SIXTY babies who suffered drug abuse in the womb were born at the Rotunda Hospital in Dublin last year, as many as 50 at the Coombe Hospital and up to 30 at the National Maternity Hospital, Holles Street. Others were born in towns around the country wherever pockets of heroin abuse exist.
"We've seen a dramatic increase which literally began 12 months ago. And it's going to get worse," says Prof Tom Clarke, paediatrician at the Rotunda. Based on last year's figures he estimates that there are now 160 pregnant drug addicts whose babies will be born this year with withdrawal symptoms.
To be one of these tiny, developing foetuses in the womb of a drug addicted mother is to pass one's earliest, developing months as an unwilling junkie. When such a mother needs a fix her unborn child gets the jitters and kicks ferociously inside her womb. When she gets her hit - which usually involves smoking or injecting heroin in combination with massive doses of a benzodiazepene - her baby calms down too and stays still for a long time.
When the infant is eventually born, usually smaller than should be the case, he or she has to spend the first weeks or months of life on a special paediatric ward suffering agonising drug withdrawal symptoms, the normal reflexes often so disturbed by the drugs that it's not even possible to suck on a bottle.
"The withdrawal usually doesn't start until a few days after they're born when whatever their mother was taking has left their system," says ward sister Mary McNally at the Rotunda. "Then they start the high pitched crying, the rapid breathing and they become hypotonic - which means their muscles are agitated and tight. They just cannot rest and you can literally see their limbs shaking. They get really, really agitated. They're sedated with oral morphine or Phenobarbital. We swaddle them tightly because this seems to give them a feeling of security.
"They need to feed more than a normal baby does because of their agitation, yet many cannot feed." It is the benzodiazepene that makes them lose their sucking reflex and they may be six, weeks old before they can take a bottle. "We have to tube feed them instead," she adds.
"We try to keep them in a calm atmosphere, not too bright and in a room at the quieter end of the ward. Yet often no matter what you do they won't sleep or eat and you just have to hold them, but you don't have the staff to give them this individual attention the whole time. I'll never forget the week that I had seven of these babies on the go at once."
Dr Michael Turner, Master of the Coombe, believes that there is "a terrible human tragedy out there in the city of Dublin at the moment. It's not just the babies who are the victims of the tragedy but the mothers themselves who in the long term may or may not be HIV positive. I would have concerns as to how these children will be parented and whether there will be a parent alive for them. And as these children grow up we may find ourselves seeing that history repeats itself."
"It's a major public health problem at the moment and it's getting worse," says Dr Elizabeth Griffin, paediatrician at the Coombe. "Mothers are using a mix of drugs - which can be worse for the baby, causing more serious symptoms, more convulsions, requiring more treatment and more prolonged treatment. They require intensive nursing which is a very costly exercise. It stretches the
Hospital special care baby units are suffering not just the pressure of caring for these babies, but also the stresses of dealing with their drug addict parents whose behaviour tends to be anti social, unpredictable and even violent. It's so bad that the Eastern Health Board plans to send drug counsellors into the maternity units to teach staff how to cope with drug addicts.
The luckiest of the babies have mothers who admit they have a drug problem, go to a clinic and get antenatal care. Pregnant addicts for whom there are no waiting lists for drug treatment are given low dose, methadone maintenance throughout the pregnancy according to a policy known as "harm reduction". This makes withdrawal after birth easier for the baby. For a mother to undergo detoxification during pregnancy is highly dangerous for the unborn baby. It is not offered unless the mother insists.
Worst off are the babies whose mothers have little or no antenatal care and who even in labour refuse to admit that they are drug abusers. It is not until the babies start exhibiting withdrawal symptoms a few days after birth that such mothers will admit their problem. For these babies whose mothers drug abuse was chaotic during pregnancy withdrawal is particularly perilous.
Even when babies have completely detoxified and become well, withdrawal symptoms may spontaneously recur weeks or months after they leave hospital - often in response to something like a chest infection. They also have an increased risk of cot death as well as behaviour and learning problems. Many of the babies are infected with HIV and hepatitis C.
"The mothers watch their babies suffering and say to me, but I was only smoking heroin. Many don't realise that smoking is as bad as injecting and that taking drugs can harm their unborn child. They'll say, if only I had known what my baby would go through I wouldn't have taken drugs'," says Mary McNally.
The huge increase in the numbers of young people smoking heroin is a major factor in the increasing numbers of babies suffering withdrawal, says Dr Joe Barry, specialist in public health, Drug Services, Eastern Health Board. Another important factor is that in many areas as many females as males are now using heroin and at a younger age.
Heroin smokers are not using condoms because, wrongly, they no longer fear HIV, believing that unprotected sex is dangerous only among IV users. They fear AIDS more than they fear pregnancy so that those who would have taken the trouble to use condoms to prevent AIDS are not as motivated to use condoms if the only risk of unprotected sex, as they see it, is having a baby.
