Drinking alcohol during pregnancy can cause fetal alcohol spectrum disorders, including
birth defects, behavioral disorders, and impaired cognitive development (
1
). Little is known about the co-use of other substances by females who drink during
pregnancy. CDC used 2015–2018 data from the National Survey on Drug Use and Health
(NSDUH) to estimate the overall and trimester-specific prevalence of self-reported
drinking in the past 12 months, current drinking, and binge drinking, overall and
by trimester, and the co-use of other substances among pregnant females aged 12–44
years. Past drinking (12 months) was reported by 64.7% of pregnant respondents. Current
drinking (at least one drink in the past 30 days) was reported by 19.6% of respondents
who were in their first trimester of pregnancy and 4.7% of respondents who were in
their second or third trimester. Binge drinking (consuming four or more drinks on
at least one occasion in the past 30 days) was reported by 10.5% of first trimester
respondents and 1.4% of second or third trimester respondents. Overall, 38.2% of pregnant
respondents who reported current drinking also reported current use of one or more
other substances. The substances used most with alcohol were tobacco and marijuana.
Self-reported drinking prevalence was substantially lower among second or third trimester
respondents than among first trimester respondents. The American College of Obstetricians
and Gynecologists (ACOG) recommends alcohol use and substance use disorders screening
for all females seeking obstetric-gynecologic care and counseling patients that there
is no known safe level of alcohol use during pregnancy (
2
).
NSDUH is a nationwide survey that uses multistage and area probability sampling to
provide information on tobacco, alcohol, and drug use, and on mental health and other
health-related issues, among U.S. civilian, noninstitutionalized persons aged ≥12
years. Surveys are conducted in respondents’ homes and use computer-assisted interviewing
methods. Female respondents report whether they are currently pregnant and the trimester
of pregnancy at the time of the interview. Weighted response rates for 2015–2018 ranged
from 66.6% to 69.3%.*
This report focuses on past 12 months drinking, current drinking and binge drinking
among pregnant respondents. Drinking alcohol during pregnancy and binge drinking in
any population are two measures of excessive drinking.
†
In addition, this report provides estimates of the prevalence of co-use of other substances
among respondents who drank alcohol. Respondents who reported ever having an alcoholic
beverage were asked how long it had been since they last drank an alcoholic beverage.
This report also examined past 12 months and past 30 days use of other substances,
including tobacco (i.e., cigarettes, cigars, smokeless tobacco, and pipes), marijuana,
opioids (prescription pain reliever misuse and heroin use), and “other substances,”
which included cocaine, hallucinogens, inhalants, methamphetamines, and the misuse
§
of sedatives, stimulants, and tranquilizers. Other substances were grouped as one
category because of the small number of pregnant females who reported using them.
Data were weighted to adjust for nonresponse and to generate nationally representative
estimates. Prevalence estimates and 95% confidence intervals (CIs) for past 12 months
drinking, current drinking, and binge drinking were calculated overall and by sociodemographic
and pregnancy characteristics (age, race/ethnicity, income, marital status, education,
employment status, insurance status, county urban/rural status, and trimester of pregnancy).
Prevalence estimates and 95% CIs for past 12 months and current drinking alone and
with co-occurring substance use among pregnant respondents also were calculated. Analyses
were conducted using SAS (version 9.4; SAS Institute) with SUDAAN (version 11.0; RTI
International) to account for the complex sampling method used in NSDUH.This activity
was reviewed by CDC and conducted consistent with CDC policies and procedures.
¶
Among 99,618 female respondents aged 12–44 years, 3,006 (3%) reported a current pregnancy.
Among pregnant respondents, past 12 months drinking, current drinking, and binge drinking
prevalence estimates were 64.7%, 9.8%, and 4.5%, respectively (Table 1). Past 12 months
drinking was reported by 76.1% of first trimester respondents and 59.8% of second
or third trimester respondents; current drinking by 19.6% of first trimester respondents
and 4.7% of second or third trimester respondents; and binge drinking by 10.5% of
first trimester respondents and 1.4% of second or third trimester respondents (p<0.001
for all comparisons) (Table 1; Figure).
