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Policy Statement:

Women, Alcohol, Other Drugs and Pregnancy

Summary of the Issue

There has been a great deal of denial about the extent to which women experience alcohol and other drug problems. This denial is even more profound when considering pregnant women. While we have made progress in expanding prevention and treatment efforts to include women, our social and medical institutions have not responded effectively to the needs of pregnant alcoholic and other drug-dependent women. Specific emphasis needs to be given to the development of specialized prevention and treatment for alcoholic and other drug-dependent women of child-bearing age.


Background

There is growing concern throughout our nation about the problems associated with alcohol and other drug use by pregnant women. The advent of crack, a highly and quickly addictive cocaine derivative, has brought these problems into sharp focus and stimulated public debate and discussion about how to respond to the needs of alcoholic and other drug-dependent women and their children. Alcoholic and other drug-dependent pregnant women have become subject to charges of child abuse and prosecution rather than to the support of the health care system. This punitive approach is fundamentally unfair to women suffering from addictive diseases and serves to drive them away from seeking both prenatal care and treatment for their alcoholism and other drug addictions. It thus works against the best interests of infants and children by involving the sanctions of the criminal law in the case of a health and medical problem. Moreover, there is increasing evidence of disparities regarding the screening and reporting of positive toxicologies of newborns, with women of color, poor women and women receiving care in public hospitals having the greatest likelihood of being subject to drug testing and subsequent reporting to legal authorities.

The National Council on Alcoholism and Drug Dependence supports efforts to educate women and their partners about specific risks associated with drug use, including alcohol, tobacco, prescription and over-the-counter medications as well as illegal drugs, during pregnancy. NCADD supports the development of prevention and treatment efforts for pregnant alcoholic and other drug-dependent women and urges policy makers to support measures which will increase access to care and decriminalize the governmental response.


Alcohol- and Other Drug-Related Birth Defects

A great deal is known about the effects of drinking on fetal development. Fetal alcohol syndrome (FAS), the most severe constellation of alcohol-related birth defects, was identified by a team of health professionals in Seattle, Washington in 1973. FAS is a cluster of symptoms including malformations of the face and skull, growth retardation either before or after birth, central nervous system problems and mental retardation. Fetal alcohol effects (FAE) are a range of birth defects which fall short of meeting the criteria for the full blown syndrome. Children with FAS and FAE are born to mothers who drank during pregnancy. It is unclear how much alcohol at what time during pregnancy causes the range of problems. NCADD perceives any alcohol consumption during pregnancy as high-risk drinking and supports a clear no-alcohol-use message as the only responsible public health message.

Cocaine use during pregnancy can cause multiple and complex problems in utero and after birth. These problems may include physical anomalies, inadequate development and dysfunction of the body's major organs and systems, including the cardiovascular, neurological and excretory systems. Infants can experience withdrawal systems if mothers have used cocaine shortly before delivery. Cocaine use may also cause precipitous delivery resulting in premature birth and problems associated with low birth weight. Sudden infant death syndrome (SIDS) occurs at a higher rate among babies exposed to cocaine.

Babies exposed prenatally to heroin tend to be low in birth weight, short for their age, and have a small head circumference. There is no evidence that opiate drug use by the mother causes malformations like those seen in FAS. Research is continuing in this area. The developing fetus does experience withdrawal as the mother goes through withdrawal. Some postnatal problems of these infants may be due to repeated withdrawals before birth. Newborn infants of opiate-dependent mothers can experience opiate withdrawal symptoms after birth.

Tobacco use during pregnancy can also interfere with healthy fetal development. Babies born to smokers are more likely to be low in birth weight, born prematurely, have lower scores on a standard test of physical functions, and die within the first year of life. It is not known exactly how the ingredients in tobacco smoke affect fetal development. It is known that tobacco smoke reduces oxygen flow to the fetus. It is clear that cessation of smoking during pregnancy will contribute to a positive pregnancy outcome.

There are risks associated with the use of other drugs during pregnancy such as PCP, barbiturates and other prescription medications. These risks vary depending on the extent and time of use. In general, all drugs are contraindicated during pregnancy unless deemed absolutely necessary and administered under the supervision of a trained health professional.

