The Psychiatric Morbidity of Women Who Give Birth to Children with Fetal Alcohol Spectrum Disorder (FASD): Results of the Manitoba Mothers and FASD Study

Abstract

French

Objective:

To investigate differences in physician-diagnosed psychiatric disorders between women who gave birth to children with a fetal alcohol spectrum disorder (FASD) diagnosis (study group) compared to women who gave birth to children without FASD (comparison group).

Methods:

We linked population-level health and social services data to clinical data on FASD diagnoses to identify study group (n = 702) and comparison group (n = 2097) women matched 1:3 on date of birth of index child, region of residence, and socioeconomic status. Regression modeling produced relative rates (RRs) for outcomes.

Results:

Mothers who gave birth to children with FASD had higher adjusted rates of substance use disorder (RR, 12.65; 95% confidence interval [CI], 8.99-17.80), personality disorder (RR, 12.93; 95% CI, 4.88-34.22), and mood and anxiety disorders (RR, 1.75; 95% CI, 1.49-2.07) before the pregnancy of the child. These mothers also had higher adjusted rates of maternal psychological distress during pregnancy (RR, 5.35; 95% CI, 4.58-6.35) and higher rates of postpartum psychological distress (RR, 1.71; 95% CI, 1.53-1.90). These women also had higher adjusted rates for antidepressant prescriptions before, during, and after the pregnancy.

Conclusions:

A significant psychiatric burden exists for women giving birth to children with FASD. Clinicians should recognise the high rates of psychiatric concerns facing mothers who give birth to children with FASD and should offer treatment and support to these women to improve their health and well-being and prevent further alcohol-exposed pregnancies.

Keywords

psychiatric disorder fetal alcohol spectrum disorder alcohol prenatal alcohol use alcohol use pregnancy psychiatric morbidity postpartum

In Canada, over 10% of women report alcohol consumption during pregnancy,¹ and in Manitoba, approximately 14% of women report prenatal alcohol use.² These statistics indicate alcohol use during pregnancy is a substantial provincial and national public health concern. Prenatal alcohol use places children at risk for fetal alcohol spectrum disorder (FASD), a diagnostic term comprising a range of effects associated with prenatal alcohol exposure.³

FASD has been recognised as the leading cause of intellectual disability in North America.⁴ Patients with FASD experience a myriad of symptoms, including sentinel facial features (smaller palpebral fissure, philtrum smoothness, and upper lip thinness) and neurodevelopmental abnormalities (motor skills, impaired cognition, language difficulties, academic challenges, memory impairment, and attention difficulties, including impulse control and hyperactivity) as well as communication, behavioural, emotional, and social difficulties.^3

–6

Over the past decade, international FASD prevalence estimates have ranged from 2% to 5%⁷ in the general population and up to 23.3% in high-risk populations.^{8

–17} Among the general population of Canada, the pooled prevalence of fetal alcohol syndrome (FAS) was estimated to be approximately 1 per 1000 for FAS and 5 per 1000 for FASD.¹⁸ The prevalence of FAS and FASD was estimated to be 38 and 16 times higher for First Nations populations, respectively.¹⁸

Research has also demonstrated that the financial burden of FASD is significant. Popova et al.¹⁹ used data from the Canadian Institute for Health Information and calculated direct health care costs (acute care, psychiatric care, day surgery, emergency department use) from patients with FASD in Canada at approximately $6.7 million. Easton et al.²⁰ investigated the cost of lost productivity due to FASD-attributable morbidity and reported losses ranging from $418 million to $1.08 billion annually. This demonstrates the immense toll this disability has on patients, families, and the health care system and highlights the need for prevention programs.

A crucial step in developing effective FASD prevention strategies is the early identification of maternal and societal risk factors that are associated with giving birth to children with FASD.

It is important to acknowledge that women who drink during pregnancy are not doing so to intentionally cause harm upon their children but because of complex social, health, and economic factors. These factors include histories of violence, sexual abuse, poverty, low socioeconomic status, social isolation, and living with partners with substance abuse issues.^21

–25 The use of alcohol during pregnancy cannot be separated from these issues and from other potentially harmful behaviours such as poor health practices, poor nutrition, and the use of other harmful substances.^21

–25

It is also important to note that historically, women of disadvantaged backgrounds were associated with a high risk of giving birth to children with FASD, but there is an increasing body of literature that is showing women of diverse backgrounds consume alcohol during pregnancy,²⁶ including women who are older, have high incomes and education, have stressful jobs, are in abusive relationships, have partners who drink heavily, or are coping with anxiety and depression.²⁶

The complex, interconnected factors that place women at risk for alcohol consumption during pregnancy also place women at higher risk for the development of psychiatric disorders.^27

–31 The comorbidity of psychiatric disorders and alcohol use and dependence has been widely reported in the literature.^{29,30,32

–35} Studies have also documented that almost two-thirds of women with alcohol use issues may have a concurrent psychiatric diagnosis, including anxiety and panic disorders, posttraumatic stress disorder, depression, eating disorders, and more severe psychiatric illness such as bipolar disorder and schizophrenia.^36,37

