Prenatal Drug Use, Once Again

A widely-covered article in the Journal of the American Medical Association documents the sharp rise in the number of newborns who were exposed to opiates during pregnancy. This and other research suggests that illicit drug use during pregnancy may be more common today than it was during the crack epidemic a quarter-century ago.

Like other public health researchers, I’m ambivalent about drawing public attention to these patterns. Last time Americans really focused on prenatal drug use, the “crack baby” panic made a difficult problem far worse. Still, as we consider how to respond when pregnant women misuse OxyContin and other diverted painkillers, it’s worth looking back at the crack experience to understand how we went astray….

Crack was a genuine disaster. If people over-reacted, they had reason for worry. Smoked rather than injected, susceptible to binge use, crack proved attractive to a population of poor, disproportionately African-American women who already faced serious challenges. Before anyone had heard of crack, many of the same women were the objects of intense public anger that eventually produced welfare reform.

Across urban America, horror stories accumulated of disheveled intoxicated women arriving for labor and delivery in medical distress, having obtained little or no prenatal care. Some of these women delivered desperately ill babies who graduated straight from the NICU to custodial care.

Researchers struggled to understand whether or how in-utero cocaine exposures caused fetal harm, or how lasting and how severe such harms would be. Meanwhile, some commentators jumped the gun, speaking of a new “bio-underclass.” Such dire predictions brought tragic consequences. One was to deter prospective parents from adopting children they feared were irreparably impaired.

Politicians trumpeted punitive policies. Most appalling were sporadic efforts to prosecute women, particularly when pregnancies resulted in fetal or infant deaths. Some such prosecutions occur today. Feminists and civil libertarians rightly oppose these efforts.

Sociologist Laura Gomez, in her valuable book Misconceiving Mothers, notes that prosecutions proved surprisingly difficult and politically self-limiting. Juries looked askance when prosecutors couldn’t prove criminal intent among mourning and remorseful defendants. Juries heard medical authorities testify that prosecution was ineffective and inhumane, that no one could definitively say that a particular mother’s crack use caused her infant’s injury or death.

Had politics permitted, states would have been wise to openly de-penalize the use of illicit drugs during pregnancy. Although data are scanty, there’s no solid evidence that criminal sanctions deter prenatal drug use. Such sanctions lead some women to go underground rather than to seek medical help. Prosecutions also drive a wedge between legal authorities and front-line medical and social service professionals, who rarely believe that prosecution is effective to help children.

Although prosecutions proved rare, pregnant crack users harbored more complicated fears that kept them from openly seeking help. Many users faced child protection issues involving older children. These posed a very real deterrent to seeking help. Others’ continued drug use violated conditions of probation or parole. There was, and is, no easy solution to these dilemmas.

Crack’s direct biological harms turned out to be vastly overstated. Tens of thousands of women used cocaine during their pregnancies. Most went undetected. They and their babies experienced no visible ill effects. Properly nurtured, identified “crack babies” proved more resilient than was initially feared, too.

These findings don’t indicate that the original fears were groundless. Rather, these fears were misdirected. Crack really did increase infant mortality, youth homicide, child maltreatment, and other social ills. Its main harms were social and behavioral, rather than directly biological. It still posed serious dangers to many mothers and children.

Twenty years ago, as today, drug use by pregnant women was mainly a pediatric, social service, and adult medicine problem that masqueraded as an obstetric one. Many cocaine-exposed infants were born healthy, yet experienced later tragedies because their mothers couldn’t care for them once they got home. Civil libertarians note that many problems originally attributed to crack were traced to other things: Tobacco and alcohol, poverty, poor nutrition, domestic violence, sexually-transmitted infections, lack of medical care. That’s right, but it’s not the whole story. Problematic maternal drug use makes it much harder to address every other threat to infant health.

Then, as today, the main challenge was to help pregnant and parenting women become the successful parents almost all genuinely wished to be. We can help challenged women by providing better and more accessible drug treatment. We can improve child welfare and home visiting services. We can more-effectively engage women disconnected from public assistance in the post-welfare-reform era. Given the reality that few drug users will ever access specialty addiction treatment, we can provide better screening and interventions within general medical care. Better regulatory policies and physician practices regarding prescription painkiller misuse would help, too.

One shouldn’t overpromise here. No single one of these measures would dramatically reduce the number of drug-exposed newborns. Each points in the right direction: improving help and monitoring, while avoiding punitive measures that cause further harm.

Drug policy has improved since the crack years. Treatment is better and more plentiful. The Affordable Care Act expands the range of available substance abuse and mental health services. Mindful of past missteps, most medical, child protection, and criminal justice professionals support less punitive responses to prenatal substance use. Problems such as prescription painkiller misuse are less concentrated among minority groups. So the accompanying debate is less tied to rancorous culture wars. This time, maybe we’re ready to address this problem with the methodical humanity it deserves. We need to be.

[Cross-posted at The Reality-Based Community]

Harold Pollack

Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago.