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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___________________________________________________________________
GAO/HRD-90-138
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.
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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.
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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.
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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.
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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.
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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-
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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.
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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.)
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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.
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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
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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 pregnanc