Social, economic and logistical barriers keep many pregnant, drug-addicted women in Iowa from accessing substance abuse treatment.
Moreover, despite attention given the problem over the years, social stigma and fear of losing custody can keep them from seeking medical care during pregnancy, an IowaWatch investigation revealed.
Each barrier is increasing the likelihood a child will be affected by the drug and face health, behavioral and developmental issues later in life.
Mothers working through substance abuse treatment and navigating the child welfare system face a series of medical evaluations, counseling sessions, court dates and testing that can seem overwhelming while dragging on longer than desired.
“It is almost setting them up from the beginning to say ‘This is hopeless.’ It feels hopeless. It feels overwhelming and very lonely,” said Judy Murphy, former meth specialist at the Iowa Department of Human Services and co-founder of the Moms Off Meth support group.
In interviews with IowaWatch over the past six months, health care and social workers said failing to seek treatment increases the likelihood of drug use continuing after the child is born, putting the child at risk of abuse and neglect. Many children raised by drug-addicted parents start using drugs as well.
Methamphetamine has a history of abuse in Iowa, and other drugs, such as prescription pain medications, are starting to raise concerns. In 2011, 62 Iowans died from overdoses of pain medications, which has surpassed traffic accidents as the leading cause of injury death in the United States.
Both meth and prescription pain medications can undermine a baby’s health and create complications at the time of delivery.
Melissa Harris, 22, discovered she was pregnant in December 2011. She had been using meth since she was 15 years old. “I was terrified. I thought it was the end of my life,” she said.
Harris, of Eldora, Iowa, already was eight weeks along. She quit meth “cold turkey.” “I found out I was pregnant on December 3 and I quit using on December 3,” she said.
She started calling treatment centers, but couldn’t get in.
“I wanted to use and I was around use, so that made it twice as hard. I felt like I had no one to turn to,” she said.
For Amy Fischels, 36, of Waterloo, the stress of being pregnant with her first child led to a relapse in her addiction to prescription pain medication and escalated her alcohol abuse.
She had gone through treatment and had been sober for two years, but when she was prescribed the medication due to complications with the pregnancy she started abusing the drugs again.
She used the pain medications during the last month of pregnancy with her son, Landon, now 6 years old.
Every year, as many as 2,500 Iowa children might be exposed to illegal drugs while still in the womb. Under Iowa law, exposing a child to illicit drugs is considered a form of child abuse and neglect. The law only covers children who are already born.
Although substance abuse treatment has proven effective, getting mothers into treatment is difficult, with an array of social and economic barriers barring access to services.Also: Take a look at the IowaWatch database for this story.
A PUBLIC HEALTH MATTER
Murphy calls drug use a public health problem that often is intertwined with underlying social problems, including poverty, domestic abuse and inadequate access to mental health care.
“Drug addiction is devastating. It can create damage to families and communities, children. And I think that that begins to blur us as a society from looking at it as a public health issue. Instead we label them as ‘bad people,’” Murphy said.
Murphy helped found the Moms Off Meth group in Ottumwa in 1999. The group provided a platform for the women to address some of the social stigma and provided resources to mothers trying to navigate the child welfare system.
Roughly 4 percent to 8 percent of pregnant women use illicit drugs, reports from the Substance Abuse and Mental Health Services Administration show.
Between 1,600 and 3,200 of the roughly 40,000 children born in Iowa each year have been exposed to drugs, said Dr. Resmiye Oral, director of the child protection program and professor of pediatrics at the University of Iowa Carver College of Medicine.
She based that on national statistics. “Mostly likely there are around 2,500 newborns exposed to drugs and we don’t catch all of them,” Oral said.
Iowa’s state figures for drug-affected infants are lower than expected, which officials say might be because Iowa does not require universal testing when a child is born.
During a 2005 study, the Iowa Alliance for Drug Endangered Children found 1,354 children tested positive for illegal drugs.
Between 2003 and 2011, more than 11,150 children were found to have illicit drugs in their system, information from the Department of Human Services shows.
Although this number can include a few children who ingested the drug it represents for the most part the number of infants found to have traces of illegal drugs at birth, a result of a mother who has used drugs during pregnancy, said Roger Munns, the department’s former spokesman.
Exposure to meth in the womb can have physical, behavioral and cognitive effects on children. The effects can vary depending on the extent of the use by the mother and how late in the pregnancy the drugs were used.
Harris’ daughter, Reagan, was born healthy last year and hasn’t shown any physical signs or symptoms of exposure to methamphetamine during the first two months of pregnancy, before Harris quit.