TABLE 1
Weighted prevalence of past 12 months and past 30 days drinking and past 30 days binge
drinking in 3,006 pregnant females aged 12–44 years, by selected characteristics —
National Survey on Drug Use and Health, United States, 2015–2018
Characteristic
% (95% CI)
Past 12 months drinking*
Past 30 days drinking*
Past 30 days binge drinking*
Overall
64.7 (62.1–67.3)
9.8 (8.5–11.1)
4.5 (3.7–5.4)
Age group (yrs)
<18
39.0 (27.3–52.1)
—†
—†
18–25
61.2 (58.0–64.3)
9.9 (7.9–12.2)
6.0 (4.5–8.1)
26–34
68.2 (64.2–72.0)
9.4 (7.6–11.5)
3.9 (2.9–5.3)
≥35
63.1 (55.5–70.1)
11.1 (7.3–16.6)
§
—†
Race/Ethnicity
White, non-Hispanic
74.9 (71.4–78.0)
9.9 (8.2–11.8)
4.0 (3.0–5.3)
Black, non-Hispanic
56.7 (51.0–62.3)
13.7 (9.8–18.9)
7.0 (4.6–10.9)
§
Hispanic
48.0 (42.2–53.7)
7.0 (4.5–10.7)
§
—†
Other
52.9 (44.0–61.7)
8.4 (4.8–14.4)
—†
Income
§
<$20,000
50.5 (45.2–55.8)
9.7 (7.3–12.8)
6.3 (4.7–8.3)
$20,000–$74,999
61.6 (57.9–65.2)
8.7 (7.0–10.8)
3.9 (2.8–5.4)
≥$75,000
78.3 (74.0–82.1)
11.4 (9.2–14.0)
4.3 (3.0–6.0)
Marital status
¶
Married
66.2 (62.2–70.0)
9.0 (7.3–11.0)
3.1 (2.2–4.3)
Not married
63.6 (59.9–67.1)
11.0 (9.1–13.3)
6.5 (5.0–8.4)
Education
¶
≤High school
49.2 (45.3–53.0)
8.9 (6.9–11.4)
5.3 (3.8–7.6)
>High school
73.3 (70.0–76.3)
10.3 (8.8–12.0)
4.0 (3.1–5.2)
Employment
¶
Full time
76.3 (73.1–79.1)
11.6 (9.7–13.9)
4.6 (3.4–6.2)
Part time
62.5 (57.2–67.5)
8.7 (5.8–12.8)
3.4 (1.9–6.2)
§
Unemployed/Other**
53.5 (49.3–57.7)
8.3 (6.4–10.6)
4.8 (3.4–6.6)
Insurance
Medicaid
54.9 (51.3–58.5)
7.6 (6.0–9.5)
3.8 (2.8–5.0)
Private
73.9 (70.2–77.3)
10.6 (8.6–13.0)
4.0 (3.0–5.5)
Uninsured/Other
††
53.2 (46.2–60.1)
13.5 (9.4–18.9)
9.5 (5.7–15.4)
§
Urban/Rural
§§
Metropolitan
65.7 (61.6–69.5)
10.3 (8.4–12.7)
3.8 (2.7–5.4)
Micropolitan
64.5 (60.6–68.2)
9.3 (7.1–12.0)
4.9 (3.7–6.6)
Rural
61.0 (55.8–66.0)
8.3 (5.9–11.7)
6.3 (3.9–9.8)
§
Trimester
¶¶
First
76.1 (72.7–79.3)
19.6 (16.8–22.7)
10.5 (8.5–13.0)
Second or third
59.8 (56.5–63.1)
4.7 (3.5–6.4)
1.4 (0.9–2.1)
Abbreviation: CI = confidence interval.
* Past 12 months use regardless of whether there was also past 30 days use; past 30
days drinking regardless of whether there was also past 30 days binge drinking; binge
drinking = consuming four or more drinks on at least one occasion in the past 30 days.
† Estimates are not presented because the relative standard error was >30%.
§
Estimate might be unstable because the relative standard error is 20%–30%.
