PREGNANCY AND PUBLIC HEALTH HYPOCRISY

By Dr. Gene Tinelli, M.D., Ph.D.

In a sane society, public health policy toward pregnancy aims to maximize those  behaviors that enhance maternal and prenatal health and minimize those behaviors that  harm maternal and prenatal health. To optimally use limited public resources, a rational  policy would use available medical research to support the most beneficial behaviors and  target the riskiest behaviors. However, we do not have a sane society. Instead, we have  a society where almost everything is corrupted by the War on Drugs, including our  health policies regarding pregnancy. Currently, these policies put both the health of the  mother and the child at risk.

Criminal Justice Professionals, not Doctors, Set Current Policy

Until recently, health care professionals set policy toward pregnancy and prenatal  development. This was certainly appropriate. Now, however, drug warriors and  prohibitionists at the state level, many with little to no health care expertise, have taken  over policy. They and only they — not mothers, not doctors or other health  professionals — dictate what is and what is not appropriate health care. 

Although the Drug War has gone on for almost a century, pregnant women were not  targeted by drug warriors until the 1980s. This was due to the rising use of cocaine  during that decade, and to the media’s response to a 1985 study(1) that was headed by  Dr. Ira Chasnoff. Dr. Chasnoff’s study reported that mothers who use cocaine had  babies with a variety of developmental problems, such as low birth weight, small head  size, increased rates of prematurity and increased rates of abruptio placenta, where the  placenta separates from the wall of the uterus. In addition, the study reported that there  were some neuro-behavioral problems, such as irritability, difficulty focusing, and some  feeding problems. When it was published in The New England Journal of Medicine, the  study created a media frenzy about an "epidemic" of crack babies that was going to  inundate America. (2) 

Chasnoff was not alone in finding problems with pregnancies where cocaine was used.  Other research has reported problems associated with cocaine use during pregnancy,  including increased exposure to sexually transmitted diseases, maternal weight loss,  nutritional deficits and polydrug use, premature detachment of the placenta, premature  birth and reduced/low birth weight, reductions in newborn body length and head  circumference, and rare birth defects including genito-urinary tract malformations and  extremely rare bone and neural tube abnormalities.

Limited Treatment Facilities

A sane response to these findings would be to reach out in as many ways as possible to  drug-using women, offering them prenatal care and treatment. But America had then,  and has now, limited treatment facilities. Of these, only a small number take pregnant  women and even fewer offer residential treatment for pregnant women with children.  (3)

Prohibitionists did not respond to the need for such facilities by offering more  treatment centers. Instead, a number of states modified their civil child protection laws  to mandate that doctors report pregnant drug-using mothers to child welfare  authorities. In addition, the definition of child neglect was expanded to encompass cases  in which a newborn is "physically dependent on" or tests positive for an illegal drug. (4)

Up until recently, no state had enacted a law that specifically criminalizes prenatal  conduct. (5) According to the Center for Reproductive Law and Policy, prosecutors  have used statutes prohibiting abuse or neglect of children to charge women for actions  that potentially harm the fetus. (6) Some have also argued that pregnant women  "delivered" drugs to "minor" children -- fetuses -- through the umbilical cord. (7) In  addition, a mother's or newborn's positive drug test has led to charges of assault with a  deadly weapon (cocaine), contributing to the delinquency of a minor, and possession of  a controlled substance. (8) In cases in which infants tested positive and died soon after  birth, women have been charged with homicide or feticide. (9) Some women have even  been prosecuted for drinking alcohol (10) or failing to follow a doctor's order to get  bed rest or refrain from sexual intercourse during pregnancy. (11)