“My whole pregnancy I was kind of distraught because I knew I had to give up things for her because that's how I was raised, you always do the things that you have to do for your children. But when I saw her, everything changed. I cried. It was crazy. I never thought I'd feel that way,” she said, as her daughter, then 6 months old, dozed her arms.
Fischels, too, said her son seems unharmed by the pain medications she abused while pregnant.
“He is completely healthy. He’s smart as a whip. He’s in kindergarten reading at a third grade level,” she said.
If hospital workers suspect a mother has been using drugs during pregnancy, drug tests of the newborn’s umbilical cord or meconium, bowel movements from the first few hours after birth, can show traces of illicit drugs.
Hospitals are required to report positive screenings to the Department of Human Services.
Until 2008, Iowa hospitals did not have a standard protocol for testing, which officials say means some drug-affected infants slipped through the cracks
The Iowa Statewide Perinatal Illicit Drug-Screening and Intervention Protocol, approved by the Perinatal Care Program Advisory Council of the Iowa Department of Public Health in 2008, was developed for standard testing.
One year after University of Iowa Hospitals and Clinics adopted the protocol, researchers saw a dramatic increase in the number of women and newborns screened and in the number of positive tests, Oral said.
The protocol has been adopted by the majority of the roughly 80 birthing hospitals in the state, said Dr. Jeffrey Segar, director of the Iowa Statewide Perinatal Care Program and University of Iowa Children’s Hospital director of neonatology.
Segar said the protocol helps prevent profiling, testing mothers based upon racial or economic stereotypes, by providing a list of 33 risk factors including visible signs of drug use, like track marks and visible tooth decay, and medical abnormalities in the mother’s or newborn’s health.If one or more risk factor is present, staff should order screening tests.
“There’s always some reluctance to take on something that can be seen as sensitive, like screening for illicit drug use. That’s the importance of having guidelines that universally apply to patients, especially in small communities where caretakers and doctors really know the mothers well,” Segar said.
Wendy Rickman, the Adult, Children and Family Services Division administrator at the Department of Human Services, said state officials are working toward universal testing, which would mandate testing of every newborn in Iowa hospitals.
When newborns test positive, social workers perform a risk assessment to see if the child is safe to go home, Rickman said.
Social workers then create a plan for the family, which often includes parents attending treatment programs.
Judee Alexander, a social worker for Allen Hospital in Waterloo, has been keeping statistics on the number of positive test results since 1990. The number of babies every year has fluctuated between 11 to 33 annually during the past decade, according to her information, which is not recorded by the hospital. Of the babies tested, the majority are negative, she said.
She said recent laws appear to have cut down on the number of meth-exposed newborns born in Allen Hospital.
The Combat Methamphetamine Epidemic Act of 2005, which went into effect in 2006, limited the sale of medications, like pseudoephedrine, that are used to manufacture meth.
Iowa is also one of 26 states that adopted technology to track the purchases between stores and states. The law has been shown to reduce the number of meth labs.
According to numbers from the Department of Public Safety, labs seized by local and state agencies dropped from a high in 2004 of 1,500 labs to 178 labs in 2007, although there has been a recent increase over the past few years.
Yet, meth use still accounts for the bulk of drug-related prison admission in Iowa, with 455 people imprisoned for meth-related offenses in 2012. Between January and September of 2012, more than 17,849 grams of meth had been seized by the Iowa Division of Narcotics Enforcement, reports from the Department of Public Safety show.
EFFECT ON CHILDREN
The Government Accountability Office, a nonpartisan investigative arm of Congress, estimated the cost of caring for drug-affected infants is four times higher than the cost for non-exposed infants.
Jonathan Klein, UI Children’s Hospital Neonatal Intensive Care Unit medical director, said staff keep an eye on newborns for signs of drug exposure.
“There are things that we see right away, like if the baby is smaller than expected, if there is a birth defect, especially in the intestinal or urinary tract, that is a possible sign of drug exposure. If the baby is extremely irritable, has a piercing cry, doesn’t sleep, has diarrhea, sweating, mottling of the skin, has tremors or seizures. Those are all signs we look for.”
Klein said the drugs that most often cause withdrawal in infants are narcotics and opioids, or prescription pain medication.
At least one baby monthly in the hospital needs treatment for drug withdrawal, he said.
Most hospitals can diagnose withdrawal symptoms in newborns, but treatment, which can include administering low, decreasing doses of morphine, sometimes requires transferring the infant to a different hospital.
Treating drug-exposed infants requires constant monitoring, but Klein said the medical issues are “simpler than the vastly more complicated societal problem.”
“Just because they (the kids) have all their fingers and toes doesn’t mean they don’t have mental or emotional issues from the drugs they were exposed to,” said Barb Malina, a counselor at the Heart of Iowa, a substance abuse treatment center for pregnant women and women with children in Cedar Rapids.
Health, behavioral and developmental issues from drug exposure can follow children into the classroom and impact them later in life.
During a long-term study at hospitals in Iowa, Oklahoma, California and Hawaii, infants exposed to methamphetamine before birth were about 3.5 times more likely to be small for their gestational age, which causes an increased risk for Type 2 diabetes and other health issues. Children born with smaller head circumference have an increased risk of developmental problems, including reading and problem-solving difficulties.
In the study, children exposed to meth were more likely to have symptoms similar to those of ADHD, attention deficit hyperactivity disorder, by the age of 5.
Researchers involved in the study said children exposed to meth before birth can avoid some of the problems if raised in a stable household.
Identifying infants exposed to drugs can protect children from abuse and neglect later on. Emotional and physical abuse frequently are associated with substance-using parents.
A 2009 study by the Iowa Department of Human Services showed 70 percent to 80 percent of open child welfare cases were related to substance abuse.
When a child is taken out of parents’ care, the department works to identify and resolve the underlying causes of abuse, which can require the parents to go into treatment or counseling. The overall goal is to reunite kids with their families within 12 months of the child entering foster care.
However, progress reports show the department isn’t meeting its goals for timely reunification. During the last reporting period, from October 2012 to March 2013, roughly 52 percent of children were reunited with their parents or caretakers within the 12 month time frame.
This can be a sign of the many intertwining issues these families have, including mental health problems and their own histories of abuse.
“Many of our families have a lot of issues going on. If we aren’t able to get down to the bottom line issue then we tend to take a longer time getting the child back home because we have to make sure that the child is safe,” Rickman, of Adult, Children and Family Services, said.
Melissa Harris held off for two months after her daughter was born before using and dealing again. She said she didn’t believe she was endangering her daughter until the Department of Human Services stepped in and sent Reagan to live with Harris’ dad.
“I never really realized how big of a problem it was until they took her away from me. There were a lot of times she was neglected. I'd prop her bottle up so I could go use or do a deal or something like that. Something that could seriously hurt her, being left in a room by herself,” Harris said.
She was separated from her daughter for 12 days.
“She got taken because it was my fault. Because I didn't take care of her. Because I had meth around her, people in and out of my house that were using, buying drugs,” she said.
She got her daughter back for supervised visits, then full custody. But the meth addiction hadn’t stopped.
“I had her back for two months, but I was losing her again. I had dropped dirty again. I was dealing again,” she said.
Harris applied for a spot at the Heart of Iowa, which is part of the Area Substance Abuse Council in Cedar Rapids. She was admitted into the residential program, which allows patients to bring their children and provides day care while the women are in treatment. The center has 36 apartments. In March, more than 50 children and 37 women were staying at the center.
The residential program lasts 90 days, although it can last up to 106 days if meth is the primary drug used.
“Yesterday I was ready to pack my things and go home. I went and I got my daughter and I took her to the apartment and I just started thinking, you know, I can't go anywhere. Because if I go anywhere I'm going to be right back where I was, because I'm not ready yet. I've been using for so long, I don't know how to live a sober life,” Harris said.
Wanda Mokry-Sellers, director of the Heart of Iowa, said keeping mothers and children together allows the women to stay longer and also helps teach parenting skills, improving their chances of staying clean after they graduate from the program.
“The children, when they start acting out, are some of the biggest (relapse) triggers for the women. Many of our moms think babies are like dolls and you can put it back on the shelf when you’re done. Children are not like that at all,” she said.
Harris said she didn’t think she could have gone to treatment without taking her daughter with her. Once she was sober, Harris said she had to face the feelings of guilt for exposing her young daughter to meth use.
“There are some things that I notice in her that maybe I wouldn't notice if I hadn't used around her, like when I leave her room, she cries because she's afraid I'm going to leave her, because of all the times that I have left her and never came back.”
Fischels, who also went through treatment at the Heart of Iowa, works with her kids to soothe their separation anxieties.
“My son asks me, pretty much on a daily basis, if he’s going to be with me forever and that’s really hard because I don’t want him to feel unsure about anything. He’s just a kid. I don’t want him to feel fear about losing me,” she said.
A NEW GENERATION
Treatment for parents can interrupt the cycle of drug use, which often moves from one generation to another.