¶ The age group <18 years was omitted for income, marital status, education, and employment
** Other = those not in the labor force.
††
Other insurance not otherwise specified.
§§
https://www.ers.usda.gov/data-products/rural-urban-continuum-codes.
¶¶ Overall, 1.3% of females reported an unknown trimester of pregnancy and were not
included in the table.
FIGURE
Weighted prevalence of past 12 months drinking, past 30 days drinking, and past 30
days binge drinking* among pregnant females
†
aged 12–44 years (N = 3,006), by trimester — National Survey on Drug Use and Health,
United States, 2015–2018
* For females, binge drinking = four or more drinks per occasion.
† Overall, 1.3% of pregnant females reported an unknown trimester of pregnancy and
were not included in the figure.
The figure is a bar chart showing the percentages of females within each of three
groupings reflecting frequency of use, who drank during their first trimester of pregnancy,
and similarly, those who drank during the second or third trimester (combined).
Among respondents who were pregnant and reported drinking in the past 12 months, 41.7%
also reported using at least one other substance in the past 12 months. The most commonly
reported substances were tobacco (30.3%), marijuana (21.9%), and opioids (7.0%) (Table
2). Among respondents who reported current drinking, 38.2% reported using at least
one other substance, most commonly tobacco (28.1%) and marijuana (20.6%) (Table 2)
TABLE 2
Weighted prevalence of substance use patterns (past 12 months and past 30 days) in
pregnant females aged 12–44 years (N = 3,006*) who drank alcohol in the past 12 months
(n = 1,851*) or the past 30 days (n = 282*) — National Survey on Drug Use and Health,
United States, 2015–2018
Substance use pattern
% (95% CI)
Past 12 months drinking†
Past 30 days (current) drinking
All pregnant females (N = 3,006*)
Any alcohol use
64.7 (62.1–67.3)
9.8 (8.5–11.1)
Alcohol use only
37.7 (35.7–39.7)
6.0 (5.0–7.2)
Alcohol and ≥1 additional substance
27.0 (25.1–29.0)
3.7 (2.9–4.7)
Other substances used§
Tobacco¶
19.6 (18.0–21.3)
2.7 (2.1–3.6)
Marijuana
14.2 (12.3–16.3)
2.0 (1.4–2.8)
Opioids**
4.5 (3.5–5.8)
—††
Other††
6.2 (5.0–7.7)
—††
Pregnant females who drank in the past 12 months (n = 1,851*) or in the past 30 days
(n = 282*)
Alcohol use only
58.3 (56.0–60.6)
61.8 (53.9–69.2)
Alcohol and ≥1 additional substance
41.7 (39.4–44.0)
38.2 (30.8–46.1)
Other substances used§
Tobacco¶
30.3 (28.0–32.8)
28.1 (21.7–35.6)
Marijuana
21.9 (19.0–25.0)
20.6 (14.5–28.3)
Opioids**
7.0 (5.5–8.9)
—††
Other§§
9.76 (7.8–11.8)
—††
Abbreviation: CI = confidence interval.
* Unweighted.
† Past 12 months use, regardless of whether there was also drinking in the past 30
days (current drinking).
§
Not mutually exclusive.
¶ Includes cigarettes, cigars, or smokeless tobacco.
** Includes prescription pain reliever misuse and heroin use.
†† Estimates are not presented because the relative standard error was >30%.
§§
Includes use of cocaine, hallucinogens, inhalants, methamphetamines, and the misuse
of sedatives, stimulants, and tranquilizers.
Overall, 19.6% of respondents who were pregnant reported past 12 months drinking and
tobacco use, 14.2% reported past 12 months drinking and marijuana use, 4.5% reported
past 12 months drinking and opioid use, 2.7% reported current drinking and tobacco
use, and 2.0% reported current drinking and marijuana use.
Discussion
During 2015–2018, approximately half of all pregnant respondents who reported current
drinking (drinking in the past 30 days) (9.8%) also reported binge drinking (4.5%).
