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Social, ethical and practical aspects of perinatal substance use
Journal of Substance Abuse Treatment, Vol. 14, No. 5, pp. 481486, 1997 Copyright © 1997 Elsevier Science Inc. Printed in the USA. All rights reserved 0740-5472/97 $17.00 + .00
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ELSEVIER
PERSONAL PERSPECTIVE
Social, Ethical and Practical Aspects of Perinatal Substance Use M E L ANDERSON, MD,* RONITH E L K , PhD,~" AND ROBERT L. ANDRES, MD~ *The Department of Internal Medicine David Grant Medical Center, Travis AFB, CA; tDepartment of Psychiatry and Behavioral Sciences; SThe Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Medical School at Houston, Houston, Texas
Abstract-Substance use in pregnancy has garnered increasing attention over the last decade as a particularly concerning facet of the larger national drug problem. This concern stems from the unique circumstance presented by pregnancy, in which the fetus may suffer harm as a result of maternal behavior. Furthermore, organizing a response to this problem is complicated by the ethically and legally challenging nature of the maternal-fetal relationship. The medical implications of perinatal substance use are profound. A discussion of these associated medical and obstetrical complications lies outside the focus of this paper, and the reader is referred to other reviews (Andres & Jones, 1994; Robins & Mills, 1993). This article is intended to assist obstetricians and others in their approach to the substance using pregnant patient. We first review the scope of this problem in social and financial terms and then review the important ethical and legal issues involved in current policymaking. Lastly, we suggest a clinical intervention focusing on education and improvement in identification and management of this subset of patients. © 1997 Elsevier Science Inc.
Keywords-pregnancy; fetus; bioethics; substance abuse; prenatal care.
DEFINITION OF TERMS
stance "abuse" is of interest; nevertheless, for the sake of clarity, the term use will be favored. "Substance addiction" has been defined as a condition of physical and psychological dependence on a substance, with deteriorating health as a result (Kaplan & Sadock, 1991). Judging whether an individual substance user has become an addict can be difficult; moreover, the forces which bring about an addiction have yet to be fully understood.
SUBSTANCE USE REFERS GENERALLY to t h e ingestion of
illicit drugs such as marijuana, cocaine, opiates, barbiturates, benzodiazepines, PCP, amphetamines, etc. The use of licit drugs, such as alcohol and nicotine, are less frequently included in this definition, despite their widespread use and undisputed potential for harm. Substance abuse, however, is a more value-laden term which implies substance use, probably over time, which is somehow detrimental or harmful. Thus, substance use need not constitute substance abuse, although they often coexist. Indeed, in the context of this article, the harm connoted by sub-
SCOPE OF THE PROBLEM Epidemiology A number of authors (Center for Disease Control, 1990; Frank et al., 1988; Gillogley, Evans, Hausen, Samuels, Batra, 1990; Hurt, 1990; Neerhof, MacGregor, Retsky, Sullivan, 1989; Zukerman et al., 1989) have provided data concerning the prevalence of substance use in preg-
Requests for reprints should be addressed to Robert L. Andres, MD, Assistant Professor, Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, 6431 Fannin Street, Suite 3.204, Houston, Texas 77030.
Received July 10, 1996; Accepted October 14, 1996.
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nancy. Chasnoff (1989) reported the results of a survey of pregnant women from 36 United States hospitals. Overall, the mean prevalence of illicit drug use was 11% (range 0.4%-27%). In 1989, 715 pregnant women seeking prenatal care in Pinellas County, Florida were screened for illicit drugs and alcohol. The overall prevalence of positive urine toxicologic tests for cocaine, opiates, and marijuana was 13.3%, increasing to 14.8% when including alcohol (Chasnoff, Landres, Barrett, 1990). Zuckerman and co-workers reported a 41% prevalence of cigarette smoking during pregnancy (Zuckerman et al., 1989), a figure supported by other authors (Andres & Jones, 1994; Gomby & Shiono, 1991). The prevalence of alcohol consumption in the Zuckerman study was 60%, with more recent data generated by Serdula indicating a rate of 25% (Serdula, Williamson, Kendrick, Anda, Byers, 1991). These high rates of alcohol and nicotine use during pregnancy are not surprising, given the reported prevalence of use among non-pregnant populations of similar age. The NIDA Household Survey of 1991 reported alcohol use in 80.1% of all women surveyed between 18 and 25 years of age, and 77.3% among those 26 to 34 years of age. Nicotine use (smoking) was reported among 40% and 35.6% of these same age groups. The true national prevalence of substance use during pregnancy is difficult to ascertain, due primarily to methodological limitations of available studies (Evans & Gillogley, 1991; Khalsa & Gfroerer, 1991; Robins & Mills, 1993). Many of these studies were conducted in urban centers or among less than fully representative patient populations and most did not examine the frequency or magnitude of use in each pregnancy. In addition, many of the data are based on urine drug screening, which may fail to detect the infrequent user or one who has abstained from use in the later stages of pregnancy (Hawks & Chiang, 1986). Lastly, substance users may fail to seek prenatal care and thus avoid detection by any established protocol. A study currently in progress sponsored by the NIDA may provide the most representative data concerning the national scope of this problem. Social Infants of substance using mothers have been shown to be at increased risk for child abuse, neglect, and placement in foster care (Black & Mayer, 1981; Regan, Ehrlich, Finnegan, 1987; Wasserman & Leventhal, 1993). These children often fail to receive adequate parenting as a result of continued maternal substance use. "Methadone mothers" were demonstrated to require more assistance in parenting, were more socially isolated, and were less likely to pursue vocational and educational activities compared to matched drug-free controls (Fiks, Johnson, & Rosen, 1985). Children regularly exposed in utero to cocaine were shown to be "at a substantially increased risk both of maltreatment and of changes in the primary