Although different drugs have different prenatal effects, the drugs discussed above have some similar effects when they are used during pregnancy. They all tend to contribute to low birth weight. They all may influence the way in which children are able to learn and interact socially. Some cause severe damage, including mental retardation and physical deformities. All contribute to heightened nervousness and irritability in newborns which may impede parent-child bonding and exacerbate post-partum stress for mothers.

It is well-known that the United States has an extraordinarily high rate of infant mortality--one of the highest in the western world. Efforts to reduce the incidence of alcohol and other drug use during pregnancy would undoubtedly contribute to a reduction in infant mortality in the nation.


Treatment for Alcoholic and Other Drug-Dependent Women

A great deal of progress has been made in the United States in our approaches to preventing and treating alcoholism and other drug addictions among women. Prior to the 1970s there were virtually no treatment options for women with alcoholism and other drug addictions. Women rarely came into treatment and when they did, the treatment that they received was based on the male experiences of alcoholism with no adjustments for the fact that a woman's life experience and physiology are different from a man's.

The 1970s was a time of dramatic change for women in need of treatment for alcoholism and other drug addictions. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) funded the first wave of women's treatment programs across the nation. Later, in 1984, the women's set-aside of the Alcohol, Drug Abuse and Mental Health Services (ADMS) block grant required that states spend 5% of their block grant award on new prevention and treatment efforts designated for women. The set-aside requirement was raised in 1988 to 10%.

Only a few prevention and treatment efforts have focused specifically on pregnant alcoholic and other drug-dependent women. There are tremendous fears among service providers about liability problems associated with treating pregnant, addicted women. There is also a great need for additional training of treatment providers about how to proceed with safe detoxification and treatment. To date, much of the reaction to treating pregnant alcoholic and other drug-dependent women has been guided by fear, lack of knowledge and lack of experience. The sad irony is that pregnancy offers an opportunity to intervene and provide treatment, yet it is at this very time that the least amount of treatment is available.

The Anti-Drug Abuse Act of 1988 included a provision to establish prevention, education, intervention and treatment demonstration projects administered through the Center for Substance Abuse Prevention (CSAP) for pregnant and postpartum alcohol- and other drug-dependent women. This program has stimulated the development of some of the first programs in the nation to address the needs of pregnant women.


Services for Children

Children born to alcoholic and other drug-dependent women and children living in homes where parents and family members are alcoholic and dependent on other drugs deserve special mention. Children born with alcohol- and other drug-related birth defects often go unrecognized. We need to improve identification and intervention services for these children. They must have access to services for ongoing treatment and special education. Children growing up in alcoholic and other drug-dependent families also need a range of prevention, intervention and treatment services. Intervention and treatment can be powerful tools in preventing future problems for these children. Child welfare services should be enhanced so that alternative living situations are available for children who need temporary foster care and permanent placement. In all cases, efforts should be made to intervene and treat families with the goal of keeping them together if appropriate and possible.


Proposed Policy Recommendations

NCADD supports the development of comprehensive efforts to address the needs of women of child-bearing age and their children. NCADD recommends the enactment of comprehensive policies at the national, state and community levels to improve prevention, education, treatment and research efforts for women. Prevention and treatment programs for women and their children should be sensitive to ethnic and cultural differences among women and employ approaches which reflect sensitivity to the particular needs of the population of women being served. Finally, enhancement of research, prevention, education and treatment initiatives tailored to address the needs of women generally, will undoubtedly reduce the numbers of alcoholic and drug-dependent pregnant women in need of services and ultimately, the number of children born with alcohol- and other drug-related birth defects.

The NCADD Board of Directors, Affiliates and Staff will work towards the enactment and implementation of the following recommendations:

Congress

  • Congress should closely monitor the states' use of the 10% women's set-aside of the ADMS block grant and insist that this money be spent consistent with the legislation (i.e., new and expanded prevention and treatment services for alcoholic and other drug-dependent women).

