oversight

Drug-Exposed Infants: A Generation at Risk

Published by the Government Accountability Office on 1990-06-28.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                              IJnitetd States   General   Accounting   Office            *     8
                                                                                             I !

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                              Report to the Chairman, Committee on                       > *I1
1                             Finance, ‘U.S. Senate


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                              DRUG-EXPOSED
                              INFANTS
                              A Generation at Risk


                                                                                141697




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             United States
GAO          General Accounting  Office
             Washington, D.C. 20648

             Human Resources          Division

             B-238209
             June 28,199O

             The Honorable Lloyd Bentsen
             Chairman, Committee on
               Finance
             United States Senate
             Dear Mr. Chairman:

             This report responds to your request, in which you expressedconcern
             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. Specif-
             ically, you asked that we assessthe (1) extent of the problem; (2) health
             effects and medical costs of infants born exposedto 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 pre-
             natal care to drug-addicted pregnant women.

             Unlike the drug epidemics of the 1960sand 197Os,which primarily
Background   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.’ 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 causecon-
             striction of blood vesselsin 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.

             Although definitive information doesnot exist about the long-term
             effects of drug use during pregnancy, researchershave reported that
             someinfants who were prenatally exposedto stimulant drugs like
             cocaine have suffered from a stroke or hemorrhage in the areas of the
             brain responsible for intellectual capacities.



             ’ Frequently used illicit drugs include crack cocaine, heroin, PCP, marijuana, amphetamines,
             methamphetamines, and barbiturates.



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                        B.228208                                                                                       .   ,




                        In addition to the effects of prenatal drug exposure, drug-abusing preg-
                        nant 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 economicproblems.
                        The Office of National Drug Control Policy is responsible for developing
                        an annual national anti-drug strategy.2The 1990 National Drug Control
                        Strategy calls for spending $10.6 billion in fiscal year 1991, with 71 per-
                        cent of the funds going to drug-supply-reduction activities and 29 per-
                        cent to reduce the demand for drugs. Under this strategy, $1.6 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 pre-
                        vention and treatment for women.
                        In addition, the Office for SubstanceAbuse Prevention within ADAMHA
                        has a program that provides demonstration grants to public and private
                        providers for model projects for substance-abusingpregnant and post-
                        partum women and their infants.

                        Moreover, two federal-state health programs are potentially available to
                        pregnant women who abusedrugs. First, the Maternal and Child Health
                        Services Block Grant program (MCH), authorized by title V of the Social
                        Security Act, provides grants to the states for health servicesto low-
                        income persons, One of the purposes of MCH is to reduce infant mor-
                        tality and the incidence of preventable diseasesand handicapping condi-
                        tions among children, frequent consequencesof drug abuseby pregnant
                        women. Second,the Medicaid program, authorized by title XIX of the
                        Social Security Act, provides federal financial assistanceto the states
                        for a broad range of health services for low-income persons.One group
                        of people that states are required to cover under Medicaid is low-income
                        pregnant women. Those pregnant drug abuserswho have low incomes
                        could qualify for servicesunder either of these programs.

                        We interviewed leading neonatologists, drug treatment officials,
Objectives, Scope,and   researchers,hospital officials, social welfare authorities, and drug-
Methodology             addicted pregnant women to determine: (1) the nqmber of drug-exposed

                        2The Office of National Drug Control Policy was established by the Anti-Drug Abuse Act of 1988.



                        Page 2                                                   GAO/HRBQ@138 Drug-Exposed Infants
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                    B-233209




                    infants, (2) their impact on the medical and social services systems, (3)
                    their health costs, and (4) the availability of drug treatment and pre-
                    natal care. We also reviewed the current literature.

                    We obtained data on drug-exposedbirths 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 diagnosesassociatedwith 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 selectedtwo hospitals in each of five cities-Boston, Chicago,
                    Los Angeles, New York, and San Antonio-in which we reviewed med-
                    ical records to determine the number of drug-exposedinfants born and
                    to assessdifferences in hospital charges between drug-exposedand
                    nonexposedinfants. 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-exposedif
                    any of the following conditions were documented in the medical record
                    of the infant or mother: (1) mother self-reported drug use during preg-
                    nancy, (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 dependent3 We also interviewed offi-
                    cials at 10 other hospitals in these cities that serve predominantly non-
                    Medicaid patients, but we did not review patient medical records. Our
                    methodology is discussedmore fully in appendix VI.
                    Our work was performed from January through April 1990 in accor-
                    dance with generally acceptedgovernment auditing standards. The
                    results are summarized below and are discussedmore fully in appen-
                    dixes I through IV.

                    Identifying infants who have been prenatally exposed to drugs is the
Many Drug-Exposed   key to providing them with effective medical and social interventions at
Infants Who Might   birth and as they grow up. Such identification is also necessaryto
Need Help Are Not   understand the nature and magnitude of the problem in order to target
                    drug treatment and prenatal care servicesto drug-addicted pregnant
Identified *        women and other servicesto infants.

                    3Alcohol use during pregnancy was not included in our definition of maternal drug use.



                    Page 3                                                    GAO/HRD-SO-133     Drug-Exposed   Infanta
B.238209

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There is no consensuson the number of infants prenatally exposedto
drugs each year. The administration’s 1989 National Drug Control
Strategy reported that an estimated 100,000 infants were exposedto
cocaineeach year.4The president of the National Association for Per-
inatal Addiction Researchand Education estimates as many as 375,000
infants may be drug exposedeach 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 preg-
nancy in 1986.”By 1988, the latest year that data were available, the
number had grown to 13,765 infants. 6a7However, this represents a sub-
stantial undercount of the total problem becausephysicians and hospi-
tals do not screen and test all women and their infants for drugs.
Researchhas found that when screening and testing is uniformly
applied, a much higher number of drug-exposedinfants 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 rigorous methods of detection.R
The average incidence of drug-exposedinfants born at hospitals with
rigorous detection procedures was closeto 16 percent of those hospitals’
births, as compared with 3 percent at hospitals with no substanceabuse
assessment.
A study conducted at a large Detroit hospital accounting for over 7,000
births used meconium testing,” a more sensitive test for detecting drug
use. The incidence of drug-exposedinfants at this hospital was 42 per-
cent or nearly 3,000 births in 1989. In contrast, when self-reported drug

4The strategy does not mention the number of infants exposed to other drugs.

“The estimate ranged from 7,178 to 11,226 at a g&percent confidence interval.

“The estimate ranged from 8,259 to 19,271 at a 96percent confidence interval,

7This survey identified drug-exposed infants baaed 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-O-CM,3rd edition:
codes 760.70,760.72,760.73, and 779.6.

sIra 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.
“Meconium is the first 2- to 3-days’ stool of a newborn infant.



