Running head: EFFECTS OF SUBSTANCE ABUSE DURING PREGNANCY

The Effects of Substance Abuse During Pregnancy on Neonates and Their Mothers
Courtney N. Coit-Fontana, Katie M. den Dulk, Caitlin A. Martinez, Paige E. Nicolosi,
Christa G. Sciabica, and Chelsea E. Shenton-Eggert
California State University, Stanislaus

EFFECTS OF SUBSTANCE ABUSE DURING PREGNANCY

Background and Significance

Prenatal substance abuse is classified as a pregnant mothers consumption of illegal
and/or legal substances. These substances include but are not limited to: alcohol, nicotine,
prescription medications, and illicit street drugs (i.e. cocaine, heroin, methamphetamine, and
marijuana). From 2010 to 2011, the U.S. Department of Health and Human Services (DHHS)
found that 5% of pregnant women between the ages of 15 and 44 used illegal substances (DHHS,
2011). Furthermore, they note 9.4% of the women in the same age group reported drinking
alcohol. Many studies have served to exemplify the possible immediate and long-lasting effects
of prenatal substance abuse for the mother and child (Delsing et al., 2011; Roberts & Pies, 2007).
To begin, substance abuse can affect a child even before birth, as mothers who abuse
drugs and/or alcohol during their pregnancy are less likely to seek prenatal care (Roberts & Pies,
2007). Additionally, up to 43% of neonates exposed to drugs and alcohol were below the 10th
percentile in birth weight (Delsing et al., 2011). Studies have shown that smoking nicotine
cigarettes during pregnancy results in lower birth rates due to an influence on fetal growth rather
than a shorter gestational period (Bailey, McCook, Hodge, & McGrady, 2011). They also noted
children who are born preterm or have a low birth weight are at a heightened risk for long term
effects such as permanent growth restriction, SIDS, brain alterations, and contracting severe
infections such as RSV.
Maternal substance abuse can also result in longer periods of infant treatment in a
neonatal unit; stays range from 6-68 days, with an average of 29 days (Johnson, Greenough, &
Gerada, 2003). Infants who have been exposed to cocaine and marijuana in utero are far more

EFFECTS OF SUBSTANCE ABUSE DURING PREGNANCY

likely to develop neurobehavioral difficulties, thus making them harder to console than infants
who are not exposed at any point during the pregnancy (Higley & Morin, 2004). Mothers and
children who suffered prenatal substance abuse and whose children are placed in out-of-home
care facilities, suffer from far more injuries, poisonings, behavioral and mental health issues,
visit the doctors more frequently, and use more prescription medication than mothers and
children who were not affected by substance abuse or whose children remained in the home
(Autti- Rm, Gissler, Halmesmki, Kahila, & Sarkola, 2012). The purpose of this literature
review is to examine the effects of pre-natal maternal substance abuse on the mother and the
neonate.
Literature Review
Roberts and Pies conducted a study in 2006. The purpose of the study was described as
an attempt to understand how drug use during pregnancy and factors related to drug use become
barriers in receiving prenatal care. The design of the study was qualitative and involved the use
of semi-structured interviews and focus group guides. Questions were open-ended as well as
close-ended. Twenty women were interviewed one-on-one, and two focus groups, one with eight
women and the other with ten, were also interviewed for a total of thirty-eight women. The
women were ethnically diverse, English-speaking, and had low-incomes. Each participant was
either pregnant at the time of the interview or had a child two years old or younger. The results
of the study identified many barriers to prenatal care related to drug use, including fear of Child
Protective Services (most common), side effects of drugs, isolation from support due to drug use,
guilt of harming the baby, delays in discovering pregnancy (making it difficult to obtain
insurance and schedule appointments), and lack of transportation and adequate finances.

