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Pregnancy, Drugs, and

Harm Reduction

Marsha Rosenbaum, Ph.D., and Katherine Irwin

INTRODUCTION

Shortly after the National Institute on Drug Abuse (NIDA) was

established in 1974, physicians and scientists expressed concern about

the effects of drug use during pregnancy. In 1974 Public Law 94-371

mandated that drug abuse and dependence among women be given

special consideration for treatment and prevention (Kandall 1996).

Subsequently, NIDA funded many research and demonstration projects

that focused on the etiology, consequences, and treatment needs of

women who use drugs. Although interest in women’s issues and Federal

funding for research continued through the 1980s and into the 1990s,

recent prevalence data indicate that the expected reduction in drug

use among women has not occurred (National Institute on Drug Abuse

1996; Substance Abuse and Mental Health Services Administration

1994). Women’s use of illicit (and licit) drugs has increased, along

with drug use during pregnancy.

The increasing size and scope of the problem of women’s substance

abuse has been exacerbated, if not caused, by two national trends. First,

poverty, homelessness, substandard education, and lack of health care

have increased since 1980 (Phillips 1991). As members of America’s

ever-growing underclass, drug users have seen their lives become more

chaotic, risky, dangerous, and violent (Currie 1993). Second, for

addicted women without financial resources, access to drug treatment

has become increasingly problematic. A decline in Federal funding for

drug treatment programs for women has occurred since 1976 (Gerstein

and Harwood 1990), with the exception of research and demonstration

studies on drug abuse among pregnant women funded by NIDA and the

Substance Abuse and Mental Health Services Administration between

1989 and 1994. Although the Office of National Drug Control Policy

advocates a shift in funding from enforcement to prevention and treatment (Brown 1995), thus far drug users have experienced little change

in access to treatment (Wenger and Rosenbaum 1994). Ironically, if

money and availability were increased, it seems unlikely that even the
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best form of drug abuse treatment could reverse the deleterious effects

of the social and political policies of the 1980s and 1990s. Lacking a

chance at the American Dream and a stake in conventional life, drug

abusers will continue to relieve their suffering through the use of painkilling and euphoria-producing substances (Rosenbaum 1989; Waldorf

et al. 1991).

In 1991, when the Pregnancy and Drug Use Study discussed in this

chapter began, the authors believed that the life circumstances of drug

users, including women and especially pregnant women, were dismal and

that policy recommendations advocating total abstinence or treatment

as a cure for addiction had not been effective. Despite the efforts of the

“War on Drugs,” drug abuse seemed here to stay, and its consequences,

such as acquired immunodeficiency syndrome (AIDS), were more dire

than ever. Given a social and economic system that almost by definition

fostered the alienation, hopelessness, and boredom that perpetuated drug

abuse, the authors also believed that a new framework was needed that

was more pragmatic and less idealistic, more reality-based and less moralistic, and more focused on what could be done rather than what should

be done.

The concept of harm reduction is simple and straightforward and does

not constitute a radical change in drug policy. Harm reduction was first

implemented in Europe and Australia primarily to deal with the AIDS

crisis. In the United States, professionals have been using the harm

reduction concept for about 30 years in the form of methadone treatment

(Rosenbaum 1995). Those who subscribe to a harm reduction perspective

deplore, yet accept, the inevitability of drug use. They advocate working

with users to minimize the harms brought about by abuse, even if the drug

use cannot be stopped completely (Nadelmann et al. 1994).

PREGNANCY AND HARM REDUCTION

In the Pregnancy and Drug Use Study, the authors and their colleagues (Sheigla Murphy, Margaret Kearney, Kimberly Theidon, and

Jeanette Irwin) interviewed 120 women in the San Francisco Bay area

who used heroin, cocaine, or methamphetamine; were pregnant or

immediately postpartum; and were not in treatment. The grounded

theory method (Strauss and Corbin 1990) was used to collect and analyze

data. Many of these women were practicing harm reduction in some

form. In the following paragraphs, some of these women and their efforts
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are described. This discussion begins with a subject’s definition of harm

reduction and proceeds with discussions of perceived levels of harm,

women’s fears, and methods of harm reduction. The conclusions contain

a modest set of policy recommendations.

Sherry provided a definition of harm reduction during pregnancy. At

the time of her interview, she was a lively 24-year-old African-American

crack smoker in her seventh month of pregnancy. Sherry chatted easily

about her attempts to lessen the harmful effects of her crack use and

articulated harm reduction strategies several times during the interview.

In the following passage, she explained her stance on the subject: “I know

I’m an addict and I do like to get high, but I don’t want to die, you know

what I’m saying? . . . So I, in my mind—this is my own philosophy—if

you’re gonna do it, you need to know when you’re getting close to the

edge and try to back up a little bit.”

Perceived Levels of Harm

Perceived harms and the ways individual women attempted to reduce

them varied and related directly to the intensity of harm they felt their

drug of choice introduced into their lives. Women who perceived their

drug use as harmful were mostly, but not exclusively, crack smokers.

