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International Rural Health
& Rural Nursing Research
Conference
Rapid City, SD
July 20, 2016
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Risks to Rural Health:
Tobacco and Other
Substance Use and Impacts
on the Health of Maternal
Child Populations
Jo Ann Walsh Dotson PhD RN
Assistant Professor of Nursing
Washington State University
College of Nursing
Spokane, WA
Objectives
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Decide, once and for all, what is and is not rural (just
kidding).
Review characteristics of women’s health and care
in rural areas.
Examine the prevalence and impact of substance
use by pregnant and parenting families.
Review policy and practice implications regarding
substance use by MCH populations in rural settings.
Consider responsibility of nurses and other health
professionals in rural settings.
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
“The well-being of mothers, infants, and
children determines the health of the next
generation and can help predict future
public health challenges for families,
communities, and the medical care
system.”
HP 2020
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Worldwide Infant Mortality Rates (IMR) - often used as an
indicator of the level of health in a country
World Rank
1
50
95
108
121
122
167
179
187
188
220
222
224
Country
AFGHANISTAN
INDIA
BRAZIL
SAUDI ARABIA
CHINA
MEXICO
UNITED STATES
CANADA
UNITED KINGDOM
AUSTRALIA
NORWAY
JAPAN
MONACO
IMR
115.08 (worst)
41.81
18.6
14.09
12.44
12.23
5.87
4.65
4.38
4.37
2.48
2.08
1.82 (best)
IMR = deaths of children under one year of age per 1,000 live births.
Source: The World Fact Book CIA 2015 Estimates
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
WHO Women’s Health Fact Sheet 2013
“Adolescent girls are increasingly using tobacco
and alcohol, which risks compromising their health,
particularly in later life. In some places girls are
using tobacco and alcohol nearly as much as boys.
For example, in the WHO Region of the Americas
(including North and South America), 23% of boys
and 21% of girls aged 13-15 reported that they
used tobacco in the previous month.”
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Rural Women’s Health
National Rural Health Association 2013
Maternal, infant, and child health rank as a top ten concern by rural
health experts.
Pregnancies to women in rural areas are more likely to be unplanned, and
the women more likely to be younger, less educated and unmarried women
and to be unplanned.
Rural women are particularly susceptible to poor prenatal care due to fewer resources
available to them.
Obstetrics providers, in particular, are in short supply in rural areas; urban counties average
nearly 35 obstetricians per 1,000 residents, while rural counties average less than 2 per
1,000 residents.
Women in rural areas are less likely to have adequate transportation, complicating the fact
that many rural hospitals do not offer obstetric services, and those that do have shortages
of providers and trained staff.
Lack of access to care has been linked with poorer outcomes among women.
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Health Disparities in Rural Women
ACOG 2014
Significant health disparities exist between rural and urban women.
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22.8% of U.S. women aged 18 years and older live in rural settings. About 20% of births in US
occur in rural areas.
U.S. rural women are more than likely to smoke cigarettes, and in some regions of the country,
have higher rates of heavy alcohol consumption.
Rural women aged 18–64 years reported the highest rates of delayed care or no medical care
due to cost (18.6%) and no health insurance coverage
Obstetric and Reproductive Health Outcomes - some studies document rural women have
• Higher rates of hospitalizations with complications during pregnancy
• Higher rates of low birth weight (LBW) and preterm birth
• More reliance on female sterilization (35%) than women living in large metropolitan (24%) or
fringe metropolitan (25%) areas
• Poorer access to contraception and more unintended pregnancies than women in more urban
areas.
• Poorer access to specialty care (OB, perinatologists and neonatologists)
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Substance Use in Pregnancy
Substance use in pregnancy typically
includes the use of tobacco, alcohol,
marijuana, and illicit drugs.
WHO defines illicit drugs as those used
for “…non-medical use that are prohibited
by international law. These drugs include:
amphetamine- type stimulants, cannabis,
cocaine, heroin and other opioids, and
MDMA (ecstasy).”
Substance dependence includes tolerance, withdrawal,
taking a drug in larger amounts over longer periods than
originally intended, the desire or ineffective attempts to
reduce or cease drug use, extensive amounts of time
involved with substance use, and persistent use despite
problems attributed to the substance.
