United States General Accounting Office
___________________________________________________________________
GAO Report to the Chairman,
Committee on Finance, U.S. Senate
___________________________________________________________________
June 1990 DRUG-EXPOSED INFANTS
A Generation at Risk
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B-238209
June 28, 1990
The Honorable Lloyd Bentsen
Chairman, Committee on
Finance
United States Senate
Dear Mr. Chairman:
This report responds to your request, in which you expressed
concern over the growing number of infants born to mothers
using drugs and the impact this is having on the nation's
health and welfare systems. Specifically, you asked that we
assess the (1) extent of the problem; (2) health effects and
medical costs of infants born exposed to drugs compared with
the costs of those who were not; (3) impact of these births
on the social welfare system; and (4) availability of drug
treatment and prenatal care to drug-addicted pregnant women.
BACKGROUND
----------
Unlike the drug epidemics of the 1960s and 1970s, which
primarily involved men addicted to heroin, the current drug
epidemic has affected many women of childbearing age. The
National Institute on Drug Abuse (NIDA) estimated that in
1988, 5 million women of childbearing age used illicit
drugs.#1 Experts attribute the increase in female drug
users to the existence of crack or smokable cocaine, which
is readily accessible, a relatively low cost drug, and
easier to use than drugs that must be injected. Cocaine,
other drugs and alcohol are often used in combination.
Use of cocaine and other drugs during pregnancy may affect
both the mother and the developing fetus. Cocaine, for
example, may cause constriction of blood vessels in the
placenta and umbilical cord, which can result in a lack of
oxygen and nutrients to the fetus, leading to poor fetal
growth and development.
1Frequently used illicit drugs include crack cocaine,
heroin, PCP, marijuana, amphetamines, methamphetamines, and
barbiturates.
1
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Although definitive information does not exist about the
long-term effects of drug use during pregnancy, researchers
have reported that some infants who were prenatally exposed
to stimulant drugs like cocaine have suffered from a stroke
or hemorrhage in the areas of the brain responsible for
intellectual capacities.
In addition to the effects of prenatal drug exposure, drug-
abusing pregnant women often imperil their health and that
of their infants in other ways. These women do not receive
the benefits of proper health care. The majority of women
of childbearing age who abuse drugs suffer from many social,
psychological, and economic problems.
The Office of National Drug Control Policy is responsible
for developing an annual national anti-drug strategy.#2 The
1990 National Drug Control Strategy calls for spending $10.6
billion in fiscal year 1991, with 71 percent of the funds
going to drug-supply-reduction activities and 29 percent to
reduce the demand for drugs. Under this strategy, $1.5
billion would be spent on drug treatment with over one-half
of the federal funds provided through the Department of
Health and Human Services (HHS) block grants to the states
administered by the Alcohol, Drug Abuse and Mental Health
Administration (ADAMHA). The states are required to set
aside at least 10 percent of these funds to provide drug
abuse prevention and treatment for women.
In addition, the Office for Substance Abuse Prevention
within ADAMHA has a program that provides demonstration
grants to public and private providers for model projects
for substance-abusing pregnant and postpartum women and
their infants.
OBJECTIVES, SCOPE, AND METHODOLOGY
----------------------------------
We interviewed leading neonatologists, drug treatment
officials, researchers, hospital officials, social welfare
authorities, and drug-addicted pregnant women to determine:
(1) the number of infants born drug-exposed, (2) their
impact on the medical and social services systems, (3)
their health costs, and (4) the availability of drug
treatment and prenatal care. We also reviewed the current
literature.
2The Office of National Drug Control Policy was established
by the Anti-Drug Abuse Act of 1988.
2
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We obtained data on drug-exposed births from 1986 through
1988 from HHS to develop a nationwide estimate of the number
of drug-exposed infants. The National Hospital Discharge
Survey collects information on the diagnoses associated with
hospitalization of adults and newborns in all nonfederal
short-stay hospitals. Newborn discharge data from the
survey for 1986 and 1988 were used to calculate nationwide
estimates.
We also selected two hospitals in each of five cities--
Boston, Chicago, Los Angeles, New York, and San Antonio--in
which we reviewed medical records to determine the number of
drug-exposed infants born and to assess differences in
hospital charges between drug-exposed and nonexposed
infants. These 10 hospitals, which accounted for 44,655
births in 1989, primarily served a high proportion of
persons receiving Medicaid and other forms of public
assistance. Births at these hospitals ranged from 5 percent
of all infants in New York City to 42 percent of all births
in San Antonio. We considered an infant to be drug-exposed
if any of the following conditions were documented in the
medical record of the infant or mother: (1) mother self-
reported drug use during pregnancy, (2) urine toxicology
results for mother or infant were positive for drug use, (3)
infant diagnosed as having drug withdrawal symptoms, or (4)
mother was diagnosed as drug dependent.#3 We also
interviewed officials at 10 other hospitals in these cities
that serve predominantly non-Medicaid patients, but we did
not review patient medical records. Our methodology is
discussed more fully in appendix VI.
Our work was performed from January through April 1990 in
accordance with generally accepted government auditing
standards. The results are summarized below and are
discussed more fully in appendixes I through IV.
MANY DRUG-EXPOSED INFANTS
-------------------------
WHO MIGHT NEED HELP
-------------------
ARE NOT IDENTIFIED
------------------
Identifying infants who have been prenatally exposed to
drugs is the key to providing them with effective medical
and social interventions at birth and as they grow up. Such
identification is also necessary to understand the nature
and magnitude of the problem in order to target drug
3Alcohol use during pregnancy was not included in our
definition of maternal drug use.
3
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treatment and prenatal care services to drug-addicted
pregnant women and other services to infants.
There is no consensus on the number of infants prenatally
exposed to drugs each year. The administration's 1989
National Drug Control Strategy reported that an estimated
100,000 infants were exposed to cocaine each year.#4 The
president of the National Association for Perinatal
Addiction Research and Education estimates as many as
375,000 infants may be drug exposed each year. Neither
estimate, however, is based on a national representative
sample of births.
Our analysis of the National Hospital Discharge Survey
identified 9,202 infants nationwide with indications of
maternal drug use during pregnancy in 1986.#5 By 1988, the
latest year that data were available, the number had grown
to 13,765 infants.#6,#7 However, this represents a
substantial undercount of the total problem because
physicians and hospitals do not screen and test all women
and their infants for drugs.
Research has found that when screening and testing is
uniformly applied, a much higher number of drug-exposed
infants are identified. For example, one recent study
documented that hospitals that assess every pregnant woman
or newborn infant through rigorous detection procedures,
such as a review of the medical history and urine toxicology
for drug exposure, had an incidence rate that was three to
five times greater than hospitals that relied on less
4The strategy does not mention the number of infants exposed
to other drugs.
5The estimate ranged from 7,178 to 11,226 at a 95-percent
confidence interval.
6The estimate ranged from 8,259 to 19,271 at a 95-percent
confidence interval.
7This survey identified drug-exposed infants based on
discharge codes indicating that the infant was affected by
maternal drug use or showed drug withdrawal symptoms.
Discharge codes refer to the International Classification of
Diseases, Ninth Revision, Clinical Modifications ICD-9-CM,
3rd edition: codes 760.70, 760.72, 760.73, and 779.5.
4
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rigorous methods of detection.#8 The average incidence of
drug-exposed infants born at hospitals with rigorous
detection procedures was close to 16 percent of those
hospitals' births, as compared with 3 percent at hospitals
with no substance abuse assessment.
A study conducted at a large Detroit hospital accounting for
over 7,000 births used meconium testing,#9 a more sensitive
test for detecting drug use. The incidence of drug-exposed
infants at this hospital was 42 percent or nearly 3,000
births in 1989. In contrast, when self-reported drug use by
the mother was the basis for identifying drug-exposed
infants, only 8 percent or nearly 600 infants were
identified.#10
Likewise, our work indicates that the National Hospital
Discharge Survey undercounts the incidence of drug-exposed
births. In our examination of medical records at 10
hospitals, we identified approximately 4,000 drug-exposed
infants born in 1989. Our estimates ranged from 13 drug-
exposed births per thousand births at one hospital to 181
per thousand births at another.
