Cocaine & Pregnancy

The rise in cocaine use and appearance of crack cocaine in the 1980s spurred fears about its effects on the developing fetus. Cocaine use during pregnancy is certainly inadvisable, yet many of the initial reports cited dangers that later studies do not support, and policies fostered during those years may have caused more harm than good. Recent press and politics have not reflected changes seen in the scientific realm.

Many reports have suggested that prenatal cocaine use can lead to an array of fetal, newborn and child development problems.

  • In 1985, a case study by Ira Chasnoff, et al., (1) which reported damaging effects of cocaine use during pregnancy, touched off a massive media response which continues today. (2)
  • Further studies reported problems associated with cocaine use during pregnancy including increased exposure to sexually transmitted diseases, (3) maternal weight loss, nutritional deficits (4) and polydrug use, (5) premature detachment of the placenta, (6) premature birth and reduced/low birth weight, reductions in newborn body length and head circumference, (7) and rare birth defects including genito-urinary tract malformations (8) and extremely rare bone (9) and neural tube (10) abnormalities.
  • Capitalizing on this research and the media excitement, many politicians enacted laws requiring health care professionals to report pregnant illicit drug users to child welfare authorities, (11) initiated policies requiring authorities to separate children from mothers who used drugs while pregnant, (12) and pursued legislation making drug use during pregnancy a criminal offense. (13)
  • In July, 1996, South Carolina's Supreme Court became the first to uphold the criminal prosecution of women for child abuse by way of prenatal drug use (penalized with a prison sentence of up to 10 years). (14)

Analyses of this early research found methodological flaws and most researchers now put forth more cautious conclusions about the effects of prenatal cocaine use.

  • A meta-analysis of most 1980s studies on prenatal cocaine use found serious methodological flaws including 1) the lack of control groups, (15) 2) failure to distinguish cocaine use from the use of other drugs, (16) 3) failure to study the ensuing health of the newborn, (17) and 4) the use of case reports alone. (18)
  • Medical personnel working with cocaine-exposed children often report them to be indistinguishable from other children. (19) Early studies which suggested a 'fetal cocaine withdrawal syndrome' were non-blind (the observers were told which infants had been exposed to cocaine). Subsequent blind studies (in which the observers did not know the status of the infants) were unable to detect the phenomenon. (20)
  • Well controlled studies find minimal or no increased risk of Sudden Infant Death Syndrome (SIDS) among cocaine-exposed infants. (21) Early studies which reported an increased risk of SIDS (22) did not control for socioeconomic characteristics.
  • A 1989 study by Gideon Koren, et al., in The Lancet, found that scientific results describing harmful effects of cocaine use during pregnancy were more likely to be accepted for conference presentation and publication than studies of equal or superior methodology showing few or no effects. (23)
  • Many animal studies (24) and some human studies (25) of chronic cocaine use (along with human studies of social cocaine use (26)) find no direct effects on newborn health or development. Others encounter varied and inconsistent results, (27) leading many researchers to believe different factors may be responsible. (28)

No causal link has been established between cocaine use and poor fetal development because these studies are correlational in nature. (29) And among the general population there has been no detectable increase in any birth defects which may be associated with cocaine use during pregnancy. (30) However, cocaine, like all recreational substances, enters the bloodstream of the developing fetus and has the potential to affect development. (31)

Much evidence points to the lack of quality prenatal care and the use of alcohol and tobacco as primary factors in poor fetal development among pregnant cocaine users.

  • Of all birth defects, 10-15% are due to environmental agents, (32) 10-15% are hereditary, (33) 1- 5% (34) are from chemical (including drug) exposure, and the rest are due to unknown factors. (35)
  • The lack of quality prenatal care services is associated with prematurity, low birth weight, and other fetal development problems. (36) Provision of quality prenatal care to heavy cocaine users (with or without drug treatment) has been shown to significantly improve fetal health and development. (37)
  • Abuse of alcohol, (38) more than any other recreational drug, causes the greatest number of and most severe birth defects: 0.19% of all newborns (about 7,600, or 1% of all newborns exposed to alcohol (39)) are diagnosed with Fetal Alcohol Syndrome, (40) and a larger number experience "fetal alcohol effects."
  • Tobacco use is strongly associated with low birth weight, prematurity, growth retardation, Sudden Infant Death Syndrome, (41) cognitive, achievement and behavioral problems (42) and, in some cases, mental retardation. (43)
  • Other factors strongly associated with poor fetal development include poverty, (44) lead exposure, (45) psychiatric problems including major depression, (46) and depressive symptoms associated with life stress, lack of social support, low weight gain, and poly-drug use. (47)

Political and legal responses to the perceived hazards of prenatal cocaine use may cause more harm than good.