Last year 59 pregnant, drug addicted mothers were treated at Trinity Court drug treatment centre in Dublin compared to only 12 in 1991, a subject on which Dr John O'Connor, consultant psychiatrist at Trinity Court, spoke at a drugs conference in Dublin Castle last Friday. "Many are coming to us at seven, eight months of pregnancy. The implications for the babies are very serious. The fear is that they will be our patients in 10-15 years. We already have a number of mothers and daughters and fathers and sons attending," he says.
It strikes me as very odd that we went through a catharsis over the rights of the unborn child in relation to abortion and so many people wanted to protect the unborn child and now that these unborn children need our help, where are these same people? Who will protect the rights of these babies? I think that the whole thing is extremely tragic and difficult questions have to be asked as to the needs and rights of the baby versus the needs and rights of the mother," says Dr O'Connor.
THERE are two issues here. One is the right of the drug abuser to procreate as opposed to the right of the foetus not to be abused in the womb by drugs. The other is the right of the drug addicted mother to bring her baby home from hospital to live with her as opposed to the baby's right to life in a more healthy environment.
"To impose birth control would be setting a very dangerous precedent," says Dr Turner.
"You would be getting into the area of eugenics," says Dr Barry. At Trinity Court addicts are offered "bucketfuls" of condoms, long term contraceptives like depoprovera and other methods but they are never imposed as the price of methadone maintenance.
Dr Turner suggests that the authorities conduct random urine tests for drug abuse just as they do for alcohol among drinking drivers. Young people testing positive could be targeted for drug treatment and education about pregnancy. Dr O'Connor, whose Trinity Court programme already has strong links to the Rotunda, believes the authorities need to go out into communities and target the young potential parents who are abusing drugs instead of waiting for young drug addicts to come to them in the throes of labour.
Everyone dealing with these mothers and babies agrees that the need for education is urgent.
The Eastern Health Board is currently involved in "developing liaisons" with all three Dublin maternity hospitals in an effort to address the problem says Dr Barry. The board has appointed four new education officers who will forget primary schools in communities where drug abuse is rife. Their specific brief will be drugs and AIDS - but not pregnancy. "Pregnancy is a diversion we do not want to get into. It's not our job to prevent pregnancy," says Dr Barry.
In the US babies of drug addict mothers have been taken into care while still in the womb. Here the prevailing ethos in the maternity hospital social work departments is that mothers and babies belong together and the vast majority of babies go home to live with their mothers.
"Instinctively I think one should always hesitate to disrupt a mother/child relationship. You need to have strong grounds to disrupt that relationship because it is so pivotal in a child's life," says Dr Turner.
Prof Clarke says that it is almost irrelevant to ask whether using drugs while pregnant is a form of abuse because the mothers concerned are so outside the realms of normal behaviour. "A baby might be just the incentive a mother needs to turn her life around and get off drugs," he adds.
Here the mother is assessed postnatal by social workers, drug clinic staff and hospital staff for her ability to stick to the methadone programme and care for her baby. If she cannot care for the child but a grandmother or non drug using partner can, then the baby is still sent home.
International research shows that physical exposure to heroin during pregnancy is not as important for the long term development of a child as the social effects of having an addicted mother. Dr John Murphy, paediatrician at Holles Street, believes that the goal should be to improve the child's environment. "Pessimists will say that these babies do very badly. Optimists will say that they do not do too badly - depending on their environment. If father is not an addict it is a better situation. We should not be fatalistic."
The environment, however, can be a fraught one. According to research at Trinity Court published in the Irish Medical Journal, half a surveyed group of drug addicted, pregnant mothers had, alcoholic fathers one third had alcoholic mothers and one quarter had mothers diagnosed with clinical depression.
A more recent study of 52 male and female drug addicts by Dr O'Connor and Dr Roy Brown at Trinity Court found that 21 per cent had experienced sexual abuse and 23 per cent had suffered regular and continuing physical violence.
IN his work at Trinity Court, Dr O'Connor has seen many cases where he doubted whether the children were better off with their mothers than they would be in foster care. A six year, follow up study of 45 pregnant women at the centre in the 1980s found that 50 per cent abused drugs chaotically and despite strong intervention many continued this behaviour after the baby was born. The study recommended the introduction of detoxification and rehabilitation programmes for drug addicted mothers after birth - a call which is yet to be heeded.
"Chaos" is the word which best describes the world which many of these babies are sent home to, in his view. "How would you feel if you were cold and hungry and being pushed in a pram around the city all day while your mother looks for her next fix?"
Tiny children who to survive must learn to adjust to their mother's drug related moods soon develop a pseudo adult manner. Dr O'Connor gives the example of a mother who was raging violently against clinic staff because she thought her methadone dose was too low. Her quietly observant toddler offered her a calming cup of water, another toddler whose drug abusing mother constantly smacked him as a way of dealing with her anxiety had learned to remain slightly out of arm's reach, but close enough so that he and she weren't separated.
"So far we are merely firefighting," says Dr Turner of the Coombe. "It seems to me that the will is not there to tackle this problem as a matter of urgency. Like most things, society will wait until it gets worse before anything, is done."