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CORK Bibliography: Pregnancy and Substance Use

83 citations. January 2011 to present

Prepared: September 2011

Adams EK; Melvin CL; Raskind-Hood C; Joski PJ; Galactionova E. Infant delivery costs related to maternal smoking: An update. Nicotine & Tobacco Research 13(8): 627-637, 2011. (45 refs.)

Introduction: Adverse maternal and infant health outcomes due to maternal smoking are well known. Previous estimates of health care costs for infants at delivery attributable to maternal smoking were $366 million, $704 per smoker, in 1996 dollars. Changes in antenatal and neonatal care, medical care inflation, and declines in the prevalence of maternal smoking call for an updated analysis. Methods: We used Pregnancy Risk Assessment Monitoring System for 2001/2002 to estimate the association of maternal smoking to Neonatal Intensive Care Unit (NICU) admission and, in turn, the length of stay for infants admitted/not admitted. Models are then used with 2003 natality files to derive predicted expenses as is and "as if" mothers did not smoke. The difference in these predicted expenses is smoking attributable expenses (SAEs). The updated analysis incorporated Hispanic ethnicity as an additional variable, data from 27 as opposed to 13 states, and updated (2004) NICU costs per night. Results: In contrast to earlier work, we find no significant association of maternal smoking and NICU admission but rather, a positive effect on the length of stay of exposed infants once admitted to the NICU. SAEs were estimated at $122 million (CI = -$29m to $285m) nationally and $279 (CI = -$76 to $653) per maternal smoker in 2004 dollars. Conclusions: Declines in maternal smoking prevalence between the mid-1990s and 2003 combined with a weaker relationship of maternal smoking to NICU admission offset medical care inflation such that infants' SAEs declined. Yet, these are significant in magnitude, incurred immediately and highly preventable.

Albrecht J; Lindsay B; Terplan M. Effect of waiting time on substance abuse treatment completion in pregnant women. Journal of Substance Abuse Treatment 41(1): 71-77, 2011. (28 refs.)

Although substance abuse treatment is associated with improved maternal and neonatal outcomes, pregnant women may be at increased risk of attrition. To explore the hypothesis that shorter waiting time for treatment is associated with increased completion, we analyzed all pregnant treatment admissions and discharges in the Treatment Episode Data Set-Discharges. There were 10,661 pregnant admissions in 2006. The effect of waiting time on treatment completion was modified by treatment setting. Immediate entry into ambulatory treatment, where most pregnant women are treated, was significantly associated with completion (odds ratio = 1.27, 95% confidence interval = 1.14-1.41). Criminal justice referral and a high school education were identified as completion predictors in all treatment settings. Waiting time impacts treatment completion in pregnant women. Resources need to be directed to ensure immediate access to treatment, particularly in the ambulatory setting.

Aliyu MH; Lynch O; Wilson RE; Alio AP; Kristensen S; Marty PJ et al. Association between tobacco use in pregnancy and placenta-associated syndromes: A population-based study. Archives of Gynecology and Obstetrics 283(4): 729-734, 2011. (33 refs.)

Cigarette smoking is an established risk factor for adverse perinatal outcomes. The purpose of this study is to examine the association between maternal smoking in pregnancy and the occurrence of placental-associated syndromes (PAS). We analyzed data from a population-based retrospective cohort of singleton deliveries that occurred in the state of Missouri from 1989 through 2005 (N = 1,224,133). The main outcome was PAS, a composite outcome defined as the occurrence of placental abruption, placenta previa, preeclampsia, small for gestational age, preterm or stillbirth. We used logistic regression models to generate adjusted odd ratios and their 95 percent confidence intervals. Non-smoking gravidas served as the referent category. The overall prevalence of prenatal smoking was 19.6%. Cigarette smoking in pregnancy was associated with the composite outcome of placental syndromes (odds ratio, 95% confidence interval = 1.59, 1.57-1.60). This association showed a dose-response relationship, with the risk of PAS increasing with increased quantity of cigarettes smoked. Similar results were observed between smoking in pregnancy and independent risks for abruption, previa, SGA, stillbirth, and preterm delivery. Maternal smoking in pregnancy is a risk factor for the development of placenta-associated syndrome. Smoking cessation interventions in pregnancy should continue to be encouraged in all maternity care settings.

Almeida ND; Koren G; Platt RW; Kramer MS. Hair biomarkers as measures of maternal tobacco smoke exposure and predictors of fetal growth. Nicotine & Tobacco Research 13(5): 328- 335, 2011. (33 refs.)

Introduction: Most biomarker studies of the effects of maternal smoking on fetal growth have been based on a single blood or urinary cotinine value, which is inadequate in capturing maternal tobacco exposure over the entire pregnancy. We used hair biomarkers to compare the associations of maternal self-reported smoking, hair nicotine, and hair cotinine with birth weight for gestational age (BW for GA) among active and passive smokers during pregnancy. Methods: We collected maternal hair in the immediate postpartum period and measured nicotine and cotinine concentrations averaged over the pregnancy in 444 term controls drawn from 5,337 participants in a multicenter nested case-control study of preterm birth. BW for GA Z-score and small for gestational age (SGA) were based on Canadian population-based standards. Results: The addition of hair nicotine to multiple linear regression models containing self-reported active smoking, hair cotinine, or both explained significantly more variance in the BW for GA Z-score (p = .01, .03 and .04, respectively). Similarly, women with hair nicotine, but not cotinine, at or above the median value had a significant increase in the risk of SGA birth (odds ratio: 3.07, 95% CI: 1.25-7.52). No significant association was observed between maternal passive smoking and BW for GA based on hair biomarkers. Conclusions: Hair nicotine is a better predictor of reductions in BW for GA than either hair cotinine or self-report. Our negative results for passive smoking suggest that previously reported small but significant effects may be explained by misclassification of active smokers as passive smokers based on self-report.

Bailey BA; Sokol RJ. Prenatal alcohol exposure and miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome. Alcohol Research & Health 34(1): 86-91, 2011. (39 refs.)

In addition to fetal alcohol syndrome and fetal alcohol spectrum disorders, prenatal alcohol exposure is associated with many other adverse pregnancy and birth outcomes. Research suggests that alcohol use during pregnancy may increase the risk of miscarriage, stillbirth, preterm delivery, and sudden infant death syndrome. This research has some inherent difficulties, such as the collection of accurate information about alcohol consumption during pregnancy and controlling for comorbid exposures and conditions. Consequently, attributing poor birth outcomes to prenatal alcohol exposure is a complicated and ongoing task, requiring continued attention to validated methodology and to identifying specific biological mechanisms.

Bakhireva LN; Savage DD. Biomarkers of Fetal Alcohol Exposure And Fetal Alcohol Effects. Alcohol Research & Health 34(1): 56-63, 2011. (55 refs.)

One of the ongoing challenges for the accurate diagnosis and treatment of children with fetal alcohol spectrum disorders (FASD) is the difficulty of confirming whether a mother drank during her pregnancy. Commonly used screening questionnaires often are unreliable, and current established biomarkers of alcohol consumption are not sensitive enough for use with many pregnant women. These limitations underscore the critical need to develop novel biomarkers with greater sensitivity for detecting moderate levels of drinking during pregnancy for longer periods of time after the last drinking episode. In addition, developing reliable biomarkers of fetal alcohol effects that can identify children at risk for adverse neurobehavioral outcomes could lead to behavioral interventions earlier in development. The use of animal models of FASD in biomarker development could accelerate progress in this challenging field of research.

Bakhireva LN; Wilsnack SC; Kristjanson A; Yevtushok L; Onishenko S; Wertelecki W et al. Paternal drinking, intimate relationship quality, and alcohol consumption in pregnant Ukrainian women. Journal of Studies on Alcohol and Drugs 72(4): 536-544, 2011. (53 refs.)

Objective: Maternal alcohol consumption during pregnancy and fetal alcohol spectrum disorders (FASDs) represent a significant public health problem. The influence of the male partner's alcohol consumption patterns and the quality of the partner's intimate relationship might be important factors to consider in the design of successful FASD prevention programs. Method: As part of the Collaborative Initiative on Fetal Alcohol Spectrum Disorders, 166 pregnant women in two regions in Ukraine participated in an in-person interview at an average gestational age of 18-19 weeks. Subjects were classified cross-sectionally as abstainers/light drinkers (n = 80), defined as low or no consumption of alcohol in the periconceptional period and none in the most recent 2 weeks of pregnancy; discontinuers (n = 43), defined as moderate to heavy alcohol use in the periconceptional period but none during the most recent 2 weeks of pregnancy; or continuing drinkers (pi = 43), defined as continued moderate to heavy alcohol use within the most recent 2 weeks of pregnancy. Women also reported on their partner's drinking behavior and on the quality of their intimate relationship. Results: Heavy paternal drinking was significantly associated with both continuing maternal drinking in the most recent 2 weeks (adjusted odds ratio [OR] = 34.1; 95% CI [5.9, 195.8]) and being a risky drinker only around conception (adjusted OR = 27.0; 95% CI [5.0, 147.7]). In addition, women who consumed alcohol during pregnancy had lower mean scores for satisfaction with partners' relationship and ability to discuss problems (p < .05) compared with light drinkers/abstainers. Conclusions: This study suggests that development of partner-based interventions, as opposed to those solely focused on maternal drinking, might be warranted as a strategy to prevent FASD.

Bjerg A; Hedman L; Perzanowski M; Lundback B; Ronmark E. A strong synergism of low birth weight and prenatal smoking on asthma in schoolchildren. Pediatrics 127(4): E905-E912, 2011. (34 refs.)

BACKGROUND: Prenatal smoke exposure is associated with airway inflammation and asthma in children. It also increases the risk of low birth weight (LBW). LBW is associated with decreased lung function independently of smoking. OBJECTIVE: To study the independent and joint effects of prenatal smoking and LBW on childhood asthma. METHODS: In 1996, all children aged 7 to 8 years in 3 cities in northern Sweden were invited to an International Study of Asthma and Allergy in Childhood questionnaire survey. This study focused on the follow-up of children aged 11 to 12 years, in which 3389 children (96%) participated. A subset of 2121 children underwent skin-prick testing. Self-reported physician-diagnosed asthma has been clinically validated. RESULTS: Mean birth weight was 3360 g in children exposed to prenatal smoking and 3571 g in nonexposed children (P < .001). The association of prenatal smoking with physician-diagnosed asthma was stronger in LBW children (risk ratio: 8.8 [95% confidence interval: 2.1-38]) than in normal birth weight children (risk ratio: 1.3 [95% confidence interval: 1.0-1.8]). LBW alone was not an independent predictor of asthma. These associations were similar in multivariate analysis, and the interaction term LBW x smoking was highly statistically significant. CONCLUSIONS: There was a strong interaction of LBW and prenatal-smoking on the risk of physician-diagnosed asthma, which has not been demonstrated previously. This was consistently seen with adjustment for known risk factors, including allergic sensitization. Plausibly, airway inflammation from prenatal smoke exposure induces obstructive symptoms more easily in the underdeveloped airways of LBW children.

Broussard CS; Rasmussen SA; Reefhuis J; Friedman JM; Jann MW; Riehle-Colarusso T et al. Maternal treatment with opioid analgesics and risk for birth defects. American Journal of Obstetrics and Gynecology 204(4): article 314.e1, 2011. (40 refs.)

OBJECTIVE: We examined whether maternal opioid treatment between 1 month before pregnancy and the first trimester was associated with birth defects. STUDY DESIGN: The National Birth Defects Prevention Study (1997 through 2005) is an ongoing population-based case-control study. We estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIS) for birth defects categories with at least 200 case infants or at least 4 exposed case infants. RESULTS: Therapeutic opioid use was reported by 2.6% of 17,449 case mothers and 2.0% of 6701 control mothers. Treatment was statistically significantly associated with conoventricular septal defects (OR, 2.7; 95% CI, 1.1-6.3), atrioventricular septal defects (OR, 2.0; 95% CI, 1.2-3.6), hypoplastic left heart syndrome (OR, 2.4; 95% CI, 1.4-4.1), spina bifida (OR, 2.0; 95% CI, 1.3-3.2), or gastroschisis (OR, 1.8; 95% CI, 1.1-2.9) in infants. CONCLUSION: Consistent with some previous investigations, our study shows an association between early pregnancy maternal opioid analgesic treatment and certain birth defects. This information should be considered by women and their physicians who are making treatment decisions during pregnancy.

Burden MJ; Westerlund A; Muckle G; Dodge N; Dewailly E; Nelson CA et al. The effects of maternal binge drinking during pregnancy on neural correlates of response inhibition and memory in childhood. Alcoholism: Clinical and Experimental Research 35(1): 69-82, 2011. (63 refs.)

Background: Although an extensive literature has documented a broad range of cognitive performance deficits in children with prenatal alcohol exposure, little is known about how the neurophysiological processes underlying these deficits may be affected. Event-related potentials (ERPs), which reflect task-specific changes in brain electrical activity, provide a method for examining multiple constituents of cognitive processing at the neural level. Methods: We recorded ERPs in 217 children from Inuit communities in Arctic Quebec (M age = 11.3 years) during 2 different tasks-Go/No-go response inhibition and continuous recognition memory. Children were classified as either alcohol-exposed (ALC) or controls (CON) depending on whether the mother reported binge drinking during pregnancy. Results: Both groups performed comparably in terms of accuracy and reaction time on the tasks, and both tasks elicited the expected effects on ERPs when responses were compared across conditions. However, the ALC group showed slower P2 latencies on Go/No-go, suggesting an altered neurophysiological response associated with initial visual processing of the stimuli. On the memory task, the ALC group showed reduced FN400 amplitude to New items, known as the familiarity effect, and reduced amplitude for the late positive component, possibly reflecting impairment in memory retrieval. Conclusions: These findings show that, even in tasks in which alcohol-exposed children exhibit behavioral performance that is comparable to controls, fetal alcohol exposure is associated with altered neurophysiological processing of response inhibition and recognition memory. The data suggest that fetal alcohol exposure is associated with reduced efficiency in the initial extracting of the meaning of a stimulus, reduced allocation of attention to the task, and poorer conscious, explicit recognition memory processing.