  • Congress should appropriate additional funds to support the Model Projects for Pregnant and Post-partum Women and Their Infants administered by the CSAP.

  • Congress should direct NIAAA and the National Institute on Drug Abuse (NIDA) to establish a join research center for alcohol and other drug problems of women.


Executive Branch

  • CSAP should convene a task force on women, alcohol, drugs and pregnancy with representatives from NIAAA, NIDA, the National Institute of Child Health and Human Development, the Office of Minority Health Affairs, the Office of Adolescent Pregnancy Programs, and lay field representation to coordinate a comprehensive federal response to the health and social services needs of pregnant alcoholic and other drug-dependent women and their children.

  • CSAP and the National Clearinghouse for Alcohol and Drug Information (NCADI) should develop materials on alcohol and other drug use during pregnancy. Campagins to disseminate this information to various professional medical and social service professionals should be established.

  • NCADI should increase efforts to develop culturally and linguistically appropriate materials on alcohol, other drugs and pregnancy for specific underserved groups of women.

  • NIAAA and NIDA should support and encourage studies which focus on alcohol, other drugs and pregnancy. Both Institutes should support longitudinal studies on children with alcohol- and other drug-related birth defects. Such defects should be made reportable to establish a data base.

  • CSAP should convene a national meeting of experts on women, alcohol, other drugs and pregnancy. One outcome of this meeting should be a monograph on state-of-the-art prevention, treatment and research efforts addressing women, alcohol, other drugs and pregnancy.

  • SAP should develop written materials and posters which address HIV infection, alcohol, other drugs and pregnancy.

  • CSAP should develop and disseminate model training programs about identification and referral of women with alcoholism and other drug dependence for health professionals, including nurses and social workers and others who interact with pregnant women.

  • The Substance Abuse and Mental Health Services Administration should require that states report on the number of pregnant women being served in publicly-funded prevention and treatment programs as part of their routine data collection efforts. Alcohol- and other drug-related birth defects should be made reportable to establish a data base.

  • The Bureau of Alcohol, Tobacco and Firearms should require that mandated health warning labels on alcoholic beverage containers regarding the risks of drinking during pregnancy be clearly legible to alcoholic beverage consumers.

  • The Children's Bureau housed in the Office of Human Development Services of the Department of Health and Human Services should fund grants and contracts that address the issues of foster care placement for children of alcoholic and drug-dependent women.

  • The Justice Department, in collaboration with the Department of Health and Human Services, should be required to develop and fund training programs for police and other law enforcement officers on the nature of alcoholism and other drug dependence, intervention processes, treatment principles, and the availability of local treatment resources.


State Legislative and Executive Bodies

  • States should mandate coordination of available health and social service resources to include but not be limited to: Alcoholism and Drug Treatment Programs, especially those agencies which provide services to women and their children; Crippled Children's Services; Early Periodic Screening Diagnosis and Treatment Programs; Developmental Disabilities services; Special Education programs; Family Planning; Aid to Families with Dependent Children; and Women, Infants and Children.

  • State agencies which manage publicly-funded alcohol and drug addiction programs should offer funding for up to three years for demonstration projects which provide services to women and their children with sufficient funds to entice providers to initiate such programs and to allow for adequate start-up time.

  • Each state should develop a task force of state executive branch agencies to coordinate provision of alcohol and drug prevention and treatment services, maternal and child health care, and child welfare services and training to health and social service professionals who serve as gatekeepers to women and their children.

  • States should avoid measures which would define alcohol and other drug use during pregnancy as prenatal child abuse and should avoid prosecutions, jailing or other punitive measures which would serve to discourage women from seeking health care services and which might be offered as a substitute for health care services.

  • States should resist the enactment of laws which identify alcoholism or other drug dependency or alcohol and other drug use as prima facie evidence of child abuse or neglect.

  • States should resist the enactment of laws or regulation which require the automatic removal of an infant from the mother solely on the basis of a positive toxicology screen of the infant.

  • States should appropriate additional funds for the development of comprehensive, multidisciplinary prenatal care and alcoholism and other drug addictions treatment services to pregnant women with alcohol and other drug problems. The continuum of services should include prenatal care, alcoholism and other drug addictions treatment, housing, job training, educational and support services.

