Shahul H. Ebrahim

Pregnancy-related substance use in the United States during 1996-1998

OBJECTIVE To provide a baseline estimate of the national prevalence of pregnancy-related illicit drug use and abstinence rates. METHODS We analyzed data collected between 1996 and 1998 from the National Household Survey on Drug Abuse, a nationally representative sample survey of 22,303 noninstitutionalized women aged 18–44 years, of whom 1249 were pregnant. RESULTS During 1996–1998, 6.4% of nonpregnant women of childbearing age and 2.8% of pregnant women reported that they used illicit drugs. Of the women who used drugs, the relative proportion of women who abstained from illicit drugs after recognition of pregnancy increased from 28% during the first trimester of pregnancy to 93% by the third trimester. However, because of postpregnancy relapse, the net pregnancy-related reduction in illicit drug use at postpartum was only 24%. Marijuana accounted for three-fourths of illicit drug use, and cocaine accounted for one-tenth of illicit drug use. Of those who used illicit drugs, over half of pregnant and two-thirds of nonpregnant women also used cigarettes and alcohol. Among the sociodemographic subgroups, pregnant and nonpregnant women who were young (18–30 years) or unmarried, and pregnant women with less than high school education had the highest rates of illicit drug use. CONCLUSION The continued burden of illicit drug use during pregnancy calls for policy efforts to enable primary care providers to identify and refer women who use substances to treatment and support services. Prevention of uptake of illicit drug use should be an integral part of public health programs for young women.

Alcohol consumption by pregnant women in the united states during 1988–1995

Objective To examine trends in alcohol use among pregnant women in the United States and to characterize pregnant women who use alcohol, with an emphasis on frequent use (at least five drinks per occasion or at least seven drinks per week) Methods We used the Behavioral Risk Factor Surveillance System data from 1988 through 1995 to obtain the percentage of pregnant women who used alcohol. We used multiple logistic models to identify subgroups of pregnant women who are at increased risk for alcohol use. Results Overall, 14.6% (869 of 5983) of pregnant women consumed alcohol and 2.1% (133 of 5983) consumed alcohol frequently. Among pregnant women, alcohol use decreased from 22.5% (95% confidence interval [CI] 20.8, 23.9) in 1988 to 9.5% (95% CI 7.9, 11.8) in 1992 and then increased to 15.3% (95% CI 13.1, 17.2) by 1995. Among pregnant women, frequent alcohol use decreased from 3.9% (95% CI 2.4, 5.2) in 1988 to 0.9% (95% CI 0.4, 1.6) in 1991 and then increased to 3.5% (95% CI 2.0, 5.1) by 1995. Pregnant women who were at high risk for alcohol use were college educated, unmarried, employed, or students, had annual household incomes of more than

Comparison of binge drinking among pregnant and nonpregnant women, United States, 1991-1995

50,000, or were smokers. Pregnant women who were at high risk for frequent alcohol use were more likely to be unmarried, or smokers. Conclusion The increasing prevalence of alcohol use among pregnant women calls for increased ascertainment of alcohol use among preconceptional and pregnant women. Brief interventions by clinicians, increased referral to alcohol treatment programs, and increased use of contraception by women of reproductive age who are problem drinkers should be considered as means of preventing alcohol-exposed pregnancies.

Prevalence of Risk Factors for Adverse Pregnancy Outcomes During Pregnancy and the Preconception Period—United States, 2002–2004

Our goal was to measure the pregnancy-related reduction in the prevalence of reported binge drinking (>/=5 alcoholic drinks per occasion) and to characterize binge drinkers among pregnant and nonpregnant women aged 18-44 years, in the United States, 1991-1995. We used the Behavioral Risk Factor Surveillance System data from 46 states. We used the prevalence rate ratio between pregnant and nonpregnant women to determine the magnitude of the reduction in reported binge drinking and multiple logistic regression models to identify characteristics associated with binge drinking. Between 1991 and 1995, the prevalence of binge drinking among pregnant women increased significantly from 0.7% (95% confidence interval 0.2-0.9) to 2.9% (95% confidence interval 2.2-3.6), whereas among nonpregnant women the prevalence changed little (11.3% vs 11.2%). Over the study period pregnant women were one fifth (prevalence rate ratio 0.2, 95% confidence interval 0.1-0.2) as likely as nonpregnant women to binge drink. Among various population subgroups of women, pregnancy-related reduction in binge drinking was smallest among black women and largest among women aged </=30 years and among those who had quit smoking. Among pregnant women binge drinking was independently associated with being unmarried, being employed, and current smoking. Among nonpregnant women binge drinking was independently associated with age </=30 years, nonblack race, college level education, being unmarried, being employed or a student, and current smoking. Clinicians serving women of childbearing age need to be aware of the recent rise in reported binge drinking during pregnancy, as well as the known risk factors for binge drinking.

