 
 
 
                              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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                 B-238209
 
 
 
                 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 pregnancy and
          recommend that drug testing be conducted.  Such factors or
          characteristics have been found to occur more often among drug-
          exposed infants than infants not exposed to drugs and include (1)
          inadequate prenatal care (defined as four or fewer prenatal care
          visits for a pregnancy of 34 or more weeks),#23 (2) low birth
          weight (defined as less than 5.5 pounds), and (3) low gestational
          age or prematurity (defined as less than 38 weeks).#24,#25  (See
          table I.2.)
 
          We were able to obtain data from 9 of the 10 hospitals in our
          review on the degree to which infants had these characteristics.
          We identified an estimated 4,391 infants with two or more
          characteristics of possible drug exposure.  The last column of
 
 
        20Enrique 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.)
 
        21Ostrea, A Prospective Study of the Prevalence of Drug Abuse Among
          Pregnant Women.
 
        22The 42 percent of births identified as drug exposed using
          meconium testing compares with 8 percent identified based on the
          mother's self-reporting drug use.
 
        23Institute of Medicine, Infant Death: An Analysis by Maternal Risk
          and Health Care.  Contrasts in Health Status, ed. D.M. Kessner,
          Vol. 1 (Washington, D.C.: National Academy of Sciences, 1973), pp.
          58-59.
 
        24Gestational age refers to the period of time, normally 40 weeks,
          from conception to an infant's birth.
 
        25Maternal demographic characteristics and socioeconomic status
          effect birth outcomes.  Infant mortality and low birth weight rates
          are higher for young, uneducated, unmarried, non-white women with
          limited financial resources.
 
                                         19
 
 
 
          APPENDIX I                                             APPENDIX I
 
 
          table I.2 shows the number of infants with two or more drug-
          exposure indicators who were not tested for drug exposure at the 9
          hospitals where we obtained data.  We estimate that at these
          hospitals during 1989, there were 2,791 potentially drug-exposed
          infants who were not tested, based on our review of hospital
          medical records.
 
 
          Table I.2:  Estimated Number of Infants With Indicators of Possible
          Drug Exposure Not Tested in Nine Hospitals, 1989
 
                                No. of Infants with
                        -------------------------------------------------
                                    Birth       Gestational
                        Less        weight         age              Two
                        than 5       less         less            or more
          Location/     prenatal     than         than             risk
          hospital      visits#a    5.5 lbs       38 weeks        factors
          ---------     --------    -------       --------        -------
          Boston
             1             69        563           682             478
             2              b          b             b               b
          Chicago
             1            342        299           620             267
             2             72        136           574             123
          Los Angeles
             1            513        176           401             176
             2          1,120        335           801             441
          New York
             1            126        283           469             242
             2            414        197           514             209
          San Antonio
             1            842        574           910             580
             2            116        335           643             275
                        -----      -----         -----           -----
          Total         3,614      2,898         5,614           2,791
                        =====      =====         =====           =====
 
         aWe included women with pregnancies of 33 or fewer weeks; however,
          they comprised a small portion of the sampled births ranging from 3
          to 11 percent of the samples at the 9 hospitals.
 
         bData were not available for this hospital to make the analysis.
 
          We also found that some hospitals where we identified low
          percentages of drug-exposed infants tended to have high percentages
          of infants with two or more indicators of possible drug exposure
          who were not tested.  (See table I.3.)  For example, one hospital
          tested no infants with these indicators of possible drug exposure;
          this hospital also had the fewest (1.3 percent) estimated drug-
          exposed infants.
 
                                         20
 
 
 
          APPENDIX I                                             APPENDIX I
 
 
          Table I.3:  Percentage of Infants With Two or More Indicators of
          Possible Drug Exposure Who Were or Were Not Tested and the
          Percentage of Drug-Exposed Infants at Nine Hospitals
 
          Figures are percentages
 
          City/                                  Infants      Drug-exposed
          hospital         Infants tested      not tested        infants
          --------         --------------      ----------     ------------
          Boston
             1                  11                 89                7.2
 
          Chicago
             1                  31                 69               18.1
             2                  61                 39                4.7
 
          Los Angeles
             1                  78                 22               14.8
             2                  30                 70                5.4
 
          New York
             1                  40                 60               12.7
             2                  46                 54               11.8
 
          San Antonio
             1                   9                 91                3.1
             2                   0                100                1.3
 
 
          In our interviews with hospital officials at 10 additional
          hospitals that predominantly serve privately insured patients in
          these five cities, we found that one-half of the hospitals did not
          have a protocol for identifying drug use during pregnancy.  Some
          hospital officials estimated drug-exposed infants represented less
          than 1 to 3 percent of births at their hospitals.  Therefore, they
          did not consider prenatal drug exposure to be serious enough to
          warrant implementing a drug testing protocol.
 
