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Policy Information Center Highlights: Vol. 2, No. 5

In This Issue:



In recent years, research on fetal alcohol syndrome and on the developmental defects linked to pregnant women's use of marijuana and cocaine have focused attention on the problem of maternal substance abuse. The National Institute on Drug Abuse's (NIDA's) 1991 National Household Survey on Drug Use showed that more than 4.5 million women of childbearing age were estimated to have used illicit drugs in the month before the survey; of these women, 601,000 appeared to be current users of cocaine. There are, however, no accurate statistics on the number of these women who were pregnant.

The report, Maternal Drug Abuse and Drug Exposed Children: Understanding the Problem, describes the extent to which pregnant women use illicit drugs, examines the prevalence of drug-exposed children, reviews drug treatment and prevention services for women, explores legal and child welfare issues related to drug-abusing women and their children, and investigates Medicaid and Social Security financing for this population. The report was compiled in order to define the problem of maternal drug abuse and prenatal drug exposure for the Department of Health and Human Services (HHS) and its component agencies.

Most of the prior attempts to quantify the prevalence of maternal substance abuse have been small-scale pilot studies, and most have yielded varying estimates. One frequently cited report found that 11 percent of pregnant women use illicit drugs and that an estimated 375,000 drug-exposed children are born annually. Another study found that 17 percent of 679 women who delivered babies at a Boston hospital in 1984 had used illegal drugs at least once during their pregnancies, while 8 percent had used cocaine. Despite the lack of accurate estimates, researchers do know that prenatal substance exposure has significant, negative effects on developing children and infants; that drug-abusing women and their children are particularly hard to reach; and that strained social service and drug treatment systems either do not have the appropriate family orientation to serve this population or simply do not have the capacity to do so.

The extent of the problem necessitates that agencies work together to serve families effectively. In particular, HHS currently is conducting research to gather better estimates of the prevalence of maternal substance abuse, is developing interventions to prevent and treat drug addiction among women of childbearing age, and is providing funding to states for rehabilitation and prevention services. Additionally, HHS is enhancing the ability of the child welfare system to assist greater numbers of drug-affected children and families and is providing Medicaid, Disability Insurance, and Supplemental Security Income for eligible individuals (including many with substance addictions) and their children. Some states also are prosecuting drug-using pregnant women under criminal statutes and are enacting legislation to require that perinatal drug abuse be reported to child protective service agencies or other authorities. The paper emphasizes that any initiatives to overcome the problem must address the fact that maternal substance abuse is a complex and multifaceted problem and that pregnant drug users have needs that cannot be solved by short-term interventions.

The report was compiled by the Sub-Group on Substance Abusing Women and Their Children within HHS' Ad Hoc Drug Policy Group. The paper's editor, Laura Feig, can be reached on 202-690-6805. The final report, #4747, is available from PIC, as is a companion document, Maternal Drug Abuse and Drug Exposed Children: A Compendium of HHS Activities, #4747.1.



In the 1980s, in response to the acquired immune deficiency syndrome (AIDS) epidemic, the Centers for Disease Control and Prevention (CDC) issued guidelines to protect health care workers against occupationally acquired infections. These guidelines addressed exposure to the human immunodeficiency virus (HIV) as well as to other bloodborne pathogens such as the hepatitis B virus. Specifically, the guidelines advised health care workers about the use of protective clothing such as masks, gowns, and gloves; the importance of hand washing; and the precautions to follow in disposing of needles and sharps. The guidelines covered a broad range of situations, including invasive procedures, dentistry, autopsies or morticians' services, dialysis, laboratory work, and environmental considerations.

The report, Compliance with CDC Guidelines to Prevent Occupational Transmission of HIV and Hepatitis B: Evaluation Findings from a National Survey of Health Care Workers, documents discussions with 2,440 patient care staff, 457 physicians, and 197 housekeeping staff to determine the extent to which health care workers are complying with the guidelines and to identify the factors influencing compliance. This information is especially important since the Occupational Safety and Health Administration (OSHA) drew on CDC's guidelines in developing standards for occupational exposure to bloodborne pathogens in 1992.

The results indicate that, even though almost all the hospitals surveyed had incorporated CDC's recommendations into their own policies, workers' self-reported compliance rates were lower than would be expected if employees followed hospital policy. Less than half of patient care staff and physicians received all three shots needed for full immunization against hepatitis B, as recommended by CDC. Only 12 percent of staff always wore gloves when giving injections, and only 10 percent consistently used protective eyewear. More than half of patient care staff recapped needles after giving injections, contrary to the CDC recommendations. Housekeeping staff, on the other hand, reported comparatively high compliance; 60 percent always wore gloves when cleaning patients' rooms, and 82 percent consistently washed their hands after removing gloves. Finally, training about the guidelines and reinforcement of the training through posters and other reminders were linked to enhanced compliance.

Based on these findings, the report recommends that workplaces subject to OSHA regulations comply with OSHA's 1992 standard for occupational exposure to bloodborne pathogens. The study also advises that the medical community make greater efforts to encourage compliance with the CDC guidelines. Finally, the report recommends that members of the health care system work together to address attitudinal barriers toward immunization for hepatitis B, that they renew initiatives to prevent employees from recapping needles, and that they continue to encourage caregivers to wear gloves and other protective clothing.