  • Criminalizing substance abuse during pregnancy discourages substance-using or abusing women from seeking prenatal care, drug treatment, and other social services (48) and sometimes leads to unnecessary abortions. (49)
  • Overloaded child welfare services are often unable to find homes for otherwise healthy children branded as "crack babies." (50)
  • Pejoratively labeling children lowers teacher and parent expectations. (51) Presented with children randomly labeled as 'cocaine-exposed' and 'normal,' childcare professionals ranked the performance of the 'cocaine-exposed' children below that of the 'normal.' (52)
  • Regardless of similar or equal levels of illicit drug use during pregnancy, (53) African-American and Latina women constitute 80% of those prosecuted for delivering drug-exposed children (54) and are much more likely than Caucasian women to be reported to child welfare agencies for prenatal drug use . (55)

Cocaine use, like other drug use, is not advisable during pregnancy. Nonetheless, dozens of studies over the past decade now indicate that 1) the pharmacological impact of cocaine has been greatly exaggerated, 2) other factors are responsible for most of the ills priorly associated with cocaine use and 3) political and legal responses have done more to exacerbate than alleviate the situation of poor and/or drug-using pregnant women.

A small number of drug treatment programs in the US will accept pregnant addicts and provide child care services. (56) Most important, however, is the need for social services which do not judge pregnant women for their drug use, but instead try to minimize potential hazards. (57) Addressing risk factors beyond cocaine use - including inadequate nutrition and health care and the use of legal drugs - increases the likelihood of a healthy mother and child.

NOTES

  1. Chasnoff IJ, Bruns, WJ, Schnoll WJ, Burns KA. Cocaine use in pregnancy.New England Journal of Medicine 1985;313:666-669. 
  2. 1980s media response -- Brief high creates a lifetime of loss. Christian Science Monitor, 10 October, 1989, 8; Sokolowski M. Cocaine baby's mom escapes abuse charges. Hollywood Sun, 7 November, 1989; Karwath R. Legislative action urged to help speed aid to 'cocaine babies.' Chicago Tribune, 5 May, 1989, sec. 2, 4; Trost C. Babies of crack users crowd hospitals, break everybody's heart. Wall Street Journal, 18 July, 1989, 1; Patner A. Handful of prosecutors start treating pregnant drug users as child abusers. Wall Street Journal, 12 May, 1989; Stein S. Prosecuting a drug baby's mom. Newsday, 21 May, 1989; Brannigan M. Mother is guilty of delivering drug in course of birth. Wall Street Journal, 17 July, 1989; Davidson J. Newborn drug exposure conviction a 'drastic' first. Los Angeles Times, 31 July, 1989, 1; Denniston L. Rise in 'cocaine babies' sparks legal action against mothers. Baltimore Sun, 6 August, 1989; Krauthammer C. Lock up pregnant addicts to save lives of their babies. Hartford Courant, 9 August, 1989, C13; Sataline S. Drug arrest focuses on threat to fetus. Hartford Courant, 9 August, 1989; Goodman E. Jailing drug mothers won't work. Washington Post, 19 August, 1989, A19; Foster C. Fetal endangerment cases increase. Christian Science Monitor, 10 October, 1989, 8; Duke L. For pregnant addict, crack comes first. Washington Post, 18 December, 1989, A1; Duke L. Crack abuser's baby is born. Washington Post, 20 December, 1989, D1; Revkin AC. Crack in the cradle. Discover 1989;10:62-69. Continuing today -- Rosenthal AM. The poisoned babies. New York Times, 16 January, 1996, A17; When babies are born addicted. Daily News, 30 January, 1996; Sexton J. Officials seek wider powers to seize children in drug homes. New York Times, 12 March, 1996, B1; Women and drugs [editorial]. Wall Street Journal, 6 June, 1996, A14; Kotulsk R. Women warned on substance abuse. Washington Post, 11 June, 1996.
  3. Gay KB, Goulding C, Sexon WR, et al. Medical correlates of high risk maternal behavior in babies born to cocaine abusing mothers. Pediatric Research 1990;27:243A. 
  4. Bauchner H, Zuckerman B, Amaro H, Frank DA, Parker S. Teratogenicity of cocaine [letter]. Journal of Pediatrics 1987;111:160-161. 
  5. Lutiger B, Grahan K, Einarson TR, Koren, G. Relationship between gestational cocaine use and pregnancy outcome: a meta-analysis. Teratology 1991;44:405-414. 
