Serving Substance Abuse Professionals Since 1993

Last Update: 10.10.09

C O R K O N L I N E

powerpoint presentations
CORK database search
resource materials
bibliographies
clinical tools
user services
newsletters
about cork
home

CORK Bibliography: Pregnancy

84 citations. January 2009 to present

Prepared: September 2009

Altink ME; Slaats-Willemse DIE; Rommelse NNJ; Buschgens CJM; Fliers EA; Arias-Vasquez A et al. Effects of maternal and paternal smoking on attentional control in children with and without ADHD. European Child and Adolescent Psychiatry 18(8): 465-475, 2009. (56 refs.)

Maternal smoking during pregnancy is a risk factor for attention-deficit/hyperactivity disorder (ADHD), but data on its adverse effects on cognitive functioning are sparse and inconsistent. Since the effect of maternal smoking during pregnancy may be due to correlated genetic risk factors rather than being a pure environmental effect, we examined the effect of prenatal exposure to smoking on attentional control, taking into account the effects of both maternal and paternal smoking, and examined whether these effects were genetically mediated by parental genotypes. We further examined whether the effect of prenatal exposure to smoking on attentional control interacted with genotypes of the child. Participants were 79 children with ADHD, ascertained for the International Multi-centre ADHD Gene project (IMAGE), and 105 normal controls. Attentional control was assessed by a visual continuous performance task. Three genetic risk factors for ADHD (DRD4 7-repeat allele of the exon 3 variable number of tandem repeats (VNTR), DAT1 10/10 genotype of the VNTR located in the 3' untranslated region, and the DAT1 6/6 genotype of the intron 8 VNTR) were included in the analyses. Paternal smoking had a negative effect on attentional control in children with ADHD and this effect appeared to be mediated by genetic risk factors. The prenatal smoking effect did not interact with genotypes of the child. Maternal smoking had no main effect on attentional control, which may be due to lower smoking rates. This study suggests that the effects of paternal smoking on attentional control in children with ADHD should be considered a proxy for ADHD and/or smoking risk genes. Future studies should examine if the results can be generalized to other cognitive domains.

Ashford KB; Hahn E; Hall L; Rayens MK; Noland M. Postpartum smoking relapse and secondhand smoke. Public Health Reports 124(4): 515-526, 2009. (42 refs.)

Objective. There has been an abundance of research evaluating prenatal and postnatal smoking abstinence programs. However, few researchers have tested postpartum relapse interventions that address secondhand smoke (SHS) exposure. Pregnant women exposed to SHS are more likely to relapse. This article explores the similarities and differences among postpartum interventions that incorporate SHS education. Generating knowledge about the components of postpartum relapse prevention interventions that do and do not achieve prolongation of abstinence is integral to the development of effective SHS interventions that help women achieve lifelong abstinence. Methods. We used a methodological review of 11 randomized, controlled trials testing the efficacy of relapse prevention interventions that address SHS exposure. We compared intervention strength, biomarker validation of home smoking and SHS, as well as abstinence and relapse rates. We examined three predictors of postpartum relapse: (1) partner smoking in the home, (2) adoption of home smoking restrictions, and (3) motivation/confidence to remain abstinent. Results. Findings revealed a need for more comprehensive SHS interventions and a clear delineation of abstinence/relapse terminology. Biomarker validation of home smoking and SHS was primarily measured by self-report, passive nicotine monitors, and hair nicotine levels. Furthermore, studies using nurse- and pediatrician-led interventions resulted in the lowest relapse rates. Conclusion. A comprehensive intervention that specifically prioritizes parental education on the health effects of SHS on the family, empowerment of the mother and family members to remain abstinent and adopt a smoke-free home smoking policy, and partner influence on smoking could result in a significant reduction in postpartum relapse rates.

Bailey BA; Cole LKJ. Rurality and birth outcomes: Findings from southern Appalachia and the potential role of pregnancy smoking. Journal of Rural Health 25(2): 141-149, 2009. (44 refs.)

Context; Rates of preterm birth (PTB) and low birth weight (LBW) vary by region, with disparities particularly evident in the Appalachian region of the South. Community conditions related to rurality likely contribute to adverse birth outcomes in this region. Purpose: This study examined associations between rurality and related community conditions, and newborn outcomes in southern Appalachia, and explored whether pregnancy smoking explained such associations. Methods: Data for all births in a southern Appalachian county over a 2-year period were extracted from hospital records. Findings: Data were available for 4,144 births, with 45 different counties of residence. Babies born to women from completely rural counties, on average, weighed 700 g less, were 1.5 inches shorter, and were born over 3 weeks earlier than less rural infants. In addition, these babies were 4.5 times more likely to be LBW, 4 times more likely to be PTB, and 5 times more likely to be admitted to the neonatal intensive care unit (NICU). Effects were also found for per capita income, poverty rate, and unemployment rate, all of which were associated with rurality. Some, but not all of the association was explained by elevated rates of pregnancy smoking. Conclusions: Babies born to women residing in rural and economically depressed counties in southern Appalachia are at substantially increased risk for poor birth outcomes. Improving these outcomes in the rural South will likely require addressing access to health services and information, health care provider retention, transportation services, employment opportunities, and availability of public health services including smoking cessation assistance.

Bakstad B; Sarfi M; Welle-Strand GK; Ravndal E. Opioid maintenance treatment during pregnancy: Occurrence and severity of neonatal abstinence syndrome. European Addiction Research 15(3): 128-134, 2009. (38 refs.)

Background: Opioid maintenance treatment (OMT) is widely used to treat pregnant women with a history of opioid dependence. This study investigated whether maternal methadone/buprenorphine dose and nicotine use in pregnancy affects the occurrence and duration of neonatal abstinence syndrome (NAS) in the infant. Methods: Forty-one pregnant women from OMT programmes in Norway who gave birth between January 2005 and January 2007 were enrolled in a national prospective study. Thirty-eight women (81% of the population) were interviewed in the last trimester of pregnancy and 3 months after delivery. Data from the European Addiction Severity Index and a questionnaire measuring enrolled birth information were compared with medical records and urine analyses. Results: Treatment requiring NAS occurred in 58% of the methadone-exposed and in 67% of the buprenorphine-exposed infants. There was no significant relationship between a maternal dose of methadone or buprenorphine in pregnancy and NAS treatment duration for the infant. The mean number of cigarettes consumed correlated significantly with NAS treatment duration for the methadone group. Birth weight for the methadone group was approximately 200 g above international findings despite high doses during pregnancy. Conclusions: Maternal methadone/buprenorphine dose predicted neither the occurrence nor the need for NAS treatment for the infant.

Biederman J; Monuteaux MC; Faraone SV; Mick E. Parsing the associations between prenatal exposure to nicotine and offspring psychopathology in a nonreferred sample. Journal of Adolescent Health 45(2): 142-148, 2009. (35 refs.)

Purpose: Several studies have suggested an association between maternal smoking during pregnancy and both attention-deficit/hyperactivity disorder (ADHD) and conduct disorder (CD) in the offspring of women who smoke during pregnancy. However, it is unclear whether one or both of the documented links are spurious, given the considerable comorbidity between these disorders. The main aim of this study was to disentangle the association between maternal smoking during pregnancy with psychopathological outcomes, adjusting for possible confounders. Methods: Two large, identically designed, longitudinal, case-control family studies of male and female probands with and without ADHD were combined. We used data from the nonreferred siblings of the probands from both studies (n = 536). All subjects were blindly assessed with structured diagnostic interviews. Logistic regression analysis was used to determine the adjusted effect of exposure to maternal smoking during pregnancy. Results: Among all siblings, maternal smoking during pregnancy was significantly associated with ADHD, independent of CD and other covariates. In contrast, maternal smoking during pregnancy was a risk factor for CD only in siblings of control probands, after adjusting for covariates. Conclusions: These results support the hypothesis that maternal smoking during pregnancy is a risk factor for both ADHD and CD, independently of each other. However, the risk for CD appears to be conditional on family risk status.

Bouwstra H; Dijk-Stigter GR; Grooten HMJ; Janssen-Plas FEM; Koopmans AJ; Mulder CD et al. Prevalence of abnormal general movements in three-month-old infants. Early Human Development 85(6): 399-403, 2009. (32 refs.)

Background: The quality of general movements (GMs) is a sensitive tool to measure neurodevelopmental condition in early infancy. No information is available on prevalence rates of abnormal GMs in the general population. Objective: To assess the prevalence of abnormal GMs in the general population of three-month-old infants and to evaluate the association of abnormal GM quality with medical and social risk factors. Method: We recruited 535 infants in six well baby clinics in The Netherlands. GMs were video-taped at the corrected age of 2 to 4 months. GM-quality was assessed by two persons unaware of the infant's history. GM-quality was classified as normal optimal (NO), normal suboptimal (SO), mildly abnormal (MA) and definitely abnormal (DA). Only the last category implies clinically relevant dysfunction. Social, perinatal and postnatal characteristics were collected and their association with DA and abnormal (DA + MA) GMs were evaluated by means of univariate and logistic regression analyses. Results: GM-quality Could be assessed reliably in 455 infants (85%). Seventeen infants (3.7%) showed DA GMs and 113 (25%) MA GMs. DA GMs were associated with preterm birth and smoking during pregnancy; abnormal (DA + MA) GMs with preterm birth, a relatively low level of paternal profession and urban living conditions. These factors explained between 3% and 7% of variance. Conclusion: The study indicates that the prevalence of definitely abnormal GMs in the general population is 3.7% and that of mildly abnormal GMs 25%. The clinically relevant definitely abnormal GMs were associated with preterm birth and smoking during pregnancy.

Burstyn I; Kapur N; Shalapay C; Bamforth F; Wild T; Liu JX et al. Evaluation of the accuracy of self-reported smoking in pregnancy when the biomarker level in an active smoker is uncertain. Nicotine & Tobacco Research 11(6): 670-678, 2009. (21 refs.)

Our main objective was to estimate smoking prevalence as well as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of self-reported smoking among pregnant women in Edmonton, Canada, at 15-16 weeks of gestation. We used serum samples to assemble a cohort of pregnant women who underwent an optional second-trimester screening for chromosomal and developmental anomalies. We determined cotinine concentrations for 92 self-reported smokers (11% of the cohort) and for 285 self-reported nonsmoking mothers, using adapted urinary cotinine assay. Self-reports were collected at the time of delivery. In a validation study, serum cotinine was determined for known smokers and nonsmokers and used, within a Bayesian statistical framework, to define the distribution of cutoffs that differentiate true smokers from nonsmokers. This distribution of cutoffs was used to construct multiple two-by-two tables to obtain the distribution of sensitivity, specificity, PPV, NPV, and prevalence. Sensitivity was poor (M = 47.4%, SD = 17.3%), but specificity was nearly perfect (M = 94.9%, SD = 1.1%). PPV (M = 66.6%, SD = 11.7%) was smaller than NPV (M = 84.7%, SD = 14.3%). In our sample, the prevalence of true smoking at 15-16 weeks of gestation was described by a skewed distribution with a mean of 21.6% (SD = 13.8%) and a median of 16.6%. The strength of the present study includes blinding of subjects to the intention to test their sera for a biomarker of smoking. A limitation was the use of a nonrandom sample restricted to pregnancies that resulted in live births. We discuss data collection methods that would elicit more accurate smoking histories from pregnant women.

Campbell R; Murphy DJ. Smoking in pregnancy. (editorial). British Medical Journal 338: article b2188, 2009. (12 refs.)

Chen XG; Woodcroft KJ. Polymorphisms in metabolic genes CYP1A1 and GSTM1 and changes in maternal smoking during pregnancy. Nicotine & Tobacco Research 11(3): 225-233, 2009. (61 refs.)

Studies have documented the role of variations in genes that encode metabolic enzymes in altering the effects of maternal smoking on child health. We assessed the association of the MspI polymorphism in CYP1A1(*2A) and the null GSTM1 with maternal smoking behavior during pregnancy. Smoking data for women during pregnancy were derived through in-person interviews and from genotyping data from buccal cell DNA for 165 smoking mothers (85% Black) accompanying their children to Children's Hospital of Michigan in Detroit. The number of daily smokers declined from 157 (95.2%) 30 days prior to pregnancy to 81 (49.1%) by the last trimester. The polymorphic variants of CYP1A1*2A (TC or CC) were positively associated with self-reduction and spontaneous quitting and negatively associated with persistent smoking. After allowing for the effect from covariates, we found the adjusted odds ratio (OR) for the association of any C allele to be 2.12 (95% CI = 1.00-4.61) for self-reduction, 1.71 (95% CI = 1.00-2.91) for ever quit smoking, and 0.53 (95% CI = 0.31-0.91) for persistent smoking. The null GSTM1 polymorphism was not associated with any of the three smoking measures. The single base substitution in the 3' noncoding region of the phase-1 metabolic gene CYP1A1 may facilitate self-reduction and quitting of tobacco smoking during pregnancy. This finding provides new data on the possible genetic etiology of maternal smoking during pregnancy and suggests the need to assess genetic factors (including metabolic genes) that modify the effectiveness of maternal tobacco cessation programs.

Chou FH; Yang YH; Kuo SH; Chan TF; Yang MS. Relationships among smoking, drinking, betel quid chewing and pregnancy-related nausea and vomiting in Taiwanese aboriginal women. Kaohsiung Journal of Medical Science 25(2): 62-69, 2009. (41 refs.)

A cross-sectional survey was conducted to investigate the associations among smoking, drinking, betel quid chewing and pregnancy-related nausea and vomiting (N/V) in Taiwanese aboriginal women. A total of 901 aboriginal women from 11 hospitals were recruited into this study. A structured questionnaire on demographic and obstetric information, smoking history, alcohol consumption, betel quid chewing habits, and N/V by checklist was used to collect data. The findings of this study indicated that the prevalence of N/V, maternal smoking, drinking, and betel quid chewing were 75.6%, (n = 682), 22.8%, (n = 201), 31.9% (n = 287), and 34.7% (n = 313) respectively. Multiple logistic regression with adjustment for age, body mass index and antiemetics use revealed significant relationships between smoking habits and N/V before confirmation of pregnancy and during pregnancy. In comparison with those who did not smoke, women smoking in excess of 10 cigarettes a day before pregnancy were 1.65 times more likely to develop N/V, and women smoking in excess of 10 cigarettes a day during pregnancy were 2.79 times more likely to develop N/V. Based on the findings of this study, smoking was associated, with a dose-response effect, with pregnancy-related N/V. Reducing the intake of cigarettes could decrease the risk of pregnancy-related N/V Health care providers should help these women decrease their uncomfortable symptoms and improve their experiences of pregnancy and birth outcome during critical times.

Clark CJ; Hill A; Jabbar K; Silverman JG. Violence during pregnancy in Jordan: Its prevalence and associated risk and protective factors. Violence Against Women 15(6): 720-735, 2009

This study estimates the lifetime prevalence of physical violence during pregnancy and examines risk and protective factors among women (N = 390) attending reproductive health clinics in Jordan. Approximately 15% reported physical violence during pregnancy. The husband was the sole perpetrator in 83% of the cases. A high frequency of quarreling, the husband's use of alcohol, attitudes supportive of a woman's duty to obey her husband, infrequent communication between the respondent and her family, and exposure to violence as a child increased the risk of violence. Consanguinity (marriage to a blood relative) and higher education levels were protective against violence during pregnancy.

