the decision to report or believed there was no other option than reporting. These cases typically involved patients who used nonprescribed opioids during pregnancy, were experiencing factors (eg, unstable housing and untreated mental health disorders) in addition to substance use, and/or left the hospital against medical advice without their infant. Moreover, some participants, mostly obstetricians and gynecologists, described cases where they felt conflicted about or disagreed with the decision to report. These cases typically involved pregnant patients using cannabis and patients reported because of hospital and/or state policy. Only 1 participant described a case where they disagreed with the decision to not report.

CONCLUSION

The participants agreed with most, but not all, child welfare reporting decisions. When participants disagreed or felt conflicted with reporting decisions, these feelings were almost entirely related to decisions to report, which, in some cases, were prompted by hospital or state policies. Policies may prompt reporting that exceeds what clinicians believe is appropriate.