          One recent study found, however, that illicit drug use is common
          among women regardless of race and socioeconomic status.  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 among both groups of women (14.8 percent overall, 16.3
 
 
 
 
 
 
                                         21
 
 
 
 
          APPENDIX I                                             APPENDIX I
 
 
          percent for women seen at public clinics, and 13.1 percent for
          those seen at private offices).#26
 
 
 
 
        26Ira J. Chasnoff, Harvey J. Landress, and Mark E. Barrett, "The
          Prevalence of Illicit Drug Use 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.
 
                                         22
 
 
          APPENDIX II                                           APPENDIX II
 
 
                            DRUG-EXPOSED INFANTS ARE LIKELY
                            -------------------------------
                            TO HAVE COSTLY HEALTH PROBLEMS
                            ------------------------------
 
          Infants prenatally exposed to drugs are more likely to need more
          medical services than infants whose mothers did not use drugs
          during pregnancy.  It is more common for drug-exposed infants to
          be born prematurely and have low birth weights.  They are more
          likely to have medical complications and longer hospitalizations
          resulting in higher hospital charges.  Median hospital charges for
          drug-exposed infants were up to four times greater than for
          nonexposed infants.
 
          DRUG-EXPOSED INFANTS
          --------------------
          ARE MORE VULNERABLE AT BIRTH
          ----------------------------
          Because drug-exposed infants are born with significantly more
          medical problems, they experience more expensive hospitalizations.
          The most frequent effects of drug exposure on infants are low birth
          weight and prematurity.  Comparing drug-exposed infants with those
          with no indication of drug exposure at 4 hospitals, we found
          differences in prenatal care received, birth weight, gestational
          age, intensity of care, and hospital length of stay.#27
 
          The proportion of infants born to drug-using women receiving
          inadequate prenatal care ranged from 29 to 70 percent of births
          compared with 8 to 34 percent of births to women who did not use
          drugs and received inadequate prenatal care.  (See fig. II.1.)
 
          Figure II.1:  Mothers of drug-exposed infants are more likely to
          obtain inadequate prenatal care (comparison at 4 hospitals)
 
 
 
 
 
 
 
 
 
 
 
        27Of the 10 hospitals we reviewed, 4 had a 10-percent or higher
          incidence of infants born drug exposed.  At these hospitals we
          had a sufficient number of cases with which to conduct more
          detailed analysis of the differences between hospital charges and
          other characteristics of drug-exposed infants and those not
          exposed to drugs.
 
                                         23
 
 
 
 
          APPENDIX II                                           APPENDIX II
 
 
          Low birth weight, defined as weighing less than 5.5 pounds, is a
          major determinant of infant mortality and places the survivors at
          increased risk of serious illness and lifelong handicaps.  We
          found significantly higher percentages of drug-exposed infants
          weighing less than 5.5 pounds than those born to women not
          identified as using drugs during their pregnancy.  In fact, the
          proportion of drug-exposed infants of low birth weight was at
          least twice as great as infants not identified as drug exposed.
          The rate of low-birth-weight infants ranged from 25 to 31 percent
          among drug-using women and 4 to 11 percent for women not
          identified as using drugs. (See fig. II.2.)
 
          Figure II.2:  Drug-exposed infants more often have a low birth
          weight as compared with nonexposed infants (comparison at 4
          hospitals)
 
 
 
 
                                         24
 
 
 
 
          APPENDIX II                                           APPENDIX II
 
 
          Infants are typically born 40 weeks after conception.  Those born
          before 38 weeks are considered premature.  Premature infants are
          frequently handicapped by physical limitations, which vary
          depending on the degree of prematurity.  These handicaps may lead
          to increased mortality and morbidity.  Generally, we found that
          drug-exposed infants were about twice as likely to be premature as
          infants not exposed to drugs.  (See fig. II.3.)
 
          Figure II.3:  Drug-exposed infants are more likely to be born
          prematurely than nonexposed infants (comparison at 4 hospitals)
 
 
 
 
 
                                         25
 
 
          APPENDIX II                                           APPENDIX II
 
 
          Finally, at two of the four hospitals, a significantly greater
          percentage of drug-exposed infants needed intensive care services
          during their hospital stay.  Drug-exposed infants were also more
          likely than those not identified as drug exposed to remain in the
          hospital for 5 or more days.
 
          HOSPITAL CHARGES ARE HIGHER
          ---------------------------
          FOR DRUG-EXPOSED INFANTS
          ------------------------
          The health problems of drug-exposed infants and their longer and
          more complicated hospitalizations are often reflected in higher
          hospital charges.  We were able to compare hospital charges
          between drug-exposed infants and infants with no indication of
          drug exposure in their medical records at three hospitals.#28  As
          shown in figure II.4, 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.
 