Crozier SR; Robinson SM; Borland SE; Godfrey KM; Cooper C; Inskip HM. Do women change their health behaviours in pregnancy? Findings from the Southampton Women's Survey. Paediatric and Perinatal Epidemiology 23(5): 446-453, 2009. (21 refs.)

A woman's life style choices before and during pregnancy have important implications for her unborn child, but information on behaviour can be unreliable when data are collected retrospectively. In particular there are no large longitudinal datasets that include information collected prospectively before pregnancy to allow accurate description of changes in behaviour into pregnancy. The Southampton Women's Survey is a longitudinal study of women in Southampton, UK, characterised when they were not pregnant and again during pregnancy. The objective of the analyses presented here is to describe the degree to which women comply with diet and life style recommendations before and during pregnancy, and changes between these time points. The analyses are based on 1490 women who delivered between 1998 and 2003 and who provided information before pregnancy and at 11 and 34 weeks' gestation. At each time point a trained research nurse ascertained smoking status and assessed food and drink consumption using a food frequency questionnaire. We derived the proportions of women who complied with recommendations not to smoke, to eat five portions of fruit and vegetables per day and to drink no more than four units of alcohol per week and 300 mg of caffeine per day. There was a notable reduction in smoking when women became pregnant: before pregnancy 27% of women smoked, whereas in early pregnancy 15% smoked. Similarly there were significant reductions in alcohol consumption and intake of caffeinated drinks: before pregnancy 54% of women drank more than four units of alcohol per week and 39% had estimated intakes of caffeine in drinks of > 300 mg per day, whereas comparable figures for early pregnancy were 10% and 16% respectively. However, there was little change in fruit and vegetable intake; the percentages of women who did not achieve the recommendation to eat at least five portions of fruit and vegetables per week were 47% before pregnancy and 46% in early pregnancy. Younger women and those with fewer educational qualifications were less likely to comply with public health recommendations. Overall, 81% of women in early pregnancy complied with at least three of the recommendations. Although there is encouraging evidence of changed health behaviours in pregnancy, young women and those with few educational qualifications may particularly benefit from targeted health initiatives.

De Genna NM; Cornelius MD; Donovan JE. Risk factors for young adult substance use among women who were teenage mothers. Addictive Behaviors 34(5): 463-470, 2009. (77 refs.)

Teenage mothers may not "mature out" of substance use during young adulthood, and this non-normative trajectory of use may contribute to negative outcomes for teenage mothers and their offspring. Pregnant teenagers (age range = 12-18 years; 68% Black) were recruited from a prenatal clinic and interviewed about their substance use, and subsequently re-interviewed six and ten years later (n = 292). Consistent with the literature, early tobacco and marijuana use were risk factors for young adult use. Other substance use. peer adolescent use and mental health indicators were more important than race and socioeconomic status (SES) in determining which teenage mothers would use tobacco, engage in binge drinking, and use marijuana as young adults. However, race and SES were significant predictors of quitting tobacco use and marijuana use by the 10-year follow-up. Depression was associated with both persistent tobacco use and marijuana use in teenage mothers. These results illustrate the long-term consequences of teenage childbearing and identify modifiable risk factors for later health risks that should be addressed among younger mothers.

Devries KM; Free CJ; Morison L; Saewyc E. Factors associated with pregnancy and STI among Aboriginal students in British Columbia. Canadian Journal of Public Health 100(3): 226-230, 2009. (34 refs.)

Background: Aboriginal adolescents are more likely to become pregnant and contract an STI than other Canadian adolescents. This study provides some of the first data on factors associated with these outcomes among Aboriginal adolescents. Methods: A secondary analysis was conducted using 2003 data from a large cross-sectional survey of British Columbia secondary school students. 445 young women and 360 young men who identified as Aboriginal and reported ever having sex were included in analyses. Associations between self-reported pregnancy and STI and I I exposure variables were examined using logistic regression. Results: Of young women, 10.6% reported a pregnancy; 10.5% of young men reported causing a pregnancy. An STI diagnosis was reported by 4.2% of young women and 3.9% of young men. In multivariate analyses for young men, ever having been sexually abused was the strongest consistent risk factor for causing a pregnancy (AOR=4.30, 95% Cl 1.64-11.25) and STI diagnosis (AOR=5.58, 95% Cl 1.61-19.37). For young women, abuse was associated with increased odds of pregnancy (AOR=10.37, 95% Cl 4.04-26.60) but not STI. Among young women, substance use was the strongest consistent risk factor for both pregnancy (AOR=3.36, 95% Cl 1.25-9.08) and STI (AOR=5.27, 95% Cl 1.50-18.42); for young men, substance use was associated with higher odds of STI (AOR=4.60, 95% Cl 1.11-19.14). Factors associated with decreased risk included community, school and family involvement. Conclusions: Health care professionals, communities and policy-makers must urgently address sexual abuse and substance use. Exploring promotion of school and community involvement and family cohesion may be useful for sexual health interventions with Aboriginal students.

D'Onofrio BM. The need for more quasi-experimental studies of alcohol consumption during pregnancy. (editorial). Addiction 104(8): 1278-1279, 2009. (18 refs.)

Downs DS; Feinberg M; Hillemeier MM; Weisman CS; Chase GA; Chuang CH et al. Design of the Central Pennsylvania Women's Health Study (CePAWHS) Strong Healthy Women intervention: Improving preconceptional health. Maternal and Child Health Journal 13(1): 18-28, 2009. (38 refs.)

Considerable evidence suggests that modifiable risk factors for adverse pregnancy outcomes such as preterm birth and low birthweight include obesity, sedentary behavior, and infections. There is a growing consensus that the preconceptional and interconceptional periods may be an ideal time for preventive intervention targeting these risk factors; enhancing health before pregnancy would subsequently reduce the risk for poor pregnancy outcomes. This paper provides an overview of the development of a health behavior intervention, Strong Healthy Women, that aims to improve women's preconceptional and interconceptional health. We describe the rationale, delivery, and targeted outcomes of the program, as well as the design of an ongoing trial currently testing program efficacy. The content areas are also discussed and include pregnancy-conception, stress, physical activity, nutrition, infection, sources of smoke in the home, and substance use. This intervention protocol may offer researchers and healthcare professionals a framework for designing other programs aiming to improve women's preconceptional health.

Dukic VM; Niessner M; Pickett KE; Benowitz NL; Wakschlag LS. Calibrating self-reported measures of maternal smoking in pregnancy via bioassays using a monte carlo approach. International Journal of Environmental Research and Public Health 6(6): 1744-1759, 2009. (29 refs.)

Maternal smoking during pregnancy is a major public health problem that has been associated with numerous short- and long-term adverse health outcomes in offspring. However, characterizing smoking exposure during pregnancy precisely has been rather difficult: self-reported measures of smoking often suffer from recall bias, deliberate misreporting, and selective non-disclosure, while single bioassay measures of nicotine metabolites only reflect recent smoking history and cannot capture the fluctuating and complex patterns of varying exposure of the fetus. Recently, Dukic et al. have proposed a statistical method for combining information from both sources in order to increase the precision of the exposure measurement and power to detect more subtle effects of smoking. In this paper, we extend the Dukic et al. method to incorporate individual variation of the metabolic parameters (such as clearance rates) into the calibration model of smoking exposure during pregnancy. We apply the new method to the Family Health and Development Project (FHDP), a small convenience sample of 96 predominantly working-class white pregnant women oversampled for smoking. We find that, on average, misreporters smoke 7.5 cigarettes more than what they report to smoke, with about one third underreporting by 1.5, one third under-reporting by about 6.5, and one third underreporting by 8.5 cigarettes. Partly due to the limited demographic heterogeneity in the FHDP sample, the results are similar to those obtained by the deterministic calibration model, whose adjustments were slightly lower (by 0.5 cigarettes on average). The new results are also, as expected, less sensitive to assumed values of cotinine half-life.

Dum M; Sobell LC; Sobell MB; Heinecke N; Voluse A; Johnson K. A Quick Drinking Screen for identifying women at risk for an alcohol-exposed pregnancy. Addictive Behaviors 34(9): 714-716, 2009. (28 refs.)

Two previous studies comparing the Quick Drinking Screen (QDS) with the Timeline Followback (TLFB) found that these two instruments yielded similar reports of alcohol use for clinical and nonclinical populations of problem drinkers. The current study evaluated the correspondence between these two drinking measures with women at risk of an Alcohol-Exposed Pregnancy (AEP). Participants were 355 women who voluntarily participated in a research study during 2005 through 2007 designed to prevent AEPs. All women were screened by phone for eligibility using the QDS and approximately 2 weeks later completed a 3-month TLFB by mail. Results of this study, analyzed in 2008, paralleled previous studies showing that the QDS and the TLFB, two very different drinking measures, collected similar aggregate drinking data for women who drink heavily and are at risk of an AEP. Correspondence between the two drinking measures met acceptable levels of reliability. The present study found that the QDS has demonstrated efficacy for screening women whose level of alcohol use puts them at risk for an AER Although the QDS does not yield detailed drinking information, it could be used when it is not possible or necessary to gather daily drinking data.

Fertig AR; Watson T. Minimum drinking age laws and infant health outcomes. Journal of Health Economics 28(3): 737-747, 2009. (52 refs.)

Alcohol policies have potentially far-reaching impacts on risky sexual behavior, prenatal health behaviors, and subsequent outcomes for infants. After finding initial evidence in the National Longitudinal Survey of Youth (NLSY) that changes in the minimum legal drinking age (MLDA) are related to prenatal drinking, we examine whether the drinking age influences birth outcomes. Using data from the National Vital Statistics (NVS) for the years 1978-1988, we find that a drinking age of 18 is associated with adverse outcomes among births to young mothers-including higher incidences of low birth weight and premature birth, but not congenital anomalies. The effects are largest among black women. We also report evidence that the MLDA laws alter the composition of births that occur. in states with lenient drinking laws, young black mothers are less likely to report paternal information on the birth certificate, Particularly in states with restrictive abortion policies. The evidence suggests that lenient drinking laws generate poor birth outcomes in part because they increase the number of unplanned pregnancies.

Fish LJ; Peterson BL; Brouwer RJN; Lyna P; Oncken CA; Swamy GK et al. Adherence to nicotine replacement therapy among pregnant smokers. Nicotine & Tobacco Research 11(5): 514-518, 2009. (20 refs.)

Introduction: This secondary analysis examined the association between adherence to nicotine replacement therapy (NRT) and smoking cessation among pregnant smokers enrolled in Baby Steps, an open-label randomized controlled trial testing cognitive-behavioral therapy (CBT) versus CBT plus NRT. Method: The analysis included only women who received NRT for whom we had complete data (N = 104). Data came from daily calendars created from recordings of counseling sessions and from telephone surveys at baseline and 38 weeks gestation. Results: Overall, 29% of the 104 women used NRT for the recommended 6 weeks and 41% used NRT as directed in the first 48 hr after a quit attempt. Ordinal logistic regression modeling indicated that using NRT as directed in the first 48 hr and having made a previous quit attempt were the strongest predictors of longer NRT use. Univariate analyses suggested that primigravid women and women who used NRT longer were more likely to report quitting at 38 weeks gestation. Discussion: Findings indicated that adherence to NRT is low among pregnant smokers, but adherence was a predictor of cessation. Future trials should emphasize adherence, particularly more days on NRT, to promote cessation during pregnancy.

Flenady V; Macphail J; New K; Devenish-Meares P; Smith J. Implementation of a clinical practice guideline for smoking cessation in a public antenatal care setting. Australian & New Zealand Journal of Obstetrics & Gynaecology 48(6): 552-558, 2009. (25 refs.)

Despite high level evidence showing that antenatal smoking cessation programs are effective in reducing the number of women who smoke during pregnancy and the number of low birthweight and preterm births, few Australian hospitals have adopted a systematic approach to assist pregnant women to stop smoking. The aim of this study was to assess the effectiveness of a smoking cessation guideline, developed specifically for clinicians providing antenatal care in public maternity hospitals, combined with an implementation program on the uptake of evidence-based practice. A clinical practice guideline was developed and an implementation strategy was tested, using a prospective before-and-after study design, at the Mater Mothers' Hospital in Brisbane. Women were surveyed in late pregnancy, pre- and post-implementation. The primary outcome measures were women's report of appropriate smoking cessation support received, specifically, information brochures and referral to Quitline. Secondary outcome measures included women's report of smoking status in late pregnancy and relapse rates. Post-implementation, more women reported receiving written materials on smoking cessation (76% vs 35%; relative risk (RR) 3.4; 95% confidence interval (CI) 2.7, 4.2) and referral to Quitline (67% vs 14%; RR 4.9; 95% CI 3.0, 8.0). While not statistically significant, fewer women post-implementation reported smoking in late pregnancy (19.5% vs 16.7%) and fewer reported smoking > 10 cigarettes per day (38% vs 25%). Clinical practice guidelines specifically designed for a public maternity care setting combined with an implementation program resulted in an increase in evidence-based practice with some indication of improved smoking behaviour for women.

Florescu A; Ferrence R; Einarson T; Selby P; Soldin O; Koren G. Methods for quantification of exposure to cigarette smoking and environmental tobacco smoke: Focus on developmental toxicology. (review). Therapeutic Drug Monitoring 31(1): 14-30, 2009. (147 refs.)

Active and passive smoking have been associated with an array of adverse effects on health. The development of valid and accurate scales of measurement for exposures associated with health risks constitutes an active area of research. Tobacco smoke exposure still lacks an ideal method of measurement. A valid estimation of the risks associated with tobacco exposure depends on accurate measurement. However, some groups of people are more reluctant than others to disclose their smoking status and exposure to tobacco. This is particularly true for pregnant women and parents of young children, whose smoking is often regarded as socially unacceptable. For others, recall of tobacco exposure may also prove difficult. Because relying on self-report and the various biases it introduces may lead to inaccurate measures of nicotine exposure, more objective solutions have been suggested. Biomarkers constitute the most commonly used objective method of ascertaining nicotine exposure. Of those available, cotinine has gained supremacy as the biomarker of choice. Traditionally, cotinine has been measured in blood, saliva, and urine. Cotinine collection and analysis from these sources has posed some difficulties, which have motivated the search for a more consistent and reliable source of this biomarker. Hair analysis is a novel, noninvasive technique used to detect the presence of drugs and metabolites in the hair shaft. Because cotinine accumulates in hair during hair growth, it is a unique measure of long-term, cumulative exposure to tobacco smoke. Although hair analysis of cotinine holds great promise, a detailed evaluation of its potential as a biomarker of nicotine exposure, is needed. No studies have been published that address this issue. Because the levels of cotinine in the body are dependent on nicotine metabolism, which in turn is affected by factors such as age and pregnancy, the characterization of hair cotinine should be population specific. This review aims at defining the sensitivity, specificity, and clinical utilization of different methods used to estimate exposure to cigarette smoking and environmental tobacco smoke.

Gaither KH; Huber LRB; Thompson ME; Huet-Hudson YM. Does the use of nicotine replacement therapy during pregnancy affect pregnancy outcomes? Maternal and Child Health Journal 13(4): 497-504, 2009. (27 refs.)