The high perception of harm expressed by these women may be

correlated with the intense media attention given in the late 1980s and

1990s to crack use during pregnancy. Heroin and methamphetamine

failed to get as much attention as crack, and this media bias may have

helped create the view in the study population that crack was a more

harmful drug to use during pregnancy. For this reason, this chapter

focuses on women whose drug of choice was crack.

Fears Motivating Harm Reduction

Women feared crack would cause fetal damage, and this concern was

evident in their accounts. Some feared crack use would cause serious

behavioral problems; others worried that their infants would be deformed;

still others feared their babies would be intellectually damaged. Although

their specific fears differed, all crack-using women believed their drug use

would definitely cause damage to their children.

For example, Rhonda was a 30-year-old African-American woman

who had smoked $100 worth of crack daily in the beginning stages of
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pregnancy. When she was 2 months pregnant, she went to a doctor,

discovered her pregnancy, and looked back in horror at the amount of

crack she had smoked. She immediately quit using crack, but the fear of

the possible physiological harms haunted her. In her third month of

pregnancy, Rhonda decided to have an abortion. The following passage

describes some of the factors in her abortion decision:

The baby was doomed from the start. I don’t care what those

doctors say when they say, “Oh, you’re pregnant and you can

stop using drugs and your body will be okay.” Mmmmmm, that’s

a lie. ’Cause my baby suffered after that and it was my fault, my

own fault. I ain’t blaming it on nothing. I’m not saying because

the doctors didn’t notice it or nothing. It was me.

Methods of Harm Reduction

Although abortion was one harm reduction method, many women

did not choose that option for personal or religious reasons. Therefore,

it became imperative to reduce drug-related harms through (1) reducing

or quitting use, (2) substituting other drugs or attempting to counteract

the effects of drugs, (3) making a lifestyle change, and (4) seeking

prenatal care.

Reducing or Quitting Use. Unfortunately, women were not often

successful at permanently abstaining from drugs. Experiencing alternating periods of drug use and abstinence from drugs was the norm for this

group. Women usually had used crack during their pregnancies in a

binge-and-purge style, with binges characterized by periods of smoking

one crack “rock” after another, a process called smoking “back to back,”

which lasted for several days during which sleeping and eating often were

inhibited. Women referred to this drug-using routine as “going on 24/7,”

a euphemism for smoking 24 hours a day, 7 days a week. Although 24/7

was a common term, women admitted that in reality they had never

gone without sleep for a whole week. A crack-using binge rarely lasted

longer than 3 or 4 days. Women often experienced interspersed periods

of abstinence, which could last from a couple of hours to several months,

between binges.

Because returning to drug use after periods of abstention was common, women attempted to balance times when they were free of drugs
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with other times when they relapsed so that the time they were drug-free

would be maximized during pregnancy. Although all forms of drug abuse

treatment were considered good methods to become drug-free, overall

drug treatment was not considered a sure path to that goal. Many women

combined drug treatment programs with their own methods of staying

away from drugs. Courtney, a 30-year-old African-American crack

smoker in her fifth month of pregnancy, described this process: “But it’s

like when the baby comes, it’s like I know I cannot mess with anything.

From when I go next week to the [outpatient drug treatment program],

I’m gonna do my best not to mess with anything until I deliver this baby.”

Like Courtney, other women used various points in the pregnancy

as markers and goals. For Courtney, the time between the interview

and her screening appointment with the drug treatment center was when

she would try to abstain on her own. After that she would rely on the

program for support in abstaining.

Other women chose to reduce their use without drug treatment.

Lindly was a 21-year-old African-American crack smoker in her first

month of pregnancy. She decided to forgo drug treatment and reduce

her level of drug use on her own. She told the authors: “I don’t stay

in the same space like I used to. I leave, I go shopping, I do something

to occupy my time. Eventually, I feel I’ll get it out of my system.”

Substituting or Counteracting. One method of harm reduction was to

combine the drug of choice with other drugs or substitute drugs perceived

as less harmful for the more harmful ones. Sherry, the 24-year-old crack

smoker mentioned above, told how difficult it was to stay away from drugs

during her pregnancy. When she wanted to smoke crack, she smoked

marijuana instead: “Yeah, I couldn’t do anything. I just smoked pot a

little bit. You know, I smoked pot. He [her husband] knew I did have a

drug problem, okay, so what he would do if he seen me getting edgy or

what he’d say, ‘Go in my closet, dear. I got some weed in there. Why

don’t you smoke some of that?’ ”

Because women’s attempts to reduce or quit drug use or substitute

other drugs were not always successful, many employed other methods

to counteract drug harm during pregnancy, including ingesting prenatal

vitamins, niacin, pickle juice, and vinegar.

Lifestyle Changes. Other harm reduction techniques included making

changes in the drug-using lifestyle. Most women acknowledged that poor

eating habits accompanied heavy immersion in “the life.” For crack
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smokers, loss of appetite was particularly pronounced and perceived as a

dire problem during pregnancy. Eating regularly, even forcing oneself to

eat on a regular basis, became a common practice. For example, Amanda

struggled constantly with her loss of appetite. The following excerpt

explains her views on eating as harm reduction:

I had to eat it. I had to put something in my baby’s system so the

drug won’t affect him or hit him as hard, because I can’t see that.