Over 200 Women Prosecuted

Estimates based on court documents, news accounts, and data collected by attorneys  representing pregnant and parenting women indicate that at least 200 women in more  than thirty states have been arrested and criminally charged for their alleged drug use or  other actions during pregnancy. (12) The majority of women prosecuted have been low- income women of color, (13) despite the fact that rates of illegal drug use are similar  across race and class lines. (14) According to one analysis, "poor Black women have  been selected for punishment as a result of an inseparable combination of their gender,  race, and economic status.” (15) Often, information indicating possible drug use has  been provided to law enforcement officials by medical personnel -- possibly in violation  of constitutional and statutory guarantees of confidentiality. (16) In many of the cases,  women have been pressured into pleading guilty or accepting plea bargains, some of  which involve jail time. However, those women who have challenged their charges have  succeeded in reversing penalties imposed on them for their prenatal conduct. In fact,  every appellate panel and most trial courts to rule on the use of existing criminal  statutes to punish women for their conduct during pregnancy have found that these  prosecutions are without legal basis, or are unconstitutional, or both.

Currently, only some states have modified their civil child protection laws to mandate  reporting to child welfare authorities or to define child neglect to encompass cases in  which a newborn is "physically dependent on" (17) or tests positive for (18) an illegal  drug. A few of these states also require reporting of fetal alcohol syndrome or evidence  of alcohol use, (19) while only one mandates reporting a positive drug test prior to  birth. (20) In some instances, such a report may only trigger an evaluation of parenting  ability and the provision of services; in others, it may become the basis for temporarily  removing custody of the newborn. (21) One state specifically prohibits the use of a lone  positive drug test as the basis for a report to child welfare authorities, (22) and several  others prohibit basing criminal proceedings solely on a positive toxicology. (23) Another  state, recognizing that such reporting raises serious issues of doctor-patient  confidentiality, provides reporting to the health department for "service coordination,"  but only if the woman consents. (24) Still another state provides that, if a woman is  informed, health care providers may test new mothers and newborns for alcohol and  other drugs, but allows a physician discretion in determining whether abuse or neglect  has occurred and reporting is required. (25)

Nevertheless, hundreds, if not thousands, of women across the country have had their  children taken away from them because of a single positive drug test. As in the criminal  context, women of color have been particularly vulnerable to losing their children, even  though white women use illegal drugs at the same rate as women of color. A study by  Dr. Chasnoff, conducted in Pinellas County, Florida, found that black women were ten  times more likely than white women to be reported to civil authorities if an infant was  prenatally exposed to an illegal drug. (26)

Although pregnant women in other states continue to face attempts to civilly commit  them for the purpose of protecting their fetuses from potential harm, (27) South  Carolina went further. Though most criminal charges filed against women for their  behavior during pregnancy are the result of individual prosecutors who pursue a few  cases, in 1989 the city of Charleston, South Carolina, established a joint effort among its  police department, prosecutor's office, and the Medical University of South Carolina  (MUSC), to punish pregnant women and new mothers who tested positive for cocaine.  (28) The policy, which ultimately would set a standard for the state, required that  pregnant women seeking obstetrical care at MUSC must submit to non-consensual drug  testing. It is important to note that MUSC is a state-funded hospital and the only medical  facility in the Charleston area to treat indigent and Medicaid patients, a majority of  whom are African-American. 

If a mother went to MUSC to give birth or for prenatal care and tested positive for  cocaine, the physicians would be forced to immediately report her to the authorities,  and she would be arrested and prosecuted. When this policy began, there was no drug  treatment available in Charleston for pregnant or parenting women. Mothers who  tested positive at MUSC were simply jailed, often moments after giving birth. 

The eventual result of this policy was a 1996 South Carolina Supreme Court decision,  Whitner v. State, which allowed a woman to be criminally prosecuted for drug use  during her pregnancy. The ruling came in the case of Cornelia Whitner, who in 1992  pleaded guilty to child neglect after her baby was born with traces of cocaine in its  system. Ms. Whitner was sentenced to eight years in prison. 

