PEDIATRICS Vol. 100 No. 2 August 1997,
p. e7
Copyright ©1997 by the American Academy of Pediatrics
ELECTRONIC ARTICLE:
Maltreatment of Children Born to Women Who Used Cocaine During
Pregnancy: A Population-based Study
,
,
From the Departments of * Pediatrics, § Epidemiology and Public
Health, and
Child Study Center, Yale University School of Medicine,
New Haven, Connecticut.
ABSTRACT
INTRODUCTION
METHODS
RESULTS
DISCUSSION
SUMMARY AND IMPLICATIONS
ACKNOWLEDGMENTS
ABBREVIATIONS
REFERENCES
Background. Previous studies of maltreatment of children born to women who used cocaine during pregnancy have relied on either selected samples of infants identified at birth or biased, high-risk samples referred to protective services.
Objective. To determine the relative risk of either maltreatment or placement outside the home during the first 2 years of life in children born to women who used cocaine during pregnancy compared with a sociodemographically similar comparison group.
Patients. We reviewed the medical records of consecutive deliveries at Yale-New Haven Hospital from August 1, 1989 through September 30, 1990. Of the 1140 women who were eligible for the study, 173 had a positive history and/or a positive urine test for cocaine; 139 of the infants were included in the study. A comparison group of infants was chosen from 526 women whose obstetric records indicated that they had not used cocaine during pregnancy based on at least two separate notations in the record. For each of the 139 cocaine-exposed infants, an infant was chosen from the comparison group based on seven matching characteristics: date of birth, race, method of payment for the hospitalization, gestational age, mother's parity, mother's age at delivery, and timing of the first prenatal visit.
Main Outcome Measures. Children's medical records at the only two hospitals in the region, the two neighborhood health centers, and the only health maintenance organization were reviewed from birth to 2 years of age. Each injury was classified by two independent reviewers who used predefined criteria to distinguish maltreatment (physical abuse, neglect, or abandonment) from unintentional injuries. Placements outside the home were categorized according to whether the placement was in foster care or with a relative.
Main Results. The children were mainly African-Americans (80%), and most were enrolled in Medicaid (96.5%). By 2 years of age, 9.3% of the infants in the cocaine-exposed group versus 1.4% in the comparison group had been maltreated [matched relative risk = 6.5; 95% confidence interval (CI) = 1.47, 28.80], and 25.9% vs 8.6% had spent some time in placement (matched relative risk = 5.0; 95% CI = 2.08, 12.01). After controlling for differences between the groups in baseline clinical and social variables, the adjusted odds ratios for both maltreatment (3.98; 95% CI = .81, 22.80) and placement (1.66; 95% CI = .74, 17.83) decreased and were no longer statistically significant.
Conclusion. In this population-based study, children born to women who used cocaine during pregnancy were at a substantially increased risk of maltreatment or placement outside the home compared with a sociodemographically similar comparison group. Differences in baseline variables between the two groups, however, partially accounted for this increased risk. Therefore, a mother's use of cocaine is more likely a marker of increased risk rather than a single explanatory variable.
Key words: child maltreatment, child abuse, neglect, cocaine, risk factors.Abuse of cocaine and crack cocaine continues to be a major problem in the United States; recent surveys indicate that as many as 15% to 20% of inner-city women have used cocaine during their pregnancies.1 Throughout the last several years, a major focus of clinicians and researchers concerned with infants born to such women has been the biological effects of in utero exposure to cocaine on the developing fetus.2 Recently, attention also has been directed toward the adverse effects of a mother's use of cocaine on the child's nurturing environment. Studies show that mothers who use cocaine have difficulties interacting with their infants, in particular, demonstrating more intrusive and hostile behaviors toward their infants.3,4 In addition, children of mothers who use cocaine are at an increased risk of more serious forms of parental dysfunction, such as maltreatment, and of placement in foster care.5
Questions about the methodology of these studies, however, have been raised. Studies have either failed to use a control group or selected controls that were not comparable to the cocaine-exposed children on important sociodemographic characteristics. In some studies, selection bias may have occurred because of preferentially including socially high-risk mothers who used cocaine. Problems also have occurred in the ascertainment of the outcome. Infants labeled as at-risk because they were born to mothers who used cocaine have been included in reports of maltreatment, and investigators have failed to consider the problem of detection bias, which may occur if clinicians are more likely to report to protective services a child's injuries because the parents are known substance abusers compared with identical injuries in children of nonsubstance abusers.10 Finally, studies have failed to consider the importance of confounding psychosocial variables11 when examining the association of maternal cocaine use and maltreatment; the use of cocaine, therefore, may be a marker for these psychosocial variables rather than a direct cause of the maltreatment.
To address these methodological issues, we conducted the following study to determine the relative risk (RR) of maltreatment or placement outside the home during the first 2 years of life in children born to women who used cocaine compared with a sociodemographically similar comparison group. In this study, we used a population-based approach to select the subjects, specific criteria to define types of maltreatment, an investigator who was blind to whether the mother used cocaine when classifying injuries as maltreatment or as unintentional injuries, and logistic regression analyses to adjust for potential confounders.
Selection of Mothers
We reviewed the medical records of all women who lived in either New Haven or one of two adjacent towns, gave birth at Yale-New Haven Hospital from August 1, 1989, through September 30, 1990, and were eligible to receive prenatal care at the Women's Center of the hospital. Women were excluded if they: 1) were less than 18 years of age at the time of delivery, 2) were using heroin or methadone during pregnancy, 3) had a fetal death or an infant who died within 48 hours of birth, or 4) delivered twins or triplets.Selection of Children
Children were eligible if they received their pediatric care at Yale-New Haven Hospital or at one of four additional sites
the only
other hospital in the greater New Haven area, either of the two
neighborhood health centers in New Haven, or the only health maintenance organization in the area. We excluded children who either
were discharged directly to foster care and spent no time during the
first 2 years of life with their biological families or were adopted at
birth.
1500 g); 5) the mother's parity (primiparous or not); 6)
the mother's age at delivery (18 years, 19 to 24 years, or 25 years or
greater); and 7) the timing of the first prenatal visit (before 28 weeks of gestation versus 28 weeks or after). When perfect matches
could not be found, we relaxed the matching criteria in the following
order: maternal age, parity, date of birth of the comparison child
compared with the index child, timing of prenatal care, and, finally,
race. We were able to identify perfect matches for 51% of the index children, and 95% were matched on at least five of the seven matching variables.
Determination of Outcomes
From the medical records, we abstracted information about all visits to the monitored health care sites. Each injury (eg, a bruise or an ingestion) or visit for suspected maltreatment (eg, a child brought to the hospital because of being found alone in an apartment) that was recorded in the record was classified by two investigators into one of the following categories (modified from previous studies12):- Physical abuse
an incident for which the information
indicated a definite or probable act of commission that resulted in
harm to the child.
- Neglect
an incident or injury that resulted from a complete
lack of parental supervision or attention; a lack of food, shelter, or
clothing; a serious health problem that resulted from or persisted because of failure to receive appropriate medical care. Delays in
immunizations were not included in this last category.
- Sexual abuse
an incident that indicated a definite or probable
sexual act performed on a child.
- Abandonment
a history that the primary caretaker left the
child in the care of another adult but failed (usually after a few days) to return to care for the child.
- Unintentional injury-neglect
an injury that might have been
prevented by more adequate parenting but did not represent a complete lack of parental supervision (eg, a soft tissue injury that occurred when a 6-month-old infant fell off a bed).
- Unintentional injury
an injury that was unlikely to be
prevented by reasonable parental supervision.
- Household or neighborhood violence
an injury to the child that
occurred because of violence that did not seem to be directed at the
child and occurred in the home or neighborhood.
- Insufficient information for classification
an incident for
which there was insufficient information in the medical record to allow
a classification.
Collection of Other Data
For each child, we recorded the health care facility, the reason for each visit, and the diagnoses. In addition, we abstracted information about the pregnancy and perinatal period. For the mother, this information included age at delivery, type of delivery, gravidity, parity, use of alcohol or tobacco, timing of first prenatal visit, and the clinicians' concerns about the care provided to previous children or the adequacy of the mother's housing situation. For the child, we abstracted information about gestational age, birth weight, Apgar scores, neonatal complications, and duration of hospitalization.Statistical Analysis
We used the
2 statistic or t test
to analyze differences in baseline characteristics. The association
between cocaine use during pregnancy and each outcome was determined by
calculating matched risk ratios (RR) and the associated 95% confidence
intervals (CI).14 We also used logistic regression with
multiple covariates to calculate an adjusted odds ratio after
controlling for baseline variables that were associated with the
occurrence of the outcome.15 The odds ratio was used as an
estimate of the RR16 Because follow-up information was
available for both groups at similar rates during the first 2 years of
the child's life, life table analyses are not presented.
