She was four minutes old, lying still on the floor with her mom, attached by the umbilical cord. An emergency dispatcher was telling the caller how to do chest compressions.
That was the night that mom and two friends were injecting heroin and doing meth in a trailer park off a back road, paramedic Dale Barnhart said. Around 11 p.m., mom went into labor, six weeks early.
The roads were snow covered. The trailer was cold.
Was the heat even on? Mr. Barnhart wondered, rushing through the door, heart monitor and canvas bag of rescue gear flapping from his arms.
“The child was blue when it came out,” said Mr. Barnhart, 25, the first medical help at the scene in rural Fayette County that night. “The child was unresponsive. The 911 dispatchers gave instructions, but they weren’t followed because everybody was high.”
The number of people using drugs while pregnant is exploding in rural pockets of America, including Fayette and Greene counties, where an increasing number of pregnant women cross the state line to West Virginia hospitals to deliver.
According to data not previously reported, 327 moms from Pennsylvania gave birth in Morgantown in 2017, with 1-in-16 of the babies having been exposed to drugs during pregnancy, according to Amna Umer, an epidemiologist at West Virginia Department of Health and Human Resources, who uses a statewide surveillance tool called Project Watch.
Three years later, the total number of births to Pennsylvania moms had ballooned to 741 in 2020, with 1-in-10 of those children exposed to drugs during pregnancy — a 60% increase in the drug-exposed birthrate.
The Pennsylvania Department of Health has not yet recognized the problem. The department relies on narrow screening criteria and 2-year-old data — the state’s most recent report is 2019. West Virginia tracks substance-exposed births in real time.
But the emerging trend among rural southwest Pennsylvania mothers should be a call for alarm, said Cathleen Palm, founder of the Center for Children’s Justice, a nonprofit advocacy group based in Berks County, on the eastern side of the state.
“We’re just not urgent enough about the level of exposure,” she said. “There’s a lack of leadership and accountability on the state level. The few things we are measuring tell us we should be sounding the alarm.”
A reporting breakdown
The Pennsylvania Department of Health only monitors opioid-affected births, newborns who develop the most severe symptoms of withdrawal — high pitched crying, poor feeding, trembling, easily startled responses.
The department doesn’t count the number of children who are exposed to other substances during pregnancy.
In West Virginia, where hundreds of rural Pennsylvania mothers go to deliver their babies each year, the state monitors eight substances that newborns may have been exposed to, including alcohol.
And while Pennsylvania relies on hospital discharge data to track substance-exposed babies — a process that can take weeks — WVU Medicine’s Ruby Memorial Hospital in Morgantown, where many Pennsylvania mothers wind up, tests umbilical cord tissue for every birth with results that can be available in as little as 12 hours.
America’s drug problem
A record 93,331 people in the U.S. died from drug overdoses in 2020, according to the federal Centers for Disease Control and Prevention, with 60% of the deaths blamed on synthetic opioids such as Purdue Pharma’s OxyContin. In September, a New York judge approved a bankruptcy settlement with Purdue, which removed the Sackler family from ownership of the company and devoted $5 billion to $10 billion to fighting the opioid epidemic.
Some victims will receive $3,500 to $48,000 each as part of the agreement. The new generation of children born to mothers who used the drugs during pregnancy weren’t part of the settlement.
In the hollows of southwestern Pennsylvania, the number of substance-exposed newborns has been rising with the number of drug overdoses in the region.
Fayette EMS, for example, which serves Fayette County, last year answered a record number of calls for mothers overdosing — calls that included three child deliveries. The service answered at least 300 total drug overdose calls as of late August.
That compares to 409 overdoses in all 12 months of 2020.
Emergency medical technician Molly Roberts, 25, who doubles as a member of Fayette EMS’ outreach to moms who used drugs during pregnancy, remembers one shift where she responded to four overdose calls in six hours.
“It was overdose, overdose, overdose,” she said. “It’s not just one overdose; it’s like the community overdoses.”
No one knows for sure how many kids are born each year to Pennsylvanian moms using drugs. There is no national screening standard for drugs or other substances, even though umbilical cord testing is considered the gold standard.
Cord tissue can reveal a parent’s use of amphetamines, opiates, cocaine and cannabinoids. By comparison, the signs of newborn substance withdrawal from opioids — the metric used in Pennsylvania — can be subject to interpretation by health care providers.