Burns L; Black E; Powers JR; Loxton D; Elliott E; Shakeshaft A et al. Geographic and maternal characteristics associated with alcohol use in pregnancy. Alcoholism: Clinical and Experimental Research 35(7): 1230-1237, 2011. (42 refs.)

Background: To date, no studies have used population-level data to investigate whether maternal location of residence (metropolitan vs. regional/remote populations) is associated with alcohol use in pregnancy. This information has important implications for appropriate service provision. Methods: Information on all live births in New South Wales Australia was linked to records of alcohol-related admissions for mothers of these births over a 6-year period (2000 to 2006). Cases were women who had at least 1 alcohol-related hospital admission during pregnancy or at birth. Controls were women who had at least 1 live birth over that same time period but no alcohol-related hospital admissions during that time. Admissions were considered to be alcohol-related based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM) code. Demographic, obstetric, and neonatal variables were compared. Results: A total of 417,464 singleton birth records were analyzed, 488 of which were coded positive for at least 1 alcohol-related ICD-10-AM diagnosis. Characteristics associated with alcohol-related admissions in pregnancy were residence in a remote/very remote area, being Australian-born, having had a previous pregnancy, smoking in the current pregnancy, and presenting late to antenatal care. Alcohol-exposed pregnancies were associated with a range of poor obstetric and neonatal outcomes, with no geographic differences noted. However, women in regional/remote areas were less likely to attend specialist obstetric hospitals. Conclusions: This study shows the need for standardized screening programs for alcohol use in pregnancy and where problematic use is detected, for clear clinical guidelines on management and referral.

Cavazos-Rehg PA; Krauss MJ; Spitznagel EL; Schootman M; Cottler LB; Bierut LJ. Substance use and the risk for sexual intercourse with and without a history of teenage pregnancy among adolescent females. Journal of Studies on Alcohol and Drugs 72(2): 194-198, 2011. (24 refs.)

Objective: The present study examined the associations between initiation and intensity of substance use and with sexual experience with and without a history of teenage pregnancy. Method: Participants: were high school females (weighted n = 3,451) who participated in the 1999-2003 Youth Risk Behavior Surveillance System, a cross-sectional, nationally representative survey. Multinomial multivariable logistic regression was used to assess the likelihood of being sexually experienced (but never pregnant) and teenage pregnancy (reference group: never had sexual intercourse) as a function of age at substance use initiation (i.e., age 12 or younger, 13-14 years of age, and age 15 or older) and intensity of substance use (i.e., nonuser, experimental/new or nondaily, nonexperimental/daily user) for alcohol, cigarettes, and marijuana, while controlling for race/ethnicity, metropolitan location, symptoms of depression, and illegal drug availability at school. Results: A major finding of our study is that substance use behaviors across each substance (alcohol, cigarettes, and marijuana) independently contributed to an increased risk in sexual intercourse experience with and without a history of teenage pregnancy (vs. nonsexually experienced females). A dose-response relationship was also observed between an increased likelihood of a teenage pregnancy and marijuana behaviors. Furthermore, the risk for teenage pregnancy was compounded for daily cigarette smokers who initiated use at age 12 or younger. Conclusions: Screening substance use behaviors can help to identify girls who may benefit from pregnancy prevention strategies. Targeting cigarette and marijuana behaviors as early as age 12 or younger may provide an added benefit. Prevention strategies should also consider the role of race above and beyond substance use behaviors.

Chang G; Orav EJ; Jones JA; Buynitsky T; Gonzalez S; Wilkins-Haug L. Self-reported alcohol and drug use in pregnant young women: A pilot study of associated factors and identification. Journal of Addiction Medicine 5(3): 221-226, 2011. (19 refs.)

Objectives: This study describes the factors associated with self-reported substance use in pregnant young women attending a hospital clinic and evaluates 3 ways in its identification. Methods: A cross-sectional study of 30 pregnant young adults who responded to a mail survey containing the CRAFFT screening tool. All completed a diagnostic interview that included self-report information on their use of alcohol and drugs before and during pregnancy, the T-ACE screening tool, and the contexts in which they would be likely to use. Medical records were reviewed. Results: One-third of participants consumed alcohol, marijuana, or both while pregnant. Many had lifetime diagnoses of alcohol (23%) or cannabis (30%) use disorders, but only 1 met criteria for current diagnosis. Age, race, education, and children at home were not associated with either prenatal alcohol or cannabis use. Before pregnancy, alcohol drinking was associated with prenatal alcohol use (P = .02) and prenatal cannabis use (P = .06). Another trend of the before-pregnancy cannabis use being associated with prenatal cannabis use (P = .08) was observed. Most participants indicated little likelihood of substance use in convivial, intimate, or negative coping contexts while pregnant. However, participants with prenatal substance use had significantly higher convivial (P = .02) and intimate (P = .01) subscale scores of the Drinking Context Scale before pregnancy. Compared to the medical record and the T-ACE, the CRAFFT was best in identifying prenatal substance use (c-statistic = 0.9). Conclusions: The CRAFFT screening instrument and asking about the contexts during which alcohol might have been consumed before pregnancy are promising approaches in the identification of prenatal substance use.

Cheng DA; Kettinger L; Uduhiri K; Hurt L. Alcohol consumption during pregnancy: Prevalence and provider assessment. Obstetrics and Gynecology 117(2, Part 1): 212-217, 2011. (19 refs.)

OBJECTIVE: To estimate the prevalence of prenatal alcohol consumption and the extent of provider screening and discussion about alcohol use during pregnancy. METHODS: Data were obtained from a stratified random sample of 12,611 mothers from Maryland who delivered live infants during the years 2001-2008 and completed the Maryland Pregnancy Risk Assessment Monitoring System survey. Analyses were conducted using Proc Surveyfreq in SAS 9.2. RESULTS: Nearly 8% (95% confidence interval 7.1-8.4) of mothers from Maryland reported alcohol consumption during the last 3 months of pregnancy. The highest prevalence of late-pregnancy alcohol consumption was reported by mothers who were non-Hispanic white, (10.9%, confidence interval 9.8-11.9), aged 35 years or older (13.4%, confidence interval 12.4-14.4), and college graduates (11.4%, confidence interval 10.2-12.6) (P<.001). Nineteen percent (confidence interval 17.6-21.0) of mothers reported that their prenatal care provider did not ask whether they were drinking alcoholic beverages, and 30% (confidence interval 28.3-30.8) reported that a healthcare provider did not counsel them about the consequences of alcohol use on the child. Reported screening and counseling were least prevalent among mothers who were non-Hispanic white, aged 35 years or older, and college graduates (P<.01). CONCLUSION: Despite the substantial number of women who continue to drink alcohol during pregnancy, healthcare providers do not routinely assess alcohol consumption or counsel all women about its harmful effects. Counseling was least prevalent among the same groups of women with the highest rates for drinking. Provider alcohol assessment, as recommended by the U. S. Surgeon General to prevent alcohol misuse, needs further promotion as a routine part of prenatal care.

Chertok IRA; Luo JH; Anderson RH. Association between changes in smoking habits in subsequent pregnancy and infant birth weight in West Virginia. Maternal and Child Health Journal 15(2): 249-254, 2011. (23 refs.)

West Virginia has one of the highest prenatal smoking prevalence rates in the nation. While overall national prenatal smoking rates have been declining, the prevalence rates in West Virginia continue to climb. Smoking in pregnancy has been associated with deleterious health outcomes in infants, including decreased birth weight. Yet, minimal research has been done on changes in smoking behaviors over time and the association of the changes in infant birth weights. The aim of the current study is to examine the change in prenatal smoking status of West Virginia women and the associated changes in infant birth weights. Population-based secondary data analysis was conducted using West Virginia birth certificates for all singleton infant siblings born between 1989 and 2006, linked based on mother. Infants born to women who smoked during pregnancy had significantly lower birth weights than infants born to non-smokers. Repeated measures analysis used to examine the changes with time showed that women who smoked during their first pregnancy but refrained from smoking during their subsequent pregnancy had significantly increased birth weight for the second infant, and conversely, infants born to women who initiated smoking with the subsequent pregnancy had significantly decreased birth weight compared to the previous infant. Findings of the study may be used to inform and to guide the development of population focused interventions to decrease maternal prenatal smoking in first and in subsequent pregnancies in an effort to improve infant birth weight outcomes.

Cluss PA; Levine MD; Landsittel D. The Pittsburgh STOP Program: Disseminating an evidence-informed intervention for low-income pregnant smokers. American Journal of Health Promotion 25(5, Supplement S): S75-S81, 2011. (37 refs.)

Purpose. Prenatal smoking is a preventable risk factor for poor perinatal outcomes and is more prevalent in pregnant smokers of low socioeconomic status (SES). We describe the intervention model and factors associated with quitting from the Pittsburgh STOP Program, an evidence-informed dissemination intervention for low-SES pregnant smokers. Setting. STOP is delivered in community health care clinics serving economically disadvantaged women. Participants. Participants were 856 pregnant women who were current smokers (93%) and recent quitters (7%). Most were white (59%) or black (35%), single (74%), young (mean age = 25), and experiencing an unplanned pregnancy (84%); 90% were insured by Medicaid/uninsured. Methods. An evidence-informed intervention for community pregnant women was delivered individually in a single-group pre-post evaluation design. Measures were demographics, participation and retention, smoking status, satisfaction, and cost. Analyses included descriptive statistics and logistic regression. Results. Participants attended an average of 4.7 sessions. Dropout rate after the first session was 5%. Over 11% of smokers quit; 48% of preenrollment spontaneous quitters remained abstinent. Factors significantly associated with quitting included race, mother's age, nicotine dependence, and number of sessions attended. Limitations. STOP is a community program with self-selected participants and no control group. Conclusion. Low-income pregnant smokers will engage in an evidence-informed cessation, program tailored for this group, with quit rates that compare to controlled research results.

Coker I; Colak A; Hasturk AG; Yildiz O; Turkon H; Halicioglu O. Maternal and cord blood homocysteine and folic acid levels in smoking and nonsmoking pregnant women. Gynecologic and Obstetric Investigation 71(4): 245-249, 2011. (28 refs.)

Introduction: The homocysteine level in blood is affected by gender, diet, smoking, folic acid and B-complex vitamins. It is known that higher than normal homocysteine levels in plasma may cause vascular endothelium dysfunction, resulting in the promotion of thrombus formation. In our study, we aimed to assess the effects of smoking during pregnancy on the homocysteine and folic acid levels of the mother and baby. Methods: The study included 58 pregnant women who had completed their 37th week of gestation: 30 women were nonsmokers (NONSM) and 28 were smokers (SM). The measurement of homocysteine and folic acid levels in all samples were performed with an Immulite 2000 analyzer, using the chemiluminescence method. Results: Maternal blood folic acid levels were significantly lower in SM (p = 0.041) than in NONSM. In SM, homocysteine levels in the umbilical cord blood were found to be significantly higher than those in NONSM (p = 0.006). Conclusion: High homocysteine levels in umbilical cord blood of smoking mothers, and the probable continuation of passive smoking for the babies after birth, make us think that the baby may have a predisposition towards vascular diseases at later periods in life.

Coleman T; Chamberlain C; Cooper S; Leonardi-Bee J. Efficacy and safety of nicotine replacement therapy for smoking cessation in pregnancy: Systematic review and meta-analysis. (review). Addiction 106(1): 52-61, 2011. (34 refs.)

Aims: To determine the efficacy and safety of nicotine replacement therapy (NRT) with or without behavioural support when used to support smoking cessation in pregnancy. Design, Setting and Participants: A systematic review of randomized controlled trials (RCTs) in which NRT was used with or without behavioural support to promote smoking cessation; trials providing unequal behavioural support to different trial groups were excluded. Measurements: Efficacy: self-reported smoking cessation in later pregnancy, validated where possible by biochemical measures with appropriate cut-points; infants' safety: mean and low birth weights (LBW), preterm birth, fetal demise and neonatal intensive care unit (NICU) admissions. Findings: Five trials, enrolling 695 pregnant, regular smokers were included in the review. The pooled risk ratio (RR) and 95% confidence Interval (CI) for smoking cessation in later pregnancy after using NRT was 1.63 (0.85, 3.14). Subgroup analysis comparing studies at lower risk of bias (placebo-RCTs) with those at higher risk of bias (non-placebo-RCTs) found that efficacy estimates varied with trial design [RR (95% CI) for cessation in placebo-RCTs 1.17 (0.83, 1.65) versus 7.81 (1.51, 40.35) for non-placebo-RCTs]. Five of the seven safety outcomes were more positive among infants born to women who had used NRT, but none of the observed differences between trial groups reached statistical significance. Conclusions: There is currently insufficient evidence to determine whether or not nicotine replacement therapy is effective or safe when used in pregnancy for smoking cessation; further research and, in particular, placebo-randomized controlled trials are required.

Crane JMG; Keough M; Murphy P; Burrage L; Hutchens D. Effects of environmental tobacco smoke on perinatal outcomes: A retrospective cohort study. International Journal of Obstetrics and Gynaecology 118(7): 865- 871, 2011. (19 refs.)