The wide range in the numbers of drug-exposed infants we
found may be associated with differences in the hospitals'
efforts to identify drug-exposed infants. One hospital, for
example, did not have a protocol for assessing drug use
during pregnancy. This hospital had the lowest incidence of
drug-exposed infants. The other 9 hospitals' protocols
required testing primarily if the mother reported her drug
use or the infant manifested drug withdrawal signs.
Hospital officials acknowledge that these screening criteria
allow many drug-exposed infants to go undetected in the
hospital. This is because many drug-exposed infants display
few overt drug withdrawal signs and many women deny using
8Ira J. Chasnoff, "Drug Use and Women: Establishing a
Standard of Care," Prenatal Use of Licit and Illicit Drugs,
ed., Donald E. Hutchings, New York: New York Academy of
Sciences, 1989.
9Meconium is the first 2- to 3-days' stool of a newborn infant.
10Enrique M. Ostrea, Jr., A Prospective Study of the
Prevalence of Drug Abuse Among Pregnant Women. Its Impact on
Perinatal Morbidity and Mortality and on the Infant Mortality
Rate in Detroit. July 13, 1989, preliminary report.
5
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drugs out of fear of being incarcerated or having their
children taken from them.
We also found that in hospitals serving primarily non-
Medicaid patients, screening for drug exposure was even less
prevalent. In our interviews with hospital officials at
these hospitals, one-half of the hospitals did not have a
protocol for identifying drug use during pregnancy. Some
hospital officials told us that the problem of prenatal drug
exposure was not considered serious enough to warrant
implementing a drug testing protocol.
However, one recent study has found that the problem of drug
use during pregnancy is just as likely to occur among
privately insured patients as among those relying on public
assistance for their health care. This study anonymously
tested for drug use among women entering private obstetric
care and women entering public health clinics for prenatal
care and found that the overall incidence of drug use was
similar between the two groups (16.3 percent for women seen
at public clinics and 13.1 percent for those seen at private
offices).#11 (See app. I.)
DRUG-EXPOSED INFANTS
--------------------
HAVE MORE HEALTH PROBLEMS
-------------------------
AND ARE MORE COSTLY
-------------------
Drug-exposed infants are more likely than infants not
exposed to drugs to suffer from a greater range of medical
problems and in some cases require costly medical care. We
compared the medical problems and costs of infants
prenatally exposed to drugs, with those who were not, at
four hospitals. At these four, we determined that at least
10 percent of the infants were prenatally exposed to
drugs.#12 The mothers of the drug-exposed infants were
more likely to have had little or no prenatal care, and the
infants had significantly lower birth weights, were often
11Ira J. Chasnoff, Harvey J. Landress, and Mark E. Barrett,
"The Prevalence of Illicit-Drug or Alcohol Use During
Pregnancy and Discrepancies in Mandatory Reporting in
Pinellas County, Florida." The New England Journal of
Medicine, Vol. 322, Apr. 26, 1990, pp. 1202-06.
12The other six hospitals did not have enough cases to enable
us to analyze differences in hospital charges and other
characteristics of drug-exposed infants and those not exposed
to drugs.
6
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premature, and had longer and more complicated hospital
stays than other infants.
Given these medical problems, hospital charges for drug-
exposed infants were up to four times greater than those for
infants with no indication of drug exposure. For example,
at one hospital the median charge for drug-exposed infants
was $5,500, while the median charge incurred by nonexposed
infants was $1,400. Charges for drug-exposed infants at
these hospitals ranged from $455 to $65,325. Because more
than 50 percent of all patients received public medical
assistance at 7 of the 10 hospitals in our study, much of
these charges were covered by federal assistance programs.
Although the long-term physical effects of prenatal drug
exposure are not well known, indications are that some of
these infants will continue to need expensive medical care
as they grow up. Because of the uncertainty of the long-
term consequences of prenatal drug exposure, the future
costs of caring for these children are unknown. (See app.
II.)
IMPACT ON SOCIAL WELFARE
------------------------
AND EDUCATIONAL SYSTEMS
-----------------------
COULD BE PROFOUND
-----------------
Drug-exposed infants often present immediate and long-term
demands on the social welfare system. Officials at several
of the hospitals in our review stated that they are
experiencing a growing number of "boarder babies"--infants
who stay in a hospital for nonmedical reasons often related
to drug-abusing families. Boarder babies are reported to
the social welfare system for foster care placement.
We also found that a substantial proportion of drug-exposed
infants did not go home from the hospital with their
parents. An estimated 1,200 of the 4,000 drug-exposed
infants born in 1989 at the 10 hospitals in our review were
placed in foster care. The cost of 1 year of foster care
for these 1,200 infants is about $7.2 million.
Not all drug-exposed infants enter the social services
system at birth; some are discharged from the hospital to
drug-abusing parents. These infants may later enter the
social services system because of the chaotic and often
dangerous environment associated with parental drug abuse--
an increasing source of child abuse and neglect. For
example, cocaine use was found to be significantly
associated with child neglect in a recent study of child-
7
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abuse investigations in Boston. Hospital officials told us
that they are seeing more young children from drug-abusing
families admitted to hospitals because they suffered
physical neglect or maltreatment at the hands of someone on
drugs.
City and state officials we contacted told us that prenatal
drug exposure and drug-abusing families are placing
increasing demands on their social welfare systems.
Although they perceived the problem to be growing, most
could not provide statistics on the numbers of drug-related
foster care placements. Officials in New York, however,
estimate that 57 percent of foster care children come from
families that allegedly are abusing drugs.
Because the estimated demand for foster care nationwide has
increased 29 percent from 1986 to 1989, there is concern as
to whether the system can adequately respond to the needs of
drug-abusing families. Specifically, problems have been
identified regarding the availability of foster parents who
are willing to accept children who have been exposed to
drugs, the quality of foster care homes, and the lack of
supportive health and social services to families who
provide foster care to these children.
Although definitive information is not yet available, many
drug-exposed infants may have long-term learning and
developmental deficiencies that could result in
underachievement and excessive school dropout rates leading
to adult illiteracy and unemployment. As increasing numbers
of drug-exposed infants reach school age, the long-term
detrimental effects of drug exposure will become more
evident. The cost of minimizing the long-term effects of
drug exposure will vary with the severity of disabilities.
For example, at a pilot preschool program for mildly
impaired prenatally drug-exposed children in Los Angeles,
the per capita cost is estimated to be $17,000 per year.
The Florida Department of Health and Rehabilitative Services
estimates that for those drug-exposed children who show
significant physiologic or neurologic impairment total
service costs to age 18 could be as high as $750,000. (See
app. III.)
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LACK OF DRUG TREATMENT AND PRENATAL
-----------------------------------
CARE IS CONTRIBUTING TO THE NUMBER
----------------------------------
OF DRUG-EXPOSED INFANTS
-----------------------
To prevent the problem of drug-exposed infants, women of
childbearing age must abstain from using drugs. To reduce
the impact of drug exposure, pregnant women who use drugs
should be encouraged to stop and be given needed treatment.
Drug Treatment Services
-----------------------
Do Not Meet the Need
--------------------
Recent studies show that if women are able to stop drug use
during pregnancy, there will be significant positive effects
in the health of the infant. The risks of low birth weight
and prematurity, which often require expensive neonatal
intensive care, are minimized by drug treatment before the
third trimester.
Many programs that provide services to women, including
pregnant women, have long waiting lists. Treatment experts
believe that unless women who have decided to seek treatment
are admitted to a treatment facility the same day, they may
not return. However, women are rarely admitted the day they
seek treatment. One treatment center in Boston received 450
calls for detoxification services during a 1-month period.
The callers were told that it usually took 1 to 2 weeks to
be admitted. They were also instructed to call back every
day to determine if a slot had become available. Of the 450
callers that month, about one-half never called back and
about 150 were eventually admitted to treatment.
Nationwide, drug treatment services are insufficient. A
1990 survey conducted by the National Association of State
Alcohol and Drug Abuse Directors, Inc. (NASADAD), estimates
that 280,000 pregnant women nationwide were in need of drug
treatment, yet less than 11 percent of them received
care.#13 Hospital and social welfare officials in each of
the five cities in our review also told us that drug
treatment services were insufficient or inadequate to meet
the demand for services of drug-addicted pregnant women.
