When Pregnant Women Use Crack
Harold Pollack,
University of Michigan
Note: Subscriptions to the FAS Drug Policy Analysis Bulletin may be requested by sending email to fas@fas.org, please be sure to reference the publication title Fifteen years ago, crack use by pregnant women emerged as a wrenching social problem. Smoked rather than injected, offering a cheap high after the 1980s cocaine price plunge, and conducive to binge use, crack brought a constellation of problems that had previously afflicted severe alcoholics, but had not been visible issues for large numbers of expectant mothers.
The true prevalence of prenatal cocaine use is unknown, especially within presumed low-risk populations that have attracted little clinical research in this policy arena. Vega and colleagues, in the most reliable study from the early 1990s, found that 1.1 percent of California expectant mothers consumed cocaine within 12 to 72 hours of labor and delivery (Vega et al, 1993). Unlike alcohol, marijuana, or opiate use, prenatal cocaine use is remarkably concentrated in poor communities of color. 7.8 percent of African-Americans-compared with 0.55 percent of Hispanics and 0.60 percent of whites-tested positive for cocaine use in this study. The problem was even more pervasive in some subgroups of the low-income population, with 1/3 of unmarried pregnant African-American Medicaid recipients in their mid-thirties testing positive for cocaine (Vega et al, 1997). Prenatal cocaine use appears less prevalent today than it was seven years ago, but it remains a significant public health concern.
Competing ideological stances dominate public discussion of these issues. On one side, conservatives regard prenatal drug use as simply child abuse in its most destructive form. For them, the pertinent question is whether medical and legal systems have the will to protect unborn children from profound harm (Condon, 1995). Public alarm about in-utero cocaine exposures provided easy political opportunities for those favoring mandatory imprisonment of drug users and drug sellers, despite significant evidence that harsh policies are less effective and more socially damaging than competing strategies to curb drug use (Inciardi, Surratt, and Saum, 1997; Greider, 1995; Caulkins et al, 1997).
On the opposite side, many feminists and advocates of "harm reduction" as the basis for drug abuse control policy see harsh policies as both foolish and unconstitutional-foolish because such policies deter pregnant women from seeking care, unconstitutional because such policies violate the autonomy of pregnant women (King, 1991). Despite the undoubted merit in these arguments, they easily glide into a discourse that wrongly trivializes severe harms to children that flow from maternal drug use. (See the useful discussion in Massing, 1998, p. 41-43.) As often happens in drug policy debate, public attention focuses on powerfully symbolic arguments, which often turn out to be both extreme and empirically ungrounded. Meanwhile, efforts by treatment providers and others to find credible middle ground receive little hearing. In my view, the search for a more sensible policy must begin with the following four points.
Perinatal crack use is largely a pediatric problem that has been misdiagnosed as an obstetric one.
Clinicians initially feared that in-utero cocaine exposures would produce severe birth defects and developmental abnormalities. These fears turned out to be largely unfounded (LaGasse, Seifer, and Lester, 1999). Viewed solely as a teratogenic agent, cocaine may be no more harmful than the (much more prevalent) use of cigarettes, and appears less harmful than heavy alcohol exposure. (Inciardi, Surratt, and Saum, 1997; Frona, Lace, Pollack, forthcoming). In light of these patterns, one might ask why prenatal tobacco use has not been proposed for criminalization.
In two related ways, however, these somewhat reassuring findings have been misinterpreted to imply that the "crack baby" problem was overblown. First, recent epidemiological debate concerns the direct biological impact of in-utero cocaine exposure. All else equal, healthy pregnant women who consume moderate amounts of cocaine usually deliver healthy infants (Inciardi, Surratt, and Saum, 1997; Finnegan & Kendall, 1997). But all is not equal. Heavy users often drink to manage side-effects of cocaine use (Kleiman, 1993). Many are malnourished, in part because they squander scarce resources to finance their habit and perhaps because cocaine suppresses appetite. Some users frequent crack houses where they are vulnerable to violence and sexually-transmitted disease (Edlin, 1994). Epidemiological studies that "control for" such factors as prenatal drinking are critically incomplete because they fail to consider ways that drug use aggravates these other health risks.