Furthermore, the increased frequency of alcohol use of these women also places them at high risk for psychiatric disorders,³⁵ as alcohol can affect the central nervous system and have detrimental effects on a person’s family and interpersonal relationships, economic and employment circumstances, and possible involvement with the justice system.²⁸

There is currently a dearth of research that investigates the psychiatric morbidity of women who give birth to children with FASD. This is the first population-based study that uses administrative data to investigate the rates of psychiatric disorders of women who give birth to children with FASD compared to women with no reported prenatal alcohol exposure. The occurrence of psychiatric disorders in women may increase the risk of developing alcohol use and dependence, as alcohol can be an agent for self-medication of symptoms associated with psychiatric disorders, including depressive and anxious symptoms, hopelessness, paranoia, impulsivity, fear, and anger.²⁷ Investigating the psychiatric health of these women before, during, and after pregnancy can provide insight into why women may drink during pregnancy, as well as identify critical time periods for targeted interventions to prevent subsequent alcohol-exposed pregnancies. This will enable clinicians and policy makers to develop focused prevention strategies that promote the psychiatric well-being of women of childbearing age at risk for drinking during pregnancy.

The objectives of this study were to compare rates of physician-diagnosed psychiatric disorders and antidepressant prescriptions during critical time periods in the lives of women who give birth to children with FASD, specifically:

Compare rates of physician-diagnosed psychiatric disorders among women whose children have FASD relative to women whose children do not have FASD 3 years before the pregnancy of the index child

Compare rates of physician-diagnosed prenatal psychological distress (mood and/or anxiety disorder 8 months before the birth of the index child) and postpartum psychological distress (mood and/or anxiety disorder 1 year after the birth of the index child) among women whose children have FASD relative to women whose children do not have FASD

Compare rates of antidepressant prescriptions among women whose children have FASD relative to women whose children do not have FASD 3 years before the pregnancy of the index child, during pregnancy, and 1 year after birth

Methods

This study used the Manitoba Mothers and FASD Study (MBMomsFASD) cohort, which is a retrospective cohort of mothers whose children were diagnosed with FASD in Manitoba and was generated to investigate risk factors, psychiatric and physical health outcomes, and health and service utilisation of these women. The details of this project’s additional investigations are available elsewhere.³⁸ This article presents the psychiatric health results.

Data Sources

This study used de-identified administrative health, social, and education data from the Population Research Data Repository housed at the Manitoba Centre for Health Policy (MCHP) and clinical assessment data from the Manitoba FASD Centre, which is the only referral/diagnostic centre for FASD in the province. See Table 1 for a description of all databases used in this study.

Table 1.

Description of Data Sets Used for Analysis.

Name of Data Set	Description of Data Set	Years of Data Used	Information Retrieved
Population Registry	A registry maintained by Manitoba Health of all Manitobans eligible to receive health services since 1970 and includes demographic information and 6-digit residential postal code.	1970/1971 to June 2013	Demographic information: region of residence
Canada Census information	Social data based on the Statistics Canada Population Census. These data were used to determine area-level income, with Manitoba population divided into income quintiles according to average-level household income, composed of 5 possible income groupings, with Q1 being the lowest and Q5 being the highest income quintile.	1996, 2001, 2006, 2013	Socioeconomic status information
Employment and Income Assistance data	Data maintained by Department of Families that provide information on Manitoba residences who receive provincial employment and income assistance.	1995/1996 to 2012/2013	Receipt of income assistance
Babies First/Families First Screening Program data	Newborn risk screen data collected as part of a home visiting program conducted by Healthy Child Manitoba. The screen is filled out by public health nurses on all families with newborns in Manitoba and captures data on biological, social, and demographic risk factors and alcohol use during pregnancy.	2003 to 2013 = Families First 2000 to 2002 = Baby First	Alcohol and drug use during pregnancy Social isolation
Insight Program data	Includes data from an outreach program where mentors provide intensive support to women who are pregnant or have recently had a baby and use substances. This data set includes information on women who have prenatal alcohol use.	1999 to 2012/2013	Alcohol and substance use during pregnancy
Hospital abstracts	Health data maintained by Manitoba Health consisting of all hospitalisations in Manitoba, including up to 16 ICD-9-CM diagnostic codes for discharges before April 1, 2004, and up to 25 ICD-10-CM diagnostic codes for discharges on or after April 1, 2004.	1984 to 2012/2013	Physical and mental health diagnoses Antenatal hospitalisations Suicide attempts
Medical/physician reimbursement claims	Health data maintained by Manitoba Health consisting of all ambulatory physician visits in Manitoba and include a single ICD-9 diagnostic code associated with each visit, coded to the third digit.	1984 to 2012/2013	Physical and mental health diagnoses Physician visits Prenatal care
Prescription claims data: Drug Programs Information Network	Data maintained by Manitoba Health containing all prescription drug claims from the Drug Programs Information Network (DPIN, an electronic, online, point-of-sale prescription drug database that connects Manitoba Health and all pharmacies in Manitoba). Contains information on all prescription drugs dispensed in Manitoba.	1995/1996 to 2012/13	Physical and mental health conditions
Manitoba FASD Centre data	Includes clinical assessments and diagnoses received under the FASD umbrella for all children referred to the Manitoba FASD Centre	1999 to 2012/2013	FASD diagnosis Children diagnosed with FASD
Vital Statistics data	A longitudinal population-based registry maintained by Manitoba’s Vital Statistics Agency that includes all Manitobans who have died since January 1970 to present and the cause of death.	1970 to 2012/2013	Cause of premature death Suicide completion
Education data: Enrolment, Marks and Assessments	Education data maintained by the Department of Education and Training that provides information on enrolment, marks, and high school completion, as well as special funding. Special education funding is provided to children with severe to profound disabilities.	1995/1996 to 2012/2013	High school completion, level of special education funding
Child and Family Services Information System (CFSIS)	A data management system that supports case tracking and reporting of services provided to children and families as they pass through the Manitoba Child and Family Services (CFS) System. This database includes information on children in care as well as information of families receiving protective and support services.	1992/1993 to 2012/2013	Involvement with child and family services

