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Policies that attempt to stop maternal drug use, through detection and punishment and its assumed deterrent effects, include surveillance-oriented drug testing, arrest, prosecution, incarceration, and temporary or permanent loss of child custody. These gender-specific policies, still currently in use in many regions of the United States, arose out of "fetal protection" initiatives in the late l980's and occurred concurrently to the upsurge in the use of smokeable cocaine among women of childbearing age (Jos. Marshall & Perlmutter, 1995; Roberts. 1997). Since 1987, prosecution of more than 200 pregnant drug users (Seigel, 1997) in the U.S. for "prenatal child abuse" has resulted in a contentious and continuing controversy about the status and treatment of pregnant drug dependent women.
Extrinsic Barriers To Treatment Punitive Policies And Fear
The women believed that detection of their prenatal drug use would inevitably occur, even when in minimal contact with these helping institutions, and that detection would lead lo loss of custody of their newborn infant and concurrently, to arrest, incarceration, and prosecution. Vances, a 33-year-old woman on methadone maintenance, was fearful of interacting with police in the context of seeking care. She stated: "…with a dirty tox screen, it could have been a lot more severe. I
As a result, the dilemma of voluntary disclosure vs. anticipation of inevitable drug testing later in pregnancy or at delivery was the subject to much solitary deliberation and anguish. Additionally, participants had a keen awareness of child welfare policies and legal actions regarding prosecution of pregnant women and removal of children, as well as other initiatives of fetal and child protection in drug affected families. Celia. a 32-year-old mother of five children, was warned about continued drug use and informed by four health and child welfare professionals that her name was on a list of high-risk pregnant women circulated to delivery rooms, clinics, and child welfare agencies in her geographic area. Though she was enrolled in methadone maintenance during her pregnancy, Celia described what she was told could still happen: "If you have another drug-exposed child within a three-year period, even if you're staying clean and sober, your child will be taken from you, and can be automatically be placed for adoption... it is a state policy...I wanted to come here to the treatment program and there wasn't an opening,.. I didn’t go to my doctor at that time in pregnancy I because of my name being on that list.. .I was really scared of that. . . that's what kept me from going to prenatal care."
Drug testing was rarely utilized in the context of a therapeutic recovery-oriented intervention, and threatening statements served to increase women's ambivalence and fear about participating in care. When referrals to substance abuse treatment were made by prenatal care providers, they also included threats regarding the loss of child custody if they did not stop using drugs. Unlike their attitudes about the necessity of prenatal care, participants viewed substance abuse treatment as a remote and unknown source of help and it was not identified as an immediate need during pregnancy. Treatment was seen primarily as a requirement in order to retain or regain custody of their children or for transitioning out of jail to a supportive environment. Although 24 of the participants had substance abuse treatment histories, treatment programs were not viewed as places that would have been of major assistance to them during pregnancy. In some cases, women construed "treatment"" to be a two or three day physical detoxification wherein no other services were provided.
Participants' status as opiate-dependent pregnant women created barriers that disrupted and delayed residential treatment entry. Opiate dependent women enrolled in narcotic treatment programs (NTP) (methadone maintenance) described being viewed by residential programs as "too complex," and program admissions were therefore delayed or refused. Misdirected child welfare mandates required that one opiate-dependent woman stop MM treatment in order for family reunification to proceed. Loss of maternal drug treatment Medicaid coverage as a result of an infant's placement In foster care was also a barrier to continued NTP treatment. Pregnancy itself was a barrier to drug treatment, as it conferred stigma and resulted in additional health care needs. Participants described treatment programs that excluded pregnant women by their claim of inappropriate services and milieu and other programs, purported to serve pregnant women, that had difficulty accepting and keeping a woman on medically indicated bedrest, providing transportation to prenatal care and serving nutritious meals.
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