Running head: SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY?

Substance Use: Does This Effect Infant Mortality?

Following the American Psychological Association’s Guidelines

Philip Aggarwal

Amanda Doran

Natalie Laurence

Ana Zarlinski

Youngstown State University

NURS 3749 Nursing Research

Mrs. Molly Roche

Summer 2017
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 2

Abstract page

Infant mortality is a noticeable problem in the United States. The United States has a high

infant mortality rate. This literature review was conducted to see if there is a relationship

between substance use and infant mortality in women and men of childbearing age. This

literature review focused on the population of the United States. In this review we looked at 12

articles from various setting such as hospitals, doctor offices, and clinics. The age range used in

the literature review was from prenatal - 24 months of age. It was found that substance use has a

link to birth defects, Sudden Infant Death Syndrome (SIDS), and Neonatal Abstinence Syndrome

(NAS). There was not enough research to conclude that there is a direct relationship between

substance use and infant mortality. More research needs to be done to see if there is a direct

correlation between the two.

Key terms: USA, substance use, drug use, opioid, pregnancy, infant mortality, Neonatal

Abstinence Syndrome, maternal, birth defects, paternal, marijuana use, Sudden Infant Death

Syndrome
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 3

Problem

The problem under the study is that substance abuse is leading to a higher infant

mortality rate, especially in the United States of America. This choice can be related to a lack of

knowledge of the effects of substance use before, during, and after pregnancy. It is up to nurses

to help prove the effects that substance use has on the development of children that can lead to

birth defects or even death. The effectiveness of proving that there is a relationship between

substance use and an increasing infant mortality rate must be carefully evaluated. The purpose of

this research is to help parents comprehend the importance and the effect that substance use has

during pre-natal care, which can lead to defects or death of infants. This research was directed to

verify that substance use in men and women of child bearing age has an increasing impact on

infant mortality.

Literature Review Introduction

We as nursing students looked at 12 research study articles that focused on several major

themes in the articles which were sperm quality, maternal use of substances while pregnant, and

the effects of drugs on infants after pregnancy. Different types of drugs where examined through

many of the medical journals and the same themes were present. The themes were that substance

use effects pre pregnancy, during pregnancy, and post-pregnancy. The theoretical framework for

the research was guided by Jean Watson theory of Human care. The emphasis Watson places on

supportive relationships and transpersonal teaching –learning between nurse and patient provide

framework for examining the effects of drug use between parents and infant mortality.
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 4

Our prediction is that those who take drugs have a higher infant mortality rate than those who do

not.

Literature Review

The focus of this study was to examine the effect of opioid dependency while pregnant

and the length of stay of the newborn. The article, Opioid Dependency in Pregnancy and Length

of Stay for Neonatal Abstinence Syndrome fixated on 152 dependent mothers who were on

Methadone maintenance (MMT, 136 mothers) and Buprenorphine maintenance (BMT, 16

mothers) therapy. The average age of these women was 25.3 years, which is fairly young in age.

With the use of these treatments and infants had physical, mental deviations and it also increased

the chance of an early delivery as well as low weight. The study claims that up to 94% exposed

babies experience withdraw symptoms including respiratory difficulties and lack of

gastrointestinal function and other serious problems (Pritham, 2012, p. 182). With this comes the

situation of high costing hospital bills with the increased length of stay and treatment. When

focusing on MMT the research concluded that 29.1% of the births were preterm and additionally

that the finding was increased if a mother abused any form of alcohol or any other illicit drug

while involved with MMT (Pritham, 2012, p. 183), which was a very noteworthy finding.

Although BMT is not official for pregnant mothers but it is permitted if the mother had

conceived at some point while pursuing the therapy (Pritham, 2012, p. 183). The article has

many fascinating findings and warnings, which need to be expressed for professionals who deal

with pregnant women during their practice in the near future. BMT neonates tended to have a

shorter length of stay (14 days) and less complications that are seen in Neonate Abstinence

Syndrome compared to MMT (21 days) and this does not include the additional 8.6 days that are

possible if there is an associated exposure to any benzodiazepines (Pritham, 2012, p. 184-187).

SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 5

Also, the researchers make a good claim mentioning their limitations to this study. The one that

stood out to me was that they were limited on information because the mothers mostly

acknowledged that they had used drugs in the past and are on a form of treatment plan. Due to

this, the researchers pointed out that they may not know the full truth of how long a substance

was used or if past treatments were effective (Pritham, 2012, p. 189).