FASD, fetal alcohol spectrum disorder; ICD-9-CM, International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Clinical Modification; ICD-10-CM, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification.

Maternal diagnoses of psychiatric disorders were obtained from the hospital discharge abstracts, medical/physician reimbursement claims, and prescription claims data. Diagnostic codes follow the Canadian Coding Standards for the International Statistical Classification of Diseases and Related Health Problems (ICD), Ninth Revision (ICD-9-CA) and Tenth Revision (ICD-10-CA). Data are de-identified and all files are linkable at the person level through the use of an encrypted personal health number. The data in the repository have been widely used for health research, and the reliability and validity of the databases have been well established.^{39

–46} It is important to note that because this study uses administrative physician, hospital, and drug claims data, the rates of psychiatric disorders presented do not accurately represent the prevalence of psychiatric disorders in this population but rates of physician health service use for psychiatric disorders. We may miss individuals who meet standard diagnostic criteria for a psychiatric disorder but did not receive a relevant diagnostic code or those individuals who have not sought care from a physician.

Study population

Group 1 (study group): mothers whose children received a clinical diagnosis of FASD

Clinical data from the Manitoba FASD Centre were used to ascertain all children and youth (birth to 21 years of age) in Manitoba who had been diagnosed with FASD between 1999 and 2012. This database was linked to administrative data from the MCHP repository to identify these children’s birth mothers. Only mothers who could be linked to their children, who had postal code information, and who were Manitoba residents registered to receive health care in the province and covered from the birth of their child until March 2013 were included.

Group 2 (comparison group): mothers whose children did not received a clinical diagnosis of FASD

Women whose children did not receive an FASD diagnosis from the Manitoba FASD Centre, with no known record of prenatal alcohol use, and whose children had no evidence of FASD from the repository were matched to the study group of women on date of month of birth of the index child, socioeconomic status, and region of residence. Matching was done at a ratio of 3 women in our comparison group for each woman in our study group. To decrease the likelihood that the comparison women had children with undiagnosed FASD, the following exclusion criteria were used: 1) women with any children assessed at the Manitoba FASD Centre; 2) women with children who had a diagnosis of FASD as recorded in hospital or physician claims data using the following ICD codes: a hospital visit with International Classification of Diseases, 9^th Revision, Clinical Modification (ICD-9-CM) code 760.71, ICD-10-CA code of 86.0, or a physician visit with any ICD-9 code 760; 3) women with children who had prescriptions for psychostimulants or risperidone; 4) women with children diagnosed with attention-deficit hyperactivity disorder (ADHD) (due to high comorbidity of FASD and ADHD diagnoses^47,48; 5) women involved in the InSight Mentoring program (a program that provides support for women with alcohol and substance abuse issues); 6) women with a history of substance abuse disorder (including alcohol) during pregnancy as indicated by the physician and hospital claims; 7) women whose newborn risk screen indicated they had used alcohol during pregnancy; and 8) women whose children received special education funding indicating they had severe to profound disabilities.

Outcome Variables

For each mother in our study and comparison groups, we calculated the total number of diagnoses of mood and anxiety disorders, substance use disorders, schizophrenia, and personality disorders 3 years before the pregnancy of the index child, prenatal psychological distress (mood and/or anxiety disorder) 8 months before the birth of the index child, and postpartum psychological distress (mood and/or anxiety disorder) 12 months after the birth of the index child. Definitions for each outcome can be found in Table 2. We also calculated the total number of women who had multiple diagnoses of psychiatric disorders (1 or 2 psychiatric disorders, 3 disorders, or 4 or more disorders). Finally, we calculated the proportion of women who had received at least 1 prescription for an antidepressant medication 3 years prior to the birth of the index child, during the pregnancy of the index child, and 1 year after the birth of the index child.

Table 2.

Definitions of Outcomes Used to Compare Rates of Mental Disorders in Women Who Gave Birth to a Child with FASD and a Matched Sample of Women Who Gave Birth to a Child without FASD.