Objective: To evaluate the effects of environmental tobacco smoke (ETS) on perinatal outcomes. Design: Retrospective cohort study. Setting: Newfoundland and Labrador, Canada. Population: Nonsmoking women with singleton gestations who delivered 1 April 2001-31 March 2009, identified through the Newfoundland and Labrador Provincial Perinatal Database. Methods: Women who self-reported exposure to ETS were compared with those who reported no exposure. Univariate analyses and multivariate linear and logistic regression analyses (adjusting for maternal age, parity, partnered status, work status, level of education, body mass index, alcohol use, illicit drug use and gestational age) were performed and odds ratios(OR; or adjusted differences) with 95% confidence intervals were calculated. Main outcome measures: Birthweight, birth length, head circumference and stillbirth. Secondary outcomes included gestational age at delivery, preterm birth < 37 and < 34 weeks of gestation, prelabour rupture of membranes, Apgar score, endotracheal intubation for resuscitation, neonatal intensive care unit admission, congenital anomalies, respiratory distress syndrome, intraventricular haemorrhage, neonatal bacterial sepsis, jaundice and neonatal metabolic abnormalities. Results: A total of 11 852 women were included: 1202(11.1%) exposed to ETS and 10 650 (89.9%) not exposed. Exposure to ETS was an independent risk factor for lower mean birthweight (-53.7 g, 95% CI -98.4 to -8.9 g), smaller head circumference (-0.24 cm, 95% CI -0.39 to -0.08 cm), shorter birth length (-0.29 cm, 95% CI -0.51 to -0.07 cm), stillbirth (OR 3.35, 95% CI 1.16-9.72, P = 0.026), and trends towards preterm birth < 34 weeks (OR 1.87, 95% CI 1.00-3.53, P = 0.05) and neonatal sepsis (OR 2.96, 95% CI 0.99-8.86). Conclusions: Exposure of nonsmoking pregnant women to ETS is associated with a number of adverse perinatal outcomes including lower birthweight, smaller head circumference and stillbirth, as well as shorter birth length. This information is important for women, their families and healthcare providers, and reinforces the continued need for increased public policy and education on prevention of exposure to ETS.

Dechanet C; Anahory T; Daude JCM; Quantin X; Reyftmann L; Hamamah S et al. Effects of cigarette smoking on reproduction. (review). Human Reproduction Update 17(1): 76-95, 2011. (216 refs.)

Background: Cigarette smoking is associated with lower fecundity rates, adverse reproductive outcomes and a higher risk of IVF failures. Over the last few decades, prevalence of smoking among women of reproductive age has increased. This review focuses on current knowledge of the potential effects of smoke toxicants on all reproductive stages and the consequences of smoke exposure on reproductive functions. methods: We conducted a systematic review of the scientific literature on the impact of cigarette smoking and smoke constituents on the different stages of reproductive function, including epidemiological, clinical and experimental studies. We attempted to create hypotheses and find explanations for the deleterious effects of cigarette smoke observed in experimental studies. Results: Cigarette smoke contains several thousand components (e. g. nicotine, polycyclic aromatic hydrocarbons and cadmium) with diverse effects. Each stage of reproductive function, folliculogenesis, steroidogenesis, embryo transport, endometrial receptivity, endometrial angiogenesis, uterine blood flow and uterine myometrium is a target for cigarette smoke components. The effects of cigarette smoke are dose-dependent and are influenced by the presence of other toxic substances and hormonal status. Individual sensitivity, dose, time and type of exposure also play a role in the impact of smoke constituents on human fertility. conclusions: All stages of reproductive functions are targets of cigarette smoke toxicants. Further studies are necessary to better understand the deleterious effects of cigarette smoke compounds on the reproductive system in order to improve health care, help to reduce cigarette smoking and provide a better knowledge of the molecular mechanisms involved in reproductive toxicology.

Delrahim-Howlett K; Chambers CD; Clapp JD; Xu RH; Duke K; Moyer RJ et al. Web-based assessment and brief intervention for alcohol use in women of childbearing potential: A report of the primary findings. Alcoholism: Clinical and Experimental Research 35(7): 1331-1338, 2011. (36 refs.)

Background: There is a need for more effective assessment and primary prevention programs aimed at accurately measuring and reducing alcohol consumption among women before conception in underserved, high-risk populations. Health information technology may serve this purpose; however, the effectiveness of such tools within this population is not known. Methods: We conducted a small-scale randomized controlled trial to test the effectiveness of an adapted web-based alcohol assessment and intervention tool among low-income, nonpregnant women of reproductive age who were receiving Women Infant and Children (WIC) services in San Diego County and who reported currently drinking at a moderate risk level. A total of 150 risky drinking participants completed a web-based assessment and were randomly assigned to either receive a personalized feedback intervention or general health information about alcohol consumption and fetal alcohol syndrome. Follow-up assessments on reported alcohol consumption were conducted via telephone at 1- and 2-months postbaseline. Participants ranged in age from 18 to 44 and were predominately Hispanic/Latina (44%). Results: At baseline, all respondents reported consuming >= 3 standard drinks on >= 1 occasion in the previous month. Outcome data were available for 131 participants. The main outcome measure was reduction in the number of risky drinking occasions, which did not differ significantly between treatment conditions (odds ratio 1.200, 95% CI 0.567 to 2.539, p = 0.634). Over 70% of the participants, however, reported a reduction in risky drinking occasions regardless of treatment condition (control 43/63, 68%; experimental 49/68, 72%). Conclusions: The results of this study demonstrate that web-based assessment of alcohol consumption among low-income women of reproductive age, as represented by WIC clients, is feasible and acceptable. The findings also suggest that detailed and interactive assessments of alcohol consumption may be sufficient for the reduction of risky drinking within this population without personalized feedback.

Dietz PM; Homa D; England LJ; Burley K; Tong VT; Dube SR et al. Estimates of nondisclosure of cigarette smoking among pregnant and nonpregnant women of reproductive age in the United States. American Journal of Epidemiology 173(3): 355-359, 2011. (14 refs.)

Although clinic-based studies have used biochemical validation to estimate the percentage of pregnant women who deny smoking but are actually smokers, a population-based estimate of nondisclosure of smoking status in US pregnant women has not been calculated. The authors analyzed data from the 1999-2006 National Health and Nutrition Examination Survey and estimated the percentage of 994 pregnant and 3,203 nonpregnant women 20-44 years of age who did not report smoking but had serum cotinine levels that exceeded the defined cut point for active smoking (nondisclosure). Active smoking was defined as self-reporting smoking or having a serum cotinine concentration that exceeded the cut point for active smoking. Overall, 13.0% (95% confidence interval (CI): 8.8, 17.1) of pregnant women and 29.7% (95% CI: 27.3, 32.1) of nonpregnant women were active smokers. Nondisclosure was higher among pregnant active smokers (22.9%, 95% CI: 11.8, 34.6) than among nonpregnant smokers (9.2%, 95% CI: 7.1, 11.2). Among pregnant active smokers, nondisclosure was associated with younger age (20-24 years). Among nonpregnant active smokers, nondisclosure was associated with Mexican-American and non-Hispanic black race/ethnicity. Studies and surveillance systems that rely on self-reported smoking status are subject to underestimation of smoking prevalence, especially among pregnant women, and underreporting may vary by demographic characteristics.

Durmus B; Kruithof CJ; Gillman MH; Willemsen SP; Hofman A; Raat H et al. Parental smoking during pregnancy, early growth, and risk of obesity in preschool children: The Generation R Study. American Journal of Clinical Nutrition 94(1): 164-171, 2011. (47 refs.)

Background: Maternal smoking during pregnancy seems to be associated with obesity in offspring. Not much is known about the specific critical exposure periods or underlying mechanisms for this association. Objective: We assessed the associations of active maternal and paternal smoking during pregnancy with early growth characteristics and risks of overweight and obesity in preschool children. Design: This study was a population-based, prospective cohort study from early fetal life until the age of 4 y in 5342 mothers and fathers and their children. Growth characteristics [head circumference, length, weight, and body mass index (BMI; in kg/m(2))] and overweight and obesity were repeatedly measured at the ages of 1, 2, 3, and 4 y. Results: In comparison with children from nonsmoking mothers, children from mothers who continued smoking during pregnancy had persistently smaller head circumferences and heights until the age of 4 y, whereas their weights were lower only until the age of 3 mo. This smaller length and normal to higher weight led to an increased BMI [SD score difference: 0.11; 95% CI: 0.02, 0.20; P < 0.05)] and an increased risk of obesity (odds ratio: 1.61; 95% CI: 1.03, 2.53; P < 0.05) at the age of 4 y. In nonsmoking mothers, paternal smoking was not associated with postnatal growth characteristics or risk of obesity in offspring. Maternal smoking during pregnancy was associated with a higher BMI at the age of 4 y in children with a normal birth weight and in those who were small for gestational age at birth. Conclusion: Our findings suggest that direct intrauterine exposure to smoke until late pregnancy leads to different height and weight growth adaptations and increased risks of overweight and obesity in preschool children.

Eiden RD; Molnar DS; Leonard KE; Colder CR; Homish GG; Maiorana N et al. Sources and frequency of secondhand smoke exposure during pregnancy. Nicotine & Tobacco Research 13(8): 653-660, 2011. (28 refs.)

Introduction: This study examined sources of exposure to secondhand smoke (SHS) during pregnancy and misclassification of women as having no SHS exposure if partner smoking was used as the only measure of SHS exposure. We also examined changes in SHS exposure across the three trimesters of pregnancy. Methods: The sample consisted of 245 pregnant women who were in a serious relationship with a partner and 106 for examination of change over time. Women's smoking status was determined by a combination of self-reports and oral fluid assays. Women's reports of partner smoking, smoking by other social network members, and frequency of exposure to SHS were obtained. Results: The most common source of SHS exposure during pregnancy was the partner (n = 245). However, reliance on the partner smoking measure alone would have misclassified a substantial number of women as having no SHS exposure during pregnancy. The importance of exposure from the general social network was also evident in the finding that among nonsmoking women with nonsmoking partners, 50% reported some level of SHS exposure in the preceding week. Contrary to expectations, there were no changes in SHS exposure across the three trimesters of pregnancy (n = 106). Conclusions: Results: highlight the need for treatment plans to target sources of exposure from other members of women's social networks in addition to partners. It may be unrealistic to expect women's cessation efforts to be successful in the face of consistent and continued SHS exposure through pregnancy.

Eiden RD; Schuetze P; Colder CR; Veira Y. Maternal cocaine use and mother-toddler aggression. Neurotoxicology and Teratology 33(3): 360-369, 2011. (84 refs.)

This study examined the direct and indirect associations between maternal cocaine use during pregnancy and mother-toddler aggression in an interactive context at 2 years of child age. We hypothesized that in addition to direct effects of cocaine exposure on maternal and child aggression, the association between maternal cocaine use and mother-toddler aggression may be indirect via higher maternal psychiatric symptoms, negative affect, or poor infant autonomic regulation at 13 months. Participants consisted of 220 (119 cocaine exposed, 101 non-cocaine exposed) mother-toddler dyads participating in an ongoing longitudinal study of prenatal cocaine exposure. Results indicated that mothers who used cocaine during pregnancy displayed higher levels of aggression toward their toddlers compared to mothers in the control group. Results from model testing indicated significant indirect associations between maternal cocaine use and maternal aggression via higher maternal negative affect as well as lower infant autonomic regulation at 13 months. Although there were no direct associations between cocaine exposure and toddler aggression, there was a significant indirect effect via lower infant autonomic regulation at 13 months. Results highlight the importance of including maternal aggression in predictive models of prenatal cocaine exposure examining child aggression. Results also emphasize the important role of infant regulation as a mechanism partially explaining associations between cocaine exposure and mother-toddler aggression.

El Marroun H; Tiemeier H; Jaddoe VWV; Hofman A; Verhulst FC; van den Brink W et al. Agreement between maternal cannabis use during pregnancy according to self-report and urinalysis in a population-based cohort: The Generation R Study. European Addiction Research 17(1): 37-43, 2011. (34 refs.)

Aim: To verify self-reported information on prenatal drug use in urine because reporting in pregnancy is sensitive to stigma and might lead to misclassification. Methods: Using semiquantitative immunochemical analysis, the presence of the urinary metabolite (11-nor-Delta 9-tetrahydrocannabinol-9-carboxylic acid) was compared to self-reported prenatal cannabis use. Sensitivity and specificity for self-report and urinalysis outcomes were calculated and Yule's Y was used as an agreement measure. Results: Urine samples were available for 3,997 pregnant women. Of these women, 92 reported having used cannabis during pregnancy (2.3%) and 71 had positive urine screens (1.8%). In total 35% of the 92 women with self-reported cannabis use also had a positive urine screen. Positive urines were relatively frequent in women reporting cannabis use before pregnancy only (7.6%) and in women with missing information (2.6%). Sensitivity and specificity of urinalysis compared to self-report were 0.46 and 0.98. Sensitivity and specificity of self-report compared to urinalysis were 0.36 and 0.99. Yule's Y amounted to 0.77, indicating substantial agreement between the measures. Conclusions: Our findings illustrate the difficulties in obtaining valid information on prenatal cannabis use. To improve the quality of cannabis use data, we suggest a 2-step approach starting with self-report.

Espy KA; Fang H; Johnson C; Stopp C; Wiebe SA; Respass J. Prenatal tobacco exposure: Developmental outcomes in the neonatal period. Developmental Psychology 47(1): 153-169, 2011. (94 refs.)

Smoking during pregnancy is a persistent public health problem that has been linked to later adverse outcomes. The neonatal period-the first month of life-carries substantial developmental change in regulatory skills and is the period when tobacco metabolites are cleared physiologically. Studies to date mostly have used cross-sectional designs that limit characterizing potential impacts of prenatal tobacco exposure on the development of key self-regulatory processes and cannot disentangle short-term withdrawal effects from residual exposure-related impacts. In this study, pregnant participants (N = 304) were recruited prospectively during pregnancy, and smoking was measured at multiple time points, with both self-report and biochemical measures. Neonatal attention, irritable reactivity, and stress dysregulation were examined longitudinally at three time points during the first month of life, and physical growth indices were measured at birth. Tobacco-exposed infants showed significantly poorer attention skills after birth, and the magnitude of the difference between exposed and nonexposed groups attenuated across the neonatal period. In contrast, exposure-related differences in irritable reactivity largely were not evident across the 1st month of life, differing marginally at 4 weeks of age only. Third-trimester smoking was associated with pervasive, deleterious, dose response impacts on physical growth measured at birth, whereas nearly all smoking indicators throughout pregnancy predicted level and growth rates of early attention. The observed neonatal pattern is consistent with the neurobiology of tobacco on the developing nervous system and fits with developmental vulnerabilities observed later in life.