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caregiver during the first 24 months of life" (Wasserman & Leventhal, 1993). Compounding the substance use itself are other attendant problems--single parenthood, poor housing, inadequate income, and lack of education (Regan et al., 1987). The current and potential social costs of this constellation of problems are evident. Financial The immediate financial costs associated with maternal substance use in pregnancy arise chiefly from the care of premature infants. In one study (Calhoun & Watson, 1991), the hospital charges for cocaine-positive mothers averaged $3,608 [control (cocaine-negative) $3,147 p < .05], and charges for cocaine-positive neonates averaged $13,222 [control (cocaine-negative) $1,297 p < .03]. The authors attributed the majority of the statistically significant differences in perinatal cost to prematurity and correspondingly longer and more complicated hospital stays. The annual economic costs associated with Fetal Alcohol Syndrome and related disorders have been estimated to exceed $300 million (Abel & Sokol, 1987). Estimates for total annual birth-related costs associated with substance use in pregnancy range from $385 million to $3 billion (Chasnoff, 1991; Fink, 1990). E T H I C A L AND L E G A L ISSUES A discussion of the independent moral status of the fetus falls outside the scope of this article. There are, however, important ethical questions surrounding this issue: Does the mother have an ethical obligation to behave in ways that benefit and not harm the fetus? To what extent may society claim an ethical obligation to protect the unborn? Further questions surround the ethics of drug testing, mandatory disclosure of toxicology results, and myriad others. Concerning the first question of maternal ethical duty, a 1992 survey of 81 obstetric and pediatric programs (Pelham & DeJong, 1992) reported that 92% of respondents agreed with this statement: "The mother has an ethical obligation to the health of the fetus. That is, once a decision to carry the conception to term has been made, she should direct her behavior to benefit and not harm the fetus." Respondents were divided (31% agree, 28% disagree, 41% undecided) in response to a second statement: "The mother has a legal obligation to the health of the fetus. That is, once the decision to carry a conception to term has been made, the state has the right to direct the mother's behavior such that it benefits and does not harm the fetus." Important principles of maternal ethical duty include the right of the mother to determine whether the pregnancy will continue and whether the conceptus has the potential to attain viability (Chervenak & McCullough, 1990a). When a mother chooses to continue a pregnancy and when a fetus is potentially viable (i.e., without se-
Issues in Perinatal Drug Use
vere abnormalities that preclude sustained extrauterine life, Trisomy 13), then there exists an important link between the fetus and the child it can become (Chervenak & McCullough, 1990b). The proposed ethical duty of the mother to the fetus, then, derives from an ethical duty to her future child, via these links. The potentially more controversial ethical question of society's claim to protect the unborn forms much of the basis for legal action against pregnant substance users. Within the past 10 to 15 years, pregnant women have been indicted and prosecuted under child abuse, drug trafficking, and even manslaughter statutes (Rubenstein, 1991). This litigation often occurs via expedient readings of statutes not intended to apply to the fetus. A few states have enacted or amended legislation to include the unborn in child abuse and neglect laws--New Jersey, Massachusetts, Florida, Indiana, Oklahoma, and California (Connolly & Marshall, 1991). In May 1989, the state of Minnesota passed a new law requiring health care practitioners to administer toxicology tests to pregnant women suspected of substance use. Positive test results must be reported to the local welfare agency. These laws are, for the most part, overly broad and remain unchallenged. Thus far, the majority of the legal discussion has occurred in court through litigation against pregnant substance users. The following summarize important cases in the history of fetal rights and maternal substance use: 1946 Bonbrest v. Kotz (Bonbrest v. Kotz, 1946). Reversing the tradition of Justice Holmes in Dietrich (1884), the US Supreme Court allowed a child injured in the birth process to recover for its injuries. This precedent allows a child who is tortiously injured after becoming a viable fetus to state a cause of action (Collins, 1983-84). 1960 Smith v. Brennan (Smith v. Brennan, 1960). The court asserted that "a child has the legal right to begin life with a sound mind and body," and thus "if the wrongful conduct of another interferes with that f i g h t . . , damages for such harm should be recoverable by the child." 1977 Reyes v. Superior Court (Reyes v. Superior Court, 1977). A woman was criminally charged under a fel-
ony-child endangerment statute after continuing to use heroin during the last 2 months of pregnancy despite being counseled by a public health nurse against doing so. The child was born addicted and underwent withdrawal (neonatal abstinence syndrome). The judge dismissed the case, ruling that the statute did not apply to the unborn. 1987 People v. Pamela Rae Stewart (People v. Stewart, 1987). A woman was criminally charged under a Cali-
fornia child support statute for failing to follow her doctor's orders while pregnant: she continued to have sexual intercourse despite being advised to refrain from doing so (she had been diagnosed with placenta previa after a prior episode of vaginal bleeding) and at delivery tested
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positive for marijuana and amphetamines in her urine. She bled for a number of hours prior to reaching the hospital and gave birth to a profoundly neurologically damaged infant who died 6 months later. The court dismissed the case on the grounds that the statute under which she was charged had not been designed or intended to control maternal behavior during pregnancy (Dobson & Eby, 1992; Sexton, 1993). 1989 State v. Johnson (State v. Johnson, 1989). A woman who gave birth to two cocaine-positive children 14 months apart was criminally charged under a Florida drug-trafficking statute, convicted, and given a 15-year sentence. She became the first woman in the United States successfully prosecuted for substance use during pregnancy. The prosecution argued that drug delivery to a minor had occurred after birth via the umbilical cord before it was clamped (Sexton, 1993). Her conviction was upheld in a split decision by Florida's 5th District Court of Appeals but was unanimously overturned by the Florida Supreme Court. The Supreme Court held that there was reasonable doubt that the drug delivery had indeed occurred after birth before the cord was clamped and, more importantly, that the state intended to treat substance using mothers and exposed neonates as a public health problem, not a criminal one (Merrick, 1993). There exists a significant literature examining the issues surrounding maternal substance use in pregnancy (Beal, 1984; Denison, 1991; Dougherty, 1985; "Maternal rights," 1988; Myers, 1984; Moss, 1990; Robin-Vergeer, 1990; Shelly, 1988; Soloman, 1991; Wilkins, 1990; Wood, 1987). However, legal action against women for their substance use in pregnancy, via litigation or through legislation, encounters many problems. First, women are protected by numerous Constitutional rights to bodily integrity, privacy, freedom to procreate, protection from cruel and unusual punishment, and rights of equal protection and due process (Garcia, 1992). Any legislation against pregnant substance users must acknowledge these Constitutional limits. Second, if a woman is indeed an addict, it is not clear that she can act with autonomy, and therefore responsibility, or that she can appreciate the consequences of her actions. If one views addiction as a disease [a topic generating debate (Garcia, 1992; Goodwin, 1979)], then punishing addicts--someone having this disease--becomes problematic. Another potential problem of enacting statutes against the pregnant substance user involves the somewhat arbitrary distinction between legal and illegal activities. Legislation protecting the fetus from harm caused by illegal maternal behavior, for example, smoking crack, might extend to legal maternal behavior such as alcohol consumption, smoking, or even failing to take vitamins or eat properly. If the goal of such legislation is to maximize maternal and fetal health, then any number of legal or illegal maternal actions might then be subject to regulation.
