Substance Use During Pregnancy: Harm Reduction Helps

Every year, millions of people become pregnant in the United States, and the health choices these future parents make impact not just them, but also their future children. But pregnancy is complicated, as anyone who works in health, medicine or public policy knows. Pregnancy and the postpartum period can strain the mental, physical and emotional health of the pregnant person, which can negatively impact not just them, but also the fetus or infant. As an example, for the roughly 20 percent of pregnant people who use tobacco, alcohol or illicit substances, protecting the health of the pregnant person decreases the risks to themselves and to their fetus or infant. In fact, mental health conditions, including substance use disorders, are associated with nearly a quarter of pregnancy-related deaths, so minimizing the impact of these conditions can save lives. 

Although some pregnant people chose the safest option, completely abstaining from illicit and addictive substances, including tobacco, alcohol and cannabis (the most commonly-used ones by this group); for others, pregnancy does not magically remove the desire to consume potentially harmful substances. While treatment can be the preferred path for some pregnant people, harm reduction is another option for those who cannot or will not abstain during pregnancy. At a time when public policy and debates around parenting are raging in virtually every state, it is time to include the tools of harm reduction in these conversations and proposals. 

Harm reduction encompasses a set of strategies that help people reduce the potential harms of engaging in risky behaviors, and many harm reduction strategies are effective and safe regardless of a person’s pregnancy status. For opioid use disorder, the “gold-standard” treatment is opioid agonist therapy (OAT) with methadone or buprenorphine, which remains true for pregnant people with opioid use disorder. In fact, the American College of Obstetricians and Gynecologists states that OAT “is preferable to medically supervised withdrawal” during pregnancy.

Another harm reduction medication that is safe to use during pregnancy is pre-exposure prophylaxis (PrEP) to reduce the risk of acquiring HIV. For pregnant and postpartum women, the likelihood of contracting HIV is two to six times greater than outside those time periods. Among pregnant people who inject drugs, the risk of HIV infection is likely even higher, due to the combination of risk factors. When taken as prescribed, PrEP is highly effective at preventing HIV transmission from sex and injection drug use. Unfortunately, less than a quarter of people who could benefit from a PrEP prescription have one, and the rate is even lower among people who inject drugs and women. Preventing HIV among pregnant and breastfeeding people also protects fetuses and infants from the risk of contracting HIV from their parent. 

Medication is not the only harm reduction strategy that can benefit people who engage in potentially harmful activities. Pregnant people who smoke combustible cigarettes are at a higher risk of many adverse pregnancy outcomes. Nevertheless, the U.S. Preventative Services Task Force recommends only behavioral interventions to quit smoking during pregnancy, concluding that there is insufficient evidence assessing the balance of benefits and harms from cessation medications and nicotine replacement therapy. In contrast, the United Kingdom recently launched a campaign to help decrease smoking among the population which includes financial incentives for pregnant people who stop smoking or switch to e-cigarettes. Although animal studies suggest nicotine use during pregnancy is associated with some detrimental effects on the pregnant person and fetus, it’s unlikely that nicotine, in the absence of the chemicals produced by combustion, is as harmful as smoking. 

Additionally, harm reduction services provided by syringe services programs can improve health outcomes for pregnant people in practical and more abstract ways. Providing pregnant people who use drugs with sterile supplies and syringes can decrease the risk of parent and fetus contracting infectious diseases. These programs also distribute naloxone, which can be used during pregnancy if a person experiences an opioid overdose, potentially saving both parent and fetus. Harm reduction service providers are focused on creating positive change without judgment or discrimination, which can decrease the experience of stigma that often accompanies substance use, especially during pregnancy. This is vital because stigma and fear of legal ramifications can discourage pregnant people from accessing prenatal and other healthcare services. Anything that encourages comprehensive prenatal care for pregnant people who use substances is vital, because early and regular prenatal care can decrease the likelihood of adverse pregnancy outcomes from substance use.

Although pregnant people face unique health circumstances, pregnancy is no reason to deny evidence-based healthcare, including harm reduction services. Through encouraging incremental changes that reduce risk, harm reduction strategies can improve health at all stages of pregnancy and keep future parents healthier and engaged in health services. Harm reduction during pregnancy is a case of what’s good for one is good for all.