Objectives: Although nicotine replacement therapies (NRT) may assist with smoking cessation, little is known about the safety of NRT use during pregnancy. Our purpose was two-fold: to determine characteristics of women prescribed or recommended NRT during pregnancy and to investigate whether NRT prescription/recommendation was associated with adverse pregnancy outcomes using data from the 2004 Pregnancy Risk Assessment Monitoring System. Methods: Smoking and NRT referral was self-reported by 5,716 women. Information on pregnancy outcomes was obtained from birth certificates. Multivariate logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Results Smokers < 35 years of age and of Hispanic, Non-Hispanic Black, and Asian/Pacific Islander race/ethnicity were less likely to be prescribed or recommended NRT during pregnancy. After adjustment for age, marital status, education, and race/ethnicity, women recommended NRT had twice the risk of low birthweight as compared to nonsmokers (OR = 1.95, 95% CI: 1.10, 3.46) while smokers had 1.31 times the risk of low birthweight (95% CI: 0.92, 1.87). Results for preterm birth were similar after adjustment for the same confounding variables (NRT: OR = 2.04, 95% CI: 1.14, 3.63 and smoking: OR = 1.09, 95% CI: 0.74, 1.61). Conclusions: Risks of low birthweight and preterm birth were highest for women prescribed or recommended NRT. These findings may be related to frequency of maternal smoking. While heavier smokers may be more likely to be recommended NRT, they also may have the most difficulty with cessation. Greater efforts should be made to ensure that these women do successfully cease smoking.

Gavaghan C. "You can't handle the truth": Medical paternalism and prenatal alcohol use. Journal of Medical Ethics 35(5): 300-303, 2009. (15 refs.)

The publication of the latest contribution to the alcohol-in-pregnancy debate, and the now customary flurry of media attention it generated, have precipitated the renewal of a series of ongoing debates about safe levels of consumption and responsible prenatal conduct. The University College London (UCL) study's finding that low levels of alcohol did not contribute to adverse behavioural outcomes-and may indeed have made a positive contribution in some cases-is unlikely to be the last word on the subject. Proving a negative correlation is notoriously difficult ( technically, impossible), and other studies have offered alternative claims. The author is not an epidemiologist, and the purpose of this article is not to evaluate the competing empirical claims. However, the question of what information and advice healthcare practitioners ought to present to pregnant women, or prospectively or potentially pregnant women, in a situation of uncertainty is one to which healthcare ethicists may have a contribution to make. In this article, it is argued that the total abstinence policy advocated by the UK's Department of Health, and even more stridently by the British Medical Association, sits uneasily with recent data and is far from ethically unproblematic. In particular, the "precautionary'' approach advocated by these bodies displays both scant regard for the autonomy of pregnant and prospectively pregnant women and a confused grasp of the principles of beneficence and non-maleficence.

Gelberg L; Andersen R; Longshore D; Leake B; Nyamathi A; Teruya C et al. Hospitalizations among homeless women: Are there ethnic and drug abuse disparities? Journal of Behavioral Health Services & Research 36(2): 212-232, 2009. (49 refs.)

This paper explores associations among the vulnerabilities of being female, being a member of a minority group, and being a drug abuser in homeless women's hospitalizations. It uses a 1997 probability survey of 974 homeless females age 15-44 in Los Angeles. In unadjusted analyses, whites were more likely than other ethnic minority groups to be hospitalized, and drug abusers were more likely to be hospitalized than non-drug abusers. Multiple logistic regression analyses indicated that factors associated with hospitalization differed considerably among the ethnic and drug-abuse subgroups. For example, ethnic disparities in inpatient health care were found for drug-abusing women, but not for those who did not abuse drugs. Pregnancy was the only important determinant of hospitalization in all subgroups (OR, 2.9-17.4). Preventing unintended pregnancy appears to be the most inclusive means of reducing hospitalization and attendant costs among homeless women.

Gilligan C; Sanson-Fisher R; Eades S; D'Este C; Kay-Lambkin F; Scheman S et al. Identifying pregnant women at risk of poor birth outcomes. Journal of Obstetrics and Gynaecology 29(3): 181-187, 2009. (29 refs.)

Pregnancy is a vulnerable period in women's lives, with a range of maternal and environmental factors impacting upon pregnancy outcome. This study sought to explore the clustering of health risks among pregnant women, and compare the characteristics of women exhibiting clustered risks. A cross-sectional study was undertaken at a large public hospital in Queensland, Australia. Cluster analysis grouped women who had similar levels of risk based on health and lifestyle factors demonstrated to be associated with adverse maternal and infant outcomes. Interviews were conducted with 437 women. The results highlight the interconnectedness of demographic and health risks, and high concentration of risks among Indigenous women. Vulnerable women can be identified and targeted for public health interventions focusing on clustered risk factors, such as alcohol, smoking and sexually transmitted infections. Opportunity exists for screening in routine primary care to identify the individuals who are at risk, rather than identifying specific risks.

Gilligan C; Sanson-Fisher RW; D'Este C; Eades S; Wenitong M. Knowledge and attitudes regarding smoking during pregnancy among Aboriginal and Torres Strait Islander women. Medical Journal of Australia 190(10): 557-561, 2009. (28 refs.)

Objective: To identify factors associated with antenatal smoking and explore characteristics of smoking behaviour among pregnant Aboriginal and Torres Strait Islander women. Design and setting: Cross-sectional study using interviewer-administered questionnaires of 145 pregnant Aboriginal and Torres Strait Islander women attending a health service in Far North Queensland between November 2005 and December 2006. Main outcome measures: Prevalence of self-reported smoking; predictors and patterns of smoking in early pregnancy; and relationships between smoking and the prevalence of predisposing, enabling and reinforcing factors, including women's knowledge about and attitudes towards smoking and the risks involved. Results: Of 145 women, 41 % (n = 60) reported being daily or occasional smokers. Knowledge about harms of smoking was generally high. Women who were smokers had a significantly higher rate of smoking partners (n = 36) than women who were non-smokers (n = 31) (77% v 41 %, P < 0.001). Level of daily stress was significantly higher among smokers than non-smokers (P = 0.001). Conclusion: Shifted population norms among Aboriginal and Torres Strait Islanders are accompanied by a shift in the factors that can effectively differentiate between smokers and non-smokers within this population. Rather than the traditional, mainstream predictors of antenatal smoking, interventions with Aboriginal and Torres Strait Islander women should focus on the social environment, and the influences of social networks and partners on the behaviour of individuals.

Goedhart G; van der Wal MF; Cuijpers P; Bonsel GJ. Psychosocial problems and continued smoking during pregnancy. Addictive Behaviors 34(4): 403-406, 2009. (23 refs.)

The present study examined the association of several psychosocial problems with continued smoking during pregnancy. Based on a population-based cohort study among pregnant women in Amsterdam (n =8266), women who smoked before pregnancy were included in this study (n=1947). Women completed a questionnaire around the 12th week of gestation. Based on whether they smoked in the past week, participants were categorized as quitters or non-quitters. Depressive symptoms (CES-D), anxiety (STAI), pregnancy-related anxiety, job strain, parenting stress and physical/sexual violence were measured. Multiple logistic regression analyses were performed. After adjustment for sociodemographic and smoking-related covariates, low and high levels of pregnancy-related anxiety, exposure to physical/sexual violence, and high job strain were significantly associated with continued smoking during pregnancy. Intensive and comprehensive smoking cessation programs are required for pregnant women, which includes the management of psychosocial problems.

Grazuleviciene R; Danileviciute A; Nadisauskiene R; Vencloviene J. Maternal smoking, GSTM1 and GSTT1 polymorphism and susceptibility to adverse pregnancy outcomes. International Journal of Environmental Research and Public Health 6(3): 1282-1297, 2009. (40 refs.)

The objective of the study was to investigate the association between maternal smoking, GSTM1, GSTT1 polymorphism, low birth weight (LBW, < 2,500 g) and intrauterine growth restriction (IUGR, < 2,500 g and gestation >= 37 weeks) risk. Within a prospective cohort study in Kaunas (Lithuania), a nested case-control study on LBW and IUGR occurrence among 646 women with genotyping of GSTT1 and GSTM1 polymorphisms who delivered live singletons was conducted. Multivariate logistic regression analysis was used to study the association of maternal smoking and polymorphism in two genes metabolizing xenobiotics. Without consideration of genotype, light-smoking (mean 4.8 cigarettes/day) during pregnancy was associated with a small increase in LBW risk, adjusted OR 1.21; 95% CI 0.44 - 3.31. The corresponding odds for IUGR risk was 1.57; 95% CI 0.45 - 5.55. The findings suggested the greater LBW risk among light-smoking mothers with the GSTM1-null genotype (OR 1.91; 95% CI 0.43 - 8.47) compared to those with GSTM1-present genotype (OR 1.11; 95% CI 0.26 - 4.47). When both GSTM1 and GSTT1 genotypes were considered, the synergistic effect was found among smoking mothers: GSTT1-present and GSTM1-null genotype OR for LBW was 3.31; 95% CI 0.60-18.4 and that for IUGR was 2.47; 95% CI 0.31 - 13.1. However there was no statistically significant interaction between maternal smoking, GSTT1-present and GSTM1-null genotypes for LBW (OR 1.45; 95% CI 0.22 - 10.1, p = 0.66) and for IUGR (OR 1.10; 95% CI 0.10 - 12.6, p = 0.93). The results of this study suggested that smoking, even at a low-level, ought to be considered a potential risk factor for adverse birth outcomes and that genetic polymorphism may contribute to individual variation in tobacco smoke response.

Gyarmathy VA; Giraudon I; Hedrich D; Montanari L; Guarita B; Wiessing L. Drug use and pregnancy: Challenges for public health. (review). Eurosurveillance 14(9): 33-36, [article 19142], 2009. (70 refs.)

Problem drug use in pregnancy affects a sizeable population in Europe. A literature review was carried out of articles in PubMed, European Monitoring Centre for Drugs and Drug Addiction publications, and related documents in order to assess public health challenges and possible intervention strategies related to problem drug use and pregnancy in Europe. It revealed the following: Involving pregnant drug users in drug treatment is likely to decrease the chances of pre- and perinatal complications related to drug use and to increase access to prenatal care. Timely medical intervention can effectively prevent vertical transmission of human immunodeficiency virus, hepatitis B virus as well as certain other sexually transmitted diseases, and would allow newborns infected with hepatitis C virus during birth to receive immediate treatment. Pregnancy may be a unique opportunity to also help women with dual diagnosis (substance use combined with mental illness) and enroll them into special treatment and support programmes. Issues related to homelessness and intimate partner violence can also be addressed with appropriate interventions. Treatment and care for pregnant drug users should offer coordinated interventions in several areas: drug use, infectious diseases, mental health, personal and social welfare, and gynaecological/obstetric care.

Handel G; Hannover W; Roske K; Thyrian JR; Rumpf HJ; Fusch C et al. Intention to change smoking in pregnant and postpartum women according to number of pregnancies. European Journal of Public Health 19(2): 218-221, 2009. (24 refs.)

Background: The status of a pregnant woman might add to the motivation to stop smoking. However, little is known about whether women who are pregnant for the first time (primigravidae) show a motivation to quit smoking that is different from women who are pregnant at least the second time (multigravidae). The goal of the current study was to compare smoking status, urge to smoke and intention to change smoking behaviour of primigravidae and multigravidae. We hypothesized that amongst primigravidae there are less current smokers, that the smokers consume less cigarettes per day, have less urge to smoke and that more stop smoking after delivery when compared with multigravidae. Methods: Among 642 women postpartum who had smoked before pregnancy smoking status, the Fagerstrm Test for Nicotine Dependence and intention to change smoking behaviour were assessed. The data were analysed with the Chi-square test, MannWhitneys U-test and the Sign-test. Results: Primigravidae smoked less cigarettes (P 0.01) and showed less urge to smoke (P 0.05) than multigravidae. They did not differ according to the intention to change smoking behaviour (P 0.05). Conclusion: Experience of first pregnancy does not seem to automatically induce more smoking cessation compared to multigravidae. Prevention measures are needed for primigravida women and multigravida women to the same extent.

Handel G; Hannover W; Roske K; Thyrian JR; Rumpf HJ; John U et al. Naturalistic changes in the readiness of postpartum women to quit smoking. Drug and Alcohol Dependence 101(3): 196-201, 2009. (38 refs.)

Background: This study involves a long-term examination of the natural behavioral changes in postpartum women undergoing smoking cessation. The analysis was based on the readiness to quit smoking as assessed using the Transtheoretical Model of intentional behavioral change. This is a secondary data analysis of a randomized controlled trial. Methods: Between May 2002 and March 2003, all women in the maternity wards of six hospitals in the German state of Mecklenburg-West Pomerania were screened for smoking before or during pregnancy. Of the women who answered in the affirmative, 871 (77%) participated in the study. We utilized a questionnaire to classify 345 women into stages of progress regarding their motivation to change their smoking behavior 4-6 weeks postpartum (TO). Participants were followed-up after 6 (T1), 12 (T2), and 18 months (T3). In addition to the descriptive analysis, latent transition analysis was applied as a statistical method to test models of patterns of change and to evaluate transitions in the stages of change over time. Results: During the time interval between consecutive follow-up surveys, 59.1% (T0/T1), 72.3% (T1/T2), and 67.9% (T2/T3) of women remained at the same stage of motivation to change. Most relapses into earlier stages occurred 6 months postpartum (T1) (31.5% of the stage transition). The patterns of change across the first three time points were best described by a model that includes stability, one-stage progressions, and one-to-four-stage regressions. Conclusions: Readiness to quit smoking in study participants did not substantially change over the span of 18 months postpartum.

Hannover W; Thyrian JR; Roske K; Grempler J; Rumpf HJ; John U; Hapke U. Smoking cessation and relapse prevention for postpartum women: Results from a randomized controlled trial at 6, 12, 18 and 24 months. Addictive Behaviors 34(1): 1-8, 2009. (39 refs.)

Aim: To test the efficacy of an aid to cessation/relapse prevention intervention for women postpartum. Method: Two-armed randomized controlled trial. Follow-ups at 6, 12, 18, and 24 months, screenings on maternity wards. Intervention group received face-to-face counseling 40 days postpartum plus telephone counseling calls 4 and 12 weeks later. Control group received usual care plus self-help material for each parent. Results: With regard to smoking cessation, 4 week point prevalence abstinent rates were higher in the treatment group at 6, 12, and 18 months (7% vs. 1%. 7% vs. 2%, and 9% vs. 1%, respectively). Sustained abstinence was higher in the treatment group at 6 months follow-up (3% vs. 0%). No difference was observed with regard to relapse prevention. Discussion: Regarding aid to cessation we observed small effects, regarding relapse prevention no effect. In order to capitalize on the opportunity childbirth poses with regard to smoking, theories on relapse prevention in smoking cessation that guide in designing interventions are needed.

Hathazi D; Lankenau SE; Sanders B; Bloom JJ. Pregnancy and sexual health among homeless young injection drug users. Journal of Adolescence 32(2): 339-355, 2009. (46 refs.)