Substance abuse is a maladaptive pattern of use that
results in clinically significant functional impairment,
characterized by one or more of the following:
• failure to fulfill reasonable obligations
• drug use in dangerous situations
• continued use despite recurrent legal, social, and
psychological problems associated with the substance.
WHO, 2006
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Substance Use by Pregnant Women
Worldwide %
US %
3.9
7
Tobacco
7
16
Alcohol
-
8.5
0.5
5.4
Marijuana
Illicit
Difficult to obtain accurate data due to:
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Underreporting of substances which are or have been illegal.
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Risk of legal sanctions by pregnant women who do report
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Definition of use is variably defined, including use in last year, trimester, month, amount.
•
Multi-drug use is common, making recall difficult.
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Trends in substance use
by pregnant women in
the US
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Cigarette use is decreasing, but this may be offset by e-cigarette
or vaping and chew.
Marijuana is the most commonly used recreation drug used
during pregnancy
Pregnant users perceive marijuana as low risk and “safe”, due in
part due to historical use to treat nausea,
Prevalence of marijuana use is expected to increase in the US,
especially in those states where recreational use is legalized
(Colorado, Washington, Alaska and Oregon) or anticipated to
pass legislation soon (Massachusetts, California, Missouri,
Hawaii, Maine, Nevada and Ohio)
Heroin use has increased slightly over the last decade, but nonmedical use of opioids has increased by over 30% in the last few
years.
Alcohol use continues, especially in conjunction with other
substances.
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
“Use of alcohol, illicit drugs
and other psychoactive
substances during pregnancy
can lead to multiple health
and social problems for both
mother and child, including
miscarriage, stillbirth, low
birthweight, prematurity,
physical malformations and
neurological damage.”
“Dependence on alcohol and
other drugs can also severely
impair an individual’s
functioning as a parent.”
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
WHO recommendations identification and
management of substance use and substance use
disorders in pregnancy
Governing principles
I. Prioritizing
prevention.
II. Ensuring access to
prevention and
treatment services
III. Respecting patient
autonomy
IV. Providing
comprehensive care.
V. Safeguarding against
discrimination and
stigmatization.
Recommendation to assure
• Screening and interventions for
hazardous substance use
• Psychosocial interventions for
substance use disorders
• Detoxification or quitting programs
for substance dependence
• Pharmacological treatment
• Support of breastfeeding with
monitoring
• Management of infants exposed to
alcohol and other psychoactive
substances
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Long Term
Short Term
Effect of prenatal drug exposure
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Effects
Nicotine
Alcohol
Marijuana
Opiates
Fetal Growth
Effect
Strong effect
No Effect
Effect
Anomalies
?
Strong effect
No Effect
No Effect
Withdrawal
No Effect
No effect
No Effect
Strong Effect
Neurobehavior
Effect
Effect
Effect
Effect
Growth
?
Strong Effect
No Effect
No Effect
Behavior
Effect
Strong Effect
Effect
Effect
Cognition
Effect
Strong Effect
Effect
?
Language
Effect
Effect
No Effect
*
Achievement
Effect
Strong Effect
Effect
*
No data
Source: Behnke & Smith (2013)
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Prevention Program Logic Model
Risk Factor
Substance Risk
Target Outcomes
Marijuana
Infant complications
including prematurity,
tremors and exaggerated
startle (Moro reflex), poor
suck
Improved infant status and
feeding
Tobacco
Low birth weight,
prematurity
Decreased maternal use,
improved birth outcomes,
decreased environmental
smoke
Alcohol
Poor birth outcomes, cooccurrence, Fetal Alcohol
Spectrum Disorder (FASD)
Decreased alcohol intake,
decreased incidence of
FASD
Opioids
neural tube defects,
congenital heart and other
Neonatal abstinence
syndrome (NAS)
Opioid management,
decreased incidence of
defects and NAS
Sources: Dotson, Henderson and McGraw, 2003
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Why do women want to quit using
substances?
1.Pregnancy (65.8%)
2.Needing help (23.7%)
3.Family (18.4%)
4.Tired of the lifestyle (16.7%).
Individuals residing in rural areas have unique beliefs, social
ties, attitudes, and financial hardships. Research about the
role of these factors in treatment access and motivation
could be used to minimize treatment barriers.
