Perinatal care for women who are addicted: Implications for Empowerment.

Author:Carter, Carolyn S.
 
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Perinatal drug abuse is the use of alcohol and other drugs among women who are pregnant. The National Institute on Drug Abuse estimates that 5.5 percent of the women in the United States have used illicit drugs while pregnant, including cocaine, marijuana, heroin, and psychotherapeutic drugs that were not prescribed by a physician. More than 18 percent used alcohol during their pregnancy, and 20.4 percent smoked cigarettes (Marwick, 1998).

Literature reports the increased use of drugs during pregnancy (Lieb & Sterk-Elifson. 1995), using therapeutic communities (Stevens & Arbiter, 1995) and neighborhood context (Perloff & Jaffee, 1999) for addressing perinatal drug abuse; access barriers for low-income ethnic minority women who are addicted and pregnant (Cook, Selig, Wedge, & Gohn-Baube, 1999); the importance of effective policy making (Harrison, 1991); referrals to child protection services (Azzi-Lessing & Olsen, 1996); and other responses to perinatal drug abuse (Azzi-Lessing & Olsen; Irwin, 1995; Lieb & Sterk-Elifson; Marwick, 1998).

Women who abuse drugs while pregnant face severe consequences, which include becoming stigmatized as immoral and deficient caregivers (Carter, 1997; Kearny, Murphy, & Rosenbaum, 1994; Lieb & Sterk-Elifson, 1995). A behavioral outcome of societal attitudes toward perinatal drug abuse is the degree to which the drug-taking behavior of pregnant women is criminalized (Lieb & Strek-Elifson). Criminalization refers to using legal approaches, such as incarceration, for medical problems of clients rather than referring them for treatment (Keigher, 1999). Community response to the increasing number of women who give birth to infants addicted to crack cocaine, for example, has been to prosecute women for perinatal drug abuse (Lieb & Sterk-Elifson). Similarly, the number of mentally ill inmates in jails and prisons is estimated as being twice that in state hospitals (Keigher).

Individuals in helping professions also display stigmatic attitudes toward perinatal drug abuse. Disparaging interactions with women in some perinatal care facilities (Irwin, 1995), for example, include rude and judgmental comments to clients and violation of their confidentiality. Uncomfortable relationships with health care providers and fear of reprisal on the part of pregnant women who are addicted make women four times less likely to receive adequate care (Carten, 1996; Cook et al., 1999), thereby creating health risks for women who are addicted, their unborn fetuses, and their other children.

In this article I discuss contemporary responses to perinatal drug abuse, including ways in which the behavior of women who abuse drugs is criminalized or subjected to legal interventions. Vignettes from an ethnographic study of 120 women who used heroin, crack cocaine, and methamphetamine while pregnant (Irwin, 1995) depict the attitudes and behaviors of health care providers, society at large, and women themselves toward maternal drug abuse. This article demonstrates how poor women and women of color encounter legal interventions--such as prosecution or reports to city or state child protective services (CPS)--more frequently for using drugs during pregnancy than their more affluent, white counterparts. Because criminalizing perinatal drug abuse presents substantial risks to the health of women and children, empowering (Gutierrez, DeLois, & GlenMaye, 1995) strategies are suggested for redefining perinatal drug abuse less as a legal issue and more as a health concern. The strategies are consistent with eleme nts of the national health plan of the U.S. Department of Health and Human Services (DHHS), such as creating access to health care and minimizing risks to maternal, infant, and child health (DHHS, 2000).

SOCIETAL ATTITUDES TOWARD PERINATAL DRUG ABUSE

Over the past 100 years, there has been an overall shift in obstetric medicine to a focus on fetal protection (Harrison, 1991). In cases involving maternal drug abuse, the shift has sometimes resulted in adversarial attitudes with sentiment favoring the well-being of fetuses and against pregnant women (Gustavsson, 1991). The following excerpts offer three perspectives toward perinatal drug abuse that have primary emphasis on unborn fetuses: The first comment reflects the attitudes of some drug dealers; the second statement is a common reaction of partners of pregnant women; and the third depicts the attitude of society at large (Irwin, 1995).

They [crack dealers] tell me that I shouldn't be doing this in the first place, but I'm gonna do it anyway. And they go, "You know it. I shouldn't even really sell you anything. I shouldn't sell you anything cause you're pregnant. I'm not gonna contribute to that."

My baby came home with crack in her system, and he [baby's father who is himself a crack dealer] don't want to claim her now.

I know one girl. She just smokes [crack] and doesn't give a damn. Her stomach is way out there, so she shouldn't be out there [using crack] anyway, cause people be like, "man, look, a pregnant woman!" (pp. 616-617)

Negative attitudes like the ones in the vignettes above are pervasive and often based on assumed medical and developmental consequences of drugs on fetuses (Coles, 1991). The concerns are both supported and refuted by research. Studies of the effects of drug use on fetal development cite problems such as low birthweight, small head size, prematurity, and small size for gestational age (LaFrance et al., 1994). A study of 11,000 infants conducted by the Brown University School of Medicine, however, showed no increase in abnormalities at birth among children who had been exposed to cocaine in utero (Marwick, 1998). Although the latter study has not followed the children into school age and is therefore inconclusive, other studies of adjustment among drug-exposed children also challenge the notion of devastating effects resulting from cocaine use during pregnancy (Carten, 1996; Frank, Augustyn, Knight, Pell, & Zuckerman, 2001). Coles (1991, 1992) concluded that the effects of the social environment are too often ignored in studies of perinatal drug abuse.

In addition to the pejorative attitudes toward women who abuse drugs during pregnancy based on ideas about adverse fetal development is the belief that drug use compromises the reproductive and caregiver roles of women (Chavkin, 1990). It is believed that women who abuse substances are unfit mothers undeserving of their children (Carter, 1997). Society sanctions women for failing to live up to preconceived gender-role expectations by using legal interventions, particularly against poor women of color who use drugs while they are pregnant (Lieb & Sterk-Elifson, 1995).

LEGAL INTERVENTIONS

Legal interventions for perinatal drug abuse may be increasing in the United States. Since 1985,240 women in 35 states have been prosecuted for using alcohol or illegal drugs while pregnant (Marwick, 1998). Eleven states have developed specific gestational-abuse statutes. The most comprehensive reporting system is in Minnesota and includes toxicological screening (Lieb & Sterk-Elifson, 1995) and "involuntary civil commitment" to drug rehabilitation of pregnant women who have used drugs. Before March 2001, eight states mandated that health care workers report neonates' positive drug toxicology as evidence of child abuse and neglect (Marwick), thus paving the way for court proceedings and actions affecting the parental rights of mothers. On March 21, 2001, the U.S. Supreme Court ruled that it is unlawful to involuntarily test pregnant women who are suspected of drug abuse. In Ferguson v. City of Charleston (2001), Charleston, South Carolina, was a litigant in the Supreme Court case and, along with Florida, enfo rced the greatest number of legal interventions (American Civil Liberties Union, 1992).

It is informative to place the legal interventions that occurred before the March 2001...

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