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 Some of the information in this report--e.g., pictures, charts, and tables--could not be be viewed as ASCII text. If you wish to obtain a complete report, call GAO report distribution at 202/275-6241 (7:30 a.m.-5:30 p.m. EST) or write to GAO, P.O. Box 6015, Gaithersburg, MD 20877. ___________________________________________________________________ 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. 1 B-238209 Although definitive information does not exist about the long-term effects of drug use during pregnancy, researchers have reported that some infants who were prenatally exposed to stimulant drugs like cocaine have suffered from a stroke or hemorrhage in the areas of the brain responsible for intellectual capacities. In addition to the effects of prenatal drug exposure, drug- abusing pregnant women often imperil their health and that of their infants in other ways. These women do not receive the benefits of proper health care. The majority of women of childbearing age who abuse drugs suffer from many social, psychological, and economic problems. The Office of National Drug Control Policy is responsible for developing an annual national anti-drug strategy.#2 The 1990 National Drug Control Strategy calls for spending $10.6 billion in fiscal year 1991, with 71 percent of the funds going to drug-supply-reduction activities and 29 percent to reduce the demand for drugs. Under this strategy, $1.5 billion would be spent on drug treatment with over one-half of the federal funds provided through the Department of Health and Human Services (HHS) block grants to the states administered by the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA). The states are required to set aside at least 10 percent of these funds to provide drug abuse prevention and treatment for women. In addition, the Office for Substance Abuse Prevention within ADAMHA has a program that provides demonstration grants to public and private providers for model projects for substance-abusing pregnant and postpartum women and their infants. OBJECTIVES, SCOPE, AND METHODOLOGY ---------------------------------- We interviewed leading neonatologists, drug treatment officials, researchers, hospital officials, social welfare authorities, and drug-addicted pregnant women to determine: (1) the number of infants born drug-exposed, (2) their impact on the medical and social services systems, (3) their health costs, and (4) the availability of drug treatment and prenatal care. We also reviewed the current literature. 2The Office of National Drug Control Policy was established by the Anti-Drug Abuse Act of 1988. 2 B-238209 We obtained data on drug-exposed births from 1986 through 1988 from HHS to develop a nationwide estimate of the number of drug-exposed infants. The National Hospital Discharge Survey collects information on the diagnoses associated with hospitalization of adults and newborns in all nonfederal short-stay hospitals. Newborn discharge data from the survey for 1986 and 1988 were used to calculate nationwide estimates. We also selected two hospitals in each of five cities-- Boston, Chicago, Los Angeles, New York, and San Antonio--in which we reviewed medical records to determine the number of drug-exposed infants born and to assess differences in hospital charges between drug-exposed and nonexposed infants. These 10 hospitals, which accounted for 44,655 births in 1989, primarily served a high proportion of persons receiving Medicaid and other forms of public assistance. Births at these hospitals ranged from 5 percent of all infants in New York City to 42 percent of all births in San Antonio. We considered an infant to be drug-exposed if any of the following conditions were documented in the medical record of the infant or mother: (1) mother self- reported drug use during pregnancy, (2) urine toxicology results for mother or infant were positive for drug use, (3) infant diagnosed as having drug withdrawal symptoms, or (4) mother was diagnosed as drug dependent.#3 We also interviewed officials at 10 other hospitals in these cities that serve predominantly non-Medicaid patients, but we did not review patient medical records. Our methodology is discussed more fully in appendix VI. Our work was performed from January through April 1990 in accordance with generally accepted government auditing standards. The results are summarized below and are discussed more fully in appendixes I through IV. MANY DRUG-EXPOSED INFANTS ------------------------- WHO MIGHT NEED HELP ------------------- ARE NOT IDENTIFIED ------------------ Identifying infants who have been prenatally exposed to drugs is the key to providing them with effective medical and social interventions at birth and as they grow up. Such identification is also necessary to understand the nature and magnitude of the problem in order to target drug 3Alcohol use during pregnancy was not included in our definition of maternal drug use. 3 B-238209 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 B-238209 rigorous methods of detection.