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    use by the mother was the basis for identifying drug-exposedinfants,
    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-exposedbirths. In our exami-
    nation of medical records at 10 hospitals, we identified approximately
    4,000 drug-exposedinfants born in 1989. Our estimates ranged from 13
    drug-exposedbirths per thousand births at one hospital to 181 per thou-
    sand births at another.
    The wide range in the numbers of drug-exposedinfants we found may
    be associatedwith differences in the hospitals’ efforts to identify drug-
    exposedinfants. One hospital, for example, did not have a protocol for
    assessingdrug use during pregnancy. This hospital had the lowest inci-
    denceof drug-exposedinfants. The other 9 hospitals’ protocols required
    testing primarily if the mother reported her drug use or the infant mani-
    fested drug withdrawal signs. Hospital officials acknowledge that these
    screeningcriteria allow many drug-exposedinfants to go undetected in
    the hospital. This is becausemany drug-exposedinfants display few
    overt drug withdrawal signs and many women deny using 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 assistancefor 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




    “‘Enrique 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.



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                           B-228208




                           similar between the two groups (16.3 percent for women seenat public
                           clinics and 13.1 percent for those seenat private offices).” (Seeapp. I.)

                           Drug-exposedinfants are more likely than infants not exposedto drugs
    Drug-Exposed Infants   to suffer from a greater range of medical problems and in somecases
    Have More Health       require costly medical care. We compared the medical problems and
    Problems and Are       costs of infants prenatally exposedto drugs, with those who were not,
                           at four hospitals. At these four, we determined that at least 10 percent
    More Costly            of the infants were prenatally exposedto drugs.‘2The mothers of the
                           drug-exposedinfants were more likely to have had little or no prenatal
                           care, and the infants had significantly lower birth weights, were often
                           premature, and had longer and more complicated hospital stays than
                           other infants.
                           Given these medical problems, hospital chargesfor drug-exposedinfants
                           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-exposedinfants was $6,600, while the median charge incurred by
                           nonexposedinfants was $1,400. Chargesfor drug-exposedinfants at
                           these hospitals ranged from $466 to $66,326. Becausemore than 60 per-
                           cent of all patients received public medical assistanceat 7 of the 10 hos-
                           pitals in our study, much of these chargeswere covered by federal
                           assistanceprograms.

                           Although the long-term physical effects of prenatal drug exposure are
                           not well known, indications are that someof these infants will continue
                           to need expensive medical care as they grow up. Becauseof the uncer-
                           tainty of the long-term consequencesof prenatal drug exposure, the
                           future costs of caring for these children are unknown. (Seeapp. II.)




                           ’ ‘Ira 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.

                           12Theother 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.



                           Page 0                                                      GAO/HRIM@l38       m-Expoeed       Infhta
                      0233209




                      Drug-exposedinfants often present immediate and long-term demands
Impact on Social      on the social welfare system. Officials atseveral of the hospitals in our
Welfare and           review stated that they are experiencing a growing number of “boarder
Educational Systems   babies”-infants who stay in a hospital for nonmedical reasonsoften
                      related to drug-abusing families. Boarder babies are reported to the
Could Be Profound     social welfare system for foster care placement.
                      We also found that a substantial proportion of drug-exposedinfants did
                      not go home from the hospital with their parents. An estimated 1,200 of
                      the 4,000 drug-exposedinfants 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-exposedinfants enter the social servicessystem at birth;
                      some are discharged from the hospital to drug-abusing parents. These
                      infants may later enter the social services system becauseof the chaotic
                      and often dangerousenvironment associatedwith parental drug
                      abuse-an increasing source of child abuse and neglect. For example,
                      cocaineuse was found to be significantly associatedwith child neglect in
                      a recent study of child-abuse investigations in Boston. Hospital officials
                      told us that they are seeingmore young children from drug-abusing fam-
                      ilies admitted to hospitals becausethey suffered physical neglect or mal-
                      treatment at the hands of someoneon 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 67 per-
                      cent of foster care children comefrom families that allegedly are
                      abusing drugs.
                      Becausethe 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 needsof drug-abusing families. Specifi-
                      cally, problems have been identified regarding the availability of foster
                      parents who are willing to accept children who have been exposedto
                      drugs, the quality of foster care homes, and the lack of supportive
                      health and social servicesto 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


                      Page 7                                     GAO/HRLMM-138   Drug-Exposed   Infknt.a
                          B-238209                                                                             1




                          that could result in underachievement and excessiveschool dropout
                          rates leading to adult illiteracy and unemployment. As increasing num-
                          bers of drug-exposedinfants reach school age,the long-term detrimental
                          effects of drug exposure will becomemore evident. The cost of mini-
                          mizing 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-exposedchildren in Los Angeles, the
                          per capita cost is estimated to be $17,000 per year. The Florida Depart-
                          ment of Health and Rehabilitative Servicesestimates that for those
                          drug-exposedchildren who show significant physiologic or neurologic
                          impairment total service costs to age 18 could be as high as $760,000.
                          (Seeapp. III.)

                          To prevent the problem of drug-exposedinfants, women of childbearing
Lack of Drug              age must abstain from using drugs. To reduce the impact of drug-
Treatment and             exposure, pregnant women who use drugs should be encouragedto stop
Prenatal Care Is          and be given neededtreatment.
Contributing to the
Number of Drug-
Exposed Infants

Drug Treatment Services   Recent studies show that if women are able to stop drug use during
Do Not Meet the Need      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 treat-
                          ment before the third trimester.
                          Many programs that provide servicesto 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. Onetreatment center in Boston
                          received 460 calls for detoxification servicesduring a l-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 becomeavailable. Of the 460 callers that month, about one-half
                          never called back and about 160 were eventually admitted to treatment.




                          Page 8                                     GAO/HRD-20-138   Drug-Exposed   Infanta
                          B-239209




                          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 caresI Hospital and social welfare officials in each of the
                          five cities in our review also told us that drug treatment serviceswere
                          insufficient or inadequate to meet the demand for servicesof drug-
                          addicted pregnant women.
                          In addition to insufficient treatment, someprograms deny servicesto
                          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 reasonstreatment centers are reluctant to
                          treat pregnant women relates to issuesof legal liability. Drug treatment
                          providers fear that certain treatments using medications and the lack of
                          prenatal care or obstetrical services at the clinics may have adverse con-
                          sequenceson the fetus and thereby exposethe providers to legal
                          problems.
                          Many other barriers to treatment exist. For example, pregnant addicts
                          we interviewed told us that becausethey 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 prosecu-
                          tion. Drug treatment and prenatal care providers told us that the
                          increasing fear of incarceration and losing children to foster care is dis-
                          couraging 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 associatedwith the births of drug-exposedinfants,
                          Through the three basic componentsof prenatal care: (1) early and con-
                          tinued risk assessment,(2) health promotion, and (3) medical and
                          psychosocial interventions and follow-up, the chancesof an unhealthy
                          infant are greatly reduced. Hospital officials told us that in addition to
                          not seeking prenatal care, somedrug-using women are now delivering


                          “‘The report did not reveal the extent to which these women sought treatment.