In addition to insufficient treatment, some programs deny
services to pregnant women. A survey of 78 drug treatment
programs in New York City found that 54 percent of them
denied treatment to pregnant women. One of the primary
reasons treatment centers are reluctant to treat pregnant
women relates to issues of legal liability. Drug treatment
providers fear that certain treatments using medications and
13The report did not reveal the extent to which these women
sought treatment.
9
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the lack of prenatal care or obstetrical services at the
clinics may have adverse consequences on the fetus and
thereby expose the providers to legal problems.
Many other barriers to treatment exist. For example,
pregnant addicts we interviewed told us that because they
had other children, the lack of child care services made it
difficult for them to seek treatment. Most treatment
programs do not provide child care services.
Another barrier to treatment for women is the fear of
criminal prosecution. Drug treatment and prenatal care
providers told us that the increasing fear of incarceration
and losing children to foster care is discouraging pregnant
women from seeking care. Women are reluctant to seek
treatment if there is a possibility of punishment. They
also fear that if their children are placed in foster care,
they will never get the children back.
Prenatal Care Is Needed
-----------------------
Prenatal care can help prevent or at least ameliorate many
of the problems and costs associated with the births of
drug-exposed infants. Through the three basic components of
prenatal care: (1) early and continued risk assessment, (2)
health promotion, and (3) medical and psychosocial
interventions and follow-up, the chances of an unhealthy
infant are greatly reduced. Hospital officials told us that
in addition to not seeking prenatal care, some drug-using
women are now delivering their infants at home in order to
prevent being reported to child welfare authorities.
Many health professionals believe comprehensive residential
drug treatment that includes prenatal care services is the
best approach to helping many women stop using drugs during
pregnancy and providing the developing infant with the best
chance of being born healthy. However, such programs are
scarce.
Massachusetts officials told us that the lack of residential
treatment slots was a major problem. Only 15 residential
treatment slots are available to pregnant addicts statewide.
California officials made similar comments. These officials
also reported that when they are unable to place drug-
addicted pregnant women in residential treatment, they try
to place these women in battered women shelters or even in
nursing homes. (See app. IV.)
10
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CONCLUSIONS
-----------
Despite growing indications of a serious national problem,
hospital procedures do not adequately identify drug use
during pregnancy. Consequently, there are no reliable data
on the number of drug-exposed infants born each year.
However, based on our review at hospitals in five cities, we
believe the number of drug-exposed infants born nationwide
each year could be very high.
A drug-exposed infant has short- and long-term health,
social, and cost implications for society. These infants
are more likely to be born premature, have a lower birth
weight, and have longer hospital stays requiring more
expensive care. Some of them will need a lifetime of
medical care; others will have considerable developmental
problems, which may impair their schooling and employment.
Preventing drug use among women of childbearing age would
reduce the number of infants born drug exposed. Providing
drug treatment and prenatal care could significantly improve
the health of infants born to women who use drugs and could
reduce the risk of long-term problems. Yet in the five
cities in our review, drug treatment was largely unavailable
and many women giving birth to drug-exposed infants are not
receiving adequate prenatal care.
MATTERS FOR CONSIDERATION
-------------------------
BY THE CONGRESS
---------------
Because the increasing number of drug-exposed infants has
become a serious health and social problem, we believe an
urgent national response is necessary. Specifically,
outreach services should be provided so that pregnant women
in need of prenatal care and drug treatment can be
identified. For these women, comprehensive drug treatment,
and prenatal care must be made available and accessible.
With additional federal funding, the large gap between the
number of women who could benefit from drug treatment and
the number of residential and outpatient slots currently
available could be reduced. If the Congress should decide
to expand the current federal resource commitment to
treatment for drug-addicted pregnant women, there are
several options that could be followed. These include:
-- Increasing the alcohol and drug abuse and mental health
services (ADMS) block grant to the states in order to
provide more federal support for drug treatment.
11
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-- Increasing the ADMS Women's Set-Aside from 10 percent
to a higher percentage to assure that expanded
treatment services under the block grant are targeted
specifically to substance-abusing pregnant women.
-- Creating a new categorical grant to provide
comprehensive prenatal care and drug treatment services
to substance-abusing pregnant women.
Although these options would require more funds in the short
term, we believe that this commitment could save money in
the long term as well as improve the lives of a future
generation of children.
- - - -
Copies of this report will be sent to the appropriate
congressional committees and subcommittees; the Secretary of
Health and Human Services; and the Director, Office of
Management and Budget, and we will make copies available to
other interested parties upon request.
If you have any questions about this report, please call me
on (202) 275-5451. Other major contributors to the report
are listed in appendix VII.
Sincerely yours,
Janet L. Shikles
Director for Health Financing
and Policy Issues
12
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CONTENTS
--------
LETTER 1
APPENDIX I
The Number of Drug-Exposed Infants May Be Seriously 16
Underestimated
The Number of Drug-Exposed Infants Could be High 16
Hospitals Lack Systematic Procedures to Identify 19
Drug-Exposed Infants
APPENDIX II
Drug-Exposed Infants Are Likely To Have Costly 23
Health Problems
Drug-Exposed Infants Are More Vulnerable At Birth 23
Hospital Charges Are Higher for Drug-Exposed 26
Infants
APPENDIX III
Prenatal Drug Abuse Has Increased Demand For 29
Social Services
Many Drug-Exposed Infants Enter Foster Care 29
Drug-Exposed Infants Are Vulnerable 33
to Developmental Problems That May
Affect Learning
APPENDIX IV
Lack of Drug Treatment and Prenatal Care 36
Contributing to the Number of Drug-Exposed Infants
Lack of Treatment for Drug-Addicted Pregnant Women 36
Prenatal Care Improves Birth Outcomes 38
APPENDIX V
Percentage Distribution of Infants Exposed to Drugs, 40
Including Cocaine
APPENDIX VI
Objectives, Scope, and Methodology 41
Hospital Selection Criteria 41
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APPENDIX VII
Major Contributors to This Report 45
BIBLIOGRAPHY 46
FIGURES
(These figures are not included, they could not be viewed as ASCII text.)
Figure II.1:Mothers of Drug-Exposed Infants are More 23
Likely to Obtain Inadequate Prenatal
Care
Figure II.2:Drug-Exposed Infants More Often Have a Low 24
Birth Weight As Compared with Nonexposed
Infants
Figure II.3:Drug-Exposed Infants Are More Likely to be 25
Born Prematurely Than Nonexposed Infants
Figure II.4:Drug-Exposed Infants Incur Higher Hospital 26
Charges than Nonexposed Infants
Figure III.1:Drug-Exposed Infants are More Likely to 30
be Admitted to Foster Care Than Nonexposed
Infants
TABLES
Table I.1:Drug-Exposed Infants Born at 10 Hospitals, 17
1989
Table I.2:Estimated Number of Infants with Indicators 20
of Possible Drug Exposure Not Tested
in Nine Hospitals, 1989
Table I.3:Percentage of Infants with Two or More 21
Indicators of Possible Drug Exposure Who Were
or Were Not Tested and the Percentage of Drug-
Exposed Infants At Nine Hospitals
Table II.1:Estimated Hospitals Charges for Drug- 28
Exposed Infants at Three Hospitals in 1989
Table VI.1:Comparison of Births at Hospitals in GAO 42
Study With Total Births in the Respective
Cities, 1988
Table VI.2:Profile of Patients at Selected Hospitals 43
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ABBREVIATIONS
-------------
ADAMHA Alcohol, Drug Abuse and Mental Health
Administration
ADMS alcohol and drug abuse and mental health services
GAO General Accounting Office
HHS Department of Health and Human Services
NASADAD National Association of State Alcohol and Drug
Abuse Directors, Inc.
