When -- despite the objections of medical groups, reproductive health advocates, and even the drug czar's office -- Tennessee Gov. Bill Haslam (R) signed into law Senate Bill 1391 late last month, the Volunteer State became the first in the nation to pass a law criminalizing pregnancy outcomes. Other states, such as Alabama and South Carolina, have used fetal harm laws to charge drug-using pregnant women, but Tennessee is the first to explicitly criminalize drug use during pregnancy.

[image:1 align:left]Passed in the midst of rising concern over prescription drug and heroin abuse and aimed, its proponents said, at protecting babies, the law allows women to be criminally charged with an "assaultive offense for the illegal use of a narcotic drug while pregnant, if her child is born addicted to or harmed by the narcotic drug or for criminal homicide if her child dies as a result of her illegal use of a narcotic drug taken while pregnant."

Felony assault can earn you up to 15 years in prison in Tennessee. And while some prosecutors have said they will only file misdemeanor charges, that's not written into the law.

Proponents cited recent reports that the number of babies being born addicted to drugs is on the rise. Such infants are diagnosed as having Neonatal Abstinence Syndrome, or withdrawal symptoms after being exposed to opiates in the womb.

"Over the past decade, we have seen a nearly ten-fold rise in the incidence of babies born with NAS in Tennessee," the state Department of Health reported. Infants with NAS stay in the hospital longer than other babies and they may have serious medical and social problems."

But the state Health Department notwithstanding, experts in the field say that NAS doesn't actually have long-term effects, it's not accurate to call newborn infants "addicted," and that misrepresenting matters by vilifying pregnant women isn't helpful. In fact, more than 40 of them said so in an open letter last month.

More generally, leading medical groups, including the American Medical Association, the American Nurses Association, the American Academy of Pediatrics, and the American Public Health Association reject the prosecution and punishment of pregnant women who use drugs. The groups mentioned above and many others said so in this 2011 document.

A coalition of medical, public health, women's rights, and social justice groups worked to oppose the bill as it made its way through the legislature, and then to convince Gov. Haslam to kill it. A petition with over 11,000 signatures urging him to veto the bill went to his office late last month. More than two dozen organizations devoted to ensuring families have access to health care likewise urged a veto, as did the American Association of Pediatrics, the National Perinatal Association, and International Doctors for Healthier Drug Policy.

Even acting drug czar Michael Botticelli raised a warning flag.

"Under the Obama administration, we've really tried to reframe drug policy not as a crime but as a public health-related issue, and that our response on the national level is that we not criminalize addiction," he said during a visit to Nashville as the governor pondered. "We want to make sure our response and our national strategy is based on the fact that addiction is a disease. What's important is that we create environments where we're really diminishing the stigma and the barriers, particularly for pregnant women, who often have a lot of shame and guilt about their substance abuse disorders."

But none of that mattered. On April 29, Haslam signed the bill into law.

"In reviewing this bill, I have had extensive conversations with experts including substance abuse, mental health, health and law enforcement officials," Haslam said in a statement. "The intent of this bill is to give law enforcement and district attorneys a tool to address illicit drug use among pregnant women through treatment programs."

"Today, the Tennessee governor has made it a crime to carry a pregnancy to term if you struggle with addiction or substance abuse," Alexa Kolbi-Molinas, staff attorney with the ACLU Reproductive Freedom Project, said in a statement in response to the signing. "This deeply misguided law will force those women who need health care the most into the shadows. Pregnant women with addictions need better access to health care, not jail time."

The statewide coalition Healthy and Free Tennessee also lambasted the new law.

"We are very sorry to see that Governor Haslam let an opportunity to do the right thing slip through his fingers," said Rebecca Terrell, the group's chairwoman."The experts could not have been clearer: this law is bad for babies and bad for Tennessee."

"This law says that women are to be held criminally accountable for the outcomes of their pregnancies," said Farah Diaz-Tello, a staff attorney with National Advocates for Pregnant Women, which was part of the coalition fighting the new law. "It essentially creates a system of separate and unequal rights. Drug ingestion is not a crime in Tennessee, just possession, and now, only pregnant women are criminalized for ingesting. They can be surveilled and punished by the state in ways different from other people. The law also treats fertilized eggs or fetuses as if they were people independent of the pregnant woman," she told the Chronicle.

[image:2 align:right caption:true]"It's the wrong response to the problem of addiction," said Diaz-Tello. "It's a health problem that is not responsive to threats and punishment. What kind of society do we want to be? Do we want to punish the people most in need of help and support? These are women largely living in poverty, women of color, who are already made vulnerable by our social policies, and now we hold them solely responsible without looking at society and what else is going on leading to pregnancy among addicted people and this horrible punitive response."

Even framing the issue as "pregnant women taking drugs" is somewhat misleading, said Diaz-Tello.