Everett-Murphy K; Paijmans J; Steyn K; Matthews C; Emmelin M; Peterson Z. Scolders, carers or friends: South African midwives' contrasting styles of communication when discussing smoking cessation with pregnant women. Midwifery 27(4): 517-524, 2011. (56 refs.)

Objective: to investigate how midwives are currently communicating with women about smoking during pregnancy with a view to involving them in a smoking cessation intervention in antenatal clinics. Design: a qualitative study using individual, in-depth interviews for data collection. Setting and participants: 24 nurses providing antenatal care to pregnant smokers attending public sector clinics in five major cities in South Africa. Findings: three archetypes of midwives, characterised by different styles of communication and approaches to smoking cessation, emerged from the analysis of the interview data. These were described as the 'Angry Scolders', the 'Benign Carers' and the 'Enthusiastic Friends'. The first type conformed to the traditional, authoritarian style of communication, where the midwife assumed a dominant, expert role. When women failed to comply with their advice, these midwives typically became angry and confrontational. The second type of midwife used a paternalistic communication style and emphasised the role of education in changing behaviour. However, these midwives had little confidence that they could influence women to quit. The third type embraced a patient-centred approach, consciously encouraging more interaction with their patients and attempting to understand change from their point of view. These midwives were optimistic of women's capacity to change and more satisfied with their current health education efforts than the first two types. The Benign Carers and Enthusiastic Friends were more open to participation in the potential intervention than the Angry Scolders. Key conclusions: the prevailing traditional, authoritarian style of communication is inappropriate for smoking cessation education and counselling as it provokes resistance and avoidance on the part of pregnant smokers. The paternalistic approach appears to be largely ineffectual, whereas the patient-centred approach elicits the most positive response from pregnant women and enhances the possibility of a trusting and cooperative relationship with the midwife. Midwives using this style are more open to fulfilling their role in smoking cessation. Implications for practice: smoking cessation interventions need to attend to not only what midwives say to pregnant women about smoking, but also how they communicate about the issue. The use of a patient-centred approach, such as brief motivational interviewing, is recommended as a means of improving counselling outcomes among pregnant smokers.

Fakhfakh R; Jellouli M; Klouz A; Ben Hamida M; Lakhal M; Belkahia C et al. Smoking during pregnancy and postpartum among Tunisian women. Journal of Maternal-Fetal & Neonatal Medicine 24(6): 859- 862, 2011. (34 refs.)

Methods. Cross-sectional analysis of data on self-reported smoking and urinary cotinine among a sample of 398 pregnant women and recently pregnant, mothers of infants under the age of 2 months, who came to the Family Planning Clinic in Tunis urban area for either prenatal or newborn care. We used quantitative colorimetric urine test based on the koonig reaction, in which pink-red chromophores formed from nicotine and its metabolites condensation with barbituric acid were extracted into acetate buffer. Results. The smoking prevalence among Tunisian pregnant women or mothers of newborn infants was 4%. The validity of self-reported daily smoking was relatively low. Among women reporting no smoking at the interview 16% misreported active smoking. According to urinary cotinine values, the smoking prevalence was 18.8%. Conclusions. These results substantiate the unreliability of self-report on smoking status among women in prenatal and postnatal period and have implications in clinical and education practice.

Fokina VM; Patrikeeva SL; Zharikova OL; Nanovskaya TN; Hankins GVD; Ahmed MS. Transplacental transfer and metabolism of buprenorphine in preterm human placenta. American Journal of Perinatology 28(1I): 25-32, 2011. (27 refs.)

We sought to determine whether gestational age affects the transplacental transfer and metabolism of buprenorphine (BUP). Transfer of BUP (10 ng/mL) and its [ 3 H]isotope was determined across placentas of 30 to 34 weeks of gestation utilizing the technique of dual perfusion of placental lobule. Concentration of the drug in trophoblast tissue and in maternal and fetal circuits was determined by liquid scintillation spectrometry. Microsomes prepared from placentas of 17 to 37 weeks of gestation were divided into three groups: late second, early third, and late third trimesters. Antibodies raised against human cytochrome P450 (CYP) isoforms were utilized to identify the enzyme(s) catalyzing BUP biotransformation by preterm placental microsomes. The amount of norbuprenorphine formed was determined by liquid chromatography-mass spectrometry (LC-MS). BUP transfer across the placentas of 30 to 34 weeks of gestation was similar to those at term. CYP19 antibodies caused 60% inhibition of BUP metabolism by microsomes of late second and early third trimesters and 85% by microsomes of late third trimester. The developmental changes occurring in human placenta between 30 weeks of gestation through term do not affect the transfer of BUP across human placenta. CYP19 is the major enzyme responsible for biotransformation of BUP beginning at 17 weeks of gestation until term.

Foley KL; Balazs P; Grenczer A; Rakoczi I. Factors associated with quit attempts and quitting among Eastern Hungarian women who smoked at the time of pregnancy. Central European Journal of Public Health 19(2): 63-66, 2011. (17 refs.)

Introduction: The purpose of this research was to assess factors associated with quit attempts and successful smoking cessation among a sample of socioeconomically disadvantaged pregnant women living in Eastern Hungary. Materials and methods: In-person interviews were conducted among 201 women residing in Eastern Hungary who self-identified as occasional or regular smokers at the time they learned they were pregnant. Results: 54% of the women were smokers at the time they learned they were pregnant. Just over half tried to quit, but only 20% were successful. Factors associated with reduced likelihood of quit attempts included being a regular (vs. occasional) smoker (OR=0.36, 95% Cl 0.13-1.00) and being Roma (vs. non-Roma) (OR=0.32, 95% Cl 0.14-0.72). Women who completed high school were 71/2 times more likely to quit (OR=7.5, 95% Cl 1.68-33.2) and those who were employed were 7% times more likely to quit (OR=7.6, 95% Cl 1.88-30.35). Regular smokers were 88% less likely to quit than occasional smokers. Discussion: Smoking cessation interventions targeting pregnant women are needed in Eastern Hungary. Efforts to integrate smoking cessation into the current excellent pre-natal care and health visitor program will reach most women who are pregnant or who have given birth within the preceding 3 years.

Gadomski A; Adams L; Tallman N; Krupa N; Jenkins P. Effectiveness of a combined prenatal and postpartum smoking cessation program. Maternal and Child Health Journal 15(2): 188-197, 2011. (22 refs.)

Women frequently quit smoking during pregnancy but then relapse postpartum. The BABY & ME-Tobacco Free program combines prenatal and postpartum smoking cessation counseling and biomarker feedback with monthly postpartum incentives. The settings included 22 sites (WIC offices and prenatal clinics) in upstate New York. A quasi-experimental design was used to evaluate this intervention, that included four face-to-face prenatal sessions with a counselor who did smoking cessation counseling, carbon monoxide testing and random saliva cotinine testing. For 1 year postpartum, mothers were biochemically tested every 3-4 weeks and, if negative, were issued a voucher for diapers. Three implementation models were studied: multi-tasking counselors at fixed sites (Models 1 and 2) versus itinerant smoking cessation specialists (Model 3). Outcomes included biochemically validated abstinence rates during pregnancy and postpartum. Logistic regression was used to identify predictors of postpartum abstinence and program dropout. Proportional hazards regression was used to compare implementation models. Of the 777 pregnant women who enrolled in the program, 588 were eligible for the postpartum program. The intention to treat pregnancy quit rate was 60%. Postpartum, Model 3 showed consistently better quit outcomes than the other models. Predictors of abstinence at 6 months postpartum are: older age (OR = 1.07, 95% C.I. 1.02-1.12), lower baseline carbon monoxide level (OR = 0.69, 95% C.I. 0.49-0.97), Model 3 (OR = 4.60, 95% C.I. 2.80-7.57) and attending more prenatal sessions (OR = 3.52; 95% C.I. 2.19-5.65). The BABY & ME-Tobacco Free program is an effective smoking cessation program for pregnant and parenting women.

Goel N; Beasley D; Rajkumar V; Banerjee S. Perinatal outcome of illicit substance use in pregnancy: Comparative and contemporary socio-clinical profile in the UK. European Journal of Pediatrics 170(2): 199-205, 2011. (23 refs.)

The aim of the study was to determine the contemporary socio-clinical profile and perinatal outcome of illicit substance use in pregnancy in a large UK city and compare with published literature. Cases were identified retrospectively from the 'cause for concern' referrals over 5 years (2003-2007). Data was collected on mother-infant pair from medical notes and laboratory records. Chi-square and Mann-Whitney U tests were used where appropriate for statistical analysis. One hundred sixty-eight women were identified as using illicit substance in pregnancy. Smoking (97.4%), unemployment (85.4%) and single status (42.3%) were frequent. Besides controlled use of methadone, heroin, cannabis and benzodiazepines were the most commonly used drugs. Hepatitis C prevalence was high (29.9%) despite low antenatal screening rates (57.7%). Neonatal morbidity was related to prematurity (22.9%), small for dates (28.6%) and neonatal abstinence syndrome (NAS; 58.9%). By day 5 of life, 95.1% of the babies developing NAS and 96.1% of those requiring pharmacological treatment were symptomatic. Of the infants developing NAS, 31.7% required pharmacological treatment. A total of 82.5% babies went home with their mother, and 21.2% were placed on the Child Protection Register. Only 14.3% were breast feeding at discharge. Illicit substance use in pregnancy continues to be associated with significant maternal and neonatal morbidity, and the socio-clinical profile in this decade appears unchanged in the UK. Hepatitis C prevalence is high, and detection should be improved through targeted antenatal screening. Where facility in the community is unavailable, 5 days of hospital stay is sufficient to safely identify babies at risk of developing NAS. Most babies were discharged home with their mother.

Gollenberg AL; Mumford SL; Cooney MA; Sundaram R; Louis GMB. Validity of retrospectively reported behaviors during the periconception window. Journal of Reproductive Medicine 56(3-4): 130-137, 2011. (31 refs.)

OBJECTIVE: To assess the validity of retrospectively reported maternal behaviors while attempting pregnancy. STUDY DESIGN: Participants in a prospective pregnancy cohort study with periconception enrollment were queried about. use of cigarettes, alcohol, vitamins and caffeine and the consumption of sport fish while attempting pregnancy. Prospective longitudinal data reported in daily diaries (gold standard) were compared with data obtained a decade later using a self-administered questionnaire. Agreement was assessed by percent agreement and Kappa coefficients. RESULTS: Among the 82 participating women, percent agreement ranged from 54-74% for the 5 behaviors. Validity was highest for smoking (Kappa = 0.43, 95% confidence interval [CI]: 0.22, 0.65) followed by fish consumption (Kappa = 0.32, 95% CI: 0.09, 0.55), caffeine (Kappa = 0.21, 95% CI: 0.09, 0.51) and alcohol (Kappa = 0.20, 95% CI: 0.08, 0.33). There were no systematic differences in agreement by time to pregnancy or pregnancy outcome. Associations between smoking and alcohol consumption and pregnancy outcomes were highly sensitive to the levels of misclassification observed in this study. CONCLUSION: Validity was poor to moderate for the 5 behaviors, though higher for more regular behaviors such as smoking and caffeine consumption. The potential for misreporting of periconception behaviors can affect inferences, and thus efforts to capture information prospectively should be promoted.

Goodman D. Buprenorphine for the treatment of perinatal opioid dependence: Pharmacology and implications for antepartum, intrapartum, and postpartum care. (review). Journal of Midwifery & Women's Health 56(3): 240- 247, 2011. (51 refs.)

Opioid dependence during pregnancy is associated with significant health risks for both the mother and her fetus. Opioid maintenance therapy with methadone (Dolophine) is the current standard of care, reduces medical and social risks associated with illicit drug use, and decreases rates of prematurity and low birth weight. However, treatment with methadone is frequently associated with neonatal abstinence syndrome. Buprenorphine is an alternative to methadone that preliminary data indicates is equivalent in safety and efficacy to methadone and significantly increases access to treatment. The pharmacology of buprenorphine and its implications for the care of pregnant women with opioid dependence are described.

Gyllstrom ME; Hellerstedt WL; McGovern PM. Independent and interactive associations of prenatal mood and substance use with infant birth outcomes. Maternal and Child Health Journal 15(2): 198-204, 2011. (34 refs.)

The main objective of this work is to examine low prenatal mood, alcohol and tobacco use and rates of preterm (PTB) and low birth weight (LBW) births among women in Minnesota between 2002 and 2006. We examined the Minnesota version of the national, cross-sectional survey of postpartum women, the Pregnancy Risk Assessment Monitoring System (MN PRAMS). Of the 11,891 women sampled in 2002-2006, 7,457 had complete data for analysis; the weighted response rates averaged 76%. The major variables of interest were: LBW, PTB, maternal mood during pregnancy, prenatal alcohol use, prenatal tobacco use and interaction terms created from the mood and substance use variables. Women with low mood who used tobacco during pregnancy were twice as likely to have a LBW infant as women who did not smoke and reported high mood (AOR = 2.12, 95% CI: 1.35, 3.33, P = 0.001). Among women who abstained from alcohol during pregnancy, those with low mood were at an increased risk for PTB (AOR = 1.95, 95% CI: 1.54-2.45, P < 0.0001) compared to women with high mood. Low maternal mood was associated with increased risks for PTB, and LBW births among MN PRAMS respondents. Substance use and low prenatal mood co-occur and the combined effect on PTB and LBW birth outcomes warrants further investigation.

