Rates of Neonatal Abstinence Syndrome

Impact of the Opioid Crisis on Pregnancy and Opioid Use Disorder in Rural Pennsylvania

Rachael Wittmer, BS

SUMMARY POINTS

• Pennsylvania’s rural counties had higher rates of neonatal abstinence syndrome based on maternal residence in 2018 and 2019 when compared to urban counties.

• Pennsylvania’s rural counties with the highest rates of neonatal abstinence syndrome were located predominately in the Western region of the state.

• Case counts by maternal residency should be used over case counts by facility to accurately understand the burden of disease within the state due to a lack of facilities in rural communities.

ANALYSIS

Background

Opioid Use Disorder (OUD) afflicts over 2 million people in the United States in 2018 [1]. Certain regions have been particularly vulnerable to the opioid epidemic, with states in the Appalachian region reporting statistically significant increases in the number and age-adjusted opioid-related deaths between 2019 and 2020 [2]. While many studies have acknowledged this ongoing public health crisis within the Appalachian region, there is less state-specific information available, including for Pennsylvania.

Disparities related to the opioid epidemic exist between rural and urban communities within Pennsylvania. The devastating effects of this epidemic seen in rural communities may be attributed to factors such as decreased employment opportunities, increased periods of isolation, and less access to health care services [3,4]. While there has been more data collected at the county level, there lacks a robust analysis of rural communities. The empirical evidence that has been collected through this statewide effort can be used to identify disease burden more accurately [5].

Pregnant women and neonates are among the populations particularly vulnerable to the impact of the opioid epidemic [6]. This group may suffer from unique consequences of exposure such as preterm birth, maternal mortality, and neonatal abstinence syndrome (NAS). NAS is characterized by physiological aspects of withdrawal at the time of birth from substances that they were exposed to in utero. Newborns with NAS receive treatment over the course of days to weeks in a neonatal intensive care unit (NICU), depending on the severity [6]. Between 1999 and 2014, OUD among pregnant women at the time of delivery quadrupled, and NAS was reported at disproportionately higher rates in rural areas [7]. In rural areas where access to hospitals and resourced NICUs are limited, receiving care may prove to be more difficult. Fortunately, as of 2018, reporting of new NAS cases is required throughout Pennsylvania. Using this valuable data, we can better understand the burden of opioid use disorder among pregnant women and corresponding NAS in rural communities to better implement policies and allocate resources to meet the needs of this patient population.

Findings

According to the 2020 US Census, 48 of Pennsylvania’s 67 counties are considered rural as outlined by the Center for Rural Pennsylvania with a population density of fewer than 291 people per square mile [8]. A separate analysis in 2020 reported that 50 counties have either no access to a hospital or birthing center with obstetric care or only access to one facility. Moreover, there were 17 counties with moderate access to obstetric services (2-4 qualifying hospitals or birthing centers), and only 3 counties had full access to obstetric services, (at least 5 hospitals or birthing centers) [9].

In the 2019 Neonatal Abstinence Report released in June 2021, 83% of all NAS-positive infants in the state of Pennsylvania tested positive for any form of opioid exposure, 69% were positive for addiction treatment drugs, and 20% were positive for opiates, oxycodone, or fentanyl [10]. In 2018, 85% of all NAS-positive infants tested positive for any form of opioid exposure, 68% were positive for addiction treatment drugs, and 22% of positive cases had detectable traces of opiates, oxycodone, or fentanyl [11]. NAS cases were reported in 2019 based on the diagnosing facility’s case count, and the case count by maternal residence in each county as shown in Figure 1 and Figure 2, respectively.

The average incidence of NAS in Pennsylvania was 16.0 cases per 1000 live births in 2018 [13] and 11.9 cases per 1000 live births in 2019 [10]. In contrast, the incidence of NAS was 7.1 per 100 births nationally in 2018 [12]. Data was unavailable for national average incidence rates in 2019 at the time of writing of this analysis. At the county level, rates of NAS are organized in Table 1 and Table 2 for 2018 and 2019, respectively [10,11]. Rates ranged from 0 to 111.1 cases per 1000 live births in 2018 and from 0 to 61.6 cases per 1000 live births in 2019.

Discussion

The burden of NAS remains heavily concentrated in rural areas of Pennsylvania. Of all cases accounted for in 2018 and 2019, the counties with the highest incidence rates also had the least number of birthing facilities that would be adequately resourced to treat NAS and the recovering mother. Counties with the leading rates of NAS were heavily concentrated in the Western region of the state, possibly due to the close proximity with states like Ohio and West Virginia which have been among the states hardest hit by the opioid epidemic. Discrepancies between case counts by the facility and maternal residence demonstrate the lack of accessibility to healthcare that has been described previously. Because NAS must be treated over the course of days to weeks, this could present challenges to mothers who are in socioeconomically disadvantaged positions. As the long-term health effects of NAS have not been well characterized, it remains a priority to investigate ways to address this barrier to care. Counties with higher population densities did not show higher rates of NAS, which may suggest that there are rural-specific social determinants of health that could explain this disparity. More work is required to pinpoint such causes.

This analysis is not without limitations. Demographic information was reported in the Pennsylvania Bureau of Epidemiology report but excluded here due to incomplete medical record abstraction. Also, the methods used to collect NAS data can vary between states and should be noted when making comparisons to national data. Discrepancies were found between reporting methods at birthing facilities in the greater Philadelphia area and other methods suggested by the state. Differences in case counts between 2018 and 2019 could be explained by variances in reporting between years. Future efforts should be made to create a robust central reporting system to better monitor NAS incidence. Lastly, before this data can be used to inform policy decisions, data on NAS rates in the years since COVID-19, and the ability of birthing facilities to adequately treat NAS cases and pregnant women with OUD should be studied.

REFERENCES

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2. Center for Disease Control and Prevention. 2019-2020 Drug Overdose Death Rate Precent Change Map. [February, 16 2021]. Accessed June 26, 2022. https://www.cdc.gov/drugoverdose/deaths/2019-2020-increase.html

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4. United States Department of Agriculture. Opioid Crisis Affects All Americans, Rural and Urban. [August 3, 2021]. Accessed June 26, 2022.

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8. Center for Rural Pennsylvania. Rural Urban Definitions. [2020]. Accessed June 28, 2022. https://www.rural.pa.gov/data/rural-urban-definitions

9. Stewart SD. Nowhere to Go:Maternity Care Desert Report 2020.MATERNITY CARE DESERT REPORT 2. Accessed June 28 2022. https://www.marchofdimes.org/materials/2020-Maternity-Care-Report.pdf

10. Health.pa.gov. Neonatal Abstinence Syndrome: 2019 Report. Updated June 2021. Accessed June 28 2022. https://www.health.pa.gov/topics/Documents/Opioids/2019%20NAS%20REPORT.pdf

11. Health.pa.gov. Neonatal Abstinence Syndrome: 2018 Report. Updated August 2019. Accessed June 28 2022. https://www.health.pa.gov/topics/Documents/Diseases%20and%20Conditions/2018%20NAS%20REPORT.pdf

12. Bhatt P, Umscheid J, Parmar N, et al. Predictors of Length of Stay and Cost of Hospitalization of Neonatal Abstinence Syndrome in the United States. Cureus. Published online July 8, 2021. doi:10.7759/cureus.16248