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Mourot-Cottet, F. Maloisel, F. Keller, T. Vogel, M. Tebacher, J. Weber, G. Kaltenbach, J. Gottenberg, B. Goichot, J. Sibilia, A. Korganow, R. Aim: We report here data on patients with established idiosyncratic drug-induced agranulocytosis, followed up in a referral centre within a university hospital. Design: Data from patients with idiosyncratic drug-induced agranulocytosis were retrospectively reviewed. Methods: All cases were extracted from a cohort study on agranulocytosis in the Strasbourg University Hospital Strasbourg, France. Results: The mean age was Several comorbidities were present in The most frequent causative drugs were: antibiotics The main primary clinical manifestations during hospitalization included: isolated fever The mean neutrophil count at nadir was 0. All febrile patients were treated with broad-spectrum antibiotics and This mean duration was reduced to 2. Outcome was favourable in Thirty-seven patients Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. If you are a member of an institution with an active account, you may be able to access content in one of the following ways:. Typically, access is provided across an institutional network to a range of IP addresses. This authentication occurs automatically, and it is not possible to sign out of an IP authenticated account. Choose this option to get remote access when outside your institution. Enter your library card number to sign in. If you cannot sign in, please contact your librarian. Many societies offer single sign-on between the society website and Oxford Academic. If you do not have a society account or have forgotten your username or password, please contact your society. Some societies use Oxford Academic personal accounts to provide access to their members. See below. 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Sign in through your institution. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents Summary. Materials and methods. Journal Article. Idiosyncratic drug-induced neutropenia and agranulocytosis. Address correspondence to Prof E. Oxford Academic. Google Scholar. Goichot , B. Revision received:. Cite Cite E. Select Format Select format. Permissions Icon Permissions. Issue Section:. You do not currently have access to this article. Download all slides. Sign in Get help with access. Institutional access Sign in through your institution Sign in through your institution. Get help with access Institutional access Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. 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Pregnant women and substance use: fear, stigma, and barriers to care

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Metrics details. Substance use during pregnancy and motherhood is both a public health and criminal justice concern. Negative health consequences associated with substance use impact both the mother and the developing fetus, and there are ongoing attempts to criminalize substance use during pregnancy that put pregnant substance-using women at risk of detection, arrest, and punishment. This study explored the experiences of substance-using mothers as they navigated health and criminal justice consequences and accessed needed resources in the community. In-depth life history interviews were conducted with 30 recently-pregnant women who had used alcohol or other drugs during their pregnancies. The three-part interview schedule included questions about past and current substance use, life history, and experiences with criminal justice authorities, child protective services, and health professionals. Women described multiple barriers to treatment and healthcare, including a lack of suitable treatment options and difficulty finding and enrolling in treatment. The findings suggest that policies that substance-using women find threatening discourage them from seeking comprehensive medical treatment during their pregnancies. The implications of the findings are discussed, particularly the need for further expansion of treatment programs and social services to meet the needs of substance-using women. Pregnant women who misuse substances alcohol, tobacco, and prescription and illicit drugs are positioned at the nexus of public health and criminal justice intervention. The impact of their substance use on their personal health and the health of their fetuses is a public health concern, as professionals in this field are dedicated to improving maternal and infant health. Figures from the most recently-published report from the National Survey of Drug Use and Health Substance Abuse and Mental Health Services Administration, state that, of pregnant women aged 15—44, 9. Of pregnant women aged 15—44, The percentage of pregnant women in this age group who report smoking tobacco in the last month has not changed significantly in the last decade, while tobacco use among nonpregnant women in the same age group has decreased slowly but significantly each year. Teenaged pregnant women have the highest rates of illicit drug use 15—17, There are no reliable nationwide estimates of the annual number of infants born after prenatal substance exposure. Between and , the incidence of NAS among hospital-born newborns increased from 1. While it is possible that some of the increase in NAS diagnoses