Association of clinical characteristics and cessation of tobacco, alcohol, and illicit drug use during pregnancy

Unique influences of pregnancy and anticipated parenting on cigarette smoking: results and implications of a within-person, between-pregnancy study

Not all pregnant individuals want to become parents and "parenting intention" can also vary within individuals during different pregnancies. Nevertheless, the potential impact of parenting intention on health-related behavior during pregnancy has been heavily underexplored. In this study, we employed a within-person between pregnancy design to estimate the effect of parenting-specific influences on smoking, separate from pregnancy-specific and individual-level influences. We quantified within-mother differences in smoking during pregnancies of infants they reared (n = 84) versus pregnancies of infants they placed for adoption at birth (n = 65) using multivariate mixed-effects Poisson regression models. Mean cigarettes/day declined as the pregnancy progressed regardless of whether infants were reared or placed. However, participants smoked fewer cigarettes/day during reared pregnancies. Relative to "adopted" pregnancies, smoking during "reared" pregnancies was lower by 24%, 41%, and 54% in first (95% CI 0.64-0.90; p = 0.001), second (95% CI 0.48-0.72; p < 0.001), and third trimesters (95% CI 0.36-0.59; p < 0.001), respectively, independent of between-pregnancy differences in maternal age, fetal sex, parity, and pregnancy complications. Female sex and nulliparity were protective. Parenting intention was associated with a protective effect on pregnancy smoking independent of pregnancy-specific influences and individual characteristics. Failure to consider the impact of parenting intention on health-related behavior during pregnancy could perpetuate an unrealistic expectation to "do what's best for the baby" and stigmatize women with unintended or unwanted pregnancies.

Tobacco treatment incorporating contingency management, nicotine replacement therapy, and behavioral counseling for pregnant women who use substances: a feasibility trial

Introduction

Most pregnant women with substance use problems smoke, and few will quit during their pregnancy. Tobacco treatment is often overlooked, with the focus usually placed on other substance use. Additionally, few targeted effective treatments for this group exist. To address this, the feasibility of an intensive tobacco treatment incorporating contingency management (CM) that featured non-face-to-face delivery was examined.

Methods

A single-arm pre-post design feasibility trial was conducted in three antenatal services that support women who use substances in metropolitan Australia. Participants were over the age of 15, had <33-week gestation, and smoked tobacco daily. They received financial incentives for daily carbon monoxide-verified smoking abstinence or reduction through an internet-based CM programme, nicotine replacement therapy (NRT) posted to women and partners or household members who smoked and telephone-delivered behavioral counseling from study enrolment to birth.

Results

Of the 101 referrals, 46 women (46%) consented. The mean (SD) age was 31(±6) years, and the gestation period was 22(±6) weeks. Nineteen (41%) of those enrolled were retained for 12-week postpartum. Of 46 women, 32 (70%) utilized CM; 32 (70%) used NRT for ≥2 weeks; 23 (50%) attended ≥1 counseling session; and 15 (22%) received NRT for partners/household members. Fifteen (33%) were verified abstinent from tobacco at delivery after a median (IQR) period of abstinence of 65(36-128) days. All non-smokers at birth utilized NRT and financial incentives, and 9/15 (60%) utilized counseling. Four (9%) were abstinent at 12-week postpartum. Median cigarettes smoked/day reduced from baseline to delivery (10(6-20) to 1(0-6) p =< 0.001). Women who quit smoking had more education (72% vs. 33% p =< 0.02), completed more CO samples (median (IQR) 101(59-157) vs. 2(0-20) p =< 0.001), and received more incentives (median (IQR) $909($225-$1980) vs. $34($3-$64) p =< 0.001). Intervention acceptability was rated favorably by participants (9 items rated 0-10 with scores >5 considered favorable).

Discussion

This study demonstrated the feasibility and acceptability of a consumer-informed, non-face-to-face intensive tobacco treatment, highlighting the potential of remotely delivered technology-based CM to reduce the health impact of tobacco smoking in high-priority populations. The intervention demonstrates scale-up potential. Future studies should extend treatment into the postpartum period, utilizing new technologies to enhance CM delivery and improve counseling provision and partner support.

Clinical trial registration

https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374196, ACTRN1261800056224.

Sexual Risk among Pregnant Women at Risk of HIV Infection in Cape Town, South Africa: What Does Alcohol Have to Do with It?

This study examines baseline associations between alcohol use and HIV sexual risk among a cohort of HIV-uninfected pregnant women (n = 1201) residing in a high HIV burdened community in Cape Town, South Africa. Alcohol use was measured using a modified version of the Alcohol Use Disorder Identification Test (AUDIT). HIV sexual risk was measured through a composite variable of four risk factors: diagnosis with a STI, self-report of > 1 recent sex partners, partner HIV serostatus (unknown or HIV+) and condomless sex at last sex. Any past year alcohol use prior to pregnancy was reported by half of participants (50%); 6.0% reported alcohol use during pregnancy. Alcohol use prior to pregnancy was associated with increased odds of being at high risk of HIV (aOR = 1.33, 95% CI 1.05-1.68, for 2 risks and aOR = 1.47, 95% CI 0.95-2.27 for 3 risks). In addition to reducing alcohol use, several other strategies to address HIV sexual risk were identified. Evidence-based interventions to address alcohol use and other HIV sexual risk behaviors during pregnancy in South Africa are desperately needed. Qualitative work exploring individual and community level drivers of alcohol use among pregnant and breastfeeding women in this setting could support development of a culturally tailored intervention to address these issues in this population.

