ajog.org
Letters to the Editors As the SMFM consult states, cfDNA screening is an important technology that has great benefits in patient care, but the details and complexities of clinical implementation are not clearly understood. It is expected that the existing guidelines will be updated to evaluate the new forthcoming data regarding test performance, expansion of testing for other conditions, and cost-effectiveness. For the question of which strategy of screening performs better in actual practice, comparative effectiveness of randomized controlled trials between cfDNA screening and traditional screening methods is needed. The goal of SMFM documents is to provide clinicians with clear, evidenced-based guidance for clinical care, which includes highlighting benefits as well as complexities and limitations of available alternatives. Society for Maternal-Fetal Medicine (SMFM) Publications Committee Society for Maternal-Fetal Medicine 409 12th Street SW Washington, DC 20024 [email protected]
REFERENCES 1. Borrell A, Stergiotou I. Cell-free DNA testing: inadequate implementation of an outstanding technique. Ultrasound Obstet Gynecol 2015;45:508-11. 2. Mennuti MT, Cherry AM, Morrissette JD, Dugoff L. Is it time to sound an alarm about false-positive cell-free DNA testing for fetal aneuploidy? Am J Obstet Gynecol 2013;209:415-9. 3. Alamillo CM, Krantz D, Evans M, Fiddler M, Pergament E. Nearly a third of abnormalities found after first-trimester screening are different than expected: 10-year experience from a single center. Prenat Diagn 2013;33:251-6. 4. Nicolaides KH, Syngelaki A, Ashoor G, Birdir C, Touzet G. Noninvasive prenatal testing for fetal trisomies in a routinely screened first-trimester population. Am J Obstet Gynecol 2012;207:374.e1-6. 5. Norton ME, Jelliffe-Pawlowski LL, Currier RJ. Chromosome abnormalities detected by current prenatal screening and noninvasive prenatal testing. Obstet Gynecol 2014;124:979-86. 6. Norton ME, Jacobsson B, Swamy GK, et al. Cell-free DNA analysis for noninvasive examination of trisomy. N Engl J Med 2015;372: 1589-97. ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 2015.06.026
Screening women for marijuana use does more harm than good TO THE EDITORS: We read with great interest the report by Ko et al,1 exploring the prevalence of marijuana use among pregnant and nonpregnant women. Clearly this is a timely issue in light of the recent changes to marijuana laws in several states. Based on the data collected from several years of the National Surveys on Drug Use and Health, the manuscript suggests that women who are pregnant or are at risk of becoming pregnant should be screened for marijuana use. Given the far-reaching implications of this suggestion and the limited data reported in the current article, we believed that at least 3 issues warranted further discussion. Universal screening of women of reproductive age for marijuana use seems unnecessarily invasive and sexist. We recognize that marijuana use, or other drug use, during pregnancy should be discouraged, but the current database does not reveal marijuana-associated fetal teratogenicity,2 highlighting the unjustified nature of the above proposal. Moreover, only women are proposed to be screened for marijuana use, which will uniquely expose them to legal consequences in regions in which the drug is banned. This concern becomes even more pressing when one considers the impact of racial discrimination in the enforcement of drug laws. Black people are about 4 times more likely to be arrested for marijuana possession than their white counterparts, despite the fact that both races used the drug at similar rates.3 In other words, black women can expect to bear the brunt of the consequences that may follow.
598 American Journal of Obstetrics & Gynecology OCTOBER 2015
Another concern is that the percentage of pregnant women who reported marijuana use is artificially inflated. Women were asked whether they were pregnant at the time of the survey; they were also asked whether they had used marijuana in the past 2e12 months. If they answered yes to both questions, then they were grouped as using marijuana during pregnancy. Because pregnancy duration is shorter than 12 months and because marijuana use could have occurred prior to becoming pregnant, it is inaccurate to refer to such women as reporting marijuana during pregnancy. In the end, in our view the proposal to screen women for marijuana use does more harm than the drug itself, and we hope that in the future greater consideration will be given to the potential negative unintended consequences of drug policy recommendations. Jill M. Stadterman Carl L. Hart, PhD Department of Psychology Columbia University New York, NY 10027 Division on Substance Abuse Department of Psychiatry College of Physicians and Surgeons of Columbia University New York State Psychiatric Institute 1051 Riverside Dr., Unit 120 New York, NY 10032 [email protected] The authors report no conflicts of interest.