          Figure II.4:  Drug-exposed infants incur higher hospital charges
          than nonexposed infants (comparison at 3 hospitals)
 
 
 
 
 
        28At 1 of the 4 hospitals, however, separate hospital charges for
          mothers and infants were not available.
 
                                         26
 
 
 
 
          APPENDIX II                                           APPENDIX II
 
 
          Over $14 million was spent on the care of drug-exposed infants at
          3 hospitals where we were able to obtain data.  (See table II.1.)
          Hospital charges for drug-exposed infants at these hospitals
          ranged from $455 to $65,325.
 
          Because more than 50 percent of patients received public medical
          assistance in 7 of the hospitals in our study, a large part of
          these costs was covered by federal assistance programs.
 
 
 
 
                                         27
 
 
 
 
          APPENDIX II                                           APPENDIX II
 
 
          Table II.1:  Estimated Hospital Charges for Drug-Exposed Infants
          at Three Hospitals in 1989
 
                        Estimated no.
                        of drug-exposed   Mean       Estimated total
          Hospital        infants        charge      hospital charges
          --------      ---------------  ------      ----------------
             1             1,187          $6,914#a     $8,206,918
 
             2               400           8,939        3,575,600
 
             3               440           6,520        2,868,800
                           -----                       ----------
          Total            2,027                      $14,651,318
                           =====                       ==========
 
         aThe charges at this hospital are based on a flat per diem rate
          and, therefore, may be underestimated.
 
          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, future medical costs of caring for these
          children are unknown.
 
 
 
 
                                         28
 
 
          APPENDIX III                                           APPENDIX III
 
                       PRENATAL DRUG ABUSE HAS INCREASED DEMAND
                       ----------------------------------------
                                  FOR SOCIAL SERVICES
                                  -------------------
 
          State, city, and hospital social services officials unanimously
          reported to us that parental drug abuse has created additional
          demands on the social services system.  These demands include the
          need for foster placements for the infant upon discharge from the
          hospital.  They also include investigations of drug-related
          neglect and abuse that in some cases result in the child's removal
          from the home.  Additionally, studies have shown that some drug-
          exposed infants will suffer long-term medical and psychological
          effects from drug exposure.  These problems may lead to learning
          disabilities, causing higher school drop-out rates and eventual
          unemployment.
 
          MANY DRUG-EXPOSED
          -----------------
          INFANTS ENTER
          -------------
          FOSTER CARE
          -----------
          We found that drug-exposed infants were significantly more likely,
          compared with infants not identified as drug-exposed, to stay in
          the hospital after their mother was discharged.  While these longer
          stays were primarily attributed to medical reasons, some hospital
          officials stated they are experiencing a growing number of infants
          staying in the hospital for nonmedical reasons.  Commonly called
          "boarder babies," the parents or relatives of these infants are
          often not willing to accept the baby or, in other cases, social
          service workers have determined that the home environment is not
          acceptable for the infant because of parental drug abuse.
          Officials from 5 of the 10 surveyed hospitals stated that their
          hospitals were experiencing increased demands for services for
          boarder babies.
 
          In addition to providing services to boarder babies, social
          service agencies must also provide services to drug-exposed
          infants referred by hospitals.  In three cities that are required
          by state law to refer drug-exposed infants to child welfare
          authorities the number of infants referred during recent years has
          increased dramatically.  In New York, referrals increased by 268
          percent over the 4-year period 1986 to 1989.  For approximately the
          same period, referrals in Los Angeles increased by 342 percent and
          in Chicago, by 1,735 percent.#29
 
 
 
        29Texas officials told us that their state does not have a legal
          requirement that drug-exposed infants be reported, and in
          Massachusetts officials said that until 1990 cocaine-exposed
          infants did not have to be reported.
 
                                         29
 
 
 
 
          APPENDIX III                                           APPENDIX III
 
          For infants who do not leave the hospital with their mother,
          additional costs are incurred in foster care services.  At 3 of
          the 4 hospitals, 26 to 58 percent of drug-exposed infants were in
          need of foster care.  In contrast, only 1 to 2 percent of infants
          born to a mother with no indication of drug use required foster
          placement.  At the fourth hospital few infants were placed in
          foster care.  (See fig. III.1.)
 
 
          Figure III.1:  Drug-exposed infants are more likely to be admitted
          to foster care than nonexposed infants (comparison at 4 hospitals)
 
 
 
 
                                         30
 
 
 
          APPENDIX III                                           APPENDIX III
 
          Although we could compare drug-exposed infants to infants not
          identified as drug exposed at only 4 hospitals, we were able to
          estimate the number of drug-exposed infants entering foster care
          at 9 hospitals.  At these 9 hospitals, the cost of providing basic
          foster care for 1 year to 1,194 infants, would be over $7.2
          million.  Basic per capita foster care costs in the cities in our
          survey ranged from $3,600 to $5,000 annually; specialized foster
          care, which includes homes that provide some medical monitoring or
          group residential facilities, may cost between $4,800 and $36,000.
 