More important, efforts to downplay the crack baby problem ignore the most poignant public health concern. Most pregnant women with serious drug problems will deliver healthy babies. However, many cannot properly care for these infants when they take them home (Hawley et al, 1995; Emmett, 1998). The key policy problem is not, therefore, preventing in-utero cocaine exposure, but rather addressing the problem posed by a group of chronic cocaine-using mothers who expose their children to severe harm-harms rooted in behavior patterns which did not begin with pregnancy and will not end with delivery.
Although prenatal tobacco use creates important health risks, as a non-intoxicant nicotine has a much smaller impact on women's ability to fulfill parenting roles. This may help explain why prenatal tobacco use, despite its high prevalence and demonstrated teratogenic properties, is not subject to greater legal sanctions.
Few women will be incarcerated for the crime of prenatal substance abuse.
Several states have enacted new laws or interpreted existing statutes to allow criminal prosecution of pregnant substance users. Some pregnant women have been incarcerated because they were found to have ingested illicit substances. Although these cases raise important social concerns, they are rare (Pearson & Thoennes, 1996). Out of 4 million births per year in the U.S., anonymous urine tests suggest that approximately 50,000 of the mothers have used cocaine within 72 hours of labor and delivery every year (Vega, Kolody, and Hwang, 1993). Moreover, recent research using hair assay techniques suggests that most cases of prenatal cocaine use go undetected by urinalysis at labor and delivery (Kline et al, 1997). (Problem drinking during pregnancy is believed to have higher prevalence, though problem drinking is more difficult to define and to detect by chemical means (Vega, Kolody, and Hwang, 1993; Streissguth et al, 1993).) Yet only approximately 300 women have been prosecuted for the crime of prenatal substance abuse in the past decade (Haack, 1997), and most of these cases have been brought within a few jurisdictions. Laura Gomez explores the reasons for this tepid response in her useful book Misconceiving Mothers (Gomez, 1997). The most basic explanation is that prosecution of pregnant women does not advance the interests of important actors within the legal system. Some prosecutors have pursued symbolic test cases, but they have little incentive to pursue these politically and legally risky cases once precedent is set. Although reliable survey data is lacking, my impression is that judges and correctional officials prefer to avoid the serious logistical problems created by incarceration of pregnant women.
No less important, punitive measures violate long-standing legal norms. American women are rarely prosecuted, and are virtually never incarcerated, for verified crimes against their children (Tjaden & Thoennes, 1992). In principle, thousands of mothers might be prosecuted for child abuse or related crimes. In practice, however, most mothers who harm their children are considered mentally disturbed rather than criminal. When the criminal justice system does become involved, it is generally to enforce compliance with medical and social service interventions.
Well before pregnancy, many women with severe substance abuse problems are heavily involved in existing correctional and social service systems, which serve them poorly.
Substance abuse and dependence is often untreated until a pregnant woman appears for prenatal care or other essential services. In many of these cases, legal authorities, social service agencies, and medical providers should have had ample warning. Many women with severe drug problems have extensive contact with AFDC/TANF agencies, child welfare authorities, substance abuse treatment, and mental health services (Kirby et al, 1999).
Jails and prisons have become especially important for prevention efforts. Women now account for 80,000 prisoners and 700,000 individuals on probation or parole. Most of these women are of child-bearing age. Many have documented histories of substance abuse, psychiatric disorders, and infectious diseases that create pregnancy risk. Yet correctional health care often neglects basic services such as pregnancy screening and detection of sexually-transmitted disease. Psychiatric services and drug treatment are often unavailable. Unless women are HIV-infected, they rarely receive effective case management to link correctional care with post-incarceration entitlements and social services (Hammett, Gaiter, & Crawford, 1998; Pollack, Khoshnood, & Eric E. Sterling, Criminal Justice Policy Foundation Altice, forthcoming). Incarcerated offenders with substance abuse problems receive notoriously inadequate treatment (Hammett, Gaiter, and Crawford, 1998; Pollack, Khoshnood, and Altice, forthcoming). These failures are merely the extreme version of the more general failure to monitor, supervise, and treat individuals known to be at high risk of substance abuse.