could be attributed to growing recognition of NAS symptoms and increased surveillance of pregnant women, it appears that prenatal exposure to substances is a significant public health problem. Concerns about fetal drug exposure have given rise to new laws and applications of existing laws that seek to deter women from using substances during their pregnancies and to punish those who do. Substance abuse during pregnancy is considered child abuse under civil child welfare statutes in seventeen states, and in three states Minnesota, South Dakota, Wisconsin it is grounds for civil commitment Murphy, In some states, the protection from prosecution is incomplete, e. In South Carolina, the ruling in Whitner v. State affirmed the conviction of criminal child neglect for a mother whose newborn tested positive for cocaine metabolites. State , The court reaffirmed its stance on the issue in State v. Gibbs was only 16 at the time. Experts who later examined the autopsy reports concluded that the more likely cause of death was umbilical cord compression. Murder charges against Gibbs were dropped in April, , after more than seven years of legal entanglements. Charges were dismissed without prejudice, leaving the possibility for charges to be refiled Fowler, Most recently, in April, , Tennessee became the first state to explicitly criminalize drug use during pregnancy through legislation. The law allows women to be charged with aggravated assault, which carries a penalty of up to 15 years in prison TN SB, It is difficult to produce an accurate count of the number of such cases, as there multiple barriers to the full identification and documentation of cases that, for example, do not result in published court opinions and do not receive public attention. These figures support the argument that punitive policies regarding substance use during pregnancy are disproportionately enforced against poor women and women of color. The record is also unfortunately out of date by almost a decade and, as the above-mentioned cases, court decisions, and legislative acts demonstrate, the arrests and prosecutions of pregnant and substance-using women continue. In some places, e. Tennessee, women charged with substance use during pregnancy may be allowed to use evidence of finding and attending treatment as an affirmative defense. However, pregnant women seeking substance use treatment may find that there are no suitable treatment programs available. Specialists are concerned that methadone treatment and other opiate replacement therapies, considered the gold standard for managing opioid addictions, will not be accepted by the courts. Furthermore, the bill did not create any new treatment options, expand existing options, or provide additional funds to care for patients Beyerstein, Two of the programs were full, leaving fewer than 50 beds available Dosani, In the late s hospital staff at the Medical University of South Carolina MUSC worked with police to search pregnant patients for evidence of drug use and facilitate in-hospital arrests. Proponents of this policy claimed that the goal was to get women into treatment because they would not go voluntarily. At the time, not a single drug treatment program in the state provided services for pregnant and parenting women Paltrow, : x. Furthermore, in spite of the claim that drug-exposed children were severely harmed and thus the justification for punishment of drug-using women , no program to treat or monitor the children existed Paltrow et al. Contrary to claims that arresting and prosecuting pregnant women will encourage them to desist from substance use and thus improve maternal and fetal health, fear of detection and punishment presents a significant barrier to care for mothers and pregnant women. The effect of stigmatization, discrimination and fear of punishment present a barrier to wanted care. This creates a health risk, since substance-using women who do receive prenatal care experience more positive birth outcomes and have greater opportunities for other health promoting interventions than women who do not receive care Berenson et al. The burden of these policies falls disproportionately on poor women and women of color, as those who use public health and social services are subject to increased surveillance and heightened risk of being tested and reported to criminal justice authorities Chasnoff et al. Women who can afford private physicians and avoid public services are likely better able to avoid testing, detection, and reporting. The probable consequence of this disparity is a widening of the health inequality across class and race divisions. The purpose of this study is to gain a greater understand of the way substance-using women navigate the health and justice systems in order to avoid criminal justice consequences and to access needed health and social support resources. The results identify the ways in which fear and stigma create barriers to care and result in unmet needs for this population. A loosely-structured interview schedule of open-ended questions helped to guide the conversation through the topics of identity, health behaviors and barriers to care. Participants were encouraged to tell their stories using their own words and narrative styles. The target population for this study was women who were pregnant or recently