The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders defines psychoactive substance dependence as a disorder that is a cluster of cognitive, behavioral, and physiologic symptoms indicating that the person has impaired control of psychoactive substance use and continues use of the substance despite adverse consequences. The symptoms of the dependence syndrome include, but are not limited to, the physiologic symptoms of tolerance and withdrawal.
In the last few years, problems associated with drug use have become epidemic. The increasing popularity of illicit drugs in the general population is reflected by the following statistics: among young adults 18 to 25 years of age, drug use increased from 8.1% in 1974 to 16-4% in 1985, whereas in the adult population over 26 years of age, drug use increased from negligible numbers to 2% during the same time.1 A proportionate increase in drug use has occurred in women of childbearing age, thereby setting the stage for an escalation in drug-induced perinatal complications. National Institute of Drug and Alcohol (NIDA) researchers estimate that 15% of the 56 million American women between the ages of 15 and 44 years are substance abusers.2 The increase in the number of drug users is paralleled by changing concepts of drug-related tetralogy. It is now recognized that while most drugs of abuse do not increase the risk of congenital malformations on a large scale, there are definite neurological and behavioral effects that place these infants at risk for long-term sequelae.3 The issues of teratogenests and neurobehavioral outcome are discussed elegantly in the articles by Dr Zimmerman, and Drs Brown and Zuckerman, respectively, including the inherent difficulties of proving a definite cause-and-effect relationship for most of the substances of abuse except alcohol.
A 1988 study of 36 US hospitals conducted by the National Association for Perinatal Addiction Research and Education found that drug-exposed infants comprised a consistent 11% of all births.3 The 1987 Community Chest and Council of Greater Cincinnati Regional Needs Assessment Study identified substance abuse as the highest priority problem in our region. In 1989, there were only 152 neonates admitted to the University of Cincinnati Hospital Nurseries whose mothers carried a diagnosis of "substance abuse." Yet, using national statistics, we estimate that approximately 3000 of the 30 000 infants born in our region in 1989 fece long-term sequelae from prenatal exposure to cocaine, alcohol, and other drugs. In the article, "Social Consequences of Substance Abuse Among Pregnant and Parenting Women," Carol E. Tracy and Harriet C. Williams discuss the reasons why only a small fraction of pregnant drug-abusing women who need treatment actually receive it. They describe not only the barriers to treatment, but also the impact of public initiatives directed toward punishing mothers and pregnant women who abuse drugs.
As cocaine has become the illicit drug of choice for millions of Americans, it has also become the illicit drug of choice for pregnant women as well as nonpregnant women of childbearing age. Prenatal abuse of cocaine and other mood-altering chemicals impacts significantly on both maternal and fetal health. Studies described in the article by Drs Glantz and Woods indicate that cocaine use results in uterine artery vasoconstriction, which decreases blood flow to the placenta and results in multiple abnormalities of placentation including abruptio placenta. Cocaine increases circulating concentrations of norepinephrine, which may increase uterine irritability and consequently increase preterm labor rates.4 Cocaineexposed infants have a high rate of fetal distress with frequent fetal heart rate abnormalities, low Apgar scores, and meconium staining of amniotic fluid.5 It has further been reported that maternal marijuana and cocaine use is associated with impaired fetal growth.6
Despite the current shift to cocaine as the primary drug of abuse, poly-drug use is common, with the majority of cocaine users also abusing marijuana, alcohol, and cigarettes (and some even heroin).7 Other environmental factors affecting perinatal outcome in pregnant substance-abusing women include poor nutrition, limited or no prenatal care, and the maternal psychopatKology resulting from the drugseeking life-style. In feet, increased perinatal morbidity and mortality is predictable when one considers that the majority of drug-dependent women neglect general health and prenatal care, as described in the Dr Benfield's article. Of interest is that the low birthweight rate, which had decreased to less than 6 per 1000 live births in our region, has shown an increase in the past 2 years and is currently 6.7 per 1000 live births in 1990. Similarly, the rate of sudden infant death syndrome (SIDS) in our community, which has been stable for the past 15 years, also appears to be increasing.
Infants bom to poly-drug abusing women are often premature, small for gestational age, and passively addicted in utero.8 They may suffer from congenital anomalies and intracranial hemorrhage. They often have difficulty sucking and are at increased risk for morbidity and death. Early behavioral responses are abnormal and neurological impairment may occur. Often, however, the babies may be asymptomatic. Nevertheless, the risk of long-term neurobehavioral handicaps is high even if the infants are not identified as being abnormal at birth. The effects of maternal substance abuse thus may not become evident for years.