ajog.org
REFERENCES 1. Ko JY, Farr SL, Tong VT, Creanga AA, Callaghan WM. Prevalence and patterns of marijuana use among pregnant and nonpregnant women of reproductive age. Am J Obstet Gynecol 2015;213:201.e1-10. 2. Mark K, Desai A, Terplan M. Marijuana use and pregnancy: prevalence, associated characteristics, and birth outcomes. Arch Womens Ment Health 2015 [Epub ahead of print]. 3. Edwards E, Bunting W, Garcia L. The war on marijuana in black and white. American Civil Liberties Union Report June 2013. Available at: https://www.aclu.org/files/assets/aclu-thewaronmarijuana-rel2.pdf. Accessed September 9, 2015. ª 2015 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.ajog.2015. 06.024
REPLY We thank Stadterman et al1 for their interest in our paper, and we would like to provide a few points of clarification. Although there is inconclusive evidence of harm regarding the sole use of marijuana during pregnancy and adverse birth and neonatal outcomes, in utero exposure to marijuana may lead to later learning and developmental impairments.2 Existing research, including our findings, suggests that concurrent use of other substances known to be teratogenic (ie, alcohol, tobacco) is common among marijuana users. Guidelines from the American College of Obstetricians and Gynecologists3 recommend universal screening for all maternal substance use, irrespective of whether a substance is legal. Universal screening could be performed by maternal self-report during clinical encounters using validated screening tools as part of a woman’s general health history. The American College of Obstetricians and Gynecologists guidelines acknowledge the complex legal issues regarding universal screening and that punitive measures resulting from substance use screening are not “applied evenly across sex, race, and socioeconomic status.” However, the guidelines state that “in fulfillment of the therapeutic obligation, physicians must make a substantial effort” to “. practice universal screening questions, brief intervention, and referral to treatment in order to provide benefit and do no harm .” and “protect confidentiality and the integrity of the physicianpatient relationship wherever possible within the requirements of legal obligations, and communicate honestly and directly with patients about what information can and cannot be protected.”3 Thus, effective screening, as well as appropriate provider training and resources for patient education and care, is needed to support pregnant women who may want assistance with cessation.
Letters to the Editors Finally, we would like to clarify that women were asked in the National Surveys on Drug Use and Health whether they used marijuana in the past month and in the past year. They were then analytically coded as past month users and past 2e12 month users. We described the timing of pregnancy and past 2e12 month use as a limitation of this data source. However, because pregnant women were on average in their second trimester, past-month use is likely reflective of use during pregnancy. Our point estimate of 3.9% is within the range of use during pregnancy reported by individual states (2.6% Hawaii and 7.1% in Alaska).4,5 In the context of legalization, monitoring use of marijuana in pregnancy, as well as unintended consequences, is needed. Jean Y. Ko, PhD Van T. Tong, MPH William M. Callaghan, MD, MPH Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention 4770 Buford Hwy Atlanta, GA 30345-3717 [email protected] The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors report no conflict of interest.