          Number of Child Abuse and
          -------------------------
          Neglect Cases Increasing
          ------------------------
          Because drug-exposed infants are often born with special problems,
          they may be more difficult to care for even under the best
          circumstances.  Some of these children are placed directly from the
          hospital into foster homes where the foster parents are often
          unaware of the children's problems and are not trained to care for
          their specialized needs.  Others return home to families that have
          trouble providing adequate care because, in many instances, drug
          abuse continues to dominate family life.
 
          A drug-exposed, low-birth-weight infant may be irritable, cry
          excessively, have difficulty bonding with the mother, and have
          problems feeding.  Many drug-using mothers may be compromised in
          their ability to interact with their infant or to understand and
          respond to their infants' basic needs.  Many of these women also
          have health and emotional problems.  The combination of the
          infant's and the mother's problems place the infant at high risk
          for child abuse and neglect.
 
          An indicator of a chaotic and dangerous home environment is the
          extent to which the social services system is called on to
          intervene to protect children from the drug-abusing lifestyles of
          their parents.  Child welfare services officials from the five
          cities we visited stated that they are investigating more drug-
          related cases of child abuse and neglect each year.  Many of these
          investigations result in foster care placement specifically for
          children under the age of 2.  Child welfare officials in San
          Antonio told us that 40 percent of all referrals made to child
          protective services involve drug or alcohol abuse in the family.
          In Los Angeles, up to 90 percent of referrals involved substance-
          abusing families.
 
          The Massachusetts Department of Social Services reports a higher
          incidence of severe injuries to young children and more families
          where the use of drugs and alcohol is being identified as a
          precipitating factor in family violence.  In 1989, the department
          conducted a study to determine the association of drug and alcohol
 
 
                                         31
 
 
 
          APPENDIX III                                           APPENDIX III
 
          use with child abuse and neglect.#30  The study found that illicit
          drug or excessive alcohol use was a factor in 64 percent of case
          investigations.  Cocaine use was found to be significantly
          associated with child neglect.  Neglect was defined as a lack of
          supervision, food, clothing, medical care, and other necessities.
          In the most severe cases there were reports of no food, milk, or
          diapers in the house; medical neglect to the extent of nontreatment
          of serious and acute injuries and illnesses; extremely dirty living
          quarters; and an absence of care and supervision for children under
          the age of 5.#31
 
          Hospital officials also told us that they are seeing an increasing
          number of young children from drug-abusing families admitted to the
          hospital because they suffered neglect or maltreatment at the hands
          of someone on drugs.  Officials described various incidents of
          children dying due to physical abuse or a drug overdose from
          inhalation or ingestion of crack cocaine.
 
          Foster Care Placements
          ----------------------
          Increasing
          ----------
          A high proportion of child protective service investigations of
          abuse or neglect involving drug abuse results in foster care
          placement.  In fact, the estimated nationwide demand for foster
          care has increased by 29 percent from 1986 to 1989.  In 1989,
          360,000 children were estimated to be in foster care across the
          country.  Much of this increase is attributed to substance abuse
          in families.
 
          According to social service officials in the five cities we
          visited, family drug-abuse problems are a contributing factor in
          the placement of children in foster care.  In New York, a review
          of a statewide random sample of foster care children found that 57
          percent of these children came from families allegedly abusing
          drugs.
 
          Foster care placements have increased substantially for children
          under the age of 1 and 2 in the states we visited.  Social service
          officials attribute this increase to drug-abusing families.  In
          Massachusetts, the number of children under age 2 admitted to
          foster care increased by 73 percent over the past 2 years.  In New
          York City, children under age 2 accounted for 36 percent of foster
 
 
        30Julia Herskowitz and others, "Substance Abuse and Family
          Violence, Part I, Identification of Drug and Alcohol Usage During
          Child Abuse Investigations in Boston."  (Massachusetts Department
          of Social Services, June, 1989).
 
        31Herskowitz, pp. 4-8.
 
                                         32
 
 
          APPENDIX III                                           APPENDIX III
 
          care admissions in 1989.  In Illinois, infants younger than 1 year
          old in foster care increased 284 percent from 1985 to 1989.
 
          Because the demand for foster care has increased nationwide,
          concerns have been raised about the social services system's
          ability to 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 for families
          who provide foster care to these children.
 