In the article Maternal Opioid Drug Use during Pregnancy and t’s Impact on Perinatal

Morbitdidty, Mortality, and the costs of Medical Care in the United states data suggests an

imperative need to evaluate, on a national level, not only the negative health outcomes associated

with maternal opioid use during pregnancy, but also the related economic cost burden on the US

healthcare system. Women of reproductive age who use and abuse opioid drugs, both

prescription and illegal, are more likely to have a lower socioeconomic status, family instability,

receive inadequate prenatal care, and suffer from alcohol, tobacco, and illicit drug use. We

looked at a study containing 1,000 participants. In the second model, they also adjusted for

tobacco, alcohol, and drug use, as well as existing medical conditions including obesity, chronic

renal failure, pre-pregnancy diabetes, and pre-pregnancy hypertension that may be related to both

maternal opioid use and the selected pregnancy outcomes. The study included frequencies,

percentages, and rates to describe prevalence of opioid use during pregnancy across maternal

age, racial/ethnic, household income, selected behavioral characteristics, and comorbidities. This

current study builds on the existing works by looking at the impact of opioid abuse during

pregnancy on a wide range of maternal and infant birth outcomes. Despite possible confusion

due to associated comorbidities, the increase in hospital costs and adverse perinatal outcomes in

the current study is likely due to neonatal abstinence syndrome and preterm deliveries. However,

the association between opioid abuse during pregnancy and adverse maternal and infant birth
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 6

outcomes persist. The results found that pregnant women who used opioids during pregnancy

were more likely to have other comorbidities, including depression, anxiety, insomnia, diabetes,

hypertension, renal diseases, and HIV infection. Also in the study, pregnant women who used or

abused opioids were also more likely than nonusers to have a prolonged hospital stay, develop

acute renal failure, and suffer mortality prior to hospital discharge.

In a study called Association between Stillbirth and Illicit Drug Use and Smoking During

Pregnancy from March 2006-September 2008 attempted to include all stillbirths and

representative live born controls by freezing umbilical cord samples for cases and controls and

frozen for analysis. Women who participated in the study whose delivery resulted in one or more

stillbirths and for women who had live births. Maternal serum was also collected at delivery. For

663 still birth deliveries 63 % had cord homogenate and 87% had maternal cotinine performed.

For 1,932 live births 1,050 had cord homogenate toxicology report as a positive result. A

uniform pathology evaluation was performed by a perinatal pathologist for the stillborn in the

study. The most common drug that was found in the study was cannabis. The study over

cannabis, smoking/second hand smoke, and illicit drug use found an increased risk of having a

stillbirth. There was an increase in the stillbirth odds ration with increasing amounts of self-

reported smoking in the third trimester. Women with stillbirths were twice as likely to report

having been addicted to illicit drugs. A positive toxicology drug screen for illicit drugs had a 2-3

fold increase in stillbirth risk. The study found that further investigation needs to happen

between to investigate what THCA can do and more affects that smoking has in fetuses during

pre-natal care.

In this study called, The Association Between Maternal Alcohol Use and Smoking in

Early Pregnancy and Congenital Cardiac Defects Alcohol use is said to be an extremely
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 7

widespread, but preventable risk factor among women seeking to become pregnant. Many

women continue to use alcohol in the early stages of pregnancy before they know they are

pregnant. Several variables were used to study the relationship between several measures of

alcohol use, including binge drinking and binge drinking on more than once occasion, and the

interaction between alcohol use and smoking. There was a significant increase in congenital

cardiac defects was found among mothers who reported binge drinking more than once in the 3

months prior to pregnancy compared to mothers who did not report binge drinking.

Smoking during pregnancy is a leading preventable cause of poor pregnancy outcomes

such as complications, infant death, and increasing risk for infertility. In Nationwide surveys, it

was found that pregnant smokers report more illicit drug use than pregnant women who were

nonsmokers. Urine specimen from 115 women who were in there 10th week of pregnancy and

when they were in their 28th week. The trial participants smoked around 18 cigarettes a day and

were found to be less than 25 years old, Caucasian, had a high school education, and did not

have private insurance. 34% of specimen from *the intake visit and 25% from the FAP

assessment tested positive for illicit drug usage. Most common substance that was detected was

marijuana, which was 90% of the drug that tested positive in the specimen. Women who tested

positive for illicit drugs also tested positive at the FAP assessment. At the end of the study it was

shown that around a quarter to a third of the pregnant women in the trial were determined to use

illicit drugs. Women who were in the study participated in trials examining the efficacy of an

incentive based smoking cessation program. They were assigned to either an abstinence

contingent where they got vouchers for retail items or non-contingent where they received

vouches for independent smoking status.

SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 8

In Infant Birth Outcomes Among Substance Using Women: Why Quitting Smoking

During Pregnancy is Just as Important as Quitting Illicit Drug Use, suggests that smoking and

illicit drug use has had an effect on the infant, whether it be by physical or mental characteristics.