  6. Ganapathy V, Leibach FH. Human placenta: a direct target for cocaine action. Placenta 1994;15:785-795. 
  7. MacGregor SN, Keith LG, Chasnoff IJ, Rosner MA, Chisum GM, Shaw P, Minogue JP. Cocaine use during pregnancy: adverse perinatal outcome. American Journal of Obstetrics and Gynecology 1987;157:686-690; Chasnoff IJ, Burns KA, Burns WJ, Schnoll SH. Prenatal drug exposure: effects on neonatal and infant growth and development. Neurobehavioral Toxicology and Teratology 1986;8:357-362; Chasnoff IJ, Griffith DR, MacGregor S, Dirkes K, Burns KA. Temporal patterns of cocaine use in pregnancy: perinatal outcome. JAMA 1989;261:1741-1744. 
  8. Chasnoff IJ, Chisum G. Genitourinary tract dismorphology and maternal cocaine use. Pediatric Research 1987;21;225A; Chasnoff IJ, Chisum GM, Kaplan WE. Maternal cocaine use and genitourinary tract malformations. Teratology 1988;37:201-204; Chavez GF, Mulinare J, Cordero JF. Maternal cocaine use during early pregnancy as a risk factor for congenital anomalies. JAMA 1989;262:795-798; Battin M, Albersheim S, Newman D. Congenital genitourinary tract abnormalities following cocaine exposure in utero. American Journal of Perinatology 1995;12:425-428. 
  9. Bingol N, Fuchs M, Diaz V, Stone RK, Gromisch DS. Teratogenicity of cocaine in humans. Journal of Pediatrics 1987;110:93-96. 
  10. Bingol N, Fuchs M, Diaz V, Stone RK, Gromisch DS. Teratogenicity of cocaine in humans. Journal of Pediatrics 1987;110:93-96. 
  11. By 1991, at least 13 states had laws mandating that health care professionals report drug using pregnant women and their newborns to child welfare authorities. State laws on pregnant women and substance abuse, 1991. Washington, DC: American College of Obstetricians and Gynecologists, Government Relations Department; 1991.
  12. See, for example, Sexton J. Officials seek wider powers to seize children in drug homes. New York Times, 12 March, 1996, B1; State laws on pregnant women and substance abuse, 1991. Washington, DC: American College of Obstetricians and Gynecologists, Government Relations Department; 1991. 
  13. By 1991, at least nine states had laws defining drug uses during pregnancy as child abuse or neglect. State laws on pregnant women and substance abuse, 1991. Washington, DC: American College of Obstetricians and Gynecologists, Government Relations Department; 1991. 
  14. State of South Carolina Supreme Court, Whitner v. State of SC, Opinion Nr. 24468, 31 May, 1996; South Carolina Supreme Court issues unprecedented ruling reinstating conviction for behavior during pregnancy. New York: Center for Reproductive Law and Policy; 1996. 
  15. According to Lutiger B, Grahan K, Einarson TR, Koren G. Relationship between gestational cocaine use and pregnancy outcome: a meta-analysis. Teratology 1991;44:405-414, studies lacking a control group include: LeBlanc PE, Parekj AJ, Naso B, Glass L. Effect of intrauterine exposure to alkaloidal cocaine ("crack"). American Journal of Diseases of Children 1987;141:937-938; Doberczak TM, Shanzer S, Senie RT, Kandall SR. Neonatal neurologic and electroencephalographic effects of intrauterine cocaine exposure. Journal of Pediatrics 1988;113:354-358; Mitchell M, Sabbagha RE, Keith L, MacGregor S, Mota JM, Minoque J. Ultrasonic growth parameters in fetuses of mothers with primary addiction to cocaine. American Journal of Obstetrics and Gynecology 1988;159:1104-1109; Graham K, Dimitrakoudis D, Pellegrini E, Koren G. Pregnancy outcome following first trimester exposure to cocaine in social users in Toronto, Canada. Veterinary and Human Toxicology 1989;31:143-148. 
  16. According to Lutiger B, Graham K, Einarson TR, Koren G. Relationship between gestational cocaine use and pregnancy outcome: a meta-analysis. Teratology 1991;44:405-414, studies failing to separate cocaine use from the use of other drugs include: Culver KW; Oro AS, Dixon SD. Perinatal cocaine and methamphetamine exposure: maternal and neonatal correlates. Journal of Pediatrics 1987;11:571- 578.; Davidson SL, Ward S, Krishna V, Bean X, Wingert W, Wachsman L. Keens T. Abnormal sleeping ventilatory pattern in infants of substance abusing mothers. American Journal of Diseases of Children 1986;140:1015- 1020; Shannon M, Lacouture PG, Roa J, Woolf A. Cocaine exposure among children seen at a pediatric hospital. Pediatrics 1989;83:337-343; Chavez CJ, Ostera EM, Stryker JC, Smialek RN. Sudden infants death syndrome among infants of drug-dependent mothers. Journal of Pediatrics 1979;95:407-409; Tenorio GM, Mubariz N, Bickers GH, Hubrid RH. Intrauterine stroke and maternal polydrug abuse. Clinical Pediatrics 1988:27:565- 567; Schwartz BR, Lage JM, Pober BR, Driscoll SG. Isolated congenital renal tubular immaturity in siblings. Human Pathology 1986;17:1259-1263. 