          DRUG-EXPOSED INFANTS ARE
          ------------------------
          VULNERABLE TO DEVELOPMENTAL
          ---------------------------
          PROBLEMS THAT MAY AFFECT
          ------------------------
          LEARNING
          --------
          Definitive information about the future of drug-exposed infants
          does not exist.  The oldest of drug-exposed infants in strict
          clinical trials designed to examine the long-term physical effects
          of prenatal drug exposure, such as developmental deficiencies, are
          under the age of 3.  In addition, long-term studies of drug-exposed
          children have not adequately controlled for the amount of drug use,
          the intensity or frequency of use, or the type of drug used.  Nor
          have studies indicated when drugs were used during the pregnancy.
 
          Results from studies to date indicate that the symptoms will vary
          among drug-exposed children.  Some children show few symptoms
          after the drugs leave their system and others are expected to show
          neurological symptoms throughout their lives.  Consequently, the
          needs of these infants will vary--from greater assistance and
          intervention for some to lesser assistance for others.#32
 
          Recent studies and surveys of neonatal programs suggest that some
          infants will suffer from central nervous system effects, including
          neurobehavioral deficiencies.#33  Researchers have reported that
          some infants identified through urine screens as positive for
          cocaine had suffered hemorrhages in the areas of the brain
          responsible for intellectual capacities.#34,#35
 
 
        32Richard P. Barth, "Educational Implications of Prenatally Drug
          Exposed Children," Social Work in Education, in press.
 
        33Hallum Hurt, "Medical Controversies in Evaluation and Management
          of Cocaine-Exposed Infants" (1989), pp. 3-4.
 
 
        34Deborah A. Frank, Briefing for the Comptroller General of the
          United States, Boston City Hospital, February 24, 1990.
 
                                         33
 
 
 
 
          APPENDIX III                                           APPENDIX III
 
 
          Observations of toddlers born to drug-using mothers imply future
          educational problems based on these children's difficulties with
          concentration and learning.  Research at the University of
          California at San Diego showed that
 
          -- 25 percent of drug-exposed children had developmental delays,
             and
 
          -- 40 percent experienced neurologic abnormalities that might
             affect their ability to socialize and function within a school
             environment.
 
          The study also found that as these children grew older their
          abilities did not develop normally in the dimensions of language,
          adaptive behavior, and fine motor and cognitive skills.#36
 
          A school environment that is poorly prepared to respond to the
          developmental disabilities of these children may allow them to go
          unresolved.  As an increasing number of drug-exposed children
          reach school age, this problem should become more evident.  One
          test of this may occur next year when a large number of children
          born to the early wave of crack cocaine users will reach
          kindergarten age.
 
          One researcher has estimated that 42 to 52 percent of children
          exposed to drugs and alcohol will require special educational
          services.#37  The degree of services needed and their cost will
          vary depending on the severity of impairment.  For example, the Los
          Angeles Unified School District began a pilot program in 1987 for
          mildly impaired preschool children prenatally exposed to drugs.
          The cost of providing the enriched school environment provided in
          the pilot program is approximately $17,000 a year per child.  At
          least one comprehensive estimate, developed by the Florida
          Department of Health and Rehabilitative Services, indicates that
 
 
        35Suzanne D. Dixon, "Effects of Transplacental Exposure to Cocaine
          and Methamphetamine on the Neonate"  The Western Journal of
          Medicine (Apr. 1989), pp. 436-42.
 
 
        36Interview with Suzanne D. Dixon, Director of Well Baby Clinic,
          University Medical Center, University of California at San Diego,
          February 14, 1990.
 
        37Judy Howard, "Developmental Patterns for Infants Prenatally
          Exposed to Drugs", Fact sheet presented to the California
          Legislative Ways and Means Committee, Perinatal Substance Abuse
          Educational Forum, February 23, 1989.
 
                                         34
 
 
 
 
          APPENDIX III                                           APPENDIX III
 
          total service costs for each drug-exposed child that shows
          significant physiologic or neurologic impairment, to the age of 18
          years, will be $750,000.
 
 
 
                                         35
 
 
 
          APPENDIX IV                                             APPENDIX IV
 
 
                       LACK OF DRUG TREATMENT AND PRENATAL CARE
                       ----------------------------------------
                  CONTRIBUTING TO THE NUMBER OF DRUG-EXPOSED INFANTS
                  --------------------------------------------------
 
          Many women are unaware of the effects of drugs on the health of
          their infant.  Other women are aware of the consequences of drug
          use and would like to stop their addictive behavior.  However,
          their efforts to get help may be unsuccessful due to insufficient
          drug treatment capacity.  In addition, there are many barriers
          blocking access to basic health services and drug treatment for
          drug-abusing pregnant women.  One major barrier is the fear women
          have that if they seek treatment they may be incarcerated or their
          children will be taken from them.
 