Licit and illicit drug use across trimesters in pregnant women endorsing past-year substance use: Results from National Survey on Drug Use and Health (2009-2019)

PURPOSE

Given the health consequences, perinatal substance use is a significant public health concern, especially as substance use rates increase among women; ongoing data regarding the rates of substance use across trimesters of pregnancy is needed.

METHODS

The present study utilized cross-sectional population-based data from the National Survey of Drug Use and Health (NSDUH) between 2009 and 2019. We aimed to explore both licit and illicit substance use assessed within each trimester among women endorsing past-year substance use. The NSDUH sample included 8,530 pregnant women.

RESULTS

Perinatal substance use was less prevalent among women in later trimesters; however, past-month substance use was observed for all substances across trimesters. The prevalence of past-month licit substance use among pregnant women ranged from 5.77 to 22.50% and past-month illicit substance use ranged from 4.67 to 14.81%. In the second trimester, lower odds of past-month substance use were observed across tobacco, alcohol, and marijuana (odds ratios [ORs] ranging from 0.29 to 0.47), when compared to the first trimester. A similar lower rate of past-month substance use was observed in the third trimester compared to the first trimester, across tobacco, alcohol, and marijuana use, as well as cocaine, prescription pain medication, and tranquilizer use (ORs ranging from 0.02 to 0.42). The likelihood of polysubstance use was lower among women in the second and third trimesters compared to the first trimester (ORs ranging from 0.09 to 0.46).

CONCLUSION

Findings indicate that a minority of women continue to use substances across all trimesters. This is especially true among women using licit substances and marijuana. These results highlight the need for improved interventions and improved access to treatment for these women.

Aspectos psicossociais da gestação de alto risco

A gestação de alto risco é caracterizada por ser um momento em que a vida ou a saúde da mãe e/ou do feto e/ou do recém-nascido está submetida a maiores chances de morte que a média da população considerada. O estudo objetivou apresentar dados sobre o perfil de gestantes de alto risco e identificar os aspectos psicossociais ligados à gravidez. A amostra foi composta por 74 mulheres grávidas em um hospital no município de Juiz de Fora, MG. Elas responderam ao PHQ-2, a EPSS, ao IDATE, ao ASSIST e a um questionário sociodemográfico e clínico. Foi possível observar a prevalência de sintomas de depressão, ansiedade, baixo suporte social e uso de substâncias na população avaliada. As análises confirmaram correlações entre características sociodemográficas, clínicas e aspetos psicossociais. Os resultados demonstram a relevância de se conhecer o perfil dessas mulheres para a melhora na elaboração de estratégias de suporte direcionadas ao enfrentamento de possíveis fatores que possam interferir no bom andamento da gestação.

Impact of prenatal exposure characterization on early risk detection: Methodologic insights for the HEALthy Brain and Child Development (HBCD) study

BACKGROUND

A major challenge in prenatal drug exposure research concerns the balance of measurement quality with sample sizes necessary to address confounders. To inform the selection of optimal exposure measures for the HEALthy Brain and Child Development (HBCD) Study, we employed integrated analysis to determine how different methods used to characterize prenatal tobacco exposure influence the detection of exposure-related risk, as reflected in normal variations in birth weight.

METHODS

Participants were N = 2323 mother-infant dyads derived from 7 independent developmental cohorts harmonized on measures of exposure, outcome (birthweight), and covariates. We compared estimates of PTE-related effects on birthweight derived from linear regression models when PTE was categorized dichotomously based on any fetal exposure (30% exposed; 69% not exposed); versus categorically, based on common patterns of maternal smoking during pregnancy (never smoked 69%; quit smoking 16%; smoked intermittently 2%; smoked persistently 13%). We secondarily explored sex differences in PTE-birthweight associations across these categorization methods.

RESULTS

When PTE was categorized dichotomously, exposure was associated with a - 125-g difference in birthweight (95% C.I. -173.7 - -76.6, p < .0001). When PTE was characterized categorically based on maternal smoking patterns, however, exposure was associated with either no difference in birthweight if mothers quit smoking by the end of the first trimester (B = -30.6, 95% C.I. -88.7-27.4, p = .30); or a - 221.8 g difference in birthweight if mothers did not [95% C.I. (-161.7 to -282.0); p < .001]. Qualitative sex differences were also detected though PTE x sex interactions did not reach statistical significance. Maternal smoking cessation during pregnancy was associated with a 239.3 g increase in birthweight for male infants, and a 114.0 g increase in birthweight for females infants (p = .07).

CONCLUSIONS

Categorization of PTE based on patterns of maternal smoking rather than the presence or absence of exposure alone revealed striking nuances in estimates of exposure-related risk. The described method that captures both between-individual and within-individual variability in prenatal drug exposure is optimal and recommended for future developmental investigations such as the HBCD Study.

Psychopathology Symptoms are Associated with Prenatal Health Practices in Pregnant Women with Heavy Smoking Levels

PURPOSE

Smoking during pregnancy may be linked to other problematic prenatal health behaviors in women. We examined interrelationships among prenatal smoking, prenatal health behaviors and mental health. The objective of this study was to examine factors that may contribute to variations in prenatal health practices among women who smoke during pregnancy.

