WHO recommendation on substances use in pregnancy

WHO recommendation on substances use in pregnancy



Health-care providers should ask all pregnant women about their use of alcohol and other substances (past and present) as early as possible in the pregnancy and at every antenatal care visit.



Publication history

First published: December 2016

Updated: No update planned

Assessed as up-to-date: December 2016



  • This strong recommendation based on low-quality evidence has been integrated from the 2014 WHO Guidelines for the identification and management of substance use and substance use disorders in pregnancy (1).
  • The overarching principles of this guideline aimed to prioritize prevention, ensure access to prevention and treatment services, respect women’s autonomy, provide comprehensive care, and safeguard against discrimination and stigmatization.
  • The GDG responsible for the recommendation noted that asking women at every ANC visit is important as some women are more likely to report sensitive information only after a trusting relationship has been established.
  • Pregnant women should be advised of the potential health risks to themselves and to their babies posed by alcohol and drug use.
  • Validated screening instruments for alcohol and other substance use and substance use disorders are available.
  • Health-care providers should be prepared to intervene or refer all pregnant women who are identified as using alcohol and/or drugs (past and present).
  • For women identified as being dependent on alcohol or drugs, further recommendations from the guideline include the following:

–– Health-care providers should at the earliest opportunity advise pregnant women dependent on alcohol or drugs to cease their alcohol or drug use and offer, or refer them to, detoxification services under medical supervision, where necessary and applicable (strong recommendation based on very low-quality evidence).

–– Health-care providers should offer a brief intervention to all pregnant women using alcohol or drugs (strong recommendation based on low-quality evidence).

  • It was decided that despite the low-quality evidence on effects of brief psychosocial interventions, the benefit (potential reduction of alcohol and substance use) outweighed any potential harms, which were considered to be minimal.
  • A brief intervention is a structured therapy of short duration (typically 5–30 minutes) offered with the aim of assisting an individual to cease or reduce use of a psychoactive substance.
  • Further guidance on interventions and strategies to identify and manage substance use and substance use disorders in pregnancy can be found in the 2014 WHO guidelines, available  at: http://www.who.int/substance_abuse/publications/pregnancy_guidelines/en/



Use of alcohol, illicit drugs and other psychoactive substances during pregnancy can lead to multiple health and social problems for both mother and child. Use of alcohol during pregnancy can lead to fetal alcohol syndrome and other harms such as spontaneous abortion, stillbirth, low birthweight, prematurity and birth defects. Dependence on alcohol and other drugs can also severely impair an individual’s functioning as a parent, spouse or partner, and instigate and trigger gender-based and domestic violence, thus significantly affecting the physical, mental and emotional development of children. Pregnancy may be an opportunity for women, their partners and other people living in their household to change their patterns of alcohol and other substance use. Health workers providing care for women with substance use disorders during pregnancy need to understand the complexity of the woman’s social, mental and physical problems in order to provide appropriate advice and support throughout pregnancy and the postpartum period. (1)



The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (2). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (3) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual)  (4) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (5) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.


Recommendation question

For this recommendation, we aimed to answer the following question:

For pregnant women (P), does screening women for alcohol and substance abuse at ANC visits (I) compared with not screening (C) improve health outcomes (O)?


Evidence summary

Further information and considerations related to this recommendation can be found in the 2014 WHO guideline, available at: http://apps.who.int/iris/bitstream/10665/107130/1/9789241548731_eng.pdf?ua=1


Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.


Research implications

The GDG did not identify any priority question related to this recommendation


Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive Health

Guidelines for identification and management of substance use and substance use disorders in pregnancy




  1. Guidelines for the identification and management of substance use and substance use disorders in pregnancy. Geneva: World Health Organization; 2014 (http://www.who. int/substance_abuse/publications/pregnancy_ guidelines/en/, accessed 29 September 2016).
  2. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  3. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  4. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016). 17. DECIDE [website].
  5. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).


Citation: WHO Reproductive Health Library. WHO recommendation on substance use in pregnancy. (December 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.