Outcome Measure	Definition
Substance abuse	A woman was considered to have a substance use disorder if 5 years prior to the birth of the child, she had the following: 1 or more hospitalisations with a diagnosis of alcohol or drug psychoses, alcohol or drug dependence, or nondependent abuse of drugs (ICD-9-CM codes 291, 292, 303, 304, 305, ICD-10-CM codes: F10-F19 and F55) OR 1 or more physician visits with a diagnosis of alcohol or drug psychoses, alcohol or drug dependence, or nondependent abuse of drugs using the same ICD-9-CM codes listed above.
Personality disorder	A women was considered to have a personality disorders if in the 5 years prior to giving birth to the child, she had the following: 1 or more hospitalisations with a diagnosis of personality disorder (ICD-9-CM code 301 or ICD-10-CA codes F34.0, F60, F61, F62, F68.1, F68.8, and F69) OR 1 or more physician visits with a diagnosis of personality disorder (ICD-9-CM code 301)
Mood and anxiety disorder	A women was considered to have mood or anxiety disorder if in the 5 years prior to giving birth to the child, she had the following: 1 or more hospitalisations with a diagnosis of depressive disorder, affective psychoses, neurotic depression, or adjustment reaction: ICD-9-CM codes 296.1-296.8, 300.4, 309, and 311; ICD-10-CA codes F31, F32, F33, F34.1, F38.0, F38.1, F41.2, F43.1, F43.2, F43.8, F53.0, and F93.0 or with a diagnosis of an anxiety state, phobic disorders, or obsessive-compulsive disorders: ICD-9-CM codes 300.0, 300.2, 300.3, and 300.7; ICD-10-CA codes F40, F41.0, F41.1, F41.3, F41.8, F41.9, F42, and F45.2 OR 1 or more hospitalisations with a diagnosis of anxiety disorders: ICD-9-CM code 300; ICD-10-CA codes F32, F34.1, F40, F41, F42, F44, F45.0, F45.1, F45.2, F48, F68.0, and F99 AND 1 or more prescriptions for an antidepressant or mood stabiliser, including medications with the ATC codes N05AN01, N05BA, and N06A OR 1 or more physician visits with a diagnosis of depressive disorder or affective psychoses: ICD-9-CM codes 296 and 311 OR 1 or more physician visits with a diagnosis of anxiety disorders: ICD-9-CM code 300 AND 1 or more prescriptions for an antidepressant or mood stabiliser, including medications with the ATC codes N05AN01, N05BA, and N06A OR 3 or more physician visits with a diagnosis of anxiety disorders or adjustment reaction: ICD-9-CM code 300 and 309
Prenatal psychological distress	A woman was considered to have prenatal psychological distress if in the 8 months prior to giving birth, she had the following: 1 or more hospitalisations with a diagnosis of depressive disorder, affective psychoses, neurotic depression, or adjustment reaction (ICD-9-CM codes 296.2-296.8, 300.4, 309, and 311; ICD-10-CA codes F31, F32, F33, F341, F38.0, F38.1, F41.2, F43.1, F43.2, F43.8, F53.0, and F93.0) OR 1 or more physician visits with a diagnosis of depressive disorder, affective psychoses, neurotic depression, or adjustment reaction (ICD-9-CM codes 296, 309, and 311) OR 1 or more hospitalisations with a diagnosis of anxiety disorders (ICD-9-CM code 300; ICD-10-CA codes F32.0, F34.1, F40, F41, F42, F44, F45.0, F451, F452, F48, F68.0, and F99) OR 1 or more prescriptions for an antidepressant or mood stabiliser (ATC codes N03AB02, N03AB52, N03AF01, N05AN01, and N06A) OR 1 or more physician visits with a diagnosis of anxiety disorders (ICD-9-CM code 300) and 1 or more prescriptions for an antidepressant or mood stabiliser (ATC codes N03AB02, N03AB52, N03AF01, N05AN01, and N06A) OR 1 or more hospitalisations with a diagnosis of anxiety states, phobic disorders, or obsessive-compulsive disorders (ICD-9-CM codes 300.0, 300.2, and 300.3; ICD-10-CA codes F40, F41.0, F41.1, F41.3, F41.8, F41.9, and F42) OR 2 or more physician visits with a diagnosis of anxiety disorders (ICD-9-CM code 300)
Postnatal psychological distress	A woman was considered to have postnatal psychological distress if in the 12 months prior to giving birth, she had the following: 1 or more hospitalisations with a diagnosis of depressive disorder, affective psychoses, neurotic depression, or adjustment reaction (ICD-9-CM codes 296.2-296.8, 300.4, 309, and 311; ICD-10-CA codes F31, F32, F33, F341, F38.0, F38.1, F41.2, F43.1, F43.2, F43.8, F53.0, and F93.0) OR 1 or more physician visits with a diagnosis of depressive disorder, affective psychoses, neurotic depression, or adjustment reaction (ICD-9-CM codes 296, 309, and 311) OR 1 or more hospitalisations with a diagnosis of anxiety disorders (ICD-9-CM code 300; ICD-10-CA codes F32.0, F34.1, F40, F41, F42, F44, F45.0, F451, F452, F48, F68.0, and F99) OR 1 or more prescriptions for an antidepressant or mood stabiliser (ATC codes N03AB02, N03AB52, N03AF01, N05AN01, and N06A) OR 1 or more physician visits with a diagnosis of anxiety disorders (ICD-9-CM code 300) and 1 or more prescriptions for an antidepressant or mood stabiliser (ATC codes N03AB02, N03AB52, N03AF01, N05AN01, and N06A) OR 1 or more hospitalisations with a diagnosis of anxiety states, phobic disorders, or obsessive-compulsive disorders (ICD-9-CM codes 300.0, 300.2, and 300.3; ICD-10-CA codes F40, F41.0, F41.1, F41.3, F41.8, F41.9, and F42) OR 2 or more physician visits with a diagnosis of anxiety disorders (ICD-9-CM code 300)
Schizophrenia	A women was considered to have schizophrenia if in the 5 years prior to giving birth, she had the following: 1 or more hospitalisations or physician visits with a diagnosis of schizophrenia: ICD-9-CM code 295 or ICD-10-CA codes F20, F21, F23.2, and F25 OR 1 or more physician visits with a diagnosis of schizophrenia: ICD-9-CM code 295
Antidepressant use	A women was considered to have taken an antidepressant if there was 1 or more prescriptions identified by: ATC drug classification codes: N06AA, N06AB, N06AF, N06AG, and N06AX