  17. According to Lutiger B, Graham K, Einarson TR, Koren G. Relationship between gestational cocaine use and pregnancy outcome: a meta-analysis. Teratology 1991;44:405-414, studies failing to examine the outcome of the fetus include: Wang CH, Schnoll SH. Prenatal cocaine use associated with down regulation of receptors in human placenta. Neurotoxicology and Teratology 1987;9:301-330; Frank DA, Zuckerman B, Amaro H, Aboagye K, Bauchner H, Cabral H, Fried L, Gingson R., Kayne H, Levenson SM, Parker S, Reece H, Vince R. Cocaine use during pregnancy: prevalence and correlates. Pediatrics 1988;82:880-895; Bateman DA, Heagarty MC. Passive free-base cocaine ("crack") inhalation by infants and toddlers. American Journal of Diseases of Children 1989;143:25-27; Shannon M, Lacouture PG, Roa J, Woolf A. Cocaine exposure among children seen at a pediatric hospital. Pediatrics 1989;83:337-343; Mitchell M, Sabbagha RE, Keith L, MacGregor S, Mota JM, Minoque J. Ultrasonic growth parameters in fetuses of mothers with primary addiction to cocaine. American Journal of Obstetrics and Gynecology 1988;159:1104-1109; Henderson CE, Torbey M. Rupture of intracranial aneurysm associated with cocaine use during pregnancy. American Journal of Perinatology 1988;5:143-143. 
  18. According to Lutiger B, Graham K, Einarson TR, Koren G. Relationship between gestational cocaine use and pregnancy outcome: a meta-analysis. Teratology 1991;44:405-414, studies using case reports alone include: Tenorio GM, Mubariz N, Bickers GH, Hubrid RH. Intrauterine stroke and maternal polydrug abuse. Clinical Pediatrics 1988;27:565-567; Henderson CE, Torbey M. Rupture of intracranial aneurysm associated with cocaine use during pregnancy. American Journal of Perinatology 1988;5:143-143; Schwartz BR, Lage JM, Pober BR, Driscoll S.G. Isolated congenital renal tubular immaturity in siblings. Human Pathology 1988;17:1259-1263; Acker D, Sachs BP, Tracey KJ, Wise WE. Abruptio placentae associated with cocaine use. American Journal of Obstetrics and Gynecology 1983;146:220-222; Bateman DA, Heagarty MC. Passive freebase cocaine ("crack") inhalation by infants and toddlers. American Journal of Diseases of Children 1989;143:25-27; Collins E, Hardwick RJ, Jeffrey H. Perinatal cocaine intoxication. Medical Journal of Australia 1989;150:331-334; Critchley HOD, Woods SM, Barson AJ, Richardson T, Lieberman BA. Fetal death in utero and cocaine abuse: case report. British Journal of Obstetrics and Gynaecology 1988;95:195- 196; Geggel RL, McInerny J, Estes NAM. Transient neonatal ventricular tachycardia associated with maternal cocaine use. American Journal of Cardiology 1989:63:383-384; Madden JD, Payne TF, Miller S. Maternal cocaine abuse and effect on the newborn. Pediatrics 1986;77:209-211; Mittleman RE, Sabbagha LK, MacGregor S, Mota JM, Minoque J. Tissue distribution of cocaine in a pregnant woman. Journal of Forensic Sciences 1989;34:481-486; Telsey AM, Merrit A, Dixon SD. Cocaine exposure in a term neonate: necrotizing enterocolitis as a complication. Clinical Pediatrics 1988:27:565-567; Teske MP, Trese MT. Retinopathy of prematurity-like fundus and persistent hyperplastic primary vitreous associated with maternal cocaine use. American Journal of Ophthalmology 1987;103:719-720; Townsend RR, Laing FC, Jeffrey RB. Placental abruption associated with cocaine abuse. American Journal of Roentgenology 1988;150:1339-1340.
  19. Kennedy D. 'Crack babies' catch up. Associated Press, 6 December, 1992. 
  20. Hadeed AJ, Siegel SR. Maternal cocaine use during pregnancy: effect on the newborn infant. Pediatrics 1989;84:205-210; Neuspiel DR, Hamel SC. Cocaine and infant behavior. Cocaine/Crack Research Working Group Newsletter 1991;2:14-25; Ryan L, Ehrlich S, Finnegan L. Cocaine abuse in pregnancy: effects on the fetus and newborn. Neurotoxicology Teratology 1987;157:686-690. 