#8 The average incidence of drug-exposed infants born at hospitals with rigorous detection procedures was close to 16 percent of those hospitals' births, as compared with 3 percent at hospitals with no substance abuse assessment. A study conducted at a large Detroit hospital accounting for over 7,000 births used meconium testing,#9 a more sensitive test for detecting drug use. The incidence of drug-exposed infants at this hospital was 42 percent or nearly 3,000 births in 1989. In contrast, when self-reported drug use by the mother was the basis for identifying drug-exposed infants, only 8 percent or nearly 600 infants were identified.#10 Likewise, our work indicates that the National Hospital Discharge Survey undercounts the incidence of drug-exposed births. In our examination of medical records at 10 hospitals, we identified approximately 4,000 drug-exposed infants born in 1989. Our estimates ranged from 13 drug- exposed births per thousand births at one hospital to 181 per thousand births at another. The wide range in the numbers of drug-exposed infants we found may be associated with differences in the hospitals' efforts to identify drug-exposed infants. One hospital, for example, did not have a protocol for assessing drug use during pregnancy. This hospital had the lowest incidence of drug-exposed infants. The other 9 hospitals' protocols required testing primarily if the mother reported her drug use or the infant manifested drug withdrawal signs. Hospital officials acknowledge that these screening criteria allow many drug-exposed infants to go undetected in the hospital. This is because many drug-exposed infants display few overt drug withdrawal signs and many women deny using 8Ira J. Chasnoff, "Drug Use and Women: Establishing a Standard of Care," Prenatal Use of Licit and Illicit Drugs, ed., Donald E. Hutchings, New York: New York Academy of Sciences, 1989. 9Meconium is the first 2- to 3-days' stool of a newborn infant. 10Enrique M. Ostrea, Jr., A Prospective Study of the Prevalence of Drug Abuse Among Pregnant Women. Its Impact on Perinatal Morbidity and Mortality and on the Infant Mortality Rate in Detroit. July 13, 1989, preliminary report. 5 B-238209 drugs out of fear of being incarcerated or having their children taken from them. We also found that in hospitals serving primarily non- Medicaid patients, screening for drug exposure was even less prevalent. In our interviews with hospital officials at these hospitals, one-half of the hospitals did not have a protocol for identifying drug use during pregnancy. Some hospital officials told us that the problem of prenatal drug exposure was not considered serious enough to warrant implementing a drug testing protocol. However, one recent study has found that the problem of drug use during pregnancy is just as likely to occur among privately insured patients as among those relying on public assistance for their health care. This study anonymously tested for drug use among women entering private obstetric care and women entering public health clinics for prenatal care and found that the overall incidence of drug use was similar between the two groups (16.3 percent for women seen at public clinics and 13.1 percent for those seen at private offices).#11 (See app. I.) DRUG-EXPOSED INFANTS -------------------- HAVE MORE HEALTH PROBLEMS ------------------------- AND ARE MORE COSTLY ------------------- Drug-exposed infants are more likely than infants not exposed to drugs to suffer from a greater range of medical problems and in some cases require costly medical care. We compared the medical problems and costs of infants prenatally exposed to drugs, with those who were not, at four hospitals. At these four, we determined that at least 10 percent of the infants were prenatally exposed to drugs.#12 The mothers of the drug-exposed infants were more likely to have had little or no prenatal care, and the infants had significantly lower birth weights, were often 11Ira J. Chasnoff, Harvey J. Landress, and Mark E. Barrett, "The Prevalence of Illicit-Drug or Alcohol Use During Pregnancy and Discrepancies in Mandatory Reporting in Pinellas County, Florida." The New England Journal of Medicine, Vol. 322, Apr. 26, 1990, pp. 1202-06. 12The other six hospitals did not have enough cases to enable us to analyze differences in hospital charges and other characteristics of drug-exposed infants and those not exposed to drugs. 