Minnesota Title V MCH Needs Assessment Fact Sheets

Pregnant Women, Mothers and Infants

Substance Use/Abuse

Summer 2004

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Size of the Problem

There are approximately 82,000 pregnancies each year in Minnesota including 68,000 live births, 13,000 abortions, and 350 fetal deaths of at least 20 weeks. These pregnancies occur to the estimated 1,096,832 women of childbearing age (15-44 years old) [1].

Minnesota’s birth certificate data (1998-2002) indicate approximately 11.4% of all Minnesota women who had a live birth smoked during pregnancy. Approximately 1% report drinking alcohol during pregnancy, and 1.5% report using street drugs, most commonly marijuana. These data are limited by a rate of 6-9% missing data and the possibility that these risk factors are generally underreported. Note: a recent review of birth certificates from 2001-2003 revealed that 269 recorded methamphetamine abuse.

The Women, Infants, and Children Nutrition Program (WIC) and the Department of Human Services’ (DHS) Medicaid data based on the Minnesota Pregnancy Assessment Form (MPAF) provide information on low income women in Minnesota. WIC data for 2002 indicate that 22.4% of their 10,700 participants smoked during pregnancy. Alcohol data indicate that 11.5% of WIC participants drank in the 3 months prior to pregnancy but no women reported drinking during the last 3 months of pregnancy (this question is asked of them at their postpartum WIC visit).

MPAF data analyzed for 54,309 pregnancies (1998-2001) reported a rate of 17.2% for “smoking more than 10 cigarettes per day this pregnancy”. The rate for any “alcohol since last menstrual period” rate was 14.5%, and “street drug use during this pregnancy” was 5.1%.

Seriousness

The national infant mortality rate for infants of smokers was 10.5 per 1,000 live births in 1999, 59% higher than the rate of 6.6 for nonsmokers [2].

Tobacco use during pregnancy results in:

  • Increased risk of conception delay, primary and secondary infertility [3]
  • Increased maternal morbidity and mortality [3]
  • Increased risk of: premature rupture of membranes, abruptio placentae, placenta previa, miscarriage, stillbirth, low birth weight, preterm birth, intrauterine growth restriction [3]
  • Increased risk of Sudden Infant Death Syndrome (SIDS), related both to prenatal exposure and environmental tobacco smoke (ETS) after birth [4]

Alcohol use during pregnancy increases the risk of Fetal Alcohol Spectrum Disorder (FASD), stillbirth, and miscarriage as well as compromising the mother’s health. Among women 18-44, Minnesota has the 3rd highest rate of frequent drinking in the U.S. defined as consuming an average of 7 or more drinks per week or 5 or more drinks on a least one occasion in the past month [5].

Similarly, use of street drugs during pregnancy exposes the fetus to a range of conditions from addiction and withdrawal after birth to birth defects, stillbirth, miscarriage, low birth weight/preterm birth, and a greater risk of infant death as well as compromising the mother’s health.

Women are more likely than men to use more than one substance at a time, and women who do so are more likely than other women to be mentally ill, and/or victims of family violence or sexual abuse and more likely to experience an unplanned or mistimed pregnancy [6].

Disparities.

Minnesota's Birth Certificate data (1998-2002):
Tobacco Use in Pregnancy
Race/Ethnicity Rate Number
Asians
2.3%
358
Whites
11.2%
30,106
Blacks
12.8%
2,423
American Indians
39.8%
2,268
Hispanic
4%
723
Non-Hispanic
12%
34,190
 
Alcohol Use in Pregnancy
Race/Ethnicity Rate Number
Asians
0.3%
42
Whites
0.8%
2,062
Blacks
2.2%
416
American Indians
8.1%
458
Hispanic
0.7%
118
Non-Hispanic
1.0%
2,881
 
Drug Use in Pregnancy
Race/Ethnicity Rate Number
Asians
0.3%
46
Whites
1.0%
2,710
Blacks
5.9%
1,104
American Indians
10.6%
580
Hispanic
1.2%
203
Non-Hispanic
1.6%
4,260
Missing data for these categories (above) was between 7-11%.

 

Minnesota's WIC Data for 2002:
Tobacco Use in Pregnancy
Race/Ethnicity Rate Number
Asian/PI
1.7%
694
White, non-Hisp.
20.3%
5,695
Black, non-Hisp.
6.6%
1,185
Hispanic
1.7%
1,359
Amer.Indian/AN
28.1%
292
WIC does not report alcohol use data by race/ethnicity and does not report any drug use data.

Economic loss.
The Centers for Disease Control (CDC) estimates that a child with FASD will cost $1.4 million over his/her lifetime for services to address their unique institutional and medical needs. Each succeeding birth by a mother who uses alcohol during pregnancy may result in a more severely affected infant [6].

The CDC estimates smoking-attributable health care costs to be approximately $800 per maternal smoker at delivery. Just a 1% decline in the proportion of pregnant women who smoke would prevent 1,300 cases of low birth weight each year and would save $21 million in direct medical costs in the U.S. [6].

If 25% of pregnant smokers on Medicaid received smoking cessation counseling and 18% of these women quit smoking, almost $10 million in excess U.S. Medicaid neonatal health care costs could be averted [6].

Interventions

All pregnant woman should be screened for smoking at their first prenatal visit and throughout their pregnancy. Providers should use the 5 A’s intervention: Ask, Advise, Assess, Assist, Arrange. Through brief counseling, providers and other staff can give pregnant smokers personalized messages about the health risks that smoking poses and self-help materials developed specifically for pregnant smokers. In practices consistently using the 5 A’s approach, quit rates have risen by 30% or more [7].

