Health and Welfare

Drug Use Among Pregnant Women

Alcohol and tobacco are the most commonly used drugs among pregnant women, according to the National Institute on Drug Abuse(NIDA).(69) Of the approximately 4 million women who give birth every year, one in eight uses alcohol, tobacco or other drugs during the week prior to delivery.(70) Rates of drinking and smoking are higher among pregnant white women than among pregnant black and Hispanic women.(71)

The CDC reports that drinking among pregnant women has increased dramatically in recent years: the number who consumed any alcohol climbed more than 60 percent from 1992 to 1995.(72) At the same time, frequent drinking (at least seven drinks in one week or five on one occasion) among pregnant women grew four-fold.(73) NIDA estimates that at least 20 percent of pregnant women smoke throughout their pregnancies.(74)

The 1992 National Pregnancy and Health Survey found that one in 20 infants born between November 1992 and August 1993 were exposed prenatally to illicit drugs, primarily marijuana and cocaine.(75) Many of these 222,000 babies were also exposed to tobacco and alcohol, since many women who use illegal drugs while pregnant also smoke and drink. Women substance abusers are much less likely to seek prenatal care than other pregnant women, increasing the potential risks to their unborn children.

Maternal alcohol, tobacco and other drug use can lead to devastating physical, neurological and behavioral problems for their children. The rate of infant deaths increases by 50 percent among babies whose mothers smoke during pregnancy,(76) and the incidence of sudden infant death syndrome is at least twice as high.(77) Respiratory infections are also more common. Smoking accounts for 20 percent of low birth weight babies.(78)

Although the long-term impact of in utero exposure to illegal drugs, particularly cocaine, on a child's physical, mental and social well-being is as yet unknown, the short-term effects are well documented. Maternal cocaine use is linked to preterm delivery, low birth weight, neonatal seizures, and a variety of fetal physical abnormalities.(80) It is also linked to a higher incidence of behavioral and learning disorders among preschoolers and school-age children.(81) However, specific drug effects are often difficult to distinguish from outcomes related to other risk factors. For example, poor nutrition and lack of prenatal care are also common among cocaine and other illegal drug users, who often drink and smoke as well, all of which increase the likelihood of negative birth outcomes.

Alcohol is responsible for a high incidence of still births, miscarriages and premature babies; it also damages the developing fetus. According to CDC, alcohol is the leading known preventable cause of birth defects and mental retardation.(82) The longer a mother drinks during her pregnancy the lower the mental capacities of her infant will be.(83) Becoming abstinent, even as late as the third trimester, can improve outcomes.

Babies born with fetal alcohol syndrome (FAS) suffer from irreversible physical and mental defects including small brains, facial abnormalities, poor coordination, short attention span and mental retardation. Children damaged to lesser degrees from alcohol exposure in utero also exhibit some of these problems. There are more than 7,000 FAS cases each year, according to the Children of Alcoholics Foundation.(84) At least three to four times as many children are born with fetal alcohol effects.(85) The cost of caring fo rinfants, children, and surviving adults with FAS amounts to more than $2 billion a year.(86)

The toxic effects of alcohol, tobacco and other drugs on the unborn child are not limited to physical and mental damage. New research suggests that drug-exposed children are more likely to become drug users themselves. Women who smoke during pregnancy increase the likelihood that their children will smoke: this correlation is stronger for daughters than for sons.(87) Moreover, adolescent daughters of women who smoked at least a pack a day while pregnant are seven times more likely to smoke than girls whose mothers did not smoke while pregnant.(88)

So grave are the consequences of maternal alcohol and other drug use that some states have instituted criminal proceedings against women who use drugs during pregnancy. The large number of "crack babies" born during the crack epidemic-estimated at 200,000 to 300,000 in the late1980s-led to criminal action in 35 states.(89) During the past decade, more than 240 women have been criminally prosecuted for drug use during pregnancy.(90)However, in every state except for South Carolina, appeals courts have rejected these cases as unconstitutional.(91) In 1998, the South Carolina Supreme Court ruled that viable fetuses are protected from maternal drug use by state child abuse laws. The U.S. Supreme Court refused to block this state ruling on appeal.

Since 1992, South Carolina has prosecuted 40 women(92); two are serving lengthy sentences for using crack during pregnancy. State officials assert that the threat of "doing time" is an effective deterrent to keep women from using drugs. They also note that a woman has many chances to go to treatment before she is actually prosecuted under South Carolina law. On the other hand, public health experts argue that the fear of being reported and the possibility of arrest prevent many women from seeking prenatal care or drug treatment. They also are afraid their children will be taken away by child welfare agencies.

