Substance abuse among pregnant women and women with children is one of the most emotionally charged issues of our day. Many physicians who provide care to these women are ignorant of aspects of substance abuse outside their own narrow confines. Ways of preventing in utero drug exposure are rarely discussed and even thought to be futile, short of instituting draconian measures. Many physicians assume that drug-dependent women have failed treatment for substance abuse or refused it and are unaware that often no treatment is available. Although "crack babies" have grabbed headlines for over 10 years, public concern has not resulted in a substantial increase in treatment programs for pregnant women and women with children, even though there has been a 500 percent increase in federal block grants for this purpose. Rather, we have taken infants and children away from their mothers -- a very expensive solution that does not prevent the birth of the next drug-exposed baby.
It is important for physicians to be knowledgeable about public health and public policy, because they are often advocates and makers of public policy and their ability to provide care may be directly affected by public policy. Numerous nonmedical issues and agencies substantially affect the treatment of drug dependency. Some widespread treatment programs are designed to serve men and often fail women, because they cannot accommodate infants and children in residential treatment, provide child care during treatment, or diagnose and treat mental illness separately from substance abuse (dual diagnoses). Nor do they provide a psychologically safe or friendly environment in which women can discuss the problems associated with their drug dependency, such as prostitution, trading sex for drugs, child abuse and neglect, and domestic violence. The criminal-justice system, the child-welfare system, the educational system, the state and federal legislatures, and the complex and changing labyrinths of reimbursement all substantially affect the development of effective treatment programs. Pregnant women, and women with children especially, need drug-dependency treatment programs that provide and integrate all the services they require and help them mediate the conflicting demands of various agencies.
Missouri developed a successful comprehensive community-based care program, the Comprehensive Substance Abuse Treatment and Rehabilitation program. This program is based on case management, including interagency case coordination, the use of multidisciplinary teams, emphasis on individualized long-term treatment, and the provision of housing and child care. A different approach in South Carolina developed because of ignorance regarding substance-abuse treatment by well-meaning obstetricians and neonatologists. There, the law requires that "suspected" pregnant drug users, predominantly black women, be tested for illicit drugs. If the test is positive, these pregnant women are required under criminal penalty to participate in drug treatment programs, although such programs often do not exist. This law has recently been upheld by the state supreme court. Lest people think that South Carolina is an exception, similar situations, without incarceration, are widespread: newborns are taken away from their mothers at birth unless the women enter drug treatment programs. But the availability of programs that accommodate women with newborns or children is very limited, even where they exist, and there are often long waits to get into them.
There are fine chapters on legislative mandates, the financing of drug-dependency treatment, the role of the courts, and child welfare in Drug-Dependent Mothers and Their Children. The chapter on teratogenic effects is an excellent presentation of fetal alcohol syndrome, but the information on other drugs is limited. The chapter on the health care needs of drug-affected children and their families is weak, because it does not focus on children and fails to discuss some specific health issues relevant to children, such as the prevention of human immunodeficiency virus and hepatitis B transmission from mother to fetus or baby, the prevalence of chronic illnesses, noncompliance with well-baby and well-child visits and immunization recommendations, and the lack of medical or immunization records when these children abruptly enter foster care. This book is appropriate for those who provide general medical care to drug-dependent women or their children and wish to have a broader understanding of the implications of drug treatment for women with infants and children. For those who work in the area of drug dependency it offers information and guidance about an oft-ignored population.
Reviewed by Delia A. Dempsey, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
Product Description
George Washington Univ. Presents a synthesis of the state of knowledge about fetal exposure to illicit drugs. Describes a comprehensive model for services, resources to deliver those services, and approaches to training personnel. 26 contributors, 24 U.S.