ATC, Anatomical Therapeutic Chemical; FASD, fetal alcohol spectrum disorder; ICD-9-CM, International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Clinical Modification; ICD-10-CA, Canadian Coding Standards for the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision; ICD-10-CM, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification.

Data Analysis

Frequencies and percentages were used to describe the study population. Adjusted relative rates (aRRs) for the outcome variables were modeled using generalised linear models (GLMs) with a Poisson distribution. A negative binomial distribution was used when data were overdispersed. Both models are suitable for nonnormally distributed data such as counts. All analyses tested for differences between groups and adjusted for covariates. Decisions regarding which covariates to exclude from the models were determined by frequency distributions and tests of significance.

The following variables were included as potential covariates in each of the models: age of mother at birth of child (18 or younger, 19 to 24, 25 to 34, 35 and higher) and socioeconomic status (SES). SES was defined using area-level data from census information. Area-level income quintiles were ranked from 1 (low) to 5 (high) on the basis of ranges of mean household income and grouped into 5 categories, with approximately 20% of the population assigned to each quintile.⁴⁹

A summary data set for the total number of events (e.g., total number of mothers with mood and anxiety disorders) was produced to model the rate of events comparing women with children with FASD and those with children without FASD. For each outcome of interest, we ran a model to test for statistical differences between our study and comparison groups.

Results

Descriptive Statistics

Our study groups consisted of women born from 1946 to 1992 with ages ranging from 14 to 46 years (Table 3). The majority of women were from an urban location. Study group women were more likely to be lone parents, were younger age at first birth, and tended to have lower SES, higher gravidity, and higher parity (Table 3).

Table 3.

Characteristics of Women Whose Children are Diagnosed with FASD and a Matched Sample of Women Whose Children Do Not Have FASD.

Characteristic	Study Group (n = 702)	Comparison Group (n = 2097)
Maternal age at birth of index child
Mean (SD), y	24.59 (6.15)	29.24 (5.69)
Range	14-43	14-46
Maternal age at birth of index child, n (%)
<18 years	72 (10.26)	231 (11.02)
18-24 years	333 (47.44)	831 (39.63)
25-29 years	146 (20.80)	525 (25.04)
30-34 years	96 (13.68)	367 (17.50)
35+ and missing^a	55 (7.83)	143 (6.82)
Missing	s^b	0
Maternal age at first birth, n (%)
<18 years	266 (37.89)	246 (11.73)
18-24 years	340 (48.43)	854 (43.06)
25-29 years	54 (7.69)	530 (25.27)
30-34 years	29 (4.13)	306 (14.59)
35+ and missing^a	13 (1.85)	112 (5.34)
Missing	s^b	0
History of teen pregnancy, n (%)	266 (37.89)	246 (11.73)
Region of residence, n (%)
Rural	251 (35.75)	764 (36.43)
Urban	451 (64.24)	1333 (63.57)
Mean household income, n (%)
Q1	466 (64.38)	1398 (66.67)
Q2	104 (14.81)	312 (14.88)
Q3	57 (8.12)	171 (8.15)
Q4	36 (5.13)	108 (5.15)
Q5	26 (3.70)	30 (1.43)
Missing	13 (1.85)	78 (3.72)
Socioeconomic status, n (%)
Low (Q1)	466 (66.38)	1398 (66.67)
Middle (Q2 and Q3)	161 (22.93)	483 (23.03)
High (Q4 and Q5)	62 (8.83)	186 (8.87)
Missing	13 (1.85)	30 (1.43)
Married at the birth of child, n (%)	66 (9.40)	773 (36.86)
Gravidity, n (%)
0-3	357 (50.85)	1966 (93.75)
≥4	306 (43.59)	113 (5.39)
Missing	39 (5.56)	18 (0.86)
Parity, n (%)
0-3	524 (74.64)	2063 (98.38)
≥4	139 (19.80)	16 (0.76)
Missing	39 (5.56)	18 (0.86)
Diagnosis of psychiatric disorder 3 years before the birth of the child, n (%)^d	580 (82.62)	566 (26.99)
Receipt of income assistance 3 years before birth of the index child	N = 345^c 63 (18.26)	N=1026^c 98 (9.55)

^aNumber of missing women was <6; therefore, the number of missing women was combined with the “over 35 age group” to ensure privacy rules of Manitoba Centre for Health Policy data were adhered to.