Handal M; Engeland A; Ronning M; Skurtveit S; Furu K. Use of prescribed opioid analgesics and co-medication with benzodiazepines in women before, during, and after pregnancy: A population-based cohort study. European Jurnal of Clinical Pharmacology 67(9): 953-960, 2011. (37 refs.)

The aim of the study was to describe the use of prescribed opioid analgesics for noncancer pain and the degree of possible concurrent co-medication with benzodiazepines to women in Norway before, during, and after pregnancy. This was a population-based cohort study based on linkage of two nationwide registries: the Medical Birth Registry of Norway, and the Norwegian Prescription Database. Prescribed opioid analgesics and benzodiazepines issued to women 3 months prior to, during, and 3 months after pregnancies were identified. The study population consisted of 194,937 singleton pregnancies beginning in March 2004 or later and ending before January 2009. About 6% of the women were dispensed opioid analgesics before, during, or after pregnancy. Almost all these women received weak opioids (99%) with short-acting codeine in combination with paracetamol (acetaminophen) as the most frequently dispensed drug. The dispensing of codeine was reduced from 24/1,000 women before pregnancy to 10/1,000 in the last trimester, increasing to 17/1,000 during the breastfeeding period. Most women were dispensed codeine once, and treatment was of short duration (about 1 week). A small group of women (n = 271) were dispensed opioids in all trimesters. Increasing benzodiazepine use was observed as the number of opioid prescriptions increased. The use of opioid analgesics in pregnant women in Norway was dominated by treatment of short duration of the weak opioid codeine. As pregnancy proceeded, opioid use was reduced. However, the increase in opioid use during the nursing period has the potential for serious adverse effects.

Hayatbakhsh MR; Kingsbury AM; Flenady V; Gilshenan KS; Hutchinson DM; Najman JM. Illicit drug use before and during pregnancy at a tertiary maternity hospital 2000-2006. Drug and Alcohol Review 30(2): 181-187, 2011. (26 refs.)

Introduction and Aims. To study the prevalence of use of illicit drugs by women of reproductive age before and during pregnancy and the changes in rates of illicit drug use in pregnancy over recent years. Design and Methods. All pregnant women attending the public antenatal clinic over a 7 year period (2000-2006) were routinely interviewed about their use of illicit drugs by a midwife at the antenatal booking visit. Measurements. Records for 25 049 women, who self-reported previous and current use of cannabis, amphetamines, ecstasy and heroin, were included in the study. Results. Cannabis was the most common illicit drug used before and during pregnancy; 9.3% of women were engaged in regular use prior to pregnancy and 2.5% were users during pregnancy. A very low proportion of women reported use of amphetamines, ecstasy or heroin in pregnancy. There was an increase in ever regular use and any past use of cannabis, amphetamines and ecstasy over time. Conclusions. The prevalence of illicit drug use by young women prior to becoming pregnant is of concern. While pregnancy appears to be a strong motivator for women to cease substance use, there is a need to study whether women resume drug use after their baby is born.

Heil SH; Jones HE; Arria A; Kaltenbach K; Coyle M; Fischer G et al. Unintended pregnancy in opioid-abusing women. Journal of Substance Abuse Treatment 40(2): 199-202, 2011. (13 refs.)

The aim of this study was to estimate the prevalence of unintended pregnancy and its three subtypes (mistimed, unwanted, and ambivalent) among opioid-abusing women. In the general population, 31%-47% of pregnancies are unintended; data on unintended pregnancy in opioid-and other drug-abusing women are lacking. Pregnant opioid-abusing women (N = 946) screened for possible enrollment in a multisite randomized controlled trial comparing opioid maintenance medications completed a standardized interview assessing sociodemographic characteristics, current and past drug use, and pregnancy intention. Almost 9 of every 10 pregnancies were unintended (86%), with comparable percentages mistimed (34%), unwanted (27%), and ambivalent (26%). Irrespective of pregnancy intention, more than 90% of the total sample had a history of drug abuse treatment, averaging more than three treatment episodes. Interventions are sorely needed to address the extremely high rate of unintended pregnancy among opioid-abusing women. Drug treatment programs are likely to be an important setting for such interventions.

Hser YI; Evans E; Huang D; Messina N. Long-term outcomes among drug-dependent mothers treated in women-only versus mixed-gender programs. Journal of Substance Abuse Treatment 41(2): 115-123, 2011. (48 refs.)

This study examined the long-term outcomes of women who were pregnant or parenting at admission to women-only (WO; n = 500) versus mixed-gender (MG; a matched sample of 500) substance abuse treatment programs. Administrative records on arrests, incarcerations, mental health services utilization, and drug treatment participation were collected, covering 3 years preadmission and 8 years postadmission. Women treated in WO programs had lower levels of arrest, mental health services utilization rates, and drug treatment participation during the first year after drug treatment. No differences were found between the two groups in the long-term trajectories except that the WO program participants had lower incarceration rates during the third year after treatment. The study findings suggest a positive short-term impact of WO versus MG programs with regard to arrest and mental health services utilization. Limited long-term gain is shown in the reductions in posttreatment incarceration. The study findings suggest the added value of specialized WO programs and begin to address the gap in knowledge regarding long-term outcomes for substance-abusing women.

Hunt BR; Whitman S. Maternal smoking in Chicago: A community-level analysis. Journal of Health Care for The Poor and Underserved 22(1): 194-210, 2011. (60 refs.)

Birth certificate data were employed to determine the prevalence of maternal smoking in Chicago communities by race and ethnicity. For purposes of comparison, we present data for the U.S. and the city of Chicago as a whole. Across the city of Chicago, 5.6% of women smoked during pregnancy, a rate much lower than the national average of 13.9%. The maternal smoking rate among non-Hispanic (NH) Black women (11.8%) was more than twice that of NH White women (4.5%) and almost 10 times that of Hispanic women (1.2%). For predominantly NH White and NH Black communities, we observed a significant, negative relationship between household income and the percentage of women who smoke during pregnancy. The prevalence of smoking among NH Black women in Chicago was particularly high, demonstrating an unmet need for appropriate interventions.

Jansson LM; DiPietro JA; Velez M; Elko A; Williams E; Milio L et al. Fetal neurobehavioral effects of exposure to methadone or buprenorphine. Neurotoxicology and Teratology 33(2): 240- 243, 2011. (24 refs.)

As part of a double-blind study of medication treatment for opioid dependence during pregnancy, 17 opioid-dependent pregnant women maintained on either buprenorphine or methadone underwent fetal monitoring at 24, 28, 32, and 36 weeks gestation. Maternal demographic information and infant outcomes did not significantly differ by medication group. Earlier in gestation (24 and 28 weeks), buprenorphine-exposed fetuses had higher levels of fetal heart rate variability, more accelerations in fetal heart rate and greater coupling between fetal heart rate and fetal movement than the methadone-exposed group (all ps<.05). Later in gestation (32 and 36 weeks), buprenorphine-exposed fetuses displayed less suppression of motor activity and longer duration of movements than the methadone-exposed group (all ps<.05). These results may have implications for the optimal treatment of the opioid-dependent pregnant woman.

Johnston V; Thomas DP; McDonnell J; Andrews RM. Maternal smoking and smoking in the household during pregnancy and postpartum: Findings from an Indigenous cohort in the Northern Territory. Medical Journal of Australia 194(10): 556- 559, 2011. (27 refs.)

Objective: To describe the trends in maternal smoking and smoking in the household for a cohort of Indigenous women followed from late pregnancy to 7 months postpartum. Design: and setting: Prospective cohort study embedded within a randomised controlled trial (RCT) performed in the Northern Territory involving partiClpants recruited between 30 June 2006 and 4 May 2010. Participants: 215 Indigenous women aged 17-39 years who had been recruited into the RCT, 162 of whom had completed their last study visit at 7 months postpartum by 1 June 2010. Main outcome measures: Smoking status of women, and smoking within their households, in their third trimester, and at 1 month, 2 months and 7 months postpartum. Results: There were complete data on women's smoking status for 121 participants. Among these, the self-reported smoking rate was 45% (95% CI 36%-55%) during pregnancy, increasing to 63% (95% CI 54%-71%) at 7 months postpartum. Of the 66 women who were non-smokers at the antenatal visit, 23 (35%; 95% CI 23%-47%) were smoking by the time their baby reached 7 months of age. Thirty-one per cent (95% CI 23%-39%) of households included people who smoked inside during the antepartum period, whereas 16% (95% CI 10%-23%) included people who smoked inside at 7 months postpartum. Conclusions: While an apparent reduction in indoor exposure to tobacco smoke during the postpartum period is encouraging, this is offset by an increase in the proportion of antenatal non-smokers who subsequently reported smoking after the birth of their child. More health care service delivery and research attention needs to be directed to smoking during pregnancy and to postpartum relapse in this population.

Jones HE; Kaltenbach K; Heil SH; Stine SM; Coyle MG; Arria AM et al. Neonatal abstinence syndrome after methadone or buprenorphine exposure. (review). Obstetrical & Gynecological Survey 66(4): 191-193, 2011. (0 refs.)

The recommended treatment for opioid dependence in pregnant women is methadone, a full mu-opioid agonist. However, in utero exposure to methadone is associated with neonatal abstinence syndrome (NAS) that is characterized by hyperirritability of the central nervous system and a dysfunctional autonomic nervous system. Management of NAS often requires prolonged hospitalization and pharmacologic intervention. A partial mu-opioid agonist, buprenorphine, has been investigated as an alternative treatment for opioid dependence but relatively few studies of this drug have been conducted in pregnant women. Some prospective open-label and controlled studies suggest that NAS occurring in neonates treated prenatally with buprenorphine was less likely to require treatment than NAS in neonates exposed to prenatal methadone. However, the results of these studies have been inconsistent. This double-blind, randomized, controlled study compared the use of buprenorphine and methadone for management of pregnant women with opioid dependency. The study subjects were 175 pregnant opioid-dependent women enrolled at 8 international sites. A total of 131 of these women completed the trial; 58 (44%) were patients receiving buprenorphine and 73 (56%) were women treated with methadone. The 5 primary neonatal outcomes included the number of neonates requiring treatment for NAS, the peak NAS score, the total amount of morphine needed to treat NAS, length of hospital stay, and head circumference. The P values for all group comparisons were calculated according to prespecified thresholds for significance. More women receiving prenatal buprenorphine (28/86, 33%) discontinued treatment as compared with those receiving prenatal methadone (16/89, 18%). In comparison with methadone, neonates of women treated with prenatal buprenorphine required significantly less morphine (mean dose, 1.1 vs. 10.4 mg; P < 0.009), had a 43% decrease in the hospital stay (10.0 vs. 17.5 days, P < 0.009), and spent 58% less time in the hospital receiving medication for NAS (4.1 vs. 9.9 days, P < 0.003). No significant differences were found between groups for other primary or secondary outcomes, including the number of neonates requiring NAS treatment, the peak NAS score, head circumference, or any other adverse neonatal or maternal outcome. These findings suggest that buprenorphine is an acceptable alternative to methadone for treatment for opioid dependency during pregnancy and with further studies, may actually be the preferred therapeutic.

Jones HE; Tuten M; O'Grady KE. Treating the partners of opioid-dependent pregnant patients: Feasibility and efficacy. American Journal of Drug and Alcohol Abuse 37(3): 170-178, 2011. (25 refs.)

Background: Drug-dependent pregnant women with intimate partners who are also drug-dependent have been found to have compromised treatment outcomes. Thus, developing a treatment to reduce a male partner's drug use is the first step in a line of research with a distal goal of improving pregnant patient's treatment outcomes. Objective: This study examined a novel intervention for engaging the male partner in drug treatment. Methods: Men targeted for intervention were non-treatment-seeking opioid users. Motivational enhancement therapy (MET), an effective non-confrontational intervention approach for evoking behavioral change, was employed to encourage treatment participation. This six-session intervention was followed by a drug-abstinent contingency-based voucher incentive program. Moreover, to help maintain drug abstinence, male partners had rapid facilitation into either opioid detoxification with aftercare or methadone maintenance. Interwoven into treatment were both couple's counseling and a men's group educational program designed to strengthen the support provided by the men to their partners during pregnancy and post-delivery. Men (n = 45) received either the novel intervention package called HOPE (Helping Other Partners Excel) or a control condition (n = 17) that received weekly support and referrals for treatment. Results: Men in the HOPE condition, compared with the usual care condition, showed increased treatment retention, transient decreases in heroin use, increased involvement in recreational activities, less reliance on public assistance, and increased social support for their pregnant partners. Conclusion and clinical significance: Results suggest that treatment of male partners is feasible and efficacious in the short term but modifications to the intervention are needed to sustain results.

Jones SC; Telenta J; Cert G; Shorten A; Johnson K. Midwives and pregnant women talk about alcohol: What advice do we give and what do they receive? Midwifery 27(4): 489-496, 2011. (39 refs.)

Background: the Australian National Health and Medical Research Council (NHMRC) recently revised its guidelines for alcohol consumption during pregnancy and breast feeding, moving from a recommendation of minimising intake to one of abstinence. Women are potentially exposed to a variety of messages about alcohol and pregnancy, including from the media and social contacts, and are likely to see midwives as the source of expert advice in understanding these contradictory messages. Objective: to explore the advice that midwives believe they give to pregnant women about alcohol consumption, and the advice that pregnant women believe they receive; the knowledge and attitudes of both groups regarding alcohol consumption and the consistency with the NHMRC guidelines; and the receptivity and comfort of both groups in discussing alcohol consumption in the context of antenatal appointments. Design: individual semi-structured interviews with midwives and pregnant women. Setting: face-to-face interviews with midwives and telephone interviews with pregnant women were conducted in two regional areas of New South Wales in 2008-2009. Participants: 12 midwives and 12 pregnant women. Findings: midwives and pregnant women consistently agreed that conversations about alcohol are generally limited to brief screening questions at the first visit, and the risks are not discussed or explained (except for high-risk women). Key conclusions: both groups expressed comfort with the idea of discussing alcohol consumption, but lacked knowledge of the risk and recommendation, and it appears that this opportunity to provide women with information is under-utilised. Implications for practice: there is a need to provide midwives with accurate information about the risks of alcohol consumption during pregnancy and effective communication tools to encourage them to discuss the risks and recommendations with their patients.