Observations from the CDC: Preventing Alcohol-Exposed Pregnancies among Women of Childbearing Age: The Necessity of a Preconceptional Approach

Objectives: To assess the prevalence of risk factors for adverse pregnancy outcome during the preconception stage and during pregnancy, and to assess differences between women in preconception and pregnancy. Methods: Data from the 2002 and 2004 Behavioral Risk Factor Surveillance System, United States, were used to estimate the prevalence of selected risk factors among women 18–44 in the preconception period (women who wanted a baby in the next 12 months, and were not using contraception, not sterile and not already pregnant) with women who reported that they were pregnant at the time of interview. Results: Major health risks were reported by substantial proportions of women in the preconceptional period and were also reported by many pregnant women, although pregnant women tended to report lower levels of risk than preconception women. For example, 54.5% of preconception women reported one or more of 3 risk factors (frequent drinking, current smoking, and absence of an HIV test), compared with 32.0% of pregnant women (p < .05). The difference in the prevalence of these three risk factors between preconception and pregnancy was significant for women with health insurance (52.5% in preconception vs. 29.4% in pregnancy, p < .05), but not for women without insurance (63.4% vs. 52.7%, p > .05). Conclusions: Women appear to be responding to messages regarding behaviors that directly affect pregnancy such as smoking, alcohol consumption and taking folic acid, but many remain unaware of the benefits of available interventions to prevent HIV transmission and birth defects. Although it appears that some women reduce their risk for adverse pregnancy outcomes after learning of their pregnancy, the data suggest that a substantial proportion of women do not. Furthermore, if such change occurs it is often too late to affect outcomes, such as birth defects resulting from alcohol consumption during the periconception period. Preconception interventions are recommended to achieve a more significant reduction in risk and further improvement in perinatal outcomes.

Sexually Transmitted Infections in Travelers: Implications for Prevention and Control

FETAL ALCOHOL SYNDROME (FAS) is regarded as one of the leading preventable causes of mental retardation in the United States.1 Although FAS is found primarily among children whose mothers were chronic, heavy alcohol consumers during pregnancy,2 ongoing research has documented a spectrum of adverse reproductive, infant, and child health outcomes resulting from prenatal alcohol exposure, some starting at thresholds as low as four drinks per week.3,4 Although surveys show that 9 of 10 women are aware of the adverse reproductive health consequences of drinking during pregnancy,1 in 1995 approximately 175,000 pregnancies were exposed to levels of alcohol known to carry increased risk for adverse pregnancy and infant outcomes.5 The adverse effects of prenatal alcohol exposure extend throughout pregnancy but are particularly deleterious to developing organ systems during the early part of the first trimester.6,7 Therefore, prevention of these adverse effects requires an approach that addresses alcohol use behaviors during the early weeks of pregnancy. As pregnancy recognition may not occur until the sixth week in many women, the maximum prevention benefit can be gained only if we find and intervene with women at greatest risk for an alcoholexposed pregnancy before they become pregnant. A prerequisite to this prevention effort is to develop a thorough understanding of the prevalence, patterns, and risk factors associated with frequent alcohol use among women of childbearing age—those who are pregnant and those who will become pregnant.

Combined tobacco and alcohol use by pregnant and reproductive-aged women in the United States.