The study was conducted by the Battelle Corporation and Westat, Incorporated, under contract to the Centers for Disease Control and Prevention.

The contact person for this report, Dr. Linda Martin, can be reached on 404-639-0983. Copies of the executive summary, #3195, are available from PIC.



In 1985, U.S. Census projections estimated that some 3.5 million children were being raised in extended family households. Approximately 1.8 million of these children were growing up in households in which their parents were not present. The ways in which these children come to live with relatives vary; for some, parents are home part or all of the time, while for others, a relative has assumed care for the child in order to avert the need for foster care placement. Other children may come into the legal custody of state child welfare agencies, which then place them in foster care with family members.

The report, Using Relatives for Foster Care, explores the last type of arrangement. The study examines how states support foster care provided by relatives and identifies issues concerning the certification and utilization of extended family members within the foster care system. To compile the report, staff of the Office of Inspector General (OIG) reviewed recently initiated research on this topic, interviewed foster care administrators in the 50 states and the District of Columbia, and examined written materials on unique aspects of a variety of programs.

Key findings include that few states even collect detailed data on relative foster care placements. Of the 29 states that do have the capability to produce some statistics, approximately 80,000 children (or more than 31 percent of the total number of foster children in the legal custody of these states) received care from relatives in fiscal year 1990. The use of these types of arrangements appears to be increasing because of state policies encouraging the maintenance of extended family ties and because of shortages of foster homes. The results also indicate, however, that formal procedures for licensing and approving relative foster homes often are lacking in many states and that relative foster parents may be held to lesser standards unless they also care for non-related children. Policies regulating foster care maintenance payments also vary between and within states.

Finally, evidence indicates that children in relative care arrangements remain the legal responsibility of the state longer than do children in alternative types of arrangements. This trend may be caused by confusion over the goals for children placed with relatives; the social difficulties of adopting children who are already part of the foster parents' extended families; and the fact that, except for in six states, the transfer of custody from the state to the relatives results in the cessation of all financial assistance -- a powerful incentive for family members not to take such action.

Because the current lack of regulations regarding relative foster homes creates a potential for harm to children, the study urges that the Administration for Children and Families (ACF) encourage states to extend existing foster home standards to relative foster care or to develop reasonable policies for using and evaluating these homes when they are not licensed or approved. The report also advises that ACF urge states to formulate consistent policies for informing approved or licensed relatives about their eligibility for financial reimbursement. In response to the second recommendation, ACF concurred that states should have such policies, that relative foster parents should be informed about the benefits for which they qualify, and that these benefits should be offered as part of routine placement procedures.

The study was conducted by the Office of Evaluation and Inspections, Region VI (Dallas Regional Office), Office of Inspector General. Copies of the final report, #4672, are available from PIC.



In 1990, America spent approximately 12 percent of the gross domestic product (GDP) for health care -- more than twice what we paid for national defense and nearly twice what we paid for education. If these trends continue, the Congressional Budget Office (CBO) projects that the United States will pay 18 percent of the GDP for health care by the year 2000.

The report, Economic Implications of Rising Health Care Costs, analyzes the special features of the health care market, assesses why health care costs are climbing, discusses the impact that health expenditures will have on employer-provided insurance, and reviews how rising costs within government health programs will affect the economy.

The study finds that numerous factors are to blame for the nation's spiraling health expenditures, primarily the rapid development of costly medical technology. Demographic changes, defensive medicine, and the spread of acquired immune deficiency syndrome (AIDS) have also played a small role in health spending.

These rising payments have far-reaching effects. First, they lead to more expensive private health insurance, with the costs ultimately being borne by employees in the form of lower wages or less generous non-medical benefits. Health care costs have absorbed much of the growth in employees' real compensation over the last two decades and, along with the slow growth in productivity, explain why workers' cash wages have hardly grown during the period. Second, rising costs are causing increasing numbers of people to join the ranks of the uninsured; in 1990, 33 million people under age 65 did not have coverage, but by the year 2000, that number is projected to include nearly 40 million individuals. Third, higher insurance costs may be distorting the nature of the labor market. Some employers have moved low-wage workers to part-time status with no health coverage or have eliminated these positions altogether and hired independent contractors instead. Finally, higher health costs have made the provision of insurance a more important factor in selecting a job.

Health expenditures have affected the federal and state governments as well. Medicare and Medicaid are the fastest growing parts of the federal budget, with the increase in these programs' share of the GDP from 1991 to 2002 projected to cost the government an added $313 billion in 2002. States also spent some $100 billion on health care in 1991, and they will likely pay as much as $244 billion for care in 2000. In the absence of precautionary measures, increases in health costs will also lead to a larger federal budget deficit.

The study was conducted by the Congressional Budget Office. Copies of the final report, #4761, are available from PIC.


Recently Acquired Reports

  • Trends in Foster Care
  • Toward a National Health Care Survey: A Data System for the 21st Century
  • AIDS: CDC's Investigation of HIV Transmissions by a Dentist



The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research and; policy-oriented projects conducted by HHS as well as other Federal departments and agencies. The PIC on-line database provides project descriptions of these studies. It is available on-line at: Inquiries regarding PIC services should be directed to Carolyn Solomon, Technical Information Specialist, at 202-690-5694. Or E-mail PIC at:

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