Research on pregnancy and sexual health among homeless youth is limited. In this Study, qualitative interviews were conducted with 41 homeless young injection drug users (IDUs) in Los Angeles with a history of pregnancy. The relationship between recent pregnancy outcomes, contraception practices. housing status, substance use, utilization of prenatal care, and histories of sexual victimization are described. A total of 81 lifetime pregnancies and 26 children were reported. Infrequent and Ineffective use of contraception was common. While pregnancy motivated some homeless youth to establish housing, miscarriages and terminations were more frequent among youth who reported being housed. Widespread access to prenatal and medical services was reported during pregnancy. but utilization varied. Many women Continued to use substances throughout pregnancy. Several youth reported childhood sexual abuse and sexual victimization while homeless. Pregnancy presents a unique opportunity to encourage positive health behaviors in a high-risk Population seldom seen in a clinical setting.

Havens JR; Simmons LA; Shannon LM; Hausen WF. Factors associated with substance use during pregnancy: Results from a national sample. Drug and Alcohol Dependence 99(1-3): 89-95, 2009. (43 refs.)

Objective: To examine the prevalence and correlates of substance use during pregnancy among women in the United States. Methods: We analyzed data from pregnant (n = 1800) and non-pregnant women (n = 37,527) aged 15-44 years who participated in the 2002 or 2003 National Survey on Drug Use and Health, a nationally representative epidemiologic Survey. Study variables included demographics, any Substance use in the prior 30 days, and possible current psychopathology. Data were analyzed using weighted chi-square and multiple logistic regressions that accounted for the complex survey design. Results: The overall prevalence of any past month substance use during pregnancy was 25.8%; the prevalence rates of past month illicit drug, cigarette and alcohol use were 4.7%, 18.9%, and 10%, respectively. Compared to the prevalence of substance use among Women in their first trimester, use was significantly lower among women in their second or third trimesters. Women who reported using Substances during pregnancy were significantly more likely to meet the criteria for possible current psychopathology and be White. Additionally, women who were employed, married, and in their second or third trimester compared to the first were significantly less likely to have used any substance during pregnancy, adjusting for age, ethnicity and income. Conclusions: Although the prevalence of substance use among pregnant women was significantly lower than non-pregnant women, some groups of women remain vulnerable to continued use, including those who are unemployed, unmarried, and experiencing possible current psychopathology. Prevention and intervention programs aimed at high-risk populations are warranted to reduce the deleterious effects of substance use on pregnancy outcomes.

Huizink AC. Moderate use of alcohol, tobacco and cannabis during pregnancy: New approaches and update on research findings. Reproductive Toxicology 28(2, Special Issue): 143-151, 2009. (102 refs.)

Interest in fetal origins of adverse offspring outcomes has grown extensively in the last decade. This has resulted in many published studies focusing on exposure in utero to substances and human offspring outcomes. Exposure to maternal substance use in pregnancy is believed to be a preventable hazard, and is therefore a main issue for public health concern and policy. However, an important question in human studies remains whether prenatal substance use exposure has an aetiological role in pathways to adverse developmental and behavioural outcomes via teratological effects. Recent insights and developments in research methodology will aid the adequate and more refined testing of associations between prenatal substance use and offspring outcomes. In particular, novel approaches could assist in disentangling the exposure to substance effects from correlated risk factors. The purpose of this manuscript is therefore to provide an overview of methodological issues involved in studies that focus on the association between maternal substance use during pregnancy and offspring's outcomes, to describe novel approaches to test these associations, and present some examples of new and well-designed studies and discuss their findings.

Jahanfar S; Sharifah H. Effects of restricted caffeine intake by mother on fetal, neonatal and pregnancy outcome. (review). Cochrane Database of Systemic Reviews 2009(2): article CD006965, 2009. (33 refs.)

Background: Maternal caffeine consumption during pregnancy may have adverse effects on fetal, neonatal and maternal outcomes. Objectives This review investigates the effects of restricting caffeine intake by mothers on fetal, neonatal and pregnancy outcomes. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register ( December 2008), scanned bibliographies of published studies and corresponded with investigators. Selection criteria: Randomised controlled trials including quasi-randomised controlled trials (RCTs) investigating the effect of caffeine and/ or supplementary caffeine versus restricted caffeine intake or placebo on pregnancy outcome. Data collection and analysis: The two review authors independently assessed trial quality and extracted data. Main results: One study met the inclusion criteria. Caffeinated instant coffee ( 568 women) was compared with decaffeinated instant coffee ( 629 women) and it was found that reducing the caffeine intake of regular coffee drinkers (3+ cups/day) during the second and third trimester by an average of 182 mg/day did not affect birthweight or length of gestation. Authors' conclusions: There is insufficient evidence to confirm or refute the effectiveness of caffeine avoidance on birthweight or other pregnancy outcomes. There is a need to conduct high-quality, double-blinded RCTs to determine whether caffeine has any effect on pregnancy outcome. PLAIN LANGUAGE SUMMARY: Caffeine is a stimulant found in tea, coffee, cola, chocolate and some over-the-counter medicines. Conflicting results found in the literature make it difficult for health professionals to advise pregnant women about avoiding caffeine during pregnancy. Clearance of caffeine from the mother's blood slows down during pregnancy. Some authors of observational studies have concluded that caffeine intake is harmful to the fetus, causing growth restriction, reduced birthweight, preterm birth or stillbirth. The newborn could also have withdrawal symptoms if the mother has a high intake of caffeine ( more than eight cups of coffee per day). Only one controlled study was identified. The study was based in Denmark. Women less than 20 weeks pregnant were randomly assigned to drinking caffeinated instant coffee ( 568 women after exclusions) or decaffeinated instant coffee ( 629 women). Drinking three cups of coffee a day in early pregnancy had no effect on birthweight, preterm births or growth restriction. Sufficient evidence is not available from randomised controlled trials to support any benefits from avoiding caffeine during pregnancy.

Janakiraman V; Gantz M; Maynard S; El-Mohandes A. Association of cotinine levels and preeclampsia among African-American women. Nicotine & Tobacco Research 11(6): 679-684, 2009. (18 refs.)

Although prior studies have shown that smoking reduces preeclampsia risk, the relationship between nicotine level and preeclampsia risk is not known. Our objective was to study the effects of smoking on the incidence of preeclampsia in African-American women using cotinine, a quantitative marker of nicotine. We performed a secondary analysis of data collected prospectively in Project District of Columbia Healthy Outcomes of Pregnancy Education. Our study included 724 African-American women. Self-reported smoking, cotinine levels, and pregnancy outcomes were examined. Some 18% of participants were smokers. Women with salivary cotinine levels greater than 200 ng/ml had infants with lower birth weights and a higher incidence of small-for-gestational-age infants than women with cotinine levels of 200 ng/ml or less. Exact logistic regression analysis revealed that women with salivary cotinine levels greater than 200 ng/ml had a significantly lower incidence of preeclampsia, compared with women with cotinine levels of 200 ng/ml or less, in unadjusted analysis (odds ratio [OR] = 0.16, 95% CI = 0-0.90). After controlling for age, parity, and medical comorbidities, the trend was observed, but the effect was no longer significant (adjusted odds ratio [AOR] = 0.19, 95% CI = 0-1.11). We found no significant differences in preeclampsia rates using lower cutoffs of cotinine exposure. We did not observe a decrease in preeclampsia incidence at low or moderate cotinine levels. Women with the highest cotinine levels may have a decreased risk for preeclampsia, although this effect was not significant after controlling for other risk factors.

Jansen PW; Tiemeier H; Looman CWN; Jaddoe VWV; Hofman A; Moll HA et al. Explaining educational inequalities in birthweight: the Generation R Study. Paediatric and Perinatal Epidemiology 23(3): 216-228, 2009. (54 refs.)

Although low socio-economic status has consistently been associated with lower birth-weight, little is known about the factors whereby socio-economic disadvantage influences birthweight. We therefore examined explanatory mechanisms that may underlie the association between the educational level of pregnant women, as an indicator of socio-economic status, and birthweight. The study was embedded within a population-based cohort study in the Netherlands. Information on maternal education, offspring's birthweight and several determinants of birthweight was available for 3546 pregnant women of Dutch origin. Infants of the lowest educated women had a statistically significantly lower birthweight than infants of the highest educated women [difference adjusted for gender and gestational age: -123 g (95% CI -167, -79)]. Parity, age of the pregnant women, hypertension, parental height and parental birthweight, marital status, pregnancy planning, financial concerns, number of people in household, weight gain and smoking habits individually explained part of the differences in birthweight, while adjustment for working hours and body mass index resulted in increases in birthweight differences between the educational levels. After full adjustment, the difference in birthweight between lowest and highest education was reduced by 66%. Our study confirmed remarkable educational inequalities in birthweight, a large part of which was explained by pregnancy characteristics, anthropometrics, the psychosocial and material situation, and lifestyle-related factors. Altering smoking habits may be an option to reduce educational differences in birthweight, as many lower-educated women tend to continue smoking during pregnancy. In order to tackle inequalities in birthweight, it is important that interventions are accessible for pregnant women in lower socioeconomic strata.

Johansson ALV; Dickman PW; Kramer MS; Cnattingius S. Maternal smoking and infant mortality: Does quitting smoking reduce the risk of infant death? Epidemiology 20(4): 590-597, 2009. (20 refs.)

Background: Maternal smoking has repeatedly been associated with increased infant mortality rates. No study has investigated whether smoking cessation influences the risk of infant death. This study estimates infant mortality after the second pregnancy in relation to smoking behavior in both the first and the second pregnancy. Methods: We used the Swedish Medical Birth Register to identify women who delivered their first and second singleton infants during 1983-2002. Maternal smoking during the 2 pregnancies was categorized into (1) never smoker, (2) quitter, (3) starter, and (4) persistent smoker. In the second pregnancy, 555,046 live births (of at least 22 completed gestational weeks) were followed for infant death within 1 year. Cox regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). Results: Compared with infants born to never smokers, the HR (95% CI) of infant mortality in the second pregnancy was 2.0 (1.7-2.4) among infants born to persistently heavy smokers, whereas among women who stopped smoking in the second pregnancy, the HRs were 1.4 (1.0-2.0) among those who had been heavy smokers in the first pregnancy, and 1.0 (0.8-1.2) among those who had been light smokers. The association of smoking during pregnancy with infant mortality was modified by infant's age, and was strongest at 4-15 weeks after birth. The smoking effect on neonatal mortality, but not postneonatal mortality, was mediated by gestational age. Conclusions: Smoking cessation reduced the risk of infant death. The smoking-related risk of neonatal mortality appears to be mediated by smoking effects on gestational age, a factor that only partly explains the association between smoking and postneonatal mortality.

Jones HE; O'Grady K; Dahne J; Johnson R; Lemoine L; Milio L et al. Management of acute postpartum pain in patients maintained on methadone or buprenorphine during pregnancy. American Journal of Drug and Alcohol Abuse 35(3): 151-156, 2009. (21 refs.)

Background: Empirical evidence is needed to guide adequate postpartum pain relief of methadone and buprenorphine stabilized patients. Objectives: To first determine the adequacy of pain control using non-opioid and opioid medication in participants stabilized on buprenorphine or methadone before a vaginal delivery. Second, to compare the amount of non-opioid and opioid medication needed for adequate pain control for buprenorphine-and methadone-maintained patients during the immediate postpartum period. Methods: Pain control adequacy and amount of non-opioid and opioid medication needed in buprenorphine- (n = 8) and methadone-maintained (n = 10) patients over the first five days postpartum were examined. Results: Pain ratings and number of opioid medication doses decreased over time in both medication groups. While the buprenorphine and methadone groups began with similar mean daily ibuprofen (IB) doses, the buprenorphine group decreased its IB use, while the methadone group increased its IB use. Conclusions and Scientific Significance: Patients treated daily with either buprenorphine or methadone can have adequate pain control postpartum with opioid medication and IB. Pain control is dependent on the opioid-agonist medication in use at delivery, and must be individualized.

Joseph JG; El-Mohandes AAE; Kiely M; El-Khorazaty MN; Gantz MG; Johnson AA et al. Reducing psychosocial and behavioral pregnancy risk factors: Results of a randomized clinical trial among high-risk pregnant African American women. American Journal of Public Health 99(6): 1053-1061, 2009. (67 refs.)

Objectives. We evaluated the efficacy of a primary care intervention targeting pregnant African American women and focusing on psychosocial and behavioral risk factors for poor reproductive outcomes (cigarette smoking, second-hand smoke exposure, depression, and intimate partner violence). Methods. Pregnant African American women (N = 1044) were randomized to an intervention or usual care group. Clinic-based, individually tailored counseling sessions were adapted from evidence-based interventions. Follow-up data were obtained for 850 women. Multiple imputation methodology was used to estimate missing data. Outcome measures were number of risks at baseline, first follow-up, and second follow-up and within-person changes in risk from baseline to the second follow-tip. Results. Number of risks did not differ between the intervention and usual care groups at baseline, the second trimester, or the third trimester. Women in the intervention group more frequently resolved some or all of their risks than did women in the usual care group (odds ratio = 1.61; 95% confidence interval = 1.08, 2.39; P = .021). Conclusions. In comparison with usual care, a clinic-based behavioral intervention significantly reduced psychosocial and behavioral pregnancy risk factors among high-risk African American women receiving prenatal care.

Kelly Y; Sacker A; Gray R; Kelly J; Wolke D et al. Light drinking in pregnancy, a risk for behavioural problems and cognitive deficits at 3 years of age? International Journal of Epidemiology 38(1): 129-140, 2009. (50 refs.)

Background The objective of this study was to determine whether there was an association between mothers' light drinking during pregnancy and risk of behavioural problems, and cognitive deficits in their children at age 3 years. Methods Data from the first two sweeps of the nationally representative prospective UK Millennium Cohort study were used. Drinking patterns during pregnancy and behavioural and cognitive outcomes were assessed during interviews and home visits. Behavioural problems were indicated by scores falling above defined clinically relevant cut-offs on the parent-report version of the Strengths and Difficulties Questionnaire (SDQ). Cognitive ability was assessed using the naming vocabulary subscale from the British Ability Scale (BAS) and the Bracken School Readiness Assessment (BSRA). Results There was a J-shaped relationship between mothers drinking during pregnancy and the likelihood of high scores (above the cut-off) on the total difficulties scale of the SDQ and the conduct problems, hyperactivity and emotional symptom SDQ subscales. Children born to light drinkers were less likely to score above the cut-offs compared with children of abstinent mothers. Children born to heavy drinkers were more likely to score above the cut-offs compared with children of abstinent mothers. Boys born to mothers who had up to 1-2 drinks per week or per occasion were less likely to have conduct problems (OR 0.59, 95% CI 0.45-0.77) and hyperactivity (OR 0.71, 95% CI 0.54-0.94). These effects remained in fully adjusted models. Girls were less likely to have emotional symptoms (OR 0.72, 95% CI 0.51-1.01) and peer problems (OR 0.68, 95% CI 0.52-0.92) compared with those born to abstainers. These effects were attenuated in fully adjusted models. Boys born to light drinkers had higher cognitive ability test scores [standard deviations, (95% CI)] BAS 0.15 (0.08-0.23) BSRA 0.24 (0.16-0.32) compared with boys born to abstainers. The difference for BAS was attenuated on adjustment for socio-economic factors, whilst the difference for BSRA remained statistically significant. Conclusions Children born to mothers who drank up to 1-2 drinks per week or per occasion during pregnancy were not at increased risk of clinically relevant behavioural difficulties or cognitive deficits compared with children of abstinent mothers. Heavy drinking during pregnancy appears to be associated with behavioural problems and cognitive deficits in offspring at age 3 years whereas light drinking does not.