                          Page 9                                                    GAO/HRD-90-138    Drug-Exposed   Infants
              B-238200




              their infants at home in order to prevent being reported to child welfare
              authorities.
              Many health professionals believe comprehensiveresidential drug treat-
              ment that includes prenatal care servicesis the best approach to helping
              many women stop using drugs during pregnancy and providing the
              developing infant with the best chanceof being born healthy. However,
              such programs are scarce.
              Massachusettsofficials told us that the lack of residential treatment
              slots was a major problem. Only 16 residential treatment slots are avail-
              able 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.(Seeapp. IV.)

              Despite growing indications of a serious national problem, hospital pro-
Conclusions   ceduresdo not adequately identify drug use during pregnancy. Conse-
              quently, 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-exposedinfants born nation-
              wide each year could be very high.

              A drug-exposedinfant has short- and long-term health, social, and cost
              implications for society, These infants are more likely to be born prema-
              ture, have a lower birth weight, and have longer hospital stays requiring
              more expensive care. Someof 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 unavail-
              able and many women giving birth to drug-exposedinfants are not
              receiving adequate prenatal care.




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                           Becausethe increasing number of drug-exposedinfants has becomea
Matters for                serious health and social problem, we believe an urgent national
Consideration by the       responseis necessary.Specifically, outreach services should be provided
Congress                   so that pregnant women in need of prenatal care and drug treatment can
                           be identified. For these women, comprehensivedrug treatment, and pre-
                           natal 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 resi-
                           dential and outpatient slots currently available could be reduced. If the
                           Congressshould decide to expand the current federal resource commit-
                           ment to treatment for drug-addicted pregnant women, there are several
                           options that could be followed. These include:
                       l Increasing the alcohol and drug abuseand mental health services (ADMS)
                         block grant to the states in order to provide more federal support for
                         drug treatment.
                       l Increasing the ADMS Women’s Set-Aside from 10 percent to a higher per-
                         centageto assure that expanded treatment services under the block
                         grant are targeted specifically to substance-abusingpregnant women.
                       . Creating a new categorical grant to provide comprehensiveprenatal
                         care and drug treatment servicesto substance-abusingpregnant women.
                       l Increasing funding of MCH specifically for substance-abusetreatment
                         for pregnant women.
                       . Requiring states to include substance-abusetreatment as part of the
                         package of services available to pregnant women under Medicaid.

                           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 congressionalcom-
                           mittees and subcommittees;the Secretary of Health and Human Ser-
                           vices; and the Director, Office of Management and Budget, and we will
                           make copies available to other interested parties upon request.




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B-228209




If you have any questions about this report, pleasecall me on (202) 27%
6461. Other major contributors to the report are listed in appendix VII.

Sincerely yours,




Janet L. Shikles
Director for Health Financing
  and Policy Issues




Page 12                                   GAO/HRD9@123   m-Expoeed       Infants
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    Page 13   GAO/HRD-90-138   Drug-Exposed   Infants
                                                                                                        II
Contents


Letter
Appendix I                                                                                          18
The Number of Drug-    The Number of Drug-ExposedInfants Could Be High
                       Hospitals Lack Systematic Proceduresto Identify Drug-
                                                                                                    18
                                                                                                    19
Exposed Infants May        Exposed Infants
Be Seriously
Underestimated
Appendix II                                                                                        24
Drug-Exposed Infants   Drug-ExposedInfants Are More Vulnerable at Birth
                       Hospital ChargesAre Higher for Drug-ExposedInfants
                                                                                                   24
                                                                                                   27
Are Likely to Have
Costly Health
Problems
Appendix III                                                                                       30
Prenatal Drug Abuse    Many Drug-ExposedInfants Enter Foster Care
                       Drug-ExposedInfants Are Vulnerable to Developmental
                                                                                                   30
                                                                                                   33
Has Increased Demand       Problems That May Affect Learning
for Social Services
Appendix IV                                                                                        36
Lack of Drug           Lack of Treatment for Drug-Addicted Pregnant Women                          36
                       Prenatal Care Improves Birth Outcomes                                       38
Treatment and
Prenatal Care
Contributing to the
Number of Drug-
Exposed Infants




                       Page 14                                 GAO/HRINO-138   Drug-Exposed   Infants
              -
Appendix V
Percentage
Distribution of Infants
Exposed to Drugs,
Including Cocaine
Appendix VI                                                                                                41
Objectives,       Scope,   and   Hospital Selection Criteria                                               41
Methodology
Appendix VII
Major Contributors to
This Report
Bibliography
Tables                           Table 1.1:Drug-ExposedInfants Born at 10 Hospitals,                       19
                                     1989
                                 Table 1.2:Estimated Number of Infants With Indicators of                  22
                                     Possible Drug Exposure Not Tested in Nine Hospitals,
                                     1989
                                 Table 1.3:Percentageof Infants With Two or More                           23
                                     Indicators of PossibleDrug Exposure Who Were or
                                     Were Not Tested and the Percentageof Drug-Exposed
                                     Infants at Nine Hospitals
                                 Table II. 1: Estimated Hospital Chargesfor Drug-Exposed                   28
                                     Infants at Three Hospitals in 1989
                                 Table VI. 1: Comparison of Births at Hospitals in GAO                     41
                                     Study With Total Births in the RespectiveCities,
                                     1988
                                 Table VI.2: Profile of Patients at SelectedHospitals                      42




                                 Page 16                                 GAO/HRD-go-198   --Exposed   Infanta
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          Contents




Figures   Figure II. 1: Mothers of Drug-ExposedInfants Are More                          26
              Likely to Obtain Inadequate Prenatal Care
          Figure 11.2:Drug-ExposedInfants More Often Have a Low                          26
              Birth Weight as Compared With NonexposedInfants
          Figure 11.3:Drug-ExposedInfants Are More Likely to Be                          27
              Born Prematurely Than NonexposedInfants
          Figure 11.4:Drug-ExposedInfants Incur Higher Hospital                          28
              ChargesThan NonexposedInfants
          Figure III. 1: Drug-ExposedInfants Are More Likely to Be                       31
              Admitted to Foster Care Than NonexposedInfants




          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
          MCH        Maternal and Child Health ServicesBlock Grant program
          NASADAD    National Association of State Alcohol and Drug Abuse
                        Directors, Inc.
          NIDA       National Institute on Drug Abuse


          Page 16                                  GAO/HRD-96-138   Drug-Exposed   Infants
Page 17   GAO/HRD-!40-138   Drug-Exposed   Infants
                                                                                                                             ,
 PPe
?l%%m&er of Drug-Exposed Infmts May Be A
Seriously Undereated

                            The identification of infants who have been prenatally exposedto drugs
                            is key to understanding the magnitude of the problem and providing
                            effective medical and social interventions for these infants. However,
                            there is no consensuson the number of drug-exposedinfants born in the
                            United States each year. A comprehensivenationwide study to specifi-
                            cally determine the incidence of drug-exposedbirths has not been done.
                            Additionally, hospitals’ procedures allow many drug-exposedinfants to
                            go undetected.