EFFECTS OF SUBSTANCE ABUSE DURING PREGNANCY

Strengths of the study included obtaining informed consent from individuals as well as
human subjects approval from University of California, Berkeley. Also, creditability was
achieved by spending over three years on the study, taking the information obtained back to
women similar to the participants, and requesting feedback from these women. Auditability was
achieved by being true to the data by quoting participants and by discussing multiple methods to
create triangulation, which involved recording interviews on audiocassette, transcribing
interviews verbatim, coding in a multiphase process, and by creating case-studies, cross-case
studies, and typologies. Fittingness and reliability are prevalent in the article because it can be
applied to different areas of nursing, such as child abuse situations. A limitation of the study was
a lack of data saturation. Also, no theoretical framework was present. Finally, only interview
participants were asked about timing of prenatal care due to an error in the focus groups.
Delsing et al. conducted a study in 2011 to examine the relationship between fetal growth
and the use of amphetamines or opiates and smoking during pregnancy. This study was a nonexperimental retrospective medical record review, which included 91 opiate-affected pregnancies
and 37 amphetamine-affected pregnancies, for a sample size of 128 pregnancies. Upon review
researchers found that the third trimester was when the effects of drug use were most apparent.
In addition, the infants that were in the opiate-affected group did not show significant variations
in their gestational birth weight when compared to the control group. However, infants in the
amphetamine-affected group showed significant differences in birth weights as well as in their
antenatal growth patterns during the third trimester of the pregnancy.
The strengths of this study were the large sample size, the use of matched control groups,
and approval by the Sydney West Area Health Service Human Research Ethics Committee.
Researchers also used appropriate statistical analyses including means and standard deviations

EFFECTS OF SUBSTANCE ABUSE DURING PREGNANCY

along with Chi-squared tests. However, there were many limitations in this study including the
retrospective methodology, a lack of a control for the amount of cigarettes smoked, and the selfreporting of amphetamine and smoking use. Another limitation was that smoking was included
in both of the groups so it is hard to tell whether or not the opiates or amphetamines had an
independent effect on fetal growth. Also, although the sample size seemed large enough, there
was no discussion of a power analysis. One of the threats to internal validity was selection bias
because the women used in this study were extracted from the local obstetric database from a
major birth center in Western sub-metropolitan Sydney, Australia. Since all of the women were
from Sydney, this was also a threat to external validity because there was no significant
generalizability. A final limitation was the lack of a theoretical framework.
ThepurposeofthestudywrittenbyBaileyetal.(2011)wastoprovethatsmoking
cigarettesduringpregnancyhasjustasmuchofanegativeeffectonadevelopingfetusand
newborninfantastakingorsmokingillegalsubstancesduringpregnancydoes.Thedesignwasa
quantitativenonexperimentaldescriptiveprospectivestudy.Thefinalsamplesizeofthestudy
was265infantswhohadbiologicdrugtestingatdelivery.Thesamplesizewasdividedinto
threesubgroups,andtheresultswerethis:forwomenwhosmokedbutdidnotuseillicitdrugs
duringtheirpregnancies,themeanbirthweightfortheirnewbornswas163grams;forwomen
whousedhardillicitdrugsbutdidnotsmokeduringtheirpregnancies,themeanweightoftheir
newbornswas317grams;andforwomenwhorefrainedfromhardillicitdrugsandsmoking
duringpregnancy,themeanweightoftheirnewbornswas352grams.Basedonthisrudimentary
evidence,itseemsclearthatsmokingduringpregnancyhasaprofoundeffectoninfant
birthweight.

EFFECTS OF SUBSTANCE ABUSE DURING PREGNANCY

Inthisstudy,therewasnostatedtheoreticalframework,buttheprotectionofhuman
participantswascarriedout.Thoughthestudyclaimedtobeusingpreviouslyvalidatedtoolsto
collectdata,noreliabilitystatisticsweregiven.Thestatisticalanalysesthatthestudyincluded
weretestedwithANOVAFtestsandANCOVAs,andthereforewererelevantandsignificant.
Onestrengthintheresultsofthestudywasthatitwasmadeclearthatsubstanceabuseduring
pregnancywasnotassociatedwithadecreaseintimeofgestation,whichwouldhavesuggested
thatsubstanceabuseshortenedtimeofgestationratherthancausingintrauterinegrowth
restriction.Therewasathreattoselectionbiasduetothefactthatwomenwerechosenbasedon
presetcriteria.Oneweaknessofthisstudythreateninginternalvalidityisthatselfreportof
substanceabusecanbeunreliable,anddrugtestsonlydetectrecentdruguse,andthereforeearly
pregnancydrugusewouldnotbedetected.Anotherlimitationtothisstudythreateninginternal
validitywastheinabilitytoseparatelyinvestigatetheinfluenceofdifferenthardillicitdrugson
birthoutcomes;thisisalsothegapintheliterature,andanimplicationforfurtherresearch.A
threattotheexternalvalidityofthisstudywasthatitwasexecutedinruralTennesseewithlittle
tonodiversityofethnicity,andthereforethedatacollectedwasnotgeneralizable.
Johnson et al. (2003) conducted a study in London, England, to investigate the length
of neonatal stay in patients who were born to substance abusing mothers. This study specifically
focused on the type of drugs consumed during pregnancy and their relationship to the length of
the infants neonatal stay. The study in question had a quantitative, non-experimental,
retrospective, chart review design. A sample of 41 infants was separated into three different
groups based on the type of drugs they were exposed to in utero: methadone substances,
methadone substances along with other drugs (heroin, cocaine, benzodiazepines, amitryptyline,
amphetamines, and/or barbiturates), or non-methadone opiates (heroin and/or dihydrocodeine).