Kim SY; England L; Dietz PM; Morrow B; Perham-Hester KA. Prenatal cigarette smoking and smokeless tobacco use among Alaska Native and white women in Alaska, 1996-2003. Maternal and Child Health Journal 13(5): 652-659, 2009. (27 refs.)

Objective: To examine trends in prenatal cigarette smoking and smokeless tobacco use among Alaska Native (AN) and white women in Alaska. Method: Using 1996-2003 data from the population-based Pregnancy Risk Assessment Monitoring System, we determined trends in self-reported prenatal tobacco use among AN and white women and used chi-square tests and multiple variable logistic regression analysis to identify maternal factors associated with prenatal tobacco use. Results Over the study period, prevalence of any tobacco use during pregnancy declined by 27% among AN women (from 55.8 to 40.9%) (P < 0.0001) and by 17% among white women (from 18.8 to 15.6%) (P < 0.0001). In 2003, among AN women the prevalence of self-reported smokeless tobacco use was 16.9%, cigarette smoking was 25.7%, and any tobacco use was 40.9%; corresponding values for white women were 0.4, 15.0, and 15.6%, respectively. Western Alaska had the highest prevalence of tobacco use. Conclusion: The prevalence of tobacco use decreased between 1996 and 2003, but remained higher among AN women than white women, especially for smokeless tobacco. Support for cessation interventions targeting pregnant women should be made a public health priority in Alaska.

Kim SY; England LJ; Kendrick JS; Dietz PM; Callaghan WM. The contribution of clinic-based interventions to reduce prenatal smoking prevalence among US women. American Journal of Public Health 99(5): 893-898, 2009. (38 refs.)

Objectives. We sought to estimate the effect of universal implementation of a clinic-based, psychosocial smoking cessation intervention for pregnant women. Methods. We used data from US birth certificates (2005) and the Pregnancy Risk Assessment Monitoring System (2004) to estimate the number of women smoking at conception. To calculate the number of women eligible to receive the cessation intervention, we used estimates from the literature of the percentage of women who quit spontaneously (23%), entered prenatal care before the third trimester (96.5%), and disclosed smoking to their provider (75%). We used the pooled relative risk (RR) for continued smoking from the 2004 Cochrane Review as our measure of the intervention's effectiveness (RR=0.94). Results. We estimated that 944240 women smoked at conception. Of these, 23.0% quit spontaneously, 6.3% quit with usual care, and an additional 3.3% quit because of the intervention, leaving 67.4% smoking throughout pregnancy. The calculated smoking prevalence in late pregnancy decreased from 16.4% to 15.6% because of the intervention. Conclusions. Universal implementation of a best-practice, clinic-based intervention would increase the total number of quitters but would not substantially reduce smoking prevalence among pregnant women.

Knopik VS. Maternal smoking during pregnancy and child outcomes: Real or spurious effect? (review). Developmental Neuropsychology 34(1): 1-36, 2009. (155 refs.)

Maternal smoking during pregnancy (MSDP) is a major public health concern with clearly established consequences to both mother and newborn (e.g., low birth weight, altered cardiorespiratory responses). MSDP has also been associated with higher rates of a variety of poor cognitive and behavioral outcomes in children, including attention deficit hyperactivity disorder (ADHD), conduct disorder, impaired learning and memory, and cognitive dysfunction. However, the evidence suggesting causal effects of MSDP for these outcomes is muddied in the existing literature due to the frequent inability to separate prenatal exposure effects from other confounding environmental and genetic factors. Carefully designed studies using genetically sensitive strategies can build on current evidence and begin to elucidate the likely complex factors contributing to associations between MSDP and child outcomes.

Lim S; Prasad MR; Samuels P; Gardner DK; Cordero L. High-dose methadone in pregnant women and its effect on duration of neonatal abstinence syndrome. American Journal of Obstetrics and Gynecology 200(1): Article Number: 70.e1, 2009. (18 refs.)

OBJECTIVE: The purpose of this study was to examine high-dose methadone in pregnant women and its effect on the duration of neonatal abstinence syndrome. STUDY DESIGN: This was a retrospective chart review of 68 neonates and their mothers who received methadone therapy during pregnancy. The last dosage of maternal methadone just before delivery and the length of treatment for neonatal abstinence syndrome were examined with an analysis of variance model. RESULTS: When the data were analyzed for methadone dosages as a continuous variable, each 1-mg increase in the last maternal methadone dosage before delivery was associated with an additional 0.18 days of infant treatment for neonatal abstinence syndrome (P < .001; 95% CI, 0.112-0.255). In other words, every increase of 5.5 mg of methadone in the mother was associated statistically with 1 additional day of neonatal abstinence syndrome treatment for the infant. Gestational age at delivery and birthweight were not statistically significant. CONCLUSION: Higher doses of maternal methadone were associated with an increase in diagnosis and longer duration of neonatal abstinence syndrome.

Lumley J; Chamberlain C; Dowswell T; Oliver S; Oakley L; Watson L. Interventions for promoting smoking cessation during pregnancy. (review). Cochrane Database of Systemic Reviews 3: article CD001055, 2009. (382 refs.)

Background: Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, low birthweight, preterm birth and has serious long-term health implications for women and babies. Smoking in pregnancy is decreasing in high-income countries and increasing in low- to middle-income countries and is strongly associated with poverty, low educational attainment, poor social support and psychological illness. Objectives: To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (June 2008), the Cochrane Tobacco Addiction Group's Trials Register (June 2008), EMBASE, PsycLIT, and CINAHL (all from January 2003 to June 2008). We contacted trial authors to locate additional unpublished data. Selection criteria: Randomised controlled trials where smoking cessation during pregnancy was a primary aim of the intervention. Data collection and analysis: Trials were identified and data extracted by one person and checked by a second. Subgroup analysis was conducted to assess the effect of risk of trial bias, intensity of the intervention and main intervention strategy used. Main results: Seventy-two trials are included. Fifty-six randomised controlled trials (over 20,000 pregnant women) and nine cluster-randomised trials (over 5000 pregnant women) provided data on smoking cessation outcomes. There was a significant reduction in smoking in late pregnancy following interventions (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.93 to 0.96), an absolute difference of six in 100 women who stopped smoking during pregnancy. However, there is significant heterogeneity in the combined data (I-2 > 60%). In the trials with the lowest risk of bias, the interventions had less effect (RR 0.97, 95% CI 0.94 to 0.99), and lower heterogeneity (I-2 = 36%). Eight trials of smoking relapse prevention (over 1000 women) showed no statistically significant reduction in relapse. Smoking cessation interventions reduced low birthweight (RR 0.83, 95% CI 0.73 to 0.95) and preterm birth (RR 0.86, 95% CI 0.74 to 0.98), and there was a 53.91g (95% CI 10.44 g to 95.38 g) increase in mean birthweight. There were no statistically significant differences in neonatal intensive care unit admissions, very low birthweight, stillbirths, perinatal or neonatal mortality but these analyses had very limited power. Authors' conclusions: Smoking cessation interventions in pregnancy reduce the proportion of women who continue to smoke in late pregnancy, and reduce low birthweight and pretermbirth. Smoking cessation interventions in pregnancy need to be implemented in all maternity care settings. Given the difficulty many pregnant women addicted to tobacco have quitting during pregnancy, population-based measures to reduce smoking and social inequalities should be supported.

Malek A; Obrist C; Wenzinger S; von Mandach U. The impact of cocaine and heroin on the placental transfer of methadone. Reproductive Biology and Endocrinology 7(article 61), 2009. (40 refs.)

Background: Methadone is the therapeutic agent of choice for the treatment of opiate addiction in pregnancy. The co-consumption (heroin, cocaine) which may influence the effects of methadone is frequent. Therefore, the impact of cocaine and heroin on the placental transfer of methadone and the placental tissue was investigated under in vitro conditions. Methods: Placentae (n = 24) were ex-vivo perfused with medium (m) (control, n = 6), m plus methadone (n = 6), m plus methadone and cocaine (n = 6) or m plus methadone and heroin (n = 6). Placental functionality parameters like antipyrine permeability, glucose consumption, lactate production, hormone production (hCG and leptin), microparticles release and the expression of P-glycoprotein were analysed. Results: Methadone accumulated in placental tissue. Methadone alone decreased the transfer of antipyrine from 0.60 +/- 0.07 to 0.50 +/- 0.06 (fetal/maternal ratio, mean +/-SD, P < 0.01), whereas the combination with cocaine or heroin increased it (0.56 +/- 0.08 to 0.68 +/- 0.13, P = 0.03 and 0.58 +/- 0.21 to 0.71 +/- 0.24; P = 0.18). Microparticles (MPs) released from syncytiotrophoblast into maternal circuit increased by 30% after cocaine or heroin (P < 0.05) and the expression of P-glycoprotein in the tissue increased by = 49% after any drug (P < 0.05). All other measured parameters did not show any significant effect when methadone was combined with cocaine or heroine. Conclusion: The combination of cocaine or heroin with methadone increase antipyrine permeability. Changes of MPs resemble findings seen in oxidative stress of syncytiotrophoblast.

Martin PR; Arria AM; Fischer G; Kaltenbach K; Heil SH; Stine SM et al. Psychopharmacologic management of opioid-dependent women during pregnancy. American Journal on Addictions 18(2): 148-156, 2009. (62 refs.)

Illicit drug use during pregnancy presents complex clinical challenges, including reducing drug use and treating psychiatric disorders. Pharmacologic treatment of psychiatric disorders in a pregnant woman requires an evaluation of the balance between potential clinical benefit and the risk of potential neonatal consequences. This study describes psychiatric symptoms in 111 opioid-dependent pregnant women and their prescribed psychotropic medications. Hypomania, generalized anxiety disorder and depression were the most common disorders for which psychiatric symptoms were endorsed. Over half of women studied were prescribed some form of psychoactive medication during pregnancy. Pharmacologic vs. non-pharmacologic treatment approaches in this patient population are discussed.

Moss DR; Cluss PA; Watt-Morse M; Pike F. Targeting pregnant and parental smokers: Long-term outcomes of a practice-based intervention. Nicotine & Tobacco Research 11(3): 278-285, 2009. (42 refs.)

This study aimed to assess the change in obstetric and pediatric provider smoking cessation practices following implementation of a practice guideline-driven office-based program. This pre-post evaluation took place between May 2003 and August 2006 in 1 pediatric and 1 obstetric hospital-based clinic. The intervention involved provider training combined with office system supports. A total of 1,080 exit interviews were collected to measure outcomes of clinic practices at baseline and at 1 month, 6 months, 1 year (obstetric), and 2 years (pediatric) after implementation. Trend analysis was used to assess change in practice rates over time. Following program implementation, pediatric provider "Ask" rates increased (49% before to 86% 2 years after, p < .0001); changes in pediatric "Advise" and "Assist" rates were not significant: 44%-59% (p = .19) and 18%-28% (p = .26), respectively. In the obstetric clinic, whereas no significant changes were detected in provider "Ask" (59%-65% 1 year after, p = .17) or "Advise" (72%-85%, p = .27) rates, "Assist" rates rose from 28% to 62% (p = .0075) 1 year after program implementation. Implementation of the office-based program achieved significantly improved trends in pediatric provider "Ask" rates and obstetric provider "Assist" rates over time. Further research is needed on office strategies to create long-term provider behavior changes in smoking cessation practices.

Moussa K; Ostergren PO; Grahn M; Kunst AE; Eek F; Essen B. Socioeconomic differences in smoking trends among pregnant women at first antenatal visit in Sweden 1982-2001: increasing importance of educational level for the total burden of smoking. Tobacco Control 18(2): 92-97, 2009. (38 refs.)

Background: There was a decrease in smoking during early pregnancy in Swedish women between 1982 and 2001. We sought to determine whether there was a parallel decrease in socioeconomic inequality in smoking. Methods: Registry data indicating educational level and smoking status at first antenatal visit in all 2 022 469 pregnancies in Sweden 1982-2001 were analysed. Prevalence differences, odds ratios based on prevalences and total attributable fractions were compared for five-year intervals. Results: The prevalence differences of smoking showed a greater decrease at the lowest and middle educational level compared with the highest educational level (14.5%, 15.7% and 10.2%, respectively) indicating reduced inequality in absolute terms. However, odds ratios regarding low educational attainment versus high, increased from 5.6 to 14.2, signifying increased inequality in relative terms. Moreover, the total attributable fraction of low and intermediate educational level regarding smoking at first antenatal visit increased from 61% to 76% during the period studied. Conclusions: Smoking at first antenatal visit in Sweden between 1982 to 2001 decreased in a way that conclusions regarding trends in inequalities in smoking at first antenatal visit depend on the type of measure applied. However, using the measure of total attributable fraction, which takes into consideration the impact of the exposure on the individual as well as the effect of the varying size of the group of exposed, the growing importance of educational level for the behaviour in the population was demonstrated.

Moussally K; Oraichi D; Berard A. Herbal products use during pregnancy: Prevalence and predictors. Pharmacoepidemiology and Drug Safety 18(6): 454-461, 2009. (34 refs.)

Purposes (1) Measure the prevalence of herbal product (HP) use, alone, and concomitantly with prescribed medications during pregnancy, (2) identify the most frequently consumed HP during gestation and (3) determine predictors of HP use at the beginning of pregnancy, and during the third trimester. Methods A questionnaire was mailed to 8505 women selected from the Quebec Pregnancy Registry which was created by the linkage of three administrative databases: RAMQ, Medical-Echo and ISQ. Women were eligible if they were continuously insured by the RAMQ drug plan for at least 12 months before the first day of gestation and during pregnancy, and if they gave birth to a live born between January 1998 and December 2003 in one of the Quebec's hospitals. Women with diabetes and psychoses, and women who delivered a baby with birth defects were selected first. Descriptive statistics and multivariate logistic regression models were used to analyse data. Results Of the 3354 women (39%) who answered the questionnaire, and were included in the study, nine per cent used HP during pregnancy. 69% of users took at least one prescribed medication concomitantly. Chamomile, green tea, peppermint and flax were the most frequently HP used. Multivariate analyses showed that body mass index (BMI), multivitamin use and one to three prescribed medications used before pregnancy were predictors of HP use at the beginning of pregnancy; adherent women, smokers and users of HP prior to pregnancy were predictors of HP use during the third trimester. Conclusion HP use alone and concomitantly with prescribed medications during pregnancy is common, and needs to be addressed by health professionals.

