Being a pregnant woman in America is a complicated affair, writes Annalisa Merelli for Quartz. Once a woman starts expecting, social and medical attitudes shift to view her a vehicle of her child’s health. This approach routinely puts women at risk – particularly when the woman in question is addicted to opioids.
A third of Americans know someone who has struggled with opioid addiction. Though it’s grown into an epidemic, an enormous amount of social stigma remains, forcing pregnant women who are addicted to opioids into a horrible bind.
If they don’t quit using drugs, they risk giving birth to babies with neonatal abstinence syndrome (NAS). But hiding their addiction or quitting cold turkey rather than discussing treatment options – which women may do because of the shame associated with opioid use, as well as the fear that their babies will be taken away – puts their health at risk.
Being “a pregnant woman on top of being an addict carries the most stigma,” explains Tricia Wright, an assistant professor at the University of Hawaii and expert in substance abuse treatment during pregnancy.
In the wake of America’s opioid crisis, a growing number of American women now find themselves in this position. And while some members of the medical community are looking to rewrite the narrative around the social push to “get clean”, the pressure for women to quit opioid use to protect their baby’s health still finds support amongst some medical practitioners, despite its associated risks.
Not a necessary evil
According to the National Institute on Drug Abuse (NIDA), the proportion of children born with NAS increased five fold between 2000 and 2012. The syndrome can be heartbreaking: As soon as 24 hours after being born, babies addicted to opioids by way of their mother’s use can develop symptoms such as tremors, high-pitched crying, irritability, poor feeding and even seizures.
Many children require pharmacologic intervention, usually with either methadone or morphine. Over the course of several weeks, babies are weaned off opioids and gradually adjust to a drug-free life.
But babies with symptoms of opioid exposure don’t necessarily need to be treated with medication, according to Stephen Patrick, a practicing neonatologist at Vanderbilt Children’s Hospital and Director of the Vanderbilt Center for Child Health Policy.
“We have over-medicalized [NAS] to a great extent,” says Patrick. At Monroe Carrell Jr. Children’s Hospital, where he practices, the approach is to avoid medication and intervene with other measures before severe NAS symptoms emerge.
The experimental program, which started as a pilot two years ago and has been extended to all opioid-exposed newborns over a year ago, focuses on promoting environmental adjustments that can increase the baby’s comfort.
These include keeping mother and baby together as much as possible, encouraging breastfeeding (which appears to reduce the severity of withdrawal in babies), and generally promoting bonding with the mother and connection with the family.
So far, the results are promising. While large percentages babies with NAS are kept in the hospital for over 100 days at some hospitals, according to Patrick, the average length of a hospital stay at Monroe for opioid-exposed newborns is five days. It’s 13 days for newborns with NAS, and 19 for newborns who need pharmacological treatment.
Moreover, upsetting as it might be to see a baby in distress, opioid-related NAS doesn’t have clear long-term consequences, and studies trying to pin down its impact on children have typically found that physical and cognitive could also be attributed to other factors concomitant with opioid exposure, like alcohol exposure, which has been shown to cause long-term damage.
And while it’s true that interrupting the use of opioids before or in the very early stages of pregnancy can reduce or eliminate the risk of NAS, it can also carry several short- and long-term risks. In its treatment guidelines, the American College of Obstetricians and Gynecologists notes that the safety of quitting while pregnant has not been established, even in medically assisted settings.
Whether a woman quits independently or through methadone-assisted detoxification, she remains at a higher risk of overdose compared to people who follow a longer-term stabilization treatment: The rate of relapse for opioid addicts can be as high as 91%, and a body that has quickly been detoxified might be at higher risk of overdose.
On top of this, interrupting opioids doesn’t completely eliminate risks for the fetus. A woman who experiences withdrawal symptoms during pregnancy might be more likely to suffer from a miscarriage, for instance, and getting off opioids can put the fetus in distress.
A woman who is on a methadone-assisted stabilization protocol, says Patrick, also has lower chances of delivering at term, and having a baby of normal birthweight. He says there is still a lot to learn about prenatal opioid exposure, and there may be longer-term effects impacting speech or attention development.
But these effects are a lot more subtle than the risk encountered by a baby born at 25 weeks, who needs to spend a lot of time in the incubator to reach normal weight and development.
Still, expectant mothers may hope to avoid NAS by suddenly quitting. And within the medical community, Wright says, many doctors still treat the health of the pregnant woman as a secondary concern, with a “great push” towards avoiding any complications for the newborn, through short-term methadone-assisted detoxification.
Further, research investigating the consequences of detoxing during pregnancy tends to focus on the short-term health of the mother or the fetus, sometimes labeling the practice safe without looking at the dangers of relapse and overdose down the line. This is particularly risky because while mothers get a lot of medical support during pregnancy, they are often unable to access consistent medical care after delivery. That’s because about half the deliveries in the US are covered by Medicaid, which runs out six weeks postpartum.
This percentage tends to be much higher amongst the women who suffer of opioid dependence – up to 85%, Wright says.
Stigma that kills
“We have known for 40 years how to treat pregnant women with opioid addiction, and give them comprehensive care,” says Wright. Most doctors recommend that pregnant women undergo a long-term treatment plan called “drug-assisted stabilization” using methadone, also known as “harm reduction” therapy.
This treatment remains sustainable for a women after she has given birth, because it’s covered under Medicaid, so new mothers can still access the treatment, even after their six-week Medicaid-provided postnatal care is done.
The treatment also doesn’t subject a women’s mind and body through the stress of full withdrawal, allowing her to focus on caring for herself and her baby.
While harm reduction – both for pregnant women and otherwise – is recognized as the best course of action, it is so at odds with the idea of “getting clean” that it is continuously subject to unsubstantiated skepticism.
The latest instance has been a research roundup by the Brookings Institute that promotes a misleading association between harm reduction and likelihood of relapse and overdose (the article was heavily criticized by experts in opioid treatment and has been edited).
The US medical community’s singular focus on a child’s welfare, while ignoring that of mothers, has led to shockingly poor results in maternal health. It’s made old practices, such as promoting detoxification as the best thing to do for the baby, hard to end. The opioid epidemic is making this tragedy worse: A study in Colorado found that more women died of accidental overdose during or shortly after pregnancy between 2004 and 2012 than they did of suicide, despite the fact that mental illness is the most common complication of pregnancy.
“I get patients who have received outdated information all the time,” says Wright. In opioid treatment, there is no advantage, she believes, to prioritizing the health of the baby at the mother’s risk. Instead, the long-term health of both mother and baby can, and should, be guaranteed.