Women substance abusers typically have multiple social, economic and health problems. Lack of accessible prenatal care compounds the damage to the unborn child. In reality, pregnant addicts often have few options other than going "cold turkey." Drug treatment is not readily available for the majority of the nation's drug addicts, both men and women. Comprehensive drug treatment for pregnant women, including prenatal and perinatal services,is very scarce.

Domestic Violence, Child Abuse and Neglect

Alcohol and other drug use is closely linked to domestic violence as well as sexual and physical abuse in which women are usually the victims. One in four women in America will be assaulted at some time by a domestic partner, according to the U.S. Department of Health and Human Services.(93) More than half of all domestic violence cases nationwide involve drinking at the time of the attack.(94) A recent study in Memphis, Tennessee, found that in 94 percent of the domestic violence calls, the assailant had used alcohol alone or in combination with cocaine, marijuana, or other drugs within six hours of the assault.(95) About 43 percent of the victims in the Memphis study had also been using alcohol and other drugs.(96)

Women with serious alcohol and other drug problems typically have been sexually or physically abused. Three in four women in drug treatment programs report having been assaulted by family members or partners; incest and rape during adolescence are common experiences.(97) Studies of crack-using mothers in New York City found that half of those who reported sexual abuse said that this abuse took place before they began using drugs.(98)

The National Women's Study (1989) found that the severity of women's dependence on alcohol and other drugs relates directly to the numbers of violent assaults she has sustained.(99) The greater the number of attacks, the more serious the drug problem a woman develops.(100) This suggests that many women turn to alcohol and other drugs as a form of self-medication in very difficult circumstances. Unfortunately, no more current information is available.

Depression and attempted suicide are common among women substance abusers. At least one in two women in drug treatment are also diagnosed with other mental disorders.(101) For many, their depressive symptoms predated their use of alcohol and other drugs, and are often related to post-traumatic stress.(102)

As many as 80 percent of child abuse cases are associated with alcohol and other drug use, according to the National Committee to Prevent Child Abuse.(103) The number of child abuse and neglect cases nationwide climbed from 1.4 million in 1986, the beginning of the crack cocaine epidemic, to 2.8 million in 1993.(104) By 1997, 502,000 children were in foster care, largely because of alcohol and other drug abuse by at least one parent.(105) The total cost of investigations, foster care and adoption services exceeds $5 billion annually.(106) Foster care children from families with substance abuse problems stay in foster care for longer periods of time.(107) They also enter foster care at younger ages than children whose families do not have substance abuse problems.(108)

Drug testing is not yet widely used in family court: as a result, most data on the extent of substance abuse problems depend on self-reports. However, some jurisdictions are now moving to establish comprehensive drug testing in order to help determine the need for treatment. In the District of Columbia Family Court, drug tests of families with abused and neglected children in 1995 (the most recent available data) revealed that two in three parents tested positive for cocaine, while one in seven tested positive for heroin and other opiates.(109)

A 1998 survey by the Child Welfare League of America examined public child welfare agencies' services for pervasive substance abuse problems among the families and children they serve.(110) Only eight of the 47 states that responded to the survey collect systematic substance abuse data on their clients; nonetheless, 80 percent of the states responding reported that parental substance abuse and poverty are the two top problems they face in their caseloads.(111) Almost half the state agencies said they take primary responsibility for management of alcohol and other drug problems and treatment in child abuse and neglect cases.(112) However, less than a third of the agencies said they were able to obtain treatment services for their clients.(113) With regard to pregnant women, the agencies reported being able to find treatment help for only one in five.(114) Very few of the agencies (4 out of 47) provide special support groups for children whose parents are dependent on alcohol and other drugs.(115) Many under the jurisdiction of child welfare agencies are in fact single women with substance abuse problems. The severe shortageof prevention and treatment services for these women and their children-many of whom also have alcohol and other drug problems-is a major obstacle in restoring them to productive, healthy lives.