O'Leary CM; Nassar N; Kurinczuk JJ; Bower C. The effect of maternal alcohol consumption on fetal growth and preterm birth. Obstetrical & Gynecological Survey 64(5): 299-300, 2009

Although numerous studies have investigated the effects of alcohol intake during pregnancy, currently available data linking prenatal alcohol exposure with abnormal fetal growth or preterm birth are inconclusive. This population-based cohort study assessed the effects of prenatal exposure to alcohol via a questionnaire given to a 10% random sample of all nonindigenous women in Western Australia who had delivered a singleton infant (n = 4719) between 1995 and 1997. The investigators examined the quantity of alcohol consumed per occasion, the frequency of consumption, and the total quantity consumed during the 3 months before and during each trimester of pregnancy. Multivariate logistic regression analysis was used to assess the possible association between alcohol consumption, both before and during pregnancy, with abnormal fetal growth (both small-for-gestational-age [SGA] and large-for-gestational-age infants [LGA]), and with preterm birth (<37 weeks of gestation). The control group consisted of infants born to abstinent women. In unadjusted analysis, moderate to heavy alcohol consumption during pregnancy was associated with an increased proportion of SGA infants born preterm. Adjustment for smoking status eliminated this effect in SGA infants. Binge drinking, defined as 5 or more drinks per occasion, in the first trimester was associated with a nonsignificant increase in the odds of preterm birth (adjusted odds ratio [aOR], 1.31; 95% confidence interval [CI], 0.67-2.58) as was binge drinking in late pregnancy (OR, 1.61; 95% CI: 0.68-3.77). Compared to the controls, women with moderate and heavy alcohol consumption had a significantly increased risk of preterm birth only if they ceased drinking before the second trimester (OR 1.78; 95% CI: 1.01-3.14). Low levels of alcohol intake during pregnancy (less than 60 gm/week or two or less standard drinks per occasion) was not associated with preterm. birth or SGA. These findings suggest that heavy and binge drinking among pregnant women may increase the likelihood of preterm birth, although the small number of patients makes the significance of these data unclear.

Ondersma SJ; Winhusen T; Erickson SJ; Stine SM; Wang Y. Motivation Enhancement Therapy with pregnant substance-abusing women: Does baseline motivation moderate efficacy? Drug and Alcohol Dependence 101(1/2): 74-79, 2009. (21 refs.)

Some evidence suggests that motivational approaches are less efficacious - or even counter-productive - with persons who are relatively motivated at baseline. The present study was conducted to examine whether disordinal moderation by baseline motivation could partially explain negative findings in a previous study [Winhusen, T., Kropp, F., Babcock, D., Hague, D., Erickson, S.J., Renz, C., Rau, L., Lewis, D., Leimberger,J., Somoza, E., 2008. Motivational enhancement therapy to improve treatment utilization and outcome in pregnant substance users. J. Subst. Abuse Treat. 35, 161-173]. Analyses also focused on the relative utility of the University of Rhode Island Change Assessment (URICA) scale, vs. a single goal question as potential moderators of Motivation Enhancement Therapy (MET). Participants were 200 pregnant women presenting for substance abuse treatment at one of four sites. Women were randomly assigned to either a three-session MET condition or treatment as usual (TAU). Generalized Estimating Equations (GEE) revealed no significant moderation effects on drug use at post-treatment. At follow-up, contrary to expectations, participants who had not set a clear quit goal at baseline were less likely to be drug-free if randomized to MET (OR = 0.48): participants who did set a clear quit goal were more likely to be drug-free if randomized to MET (OR = 2.53). No moderating effects were identified via the URICA. Disordinal moderation of MET efficacy by baseline motivation may have contributed somewhat to the negative results of the [Winhusen, T., Kropp, F., Babcock, D., Hague, D., Erickson, S.J., Renz, C., Rau, L., Lewis, D., Leimberger, J., Somoza, E., 2008. Motivational enhancement therapy to improve treatment utilization and outcome in pregnant substance users.J. Subst. Abuse Treat. 35,161-173] study, but in the opposite direction expected. A simple question regarding intent to quit may be useful in identifying persons who may differentially respond to motivational interventions. However, moderation effects are unstable, may be best identified with alternate methodologies, and may operate differently among pregnant women.

Paek YJ; Kang JB; Myung SK; Lee DH; Seong MW; Seo HG et al. Self-reported exposure to second-hand smoke and positive urinary cotinine in pregnant nonsmokers. Yonsei Medical Journal 50(3): 345-351, 2009. (17 refs.)

This cross-sectional study aimed to examine the association between self-reported exposure status to second-hand smoke and urinary cotinine level in pregnant nonsmokers. Materials and Methods: We recruited pregnant nonsmokers from the prenatal care clinics of a university hospital and two community health centers, and their urinary cotinine concentrations were measured. Results: Among a total of 412 pregnant nonsmokers, the proportions of self-reported exposure to second-hand smoke and positive urinary cotinine level were 60.4% and 3.4%, respectively. Among those, 4.8% of the participants who reported exposure to second-hand smoke had cotinine levels of 40 ng/mL (the kappa value = 0.029, p = 0.049). Among those who reported living with smokers (n = 170), "smoking currently permitted in the whole house" (vs. not permitted at home) was associated with positive urinary cotinine in the univariable analysis. Furthermore, this variable showed a significant association with positive urinary cotinine in the stepwise multiple logistic regression analysis [Odds ratio (OR), 15.6; 95% Confidence interval (CI) = 2.1-115.4]. Conclusion: In the current study, the association between self-reported exposure status to second-hand smoke and positive urinary cotinine in pregnant nonsmokers was poor. "Smoking currently permitted in the whole house" was a significant factor of positive urinary cotinine in pregnant nonsmokers. Furthermore, we suggest that a complete smoking ban at home should be considered to avoid potential adverse effects on pregnancy outcomes due to second-hand smoke.

Page RL; Ellison CG; Lee J. Does religiosity affect health risk behaviors in pregnant and postpartum women? Maternal and Child Health Journal 13(5): 621-632, 2009. (58 refs.)

Objectives: We examined the association between religious involvement and health risk behaviors such as smoking, drinking, marijuana use, and having multiple sex partners among a multiethnic sample of pregnant and postpartum women. Methods: Using data from the National Survey of Family Growth, we estimated multivariate logistic regression models to determine the association between various aspects of religious involvement (e.g., attendance, salience, and denomination) and certain behaviors known to be risky for pregnant women and their offspring. Results Frequent (more than once a week) and regular (once a week) attenders at religious services had 80% and 60% (respectively) lower odds of drinking alcohol compared to women who attended less than once a week. Similar patterns surfaced with regard to smoking tobacco with the odds of smoking roughly 85% lower (OR = 0.146, P < 0.001) among frequent attenders, and nearly 65% lower among regular attenders (OR = 0.369, P < 0.001). For smoking marijuana, religious attendance again emerges as a strong predictor. The odds of marijuana smoking are nearly 75% lower for women who attend services frequently (OR = 0.260, P < 0.05) and more than 65% lower for those who attend regularly (OR = 0.343, P < 0.01), as compared with their counterparts who attend services less often. Conclusions: Religious attendance emerged as an important correlate of less-risky health behaviors among this nationwide sample of pregnant and postpartum women. Future research should include an examination of the links between religious involvement and other important lifestyle factors that may influence maternal and child health.

Parackal SM; Parackal MK; Harraway JA; Ferguson EL. Opinions of non-pregnant New Zealand women aged 16-40 years about the safety of alcohol consumption during pregnancy. Drug and Alcohol Review 28(2): 135-141, 2009. (28 refs.)

Introduction and Aims. Premenopausal women's opinions on the safety of alcohol consumption during pregnancy are not well documented. This study aims to assess the opinions of New Zealand women on the safety of alcohol consumption in pregnancy and the sociodemographic and lifestyle factors associated with these opinions. Design and Methods. A nationwide, cross-sectional survey was conducted in 2005 on a random sample of 1109 non-pregnant women aged 16-40 years. Data were collected via an interviewer-administered questionnaire using a web-assisted telephone interviewing system. Results. Overall, 44% (95% confidence interval 41-47) of women surveyed were of the opinion that no alcohol is safe in pregnancy. Those who stated that no alcohol is safe in pregnancy were more likely to be of Pacific Island ethnicity (P < 0.05) and abstainers (P < 0.001). Women who drank more than two standard drinks of alcohol on a typical occasion and/or who binged were more likely to be of the opinion that 'more than one standard drink' of alcohol is safe on a typical drinking day during pregnancy (P < 0.001). Discussion and Conclusions. The association of drinking style with opinions about the safety of alcohol consumption in pregnancy accentuates the need for public health education to reduce risky drinking behaviours in this population. Such efforts may also address the risk associated with many women unintentionally drinking in early pregnancy, especially if the pregnancy is unplanned.

Paz MS; Smith LM; LaGasse LL; Derauf C; Grant P; Shah R et al. Maternal depression and neurobehavior in newborns prenatally exposed to methamphetamine. Neurotoxicology and Teratology 31(3): 177-182, 2009. (60 refs.)

Background: The effects of maternal depression on neonatal neurodevelopment in MA exposed neonates have not been well characterized. Objective: To determine the neurobehavioral effects of maternal depressive symptoms on neonates exposed and not exposed to methamphetamine (MA) using the NICU Network Neurobehavioral Scale (NNNS). Design: The purpose of the IDEAL study is to determine the effects of prenatal MA exposure on child outcome. IDEAL screened 13,808 subjects, 1632 were eligible and consented and 176 mothers were enrolled. Only biological mothers with Custody of their child at the one-month visit (n = 50 MA; n = 86 comparison) had the Addiction Severity Index (ASI) administered. The NNNS was administered to the neonate by an examiner blinded to MA exposure within the first five days of life. General Linear Models tested the effects of maternal depression and prenatal MA exposure on NNNS outcomes, with and without covariates. Significance was accepted at p<.05. Results: After adjusting for covariates, regardless of exposure status, maternal depressive symptoms were associated with lower handling and arousal scores, elevated physiological stress scores and an increased incidence of hypotonicity. When adjusting for covariates, MA exposure was associated with lower arousal and higher lethargy scores. Conclusions: Maternal depressive symptoms are associated with neurodevelopmental patterns of decreased arousal and increased stress. Prenatal MA exposure combined with maternal depression was not associated with any additional neonatal neurodevelopmental differences.

Peppone LJ; Piazza KM; Mahoney MC; Morrow GR; Mustian KM; Palesh OG et al. Associations between adult and childhood secondhand smoke exposures and fecundity and fetal loss among women who visited a cancer hospital. Tobacco Control 18(2): 115-120, 2009. (42 refs.)

Background: A large percentage of the population continues to be exposed to secondhand smoke (SHS). Although studies have consistently linked active smoking to various pregnancy outcomes, results from the few studies examining SHS exposure and pregnancy difficulties have been inconsistent. Methods: Approximately 4800 women who presented to Roswell Park Cancer Institute between 1982 and 1998 and reported being pregnant at least once were queried about their childhood and adult exposures to SHS using a standardised questionnaire. Women were asked to report on selected prenatal pregnancy outcomes (fetal loss and difficulty becoming pregnant). Results: Approximately 11.3% of women reported difficulty becoming pregnant, while 32% reported a fetal loss or 12.4% reported multiple fetal losses. 40% reported any prenatal pregnancy difficulty (fetal loss and/or difficulty becoming pregnant). SHS exposures from their parents were associated with difficulty becoming pregnant (OR = 1.27, 95% CI 1.03 to 1.56) and lasting. 1 year (OR = 1.34, 95% CI 1.12 to 1.60). Exposure to SHS in both at home during childhood and at the time of survey completion was also associated with fetal loss (OR = 1.39, 95% CI 1.17 to 1.66) and multiple fetal losses (OR = 1.62, 95% CI 1.25 to 2.11). Increasing current daily hours of SHS exposure as an adult was related to the occurrence of both multiple fetal loss and reduced fecundity (p(trend) < 0.05). Conclusions: Reports of exposures to SHS during childhood and as an adult were associated with increased odds for prenatal pregnancy difficulties. These findings underscore the public health perspective that all people, especially women in their reproductive years, should be fully protected from tobacco smoke.

Petersen Z; Nilsson M; Everett K; Emmelin M. Possibilities for transparency and trust in the communication between midwives and pregnant women: The case of smoking. Midwifery 25(4): 382-391, 2009. (23 refs.)

Objective: to explore barriers to and possibilities for interactive communication between midwives and pregnant women regarding smoking behaviour during pregnancy. Design: the study was based on a qualitative research design aiming at a Grounded Theory analysis of interviews with pregnant women. Setting: public sector antenatal clinics in Cape Town, South Africa predominantly providing care to women of mixed ancestry. Informants: in-depth interviews with 12 pregnant women purposively selected on the basis of smoking behaviour, age and marital status to reach maximum variation. Findings: the findings indicated low levels of transparency and trust in antenatal visits. Lack of trust was related to categories such as conflicting personal capabilities and socio-cultural and medical expectations, combined with a didactic approach from caregivers. The unworthy woman was identified as the core category of the interviews describing how women feet in their relationship with midwives. A theoretical model illustrates possibilities for change in relation to an ideal situation where a supportive caregiver, congruent expectations and capabilities result in women feeling visible. Key conclusions and implications for practice: culturally appropriate smoking cessation interventions should be of high priority. Training in patient-centred counselling for midwives is necessary for creating an open dialogue with pregnant mothers about their smoking habits. The time constraint experienced by midwives also suggests that other methods apart from midwife counselling should be investigated for inclusion in the clinical setting.

Pickett KE; Rathouz PJ; Dukic V; Kasza K; Niessner M; Wright RJ et al. The complex enterprise of modelling prenatal exposure to cigarettes: What is 'enough'? Paediatric and Perinatal Epidemiology 23(2): 160-170, 2009. (29 refs.)

While there is a burgeoning body of research linking smoking during pregnancy to problem behaviour in offspring, a major criticism of this work has been the crude measurement of exposure in these studies (e.g. retrospective, self-reported only) that could lead to biased estimates. To address this issue, we used a pregnancy cohort with repeated prospective measures of exposure as well as biological assays to generate estimates of exposure patterns using a range of modelling techniques. In this paper we report on the analytical approaches we have developed, including patterns of exposure over time and best-estimate approaches that combine self-report and cotinine measures, and compare their predictive value in relation to different dimensions of fetal growth as a first step towards examining the utility of greater precision of exposure measurement. Surprisingly, in this sample the more complex assessments of exposure, including biological measures, generally did not perform better than simple indicators of exposure based on repeated self-report measures, with one exception: a combined self-report cotinine 'best estimate' of third trimester exposure was uniquely associated with lower brain : body ratio. Further study is needed using more sophisticated cotinine assays and testing prediction of a range of outcomes to ascertain whether these findings represent true differences or are specific to the sample, methods and outcomes used. Such research will inform the development of guidelines for adequate exposure characterisation in developmental studies.

Raymond N; Beer C; Glazebrook C; Sayal K. Pregnant women's attitudes towards alcohol consumption. BMC Public Health 9: article 175, 2009. (34 refs.)

Background: There is uncertainty as to whether there is a safe threshold for drinking alcohol during pregnancy. We explored pregnant women's attitudes towards drinking alcohol in pregnancy and their attitudes towards sources of information about drinking in pregnancy following recent changes in UK government guidance. Methods: A qualitative study involving individual, semi-structured interviews with 20 pregnant women recruited from community organisations in the UK. Interview transcripts were analysed qualitatively using thematic analysis. Results: Most women found information and advice about safe levels of drinking in pregnancy confusing and lacking in evidence and detail. Although most women considered that there were risks involved with drinking in pregnancy and these perceptions influenced their behaviour, only six women reported abstinence. Women reported being influenced by advice from family and friends and their experiences of previous pregnancies. Many had received no individual advice from general practitioners or midwives relating to drinking during pregnancy. Conclusion: Pregnant women wished to take responsibility for their own health and make choices based on informed advice. In order to do so, they require clear and consistent advice about safe levels of drinking from policy makers and health professionals. This is an important issue as women might drink socially during their pregnancy.