NIDA National Institute on Drug Abuse
15
APPENDIX I APPENDIX I
THE NUMBER OF DRUG-EXPOSED INFANTS
----------------------------------
MAY BE SERIOUSLY UNDERESTIMATED
-------------------------------
The identification of infants who have been prenatally exposed to
drugs is key to understanding the magnitude of the problem and
providing effective medical and social interventions for these
infants. However, there is no consensus on the number of drug-
exposed infants born in the United States each year. A
comprehensive nationwide study to specifically determine the
incidence of drug-exposed births has not been done. Additionally,
hospitals' procedures allow many drug-exposed infants to go
undetected.
THE NUMBER OF DRUG-EXPOSED
--------------------------
INFANTS COULD BE HIGH
---------------------
Based on data from the National Center for Health Statistics'
National Hospital Discharge Survey, which includes a representative
sample of all births, an estimated 9,202 drug-exposed infants were
born in 1986 in the United States.#14 By 1988, the latest year
that data were available, the number had grown to 13,765
infants.#15 However, this is likely to be a substantial undercount
of the problem. At present, physicians and hospitals do not
routinely screen and test all women and their infants for drugs.
Recent studies have found that when screening and testing are
uniformly applied, a much higher number of drug-exposed infants is
identified.
One study found that hospitals that assess every pregnant woman or
newborn infant through a medical history and urine toxicology had
an incidence rate that was three to five times greater than
hospitals that relied on less rigorous methods of detection.#16
The average incidence of drug-exposed infants born at hospitals
with rigorous detection procedures was close to 16 percent of all
births as compared with 3 percent of births at hospitals with no
substance-abuse assessment.
14The estimate ranged from 7,178 to 11,226 at a 95-percent
confidence interval.
15The estimate ranged from 8,259 to 19,271 at a 95-percent
confidence interval.
16Ira J. Chasnoff, "Drug Use and Women: Establishing a Standard
of Care," Prenatal Use of Licit and Illicit Drugs, ed. Donald E.
Hutchings. New York: New York Academy of Sciences, 1989.
16
APPENDIX I APPENDIX I
Likewise, our work indicates that the National Hospital Discharge
Survey underreports the incidence of drug-exposed births. Based on
our review of the medical records for both the women and their
infants at 10 hospitals, an estimated 3,904 drug-exposed infants
were born at these hospitals in 1989. (See table I.1.)#17
Estimates of the number of these infants ranged from a low of 13
per 1,000 births at one hospital to a high of 181 births per 1,000
at another. Maternal cocaine use was estimated to range from less
than 1 percent to 12 percent among the hospitals.
Table I.1: Drug-Exposed Infants Born at 10 Hospitals, 1989
----------------------------------------------------------
Estimated no.
of drug-exposed Estimated no.
Location/ infants per Total no. of drug-
hospital 1,000 births of births exposed infants
--------- --------------- --------- ---------------
Boston
1 72 3,294 237
2 89 1,438a 128
Chicago
1 181 3,604 652
2 47 4,250a 200
Los Angeles
1 148 8,020 1,187
2 54 8,175 441
New York
1 127 3,147 400
2 118 3,726 440
San Antonio
1 31 5,688 176
2 13 3,312 43
Total 44,655 3,904
aThe actual number of births is not available; therefore, the total
number of births for the year is estimated.
17Appendix V provides more detailed information on the degree of
drug-exposed infants identified at the 10 hospitals.
17
APPENDIX I APPENDIX I
HOSPITALS LACK SYSTEMATIC
-------------------------
PROCEDURES TO IDENTIFY
----------------------
DRUG-EXPOSED INFANTS
--------------------
We also found that the wide range in the number of drug-exposed
infants we identified at the different hospitals in our review may
be associated with the effort taken by hospitals to identify drug-
exposed infants. For example, one of the 10 hospitals did not have
a protocol for assessing drug use during pregnancy. This hospital
had the lowest incidence of drug-exposed infants. Protocols at the
remaining 9 hospitals did not require systematic screening and
testing of every mother and infant for potential substance use or
exposure. Instead, the protocols primarily required testing if the
mother reported her drug use or if drug withdrawal signs became
manifest in the infant.
Hospital officials acknowledge that these screening criteria allow
many drug-exposed infants to remain unidentified in the hospital.
For example, women often deny using drugs because they do not want
to be reported to the authorities for fear of being incarcerated or
having their children taken from them.
In addition, many cocaine-exposed infants display few overt drug
withdrawal signs. Some will show no signs of drug withdrawal,
while for others withdrawal signs may be mild or will not appear
until several days after hospital discharge. The visual signs of
drug exposure vary from severe symptoms to milder symptoms of
irritability and restlessness, poor feeding, and crying. Since
these milder symptoms are nonspecific, maternal drug use may not be
suspected unless urine testing is conducted.
Even when hospitals do conduct urinalysis, drug use may go
undetected if drug concentrations within the body are too low.
Urinalysis can only detect drugs used within the past 24 to 72
hours. According to recent studies, hair analysis and meconium
analysis, two testing methods for detecting drug use, have
advantages over urinalysis because they are more accurate or can
detect drug use over a longer period of time after drug use has
occurred.#18,#19,#20 One of the studies, conducted at a large
18Meconium is the first 2- to 3-days' stool of a newborn infant.
19Karen Graham and others, "Determination of Gestational Cocaine
Exposure by Hair Analysis," Journal of the American Medical
Association, Vol. 262 (Dec. 15, 1989), pp. 3328-30.
18
APPENDIX I APPENDIX I
urban hospital in Detroit accounting for over 7,000 births
annually, used meconium analysis to detect drug use during
pregnancy.#21 Preliminary results revealed that 42 percent of
infants were found to be drug-exposed in 1989.#22 However, the
hospitals in our review that conducted testing for drug exposure
relied exclusively on urinalysis.
When an infant does not show signs of drug withdrawal or the mother
does not self-report drug use, a physician may consider other
factors as presumptive of drug exposure during pregnancy and
recommend that drug testing be conducted. Such factors or
characteristics have been found to occur more often among drug-
exposed infants than infants not exposed to drugs and include (1)
inadequate prenatal care (defined as four or fewer prenatal care
visits for a pregnancy of 34 or more weeks),#23 (2) low birth
weight (defined as less than 5.5 pounds), and (3) low gestational
age or prematurity (defined as less than 38 weeks).#24,#25 (See
table I.2.)
We were able to obtain data from 9 of the 10 hospitals in our
review on the degree to which infants had these characteristics.
We identified an estimated 4,391 infants with two or more
characteristics of possible drug exposure. The last column of
20Enrique M. Ostrea, Jr., A Prospective Study of the Prevalence of
Drug Abuse Among Pregnant Women. Its Impact on Perinatal Morbidity
and Mortality and on the Infant Mortality Rate in Detroit. (July
13, 1989, preliminary report.)
21Ostrea, A Prospective Study of the Prevalence of Drug Abuse Among
Pregnant Women.
22The 42 percent of births identified as drug exposed using
meconium testing compares with 8 percent identified based on the
mother's self-reporting drug use.
23Institute of Medicine, Infant Death: An Analysis by Maternal Risk
and Health Care. Contrasts in Health Status, ed. D.M. Kessner,
Vol. 1 (Washington, D.C.: National Academy of Sciences, 1973), pp.
58-59.
24Gestational age refers to the period of time, normally 40 weeks,
from conception to an infant's birth.
25Maternal demographic characteristics and socioeconomic status
effect birth outcomes. Infant mortality and low birth weight rates
are higher for young, uneducated, unmarried, non-white women with
limited financial resources.
19
APPENDIX I APPENDIX I
table I.2 shows the number of infants with two or more drug-
exposure indicators who were not tested for drug exposure at the 9
hospitals where we obtained data. We estimate that at these
hospitals during 1989, there were 2,791 potentially drug-exposed
infants who were not tested, based on our review of hospital
medical records.