  • States should encourage linkages between alcoholism and drug treatment programs and the criminal justice system so that alcoholic and drug-dependent women who enter the criminal justice system can receive appropriate identification, referral and treatment services.

  • States should enact legislation requiring the posting of warning signs at points of purchase of alcoholic beverages alerting the public to the dangers of drinking during pregnancy. These signs should be available in other languages, if appropriate, to meet the needs of ethnic populations.


Research

  • Research is needed on the long-term impact of drug exposure on the health and development of children; comparisons between children raised in foster care to those supported in their biological homes; cost/benefit analyses of the efficacy of various prevention strategies on health and social welfare costs.

  • Research is needed on the male contribution to birth abnormalities related to alcohol and other drug use.


Prevention

  • Schools should offer age-appropriate alcohol and other drug education programs which include specific information on the dangers associated with drinking alcohol, smoking cigarettes, and using other drugs during pregnancy. Appropriate programming for pregnant teens should also be made available in schools.

  • Local governing bodies should offer educational materials on the dangers associated with drinking alcohol, smoking cigarettes, and using other drugs during pregnancy when individuals apply for marriage licenses. These materials should be made available, if appropriate, in languages suitable to other ethnic populations.

  • Schools providing education for health professionals should include education and requirements for continuing education on alcohol- and other drug-related birth defects and identification and treatment of alcoholic and other drug-dependent women.

  • State agencies should offer training on innovative methods to prevent and identify high-risk alcohol and other drug use among women.

  • Health professionals and agencies which provide family planning services should also provide educational materials about alcohol and drug use during pregnancy. Plans for referral to treatment, when needed, should be established.

  • All local health officers who issue marriage licenses should be educated on the subjects of alcoholism and other addictions, and alcohol and other drug use during pregnancy. They should also be provided with educational materials to be distributed to marriage license applicants.


Treatment

  • State and local agencies with responsibility for managing publicly funded alcoholism and other drug addictions programs should offer training for treatment providers on intervening and treating pregnant alcoholic and other drug-dependent women.

  • State and local agencies with responsibility for managing publicly funded alcoholism and other drug addictions programs should ensure that there are an adequate number of residential and outpatient treatment programs with comprehensive childcare components. Treatment programs serving women and their children should be prepared to offer services to the significant others of alcoholic and drug-dependent women, including their male partners.

  • State and local agencies should ensure that physicians and other health professionals providing services to pregnant alcoholic and other drug-dependent pregnant women offer their clients strict confidentiality protections within the confines of existing law.

  • States should resist efforts to weaken confidentiality protections for pregnant alcoholic and other drug-dependent women seeking prenatal care or alcoholism and/or drug treatment services.

  • Whenever possible, individuals including women of child-bearing age and pregnant women, should have the opportunity to receive an evaluation and assessment from an independent community-based referral agency capable of directing them to the most appropriate program.

  • States should utilize mandated prevention funding from their allotment of the ADMS block grant to support prevention, education and intervention aimed at reducing alcohol and other drug problems among women of child-bearing age and at facilitating early intervention for women already dependent on alcohol and other drugs.

  • State and local agencies with responsibility for managing publicly funded alcoholism and other drug addictions programs should withdraw funds from programs which refuse admission to pregnant women.


Child Welfare

  • States should support the development of adequate child protection services to provide alternative placements for infants and children who need to be removed from the care of their parents.

  • Federal and state governments should support the provision of comprehensive health and social services to alcohol- and other drug-affected infants and children, as well as children living in homes with alcoholism and other drug addictions.

  • State alcohol and drug agencies should fund or co-fund staff positions within the child welfare system designated to identify and intervene with pregnant women and parents who are alcoholic and/or drug dependent as well as to educate the child welfare personnel about alcoholism and drug addiction.

Approved by the Delegate Assembly (April 28, 1990) and adopted by the Board of Directors of the National Council on Alcoholism and Drug Dependence, Inc. (April 29, 1990).

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