Cocaine and Pregnancy—Time to Look at the Evidence

present a systematic review of studies assessing possible relationships between maternal cocaine use during pregnancy and several childhood outcomes. The authors are thoughtful and rigorous in their approach and carefully evaluate the physiological plausibility of the outcomes under question and the methodological strengths and constraints of the studies reviewed. They considered 36 studies worthy of review; these reported on 17 prospectively recruited cohorts with examiners blinded to cocaine exposure status. At the end of their effort, Frank et al conclude that crack/ cocaine exposure in utero has not been demonstrated to affect physical growth; that it does not appear to independently affect developmental scores in the first 6 years (although there are insufficient data to assess this for infants born preterm); that findings are mixed regarding early motor development but any effect appears to be transient and may, in fact, reflect tobacco exposure; and that exposure may be associated with modest alterations of certain physiological responses to behavioral stimuli that are of unknown clinical importance. In sum, the data are not persuasive that in utero exposure to cocaine has major adverse developmental consequences in early childhood— and certainly not ones separable from those associated with other exposures and environmental risks. Since many cocaine users also use other illegal drugs, drink alcohol, and smoke cigarettes, it is methodologically daunting to sort out consequences attributable to cocaine alone. Frank et al conclude that even those studies best designed to tackle this challenge fail to demonstrate that cocaine use by pregnant women leads to childhood devastation. The authors acknowledge limitations to their approach: data on postnatal sequelae must be considered preliminary, any differential attrition could bias results, and classification of exposure based on interview may be imprecise. Moreover, the studies in the meta-analysis do not include follow-up into middle school years and adolescence. However, even if future research reveals cocaine-related harm to the fetus, the modest and inconsistent nature of the findings to date suggest that these harms are unlikely to be of the magnitude of those associated with in utero exposure to the legal drugs tobacco and alcohol. Why then all the hullabaloo about crack babies? Why then the prosecution of 200 women who used cocaine while pregnant? Why was a program established to pay $200 to crackusing women as an incentive to become sterilized? What’s going on? The answer, perhaps, is 2-fold. The “crack baby” became the poster child for 1 side in each of 2 heated controversies in the United States: the war on drugs and the struggle over abortion. The war on drugs focused on individual moral failing rather than social circumstance, and comprised several basic approaches: an emphasis on drug law enforcement; an increase in severity of criminal justice penalties, including mandatory minimum sentences; and a comparative deemphasis on treatment of drug addiction. The escalation of this war occurred during the Reagan Administration, coincident with the rise of unemployment, homelessness, and urban poverty that fueled the crack epidemic. While cocaine in inhalation form had been a popular drug for the upper middle class in the 1970s, it did not draw the same media or political attention or severity of criminal justice response as did crack smoking by inner-city youth. There have been dramatic consequences of the war on drugs. The number of incarcerated individuals in the United States has more than tripled, resulting in the United States having the second highest incarceration rate in the world. Average length of sentence for drug offenders has tripled as well, while the proportion of inmates receiving treatment for substance abuse disorders has more than halved. While men still predominate within the incarcerated population, the proportion of women has increased sharply and at nearly double the rate for men. This increase has been most dramatic for minority women. From 1986 to 1991 the number of women incarcerated in state prisons for drug offenses increased by 828% for black women, by 328% for Hispanic women, and by 241% for white women. There have also been important public health consequences. Research regarding the physiological and behavioral components of addiction and development of treat-