Based on a review of 1214 consecutive obstetric records, 1140 pregnant women were eligible for the study. Of these, 173 (15%) were eligible to be in the cocaine-using group, 526 (46%) were eligible to be in the comparison group, and the remaining 441 (39%) had less than two notations in the mother's record and were considered ineligible. Of the 173 mothers who were positive for cocaine, 139 of their infants were included in the study; the remaining infants were excluded for the following reasons: 21 did not receive their pediatric care at the monitored health care sites, 7 were discharged to foster care and spent no time with their biological mothers, 5 had information only about the postpartum period in the records and there was no information at the five health care sites, and 1 record could not be located. For each of the 139 cocaine-exposed infants a matched infant was chosen from the comparison group.
Table 1.
Matched Characteristics of Sample
Table 2.
Nonmatched Perinatal Characteristics of Sample
Table 3.
Percentage of Children With Documented Visits at or Beyond Listed Age
Table 4.
Outcomes in Cocaine-exposed and Comparison Children
Table 5.
Placements in Cocaine-exposed and Comparison Children
lack of prenatal care and clinicians' concerns
about housing. This adjusted odds ratio, which was not statistically
significant, was decreased compared with the unadjusted odds ratio of
7.06 (95% CI = 1.56, 31.93). When the outcome of placement was
examined, the adjusted odds ratio was 1.66 (95% CI = .74, 17.83)
after controlling for three variables
either maltreatment or placement
of an older sibling, use of alcohol during pregnancy, and greater than
a 1-day stay in the neonatal intensive care unit. The adjusted value
was decreased compared with the unadjusted value of 3.70 (95% CI = 1.83, 7.47). Thus, for both outcomes, the differences in the
occurrences of baseline variables between the cocaine-exposed and
comparison groups accounted in part for the elevated unadjusted values.
In this population-based study, we showed that by 2 years of age, children born to mothers who used cocaine during pregnancy were 6.5 times more likely to be maltreated and 5.0 times more likely to be placed outside the home compared with a sociodemographically similar comparison group. Almost all of the episodes of maltreatment to the children in the cocaine-exposed group were attributable to neglect or abandonment. No episodes of sexual abuse were noted in either group, probably because of the young age of the children. In addition, approximately 25% of the children in the cocaine-exposed group spent some time during the first 2 years of their life being cared for outside their homes either in foster care or with a relative, indicating that these mothers had substantial problems providing adequate care to their children.
Methodological Improvements
There are several methodological improvements in our study compared with others that have examined the relationship between the use of cocaine and subsequent maltreatment or placements of the child outside the home. First, we identified pregnant women who used cocaine by reviewing the obstetric records of all eligible women as opposed to using a selective approach that identified only socially high-risk users of cocaine. We chose the period of study because by 1989 clinicians in New Haven were regularly asking pregnant women about their use of cocaine.Limitations
There are several limitations to this study. First, to identify mothers who used cocaine during pregnancy, we relied on maternal history and urine screening, which is not considered the most accurate approach to classification. Although systematic screening by analysis of meconium17 may have provided more complete data, our results collected from medical records are similar to those collected in a prospective research study that began in the prenatal clinic at Yale-New Haven Hospital shortly after we completed enrollment in our study. In that prospective study, which identified women who used cocaine during pregnancy by a structured interview and systematic urine testing, the rate of cocaine use was 16.5% (Lago JA, Schottenfeld RS, Pakes J, Forsyth BW. Primary care-based interventions for pregnant cocaine-abusing women: comparison of treatment enrollees and refusers. Presented at Problems of Drug Dependence, Proceedings of 55th Annual Scientific Meeting, Toronto, Canada, 1993). The rate in our study was 15%, which is not substantially different from that of the prospective study. If women who used cocaine were not recognized in our study and incorrectly classified in the comparison group, our results would tend to underestimate the true difference between the two groups.In summary, in our sample of poor, inner-city women, we found an association between maternal cocaine use and the occurrence of maltreatment (particularly neglect) and placements outside the home. The use of a population-based approach to sampling resulted in a weaker association than had previously been reported. The use of logistic regression analyses indicated that certain social and clinical characteristics of the mothers who used cocaine also were strongly associated with the outcomes and suggested that the use of cocaine is a marker of risk rather than a single explanatory variable.
Received for publication Nov 4, 1996; accepted Mar 3, 1997.
Presented in part on May 3, 1994 at the 34th Annual Meeting of the Ambulatory Pediatric Association.
Reprint requests to (J.M.L.) Department of Pediatrics, Yale University School of Medicine, 333 Cedar St, New Haven, CT 06520-8064.
This research was funded by grant 90-CA-1468 from the National Center on Child Abuse and Neglect, Administration for Children and Families.
The authors greatly appreciate the critical review of Dr. Eugene Shapiro, the clerical assistance of Julia Robertson, and the research assistance of Eric Frehm and Kelli H. Chang.
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Pediatrics (ISSN 0031 4005). Copyright ©1997 by the American Academy of Pediatrics
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