METHODS

Birth mothers from an adoption study (N = 912) were interviewed about prenatal smoking, health behaviors, and mental health symptoms at 5 months postpartum.

RESULTS

One-quarter of participants (N = 222) reported smoking 6 or more cigarettes daily for at least 1 trimester. For mothers who smoked more than 6 cigarettes daily, higher levels of antisocial behaviors (β =  - .14, p = .03) and depressive symptoms (β =  - .17, p = .03) were associated with less frequent prenatal folate use; antisocial behaviors and depressive symptoms were not associated for prenatal folate use among women who did not smoke more than 6 cigarettes daily. For mothers who did not smoke more than 6 cigarettes daily, more depressive symptoms were associated with fewer prenatal care visits (β = .12, p = .01). Antisocial behaviors and anxiety symptoms were not associated with prenatal care visits in either group of mothers. CONCLUSIONS FOR PRACTICE: Maternal antisocial behaviors and depressive symptoms during pregnancy may be markers for poorer adherence to recommendations for folate supplementation among women who smoke 6 or more cigarettes daily during pregnancy, independent of adequacy of prenatal care.

Are personality traits associated with smoking and alcohol use prior to and during pregnancy?

Cigarette smoking and alcohol consumption during pregnancy can have detrimental effects on the developing fetus, including fetal alcohol syndrome and low birth weight. Surprisingly little is known about the association of personality traits with smoking and alcohol consumption in the specific subpopulation of pregnant women. This study analyzed data from a geographically diverse sample of 603 pregnant women, aged 18 years and older, who provided information regarding their smoking and drinking habits before and during pregnancy. We compared women who consumed alcohol or smoked cigarettes before pregnancy with women who quit or continued smoking or drinking during pregnancy. Associations between personality and maladaptive behaviors prior to and during pregnancy were modeled using logistic regression. The study revealed that women who scored high on openness to experience were significantly more likely to continue alcohol consumption during pregnancy (OR = 1.07, 95% CI 1.01, 1.14, p = .02). This association was maintained after adjusting for potential confounds. This study demonstrated a significant relationship between personality traits and women's likelihood of continued alcohol consumption prior to and during pregnancy. Understanding personality-based determinants of health-detrimental behavior is important in order to design interventions that aim at decreasing rates of maladaptive health behaviors among pregnant women.

The Early Growth and Development Study: A Dual-Family Adoption Study from Birth Through Adolescence

The Early Growth and Development Study (EGDS) is a prospective adoption study of birth parents, adoptive parents and adopted children (n = 561 adoptees). The original sample has been expanded to include siblings of the EGDS adoptees who were reared by the birth mother and assessed beginning at age 7 years (n = 217 biological children), and additional siblings in both the birth and adoptive family homes, recruited when the adoptees were 8-15 years old (n = 823). The overall study aims are to examine how family, peer and contextual processes affect child and adolescent adjustment, and to examine their interplay (mediation, moderation) with genetic influences. Adoptive and birth parents were originally recruited through adoption agencies located throughout the USA following the birth of a child. Assessments are ongoing and occurred in 9 month's intervals until the adoptees turned 3 years of age, and in 1 to 2 year intervals thereafter through age 15. Data collection includes the following primary constructs: child temperament, behavior problems, mental health, peer relations, executive functioning, school performance and health; birth and adoptive parent personality characteristics, mental health, health, context, substance use, parenting and marital relations; and the prenatal environment. Findings highlight the power of the adoption design to detect environmental influences on child development and provide evidence of complex interactions and correlations between genetic, prenatal environmental and postnatal environmental influences on a range of child outcomes. The study sample, procedures and an overview of findings are summarized and ongoing assessment activities are described.

Pregnancy-Associated Death in Utah: Contribution of Drug-Induced Deaths

OBJECTIVE

Drug-induced deaths, defined as intentional or unintentional consumption of illicit substances or diverted medications leading to death, are the leading cause of death for reproductive-age women in the United States. Our objective was to describe pregnancy-associated deaths attributed to drug-induced causes to identify opportunities for intervention.

METHODS

Using the Utah Perinatal Morality Review Committee database, we performed a retrospective cohort study of all pregnancy-associated deaths-death of a woman during pregnancy or within 1 year from the end of pregnancy-from 2005 to 2014. We performed a detailed descriptive analysis of women with drug-induced deaths. We compared characteristics of women with drug-induced and other pregnancy-associated deaths.

RESULTS

From 2005 to 2014, 136 pregnancy-associated deaths were identified. Drug-induced death was the leading cause of pregnancy-associated death (n=35, 26%) and 89% occurred in the postpartum period. More specifically, those with a drug-induced death were more likely to die in the late postpartum period, defined as death occurring within 43 days to 1 year of the end of the pregnancy, (n=28/35, 80%) compared with women whose deaths were from other pregnancy-associated causes (n=34/101, 34%) (P<.001). The majority of drug-induced deaths were attributed to opioids (n=27/35, 77%), prescription opioids (n=21/35, 60%), and polysubstance use (n=29/35, 83%). From 2005 to 2014, the pregnancy-associated mortality ratio increased 76%, from 23.3 in 2005 to 41.0 in 2014. During this same time period, the drug-induced pregnancy-associated mortality ratio increased 200%, from 3.9 in 2005 to 11.7 in 2014.