6 B-238209 premature, and had longer and more complicated hospital stays than other infants. Given these medical problems, hospital charges for drug- exposed infants were up to four times greater than those for infants with no indication of drug exposure. For example, at one hospital the median charge for drug-exposed infants was $5,500, while the median charge incurred by nonexposed infants was $1,400. Charges for drug-exposed infants at these hospitals ranged from $455 to $65,325. Because more than 50 percent of all patients received public medical assistance at 7 of the 10 hospitals in our study, much of these charges were covered by federal assistance programs. Although the long-term physical effects of prenatal drug exposure are not well known, indications are that some of these infants will continue to need expensive medical care as they grow up. Because of the uncertainty of the long- term consequences of prenatal drug exposure, the future costs of caring for these children are unknown. (See app. II.) IMPACT ON SOCIAL WELFARE ------------------------ AND EDUCATIONAL SYSTEMS ----------------------- COULD BE PROFOUND ----------------- Drug-exposed infants often present immediate and long-term demands on the social welfare system. Officials at several of the hospitals in our review stated that they are experiencing a growing number of "boarder babies"--infants who stay in a hospital for nonmedical reasons often related to drug-abusing families. Boarder babies are reported to the social welfare system for foster care placement. We also found that a substantial proportion of drug-exposed infants did not go home from the hospital with their parents. An estimated 1,200 of the 4,000 drug-exposed infants born in 1989 at the 10 hospitals in our review were placed in foster care. The cost of 1 year of foster care for these 1,200 infants is about $7.2 million. Not all drug-exposed infants enter the social services system at birth; some are discharged from the hospital to drug-abusing parents. These infants may later enter the social services system because of the chaotic and often dangerous environment associated with parental drug abuse-- an increasing source of child abuse and neglect. For example, cocaine use was found to be significantly associated with child neglect in a recent study of child- 7 B-238209 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.) 8 B-238209 LACK OF DRUG TREATMENT AND PRENATAL ----------------------------------- CARE IS CONTRIBUTING TO THE NUMBER ---------------------------------- OF DRUG-EXPOSED INFANTS ----------------------- To prevent the problem of drug-exposed infants, women of childbearing age must abstain from using drugs. To reduce the impact of drug exposure, pregnant women who use drugs should be encouraged to stop and be given needed treatment. Drug Treatment Services ----------------------- Do Not Meet the Need -------------------- Recent studies show that if women are able to stop drug use during pregnancy, there will be significant positive effects in the health of the infant. The risks of low birth weight and prematurity, which often require expensive neonatal intensive care, are minimized by drug treatment before the third trimester. Many programs that provide services to women, including pregnant women, have long waiting lists. Treatment experts believe that unless women who have decided to seek treatment are admitted to a treatment facility the same day, they may not return. However, women are rarely admitted the day they seek treatment. One treatment center in Boston received 450 calls for detoxification services during a 1-month period. The callers were told that it usually took 1 to 2 weeks to be admitted. They were also instructed to call back every day to determine if a slot had become available. Of the 450 callers that month, about one-half never called back and about 150 were eventually admitted to treatment. Nationwide, drug treatment services are insufficient. A 1990 survey conducted by the National Association of State Alcohol and Drug Abuse Directors, Inc. (NASADAD), estimates that 280,000 pregnant women nationwide were in need of drug treatment, yet less than 11 percent of them received care.#13 Hospital and social welfare officials in each of the five cities in our review also told us that drug treatment services were insufficient or inadequate to meet the demand for services of drug-addicted pregnant women. In addition to insufficient treatment, some programs deny services to pregnant women. A survey of 78 drug treatment programs in New York City found that 54 percent of them denied treatment to pregnant women. One of the primary reasons treatment centers are reluctant to treat pregnant women relates to issues of legal liability. Drug treatment providers fear that certain treatments using medications and 13The report did not reveal the extent to which these women sought treatment. 