EFFECTS OF SUBSTANCE ABUSE DURING PREGNANCY

The study proved that infants who were exposed to methadone substances and/or other drugs in
utero require a longer neonatal stay then those infants who are only exposed to non-methadone
opiates.
Significant limitations of this study include the facts that 41 infants were chosen because
they were consecutively admitted to the neonatal unit (selection bias) and that the standard of
care in Kings College Hospitals neonatal unit changed over the course of the ten-years in which
the infants were born (issue of instrumentation). The lack of criteria used to select the studys
sample and the change in the neonatal units procedure are both threats to internal validity.
Another limitation includes the lack of generalizability, as all 41 infants were admitted to Kings
College Hospital in London and none of their ethnicities were mentioned, both of which are
threats to external validity. Also, the article was lacking a theoretical framework and proof of a
power analysis. A final limitation was that the article failed to provide proof of the protection of
human participants. Strengths of the study include an appropriate analysis of the data collected
(X2, Kruskal-Wallis, Mann-Whitney U-Test) and, based on the fact that all infants included in the
study were a result of full term births, it is implied that infants were not admitted into the
neonatal unit because of prematurity.
In 2004 a study by Higley and Morin, was performed to study the behavior of substanceexposed newborns in relation to the involvement of their mothers in a substance abuse program
during pregnancy. A retrospective chart review of 103 infants and mothers involved in the
substance abuse program comprised the sample. The infants were comprised of 59 males and 44
females and charts were reviewed for 103 substance abusing mothers (78.2% of whom used
multiple drugs). The 103 selected were a convenience sample from the 130 who willingly
participated in the substance abuse program offered. After collecting the data, using the

EFFECTS OF SUBSTANCE ABUSE DURING PREGNANCY

Neonatal Behavioral Assessment Scale (NBAS) and reviewing charts, the researchers were able
to present the results of prenatal substance abuse on newborns. Results revealed a significant
number of the newborns experienced difficulty in being consoled and were incapable of
consoling themselves. An unexpected consequence of research proved an increase in mothers
postpartum involvement in learning how to interact with their child as well as a decrease in the
number of mothers abusing substances.
Some noticeable limitations of this study were related to the sample of mothers used. A
convenience sample of women (65% of which were African American) that are were serviced by
the facility providing care were observed, therefore increasing the risk of bias and threatening
external validity with generalizability. A limitation was the absence of a control group. There
were different cases of drug abuse at varying periods of pregnancy, but there was a lack of
infants reviewed that had no chance of substance-exposure. Reliability is questionable regarding
the instrument of the NBAS to observe the newborn on their behavioral and neurologic capacity
therefore posing a threat to internal validity. The researchers did discuss their limitations. A
power analysis was not used in the process of the study and theoretical framework was not
mentioned creating more limitations. In the collection of data, strengths are seen with the use of
the NBAS instrument equally on every newborn as well as the researchers fully identifying and
describing the instrument. In this study measures of comfort were provided for the participants,
but there was no mention of protection of human rights providing another limitation.
In early 2012, Autti- Rm et al. published a study that aimed to investigate the relations
between postnatal maternal morbidity, child morbidity, and welfare interventions in families with
prenatal alcohol or substance abuse. Researchers accomplished this using a register-based
longitudinal retrospective cohort design which included 638 children born to 524 women

