The news report took us by surprise: “Fentanyl exposure during pregnancy is linked to a new medical syndrome in babies.” The piece reported on a study recently published in the journal Genetics Medicine, which found that 10 infants showed evidence of having been harmed by exposure to the drug in utero. Fifty years ago, medical literature reported a similarly new (to the modern medical community) finding that alcohol exposure during pregnancy led to a distinct syndrome in infants.
Both of us have studied and written about this history — Janet Golden in her book Message in a Bottle: The Making of Fetal Alcohol Syndrome, and Grace Howard in her forthcoming book The Pregnancy Police: Conceiving Crime, Arresting Personhood. We did not expect to see a new discovery of prenatal exposure and infant harms in 2023, but we understand well how these discoveries come to play a role in medicine, public health, the media, and most importantly, the lives of pregnant people.
Is fentanyl exposure in utero the precise cause of the congenital anomalies — or what the study authors call a “novel embryopathy” seen in babies? It is certainly possible. The signs they point to include small heads, underdeveloped jaws and conjoined toes. However, this study must be viewed alongside its limitations — a lesson we hope has been learned from the past.
In 1985, a study positing an association between crack cocaine exposure in utero and a variety of amorphous symptoms in newborns was published, sparking a media frenzy. Crack cocaine was already highly stigmatized — a new, apparently uniquely addictive drug primarily used by impoverished Black people in urban areas. Before long, predictions of a ruined generation of crack-damaged children proliferated, describing a veritable hoard of anti-social, inherently violent kids in inner cities.
But these predictions never came true. The study, which the author himself cautioned as preliminary, lacked control groups and relied on only a handful of cases. As subsequent research has shown, poverty is a better indicator of health and well-being than prenatal exposure to crack cocaine. Even as the so-called “crack-baby syndrome,” myth has been debunked, the racist and false narrative that impoverished Black women are breeding a “biological underclass” has lingered.
Several elements of this recent study raise red flags, including its sample size of only 10 cases, and its assertion that infants exposed to nonprescription opioids have “an overall distinctive appearance that was hard to put into words.” If fentanyl or other substances delivered along with it prove to be teratogenic (to cause congenital anomalies following fetal exposure), other indications of harm may follow as the infants grow older. The research agenda is clear; investigations will need to determine whether it is the fentanyl — or its combination with other substances — that is the cause of the observed anomalies, as well as the role played by environmental factors and other variables such as poverty or maternal malnutrition.
The scientific pathways for studying this possible new teratogen are well trod. So, too, are the alleyways that lead from scientific investigation to social control. The crack cocaine crisis was met with increased criminalization and harmful reductions in the kinds of social services that can improve pregnancy outcomes. Substance use, especially among pregnant people, has been seen as a moral failure. While some have noted that the opioid crisis has been correctly framed as a public health crisis (because it is seen as primarily impacting white people), this has not translated into less condemnation for pregnant people who use drugs.
If fentanyl is found to cause congenital anomalies, people who use the drug should not be subject to legal penalties. Not only does this hold pregnant people to a separate and lesser legal standard than other people, but criminalizing substance use during pregnancy has been found to worsen maternal and infant health, driving people away from care.
For the most marginalized and vulnerable people, especially pregnant people who use drugs, quality care isn’t always available or accessible. Most drug treatment programs do not work with pregnant patients, who are seen as an insurance liability. Those that do treat pregnant people may be of questionable quality. Only 51 percent of drug treatment facilities in the United States are accredited. The closure of rural hospitals with labor and delivery units, and decreased access to abortion across the U.S., has left pregnant drug users with even fewer options.
The idea of a pregnant person taking fentanyl may be alarming, but it is reality. (Indeed, fentanyl is routinely given for pain during birth labor.) Sometimes, people with substance use disorder become pregnant. Surely, a pregnant person with substance use disorder is safer when they can access the full scope of health care, nutritious food and clean water, and a safe place to sleep.
The failure to deliver these services needs to be seen as contributing to the problem identified in the medical literature. But the history of pregnancy policing, which has seen the arrest, prosecution and incarceration of thousands of people, and the separation of parents from children, makes us fearful that public debate will turn instead to stigma, incarceration and family separation.
We are not naïve enough to think that the “discovery” of a fentanyl-related syndrome is going to lead to needed services, but it should. Knowing what we do about the past failures to understand pregnancy and the use of dangerous legal and illegal substances, it is critical not to remain silent as this new finding makes its way into public consciousness.