pregnant within the last twelve months and who had used alcohol, tobacco, illicit drugs, or misused prescription or over-the-counter medications at any time during their most recent pregnancies. The targeted sample size was 30 women. The sample was drawn from a post-industrial Midwestern city with a population of approximately , residents. Recruitment flyers were posted in the maternity wards of local hospitals and at drug treatment centers, community centers and service enrollment offices. Flyers posted at local transportation hubs e. Women who completed interviews were also invited to refer others to the study. In fact, invitation was not usually necessary; women volunteered to pass along recruitment materials to other women they knew might like to participate. These recruitment strategies proved highly effective and all 30 interviews were completed during a five-week period. Due to the broad scope of the recruitment criteria, very few women were turned away. Those who were did not meet the criteria e. Interviews were completed in a single session in a place where women felt comfortable. The sample consists of 30 women between the ages of 19 and 41 Table 1. The mean age is Two of these women were of mixed race, one woman was adopted and did not know the races of her parents, and the fourth preferred not to answer. The criteria for participation in the study included being currently pregnant or having recently within the past 12 months given birth. Six women The most common benzodiazepines used by participants were Valium and Xanax. Less common were other substances including cocaine, methamphetamine, heroin and hallucinogens. For example, 14 The interview recordings were manually transcribed and coded for the themes of detection-avoidance strategies and experiences accessing treatment. Several common strategies and experiences were identified. Women reported feeling fear of being identified as substance-users by medical professionals or other authorities and discussed their strategies for avoiding detection. Finally, women talked about their experiences of seeking treatment for their substance use, the barriers they encountered, and which types of treatment were most effective for them and why. Twenty-two women The remaining eight women For most of these women, this was because they were not using illegal substances. Though they recognized the harmful effects of alcohol and tobacco, they were not worried about being tested, having positive test results, losing their children or being arrested. Some women were simply unaware that they might be tested at prenatal visits or at the hospital and that they could lose their children. Interviewer : Did you have any concerns about CPS taking the children? Brittany : I guess I would say no, only because nothing like that had happened before. Brittany had permanently lost custody of her three boys. She had managed to keep her opioid addiction a secret for many years until it spiraled out of control. She spoke about how her addiction had never resulted in contact with the police because it was her boyfriend who would take risks and go out to buy their heroin. Women who were using illegal substances and did not feel afraid of being identified as substance users were the exception. Pregnancy was a time of great uncertainty for most of the women, and this was compounded by the threat of detection. This was especially true for women who did not know what to expect at prenatal appointments or delivery. Some women believed they were drug-tested at every prenatal visit and that every baby delivered at the hospital had his or her meconium tested for drugs. Other women felt that the decision to test mothers and babies was on a case-by-case basis. Are you going to test me and the baby? Some uncertainty may be attributable to variation in testing and reporting policies between different obstetric clinics and hospitals. Medical organizations have some discretion in their policy decisions, although they are of course subject to federal and state laws and administrative codes. At the federal level, hospitals must comply with the Keeping Children Safe Act of , which added requirements to the Child Abuse and Treatment Act. Under the act, states are required to develop procedures requiring healthcare providers to notify CPS if they suspect a child has been subjected to drugs, or is suffering from withdrawal symptoms at birth. Individual clinics and hospitals likely have varying internal policies regarding what is to be detected through urinalysis, along with other testing and reporting procedures. It is unlikely that most women are aware of the numerous federal and state laws and policies. To manage the risk and uncertainty of being identified as a substance-using pregnant woman, women in this study adopted various strategies. Some strategies seemed pro-social and pro-health, like being honest with medical practitioners or seeking out treatment. Other strategies seemed more damaging, like isolating oneself from friends and family who might detect the substance use, hiding or denying the pregnancy, timing prenatal appointments so that persistent substance use would not show up in drug tests, skipping some prenatal visits or avoiding prenatal care altogether. They felt that being honest showed that they were good mothers despite their