^bCrude rate suppressed if n < 6.

^cIncome assistance data is available after 1995, we limited the denominator to women who had babies after 1998 to ensure three years of data were available before the birth of the child to evaluate the number of women who had income assistance three years before the birth of their children; 345 women in our study group and 1026 women in our control group had babies after 1998.

^dIncludes substance abuse, personality disorder, mood and anxiety disorder, prenatal psychological distress, postnatal psychological distress, and schizophrenia.

Rates of Physician-Diagnosed Psychiatric Disorders

Women in the study group had a higher number of unique psychiatric diagnoses (including prenatal and postnatal psychological distress, personality disorder, substance use disorder, mood and anxiety disorders, and schizophrenia) compared to the comparison group (mean number of psychiatric disorders = 2.13 versus 0.79, respectively). Eighty percent of women in the study group had a diagnosis of a psychiatric disorder before the birth of their child, during their pregnancy, or during the postpartum period compared to 27% of the comparison group. Almost 30% of women in the study group had 3 or more psychiatric disorders versus 6% of the comparison group (Figure 1).

Figure 1.

Number of mental disorder diagnoses of women who gave birth to a child with fetal alcohol spectrum disorder (FASD) and a matched sample of women who gave birth to a child without FASD. Includes substance abuse, personality disorder, mood and anxiety disorder, prenatal psychological distress, postnatal psychological distress, and schizophrenia.

Rates of physician-diagnosed psychiatric disorders before pregnancy (the preconception period): Women in the study group had higher adjusted rates of substance use disorder (aRR, 12.65; 95% CI, 8.99-17.80), personality disorder (aRR, 12.93; 95% CI, 4.88-34.22), and mood and anxiety disorder (aRR, 1.75; 95% CI, 1.49-2.07) 3 years before the pregnancy of their child compared to the comparison group (Table 4). There were few women diagnosed with schizophrenia in both groups, and therefore regression analyses were not conducted.

During pregnancy (the prenatal period): Women in the study group had a higher rate of prenatal psychological distress (aRR, 5.35; 95% CI, 4.58-6.35) (Table 4).

After pregnancy (the postnatal period): Women in the study group had a higher rate of postpartum psychological distress (RR, 1.71; 95% CI, 1.53-1.90) compared to the comparison group (Table 4).

Rates of prescribed antidepressants: Women in the study group had significantly higher rates of antidepressant prescriptions before pregnancy (RR, 3.37; 95% CI, 2.47-4.58), during pregnancy (RR, 4.88; 95% CI, 3.00-7.97), and after pregnancy (RR, 3.48, CI 2.47-4.90) compared to the comparison group (Table 5).

Table 4.

Rates of Mental Disorders of Women Who Gave Birth to a Child with FASD and a Matched Sample of Women Who Gave Birth to a Child without FASD.

	Study Cohort: Crude Rate (%)		Effect Estimate: Adjusted RR (95% CI)
Outcome	Study Group (n = 702)	Comparison Group (n = 2097)	Study vs. Comparison Group
Substance abuse^a	179 (25.50)	41 (1.96)	12.65 (8.99,17.80)
Personality disorder^a	22 (3.13)	6 (0.29)	12.93 (4.88-34.22)
Mood and anxiety disorder^a	237 (33.76)	397 (19.93)	1.75 (1.49-2.07)
Prenatal psychological distress^b	529 (75.36)	293 (13.97)	5.35 (4.58-6.25)
Postnatal psychological distress^c	528 (75.21)	923 (44.02)	1.71 (1.53-1.90)
Schizophrenia^a	<6^d	7 (0.33)	NA

Note: Adjusted for age at birth of index child, socioeconomic and status. Bolded RRs are statistically significant. CI, confidence interval; FASD, fetal alcohol spectrum disorder; NA, regression analysis not appropriate due to small number of outcome events in both study groups; RR, relative rate.

^aDiagnosis 3 years before the pregnancy of the child.

^bDiagnosis 8 months before the birth of the child.

^cDiagnosis 12 months after the birth of the child.

^dCrude rate suppressed if n < 6.

Table 5.

Use of Antidepressant Medications by Women Who Gave Birth to a Child with FASD and a Matched Sample of Women Who Gave Birth to a Child without FASD.

	Study Cohort: Crude Rate (%)		Effect Estimate: Adjusted RR (95% CI)
Outcome	Study Group (n = 702)	Comparison Group (n = 2097)	Study vs. Comparison Group
Antidepressant medication use 3 years before pregnancy	109 (15.53)	98 (4.67)	3.37 (2.47-4.58)
Antidepressant medication use during prenatal period	48 (6.84)	29 (1.38)	4.88 (3.00-7.97)
Antidepressant medication use 1 year after pregnancy	85 (12.11)	76 (3.62)	3.48 (2.47-4.90)

Note: Adjusted for age at birth of index child and socioeconomic status. Antidepressant medication use refers to at least 1 prescription during the specified time period. Bolded RRs are statistically significant. CI, confidence interval; FASD, fetal alcohol spectrum disorder; RR, relative rate.