          LACK OF TREATMENT FOR
          ---------------------
          DRUG-ADDICTED PREGNANT WOMEN
          ----------------------------
          The best way to prevent the problem of drug-exposed infants is to
          prevent drug use among women of childbearing age.  Pregnant woman
          who use drugs should be encouraged to stop in order to reduce the
          potential problems associated with prenatal drug exposure.
          According to one researcher, if women stop using cocaine before
          the third trimester the risks of low birth weight and prematurity,
          which often require expensive neonatal intensive care, are greatly
          reduced.#38
 
          Nationwide, however, drug treatment services are insufficient.  A
          1990 survey by the National Association of State Alcohol and Drug
          Abuse Directors, Inc. (NASADAD), found that an estimated 280,000
          pregnant women nationwide were in need of drug treatment, yet less
          than 11 percent of them received care.#39  Hospital and social
          welfare officials in each of the five cities in our study also
          told us that drug treatment services were insufficient or
          inadequate to meet the demand for services for drug-addicted
          pregnant women.
 
          In addition to insufficient treatment, some treatment programs
          deny services to drug-addicted pregnant women.  A survey of 78
          drug treatment programs in New York City found that 54 percent of
          them denied treatment to women who were pregnant.  One of the
          primary reasons that programs are reluctant to treat pregnant
          women relates to issues of legal liability.  Drug treatment
 
 
        38Deborah A. Frank, Briefing for the Comptroller General of the
          United States, Boston City Hospital, February 24, 1990.
 
        39The report did not reveal the extent to which these women sought
          treatment.
 
                                         36
 
 
 
 
          APPENDIX IV                                             APPENDIX IV
 
 
          providers fear that certain treatment medications and 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 programs that provide services for 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 on the day that they seek treatment.
          One treatment center in Boston received 450 calls for
          detoxification services during a 1-month period.  The callers were
          told that no slots were available and 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.
 
          Many other barriers to treatment exist.  Historically, treatment
          programs were designed to treat the addiction problems of men.
          Thus, many programs are not tailored to meet the needs of pregnant
          women.  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.  Pregnant addicts may
          have additional needs, such as prenatal care and parenting,
          educational, and nutritional guidance, that are not provided in
          most treatment programs.
 
          Another barrier to treatment for women is their fear of criminal
          prosecution.  Drug treatment and prenatal care providers told us
          that the increasing fear of incarceration and loss of 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.
 
          Many health professionals believe that comprehensive residential
          drug treatment, including prenatal care, is the best approach to
          helping many women abstain from using drugs during pregnancy and
          assuring that the developing fetus has the best chance of being
          born healthy.
 
          However, residential treatment programs for women are scarce.  In
          Massachusetts, residents have access to only 15 residential
          treatment slots for pregnant women in the entire state.  Social
          service officials at one California hospital expressed their
          frustration with the lack of residential drug treatment programs
          and other programs that could provide a stable environment to a
          pregnant addict.  When they are unable to place drug-addicted
 
                                         37
 
 
 
          APPENDIX IV                                             APPENDIX IV
 
 
          pregnant women in residential treatment they try alternatives,
          including battered women shelters or even nursing homes.
 
          Residential treatment allows for several needs to be addressed at
          the same time, thus reducing problems of fragmentation and
          inaccessibility of services.  For example, the interconnected
          problems of homelessness, substance abuse, maternal and child
          health, and parenting are addressed in the few residential
          programs that exist.  In addition, these programs limit access to
          drugs and remove women from the environments in which they became
          dependent.
 
          PRENATAL CARE IMPROVES
          ----------------------
          BIRTH OUTCOMES
          --------------
          When both drug treatment and prenatal care services are provided
          for drug-addicted pregnant women, the results are dramatic.  The
          three basic components of prenatal care are: (1) early and
          continued risk assessment, (2) health promotion, and (3) medical
          and psychosocial interventions and follow-up.  One intervention
          program reported a significant drop in low-birth-weight babies
          born to drug-abusing mothers who had been provided with drug
          treatment and prenatal care.#40  The incidence of low birth weight
          among infants born to drug-abusing mothers receiving such care
          dropped from 50 to 18 percent.
 
          Early and comprehensive prenatal care is associated with lower
          rates of infants born with low birth weight.  Our work and that of
          others showed that the incidence of low birth weight among drug-
          exposed infants is high.  Low birth weight is the most significant
          factor in determining infant death and disability as well as higher
          health costs.  Prenatal care increases the chances that healthier
          infants will be born.
 
          Prenatal care is a cost-effective program.  The Office of
          Technology Assessment estimates that for every low-birth-weight
          birth averted by earlier or more frequent prenatal care, the U.S.
          health care system saves between $14,000 and $30,000 in short- and
          long-term health care costs associated with low birth weight.
 