HIV/AIDS

Women are one of the fastest growing group of new AIDS cases in the United States, largely because of drugs. In 1997, women accounted for 23 percent of AIDS cases, compared to 7 percent in 1985.(116) Of the 98,468 women diagnosed with AIDS, two in three women contracted the virus from injection drug useor sexual contact with injection drug users.(117) In 1997, women accounted for 5,687 new drug-related AIDS cases.(118) Healthcare costs for these new cases, not including protease inhibitors, is $29.3 million a year.(119) Lifetime healthcare costs for all drug-related AIDS cases in women exceeds $6.1 billion.(120)

Women are the fastest growing group of new HIV cases in the United States.(121) The number of new cases among women increased 13 percent between 1993 and 1997, while decreasing 12 percent among men overall, and 17 percent among homosexual men.(122) The increase is largely because of drugs. Among teenage girls, the number of new HIV infections is outpacing that of males the same age.(123) Recent research reports that women infected with HIV develop AIDS more quickly than men.(124)

In 1996, AIDS became the third leading cause of death among women of reproductive age in the United States, and the number one cause of death for black women of that age.(125) More than half of pediatric AIDS cases are attributed to intravenous drug use by the mother or one of her sexual partners.(126) Almost half of HIV-infected pregnant women use illicit drugs during pregnancy, primarily cocaine, and many use multiple drugs.(127) Perinatal transmission of HIV to the fetus is nearly twice as likely among drug users than other pregnant women with HIV (27 percent vs. 16 percent).(128) A number of factors may account for this difference. For instance, drug users may be less likely than other pregnant women to receive AZT and other HIV treatments known to reduce transmission during labor. In addition, drug users are more likely to be infected with multiple strains of the HIV virus, and are therefore harder to treat effectively.

Drug Treatment for Women and Their Children

Women substance abusers account for almost one-third of the total number of people in treatment in 1996 (the most recent available data).(129) This represents an increase since 1980, when one-quarter of all treatment clients were women.(130) However, special services for women addicts are still very limited. The1996 Uniform Facility Data Set found that only 6 percent of the treatment programs surveyed provided prenatal care; 4.2 percent offered perinatal care, and 11.5 percent offered child care.(131)

A decade ago, very few programs admitted pregnant addicts, particularly for residential treatment. Although many more programs now accept pregnant addicts, child care services remain scarce. A 1993 study of outpatient and residential programs reported that several major cities, including New York, did not provide residential treatment with child care for pregnant addicts.(132)

The lack of specialized treatment opportunities translates into greatly increased health and social costs. According to a study in Washington State, Medicaid expenses during the first two years of life of an infant born to an untreated substance abusing woman were 1.4 times higher than those incurred for infants born to treated substance abusing women.(133)The difference in dollar terms amounted to $1,800 per infant. In Ohio, special treatment programs for pregnant addicts reported that 1,908 drug-free babies were born from 1993-1997.(134) The estimated cost savings was $88.2 million with immeasurable improvements in the quality of life for the families and children involved.(135)

The 1998 Services Research Outcomes Study, which surveyed several thousand addicts five years after their discharge from treatment, found that women respond better to treatment than men.(136) Although rates of illicit drug use were higher among women than among men before treatment, women reported almost twice as great a reduction as did men in the five years after treatment.(137)The 1996 National Treatment Improvement Evaluation Study also found that women addicts showed marked improvements in the year following treatment.(138) Among the treated group, arrests declined by two-thirds while drug use dropped by almost half.(139)

Most drug treatment models were originally designed for male addicts. The past decade of experience suggests that certain features are particularly important in addressing women's treatment needs. Children are a central reality in the lives of most women. Unless programs provide help with children, women often cannot participate. Several treatment outcome studies have found that women who have their children with them during residential treatment are less likely to drop out and are more successful after treatment than women whose children are not with them during treatment.(140/141/142) Moreover, having children accompany mothers in both non-residential and residential treatment provides an opportunity for women to learn more about parenting skills in a safe therapeutic setting.

Sexual and physical abuse, domestic violence and depression are widespread among women addicts; these concerns must be addressed in order to prevent relapse. Research indicates that women-only programs tend to be more effective than co-ed, primarily because women feel more able to talk openly about their experiences.(143) Since many women entering treatment have multiple problems, programs should offer access to comprehensive services, ranging from family planning, physical and mental health care, job training, parenting and family building skills. This model departs from traditional drug treatment which concentrates almost exclusively on addressing the addictive behavior rather than the constellation of other problems that often accompany addiction in women.

Related Data Tables   |   Next Section

Keeping Score 1998
Introduction | Drug Use and Attitudes | Healthand Welfare |
Drugs and Crime | Lookingto the Future | Data Tables | Endnotes

Spotlight | Methadone Maintenance Treatment | Welfare Reform and Drug Abuse
Women and Drug Abuse: Court Innovations

Programs | Prevention Programs | Pregnant and Parenting Women's Programs
Family Treatment Programs| Criminal Justice Programs

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