Pregnancy, Drug Use, and Why Prison Is Not the Solution

@HuffPost

In New Hampshire, a bill to redefine opioid use or addiction in “custodial parents,” including pregnant women, as child abuse is making its way through the legislature, despite vocal objection from the state’s medical community. Much media treatment of this bill and similar bills in other states presumes women are not generally held criminally responsible for terminating—or losing—a pregnancy.

This illusion is increasingly hard to sustain.

In March 2015, Purvi Patel, a 33-year-old woman in Indiana, was sentenced to 20 years imprisonment for, prosecutors claim, inducing an abortion. Patel has maintained she had a miscarriage, and has never tested positive for any of the abortifacients the prosecution claims she took. In fact, the pathologist for the prosecution partially relied on the long discredited “lung test“ to determine if the recovered fetus had been born alive: a practice from the 17th century disproven as bad science over a century ago. Whether a miscarriage or an induced abortion, it is clear that Patel is in jail for not carrying a pregnancy to term.

Indeed, state legislators increasingly seek to hold women criminally responsible for not having healthy pregnancy outcomes. Since the beginning of this year, at least eight state legislatures have introduced bills to redefine legal personhood as starting at “fertilization” or “conception.” Though voters have generally rejected personhood measures when put to a vote—three times in Colorado alone—they keep resurfacing in new versions.

From a medical perspective, fetal personhood bills make no sense. “Conception“ is not a medical term and is interchangeably used to refer to the moment an ovum is fertilized and the moment a fertilized ovum implants in the uterine lining. “Fertilization“ is a medical term—referring to fusion of male and female gametes to form a zygote—but not all fertilized ova implant in the uterine lining (that is: not all result in a pregnancy), and the precise moment of both fertilization and implantation is hard to determine. As a result, the length of a pregnancy is usually calculated with reference to the pregnant woman’s last period—when she clearly was not pregnant yet—because that moment is an observable factor that can be defined.

There are also obvious logistical problems with fetal personhood bills. An estimated 10 to 20 percent of known pregnancies end in miscarriages, with the actual number likely much higher as many women miscarry before they know they are pregnant. In addition, the risk of miscarriage is higher for specific groups of women, such as older women, women with weight problems, women who have already miscarried, those who have contracted infections or who have immune response issues, and those who regularly use drugs, including alcohol and nicotine.

As a result, the implementation of fetal personhood laws would require unconstitutional discrimination and invasion of privacy. If a fertilized ovum has the same rights as a person after birth, each miscarriage (or failure to implant) would need to be scrutinized for intentional or reckless neglect. Detection would only be possible by registering all incidents of unprotected sex, and effective surveillance would require regular pregnancy testing, in particular of women at risk of miscarriage (think mandatory weekly pregnancy testing for women over 40 until they reach menopause). Of course, no one is advocating this.

Proponents of punitive pregnancy-related provisions have, however, successfully advocated for the growing surveillance of pregnant women from marginalized or stigmatized communities through social services, and in particular through medical providers. The organization National Advocates for Pregnant Women has documented the growing arsenal of state laws that treat drug use and addiction in pregnant women as a form of child abuse. Because health care providers in all states must report child abuse to the authorities, this reframing forces doctors and nurses to breach patient confidentiality for pregnant women who admit to struggling with drug use or addiction. The predictable result is a breakdown in the therapeutic relationship at best, and at worst, a reluctance to seek care at all for the women who arguably need it the most.

Many of these bills are pushed through without consulting the medical community, which is the case for the bill currently pending in New Hampshire. House hearings are under way, and both pediatricians and obstetric-gynecologists will testify to its predictably disastrous effects on the provision of addiction treatment and child welfare.

To be sure, both child abuse and drug addiction are serious matters, which require appropriate state support. Attempts to redefine drug use or addiction as child abuse in pregnant women, however, disregard the medical and psychological needs of both abused children and pregnant women. Advocates of such legislation are attempting to transform the fiction of fetal personhood into law by appropriating the problem of child abuse and punishing pregnant women in need of treatment for substance dependency or addiction.

A fetus is not a child and a women’s right to choose an elective abortion should not be circumvented by legislating punishment for women in need of treatment for substance use disorders. Legislators should listen to the medical community. Whether the conversation is about elective abortion, treatment for substance use disorder, or any other medical intervention, decisions about care are best made by the patient in private consultation with her doctor.

Teenagers Have Sex: Deal With It

@RHRealityCheck

This week, a two-year-old program allowing New York City schools to distribute emergency contraception (EC) in high schools finally made news, and not in a good way. Though schools allow parents to “opt out” of the program, some parents say they should have been asked to “opt in.”

This would make it even harder for kids to access EC (sometimes known as the “morning-after” pill). This is a serious mistake. I don’t think parents should be asked at all. They should be informed when their child enters high school that EC is available, and again if or when their daughter needs it. The health professional should also have the option of not informing parents at all, if the child expresses compelling reasons not to do so.