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Lastly, enacting criminal or civil statutes against the pregnant substance user may worsen the situation by discouraging these women from seeking formal prenatal care. Faced with the threat of legal action for their substance use, these women may attempt to carry and deliver their infants outside the medical establishment to avoid detection. They may also consider aborting the pregnancy as an alternative to incarceration or other punishment (Harrison, 1991) for harm caused to the fetus. Without prenatal care, the general health of the mother and child will likely suffer (Racine, Joyce, & Anderson, 1993), the substance use will likely continue, and health care costs will further increase (Oberman, 1990). THE CLINICAL INTERVENTION Clinicians caring for the pregnant substance user have a unique opportunity to address both the behavioral and the medical/obstetrical issues which arise. Clearly, our society and the medical establishment embrace prenatal care in general for its manifest health benefits. The premise of this clinical intervention is that the pregnancy represents a "window of opportunity" in which substance use can be detected and treatment offered, primarily by maximizing prenatal care for these patients. There are data indicating that many pregnant women independently decrease their use of alcohol, nicotine, and illicit drugs. Enrolling patients in specialized programs that offer intensive drug counseling can significantly enhance changes in drug use patterns (Elk et al. 1994). To increase the rate of enrollment in prenatal care, we must improve access and increase awareness. Unfortunately, pregnant substance users encounter special obstacles that can deter them from seeking prenatal care (Racine et al. 1993)--they may deny the gravity of the situation, they may be overwhelmed by the addiction itself, and they are often inexperienced at caring for themselves. A significant portion of these patients suffer from mental health problems-most commonly depression (Jessup & Roth, 1988; Schuckit, 1979). Pregnant women who would otherwise seek prenatal care may fear being reported to authorities, facing prosecution for their substance use, or even losing custody of the child. Not uncommonly, these women harbor tremendous guilt and shame (Deren, 1986; Harrison, 1991; Rosenbaum, 1979), which can be exacerbated by the disapproval they sense from health care providers. These formidable obstacles underscore the importance of maintaining a non-judgmental approach to these patients and utilizing referral to specialized multidisciplinary clinics where available. Participation in prenatal clinics designed to meet the complex medical and social needs of these patients has been associated with improvement in overall perinatal outcome (Andres, Wilson, Elk, & Grabowski, 1994; MacGregor, Keith, Bachicha, & Chasnoff, 1989; Racine et al., 1993). An important aspect of these efforts is patient education regarding the deleterious effects of their substance use on the fetus. In addition,
appropriate screening for preterm labor, abnormalities of fetal growth, and associated medical complications must be undertaken to optimize perinatal outcome. These efforts depend upon correct identification of substance use among patients attending prenatal clinics as well as the substantial number of patients who receive their prenatal care by haphazard and infrequent visits to different hospitals and various emergency rooms. Clinicians must retain a high level of clinical suspicion for substance use--some evidence suggests that current levels of suspicion and testing fail to detect the majority of cases (Maynard, 1991). While the search for substance use should extend to all patients, several studies have unfortunately shown a racial bias in both drug testing and reporting (Chasnoff et al., 1990; Chavkin, 1991). To complement this increased vigilance in patient screening, clinicians should further review the signs and symptoms of substance use and the techniques of obtaining an accurate drug use history (Jessup, 1990; Jessup & Roth, 1988; Lowinson, 1992). Medical education must strive to improve this aspect of training. Assuring patients of confidentiality and advocacy will encourage them to trust and to disclose. Lastly, as a routine part of prenatal care, education concerning the effects of substance use should be provided to all patients, not limited to those judged to be at risk. Clinicians should familiarize themselves with the local requirements for drug testing and reporting (Horowitz, 1991)--recent data showed that over half (52%) of the respondents to a questionnaire surveying obstetric and pediatric programs were unaware of their state's requirements for reporting prenatal cocaine use (Pelham & DeJong, 1992). Health care providers also need to fully investigate the available treatment options for these patients. Maximizing these options becomes especially important as there are generally an inadequate number of rehabilitation programs (Oberman, 1990; Racine et al., 1993) and a significant number that categorically refuse treatment to pregnant women (Chavkin, Allen, Oberman, 1991; Chavkin & Kandall, 1990). CONCLUSION The complex problem of substance use in pregnancy raises numerous medical, ethical, social, and financial concerns. While debate among policymakers is ongoing, clinicians must care for these patients on a daily basis. Non-judgmental, non-punitive prenatal care, with high indices of clinical suspicion and vigilant screening, forms an important clinical intervention. In this way, clinicians have a unique opportunity to make a difference for these patients and improve the health of both mother and child. REFERENCES Abel, E.L., & Sokol, R.J. (1987). Incidence of fetal alcohol syndrome (FAS) and FAS-related anomalies. Drug and Alcohol Dependence, 266, 51-70.
Issues in Perinatal Drug Use Andres, R.L., & Jones, K.L. (1994). Social and illicit drug use in pregnancy. In R.K. Creasy & R. Resnik (Eds.), Maternal-Fetal Medicine (3rd ed.) (pp. 182-198). Philadelphia: W.B. Saunders. Andres, R.L., Wilson, P.D., Elk, R., & Grabowski, J. (1994). Adjunctive behavioral therapy is associated with a decrease in the incidence of preterm labor and delivery in pregnant drug users. American Journal of Obstetrics and Gynecology, 170, 333. Beak R. (1984). Can I sue mommy?: An analysis of a woman's tort liability for prenatal injuries to her child born alive. San Diego Law Review, 21,325-370. Black, R. & Mayer, J. (1981). Parents with special problems: Alcoholism and opiate addiction. In H. Kempe & R. Helfer (Eds.), The battered child (3rd ed.) Chicago: University of Chicago Press. Bonbrest v. Kotz, F. Suppl. 65:138 (D.D.C. 1946). Calhoun, B.C., & Watson, P.T. (1991). The cost of maternal cocaine abuse: I. Perinatal cost. Obstetrics & Gynecology, 78, 731-734. Center for Disease Control. (1990). Prevalence of illicit drug use by pregnant women--Rhode Island. Morbidity and Mortality Weekly Report, 39, 225. Chasnoff, I.J. (1989). Drug use and women: establishing a standard of care. Annals of the New York Academy of Sciences, 562, 208-210. Chasnoff, l.J. (1991). Drugs, alcohol, pregnancy, and the neonate: pay now or pay later. Journal of the American Medical Association, 266, 1567-1568. Chasnoff, I.J., Landres, H.J., & Barrett, M.E. (1990). The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. New England Journal of Medicine, 322, 1202-1206. Chavkin, W.C. (1991). Mandatory treatment for drug use during pregnancy. Journal of the American Medical Association, 266, 1556--1561. Chavkin, W.C., Allen, M.H., & Oberman, M. (1991). Drug abuse and pregnancy: some questions on public policy, clinical management, and maternal and fetal rights. Birth, 18, 107-112. Chavkin, W.C., & Kandall, S.R. (1990). Between a rock and a hard place: Perinatal drug abuse. Pediatrics, 85, 223-225. Chervenak F.A., & McCullough L.B. (1990a). Does obstetric ethics have any role in the obstetrician's response to the abortion controversy? American Journal of Obstetrics & Gynecology, 163, 1425-1429. Chervenak, F.A. & McCullough, L.B. (1990b). Preventive ethics strategies for drug abuse during pregnancy. Journal of Clinical Ethics, 1, 157-158. Collins, E.F. (1983-1984). An overview and analysis: prenatal torts, preconception torts, wrongful life, wrongful death, and wrongful birth: Time for a new framework. Journal of Family l~;w, 22, 677709. Connolly, W.B., & Marshall, A.B. (1991) Drug addiction, pregnancy, and childbirth: legal issues for the medical and social services communities. Clinics in Perinatology, 18, 147-186. Denison, J. (1991). The efficacy and constitutionality of criminal punishment for maternal substance abuse. Southern California Law Review, 64, 1103-1141. Deren, S. (1986). Children of substance abusers: a review of the literature. Journal of Substance Abuse Treatment, 3, 77-94. Dobson, T., & Eby, K. (1992). Criminal liability for substance abuse during pregnancy: the controversy of maternal v. fetal rights. Saint Louis Law Journal, 36, 655-694. Dougherty, C.J. (1985). The right to begin life with a sound body and mind: fetal patients and conflicts with their mothers. Universi O" of Detroit La~ Review, 63, 89-117. Elk, R., Schmitz, J., Manfredi, L., Rhoades, H., Andres, R.L., & Grabowski, J. (1994). Brief report: cessation of cocaine use during pregnancy: a preliminary comparison. Addictive Behaviors, 19, 697-702. Evans, A.T., & Gillogley, K.M. (1991). Drug use in pregnancy: obstetric perspectives. Clinics in Perinatology, 18, 23-32. Fiks, K., Johnson, H.L., & Rosen, T.S. (1985). Methadone maintained mothers: 3-year follow-up of parental functioning. International Journal ~?fthe Addictions, 20, 651-660.