substance use and they hoped that doctors and nurses would appreciate their honesty and affirm their motherhood identities:. Interviewer : Are you worried about them drug-testing you or anything like that? Vicki : Yeah. With me being so blunt, so open and wanting the help, I think it shied a lot of people away from being so concerned or disturbed. In these excerpts from interviews with Vicki, a methamphetamine user, and Kim, who was using alcohol and marijuana, both women express their hope that being up-front with doctors would help them be perceived as good mothers who were concerned about the health of their fetuses, resisting the master narrative of substance-using mothers who are selfish and unconcerned. Vicki was pregnant at the time of her interview and was yet to see if her strategy would be successful. Kim had stopped smoking marijuana before the birth of her daughter and was only using alcohol albeit heavily , so she did not have any contact with CPS. Not all women were pleased with the outcome of their strategy to be honest with their doctors. Melinda had been honest with her doctors about her opioid and benzodiazepine use but felt that this strategy had not worked for her, because she was unhappy about how long her son had to stay in the nursery before he could come home with her:. Melinda : I would never advise somebody to have a child \[at the hospital\]. I thought I was helping my child by being honest during my pregnancy, I thought I was helping him if I was honest with my doctors. The risk of being honest may be lower when women are using legal or socially-accepted substances or when a woman has a trusting relationship with her medical provider. The relationship between a woman and her medical provider might be one way that socioeconomic status grants some substance-using women privileges and health benefits. If a woman has health insurance and a private doctor with whom she has a long history, honesty may be a safe strategy that allows her to receive support and treatment specific to her risk status. These possibilities suggest an area in need of further research. Another set of strategies women employed was to keep to themselves, avoiding friends and family who might report them to CPS. For two women, this went as far as concealing or denying their pregnancies:. Interviewer : Did you do anything to try and hide it or avoid getting caught? And I lied, a lot. Of course, pregnancies are typically only concealable for a limited amount of time. Another strategy for women was to socially isolate themselves from anyone who might report them to CPS:. Alice : Yes, yes. These third parties included roommates and friends, family members, ex-partners, and neighbors. Some of these reports were made out of concern for the children, but many reports were identified by the women as acts of retaliation. For example, a mother would get into an argument with another woman and that woman would report her to CPS in retaliation. In another case, a mother broke up with her abusive boyfriend and, in retaliation, he called CPS and told them she was pregnant and smoking marijuana. Other women had family members who wanted custody of their children and would call CPS very frequently, forcing CPS to investigate every time even though they had found time and time again that the children were happy and healthy. In light of these experiences, women may feel that isolating themselves is an effective strategy for avoiding contact with CPS and law enforcement. This strategy included scheduling visits around their substance use so that any tests would come up negative, skipping some visits, or avoiding prenatal care altogether. Women who used substances that are only detectable through urinalysis for several days after use were able to schedule their appointments around their substance use. Interviewer : And during this time, while you were pregnant, were you ever worried that if you went to a doctor, they would drug test you? Sarah : Kind of, yeah. Kind of. But that was only a couple of days after I did the heroin. Denise : I drank a lot of water. I always made sure that I stopped certain stuff before I went in. I had it already charted out for how long it took to get out of my system, this, that and third, like, I made sure I had my stuff on lock. Some women, like Denise and Amelia, seemed proud of their ability to avoid detection. By doing so, they were able to avoid positive prenatal drug tests. This method is not effective for avoiding detection at delivery, though, because meconium begins to form in the second trimester of pregnancy and a positive test can indicate substance use a month or longer prior to delivery Farst et al. This is an important consideration if meconium testing is triggered only by positive prenatal tests, as women who use substances that pass quickly through the body may successfully evade detection at prenatal appointments and also at delivery. I would skip appointments and things, and stretch them out. Interviewer : And did worrying about being involved with CPS or getting her taken away, did it keep you from doing anything you might otherwise do? Alice : Because I was taking drugs, well, not drugs-drugs, I was down there smoking on marijuana and drinking liquor. And they told me if they see THC or something like that in my system, then protective