Sexually transmissible diseases (STDs), the most common notifiable infectious conditions, remain major threats to reproductive and public health worldwide. Travelers are particularly vulnerable to STDs, because of voluntary or involuntary sexual behavior while abroad, and are significant vectors who introduce new pathogens and resistant strains to unaffected parts of the world. This article outlines some key issues that travel medicine specialists and other clinicians should revisit when providing services to travelers. We discuss obstacles to promoting sexual health, including the diversity of the target group, unanticipated opportunities for sexual risk, ambivalent cooperation by the travel and tourism industries, poorly developed travel health sectors, illegal migration and sex tourism, and lack of research about the association between travel and STDs. We also outlined some programmatic aspects of public health that should be identified and addressed for the promotion of sexual health among travelers.

Overcoming social and health inequalities among U.S. women of reproductive age—Challenges to the nation's health in the 21st century☆

Objective To assess trends in the concurrent use of alcohol and tobacco among pregnant women. Methods Using behavioral risk factor surveillance system data from 1987 through 1997, we determined the prevalence of concurrent tobacco and alcohol use among women aged 18–44 years by pregnancy status and indirectly estimated pregnancy-related disuse rates. Results The percentage of women who used alcohol and tobacco decreased significantly from 1987 to 1990 among pregnant (5.4% to 3.0%) and nonpregnant women (17.6% to 14.2%), but thereafter did not change significantly. The estimated pregnancy-related disuse rate of tobacco and alcohol increased insignificantly from 70% in 1987 to 82% in 1997. Among women who used both substances, pregnancy-related disuse was slightly greater for alcohol alone (74%) than for tobacco alone (52%). There was not a significant decline in concurrent use of tobacco and alcohol between 1987 and 1997 among women 18–20 years old (pregnant, 4.4% to 3.6%; nonpregnant, 13.5% to 13.7%). That age group also showed a smaller pregnancy-related disuse rate than older women (1997, 74% versus 83%). Conclusion The steady trend in concurrent use of tobacco and alcohol by young women emphasizes the need for enhanced efforts to reduce the initiation of tobacco and alcohol use by young people. Women who report abuse of tobacco or alcohol should be evaluated for abuse of both substances, and interventions should address abuse of both substances.

Reasons for not using condoms among the Hong Kong Chinese population: implications for HIV and STD prevention

OBJECTIVE To frame the discussion of the nations health within the context of maternal and child health. METHODS We used national data or estimates to assess the burden of 46 determinants. RESULTS During 2002-2004, U.S. women of reproductive age experienced significant challenges from macrosocial determinants, to health care access, and to their individual health preservation. Two-thirds of women do not consume recommended levels of fruits and vegetables. Overall, 29% experienced income poverty, 16.3% were uninsured. About one in four women of reproductive age lived with poor social capital. Compared with white women of reproductive age, non-white women reported higher levels of dissatisfaction with the health care system and race-related discrimination. Among all U.S. women, chronic diseases contributed to the top nine leading causes of disability adjusted life years. About one-third of women had no prophylactic dental visits in the past year, or consumed alcohol at harmful levels and smoked tobacco. One in three women who had a child born recently did not breast feed their babies. Demographics of women who are at increased risk for the above indicators predominate among the socioeconomically disadvantaged. CONCLUSIONS At least three-fourths of the U.S. women of reproductive age were at risk for poor health of their own and their offspring. Social intermediation and health policy changes are needed to increase the benefits of available health and social sector interventions to women and thereby to their offspring.

Burden of Disease Resulting from Hemophilia in the U.S.

Objective: To assess the prevalence and reasons for non-use of condoms among the Hong Kong Chinese population and obtain baseline data to monitor sexual behavioural change. Methods: Cross sectional self administered questionnaire surveys in convenience sampled groups of Hong Kong Chinese residents were carried out. Results: Of the 1508 respondents, 24% reported consistent condom use and 76% inconsistent use. Overall, 17% of respondents reported having sex with strangers. People who were at increased risk for inconsistent condom use included STD clinics attendees, those who never married, and those reporting low self efficacy for condom use or sex with strangers. Common reasons for not using condoms were trust in partner, use of other contraceptives, and reduced sensation while using condoms. Conclusions: Given the reported high prevalence of travel and sexual contact with strangers, and misconceptions about condoms among the Hong Kong Chinese population, innovative condom social marketing campaigns are needed. Periodic monitoring of condom use behaviours should be an integral part of HIV/STD surveillance activity.