Kellogg A; Rose CH; Harms RH; Watson WJ. Current trends in narcotic use in pregnancy and neonatal outcomes. American Journal of Obstetrics and Gynecology 204(3): e-article 259, 2011. (11 refs.)

OBJECTIVE: The purpose of this study was to evaluate trends and prevalence of chronic prescription narcotic use during pregnancy and the subsequent neonatal outcomes. STUDY DESIGN: We conducted a retrospective cohort study of all deliveries at Mayo Clinic from 1998 through 2009; the data was obtained from prospectively maintained obstetrics and neonatal databases. RESULTS: Over the study time period, there were 26,314 deliveries; 167 women used prescription narcotics chronically during pregnancy. The prevalence of women who used chronic narcotics during their pregnancy increased over the time period from 1998-2009 (P < .0001). Neonatal withdrawal syndrome occurred in 10 of neonates (5.6%), and all but 1 of these neonates required pharmacologic treatment for the disease. CONCLUSION: Chronic narcotic use during pregnancy is increasing in prevalence. Neonatal withdrawal syndrome occurred in 5.6% of the exposed neonates. Although neonatal withdrawal syndrome is uncommon, it is clinically significant. Physicians need to consider the risks and benefits carefully when prescribing narcotic pain medications during pregnancy.

Kelly PJ; Goudar SS; Chakraborty H; Moore J; Derman R; Kodkany B et al. Pregnant women and children's exposure to tobacco and solid fuel smoke in southwestern India. Journal of Maternal-Fetal & Neonatal Medicine 24(7): 973-977, 2011. (10 refs.)

Methods. We conducted a survey of exposure to second-hand smoke (SHS) and solid fuel smoke (SFS) among 736 pregnant women. Odds ratios (OR) and 95%% confidence intervals (CI) were computed using logistic regression models to assess the relationship between demographic variables and exposure to SHS and to SFS. Results. aEuro integral While few respondents smoked cigarettes, 19.9%% of women and 27.8%% of children were frequently or always exposed to SHS, and 43.5%% were at high and 46.7%% at medium risk for SFE. Low educational levels and illiteracy were associated with exposure. Conclusions. Smoke exposure is a serious health risk for many poor women and children in India.

Kothari CL; Wendt A; Liggins O; Overton J; Sweezy LD. Assessing maternal risk for fetal-infant mortality: A population-based study to prioritize risk reduction in a healthy start community. Maternal and Child Health Journal 15(1): 68-76, 2011. (42 refs.)

Study goals were to distinguish between maternal risk factors for fetal versus infant mortality, and to identify which maternal characteristics contributed the greatest risk of mortality overall. This case-control retrospective study abstracted data on more than forty maternal characteristics from 261 prenatal and delivery records: all 26 fetal deaths, all 40 infant deaths and 195 randomly selected surviving births in a high-mortality Healthy Start community. Bivariate and multivariate analyses were conducted. The fetal-mortality population was significantly more likely than the infant-mortality population to have no insurance (P = .047), inadequate prenatal care (P = .039) and previous fetal death (P = .021). Comparing the combined mortality population with the surviving sample, two tiers of risk emerged: Rare-but-lethal risks, including no prenatal care (P < .001) and Child-Protective-Service involvement (P = .001), and common-and-dangerous risks, including inadequate maternal weight gain (OR = 13.55), drug or alcohol abuse (OR = 8.67), obesity (OR = 2.77) and anemia (OR = 3.61). Both fetal and infant mortality groups must be considered when identifying maternal risks. Inadequate prenatal weight gain, obesity and anemia contribute as much to feto-infant mortality as substance abuse. Public health efforts to improve maternal nutrition and healthy weight should be redoubled.

Kuehn BM. Buprenorphine during pregnancy. (editorial). Journal of the American Medical Association 305(4): problem ?348-348, 2011. (0 refs.)

Lau C; Rogers JM; Desai M; Ross MG. Fetal programming of adult disease: Implications for prenatal care. Obstetrics and Gynecology 117(4): 978-985, 2011. (80 refs.)

The obesity epidemic, including a marked increase in the prevalence of obesity among pregnant women, represents a critical public health problem in the United States and throughout the world. Over the past two decades, it has been increasingly recognized that the risk of adult health disorders, particularly metabolic syndrome, can be markedly influenced by prenatal and infant environmental exposures (ie, developmental programming). Low birth weight, together with infant catch-up growth, is associated with a significant risk of adult obesity and cardiovascular disease, as well as adverse effects on pulmonary, renal, and cerebral function. Conversely, exposure to maternal obesity or high birth weight also represents an increased risk for childhood and adult obesity. In addition, fetal exposure to select chemicals (eg, phytoestrogens) or environmental pollutants (eg, tobacco smoke) may affect the predisposition to adult disease. Animal models have confirmed human epidemiologic findings and provided insight into putative programming mechanisms, including altered organ development, cellular signaling responses, and epigenetic modifications (ie, control of gene expression without modification of DNA sequence). Prenatal care is transitioning to incorporate goals of optimizing maternal, fetal, and neonatal health to prevent or reduce adult-onset diseases. Guidelines regarding optimal pregnancy nutrition and weight gain, management of low-and high-fetal-weight pregnancies, use of maternal glucocorticoids, and newborn feeding strategies, among others, have yet to fully integrate long-term consequences on adult health.

Leonardi-Bee J; Britton J; Venn A. Secondhand smoke and adverse fetal outcomes in nonsmoking pregnant women: A meta-analysis. Pediatrics 127(4): 734-741, 2011. (50 refs.)

OBJECTIVE: To determine the risk of adverse fetal outcomes of secondhand smoke exposure in nonsmoking pregnant women. METHODS: This was a systematic review and meta-analysis in accordance with Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We searched Medline and Embase (to March 2009) and reference lists for eligible studies; no language restrictions were imposed. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by using random-effect models. Our search was for epidemiologic studies of maternal exposure to secondhand smoke during pregnancy in nonsmoking pregnant women. The main outcome measures were spontaneous abortion, perinatal and neonatal death, stillbirth, and congenital malformations. RESULTS: We identified 19 studies that assessed the effects of secondhand smoke exposure in nonsmoking pregnant women. We found no evidence of a statistically significant effect of secondhand smoke exposure on the risk of spontaneous abortion (OR: 1.17 [95% CI: 0.88-1.54]; 6 studies). However, secondhand smoke exposure significantly increased the risk of stillbirth (OR: 1.23 [95% CI: 1.09-1.38]; 4 studies) and congenital malformation (OR: 1.13 [95% CI: 1.01-1.26]; 7 studies), although none of the associations with specific congenital abnormalities were individually significant. Secondhand smoke exposure had no significant effect on perinatal or neonatal death. CONCLUSIONS: Pregnant women who are exposed to secondhand smoke are estimated to be 23% more likely to experience stillbirth and 13% more likely give birth to a child with a congenital malformation. Because the timing and mechanism of this effect is not clear, it is important to prevent secondhand smoke exposure in women before and during pregnancy.

Maritz GS; Harding R. Life-long programming implications of exposure to tobacco smoking and nicotine before and soon after birth: Evidence for altered lung development. International Journal of Environmental Research and Public Health 8(3): 875-898, 2011. (134 refs.)

Tobacco smoking during pregnancy remains common, especially in indigenous communities, and likely contributes to respiratory illness in exposed offspring. It is now well established that components of tobacco smoke, notably nicotine, can affect multiple organs in the fetus and newborn, potentially with life-long consequences. Recent studies have shown that nicotine can permanently affect the developing lung such that its final structure and function are adversely affected; these changes can increase the risk of respiratory illness and accelerate the decline in lung function with age. In this review we discuss the impact of maternal smoking on the lungs and consider the evidence that smoking can have life-long, programming consequences for exposed offspring. Exposure to maternal tobacco smoking and nicotine intake during pregnancy and lactation changes the genetic program that controls the development and aging of the lungs of the offspring. Changes in the conducting airways and alveoli reduce lung function in exposed offspring, rendering the lungs more susceptible to obstructive lung disease and accelerating lung aging. Although it is generally accepted that prevention of maternal smoking during pregnancy and lactation is essential, current knowledge of the effects of nicotine on lung development does not support the use of nicotine replacement therapy in this group.

Massey SH; Lieberman DZ; Reiss D; Leve LD; Shaw DS; Neiderhiser JM. Association of clinical characteristics and cessation of tobacco, alcohol, and illicit drug use during pregnancy. American Journal on Addictions 20(2): 143-150, 2011. (46 refs.)

Pregnancy is a time of relative urgency and opportunity for the treatment of substance use disorders in women, yet little is known about modifiable factors that contribute to successful abstinence. We examined self-worth, depression, anxiety, and novelty seeking in the context of substance use cessation during pregnancy in a sample of women with a high prevalence of substance abuse. Subjects were 448 birth mothers who participated in a prospective adoption study. Discontinuation rates were: tobacco 22.2%, alcohol 64.7%, marijuana 77.2%, and other drugs, 73.7-100%. Depression, anxiety, and novelty seeking were lower among women who discontinued substance use, compared to those who did not. Self-worth was higher in women who discontinued substance use. Among 110 polysubstance users, the number of substances discontinued during pregnancy was correlated with depression, anxiety, and self-worth in the hypothesized direction. Possible clinical implications are discussed.

Matijasevich A; Brion MJ; Menezes AM; Barros AJD; Santos IS; Barros FC. Maternal smoking during pregnancy and offspring growth in childhood: 1993 and 2004 Pelotas cohort studies. Archives of Disease in Childhood 96(6): 519- 525, 2011. (32 refs.)

Objective To explore the effects of maternal smoking during pregnancy on offspring growth using three approaches: (1) multiple adjustments for socioeconomic and parental factors, (2) maternal-paternal comparisons as a test of putative intrauterine effects and (3) comparisons between two birth cohort studies. Methods Population-based birth cohort studies were carried out in Pelotas, Brazil, in 1993 and 2004. Cohort members were followed up at 3, 12, 24 and 48 months. Multiple linear regression analysis was used to examine the relationships between maternal and paternal prenatal smoking and offspring anthropometric indices. In the 2004 cohort, the association of smoking with trunk length, leg length and leg-to-sitting-height ratio at 48 months was also explored. Results: Maternal smoking during pregnancy was associated with reduced z scores of length/height-for-age at each follow-up in both cohorts and reduced leg length at 48 months in the 2004 cohort. Children older than 3 months born to smoking women showed a higher body mass index-for-age z score than children of nonsmoking women. Conclusions: The results of this study strongly support the hypothesis that maternal smoking during pregnancy impairs linear growth and promotes overweight in childhood.

May PA; Gossage JP. Maternal risk factors for fetal alcohol spectrum disorders not as simple as it might seem. Alcohol Research & Health 34(1): 15-26, 2011. (76 refs.)

Gathering information about drinking during pregnancy is one of the most difficult aspects of studying fetal alcohol spectrum disorders (FASD). This information is critical to linking specific risk factors to any particular diagnosis within the FASD continuum. This article reviews highlights from the literature on maternal risk factors for FASD and illustrates that maternal risk is multidimensional, including factors related to quantity, frequency, and timing of alcohol exposure; maternal age; number of pregnancies; number of times the mother has given birth; the mother's body size; nutrition; socioeconomic status; metabolism; religion; spirituality; depression; other drug use; and social relationships. More research is needed to more clearly define what type of individual behavioral, physical and genetic factors are most likely to lead to having children with FASD.

Milligan K; Niccols A; Sword W; Thabane L; Henderson J; Smith A. Length of stay and treatment completion for mothers with substance abuse issues in integrated treatment programmes. Drugs: Education, Prevention and Policy 18(3): 219-227, 2011. (33 refs.)

Aim: To examine the effects of integrated treatment programmes (those with addiction services and pregnancy-, parenting- or child-related services) on length of stay and treatment completion. Methods: We systematically reviewed studies published between 1990 and 2008 comparing integrated programmes with non-integrated programmes on length of stay (number of studies [K] = 3, number of participants [n] = 1910) and treatment completion (K = 6, n = 2556). We performed meta-analyses using standardized mean differences (d) of effect size estimates. Findings: There was a significant advantage of integrated treatment programmes over non-integrated treatment in the number of days women spent in treatment (d = 0.35, p < 0.0001) but not treatment completion (d = 0.38, p = 0.09). Conclusions: This meta-analysis is the first systematic quantitative review of studies evaluating the impact of integrated programmes. Findings suggest that integrated programmes may be associated with a small advantage over non-integrated programmes in length of stay. This review highlights the need for further research with improved methodology, quality, and reporting to improve our understanding of how best to engage, retain and support mothers with substance abuse issues in treatment.

Mohsin M; Bauman AE; Forero R. Socioeconomic correlates and trends in smoking in pregnancy in New South Wales, Australia. Journal of Epidemiology and Community Health 65(8): 727-732, 2011. (40 refs.)