  21. Bauchner H, Zuckerman B, McClain M, Frank D, Fried LE, Kayne H. Risk of Sudden Infant Death Syndrome among infants with in utero exposure to cocaine. Journal of Pediatrics 1988;113:831- 834. 
  22. Chavez GF, Mulinare J, Cordero JF. Maternal cocaine use during early pregnancy as a risk factor for congenital anomalies. JAMA 1989;262:795-798; Chasnoff IJ, Hunt C, Kletter R, et al. Increased risk of SIDS and respiratory pattern abnormalities in cocaine-exposed infants. Pediatric Research 1986;20:425A; Riley JG, Brodsky NL, Porat R. Risk for SIDS in infants with in utero cocaine exposure: a prospective study. Pediatric Research 1988;23:454A. 
  23. Koren G, Graham K, Shear H, Einarson T. Bias against the null hypothesis: the reproductive hazards of cocaine. Lancet 1989;8677:1440-1442. 
  24. Schama KF, Howell LL, Byrd LD, Kitchens AJ. Postnatal growth of Rhesus monkeys exposed prenatally to cocaine. Presented at the Annual Meeting of the American Psychological Association; August 1995, New York; Ellis JE, Byrd LD, Howell LL, Lambert SR, Fernandes A. Physical/neurobehavioral effects of cocaine exposure in utero. Southern Medical Journal 1994;87:S64; Fung YK, Reed JA, Lau YS. Prenatal cocaine exposure fails to modify neurobehavioral responses and the striatal dopaminergic system in newborn rats. General Pharmacology 1989;20:689-693; Sobrian SK, Burton LE, Robinson NL, Ashe WK, James H, Stokes DL, Turner LM. Neurobehavioral and immunological effects of prenatal cocaine exposure in rat. Pharmacology Biochemistry and Behavior 1990;35:617-629; Smith RF, Mattran KM, Kurkjian MF, Kurtz SL. Alterations in offspring behavior induced by chronic prenatal cocaine dosing. Neurotoxicology and Teratology 1989;11:35- 38; Wiggins RC, Ruiz B. Development under the influence of cocaine: comparison of the effects of daily cocaine treatment and resulting undernutrition on pregnancy and early growth in a large population of rats. Metabolic Brain Disease 1990;5:85-99 [60 mg/kg/day (4.5g/human/day) had normal survival rate, gestation length and litter size]; Owiny JR, Myers T, Massmann GA, Sadowsky DW, Jenkins S, Nathaniels PW, Lack of effect of maternal cocaine administration on myometrial electromyogram and maternal plasma oxytocin concentrations in pregnant sheep at 124- 145 days gestational age. Obstetrics and Gynecology 1992;79:81-84. 
  25. Tuboku-Metzger AJ, O'Shea JS, Campbell RM, Hulse JE, Bugg GW, Jones DW. Cardiovascular effects of cocaine in neonates exposed prenatally. American Journal of Perinatology 1996;13:1- 4; Woods NS, Eyler FD, Behnke M, Conlon M. Cocaine use during pregnancy: maternal depressive symptoms and infant neurobehavior over the first month. Infant Behavior and Development 1993;16:83-98; Coles CD, Platzman KA, Smith I, James ME, Falek A. Effects of cocaine and alcohol use in pregnancy on neonatal growth and neurobehavioral status. Neurotoxicology and Teratology 1992;14:23-33. 
  26. Graham K, Feigenbaum A, Pastuszak A, Nulman I, Weksberg R, Einarson T, Goldberg S, Ashby S, Koren G. Pregnancy outcome and infant development following gestational cocaine use by social cocaine users in Toronto, Canada. Clinical Investigations in Medicine 1992;15:384-394. [no differences between cocaine, marijuana, and drug-free]; Graham K, Dimitrakoudis D, Pellegrini E, Koren G. Pregnancy outcome following first trimester exposure to cocaine in social users in Toronto, Canada. Veterinary and Human Toxicology 1989;31:143-148; Richardson GA, Day NL. Maternal and neonatal effects of moderate cocaine use during pregnancy. Neurotoxicology and Teratology 1991;13:455-460. 
  27. Neuspiel DR, Hamel SC. Cocaine and infant behavior. Cocaine/Crack Research Working Group Newsletter 1991;2:14-25; Lutiger B, Graham K, Einarson TR, Koren G. Relationship between gestational cocaine use and pregnancy outcome: a meta-analysis. Teratology 1991;44:405-414. 