REFERENCES 1. Stadterman JM, Hart CL. Screening women for marijuana use does more harm than good. Am J Obstet Gynecol 2015;213:598-9. 2. Jaques SC, Kingsbury A, Henshcke P, et al. Cannabis, the pregnant woman and her child: weeding out the myths. J Perinatol 2014;34: 417-24. 3. American College of Obstetricians and Gynecologists. At-risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice. ACOG Committee opinion no. 422. Obstet Gynecol 2008;112: 1449-60. 4. Roberson EK, Hurwitz EL. Prescription drug use during and immediately before pregnancy in Hawai’i—findings from the Hawai’i Pregnancy Risk Assessment Monitoring System, 2009e2011. Hawaii J Med Public Health 2014;73:382-6. 5. Perham-Hester K, Baldwin-Johnson C. Marijuana use among women delivering live births in Alaska, 2002e2011. State of Alaska Epidemiology Bulletin. State of Alaska, Department of Health and Social Services, Division of Public Health, Section of Epidemiology. 2015. Available at: http://www.epi.hss.state.ak.us/bulletins/docs/b2015_05.pdf. Accessed April 10, 2015. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.ajog.2015.06.023
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Letters to the Editors As the SMFM consult states, cfDNA screening is an important technology that has great benefits in patient care, but the details and complexities of clinical implementation are not clearly understood. It is expected that the existing guidelines will be updated to evaluate the new forthcoming data regarding test performance, expansion of testing for other conditions, and cost-effectiveness. For the question of which strategy of screening performs better in actual practice, comparative effectiveness of randomized controlled trials between cfDNA screening and traditional screening methods is needed. The goal of SMFM documents is to provide clinicians with clear, evidenced-based guidance for clinical care, which includes highlighting benefits as well as complexities and limitations of available alternatives. Society for Maternal-Fetal Medicine (SMFM) Publications Committee Society for Maternal-Fetal Medicine 409 12th Street SW Washington, DC 20024 [email protected]
REFERENCES 1. Borrell A, Stergiotou I. Cell-free DNA testing: inadequate implementation of an outstanding technique. Ultrasound Obstet Gynecol 2015;45:508-11. 2. Mennuti MT, Cherry AM, Morrissette JD, Dugoff L. Is it time to sound an alarm about false-positive cell-free DNA testing for fetal aneuploidy? Am J Obstet Gynecol 2013;209:415-9. 3. Alamillo CM, Krantz D, Evans M, Fiddler M, Pergament E. Nearly a third of abnormalities found after first-trimester screening are different than expected: 10-year experience from a single center. Prenat Diagn 2013;33:251-6. 4. Nicolaides KH, Syngelaki A, Ashoor G, Birdir C, Touzet G. Noninvasive prenatal testing for fetal trisomies in a routinely screened first-trimester population. Am J Obstet Gynecol 2012;207:374.e1-6. 5. Norton ME, Jelliffe-Pawlowski LL, Currier RJ. Chromosome abnormalities detected by current prenatal screening and noninvasive prenatal testing. Obstet Gynecol 2014;124:979-86. 6. Norton ME, Jacobsson B, Swamy GK, et al. Cell-free DNA analysis for noninvasive examination of trisomy. N Engl J Med 2015;372: 1589-97. ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog. 2015.06.026
Screening women for marijuana use does more harm than good TO THE EDITORS: We read with great interest the report by Ko et al,1 exploring the prevalence of marijuana use among pregnant and nonpregnant women. Clearly this is a timely issue in light of the recent changes to marijuana laws in several states. Based on the data collected from several years of the National Surveys on Drug Use and Health, the manuscript suggests that women who are pregnant or are at risk of becoming pregnant should be screened for marijuana use. Given the far-reaching implications of this suggestion and the limited data reported in the current article, we believed that at least 3 issues warranted further discussion. Universal screening of women of reproductive age for marijuana use seems unnecessarily invasive and sexist. We recognize that marijuana use, or other drug use, during pregnancy should be discouraged, but the current database does not reveal marijuana-associated fetal teratogenicity,2 highlighting the unjustified nature of the above proposal. Moreover, only women are proposed to be screened for marijuana use, which will uniquely expose them to legal consequences in regions in which the drug is banned. This concern becomes even more pressing when one considers the impact of racial discrimination in the enforcement of drug laws. Black people are about 4 times more likely to be arrested for marijuana possession than their white counterparts, despite the fact that both races used the drug at similar rates.3 In other words, black women can expect to bear the brunt of the consequences that may follow.
598 American Journal of Obstetrics & Gynecology OCTOBER 2015
Another concern is that the percentage of pregnant women who reported marijuana use is artificially inflated. Women were asked whether they were pregnant at the time of the survey; they were also asked whether they had used marijuana in the past 2e12 months. If they answered yes to both questions, then they were grouped as using marijuana during pregnancy. Because pregnancy duration is shorter than 12 months and because marijuana use could have occurred prior to becoming pregnant, it is inaccurate to refer to such women as reporting marijuana during pregnancy. In the end, in our view the proposal to screen women for marijuana use does more harm than the drug itself, and we hope that in the future greater consideration will be given to the potential negative unintended consequences of drug policy recommendations. Jill M. Stadterman Carl L. Hart, PhD Department of Psychology Columbia University New York, NY 10027 Division on Substance Abuse Department of Psychiatry College of Physicians and Surgeons of Columbia University New York State Psychiatric Institute 1051 Riverside Dr., Unit 120 New York, NY 10032 [email protected] The authors report no conflicts of interest.