Table I.2: Estimated Number of Infants With Indicators of Possible
Drug Exposure Not Tested in Nine Hospitals, 1989
No. of Infants with
-------------------------------------------------
Birth Gestational
Less weight age Two
than 5 less less or more
Location/ prenatal than than risk
hospital visits#a 5.5 lbs 38 weeks factors
--------- -------- ------- -------- -------
Boston
1 69 563 682 478
2 b b b b
Chicago
1 342 299 620 267
2 72 136 574 123
Los Angeles
1 513 176 401 176
2 1,120 335 801 441
New York
1 126 283 469 242
2 414 197 514 209
San Antonio
1 842 574 910 580
2 116 335 643 275
----- ----- ----- -----
Total 3,614 2,898 5,614 2,791
===== ===== ===== =====
aWe included women with pregnancies of 33 or fewer weeks; however,
they comprised a small portion of the sampled births ranging from 3
to 11 percent of the samples at the 9 hospitals.
bData were not available for this hospital to make the analysis.
We also found that some hospitals where we identified low
percentages of drug-exposed infants tended to have high percentages
of infants with two or more indicators of possible drug exposure
who were not tested. (See table I.3.) For example, one hospital
tested no infants with these indicators of possible drug exposure;
this hospital also had the fewest (1.3 percent) estimated drug-
exposed infants.
20
APPENDIX I APPENDIX I
Table I.3: Percentage of Infants With Two or More Indicators of
Possible Drug Exposure Who Were or Were Not Tested and the
Percentage of Drug-Exposed Infants at Nine Hospitals
Figures are percentages
City/ Infants Drug-exposed
hospital Infants tested not tested infants
-------- -------------- ---------- ------------
Boston
1 11 89 7.2
Chicago
1 31 69 18.1
2 61 39 4.7
Los Angeles
1 78 22 14.8
2 30 70 5.4
New York
1 40 60 12.7
2 46 54 11.8
San Antonio
1 9 91 3.1
2 0 100 1.3
In our interviews with hospital officials at 10 additional
hospitals that predominantly serve privately insured patients in
these five cities, we found that one-half of the hospitals did not
have a protocol for identifying drug use during pregnancy. Some
hospital officials estimated drug-exposed infants represented less
than 1 to 3 percent of births at their hospitals. Therefore, they
did not consider prenatal drug exposure to be serious enough to
warrant implementing a drug testing protocol.
One recent study found, however, that illicit drug use is common
among women regardless of race and socioeconomic status. This
study anonymously tested for drug use among women entering private
obstetric care and women entering public health clinics for
prenatal care and found that the overall incidence of drug use was
similar among both groups of women (14.8 percent overall, 16.3
21
APPENDIX I APPENDIX I
percent for women seen at public clinics, and 13.1 percent for
those seen at private offices).#26
26Ira J. Chasnoff, Harvey J. Landress, and Mark E. Barrett, "The
Prevalence of Illicit Drug Use or Alcohol Use During Pregnancy and
Discrepancies in Mandatory Reporting in Pinellas County, Florida,"
The New England Journal of Medicine, Vol. 322 (Apr. 26, 1990), pp.
1202-06.
22
APPENDIX II APPENDIX II
DRUG-EXPOSED INFANTS ARE LIKELY
-------------------------------
TO HAVE COSTLY HEALTH PROBLEMS
------------------------------
Infants prenatally exposed to drugs are more likely to need more
medical services than infants whose mothers did not use drugs
during pregnancy. It is more common for drug-exposed infants to
be born prematurely and have low birth weights. They are more
likely to have medical complications and longer hospitalizations
resulting in higher hospital charges. Median hospital charges for
drug-exposed infants were up to four times greater than for
nonexposed infants.
DRUG-EXPOSED INFANTS
--------------------
ARE MORE VULNERABLE AT BIRTH
----------------------------
Because drug-exposed infants are born with significantly more
medical problems, they experience more expensive hospitalizations.
The most frequent effects of drug exposure on infants are low birth
weight and prematurity. Comparing drug-exposed infants with those
with no indication of drug exposure at 4 hospitals, we found
differences in prenatal care received, birth weight, gestational
age, intensity of care, and hospital length of stay.#27
The proportion of infants born to drug-using women receiving
inadequate prenatal care ranged from 29 to 70 percent of births
compared with 8 to 34 percent of births to women who did not use
drugs and received inadequate prenatal care. (See fig. II.1.)
Figure II.1: Mothers of drug-exposed infants are more likely to
obtain inadequate prenatal care (comparison at 4 hospitals)
27Of the 10 hospitals we reviewed, 4 had a 10-percent or higher
incidence of infants born drug exposed. At these hospitals we
had a sufficient number of cases with which to conduct more
detailed analysis of the differences between hospital charges and
other characteristics of drug-exposed infants and those not
exposed to drugs.
23
APPENDIX II APPENDIX II
Low birth weight, defined as weighing less than 5.5 pounds, is a
major determinant of infant mortality and places the survivors at
increased risk of serious illness and lifelong handicaps. We
found significantly higher percentages of drug-exposed infants
weighing less than 5.5 pounds than those born to women not
identified as using drugs during their pregnancy. In fact, the
proportion of drug-exposed infants of low birth weight was at
least twice as great as infants not identified as drug exposed.
The rate of low-birth-weight infants ranged from 25 to 31 percent
among drug-using women and 4 to 11 percent for women not
identified as using drugs. (See fig. II.2.)
Figure II.2: Drug-exposed infants more often have a low birth
weight as compared with nonexposed infants (comparison at 4
hospitals)
24
APPENDIX II APPENDIX II
Infants are typically born 40 weeks after conception. Those born
before 38 weeks are considered premature. Premature infants are
frequently handicapped by physical limitations, which vary
depending on the degree of prematurity. These handicaps may lead
to increased mortality and morbidity. Generally, we found that
drug-exposed infants were about twice as likely to be premature as
infants not exposed to drugs. (See fig. II.3.)
Figure II.3: Drug-exposed infants are more likely to be born
prematurely than nonexposed infants (comparison at 4 hospitals)
25
APPENDIX II APPENDIX II
Finally, at two of the four hospitals, a significantly greater
percentage of drug-exposed infants needed intensive care services
during their hospital stay. Drug-exposed infants were also more
likely than those not identified as drug exposed to remain in the
hospital for 5 or more days.
HOSPITAL CHARGES ARE HIGHER
---------------------------
FOR DRUG-EXPOSED INFANTS
------------------------
The health problems of drug-exposed infants and their longer and
more complicated hospitalizations are often reflected in higher
hospital charges. We were able to compare hospital charges
between drug-exposed infants and infants with no indication of
drug exposure in their medical records at three hospitals.#28 As
shown in figure II.4, hospital charges for drug-exposed infants
were up to four times greater than those for infants with no
indication of drug exposure. For example, at one hospital the
median charge for drug-exposed infants was $5,500, while the median
charge incurred by nonexposed infants was $1,400.
Figure II.4: Drug-exposed infants incur higher hospital charges
than nonexposed infants (comparison at 3 hospitals)
28At 1 of the 4 hospitals, however, separate hospital charges for
mothers and infants were not available.
26
APPENDIX II APPENDIX II
Over $14 million was spent on the care of drug-exposed infants at
3 hospitals where we were able to obtain data. (See table II.1.)
Hospital charges for drug-exposed infants at these hospitals
ranged from $455 to $65,325.
Because more than 50 percent of patients received public medical
assistance in 7 of the hospitals in our study, a large part of
these costs was covered by federal assistance programs.
27
APPENDIX II APPENDIX II
Table II.1: Estimated Hospital Charges for Drug-Exposed Infants
at Three Hospitals in 1989
Estimated no.
of drug-exposed Mean Estimated total
Hospital infants charge hospital charges
-------- --------------- ------ ----------------
1 1,187 $6,914#a $8,206,918
2 400 8,939 3,575,600
3 440 6,520 2,868,800
----- ----------
Total 2,027 $14,651,318
===== ==========
aThe charges at this hospital are based on a flat per diem rate
and, therefore, may be underestimated.
Although the long-term physical effects of prenatal drug exposure
are not well known, indications are that some of these infants
will continue to need expensive medical care as they grow up.
Because of the uncertainty of the long-term consequences of
prenatal drug exposure, future medical costs of caring for these
children are unknown.