CONCLUSION

Drug-induced death is the leading cause of pregnancy-associated death in Utah and occurs primarily in the late postpartum period. Interventional studies focused on identifying and treating women at risk of drug-induced death are urgently needed.

Obstetric patients' perspectives on functional magnetic neuroimaging research in pregnant women

Magnetic resonance neuroimaging (MRI) studies of healthy pregnant women could identify key mechanisms of spontaneous health behavior changes observed in expectant mothers as novel intervention targets, but are currently unprecedented. As balancing potential benefits of research with unknown risks, including participant perceptions of risk, is foundational to ethical conduct, we surveyed a convenience obstetric sample to understand pregnant women's perspectives on this issue. Respondents were 76 pregnant women (modal age of 30-39 years; 64% multiparous) presenting for obstetric care from April to June 2016 at privately and publicly funded clinics at an urban academic medical center in the Midwestern USA. Following a written description about functional magnetic resonance neuroimaging (fMRI) and its known and unknown risks, women were queried on their willingness to participate in a hypothetical study involving fMRI during pregnancy, and specific concerns about doing so, if hesitant or unwilling. Willingness to participate was "yes" (28.4%, n = 21), "maybe" (28.4%, n = 21), and "no" (43.2%, n = 32). Among those responding "maybe" or "no" (n = 53, 73.6%), 11 women (20.7%) articulated concern about the fetus. Other concerns expressed were time commitment (n = 11, 20.7%) and discomfort being in an MRI machine (n = 4; 7.5%). Pregnant women may be open to participating in research involving MRI provided concerns about fetal health, time, and personal comfort are addressed.

The Potential Utility for Massage Therapy During Pregnancy to Decrease Stress and Tobacco Use

BACKGROUND

A significant number of women continue to smoke tobacco during pregnancy despite the increased risk of complications to fetal and infant development. Therefore, effective interventions are needed to assist pregnant women with the process of tobacco cessation. Traditional counseling programs have demonstrated some success; however, novel approaches that target stress as a mechanism in the maintenance of addiction would be valuable.

OBJECTIVE

To examine the role of stress in addiction and the utility of massage therapy to decrease stress during pregnancy.

CONCLUSION

Preliminary evidence suggests massage therapy may be beneficial to decreasing tobacco use, and research in pregnant populations is needed.

Additive drug-specific and sex-specific risks associated with co-use of marijuana and tobacco during pregnancy: Evidence from 3 recent developmental cohorts (2003-2015)

BACKGROUND

Methodologic challenges related to the concomitant use (co-use) of substances and changes in policy and potency of marijuana contribute to ongoing uncertainty about risks to fetal neurodevelopment associated with prenatal marijuana use. In this study, we examined two biomarkers of fetal neurodevelopmental risk-birth weight and length of gestation-associated with prenatal marijuana use, independent of tobacco (TOB), alcohol (ALC), other drug use (OTH), and socioeconomic risk (SES), in a pooled sample (N = 1191) derived from 3 recent developmental cohorts (2003-2015) with state-of-the-art substance use measures. We examined differential associations by infant sex, and multiplicative effects associated with co-use of MJ and TOB.

METHODS

Participants were mother-infant dyads with complete data on all study variables derived from Growing Up Healthy (n = 251), Behavior and Mood in Babies and Mothers (Cohorts 1 and 2; n = 315), and the Early Growth and Development Study (N = 625). We estimated direct effects on birth weight and length of gestation associated with MJ, TOB, and co-use (MJ x TOB), using linear regression analysis in the full sample, and in male (n = 654) and female (n = 537) infants, separately.

RESULTS

Mean birth weight and length of gestation were 3277 g (SD = 543) and 37.8 weeks (SD = 2.0), respectively. Rates of prenatal use were as follows: any use, n = 748 (62.8%); MJ use, n = 273 (22.9%); TOB use, n = 608 (51.0%); co-use of MJ and TOB, n = 230 (19.3%); ALC use, n = 464 (39.0%); and OTH use n = 115 (9.7%.) For all infants, unique effects on birth weight were observed for any MJ use [B(SE) = -84.367(38.271), 95% C.I. -159.453 to -9.281, p = .028], any TOB use [B(SE) = -0.99.416(34.418), 95% C.I. -166.942 to -31.889, p = .004], and each cigarette/day in mean TOB use [B(SE) = -12.233(3.427), 95% C.I. -18.995 to -5.510, p < .001]. Additional effects of co-use on birth weight, beyond these drug-specific effects, were not supported. In analyses stratified by sex, while TOB use was associated with lower birth weight in both sexes, MJ use during pregnancy was associated with lower birth weight of male infants [B(SE) = -153.1 (54.20); 95% C.I. -259.5 to -46.7, p = .005], but not female infants [B(SE) = 8.3(53.1), 95% C.I. -96.024 to 112.551, p = .876]. TOB, MJ, and their co-use were not associated with length of gestation.

CONCLUSIONS

In this sample, intrauterine co-exposure to MJ and TOB was associated with an estimated 18% reduction in birth weight not attributable to earlier delivery, exposure to ALC or OTH drugs, nor to maternal SES. We found evidence for greater susceptibility of male fetuses to any prenatal MJ exposure. Examination of dose-dependence in relationships found in this study, using continuous measures of exposure, is an important next step. Finally, we underscore the need to consider (a) the potential moderating influence of fetal sex on exposure-related neurodevelopmental risks; and (b) the importance of quantifying expressions of risk through subtle alterations, rather than dichotomous outcomes.