"This case is about ensuring newborns a healthy future," said Margaret Crawford, board  chair of The Alliance for South Carolina's Children. "South Carolina's Attorney General  Charles Condon thinks jail will deter substance abuse. However, treatment centers are  already reporting that far fewer women are seeking treatment and prenatal care due to  this policy – causing further harm to women, children and families. "

"South Carolina Attorney General Condon's War on Drugs has turned into a war on  pregnant women who need treatment," said Daniel Abrahamson, Director of Legal  Affairs for the Lindesmith Center and one of the attorneys representing the broad array  of health organizations in this case before the High Court. "Sadly, Attorney General  Condon has ignored the countless pleas of physicians and alcohol and drug treatment  providers to treat, not prosecute, pregnant women suffering from chemical dependence.  Now, the women and children most in need of help are suffering horribly as a result of  Mr. Condon's misguided and Draconian policies.”

Uniting Against Punitive Policies

Public health organizations, including the American Medical Association and the  American Public Health Association, oppose the prosecution of pregnant women who  use drugs. In addition, the Lindesmith Center’s Office of Legal Affairs, in conjunction  with nearly two dozen medical and public health organizations, has submitted an amicus  ("Friend of the Court") brief to the U.S. Supreme Court in support of plaintiffs in  Ferguson v. The City of Charleston. In addition, 10 women, including nine women of  color, arrested for testing positive, challenged the policy on various constitutional and  statutory grounds and are now asking the United States Supreme Court to overturn the  Fourth Circuit’s decision to uphold the policy. 

All these groups recognize that South Carolina’s current approach will only keep the  women who most need prenatal care from seeking it for fear of being imprisoned and  prosecuted and losing their children. In addition, this policy harms the mothers by  keeping them from going to a doctor for drug treatment. The American Academy of  Pediatrics has stated, "punitive measures taken toward pregnant women, such as  criminal prosecution and incarceration, have no proven benefits for infant health.” (29)  In fact, studies indicate that drug-using women who receive prenatal care have healthier  children. (30)

Studying the Cocaine Studies

Before we fill overcrowded prisons with pregnant women and mothers, a look at the  research that followed Chasnoff’s initial study is warranted. 

A meta-analysis of most 1980s studies on prenatal cocaine use found serious  methodological flaws, such as a lack of control groups, failure to distinguish cocaine use  from the use of other drugs, failure to study the ensuing health of the newborn, and the  use of case reports alone. (31)Presented with children randomly labeled "prenatally  cocaine-exposed" and "normal," childcare professionals ranked the performance of the  "prenatally cocaine-exposed" children below that of "normal," despite the actual  performance. (32) But when medical personnel did not know beforehand which infants  were exposed to cocaine, they could not detect cocaine withdrawal syndrome. (33)  Well-controlled studies found no increase in Sudden Infant Death Syndrome. In  addition, no causal link could be established between cocaine use and poor fetal  development, even though cocaine, like many drugs and medicines, enters the  bloodstream of the developing fetus and has the potential to affect development. Among  the general population, there has been no detectable increase in birth defects that may  be associated with cocaine use during pregnancy. (34)

The problem with making a direct causal link comes from the fact that the problems  suffered by children exposed to cocaine can stem from many factors. For example, many  are born prematurely to mothers who had little or no prenatal care and are returned to  a neglectful environment. The lack of quality prenatal care is associated with undesirable  effects often attributed to cocaine exposure: prematurity, low birth weight and fetal or  infant death. (35) But cocaine itself has not been proven to be any more damaging than  any other drug used by pregnant women, and children with Fetal Alcohol Syndrome are  much more likely than crack or cocaine babies to suffer from mental retardation that is  permanent. (36-40)

Research paid for by the National Institute on Drug Abuse and the Albert Einstein  Medical Center in Philadelphia states that, "Although numerous animal experiments and  some human data show potent effects of cocaine on the central nervous system, we  were unable to detect any difference in performance, verbal or full scale IP [intelligence]  scores between cocaine-exposed and control children at age 4 years.” (41)

Alcohol, Tobacco, Do the Most Harm

Abuse of alcohol, more than any other recreational drug, causes the greatest number of  and most severe birth defects: 9.1/1000 or approximately 1/100 live births are diagnosed  with Fetal Alcohol Syndrome or alcohol-related neuro-developmental disorder, and a  larger number experience "fetal alcohol effects.” (42)