28
APPENDIX III APPENDIX III
PRENATAL DRUG ABUSE HAS INCREASED DEMAND
----------------------------------------
FOR SOCIAL SERVICES
-------------------
State, city, and hospital social services officials unanimously
reported to us that parental drug abuse has created additional
demands on the social services system. These demands include the
need for foster placements for the infant upon discharge from the
hospital. They also include investigations of drug-related
neglect and abuse that in some cases result in the child's removal
from the home. Additionally, studies have shown that some drug-
exposed infants will suffer long-term medical and psychological
effects from drug exposure. These problems may lead to learning
disabilities, causing higher school drop-out rates and eventual
unemployment.
MANY DRUG-EXPOSED
-----------------
INFANTS ENTER
-------------
FOSTER CARE
-----------
We found that drug-exposed infants were significantly more likely,
compared with infants not identified as drug-exposed, to stay in
the hospital after their mother was discharged. While these longer
stays were primarily attributed to medical reasons, some hospital
officials stated they are experiencing a growing number of infants
staying in the hospital for nonmedical reasons. Commonly called
"boarder babies," the parents or relatives of these infants are
often not willing to accept the baby or, in other cases, social
service workers have determined that the home environment is not
acceptable for the infant because of parental drug abuse.
Officials from 5 of the 10 surveyed hospitals stated that their
hospitals were experiencing increased demands for services for
boarder babies.
In addition to providing services to boarder babies, social
service agencies must also provide services to drug-exposed
infants referred by hospitals. In three cities that are required
by state law to refer drug-exposed infants to child welfare
authorities the number of infants referred during recent years has
increased dramatically. In New York, referrals increased by 268
percent over the 4-year period 1986 to 1989. For approximately the
same period, referrals in Los Angeles increased by 342 percent and
in Chicago, by 1,735 percent.#29
29Texas officials told us that their state does not have a legal
requirement that drug-exposed infants be reported, and in
Massachusetts officials said that until 1990 cocaine-exposed
infants did not have to be reported.
29
APPENDIX III APPENDIX III
For infants who do not leave the hospital with their mother,
additional costs are incurred in foster care services. At 3 of
the 4 hospitals, 26 to 58 percent of drug-exposed infants were in
need of foster care. In contrast, only 1 to 2 percent of infants
born to a mother with no indication of drug use required foster
placement. At the fourth hospital few infants were placed in
foster care. (See fig. III.1.)
Figure III.1: Drug-exposed infants are more likely to be admitted
to foster care than nonexposed infants (comparison at 4 hospitals)
30
APPENDIX III APPENDIX III
Although we could compare drug-exposed infants to infants not
identified as drug exposed at only 4 hospitals, we were able to
estimate the number of drug-exposed infants entering foster care
at 9 hospitals. At these 9 hospitals, the cost of providing basic
foster care for 1 year to 1,194 infants, would be over $7.2
million. Basic per capita foster care costs in the cities in our
survey ranged from $3,600 to $5,000 annually; specialized foster
care, which includes homes that provide some medical monitoring or
group residential facilities, may cost between $4,800 and $36,000.
Number of Child Abuse and
-------------------------
Neglect Cases Increasing
------------------------
Because drug-exposed infants are often born with special problems,
they may be more difficult to care for even under the best
circumstances. Some of these children are placed directly from the
hospital into foster homes where the foster parents are often
unaware of the children's problems and are not trained to care for
their specialized needs. Others return home to families that have
trouble providing adequate care because, in many instances, drug
abuse continues to dominate family life.
A drug-exposed, low-birth-weight infant may be irritable, cry
excessively, have difficulty bonding with the mother, and have
problems feeding. Many drug-using mothers may be compromised in
their ability to interact with their infant or to understand and
respond to their infants' basic needs. Many of these women also
have health and emotional problems. The combination of the
infant's and the mother's problems place the infant at high risk
for child abuse and neglect.
An indicator of a chaotic and dangerous home environment is the
extent to which the social services system is called on to
intervene to protect children from the drug-abusing lifestyles of
their parents. Child welfare services officials from the five
cities we visited stated that they are investigating more drug-
related cases of child abuse and neglect each year. Many of these
investigations result in foster care placement specifically for
children under the age of 2. Child welfare officials in San
Antonio told us that 40 percent of all referrals made to child
protective services involve drug or alcohol abuse in the family.
In Los Angeles, up to 90 percent of referrals involved substance-
abusing families.
The Massachusetts Department of Social Services reports a higher
incidence of severe injuries to young children and more families
where the use of drugs and alcohol is being identified as a
precipitating factor in family violence. In 1989, the department
conducted a study to determine the association of drug and alcohol
31
APPENDIX III APPENDIX III
use with child abuse and neglect.#30 The study found that illicit
drug or excessive alcohol use was a factor in 64 percent of case
investigations. Cocaine use was found to be significantly
associated with child neglect. Neglect was defined as a lack of
supervision, food, clothing, medical care, and other necessities.
In the most severe cases there were reports of no food, milk, or
diapers in the house; medical neglect to the extent of nontreatment
of serious and acute injuries and illnesses; extremely dirty living
quarters; and an absence of care and supervision for children under
the age of 5.#31
Hospital officials also told us that they are seeing an increasing
number of young children from drug-abusing families admitted to the
hospital because they suffered neglect or maltreatment at the hands
of someone on drugs. Officials described various incidents of
children dying due to physical abuse or a drug overdose from
inhalation or ingestion of crack cocaine.
Foster Care Placements
----------------------
Increasing
----------
A high proportion of child protective service investigations of
abuse or neglect involving drug abuse results in foster care
placement. In fact, the estimated nationwide demand for foster
care has increased by 29 percent from 1986 to 1989. In 1989,
360,000 children were estimated to be in foster care across the
country. Much of this increase is attributed to substance abuse
in families.
According to social service officials in the five cities we
visited, family drug-abuse problems are a contributing factor in
the placement of children in foster care. In New York, a review
of a statewide random sample of foster care children found that 57
percent of these children came from families allegedly abusing
drugs.
Foster care placements have increased substantially for children
under the age of 1 and 2 in the states we visited. Social service
officials attribute this increase to drug-abusing families. In
Massachusetts, the number of children under age 2 admitted to
foster care increased by 73 percent over the past 2 years. In New
York City, children under age 2 accounted for 36 percent of foster
30Julia Herskowitz and others, "Substance Abuse and Family
Violence, Part I, Identification of Drug and Alcohol Usage During
Child Abuse Investigations in Boston." (Massachusetts Department
of Social Services, June, 1989).
31Herskowitz, pp. 4-8.
32
APPENDIX III APPENDIX III
care admissions in 1989. In Illinois, infants younger than 1 year
old in foster care increased 284 percent from 1985 to 1989.
Because the demand for foster care has increased nationwide,
concerns have been raised about the social services system's
ability to respond to the needs of drug-abusing families.
Specifically, problems have been identified regarding the
availability of foster parents who are willing to accept children
who have been exposed to drugs, the quality of foster care homes,
and the lack of supportive health and social services for families
who provide foster care to these children.
DRUG-EXPOSED INFANTS ARE
------------------------
VULNERABLE TO DEVELOPMENTAL
---------------------------
PROBLEMS THAT MAY AFFECT
------------------------
LEARNING
--------
Definitive information about the future of drug-exposed infants
does not exist. The oldest of drug-exposed infants in strict
clinical trials designed to examine the long-term physical effects
of prenatal drug exposure, such as developmental deficiencies, are
under the age of 3. In addition, long-term studies of drug-exposed
children have not adequately controlled for the amount of drug use,
the intensity or frequency of use, or the type of drug used. Nor
have studies indicated when drugs were used during the pregnancy.
Results from studies to date indicate that the symptoms will vary
among drug-exposed children. Some children show few symptoms
after the drugs leave their system and others are expected to show
neurological symptoms throughout their lives. Consequently, the
needs of these infants will vary--from greater assistance and
intervention for some to lesser assistance for others.#32
Recent studies and surveys of neonatal programs suggest that some
infants will suffer from central nervous system effects, including
neurobehavioral deficiencies.#33 Researchers have reported that
some infants identified through urine screens as positive for
cocaine had suffered hemorrhages in the areas of the brain
responsible for intellectual capacities.#34,#35
32Richard P. Barth, "Educational Implications of Prenatally Drug
Exposed Children," Social Work in Education, in press.