Roelands J; Jamison MG; Lyerly AD; James AH. Consequences of smoking during pregnancy on maternal health. Journal of Women's Health 18(6): 867-872, 2009. (30 refs.)

Objective: To estimate the incidence of maternal cardiovascular and pulmonary events and the prevalence of other comorbid conditions among pregnant smokers. Methods: We queried the Nationwide Inpatient Sample (NIS)from the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality (AHRQ) for pregnancy-related discharge codes for the years 2000-2004. The prevalence of various conditions and the incidence of various complications were compared between smokers and nonsmokers. Results: The majority of smokers were young and white and had public insurance. Smokers were more likely to have experienced deep vein thrombosis (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.1, 1.6), stroke (OR 1.7, 95% CI 1.2, 2.5), pulmonary embolus (OR 2.5, 95% CI 2.1, 3.0), and myocardial infarction (OR 4.6, 95% CI 3.3, 6.4). They were 3 times more likely to have experienced influenza or pneumonia (OR 2.9, 95% CI 2.7, 3.2) and 15 times more likely to have bronchitis (OR 15.2, 95% CI 12.8, 18.2). They were more likely to suffer from a number of comorbidities, including asthma (OR 4.0, 95% CI 3.7, 4.2) and gastrointestinal ulcers (OR 3.7, 95% CI 2.6, 5.5). Although they were less likely to have experienced gestational diabetes (OR 0.9, 95% CI 0.9, 1.0), preeclampsia (OR 0.8, 95% CI 0.8, 0.9), or eclampsia (OR 0.7, 95% CI 0.6, 0.9), they were more than 5 times as likely to have experienced an ectopic pregnancy (OR 5.4, 95% CI 4.6, 6.3). Conclusions: Smoking has a negative impact on maternal health. Counseling about the risks of smoking in pregnancy should include not only fetal risks but maternal risks as well.

Rogers JM. Tobacco and pregnancy. Reproductive Toxicology 28(2, Special Issue): 152-160, 2009. (127 refs.)

This paper will review the epidemiology of the impact of cigarette smoking and other forms of tobacco exposure on human development. Sources of exposure described include cigarettes and other forms of smoked tobacco, secondhand (environmental) tobacco smoke, several forms of smokeless tobacco, and nicotine from nicotine replacement therapy. Exposure is immense and worldwide, most of it due to smoking, but in some parts of the world and in some populations, smoking is exceeded by smokeless tobacco use. Nicotine and carbon monoxide exposure are of large concern, but cigarette smoke contains over 4000 chemical constituents and additives including known carcinogens, toxic heavy metals, and many chemicals untested for developmental toxicity. The impact of tobacco on human development will be reviewed. Fertility, conception, survival of the conceptus, most phases and aspects of development studied to date, as well as postnatal survival and health are adversely impacted by maternal tobacco use or exposure. Effects in surviving offspring are probably life-long, and are still being elucidated. It is hoped that this review will serve to keep a focus on the critical and continuing problem of tobacco use impacting human development.

Ross LE; Dennis CL. The prevalence of postpartum depression among women with substance use, an abuse history, or chronic Illness: A systematic review (review). Journal of Women's Health 18(4): 475-486, 2009. (49 refs.)

Background: Although much is known about risk factors for postpartum depression (PPD), many potentially important clinical variables have still not been investigated. In this systematic literature review, we examine the published evidence for the prevalence of PPD among three populations of women commonly seen by providers of perinatal care: women who use substances, women with current or past experiences of abuse, and women with chronic illness. Methods: We searched Medline, CINAHL, EMBASE, PsycINFO, and the Cochrane Library from their start dates through to August 1, 2008, using keywords relevant to depression and each of the three target clinical populations. All published, peer-reviewed papers in English or French were included in the review if a standardized assessment of depression between 3 and 52 weeks postpartum was used and if either the prevalence of PPD in the target population or a comparison of depression scores between the target population and a control group were reported. Results: Seventeen papers were included in the review. There were high rates of PPD among substance-using women and those with current or past experiences of abuse. However, little evidence was found to suggest an increased risk for depression among women with chronic illness. Conclusions: Few eligible studies were identified for each clinical population of interest. Despite limitations of the studies reviewed, the results indicate that both substance use and current or past experiences of abuse are associated with increased risk for PPD. Targeted clinical interventions for these women may be beneficial.

Sayal K. Commentary. Light drinking in pregnancy: Can a glass or two hurt? (editorial). International Journal of Epidemiology 38(1): 140-142, 2009. (11 refs.)

Scott JR. Effects of restricted caffeine intake by mother on fetal, neonatal, and pregnancy outcome. (editorial). Obstetrics and Gynecology 114(1): 161-162 [article CD006965], 2009. (5 refs.)

BACKGROUND: Maternal caffeine consumption during pregnancy may have adverse effects on fetal, neonatal and maternal outcomes. OBJECTIVES: This review investigates the effects of restricting caffeine intake by mothers on fetal, neonatal and pregnancy outcomes. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Child birth Group's Trials Register (December 2008), scanned bibliographies of published studies and corresponded with investigators. SELECTION CRITERIA: Randomized controlled trials including quasi-randomized controlled trials (RCTs) investigating the effect of caffeine and/or supplementary caffeine versus restricted caffeine intake or placebo on pregnancy outcome. DATA COLLECTION AND ANALYSIS: The two review authors independently assessed trial quality and extracted data. MAIN RESULTS: One study met the inclusion criteria. Caffeinated instant coffee (568 women) was compared with decaffeinated instant coffee (629 women) and it was found that reducing the caffeine intake of regular coffee drinkers (3+ cups/day) during the second and third trimester by an average of 182 mg/day did not affect birthweight or length of gestation. AUTHORS' CONCLUSION: There is insufficient evidence to confirm or refute the effectiveness of caffeine avoidance on birthweight or other pregnancy outcomes. There is a need to conduct high-quality, double-blinded RCTs to determine whether caffeine has any effect on pregnancy outcome.

Scott TJL; Heil SH; Higgins ST; Badger GJ; Bernstein IM. Depressive symptoms predict smoking status among pregnant women. Addictive Behaviors 34(8): 705-708, 2009. (14 refs.)

The current study assessed self-reported psychopathology in women who spontaneously quit or continued smoking after learning that they are pregnant and examined whether any potential differences remained after control for confounding variables. All participants (77 smokers and 50 spontaneous quitters) completed 3 assessments of psychological functioning prior to enrollment in either smoking cessation or relapse prevention studies. Assessments included the Brief Symptom Inventory (BSI): the Beck Depression Inventory (BDI); and the Adult Self-Report (ASR). Smokers and spontaneous quitters differed on sociodemographic and smoking characteristics. In terms of psychological functioning, smokers reported significantly more depression/anxiety symptoms and withdrawn behavior than spontaneous quitters on the BSI and the ASR. Higher depression scores on the BSI were associated with increased odds of continued smoking, even after controlling for sociodemographic and smoking variables in multivariate analyses. These results suggest that depressive symptoms may be an independent contributor to the problem of continued smoking during pregnancy, which may have implications for smoking-cessation interventions among pregnant women.

Shields B; Hill A; Bilous M; Knight B; Hattersley AT; Bilous RW et al. Cigarette smoking during pregnancy is associated with alterations in maternal and fetal thyroid function. Journal of Clinical Endocrinology and Metabolism 94(2): 570-574, 2009. (21 refs.)

Context: Studies in the general population have shown lower serum TSH levels in smokers as compared with nonsmokers. Aim: Our aim was to examine whether smoking is associated with changes in thyroid function of pregnant women and their fetus. Subjects and Methods: We examined the relationship between smoking and thyroid function (serum TSH, free T-4, and free T-3) in two independent cohorts of pregnant women without a history of thyroid disorder or an overt biochemical thyroid dysfunction: 1) first-trimester cohort (median gestation 9 wk) (n = 1428) and 2) third-trimester cohort (gestation 28 wk) (n = 927). We also analyzed the relationship between maternal smoking and thyroid hormone levels in cord serum of 618 full-term babies born to the women in the third-trimester cohort. Results: In smokers compared with nonsmokers, median serum TSH was lower (first-trimester cohort: 1.02 vs. 1.17 mlU/liter, P = 0.001; third-trimester cohort: 1.72 vs. 1.90 mlU/liter, P = 0.037), and median serum FT3 was higher (first-trimester cohort: 5.1 vs. 4.9 pmol/liter, P < 0.0001; third-trimester cohort: 4.4 vs. 4.1 pmol/liter, P = 0.0001). In both cohorts, serum FT4 in smokers and nonsmokers were similar. The prevalence of anti-thyroperoxidase antibodies was also similar in smokers and nonsmokers in both cohorts. Cord serum TSH of babies born to smokers was lower than of those born to nonsmokers (6.7 vs. 8.1 mlU/liter, P = 0.009). Conclusions: Cigarette smoking is associated with changes in maternal thyroid function throughout the pregnancy and in fetal thyroid function as measured in cord blood samples.

Smith EJ; Lui S; Terplan M. Pharmacologic interventions for pregnant women enrolled in alcohol treatment. (review). Cochrane Database of Systemic Reviews 3(article CD007361), 2009. (67 refs.)

Background: Excessive alcohol use during pregnancy has been associated with adverse maternal and neonatal effects. It is therefore important to develop and evaluate effective interventions during this important time in a woman's life. To our knowledge there have been no systematic reviews of randomised control trials (RCT) in this population. Objectives To evaluate the effectiveness of pharmacologic interventions in pregnant women enrolled in alcohol treatment programs for improving birth and neonatal outcomes, maternal abstinence and treatment retention. Search strategy: We searched the Cochrane Drugs and Alcohol Group's Trial register (August 2008); MEDLINE (1.1950 to 6.2008); EMBASE (1.1974-8.2008); CINAHL (1.1982-6.2008); PsycInfo (1.1806-6.2008), and reference lists of articles. Selection criteria: We sought to include randomised or quasi-randomised studies comparing any pharmacologic intervention versus other pharmacologic treatment alone or in association with psychosocial treatment, placebo, non-intervention or psychosocial intervention. Data collection and analysis: Two review authors independently assessed trials for inclusion in the review. Included studies were to be assessed using standardized data extraction and quality assessment forms. No suitable trials were identified. Main results: The search strategy identified 793 citations. Twenty-three citations were deemed relevant for full text review; an additional ten articles were retrieved through hand searching references, for a total of thirty-three articles. Following full text review no articles met the inclusion criteria. Data extraction and assessment of methodological quality were therefore not possible. Authors' conclusions: The review question remains unanswered as there were no randomised control trials found relevant to the topic. There is a need for high quality research to determine the effectiveness of pharmacologic interventions in pregnant women enrolled in alcohol treatment program.

Stade BC; Bailey C; Dzendoletas D; Sgro M; Dowswell T; Bennett D. Psychological and/or educational interventions for reducing alcohol consumption in pregnant women and women planning pregnancy. (review). Cochrane Database of Systemic Reviews 2009(2): article CD004228, 2009. (91 refs.)

Background: It is estimated that more than 20% of pregnant women worldwide consume alcohol. Current research suggests that alcohol intake of seven or more standard drinks (one standard drink = 13.6 grams of absolute alcohol) per week during pregnancy places the baby at risk of serious, lifelong developmental and cognitive disabilities. Psychological and educational interventions may help women to reduce their alcohol intake during pregnancy. Objectives: To determine the effectiveness of psychological and educational interventions to reduce alcohol consumption during pregnancy in pregnant women or women planning pregnancy. Search strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (August 2008), CENTRAL (The Cochrane Library 2007, Issue 4), MEDLINE (1966 to November 2007), EMBASE (1980 to November 2007), CINAHL (1982 to November 2007), Counsel. Lit (1980 to November 2007), PsycLIT (1974 to November 2007) and PsycINFO (1967 to November 2007) and checked cited references from retrieved articles. Selection criteria: Randomized controlled trials examining the effectiveness of psychological and educational interventions for reducing consumption of alcohol among pregnant women, or women planning for pregnancy. Data collection and analysis At least two review authors independently extracted information from the results sections of the included studies. Main results: Four studies met the inclusion criteria (715 pregnant women), and reported on at least one of the outcomes of interest. We performed no meta-analyses as the interventions and outcomes measured in the studies were not sufficiently similar. For most outcomes there were no significant differences between groups; and results relating to abstaining or reducing alcohol consumption were mixed. Results from individual studies suggest that interventions may encourage women to abstain from alcohol in pregnancy. There was very little information provided on the effects of interventions on the health of mothers and babies. Authors' conclusions: The evidence from the limited number of studies suggests that psychological and educational interventions may result in increased abstinence from alcohol, and a reduction in alcohol consumption among pregnant women. However, results were not consistent, and the paucity of studies, the number of total participants, the high risk of bias of some of the studies, and the complexity of interventions limits our ability to determine the type of intervention which would be most effective in increasing abstinence from, or reducing the consumption of, alcohol among pregnant women.

Stotts AL; Groff JY; Elasquez MMV; Benjamin-Garner R; Green C; Carbonari JP et al. Ultrasound feedback and motivational interviewing targeting smoking cessation in the second and third trimesters of pregnancy. Nicotine & Tobacco Research 11(8): 961-968, 2009. (45 refs.)

Introduction: Cigarette smoking during pregnancy is associated with poor maternal and child health outcomes. Effective interventions to increase smoking cessation rates are needed particularly for pregnant women unable to quit in their first trimester. Real-time ultrasound feedback focused on potential effects of smoking on the fetus may be an effective treatment adjunct, improving smoking outcomes. Methods: A prospective randomized trial was conducted to evaluate the efficacy of a smoking cessation intervention consisting of personalized feedback during ultrasound plus motivational interviewing-based counseling sessions. Pregnant smokers (N - 360) between 16 and 26 weeks of gestation were randomly assigned to one of three groups: Best Practice (BP) only, Best Practice plus ultrasound feedback (BP+US), or Motivational Interviewing-based counseling plus ultrasound feedback (MI+US). Assessments were conducted at baseline and end of pregnancy (EOP). Results: Analyses of cotinine-verified self-reported smoking status at EOP indicated that 10.8% of the BP group was not smoking at EOP; 14.2% in the BP+US condition and 18.3% who received MI+US were abstinent, but differences were not statistically significant. Intervention effects were found conditional upon level of baseline smoking, however. Nearly 34% of light smokers (<= 10 cigarettes/day) in the MI+US condition were abstinent at EOP, followed by 25.8% and 15.6% in the BP+US and BP conditions, respectively. Heavy smokers (>10 cigarettes/day) were notably unaffected by the intervention. Discussion: Future research should confirm benefit of motivational interviewing plus ultrasound feedback for pregnant light smokers and explore mechanisms of action. Innovative interventions for pregnant women smoking at high levels are sorely needed.

Sun YL; Strandberg-Larsen K; Vestergaard M; Christensen J; Andersen AMN; Gronbaek M et al. Binge drinking during pregnancy and risk of seizures in childhood: A study based on the Danish National Birth Cohort. American Journal of Epidemiology 169(3): 313-322, 2009. (41 refs.)