485 Fink. D.J. (1990). Effects of crack and cocaine on infants: a brief review of the literature. Clearinghouse Review, 24, 460-466. Frank, D.A., Zuckerman, B.S., Amaro, H., Aboagye, K., Bauchner, H., Cabral, H., Fried, L., Hingson, R., Kayne, H., & Levinson, S.M. (1988). Cocaine use during pregnancy: prevalence and correlates. Pediatrics, 82, 888-895. Garcia, S.A. (1992). Drug addiction and mother/child welfare: rights, laws, and discretionary decisionmaking. Journal of Legal Medicine, 13, 129-203. Gillogley, K.M., Evans, A.T., Hausen, R. Samuels, S.J., & Batra, K.K. (1990). the perinatal impact of use of cocaine, amphetamine, and opiate use detected by universal intrapartum screening. American Journal of Obstetrics and Gynecology, 163, 1535-1542. Gomby, D.S., & Shiono, P.H. (1991). Estimating the number of substance-exposed infants. In Behrman, R.E. (Ed.), The future of children. Los Altos: The Center for the Future of Children, The David and Lucille Packard Foundation. Goodwin, D.W. (1979). Alcoholism and heredity. A review and hypothesis. Archives of General Psychiatry, 36, 57-61. Harrison, M. (1991). Drug addiction in pregnancy: the interface of science, emotion, and social policy. Journal of Substance Abuse Freatment, 8, 261-268. Hawks, R.L., & Chiang, C.N. (1986). Urine testing for drugs of abuse. NIDA Research Monograph, 73. Horowitz, R.M. (1991). Drug use in pregnancy: To test, to tell--legal implications for the physicians. Seminars in Perinatology, 15, 324-330. Hurt, H. (1990). 1000 babies: Philadelphia 1989. Pediatric Research, 27, 93A (Suppl.). Jessup, M. (1990). The treatment of perinatal addiction: Identification, intervention, and advocacy. Western Journal of Medicine, 152, 553-558. Jessup, M., & Roth, R. (1988). clinical and legal perspectives on prenatal drug and alcohol use: guidelines for individual and community response. Medicine and Law, 7, 377-389. Kaplan, H.I., & Sadock, BJ. (1991). DSM-III-R. In H.I. Kaplan & B.J. Sadock (Eds.), Synopsis of psychiatry, behavioral sciences, clinical psychiatry (6th ed,) (p. 279). New York: Williams & Wilkins. Khalsa, J.H., & Gfroerer, J. (1991). Epidemiology and health consequences of drug abuse4 among pregnant women. Seminars in Perinatology, 15, 265-270. Lowinson, J.H. (1992). Substance abuse--A comprehensive textbook (2nd ed.). New York: Williams and Wilkens. MacGregor, S.N., Keith, L.G., Bachicha, J.A., & Chasnoff, I.J. (1989). Cocaine abuse during pregnancy: correlation between prenatal care and perinatal outcome. Obstetrics and Gynecology, 74, 882-885. Maternal rights and fetal wrongs: The case against criminilization of "fetal abuse" (1988). Harvard Law Review, 101,994-1012. Maynard, E.C. (1991). Testing for maternal drug abuse: How much is enough? Pediatrics, 87, 742. Merrick, J.C. (1993) Maternal substance abuse during pregnancy: Policy implications in the United States. Journal of" Legal Medicine, 14, 57-71. Moss, K. (1990). Substance abuse during pregnancy. Han,ard Women's Law Journal, 13, 278-299. Myers, J.B. (1984). Abuse and neglect of the unborn: Can the state intervene? Duquesne Law Review, 23, 1-76. Neerhof, M.G., MacGregor, S.N., Retsky, S.S., & Sullivan, T.P. (1989). Cocaine abuse during pregnancy: peripartum prevalence and perinatal outcome. American Journal of Obstetrics and Gynecology, 161,633-638. Oberman, M. (1990). Sex drugs, and pregnant addicts: an ethical and legal critique of societal response to pregnant addicts. Journal of Clinical Ethics, 1, 145-152. Pelham, T.L., & DeJong, A.R. (1992). Nationwide practices for screening and reporting prenatal cocaine abuse: A survey of teaching programs. Child Abuse and Neglect, 16, 763-770. People v. Stewart, No. M508197 (San Diego Municipal Court, February 26, 1987).
486 Racine, A., Joyce, T., & Anderson, R. (1993). The association between prenatal care and birth weight among women exposed to cocaine in New York City. Journal of the American Medical Association, 270, 1581-1586. Regan, D.O., Ehrlich, S.M., & Finnegan, L.P. (1987). Infants of drug addicts: At risk for child abuse, neglect, and placement in foster care. Neurotoxicology & Teratology, 9, 315-319. Reyes v. Superior Court (1977) Cal Rptr, 141:912. Robin-Vergeer, B.I. (1990). The problem of drug-exposed newborns: a return to principled intervention. Stanford Law Review, 42, 745-809. Robins, L.N., & Mills, J.L. (1993). Effects of in utero exposure to street drugs. American Journal of Public Health, 83, 2-32 (Suppl.). Rosenbaum, M. (1979) Difficulties in taking care of business: women addicts as mothers. American Journal of Drug and Alcohol Abuse, 6, 431-446. Rubenstein, L. (1991). Prosecuting maternal substance abusers: an unjustified and ineffective policy. Yale Law Policy Review, 9, 130--160. Schuckit, M.A. (1979). Drug and alcohol abuse: a clinical guide to diagnosis and treatment. New York and London: Plenum Press. Serdula, M., Williamson, D.F., Kendrick, J.S., Anda, R.F., & Byers, T. (1991). Trends in alcohol consumption by pregnant women--1985 through 1988. Journal of the American Medical Association, 265, 876-879.
M. Anderson et al. Sexton, P.A. (1993). Imposing criminal sanction on pregnant drug users: Throwing the baby out with the bathwater. Washburn Law Journal, 32, 410-430. Shelly, B. (1988). Maternal substance abuse: The next step in the protection of fetal rights? Dickinson Law Review, 92, 691-715. Smith v. Brennan, A. 2d. 157:497 (New Jersey 1960). Solomon, R.I. (1991). Future fear: prenatal duties imposed by private parties. American Journal of Law Medicine, 17, 411-434. State v. Johnson, No. E89-890-CFA (18th Jud. Cir. For Seminole County, Florida, July 13, 1989). Wasserman, D.R., & Leventhal, J.M. (1993). Maltreatment of children born to cocaine-dependent mothers. American Journal of Diseases of Children, 147, 1324-1328. Wilkins, M.D. (1990). Solving the problem of prenatal substance abuse: An analysis of punitive and rehabilitative approaches. Emor3, Law Journal, 39, 1401-1442. Wood, C.W. (1987). Parental rights termination: Are the interests of parents, children, and the state mutually exclusive? Stetson Law Review, 17, 295-318. Zuckerman, B.S., Frank, D.A., Hingson, R., Amaro, H., Levenson, S.M., Kayne, H., Parker, S., Vinci, R., Aboagye, K., & Fried, L.E. (1989). Effects of maternal marijuana and cocaine use on fetal growth. New England Journal of Medicine, 320, 762-768.
