Cocaine and Pregnancy—Time to Look at the Evidence

Abstract

I N THIS ISSUE OF THE JOURNAL, FRANK AND COLLEAGUES 1 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 childhoodand 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 find-ings 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? 2 Why was a program established to pay $200 to crackusing women as an incentive to become sterilized? 2 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...

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