It's been 13 years since Cynthia Crone, MNSc, APN, RN, answered the telephone call that changed her life. On the line was a doctor searching for a treatment facility for a pregnant crack addict. He asked Crone, then working with high-risk pregnancies at the University of Arkansas for Medical Sciences, for help.

"I called and called, and there was nothing," she said.

The incident drove her to create Arkansas CARES, a residential and outpatient treatment center for addiction-affected families. She is the organization's executive director.

Crone is one of a number of nurses working in the field of maternal substance addiction. Women have historically received less attention than men in research on addiction, but in the past few years, the medical community has begun to focus on the special problems that female addicts face.

Nurses who work with addicted mothers say nursing's holistic approach and emphasis on day-to-day care put nurses in an ideal position to help addicted mothers. Their reward, these nurses say, is watching women and children rebuild lives that often have been devastated by drugs.

Along with addiction, medical science better understands the problems that drugs, alcohol and tobacco can cause a developing fetus. Given the extensive public information campaign about these problems, nurses like Crone know just how much some of these addict mothers can be despised for exposing their fetuses to drugs.

"It is so counter to everything we believe in, to not put your child above everything," she said. "We assume as a society that it's a moral failure, that she could stop if she wanted to."

Although society still stigmatizes these women, medical research is reaching the conclusion that addiction is a chronic, brain-based disease, Crone said.

"Part of addiction is the compulsion to use despite negative consequences," she said. "There are brain changes that result in addicted persons choosing to use drugs over life itself. They will choose it over their children."

Dependence on drugs often isn't the only issue facing addicted mothers. Many have mental health problems. Others have been physically or emotionally abused, often by their own parents. Some have lived through major trauma.

A Substance Abuse and Mental Health Services Administration study of 50 residential treatment centers shows the stark situation that many drug-addicted mothers face.

The study, released in September, included 5,110 women who were in the programs. Ninety-two percent were unemployed, 64 percent had a physical >> disorder, 50 percent had mental health disorders and 76 percent had experienced abuse.

The women had been addicted to alcohol or drugs for an average of 15 years, according to the study.

Women with these hardships sometimes turn to drugs to self-medicate, said Karen Starr, MSN, RN, a psychiatric-mental health nurse practitioner and faculty member at Vanderbilt University's School of Medicine and past board president of Renewal House, a Nashville, Tenn., residential treatment center for addicted mothers.

"[Pregnant] women who are addicted to substances aren't trying to hurt their babies," she said. "They're used to treating themselves badly, and they haven't begun to differentiate that the fetus is a different person. They treat [the fetus] that way because that's how they've been treated."

Innocent victims

As much as nurses can understand the problems that lead a woman into addiction, they also know the deleterious effects that drug or alcohol abuse have on a fetus and on children.

Women who abuse alcohol and other drugs during pregnancy are more likely to deliver early and to have smaller babies, which can mean health and developmental problems for a child.

Additional problems are associated with using drugs or drinking during pregnancy, according to a 2002 fact sheet from the University of Michigan Health System.

The babies of heroin and cocaine addicts are more frequently born addicted. The chance that a fetus could die is higher in drug and alcohol users than other women.

Children can have persistent physical, behavioral and emotional problems, and fetal alcohol syndrome is one of the top three causes of birth defects, according to the sheet.

Helping women understand and deal with these risks is part of Mary Gonzales' job. Gonzales, RN, is the residential nurse for Arapahoe House, a Thornton, Colo., treatment center with programs for both pregnant drug addicts and addicts with children.

When the women first arrive, many don't know how to be parents, Gonzales said. "That's something that they really haven't had an opportunity to be part of, because drugs take you away from your family," she said.

Gonzales prepares the women for some of the difficulties they could have with newborns. Babies born to mothers who used crack during pregnancy often are easily startled, she said. They can be irritable and don't want to be held closely, which can be hard for a mother, she said.

"If you're trying to stop the addiction, that's hard enough, but to try to bond with a baby that has some of those characteristics makes it even more difficult," Gonzales said.

Arapahoe House offers parenting and family classes to help the women get through situations like these during infancy and as children grow older. Gonzales also helps keep the mothers and their children healthy by planning treatments for acute problems or chronic diseases. She also determines when clients should go to a hospital or visit a doctor.

For Gonzales, the payoff of her work is seeing the babies. "It's very rewarding to see women have healthy babies, or healthier babies than they expected," she said.

While some nurses say drug use among pregnant women seems to be increasing, it's difficult to quantify because data from the past isn't available.

About 4 percent of pregnant women in the United States surveyed in 1999 said they had used illicit drugs in the past month, according to a 2001 report from SAMHSA.

Nurses who don't work in addiction treatment centers for women may still interact with addicted mothers, said Marty Jessup, Ph.D., RN, a postdoctoral fellow of the Institute for Health Policy Studies at the University of California, San Francisco, who has worked on issues in addiction treatment for the past 25 years.

Alcohol addiction, perhaps one of the most damaging kinds of addiction for a fetus or a child, shows up everywhere.

"People with alcohol problems are in every setting," Jessup said.

Nurses "are in such a good position with the clinical knowledge and experience to describe and define the policy issues for people in this situation," she said. "I think another really important thing for nurses to do is to extend hope to their patients."

Back on track

Although it may be heartbreaking, the situation for drug and alcohol addicted mothers is far from hopeless.

Sixty percent of the women in the substance abuse study reported being alcohol and drug-free throughout the six months after they were discharged from residential addiction treatment centers. They were more likely to have a job and less likely to be living with an alcohol or drug using partner than before treatment.

The women's parenting skills also improved. Before treatment, many of the women risked losing their children, and just 54 percent had custody of any children. After treatment, 75 percent had custody of one or more children.

The drug-free rate at Arkansas CARES is even higher, according to Crone. In a multiyear study published in 2001 in the Journal of Substance Abuse Treatment, 85 percent of the center's clients reported being drug-free one year after treatment, she said.

Crone thinks part of the center's success is due to its strong nursing philosophy of holistic, integrated care.

Helping women repair their lives and their children's lives has become Crone's passion.

One of her success stories is that of a young woman and her daughter. The woman, then 26, came to Arkansas CARES addicted to crack cocaine, alcohol and tobacco. She had difficulty caring for her 16-month-old daughter, who was in and out of the hospital five times during her mother's first eight months of treatment.

Several years after completing the residential treatment and outpatient programs, the woman has become a role model for other clients. She is employed and drug-free. On the third anniversary of her sobriety, she threw a party for the center's staff.

Best of all, the woman is a better parent. Her daughter, who once communicated only by kicking, biting and scratching, is now a friendly, articulate 5-year-old.

"It feels wonderful when you see families and children doing well and being healthy," Crone said.

"I think it's very fulfilling to see people regaining their lives."

Contact Jessica Scully at jessicam_scully@yahoo.com.