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ELSEVIER
PERSONAL PERSPECTIVE
Social, Ethical and Practical Aspects of Perinatal Substance Use M E L ANDERSON, MD,* RONITH E L K , PhD,~" AND ROBERT L. ANDRES, MD~ *The Department of Internal Medicine David Grant Medical Center, Travis AFB, CA; tDepartment of Psychiatry and Behavioral Sciences; SThe Department of Obstetrics, Gynecology and Reproductive Sciences, The University of Texas Medical School at Houston, Houston, Texas
Abstract-Substance use in pregnancy has garnered increasing attention over the last decade as a particularly concerning facet of the larger national drug problem. This concern stems from the unique circumstance presented by pregnancy, in which the fetus may suffer harm as a result of maternal behavior. Furthermore, organizing a response to this problem is complicated by the ethically and legally challenging nature of the maternal-fetal relationship. The medical implications of perinatal substance use are profound. A discussion of these associated medical and obstetrical complications lies outside the focus of this paper, and the reader is referred to other reviews (Andres & Jones, 1994; Robins & Mills, 1993). This article is intended to assist obstetricians and others in their approach to the substance using pregnant patient. We first review the scope of this problem in social and financial terms and then review the important ethical and legal issues involved in current policymaking. Lastly, we suggest a clinical intervention focusing on education and improvement in identification and management of this subset of patients. © 1997 Elsevier Science Inc.
Keywords-pregnancy; fetus; bioethics; substance abuse; prenatal care.
DEFINITION OF TERMS
stance "abuse" is of interest; nevertheless, for the sake of clarity, the term use will be favored. "Substance addiction" has been defined as a condition of physical and psychological dependence on a substance, with deteriorating health as a result (Kaplan & Sadock, 1991). Judging whether an individual substance user has become an addict can be difficult; moreover, the forces which bring about an addiction have yet to be fully understood.
SUBSTANCE USE REFERS GENERALLY to t h e ingestion of
illicit drugs such as marijuana, cocaine, opiates, barbiturates, benzodiazepines, PCP, amphetamines, etc. The use of licit drugs, such as alcohol and nicotine, are less frequently included in this definition, despite their widespread use and undisputed potential for harm. Substance abuse, however, is a more value-laden term which implies substance use, probably over time, which is somehow detrimental or harmful. Thus, substance use need not constitute substance abuse, although they often coexist. Indeed, in the context of this article, the harm connoted by sub-
SCOPE OF THE PROBLEM Epidemiology A number of authors (Center for Disease Control, 1990; Frank et al., 1988; Gillogley, Evans, Hausen, Samuels, Batra, 1990; Hurt, 1990; Neerhof, MacGregor, Retsky, Sullivan, 1989; Zukerman et al., 1989) have provided data concerning the prevalence of substance use in preg-
Requests for reprints should be addressed to Robert L. Andres, MD, Assistant Professor, Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, 6431 Fannin Street, Suite 3.204, Houston, Texas 77030.
Received July 10, 1996; Accepted October 14, 1996.
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nancy. Chasnoff (1989) reported the results of a survey of pregnant women from 36 United States hospitals. Overall, the mean prevalence of illicit drug use was 11% (range 0.4%-27%). In 1989, 715 pregnant women seeking prenatal care in Pinellas County, Florida were screened for illicit drugs and alcohol. The overall prevalence of positive urine toxicologic tests for cocaine, opiates, and marijuana was 13.3%, increasing to 14.8% when including alcohol (Chasnoff, Landres, Barrett, 1990). Zuckerman and co-workers reported a 41% prevalence of cigarette smoking during pregnancy (Zuckerman et al., 1989), a figure supported by other authors (Andres & Jones, 1994; Gomby & Shiono, 1991). The prevalence of alcohol consumption in the Zuckerman study was 60%, with more recent data generated by Serdula indicating a rate of 25% (Serdula, Williamson, Kendrick, Anda, Byers, 1991). These high rates of alcohol and nicotine use during pregnancy are not surprising, given the reported prevalence of use among non-pregnant populations of similar age. The NIDA Household Survey of 1991 reported alcohol use in 80.1% of all women surveyed between 18 and 25 years of age, and 77.3% among those 26 to 34 years of age. Nicotine use (smoking) was reported among 40% and 35.6% of these same age groups. The true national prevalence of substance use during pregnancy is difficult to ascertain, due primarily to methodological limitations of available studies (Evans & Gillogley, 1991; Khalsa & Gfroerer, 1991; Robins & Mills, 1993). Many of these studies were conducted in urban centers or among less than fully representative patient populations and most did not examine the frequency or magnitude of use in each pregnancy. In addition, many of the data are based on urine drug screening, which may fail to detect the infrequent user or one who has abstained from use in the later stages of pregnancy (Hawks & Chiang, 1986). Lastly, substance users may fail to seek prenatal care and thus avoid detection by any established protocol. A study currently in progress sponsored by the NIDA may provide the most representative data concerning the national scope of this problem. Social Infants of substance using mothers have been shown to be at increased risk for child abuse, neglect, and placement in foster care (Black & Mayer, 1981; Regan, Ehrlich, Finnegan, 1987; Wasserman & Leventhal, 1993). These children often fail to receive adequate parenting as a result of continued maternal substance use. "Methadone mothers" were demonstrated to require more assistance in parenting, were more socially isolated, and were less likely to pursue vocational and educational activities compared to matched drug-free controls (Fiks, Johnson, & Rosen, 1985). Children regularly exposed in utero to cocaine were shown to be "at a substantially increased risk both of maltreatment and of changes in the primary
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caregiver during the first 24 months of life" (Wasserman & Leventhal, 1993). Compounding the substance use itself are other attendant problems--single parenthood, poor housing, inadequate income, and lack of education (Regan et al., 1987). The current and potential social costs of this constellation of problems are evident. Financial The immediate financial costs associated with maternal substance use in pregnancy arise chiefly from the care of premature infants. In one study (Calhoun & Watson, 1991), the hospital charges for cocaine-positive mothers averaged $3,608 [control (cocaine-negative) $3,147 p < .05], and charges for cocaine-positive neonates averaged $13,222 [control (cocaine-negative) $1,297 p < .03]. The authors attributed the majority of the statistically significant differences in perinatal cost to prematurity and correspondingly longer and more complicated hospital stays. The annual economic costs associated with Fetal Alcohol Syndrome and related disorders have been estimated to exceed $300 million (Abel & Sokol, 1987). Estimates for total annual birth-related costs associated with substance use in pregnancy range from $385 million to $3 billion (Chasnoff, 1991; Fink, 1990). E T H I C A L AND