Tobacco use is also strongly associated with low birth weight, prematurity and growth  retardation, Sudden Infant Death Syndrome, low cognitive achievement, behavioral  problems, and, in some cases, mental retardation. Also, urine samples collected from  newborn infants of mothers who smoked during pregnancy detected breakdown  products of nitrosaminoketone, a known carcinogen and a chemical found only in  tobacco. (43-47)

Ill Effects of Poverty on Children Can Last a Lifetime

Nevertheless, the risks of alcohol and tobacco are not what caught the media’s  attention. Crack babies caught its attention. Chasnoff painted a dark picture behind  society's morbid embrace of crack babies. "The image of the crack baby really moved  out there," he said. "Politicians really picked it up. It worked into the trend of writing  about the underclass. It's sexy, it's interesting, it sells newspapers and it perpetuates the  us-versus-them idea." In fact, said Chasnoff, "Poverty is the worst thing that can happen  to a child.” (48)

Indeed, factors strongly associated with poor fetal development include the stressors  and health risks associated with poverty: lead exposure, psychiatric problems such as  major depression and depressive symptoms associated with life stress, lack of social  support, low weight gain, and polydrug use. (49-52)

These factors also affect children long after they are born, making it difficult for them to  succeed in school and increasing the risk that they will develop poor relationships with  drugs or develop other self-destructive or abusive behaviors. The 6-year-old boy who  lived in a crack house where he stole a gun and shot a classmate is a tragic case in point.

What do we make of all the research to date? Most of the evidence points to the lack of  quality prenatal care and the use of alcohol and tobacco as primary factors in poor fetal  development among pregnant cocaine users. Of all birth defects, 10-15% are due to  environmental agents (53), 10-15% are hereditary (54), 1- 5% are from chemical  (including drug) exposure (55,56) and the rest are due to unknown factors. (57)

Poor prenatal care often results in premature births, low birth weight, and other fetal  development problems, while provision of quality prenatal care to heavy cocaine users  (with or without drug treatment) has been shown to significantly improve fetal health  and development and reduce substance use. (58)

So what should we do now? If we are truly concerned about maternal and fetal health  and we want to follow the War on Drugs mentality and the South Carolina court  decision, then we should also begin to criminally prosecute pregnant women who use  alcohol or smoke nicotine cigarettes. If this sounds insane, at least it is not hypocritical.  What is insane is that not only are we punishing pregnant women and mothers who are  chemically dependent, we are reducing drug treatment for women, thus locking poor  women in a cycle of poverty, worsening the most noxious factor for their fetuses,  poverty. (59,60) Criminalizing substance abuse during pregnancy discourages substance- using or abusing women from seeking prenatal care, drug treatment, and other social  services, and sometimes leads to unnecessary abortions. (61, 62)

Punishing substance users and abusers during their pregnancies threatens the health of  the mothers and children, and seriously compromises women's rights to privacy. It also  ignores the serious shortage of drug treatment programs for pregnant and parenting  women and fails to address the overall lack of access to reproductive health care  services. The author of a recent study on the effectiveness of mandatory treatment  concluded, "the children of drug-using mothers may be most effectively served by the  development of available, efficacious, and welcoming services for women and families.”  (63)

We have created a system that severely punishes those who use certain illicit  substances that cause mild to moderate harm, virtually ignores the use of substances  that cause much greater harm, and encourages the creation of a poorer prenatal  environment for those most at risk. This is not an optimal public health policy.

We need to stop this insanity. Our children and our future are at grave risk. We need  to end the Drug War now. 