                            Basedon data from the National Center for Health Statistics’ National
The Number of Drug-         Hospital Discharge Survey, which includes a representative sample of
Exposed   Infants   Could   all births, an estimated 9,202 drug-exposedinfants were born in 1986 in
E3eHigh                     the United States.’ By 1988, the latest year that data were available, the
                            number had grown to 13,765 infants.2 However, this is likely to be a
                            substantial under-countof the problem. At present, physicians and hos-
                            pitals do not routinely screen and test all women and their infants for
                            drugs. Recentstudies have found that when screening and testing are
                            uniformly applied, a much higher number of drug-exposedinfants is
                            identified.
                            One study found that hospitals that assessevery 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.3The averageincidence of
                            drug-exposedinfants born at hospitals with rigorous detection proce-
                            dures was closeto 16 percent of all births as compared with 3 percent of
                            births at hospitals with no substance-abuseassessment.
                            Likewise, our work indicates that the National Hospital Discharge
                            Survey underreports the incidence of drug-exposedbirths. Basedon our
                            review of the medical records for both the women and their infants at
                            10 hospitals, an estimated 3,904 drug-exposedinfants were born at
                            these hospitals in 1989. (Seetable 1.1.)”Estimates of the number of these
                            infants ranged from a low of 13 per 1,000 births at one hospital to a

                            ‘The estimate ranged from 7,178 to 11,226 at a g&percent confidence interval.
                            “The estimate ranged from 8,269 to 19,271 at a QEqercent confidence interval.

                            31raJ. 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.

                            4Appendii V provides more detailed information on the degree of drug-exposed infants identified at
                            the 10 hospitals.



                            Page 18                                                   GAO/HRD-90-138        Drug-Expaeed   Infanta
                                          The Number of W-Expoeed Infanta May Be
                                          Seriously   Underestlmsted




                                          high of 181 births per 1,000 at another. Maternal cocaineuse was esti-
                                          mated to range from less than 1 percent to 12 percent among the
                                          hospitals.
Table 1.1: Drug-Exposed Infant8 Born at
10 Horpltalr, 1999                                                              Estimated no. of                 Total
                                                                           drug-exposed Infant6                                   Eatlmated no. of
                                                                                 DW 1.000 births             of bit;         drua-exoosed infants
                                          Boston
                                                  1                                                 72           3,294                                 237
                                               2                                                    89           1 ,438a                               128
                                          Chicaao
                                               1                                                   181           3,604                                 652
                                               2                                                    47           4,250a                                200
                                          Los Anaeles
                                               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 esti-
                                          mated.



                                          We also found that the wide range in the number of drug-exposed
Hospitals Lack                            infants we identified at the different hospitals in our review may be
Systematic Procedures                     associatedwith the effort taken by hospitals to identify drug-exposed
to Identify Drug-                         infants. For example, one of the 10 hospitals did not have a protocol for
                                          assessingdrug use during pregnancy. This hospital had the lowest inci-
Exposed Infants                           dence of drug-exposedinfants. Protocols at the remaining 9 hospitals
                                          did not require systematic screeningand testing of every mother and
                                          infant for potential substanceuse or exposure. Instead, the protocols
                                          primarily required testing if the mother reported her drug use or if drug
                                          withdrawal signs becamemanifest in the infant.
                                          Hospital officials acknowledge that these screeningcriteria allow many
                                          drug-exposedinfants to remain unidentified in the hospital, For
                                          example, women often deny using drugs becausethey do not want to be



                                          Page 19                                                         GAO/HRD-90-138       Drug-Exposed     Infanta
Appemdix I
The Number of Drug%xpmed         Infants   May Be
Seriously Underestimated




reported to the authorities for fear of being incarcerated or having their
children taken from them.
In addition, many cocaine-exposedinfants display few overt drug with-
drawal signs. Somewill 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 severesymptoms to milder symptoms of irritability and restless-
ness,poor feeding, and crying. Sincethese milder symptoms are nonspe-
cific, maternal drug use may not be suspectedunless 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 advantagesover urinalysis becausethey are
more accurate or can detect drug use over a longer period of time after
drug use has occurred..5,6,7
                          One of the studies, conducted at a large urban
hospital in Detroit accounting for over 7,000 births annually, used
meconium analysis to detect drug use during pregnancy.RPreliminary
results revealed that 42 percent of infants were found to be drug-
exposedin 1989.RHowever, 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 recommendthat
drug testing be conducted. Such factors or characteristics have been
found to occur more often among drug-exposedinfants than infants not
exposedto drugs and include (1) inadequate prenatal care (defined as
four or fewer prenatal care visits for a pregnancy of 34 or more

aMeconium is the first 2- to 3-days’ stool of a newborn infant.
“Karen Graham and others, “Determination of Gestational Cocaine Exposure by Hair Analysis,”
Journal of the American Medical Association, Vol. 262 (Dec. 16, 1989), pp. 3328-30.

7Enrique 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 Hate in Detroit.
[July 14, lY8Y, prelimmary report.)

‘Ostrea, A Prospective Study of the Prevalence of Drug Abuse Among Pregnant Women.
“The 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.



Page 20                                                      GAO/HRD-90-138   Drug-Exposed   Infants
Appendix I
The Number of Drug-Exposed      Infants   May Be
Seriously Underestimated




weeks),lO(2) low birth weight (defined as less than 6.6 pounds), and (3)
low gestational age or prematurity (defined as less than 38 weeks).uJz
(Seetable 1.2.)

We were able to obtain data from 9 of the 10 hospitals in our review on
the degreeto 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 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.




‘oInstitute of Medicine, Infant Death: An Analysis by Maternal Risk and Health Care. Contrasts in
Health Status, ed. D.M. Kessner, Vol. 1 (Washington, DC.: National Academy of Sciences, 1973), pp.
68-69.
“Gestational age refers to the period of time, normally 40 weeks, from conception to an infant’s
birth.
‘“Maternal demographic characteristics and socioeconomic status effect birth outcomes. Infant mor-
tality and low birth weight rates are higher for young, uneducated, unmarried, non-white women
with limited financial resources.



Page 21                                                    GAO/HRD-90438      Drug-Exposed    Infants
                                         Appendix I
                                         The Number of Drug-Exposed        Manta    May Be
                                         Sedoualy Underestimated




Table 1.2: Eatlmated Number of Infants
With Indlcaton of Poralble Drug                                                                       No. of Infants with
Exporure Not Tested In Nine Hospitals,                                     Leso than 5           Birth weight        GestatIonal               Two
1999                                                                                                 less than     age less than           or more
                                         Locatlon/hospltal                     prggi                    5.5 Ibs        38 weeks        risk factors
                                         Boston
                                              1                                         69                  563             682                 478
                                                                                             b                    b                b                  b
                                              2
                                         Chicago
                                              1                                        342                  299             620                 267
                                              2                                         72                  136             574                 123
                                         Los Angeles
                                              1                                       513                   176             401                 176
                                              2                                     1.120                   335             601                 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                2,598             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 somehospitals where we identified low percentages
                                         of drug-exposedinfants tended to have high percentagesof infants with
                                         two or more indicators of possible drug exposure who were not tested.
                                         (Seetable 1.3.)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-exposedinfants.




