Prevention of substance use during pregnancy - Lecture by Dr. Renata Azevedo

Drug use in Brazil is a real public health problem. When used in a problematic way, it can provoke or increase family crises and violence.

The use or dependence of psychoactive substances by pregnant women is quite worrying, since pregnancy is a period of significant transformations in the woman's body and in her psycho-emotional state.

In addition to the problems it causes to the pregnant user, the baby also suffers losses, since most psychoactive substances cross the placental barrier and reach the fetus's bloodstream.

That is why it is so important to prevent the use of substances during pregnancy and, to talk about it, the 7th Freemind International Congress 2022 invited Dr. Renata Azevedo, who is a Psychiatrist, vice president of ABEAD - Brazilian Association of Studies on Alcohol and other Drugs, associate professor in exclusive dedication and current head of the Department of Medical Psychology and Psychiatry at the Faculty of Medical Sciences of the State University of Campinas (UNICAMP).

The lecture can be seen in full on Freemind's YouTube in Portuguese and in English it is possible to download his presentation on the Freemind website, in the Congress 2022 tab.

And she begins by reminding us that, historically, drug use has always been a male phenomenon, much higher among men than among women.

This fact guided research on problems related to drug use, prevention proposals, lines of care, training of professionals and availability of treatment.

However, this pattern has changed rapidly, especially in the last decade. And we can see this clearly when comparing the data obtained in LENAD I and LENAD II – National Surveys on the patterns of alcohol and drug consumption, carried out by UNIAD/INPAD/UNIFESP in the years 2006 and 2012, respectively.

Smoking reduction has been declining over the years, but at much lower rates for women when compared to reduction rates for men.

Binge drinking, which is drinking while intoxicating, on the other hand, has been increasing in both men and women, but in them in greater proportion. Another worrying fact is that, in 2006, only 1% of girls up to 11 years of age had already started drinking alcoholic beverages and this percentage increased to 4% in 2012, while the rates among boys remained the same – 5%.

This was repeated in the 15 to 17 age group: men maintained the rate of 41% and women migrated from 28 to 32%.

In the 2019 PeNSE – National School Health Survey, carried out specifically in the school environment, it can be seen that in the comparison between the use of experimentation with alcoholic beverages is higher in girls than in boys, while the rate of use of cigarettes and illicit substances is identical among them.

This research also shows important data when it comes to addressing substance use in women, during pregnancy or outside of it, which is the interrelationship between substance use and emotional issues: 27% of adolescent women between the ages of 13 and 17 report negative mental health compared to 8% of boys who self-evaluate in the same way.

LENAD also pointed out significant rates of depression in women who use substances. In other words, it is not possible to speak of an approach among women without taking into account the aspects that are particular to physical suffering.

In the West, the prevalence rate of unplanned pregnancies is between 30 and 50% and substance use is related to this, which makes the situation very painful.

Another factor to consider is that women who use substances tend to use reproductive health services less for fear of stigma, for difficulties in discussing their sexual history, and for fear of losing their children if they report substance use. All of this causes them to have lower adherence to interventions during pregnancy.

When health services are prepared, empathetic and qualified, there are changes in practices and women make choices that favor family planning.

Another important aspect when thinking about the gestational period is to take into account that, for most women, pregnancy and the arrival of the baby is a time of joy, hope for the future and renewal, which makes pregnancy be considered as a motivator for the adoption of healthy habits, including the cessation of substance use.

This, however, is not a guarantee of protection for women in relation to mental health problems. Studies show that one in 3 women have some type of mental disorder during pregnancy. What is most talked about are puerperal depression, but it is estimated that 40% of these puerperal depressions are, in reality, gestational depressions that were not detected during prenatal care.

Due to the fact that there is a lot of underreporting of substance use during pregnancy, studies on the clinical consequences of this use are impaired and it is difficult to attribute the consequence of an abortion, for example, to the use of one or another drug (since there is often polyconsumption) or to the fact that the pregnant woman did not eat well during pregnancy or did not receive adequate prenatal care.

This makes it difficult for obstetricians to talk about the real harm that substance use can bring, and as a result, the intervention ends up being impaired.

Despite all this, there is already a lot of information available that needs to be passed on to pregnant women in an appropriate way so that they can assess, in their decision-making process, the risk of substance use during their lives and, especially, during pregnancy.

We can mention some already known and irrefutable consequences of the use of some substances:

TOBACCO

• Increased chance of miscarriage
• Increased chance of poor intrauterine growth, which leads to an increased ICU time
• Premature births, with a subsequent increase in the chance of sudden death of the baby
• Low birth weight babies
• Haematological abnormalities
• Cognitive conditions and psychomotor changes, such as increased chance of ADHD in childhood

ALCOHOL

• Changes in relation to intrauterine growth
• Various malformations, the best known being APS – Fetal Alcohol Syndrome, the main preventable cause of intellectual disability

COCAINE

Cocaine brings an additional difficulty: isolating what is a consequence of its use alone, since a pregnant woman or cocaine user is rarely not also a user of other substances.

• Increased chance of miscarriage
• A series of fetal malformations and consequences in newborns, especially hyperactivity later in childhood and adolescence.

MARIJUANA

There has been a great increase in the number of studies regarding the impact of marijuana on pregnancy and with this it is possible to say with certainty that marijuana should not be used during pregnancy or breastfeeding. It is also known that it is not a good way to deal with nausea.

Marijuana has also been known for a long time as an aggravator of a good neonatal outcome due to a number of factors: psychiatric comorbidities (especially mood disorders), poor evolution of previous pregnancies, repeated miscarriages, unwanted pregnancies, domestic violence, lack of social support and history of sexual violence, among others.

At the mental health outpatient clinic of the Center for Comprehensive Attention to Women's Health – CAISM, of the State University of Campinas – UNICAMP, coordinated by Dr. Renata Azevedo, a follow-up study of pregnant women has been carried out that found a very expressive rate of mental disorder: 41% rate of anxiety, 31% rate of depression and 9.5% of suicidal behavior during pregnancy. And when taking into account the use of substances, it was found that almost 10% are smokers, the rate of marijuana use is higher than the rate of alcohol use, which is 5%.

An intervention work was then carried out with pregnant women using substances and it was possible to observe that many pregnant women spontaneously stopped using them, which is always a very encouraging fact.

It is necessary to work with pregnant women on a motivational intervention, providing information in an empathetic and non-judgmental way, assessing the barriers they have and facilitating access to formal care, always instilling hope that they are capable of making this change.

It is necessary to break the stigma regarding the use of substances in women and, especially, among pregnant women, because this prevents them from seeking health services. If they don't seek services, the supply of services is diminished and this becomes a vicious circle.

So, the key points to finish:

- Health promotion strategies, especially reproductive health, are fundamental and prevention strategies aimed at women are specific.

 - Focus the approach on the mother-baby binomial and not only on the baby's health, which is what is usually done; So focus on the needs of the mother to increase the motivation for abstinence, obviously also taking care of the baby, but talking about her.

- Evaluate the support network, with emphasis mainly on the partner, intra-family substance use, and possible situations of violence

- Identify and treat comorbidities, particularly depression and

- Set short-term goals and quickly readjust to the patient's needs.

And, above all, to remember that maternal mental health is one of the crucial elements for healthy development in the lives of all of us.