Among pregnant females who reported current drinking, 38.2% also reported current
use of one or more other substances, including tobacco, marijuana, opioids, and other
substances. The estimates of current drinking and binge drinking among pregnant females
are consistent with recent analyses using data from the 2015–2017 Behavioral Risk
Factor Surveillance System, which reported current drinking and binge drinking estimates
of 11.5% and 3.9%, respectively, among pregnant respondents aged 18–44 years (
3
). The current analysis adds to previous findings by including trimester-specific
estimates showing higher self-reported drinking in first trimester respondents, suggesting
that some respondents who drank before pregnancy might have quit by mid-to-late pregnancy,
and by providing estimates indicating that co-use of other substances is common.
Few population-based reports consider co-use of other substances among pregnant females
who drink alcohol. In this report, current drinking overall and in combination with
one or more other substances were substantially lower than past 12 months drinking,
suggesting that females decrease their use after they know they are pregnant. Alcohol
exposure during pregnancy can adversely affect fetal development, resulting in behavioral
disorders, impaired intellectual development, and birth defects (
1
). It also has been associated with miscarriage and stillbirth (
4
). Although supporting data are sparse, alcohol exposure combined with exposure to
other substances could worsen pregnancy outcomes. Prenatal exposure to substances
included in this analysis has been associated with adverse health outcomes, including
preterm birth, sudden infant death syndrome, and preterm-related death (exposure to
tobacco) (
5
); low birth weight (tobacco, marijuana) (
5
,
6
); and altered fetal brain development (tobacco, marijuana) (
5
–
8
). A review of prenatal substance exposure and neuroimaging suggests that in utero
exposure to substances other than alcohol, including marijuana, nicotine, cocaine,
methamphetamine, opioids, or combinations of substances, is associated with long-term
effects on cognition and with altered brain connectivity and white matter deficits
(
9
).
The findings in this report are subject to at least four limitations. First, data
are self-reported and therefore subject to social desirability bias; respondents might
underreport substance use because of social stigma and legal implications. Second,
because NSDUH only ascertains past 12 months and past 30 days substance use in a cross-sectional
sample, patterns across individual pregnancies are unknown. Estimates of any substance
use during the length of an entire pregnancy would likely be higher than estimates
of past 30 days use. Third, limited sample size necessitated the suppression of some
prevalence estimates. Finally, some pregnancies might not have been recognized at
the time of the interview, resulting in misclassification by pregnancy status. Alcohol
use and other substance use presumably are lower in recognized than in unrecognized
pregnancies, resulting in underestimation of exposure levels.
The U.S. Preventive Services Task Force recommends alcohol screening and brief behavioral
counseling in primary care settings for all adults aged ≥18 years (
10
). ACOG recommends alcohol use screening for all females seeking obstetric-gynecologic
care and counseling patients that there is no known safe level of alcohol use during
pregnancy (
2
). ACOG also recommends routine universal screening for substance use disorders with
validated screening tools or through conversations with patients. Although ACOG does
not have recommendations specific to polysubstance use, the findings of this report
indicate that a substantial percentage of females who use alcohol during early pregnancy
also use one or more other substances, especially tobacco or marijuana. Females could
benefit from screening and interventions in pregnancy to reduce alcohol and polysubstance
use and from referral for those in need of treatment. Successful reduction in substance
exposures during pregnancy could improve the health of mothers and their children.
Summary
What is already known about this topic?
Drinking alcohol during pregnancy can cause miscarriage, stillbirth, and fetal alcohol
spectrum disorders; however, approximately one in nine pregnant females report current
drinking. Little is known about the co-use of other substances by females who drink
during pregnancy.
What is added by this report?
Pregnant respondents in the first trimester reported higher current alcohol use than
respondents in the second or third trimester. Among first trimester respondents, 19.6%
reported current alcohol use and 10.5% reported binge drinking; among second or third
trimester respondents, current drinking and binge drinking were reported by 4.7% and
1.4%, respectively. Approximately 40% of pregnant females reporting current drinking
also reported current use of other substances.
What are the implications for public health?
Co-use of other substances is common among females who drink alcohol during pregnancy.
Screening and interventions for alcohol and other substances in pregnancy could improve
the health of mothers and their children.