REFERENCES:

1. Chasnoff IJ, Bruns, WJ, Schnoll WJ, Burns KA, Cocaine use in pregnancy, New England Journal  of Medicine 313: 666-669 (1985)

2. Greider, Katharine. "Crackpot Ideas.” Mother Jones. July/Aug,, pp 53-56 (1995)

3. Humphries D.,et al, Mothers and Children, drugs and crack: Reacton to maternal drug  dependence, Women and Criminal Justice 199w;1:81-99

4. Wendy Chavkin et al., Efforts to Reduce Perinatal Mortality, HIV, and Drug Addiction: Survey  of the States, 50 JAMWA 164: 164-65 (1995)

5. The Center for Reproductive Law & Policy, Punishing Women for their Behavior During  Pregnancy: An Approach That Undermines Women's Health and Children's Interests. New  York: Center for Reproductive Law & Policy, 1996

6. See, e.g., Commonwealth v. Welch, 864 S.W.2d 280 (Ky. 1993) (affirming reversal of child  abuse conviction,finding that to construe the child abuse statute to apply to a woman's prenatal  conduct would make the statute impermissibly vague and violate legislative intent); Sherriff v  Encoe, 885 P.2d 596, 598 (Nev. 1994) (child abuse statute inapplicable to woman who used  methamphetamines during pregnancy; to hold otherwise would "open the floodgates to  prosecution of pregnant women who ingest such things as alcohol, nicotine, and a range of  miscellaneous, otherwise legal, toxins"); Commonwealth v Kemp, 75 Westmoreland L.J. 5 (Pa.  Ct. C.P. 1992), aff'd, 643 A.2d 705 (Pa. Super. Ct. 1994) (affirming dismissal of charges of  recklessly endangering another person or endangering the welfare of a child against a pregnant  woman who allegedly ingested cocaine while pregnant; finding that neither "child" nor "person"  include an unborn "fetus"). 

7. See, e.g., Johnson v. State, 602 So. 2d 1288 (Fla. 1992) (reversing a woman's convictions for  "delivering drugs to a minor" via the umbilical cord); People v Hardy, 469 N.W.2d 50 (Mich. Ct.  App.) (statute prohibiting delivery of cocaine to children was not intended to apply to pregnant  drug users), leave to appeal denied, 471 N.W.2d 619 (Mich. 1991). 

8. See, e.g., State v Inzar, Nos. 90CRS6960, 90CRS6961 (N.C. Super. Ct. Robeson Cty. Apr. 9,  1991), appeal dismissed, No. 9116SC778 (N.C. Ct. App. Aug. 30, 1991) (dismissing charges  against a woman who allegedly used "Crack" during her pregnancy under statutes prohibiting  assault with a deadly weapon and delivery of a controlled substance because a fetus is not a  person within the meaning of the statutes); State v. Alexander, No. CF-92-2047, Transcript of  Decision (Okla. Dist. Ct. Tulsa Cty. Aug. 31, 1992) (dismissing charges of unlawful possession of  a controlled substance and unlawful delivery of a controlled substance to a minor brought  against a woman who ingested illegal drugs while pregnant, finding that the presence of drugs in  defendant's system does not constitute possession and transfer of the drug through the umbilical  cord is not "volitional"). 

9. See People v. Jones, No. 93-5, Reporter's Transcript (Cal. Juv. Ct. Siskiyou Cty. July 28, 1993)  (dismissing homicide charges against woman whose newborn died allegedly as a result of  prenatal drug use, finding that legislative history did not support application of murder statute to  fetus's death); Jaurigue v Justice Court, No. 18988, Reporter's Transcript (Cal. Super. Ct. San  Benito Cty Aug. 21, 1992) (dismissing fetal homicide charges against woman who suffered  stillbirth allegedly as a result of her prenatal drug use, finding that neither legislative history nor  the statute's language suggested that a mother could be prosecuted for murder for her fetus's  death), writ denied, (Cal. Ct. App. 1992); State v Barnett, No. 02DO4-9308-CF-00611 (Ind.  Super. Ct. Allen Cty. Feb. 11, 1994) (notice accepting state's motion to withdraw child abuse  charges and dismissing homicide charges brought against woman whose infant tested positive for  cocaine and (lied shortly after its premature birth). 

