Polysubstance Use in Pregnancy

Research suggests that the use of more than one substance, also known as polysubstance use, during pregnancy is common. More research is needed to understand the possible effects from exposure to multiple substances compared to one substance during pregnancy. Increased evidence-based practices, such as screening and follow-up as appropriate, can help to reduce substance exposure during pregnancy and improve the health of women and their children.

Substance use during pregnancy can have various effects on a developing baby

• Alcohol use during pregnancy can cause miscarriage, stillbirth, and a range of lifelong birth defects and developmental disabilities. These disabilities are known as fetal alcohol spectrum disorders (FASDs).
• Opioid use during pregnancy has been linked to poor fetal growth, preterm birth, stillbirth, specific birth defects, and neonatal abstinence syndrome (NAS).
• Cigarette smoking during pregnancy increases the risk of health problems for developing babies, such as preterm birth, low birth weight, and birth defects of the mouth and lip. Smoking during and after pregnancy also increases the risk of sudden infant death syndrome (SIDS). In addition, tobacco products containing nicotine (the addictive drug found in tobacco) and e-cigarettes are not safe to use during pregnancy.
• Some research shows that marijuana use during pregnancy is linked to low birth weight. It may also increase the chances for developmental problems for a child, such as problems with attention and learning. Further research is needed to better understand how marijuana may affect pregnant women and developing babies.

Polysubstance use is common in pregnancy

Many women may use more than one substance during pregnancy. For example,

• a 2015 study found that pregnant women prescribed opioid pain medication were more likely to smoke tobacco compared to those who did not use opioids;¹
• a 2017 study found that more than half of pregnant women who used opioids for nonmedical reasons reported drinking more than five drinks with alcohol per day during a 1-month period of time;² and
• a study published in 2020 found that among women who continued marijuana use before and during pregnancy, 74% also smoked cigarettes during their pregnancy.³

Impacts of polysubstance use on infants are not well known

The effects of polysubstance use on a developing baby are not well known. Limitations to data collection can include the following:

• Data sources are often limited to self-reported information, which might be underreported because of stigma and legal implications.
• The timing of substance use during pregnancy can be difficult to determine. For example, some surveys ask about use in the past 12 months or past 30 days, so patterns across individual pregnancies are not known.
• Some respondents may not know they are pregnant at the time of a survey, which could lead to an underestimation of substance use during pregnancy.
• Studies often examine use of a single substance, but polysubstance use is not always accounted for in analyses.

More research is needed to better understand the effects of polysubstance use during pregnancy on women and their babies. This information could help explain the effects of prenatal polysubstance use compared to the effects of each individual substance.

Clinical preventive services recommendations

The U.S. Preventive Services Task Forceexternal icon (USPSTF) makes recommendations about the effectiveness of specific clinical preventive services. These recommendations are based on the evidence of both the benefits and harms of the service. For substance use among adults, including pregnant persons, the USPSTF currently provides the following recommendations:

• Unhealthy Drug Use: Screeningexternal icon (2020)
  • “The USPSTF recommends screening by asking questions about unhealthy drug use in adults age 18 years or older. Screening should be implemented when services for accurate diagnosis, effective treatment, and appropriate care can be offered or referred.” (Grade Bexternal icon)
  • Applies to adults 18 years or older, including pregnant and postpartum persons, and adolescents aged 12–17 years in primary care settings
• Unhealthy Alcohol Use: Screening and Behavioral Counseling Interventionsexternal icon (2018)
  • “The USPSTF recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use.” (Grade Bexternal icon)
  • Applies to adults 18 years or older, including pregnant women
• Tobacco Smoking Cessation in Adults, Including Pregnant Womenexternal icon (2015)
  • “The USPSTF recommends that clinicians ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco.” (Grade Aexternal icon)
  • Applies to adults aged 18 years or older, including pregnant women

Key Findings: Alcohol use and co-use of other substances among pregnant females aged 12–44 years – United States, 2015–2018

In a 2020 Morbidity and Mortality Weekly Report article,⁴ CDC scientists found that about 10% of pregnant women reported current alcohol use. The use of other substances was common among pregnant women who reported alcohol use—about 40% reported current use of one or more other substances. Alcohol use during pregnancy can cause birth defects and developmental problems known as fetal alcohol spectrum disorders. Less is known about the use of other substances among women who report alcohol use during pregnancy. Increased screening and interventions for alcohol and other substance use in pregnancy could improve the health of women and their children.

Read the Key Findings.

From MMWR and Medscape: Get free continuing educationexternal icon.

Our Work

CDC Public Health Grand Rounds: Reducing Polysubstance Use in Pregnancy

This session discussed adverse maternal and child health outcomes caused by polysubstance use, how data can improve our understanding of polysubstance use, and how screening and brief interventions may reduce prenatal substance exposure and improve the health of pregnant persons and infants.

To view the August 2020 presentation and access additional resources, please visit the session page.

This session of Public Health Grand Rounds is available for free Continuing Education credit.

CDC’s National Center on Birth Defects and Developmental Disabilities (NCBDDD) works to address substance use during pregnancy. NCBDDD also works to improve care for affected individuals and their families. CDC does this work through

• collecting and analyzing data on
  • substance exposure during pregnancy,
  • the impact of evidence-based programs, and
  • the occurrence of negative infant outcomes;
• implementing programs to inform policies for practice and systems change;
• working with partners to develop and implement evidence-based interventions and clinical guidelines for the care of mothers and babies; and
• conducting communication activities to increase awareness and sharing new findings in a timely manner.

More Information

• AAP: Fetal Alcohol Spectrum Disorders Programexternal icon
• AAP: Substance Use and Preventionexternal icon
• ACOG: Fetal Alcohol Spectrum Disorders Preventionexternal icon
• ACOG: Marijuana and Pregnancyexternal icon
• ACOG: Opioid Use Disorder and Pregnancyexternal icon
• ACOG: Tobacco and Pregnancyexternal icon
• CDC: Alcohol Screening and Brief Intervention
• CDC: Fetal Alcohol Spectrum Disorders
• CDC: MAT-LINK
• CDC: Opioid Use During Pregnancy
• CDC: Smoking During Pregnancy
• CDC: Substance Use During Pregnancy
• CDC: What You Need to Know About Marijuana Use and Pregnancy
• March of Dimes: Beyond Labels – Substance Use and Pregnancyexternal icon
• National Organization on Fetal Alcohol Syndrome (NOFAS)external icon
• SAMHSA: Marijuana and Pregnancyexternal icon
• SAMHSA: Opioid Use Disorder and Pregnancypdf iconexternal icon

¹Patrick SW, Dudley J, Martin PR, et al. Prescription opioid epidemic and infant outcomes. Pediatrics 2015;135(5):842–850.
²Jarlenski M, Barry CL, Gollust S, et al. Polysubstance use among US women of reproductive age who use opioids for nonmedical reasons. Am J Public Health 2017; 107(8):1308–1310.
³Ko JY, Coy KC, Haight SC, et al. Characteristics of marijuana use during pregnancy – eight states, Pregnancy Risk Assessment Monitoring System, 2017. MMWR Morb Mortal Wkly Rep 2020; 69(32): 1058-1063.
⁴England LJ, Bennett C, Denny CH, et al. Alcohol use and co-use of other substances among pregnant females aged 12–44 years – United States, 2015–2018. MMWR Morb Mortal Wkly Rep 2020; 69(31): 1009-1014.