Jennifer Kostoff had been in a heroin rehabilitation program for a little more than a week when a routine blood screen showed she was pregnant. Caregivers told her she would have to leave. She could be a liability.
The inpatient center near her Granite City, Ill., home had prescribed her Suboxone — a drug often used to control cravings and drug withdrawal symptoms — but said last September that it could harm her unborn child. Kostoff worried that withdrawal wouldn’t be safe for the baby, either. And would seeking treatment elsewhere lead her to trouble with law enforcement or a loss of custody of her baby?
“Most people think, ‘How could you not stop with a baby in your belly?’ ” Kostoff said. “But the physical cravings, the mental cravings, they take over despite what’s going on with your body.”
As the nation’s opioid crisis has deepened, the number of drug treatment centers for pregnant women has grown. But experts and advocates say there aren’t enough services for pregnant women to meet the demand, and many don’t offer the drugs doctors would normally use to treat addiction because they are concerned about the effects they might have on a fetus. And some laws requiring that babies going through withdrawal be removed from their mother’s care can be a deterrent to seeking help, they said.
Nineteen states have either created or funded drug treatment programs for pregnant women; 24 states and the District of Columbia consider drug use during pregnancy to be child abuse under civil child-welfare statutes, according to the Guttmacher Institute, a reproductive rights research and advocacy organization.
Fewer than a quarter of the nation’s substance abuse treatment centers offer services tailored to pregnant or postpartum women, according to the most recent survey from the Substance Abuse and Mental Health Administration. Of those centers, a fraction offer recovery drugs to reduce cravings and withdrawal symptoms. Experts say that quitting drug use without the use of such medications has a higher incidence of relapse and can be stressful on a fetus.
“Oftentimes what I see is that we treat pregnant women even worse than we treat the general population with opioid use disorder,” said Stephen Patrick, a neonatologist and assistant professor at Vanderbilt University School of Medicine in Nashville. “We should be offering them more compassion.”
But some doctors and caregivers are wary of pregnant women receiving opioid addiction treatment drugs, which carry the potential for abuse.
And child-welfare advocates and law enforcement officers are reeling from cases in which parents seem to choose drugs over their young children.
In April, a mother who was abusing pills and heroin in Utah crushed Suboxone pills and rubbed them onto her newborn daughter’s gums while nurses were out of the room, hoping to mask the child’s symptoms of drug withdrawal. She and the baby’s father were later arrested.
Two people in Allegheny County, Pa., were found dead in their home last October after their 7-year-old daughter told her bus driver she couldn’t wake her parents. Local police found three other children in the home; one of them was 9 months old.
Butler County, Ohio, Sheriff Richard K. Jones told The Washington Post in July that three babies were born in his jail within 18 months and that “the judges, to save the babies” had sentenced the mothers to jail, only to find that the women “induce labor so they can get back out and do more heroin.”
Throughout periods of alarm regarding drug abuse, some state legislatures have passed laws directing pregnant women to seek treatment or face arrest. Such laws exist in Alabama and Wisconsin, and Missouri state Rep. Jered Taylor (R) has introduced a bill that would make nonprescription drug use while pregnant a misdemeanor offense, which he said could encourage women to quit using.
“If they’re able to successfully complete a treatment program, the sentence is dropped,” Taylor said. “I’m open to changes, but this has been a huge problem, and I don’t think enough people realize it.”
Doctors in many states are legally required to report cases involving newborn withdrawal symptoms directly to child-welfare agencies. It was estimated in 2012 that in the United States, a baby was born with withdrawal symptoms every 25 minutes. Babies exposed to drugs are also at higher risk for preterm birth and low birth weight, and studies show that they could have long-term behavioral problems.
Some advocacy groups worry that mandatory reporting regulations could make women fearful of coming forward for help.
“We have to ensure that people have access where there are medications like methadone, buprenorphine, Subutex, to those services, not only because it might benefit the future child but because it benefits the person herself,” said Lynn Paltrow, executive director and founder of National Advocates for Pregnant Women.
Knowledge of the child-welfare reporting requirement in some states and a lack of information about its intentions can lead women to assume they’ll immediately lose custody of their child if the baby tests positive for illicit drugs.
That’s what drove Desiree Richardson away from care.
In February 2016, Richardson went into labor on a snowy, residential road in Missouri while high on heroin. She panicked, knocked on the door of a nearby home, and gave birth to her son Da’Khorous in a stranger’s bathroom.
Richardson never went to a doctor for prenatal care and unsuccessfully tried to quit using heroin multiple times. She worried that if she told a doctor the truth about her addiction, she’d lose her four other children.
She was right: Richardson lost custody of all her children and was sent to jail on a previous theft charge. She is now in recovery and has her children back at home, but she believes that if she had found and accepted a support system early on, it would have been easier.
“It’s hard being a single mom and being in recovery. I was scared,” Richardson said. “I am that person that nobody thought would get clean, but it’s possible to change your life.”
Kimberly Spence, a neonatologist at SSM Health Cardinal Glennon Children’s Hospital in St. Louis, often cares for newborns diagnosed with withdrawal, typically putting them on a tapering dose of morphine to reduce withdrawal symptoms. She suggests that allowing the babies to be close to their mothers — rather than taking them away — can be helpful.
“These mothers will stay clean if we show them that they can bond with the baby, that they are successful,” Spence said, noting that taking the baby away can exacerbate the mother’s drug problem. “They no longer have a reason to want to stay clean.”
Kostoff, 35, who was forced out of her drug treatment program in Illinois when it was discovered she was pregnant, ultimately found a doctor at the Women and Infant Substance Help Center at SSM Health St. Mary’s Hospital in St. Louis who would give her the drugs to stop her withdrawal symptoms. On April 5, she delivered a preterm baby girl — Rikki Lynn — who showed some symptoms of drug withdrawal but was otherwise healthy. Such withdrawal-like symptoms in newborns often include tremors, excessive crying and trouble sleeping, and in some states trigger a call to child-welfare agencies.
Kostoff took her home without child-welfare agents investigating her family.
The help she received during her pregnancy — combined with her determination to quit using drugs — made a significant difference for Kostoff. She found a doctor willing to treat her, received support from her husband and was committed to the treatment, even reading substance abuse recovery books while hospitalized with the baby.
“You may have all the willingness to stop because you want a healthy baby, you want to keep that baby,” Kostoff said. “But without that help, you can’t break that cycle.”