I cannot see knowing you have a weakness and sitting up there

smoking and knowing you have a life in you, too, at the same

time and not feeding your child, because basically what that boils

down to . . . [is] “Yeah I know I’m hurting my child.” But if you

know that your weakness is there . . . you’re going to try to help

your child at the same time. You’re gonna feed it. Even though

you’re doing something wrong, even though you’re doing something that is not basically right and you have no control over

the drug or the weaknesses that you have, you have control over

whether you feed your child while he’s inside you.

Other lifestyle changes included forcing oneself to sleep, moving

away from friends or family members who were using drugs, or moving

out of neighborhoods where drug use was rampant.

Harm reduction was not static. Women mixed and matched several

different techniques at different times during their pregnancies. For

example, Sherry tried numerous times to reduce her crack use, but

continually failed because her husband and most of the people living

in her building, one of the largest projects in San Francisco, were crack

smokers. Before her pregnancy, people often used her apartment to

smoke in private or to sell crack. They often “kicked her down” a rock

or two as payment for the use of her apartment. After she discovered she

was pregnant, Sherry felt this routine was compromising her chances for

a healthy pregnancy. Eventually, she and her husband abandoned their

apartment in the projects and moved in with her husband’s relatives in

a city 80 miles away where she successfully stopped smoking crack by

substituting marijuana for crack whenever she felt the urge to use.

Prenatal Care. Health care, and more specifically prenatal care, was

perceived as one of the best ways to improve one’s health during pregnancy. Women who believed their drug use posed grave threats to fetal
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well-being had unique relationships to health care. Overall, they were

more likely to disclose their drug-using status to health care providers

as a way of enlisting providers’ cooperation in maximizing their health.

Women looked at providers’ medical expertise and the various technological advances of traditional health care as powerful harm reduction

resources.

Amanda, mentioned above, told her doctor about her crack use

as a way of alerting her doctor to the tenuousness of her pregnancy.

In addition to technological advances, she felt her provider could give

her valuable information she could use to improve her health. In the

following passage, she describes her relationship to her provider:

“When I go to my prenatal care appointment, I’ll tell the doctor,

‘I ——ed up. I smoked. Is my baby okay? I don’t want nothing to

happen to him. Please don’t let nothing happen to my baby . . .’

I’m learning and wanting to know all these things so it’ll help me

further help my baby.”

Unfortunately, women’s attempts to improve their health through

traditional health care were problematic. Crack users often found that

after disclosing their drug-using status, they were judged harshly by

health care providers. Jessie, for example, had just given birth to her

first crack-exposed child when she was interviewed. The uncomfortable

memories of her hospital experiences were fresh in her mind. During

Jessie’s first two pregnancies, she had not smoked crack or missed a single

prenatal appointment, and at the births, the nurses and doctors were

supportive. However, during her most recent pregnancy, she smoked

crack almost continually and managed to keep only two prenatal appointments. When she gave birth, the nurses and doctors treated her

like “a dirty little crack addict.” Looking back at her own experiences

and those of others, she explained why women in her position fail to

get prenatal care:

I know a lot of mothers say that they don’t get prenatal care

’cause they feel like as soon as they walk through the door, they

will be judged, “Oh, you’re a crack-head. Why the —— did you

get pregnant anyway?” So they don’t get prenatal care . . .

They have those commercials about addicts that don’t get

prenatal care because they just don’t give a ——. They do give

a ——, but they are thinking about how they gonna be looked
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at when they walk in the hospital door, like they not good

enough to be pregnant.

Like Jessie, women who received harsh judgments during or immediately after pregnancy were reluctant to continue to endure further

ridicule. Therefore, women in this group had to navigate a precarious

path between their efforts to reduce drug-related harms and their

efforts to avoid persecution. Although few women avoided health care

altogether, many admitted they did not get as much health care as they

would have liked.

CONCLUSIONS

The data presented above indicate that pregnant drug users often

practice harm reduction in some form or another. Given their own

efforts, the following suggestions for intervention might help:

1. Women should have better information so that their harm

reduction efforts are more effective.

2. Those who intervene should stop judging these women and,

instead, facilitate their efforts.

3. Women should have access to health care (1) without risk of

losing their children to child protective services, (2) without

humiliation, and (3) without having to be totally abstinent.

4. Finally, professionals in research and treatment must learn to

settle for less because insisting on total abstinence may exacerbate the problem.

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ACKNOWLEDGMENTS

This chapter was prepared with support from National Institute on

Drug Abuse grant DA-06832. The authors also would like to acknowledge the contributions of Sheigla Murphy, Ph.D., who served as

coprincipal investigator.

AUTHORS

Marsha Rosenbaum, Ph.D.

Director

The Lindesmith Center-West

2233 Lombard Street

San Francisco, CA 94123

(415) 921-4987 (Tel)

(415) 921-1912 (Fax)

marsharose@aol.com (E-mail)
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Katherine Irwin

Department of Sociology

University of Colorado

Boulder, CO 80309

(303) 786-9784 (Tel)

irwin@rastro.colorado.edu (E-mail)