More than 85 percent of women under correctional supervision are on probation, parole, or other community arrangements rather than in prison or jail. Those who are actually incarcerated are often released to the general community with little attention to predictable health problems or psychosocial concerns (Thompson et al, 1998). Many of these women lack health insurance, even if they are nominally eligible. There is substantial evidence that physicians tend to both underdiagnose and undertreat substance abuse disorders, a matter of particular concern in this population. Perfunctory family planning services foster unintended pregnancy among women with high rates of substance abuse. Social-welfare agencies (income support, child welfare, housing) often deal poorly with the substance abuse problems of their clients.
Reasonable policy must balance incentives to obtain needed care with the need to provide firm sanctions for the most chronic offenders.
Civil libertarians and most clinicians believe that harsh policies will deter substance abusers from obtaining needed care. The case for leniency is especially compelling for casual or infrequent users, whose substance-related behavior is often harmless. Some states require mandatory reporting of casual users who test positive early in pregnancy. Because medical providers do not believe that reports produce useful intervention, these regulations are widely flouted in some cases with good reason (Zellman, Jacobson, & Bell, 1997). Ironically, mandatory reporting may create perverse incentives for medical and social service providers to overlook danger signs of substance abuse, and to avoid clinical tests that create legally binding requirements to act against patient interests.
In considering these tradeoffs, however, one must recognize that chronic abusers will always have reasons to delay prenatal care and to conceal drug use. Many women with serious drug problems are already under child protective supervision in cases involving older children (Pearson & Thoennes, 1996). Partly for this reason, pediatricians have proved more vocal than obstetricians in advocating policies to identify and treat maternal substance abuse (Gomez, 1997; Zellman, Jacobson, and Bell, 1997). Mandated treatment would also increase the adherence of some high-risk users. Research from the Perinatal-20 trials suggests that legal and child-protective sanctions are important to recruitment and retention of high-risk women. Court-referred women are more likely than comparable peers to enter treatment. Perhaps more important, supervised women are less likely to drop out before the end of their clinical course (Howard & Beckwith, 1996; Lewis et al, 1996).
The right balance of persuasion and coercion may have changed as the treatment community responds to the special needs of pregnant and parenting women. During the early 1990s, South Carolina imprisoned a group of pregnant women who refused to obtain treatment. When this harsh policy was imposed, the state lacked residential treatment to accommodate pregnant women. Traditional facilities designed for male clients often neglect the responsibilities and problems of drug-dependent women. Even the diagnostic instruments reflect that substance abuse is a traditionally male disorder; t only one item on the 123-item Addiction Severity Index, for example, deals with parenting roles (Schottenfeld et al, 1994).
Slowly, however, policymakers have begun to remedy this situation. Federal block grants now require states to expand services to pregnant and parenting women. States must place pregnant women into treatment or interim services within 48 hours, and must give pregnant women priority for facilities that can provide needed services. These policies, and the mood behind them, seem to have improved treatment access for pregnant women. Some localities claim to offer "treatment on demand" for this group. Ironically, within a capacity-constrained treatment system, such policies may have the unintended consequence of displacing other high-priority populations such as dual-diagnosis patients and those at high risk for HIV infection.
An especially promising innovation is to provide drug treatment within a broader family-centered approach (Schottenfeld et al, 1994). Concern for children provides powerful motivation for many women to pursue treatment in the first place (Welle, Falkin, and Jainchill, 1998). In some cases, social welfare agencies order women to complete treatment to retain or recover child custody (Howell & Chasnoff, 1999). Child care and parent skills training appear to improve patient satisfaction and long-term adherence to substance abuse treatment (Camp & Finkelstein, 1997). Equally important, such services are likely to help extremely needy children, many of whom have experienced abuse or neglect. With the advent of welfare reform, states are also experimenting with new ways to identify and treat substance abuse among recipients of public aid. Several are examining the use of chemical testing of new and continuing recipients. Recent experience in Michigan suggests that most recipients who fail such tests are casual marijuana users whose behavior may not hinder their economic prospects or social performance (Jayakody, Danziger, and Pollack, 1998). A more promising approach, pursued in Oregon and other states, is to focus on individuals who violate work requirements or who show other tangible signs of diminished social performance (Kirby et al, 1999).