L E G A L ISSUES A discussion of the independent moral status of the fetus falls outside the scope of this article. There are, however, important ethical questions surrounding this issue: Does the mother have an ethical obligation to behave in ways that benefit and not harm the fetus? To what extent may society claim an ethical obligation to protect the unborn? Further questions surround the ethics of drug testing, mandatory disclosure of toxicology results, and myriad others. Concerning the first question of maternal ethical duty, a 1992 survey of 81 obstetric and pediatric programs (Pelham & DeJong, 1992) reported that 92% of respondents agreed with this statement: "The mother has an ethical obligation to the health of the fetus. That is, once a decision to carry the conception to term has been made, she should direct her behavior to benefit and not harm the fetus." Respondents were divided (31% agree, 28% disagree, 41% undecided) in response to a second statement: "The mother has a legal obligation to the health of the fetus. That is, once the decision to carry a conception to term has been made, the state has the right to direct the mother's behavior such that it benefits and does not harm the fetus." Important principles of maternal ethical duty include the right of the mother to determine whether the pregnancy will continue and whether the conceptus has the potential to attain viability (Chervenak & McCullough, 1990a). When a mother chooses to continue a pregnancy and when a fetus is potentially viable (i.e., without se-
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vere abnormalities that preclude sustained extrauterine life, Trisomy 13), then there exists an important link between the fetus and the child it can become (Chervenak & McCullough, 1990b). The proposed ethical duty of the mother to the fetus, then, derives from an ethical duty to her future child, via these links. The potentially more controversial ethical question of society's claim to protect the unborn forms much of the basis for legal action against pregnant substance users. Within the past 10 to 15 years, pregnant women have been indicted and prosecuted under child abuse, drug trafficking, and even manslaughter statutes (Rubenstein, 1991). This litigation often occurs via expedient readings of statutes not intended to apply to the fetus. A few states have enacted or amended legislation to include the unborn in child abuse and neglect laws--New Jersey, Massachusetts, Florida, Indiana, Oklahoma, and California (Connolly & Marshall, 1991). In May 1989, the state of Minnesota passed a new law requiring health care practitioners to administer toxicology tests to pregnant women suspected of substance use. Positive test results must be reported to the local welfare agency. These laws are, for the most part, overly broad and remain unchallenged. Thus far, the majority of the legal discussion has occurred in court through litigation against pregnant substance users. The following summarize important cases in the history of fetal rights and maternal substance use: 1946 Bonbrest v. Kotz (Bonbrest v. Kotz, 1946). Reversing the tradition of Justice Holmes in Dietrich (1884), the US Supreme Court allowed a child injured in the birth process to recover for its injuries. This precedent allows a child who is tortiously injured after becoming a viable fetus to state a cause of action (Collins, 1983-84). 1960 Smith v. Brennan (Smith v. Brennan, 1960). The court asserted that "a child has the legal right to begin life with a sound mind and body," and thus "if the wrongful conduct of another interferes with that f i g h t . . , damages for such harm should be recoverable by the child." 1977 Reyes v. Superior Court (Reyes v. Superior Court, 1977). A woman was criminally charged under a fel-
ony-child endangerment statute after continuing to use heroin during the last 2 months of pregnancy despite being counseled by a public health nurse against doing so. The child was born addicted and underwent withdrawal (neonatal abstinence syndrome). The judge dismissed the case, ruling that the statute did not apply to the unborn. 1987 People v. Pamela Rae Stewart (People v. Stewart, 1987). A woman was criminally charged under a Cali-
fornia child support statute for failing to follow her doctor's orders while pregnant: she continued to have sexual intercourse despite being advised to refrain from doing so (she had been diagnosed with placenta previa after a prior episode of vaginal bleeding) and at delivery tested
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positive for marijuana and amphetamines in her urine. She bled for a number of hours prior to reaching the hospital and gave birth to a profoundly neurologically damaged infant who died 6 months later. The court dismissed the case on the grounds that the statute under which she was charged had not been designed or intended to control maternal behavior during pregnancy (Dobson & Eby, 1992; Sexton, 1993). 1989 State v. Johnson (State v. Johnson, 1989). A woman who gave birth to two cocaine-positive children 14 months apart was criminally charged under a Florida drug-trafficking statute, convicted, and given a 15-year sentence. She became the first woman in the United States successfully prosecuted for substance use during pregnancy. The prosecution argued that drug delivery to a minor had occurred after birth via the umbilical cord before it was clamped (Sexton, 1993). Her conviction was upheld in a split decision by Florida's 5th District Court of Appeals but was unanimously overturned by the Florida Supreme Court. The Supreme Court held that there was reasonable doubt that the drug delivery had indeed occurred after birth before the cord was clamped and, more importantly, that the state intended to treat substance using mothers and exposed neonates as a public health problem, not a criminal one (Merrick, 1993). There exists a significant literature examining the issues surrounding maternal substance use in pregnancy (Beal, 1984; Denison, 1991; Dougherty, 1985; "Maternal rights," 1988; Myers, 1984; Moss, 1990; Robin-Vergeer, 1990; Shelly, 1988; Soloman, 1991; Wilkins, 1990; Wood, 1987). However, legal action against women for their substance use in pregnancy, via litigation or through legislation, encounters many problems. First, women are protected by numerous Constitutional rights to bodily integrity, privacy, freedom to procreate, protection from cruel and unusual punishment, and rights of equal protection and due process (Garcia, 1992). Any legislation against pregnant substance users must acknowledge these Constitutional limits. Second, if a woman is indeed an addict, it is not clear that she can act with autonomy, and therefore responsibility, or that she can appreciate the consequences of her actions. If one views addiction as a disease [a topic generating debate (Garcia, 1992; Goodwin, 1979)], then punishing addicts--someone having this disease--becomes problematic. Another potential problem of enacting statutes against the pregnant substance user involves the somewhat arbitrary distinction between legal and illegal activities. Legislation protecting the fetus from harm caused by illegal maternal behavior, for example, smoking crack, might extend to legal maternal behavior such as alcohol consumption, smoking, or even failing to take vitamins or eat properly. If the goal of such legislation is to maximize maternal and fetal health, then any number of legal or illegal maternal actions might then be subject to regulation.