Women of childbearing age should be screened for alcohol use/abuse and referred as appropriate at all of their health care visits whether pregnant or not. Prevention of FASD through community and family education is also an effective intervention. Economic, social, and emotional costs for communities and families may be reduced by encouraging substance abuse treatment and contraception to prevent alcohol exposure in succeeding births [6].

Residential treatment for pregnant and parenting women that accommodates women and their children has demonstrated reduced substance use (over 60% of women were chemical-free for 6 months after discharge) and improved birth outcomes [8]. In Minnesota, a few chemical dependency treatment programs accept pregnant substance abusers but there continues to be a shortage of residential treatment that accommodates women who need to bring their children with them.

Status

Minnesota Resources
MDH has had State FAS prevention funding since 1998 for local grant projects and public and professional education. Currently, 13 programs are funded to prevent FASD including:

  • Twin Cities Healthy Start, Support Sisters
  • Hennepin County Community Health Department
  • Red Lake Substance Abuse Prevention and Treatment
  • Thunder Spirit Center at Chrysalis
  • Carver-Scott Educational Cooperative

This funding has recently been allocated to the Minnesota Organization on Fetal Alcohol Syndrome (MOFAS). MOFAS is a nonprofit organization that provides services to metro families affected by FASD and has a community and professional education campaign to prevent FASD.

MDH now has a 5 year grant from the CDC to prevent alcohol-exposed pregnancies by enhancing capacity among community partners to implement alcohol and contraception screening and behavior change interventions with women of childbearing age. The grant also develops MDH’s surveillance capacity to monitor FASD, women’s drinking, and women’s contraception and provides for an ongoing resource and referral system for FASD-affected families.

MDH has received technical assistance from federal agencies to create a State Partnership for Tobacco Cessation and Prevention for Women of Childbearing Age. Currently, this partnership includes staff from MDH’s Maternal and Child Health and Tobacco Prevention Sections, Planned Parenthood of MN and MN’s Section of the American College of Obstetricians and Gynecologists (ACOG). Several key stakeholders have written letters of support to expand and fully implement this Partnership and funding is being sought. Potential outcomes would be statewide provider education on implementing the 5 A’s, enhancements to the state’s Tobacco Quitline managed by The Minnesota Partnership for Action Against Tobacco (MPAAT), and support for environmental changes in Minnesota such as improvements in Minnesota’s Clean Indoor Air policies.

Minnesota, through MPAAT, has a telephone quitline system that provides counseling and self-help materials to callers and also refers them to their own health plan’s tobacco cessation program as appropriate.

MDH’s Tobacco Prevention and Control Section and MPAAT fund tobacco prevention and research projects in local communities throughout the state.

Minnesota’s Medicaid program reimburses providers for tobacco cessation counseling for pregnant women.

The Maternal and Child Health Section provides pregnancy-specific self-help materials for cessation to local public health, WIC agencies, tribal health, and community-based organizations serving pregnant women throughout the state.

The following programs funded by the Department of Human Services provide counseling, support, referrals, and home visiting by PHNs, social workers, and chemical health specialists to pregnant women who use drugs:

  • Ramsey County’s Mothers First
  • Hennepin County’s Project Child
  • St. Louis County’s Superior Babies
  • Meeker, McLeod, Sibley Counties’ Project Harmony

The Circle of Women is a University of Minnesota program which provides group sessions, home visiting, advocacy, and family support and guidance to improve parenting skills. The target population is women identified during/shortly after pregnancy as substance users (alcohol, “crack”, cocaine, heroin, methamphetamine).

Community Awareness
A statewide phone survey of Minnesota women aged 18-45 revealed high (66-70%) community awareness of the harm substance use during pregnancy can cause. However, most surveyed believed the greatest harm was caused by “crack” cocaine. Most younger women had seen public service messages in bars regarding alcohol and pregnancy. But prevailing social norms around drinking and the occurrence of unintended pregnancies were barriers to following the message. Women whose doctors advised them to stop smoking during pregnancy were more likely to quit or cut down than those who had not been advised by their doctor. Overall, the survey provided specific guidance to public health to focus on prepregnancy education, younger women, and to encourage providers to counsel women on substance use [9].

References

1. Minnesota Center for Health Statistics
2. Mathews, TJ, et al. 2002. Infant mortality statistics from the 1999 period linked birth/infant death data set. National Vital Statistics Reports, CDC. 50(4): 1-28.
3. Centers for Disease Control and Prevention. Women and smoking: a report of the Surgeon General (Executive Summary). MMWR 2002. 51(No. RR-12): inclusive page numbers.
4. Wisborg, K. et al. 2000. A prospective study of smoking during pregnancy and SIDS. Arch Dis Child. 83: 203-206.
5. CDC. Alcohol consumption among pregnant and childbearing-age women-US, 1991 and 1995. MMWR. 1997, 46 (16):346-350.
6. MDH. 2004. Women and substance use in the childbearing years, a prevention primer.
7. CDC. Annual smoking-attributable mortality, years of potential life lost and economic costs—US, 1995-1999. MMWR 2002, 51(14):300-3.
8. SAMHSA. 2001. 1993-2000 Residential treatment programs for pregnant and parenting women. Alcoholism & Drug Abuse Weekly.13(35):3.
9. Mueller. 1994. Alcohol, tobacco and pregnancy: The beliefs and practices of Minnesota women. Wilder for MDH.