Positive parenting behaviors in women who spontaneously quit smoking during pregnancy: Clues to putative targets for preventive interventions

BACKGROUND

While the majority of pregnant smokers do not respond to intervention, little is known about how a subset of pregnant smokers known as spontaneous quitters achieve sustained biologically-confirmed abstinence through delivery in the absence of intervention. We explore a developmental framework to address this question by viewing spontaneous quitting as an adaptive parenting behavior, facilitated by abilities necessary for sensitive parenting, or responsiveness. Utilizing existing data, we examined responsiveness from parenting assessments in women who exhibited a variety of smoking patterns during pregnancy, including spontaneous quitting.

METHODS

Participants were N = 305 pregnant women assessed for smoking prospectively and biochemically at 16 weeks, 28 weeks, delivery, and 4 weeks postpartum, then reassessed with their children 5 years later with directly-observed home- and lab-based measures of parenting. We used linear regression analysis to compare spontaneous quitters with women who exhibited other prenatal smoking patterns on parenting responsiveness, controlling for potential confounders.

RESULTS

In home-based observations, spontaneous quitters (n = 22) exhibited greater responsiveness with their children relative to intermittent pregnancy smokers [n = 70; β = 0.258, p = .022]; persistent pregnancy smokers [n = 66; β = 0.228, p = .040]; former smokers (quit before pregnancy) [n = 78; β = 266, p = .028]; and never smokers [n = 69; β = 0.312, p = .009]. Hypothesized differences were not observed in lab-based and self-report measures.

CONCLUSIONS

Putative protective characteristics in spontaneous quitters were captured in mother-child interactions at home, but not in lab-based and maternal report measures of responsiveness. Specification of these characteristics using prospective designs that oversample for spontaneous quitters is recommended to enable translation to preventive interventions.

Changes in Alcohol, Tobacco, and Other Drug Use Over Five Years After Receiving Versus Being Denied a Pregnancy Termination

OBJECTIVE

Research on effects of pregnancy termination on women's alcohol, tobacco, and other drug (ATOD) use suffers from methodological and conceptual problems. Improving on prior methodologies, this study examines changes in ATOD use over 5 years among women seeking terminations.

METHOD

Data are from the Turnaway Study, a longitudinal study of 956 women seeking terminations at 30 U.S. facilities. Participants presented just below a facility's gestational limit and received terminations (Near-Limits) or just beyond the limit and were denied terminations (Turnaways). Using mixed-effects logistic regression, we assessed differences in ATOD use over 5 years among Near-Limits and Turnaways.

RESULTS

There were no differences in ATOD use before pregnancy recognition; 1 week after termination seeking, Turnaways had lower odds than Near-Limits of any and heavy episodic alcohol use (p < .001), but not alcohol problem symptoms, tobacco use, or other drug use. Although both groups increased in any alcohol use over time, Turnaways increased more rapidly. Neither group increased any other ATOD measures over time. Turnaways' lower odds of heavy episodic alcohol use at 1 week after termination seeking were maintained throughout the subsequent 5 years. There was no differential change in problem alcohol use or in tobacco or other drug use over time, yet fewer Turnaways than Near-Limits reported problem alcohol symptoms 6 months through 3.5 years.

CONCLUSIONS

There is no indication that terminating a pregnancy led women to increase heavy episodic or problem alcohol use or to increase tobacco or other drug use. Women denied terminations had temporary or sustained reductions in all alcohol measures, but not tobacco or other drugs, suggesting that relationships between pregnancy/parenting and ATOD differ across substances.

Specification of Change Mechanisms in Pregnant Smokers for Malleable Target Identification: A Novel Approach to a Tenacious Public Health Problem

Maternal smoking during pregnancy (MSDP) continues to be a leading modifiable risk factor for perinatal complications and a range of neurodevelopmental and cardio-metabolic outcomes across the lifespan. Despite 40 years of intervention research less than one in five pregnant smokers who receive an intervention quit by delivery. Within this context, recognition of pregnancy is commonly associated with abrupt suspension or reduction of smoking in the absence of intervention, yet has not been investigated as a volitional target. The goal of this article is to provide the empirical foundation for a novel direction of research aimed at identifying malleable targets for intervention through the specification of behavior change mechanisms specific to pregnant women. To do so, we: (1) summarize progress on MSDP in the United States generated from conventional empirical approaches to health behavior change; (2) discuss the phenomenon of spontaneous change in the absence of intervention among pregnant smokers to illustrate the need for mechanistic specification of behavior change motivated by concern for fetal well-being; (3) summarize component processes in neurobiological models of parental and non-parental social behaviors as a conceptual framework for understanding change mechanisms during pregnancy; (4) discuss the evidence for the malleability of these processes to support their translational relevance for preventive interventions; and (5) propose a roadmap for validating the proposed change mechanism using an experimental medicine approach. A greater understanding of social and interpersonal processes that facilitate health behavior change among expectant mothers and how these processes differ interindividually could yield novel volitional targets for prenatal interventions. More broadly, explicating other-oriented mechanisms of behavior change during pregnancy could serve as a paradigm for understanding how social and interpersonal processes positively influence health behaviors across the lifespan.