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Lastly, enacting criminal or civil statutes against the pregnant substance user may worsen the situation by discouraging these women from seeking formal prenatal care. Faced with the threat of legal action for their substance use, these women may attempt to carry and deliver their infants outside the medical establishment to avoid detection. They may also consider aborting the pregnancy as an alternative to incarceration or other punishment (Harrison, 1991) for harm caused to the fetus. Without prenatal care, the general health of the mother and child will likely suffer (Racine, Joyce, & Anderson, 1993), the substance use will likely continue, and health care costs will further increase (Oberman, 1990). THE CLINICAL INTERVENTION Clinicians caring for the pregnant substance user have a unique opportunity to address both the behavioral and the medical/obstetrical issues which arise. Clearly, our society and the medical establishment embrace prenatal care in general for its manifest health benefits. The premise of this clinical intervention is that the pregnancy represents a "window of opportunity" in which substance use can be detected and treatment offered, primarily by maximizing prenatal care for these patients. There are data indicating that many pregnant women independently decrease their use of alcohol, nicotine, and illicit drugs. Enrolling patients in specialized programs that offer intensive drug counseling can significantly enhance changes in drug use patterns (Elk et al. 1994). To increase the rate of enrollment in prenatal care, we must improve access and increase awareness. Unfortunately, pregnant substance users encounter special obstacles that can deter them from seeking prenatal care (Racine et al. 1993)--they may deny the gravity of the situation, they may be overwhelmed by the addiction itself, and they are often inexperienced at caring for themselves. A significant portion of these patients suffer from mental health problems-most commonly depression (Jessup & Roth, 1988; Schuckit, 1979). Pregnant women who would otherwise seek prenatal care may fear being reported to authorities, facing prosecution for their substance use, or even losing custody of the child. Not uncommonly, these women harbor tremendous guilt and shame (Deren, 1986; Harrison, 1991; Rosenbaum, 1979), which can be exacerbated by the disapproval they sense from health care providers. These formidable obstacles underscore the importance of maintaining a non-judgmental approach to these patients and utilizing referral to specialized multidisciplinary clinics where available. Participation in prenatal clinics designed to meet the complex medical and social needs of these patients has been associated with improvement in overall perinatal outcome (Andres, Wilson, Elk, & Grabowski, 1994; MacGregor, Keith, Bachicha, & Chasnoff, 1989; Racine et al., 1993). An important aspect of these efforts is patient education regarding the deleterious effects of their substance use on the fetus. In addition,
appropriate screening for preterm labor, abnormalities of fetal growth, and associated medical complications must be undertaken to optimize perinatal outcome. These efforts depend upon correct identification of substance use among patients attending prenatal clinics as well as the substantial number of patients who receive their prenatal care by haphazard and infrequent visits to different hospitals and various emergency rooms. Clinicians must retain a high level of clinical suspicion for substance use--some evidence suggests that current levels of suspicion and testing fail to detect the majority of cases (Maynard, 1991). While the search for substance use should extend to all patients, several studies have unfortunately shown a racial bias in both drug testing and reporting (Chasnoff et al., 1990; Chavkin, 1991). To complement this increased vigilance in patient screening, clinicians should further review the signs and symptoms of substance use and the techniques of obtaining an accurate drug use history (Jessup, 1990; Jessup & Roth, 1988; Lowinson, 1992). Medical education must strive to improve this aspect of training. Assuring patients of confidentiality and advocacy will encourage them to trust and to disclose. Lastly, as a routine part of prenatal care, education concerning the effects of substance use should be provided to all patients, not limited to those judged to be at risk. Clinicians should familiarize themselves with the local requirements for drug testing and reporting (Horowitz, 1991)--recent data showed that over half (52%) of the respondents to a questionnaire surveying obstetric and pediatric programs were unaware of their state's requirements for reporting prenatal cocaine use (Pelham & DeJong, 1992). Health care providers also need to fully investigate the available treatment options for these patients. Maximizing these options becomes especially important as there are generally an inadequate number of rehabilitation programs (Oberman, 1990; Racine et al., 1993) and a significant number that categorically refuse treatment to pregnant women (Chavkin, Allen, Oberman, 1991; Chavkin & Kandall, 1990). CONCLUSION The complex problem of substance use in pregnancy raises numerous medical, ethical, social, and financial concerns. While debate among policymakers is ongoing, clinicians must care for these patients on a daily basis. Non-judgmental, non-punitive prenatal care, with high indices of clinical suspicion and vigilant screening, forms an important clinical intervention. In this way, clinicians have a unique opportunity to make a difference for these patients and improve the health of both mother and child. REFERENCES Abel, E.L., & Sokol, R.J. (1987). Incidence of fetal alcohol syndrome (FAS) and FAS-related anomalies. Drug and Alcohol Dependence, 266, 51-70.
Issues in Perinatal Drug Use Andres, R.L., & Jones, K.L. (1994). Social and illicit drug use in pregnancy. In R.K. Creasy & R. Resnik (Eds.), Maternal-Fetal Medicine (3rd ed.) (pp. 182-198). Philadelphia: W.B. Saunders. Andres, R.L., Wilson, P.D., Elk, R., & Grabowski, J. (1994). Adjunctive behavioral therapy is associated with a decrease in the incidence of preterm labor and delivery in pregnant drug users. American Journal of Obstetrics and Gynecology, 170, 333. Beak R. (1984). Can I sue mommy?: An analysis of a woman's tort liability for prenatal injuries to her child born alive. San Diego Law Review, 21,325-370. Black, R. & Mayer, J. (1981). Parents with special problems: Alcoholism and opiate addiction. In H. Kempe & R. Helfer (Eds.), The battered child (3rd ed.) Chicago: University of Chicago Press. Bonbrest v. Kotz, F. Suppl. 65:138 (D.D.C. 1946). Calhoun, B.C., & Watson, P.T. (1991). The cost of maternal cocaine abuse: I. Perinatal cost. Obstetrics & Gynecology, 78, 731-734. Center for Disease Control. (1990). Prevalence of illicit drug use by pregnant women--Rhode Island. Morbidity and Mortality Weekly Report, 39, 225. Chasnoff, I.J. (1989). Drug use and women: establishing a standard of care. Annals of the New York Academy of Sciences, 562, 208-210. Chasnoff, l.J. (1991). Drugs, alcohol, pregnancy, and the neonate: pay now or pay later. Journal of the American Medical Association, 266, 1567-1568. Chasnoff, I.J., Landres, H.J., & Barrett, M.E. (1990). The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. New England Journal of Medicine, 322, 1202-1206. Chavkin, W.C. (1991). Mandatory treatment for drug use during pregnancy. Journal of the American Medical Association, 266, 1556--1561. Chavkin, W.C., Allen, M.H., & Oberman, M. (1991). Drug abuse and pregnancy: some questions on public policy, clinical management, and maternal and fetal rights. Birth, 18, 107-112. Chavkin, W.C., & Kandall, S.R. (1990). Between a rock and a hard place: Perinatal drug abuse. Pediatrics, 85, 223-225. Chervenak F.A., & McCullough L.B. (1990a). Does obstetric ethics have any role in the obstetrician's response to the abortion controversy? American Journal of Obstetrics & Gynecology, 163, 1425-1429. Chervenak, F.A. & McCullough, L.B. (1990b). Preventive ethics strategies for drug abuse during pregnancy. Journal of Clinical Ethics, 1, 157-158. Collins, E.F. (1983-1984). An overview and analysis: prenatal torts, preconception torts, wrongful life, wrongful death, and wrongful birth: Time for a new framework. Journal of Family l~;w, 22, 677709. Connolly, W.B., & Marshall, A.B. (1991) Drug addiction, pregnancy, and childbirth: legal issues for the medical and social services communities. Clinics in Perinatology, 18, 147-186. Denison, J. (1991). The efficacy and constitutionality of criminal punishment for maternal substance abuse. Southern California Law Review, 64, 1103-1141. Deren, S. (1986). Children of substance abusers: a review of the literature. Journal of Substance Abuse Treatment, 3, 77-94. Dobson, T., & Eby, K. (1992). Criminal liability for substance abuse during pregnancy: the controversy of maternal v. fetal rights. Saint Louis Law Journal, 36, 655-694. Dougherty, C.J. (1985). The right to begin life with a sound body and mind: fetal patients and conflicts with their mothers. Universi O" of Detroit La~ Review, 63, 89-117. Elk, R., Schmitz, J., Manfredi, L., Rhoades, H., Andres, R.L., & Grabowski, J. (1994). Brief report: cessation of cocaine use during pregnancy: a preliminary comparison. Addictive Behaviors, 19, 697-702. Evans, A.T., & Gillogley, K.M. (1991). Drug use in pregnancy: obstetric perspectives. Clinics in Perinatology, 18, 23-32. Fiks, K., Johnson, H.L., & Rosen, T.S. (1985). Methadone maintained mothers: 3-year follow-up of parental functioning. International Journal ~?fthe Addictions, 20, 651-660.