Seizures are often found in children with fetal alcohol syndrome, but it is not known whether binge drinking during pregnancy by nonalcoholic women is associated with an increased risk of seizure disorders in children. The authors conducted a population-based cohort study of 80,526 liveborn singletons in the Danish National Birth Cohort (1996-2002). Information on maternal binge drinking (intake of >= 5 drinks on a single occasion) was collected in 2 computer-assisted telephone interviews during pregnancy. Children were followed for up to 8 years. Information on neonatal seizures, epilepsy, and febrile seizures was retrieved from the Danish National Hospitalital Register. Results showed that exposure to binge drinking episodes during pregnancy was not associated with an increased risk of seizure disorders in children, except for those exposed at 11-16 gestational weeks. These children had a 3.15-fold increased risk of neonatal seizures (95% confidence interval: 1.37, 7.25) and a 1.81-fold increased risk of epilepsy (95% confidence interval: 1.13, 2.90). These findings suggest that maternal binge drinking during a specific time period of pregnancy may be associated with an increased risk of specific seizure disorders in the offspring. The results are exploratory, however, and need to be replicated.

Terplan M; Garrett J; Hartmann K. Gestational age at enrollment and continued substance use among pregnant women in drug treatment. Journal of Addictive Diseases 28(2): 103-112, 2009. (46 refs.)

Substance use during pregnancy is associated with poor obstetrical and neonatal outcomes. Although intervention for substance use including alcohol improves pregnancy outcomes, a substantial number of women continue to use drugs or consume alcohol during treatment. To determine whether gestational age at entry into treatment (specifically first trimester enrollment) was associated with lower risk of continued substance use, we analyzed the North Carolina Treatment Outcomes and Program Performance System, an administrative database of drug treatment clinics, between 2000 and 2004. There were 847 pregnant women using substances who met our inclusion criteria. Demographic and other risk factor data were collected. We conducted logistic regression and a Generalized Estimating Equation analysis. Gestational age at enrollment was not associated with continued substance use (odds ratio [OR] = 0.88; 95% confidence interval [CI] = 0.51, 1.51). Women who had child care provided, were less likely to continue substance use (OR = 0.64; 95% CI = 0.48, 0.84), whereas those referred from the criminal justice system were more likely to continue (OR = 1.53; 95% CI = 1.01, 2.30). Although earlier gestational age at enrollment in treatment does not predict greater abstinence at any time point, this data does suggest that the provision of childcare may improve treatment success.

Terplan M; Smith EJ; Kozloski MJ; Pollack HA. Methamphetamine use among pregnant women. Obstetrics and Gynecology 113(6): 1285-1291, 2009. (35 refs.)

OBJECTIVE: To estimate trends in the prevalence of methamphetamine treatment during pregnancy in the United States. METHODS: Data were obtained from the Treatment Episode Data Set, an administrative data set that captures admissions to federally funded treatment centers in the United States. Demographic and treatment-related measures were examined among women admitted for methamphetamine use and stratified by year of admission to assess trends over time. RESULTS: From 1994 to 2006 there were 245,970 pregnant women admitted. In 1994, methamphetamine accounted for 8% of admitted pregnant women, rising to 24% by 2006. This proportion was higher than methamphetamine admissions among both nonpregnant women (12%) and men (7%). The majority of methamphetamine admissions occurred in the West (73%) among white (64%) unemployed (88%) women. Over the time of analysis, women admitted for methamphetamine treatment became sicker (measured by increasing co-occurring psychiatric disorders) and more marginalized (measured by increasing dependent-living situations and criminal justice involvement). CONCLUSION: Methamphetamine has become the primary substance compelling treatment during pregnancy. Our findings suggest a need for more effective drug and alcohol screening by clinicians who are positioned to identify and address such concerns outside the criminal justice system.

Varvarigou AA; Asimakopoulou A; Beratis NG. Impact of maternal smoking on birth size: Effect of parity and sex dimorphism. Neonatology 95(1): 61-67, 2009. (30 refs.)

Background: Maternal smoking during pregnancy causes a delay of intrauterine growth. Objective: To examine the effect of maternal smoking during pregnancy on fetal growth in relationship to maternal parity, age and number of cigarettes smoked/day, and offspring's gender. Subjects: We studied 2,108 term newborns (1,102 male, 1,006 female) delivered at the General University Hospital of Patras from 1994 to 2004. The 1,443 were born to mothers who did not smoke and 665 to mothers who smoked during pregnancy. Methods: Birth weight, length and head circumference were measured prospectively in all newborns. Also, maternal smoking status and number of cigarettes smoked per day, age, and parity were recorded. For the analysis, t test, one-way ANOVA, Mann-Whitney U test, Spearman rank correlation, and factorial MANOVA with covariates were used. Results: With increasing parity, in the neonates of nonsmoking mothers there was a gradual increase of growth, whereas in neonates of smoking mothers there was a gradual decrease of growth. This effect was more pronounced in males. A significant negative main effect on growth resulted from the interaction of smoking with parity (p = 0.013), and with gender and parity (p = 0.001). There was a significant negative correlation between number of cigarettes smoked per day and growth, the strength of which increased with parity, mainly in males. Conclusion: Maternal smoking during pregnancy causes a delay in fetal growth, which is greater in male offspring, an effect that is enhanced with parity but is independent of maternal age.

Walker MB; Tekin E; Wallace S; Wallace Sally. Teen smoking and birth outcomes. Southern Economic Journal 75(3): 892-907, 2009. (24 refs.)

Teen mothers in the United States are more likely to give birth to low birth weight babies. Substantial evidence indicates that smoking is a risk factor correlated with low birth weight. Low birth weight is a costly outcome for parents, children, and society at large. This paper examines the causal link between teen smoking behavior and low birth weight. We use a variety of empirical techniques, including fixed effects and a matching estimator, to identify the impact of smoking on babies of teen and nonteen mothers. Both ordinary least squares and matching estimators yield large impacts of smoking on birth weight for teens and adults. However, to the extent that unobservables are fixed over time, they can be controlled using fixed effects. These estimates indicate that the impact of smoking on birth weight is diminished, and there are small differences in the impact of smoking on birth weight between teens and nonteens.

Walton-Moss BJ; McIntosh LC; Conrad J; Kiefer E. Health status and birth outcomes manog pregnant women in substance abuse treatment. Women's Health Issues 19(3): 167-175, 2009. (42 refs.)

Purpose. We sought to examine the physical and mental health status and low birthweight and preterm birth among low-income pregnant women in substance abuse treatment. Methods. A prospective correlational design was used with 84 pregnant women enrolled in a university-affiliated, comprehensive, hospital-based substance abuse treatment program. The majority of the sample reported heroin as their primary substance of abuse. Results. Approximately 39% of the infants were born preterm and 27.5% were low birthweight. Poorer perception of current health, cocaine as the primary substance of abuse, and number of prior substance abuse treatment admissions were independently associated with preterm birth. Being African American and a poorer perception of current health were independently associated with low birthweight. Conclusion. Asking about perceptions of their current health is a useful addition to comprehensive assessment for pregnant women with substance abuse problems in any setting. Further knowledge of women's physical and mental health status will improve identification of those who are at even greater risk in a group at high risk overall.

Waylen AL; Metwally M; Jones GL; Wilkinson AJ; Ledger WL. Effects of cigarette smoking upon clinical outcomes of assisted reproduction: A meta-analysis. (review). Human Reproduction Update 15(1): 31-44, 2009. (52 refs.)

The aim of this meta-analysis was to investigate whether any difference exists in success rate of clinical outcomes of assisted reproductive technologies (ART) between women who actively smoke cigarettes at the time of treatment and those who do not. An intensive computerized search was conducted on published literature from eight databases, using search terms related to smoking, assisted reproduction and outcome measures. Eligible studies compared outcomes of ART between cigarette smoking patients and a control group of non-smoking patients and reported on live birth rate per cycle, clinical pregnancy rate per cycle, ectopic pregnancy rate per pregnancy or spontaneous miscarriage rate per pregnancy, and 21 studies were included in the meta-analyses. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated for the data, and statistical heterogeneity was tested for using chi(2) and I-2 values. A systematic review examined the effect of smoking upon fertilization rates across 17 studies. Smoking patients demonstrated significantly lower odds of live birth per cycle (OR 0.54, 95% CI 0.30-0.99), significantly lower odds of clinical pregnancy per cycle (OR 0.56, 95% CI 0.43-0.73), significantly higher odds of spontaneous miscarriage (OR 2.65, 95% CI 1.33-5.30) and significantly higher odds of ectopic pregnancy (OR 15.69, 95% CI 2.87-85.76). A systematic literature review revealed that fertilization rates were not significantly different between smoking and non-smoking groups in most studies. This meta-analysis provides compelling evidence for a significant negative effect of cigarette smoking upon clinical outcomes of ART and should be presented to infertility patients who smoke cigarettes in order to optimize success rates.

Willoughby MT; Kollins SH; McClernon FJ. Association between smoking and retrospectively reported attention-deficit/hyperactivity disorder symptoms in a large sample of new mothers. Nicotine & Tobacco Research 11(3): 313-322, 2009. (32 refs.)

This study investigated the association between retrospectively reported attention-deficit/hyperactivity disorder (ADHD) symptoms experienced during childhood and five cigarette smoking-related outcomes in adulthood. A large sample (N = 1,117) of new mothers participating in an ongoing longitudinal study completed retrospective reports of their childhood ADHD symptomatology, as well as concurrent and retrospective reports of their smoking behavior. Linear regression models tested the association between ADHD symptomatology and smoking outcomes. Childhood ADHD symptomatology was predictive of the number of cigarettes smoked per day currently and during pregnancy, as well as the age at onset of smoking. We found nonlinear associations between hyperactive-impulsive symptoms and the number of cigarettes smoked per day in pregnancy, as well as between inattentive symptoms and the number of cigarettes smoked per day currently. Women who retrospectively reported intermediate levels of ADHD symptoms during their childhood reported smoking more cigarettes per day than women who reported low or high levels of ADHD symptoms during childhood. We also found multiplicative relationship between inattentive and hyperactive-impulsive symptoms, such that inattentive symptoms were predictive of an earlier age at smoking onset only when hyperactive-impulsive symptoms were low; moreover, the magnitude of this association was stronger for Black relative to White women. These findings demonstrate the importance of considering differential effects of ADHD symptoms and smoking outcomes as a function of sex and race. They also represent a potentially indirect means through which women who have even a moderate childhood history of ADHD symptomatology may create a set of circumstances that compromise the health and well-being of their own children.

Winklbaur B; Baewert A; Jagsch R; Rohrmeister K; Metz V; Jachmann CA et al. Association between prenatal tobacco exposure and outcome of neonates born to opioid-maintained mothers. European Addiction Research 15(3): 150-156, 2009. (35 refs.)

Background: Prenatal nicotine exposure is associated with increased neonatal mortality, low birth weight, and smaller head circumference. Opioid-dependent pregnant women show a particularly high prevalence of tobacco smoking and are at greater risk for additional adverse events. However, little is known about the impact of tobacco smoking on opioid-maintained pregnant women and neonatal outcomes. Patients and Methods: This study examined the effect of cigarette smoking on 139 opioid-maintained pregnant women and their neonates. Forty-five percent of the participants were maintained on slow-release oral morphine (SROM), 39% received methadone maintenance, and 16% received buprenorphine. Participants were divided into two groups: (1) women who reported a low cigarette consumption of <= 10 cigarettes/day (56.8%) and (2) those reporting heavy consumption of >= 20 cigarettes/day (43.2%). Neonatal outcome measures were assessed, and a standardized Finnegan score was applied to determine the neonatal abstinence syndrome (NAS). Results: Fifty-two percent of the newborns did not require treatment for NAS (54% of neonates born to methadone-maintained mothers, 30% born to SROM-maintained mothers, and 95% born to buprenorphine-maintained mothers; p < 0.001). Heavy cigarette consumption was associated with significantly lower neonatal birth weight (p < 0.001), smaller birth length (p = 0.017) as well as with the severity of NAS (p = 0.03). With regard to concomitant consumption of opioids (p = 0.54), cocaine (p = 0.25), amphetamines (p = 0.90) or benzodiazepines (p = 0.09), no significant differences between heavy or low nicotine consumption were noted. Conclusion: Heavy tobacco smoking in opioid-maintained pregnant women is associated with adverse medical and developmental consequences for the newborn. Future treatment programs for this target group should focus on an individualized approach to opioid maintenance therapy in addition to offering specially tailored counseling for smoking cessation.

Yang QY; Wen SW; Phillips K; Oppenheimer L; Black D; Walker MC. Comparison of maternal risk factors between placental abruption and placenta previa. American Journal of Perinatology 26(4): 279-286, 2009. (33 refs.)

The purpose of this study was to compare risk factors between placental abruption and placenta previa among primiparous and multiparous singleton pregnancies. We analyzed data from a population-based retrospective cohort with singleton pregnancies in the United States for 1995 to 2000. Maternal risk factors for placenta previa and placental abruption were examined using multiple logistic regressions. A total of 5,630,854 primiparous and 11,026,768 multiparous singleton pregnancies were available for filial analyses after excluding subjects with missing information on outcomes or important exposures. Placental abruption was recorded in 4.8 per 1000 primiparous singleton births and 5.9 per 1000 multiparous singleton pregnancies. The occurrence of placenta previa was 1.9 per 1000 primiparous singleton pregnancies and 3.9 per 1000 multiparous singleton pregnancies. The effects of maternal age, race, parity, and previous cesarean section were stronger on placenta previa than on placental abruption, and the effects of cigarette smoking, alcohol drinking, and prenatal care were stronger on placental abruption than on placenta previa. A composite outcome of selected medical and pregnancy complications was related with placental abruption but not with placental previa. Placental abruption is more likely to be affected by conditions occurring during pregnancy, and placenta previa is more likely to be affected by conditions existing prior to pregnancy.

Yao TT; Lee AH; Mao ZZ. Potential unintended consequences of smoke-free policies in public places on pregnant women in China. American Journal of Preventive Medicine 37(2, Supplement S): S159-S164, 2009. (34 refs.)

Background: Smoke-free policies in public places have become more common in China. Little is known, however, about the potential Unintended consequences of such policies on pregnant women. Methods: The study was conducted in 2006 in Chengdu, China. Nonsmoking pregnant women (N=55) whose husband were smokers participated in a study of their knowledge about secondhand smoke and smoke-free policies, their exposure to secondhand smoke, and their husbands' smoking status at home. This study presents descriptive statistics, analyses based on family income and pregnant women's education level, and the findings of focus group discussions that examined the potential unintended consequences of the smoke-free policies on pregnant women. Results: Exposure to secondhand smoke at home was reported by 69.1% of the pregnant women. Both family income and the education level of the pregnant women had a significant (p<0.05) association with exposure to secondhand smoke. The four main potential unintended consequences of the smoke-free policies were: (1) increased exposure of pregnant women to secondhand smoke at home; (2) reduced work efficiency; (3) adverse effect on family harmony; and (4) poor air quality at home. Conclusions: Education is needed to increase knowledge of secondhand smoke among smokers and nonsmokers alike. When the smoking location is shifted from public places and workplaces to home, women, and in particular pregnant women, become the victims. Policymakers should recognize such potential unintended consequences and take necessary measures to increase awareness about the harms of secondhand smoke.