Jackson and Shannon, 2012
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Practice Implications
Health Care Providers
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In the absence of research, and because of concerns regarding impaired
neurodevelopment, ACOG recommends that women who are pregnant or
contemplating pregnancy should be encouraged to discontinue all
substances.
Seek education and resources about detection, notably the Prenatal Risk
Overview, which has been integrated into many EHRs.
Improve your own skills – training DOES improve your skills. RX for Change
Public Health
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Efforts to address marijuana use should be coordinated with tobacco and
alcohol prevention.
State and federal surveys must be changed to separate marijuana from
“illicit” drug lists in order to increase accuracy of reporting.
State birth certificates should be changed to add marijuana use to reporting
alongside alcohol and tobacco use
Careful monitoring of THC levels in marijuana production settings
Increase efforts to develop a clear message regarding marijuana use
Being alert to efforts to recruit female smokers and respond accordingly
integrity | caring | altruism | social justice | maximizing human potential
WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Nicotine addiction and treatment is important!
• Tobacco use has been causally linked to
diminished birth weight again and again (and
again…)
• Pregnant women receive mixed messages about
tobacco use – “it’s important you don’t drink, or
use other substances, but it’s OK to smoke if you
must”
• Tobacco use is often used
in association with other
substances
• Nicotine is a serious addiction
• Don’t confuse the clients!
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
P O L I C Y M A K E R I M P L I C AT I O N S
• Examine the cost of inaction
• Listen to communities regarding their needs and
challenges
• Support research on the topic of addictions and
treatment
• Support innovation
• Allocate EQUITABLY
A C A D E M I C / R E S E A R C H I M P L I C AT I O N S
• Translational research →
sustainable programs
• Interprofessional educational
efforts on substance abuse and
tobacco cessation counseling
• Partner with private and public
providers to evaluate
effectiveness of programming to
create responsive and
innovative programs for
communities
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
References
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Alharbi, F.F. and N. el-Guebaly. (2014). Exploring the Management of Cannabis Use Among Women and During Pregnancy. Addictive
Disorders & Their Treatment. 13(2): p. 93-100.
Baewert A, Jagsch R, Metz V, et al. (2012) Influence of site differences between urban and rural American and Central European opioiddependent pregnant women and neonatal outcome characteristics. European Addiction. 18(3):130-139
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 And Child Health Journal. 16(2):414-422.
Day, N.L., L. Goldschmidt, and C.A. Thomas. (2006) Prenatal marijuana exposure contributes to the prediction of marijuana use at age
14. Addiction. 101(9): p. 1313-1322.
Dotson, J. A., Henderson, D., & Magraw, M. (2003). A public health program for preventing fetal alcohol syndrome among women at risk
in Montana. Neurotoxicology & Teratology, 25(6), 757.
Garry, A., Rigourd, V., Amirouche, A., Fauroux, V., Aubry, S., and Serreau, R. (2009). Cannabis and Breastfeeding. Journal of
Toxicology. Article ID 598149, 5 pages, DOI 10.11552009596149..
Harrison, P.A., A. Godecker, and A. Sidebottom. (2012). Validity of the Prenatal Risk Overview for Detecting Drug Use Disorders in
Pregnancy. Public Health Nursing. 29(6): p. 563-573.
Heil S, Sigmon S, Jones H, Wagner M. (2008). Comparison of Characteristics of Opioid-Using Pregnant Women in Rural and Urban
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Jackson A, Shannon L. (2012). Examining Barriers to and Motivations for Substance Abuse Treatment Among Pregnant Women: Does
Urban-Rural Residence Matter?. Women & Health. 52(6):570-586.
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Substance Abuse and Mental Health Services Administration, Editor. 2012-2013.
Shishani, K., Stevens, K., Dotson, J., & Riebe, C. (2013). Improving nursing students' knowledge using online education and simulation to
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Tzilos, G., Hess, L., Chien-Wen Kao, J., and Zlotnick, C. Tzilos, G. (2013). Characteristics of perinatal women seeking treatment for
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integrity | caring | altruism | social justice | maximizing human potential
WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING
Thank you from Washington State
University College of Nursing!
Questions/Comments
Jo Ann Dotson at [email protected]
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WASHINGTON STATE UNIVERSITY COLLEGE OF NURSING