The Perinatal Risk Index: Early Risks Experienced by Domestic Adoptees in the United States

We aimed to assess comprehensively the prevalence of perinatal risks experienced by a potentially high-risk yet understudied population of children domestically adopted in the United States. Data are from participant report and medical records from mothers (n = 580) who completed a domestic adoption placement with nonrelatives at or near birth (Mean placement age = 7 days). We describe a comprehensive measure of perinatal risks, including divergences from previous assessment tools and the incorporation of multiple reporters, and report the prevalence of various types of perinatal risks. The prevalence of each specific risk factor was generally low, although several risks were more prevalent in this sample than estimates from nationally representative publicly available data. Nearly the entire sample (99%) experienced some type of risk exposure. Birth mothers who placed their children for adoption domestically in the US experience higher levels of perinatal risks than the national average, but not for all specific types of risk. Thus, the developmental trajectories of children adopted domestically may systematically differ from the general population to the extent that these specific perinatal risks impact development.

Maternal personality traits associated with patterns of prenatal smoking and exposure: Implications for etiologic and prevention research

BACKGROUND

Little is known about the characteristics of women who smoke during pregnancy beyond demographic factors. We examined the relationship between novelty seeking, harm avoidance, and self-directedness and (a) abstinence from smoking during pregnancy and (b) average daily cigarette consumption during pregnancy.

METHODS

Participants were 826 birth mothers who made adoption placements in the Early Growth and Development Study and completed the Temperament and Character Inventory - Short Form, and interview-based smoking assessments 3-6 months postpartum. Never smokers (n=199), pregnancy abstainers (n=277), pregnancy light smokers (n=184), and pregnancy heavy smokers (n=166) were compared on personality dimensions and smoking-related processes. Using regression analyses we examined relationships between personality and (a) abstinence versus smoking during pregnancy; and (b) average daily cigarette consumption among lifetime smokers, controlling for nicotine dependence, birth father substance dependence, maternal antisocial behavior, and depressive symptoms during pregnancy.

RESULTS

Smokers with higher self-directedness and lower harm avoidance were more likely to abstain during pregnancy [O.R. 1.380; 95% C.I. (1.065-1.787); B(SE)=.322(.132); p=.015] and [O.R. .713; 95% C.I. (.543-.935); B(SE)=-.339(.138); p=.014], respectively. Novelty seeking differentiated never smokers from lifetime smokers (t=-3.487; p=.001), but was not significant in multivariate models. Lifetime smokers who abstained during pregnancy reported fewer depressive symptoms relative to never smokers.

CONCLUSIONS

Personality dimensions associated with abstinence from smoking and cigarettes per day during pregnancy may be important to consider in etiologic and intervention research.

History of childhood sexual abuse and risk of prenatal and postpartum depression or depressive symptoms: an epidemiologic review

The objective of this review is to summarize the literature (and to the extent possible, report the magnitude and direction of the association) concerning history of childhood sexual abuse (CSA) and depression or depressive symptoms among pregnant and postpartum women. Publications were identified through literature searches of seven databases (PubMed, EMBASE, PyscINFO, CINAHL, Web of Science, BIOSIS, and Science Direct) using keywords including "child abuse," "depression," "pregnancy," "prenatal," "pregnancy," and "postpartum." The literature search yielded seven eligible studies on the prenatal period and another seven studies on the postpartum period. All but one prenatal study observed statistically significant positive associations of CSA with depression or depressive symptoms during pregnancy. Findings on the association of CSA with postpartum depression or depressive symptoms were inconsistent; pooled unadjusted and adjusted odds ratios were 1.82 (95 % confidence interval (CI) 0.92, 3.60) and 1.20 (95 % CI 0.81, 1.76). In sum, findings suggest a positive association of history of CSA with depression and depressive symptoms in the prenatal period. Findings on the postpartum period were inconsistent. Clinical and public health implications of evidence from the available literature are discussed, as are desirable study design characteristics of future research.

Receiving Versus Being Denied a Pregnancy Termination and Subsequent Alcohol Use: A Longitudinal Study

AIM

Research finds women who terminate pregnancies are at risk of subsequent problematic alcohol use, but methodological and conceptual problems are common. This study examines the relationship between receiving versus being denied termination and subsequent alcohol use.

METHODS

Data are from a prospective, longitudinal study of US women seeking pregnancy terminations. Participants presented just before a facility's gestational limit and received terminations (Near Limits, n = 452) or just beyond the limit and were denied terminations (Turnaways, n = 231).

RESULTS

Groups did not differ in alcohol use before pregnancy recognition. One week after termination-seeking (Turnaways still pregnant, Near Limits not), Turnaways had lower odds of any and binge alcohol use, but did not differ on 1+ problem symptoms. Over 2.5 years, both Near Limits and Turnaways increased any and binge alcohol use, with Turnaways increasing more rapidly. The groups did not converge again on any or binge use. For Near Limits, any alcohol use surpassed the pre-pregnancy recognition level, but binge use did not. Changes in problem symptoms over time were not evident for either group.

CONCLUSION

While women who had a termination were more likely to report any and binge alcohol use than women who had a child, this difference was due to a reduction in consumption among women having the child rather than an increase in consumption among women having a termination. Thus, assertions that having a termination leads women to increase alcohol use to cope with having had a termination are not supported.