Discussion

Among women whose children had an FASD diagnosis, 80% had at least 1 psychiatric disorder before the birth of their child, 75% had a diagnosis of prenatal psychological distress, and 75% had a diagnosis of postpartum psychological distress, indicating a substantial burden of psychiatric illness exists in this population. The results of this article identify multiple points where targeted psychiatric interventions can be implemented among women who are at risk for alcohol use during pregnancy, specifically before, during, and after pregnancy.

1. Before pregnancy (the preconception period): The significantly increased risk of having a psychiatric disorder, including substance use disorder, personality disorder, and mood and anxiety disorders, 3 years prior to pregnancy among our study group indicates that the presence of psychiatric illness during the preconception period may be a risk factor for drinking during pregnancy. These results provide context to possible underlying reasons why women drink during pregnancy, as these women may be self-medicating and using alcohol to cope with symptoms associated with psychiatric disorders that exist before they conceive.

These results identify the importance of targeted psychiatric interventions that help women who are at risk for alcohol consumption during pregnancy manage their psychiatric illness during the preconception period. Clinicians providing psychiatric treatment to women in childbearing years who consume alcohol should be aware of the increased risk these women have of not being able to stop alcohol consumption during pregnancy; therefore, targeted preconception counselling that integrates psychiatric treatment as well as alcohol reduction strategies should be used in this population. Since a large number of pregnancies are unplanned, this counselling can also include birth control and family planning strategies that will help reduce the incidence of future alcohol-exposed pregnancies.

Research has demonstrated that the identification of substance abuse and maternal risk factors during the preconception period provides opportunities for health care professionals to assist women in reducing major health risks.⁵⁰ Research has also demonstrated that preconception counselling can lead to reductions in alcohol consumption, especially during the first trimester. Our study results demonstrate the need for clinicians providing care to integrate psychiatric counselling and alcohol reduction counselling for women who present with risk factors to give birth to children with FASD.

2. During pregnancy (the prenatal period): A substantial number of women in our study group had a high burden of psychiatric illness during their pregnancies, during which they consumed alcohol. Evidence demonstrates that psychiatric disorders, specifically prenatal psychological distress (including anxiety and depression), can have adverse side effects on mothers and children, including preterm birth and low birth weight,⁵¹ developmental delay in children,^52,53 impaired mother and child bonding,⁵⁴ and ADHD in children.⁵⁵ This study provides evidence that alcohol consumption during pregnancy may be an additional adverse side effect of prenatal psychological stress in women of childbearing years.

The significantly higher risk of prenatal psychological distress in women who give birth to children with FASD demonstrates that FASD prevention should include increased accessible, affordable, and nonjudgemental resources to improve the psychiatric health of women of childbearing years with psychiatric concerns. Moreover, not all children with FASD exhibit the same level of severity of symptoms,⁴ and as stated above, the presence of psychiatric disorders is known to have adverse effects on child outcomes.^52,53 Future work should investigate the extent to which FASD symptoms and outcomes for children are moderated by maternal psychiatric disorders.

Furthermore, a significantly higher rate of women who gave birth to children with FASD compared to our comparison group took antidepressants during pregnancy. There is conflicting evidence in the literature regarding the safety of antidepressant use during the perinatal period, with some studies demonstrating adverse effects in children, including low birth weight, congenital malformations, and persistent pulmonary hypertension in infants.⁵⁶ Antidepressants have also been shown to mitigate adverse effects in children exposed to maternal depression during pregnancy⁵⁶ and may play a role in decreasing primary or secondary symptoms present in children with FASD. Further research investigating the effects of antidepressants on children born with prenatal alcohol exposure should explore the potentially mediating or moderating effects of antidepressants on prenatal alcohol use and the manifestation of FASD symptoms.

3. After pregnancy (the postnatal period): The significantly higher rates of postpartum depression in women who give birth to children with FASD indicate the need for targeted and specific support resources after the birth of a child exposed in utero to alcohol. Studies have demonstrated that early interventions that improve maternal psychiatric health in pregnancy and the postpartum period can improve infant, child, and maternal outcomes.^57
–59 Targeted interventions to improve the psychiatric health of women at risk for alcohol abuse during childbearing years and pregnancy may not only improve both maternal and child outcomes but also potentially decrease the risk for subsequent children born with FASD through alcohol reduction and cessation strategies.

The results of this study are consistent with the few published studies in this area. A study by Astley et al²¹ surveyed 80 birth mothers of children with fetal alcohol syndrome to generate a profile of these women. They reported that 96% of women had 1 to 10 psychiatric disorders.²¹ A more recent study investigated the psychological distress among Plains Indian mothers with children referred to screening for FASD using maternal interview data and reported that 19% of women had psychological distress, including symptoms of depression and anxiety.⁶⁰ However, both of these studies used survey data, which are limited by selection bias, as women seeking psychiatric health services may be more likely to participate in surveys. Women participating in surveys may also exhibit recall bias.⁶¹ Women may have been pregnant several years in the past compared to when the surveys were administered, thus decreasing accuracy of their ability to recall diagnosis received around that time period.