 
        40Loretta P. Finnegan, M.D., Executive Director of Family Center,
          Professor of Pediatrics and Professor of Psychiatry and Human
          Behavior, Jefferson Medical College of Thomas Jefferson
          University, Philadelphia, Pennsylvania, Testimony before the
          Subcommittee on Children, Family, Drugs, and Alcoholism, Committee
          on Labor and Human Resources, United States Senate, February 5,
          1990.
 
 
                                         38
 
 
 
 
          APPENDIX IV                                             APPENDIX IV
 
 
          These savings are great compared with the average cost for
          professional services associated with prenatal care that can run
          as low as $500.
 
          According to the National Commission to Prevent Infant Mortality,
          the barriers to accessing prenatal care are formidable, including
          financial, policy, system, provider, and patient barriers.  In
          addition, others report that drug-addicted pregnant women refrain
          from seeking prenatal care because they fear that punitive actions
          will be taken if they are found to have used or abused drugs during
          pregnancy.  Several hospital and public health officials believe
          that punitive actions, such as incarceration of drug-abusing
          pregnant mothers, have a negative impact on the lives of these
          women and their children.
 
          Hospital officials told us that in addition to not seeking
          prenatal care, some women are now delivering their infants at home
          in order to prevent the state from discovering their drug use.  An
          example was given of one mother who delivered her baby at home and
          subsequently called the hospital for medical advice because the
          infant had become very sick.  The mother was finally persuaded to
          bring the infant into the hospital.  The consequent care of this
          baby was very costly.
 
 
 
 
                                         39
 
 
 
 
      APPENDIX V                                                APPENDIX V
 
 
        PERCENTAGE DISTRIBUTION OF INFANTS EXPOSED TO DRUGS, INCLUDING COCAINE
        ----------------------------------------------------------------------
      Figures are percentages
 
                         Drug-        Sampling        Cocaine-         Sampling
      Hospital     exposed infants    error#b      exposed infants     error#b
      --------     ---------------    ---------    ---------------     --------
         1               1.3            1.0              0.3             0.4
 
         2               3.1            1.6              0.8             0.8
 
         3               4.7            2.0              2.7             1.5
 
         4               5.4            2.3              3.9             1.9
 
         5               7.2            2.4              4.5             1.9
 
         6a              8.9             --               --              --
 
         7              11.8            2.9             11.0             2.8
 
         8              12.7            2.9              8.5             2.4
 
         9              14.8            3.8             11.6             3.4
 
        10              18.1            4.2              8.6             2.9
 
 
 
      aFrom this hospital we identified drug-exposed infants from the
       universe of births and, therefore, there is no sampling error.
       We were unable to distinguish the type of drugs used.
 
      bSampling errors are at the 95-percent confidence level.
 
 
 
 
                                                 40
 
 
 
 
          APPENDIX VI                                           APPENDIX VI
 
 
                          OBJECTIVES, SCOPE, AND METHODOLOGY
                          ----------------------------------
 
      To develop a national estimate of drug-exposed infants we obtained data
      from the National Hospital Discharge Survey conducted by HHS's National
      Center for Health Statistics for the years 1980 to 1988.  The National
      Hospital Discharge Survey is based on an annual survey of a
      representative sample of U.S hospitals.  The survey collects information
      on the diagnoses associated with hospitalization of adults and newborns
      in all nonfederal short-stay hospitals.  Newborn discharge data for 1986
      and 1988 were used to calculate national estimates.  Data before 1986
      were considered nonreportable due to a small number of sample cases of
      newborns with a drug-related discharge diagnosis.
 
      To determine the extent of drug-exposed infants we reviewed medical
      records at 2 hospitals in each of five cities--Boston, Chicago, Los
      Angeles, New York, and San Antonio.  Mostly located in the inner city,
      8 of these hospitals serve a high proportion of low-income patients
      likely to need federal assistance and supportive services.  The
      remaining 2 hospitals did not serve a high proportion of low-income
      patients, but received referrals from other hospitals in their
      respective cities of potentially complicated births, including drug-
      using pregnant women.  Our review of medical records at the 10
      hospitals (2 hospitals in each of these cities) covered a
      representative sample of 44,655 births in 1989.
 
      HOSPITAL SELECTION CRITERIA
      ---------------------------
      Our hospital selections were based on a high incidence of births per
      year and the availability of a neonatal intensive care unit in addition
      to location and numbers of Medicaid patients.  Table VI.1 compares the
      number of births at the hospitals we selected with other hospitals in
      the five cities, and table VI.2 provides patient profile information
      for the selected hospitals.
 