Fragmentation in how birth data are collected across the U.S., and chronic underfunding of child health programs means that only a small number of children born substance exposed are being captured, said neonatologist Stephen W. Patrick, who is director of the Vanderbilt Center for Child Health Policy in Nashville, Tenn. Some 400,000 children are born in the U.S. exposed to drugs each year, but only 5% are identified at birth.
Moreover, there is little coordination between identifying these children and getting them early intervention care that would help them thrive, he said.
“The overall aim should be helping moms and babies, and it should be about all substances, legal and illegal,” he said. “If we are not using the data to improve outcomes, then what are we using the data for?”
Crossing the border to give birth
Neither Fayette nor Greene counties have a maternity hospital — Uniontown Hospital, the only facility in the area providing maternity services, closed its obstetrics unit in 2019 — so hundreds of pregnant women from Pennsylvania go to hospitals in Morgantown, W.Va., to deliver their babies each year.
And at Morgantown hospitals, the number of births to Pennsylvania mothers using drugs is escalating along with the number of newborns suffering the most serious effects of drug use.
The number of babies born to Pennsylvania moms showing signs of substance withdrawal jumped to 50 births in 2020 from 8 in 2017, a six-fold increase in three years.
Tracking the problem is the first challenge in Pennsylvania, according to Richard Rinehart, executive director of Cornerstone Care Community Health Centers, a nonprofit group of medical practices in Greene County.
“Our public health structure in Pennsylvania has become a disgrace,” he said. “There’s really no public health infrastructure to monitor this stuff. It is invisible, pushed off into the hills and hollows. And it’s insidious.”
In fact, the state’s current data collection system doesn’t actually see a problem here.
Based on the state’s delayed data collection and narrow screening criteria, the Pennsylvania Department of Health says the issue of newborn substance dependence has been easing in Fayette and Greene counties between 2018 and 2019, the most recent numbers available, a department spokeswoman said.
The impact on kids
While drug use during pregnancy may be an insidious social problem, it affects kids in ways that are not always well understood, said Dr. M. Cody Smith, 38, a Uniontown native and a neonatologist at WVU Medicine’s Ruby Memorial Hospital in Morgantown.
Dr. Smith was starting a 96-hour turn in Ruby Memorial’s neonatal intensive care unit, which was over capacity with 58 infants — at least 1 out of 5 of whom were born substance exposed.
“Lots of meth,” Dr. Smith said.
The mother of one newborn was using heroin while pregnant and lost custody of the child, but foster care arrangements were incomplete. The 28-day-old girl had no visitors in an NICU with rocking chairs.
The little girl, an angry red rash around her mouth, fussed quietly in a ward of cribs, struggling with an infection.
“We are her family,” a NICU nurse said.
About 40% of substance-exposed babies, many born underweight or early, will show muscle rigidity and other signs of drug withdrawal. Sometimes the moms of these children check out of the hospital early without good contact information, leaving their babies behind so child protection authorities can take care of them.
And even when parents desperately want to keep their babies, they are often walled off from the rest of the world by the shame and stigma of giving birth while using drugs or other substances, said Candy Cooley, a Morgantown native, and peer recovery support specialist for young mothers at WVU.
“There’s this idea that people are making a choice to use,” said Ms. Cooley, 49, a former heroin addict who has been in recovery for 10 years. “Maybe that first use was a choice. But at some point, this just isn’t someone having fun.
“They’re just trying to survive, trying not to be sick, physically and mentally.”
Deception becomes a way to hide substance abuse, separating users from the community, said Laura Lander, an associate professor and addiction therapist who counsels recovering mothers at a West Virginia University clinic.
“Lying is a way of life. It’s building a defense system,” she said. “It protects the addiction. I don’t assume they will trust me.”
Multiple efforts by the Pittsburgh Post-Gazette to talk with women who use substances during pregnancy were unsuccessful.
Between 16% and 18% of Ruby Memorial’s NICU babies go into foster care rather than going home to their parents, mostly because of illegal drug use, Dr. Smith said.
Child welfare workers say the surge of parents losing custody because of drug use in recent years in West Virginia — which has the highest rate per population of drug overdose deaths in the U.S. — has created a backup.
Some 8,000 kids are in foster care in the state while there are only an average 4,000 certified foster homes, said Alexandria Hamler, who matches kids with foster parents at Pressley Ridge, a Pittsburgh-based social service nonprofit with operations in West Virginia.