To our knowledge, the rates of prenatal psychological distress have only been reported in a report investigating the perinatal health of women in Manitoba, and this definition has not been used in any other population-based maternity studies in Canada.⁶² Our rates are much higher compared to rates of prenatal and postpartum psychological distress reported for women in the general population in Manitoba, which were 7.5% and 13.8%, respectively.⁶² While definitions of psychological distress and psychiatric disorders vary widely in the literature, general population rates of psychiatric disorders among the Canadian population are reported at approximately 13%,⁶³ and rates of postpartum depression have been reported to be approximately 7% in Canada.⁶⁴ Our rates were much higher, which may be attributed to differences in definition or because women in both of our study groups are of lower SES and may be a higher risk group for psychiatric illness.⁶²

Strengths and Limitations

Administrative data eliminate selection and recall bias, thus offering more valid information when investigating health services utilisation.^40,45,46 The use of administrative data in the present study also provides the largest sample size of women who have given birth to children with FASD to date in Canada and enhances the accuracy of psychiatric disorder diagnoses compared to studies using primary data collection. Furthermore, the use of pharmaceutical data in investigating the use of antidepressants before, during, and after pregnancy confirms the substantial rates of psychiatric disorders observed in our study population and identifies areas for future research.

A limitation of this study is the use of a clinically referred FASD sample, as opposed to a population-based sample, limiting the generalisability of the findings. However, the use of this clinically based sample is also a strength, as the children in this study have undergone an accurate and comprehensive multidisciplinary assessment in a central tertiary-level provincial diagnostic clinic that follows the Canadian guidelines and updated guidelines for the diagnosis of FASD.^3,4 While mothers of children with FASD who are not referred to the clinic for assessment were not included in our study, this is the largest sample size of women who have given birth to a child with a confirmed clinical diagnosis of FASD in Canada. Due to the changes in FASD diagnostic guidelines over the course of the study period (e.g., the change in growth restriction not being a requirement for a diagnosis), we may be missing children who did not meet one set of guidelines as compared to another, and thus the number of women included in our study may be underrepresenting women who have children with FASD in Manitoba; future work should be done validating both sets of diagnostic criteria in identifying birth mothers of children with FASD.

While we have taken great care in excluding all mothers with possible prenatal alcohol exposure and children with a diagnosis of FASD, we cannot be certain that there are no women in our comparison group who do not have unreported prenatal alcohol use or children with undiagnosed FASD. However, this would serve to weaken rather than strengthen our findings.

In addition, as in all studies using administrative databases, this study is reliant on the accuracy of physician coding; however, as previously stated, MCHP data have been extensively validated for conducting this type of research.^{40,42

–46}

Finally, this study is dependent on women making contact with the health care system and would exclude women with undiagnosed psychiatric disorders, women who have not been assigned with relevant diagnostic codes, or mothers of children with undiagnosed FASD. Women who have only sought nonpharmacological care from a psychologist or support group would also be excluded. Thus, as previously stated, this study does not report prevalence rates of psychiatric disorders in our cohort but the prevalence of physician health service use for psychiatric illness. Therefore, the burden of psychiatric illness in this group may be underestimated.

Conclusions

This study presents novel data regarding the complex psychiatric issues faced by women who have given birth to children with FASD. Our findings indicate that the prevention of alcohol consumption in pregnancy should include a focus on improving the psychiatric health of women. Support programs and interventions that improve the psychiatric health of women at risk for alcohol consumption during pregnancy should be an integral part of policies targeted at decreasing alcohol use during pregnancy. Women with psychiatric disorders who use alcohol should be provided education about the risks of using alcohol when pregnant and compassionate, evidence-based support for the cessation of alcohol consumption during pregnancy. The significantly higher rates of postpartum psychological distress observed in women who have given birth to children with FASD also indicate the need for increasing treatment resources that focus on improving psychiatric health for these women. Furthermore, services to improve postpartum psychiatric health in this group of women may also prevent subsequent alcohol exposed pregnancies, thereby preventing further FASD births.

Footnotes

Acknowledgements

The authors acknowledge the Manitoba Centre for Health Policy for use of data contained in the Population Health Research Data Repository under project file HIPC#2013/2014-20 of the Government of Manitoba’s Health Information Privacy Committee and under project HS16460 (H2013:221) of the University of Manitoba Health Research Ethics Board, as well as the following data providers: the Manitoba FASD Centre and the Winnipeg Regional Health Authority, Healthy Child Manitoba Office, Manitoba Families, and the Department of Education and Training. The results and conclusions are those of the authors, and no official endorsement by the Manitoba Centre for Health Policy, Manitoba Health, Seniors & Active Living, or other data providers is intended or should be inferred.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding from this project was received from 2 graduate studentship awards from Research Manitoba, the PhD Dissertation Award from Research Manitoba, and the Evelyn Shapiro Award for Health Services Research from the Manitoba Centre for Health Policy and from the Canadian Foundation for Fetal Alcohol Research.

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