Conclusion
When the problem of prenatal crack use first emerged, some conservatives hoped (as many liberals feared) that voters, policymakers, and the courts would willingly embrace harsh measures directed at the women. By and large, this did not happen. Although many explanations might be proposed, the simplest and most compelling one is that the interested public, health care providers, and many within the legal system itself are deeply ambivalent towards any intervention that would regulate intimate behaviors to advance social good.
In my view, both the nation and drug-using women have benefited from efforts by feminists and civil libertarians to mobilize this ambivalence, to protect reproductive autonomy while searching for a more humane and effective policy response. However, this constitutional focus has brought a heavy price. The crack problem might have occasioned serious discussion about how to help the core group of women whose lives and families are damaged by chronic substance abuse, about how to serve poor communities where these behaviors are most prevalent.
Instead, we have spent 15 years debating whether we are too lenient or too harsh towards pregnant abusers when the real problem is that we are simply neglectful. It is all too easy for a drug-dependent woman to be defeated by needless bureaucracy and by her own ambivalence in the search for needed treatment, to become isolated from the health care system until she presents at a public clinic requiring crisis intervention. It is also too easy for women with serious substance abuse problems to evade accountability for behavior that threatens themselves and others. Within a fragmented and often incompetent welfare system, it is too easy for recipients with known or likely drug problems to evade oversight when they create serious and predictable threats to the well-being of their children.
These problems arise most poignantly during pregnancy. However, they are hardly unique to expectant mothers. Public policy would gain from greater moral reflection about maternal-fetal conflicts that admit no painless solutions (Burtt, 1994). I suspect that the resulting policies would offer a more generous, more explicitly paternalist and directive approach to drug-dependent parents and pregnant women.
In any event, the most important task is not to resolve basic moral questions, but to improve the capacity of beleaguered bureaucracies to accomplish what obviously must be done under any reasonable view. The reproductive rights debate would be less divisive and less necessary if we had systems to track severe substance abusers regardless of pregnancy, if effective drug treatment, family planning, and medical care were carefully linked with correctional and social service systems, if child protective services offered continuing and competent supervision of known offenders. Can we create such systems given the poor starting-point of essential institutions? After 15 years, public discourse that disparages or excuses drug-using women will not help us answer that question.
Sources
Burtt, S., Reproductive Responsibilities: Rethinking the Fetal Rights Debate. Policy Sciences, 1994. 27: p. 179-196.
Camp, J.M. and N. Finkelstein, Parenting Training for Women in Residential Substance AbuseTreatment: Results of a Demonstration Project. Journal of Substance Abuse Treatment, 1997. 14(5): p. 411-422.
Caulkins, J.P., et al., Mandatory Minimum Drug Sentences: Throwing Away the Key or Taxpayers' Money? 1997, Santa Monica: RAND.
Condon, C.M., Clinton's Cocaine Babies: Why Won't the Administration Let Us Save Our Children? Policy Review, 1995. 72: p. 12-15.
Edlin, B., et al., Intersecting Epidemics-Crack Cocaine Use and HIV Infection among Inner-City Young Adults. New England Journal of Medicine, 1994. 331(21): p. 1422-7.
Emmett, G., What Happened to the 'Crack Babies'? Drug Policy Analysis Bulletin, 1998. 4.
Finnegan, L. and S. Kendall, Maternal and neonatal effects of alcohol and drugs, in Substance abuse: A Comprehensive Textbook, J. Lowinson, Editor. 1997, Williams & Wilkins: Baltimore. p. 513-534.
Gomez, L., Misconceiving Mothers. 1997, Philadelphia: Temple University Press.
Greider, K., Crackpot Ideas, in Mother Jones. 1995. p. 53-56.
Haack, M., Drug-Dependent Women and their Children: Issues in Public Policy and Public Health. 1997, New York: Springer.
Hammett, T.M., J.L. Gaiter, and C. Crawford, Reaching Seriously At-Risk Populations: Health Interventions in Criminal Justice Settings. Health Education and Behavior, 1998. 25: p. 99-120.
Hawley, T., et al., Children of addicted mothers: effects of the crack epidemic on the caregiving environment and the development of pre-schoolers. American Journal of Orthopsychiatry, 1995. 65(3): p. 364-379.