“The rate they’re coming in is a lot faster than we can get people certified,” Ms. Hamler said. “The foster care system in West Virginia, like everywhere else, is broken. And the treatment options for addiction in West Virginia — there’s not a lot.”
When foster care is not available, children in the custody of West Virginia are referred to shelters, then child care institutions, including some out of state, where there have been problems.
The mismatch was less dire a few miles across the state line in Pennsylvania, where the state Department of Human Services reported 13,564 kids in foster care in Pennsylvania as of March 31, with 12,970 licensed foster homes — a shortfall of about 600 homes.
Contractions, then bleeding
At 10:50 p.m. that cold night in the trailer park, the woman in labor called 911 and told dispatchers that it felt like her water broke. She was feeling contractions three to five minutes apart.
Four minutes later, she said she was bleeding badly. Fayette EMS paramedic Mr. Barnhart was already en route, the headlights of the emergency SUV he drove reflecting icy roads.
The baby girl was born, quiet and blue on the floor of the trailer. A dispatcher was giving instructions for chest compressions to take over the work of the heart and circulate blood through the child’s tiny body.
At 10:59 p.m., Mr. Barnhart pulled up outside, grabbed a heart monitor and canvas bag bulging with rescue gear.
He remembered going over the simple mnemonic: ABC, ABC, ABC, something he’d learned as a 14-year-old junior volunteer firefighter mastering the first lessons of CPR. Airway, breathing, circulation, the immutable ordering of priorities in saving a life.
The first of two Fayette EMS ambulances arrived to help at 11:04 p.m.; the second came four minutes later.
Emergency medical technicians scrambled inside as Mr. Barnhart cut and tied off the umbilical cord, placed a face mask over the infant’s mouth and nose and began pushing oxygen into her lungs by gently squeezing a rubber bladder connected to the mask.
He wrapped her in a blanket for warming.
It wasn’t going to be enough. He had to make a better way to get oxygen into her bloodstream by inserting a tiny plastic tube into her lungs, which would be much more effective than the face mask.
First, he had to stop pushing oxygen into her lungs, open her mouth and peer down into her trachea to find a clear path to her lungs — every moment depriving her of oxygen from the face mask.
He threaded the tube toward her lungs and missed; he tried a second time and failed again, wincing with every passing second. The newborn girl hadn’t yet cried for the first time.
Time was running out. He began getting mom and baby ready for the trip to the hospital, squeezing oxygen into the newborn’s lungs through the face mask without stopping.
Despite the chaos and the intubation failures, both arrived at the hospital breathing on their own and conscious. Mr. Barnhart doesn’t know what happened to them after that; he doesn’t often follow patients through the medical system, he said.
“Sometimes things are out of our hands,” he said.
‘Love on them’
Dr. Smith’s long stint in the NICU is in the rearview mirror, and he’s preparing to talk to about 20 foster parents on a Zoom call from a new office at WVU Medicine in Morgantown, where boxes of books and office supplies wait to be unpacked.
The foster parents are caring for children who’ve been exposed to substances before birth, and the parents are eager to learn what to expect.
“These kids are hard to take care of,” he tells them plainly. “They are fussy, irritable, but they can overcome a lot of these things with good services.”
Getting those services is not always easy, he said.
The potential for lazy eye, smaller than normal heads, hearing problems and missed developmental milestones — identifying colors and shapes at the appropriate ages, for example — are among the issues that foster parents should be aware of, the 38-year-old Dr. Smith told them.
Behavioral problems, attention deficit and other issues have been reported as these kids get older, but the substance-exposure effects later in life have not been well studied.
In Greene County, where the county seat of Waynesburg sits virtually atop a played-out coal mine and where methamphetamines replaced opioids as an illegal drug of choice in recent years, caring for children exposed to substances before birth is full of unknowns, said Mike Holloway Jr., deputy director, Greene County Children & Youth Services.
“We just don’t have the data as a state to suggest what kind of long-term repercussions there will be for these families,” he said.
Meanwhile, the Zoom call with foster parents ends, and Dr. Smith, the eldest son of a coal miner father and beautician mother, was worn out from working the crowded NICU. He was thinking about vacationing on the beach the next week with his wife and two young kids.
But he’ll be back for his patients, whom he calls “kiddos,” encouraging foster parents, nurses and others to “love on them.”
“Babies scared me for a long time,” he said with a weak chuckle. “I really love these kids, the fussy ones that drive people nuts. You can fix that.”
Kris B. Mamula: firstname.lastname@example.org or 412-263-1699