33Hallum Hurt, "Medical Controversies in Evaluation and Management
of Cocaine-Exposed Infants" (1989), pp. 3-4.
34Deborah A. Frank, Briefing for the Comptroller General of the
United States, Boston City Hospital, February 24, 1990.
33
APPENDIX III APPENDIX III
Observations of toddlers born to drug-using mothers imply future
educational problems based on these children's difficulties with
concentration and learning. Research at the University of
California at San Diego showed that
-- 25 percent of drug-exposed children had developmental delays,
and
-- 40 percent experienced neurologic abnormalities that might
affect their ability to socialize and function within a school
environment.
The study also found that as these children grew older their
abilities did not develop normally in the dimensions of language,
adaptive behavior, and fine motor and cognitive skills.#36
A school environment that is poorly prepared to respond to the
developmental disabilities of these children may allow them to go
unresolved. As an increasing number of drug-exposed children
reach school age, this problem should become more evident. One
test of this may occur next year when a large number of children
born to the early wave of crack cocaine users will reach
kindergarten age.
One researcher has estimated that 42 to 52 percent of children
exposed to drugs and alcohol will require special educational
services.#37 The degree of services needed and their cost will
vary depending on the severity of impairment. For example, the Los
Angeles Unified School District began a pilot program in 1987 for
mildly impaired preschool children prenatally exposed to drugs.
The cost of providing the enriched school environment provided in
the pilot program is approximately $17,000 a year per child. At
least one comprehensive estimate, developed by the Florida
Department of Health and Rehabilitative Services, indicates that
35Suzanne D. Dixon, "Effects of Transplacental Exposure to Cocaine
and Methamphetamine on the Neonate" The Western Journal of
Medicine (Apr. 1989), pp. 436-42.
36Interview with Suzanne D. Dixon, Director of Well Baby Clinic,
University Medical Center, University of California at San Diego,
February 14, 1990.
37Judy Howard, "Developmental Patterns for Infants Prenatally
Exposed to Drugs", Fact sheet presented to the California
Legislative Ways and Means Committee, Perinatal Substance Abuse
Educational Forum, February 23, 1989.
34
APPENDIX III APPENDIX III
total service costs for each drug-exposed child that shows
significant physiologic or neurologic impairment, to the age of 18
years, will be $750,000.
35
APPENDIX IV APPENDIX IV
LACK OF DRUG TREATMENT AND PRENATAL CARE
----------------------------------------
CONTRIBUTING TO THE NUMBER OF DRUG-EXPOSED INFANTS
--------------------------------------------------
Many women are unaware of the effects of drugs on the health of
their infant. Other women are aware of the consequences of drug
use and would like to stop their addictive behavior. However,
their efforts to get help may be unsuccessful due to insufficient
drug treatment capacity. In addition, there are many barriers
blocking access to basic health services and drug treatment for
drug-abusing pregnant women. One major barrier is the fear women
have that if they seek treatment they may be incarcerated or their
children will be taken from them.
LACK OF TREATMENT FOR
---------------------
DRUG-ADDICTED PREGNANT WOMEN
----------------------------
The best way to prevent the problem of drug-exposed infants is to
prevent drug use among women of childbearing age. Pregnant woman
who use drugs should be encouraged to stop in order to reduce the
potential problems associated with prenatal drug exposure.
According to one researcher, if women stop using cocaine before
the third trimester the risks of low birth weight and prematurity,
which often require expensive neonatal intensive care, are greatly
reduced.#38
Nationwide, however, drug treatment services are insufficient. A
1990 survey by the National Association of State Alcohol and Drug
Abuse Directors, Inc. (NASADAD), found that an estimated 280,000
pregnant women nationwide were in need of drug treatment, yet less
than 11 percent of them received care.#39 Hospital and social
welfare officials in each of the five cities in our study also
told us that drug treatment services were insufficient or
inadequate to meet the demand for services for drug-addicted
pregnant women.
In addition to insufficient treatment, some treatment programs
deny services to drug-addicted pregnant women. A survey of 78
drug treatment programs in New York City found that 54 percent of
them denied treatment to women who were pregnant. One of the
primary reasons that programs are reluctant to treat pregnant
women relates to issues of legal liability. Drug treatment
38Deborah A. Frank, Briefing for the Comptroller General of the
United States, Boston City Hospital, February 24, 1990.
39The report did not reveal the extent to which these women sought
treatment.
36
APPENDIX IV APPENDIX IV
providers fear that certain treatment medications and the lack of
prenatal care or obstetrical services at the clinics may have
adverse consequences on the fetus and thereby expose the providers
to legal problems.
Many programs that provide services for women, including pregnant
women, have long waiting lists. Treatment experts believe that
unless women who have decided to seek treatment are admitted to a
treatment facility the same day, they may not return. However,
women are rarely admitted on the day that they seek treatment.
One treatment center in Boston received 450 calls for
detoxification services during a 1-month period. The callers were
told that no slots were available and that it usually took 1 to 2
weeks to be admitted. They were also instructed to call back every
day to determine if a slot had become available. Of the 450
callers that month, about one-half never called back and about 150
were eventually admitted to treatment.
Many other barriers to treatment exist. Historically, treatment
programs were designed to treat the addiction problems of men.
Thus, many programs are not tailored to meet the needs of pregnant
women. For example, pregnant addicts we interviewed told us that
because they had other children the lack of child care services
made it difficult for them to seek treatment. Pregnant addicts may
have additional needs, such as prenatal care and parenting,
educational, and nutritional guidance, that are not provided in
most treatment programs.
Another barrier to treatment for women is their fear of criminal
prosecution. Drug treatment and prenatal care providers told us
that the increasing fear of incarceration and loss of children to
foster care is discouraging pregnant women from seeking care.
Women are reluctant to seek treatment if there is a possibility of
punishment. They also fear that if their children are placed in
foster care, they will never get the children back.
Many health professionals believe that comprehensive residential
drug treatment, including prenatal care, is the best approach to
helping many women abstain from using drugs during pregnancy and
assuring that the developing fetus has the best chance of being
born healthy.
However, residential treatment programs for women are scarce. In
Massachusetts, residents have access to only 15 residential
treatment slots for pregnant women in the entire state. Social
service officials at one California hospital expressed their
frustration with the lack of residential drug treatment programs
and other programs that could provide a stable environment to a
pregnant addict. When they are unable to place drug-addicted
37
APPENDIX IV APPENDIX IV
pregnant women in residential treatment they try alternatives,
including battered women shelters or even nursing homes.
Residential treatment allows for several needs to be addressed at
the same time, thus reducing problems of fragmentation and
inaccessibility of services. For example, the interconnected
problems of homelessness, substance abuse, maternal and child
health, and parenting are addressed in the few residential
programs that exist. In addition, these programs limit access to
drugs and remove women from the environments in which they became
dependent.
PRENATAL CARE IMPROVES
----------------------
BIRTH OUTCOMES
--------------
When both drug treatment and prenatal care services are provided
for drug-addicted pregnant women, the results are dramatic. The
three basic components of prenatal care are: (1) early and
continued risk assessment, (2) health promotion, and (3) medical
and psychosocial interventions and follow-up. One intervention
program reported a significant drop in low-birth-weight babies
born to drug-abusing mothers who had been provided with drug
treatment and prenatal care.#40 The incidence of low birth weight
among infants born to drug-abusing mothers receiving such care
dropped from 50 to 18 percent.
Early and comprehensive prenatal care is associated with lower
rates of infants born with low birth weight. Our work and that of
others showed that the incidence of low birth weight among drug-
exposed infants is high. Low birth weight is the most significant
factor in determining infant death and disability as well as higher
health costs. Prenatal care increases the chances that healthier
infants will be born.
Prenatal care is a cost-effective program. The Office of
Technology Assessment estimates that for every low-birth-weight
birth averted by earlier or more frequent prenatal care, the U.S.
health care system saves between $14,000 and $30,000 in short- and
long-term health care costs associated with low birth weight.