  28. Coles CD, Platzman KA, Smith I, James ME, Falek A. Effects of cocaine and alcohol use in pregnancy on neonatal growth and neurobehavioral status. Neurotoxicology and Teratology 1992;14:23- 33; Neuspiel DR, Hamel SC. Maternal cocaine and infant outcome. Neurotoxicology and Teratology 1991;13:229-233; Woods NS, Eyler FD, Belinke M, Conlon M. Cocaine use during pregnancy: maternal depressive symptoms and infant neurobehavior over the first month. Infant Behavior and Development 1991;16:83-98; [no effect on Brazelton scores at birth or 1 year]; Little BB, Snell LM, Palmore MK, Gilstrap LC. Cocaine use in pregnant women in a large public hospital. American Journal of Perinatology 1989;5:157-160; Hutchings DE. The puzzle of cocaine's effects following maternal use during pregnancy: are there reconcilable differences? Neurotoxicology and Teratology 1993;15:281-286; Chasnoff IJ. Missing pieces of the puzzle. Neurotoxicology and Teratology 1993;15:287-288; Church MW. Does cocaine cause birth defects? Neurotoxicology and Teratology 1993;15:289; Coles CD. Saying goodbye to the 'crack baby.' Neurotoxicology and Teratology 1993;15:290-292; Day NL, Richardson FA. Cocaine use and crack babies: science, the media, and miscommunication. Neurotoxicology and Teratology 1993;15:293-294; Dow-Edwards D. The puzzle of cocaine's effects following maternal use during pregnancy: still unsolved. Neurotoxicology and Teratology 1993;15:295-296; Fantel AG. Puzzle of cocaine's effects following maternal use during pregnancy: are there reconcilable differences? Neurotoxicology and Teratology 1993;15:197; Frank DA, Zuckerman BS. Children exposed to cocaine prenatally: pieces of the puzzle. Neurotoxicology and Teratology 1993;15:298-300; Koren G. Cocaine and the human fetus: the concept of teratophilia. Neurotoxicology and Teratology 1993;15:301-304; Neuspiel DR. Cocaine and the fetus: mythology of severe risk. Neurotoxicology and Teratology, 1993;15:305-306; Also see Fromberg E. Cocaine and pregnancy: hype or science? a review of the literature. Extension of a presentation at a meeting of medical specialists, May 30, 1991, Erasmus University, Rotterdam, Netherlands; Neuspeil DR, Hamel SC. Neurobehavioral sequelae of fetal cocaine exposure [letter]. Journal of Pediatrics 1992;120:661; Streissguth AP, Finnegan LP. Effects of prenatal alcohol and drugs. In: Kinney J, ed. Clinical Manual of Substance Abuse. 2d ed. St. Louis, MO: Mosby; 1996:254-271; Talan J. Study on coke cites environment. Newsday 16 May, 1991, 31. 
  29. Neuspiel, DR. Cocaine-associated abnormalities may not be causally related. American Journal of Diseases of Children 1992;146:278-279; Neuspiel DR. Behavior in cocaine-exposed infants and children: association versus causality. Drug and Alcohol Dependence 1994;36:101-107. 
  30. Martin ML, Khoury MJ, Cordero JF, Waters GD. Trends in rates of multiple vascular disruption defects, Atlanta, 1968-1989. Teratology 1992;45:647-653. 
  31. At least one study suggests that cocaine may not cross the placenta in all women: Potter S, Klein J, Valiante G, Stack D, Papageorgiou A, Stott W, Lewis D, Koren G, Zelazo PR. Maternal cocaine use without evidence of fetal exposure. Journal of Pediatrics 1994;125:652-654. 
  32. Hutchings D. Prenatal exposure and the problem of causal inference. In: Pinkert TM, ed. Current Research on the Consequences of Maternal Drug Abuse. Rockville, MD: National Institute of Drug Abuse; 1985:6-19. 
  33. Hutchings D. Prenatal exposure and the problem of causal inference. In TM Pinkert, ed., Current Research on the Consequences of Maternal Drug Abuse. Rockville, MD: National Institute of Drug Abuse; 1985:6-19. 
  34. 1% -- Beckman DA, Brent RL. Mechanisms of teratogensis. Annual Review of Pharmacology and Toxicology 1984;24:482-500; 5% -- Dattel BJ. Substance abuse in pregnancy. Seminars in Perinatology 1990;14:179-187. 
  35. Gustavsson NS. Drug exposed infants and their mothers: facts, myths and needs. Social Work in Health Care 1992;16:87-100. 