9 B-238209 the lack of prenatal care or obstetrical services at the clinics may have adverse consequences on the fetus and thereby expose the providers to legal problems. Many other barriers to treatment exist. For example, pregnant addicts we interviewed told us that because they had other children, the lack of child care services made it difficult for them to seek treatment. Most treatment programs do not provide child care services. Another barrier to treatment for women is the fear of criminal prosecution. Drug treatment and prenatal care providers told us that the increasing fear of incarceration and losing children to foster care is discouraging pregnant women from seeking care. Women are reluctant to seek treatment if there is a possibility of punishment. They also fear that if their children are placed in foster care, they will never get the children back. Prenatal Care Is Needed ----------------------- Prenatal care can help prevent or at least ameliorate many of the problems and costs associated with the births of drug-exposed infants. Through the three basic components of prenatal care: (1) early and continued risk assessment, (2) health promotion, and (3) medical and psychosocial interventions and follow-up, the chances of an unhealthy infant are greatly reduced. Hospital officials told us that in addition to not seeking prenatal care, some drug-using women are now delivering their infants at home in order to prevent being reported to child welfare authorities. Many health professionals believe comprehensive residential drug treatment that includes prenatal care services is the best approach to helping many women stop using drugs during pregnancy and providing the developing infant with the best chance of being born healthy. However, such programs are scarce. Massachusetts officials told us that the lack of residential treatment slots was a major problem. Only 15 residential treatment slots are available to pregnant addicts statewide. California officials made similar comments. These officials also reported that when they are unable to place drug- addicted pregnant women in residential treatment, they try to place these women in battered women shelters or even in nursing homes. (See app. IV.) 10 B-238209 CONCLUSIONS ----------- Despite growing indications of a serious national problem, hospital procedures do not adequately identify drug use during pregnancy. Consequently, there are no reliable data on the number of drug-exposed infants born each year. However, based on our review at hospitals in five cities, we believe the number of drug-exposed infants born nationwide each year could be very high. A drug-exposed infant has short- and long-term health, social, and cost implications for society. These infants are more likely to be born premature, have a lower birth weight, and have longer hospital stays requiring more expensive care. Some of them will need a lifetime of medical care; others will have considerable developmental problems, which may impair their schooling and employment. Preventing drug use among women of childbearing age would reduce the number of infants born drug exposed. Providing drug treatment and prenatal care could significantly improve the health of infants born to women who use drugs and could reduce the risk of long-term problems. Yet in the five cities in our review, drug treatment was largely unavailable and many women giving birth to drug-exposed infants are not receiving adequate prenatal care. MATTERS FOR CONSIDERATION ------------------------- BY THE CONGRESS --------------- Because the increasing number of drug-exposed infants has become a serious health and social problem, we believe an urgent national response is necessary. Specifically, outreach services should be provided so that pregnant women in need of prenatal care and drug treatment can be identified. For these women, comprehensive drug treatment, and prenatal care must be made available and accessible. With additional federal funding, the large gap between the number of women who could benefit from drug treatment and the number of residential and outpatient slots currently available could be reduced. If the Congress should decide to expand the current federal resource commitment to treatment for drug-addicted pregnant women, there are several options that could be followed. These include: -- Increasing the alcohol and drug abuse and mental health services (ADMS) block grant to the states in order to provide more federal support for drug treatment. 11 B-238209 -- Increasing the ADMS Women's Set-Aside from 10 percent to a higher percentage to assure that expanded treatment services under the block grant are targeted specifically to substance-abusing pregnant women. -- Creating a new categorical grant to provide comprehensive prenatal care and drug treatment services to substance-abusing pregnant women. Although these options would require more funds in the short term, we believe that this commitment could save money in the long term as well as improve the lives of a future generation of children. - - - - Copies of this report will be sent to the appropriate congressional committees and subcommittees; the Secretary of Health and Human Services; and the Director, Office of Management and Budget, and we will make copies available to other interested parties upon request. If you have any questions about this report, please call me on (202) 275-5451. Other major contributors to the report are listed in appendix VII. Sincerely yours, Janet L. Shikles Director for Health Financing and Policy Issues 12 B-238209 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 13 B-238209 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 14 B-238209 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