Objective. This study describes trends (1994-2007) in smoking in pregnancy (SIP) among an Australian population sample of women. This study also examines trends in the socioeconomic distribution of SIP over the 14-year period. Methods. Bivariate and multiple logistic regression analyses of the NSW Midwives Data Collection were used to explore the associations and trends in SIP by sociodemographic factors. Results. The prevalence of SIP in New South Wales (NSW) declined from 22.1% (1994) to 13.5% in 2007. However, the largest decrease in SIP rates was among the highest socioeconomic group (67.9% decline), and smaller declines were observed among teenage and remote rural mothers. Maternal age, ethnicity, Aboriginality, area of remoteness and socioeconomic status were independently associated with SIP. The distribution of NSW mothers has changed, with fewer younger mothers and more from an Asian background. Conclusion. This study reported large declines in SIP prevalence, with a population effect similar to that expected following exposure to (Cochrane-defined) intensive behavioural interventions. However, no specially targeted public health efforts were made during this period to influence SIP, so that social norm change is the likely explanation for these population health changes. The relative decline in SIP was smaller among low-socioeconomic status mothers, by language spoken at home, Aboriginality and area of remoteness, suggesting that inequalities in SIP have increased over this 14-year period. This information informs equity-based approaches to targeting further smoking cessation programs for pregnant Australian women.

Moraes CL; da Silva TDT; Reichenheim ME; Azevedo GL; Oliveira ASD; Braga JU. Physical violence between intimate partners during pregnancy and postpartum: A prediction model for use in primary health care facilities. Paediatric and Perinatal Epidemiology 25(5): 478-486, 2011. (50 refs.)

This article offers a simple predictive model of physical intimate partner violence (PIPV) to be used by primary health care (PHC) professionals. The sample comprised 811 mothers of children <5 months old attending PHC facilities in Rio de Janeiro, Brazil. A multinomial logit model was used. Measured by the Revised Conflict Tactics Scales, PIPV was classified in three levels (absence, at least one episode during pregnancy or postpartum, and presence in both periods). Socio-economic, demographic and life style variables were considered as potential predictors. Maternal age <20 years, an education of <8 years of schooling, raising >2 children under 5, tobacco smoking, alcohol misuse and illicit drug use by the mother and/or partner, and perception of baby's ill-health were identified as predictors of PIPV. The model-projected prevalence of PIPV for pregnancy and/or postpartum was just 10.1% in the absence of these characteristics, whereas this increased to 96.4% when all the seven characteristics were present. Child, maternal and family characteristics greatly increase the likelihood of PIPV and could be used together as screening indicators.

Muckle G; Laflamme D; Gagnon J; Boucher O; Jacobson JL; Jacobson SW. Alcohol, smoking, and drug use among Inuit women of childbearing age during pregnancy and the risk to children. Alcoholism: Clinical and Experimental Research 35(6): 1081- 1091, 2011. (62 refs.)

Background: Alcohol consumption during pregnancy, a known teratogen often associated with drug use and smoking is a well-known public health concern. Aim: This study provides prevalence data for alcohol, smoking, and illicit drug use before, during, and after pregnancy among Inuit. Factors associated with alcohol use are also identified. Methods: Two hundred and eight Inuit women from Arctic Quebec were interviewed at mid-pregnancy, and at 1 and 11 months postpartum to provide descriptive data on smoking, alcohol, and drug use during pregnancy, and the year before and after pregnancy. Sociodemographic and family characteristics potentially associated with alcohol use were documented. Results: Ninety-two percent of the women reported smoking and 61% reported drinking during pregnancy. Episodes of binging during pregnancy were reported by 62% of the alcohol users, which correspond to 38% of pregnant women. Thirty-six percent of the participants reported using marijuana during pregnancy. Alcohol use and binge drinking during pregnancy were more likely to be reported by women who lived in less crowded houses, had a better knowledge of a second language, drank alcohol more often and in larger amounts prior to pregnancy, and used illicit drugs. Binge drinkers were more likely to be single women and to have had fewer previous pregnancies. Postpartum distress and violence were more likely to be experienced by women who used alcohol during pregnancy. Binge drinking during pregnancy was best predicted by drinking habits before pregnancy, maternal symptoms of depression, the use of illicit drugs during pregnancy, and the number of young children living with the mother. Conclusions: These results confirm that alcohol is a major risk factor to maternal and child health in this population, underscoring the need for culturally relevant and effective prevention programs.

Murin S; Rafii R; Bilello K. Smoking and smoking cessation in pregnancy. Clinics in Chest Medicine 32(1): 75-+, 2011. (90 refs.)

Smoking during pregnancy is among the leading preventable causes of adverse maternal and fetal outcomes. Smoking prevalence among young women is the primary determinant of smoking prevalence during pregnancy. Smoking among women of childbearing age is associated with reduced fertility, increased complications of pregnancy, and a variety of adverse fetal outcomes. There is increasing evidence of lasting adverse effects on offspring. Guidelines for smoking cessation during pregnancy have been developed. This article reviews the epidemiology of smoking during pregnancy, the adverse effects of smoking on the mother, fetus, and offspring, and recommended approaches to smoking cessation for pregnant women.

Nomura Y; Gilman SE; Buka SL. Maternal smoking during pregnancy and risk of alcohol use disorders among adult offspring. Journal of Studies on Alcohol and Drugs 72(2): 199-209, 2011. (88 refs.)

Objective: The aim of this study was to evaluate the association between maternal smoking during pregnancy (MSP) and lifetime risk for alcohol use disorder (AUD) and to explore possible mechanisms through which MSP may be related to neurobehavioral conditions during infancy and childhood, which could, in turn, lead to increased risk for AUD. Method: A sample of 1,625 individuals was followed from pregnancy for more than 40 years. Capitalizing on the long follow-up time, we used survival analysis to examine lifetime risks of AUD (diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) in relation to levels of MSP (none, < 20 cigarettes/day, and >= 20 cigarettes/day). We then used structural equation modeling to test hypotheses regarding potential mechanisms, including lower birth weight, neurological abnormalities, poorer academic functioning, and behavioral dysregulation. Results: Relative to unexposed offspring, offspring of mothers who smoked 20 cigarettes per day or more exhibited greater risks for AUD (hazard ratio = 1.31, 95% CI [1.08, 1.59]). However, no differences were observed among offspring exposed to fewer than 20 cigarettes per day. In structural equation models, MSP was associated with neurobehavioral problems during infancy and childhood, which, in turn, were associated with an increased risk for adult AUD. Conclusions: MSP was associated with an increased lifetime risk for AUD. Adverse consequences were evident from birth to adulthood. A two-pronged remedial intervention targeted at both the mother (to reduce smoking during pregnancy) and child (to improve academic functioning) may reduce the risk for subsequent AUD.

Obel C; Olsen J; Henriksen TB; Rodriguez A; Jarvelin MR; Moilanen I et al. Is maternal smoking during pregnancy a risk factor for Hyperkinetic disorder?-findings from a sibling design. International Journal of Epidemiology 40(2): 338-345, 2011. (24 refs.)

Background: Studies have consistently shown that pregnancy smoking is associated with twice the risk of hyperactivity/inattention problems in the offspring. An association of this magnitude may indicate behavioural difficulties as one of the most important health effects related to smoking during pregnancy. However, social and genetic confounders may fully or partially account for these findings. Methods: A cohort including all singletons born in Finland from 1 January 1987 through 31 December 2001 was followed until 1 January 2006 based on linkage of national registers. Data were available for 97% (N = 868 449) of the population. We followed singleton children of smoking and non-smoking mothers until they had an International Classification of Diseases, 10th revision, diagnosis of hyperkinetic disorder (HKD) or to the end of the observation period. We used sibling-matched Cox regression analyses to control for social and genetic confounding. Results We found a much smaller association between exposure to maternal smoking during pregnancy and risk of HKD in children using the sibling-matched analysis [hazards ratio (HR) = 1.20, 95% confidence interval (CI) 0.97-1.49] than was observed in the entire cohort (HR 2.01, 95% CI 1.90-2.12). Conclusions: Our findings suggest that the strong association found in previous studies may be due to time-stable familial factors, such as environmental and genetic factors. If smoking is a causal factor, the effect is small and less important than what the previous studies indicate.

Payne JM; France KE; Henley N; D'Antoine HA; Bartu AE; O'Leary CM et al. RE-AIM evaluation of the Alcohol and Pregnancy Project: Educational resources to inform health professionals about prenatal alcohol exposure and fetal alcohol spectrum disorder. Evaluation & the Health Professions 34(1): 57-80, 2011. (29 refs.)

The objective was to evaluate the Alcohol and Pregnancy Project that provided health professionals in Western Australia (WA) with educational resources to inform them about prevention of prenatal alcohol exposure and fetal alcohol spectrum disorder (FASD). The authors developed, produced, and distributed educational resources to 3,348 health professionals in WA. Six months later, they surveyed 1,483 of these health professionals. The authors used the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance) to evaluate the project. The educational resources were effective in producing a 31% increase in the proportion of health professionals who routinely provided pregnant women with information about the consequences of drinking alcohol during pregnancy. One hundred percent of the settings adopted the project, it reached 96.3% of the target population, it was implemented as intended, and the resources were maintained (http: www.ichr.uwa.edu.au/alcoholandpregnancy). The educational resources for health professionals have potential to contribute to reducing prenatal alcohol exposure and FASD.

Pizarro D; Habli M; Grier M; Bombrys A; Sibai B; Livingston J. Higher maternal doses of methadone does not increase neonatal abstinence syndrome. Journal of Substance Abuse Treatment 40(3): 295-298, 2011. (14 refs.)

Objective: The purpose of this study is to assess the incidence of clinically significant neonatal abstinence syndrome (NAS) based on maternal antenatal methadone dosing in women with a history of narcotic dependence. Study design: A retrospective review of 174 pregnant women on methadone maintenance was performed. Data were stratified based on maternal methadone dose at delivery: low (0-50 mg/day, n = 59), medium (51-100 mg/day, n = 63), and high (>100 mg/day, a = 52). NAS was defined by Finnegan as score greater than 7 on two occasions. Outcome measures were rate and severity of NAS, birth weight, preterm birth rate, and neonatal morbidities and mortality. Results: The rates of NAS (40.7% vs. 52.4% vs. 40.8%, p > .05), birth weight, and neonatal morbidities were similar regardless of the maternal methadone dose. Although there was a trend toward earlier delivery, the rate of preterm birth among the three groups (low dose, 17%; medium dose, 19%; high dose, 27%; p > .05) was not statistically significant. Conclusion: Higher maintenance dosing of methadone is not associated with increased rate or severity of NAS or other adverse perinatal outcomes. Concerns about NAS should not restrict the methadone dosing during pregnancy. Methadone dosing should not be restricted to lower dosing during pregnancy.

Radcliffe P. Motherhood, pregnancy, and the negotiation of identity: The moral career of drug treatment. Social Science & Medicine 72(6): 984- 991, 2011. (50 refs.)

In this paper I seek to engage with literature on recovery by focusing on gendered identity and motherhood in accounts of pregnant and postpartum women. Interview accounts are analysed as the site of moral work where women use discursive strategies to present themselves as plausible mothers and locate themselves in relation to a moral career of drug treatment and motherhood. I make the case that this performative work entails the representation of lived practices as well as the presentation of self. I argue that opportunities need to be provided for pregnant and postpartum drug users to engage with services and that their performative work needs to be acknowledged by professionals in order that non-stigmatising identities can be endorsed.

Rayburn WF; Brennan MC. Periconception warnings about prescribing opioids. (editorial). American Journal of Obstetrics and Gynecology 204(4): 281-282, 2011. (10 refs.)

Roberts SCM; Pies C. Complex calculations: How drug use during pregnancy becomes a barrier to prenatal care. Maternal and Child Health Journal 15(3): 333-341, 2011. (45 refs.)

Pregnant women who use drugs are more likely to receive little or no prenatal care. This study sought to understand how drug use and factors associated with drug use influence women's prenatal care use. A total of 20 semi-structured interviews and 2 focus groups were conducted with a racially/ethnically diverse sample of low-income women using alcohol and drugs in a California county. Women using drugs attend and avoid prenatal care for reasons not connected to their drug use: concern for the health of their baby, social support, and extrinsic barriers such as health insurance and transportation. Drug use itself is a barrier for a few women. In addition to drug use, women experience multiple simultaneous risk factors. Both the drug use and the multiple simultaneous risk factors make resolving extrinsic barriers more difficult. Women also fear the effects of drug use on their baby's health and fear being reported to Child Protective Services, each of which influence women's prenatal care use. Increasing the number of pregnant women who use drugs who receive prenatal care requires systems-level rather than only individual-level changes. These changes require a paradigm shift to viewing drug use in context of the person and society and acceptance of responsibility for unintended consequences of public health bureaucratic procedures and messages about effects of drug use during pregnancy.

Rossi BV; Berry KF; Hornstein MD; Cramer DW; Ehrlich S; Missmer SA. Effect of alcohol consumption on in vitro fertilization. Obstetrics and Gynecology 117(1): 136-142, 2011. (21 refs.)

OBJECTIVE: To estimate whether alcohol use at the initiation of an in vitro fertilization (IVF) cycle is associated with IVF outcomes. METHODS: In this prospective cohort study, men and women completed a self-administered questionnaire before their first IVF cycle. Participants reported alcohol type, amount, and frequency consumed. Discrete survival analysis was applied to calculate the odds ratio (OR) and 95% confidence interval (CI) for live birth-the primary outcome. Secondary outcomes were cycle characteristics and points of failure in the IVF process (cycle cancellation, failed fertilization, implantation failure, and spontaneous abortion). We conducted multicycle analyses with final models adjusted for potential confounders that included cycle number, cigarette use, body mass index, and age. RESULTS: A total of 2,545 couples contributed 4,729 cycles. Forty-one percent of women and 58% of men drank one to six drinks per week. Women drinking at least four drinks per week had 16% less odds of a live birth rate compared with those who drank fewer than four drinks per week (OR 0.84, CI 0.71-0.99). For couples in which both partners drank at least four drinks per week, the odds of live birth were 21% lower compared with couples in which both drank fewer than four drinks per week (OR 0.79; CI 0.66-0.96). CONCLUSION: Consumption of as few as four alcoholic drinks per week is associated with a decrease in IVF live birth rate.

Salihu HM; Kornosky JL; Lynch O; Alio AP; August EM; Marty PJ. Impact of prenatal alcohol consumption on placenta-associated syndromes. Alcohol 45(1): 73-79, 2011. (31 refs.)

