- Women of childbearing years represent about 1 out of every 4 individuals globally.
- The total population of women aged 15-44 in the UK in 2014 was 22.5 million with a total of 695,000 births (Office for National Statistics, 2014).
- In 2015, 1.6 billion women aged 15-44 years accounted for about 45% of the total female population (US Census Bureau, 2015).
- Women of childbearing years are projected to increase by over 0.4 billion between 2002-2050 (US Census Bureau, 2015).
- In 2012, there were almost 63 million women in the US aged 15-44 of whom 6% resulted in 3.9 million births (US Census Bureau).
Given these statistics, women of childbearing years who represent a significant portion of the population and pregnancy, both intended and unintended, should be considered when addressing the health of our population. Substance use and overdose-related deaths are a public-health crisis and women represent a significant portion of this.
An alarming 30% of people addicted to substances are women of childbearing years aged 15-44.
The National Survey on Drug Use and Health showed that 5% of pregnant women in the US report using illicit substances in the past month, compared to 10% of nonpregnant women (SAMHSA, 2015). Alcohol use among pregnant women was 16.4% compared to 53.2% of nonpregnant women. These results, while promising, might be conservative due to stigma and fear of reporting, and might have not included women who did not know they were pregnant. NSDUH data also suggests that substance use curtails during pregnancy but resumes after pregnancy.
Various risk factors exist for illicit substance use, including family history of drug addiction, history of addiction to any drug (including tobacco), history of psychiatric or psychological illness, and history of childhood trauma (SAMHSA, 2015). Research suggests that 55% to 99% of women who abused substances had a significant trauma history (Najavits et al, 1997). Other risk factors include involvement in an intimate relationship with a partner who abuses substances. Protective factors include marriage and partner support.
Women are more likely than men to experience co-occurring substance use and mental-health disorders. It is estimated that 72% of women diagnosed with alcohol use disorder have co-occurring psychiatric illness, and 86% diagnosed with alcohol dependence have co-occurring psychiatric illness (Kessler et al, 1997). Anxiety disorders, depression, PTSD and eating disorders are the most common co-occurring psychiatric illnesses among women (Agrawal et al, 2005).
Management of a pregnancy in a substance-abusing woman can be complex and involve psychosocial, medical and addiction issues. The perinatal period is a critical transitional time in a woman’s life where healthcare providers – and even employers – must address concerns with substance use and mental-health issues.
Perinatal depression is estimated to affect 10% to 15% of women globally and is considered the most significant risk factor for postpartum depression (Agency for Healthcare Research and Quality, 2015; Melville, Gavin, Guo, Fan & Katon, 2010; WHO, 2012b). A systematic review revealed that postpartum depression symptoms were present in 19.7% to 46% of postpartum women who abused substances and those with a history of substance use (Chapman & Wu, 2013). In a sample of 125 women, one-third of opiate-addicted mothers screened positive for major depression, and almost half experienced postpartum depression six weeks post-delivery (Hoolbrook & Kaltenbach, 2012).
Perinatal women experiencing depression might be at a higher risk for substance use as a means to self-medicate. Addressing substance use and co-occurring mental health concerns is imperative for a positive outcome for the mother, unborn child and family.
Substance use during pregnancy has been linked with negative outcomes, including increased morbidity and mortality for the woman and her child. Pregnant women abusing substances are less likely to obtain consistent obstetric care and have poor medical follow up. Obstetric complications associated with opiate dependence include miscarriage, preterm labour and postpartum haemorrhage.
Adverse outcomes for the foetus include stillbirth, prematurity, intrauterine growth retardation and neonatal abstinence syndrome. In a sample of 247 subjects, cocaine and heroin use were both positively associated with IUGR, preterm delivery and low birth weight (Pinto et al, 2010).
Healthcare providers are at
an optimal position to screen
for substance use
among perinatal women, and employers to urge them to do so.
Women with histories of psychiatric or substance use should raise concerns and trigger focused assessment on substance use. Screening for the use of substances should occur routinely in obstetric/gynaecology, primary care and psychiatric practices to immediately capture substance use among perinatal women and result in referral for treatment. Evidence-based substance use screening tools for perinatal women include Assist, Crafft, Substance Use Risk Profile-Pregnancy Scale, T-ACE, TICS and Tweak (Goodman & Wolff, 2013). These range in sensitivity from 50% to 91% and are validated for prenatal and pregnant women (Goodman & Wolff, 2013).
Agency for Healthcare Research and Quality. (2015). Depression screening why is this important? Retrieved from http://www.ahrq.gov/professionals/prevention-chroniccare/healthier-pregnancy/preventive/depression.html#care
Agrawal, A., Gardner, C., Prescott, C. & Kendler, K. (2005). The differential impact of risk factors on illicit drug involvement in females. Social Psychiatry and Psychiatric Epidemiology, 40(6), 454-466. Chapman, S., & Wu, L. (2013). Postpartum substance use and depressive symptoms: a review. Women’s Health, 53(5), 479-503. doi: http://dx.doi.org/10.1080%2F03630242.2013.804025
Goodman, D., & Wolff, K. (2013). Screening for substance abuse in women’s health: a public health imperative. Journal of Midwifery & Women’s Health, 58, 278-287. doi:10.1111/jmwh.12035.
Hoolbrook, A. & Kaltenbach, K. (2012). Co-occurring psychiatric symptoms in opioid-dependent women: the prevalence of antenatal and postnatal depression. The American Journal of Drug and Alcohol Abuse, 38(6), 575-579.
Kessler, R, McGonagle, K., Zhao, S., Nelson, C., Hughes, M., Eshleman, S., Wittchen, H. & Kendler, K. (1997). Lifetime and 12- month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51(1), 8-19.
Melville, J., Gavin, A., Guo, Y., Fan, M., & Katon, W. (2010). Depressive disorders during pregnancy. Obstetrics & Gynecology, 116(5), 1064-1070.
Najavits, L, Weiss, R., & Shaw, S. (1997). The link between substance abuse and posttraumatic stress disorder in women: A research review. The American Journal on Addictions, 6(4), 273-283.
Office for National Statistics (2014). Birth summary tables, England and Wales: 2014. Retrieved from http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeaths andmarriages/livebirths/bulletins/birthsummarytablesenglandand wales/2015-07-15
Pinto, S., Dodd, S., Walkinshaw, S., Siney, C., Kakkar, P., Mousa, H. (2010). Substance abuse during pregnancy: effect on pregnancy outcomes. European Journal of Obstetrics & Gynecology and Reproductive Biology, 150(2), 137-141. doi: http://dx.doi.org/10.1016/j.ejogrb.2010.02.026
U.S. Census Bureau (2012). Fertility of women in the United States: 2012. Retrieved from https://www.census.gov/content/dam/Census/library/publications/2 014/demo/p20-575.pdf
U.S. Census Bureau (2015). International database. Retrieved from http://www.census.gov/population/international/data/idb/region.php?N=%20Results%20&T=5&A=both&RT=0&Y=2015&R=1&C
World Health Organization (WHO). (2012b). Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review. Retrieved from http://www.who.int/bulletin/volumes/90/2/11- 091850/en/