By Valerie Nelson
Illustration by Malcolm Garris/PhotoDisc
November 5, 1998

The "do-drugs, go-to-jail" refrain makes a good sound bite, but it might make bad healthcare policy for women who use drugs during pregnancy. Arresting and imprisoning pregnant women who use hard drugs is a punishment not fitting the illness, according to a recent study and many healthcare providers, who see addiction primarily as a disease.

Many pregnant drug users avoid prenatal care because they are afraid of going to jail and losing custody of their children, said Mary Faith Marshall, PhD, co-author of a report funded by The Robert Wood Johnson Foundation. These fears point to the need for policies that make the care provider’s role paramount, and treatment, not punishment, the goal, the report and others say.

Marshall said healthcare professionals should be most concerned about treating pregnant substance abusers’ addictions instead of turning these patients over to law enforcement. "It is unethical to ask or require clinicians to act as agents of the state," Marshall said. "It’s hard to have a good relationship to treat someone’s addiction in that context. It’s a totally untenable position for nurses to be in."

The report was written in response to South Carolina’s policy of incarcerating pregnant women who abuse drugs or alcohol. Minnesota recently passed similar legislation, and other states are taking steps toward similar interventions—such as mandatory reporting requirements—even though research shows this isn’t the best path, said Marshall, director of the bioethics program at the Medical University of South Carolina in Charleston.

Research shows women in general, and pregnant prisoners in particular, receive substantially fewer services than the male population, said Leslie Acoca, MA, MFCC, director of the Women’s and Girl’s Institute on National Crime and Delinquency, based in San Francisco. "It’s very clear that [pregnant substance abusers] should be in a treatment-based environment rather than a punitive correctional environment," Acoca said. Her information is culled from a separate Robert Wood Johnson Foundation study she expects to complete this spring that could serve as a blueprint for treatment in the area of women, substance abuse, and pregnancy in prison.

"Every birth or pregnancy in an incarcerated setting has to be considered high risk. The resources are just not there," Acoca said. "[Prisons] are not set up to deliver high-quality perinatal services for high-risk mother-infant pairs. That’s an absurdity."

Marshall said healthcare providers should look beyond these substance abusers’ addictions and consider what led the women to abuse drugs. A continuum of care model generally works the best, one that looks at the disparate social factors figuring into the substance abuse. Women who abuse drugs often are poor, victims of domestic violence, or poorly educated and may lack job skills, she said. Such issues need to be considered during treatment.

Deb Olscher, RN, an ob/gyn nurse practitioner for the Infant Intervention Program at Parkland Health & Hospital System in Dallas, concurs. "It’s rare that I have found patients who have not had huge other issues in their lives. They’ve had moms and dads who were in prison, sexual abuse, parents who were drug addicts. A great amount have had huge childhood issues themselves. You think, Where does the cycle end?"

Olscher helped establish Parkland’s program about nine years ago when the hospital realized pregnant substance abusers needed to receive prenatal care. "We provide the service in such a way that it is nonthreatening," she said.

"We found that instead of taking the punitive approach—saying, ‘You are a bad person, you are a bad mommy’—this program nurtures moms into getting treatment." Olscher said Parkland tries to establish a supportive environment for patients where the mothers see the same healthcare providers each visit. "Our philosophy is that if the mom and baby stay together, they can get healthy together," she said.

Patients should be counseled on the legal ramifications of their drug use, then steered into a drug treatment program, said Jean Rhodes, PhD, continuum of care manager with the outcomes management program at the Medical University of South Carolina College of Medicine. Rhodes contributed to the Robert Wood Johnson report against criminalization of pregnant substance abusers, released in August.

It is important to recognize from the beginning that pregnant women need to be eased into treatment, Olscher said. To that end, Parkland created a support group with the purpose of nudging members into treatment. "They learn that they really need each other," Olscher said. "They need to know they are all in the same boat. It breaks through some of the denial and gets them in to treatment."

The issue is such a hot topic that graduate students in the nurse practitioner program at the University of Texas at Arlington debate it as a class assignment. One student argues for the mother’s rights, the other for the fetus. The debate helps students discuss the ethical concerns of treatment vs. imprisonment, said Diane Snow, PhD, RN, director of the psychiatric mental health nurse practitioner program at the University of Texas at Arlington School of Nursing.