EFFECTS OF SUBSTANCE ABUSE DURING PREGNANCY

followed-up during pregnancy who were identified with significant alcohol or substance abuse
during pregnancy along with 1914 non-exposed children as control who were matched for
maternal age, parity, number of fetuses, month of birth, and delivery hospital of the index child
in at Taisto Sarkola, Childrens Hospital, University of Helsinki and Helsinki University Central
Hospital in Finland. Upon review researchers found postnatal maternal substance abuse-related
morbidity to be significantly associated with early child morbidity, use of medication and
earliness of out-of-home-care use.
Some of the limitations to this study included lack of detailed background information
(socioeconomic status) and the need for simple selection criteria (selection bias), both threats to
internal validity, both acknowledged by the author. Because the study only sampled women in
one locale, Finland, the results offer no significant generalizability, posing a threat to the external
validity. Furthermore, researches failed to provide any theoretical framework. The strengths of
this study included a measured control matching maternal age, parity, number of fetuses, and
month of birth and delivery hospital of the index child, a large and according to researchers
appropriate sample size, proper anonymous data analysis and use of statistics (T-test, chi-square
test, and Fishers exact test) performed by a statistical authority, proven reliable by mandatory
national health and social welfare registers. Finally, protection of human participants as all data
was collected according to the Declaration of Helsinki and approved by ethical review boards of
the Helsinki University Central Hospitals for Children and Adolescents along with Obstetrics and
Gynecology and permission from all authorities, which maintain the data registries.
Implications for Practice

Implement more education and resource connecting services for women who abused
substances before, during, and after their pregnancy.

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Incorporating the use of the Neonatal Behavioral Assessment Scale (NBAS) into clinical
practice to provide guidelines for stimulation, expectations and reactions to infants.

Provide weekly substance abuse programs for drug using women during pregnancy to
lower the mother and infants drug, alcohol, and nicotine exposure, resulting in increased
fetal as well as maternal weight gain.
All studies presented uniformly recognized that maternal prenatal and postnatal substance

abuse have the potential to negatively affect the mental, physical, and emotional well-being of
the fetus and mother. Overarching gaps in the literature were the inability of researchers to
separate the effects of specific substances based on the prevalence of overlapping substance
abuse and controlling for nutritional habits when assessing birth weights. Future implications for
research include finding measures that can pinpoint the affects attributed to frequency, duration,
and specific drug use along with nutritional deficiencies.

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References
Autti-Rm, I., Gissler, M., Halmesmki, E., Kahila, H., & Sarkola, T. (2012). Alcohol and
substance abuse identified during pregnancy: Maternal morbidity, child morbidity and
welfare interventions. Acta Paediatrica Nurturing the Child, 101, 784-790.
doi:10.1111/j.1651-2227.2012.02670.x
Bailey, B., McCook, J., Hodge, A., & McGrady, L. (2012). Infant birth outcomes among
substance using women: Why quitting smoking during pregnancy is just as important as
quitting illicit drug use. Maternal & Child Health Journal, 16(2), 414-422.
doi:10.1007/s10995-011-0776-y
DHHS. (2011). Results from the 2011 National Survey on Drug Use and Health: Summary of
National Findings (HHS Publication No. 12-4713). Retrieved from
http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.pdf
Delsing, C., Van den Wittenboaer, E., Liu A. J. W., Peek, J., Quinton, A., Mongelli, M.,
Nanan, R. (2011). The relationship between maternal opiate use, amphetamine
use and

smoking on fetal growth. Australian and New Zealand Journal of

Obstetrics and

Gynecology, 51, 446-451. doi: 10.1111/j. 1479-828x. 2011.01342.x

Higley, A. M., & Morin, K. H. (2004). Behavioral responses of substance-exposed newborns: A

retrospective study. Applied Nursing Research, 17, 32-40. doi:10.1016/j.apnr.2003.10.007
Johnson, K., Greenough, A., & Gerada, C. (2003). Maternal drug use and length of neonatal unit
stay. Addiction, 98(6), 785-789
Roberts, S. M., & Pies, C. (2007). Complex calculations: How drug use during pregnancy
becomes a barrier to prenatal care. Maternal and Child Health Journal, 15(3), 333-341.
doi:10.1007/s10995-010-0594-7

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