                  Y




                                         Page 22                                                        GAO/HRD!3O-138    Drug-Exposed     Infants
                                            Appendix I
                                            The Number of Drug-Exposed      Infants   May Be
                                            Seriously Underestimated




Table 1.3: Percentage of Infant8 With Two
or More IndlCatOr8 Of PO88ibk Drug          Figures are percentages
Exposure Who Were or Were Not Teated                                                           Infants            Infants            Drug-exposed
and the Percentage of Drug-Exposed          City/horpital                                       tested         not tested                   Infant8
Infant8 at Nine Horpltalo                   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 identi-
                                            fying drug use during pregnancy. Somehospital officials estimated drug-
                                            exposedinfants 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 socioeconomicstatus. This study anony-
                                            mously 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 percent for women seenat public
                                            clinics, and 13.1 percent for those seenat private offices).13




                                            131raJ. Chamoff, 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, ISSO), pp. 1202-06.



                                            Page 23                                                      GAO/HRD-90-138        Drug4xposed   Infants
Appendix II

Drug-Exposed Infants Are Likely to Have
Costly Health Problems

                       Infants prenatally exposedto drugs are more likely to need more med-
                       ical servicesthan infants whose mothers did not use drugs during preg-
                       nancy. It is more common for drug-exposedinfants 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 chargesfor drug-exposedinfants were
                       up to four times greater than for nonexposedinfants.

                       Becausedrug-exposedinfants are born with significantly more medical
Drug-Exposed Infants   problems, they experience more expensive hospitalizations. The most
Are More Vulnerable    frequent effects of drug exposure on infants are low birth weight and
at Birth               prematurity. Comparing drug-exposedinfants with those with no indi-
                       cation of drug exposure at 4 hospitals, we found differences in prenatal
                       care received, birth weight, gestational age, intensity of care, and hos-
                       pital length of stay.’

                       The proportion of infants born to drug-using women receiving inade-
                       quate 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. (Seefig. 11.1.)




                       ‘Of the 10 hospitals we reviewed, 4 had a lo-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.



                       Pa’ge 24                                                  GAO/llRB9O.13S Drug-Exposed hfanta
                                      Appendix         II
                                      Drug#xpoaed             Infanta   Are Likely   to Have
                                      Costly        Health    Problems




Flgure 11.1:Mothers of Drug-Exposed
Infant8 Are More Likely to Obtain
Inadequate Prenatal Care              Estlmatsd prrcrnt of Infants born to mothrn             rscolvlng lnadsquats pnnatal oars
(Comparison at 4 Hospitals)           70
                                      55
                                      60
                                      55
                                      50




                                      25
                                      20
                                      15
                                      10
                                       5
                                       0

                                               1                          2                       3                   4
                                               Hospitals

                                               II            Drug-exposed infants
                                                             Infants not identified as drug exposed


                                      Low birth weight, defined as weighing less than 5.6 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 percentagesof drug-exposedinfants weighing less than 6.5
                                      pounds than those born to women not identified as using drugs during
                                      their pregnancy. In fact, the proportion of drug-exposedinfants 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 per-
                                      cent among drug-using women and 4 to 11 percent for women not identi-
                                      fied as using drugs. (Seefig. 11.2.)




                                      Page 25                                                                  GAO/HRLMJ-138      Drug-Exposed   Infants
                                                                                                                                 ,

                                        Appendix II
                                        Drug-~           Infants Are Likely      to Have
                                        Caetly Health    Problema




Flaure 11.2:Drua-Exporod Infanta More
Often Have a Low ilrth Weight a8
Compared Wlth Nonexposed Infant8        as Emtlmatod porant of low bbth woighl infants
(Comparison at 4 Hospitals)




                                             1                       2                       3
                                             HOSpltd*

                                                        Drug-exposed infant8
                                                        Infants not identified aa drug exposed



                                        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
                                        degreeof prematurity. These handicaps may lead to increased mortality
                                        and morbidity. Generally, we found that drug-exposedinfants were
                                        about twice as likely to be premature as infants not exposedto drugs.
                                        (Seefig. 11.3.)




                                        Page 26                                                  GAO/IfRIMO-138   Drug-Expoeed       Infanta
 .                                        APpeA      IJ
                                          Drug-JZxpawd       Infanta   Axe Ukely     to Have
                                          Fatly Health Problems




Flgure 11.3:Drug-Exporrd Infant8 Are
More Likely to Be Born Prematurely Than
Nonexpoaed Infant8                        Edlmaiod porcrnt of Infanta born pnmatunly
(Comparison at 4 Hospitals)               SO

                                          45

                                          40

                                          35

                                          30

                                          25

                                          20

                                          15

                                          10

                                           5



                                                 1                       2                       3          4
                                                 Hwpitals

                                                            Drug-expossd infant8
                                                            Infants not ldenfified aa drug exposed


                                          Finally, at two of the four hospitals, a significantly greater percentage
                                          of drug-exposedinfants neededintensive care services during their hos-
                                          pital stay. Drug-exposedinfants were also more likely than those not
                                          identified as drug exposedto remain in the hospital for 6 or more days.

                                          The health problems of drug-exposedinfants and their longer and more
Hospital Charges Are                      complicated hospitalizations are often reflected in higher hospital
Higher for Drug-                          charges.We were able to compare hospital chargesbetween drug-
Exposed Infants                           exposed infants and infants with no indication of drug exposure in their
                                          medical records at three hospitals2 As shown in figure 11.4,hospital
                                          charges for drug-exposedinfants 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-exposedinfants was $5,500,
                                          while the median charge incurred by nonexposedinfants was $1,400.



                                          “At 1 of the 4 hospitals, however, separate hospital charges for mothers and infants were not
                                          available.




                                          Page 27                                                    GAO/HRD90-138      Drug-Exposed      Infants
                                        Appendix Il
                                        Drug-Exposed      Infants Are Likely         to Have
                                        Costly Health     Problems




Higher Hospital Charges Than
Nonexposed Infants                      Modian Hospkal Charge8
(Comparison at 3 Hospitals)             6000
                                        5300
                                        5000
                                        43w
                                        4000
                                        3!Ioo
                                        3000
                                        2600
                                        2000
                                        1500
                                        1000
                                         600
                                            0

                                                  1                        2
                                                  Hospitals


                                                 L-J          Drug-exposed infants
                                                              Infants not identified as drug exposed



                                        Over $14 million was spent on the care of drug-exposedinfants at 3 hos-
                                        pitals where we were able to obtain data. (Seetable 11.1.)Hospital
                                        charges for drug-exposedinfants at these hospitals ranged from $455 to
                                        $65,325.