First, some context for how the program was conceived and implemented.

New York State has the eleventh-highest teenage pregnancy rate in the nation, with almost 60 pregnancies per 1,000 girls, ages 15-to-19 each year. Thirteen percent of U.S. teens have had sex at age 15, and about 70 percent by the time they are age 19. In New York State, approximately 40 percent of high-school students are sexually active. While 85 percent of teenagers say they use contraception during their first sexual encounter, contraception has been known to fail (and teenagers have been known to exaggerate.) Then there are the remaining 15 percent (plus) who don’t use any protection.

Clearly, high school—and potentially middle school—is ground zero for prevention. New York City has stepped up to the plate in recent years with the morning-after pill program and a city-wide sex-education mandate.

The teen-pregnancy rate in New York and other states with similar rates is not likely to drop anytime soon. A month ago, a New York Civil Liberties Union report on sex education in New York state revealed how little and how poorly students are being prepared for the sex they are having. And at what cost. Those under the age of 19 account for approximately one-third of all newly diagnosed sexually transmitted infections in the state. And not surprisingly, teen mothers are much less likely to graduate from high school than their peers who are not pregnant.

Here are a few other thoughts on why comprehensive sex education should be mandatory, and the morning-after pill available to all high-school students, regardless of where they live.

• Many teens have sex, whether you tell them about it or not. And telling them not to have sex definitely does not work. Abstinence-only sex education has been proven to fail time and again. My devoutly Catholic adoptive mother, a lifelong education professional, told me more than once that working in middle schools made her want to stand in the hallways and hand out condoms.
  
  
  
• The majority of teenagers, especially younger ones, do talk to their parents about sex. Those who do not usually have good reasons not to. Studies have shown that kids are very good at predicting their parents’ reactions. Even those who do talk to their parents don’t always get the full picture. More than three-fourths of teenagers don’t know how to bring up sexual-health issues that their parents haven’t already addressed. If parents do not bring up the morning-after pill or any other contraceptive option, teenagers may have to depend on piecemeal (and often incorrect) information from peers.
  
   
• The morning-after pill safely prevents pregnancy after a condom has broken; after a sexual encounter in which the partners were too embarrassed to ask about contraception; after rape; or in any other emergency. But the morning-after pill is effective only when used within a narrow time frame. If EC is readily available in schools, it can speed up the process.

The fact is, I can't imagine what would possess a parent to prevent his or her child from accessing information or health care they might need.

More important, I don’t believe parents have the right to do so. Children are entitled to be heard, and to have their interests protected. If there is anything I have learned from interviewing teen mothers across the Americas, it’s that we cannot assume that parental decision making in the area of sexuality is always in the child’s best interest.

I am not a disinterested party. My daughter, if things go as planned, will be a New York City high-school student in five years. Statistically speaking, she is likely to have sex at some point shortly thereafter. I want her and her classmates to be able to negotiate safe, consensual, and enjoyable sex. I want her to have access to the morning-after pill as soon as possible, should she need it—whether at school or over the counter at the pharmacy.

The real news flash of the week should have been: Teenagers have sex. Deal with it.

Bloomberg's Breastfeeding Initiative: Let's Start With Paid Parental Leave....

@RHRealityCheck

New York City Mayor Michael Bloomberg has again been the focus of criticism for promoting a “nanny state,” this time for his initiative to further breastfeeding by preventing hospitals from displaying and promoting breast milk substitutes. The many voices in the outpouring of criticism that followed the unveiling of Bloomberg’s new plan are right about one thing: most women's decision to breastfeed is not determined by where and whether hospitals display breast milk substitutes on their shelves. But most criticism has focused on a somewhat illusionary notion: choice.

And by this I don't mean that women in the United States have no choice in the matter: obviously, we do.

What I mean is that choices, everywhere, are determined by our circumstances. When a substantially larger percentage of women in Western European countries, as compared to the United States, consistently choose to breastfeed and to continue to breastfeed past 3 months, logic has it that circumstances in those countries facilitate the healthier choice (which, undisputedly, in most cases is continued and exclusive breastfeeding for at least 6 months).

And what are those circumstances?

Here's a hint: it's not that European countries hide breast milk substitutes on the back shelves far away from maternity wards. Sure, many hospitals in Europe aggressively discourage bottle-feeding, but breast milk substitutes are freely available and the shaming of non-breastfeeding mothers—which many critics of Bloomberg's initiative rightly point to as counterproductive—is no more or less strong than in the United States.

The fact that more women breastfeed in Europe is also not an indication of European women lagging behind their American sisters in terms of emancipation and modern living. If true, this might make European women more likely to live traditional homemaker lives with time to breastfeed. Women in Europe face different, not more, obstacles to equality than women in the United States. The pay gap between men and women has long been less pronounced in Europe than in the United States, whereas legal protections against sexual harassment are stronger in the United States than in most European countries.

Many of those who criticize Bloomberg's initiative refer to the fact that some women just can’t breastfeed, and they shouldn’t be made to think they are lesser or worse mothers because of it. And, yes, that is obviously an issue. Some women just do not produce milk, regardless of how long and how well they teach their newborns to suckle. But it would be facile (and, frankly, naïve) to conclude from the difference in breastfeeding statistics that substantially fewer women living in the United States are physically able to breastfeed. There is, after all, nothing in the water (one would hope) that so systematically impairs our bodily functions.

There is, however, something in our laws. The key difference between Europe and the United States when it comes to breastfeeding are legal protections of paid parental leave, paid sick leave, and, in some cases allowances for longer lunch hours to breastfeed.

Consider this: in Denmark, where I gave birth and started breastfeeding my daughter, women have a right to at least 46 weeks paid leave after birth (unless your union got you a better deal). After living seven months in Peru (where women are entitled by law to 90 days paid leave to be taken before or after birth, and an additional one-hour break for breastfeeding while at work until the new baby is six months old), I moved to the United States for a full-time job. My daughter was then eight months old and had until then been exclusively breastfed.

My conditions were comparatively good. I had an office with a lock on the door, and I could organize my meetings and other work around the regular pumping I needed to do to maintain the flow of milk. Crucially, there was a fridge where I could store the pumped milk to later bring home to my daughter. Even so, my milk production, which
had until then been copious, all but seized in a few months, largely due to the difficulties in keeping a rigorously regular pumping (and water intake) schedule and—who am I kidding—the physical discomfort the pumping caused. And I am not alone. Many women find it hard to keep up a steady breast milk supply when returning to work after time at home.

So imagine what might happen to a new mother without such discretionary protection, and with only the narrow extended (and unpaid) sick leave afforded by the law. She'd be back to work after 12 weeks (or less) of unpaid leave, often have no place to pump, no allowance for time to pump, and no place to store the milk.

Equally to the point, the oddly myopic view of what's at stake in the breastfeeding debate that was displayed in last week's criticism of Bloomberg's initiative suggests that new mothers enjoy little understanding from co-workers, employers, or even those claiming to represent women's best interests.

At best, we are encouraged to feel empowered in rejecting breastfeeding and Mayor Bloomberg's blame politics. At worst, we are told bottle-feeding is the price we pay for equality. The former is a limited read of reality, while the latter is just plain wrong. There are more effective ways than blame and coercion to encourage healthy breastfeeding for women who want to lactate and are physically able to do so, starting with paid parental leave.

Deserving vs. Undeserving? Everyone "Deserves" Human Rights

@RHRealityCheck

Most of the issues highlighted during this year’s run-up to the US presidential election are framed in terms of separating the deserving from the undeserving. Abortion for rape victims, but not those who want to have sex. Immigration for the politically persecuted, but not those who move across borders because they need to find a job. Marriage benefits for those who have sex with the right people in the right way.

This debate misses the point in two key ways.

At the most basic level, the issues at hand are basic human rights and not dependent on who "deserves" what: we have a right to access to abortion, health care, work, and freedom and movement because we are humans, not because we deserve it.

But also as a political process, it is ineffectual to focus policy debates on whether or not specific people deserve the services and public goods they clearly need.

I was reminded of this the other day as I was boarding a plane and the flight attendant asked me about the meaning of my t-shirt which read: “Immigration is the sincerest form of flattery.”

"But does that mean you are for it or against it, though,” he asked. I was stumped for words.

Immigration is a reality, just like so many other issues people insist on declaring themselves “for” or “against.” Abortion, adolescent pregnancy, sex outside marriage, sex work, identifying as lesbian, gay, bisexual, transgender, or intersex… the list could go on.

None of these issues is fringe. One in three women in the United States will have an abortion by the age of 45. Every year, 750,000 girls between the age of 15 and 19 get pregnant in the United States. Ninety-five percent of all Americans have sex before they get married (or have sex and may never get married). While it is difficult to estimate the number of sex workers, the National Task Force on Prostitution estimates that over one million people in the United States have worked as sex workers. And a 2011 study shows that almost 9 million adults identify as lesbian, gay, bisexual,transgender, or intersex, i.e. about 4 percent of the US population. As for immigration, very few people in the United States do not trace their ancestry—even their recent ancestry—to immigration.

But more to the point, none of these issues will change through declaring them good or bad. The focus for a policy maker should be how to generate policies that most effectively guarantee the maximum level of welfare and human rights-enjoyment for everyone. And from that perspective, whether someone is “deserving” or not is irrelevant.

Abortion and adolescent pregnancy numbers depend on access to comprehensive sex education and contraception. Choices about sex work and immigration to a large extent depend on available work and whether individuals are able to provide for themselves and their families in any other way. And those who believe they can change someone’s sexual orientation or gender identity just by saying they “don’t believe in homosexuality” are more delusional than most. Even those who make a career out of not believing in homosexuality can’t change their own (completely legitimate) sexual orientation.

There is, of course, an enormous difference between the issues high-lighted here: some are medical procedures, some life experiences, some innate traits. However that may be public policy on health, sexuality, immigration, and employment should not be designed to punish us for being who we are or for doing what we feel we need to do, but rather make sure everyone is equally empowered to make the best choices for themselves.

Sensationalizing Drug Use in Pregnant Women: How the Media Perpetuates Racist and Ineffective Policies

@RHRealitycheck

Well before anyone could be certain of how Whitney Houston died, several news outlets rushed to describe her as a “crack cocaine user.” And in all likelihood many will think of the popular singer as succumbing to illegal drugs, even if alcohol eventually is found to be more closely related to her demise.

This is not all that different from how the media deals with infant and child health.

Regardless of the actual causes behind low birth weight, infant mortality, and early childhood health issues, media reports are sure to blame the “crack baby syndrome” or, more recently, women’s abuse of prescription pain killers.

This kneejerk reaction is unhelpful for a number of reasons.

First of all, a pregnant woman’s use of illicit drugs is neither the only nor the most damaging pregnancy phenomenon from the point of view of infant health.

Take, for example, legal drugs, such as alcohol and cigarettes. Peer reviewed research shows that over-consumption of alcohol can cause fetal alcohol syndrome (linked with permanent mental retardation), whereas cocaine seems to act only as one contributing factor in some pregnancies to increase non-permanent risk factors such as low birth weight. Approximately twice as many pregnant women drink alcohol frequently as use illicit drugs frequently during their pregnancies.

Epidemiological research published in the mid 1990s shows that the use of tobacco products in the United States at the time was responsible, each year, for tens of thousands of tobacco-induced miscarriages, infants born with low birth weight, infants who require admission to neonatal intensive care units, as well as an estimated 1900 to 4800 infant deaths. Though smoking has gone down over the past decades, around 17 percent of adult women in the United States still smoke, and generally continue to smoke during their pregnancies.

Even drugs administered to women who are in fertility treatment have been associated with low birth weight and premature birth.

Or let’s set aside drugs altogether. Malnutrition in pregnant women is one of the main causes of low birth weight and infant mortality worldwide. In this sense, it is worth noting that food insecurity and hunger has grown steadily in the United States since the start of the latest financial crisis in 2008. (Food insecurity exists whenever the availability of nutritionally-adequate and safe foods or the ability to acquire foods is limited or uncertain). According to the latest figures, about 17.2 million households in the United States suffered food insecurity in 2010, the highest number ever registered. Yet the government’s food stamp program is increasingly under attack by pundits and politicians.

Secondly, even a superficial read of arrest and prosecution figures for drug use during pregnancy reveal such a severe race and class bias that the very legitimacy of the approach must be questioned.

Since 1985, 80 percent of the more than 200 pregnant women or new mothers in over 20 states who have been arrested and charged with crimes related to substance use during pregnancy were black or Latina. In 2000, research in Pinellas County in Florida found that while white women and women of color used illegal drugs at comparable rates, black women were 10 times more likely than white women to be reported for child abuse related to substance use during pregnancy. That same year, data from the National Institute on Drug Abuse showed that while black women had a higher overall rate of illicit drug use than white women, most women who use illegal drugs during pregnancy were white. Even so, 41 of the 42 women arrested in South Carolina under a mandatory drug testing program were black. (The program was suspended in the mid-1990s because of allegations of racial discrimination).

Meanwhile, research published in 2006 shows that newborns with white mothers are much more at risk of alcohol and tobacco exposure than newborns with black or Latina mothers.

Moreover, in many cases women with private health insurance are not mandatorily tested for illicit drug use during pregnancy. In this sense, poverty itself is what singles a pregnant woman out for persecution. It is no coincidence that the main focus for drug prosecutions for pregnant women in the United States is crack cocaine, a drug almost exclusively used by the resource-poor. As Whitney Houston herself famously said in an interview in 2002: “I make too much money to ever smoke crack.”

The point here is not that pregnant women should use cocaine, or that the government—and society as a whole—does not have a legitimate interest in ensuring infant and child health.

The point is that the prosecution of drug use in pregnant women does nothing to fulfill a legitimate policy goal and in fact seems to be racially motivated—at least in the implementation—rather than spurred by a concern for children.

In fact, if the objective is to improve infant and child health, efforts to overcome poor nutrition, alcohol addiction, lack of adequate health care, physical abuse, and/or homelessness would make for much better investments. Sadly, such policies don’t make for as sensational news.