 
 
                                                 41
 
 
 
 
          APPENDIX VI                                           APPENDIX VI
 
 
 
      Table VI.1: Comparison of Births at Hospitals in GAO Study With Total
      Births in the Respective Cities, 1988
 
 
                         All hospitals            Hospitals in GAO study
                         --------------------     ----------------------
                           No. of
                         hospitals                           Percent of
                           with        No. of      No. of    all births
      City               bassinets     births      births    in city
      ----               ---------     ------      ------    ----------
      Boston                 5         19,500      4,969        25.5
 
      Chicago               30         49,168      7,200        15.7
 
      Los Angeles           27         81,379     15,231        19.9
 
      New York              41        119,320      6,432         5.4
 
      San Antonio           10         22,061      9,331        42.3
 
 
 
 
                                                 42
 
 
 
          APPENDIX VI                                           APPENDIX VI
 
 
 
      Table VI.2: Profile of Patients at Selected Hospitals
 
                                    Race             Insurance status
                          ----------------------    ------------------
      City/Hospital       Black  Hispanic  White    Medicaid   Private
      -------------       -----  --------  -----    --------   -------
      Boston
        120.9             5.5    67.3     34.0        59.9
        264.6            18.7    12.1     51.4        13.0
 
      Chicago
            1            57.0    34.1      7.8        75.0     15.9
            2            18.7     4.7     70.7        15.8     83.3
 
      Los Angeles
            1            19.8    79.1      0.5        74.9      1.8
            2             4.3    83.2      9.0        88.6      1.3
 
      New York
            1            31.8    56.7      8.4        63.9     29.3
            2            30.8    59.9      5.0        70.8     12.9
 
      San Antonio
            1             5.5    80.2     13.6        46.1      8.7
            2             7.5    84.5      7.7        64.2     32.0
 
 
      At these hospitals we conducted a detailed review of a random sample of
      medical records of mothers and their infants who were born between
      January 1 and June 30, 1989, to estimate the number of drug-exposed
      infants.#41 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.  We also
      interviewed hospital personnel to obtain their procedures for
      identifying drug-exposed infants.
 
      To assess the medical and social impact of these births, we interviewed
      hospital, state, and local social services representatives regarding the
 
 
        41At each of 9 hospitals, we randomly selected 400 mothers' medical
          records and the corresponding medical records for their infants.
          At the 9 hospitals the percentage of medical records unavailable
          for review ranged from less than 1 to 7 percent.  At the tenth
          hospital, we did not review medical records but received a data
          tape with information on all births occurring during the first 5
          months of 1989.
 
                                                 43
 
 
 
          APPENDIX VI                                           APPENDIX VI
 
 
      impact of drug-exposed infants on the medical and social services
      systems.  In our discussions with these officials we also determined
      the extent to which drug-addicted pregnant women are receiving drug
      treatment.
 
      We also interviewed officials at 10 additional hospitals in these
      cities to determine the extent of drug-exposed infants at these
      hospitals.  These hospitals serve predominantly private-pay clientele.
      We did not review medical records to determine the extent of drug-
      exposed infants at these hospitals.
 
      To gain further insight as to the consequences of maternal drug use, we
      interviewed leading drug treatment experts, neonatologists, researchers,
      social welfare officials, and drug-addicted pregnant women.  We also
      reviewed research conducted to determine the incidence of drug-exposed
      infants and the effects of drugs on the health of mothers and infants.
 
 
 
 
                                                 44
 
 
 
 
          APPENDIX VII                                         APPENDIX VII
 
 
 
 
                           MAJOR CONTRIBUTORS TO THIS REPORT
                           ---------------------------------
      HUMAN RESOURCES DIVISION, WASHINGTON, D.C.
      ------------------------------------------
      Mark V. Nadel, Associate Director, National and Public Health Issues
      (202) 275-6195
      Rose Marie Martinez, Assignment Manager
      Roy B. Hogberg, Evaluator-in-Charge
      Frances A. Kanach, Senior Evaluator
      Susan L. Sullivan, Social Science Analyst
 
      BOSTON REGIONAL OFFICE
      ----------------------
      Robert D. Dee, Regional Assignment Manager
      Lionel A. Ferguson, Evaluator
 
      CHICAGO REGIONAL OFFICE
      -----------------------
      Karyn L. Bell, Site Senior
 
      DALLAS REGIONAL OFFICE
      ----------------------
      Larry J. Junek, Site Senior
      Martin B. Fortner, Jr., Site Senior
 
      LOS ANGELES REGIONAL OFFICE
      ---------------------------
      Denise R. Dias, Site Senior
 
      NEW YORK REGIONAL OFFICE
      ------------------------
      Patrice J. Hogan, Regional Assignment Manager
 
 
 
                                                 45
 
 
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                                                 48

