The rate of drug-exposed newborns is spiking across New Mexico, as are entries into the foster care system. Is there a link?
While being examined by a gynecologist, a pregnant Doralee Urban did her utmost to keep calm and hide the track marks dotting her arms and neck.
The staff at a medical clinic in Pecos, New Mexico, a small village north of Albuquerque, made no sign that they were on to Urban’s injection drug use.
Some weeks went by and Urban, with big, brown eyes – a small heart-shaped tattoo under the left the one – was due for her second appointment.
“I mean — it was so obvious I was high and using and I thought, ‘Oh my god she knows.’”
Still, no word from the gynecologist that anything was amiss.
Come time for her third appointment, Urban, out of fear, never showed.
At 30 years old, Urban was pregnant, addicted and afraid. If caught using by her provider, Urban thought she’d lose custody of her first daughter — who was born four years before — and potentially the custody of her unborn child.
Not knowing who to trust or where to turn for support, Urban continued using cheap and abundant black tar heroin, her fear ultimately driving her to take action she can’t later undo.
Urban’s struggle points to a growing trend affecting pregnant women across America.
From 2004 to 2013, the proportion of infants born exposed to drugs — mainly opioids — increased nearly sevenfold in rural counties, almost double the increase in urban areas, according to a study published in JAMA Pediatrics in 2017. While the rate of drug-exposed babies born in New Mexico soared, so did the number of children entering foster care, which rose 16 percent from 2012 to 2015 .
Though seemingly connected, the correlation between pregnant moms struggling with addiction and children entering the foster care system is difficult to untangle in a majority rural state plagued by cycles of poverty and addiction. Exacerbating the trouble in linking higher rates of foster care to increased drug use is that New Mexico’s Children, Youth and Families Department has a publicity problem. One that could help explain why more and more children are entering foster care.
Treatment vs. Punishment
Alabama, Tennessee and South Carolina are the only states in America where it is considered a crime for a mother to be using drugs while she’s pregnant. But pregnant mothers in New Mexico have been prosecuted for using drugs.
So Urban and others are afraid they’ll be punished for their addiction, and are justifiably panicked over losing their babies to protective services.
Hospital policies vary, but if a baby tests positive for drugs in New Mexico, then the youth and families department will likely be notified.
Denicia Cadena, policy director of Young Women United, a community-building organization for and by young women of color, thinks sounding the alarm for every positive drug screen is unnecessary and prone to bias.
“A lot of these women have lived through trauma,” Cadena said. “You can imagine how scared they are when they hear protective services are coming after they deliver their babies.”
Cadena says women have every right to be afraid. New Mexico’s youth and families department has argued in court that prenatal drug exposure alone is sufficient grounds for establishing neglect.
A more balanced approach to prenatal drug exposure detected by hospitals can be found in criteria drafted by the University of New Mexico. It’s what providers like Marcia Panagakos, a licensed social worker specializing in obstetrics and pediatrics at Christus St. Vincent Hospital in Santa Fe, use to determine when a referral to protective services is warranted.
There are a few red flags says Panagakos, a self-described “baby advocate.” A mother showing up to deliver a baby with little to no prior prenatal care will likely trigger a referral. Or if a mother shares that’s she’s been using drugs but hasn’t been actively receiving treatment.
“If a mom with an opioid addiction only tests positive for methadone or buprenorphine, then there is no CYFD referral,” Panagakos said, because those drugs are prescribed to treat the mom’s addiction and stabilize the fetus. Medical research shows these drugs pose little to no harm to the womb.
Prescribing methadone or buprenorphine to pregnant mothers who have opioid addiction is the gold standard in medicine, based on four decades of research. If pregnant moms with opioid use disorder abruptly stop using during the first and third trimester, it can harm the fetus. Suddenly quitting may result in miscarriage or even stillbirth.
Methadone and buprenorphine, in conjunction with other therapies, are used at the Milagro Program, an outpatient clinic affiliated with the University of New Mexico Hospital, which specializes in treating pregnant women with substance use disorders.
“Of the 200 women we treat a year, roughly 180 have opioid use disorders,” said Dr. Larry Leema, Milagro’s medical director .“If a pregnant mom shows up late in her pregnancy with no prenatal care and is actively using, then it’s likely protective services will be called in.”
“Since our program has expanded in size, I’d expect it to mean less babies going into foster care because of drugs,” Dr. Leeman said. “Because that means more mothers are getting services before delivering.”
Substance Use and the System
New Mexico’s hospital discharge data, on par with nationwide trends, continues to see more newborns suffering from uncomfortable drug withdrawals.
In 2015, roughly 10 babies per 1,000 were born with a drug withdrawal syndrome in New Mexico’s hospitals, according to New Mexico’s Department of Health. Bernalillo County, where Milagro is based, saw 14.2 drug exposed births per 1,000 in 2015, a 57 percent jump from 2011.
In contrast, rural Rio Arriba County, located on the border of Colorado and New Mexico, saw 64.6 drug-exposed births per 1,000 in 2015 – an increase of over 100 percent since 2011, and six times the rate of the state’s average.
“The opioid epidemic is nothing new for Northern New Mexico,” said Bob Deane, supervisor of clinical services at Valley Community Health Center located in rural Española, a town with one of the highest overdose mortality rates in the country. “It’s a chronic problem that goes back generations. It’s only now getting attention because middle-class white people are dying on the East Coast.”
Deane says drug use, opioids in particular, causes the majority of the referrals to youth and families in the region he practices.
“Most of the young people coming into our buprenorphine clinic are either currently in the system or have prior involvement,” he said.
“I definitely see a clear link between drug use and kids entering the foster care system,” Deane said, adding it’s been that way for the17 years he’s worked in Northern New Mexico.
But in densely populated areas like Albuquerque — where Milagro is based — the effect of opioids on the foster care system is less apparent.
Milagro works in tandem with Dr. Andrew Hsi’s FOCUS program, which supports the development of at-risk newborns and children, some of whom have prenatal drug exposure. Asked whether opioid use among pregnant moms is driving up foster care rates, Dr. Hsi had this to say:
“Personally, I think kids entering foster care in New Mexico is not so much determined from drug-using parents or if their children may be exposed.” Rather, Dr. Hsi thinks the foster care entries uptick has more to do with “the child protection system and its process of investigation and safety determination.”
Ezra Spitzer, executive director of New Mexico Child Advocacy Networks, seems to agree.
“These high profile cases involved the deaths of children who did not enter care, but who had various levels of interaction with the system,” Spitzer said. “Some of us have wondered if the increase has been an overreaction, that the department right now is on the defensive.”
New Mexico’s Children Youth and Families did not return e-mails or phone calls for this story.
“While we’re committed to improving the health and well-being of all New Mexicans, especially our children, we haven’t evaluated the relationship between the number of children entering the foster care system and neonatal abstinence syndrome in New Mexico,” said Paul Rhien, who works at New Mexico’s Department of Health.
A Pregnant Mother’s Fear
The phrases “cycles of poverty” and “generations of trauma” were brought up in almost every interview while researching drug use and foster care in New Mexico.
The trauma experienced by Urban, who was crippled with fear while pregnant and addicted, fueled her drug addiction, and eventually led her to terminate her second pregnancy after her partner became violent one night.
Fearing for her own life, and the lives of her four-year-old daughter and unborn baby, Urban dialed 911 and SWAT arrived.
“I had broken glass stuck in my feet when police asked for my urine,” Urban said. “They found out I was using and pregnant – they called in youth and families.”
Urban said protective services told her that she needed to find someone to take care of her daughter or they would find her a place that would. Unable to reach out to her own family members, who had problems of their own, Urban called her daughter’s fraternal grandmother who accepted responsibility for the child.
Meantime, Urban was given six weeks to show youth and families that she was “fit” for mothering.
Urban left the police station that night without her daughter. She came home to a house “ransacked” by the police. She was pregnant, afraid and, heartbreakingly, alone.
“After that night I used more than I ever had,” she said. “I hoped the shot would stop my heart.”
Not long after the violent episode, followed by a dark binge, Urban decided to terminate her second pregnancy.
“I couldn’t bring myself to put a baby through the kind of life I was living.”
It’s too many stories like Urban’s that fuel Cadena’s activism at Young Women’s United.
As policy director, the fast-talking Cadena finds ways to support women who she calls “mamas” like Urban.
“How come no one asked her if she was OK to go home after she was attacked that night?” Cadena asked after hearing Urban’s troubling night of violence. “No one asked, ‘What do you need, Dora? Housing, food, counseling – maybe help getting out of these situations.’”
Cadena thinks women like Urban deserve all the above.
“Healthcare providers are right to worry about health and safety of the baby,” Cadena said. “But generations of trauma have led that mother up to that point.”
So healthcare and social services, Cadena says, also need to focus on supporting a healthy mom and a healthy family. That means getting drug-using partners, whether they’re men or women, the right kind of support, too.
Urban was eventually arrested for burglarizing a drug dealer. Instead of jail, she was offered transitional living.
Now, she no longer uses drugs.
“I met a man on the same path as me who wants what I want,” Urban said. “We’re expecting a child of our own.”
Though she never lost custody of her first daughter, who’s now 7, youth and families recently approved their reunification.
“No one ever told me that my life is worth fighting for,” Urban said. As an advocate, that’s her message to other moms who struggle with addiction.
“If their life matters, then their baby will be fine.”
Zachary Siegel is a master’s degree candidate at the University of Southern California’s Annenberg School for Communication and Journalism. He covers science and health for numerous news outlets. Follow him on Twitter.