services would get involved. Research repeatedly demonstrates that substance-using women who receive prenatal care experience more positive birth outcomes and have greater opportunities for other health promoting interventions than women who do not receive care Berenson et al. Prenatal care appointments provide practitioners the opportunity to connect women to needed resources, to screen them for dangerous illnesses or injuries, to screen for intimate partner abuse victimization, and to implement many other public health interventions. By adopting policies that scare women away from treatment, clinics and health organizations lose the opportunity to intervene and promote maternal and infant health. Twenty women Two of these ten women used methamphetamine, one used assorted prescription pills, and a fourth used hallucinogens. The twenty women who had experience with substance abuse treatment had explored a variety of different programs, from short-term detox and outpatient support groups to residential treatment and long-term methadone maintenance. Each program type came with its own limitations and barriers to entry. Three women had sought out treatment facilities that would allow them to detox most commonly from opioids. These programs were very short-term, usually less than a week, and offered medically-assisted or unmedicated detox. Women were in agreement that unmedicated detox was an awful experience and that they would only stay at places that would give them medication to help with their withdrawal symptoms. At some places, such medication was promised but not delivered:. Tasha : When I went there, oh my God, \[treatment center\] was awful. I wouldn't send my dog there. I went there during the day and the lady was really nice. And that night, they refused to give me anything to help with the withdrawals and I was freaking out and I was sick and I had just had it. Two o'clock in the morning, I ended up walking out of there. They wouldn't help, they just basically looked at me like I was some horrible drug addict. Even if Tasha had stayed and detoxed, such programs frequently offer little in the way of aftercare unless they are paired with residential or outpatient counseling. Women who had detoxed, with or without medical assistance, reported that the process did nothing to address the triggers for their substance use. They spent up to a week in detox but then returned to the same environment and same social setting they had been in when they were using. A problem with detox is that it is rarely a possibility for women who are already pregnant. Though the physical withdrawal symptoms are unpleasant for adults, they can be lethal for the fetus. For substance-dependent women who wanted to continue their pregnancies, withdrawal was a dangerous choice, and few medical professionals would agree to supervise the process. Kellie : It was just the whole, I guess liability issue of the miscarriage associated with treatment and withdrawal of the pregnancy that really scared people. Instead, they gave her more opioids to stave off the withdrawal and then turned her away. Kellie continued to use heroin while seeking out other treatment possibilities. Opioid replacement therapy is the practice of replacing illegal opioids with longer-acting opioids like methadone or buprenorphine administered under medical supervision. Methadone emerged as a treatment solution for heroin addiction in the s. It is recognized as the most effective treatment for heroin addiction according to reviews by the Institute of Medicine and the National Institutes of Health Despite such robust evidence of the benefits of methadone maintenance therapy, it remains, for some, a highly controversial practice. Since their beginning, methadone programs have been accused of merely substituting one drug for another Joseph et al. Methadone maintenance programs have been cited as an example of evidence-based medical programs that have been adversely impacted by misperceptions and biases, limiting their implementation and reach Gordis, As a result, patients fear that the stigma associated with being a methadone user will negatively impact their jobs, their social relationships and the medical care they receive Joseph, Stigma and discrimination appear to be powerful forces preventing the full acceptance of methadone treatment, and likely impacts both pregnant and non-pregnant women seeking treatment. The controversy surrounding methadone maintenance was demonstrated by women in the current study. Eleven women had, at some point in their lives, sought opioid replacement therapy with methadone or buprenorphine, another partial opioid agonist more recently approved for opioid addiction treatment and known by common product names like Suboxone and Subutex FDA, Although most women were overwhelmingly in favor of opioid replacement therapy, many of the same women were concerned about never being able to stop taking methadone. Others were less effusively appreciative of methadone treatment but still felt that they could not have achieved sobriety without it:. Eleanor : I needed something — no. So you know, with a little help I was able to pretty much beat my addiction. Most women shared similar experiences, but two women expressed a strong dislike for methadone maintenance. Naomi explicitly described many of the