Smdke Signals
' " February 1991
p'age'lO '
Health Information
The Effects of Drug Use by Pregnant Women: An Overview
By Ernest C. Wynne, 10, M.D.
Obstetrician-Gynecologist
There is persuasive evidence of increased substance
abuse by pregnant women, and some of it occurs without
the woman's full knowledge of the consequences. One
of the worst results of the crack epidemic has been the
dramatic increase in maternal substance abuse and the
subsequent separation of the mother and infant. Many
of these infants are deprived of maternal bonding until
their mothers are able to receive successful drug abuse
treatment. Many programs have demonstrated that
these mothers do love their infants, and given the right
support systems, these women are capable of nurturing
and caring for their infants. Women are consistently
able to demonstrate better compliance profiles in
treatment than men, but delay to entrance into treat
ment after detection does seem to have a detrimental
effect on positive results. It has been said that it is easy
to confuse the aggressiveness that many drug abusers
present to health providers and others, when in truth,
what they seek is greater power and control over their
lives.
In Minnesota, 15 of all children are born poor; 36
of Black children are born poor; and 27 of Hispanic
children are born poor as defined by income criteria. Of
the 12,000 Minnesota babies born in 1985, one-fifth did
not receive early prenatal care. Being poor correlates
highly with poor access to health care. These factors are
known contributors to adverse outcomes in pregnancy,
and there are a multitude of reasons why these numbers
are going to continue to rise in Minnesota.
We already know that pregnancy and drug abuse are
two of the major health and social problems affecting
socially marginal youth today. Together their effect is
not additive, but multiplied, and the incidence of their
occurrence seems to be rising exponentially. The Black,
American Indian, and Hispanic populations are highly
visible, partly because they are the most studied popula
tions in United States medical schools and important
statistics have been compiled. In terms of cocaine
abuse, approximately 20 million Americans have used
the drug and 5 million use it regularly. It is the number
one illicitly used drug by women of childbearing age.
Opiates are not known to cause fetal malformation, but
cocaine is highly suspect. Few cocaine abusers take only
one drug, usually using marijuana, benzodiazepines, as
well as cigarettes and alcohol. Indeed, the woman with
multiple drug abuses may be somewhat protected from
the more toxic cocaine abuse. Frequent emergency
room visits are common in the chemically dependent
woman's care, but prenatal care is not.
The natives in the Andes have been chewing the leaves
of the coca bush for centuries to cope with hunger and
fatigue. Under current conditions in its native South
American highlands habitat, enough cocaine can be
grown in ten square mile area to supply much of the
demand of the United States. The U.S. drug traffic is
known to be immensely profitable, partly because it is
illegal, but it is also well organized and able to import a
surplus of the product into this country. This broad
availability of the drug allows it to be purchased by the
curious or casual consumer. In a way, cocaine use has
changed the classic picture of drug addicts in America,
where now all social classes can be included as users.
Harlem Hospital in New York has reported that 10
of all its newborns had positive urine screens for
cocaine. Infants delivered to mothers who have used
cocaine during pregnancy tend to be shorter, of lower
birth weight, and to have smaller head circumferences
than infants of drug free mothers. The rate of Sudden
Infant Death Syndrome (SIDS) has increased among
drug dependent mothers, and the rate of SIDS in
cocaine exposed infants is three times the rate of heroin
or methadone exposed infants. Though Minneapolis has
a lower than national average for infant mortality, the
rate in Minneapolis for Blacks and other minorities
remains almost two and one-half times that of whites.
Prenatal care visits, marital status, education, maternal
age, and area of residence are all negatives in socially
marginal populations, and the fear of exposure often
drives addicted women to ignore complications' that
arise during pregnancy rather than risk confronting their
dependencies. The high percentage of infant mortality
among pregnant addicts is in large part related to their
delivery of premature and low birth weight infants. The
single most recurring factor is lack of prenatal care. The
typical patient is one who is fearful, apprehensive,
uncooperative, and apparently self-centered. She
seemingly expects to suffer and almost appears to want
to. She can be easily driven to flight.
Currently at Hennepin County Medical Center in
Minneapolis, there are four to five acute complications
of cocaine in pregnancy per week. Many of these
patients have had no previous prenatal care, or have just
moved from another state. In an institution that delivers
approximately 2,000 babies per year, that equates to
10 incidence of infant morbidity. The complications
recognized in cocaine abuse in pregnancy are placenta
abruption, cerebral stroke in either the mother or the
fetus, cardiac arrhythmias, but most commonly prema
ture labor and low birth rate. It is significant that the
majority of babies who die weigh less than 2500 grams,
and if a baby weighs less than 2500 grams at birth, it
stands a 10 chance of dying during the first year of life.
We recently had an incident where a mother took
cocaine to induce a labor, demonstrating the power of
"coke" and its instant results. There may be other
effects of chemical abuse that are not being recognized,
because we do not know the true incidence of chemical
abuse in pregnancy.
There is an answer for these mothers, and a chance to
say "Yes" to something. The fundamental need is for
the opportunity for recognition of self-worth, self
esteem, and an ability to escape from a hostile environ
ment free from the use of chemical agents. While many
medications and techniques are available to take away
the cravings, environmental support systems are re
quired for the continued well being of the family. One
needs to cope with the fears and dependencies that
drove the patient to substance abuse in the first place.
The encouragement of a constructive expression of indi
viduality is important. Often drug abuse activities have
invaded the woman's life, rather than having been
sought out. She is intelligent, but trapped by an abusive
relationship which is reinforced by a hostile environ
ment, without much hope to escape. Her world is
destructive and enslaving to the unborn fetus and
herself. This pattern threatens to repeat itself for gen
erations unless there is intervention. We need to treat
the etiology of this behavior, not the symptoms.
"Often drug abuse activities have invaded
the women's life, rather than having been
sought out. She is intelligent, but trapped by.
an abusive relationship which is reinforced
by a hostile environment whitout much hope
to escape. Her world is desructive and
enslaving to the unborn fetus and herself. "
A prenatal substance abuse program must be included
in any effort to reduce infant mortality in this country,
but it must be a comprehensive program. The program
must aid in identifying substance abusers, assist them to
enroll and remain in prenatal care, and also assist them
in removing the environmental influences which ad
versely affect the family. They must have efficient and
effective referrals from hospital emergency rooms,
community referral agencies, as well as the court system
and the work place. Advocacy, psychosocial, and
educational support services are essential, but so are job
placement and day care. Follow up and continued
emotional support is required to break the link bonding
the mother to a life of despair. Preconceptual coun
selling will be of critical importance because of the high
early pregnancy loss associated with cocaine and other
drug abuses. The interview must be non-threatening or
there will be difficulty in identifying the illicit drug
abuse.
The question of the legal obligation of the drug abusing
mother to the unborn fetus is an important one with
many ramifications. Would enforcement encourage
truthful reporting or discourage drug abuse? Can a
woman be self-incriminating by reporting drug abuses in
pregnancy? What is the responsibility of medical
profession in identifying chemical abusers, and how does
that affect the doctor-patient relationship of trust that
we encourage? I believe that a residential chemical
abuse treatment program is the model for success, but it
must allow for continued maternal-child bonding.
- Courtesy of The Communicator