Pregnant Drug Users: Scapegoats of the Reagan/Bush and Clinton Era Economics

January 13, 2001

By: Sheigla Murphy and Paloma Sales


INTRODUCTION

In this paper we present analyses of two National Institute on Drug Abuse-funded studies entitled, "An Ethnographic Study of Pregnancy and Drug Use" (Rosenbaum and Murphy 1991-94) and "An Ethnography of Victimization, Pregnancy and Drug Use," (Murphy 1995-98). Our goal is to explicate the ways in which pregnant drug users in the San Francisco Bay Area experienced, coped with and protected themselves from increasing stigmatization, abuse and punishment while enduring a period of fiscal retrenchment of government assistance programs.

Beginning in the 1980s, there has been a trend toward social welfare programs changing from the federally mandated and funded programs developed in the 1960s, to the state-by-state directed programs funded through federal block grant mechanisms. These policies were advanced during the Reagan/Bush administrations and continued during the Clinton era. As a result of shrinking budgets at the state level, numerous social service programs shifted to public subsidization supervised by local governments and finally, to privatization or the purchase of privately produced services. Historically, human service program provision tends to be downsized as programs move from federal to state to local supervision (Feldstein 1988).

For pregnant drug users with limited means, these funding decisions created barriers and denied access to cost effective services that would enable them to improve their lives. As a result, they were forced to find alternative resources and to construct survival strategies. The women we interviewed reported drug use helped them overcome some of the adversities in their daily lives. It was sometimes a source of income and usually a source of solace and recreation. Although drug use helped interviewees survive on a day-to-day basis, in the long term, women faced severe consequences. In a political context of social welfare reform, our interviewees' ability to care for themselves and their children was extremely compromised. Our collection of data over an seven-year period enabled us to chart interviewees perspectives and experiences within changing social and policy climates. In the following, we detail the ways in which pregnant drug users served as ideological offensives in the United States war on drugs. Pernicious images of drug using mothers having babies for the sole purpose of qualifying for government handouts in order to buy drugs and then neglecting and abusing these children were promulgated by the media and politicians (Campbell 2000; Humphries 1999).

These images contributed to the passage of legislation and funding allocations that resulted in the wholesale reduction of social welfare services to all poor women and children. The war on drugs has always been a war on the poor, particularly people of color (Maher 1992; Murphy and Rosenbaum 1999). In 2001, it is clear that drug use and drug users have played a very important role in defining women's and children's poverty as an individual behavioral problem rather than the result of systematic, structural economic inequities.

METHODS

An Ethnographic Study of Pregnancy and Drugs

"An Ethnographic Study of Pregnancy and Drugs" conducted between 1991-1994 was a study of drug use during pregnancy in the San Francisco Bay Area (Rosenbaum and Murphy 1991-94). We employed fieldwork, depth-interviewing and closed-ended questions as the primary data gathering tools. We interviewed a total of 120 pregnant or postpartum adult women who were using heroin, methamphetamine or cocaine singly or in combination for a minimum of 25 days during their current or most recent pregnancy. Women who were enrolled in drug treatment more than five days within a four-week period were not included in the study. Those women who were in treatment for less than five days had to have returned to drug use for five or more days since their last day of treatment. These criteria allowed us to interview women who had brief encounters with drug treatment and had subsequently returned to drug use. Therefore, we were able to explore women's reasons for leaving treatment.

In order to fully explore AIDS risks, attitudes and behaviors, half (twenty) of the women interviewed in each of the three stages of pregnancy (discovery, five months to delivery and six months postpartum) were intravenous drug users (IDUs). IDUs were defined as those women who had injected heroin, cocaine, or methamphetamine at least once a week during the six months prior to discovering their pregnancy. These inclusion criteria permitted us to examine the changes in drug administration before and after the onset of pregnancy. Non-injection drug users were defined as any woman who had not injected drugs in the previous two years. Each of our subgroups, IDU and non-IDU in each stage of pregnancy consisted of twenty subjects. Our past research demonstrated that a minimum of 20 interviews is necessary to discover meaningful patterns and to produce a robust theoretical framework.

In the course of the life history interviews the interviewer and study participant explored the introduction and initiation to each drug used, social environments of use, pressures to use or not to use, the relationship of pregnancy to patterns of use, and barriers to treatment. The other areas of inquiry included methods of ingesting drugs; violence; involvement in criminal activities; and high-risk AIDS behavior (including needle sharing and sexual practices); level of involvement in prenatal care; living arrangements and sources of income.

The ethnic breakdown of the sample was 53% African American (n=64), 34% white (n=41), 7% Latinas (n=9), and the remaining 6% were Asian, Native American or Pacific Islander. Eighty-eight percent of the women relied on public assistance to support themselves and their children. Approximately 40% were homeless at the time of interview and another 20% lived in publicly subsidized housing projects in neighborhoods characterized by high levels of drug sales, drug use and violent crime.

An Ethnography of Victimization, Pregnancy and Drug Use

Our second study entitled "An Ethnography of Victimization Pregnancy and Drug Use" conducted between 1995 - 1998 was an exploratory depth-interview study of pregnant drug users who experienced one or more victimizations (physical, sexual and/or emotional) while pregnant (Murphy 1995-98). This project was developed as a result of findings from the previous study of pregnancy and drug use which indicated pregnant drug users experienced an extremely high incidence of violence. Of the 120 women we had interviewed in the previous study, 78 (65%) were or had been in abusive relationships. We began this project by using ethnographic field work methods to locate and recruit women who were pregnant or recently pregnant and had used marijuana, crack/cocaine, heroin/opiates and/or methamphetamine singly or in combination. During the first phase of the study we collected information concerning demographics, family, drug use, relationship and reproductive histories employing a structured questionnaire. This instrument was designed to measure levels of drug use and victimization. Those who had experienced violence while pregnant were asked to participate in the second phase, a qualitative depth interview focusing on their drug use and victimization histories with an emphasis on victimizations experienced during pregnancy. Originally we estimated that we would have to recruit approximately 300 women in order to enroll 100 who had experienced victimizations and agreed to participate in the second phase. As it turned out, we only had to recruit 126 women, since 79% (n=100) of the women we surveyed had experienced physical and emotional violence during their most recent pregnancy. Violence was much more prevalent than we had estimated.

The mean age for this sample was 29. Only 9% were married, 63% were in a relationship and 28% were single. Fifty-two percent were African-Americans, 27% white, 15% Latina, 6% Native American or Asian/Pacific Islanders. Forty-one percent were primarily crack users, 28% marijuana users, 19% heroin users, 7% used powder cocaine, and 5% used methamphetamine. They had inadequate financial resources, lived in substandard housing, lacked marketable job skills and adequate support systems. They had one-fourth the income and more children (2.2 versus 1.6) than the general population of women in the San Francisco Bay Area (U.S. Census Bureau, 1990). They were three times as likely to have dropped out of high school and far less likely to have been in college. Fifty-seven percent of the sample had no permanent housing. Of those, 27 (37%) were temporarily living in a friend's or relative's home, 23 (32%) were homeless, 15 (21%) lived in SRO (single room only) hotels, and 7 (10%) lived in residential treatment facilities or group homes. Over two-fifths of the sample (42.9%) reported they had been homeless for three or more days in the six months prior to the interview.

Throughout this paper when we quote directly from interviewee's transcribed narratives we will indicate in which of the two studies (PAD for the first study, PAV for the second study) the interviewee participated. Participants in both projects were predominantly women of color, unemployed and living close to if not below the poverty level. They were directly impacted by cuts in social spending during the Reagan, Bush and Clinton administrations.

WELFARE REFORM

Welfare reform was a direct consequence of changes in how poverty was defined. During the Great Depression, when high unemployment created a large population of impoverished people in the United States, poverty was defined as a structural problem stemming from blocked opportunities. Poverty was seen as something that government intervention could break because people needed a "hand up" in order to actively rejoin the economy (Patterson 1981, p. 142). The New Deal of the 1930s included programs to help aging workers, the unemployed, and the poor. Economic growth in the United States following World War II allowed for taxing and spending policies that afforded national financing of a wide array of social services for impoverished segments of society. In this context, social welfare programs flourished.


Social welfare programs were further expanded, particularly in the aftermath of the Civil Rights movement. Racial discrimination as a source of inequality became a legislative focus. Media coverage of Civil Rights protestors being arrested by police during peaceful marches portrayed the law and the status quo negatively (McAdam 1996). The Civil Rights movement effectively brought attention to racial inequality in America reinforcing the tenet that poverty was not an individual behavioral problem, but a systematic and structural problem. The high rates of poverty among blacks indicated that blacks were being systematically excluded from the economy through lack of opportunity for advancement. Inferior education in racially segregated schools yielded limited employment possibilities and career advancement, which in turn decreased income earning capacity. Curtailed earning capacity made it nearly impossible to escape poverty. The inability to break out of poverty resulted in disillusionment with the system. Negative attitudes and expectations regarding the economy were then passed on to the children of the poor and impoverishment continued. This disillusionment with a biased system was reflected in films like West Side Story where juvenile delinquency was portrayed as a new social problem attributed to institutionalized poverty and lack of opportunity, not individual deviant behavior. Poverty continued to be attributed to America's racially biased economic system (Patterson 1981).

The War on Poverty policies of the mid 60s and early 70s opened doors of opportunity for economic advancement (Patterson 1981). Some of these new programs included community action programs that empowered communities by allowing them to assess what their community needed and how to spend government funds. The Head Start program provided breakfast to poor children in order to optimize their performance in school. The JOBS corps offered job training and placement services. New policies also created floors or safety nets below which no American was supposed to fall (Patterson 1981). These safety nets or floors included the creation of a two-tier medical insurance program: the federal program, Medicare, benefitting the elderly, and the state program, Medicaid, benefitting the poor. Aid to Families with Dependent Children (AFDC) and Social Security Insurance (SSI) provided in-kind assistance in the form of food stamps, subsidized housing, and income assistance to families with children, the disabled and the elderly who did not qualify for social security.

However, as this historic cycle of growth came to an end in the 1970s, what O'Connor (1973, p.2) has called "the fiscal crisis of the state" became a palpable reality. Simply put, the fiscal crisis was the growing excess of demand for services over the capacity to finance them. Conservatives condemned the paternalistic government approach complaining that welfare programs were coddling those who were not working. As the 70s came to an end, poverty was no longer seen as a structural problem, but as an individual behavioral problem.

Pregnant Drug Users as Ideological Offensives

Vincente Navarro, a medical sociologist who analyzed trends in national and international health care provision, reminds us that radical restructuring of the social welfare system ". . .cannot take place only by repression but has to rely on active ideological offensive that could create a new consensus around a new set of values, beliefs and practices" (1986, p.26).

Employing Navarro's suggested analytical lens, we can examine how the media images of the "welfare queen" and pregnant crack smokers as inhuman monsters during the waning years of the twentieth century can be understood as such an active ideological offensive. We contend that the social construction of the "welfare queen" and the so-called "crack baby" functioned to legitimate the downsizing and de-funding of services for poor women and their children in the inner cities, who were also disproportionately women and children of color.

The Social Construction of the "Welfare Queen"

During the 1980s, the poor were seen as an underclass engaged in dysfunctional behavior with values that differed from those of mainstream Americans. They were depicted in news reports as drug users, criminals and freeloaders who did not live up to mainstream standards (Humphries 1999). The stigmatization of the poor was buttressed by the Reagan administration's characterization of the "Welfare Queen" (the undeserving poor) as an African American urban female having babies in order to collect welfare, racializing the responses of mainstream America to welfare reform (Sales and Murphy 2000). Race is often a central force in determining how social problems are defined and in shaping which policy solutions are considered appropriate or possible. Media coverage of the shocking behavior of this already marginalized and stigmatized population sold newspapers and yielded high television ratings
(Campbell 2000; Cook 1998; Iyengar 1991). The unpopular press directed at the poor made welfare reform a good political position for politicians. Ronald Reagan was a vocal opponent of welfare programs, criticizing the policies of the 60s and 70s by claiming we had fought the war on poverty and that poverty had won. His argument was based on the dramatic growth in the welfare rolls during the 1970s. However, more families on welfare did not mean more Americans were poor. More people were on welfare because program changes made it easier for income-eligible families to get benefits (Besharov 2000; Yoo 2000). Patterson (1981) explains how receiving welfare benefits actually raised these families' incomes above the poverty line. He calculated "pretransfer" incomes of the poor (before factoring in welfare benefits) and their "posttransfer" incomes (after factoring in welfare benefits), finding that "[t]he decisive role of social welfare in reducing poverty is clear from a snapshot of pre- and posttransfer poverty in 1974. Without any public programs, 20.2 million American families, more than one-quarter of the total population would have been poor. With social insurance and public aid . . . Medicaid, food stamps, and other in-kind benefits, the number fell to 5.4 million, or 6.9 percent of all families" (pp. 165-6). Nevertheless, the media were already disseminating images that shaped public opinion concerning poverty as a behavioral problem. Reagan's trickle-down economic plan was aimed at ending the welfare system that coddled the poor. Such a plan justified concentrated wealth and economic power because theoretically, the wealth would trickle down and benefit the masses, eventually eliminating poverty.

As public opinion was swayed toward blaming the individual for his/her condition, Reagan's economic policies garnered broad bi-partisan support resulting in the modification and reduction in welfare programs including food stamps; school breakfast and lunch programs; and supplemental food programs for pregnant women, mothers and infants with little opposition or public outcry. Numerous nationwide studies of hunger conducted between 1982 and 1986 found that hunger, virtually eliminated in the 1960s and 1970s, had reappeared in the 1980s as a serious national problem (Maital and Morgan 1992). By 1988, women on AFDC were expected to actively seek employment even though AFDC was a social program originally designed to allow women to remain home and raise their children.

The Social Construction of the "Crack Baby"

Beginning in 1988, a new social problem, crack use, captured the nation's attention (Reinarman and Levine 1989; Reinarman, Waldorf et al. 1997). The image of poor inner city African-Americans whose mothering instincts had been destroyed by crack was highly publicized and widely accepted (Campbell 2000; Humphries 1999). Numerous media stories reported that the coming generation would comprise untold numbers of permanently impaired crack babies. It was predicted these impaired infants would topple the health care delivery and educational systems due to their expensive and lifelong problems. During the same time period, however, there was no comparable public discourse concerning the likelihood of huge expenditures of public resources for a much larger group of problematic infants, tobacco babies, despite considerable available scientific evidence documenting the serious implications for the unborn of maternal tobacco smoking (Armstong, McDonald et al. 1992; McDonald, Armstrong et al. 1992).

In 1991, findings began to emerge contradicting previous predictions about pregnant crack users creating a bio-underclass, or generation of permanently impaired children. It now appeared the relationship between maternal crack smoking and fetal morbidity was far from clear (Lutiger, Graham et al. 1991; Chasnoff 1992; Coles, Platzman et al. 1992). Poverty and lack of prenatal care were, in all probability, more significant contributing factors for the symptoms attributed to maternal crack-smoking (Mozes 1999). Other important work was done following up crack-exposed children which indicated that with proper care and parenting, by school age children developed on a par with their unexposed peers (Barth 1991; Coles, Platzman et al. 1992). During the same time period, there was no political move to jail tobacco-smoking pregnant women, or to force them to go to treatment, or to take away their children. Tobacco smoking was viewed as an unfortunate habit pregnant women should try to avoid. By contrast, crack smoking pregnant women and mothers were jailed, sentenced to treatment or lost custody of their children (Siegal 1990; Humphries, Dawson et al. 1992; Humphries 1999). Clearly crack dealers did not have as much political power as the managers of the tobacco industry. As Gusfield's (1981) important work on the development of public problems indicates, the capacity of certain groups to never have their situations labeled as public problems is a measure of their political power.

There are ideological explanations for why these infants continued to be labeled crack babies rather than, in light of scientific findings, poverty babies. In an era of fiscal retrenchment, the notion of poverty babies might engender public sympathy and interfere with the conservative drive to demolish social welfare programs.

The discourse continued to be manipulated to construct public images of urban recipients of federal entitlement programs (e.g., Aid to Families with Dependent Children) as unfit mothers selling their children's food stamps to buy their next crack rock. Such images performed a legitimating function for legislators trying to promote social policies that would reduce resources for all poor women and children, whether or not they abused drugs (Campbell 2000; Humphries 1999; Maher 1992). Throughout the last two decades, the administration of human welfare programs has been turned over to state and local governments, and this has usually resulted in shrinking service provision. This has coincided with an onslaught of negative media depictions of women on welfare, particularly women of color, as undeserving of public support due to their presumed drug abuse and child neglect.

The ideologies that emerged throughout the 1990s reflected the nation's view of individual responsibility for poverty. Mead (1992) took the position that the problem with poverty was not a lack of jobs, but poor people's lack of ability and discipline to hold down a job. He asserted that if government forced the poor to work it would lead to the collapse of the culture of poverty. Mead argued that government can change the undesirable behavior of the poor. Murray (1993) presented a more extreme view by claiming illegitimate birth was the sole reason for poverty. He postulated that if the government cut AFDC and other welfare programs, the poor would have no choice but to stop having babies and go to work. These ideologies, bolstered by negative media images of the impoverished, influenced public policy in the 1990s.

Between 1993 and 1996, welfare-to-work programs decreased the number of families on AFDC by 40 percent (Tepperman 1998). This does not mean that such programs were successful in eliminating poverty. They were simply effective in reducing the number of families on the welfare rolls. People leaving welfare for work typically earn $6 an hour which translates to $1,000.00 a month for a 40 hour week. Most of these jobs do not include insurance benefits. This level of income is still below the poverty line (Tepperman 1998). In 1996, Congress passed and President Clinton signed the Personal Responsibility and Work Opportunity Reconciliation Act (1996). The act's title alone reflects the move toward individual responsibility and away from state accountability. The new law, fully implemented nationwide by 1997, changed welfare from an entitlement program to state block grants (Burtless and Weaver 1997). Benefits were no longer guaranteed predicated on economic criteria alone. Distribution of benefits depended on the availability of funds in the block grant. The qualifying criteria and amount of benefits was left to the discretion of individual states. New time restrictions were implemented with a maximum of two consecutive years and a lifetime cap of five years after which recipients are required to secure employment. Recipients are now required to actively participate in job training and seek employment while receiving benefits, reflecting Mead's recommendation that government force the poor to work. The new law also echoes Murray's concerns that poverty is caused by illegitimate births. Teenage mothers are now required to live with their parents in order to receive benefits, preventing them from establishing their own welfare households. Benefits do not increase with the birth of additional children while enrolled. Food stamps and SSI are denied to legal immigrants. States are allowed to set shorter time limits, presenting a potential race to the bottom where states export their welfare recipients to more lenient neighboring states (Burtless and Weaver 1997). The new strict work requirements present a daunting problem for women who are expected to work and get off welfare while shouldering the responsibility of raising their children. Adequate and affordable childcare for working mothers remains problematic. While expectations regarding women's participation in the labor force have changed, expectations regarding women's primary responsibility for child rearing have not.

POLICY CONTEXTS

Drug Using Mothers-to-Be

Reproductive decisions for the women in our study were not economically driven as advanced by the Reagan administration and various news reports. Pregnancy was a period of deep, internal conflict. As with most pregnant women, the discovery period was characterized by ambivalence. Women identified body changes, ascribing or denying them as symptoms of pregnancy. This stage could last a few weeks through several months or more, during which women would privately alternate between admitting and denying being pregnant. This is what we termed the beginning of the private dilemma, because a public discussion (even with the father) was tantamount to acceptance of the impending birth. Public expressions of a woman's private suspicions usually meant her significant others would insist she get some concrete confirmation (a pregnancy test) or began interacting with her as a mother-to-be.

There were numerous reasons for this ambivalence. Many women both wanted and did not want to be pregnant. Children are an expensive and long-term commitment. For many women, pregnancy would result in deepening or sometimes initial commitment to their relationship with the father (this could be a pro or a con). Pregnancy also had a significant emotional component for most women. They expected to receive love from the baby, "someone of my own to love." Love from the father as in, "If I give him a baby, our love will grow stronger and more solid."

Drug-using women had to deal with another powerful source of ambivalence. Acceptance/announcement of pregnancy meant they (and most others) believed they should stop all drug and alcohol use immediately. Drug use was a form of recreation and also helped them to cope with emotional and physical problems stemming from the victimizations and traumas most had endured since early childhood (Sales and Murphy 2000). Tracy, a 39-year-old crack user found that the physical abuse intensified her insecurities; drug use helped her feel better about herself, promoting good feelings.

It (abuse) brought my self esteem down, very low. I looked very ugly. He told me I was ugly and I was nothing, don't nobody want me. Don't nobody care. And I believed him because my mother wasn't there, so I mean, what else was I to believe? I believed that nobody cared. And I just stayed in my own little world, and I guess that's when crack comforted me the most. (PAV)

For some women, the belief that their drug use had already damaged the developing fetus provided an acceptable rationale for terminating pregnancies. For others, denial of pregnancy was a way to have it both ways because they wanted the baby, but they also wanted to continue using drugs.

This private dilemma had implications for maternal and fetal health. Keeping the pregnancy private with no safe place where women could discuss ambivalent feelings and concerns had implications for obtaining health care and help during the pregnancy. It was complicated by the social, familial, moral, economic, and emotional issues that surrounded decisions to terminate or continue pregnancies. These issues (often in conflict with each other) served to prolong this discovery period and exacerbated the difficulty of women obtaining effective educational, medical, familial support or interventions. Women often did not accept the pregnancy until well into the second trimester as in Ellen's case:

Once the baby started moving, I guess, is what kind of really triggered me to get out there over to the hospital . . . I knew I was pregnant but didn't know for sure how far. So when the baby started moving, that like told me. I knew I was in the fifth month. (PAD)

Pregnancy increased women's responsibilities. The woman was now responsible for the effects/consequences of her drug use on her unborn baby. During pregnancy, protecting the baby's well-being included eating and sleeping regularly and seeking prenatal care. However, even after accepting the pregnancy, most women were reticent to go to prenatal care, especially if they believed they would lose custody of older children as well as the baby-to-be or be stigmatized or arrested. When asked what made it difficult for participants to go to prenatal care, the top four reasons mentioned were: 1) "worried that they will turn me in to Child Protective Services," 2) "worried that they may take my baby away," 3) "worried that the health care provider will look down on me or treat me badly because I use drugs," 4) "worried that they may turn me in to the police for drug use." Angela, a white marijuana user attended prenatal care, but was always cautious and never disclosed her drug use to her doctor because she feared she would lose custody of her baby:

I never gave them any indications to make them think that I was using. I was scared that if they knew, they would take my baby away from me. So, I never went in high. (PAV)

Joanna, a 32-year-old African-American crack user went to San Francisco General for her first appointment and never returned:

Why I haven't been back? `Cause I haven't been clean or nothin' and I'm scared somethin' else may happen when I go up there, `cause my test, I know I was dirty when I went. So, I'm scared they may lock me up. (PAV)

Some of the women were told directly by the health care provider that drug use could lead to the loss of their children. Eileen, a white, 21-year-old methamphetamine user related the conversation she had with a health care provider at a prenatal clinic:

She asked me if I was doin' drugs and I lied, I said I only smoke weed. She was tellin' me, 'Well, you know, I'm not gonna tell you not to do it because weed isn't that bad for your baby but I could a sworn there was some crank [methamphetamine] in your system. Are you doin' crank?' And I told her, I lied and said that I was around someone that was smoking it. 'The weed is all right, the weed is not, we don't really know what the weed is gonna do to the baby. But you need to stay away from the people that are doing hard dope' cause it keeps showing up in your system. And we're gonna end up taking your baby away.' (PAV)

Women balanced their babies' health needs with the risk of not being able to raise the baby themselves. They struggled with the question: In the long-term was it better for the baby to tell or not to tell? Although participants had very low rates of prenatal care attendance Ð 67% went between 0 and 2 times Ð they adopted their own strategies for maximizing their chances of carrying out a healthy pregnancy. A significant number (48%) reduced their drug use during the period between the fifth month of pregnancy and childbirth. A smaller number (20%) reduced their drug consumption during the first four months of pregnancy. However, we must consider that an interrupted menstrual cycle (amenorrhea) is a consequence of heavy drug use. Some women may not have realized they were pregnant until they began to show, thereby unwittingly postponing harm reduction strategies until the second stage of pregnancy. Amanda, a 34-year-old white woman managed to reduce her drug use:

Yes. I would try to cut down, but not every time but I did a few times. Yeah, when I was younger it was easier too, and then, well, as time went on it got harder, and now this pregnancy, it was very difficult but I cut down quite a bit. (PAV)

In addition to reducing drug consumption, the women also became conscientious about taking prenatal vitamins, eating well and getting as much rest as they could. Some, like Laura, even monitored the baby's movement and heartbeat:

I had a stethoscope. I listened to my baby's heartbeat every single day. I ate so much food while I was pregnant, from morning till I went to sleep. And I slept every night. I listened to the baby's heartbeat constantly. I documented her movements. I made sure I ate fantastic. I doubled up on prenatal vitamins because of the methamphetamine use `cause it would drain your body of nutrients. So I would double up on my prenatals. (PAV)

Birth was the final showdown, the end point of the troubled trajectory of their pregnancies. An important component of the final showdown was the public unveiling, the moment when women confronted their previously private fears and the baby was born. Jackie related her fear of giving birth to a drug damaged baby:

I'm worried. I really am. But then I pray to God, 'I'm trying. Just bear with me. Just please help my baby to be all right' . . . because if my child comes out and there's something wrong with it, I'll feel real shitty. I mean, I'll feel extra bad. (PAD)

Birth was, at the same time, a public moment when delivery-room staff evaluated the newborn's health, interpreted the possible causes of any negative outcomes and decided whether to initiate social welfare responses including the newborn and older children's removal from the home. Birth, and the multiple emotions which usually accompany this life transforming event, was often complicated by interviewees' heightened concerns for their infant's health. Even positive newborn outcomes did not absolve women from the guilt resulting from their drug use and its effects on their children's health and well-being. Some women noted that their babies were not as damaged as they expected and some reported no drug-related problems.

The other dimension of the final showdown was battling the baby snatchers since birth was the period of time when continued custody of children was most imperiled. Eliza, a 29-year-old African-American heroin user feared her baby would be taken away:

Well, you know, just heard about it from different people. And most drug addicts, you know, they say, 'Before you have your baby, stop using. They testing these babies. They taking babies.' And I say, 'God, you don't go through all of this to go to the hospital and have a baby for them to take it.'(PAD)

Women who retained custody began their mothering careers as failures because they used drugs during pregnancy and endangered their children. Women who lost custody of their infants usually began abusing their drugs of choice immediately, surpassing previous heaviest use periods trying to drown painful guilt and self-blame. Despite lifelong gender, race and class-based subjugation and stigmatizing drug use, study participants implemented strategies to reduce fetal harms and claim respectable social identities. These private struggles were embedded in a socioeconomic context characterized by increasing degradation and deprivation, and decreasing social support. Mothering must be placed in its historical and political framework in order to understand its importance for the women's sense of self and social position. It is also necessary to explicate the policy context in which our study participants began or postponed motherhood.

Mothering

Mothering is a social role with tremendous responsibilities, precious little preparation and ambiguous standards of good practice. People do not necessarily know how to tell a woman to mother, but everybody seems to know when she is doing it wrong. Being labeled an "unfit mother" has horrendous social consequences of personal and social condemnation and social isolation. (Maher 1992; Murphy and Rosenbaum 1999). Psychoanalyst Estella Welldon (1988) described the difficulties mothering presents for women:

Women are expected to carry out the difficult and responsible task of motherhood without having had much, if any, emotional preparation for it. Their responsibility is to bring up healthy and stable babies who will adapt happily to growing external demands. In fact, women really are in too lonely a position to deliver the goods properly, and this marks a fundamental difference between men and women....Mothers are expected by society to behave as if they had been provided with magic wands which not only free them from previous conflicts, but also equip them to deal with the new emergencies of motherhood with skill, precision, and dexterity (pp.17-18).

With all its loneliness, difficulty and ambiguity, becoming a mother continues to be the means by which many women achieve full adult status and demonstrate their feminine identity (Chodorow 1978; Oakley 1980; Notman and Nadelson 1982; Salmon 1985). Although the last fifty years have brought enormous changes in women's participation in the paid labor market, women continue to be defined in terms of their reproductive functions. Thus, failure to properly perform mothering responsibilities is tantamount to failure as a woman (Chodorow 1978; Maher 1992).

Our interviewees' mothering standards and values resonated with those of most American mothers: mothers should protect their children from harm; keep them fed, warm, presentably dressed and clean; and see they are educated, prepared for the work world and shown right from wrong. These goals are a tall order under conditions of lifelong victimization, lack of skills and education, unplanned childbearing, single parenting, violent and unsafe housing and scarcity of resources, not only for children's play and learning but for the basics, such as food, clothing, and shelter. Nevertheless our interviewees tended to hold themselves personally accountable for their poverty and for caring for their children. It was within the context of welfare reform promulgated during the Reagan/Bush and Clinton eras that drug using women were expected to fulfill an idealized mothering role, perhaps the most pernicious offensive against those most stigmatized and most in need of support and assistance.

POLICY OUTCOMES

The full impact of the reduction in social services remains to be seen. Since the implementation of the Personal Responsibility and Work Opportunity Act of 1996, there has been a drastic reduction in the welfare rolls and both the Republican congress and President Clinton took credit touting the success of their welfare reform policies (Miller 1998). However, the success of welfare reform depends upon how it is measured. If success is measured by the reduction in numbers of people receiving welfare benefits, then welfare reform has succeeded. If success is measured by the reduction of the number of poor Americans, then welfare reform is a systematic failure. The booming economy of the late 1990s certainly had an effect on the number of people who left welfare for work. But that is not the only explanation. Just as a more accessible program led to an increase in the welfare rolls in the 70s, the more daunting challenges presented by 21st century welfare program requirements caused a drastic reduction in the rolls. The emphasis on immediate job placement and on-the-job work experience is problematic. Many welfare agencies have an on-site bank of phones from which applicants must call as many as 20 potential employers before they are allowed to apply for benefits. Many walk out after being told about the requirement and never even apply for welfare (Besharov 2000).

Another reason for the drop in welfare recipients is the "hassle factor", where welfare benefits can be reduced or eliminated if participants do not comply with behavior-related rules (Besharov 2000, p.20). For example, parents are required to immunize their children or participate in parenting skills classes or risk losing benefits. Such behavior-related rules are not required of the general population implying that poor parents are somehow less qualified to parent than their more affluent counterparts. The increasing demands and obstacles to continue receiving welfare benefits may also contribute to the reduction in welfare recipients. Surveys of people who have left welfare indicate they left because of "unfriendly caseworkers" or that they felt "hassled" and that the welfare program simply wants to "get rid of people" (Besharov 2000, p.21). In addition, many welfare mothers have left welfare without employment. We compared interviewees from our first study (PAD) with the women in our second study (PAV) on various income variables. Our findings demonstrate that more women in the PAD study reported some form of government assistance as their main source of income than the women in the PAV study (82% vs 67% respectively). These numbers reflect the decrease in welfare recipients, but not due to a move from welfare to work, since none of the women in the PAV study reported employment as their main source of income. They were, however more likely to be involved in illegal income generating activities than the women in the PAD study. Seven percent of the women in the PAD study reported illegal occupations as their main source of income compared with 17 percent of the women in the PAV study, almost two and a half times more. There were no significant differences between the two groups in terms of age or racial composition.

For those who were on AFDC, illegal activities supplemented their meager income, as Donna, an African American heroin user explains:

Well, I had legal income which is AFDC. At that time I was livin' with my (boyfriend), he was hustlin', which, you know, anything I had that I couldn't get with that little old bitty money they give you, he hustled and got it, you know what I'm sayin'? But when we broke up, I didn't have no, no job training, no nothin' so I tried to pick up where he left off and it lasted for about a year or so. But after that, you know, they started cracking down, I got busted. And I'd never been to jail before, but I went to jail, they gave me three months. That was the hardest thing I did in my life. I had never been separated from my kids and, I never wanna be separated from 'em again. That was the hardest thing, girl. (PAV)

Studies suggest that mothers who leave welfare have secured other non-employment sources of support, such as social security income; and family support, like financial assistance and free housing (Besharov 2000). The women in our PAV study relied on illegal activities to replace welfare income.

The implications of this phenomenon (people leaving welfare without employment) are multifaceted. First, there is an increased burden on those family members who take in relatives that have been terminated from or have voluntarily left welfare. Will family members in turn become impoverished? There is also a concern that as people lose their benefits, particularly health benefits, the cities and urban counties where the poor are concentrated will have to foot the bill for medical care as the medically indigent flood clinics and emergency rooms. Will an increase in criminal activity to supplement income lead to more incarcerated women, hence more children in the foster care system? It remains in question whether local governments can and will assume this burden or simply shift the responsibility elsewhere. As Weir (1997) explains, "The real danger is that the law will create a new class of 'invisible poor,' handed off by each level of government to the next, shifted among programs until they fall out of the social welfare system altogether, uncounted in official statistics, but all too visible on our city streets" (1997:30).

For those who have found employment, many hold temporary or part-time jobs. Even those fully employed earn below poverty levels and need economic assistance. How long will they be willing to complacently work in low wage jobs without the possibility of emerging from poverty? Many will not have found a job after their two-year eligibility cap is met. They too will need economic assistance after being terminated from the welfare rolls. With continued drastic reductions in social welfare benefits, it is very possible that we will face widespread poverty, an increase in crime, a deterioration of urban areas and most importantly, poor malnourished children who will grow into adults with limited access to marketable job skills.

In 2001 the policy context is one of fiscal retrenchment and diminished public support for social welfare services. Nonetheless, in order to begin to address the problems our study participants experienced, federal funding for social welfare programs needs to be substantially increased, not cut. In the following, we outline the implications of our findings for the formulation of more effective social policies.

ALTERNATIVE WELFARE REFORMS

Policies which support families by providing guaranteed family income, housing, help with employment (when appropriate) and other sorts of ancillary services would have better served the women in our study when they were children. These policies would certainly serve them as mothers. Establishing a national health service, with women-oriented drug treatment, would ensure that all women and their children have access to comprehensive health care over their entire life course.

Health and social welfare programs enabling families to stay together while a mother receives education, drug treatment, and help with parenting are the most promising roads back to conventional roles for mothers. Legislative, legal and political practices which obstruct a mother's continuing contact or involvement with her children or send her to jail, serve only to destroy the relationship critical to the stability and well-being of both the mother and child. In the following, we begin our discussion of policy implications by examining child removal policies, housing, guaranteed family income, health care, and finally, drug treatment.

Child Removal

Beginning in the late 1980s, there has been a staggering increase in the number of children removed from their biological parents' custody:

Our survey of all fifty states' child welfare agencies revealed an unprecedented surge in the number of children removed from their parents and placed in foster care. APWA (American Public Welfare Association) estimates that, in June 1987, there were about 280,000 children in foster care; by June of 1990 the number is projected to increase to 360,000. That is a 29 percent increase in just 36 months - - and the numbers are still rising (Besharov 1990:24).

California and New York together are responsible for fifty-five percent of the increase and children of Color have been grossly over represented (Besharov 1990). In 1990 in California, for the first time in the state's history, the absolute number of African-American children in foster care exceeded the number of whites, even though less than 10 percent of the state's children are African-American (Besharov 1990).

Child removal policies were also in vogue in the nineteenth century and then, like today, the children of the poor were over represented in institutions.

[D]istrust of the poor meant that children of poor, immigrant, and single mothers were over represented among those removed from their families. Some mothers (and fathers) who could not care for their children placed them in institutions voluntarily. Other children were removed from their homes due to legitimate discoveries of child abuse and neglect. But large numbers of poor parents lost the right to raise their own children because they were seen as deviating from prescribed homemaker and breadwinner roles (Abramovitz 1988:167).

By the end of the nineteenth century, child removal policies lost their political support:

The earlier preference for breaking up families as the most morally and economically efficient method of enforcing prevailing work and family norms and maintaining the future labor force lost some, if not all, of its favor (Abramovitz 1988:170).

The twentieth century rationale for child removal is also based upon poor families' deviation from socially prescribed drug using patterns. Today, women who use illegal drugs are at risk of having their children removed from their homes and institutionalized or placed in foster care. In the early years of this century, policies supporting placement of children in institutions or foster care situations were instituted and implemented. In the late 1980s and 1990s, social welfare practices returned to policies which prevailed in the previous century.

As we should have learned from historical child removal practices, children may not always be best served by removing them from their families. Foster care is often little better than the conditions from which children were removed. It also lacks the caring of the natural mother, one of few sources of comfort for children in a frightening world (Jackson and Berry 1994).

The women we interviewed who lost custody of their children through Child Protection Services interventions faced tremendous obstacles to regain custody. There were court dates to be kept, proof of drug treatment, stable housing, and attendance in parenting classes to be demonstrated. These hurdles were huge for single women without quality educations, housing assistance, or welfare benefits, and minimal job experience or training. The few women who had job experience were more able to re-enter the working world. Mothers whose families kept their children in informal arrangements had fewer obstacles to regaining custody.

As we have outlined, motherhood was the basis for most women's sense of self and social worth. Tracy explained what her children meant to her:

Well, my self esteem now, from previous times is way up. I have more faith in myself, because I have children. I don't depend on my mother. She's never been there for me, so now by me having children I look at them and think about what my mother did. And it makes me feel good. So, my children are my self esteem. They keep me happy. (PAV)

When their children were forcibly removed, they lost the only shred of positive self-image left to them. There was no longer any reason not to be "high all the time." The guilt, worry, and pain these women experienced when their children were out of sight often provided another reason for continued heavy drug use and loss of control. Amanda gave up completely after losing her children:

. . . after losing my kids to the system. I was just convinced I'd never be able to get `em back, you know, and so I let it become a reality. I never, and I've been homeless now for, ever since then. I thought to myself: Well, I ain't got my kids. I don't need a home no more. And I haven't bothered to even try to do anything, until I became pregnant with _______. He saved my life, he did. God gave me one more chance by giving me that child. (PAV)

Many like Amanda saw a new baby as another chance to turn their lives around. The new baby renewed their self-esteem. A second chance at motherhood was the opportunity to prove to themselves and to others that they were worth something. Amanda continues:

All of a sudden I felt good again. All of a sudden I felt strong again. All of a sudden I felt loved again. All of a sudden I felt like I had a purpose, and I've been workin' harder than I ever have in one year to get my life together and, and I've done more than I have ever done in one year. (PAV)

Housing

While many of their male partners bounced in and out of jail, many of our interviewees and children were doing time in SRO (single room only) hotels and housing projects. In addition to the deplorable conditions of the majority of these dwellings, the prevalence of drug selling, using and violence in these neighborhoods was staggering. Our interviewees described their housing projects as strewn with dead bodies, with children afraid to sit in front of windows for fear of being shot. The following quote from Rhonda's narrative haunted the PAD staff:

[The housing projects] the way they used to be they was tall buildings and short buildings, stone, concrete, a concrete jungle, babies would fall out the windows, babies would come out the house, be coming down the stairs underneath these little windows on the stairs, you would see babies falling from like eleven floors on down, falling out the windows, hitting on the pavement. People getting throwed out the windows, people coming in selling drugs, shooting drugs anywhere they please. Dead bodies here, dead bodies there. (PAD)

When the women spoke longingly of living "anywhere but here," the appeal of what Waldorf (1973) called the geographic cure, (moving away from the places one has used drugs) was compelling. While middle-class mothers-to-be engage in preparations for impending births, like carefully preparing a nursery, Denise felt stressed about bringing her baby home to a place that lacked the basic necessities:

I don't want welfare. All I wanted was the Housing Authority, `cause where I can stay at right now I cannot lay my baby there. It's just too -- I don't have a bathroom in my room and I don't have a kitchen area and no shower, no bath and stuff like that. So I have to move. And I want a job and I want to go to school, 'cause I don't want to be in the system no more. I mean, I have time that's Ð`cause I'm not dumb. And it's all the time sitting all day, and the problem in the hotel is everybody get high. Everybody get high. (PAD)

What might be the impact of constant, ambient violence on a developing fetus? While scant research has been conducted in the United States, we might begin to extrapolate (while keeping in mind the potential cultural differences) from a fascinating study conducted in Chile by Zapata and colleagues (1992) from the University of California at Berkeley. The goal of the study was to measure the impact of living in a highly violent environment on pregnancy outcomes. Employing a retrospective study design, the researchers were able to compare differences in pregnancy outcomes between women living with high levels of sociopolitical violence and women living in less violent conditions. Zapata and colleagues concluded:

After adjusting for potential confounders, [it was determined] that high levels of sociopolitical violence were associated with an approximately fivefold increase in risk of pregnancy complications (1992:689).

In order to intervene effectively in poor women and their children's lives, available, safe and affordable housing is essential.

Guaranteed Family Income

If stable living environments for growing children are indeed a policy goal, then a guaranteed subsistence income for children and their care givers would be cost effective from both a fiscal and a humanistic perspective. For example, in New York City foster care payments for children less than five years old are two and one-half times higher than AFDC payments for the same child (Besharov 1990). This figure begs the question, why not raise the AFDC payments and ease the economic devastation that most assuredly contributes to the women's drug abuse? Why continue to pay more to non-biological care givers than we do to birth parents?

Health Care

We believe adequate health care should be available for all people. The United States is the only western democracy, besides South Africa, that does not have some form of national health service. We do not believe the United States is in very good company regarding its health care provision system.

That said, we now focus specifically on the provision of prenatal and reproductive health care for pregnant drug users. As we have detailed, what emerged from women's narratives was the irony of prenatal care as a risk factor, rather than a risk reduction strategy. Although some of the study participants had positive experiences, for many, seeking prenatal care was a source of anxiety and a maternal risk factor in and of itself. Poland and colleagues (1993) interviewed 142 low-income postpartum women to determine their attitudes regarding possible effects of a punitive law on the behavior of substance using pregnant women. The purpose of the study was to investigate women's attitudes about whether or not pregnant drug users should be prosecuted, and to determine whether punitive legislation directed at this group would deter women from seeking prenatal care and participating in drug treatment programs. Their key finding was the study participants believed strongly that punitive legislation would further alienate pregnant drug users from seeking needed health care. These women were convinced women would "go underground" to avoid detection and treatment for fear of incarceration and loss of custody of their children. This opinion was held both by women who did and did not use drugs themselves during pregnancy. Several women interviewed noted: "These laws are just for poor black women, not rich white ones!"(p. 202). Similarly, Chavkin and colleagues' (1991) work suggests:

Attempts to criminalize drug use during pregnancy may further deter [pregnant women] from seeking care or from giving accurate information to health care providers. Anecdotal reports suggest that efforts to detect maternal drug use by means of urine toxicology testing of the newborn may even frighten some women away from delivering in hospitals (p. 107).

Sources within the medical community note that in South Carolina, where prosecutors have filed criminal charges against women who allegedly used drugs during pregnancy, there has been a rise in the number of women giving birth at home, in taxis, and in bathrooms (Chavkin, Allen, and Oberman, 1991).

Clearly, punitive policies are counterproductive. While the connection between drug use and fetal impairment is ambiguous (with the notable exception of tobacco and alcohol), we do know that poor health in general, malnourishment, chronic stress, and illness certainly impacts both mother and infant adversely. Our findings indicate it is more beneficial to promote women's perceptions of health care as one of the harm reduction strategies they employ, rather than constituting yet another risk in their lives.

DISCUSSION

Most of the women in our study populations (91%) had been used and abused since birth, with relatives and guardians sexually assaulting or emotionally abusing them throughout their childhoods. If they were placed in foster care, that system often failed to protect them as well. Home problems interfered with schooling and lack of quality education decreased job opportunities. Teenage pregnancies truncated childhoods. Many of the interviewees were babies who had babies. Seventy-seven percent of our study participants had older children. Of those, 36% were mothers by the time they were 18 years of age. Seventy percent had become mothers by the age of 21. Violence was everywhere, in their own homes, in the next project apartment, and outside on the streets. The 1990s brought a different and, in some ways, more virulent kind of abuse. Pregnant drug users were now used as part of a larger ideological offensive to legitimate the wholesale reduction of social welfare services to all poor women and children. We believe history may prove this last to be the most devastating abuse of all.

Women's drug use during pregnancy reveals more about the low point in social conditions in the United States than about the powers of any particular drug. Our unrealistic social expectations for women; hiring discrimination; and lack of a national health care system and social services for women and children, all conspire to block legitimate routes to satisfaction and well-being. Women's drug use during pregnancy cannot be understood apart from the social and economic contexts in which these experiences were embedded. The greatest threat to effective parenting and child survival is a system that perpetuates racism, poverty, violence, hardship and desperation. Rather than indicting pregnant drug users for their addictions and compulsions, we would do well to look at the impossible conditions in which these women and their children live their lives.


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Submitted to Social Justice
Special Issues: In the Aftermath of Welfare "reform"
Sylvie Tourigny and Delores Jones-Brown, Editors

The authors are most indebted to the study participants who so generously and candidly shared with us their experiences regarding pregnancy, drug use and violence. This research was supported by a grant from the National Institute on Drug Abuse, Coryl Jones, Ph.D., Project Officer