arguments made against opioid replacement. She had recently used Suboxone buprenorphine to recover from her dependence on opioid painkillers but had made a point to wean herself from it quickly thereafter:. Naomi : Yep. I was in their detox facility for three days, and then I went into their residential program. Naomi : Nope. I think \[Suboxone maintenance\] is retarded \[ laughs \]. All it is is a legal way for you to get high. All it is is a state-funded way for you to get high. As with other treatment options, women encountered barriers to enrolling in methadone programs. Interestingly, the barriers they encountered were the opposite of what one might expect. Women who were pregnant were able to enroll in programs immediately:. Interviewer : How was your experience trying to get into \[the methadone clinic\]? Cora : It was really easy, because I was pregnant, so I got on the same day. Women who sought out methadone maintenance treatment when they were pregnant had no difficulty enrolling in a clinic. Women who were not pregnant when seeking treatment were not so successful. Brittany had unsuccessfully sought methadone treatment after the birth of her second son and had not been able to overcome the barriers she encountered. She continued to use and became pregnant again, and finally lost custody of all three of her children. Whereas the other one it was different, it was like they wanted us to wait a couple of weeks in between, you know. And you have like a fleeting moment between when you have the money in your hand and you wanna start \[treatment and\] when you start shutting down, so…. Once enrolled in methadone programs, women were concerned about continuing to pay their bills. Women who were pregnant or who had recently given birth were eligible for Medicaid, which would cover the cost of treatment, but they worried about what would happen to them once they no longer had insurance:. But I would just have to find — I would have to find a way to pay for it. Other women were cobbling together some Medicaid allowances and assorted grants, but were facing the possibility of being rapidly tapered off methadone if they could not afford to continue paying for it:. Finally, women who did take methadone during their pregnancies felt that there was insufficient information about what they should expect at the hospital and when they brought their infants home. Methadone has been deemed safe for use during pregnancy but can still produce symptoms of withdrawal in exposed infants. Alyssa : But man, having my daughter, being on methadone, I know it changed my life, but shoot, I went and got my tubes tied. Alyssa : Watching my daughter go through it? Yeah, that bad. We were in the hospital five weeks, she was on a very high dose of morphine, and she had to be on phenobarbital and just, it sucked. Others were unprepared for how they would be treated at the hospital. In some cases, they were informed by medical personnel that CPS was called for all mothers using methadone, whether it was prescribed or not. Others reported that CPS was mistakenly called. Kellie felt trapped by hospital policies about methadone use, as she thought that enrolling in the methadone clinic would help her escape involvement with CPS:. Fifteen women, half of all women in the study, had experience with residential or in-patient treatment programs. And a lot of that has so much anger in me, anger towards my mom, towards the court system, towards everybody that failed me all my life, as a child. And then, you know, anger at myself with losing \[custody\]. Once I dealt with all of that, it really, really changed who I was inside and it made me stronger. You would think I had a lot of strength going through everything I went through, but I just buried everything under drugs. Natalie had been in other residential programs before RSAT and had not found them effective. After leaving prison, she did return to substance use briefly before desisting for some time. At the time of her interview, she reported that she had relapsed for a few months at the beginning of the current year and became pregnant at the end of that period, and now she felt that she would be clean for good. Hazel had been to a residential treatment program to help her overcome her addiction to crack cocaine. She found the classes offered there very helpful, both in their instruction but also for the social opportunities:. Hazel : Well, the classes helped, too. They had classes in the rehab, the lifestyle changes class, different classes I could take. The, um, I say the lifestyles class is the one that helped me more, because they helped me to prepare for what the real life was really all about, and beside the drugs and all that, I was actually somebody else. Women felt that residential treatment was not effective if it was too short or there was no outpatient support. Those women who left residential programs and returned to substance-using social networks and environments also returned to substance use. Elizabeth had recently spent two weeks in treatment but was not optimistic about the future:. Elizabeth : I started back drinking. Interviewer : So the real world is not the same as the treatment world? Elizabeth : No. Lot of temptation. In interviews with women who had sought residential treatment during their pregnancies, references