Howard, J. and L. Beckwith, Issues in Subject Recruitment and Retention With Pregnant and Parenting Substance-Abusing Women, in Treatment for Drug-Exposed Women and their Children, E.R. Rahdert, Editor. 1996, National Institute on Drug Abuse: Rockville, MD.
Howell, E. and I. Chasnoff, Perinatal Substance Abuse Treatment: Findings From Focus Groups With Clients and Providers. Journal of Substance Abuse Treatment, 1999. 17(1-2): p. 139-148.
Inciardi, J., H. Surratt, and C. Saum, Cocaine-Exposed Infants. Drugs, Health, and Social Policy, ed. J. Inciardi. Vol. 5. 1997, Thousand Oaks: Sage.
Jayakody, R., S. Danziger, and H. Pollack, Welfare Reform, Substance Use, and Mental Health, 1998, University of Michigan Program on Poverty and Social Welfare Policy (Under review for Publication): Ann Arbor, MI.
King, P.A., Helping Women Helping Children. Milbank Quarterly, 1991. 69: p. 595-621.
Kirby, G., et al., Integrating Alcohol and Drug Treatment into a Work-Oriented Welfare Program: Lessons from Oregon. 1999, Mathematica Policy Research: Washington, DC.
Kleiman, M., Against Excess: Drug Policy for Results. 1993, New York: Basic Books.
Kline, J., et al., Cocaine use during pregnancy: sensitive detection by hair assay. American Journal of Public Health, 1997. 87(3): p. 352-3588.
LaGasse, L., R. Seifer, and B. Lester, Interpreting research on prenatal substance exposure in the context of multiple confounding factors. Clinical Perinatology, 1999. 26(1): p. 39-54.
Lewis, R., et al., Retention Issues Involving Drug-Abusing Women in Treatment Research, in Treatment for drug-exposed women and their children, E.R. Rahdert, Editor. 1996, National Institute on Drug Abuse: Rockville, Md. p. 110-122.
Massing, M., The Fix. 1998, New York, NY: Simon and Schuster.
Pearson, J., and Nancy Thoennes., What Happens to Pregnant Substance Abusers and their Babies? Juvenile and Family Court Journal, 1996.
Pollack, H., K. Khoshnood, and F. Altice, Health Care Delivery Strategies for Criminal Offenders. Journal of Health Care Finance, forthcoming. 26(1): p. 1-17.
Schottenfeld, R., et al., A Comprehensive Public Health Approach, in When Drug Addicts Have Children, D. Besharov, Editor. 1994, Child Welfare League of America/American Enterprise Institute: Washington, DC.
Streissguth, A., et al., The Enduring Effects of Prenatal Alcohol Exposure. 1993, Ann Arbor: University of Michigan Press.
Thompson, A., et al., Evaluation of an innovative program to address the health and social service needs of drug-using women with or at risk for HIV infection. Journal of Community Health, 1998. 23(6): p. 419-40.
Tjaden, P. and N. Thoennes, Predictors of Legal Intervention in Child Maltreatment Cases. Child Abuse and Neglect, 1992. 16: p. 807-821.
Vega, W., et al., Effects of Age on Perinatal Substance Abuse among Whites and African Americans. American Journal of Drug and Alcohol Abuse, 1997. 23(3): p. 431-51.
Vega, W., et al, Prenatal substance abuse in California: Findings from the Perinatal Substance Exposure Study. New England Journal of Medicine, 1993. 329(12): p. 850-854.
Vega, W., B. Kolody, and J. Hwang, Prevalence and Magnitude of Perinatal Substance Exposures in California. New England Journal of Medicine, 1993. 329: p. 850-854.
Welle, D., G. Falkin, and N. Jainchill, Current Approaches to Drug Treatment for Women Offenders. Journal of Substance Abuse Treatment, 1998. 15(2): p. 151-163.
Zellman, G., P. Jacobson, and R. Bell, Influencing Physician Response to Prenatal Substance Exposure through State Legislation and Work-Place Policies. Addiction, 1997. 92: p. 1123-1131.
Drug Policy Analysis Bulletin
c/o Federation of American Scientists
307 Massachusetts Ave., NE
Washington, DC 20002