The article believes that smoking is just as harmful as illicit drug use, but concludes that there

needs to be in depth studies done to appropriately validate this claim. In study through different

requirements the total of number of participants that were looked at where 652, but went down to

265 women that meet all requirements. Participants were paid $20 per interview, which were

interviewed twice. The study was done at two local hospital systems in Northeast Tennessee

.Information about whether the mother was using any substances was evaluated by a USD test

and self-report. The study came to a conclusion that smoking has twice the impact on birthweight

compared to illicit drug use. The risk of having a lower birth weight, brain alterations, Sudden

Infant Death Syndrome, infections, and cognitive/academic defects can be associated with a

lower birth weight due to choosing to use substances, especially smoking. It was also found in

this study that women who used illicit drugs during pregnancy also smoked and were poly-drug

users, along with psychosocial and other medical risk factors.

According to a study called Increasing Incidence of the Neonatal Abstinence Syndrome in

the U.S neonatal ICU, Neonatal abstinence syndrome is a drug-withdrawal syndrome that most

commonly occurs after in utero contact with opioids. The frequency is known to have increased

during the past decade. Data was evaluated from infants with the neonatal abstinence syndrome

from 2004 through 2013 in 299 neonatal intensive care units across the United States. Among

674,845 infants admitted to NICUs, 10,327 were identified with the neonatal abstinence

syndrome. From 2004 through 2013 neonatal abstinence syndrome was responsible for a
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 9

substantial and growing portion of resources dedicated to critically ill neonates in NICUs

nationwide.

The article Maternal and Paternal Recreational Drug Use and Sudden Death, focuses on

the results of a study that tried to determine how the effects of drugs used in the mother and

father affected the conception, pregnancy, and postnatal process during the infants first year of

life and how it affected the child. This was a study done in California with 239 infants that died

of SIDS and 239 infants that matched on all health levels with the care of their parents. It was a

case control study. The conclusion of this study was there was no association with SIDS and

recreational drug use with the parents but marijuana use was associated with SIDS in both the

mother and father. Maternal substance abuse affected the children way more than paternal

substance use. However paternal substance use was still a factor in SIDS of the child. The most

apparent substance abuse in mothers that caused SIDS were opiates, stimulants, and

tranquilizers. Substance abuse is the third leading cause of death in infants from 1 month to 1

year.

The article Mortality Risk Associated with Paternal Drug and Alcohol Use in California,

focused in on the maternal use of substances during pregnancy. It did not include paternal use.

The study showed the relationship between maternal use of drugs and alcohol and how it could

have affected fetal, neonatal, and post neonatal mortality. This study was done in California with

birth and death certificate data were used to identify drug/alcohol-diagnosed births. There was no

number identified as to how many certificates they looked at exactly, however, they did estimate

to look at approximately 4,500,000 death certificates. The results of this study showed

association with maternal use and mortality rate of infants was greatly increased when the

mother used specifically cocaine as the drug but alcohol and other recreational drugs played a
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 10

key role in the increase of infant mortality. The article states that increased collaboration with

drug treatment programs and closer follow-up for drug-using women and their children may

improve mortality outcomes. This study was done with children in the ages between the first

month and second year. Doctors conducted this study

The article of “Prenatal Tobacco, Marijuana, Stimulant, and Opiate Exposure: Outcomes

and Practice Implications,” focused in only on drug use in the mother during pregnancy and how

it affected the developing fetus and child’s overall outcome. The drugs studied were tobacco,

marijuana, stimulants, and opiates. The study not only considered how the child was born but the

timing of the drug use with the mother, any other mixtures of drugs, and health/environmental

factors. The study focused on women of child bearing age. The study is a comprehensive study

of looking individually at tobacco, marijuana, and opiates across many different areas in the

USA. The study does not specify specifically the number that each individual study looked at.

The conclusion of this study was substance use during pregnancy can affect the developing fetus

both directly, through passage of the drug through the placenta, and indirectly, through poor

maternal health habits and environmental conditions. Each child must be individually assessed

for his or her risk factors, developmental difficulty, and their caregiving environment.

Developmental outcomes may be saved by interventions that occur early in life, are tailored for

the alcohol or drug specific problems, and target the mother’s level of stress and continued

substance.