to the same treatment facility repeatedly arose. It became obvious that women were talking about this single treatment facility because, to their knowledge, it is the only residential substance abuse treatment program in the state that will accept pregnant women. None of them would accept pregnant women unless I was already detoxed or on a methadone maintenance. And they are, as far as I know, the only place in the state that will take pregnant women who are, you know, addicted to opiates and have to go through withdrawal or be put on methadone or whatnot. But unfortunately I did not find them until I was probably about seven and a half months along…. The facility women mentioned is located miles from the study site. At this location, there is an option for children to stay at the facility with their mothers. Childcare during treatment has previously been identified as a barrier to care for substance-using mothers Blume, ; Center for Substance Abuse Treatment, ; Finklestein, ; Marsh et al. Cora : Yeah, I went somewhere where I could take my kids, and I ended up taking my youngest, and she ended up getting abused by other children in there that had it way worse than my kids had it. The current analysis provides an overview of the issues substance-using mothers encounter when negotiating prenatal care, hospital delivery, and seeking substance abuse treatment. Women discussed the strategies they employed to avoid being detected as substance-users or, in some cases, explained why they had not feared detection. Women who used alcohol and tobacco were less likely to fear being identified by medical professionals or law enforcement authorities than women who were using illicit substances. Some women who were using illicit substances were not afraid because they had no personal or vicarious experience with the consequences of detection, particularly loss of custody. Of the women who did fear detection, some were up-front and honest with their doctors, and they felt that this would protect them from the worst consequences because their doctors and nurses would appreciate their honesty. Others hid or denied their pregnancies, isolated themselves away from others who might report them to authorities, and delayed or avoided prenatal care. Some women were honest with medical professionals but then experienced poor treatment, making them less likely to be honest again in the future. Women also shared their experiences accessing substance use treatment. The benefits and drawbacks of different treatment options were discussed, as well as the barriers women encountered as they searched for and received treatment. These findings demonstrate that women are in need of more treatment options, better access to the treatment of their choice, and more support for staying in treatment. The women in this study revealed that in their searches for residential treatment centers they could locate only one facility that would accept pregnant women or women who needed to bring their children with them. This treatment facility is located more than a hundred miles from the study site, making transportation and visitation expensive and time-consuming. Women would benefit from an increased number of residential care facilities. There are several methadone clinics in the study area and women who sought treatment there when pregnant were pleased to find that their status as pregnant women afford them expedited enrollment in treatment. This is an excellent policy that should be continued, as most women spoke positively about their experiences on methadone. However, when women sought methadone treatment between pregnancies, they faced waiting periods of days or weeks. During this delay, women continued to engage in risky substance use and, in some cases, lost their desire to enter treatment. Increased funding for methadone treatment clinics to support larger client populations would help to cut down on these waiting periods and get women into treatment when they are motivated to enroll. In general, women harbored some misconceptions about methadone and were unclear about the treatment process. They were concerned that if they start taking methadone, they would never be able to stop. Women who were pregnant and on methadone were not well-informed about what to expect when their babies were born. This lack of information left women feeling confused, vulnerable and in some cases misled or betrayed by treatment professionals. Better communication between medical staff and mothers may help to ease some of this confusion and reduce feelings of stigmatization and unfair treatment. Methadone clinics should offer information sessions and materials to help prepare pregnant women for the experience of delivering their babies at hospitals, including what to expect in regard to pain management, infant withdrawal symptoms, CPS involvement, treatment approaches for withdrawing infants, and how to work with doctors and nurses to help the process go smoothly. These information sessions could also include advice for comforting methadone-exposed babies once they come home. A major implication is that women would benefit from some sort of wrap-around or comprehensive care and professional advocacy. The few women in the study who were working with public health nurses were appreciative of the way the nurses were