                                        Becausemore than 50 percent of patients received public medical assis-
                                        tance in 7 of the hospitals in our study, a large part of these costs was
                                        covered by federal assistanceprograms.
Table 11.1:Estlmated Hospital Charges
for Drug-Exposed Infants at Three                                                        Estimated no. of
Hoopltalr In 1999                                                                          drug-exposed           Mean          Estimated total
                                        Hospital                                                  Infants        charge        horpltal charges
                                        1                                                              1,187      $6,914=              $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.




                                        Page 28                                                            GAO/HRD-90-138   Drug-Exposed   Infante
Appendix II
Drug-Exposed    Infants Are Likely   to Have
Costly Health   Problems




Although the long-term physical effects of prenatal drug exposure are
not well known, indications are that someof these infants will continue
to need expensive medical care as they grow up, Becauseof the uncer-
tainty of the long-term consequencesof prenatal drug exposure, future
medical costs of caring for these children are unknown.                 k




Page 29                                        GAO/HRD-99-138   Drug-Exposed   Infants
                                                                                                                      <         f”
                                                                                                                                I
Appendix III

Prenatal Drug Abuse Has Increased Demand for
Social Services

                       State, city, and hospital social servicesofficials unanimously reported to
                       us that parental drug abusehas created additional demandson the
                       social services system. These demandsinclude the need for foster place-
                       ments for the infant upon discharge from the hospital. They also include
                       investigations of drug-related neglect and abusethat in somecases
                       result in the child’s removal from the home. Additionally, studies have
                       shown that somedrug-exposedinfants 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.

                       We found that drug-exposedinfants were significantly more likely, com-
Many Drug-Exposed      pared with infants not identified as drug-exposed,to stay in the hospital
Infants Enter Foster   after their mother was discharged. While these longer stays were prima-
Care                   rily attributed to medical reasons,somehospital officials stated they are
                       experiencing a growing number of infants staying in the hospital for
                       nor-medical 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 envi-
                       ronment is not acceptablefor the infant becauseof parental drug abuse.
                       Officials from 6 of the 10 surveyed hospitals stated that their hospitals
                       were experiencing increased demands for servicesfor boarder babies.
                       In addition to providing servicesto boarder babies, social service agen-
                       cies must also provide servicesto drug-exposedinfants referred by hos-
                       pitals. 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 increasedby 268 percent over the 4-year period 1986 to 1989.
                       For approximately the sameperiod, referrals in Los Angeles increased
                       by 342 percent and in Chicago,by 1,736 percent,’
                       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
                       68 percent of drug-exposedinfants were in need of foster care. In con-
                       trast, 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. (Seefig. III.1 .)

                       ‘Texas officials told us that their state does not have a legal requirement that drug-exposed infants
                       be;yez$yd         in Massachusetts officials said that until 1990 cocaine-exposed infants did not have




                       Page 30                                                     GAO/HItLW@138      Dru&Expod       Infanta
                                        Appendix   III
                                        Prenatal Drng Abuse Han Incred              Demand
                                        for Social services




Figure 111.1:Drug-Exposed Infants Are
More Llkdy to 60 Admitted to Footer
                                        50   Eetimatod psrcant ot Infants admittad to tostar cm
Care Than Nonexpo8ed Infant8
(Comparison at 4 Hospitals)             65
                                        50
                                        45
                                        40
                                        35
                                        30
                                        2s
                                        20
                                        15
                                        10




                                              1                       2
                                              HCSplt8lS

                                                         Drug-exposed infants
                                             czl
                                                         Infants not exposed to drugs



                                        Although we could compare drug-exposedinfants to infants not identi-
                                        fied as drug exposed at only 4 hospitals, we were able to estimate the
                                        number of drug-exposedinfants 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 $6,000 annually;
                                        specialized foster care, which includes homesthat provide some medical
                                        monitoring or group residential facilities, may cost between $4,800 and
                                        $36,000.


Number of Child Abuse                   Becausedrug-exposedinfants are often born with special problems,
and Neglect Cases                       they may be more difficult to care for even under the best circum-
                                        stances.Someof these children are placed directly from the hospital into
Increasing                              foster homes where the foster parents are often unaware of the chil-
                                        dren’s problems and are not trained to care for their specialized needs.
                                        Others return home to families that have trouble providing adequate
                       Y                care because,in many instances, drug abusecontinues to dominate
                                        family life.


                                        Page 31                                                   GAO/IiRBBO-133   Drug-Exposed   Infants
Appendix Ul
Prenatal Drug Abuse Haa Increased Lkmmd
for socm   services




A drug-exposed,low-birth-weight infant may be irritable, cry exces-
sively, 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 emo-
tional 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 casesof child abuseand neglect each
year. Many of these investigations result in foster care placement specif-
ically 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 abusein the family. In Los Angeles, up
to 90 percent of referrals involved substance-abusingfamilies.
The MassachusettsDepartment of Social Servicesreports a higher inci-
denceof severeinjuries 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 use with child abuse and neglect2
The study found that illicit drug or excessivealcohol use was a factor in
64 percent of caseinvestigations. Cocaineuse was found to be signifi-
cantly associatedwith child neglect. Neglect was defined as a lack of
supervision, food, clothing, medical care, and other necessities.In the
most severecasesthere 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
absenceof care and supervision for children under the age of 5.3

Hospital officials also told us that they are seeingan increasing number
of young children from drug-abusing families admitted to the hospital
becausethey suffered neglect or maltreatment at the hands of someone
on drugs. Officials described various incidents of children dying due to


“Julia 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).
“Herskowitz, pp. 4-8.



Page 32                                                   GAO/HRD-M-138      Drug-Exposed    Infants
                         Appendix III
                         Prenatal Drug Abuse Has Increased   Demand
                         for Social !3ervices




                         physical abuseor a drug overdosefrom inhalation or ingestion of crack
                         cocaine.


Foster Care Placements   A high proportion of child protective service investigations of abuseor
Increasing               neglect involving drug abuseresults in foster care placement. In fact, the
                         estimated nationwide demand for foster care has increased by 29 per-
                         cent from 1986 to 1989, In 1989,360,OOOchildren were estimated to be
                         in foster care acrossthe country. Much of this increase is attributed to
                         substanceabusein families.
                         According to social service officials in the five cities we visited, family
                         drug-abuseproblems are a contributing factor in the placement of chil-
                         dren in foster care. In New York, a review of a statewide random sample
                         of foster care children found that 67 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 attri-
                         bute 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 care admissions in 1989. In Illinois,
                         infants younger than 1 year old in foster care increased 284 percent
                         from 1985 to 1989.

                         Becausethe demand for foster care has increased nationwide, concerns
                         have been raised about the social services system’s ability to respond to
                         the needsof drug-abusing families. Specifically, problems have been
                         identified regarding the availability of foster parents who are willing to
                         accept children who have been exposedto 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.

