Statement on Perinatal Substance Use (from NPA)

NPA Position Statement 2017 www.nationalperinatal.org

Perinatal Substance Use

The United States is in the midst of what is understandably being called an opioid epidemic.
Public health data describe rising rates of opioid use and misuse.1 A dramatic increase in
overdoses associated with opioid use has focused our attention on the risks of substance use
and dependence.2 Those risks are of special concern during the perinatal period when the
effects of substance use can be amplified. While we know that pregnant people use illicit
substances at half the rate of their non-pregnant peers – and use less during their third trimester
– the rates of substance use and, therefore, infants exposed to substances is still high with more
than 400,000 infants exposed to alcohol or illicit drugs in utero each year.1
While the perinatal period presents unique risks for those who are substance dependent and
their babies, it is also a time when there are unique opportunities for positive intervention. As
clinicians, mental health, and community health care providers, it is imperative that we
understand the nature of perinatal substance use disorders and provide interventions and care
that preserve the parent-infant dyad, promote parenting potential, and support the baby’s
health and development.
Substance use disorders seldom begin during a pregnancy.3 People typically have long histories
of problematic substance use that also include periods of abstinence which predate their
pregnancy.4 So the subset of pregnant people who continue substance misuse during pregnancy
is most likely those who qualify for diagnosis of a Substance Use Disorder.5
Some factors that correlate with perinatal substance use disorder include depression, intimate
partner violence, sexual abuse, and childhood trauma.6 We know that many substances have
positive psychotherapeutic effects.7 In many cases, people initiate substance use to cope with
and manage over-powering emotions associated with trauma. Because they are often
criminalized and marginalized, substance use and illicit substance use can carry additional risks
unrelated to their pharmacological effects. Substance use can increase risk of structural
violence, imbalance of power in intimate relationships, and involvement with the criminal
justice system, all of which can contribute to new experiences of trauma.6, 7
The National Perinatal Association views perinatal substance use as a major health care concern
for perinatal providers, advocates, pregnant people, and their families. We are grateful for an
emerging body of evidence that tells us how to deliver timely and appropriate perinatal care for
this population. While we acknowledge that there are barriers that keep pregnant people from
accessing this care, we believe that perinatal providers have a duty to help remove those
barriers.

Background:

There is significant variability in health care, child welfare, and criminal approaches to caring for
pregnant and parenting people with a perinatal substance use disorder. Many states have
approached this health care issue as a legal issue and have criminalized substance use as a form
of child abuse or neglect.8 Ongoing research over the last twenty-five years has demonstrated
that incarceration or the threat of incarceration does not decrease substance use disorder in
pregnancy.8, 9, 10. 11 All states are required to have a child welfare response for anyone using
substances during pregnancy. Even though the child welfare system does not incarcerate
parents, the initial call made to child protective services can result in babies being separated
from their parents and may eventually result in the termination of parental rights.
Treating this personal and public health issue as a criminal issue – or a deficiency in parenting
that warrants child welfare intervention – results in pregnant and parenting people avoiding
prenatal and obstetric care and putting the health of themselves and their infants at increased
risk.12 Parents are rightly and understandably fearful that seeking prenatal care, disclosing
substance use, and initiating treatment for a Substance Use Disorder may result in harmful and
punitive child welfare involvement.13 This, unfortunately, increases the risk of obstetrical
complications, preterm birth, and delivery of low birth weight infants. It also contributes to
higher rates of unmanaged Neonatal Abstinence Syndrome. 8
Health care providers should seek opportunities to educate themselves more fully on the issues
that accompany and contribute to substance use, misuse, and dependence. Screening questions
for problematic substance use should be a routine practice in every health care setting. Perinatal
providers have a special responsibility because women are at highest risk for developing a
substance use disorder during their reproductive years (18–44), especially ages 18–29.14 It is also
critical that we address the effects of poly-substance use, as it is the norm when we describe
perinatal exposure and dependence.5
Optimal perinatal care requires a trusting relationship between providers and pregnant and
parenting clients that supports open and honest communication about substance use. A patientcentered
model for screening, brief intervention, and referral to treatment (SBIRT) that adopts
the best practices of motivational interviewing is an effective way to determine the level of care
that is appropriate for each client.15 The use of screening models like SBIRT should not be
confused with the practice of drug testing. The testing of a pregnant patients’ blood, saliva, or
urine for licit and illicit substances as a form of surveillance or as a tool for providing evidence of
criminal conduct, child abuse, child endangerment, or criminal neglect undermines the trust
between patients and providers and is contrary to professional ethics.12
It must also be noted that the negative consequences associated with perinatal substance use
are disproportionately born by non-white perinatal patients even though evidence supports the
notion that rates of use are similar across racial classifications.16 The assumption that universal
screening or surveillance can remedy those disparities is not supported by the evidence.17
www.nationalperinatal.org
Current research and practice has found that when parents partner in their prenatal care with
supportive and knowledgeable staff, receive coordinated care to address the negative
consequences of their substance use, and are able to room-in with their infant after delivery,
the parent-infant bond is preserved and outcomes are better.18, 19 Examples of potentially
better practices are programs where pregnant people with a perinatal substance use disorder
can receive both their prenatal care and substance use treatment in the same health care clinic
or inpatient facility. Research is ongoing as to the efficacy of these models.
Position:
Pregnant and parenting patients with Substance Use Disorders have the same needs as any
other pregnant and parenting client. They also have needs that are specific to their substance
use. The National Perinatal Association supports comprehensive treatment programs for
pregnant and parenting people with perinatal substance use disorder. Such programs must
incorporate gender-specific, developmentally-appropriate, trauma-informed care. It is essential
to work from a Harm Reduction model, promoting “Any Positive Change” as determined by the
client, including plans ranging from abstinence, to decreased use, to safer use. Client
abandonment in the case of continued use is unacceptable. Options for treatment should
include, at minimum, Medication-Assisted Treatment (MAT), group and/or individual
counseling, crisis intervention, overdose prevention, mental health assessment and treatment,
dental care, parenting classes and support, and social services such as housing, employment
assistance, and WIC.1, 3, 8, 20
In order to continue improvement in perinatal outcomes, NPA encourages ongoing research
regarding rooming-in practices for parents and infants in the postpartum period and access to
health care clinics that provide prenatal and substance use treatment in one setting.
The threats of discrimination, incarceration, loss of parental rights, and loss of personal
autonomy are powerful deterrents to seeking appropriate perinatal care.21 Perinatal providers
promote better practices when they adopt language, attitudes, and behaviors that reduce
stigma and promote honest and open communication about perinatal substance use.
The National Perinatal Association opposes any legal measures that involve the criminal justice
system for drug use during pregnancy. Any statute which criminalizes substance use during
pregnancy is inherently discriminatory in addition to being counterproductive to the goal of
improving maternal and neonatal outcomes.20 Criminalization and incarceration are ineffective
and harmful to the health of the pregnant person and their infant.8 The child welfare system is
overwhelmed, and in too many cases, cannot provide appropriate support to either parents who
are adjudicated neglectful because of perinatal substance use or to their children.22
The National Perinatal Association supports full funding for treatment services, prenatal care,
and counseling to support clients in their safer use, recovery, and/or sobriety. Medicaid and
insurance companies must be committed to serving this population with evidence-based
individual and public health approaches. It is imperative that perinatal substance use disorder
be viewed as a health care issue comparable to other disease processes that have genetic,
environmental, socioeconomic, clinical, and behavioral components.15, 23

Summary:

NPA encourages all health care providers and partners to discuss substance use during
pregnancy with their clients and to support screening discussions and referral to appropriate
treatment programs in a timely manner. NPA supports fully-funded health care clinics that care
for those with perinatal substance use disorder as an effective solution to this crisis. NPA
believes that criminal and civil-legal interventions are not effective and opposes their use with
this uniquely vulnerable population.
References:
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Replaces: Substance Abuse among Pregnant Women, 2012
Originated: Erika Goyer, BA; Bernadette Hoppe, Esq, JD,
MA, MPH; Cheryl Milford, EdS; Joelle Puccio, BSN, RN
September 2017
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