available to answer their questions, help them with transportation to and from appointments, and help them access resources like car seats, cribs, baby clothes, and childcare assistance. Expanding similar programs to increase enrollment and funding support would likely be of great benefit to women in similar situations. Home-visitation nursing programs show great return on investment for at-risk populations Eckenrode et al. Such programs should be considered a very strong policy option for pregnant women and mothers struggling with substance use. The findings of this small, exploratory study have important limitations. The current research presents the perspectives of substance-using mothers. They expressed frustration and anger with the system, which included treatment professions, CPS caseworkers, judges, attorneys, social service providers and law enforcement. Substance use during pregnancy and motherhood is an emotionally-charged social problem in need of a compassionate and evidence-based solution. Their perceptions of barriers to care and the types of treatment they receive have important implications for their likelihood of compliance with treatment and potential desistance from substance use. This study provided an outlet for their voices and has identified promising avenues for future research and policy development. Future research should continue in this direction with the goal of improving maternal and infant health outcomes for this population. Drug-exposed infants. Pediatrics, 86 , — Google Scholar. American College of Obstetricians and Gynecologists. Washington, D. 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Punishing drug addicts who have babies: Women of color, equality, and the right of privacy. Harvard Law Review, 7 , — Killing the black body. New York: Vintage Books. Complex calculations: how drug use during pregnancy becomes a barrier to prenatal care. Maternal and Child Health Journal, 15 3 , — State v. McKnight , S. SMA 12— Thompson, C. Qualitative research into nurse decision making: Factors for consideration in theoretical sampling. Qualitative Health Research, 9 6 , — Whitner v. State of South Carolina , S. Woliver, L. The political geographies of pregnancy. Urbana: University of Illinois Press. Download references. You can also search for this author in PubMed Google Scholar. Correspondence to Rebecca Stone. Reprints and permissions. Stone, R. Pregnant women and substance use: fear, stigma, and barriers to care. Health Justice 3 , 2 Download citation. Published : 12 February Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Abstract Background Substance use during pregnancy and motherhood is both a public health and criminal justice concern. Methods In-depth life history interviews were conducted with 30 recently-pregnant women who had used alcohol or other drugs during their pregnancies. Conclusion The findings suggest that policies that substance-using women find threatening discourage them from seeking comprehensive medical treatment during their pregnancies. Background Pregnant women who misuse substances alcohol, tobacco, and prescription and illicit drugs are positioned at the nexus of public health and criminal justice intervention. Results The interview recordings were manually transcribed and coded for the themes of detection-avoidance strategies and experiences accessing treatment. Fear of detection Twenty-two women Interviewer : Do you know if they drug test every baby? Vicki : \[ emphatic \] Yeah. Interviewer : Do you still go \[to your appointments\]? Elsie : Yeah. Alice : My third child, I had no prenatal care. Interviewer : For what reason? Interviewer : So you walked out of there? Tasha : Mmhmm \[yes\], gave up on that and went right back to using. Interviewer : Suboxone? Interviewer : So you got the Suboxone at \[treatment facility\]? Interviewer : Are you still on the Suboxone? Interviewer : So there was a lot of messing around? Interviewer : Really? That bad, huh? Interviewer : When were you there? Elizabeth : I went on the 21 st , I think. Interviewer : Oh, wow, you were just there. So after release? Discussion and conclusions The current analysis provides an overview of the issues substance-using mothers encounter when negotiating prenatal care, hospital delivery, and seeking substance abuse treatment. Google Scholar American Psychiatric Association. Google Scholar Banwell, C. Article Google Scholar Beyerstein, L. Google Scholar Boyd, SC. Google Scholar Bureau of Justice Assistance. Article Google Scholar Dosani, S. Google Scholar Finklestein, N. Google Scholar Flavin, J. Google Scholar Fowler, S. Google Scholar Gordis, E. Article Google Scholar Institute of Medicine. Google Scholar Joseph, H. Google Scholar Karoly, LA. Google Scholar March of Dimes. Article Google Scholar McKnight v. Google Scholar Paltrow, LM. Article Google Scholar Roberts, D. Article Google Scholar State v. Google Scholar Thompson, C. Google Scholar Whitner v. Google Scholar Download references. Additional information Competing interests The author declares that she has no competing interests. About this article. Cite this article Stone, R. Copy to clipboard. Contact us Submission enquiries: Access here and click Contact Us General enquiries: journalsubmissions springernature.

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