Although this journal was not published to focus on drug use while pregnant, the journal

The Transfer of Drugs and Therapeutics Into Human Breast Milk: An Update on Selected

Topics, spotlights the effects on the transfer of a small amount of certain drugs through breast

milk during and post pregnancy, in mothers producing and lactating milk. Recommending the
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 11

termination of drug and alcohol use while pregnant is increasing over the years and can be

accomplished but remaining that short-term sobriety while breastfeeding is often overlooked and

not fully thought about by parents (Sachs, 2013, p.799). Meaning, that mothers may not know

that they are indirectly harming their infant while using these even though they are not pregnant.

This journal was not a carried out study performed by the author but rather was an update on new

evidence the journal wanted to publish. As we know specific drugs are organized in groups and

may have a large impact on pregnancy, thus the restriction warnings on many drug

classifications and substances. Some of these factors that affect the infant include minor effects

such as decreased sleep and vomiting caused by alcohol (Koren, 2002) compared to major

effects such as preterm infant, which can be caused by benzodiazepines (Jain, 2005), infant

intoxication from the use of cocaine (Winecker, 2001) and death due to using methamphetamine,

which has a 48-hour duration in the breast milk (Bartu, 2009). In conclusion, after reviewing the

material provided not all therapeutics or drugs aren’t as severe as others, but some have the

potential to do serious damage physically and cognitively. More research is needed to determine

about how much of a drug is secreted into the milk and which ones are more strenuous to

provoke a heavier effect.

According to the study, Maternal use of Marijuana During Pregnancy and Lactation:

implications for Infant and Child Development and Their Well-Being Cannabis is one of the

most widely used drugs in the USA among women who are of reproductive age. During their

study they had a sample size of 17,934 females of child bearing age. Marijuana use during

pregnancy and breastfeeding can have adverse effects with infant child development

neurologically and cognitively. With animal and human studies of fetal brain tissue has been

documented. This research has shown that there is a positive association between parental drug
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 12

use and child development. Parenting skills can be altered when using marijuana and along with

abuse and child endangerment. In 2013 daily use of marijuana was reported by 16.2 % of

pregnant users in the study and of that 16.2%, 18.1% of them meet the criteria for abuse and

dependence. Out of the non-pregnant women 12.8% claiming to be users. Endocannabinoids

modulate regulation of movement, memory, appetite, thermoregulation, pain, and immunity in

the body. This plays a big role in the beginning or early pregnancy and over stimulation with the

CB1 receptors with these drugs in the placenta can impair fetal growth by inhibiting

cytorophoblastic proliferation which is vital in embryo survival and brain development. The

lipophilic characteristics of cannabinoids allow them to cross blood brain barriers and placental

membranes. Cannabis can affect neurotransmitters like dopaminergic neurons that see early on in

brain development. When dopamine is disturbed there is an increase with neuropsychiatric

disorders. THC is another type of drug that was found in human infant feces which shows that it

can be absorbed and metabolized in infants and fetuses. It goes to the brain and can be stored in

fat tissues for weeks-months. Use of cannabis in studies can have an association with stillbirths,

preterm labor. Intrauterine growth restriction, and increase in birth defects. The National Institute

of Child Health and Human Development Stillbirth and Collaborative research Network reported

that cannabis use with stillbirth odds ratio is 2.34:95R confidence interval on a scale of 1.13-

4.811. In this study after the control of smoking, alcohol, and use of other drugs it was also found

that a lower birth weight was associated with cannabis use. Infants that receive secondhand

smoke have a greater rate of respiratory problems such as, childhood asthma, bronchitis, and

pneumonia. Public Health Authorities has not resolved the issue of to what degree does parenting

skills become affected with marijuana use. Prenatal substance exposure is associated with 2-3

times more likely increased risk of child maltreatment. A telephone survey was done with 3,203
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 13

people in mid-size cities in California about abuse and neglectful parents. Marijuana users self-

identified with an increase in frequency of child physical abuse, but did not report the abuse.

Another problem with marijuana is that it can be edible now and children can get into it because

of the new colors and fancy packaging. In this study it was proven that many who used

marijuana also abused other substances.

In the review we nursing students found various limitations throughout the studies that

were researched. Most articles had a smaller sample size, focusing on the United States. The lack

of quality of literature found for the specifications of the topic. Self-report of drug use is not

always accurate, so this also can be a factor.

During our literature review we have found that there is not a proven relationship

between the effects of substances and infant mortality. What was found was there is a

relationship between drugs and the effects of body functions such as low birth rate, disabilities in

infants, and SIDS/NAS. As future nurses we need to advocate for more in depth research to see

if there is a correlation between infant mortality and substance use. Also, we need to familiarize

women of child bearing age about the risk of using opioids while trying to conceive. Being

informative and upfront about this subject with our patients is the best way to achieve better

outcomes.
SUBSTANCE USE: DOES THIS EFFECT INFANT MORTALITY? 14

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