  36. Klein L, Goldenberg RL. Prenatal care and its effect on preterm birth and low birth weight. In: Merkatz IR, Thompson JE, eds. New Perspectives on Prenatal Care. New York: Elsevier; 1990:501- 529; MacGregor SN, Keith LG, Bachicha JA, Chasnoff IJ. Cocaine abuse during pregnancy: correlation between prenatal care and perinatal outcome. Obstetrics and Gynecology 1989;74:882-885. 
  37. Chazotte C, Youchah J, Freda MC. Cocaine use during pregnancy and low birth weight: the impact of prenatal care and drug treatment. Seminars in Perinatology 1995;19;293-300. 
  38. Streissguth AP, Sampson PD, Barr HM. Neurobehavioral dose-response effects of prenatal alcohol exposure in humans from infancy to adulthood. Annals of the New York Academy of Science 1989;562:145-158. 
  39. National Institute on Drug Abuse. National Pregnancy and Health Survey: drug use among women delivering live births, 1992. Rockville, MD: U.S. Department of Health and Human Services. National Institutes of Health publication 96-3819 -- found that 18.8%, or 757,000 of all newborns had been exposed to alcohol and 1.1%, or 45,000 newborns had been exposed to cocaine. 
  40. See Gustavsson NS. Drug exposed infants and their mothers: facts, myths and needs," Social Work in Health Care 1992;16:87-100. 
  41. Rush, D, Callahan KR. Exposure to passive cigarette smoking and child development: a critical review. Annals of the New York Academy of Science 1989;562:145-158; Nordentoft M, Lou HC, Hansen D, Nim J, Pryds O, Rubin P, Hemmingsen R. Intrauterine growth retardation and premature delivery: the influence of maternal smoking and psychosocial factors. American Journal of Public Health 1996;86:347-354; Castro LC, Azen C, Hobel CJ, Platt LD. Maternal tobacco use and substance abuse reported prevalence rates and associations with the delivery of small for gestational age neonates. Obstetrics and Gynecology 1993;81:396-401. 
  42. Broman SH, Nichols PL, Kennedy WA. Pre-school Intelligence Quotient: prenatal and early developmental correlates. New York: John Wiley; 1975; Hardy JB, Mellits ED, Does maternal smoking during pregnancy have a long-term effect on the child? Lancet 1972;2:1332-1336; Landesmann-Dwyer W, Emanual I. Smoking during pregnancy. Teratology 1979;19:119-126 
  43. Early studies (1960/70s) did not find cognitive and behavioral developmental deficits: Broman SH, Nichols PL, Kennedy WA. Pre-school Intelligence Quotient: prenatal and early developmental correlates. New York: John Wiley; 1975. Hardy JB, Mellits ED. Does maternal smoking during pregnancy have a long-term effect on the child? Lancet 1972;791:1332-1336; Landesmann-Dwyer W, Emanual I. Smoking during pregnancy. Teratology 1979;19:119-126. Although such results became prominent in the 1980s: Naeya RL, Peters EC. Mental development of children whose mothers smoked during pregnancy. Obstetrics and Gynecology 1984;64:601-607; Fogelman KR, Manor O. Smoking in pregnancy and development into early adulthood. British Medical Journal 1988;297:1233-1236; Sexton M, Fox NL, Hebel JR. Prenatal exposure to tobacco II: effects on cognitive functioning at age three. International Journal of Epidemiology 1990;19:72-77; Olds DI, Henderson CR, Tatlebaum R. Intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics 1994;93:221-227; Abel AL. Smoking during pregnancy: a review of effects on growth and development of offspring. Human Biology 1980;42:593-625; Naeya RL. Cognitive and behavioral abnormalities in children whose mothers smoked cigarettes during pregnancy. Journal of Developmental Behavioral Pediatrics 1992;13:425-428; Drews CD, Murphy CC, Yeargin-Allsopp M, Decouflé P. The relationship between idiopathic mental retardation and maternal smoking during pregnancy. Pediatrics 1996;97:547-553.
  44. Parker S. Double jeopardy: the impact of poverty on early child development. Pediatric Clinics of North America 1988;35:1227-1240. 
  45. Ruff HA, Bijur PE. The effects of low to moderate lead levels on neurobehavioral functioning in children: toward a conceptual model. Journal of Developmental and Behavioral Pediatrics 1989;10:103-109. 
  46. Griffin ML, Weiss RD, Mirin SM, Lange U. A comparison of male and female cocaine abusers. Archives of General Psychiatry 1989;46:122-126. 
  47. Zuckerman B, Amaro H, Bauchner H, Cabral H. Depressive symptoms during pregnancy: relationship to poor health behaviors. American Journal of Obstetrics and Gynecology1989;160:1107-1111. 