"We often make the mistake of thinking of people using drugs during pregnancy as pregnant women who became addicted to drugs when it should be the other way around," she said. "The reasons for addiction are complex and often gender-based. Women who have experienced violence and trauma are often self-medicating, and there is a lot of unresolved pain and trauma out there. And half the pregnancies in our country are unintended, which disproportionately affects women on the margins. It's not like someone wakes up pregnant one day and decides they want to do drugs."

The law will not operate in a vacuum. Tennessee is one of those states that has refused to expand Medicaid and has rejected the Affordable Care Act. It is more difficult for poor women there to get access to health care services, including drug treatment, but now it will be easier to prosecute them.

"This is definitely for the most part going to affect poor, marginalized, predominantly rural women," said Cherisse Scott, founder of SisterReach, a Memphis-based group working for reproductive justice for women and girls in the city and the Mid-South area. "That's because of the many barriers they face. Many rural areas just don't have the facilities to offer help to these women."

Scott also bemoaned the criminalization of pregnant women who use drugs under the law, a process of stigmatization and punishment only made more severe for women lacking resources.

"Low income women, women of color, already have issues navigating the court system, and many don't have any kind of support system," she said. "When their children are taken, they don't have the resources to get them back. And the other piece of this is that jails aren't hospitals or treatment centers. They don't offer women an opportunity to be properly rehabilitated from drug use."

And then there's the aftermath of a criminal conviction.

"If you look at this through the lens of racial and reproductive justice, how does a woman with this on her record bounce back, how does she get a job? With a criminal background, she will be further locked out," said Scott. "These are the kinds of barriers and issues that will ultimately hurt the mothers of Tennessee. We can't support legislation that uses criminalization as a means of rehabilitating people," she told the Chronicle.

"Our lawmakers had good intentions, but they didn't think it through," said Scott. "They seem to be very ready to separate mothers and children as a way of helping, and we don't see it like that, especially when there are rehab programs that keep mother and children together."

The new law is also generating alarm with advocates for people who use opioid maintenance therapy to deal with opiate addictions. Methadone and buprenorphine maintenance are the gold standard for treating pregnant women addicted to narcotics. While state health officials have said they interpret the law to mean that a pregnant woman on methadone maintenance would not be in violation of it, there is no language in it that explicitly says that.

"I asked the governor to veto the bill because that exclusion wasn't made," said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence. "The real question is whether some representative for the attorney general's office or a DA or child protection services interprets it that way. This is a potential problem. When you're talking about child protection, it's not unusual for a judge or child protection worker to say to a pregnant mom 'You can't be on methadone.' I hope this law will not be used as a method of forcing maintained patients out of care."

While babies born to opiate-addicted women can suffer from Neonatal Abstinence Syndrome, or withdrawals, they can be treated for that, mainly by slowly tapering the dose of opiates. But, Parrino said, not all pregnant mothers on methadone maintenance have babies with the syndrome, and consequences for fetuses can be serious if mothers are forced off opiates during their pregnancies.

"What happens to a fetus if you force mom to end her medication?" he asked. "In the first trimester, a sudden decrease can be harmful to the fetus. There could be spontaneous abortion. It's in the literature. That's why laws like this raise concerns in people who have some knowledge about how pregnant women are treated."

Parrino, too, saw race a playing a role, but in an unexpected way.

"What I am seeing for the first time in 30 years is a real interest by elected officials, many US senators and governors and legislators, who can't wrap their heads around why white teens and 20-somethings from middle class families in the suburbs and rural areas are shooting heroin," Parrino observed. "Those elected officials are right to be worried. This legislation in Tennessee is a result of those dynamics."

While the law may have been passed with the best motives, "the problem is the criminalization aspect," said Parrino. "Even if it can be explained as having a reasonably good intention of getting pregnant women not to use drugs and go to treatment, you are unwittingly subverting that goal by saying that being in methadone maintenance might be seen as not complete treatment. That uncertainty is creating anxiety."

The new law is set to go into effect on July 1, but efforts are already underway to block it and, barring that, to mitigate its effects.

"We're still trying to figure out the best plan of action," Scott said. "We want to figure out the best way to support women who are going to be victims of this policy. At the grass roots level, that means education, awareness, getting the word out through rehab centers to let the women know this is coming. Then we have to figure out what is the legal strategy to try to change this law. We're working on it."

"We're thinking about a legal challenge, especially on constitutional grounds," said Diaz-Tello. "We have worked with public defenders in Tennessee and other states on challenging similar laws on constitutional grounds. There's also the possibility of an affirmative suit to get the law enjoined. It would be ideal to stop this law before anyone gets arrested under it."

Barring the successful blocking of the law, drug-addicted pregnant women in Tennessee will face the tender mercies of the criminal justice system. But not all of them, of course.

"Race and class plays a role as always," said Scott. "Poor mothers go to jail; mothers with access to more resources may not be penalized at all. Women who have access to health care and can afford private prenatal care and treatment will get treatment; women who have no alternative but public aid or a public health clinic will be disproportionately impacted as always. Nothing's changed as far as race and class."