10. See State v. Pfannenstiel, No. 1-90-8CR (Wyo. Cty. Ct. Albany Cty. Jan. 5, 1990) (pregnant  woman charged with child abuse for drinking alcohol); Joan Little, Woman Jailed After Baby Is  Born Intoxicated, St. Louis Post-Dispatch, Nov. 26, 1991, at 3A (woman was charged with  second-degree assault and child endangerment after her son was allegedly born with signs of  fetal alcohol syndrome). 

11. See People v. Stewart, No. M508197, Reporter's Transcript, at 4 (Cal. Mun. Ct. San Diego  Cty. Feb. 26, 1987) (pregnant woman charged under a criminal child support statute for failing  to follow doctor's advice to get bed rest, to abstain from sexual intercourse, and to seek  prompt medical attention when she experienced bleeding). 

12. Lynn M. Paltrow, Criminal Prosecutions Against Pregnant Women: National Update and  Overview (1992): The Center for Reproductive Law and Policy, In the Courts: Decisions  Involving Penalties Imposed Against Women for Their Conduct During Pregnancy (Feb. 1996). 

13. Gina Kolata, Bias Seen Against Pregnant Addicts, N.Y Times, July 20, 1990, at A13. 

14. As a survey by the Southern Regional Project on Infant Mortality concluded:

Newspaper reports in the 1980s sensationalized the use of crack cocaine and  created a new picture of the typical female addict: young, poor, black, urban, on welfare, the  mother of many children, and addicted to crack. In interviewing nearly 200 women for this  study, a very different picture of the typical chemically dependent woman emerges. She is  most likely white, divorced or never married, age 31, a high school graduate, on public  assistance, the mother of two or three children, and addicted to alcohol and one other  drug. It is clear from the women we interviewed that substance abuse among women is not  a problem confined to those who are poor, black, or urban, but crosses racial, class,  economic and geographic boundaries. -- Shelly Gehshan, Southern Regional Project on Infant  Mortality, A Step Toward Recovery 1 (1993). 

15. Dorothy E. Roberts, Punishing Drug Addicts Who Have Babies: Women of Color, Equality,  And the Right of Privacy, 104 Harv. L. Rev. 1419, 1424 (1991). 

16. One federal law provides that, except under limited circumstances, "[r]ecords of the  identity, diagnosis, prognosis, or treatment of any patient ... maintained in connection with the  performance of any program or activity relating to substance abuse education, prevention,  training, treatment, rehabilitation, or research, which is conducted, regulated, or directly or  indirectly assisted by any department or agency of the United States shall ... be confidential ...”  42 U.S.C. 290dd-2 (1995). See also Legal Action Center, Confidentiality: A Guide to the Federal  Laws and Regulations (1991); Legal Action Center, Dispelling the Myth: Legal Issues of  Treatment Programs Serving Pregnant Addicts (1994).

17. See, e.g, Fla. Stat. ch. 415.503 (1995); Mass. Ann. Laws ch. 119, 51A (Law. Co- op. 1995);  Okla. Stat. tit. 63, 1-550.3(A) (1995); Utah Code Ann. 62A-4a-404 (1995). 

18. See, eg, Ill. Comp. Stat. Ann. ch. 325, para. 5/3 (1995); Ind. Code 31-6-4-3.1 (a) (1) (B)  (1995); Iowa Code 232.77(2) (1995); Minn. Star. 626.5562(2) (1995). A survey of state  maternal/child health and drug treatment agency directors found that other states may, as a  matter of policy, require reporting to child protective authorities of pregnant women or infants  with positive toxicology results, and/or define a positive result as evidence of child neglect or  abuse. Wendy Chavkin et al., Efforts to Reduce Perinatal Mortality, HIV, and Drug Addiction:  Survey of the States, 50 JAMWA 164: 164-65 (1995). 

19. See, eg., Ind. Code 31-6-4-3.1 (a) (1) (1995); Utah Code Ann. 62A-4a-404 (1995). 

20. See Minn. Stat. 626.5662(2) (1995). 

21. See Bonnie Baird Wilford & Jacqueline Morgan, Intergovernmental Health Policy Project,  Families at Risk: Analysis of State Initiatives to Aid Drug-Exposed Infants and Their Families 34- 47 (1993). 