Perinatal substance use: a prospective evaluation of abstinence and relapse

BACKGROUND

Substance use decreases in pregnancy but little prospective data are available on the rates of abstinence and relapse for specific substances. This study compared rates of abstinence in pregnancy and relapse postpartum for nicotine cigarettes, alcohol, marijuana, and cocaine.

METHODS

Data from 152 women drawn from a randomized controlled trial comparing psychological treatments for substance use in pregnancy were analyzed. Self-reports of substance use and urine for toxicology testing throughout pregnancy and 3-months, 12-months and 24-months post-delivery were collected. Multivariate Cox models were used to compare rates of abstinence and relapse across substances.

RESULTS

In pregnancy, 83% of all women achieved abstinence to at least one substance. The mean (SE) days to abstinence was 145.81 (9.17), 132.01 (6.17), 151.52 (6.24), and 148.91 (7.68) for cigarettes, alcohol, marijuana and cocaine, respectively. Participants were more likely to achieve abstinence from alcohol (HR 7.24; 95% CI 4.47-11.72), marijuana (HR 4.06; 95% CI 1.87-6.22), and cocaine (HR 3.41; 95% CI 2.53-6.51), than cigarettes. Postpartum, 80% of women abstinent in the last month of pregnancy relapsed to at least one substance. The mean days to relapse was 109.67 (26.34), 127.73 (21.29), 138.35 (25.46), and 287.55 (95.85) for cigarettes, alcohol, marijuana and cocaine, respectively. Relapse to cocaine was only 34% (HR 0.34; 95% CI 0.15-0.77) that of cigarettes.

CONCLUSIONS

Pregnancy-related abstinence rates were high for all substances except cigarettes. Postpartum relapse was common, with cocaine using women being less likely to relapse after attaining abstinence compared to women using cigarettes, alcohol or marijuana.

Preliminary evidence for the interaction of the oxytocin receptor gene (oxtr) and face processing in differentiating prenatal smoking patterns

Prenatal smoking cessation has been described as an empathic action "for the baby," but this has not been empirically demonstrated. We capitalized on a genetically-characterized extant dataset with outstanding measurement of prenatal smoking patterns and maternal face processing data (as an indicator of empathy) to test this hypothesis, and explore how empathy and smoking patterns may be moderated by a genetic substrate of empathy, the oxytocin receptor gene (OXTR). Participants were 143 Caucasian women from the East Boston family study with repeated prospective reports of smoking level, adjusted based on repeated cotinine bioassays. Salivary DNA and face processing (Diagnostic Analysis of Nonverbal Accuracy-2) were assessed 14 years later at an adolescent follow-up of offspring. Two-thirds of participants reported smoking prior to pregnancy recognition. Of these, 21% quit during pregnancy; 56% reduced smoking, and 22% smoked persistently at the same level. A significant interaction between face processing and OXTR variants previously associated with increased sensitivity to social context, rs53576GG and rs2254298A, was found (β = -.181; p = .015); greater ability to identify distress in others was associated with lower levels of smoking during pregnancy for rs53576(GG)/rs2254298(A) individuals (p = .013), but not for other genotypes (p = .892). Testing this "empathy hypothesis of prenatal smoking cessation" in larger studies designed to examine this question can elucidate whether interventions to enhance empathy can improve prenatal smoking cessation rates.

Perceived neighborhood safety, recovery capital, and successful outcomes among mothers 10 years after substance abuse treatment

This study examines perceived neighborhood characteristics associated with successful outcome among mothers 10 years after being treated for substance use disorders. Data were obtained from 713 mothers first studied at admission to drug treatment in California in 2000-2002 and followed up in 2009-2011. At follow-up, 53.6% of mothers had a successful outcome (i.e., no use of illicit drugs and not involved with the criminal justice system). Perceived neighborhood safety almost doubled the odds of success. Perceived neighborhood safety interacted with social involvement, decreasing the odds of success among mothers who reported more versus less neighborhood social involvement. Perceived neighborhood climate is associated with long-term outcomes among mothers with substance use disorders independent of individual-level characteristics, underscoring the need for further efforts to understand its interaction with recovery capital in ways that promote and impede health.

Explaining long-term outcomes among drug dependent mothers treated in women-only versus mixed-gender programs

Specialized substance abuse treatment for parenting women is thought to improve outcomes, but long-term impacts and how they occur are poorly understood. Utilizing a sample of 789 California mothers followed for 10 years after admission to women-only (WO) or mixed-gender (MG) drug treatment, we examine the relationship between WO treatment and outcomes and whether it is mediated by post-treatment exposures to criminal justice and health services systems. At follow-up, 48% of mothers had a successful outcome (i.e., no use of illicit drugs, not involved with the criminal justice system, alive). Controlling for patient characteristics, WO (vs. MG) treatment increased the odds of successful outcome by 44%. In the structural equation model WO treatment was associated with fewer post-treatment arrests, which was associated with better outcomes. Women-only substance abuse treatment has long-term benefits for drug-dependent mothers, a relationship that may be partially explained by post-treatment exposure to the criminal justice system. Findings underscore additional leverage points for relapse prevention and recovery-supportive efforts for drug-dependent mothers.

