Reproductive health and blurred professional boundaries

We recognize that many of the issues raised are not simple. Our proposal calls for the same thoughtful deliberation applied in other settings to be brought to bear on reproductive health care. Some have already tried alternative approaches. In Albuquerque, New Mexico, a university hospital neonatologist and the district attorney have collaborated to create an alternative to sentencing program for women who are arrested for drug-related crimes and found to be both pregnant and drug addicted. Rather than proceed with criminal sanctions, these women are offered entry into a drug treatment program that is geared to families with young children and run by the pediatrics department. Here, the physician and the district attorney collaboratively responded in ways congruent with the professional integrity of each. In another example in Portland, Oregon, physicians, drug treatment providers, and child protective social service representatives cooperatively defeated a legislative proposal to mandatorily test and report pregnant women for illicit drug use and, instead, formed a task force to jointly develop state policy regarding the issue. Drug use, HIV infection, child abuse, and poverty are all cause for alarm. Yet it is critical that our frustration about these difficult problems not be translated into blaming individuals for "deviance," or into short-term inadequate responses. In developing policy we should consider the impact on the legal and ethical rights and obligations of both patient and physician. For every course, we should evaluate both immediate and long-term efficacy, the consequences for the doctor-patient relationship, and the consequences for medical integrity. In the midst of the present regulatory and fiscal turmoil affecting health care, we urge physicians to be careful and deliberate in the policies they embrace and the actions they take.

The accessibility of drug treatment for pregnant women: a survey of programs in five cities

Through simulated calls to 294 drug treatment programs in five cities, this study investigated access for pregnant women and compared New York City's provision of services in 1989 to that in 1993. In all sites, the majority of programs accepted pregnant women. There was also a marked improvement in the availability of services in New York City. Yet options were more limited for Medicaid recipients and women needing child care, and an appointment or referral for prenatal care was usually not offered. Although the door for treatment may be opening for pregnant women, institutional barriers still remain.

Finding common ground: the necessity of an integrated agenda for women's and children's health

During the past decade, a new term has entered the medical/legal lexicon : maternal-fetal conflict. Implicit in the terminology is the assumption that a pregnant woman and her fetus have separate and competing rights. This concept has stimulated extensive legal and ethical debate, primarily in the context of medical interventions (cesarean sections and blood transfusions) forced on unwilling pregnant women, and in corporate efforts to bar fertile women from hazardous jobs. On one side of the debate are the proponents of the future child's right to be born of sound mind and body, and society's interest in the delivery of healthy newborns. On the other side, are advocates of a woman's right to reproductive autonomy, bodily integrity, due process, confidential medical treatment, and freedom from gender discrimination. Neither side has challenged the formulation of the problem, or has examined its permeation into public health policy.

Model Programs Addressing Perinatal Drug Exposure and Human Immunodeficiency Virus Infection: Integrating Women's and Children's Needs

Many of the efforts to address perinatal drug exposure and human immunodeficiency virus infection have been influenced by a perspective of conflict between the interests of mother and infant. This article highlights several programs that integrate women's and children's services while dealing with these health issues. It discusses the challenges encountered by these programs, such as funding restrictions, institutional barriers, professional attitudes, regulatory constraints, and local political issues. It presents strategies for overcoming these barriers including the creative coordination of funding streams, innovative relationships with child protective agencies, effective collaboration with other agencies, and advocacy on behalf of clients and programs, and makes recommendations for certain policy changes, which could foster the development of programs that serve women and children together.

Psychiatric histories of drug using mothers: treatment implications

One hundred forty six crack/cocaine using mothers in New York City were interviewed in a cross sectional study about life histories and drug related behaviors. Forty one (28%) reported histories of previous psychiatric medication or hospitalization. These women were significantly more likely than the rest of the sample to currently be in drug treatment; to have sexual abuse histories; and to be currently involved with men who urged them to use crack during pregnancy. Within this group, two subgroups were distinguishable: one, who had been sexually abused and initiated drug use early, and the other whose psychiatric and drug use histories were not associated with sexual abuse. The implications of these findings for screening, treatment planning, and future research are discussed.

Drug abuse and pregnancy: some questions on public policy, clinical management, and maternal and fetal rights

An estimated 9202 drug-exposed infants were born in the United States in 1986 according to the National Center for Health Statistics; the number increased to 13,765 in 1988. These figures were substantially underreported, however, notes the 1990 report by the U.S. General Accounting Office (GAO) (1). It surveyed 10 hospitals, two each in Boston, Chicago, Los Angeles, New York, and San Antonio, accounting for 44,655 births, of which approximately 4000 resulted in drug-exposed infants in 1989. Maternal cocaine use was estimated to range from below 1 to 12 percent among the 10 hospitals. The GAO report concluded that the number of these infants born nationwide each year could be "very high," and that in these five cities the unavailability of drug treatment and lack of adequate prenatal care are contributing to the problem (1). Two health professionals and a health lawyer were invited to respond to some questions about the problems of cocaine and substance abuse by pregnant women and how maternity caregivers, health and social service agencies, law, and society are dealing with the issues.

Ascertainment of maternal deaths in New York City

Maternal deaths in New York City are defined as deaths from any cause in a woman while pregnant or within six months of pregnancy termination. Pilot studies seeking to improve maternal death ascertainment found that selected medical examiner reports contributed an additional 10.5 percent of the total maternal deaths, vital statistics review contributed 6.3 percent, linkage of death tapes of women of reproductive age to live birth and fetal death tapes contributed 1.0 percent. Medical examiner cases should be incorporated into surveillance data for accurate ascertainment of pregnancy associated deaths.

Pregnancy-related mortality in New York City, 1980 to 1984: causes of death and associated risk factors

To identify causes and risk factors for pregnancy-related mortality in New York City, we analyzed 224 pregnancy-related deaths that occurred from 1980 to 1984. The leading causes of death were ectopic pregnancy complications, embolism, intrapartum cardiac arrest, and hypertension. Mortality ratios were determined by comparing the characteristics of the women whose death was pregnancy-related with those of women who had survived delivery of a live infant in New York City during the same period. Black and Hispanic women had mortality ratios that were respectively 4.2 and 2.0 times higher than those for white, non-Hispanic women. In comparison with women aged 20 to 24, those older than 30 were more than twice as likely to die from pregnancy-related causes, and those older than 40 were five times as likely to do so. Other factors that were associated with an increased risk of pregnancy-related mortality included 9 to 11 years of education, lack of private medical insurance, more than five previous pregnancies, and fewer than five prenatal visits. This study suggests that changes in current maternal-health and family-planning services will be required to achieve further reductions in preventable pregnancy-related mortality.