“Drug use is often a family illness. Children learn it. Often the mothers don’t realize until they get here how disfunctional their families are. They don’t know what a family unit should look like and act like. It’s an overwhelming task sometimes, but we have a chance to prevent the next generation of users,” said Fred Mishler, coordinator of patient support at the Heart of Iowa.
Fischels, whose parents were alcoholics as well, said she worries her kids might one day follow in her shoes.
“I worried about that the day they were born. It is just a constant worry because of the way they’ve grown up so far. There’s another possible generation of alcoholics and addicts. It’s scary,” she said.
Drug addictions often start at a young age.
Harris first tried meth in high school. She was drawn to the drug because it gave her a “sense of energy, feeling good about myself.”
“I was babysitting a friend’s kids and she came back with some meth and at first I would just use when I went over there. Then six months later, I’m dealing meth myself, at 15 years old,” she said.
“Ever since I got into making as much money as I can make from meth it's kind of been hard to steer away from. It's a quick, easy way to pay my bills.”
She started using intravenous meth to get a bigger high.
Although she graduated high school, she said she wasn’t focused on learning or achieving.
“I have a degree, but I don’t have an education. I keep thinking, when my daughter is in 7th grade and needs help with her math homework, what will I do?”
HOW IOWA IS TRYING TO DEAL WITH THIS
During the past state legislative session, Rep. Clel Baudler, R-Greenfield, sponsored a bill that would have made it a Class D felony under child endangerment if a newborn is found to have traces of an illegal drug within the first three days of birth. The charge could have sent mothers to prison for up to five years or a fine of up to $7,500.
“I would hope it would open their eyes enough that they would get treatment,” Baudler said in an interview with IowaWatch earlier this year.
“I don’t care about their social stigma. I want them to get treatment so their kids don’t grow up in a home with drugs that will continue to spiral society on down.”
The bill didn’t pass, but it raised concerns among health care and social workers, who said they feared criminalizing drug use by pregnant women could be dangerous for the health of the baby if it prevents women from coming into the hospital.
“Once word gets out that women are going to be charged, what are they going to do? They are not going to stop taking drugs. They are going to stop going to the hospital,” Oral, of the UI Children’s Hospital, said.
“Pregnant women do their best to reduce their substance abuse during pregnancy. They are not monsters or lacking in moral judgement. Overwhelmingly, the women I worked with tried to reduce their use as much as they could stand,” she said.
Lori Berry, a social worker for Allen Hospital in Waterloo, said many of the women who come in face domestic violence, financial struggles and mental health issues that complicate access to health care.
Many addicted women are also afraid to go in for prenatal exams or let their doctor know about their addiction.
“It’s kind of scary for the women thinking about what could happen, especially if it is someone who had their children taken away before. They are sometimes hesitant to get involved in programs that would be viewed as positive steps, like treatment and prenatal care,” Berry said.
Women who seek treatment often face a series of economic and logistical barriers. For women in rural areas or in towns without treatment facilities, travel is challenging.
“You’re seeing layers of barriers: Lack of transportation. They might not have a license or car insurance. They might have a really crappy car. It doesn’t work very well. It’s held together by duct tape and bungee cords,” Murphy, who currently works at First Resources in Ottumwa, said.
Lack of insurance and undiagnosed mental health issues also complicate the process, she said.
Murphy said more resources are available to substance-using mothers today than there were in the nineties when she started working in the field, but there is still a need for more treatment centers.
“Meth is still a huge problem. There was that hope that, once they did the pseudoephedrine law that really helped to slow down the meth lab explosion, meth use would decrease. But meth use is still alive and well,” she said.
Harris said she thinks she has closed the door on her addiction, but that doesn’t mean she can forget about it.
“I wake up and I'm thinking about meth. I go to bed and I'm thinking about it,” she said.
Harris said she has seen some effects of her meth abuse mirrored in her daughter’s behavior, but said her daughter is healthy and doesn’t appear to have any developmental effects.
“My daughter's still young and I'm lucky enough to be one of those mothers that my daughter doesn't ever have to remember my drug addiction. She doesn't ever have to remember the worry and the hurt that some of children go through being children of addicts,” Harris said.
After treatment, Harris said she looked forward to walking out the doors with her daughter and starting a new life.
“I'm hoping that when I do finally get out and I'm on my own with my daughter that I don't do anything to separate us again. So she can have a normal life, because she deserves a normal life. Because, you know, she doesn't deserve to be unhappy and unstable and not know if I'm ever coming home or if she's going to be taken care of.
“She deserves to have that sense of security.”This IowaWatch story was published in The Courier (Waterloo-Cedar Falls) and The Gazette (Cedar Rapids).