The Early Growth and Development Study: a prospective adoption study from birth through middle childhood

The Early Growth and Development Study is a prospective adoption study of birth parents, adoptive parents, and adopted children recruited in two cohorts (N = 561 triads). The primary study aims are to examine how family, peer, and contextual processes affect children's adjustment, and to examine their interplay (mediation, moderation) with genetic influences. Participants were recruited through adoption agencies located throughout the United States following the birth of a child. Assessments are ongoing, in 9-month intervals until the child reaches 3 years of age and in 1-year intervals thereafter through age 9. Data collection includes the following primary constructs: child temperament, social behavior, school performance, mental health, and health; birth and adoptive parent personality characteristics, mental health, competence, stress, health, context, substance use, parenting, and marital relations; and pregnancy use of drugs and maternal stress during pregnancy. DNA and salivary cortisol samples have also been collected. Analyses have indicated evidence for genotype-environment interactions during early childhood. Study procedures, sample representativeness (including tests of potential confounds in the adoption design), and an overview of findings to date are summarized, and future plans are described.

Intergenerational transmission of risk for social inhibition: the interplay between parental responsiveness and genetic influences

To better understand mechanisms underlying the intergenerational transmission of social anxiety, we used a prospective adoption design to examine the roles of genetic influences (inferred from birth mothers' social phobia) and rearing environment (adoptive mothers' and fathers' responsiveness) on the development of socially inhibited, anxious behaviors in children between 18 and 27 months of age. The sample consisted of 275 adoption-linked families, each including an adopted child, adoptive parents, and a birth mother. Results indicated that children whose birth mothers met criteria for the diagnosis of social phobia showed elevated levels of observed behavioral inhibition in a social situation at 27 months of age if their adoptive mothers provided less emotionally and verbally responsive rearing environments at 18 months of age. Conversely, in the context of higher levels of maternal responsiveness, children of birth mothers with a history of social phobia did not show elevated levels of behavioral inhibition. These findings on maternal responsiveness were replicated in a model predicting parent reports of child social anxiety. The findings are discussed in terms of gene-environment interactions in the intergenerational transmission of social anxiety.

Maternal self concept as a provider and cessation of substance use during pregnancy

OBJECTIVE

Maternal substance use during pregnancy is a common modifiable risk factor for poor birth outcomes, and is associated with long term psychological risks to offspring. As self concept is known to affect substance use behaviors in non-pregnant women, we hypothesized that self concept as a provider may be particularly salient to cessation of use during pregnancy. To isolate psychological processes specific to pregnancy from those associated with the transition to parenthood, we examined birth mothers who made adoption placements participating in the Early Growth and Development Study.

METHODS

We obtained lifetime and pregnancy substance use history and psychological measures at 3 to 4months postpartum from 693 women recruited from the Northwest, Southwest, and Mid-Atlantic regions of the United States. Life history calendar and computer-assisted personal interviewing methods were used to minimize reporting bias. Using logistic regression, we assessed the association of self concept as an adequate provider with cessation of substance use during pregnancy, controlling for sociodemographic variables, depressive symptoms experienced during pregnancy, past year antisocial behaviors, family history of substance abuse, timing of pregnancy recognition, timing of initiation of prenatal care, and emotional adjustment to the adoption decision.

RESULTS

More positive self-concept as an adequate provider was independently associated with cessation of substance use and earlier initiation of prenatal care during pregnancy [OR=1.223; 95% C.I. (1.005-1.489); B(SE)=.201(.100)]. Familial substance abuse, depressive symptoms, and antisocial behaviors during pregnancy, were also independent predictors, and more strongly associated with cessation [OR=.531; 95% C.I. (.375-.751); B(SE)=-.634 (.178)], [OR. 940; 95% C.I. (.906-.975); B(SE)=-.062 (.019)], [OR=.961; 95% C.I. (.927-.996); B(SE)=-.040 (.018)].

CONCLUSIONS

Enhancing maternal identity as a provider for the fetus during pregnancy, along with treatment of depression, may improve motivation to stop substance use.

Fetal alcohol exposure leads to abnormal olfactory bulb development and impaired odor discrimination in adult mice

Background

Children whose mothers consumed alcohol during pregnancy exhibit widespread brain abnormalities and a complex array of behavioral disturbances. Here, we used a mouse model of fetal alcohol exposure to investigate relationships between brain abnormalities and specific behavioral alterations during adulthood.

Results

Mice drank a 10% ethanol solution throughout pregnancy. When fetal alcohol-exposed offspring reached adulthood, we used high resolution MRI to conduct a brain-wide screen for structural changes and found that the largest reduction in volume occurred in the olfactory bulbs. Next, we tested adult mice in an associative olfactory task and found that fetal alcohol exposure impaired discrimination between similar odors but left odor memory intact. Finally, we investigated olfactory bulb neurogenesis as a potential mechanism by performing an in vitro neurosphere assay, in vivo labeling of new cells using BrdU, and in vivo labeling of new cells using a transgenic reporter system. We found that fetal alcohol exposure decreased the number of neural precursor cells in the subependymal zone and the number of new cells in the olfactory bulbs during the first few postnatal weeks.

Conclusions

Using a combination of techniques, including structural brain imaging, in vitro and in vivo cell detection methods, and behavioral testing, we found that fetal alcohol exposure results in smaller olfactory bulbs and impairments in odor discrimination that persist into adulthood. Furthermore, we found that these abnormalities in olfactory bulb structure and function may arise from deficits in the generation of new olfactory bulb neurons during early postnatal development.