The biology of placental and fetal development suggests that alcohol may play a significant role in increasing the risk of feto-infant morbidity and mortality, but study results are inconsistent and the mechanism remains poorly defined. Previous studies have not examined the risk of placenta-associated syndromes (PASs: defined as the occurrence of either placental abruption, placenta previa, preeclampsia, small for gestational age, preterm, or stillbirth) as a unique entity. Therefore, we sought to examine the relationship between prenatal alcohol use and the risk of PAS among singleton births in the Missouri maternally linked data files covering the period 1989-2005. Logistic regression with adjustment for intracluster correlation was used to generate adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Compared with nondrinkers, drinkers were more likely to be smokers, 35 years of age or older, black, and multiparous. Drinkers had an increased risk of PAS (OR = 1.26, 95% CI = 1.22,1.31) when compared with their nondrinking counterparts. The risk of PAS was progressively amplified with increasing prenatal alcohol consumption (P for trend <.01). Women who reported consuming five or more alcoholic drinks per week had more than twofold increased risk of PASs, whereas women in the lowest drinking category (one to two drinks per week) had only a slight increased risk of PAS (OR = 1.09, 95% CI = 1.05, 1.14). Enhanced understanding of the mechanism by which prenatal alcohol consumption leads to PAS may aid in the development of more targeted interventions designed to prevent adverse pregnancy outcomes. Screening women for alcohol use may assist providers in protecting developing fetuses from the potential dangers of prenatal alcohol use.

Sanders JL. What might have been: Sullivan may have impacted modern prenatal alcohol research under different circumstances. (editorial). International Journal of Epidemiology 40(2): 283-285, 2011. (21 refs.)

Shamu S; Abrahams N; Temmerman M; Musekiwa A; Zarowsky C. A systematic review of African studies on intimate partner violence against pregnant women: Prevalence and risk factors. (review). PLoS ONE 6(3): article e17591, 2011. (58 refs.)

Background: Intimate partner violence (IPV) is very high in Africa. However, information obtained from the increasing number of African studies on IPV among pregnant women has not been scientifically analyzed. This paper presents a systematic review summing up the evidence from African studies on IPV prevalence and risk factors among pregnant women. Methods: A key-word defined search of various electronic databases, specific journals and reference lists on IPV prevalence and risk factors during pregnancy resulted in 19 peer-reviewed journal articles which matched our inclusion criteria. Quantitative articles about pregnant women from Africa published in English between 2000 and 2010 were reviewed. At least two reviewers assessed each paper for quality and content. We conducted meta-analysis of prevalence data and reported odds ratios of risk factors. Results: The prevalence of IPV during pregnancy ranges from 2% to 57% (n = 13 studies) with meta-analysis yielding an overall prevalence of 15.23% (95% CI: 14.38 to 16.08%). After adjustment for known confounders, five studies retained significant associations between HIV and IPV during pregnancy (OR1.48-3.10). Five studies demonstrated strong evidence that a history of violence is significantly associated with IPV in pregnancy and alcohol abuse by a partner also increases a woman's chances of being abused during pregnancy (OR 2.89-11.60). Other risk factors include risky sexual behaviours, low socioeconomic status and young age. Conclusion: The prevalence of IPV among pregnant women in Africa is one of the highest reported globally. The major risk factors included HIV infection, history of violence and alcohol and drug use. This evidence points to the importance of further research to both better understand IPV during pregnancy and feed into interventions in reproductive health services to prevent and minimize the impact of such violence.

Simmons RW; Madra NJ; Levy SS; Riley EP; Mattson SN. Co-regulation of movement speed and accuracy by children with heavy prenatal alcohol exposure. Perceptual and Motor Skills 112(1): 172-182, 2011. (37 refs.)

The study investigated how children with heavy prenatal alcohol exposure regulate movement speed and accuracy during goal-directed movements. 16 children ages 7 to 17 years with confirmed histories of heavy in utero alcohol exposure, and 21 nonalcohol-exposed control children completed a series of reciprocal tapping movements between two spatial targets. 5 different targets sets were presented, representing a range of task difficulty between 2 and 6 bits of information. Estimates of percent error rate, movement time, slope, and linear fit of the resulting curve confirmed that for goal-directed, reciprocal tapping responses, performance of the group with prenatal alcohol exposure was described by a linear function, as predicted by Fitts' law, by sacrificing movement accuracy. The index of performance was the same for the two groups: it initially increased, then leveled off for more difficult movements.

Sullivan WC. A note on the influence of maternal inebriety on the offspring. (reprint from 1899). International Journal of Epidemiology 40(2): 278-282, 2011. (12 refs.)

Author's Introduction: The object of the following paper is to present the result of a number of observations touching certain aspects of the question of habitual inebriety, notably the r�le of maternal alcoholism as an agent in race degeneracy. . . . I have selected from the female population of Liverpool Prison, amongst whom habitual inebriety is very prevalent, a series of cases of chronic drunkards who have borne children; and from the history of these children, and more particularly from the indications given by the infant mortality, I have sought to illustrate the mode in which the maternal intoxication appears to have reacted on the development of the offspring. In the selection I have endeavoured, as far as possible, to choose cases in which alcoholism occurred uncomplicated by other degenerative factors. Author's Conclusion: The observations which we have thus briefly analysed enable us to form a fairly clear idea of the mode in which maternal inebriety reacts upon the offspring. We are familiar with the fact, clearly established by Morel, that the chronic alcoholism of one or both parents frequently appears as the first moment in the degenerative career of a family; that it represents a state of artificial degradation of the organism, capable of transmission in augmented force to the descendants, and culminating in some four generations in the extinction of the stock. In the case of maternal inebriety we have the same mode of action to consider, but with it, and very much more potent, we have the continued toxic influence exercised on the developing embryo throughout pregnancy. The brilliant researches of F�r� in the field of experimental teratology have sufficiently demonstrated the gravity of this influence. We have, further, to bear in mind the possible effect of alcoholic excesses during lactation. Lastly, reinforcing all these modes of influence, we have the detrimental effects, positive and negative, of the deterioration of the milieu as an indirect consequence of the mother's drunkenness.

Swamy GK; Reddick KLB; Brouwer RJN; Pollak KI; Myers ER. Smoking prevalence in early pregnancy: Comparison of self-report and anonymous urine cotinine testing. Journal of Maternal-Fetal & Neonatal Medicine 24(1): 86-90, 2011. (28 refs.)

Objective. Societal pressures against smoking during pregnancy may lead to a reduction in disclosure of smoking status. The objective of this study was to compare prevalence of smoking at prenatal intake by self-report with anonymous biochemical validation. Methods. Women receiving care at the Duke Obstetrics Clinic from February 2005 through January 2006 were eligible for evaluation. Self-reported smoking and urine samples were obtained anonymously at prenatal intake. The NicCheck (TM) I semi-quantitative dipstick was used to detect urinary nicotine, cotinine, and 3-hydroxycotinine. The difference, with 95% confidence interval, between the proportions of smokers by self-report and urine testing was calculated for (1) high-positive vs. low-positive and negative results combined and (2) any positive vs. negative results. Results. Among 297 subjects, self-reported smoking was 18.2 vs. 14.8% for low-positive and negative results combined with an absolute difference of 3.4%, [-2.9%, 9.6%]. When comparing self-report with any positive result (43.1%), the absolute difference was 24.9%, [17.4%, 32.1%]. Conclusions. Our findings suggest that most pregnant women disclose their smoking and many nonsmokers may have significant second-hand exposure. Universal urinary cotinine screening of pregnant women could aid in appropriately counseling women about second-hand exposure as well as monitoring women at high risk for adverse pregnancy outcomes.

Vardavas CI; Patelarou E; Grander M; Chatzi L; Palm B; Fthenou E et al. The association between active/passive smoking and toxic metals among pregnant women in Greece. Xenobiotica 41(6): 456- 463, 2011. (45 refs.)

1. Exposure to toxic metals during pregnancy may have detrimental effects on foetal development. We assessed the role of sociodemographic characteristics and active and passive smoking on blood concentrations of metals (As, Cd, Pb, Hg, Sb, U, Mn and Mo). 2. Venous blood drawn from 50 pregnant women, randomly selected from the mother-child birth cohort 'Rhea'. Extensive questionnaire data on active and passive smoking were collected. Urinary cotinine was measured to validate self-reported exposure and non-smoking status. 3. Smokers had higher concentrations of Cd (1.0 mu g/L) as compared with non-smokers (0.29 mu g/L, P < 0.001) and a tendency for higher As and Hg. Among non-smokers, blood As and Hg concentrations were also associated with exposure to passive smoking in public venues and the family home and to overall greater secondhand smoke (SHS) exposure (As: 0.97 mu g/L among heavy-exposed compared with 0.20 mu g/L among the low-exposed, P < 0.05; Hg: 2.1 mu g/L vs. 0.9 mu g/L respectively, P < 0.05). Controlling for fish and seafood intake altered the statistical significance but not the direction of the above associations. 4. Smoking was associated with higher Cd concentrations in pregnant women, although the association between passive smoking and elevated As and Hg concentrations was indicative, however inconclusive.

Vezina-Im LA; Godin G. Psychosocial determinants of intention to abstain from drinking alcohol while pregnant among a sample of women of childbearing age. Addiction Research & Theory 19(2): 128-137, 2011. (60 refs.)

In many countries, not drinking alcohol during pregnancy is strongly recommended, since consuming alcohol can be hazardous for the unborn child. Despite this, a number of women drink alcohol while pregnant. The two objectives of the study were to identify (1) the determinants of intention to abstain from drinking alcohol while pregnant among 167 women of childbearing age between 18 and 44 years and (2) the factors that programmes promoting alcohol abstinence during pregnancy should consider. Data were collected using a questionnaire based on an extended version of the theory of planned behaviour. A large majority of the participants reported consuming alcohol on a regular basis. Although most of them expressed a strong intention to abstain from alcohol during pregnancy, about one woman in four did not have a firm intention. A logistic regression analysis revealed that the four determinants of intention were moral norm (odds ratio (OR) 12.97; 95% confidence interval (CI95%): 3.83=43.91), anticipated regret (OR = 11.43; CI95%: 3.46=37.75), attitude (OR 7.49; CI95%: 2.37=23.64) and perceived behavioural control (OR 3.60; CI95% 1.11=11.65). Moreover, a discriminant analysis identified specific beliefs significantly related to intention not to consume alcohol while pregnant. These results can prove useful in guiding the development of a programme promoting alcohol abstinence among women of childbearing age in order to reduce the number of unborn children exposed to alcohol during pregnancy.

Webb DA; Culhane JF; Mathew L; Bloch JR; Goldenberg RL. Incident smoking during pregnancy and the postpartum period in a low-income urban population. Public Health Reports 126(1): 50-59, 2011. (41 refs.)

Objectives. We determined the prevalence of first lifetime use of cigarettes during pregnancy or in the early postpartum period (incident smoking) and identified sociodemographic and health-related characteristics of incident smokers. Methods. We used statistics based on data from a longitudinal study of a large cohort of pregnant, low-income, urban women (n=1,676) to describe the timing of first-time use and to compare incident smokers with those who had never smoked and those who had already smoked prior to pregnancy. Results. About one in 10 (10.2%) women who had not previously smoked initiated cigarette smoking during pregnancy or in the early postpartum period. Compared with those who had never smoked, incident smokers were more likely to report high levels of stress and to have elevated levels of depressive symptomatology, which may be rooted in relatively poor social and economic conditions. Conclusion. A significant number of women may be initiating smoking during pregnancy or in the early postpartum period. These women have characteristics that are consistent with the risk factors associated with smoking. Further research is warranted to determine prevalence in other populations, identify the risk factors for incident smoking, and assess the potential for primary prevention efforts designed to help women who had previously avoided cigarette use to remain smoke-free throughout pregnancy and in the postpartum period.

Wehby GL; Fletcher JM; Lehrer SF; Moreno LM; Murray JC; Wilcox A; Lie RT. A genetics instrumental variables analysis of the effects of prenatal smoking on birth weight: Evidence from two samples. Biodemography and Social Biology 57(1, special issue): 3- 32, 2011. (73 refs.)

There is a large literature showing the detrimental effects of prenatal smoking on birth and childhood health outcomes. It is somewhat unclear, though, whether these effects are causal or reflect other characteristics and choices by mothers who choose to smoke that may also affect child health outcomes or biased reporting of smoking. In this paper, we use genetic markers that predict smoking behaviors as instruments to address the endogeneity of smoking choices in the production of birth and childhood health outcomes. Our results indicate that prenatal smoking produces more dramatic declines in birth weight than estimates that ignore the endogeneity of prenatal smoking, which is consistent with previous studies with non-genetic instruments. We use data from two distinct samples from Norway and the United States with different measured instruments and find nearly identical results. The study provides a novel application that can be extended to study several behavioral impacts on health and social and economic outcomes.

Yee LM; Wu D. False-positive amphetamine toxicology screen results in three pregnant women using labetalol. Obstetrics and Gynecology 117(2, Part 2 Supplement): 503-506, 2011. (8 refs.)

BACKGROUND: Labetalol is commonly used for control of hypertension in pregnancy. A component of the workup for new-onset hypertension in pregnancy often includes a urine drug screen. A labetalol metabolite is structurally similar to amphetamine and methamphetamine, thus causing potential cross-reactivity in drug immunoassays. CASES: We present one case of cocaine-induced hypertensive crisis superimposed on chronic hypertension and two cases of severe preeclampsia for which patients required escalating doses of labetalol for hypertension, with subsequent false-positive amphetamine urine drug screen results. CONCLUSION: In pregnant women requiring labetalol for treatment of hypertensive disease, a urine drug screen may be falsely positive for amphetamines and methamphetamines. Providers should be cognizant of this possibility when interpreting the results of urine drug screens.