22. See Cal. Penal Code 11165.13 (Deering 1995). 

23. See, eg., Iowa Code 232.77(2) (1995); Ky. Rev. Stat. Ann. 214.160(5) (Michie 1995). 

24. See Kan. Stat. Ann. 65-1,163 (1994). 

25. See Ky. Rev. Stat. Ann 214.160 (Michie 1995). 

26. Ira J. Chasnoff et al., The Prevalence of Illicit-Drug or Alcohol Use During Pregnancy and  Discrepancies in Mandatory Reporting in Pinellas County, Florida, 322 New Eng. L Med. 1202:  1204 (1990).

27. Wendy Chavkin, Mandatory Treatment for Drug Use During Pregnancy, JAMA 266: 1556  (1991)

28. Philip H. Jos, et al., The Charleston Policy on Cocaine Use During Pregnancy: A Cautionary  Tale, 23 J.L. Med. & Ethics 120 (1995). See also Plaintiffs' Memorandum in Support of their  Partial Cross-Motion for Summary Judgment and in Opposition to Defendants' Motion for  Summary Judgment, Ferguson v City of Charleston, No. 2:93-2624-2 (D.S.C. filed Oct. 5, 1993).

29. American Academy of Pediatrics, Committee on Substance Abuse, Drug-Exposed Infants,  Pediatrics 86: 639-641 (1990).

30. Andrew Racine et al., The Association Between Prenatal Care and Birth Weight Among  Women Exposed to Cocaine in New York City, JAMA 270: 1581 (1993).

31. Lutiger B, Grahan K, Einarson TR, Koren G. Relationship between gestational cocaine use  and pregnancy outcome: a meta-analysis. Teratology 44: 405-414 (1991)

32. Thurman SK, Brobeil RA, Duccette JP, Hurt H, Prenatally Exposed to Cocaine: Does the  Label Matter, Journal of Early Intervention 18: 119-130 (1994)

33. Kennedy D. 'Crack babies' catch up. Associated Press, 6 December, 1992

34. Bauchner H, Zuckerman B, McClain M, Frank D, Fried LE, Kayne H. Risk of Sudden Infant  Death Syndrome among infants with in utero exposure to cocaine. Journal of Pediatrics 113:  831-834 (1988). 

35. Klein L & Goldenberg RL, Prenatal Care and its effect of preterm birth and low birth weight,  in Merhatz IR & Thompson JE (eds), New Perspectives of Prenatal Care New York, NY: Elsever  (1990), pp 511-513

36. Gustavsson NS. Drug exposed infants and their mothers: facts, myths and needs. Social  Work in Health Care 16: 87-100 (1992)

37. Klein L, Goldenberg RL. Prenatal care and its effect on preterm birth and low birth weight.  In: Merkatz IR, Thompson JE, eds. New Perspectives on Prenatal Care. New York: Elsevier;  1990: 501-529

38. MacGregor SN, Keith LG, Bachicha JA, Chasnoff IJ. Cocaine abuse during pregnancy:  correlation between prenatal care and perinatal outcome. Obstetrics and Gynecology 74: 882- 885 (1989)

39. Chazotte C, Youchah J, Freda MC. Cocaine use during pregnancy and low birth weight: the  impact of prenatal care and drug treatment. Seminars in Perinatology 19: 293-300 (1995)

40. Streissguth AP, Sampson PD, Barr HM. Neurobehavioral dose-response effects of prenatal  alcohol exposure in humans from infancy to adulthood. Annals of the New York Academy of  Science 562: 145-158 (1989)

41. Hurt H, Malmud E, Betancourt Lbraitman LE, Brodsky BL, Giannetta J, Children with inutero  cocaine exposure do not differ from control subjects on intelligence testin, Archives of  Pediatrics and Adolescent Medicine 151: 1237-1241 (1997)

42. National Institute on Drug Abuse. National Pregnancy and Health Survey: drug use among  women delivering live births, 1992. Rockville, MD: U.S. Department of Health and Human  Services. National Institutes of Health publication 96-3819 -- found that 18.8%, or 757,000 of all  newborns had been exposed to alcohol and 1.1%, or 45,000 newborns had been exposed to  cocaine.