485 Fink. D.J. (1990). Effects of crack and cocaine on infants: a brief review of the literature. Clearinghouse Review, 24, 460-466. Frank, D.A., Zuckerman, B.S., Amaro, H., Aboagye, K., Bauchner, H., Cabral, H., Fried, L., Hingson, R., Kayne, H., & Levinson, S.M. (1988). Cocaine use during pregnancy: prevalence and correlates. Pediatrics, 82, 888-895. Garcia, S.A. (1992). Drug addiction and mother/child welfare: rights, laws, and discretionary decisionmaking. Journal of Legal Medicine, 13, 129-203. Gillogley, K.M., Evans, A.T., Hausen, R. Samuels, S.J., & Batra, K.K. (1990). the perinatal impact of use of cocaine, amphetamine, and opiate use detected by universal intrapartum screening. American Journal of Obstetrics and Gynecology, 163, 1535-1542. Gomby, D.S., & Shiono, P.H. (1991). Estimating the number of substance-exposed infants. In Behrman, R.E. (Ed.), The future of children. Los Altos: The Center for the Future of Children, The David and Lucille Packard Foundation. Goodwin, D.W. (1979). Alcoholism and heredity. A review and hypothesis. Archives of General Psychiatry, 36, 57-61. Harrison, M. (1991). Drug addiction in pregnancy: the interface of science, emotion, and social policy. Journal of Substance Abuse Freatment, 8, 261-268. Hawks, R.L., & Chiang, C.N. (1986). Urine testing for drugs of abuse. NIDA Research Monograph, 73. Horowitz, R.M. (1991). Drug use in pregnancy: To test, to tell--legal implications for the physicians. Seminars in Perinatology, 15, 324-330. Hurt, H. (1990). 1000 babies: Philadelphia 1989. Pediatric Research, 27, 93A (Suppl.). Jessup, M. (1990). The treatment of perinatal addiction: Identification, intervention, and advocacy. Western Journal of Medicine, 152, 553-558. Jessup, M., & Roth, R. (1988). clinical and legal perspectives on prenatal drug and alcohol use: guidelines for individual and community response. Medicine and Law, 7, 377-389. Kaplan, H.I., & Sadock, BJ. (1991). DSM-III-R. In H.I. Kaplan & B.J. Sadock (Eds.), Synopsis of psychiatry, behavioral sciences, clinical psychiatry (6th ed,) (p. 279). New York: Williams & Wilkins. Khalsa, J.H., & Gfroerer, J. (1991). Epidemiology and health consequences of drug abuse4 among pregnant women. Seminars in Perinatology, 15, 265-270. Lowinson, J.H. (1992). Substance abuse--A comprehensive textbook (2nd ed.). New York: Williams and Wilkens. MacGregor, S.N., Keith, L.G., Bachicha, J.A., & Chasnoff, I.J. (1989). Cocaine abuse during pregnancy: correlation between prenatal care and perinatal outcome. Obstetrics and Gynecology, 74, 882-885. Maternal rights and fetal wrongs: The case against criminilization of "fetal abuse" (1988). Harvard Law Review, 101,994-1012. Maynard, E.C. (1991). Testing for maternal drug abuse: How much is enough? Pediatrics, 87, 742. Merrick, J.C. (1993) Maternal substance abuse during pregnancy: Policy implications in the United States. Journal of" Legal Medicine, 14, 57-71. Moss, K. (1990). Substance abuse during pregnancy. Han,ard Women's Law Journal, 13, 278-299. Myers, J.B. (1984). Abuse and neglect of the unborn: Can the state intervene? Duquesne Law Review, 23, 1-76. Neerhof, M.G., MacGregor, S.N., Retsky, S.S., & Sullivan, T.P. (1989). Cocaine abuse during pregnancy: peripartum prevalence and perinatal outcome. American Journal of Obstetrics and Gynecology, 161,633-638. Oberman, M. (1990). Sex drugs, and pregnant addicts: an ethical and legal critique of societal response to pregnant addicts. Journal of Clinical Ethics, 1, 145-152. Pelham, T.L., & DeJong, A.R. (1992). Nationwide practices for screening and reporting prenatal cocaine abuse: A survey of teaching programs. Child Abuse and Neglect, 16, 763-770. People v. Stewart, No. M508197 (San Diego Municipal Court, February 26, 1987).
486 Racine, A., Joyce, T., & Anderson, R. (1993). The association between prenatal care and birth weight among women exposed to cocaine in New York City. Journal of the American Medical Association, 270, 1581-1586. Regan, D.O., Ehrlich, S.M., & Finnegan, L.P. (1987). Infants of drug addicts: At risk for child abuse, neglect, and placement in foster care. Neurotoxicology & Teratology, 9, 315-319. Reyes v. Superior Court (1977) Cal Rptr, 141:912. Robin-Vergeer, B.I. (1990). The problem of drug-exposed newborns: a return to principled intervention. Stanford Law Review, 42, 745-809. Robins, L.N., & Mills, J.L. (1993). Effects of in utero exposure to street drugs. American Journal of Public Health, 83, 2-32 (Suppl.). Rosenbaum, M. (1979) Difficulties in taking care of business: women addicts as mothers. American Journal of Drug and Alcohol Abuse, 6, 431-446. Rubenstein, L. (1991). Prosecuting maternal substance abusers: an unjustified and ineffective policy. Yale Law Policy Review, 9, 130--160. Schuckit, M.A. (1979). Drug and alcohol abuse: a clinical guide to diagnosis and treatment. New York and London: Plenum Press. Serdula, M., Williamson, D.F., Kendrick, J.S., Anda, R.F., & Byers, T. (1991). Trends in alcohol consumption by pregnant women--1985 through 1988. Journal of the American Medical Association, 265, 876-879.
M. Anderson et al. Sexton, P.A. (1993). Imposing criminal sanction on pregnant drug users: Throwing the baby out with the bathwater. Washburn Law Journal, 32, 410-430. Shelly, B. (1988). Maternal substance abuse: The next step in the protection of fetal rights? Dickinson Law Review, 92, 691-715. Smith v. Brennan, A. 2d. 157:497 (New Jersey 1960). Solomon, R.I. (1991). Future fear: prenatal duties imposed by private parties. American Journal of Law Medicine, 17, 411-434. State v. Johnson, No. E89-890-CFA (18th Jud. Cir. For Seminole County, Florida, July 13, 1989). Wasserman, D.R., & Leventhal, J.M. (1993). Maltreatment of children born to cocaine-dependent mothers. American Journal of Diseases of Children, 147, 1324-1328. Wilkins, M.D. (1990). Solving the problem of prenatal substance abuse: An analysis of punitive and rehabilitative approaches. Emor3, Law Journal, 39, 1401-1442. Wood, C.W. (1987). Parental rights termination: Are the interests of parents, children, and the state mutually exclusive? Stetson Law Review, 17, 295-318. Zuckerman, B.S., Frank, D.A., Hingson, R., Amaro, H., Levenson, S.M., Kayne, H., Parker, S., Vinci, R., Aboagye, K., & Fried, L.E. (1989). Effects of maternal marijuana and cocaine use on fetal growth. New England Journal of Medicine, 320, 762-768.