  48. Women who use drugs while pregnant may avoid services for fear of criminal prosecution and/or losing their children to child welfare authorities: Pollit K. 'Fetal rights': a new assault on feminism. Nation 1990;250:409-418; Cole HM. Legal interventions during pregnancy: court-ordered medical treatment and legal penalties for potentially harmful behavior by pregnant women. JAMA 1990;264:2663-2670; Poland ML, Dombrowski MP, Ager JW, Sokol, RJ. Punishing pregnant drug users: enhancing the flight from care. Drug and Alcohol Dependence 1993;31:199-203. 
  49. Perceiving their child to be irreparably damaged by maternal cocaine consumption during early pregnancy, some women opt for abortions: Koren G, Gladstone D, Robeson C, Robieux I. The perception of teratogenic risk of cocaine. Teratology 1992;46:567-571. 
  50. New York Times, 19 May, 1990, 1; New York Times, 21 September, 1990, p1; Neuspiel D. Infant 'abandonment' by drug-using mothers: blaming the victims? [letter]. Archives of Pediatric and Adolescent Medicine 1994;148:437-438; Neuspiel D, Zingman TM, Templeton VH, DiStabile P, Drucker E. Custody of cocaine-exposed newborns: determinants of discharge decisions. American Journal of Public Health 1993;83:1726-1729. 
  51. Rosenthal R, Jacobson L. Pygmalion in the classroom: teacher expectation and pupils' intellectual development. New York: Holt Rinehart & Winston; 1968; Neuspiel DR. On pejorative labeling of cocaine exposed children. Journal of Substance Abuse Treatment 1993;10:407; Gillung S, Dwyer A. Labels and teacher expectations. Exceptional Children 1977;43:464-465. 
  52. Thurman, SK, Brobeil RA; Ducette JP; Hurt H. Prenatally exposed to cocaine: Does the label matter? Journal of Early Intervention 1994;18:119-130; Also see Woods NS, Eyler FD, Conlon M, Wobie K, Behnke M, Anderson C, Maag L. Pygmalion in the cradle: observer bias against cocaine-exposed infants. Presented at the Ninth Biennial International Conference on Infant Studies; June 1994, Paris, France. Infant Behavior and Development. 1994;17:1020. 
  53. Schwartz RH., Lewis DC, Hoffman NG, Kyriazi N. Cocaine and marijuana use by medical students before and during medical school. Archives of Internal Medicine 1990;150:883-886; O'Malley PM, Bachman JG, Johnston LD. Period, age, and cohort effects on substance use among young Americans: a decade of change, 1976-86. American Journal of Public Health 1988;78:1315-1321. 
  54. Johns CJ. Power, Ideology, and the War on Drugs: Nothing Succeeds Like Failure. New York: Praeger; 1992; see Neuspiel DR. Racism and perinatal addiction. Ethnicity and Disease 1996;6:47-55. 
  55. Chasnoff IJ, Landress HJ, Barrett ME. The prevalence of illicit-drug or alcohol use during pregnancy and discrepancies in mandatory reporting in Pinellas County, Florida. New England Journal of Medicine 1990;322:1202-1206. 
  56. Humphries D, et al. Mothers and children, drugs and crack: reactions to maternal drug dependency. Women and Criminal Justice 1992;1:81-99 overviews US programs that combine prenatal care with drug treatment, including Born Free, associated with the San Diego Medical Center; Harlem Hospital Center; Hutzel Hospital in Detroit encourages patients to enter the Hutzel Recovery Center; Neil J. Houston House in the Roxbury section of Boston serves convicted pregnant addicts; and Family Center at Thomas Jefferson Medical College of Thomas Jefferson University. Other programs rely on court referrals for patients: e.g., MABON, Hale House, CARE. Another study describes the use of a therapeutic community: Egelko S, Galanter M, Edwards H, Marinelli K, Treatment of perinatal cocaine addiction: use of the modified therapeutic community. American Journal of Drug and Alcohol Abuse 1996;22:185-202. 
  57. Kearney MH, Murphy S, Irwin K, Rosenbaum M. Salvaging self: a grounded theory of pregnancy on crack cocaine. Nursing Research 1995;44:208-213; Also see Chavkin W, Paone D, Friedmann P, Wilets I. Reframing the debate: toward effective treatment for inner city drug-abusing mothers. Bulletin of the New York Academy of Medicine 1993;70:50-68. Programs outside of the US that attempt to fill these needs include: In Britain, a liaison service for pregnant opiate addicts: see Dawe S, Gerada C, Strang J. Establishment of a liaison service for pregnant opiate-dependent women. British Journal of Addiction 1992;87:867-871; and Canada's Motherisk program: see Koren G. Graham K. Cocaine in pregnancy: analysis of fetal risk. Veterinary and Human Toxicology 1992;34:263-264.