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
ca