43. Rush, D, Callahan KR. Exposure to passive cigarette smoking and child development: a  critical review. Annals of the New York Academy of Science 562: 145-158 (1989)

44. Nordentoft M, Lou HC, Hansen D, Nim J, Pryds O, Rubin P, Hemmingsen R. Intrauterine  growth retardation and premature delivery: the influence of maternal smoking and psychosocial  factors. American Journal of Public Health 86: 347-354 (1996)

45. Castro LC, Azen C, Hobel CJ, Platt LD. Maternal tobacco use and substance abuse reported  prevalence rates and associations with the delivery of small for gestational age neonates.  Obstetrics and Gynecology 81, 396-401 (1993)

46. Broman SH, Nichols PL, Kennedy WA. Pre-school Intelligence Quotient: prenatal and early  developmental correlates. New York: John Wiley; 1975; Hardy JB, Mellits ED, Does maternal  smoking during pregnancy have a long-term effect on the child? Lancet 2: 1332-1336 (1972)

47. Landesmann-Dwyer W, Emanual I. Smoking during pregnancy. Teratology 19: 119-126  (1979)

48. Kennedy, Dana: 'Crack Babies' Catch Up. Santa Cruz. Sentinel, December 6.  Associated Press. 

49. Parker S. Double jeopardy: the impact of poverty on early child development. Pediatric  Clinics of North America 35: 1227-1240 (1988) 

50. Ruff HA, Bijur PE. The effects of low to moderate lead levels on neurobehavioral functioning  in children: toward a conceptual model. Journal of Developmental and Behavioral Pediatrics 10:  103-109 (1989) 

51. Griffin ML, Weiss RD, Mirin SM, Lange U. A comparison of male and female cocaine abusers.  Archives of General Psychiatry 46: 122-126(1989)

52. Zuckerman B, Amaro H, Bauchner H, Cabral H. Depressive symptoms during pregnancy:  relationship to poor health behaviors. American Journal of Obstetrics and Gynecology 160:  1107-1111 (1989)

53. Hutchings D. Prenatal exposure and the problem of causal inference. In: Pinkert TM, ed.  Current Research on the Consequences of Maternal Drug Abuse. Rockville, MD: National  Institute of Drug Abuse; 1985: 6-19.

54. Beckman DA, Brent RL. Mechanisms of teratogensis. Annual Review of Pharmacology and  Toxicology 24:482-500 (1984)

55. Dattel BJ. Substance abuse in pregnancy. Seminars in Perinatology 14:179-187 (1990)

56. Gustavsson NS. Drug exposed infants and their mothers: facts, myths and needs. Social  Work in Health Care 16: 87-100 (1992)

57. Gerstein D. and Harwood, H. eds, Treating Durug Problems Vol 1: A study of the evolution,  Effectiveness, and Financing of Public and Private Drug Treatment Systems. Washington DC:  National Academy Press 1990

58. Streissguth et al. Neurobehavioral dose-response effects of prenatal alcohol exposure in  humans from infancy to adulthood. Annals of the New York Academy of Science 562: 145-158  (1989)

59. Parker S. Double jeopardy: the impact of poverty on early child development. Pediatric  Clinics of North America 35: 1227-1240 (1988)

60. Cole HM, Legal interventions during pregnancy: Court-ordered medical treatment and legal  penalties for potentially harmful begavior by pregnant women, Journal of the American Medical  Association 364: 2663-2670 (1990)

61. Polan ML, Bombrowski MP, Ager JW, & Sokol RJ, Punishing pregnant drug users: Enhancing  the flight from care, Drug and Alcohol Dependence 31: 199-203 (1993)

62. Koren G, Gladstone D, Robeson C & Robieux I, The perception of teratogenic risk of  cocaine, Teratology 46: 567-571 (1992)

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