                         Definitive information about the future of drug-exposedinfants doesnot
Drug-Exposed Infants     exist. The oldest of drug-exposedinfants in strict clinical trials designed
Are Vulnerable to        to examine the long-term physical effects of prenatal drug exposure,
Developmental            such as developmental deficiencies, are under the age of 3. In addition,
                         long-term studies of drug-exposedchildren have not adequately con-
Problems That May        trolled for the amount of drug use, the intensity or frequency of use, or
Affect Learning          the type of drug used. Nor have studies indicated when drugs were used
                         during the pregnancy.


                         Page 33                                      GAO/HRD-90-139   Drug-Exposed   Infants
    AppendJx III
    PrenatalDrugAbu6eHuIncressedDemand
    for &xial Seruices




    Results from studies to date indicate that the symptoms will vary among
    drug-exposedchildren. Somechildren show few symptoms after the
    drugs leave their system and others are expected to show neurological
    symptoms throughout their lives. Consequently, the needsof these
    infants will vary-from greater assistanceand intervention for some,to
    lesser assistancefor others.4

    Recent studies and surveys of neonatal programs suggestthat some
    infants will suffer from central nervous system effects, including
    neurobehavioral deficiencies.6Researchershave reported that some
    infants identified through urine screensas positive for cocaine had suf-
    fered hemorrhages in the areas of the brain responsible for intellectual
    capacities.0f7
    Observations of toddlers born to drug-using mothers imply future edu-
    cational problems based on these children’s difficulties with concentra-
    tion and learning. Researchat the University of California at San Diego
    showed that
. 26 percent of drug-exposedchildren had developmental delays, and
l 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.8
    A school environment that is poorly prepared to respond to the develop-
    mental disabilities of these children may allow them to go unresolved.
    As an increasing number of drug-exposedchildren reach school age,this
    problem should becomemore evident. Onetest of this may occur next

    4Rkhard P. Barth, “Educational Implications of Prenatally Drug Exposed Children,” Social Work in
    Education, in press.

    sHallurn Hurt, “Medical Controversies in Evaluation and Management of Cocaine-Exposed Infants”
    (1989), pp. 3-4.

    %borah A. Frank, Briefing for the Comptroller General of the United States, Boston City Hospital,
    February 24,lQQO.

    ‘Suzanne D. Dixon, “Effects of Transplacental Exposure to Cocaine and Methamphetamine on the
    Neonate” The Western Journal of Medicine (Apr. 1989) pp. 436-42.
    %terview with Suzanne D. Dixon, Director of Well Baby Clinic, University Medical Center, Unlver-
    sky of California at San Diego, February 14, 1990.



    Page 34                                                  GAO/HRJMO-138      Dru@JSxpomd     Infanta
Pmnatal Dnq Abum liao Increased      Demand
for SodaI servleeo




year when a large number of children born to the early wave of crack
cocaineusers will reach kindergarten age.
Oneresearcher has estimated that 42 to 62 percent of children exposed
to drugs and alcohol will require special educational services.gThe
degreeof servicesneededand 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 exposedto 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 comprehensiveestimate, devel-
oped by the Florida Department of Health and Rehabilitative Services,
indicates that total service costs for each drug-exposedchild that shows
significant physiologic or neurologic impairment, to the age of 18 years,
will be $760,000.




‘Judy Howard, “Developmental Patterns for Infants Prenatally Exposed to Drugs”, Fact sheet
presented to the California Legislative Ways and Means Committee, Perinatal Substance Abuse Edu-
cational Forum, February 23,lQSQ.



Page 35                                                 GAO/IlRDQO-138     DnqExposed     Infants
                                                                                                                        .
Annendix 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 consequencesof drug use and
                        would like to stop their addictive behavior, However, their efforts to get
                        help may be unsuccessfuldue to insufficient drug treatment capacity. In
                        addition, there are many barriers blocking accessto basic health ser-
                        vices and drug treatment for drug-abusing pregnant women. Onemajor
                        barrier is the fear women have that if they seektreatment they may be
                        incarcerated or their children will be taken from them.

                        The best way to prevent the problem of drug-exposedinfants is to pre-
Lack of Treatment for   vent drug use among women of childbearing age.Pregnant woman who
Drug-Addicted           use drugs should be encouragedto stop in order to reduce the potential
Pregnant Women          problems associatedwith prenatal drug exposure. According to one
                        researcher, if women stop using cocainebefore the third trimester the
                        risks of low birth weight and prematurity, which often require expen-
                        sive neonatal intensive care, are greatly reduced.’
                        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 per-
                        cent of them received care.2Hospital 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, sometreatment programs deny ser-
                        vices to drug-addicted pregnant women. A survey of 78 drug treatment
                        programs in New York City found that 54 percent of them denied treat-
                        ment to women who were pregnant. One of the primary reasonsthat
                        programs are reluctant to treat pregnant women relates to issuesof legal
                        liability. Drug treatment providers fear that certain treatment medica-
                        tions and the lack of prenatal care or obstetrical services at the clinics
                        may have adverse consequenceson the fetus and thereby exposethe
                        providers to legal problems.
                        Many programs that provide servicesfor women, including pregnant
                        women, have long waiting lists. Treatment experts believe that unless
                        ‘Deborah A. Frank, Briefing for the Comptroller General of the United States, BostonCity    Hospital,
                        February 24, 1990.

                        Z’I’hc report did not reveal the extent to which these women sought treatment.



                        Page 36                                                    GAO/HRD-90-138        Drug-Exposed       Infanta
Appendix IV
Lack of Drug Treatment and Prenatal    Care
Contributing  to the Number of Drug-
Exposed Infants




women who have decided to seek treatment are admitted to a treatment
facility the sameday, they may not return. However, women are rarely
admitted on the day that they seek treatment. One treatment center in
Boston received 460 calls for detoxification servicesduring a l-month
period. The callers were told that no slots were available and that it usu-
ally took 1 to 2 weeks to be admitted. They were also instructed to call
back every day to determine if a slot had becomeavailable. 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 designedto treat the addiction problems of men. Thus, many pro-
grams are not tailored to meet the needsof pregnant women. For
example, pregnant addicts we interviewed told us that becausethey 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 prose-
cution. Drug treatment and prenatal care providers told us that the
increasing fear of incarceration and loss of children to foster care is dis-
couraging 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 comprehensiveresidential 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 chanceof being born healthy. Residen-
tial treatment allows for several needsto be addressedat the sametime,
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 addressedin the
few residential programs that exist. In addition, these programs limit
accessto drugs and remove women from the environments in which
they becamedependent.
However, residential treatment programs for women are scarce.In Mas-
sachusetts,residents have accessto only 15 residential treatment slots
for pregnant women in the entire state. Social service officials at one



Page 37                                       GAO/HRD-90-138   Drug-Exposed   Infants
                 Appendix Iv
                 Lack of Drug Treatment and Prenatal      Care
                 Contributing    to the Number of Drug-
                 ExPol3edInfante




                 California hospital expressedtheir frustration with the lack of residen-
                 tial drug treatment programs and other programs that could provide a
                 stable environment to a pregnant addict. When they are unable to place
                 drug-addicted pregnant women in residential treatment they try alterna-
                 tives, including battered women shelters or even nursing homes.