40Loretta P. Finnegan, M.D., Executive Director of Family Center,
Professor of Pediatrics and Professor of Psychiatry and Human
Behavior, Jefferson Medical College of Thomas Jefferson
University, Philadelphia, Pennsylvania, Testimony before the
Subcommittee on Children, Family, Drugs, and Alcoholism, Committee
on Labor and Human Resources, United States Senate, February 5,
1990.
38
APPENDIX IV APPENDIX IV
These savings are great compared with the average cost for
professional services associated with prenatal care that can run
as low as $500.
According to the National Commission to Prevent Infant Mortality,
the barriers to accessing prenatal care are formidable, including
financial, policy, system, provider, and patient barriers. In
addition, others report that drug-addicted pregnant women refrain
from seeking prenatal care because they fear that punitive actions
will be taken if they are found to have used or abused drugs during
pregnancy. Several hospital and public health officials believe
that punitive actions, such as incarceration of drug-abusing
pregnant mothers, have a negative impact on the lives of these
women and their children.
Hospital officials told us that in addition to not seeking
prenatal care, some women are now delivering their infants at home
in order to prevent the state from discovering their drug use. An
example was given of one mother who delivered her baby at home and
subsequently called the hospital for medical advice because the
infant had become very sick. The mother was finally persuaded to
bring the infant into the hospital. The consequent care of this
baby was very costly.
39
APPENDIX V APPENDIX V
PERCENTAGE DISTRIBUTION OF INFANTS EXPOSED TO DRUGS, INCLUDING COCAINE
----------------------------------------------------------------------
Figures are percentages
Drug- Sampling Cocaine- Sampling
Hospital exposed infants error#b exposed infants error#b
-------- --------------- --------- --------------- --------
1 1.3 1.0 0.3 0.4
2 3.1 1.6 0.8 0.8
3 4.7 2.0 2.7 1.5
4 5.4 2.3 3.9 1.9
5 7.2 2.4 4.5 1.9
6a 8.9 -- -- --
7 11.8 2.9 11.0 2.8
8 12.7 2.9 8.5 2.4
9 14.8 3.8 11.6 3.4
10 18.1 4.2 8.6 2.9
aFrom this hospital we identified drug-exposed infants from the
universe of births and, therefore, there is no sampling error.
We were unable to distinguish the type of drugs used.
bSampling errors are at the 95-percent confidence level.
40
APPENDIX VI APPENDIX VI
OBJECTIVES, SCOPE, AND METHODOLOGY
----------------------------------
To develop a national estimate of drug-exposed infants we obtained data
from the National Hospital Discharge Survey conducted by HHS's National
Center for Health Statistics for the years 1980 to 1988. The National
Hospital Discharge Survey is based on an annual survey of a
representative sample of U.S hospitals. The survey collects information
on the diagnoses associated with hospitalization of adults and newborns
in all nonfederal short-stay hospitals. Newborn discharge data for 1986
and 1988 were used to calculate national estimates. Data before 1986
were considered nonreportable due to a small number of sample cases of
newborns with a drug-related discharge diagnosis.
To determine the extent of drug-exposed infants we reviewed medical
records at 2 hospitals in each of five cities--Boston, Chicago, Los
Angeles, New York, and San Antonio. Mostly located in the inner city,
8 of these hospitals serve a high proportion of low-income patients
likely to need federal assistance and supportive services. The
remaining 2 hospitals did not serve a high proportion of low-income
patients, but received referrals from other hospitals in their
respective cities of potentially complicated births, including drug-
using pregnant women. Our review of medical records at the 10
hospitals (2 hospitals in each of these cities) covered a
representative sample of 44,655 births in 1989.
HOSPITAL SELECTION CRITERIA
---------------------------
Our hospital selections were based on a high incidence of births per
year and the availability of a neonatal intensive care unit in addition
to location and numbers of Medicaid patients. Table VI.1 compares the
number of births at the hospitals we selected with other hospitals in
the five cities, and table VI.2 provides patient profile information
for the selected hospitals.
41
APPENDIX VI APPENDIX VI
Table VI.1: Comparison of Births at Hospitals in GAO Study With Total
Births in the Respective Cities, 1988
All hospitals Hospitals in GAO study
-------------------- ----------------------
No. of
hospitals Percent of
with No. of No. of all births
City bassinets births births in city
---- --------- ------ ------ ----------
Boston 5 19,500 4,969 25.5
Chicago 30 49,168 7,200 15.7
Los Angeles 27 81,379 15,231 19.9
New York 41 119,320 6,432 5.4
San Antonio 10 22,061 9,331 42.3
42
APPENDIX VI APPENDIX VI
Table VI.2: Profile of Patients at Selected Hospitals
Race Insurance status
---------------------- ------------------
City/Hospital Black Hispanic White Medicaid Private
------------- ----- -------- ----- -------- -------
Boston
120.9 5.5 67.3 34.0 59.9
264.6 18.7 12.1 51.4 13.0
Chicago
1 57.0 34.1 7.8 75.0 15.9
2 18.7 4.7 70.7 15.8 83.3
Los Angeles
1 19.8 79.1 0.5 74.9 1.8
2 4.3 83.2 9.0 88.6 1.3
New York
1 31.8 56.7 8.4 63.9 29.3
2 30.8 59.9 5.0 70.8 12.9
San Antonio
1 5.5 80.2 13.6 46.1 8.7
2 7.5 84.5 7.7 64.2 32.0
At these hospitals we conducted a detailed review of a random sample of
medical records of mothers and their infants who were born between
January 1 and June 30, 1989, to estimate the number of drug-exposed
infants.#41 We considered an infant to be drug-exposed if any of the
following conditions were documented in the medical record of the
infant or mother: (1) mother self-reported drug use during
pregnancy, (2) urine toxicology results for mother or infant were
positive for drug use, (3) infant diagnosed as having drug withdrawal
symptoms, or (4) mother was diagnosed as drug dependent. We also
interviewed hospital personnel to obtain their procedures for
identifying drug-exposed infants.
To assess the medical and social impact of these births, we interviewed
hospital, state, and local social services representatives regarding the
41At each of 9 hospitals, we randomly selected 400 mothers' medical
records and the corresponding medical records for their infants.
At the 9 hospitals the percentage of medical records unavailable
for review ranged from less than 1 to 7 percent. At the tenth
hospital, we did not review medical records but received a data
tape with information on all births occurring during the first 5
months of 1989.
43
APPENDIX VI APPENDIX VI
impact of drug-exposed infants on the medical and social services
systems. In our discussions with these officials we also determined
the extent to which drug-addicted pregnant women are receiving drug
treatment.
We also interviewed officials at 10 additional hospitals in these
cities to determine the extent of drug-exposed infants at these
hospitals. These hospitals serve predominantly private-pay clientele.
We did not review medical records to determine the extent of drug-
exposed infants at these hospitals.
To gain further insight as to the consequences of maternal drug use, we
interviewed leading drug treatment experts, neonatologists, researchers,
social welfare officials, and drug-addicted pregnant women. We also
reviewed research conducted to determine the incidence of drug-exposed
infants and the effects of drugs on the health of mothers and infants.
44
APPENDIX VII APPENDIX VII
MAJOR CONTRIBUTORS TO THIS REPORT
---------------------------------
HUMAN RESOURCES DIVISION, WASHINGTON, D.C.
------------------------------------------
Mark V. Nadel, Associate Director, National and Public Health Issues
(202) 275-6195
Rose Marie Martinez, Assignment Manager
Roy B. Hogberg, Evaluator-in-Charge
Frances A. Kanach, Senior Evaluator
Susan L. Sullivan, Social Science Analyst
BOSTON REGIONAL OFFICE
----------------------
Robert D. Dee, Regional Assignment Manager
Lionel A. Ferguson, Evaluator
CHICAGO REGIONAL OFFICE
-----------------------
Karyn L. Bell, Site Senior
DALLAS REGIONAL OFFICE
----------------------
Larry J. Junek, Site Senior
Martin B. Fortner, Jr., Site Senior
LOS ANGELES REGIONAL OFFICE
---------------------------
Denise R. Dias, Site Senior
NEW YORK REGIONAL OFFICE
------------------------
Patrice J. Hogan, Regional Assignment Manager
45
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