The initial interaction between the mother and infant lays the foundation for normal behavioral development, and the character of the mother's response to her baby is greatly responsible for the occurrence of abnormal infant behavior.9 The potential for interactional difficulties is greatest in the case of drug-abusing mothers because drug abuse affects both the mother and infant, especially since both members begin the« relationship highly vulnerable to pathologic interaction. The problem may be compounded by lack of personal resources including a usually absent or no spouse and low socioeconomic status.
Women who are substance abusers have misperceptions of their infants. Instead of viewing the infant as someone who requires attention, they often perceive their infant as a burden. Their inability to parent may be caused by decreased emotional involvement, disaffection, impaired communication, and increased resentment and hostility. Therefore, a strong component of any form of counseling must focus on increasing these patients' self-esteem to improve their self-image. Women need a positive self-concept so they can invest energy in caring for others. Improving self-esteem, coping skills, and problem-solving skills must be incorporated into parenting curricula to aid the mothers in bonding with their unborn babies or newborn infants.
In summary, the consequences of drug abuse during pregnancy can be hazardous both for the mother and the fetus. Infants exposed to drugs of abuse in utero pose a heavy burden in direct and indirect medical costs, and the societal costs as these infants grow into maladjusted, possibly neurologically impaired adolescents remain incalculable. A number of preliminary studies suggest that when women who are substance abusers receive specialized prenatal care, they have fewer pregnancy complications and their newborns are more likely to be full-term with fewer deficits and normal birth weight.10 Although specialized prenatal care is essential to ensure a healthy pregnancy outcome, the most effective way to address the complex needs of this population is through a comprehensive and multidisciplinary system of service delivery and case management. The issues of identification and enrollment into special prenatal care programs are crucial if appropriate pre- and postnatal services are to be provided to the infant and mother.
Health-care programs for substance- abusing women are often fragmented with specialty care being provided at multiple sites on different days of the week, and there is usually minimal interaction, communication, and coordination among the different care providers. In order to achieve even a modicum of success, a multiagency and multidisciplinary approach that coordinates and provides formal linkage between the community at large and major medical and social service systems must be used. Community level organizations, as well as the legal and judicial systems, need to uniformly identify, engage, and refer the target population using a nonjudgmental and positive approach. The program design should incorporate a single-site, comprehensive care setting for substance abuse counseling and treatment by skilled psychiatrists and counselors, prenatal care and delivery by specialists, and initial infant care and psychomotor evaluation by neonatologists with the availability of a neonatal intensive care unit if needed. Long-term infant follow-up must be provided with early intervention programs to ensure maximum benefit.
1. Chasnoff IJ. The Interface of Perniami Addiction. Drags, Alcohol. Pregnancy and Parenting. Hingham, Mass: Klewer Academic Publishers; 1989:1-3.
2. Data from New York Academy of Science conference and based on 1 985 nan'onai household slavey of drug abuse. Rockville, Md: National Institute on Drug Abuse; 1985.
3. Innocent Addicts: High Rate of Perinatal Drag Abuse Found. National Association for Perinatal Addiction Research and Education; 1988.
4. Woods JR, PlessingerMA, Clark KE Effect of cocaine on uterine blood flow and fetal oxygenation. JAMA. 1987:257:957-961.
5. Little BB, Snell LM, Klein VR, Gilsrrap LC III. Cocaine abuse during pregnancy: maternal and fetal implications. Obitei Gynecol. 1989;7Z: 157-160.
6. Zuckerman B, frank U Hingson R, et al Effects of maternal marijuana and cocaine use on fetal growth. N Engl J. Med. 1989; 3 20:762-768.
7. Finnigan IB1 ed. Drag Dependency m Pregnancy: Cimicol Management of Mother ana CMd. A Manual for Medical Professionals and Rira-Professionals Prepared for the Notional Institute of Drug Abuse, Service Research Brand. Washington, DC: US Government Printing Office; 1978.
8. Hutchings DE Methadone and lieroin during pregnancy: a review of behavioral effects in human and animal oflspring. Neurabehav Toacoi Tenttal. 1982;4:429-434.
9. Bums W, Bums K. Parenting Djjfunction in ChemKaäy Dependent Women. Hingham, Mass: Klewet Academic Publishers; 1989:159-171.
10. Suffer F, Brotman R. A comprehensive care program fot pregnant addicts: obstetrical, neonatal, and child development outcomes. Im } Addict. 1984; 19:1 99-2 19.