ajog.org
REFERENCES 1. Ko JY, Farr SL, Tong VT, Creanga AA, Callaghan WM. Prevalence and patterns of marijuana use among pregnant and nonpregnant women of reproductive age. Am J Obstet Gynecol 2015;213:201.e1-10. 2. Mark K, Desai A, Terplan M. Marijuana use and pregnancy: prevalence, associated characteristics, and birth outcomes. Arch Womens Ment Health 2015 [Epub ahead of print]. 3. Edwards E, Bunting W, Garcia L. The war on marijuana in black and white. American Civil Liberties Union Report June 2013. Available at: https://www.aclu.org/files/assets/aclu-thewaronmarijuana-rel2.pdf. Accessed September 9, 2015. ª 2015 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.ajog.2015. 06.024
REPLY We thank Stadterman et al1 for their interest in our paper, and we would like to provide a few points of clarification. Although there is inconclusive evidence of harm regarding the sole use of marijuana during pregnancy and adverse birth and neonatal outcomes, in utero exposure to marijuana may lead to later learning and developmental impairments.2 Existing research, including our findings, suggests that concurrent use of other substances known to be teratogenic (ie, alcohol, tobacco) is common among marijuana users. Guidelines from the American College of Obstetricians and Gynecologists3 recommend universal screening for all maternal substance use, irrespective of whether a substance is legal. Universal screening could be performed by maternal self-report during clinical encounters using validated screening tools as part of a woman’s general health history. The American College of Obstetricians and Gynecologists guidelines acknowledge the complex legal issues regarding universal screening and that punitive measures resulting from substance use screening are not “applied evenly across sex, race, and socioeconomic status.” However, the guidelines state that “in fulfillment of the therapeutic obligation, physicians must make a substantial effort” to “. practice universal screening questions, brief intervention, and referral to treatment in order to provide benefit and do no harm .” and “protect confidentiality and the integrity of the physicianpatient relationship wherever possible within the requirements of legal obligations, and communicate honestly and directly with patients about what information can and cannot be protected.”3 Thus, effective screening, as well as appropriate provider training and resources for patient education and care, is needed to support pregnant women who may want assistance with cessation.
Letters to the Editors Finally, we would like to clarify that women were asked in the National Surveys on Drug Use and Health whether they used marijuana in the past month and in the past year. They were then analytically coded as past month users and past 2e12 month users. We described the timing of pregnancy and past 2e12 month use as a limitation of this data source. However, because pregnant women were on average in their second trimester, past-month use is likely reflective of use during pregnancy. Our point estimate of 3.9% is within the range of use during pregnancy reported by individual states (2.6% Hawaii and 7.1% in Alaska).4,5 In the context of legalization, monitoring use of marijuana in pregnancy, as well as unintended consequences, is needed. Jean Y. Ko, PhD Van T. Tong, MPH William M. Callaghan, MD, MPH Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention 4770 Buford Hwy Atlanta, GA 30345-3717 [email protected] The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. The authors report no conflict of interest.
REFERENCES 1. Stadterman JM, Hart CL. Screening women for marijuana use does more harm than good. Am J Obstet Gynecol 2015;213:598-9. 2. Jaques SC, Kingsbury A, Henshcke P, et al. Cannabis, the pregnant woman and her child: weeding out the myths. J Perinatol 2014;34: 417-24. 3. American College of Obstetricians and Gynecologists. At-risk drinking and illicit drug use: ethical issues in obstetric and gynecologic practice. ACOG Committee opinion no. 422. Obstet Gynecol 2008;112: 1449-60. 4. Roberson EK, Hurwitz EL. Prescription drug use during and immediately before pregnancy in Hawai’i—findings from the Hawai’i Pregnancy Risk Assessment Monitoring System, 2009e2011. Hawaii J Med Public Health 2014;73:382-6. 5. Perham-Hester K, Baldwin-Johnson C. Marijuana use among women delivering live births in Alaska, 2002e2011. State of Alaska Epidemiology Bulletin. State of Alaska, Department of Health and Social Services, Division of Public Health, Section of Epidemiology. 2015. Available at: http://www.epi.hss.state.ak.us/bulletins/docs/b2015_05.pdf. Accessed April 10, 2015. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.ajog.2015.06.023
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