                 When both drug treatment and prenatal care services are provided for
Prenatal Care    drug-addicted pregnant women, the results are dramatic. The three
Improves Birth   basic components of prenatal care are: (1) early and continued risk
Outcomes         assessment,(2) health promotion, and (3) medical and psychosocial
                 interventions and follow-up. One intervention program reported a sig-
                 nificant drop in low-birth-weight babies born to drug-abusing mothers
                 who had been provided with drug treatment and prenatal carea The
                 incidence of low birth weight among infants born to drug-abusing
                 mothers receiving such care dropped from 60 to 18 percent.
                 Early and comprehensiveprenatal care is associatedwith 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-exposedinfants is
                 high. Low birth weight is the most significant factor in determining
                 infant death and disability as well as higher health costs.Prenatal care
                 increasesthe chancesthat healthier infants will be born.
                 Prenatal care is a cost-effective program. The Office of Technology
                 Assessmentestimates 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
                 associatedwith low birth weight. These savings are great compared
                 with the average cost for professional services associatedwith prenatal
                 care that can run as low as $600.
                 According to the National Commissionto Prevent Infant Mortality, the
                 barriers to accessingprenatal 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
                 becausethey fear that punitive actions will be taken if they are found to
                 have used or abuseddrugs during pregnancy. Several hospital and

                 3Loretta P. Finnegan, M.D., Executive Diictor of Family Center, Professor of Pediatrics and Prw
                 fessor 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 6,lQQQ.



                 Page 38                                                  GAO/IiRD-90-138    Drug-Exposed   Infanta
.
    Appen& lv
    Lack of Drug Treatment and Prenatal     Care
    contributing   to the Number of Drug-
    Exposed lnfallta




    public health officials believe that punitive actions, such as incarcera-
    tion 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,
    somewomen are now delivering their infants at home in order to pre-
    vent 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 becausethe infant had becomevery sick.
    The mother was finally persuaded to bring the infant into the hospital.
    The consequentcare of this baby was very costly.




    Page   39                                      GAO/IIRD-fM)-138   Drug&qmed   Infanta
Appendix V

PercentageDistribution of Infmts Exposed i ‘I
Drugs, Including Cocaine

               Fiaures are Dercentaaes
                                                                                         Cocaine-
                                        Drug-exposed                 Sampling,           exposed                Sampling
               HosDltal                        infants                  error              infants                 error
               1                                        1.3                  1.0                 0.3                   0.4

                              ---..-~                                        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
               a                                       12.7                  2.9                 8.5                   2.4
               9                                                                                                       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.

               “Sampling errors are at the 95percent    confidence   level




               Page 40                                                        GAO/HRD-90-138     Drug-Exposed     Infants
Appendix VI

Objectives, Scope,and Methodology


                                           To develop a national estimate of drug-exposedinfants we obtained data
                                           from the National Hospital Discharge Survey conducted by HHS'S
                                           National Center for Health Statistics for the years 1080 to 1088. The
                                           National Hospital DischargeSurvey is basedon an annual survey of a
                                           representative sample of US hospitals. The survey collects information
                                           on the diagnosesassociatedwith 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 considerednonreportable due to a small number of sample casesof
                                           newborns with a drug-related discharge diagnosis.
                                           To determine the extent of drug-exposedinfants 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 assistanceand supportive services.The remaining 2 hos-
                                           pitals 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.

                                           Our hospital selectionswere based on a high incidence of births per year
Hospital Selection                         and the availability of a neonatal intensive care unit in addition to loca-
Criteria                                   tion and numbers of Medicaid patients. Table VI. 1 comparesthe number
                                           of births at the hospitals we selectedwith other hospitals in the five
                                           cities, and table VI.2 provides patient profile information for the
                                           selected hospitals.
Table VI.1: Comparison of Birth8 at
Hospltalr In GAO Study With Total Births                                All hospitals
In the Respective Cltles, 1988                                             No. of                         Hospitals in GAO study
                                                                  hospitals with         No. of             No. of     Percent of all
                                           city                       bassinets          births             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




                                           Page 41                                           GAO/~W-138         Drug-Exposed   Infants
                                              Appendix   VI
                                              Objectives, Scope,and Methodology




Table V1.2: Protlle of Patlents at Selected
HO8pltal8                                                                                Race                                Ineurance etatue
                                              Clty/Ho8pltal                  Black       Hl8panlC     White                 Medicaid     Private
                                              Boston
                                                   1                           20.9             5.5      67.3                      34.0          59.9
                                                   2                           64.6            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.’ We considered an infant to be drug-exposedif any of the fol-
                                              lowing 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 diagnosedas drug dependent. We also interviewed hospital per-
                                              sonnel to obtain their procedures for identifying drug-exposedinfants.
                                              To assessthe medical and social impact of these births, we interviewed
                                              hospital, state, and local social servicesrepresentatives regarding the
                                              impact of drug-exposedinfants on the medical and social services sys-
                                              tems. In our discussionswith these officials we also determined the
                                              extent to which drug-addicted pregnant women are receiving drug
                                              treatment.



                                              ‘At 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 6 months of 1989.



                                              Page 42                                                     GAO/lflUWS128      Drug-Exposed    Infantn
Appendix VI
Objectivea, Scope, and Methodology




We also interviewed officials at 10 additional hospitals in these cities to
determine the extent of drug-exposedinfants at these hospitals. These
hospitals serve predominantly private-pay clientele. We did not review
medical records to determine the extent of drug-exposedinfants at these
hospitals.
To gain further insight as to the consequencesof 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.




Page 43                                    GAO/HRD-30.138   Drug-Exposed   Infanta
                                                                                                      t
 Ppe
                                                                                                          r,
kGF Contributors to This Report


                             Mark V. Nadel, Associate Director, National and Public Health Issues
Human Resources                (202) 276-6196
Division,                    RoseMarie Martinez, Assignment Manager
Washington, DC.              Roy B. Hogberg, Evaluator-in-Charge
                             FrancesA. Kanach, Senior Evaluator
                             SusanL. Sullivan, Social ScienceAnalyst

                             Robert D. Dee,Regional Assignment Manager
Boston   Regiona1   Office   Lionel A. Ferguson, Evaluator

                             Karyn L. Bell, Site Senior
Chicago Regional
Office

Dallas   Regional   00
                             Martin B. Fortner, Jr., Site Senior

                         -
                             Denise R. Dias, Site Senior
Los Angeles Regional
Office

                             Patrice J. Hogan, Regional Assignment Manager
New York Regional
Office     -




             w




                             Page 44                                  GAO/IilUMO-138   Drug-Expoeea   Infanta
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