LOS ANGELES TIMES INTERVIEW: Lynn Yonekura : Using Medicine for Social Change: Treating Addicted Moms and Babies

Their babies are usually born prematurely and require long, expensive hospital stays. The newborns may have a wide variety of birth defects. If they make it past the critical first months, they face an uncertain future that may reveal learning disabilities, dysfunctional motor skills and mental retardation.

These are the children of women addicted to drugs or alcohol. If these women are also poor--as many are--they have few options. Many prenatal programs won’t accept addicts or alcoholics, and many detox programs won’t accept pregnant women.

Enter Lynn Yonekura. Since 1987, she’s been running programs for pregnant addicts. As chief of obstetrics at Harbor/UCLA Medical Center, she developed a slate of comprehensive services for chemically dependent mothers-to-be, providing treatment, prenatal care, social services and continuing care after delivery. Yonekura moved to the California Medical Center last year, and while maintaining her program at Harbor, she’s developing a new one for residents of the city’s Pico-Union area. A skilled grant-proposal writer, Yonekura seems able to attract funding even during times of fiscal austerity. She’s lobbied on the state and national levels as an advocate for prenatal care and an approach toward drug addiction that transcends the criminal-justice system.

Yonekura’s Japanese-American parents met in an internment camp during World War II. They stressed education, and their daughter got a good one--private girls’ school, Pomona College, USC Medical School. Rather than set up a private practice, Yonekura chose to work with poor patients. In the 1980s, she was alarmed by the growing number of babies she delivered who were born intoxicated with cocaine or other drugs. That led to her pioneering work with drug-addicted mothers. Yonekura has proven to be something of a master at using medicine as a tool for social change--having achieved success at getting mothers off drugs and having them deliver healthy babies, she’s now focusing on long-term programs she hopes can help break the cycle of poverty and addiction.

Yonekura is herself the mother of a 13-year-old daughter. She met her husband, also a physician, during an emergency Cesarean section on the first day of her residency. Her office is Spartan, save for a Picasso print--a portrait of a mother nursing her child.

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Question: How widespread is the problem of children born with drugs in their bloodstreams?

Answer: Based on some surveillance studies that have been done, approximately 11% of the babies born in the United States are substance-exposed during pregnancy. We don’t know if that means chronic exposure, but it’s probably a fair figure of babies born with “drugs on board.”

Q: I understand the mothers of these children often find themselves caught in dilemma--why it is so difficult for them to get prenatal care and drug treatment?

A: It’s really a Catch-22, because if she is truthful when she goes to seek prenatal care, and she says, “I am an addict” or “I am an alcoholic,” some doctors won’t serve her--they won’t take her case because she has a high risk for many complications, and they don’t want to assume that liability. Then if she goes to a drug-treatment center, those programs may not serve her because they are also afraid of the complications and liability.

A few years back, when he was a senator, (Gov.) Pete Wilson came to talk to a group of my patients, and they told him how difficult it was to find prenatal care, and how difficult to find drug treatment. At that time, his position was that if a pregnant woman didn’t get prenatal care, and if she didn’t get drug treatment, you put her in jail. I think these women persuaded him that was not a fair thing to do. Since then, I think he’s become more of an advocate--he understands now that if a woman is honest, that kind of care is often not available.

Q: What’s the role of the justice system in all this? Many people would say if a woman is pregnant and continues to use drugs or alcohol, she’s guilty of abusing her unborn baby and should be jailed. Do you disagree?

A: With addiction, we have to get away from the mind-set that it is something to be punished. When you look at the background of female addicts, most were children of addicts or alcoholics or mentally disturbed parents. Most--maybe 90%--were sexually abused as children. They already have a lot of strikes against them. They use drugs to cope. They really do drink to forget, and they have a great deal which needs to be forgotten. They’ve been punished enough.

And we can’t write them off. At our prenatal clinic, we get 80% to 90% of our women drug-free before they deliver. They deliver babies at term who are healthy. Now we are working on continuing services, because we understand the need to work with these women over the long term.

To help these families, it takes a large team of people, and doctors actually play a very small role. You need the social worker--the case manager, as we call them--who coordinates all the services and makes sure they get them. And there is a role for the Family Court, which can mandate treatment, because sometimes that’s what it takes. Most of the time women say, “I’m here for my children, I know the courts will take them away unless I get treatment.” So there is a positive side to court involvement.

On the other hand, we have to recognize that some of our systems are almost as dysfunctional as the patients. In spite of being well-meaning, they don’t have the ability to follow through. We’re trying to design a system that can do just that--that can tell a judge which women need to be mandated into treatment, and what kind of treatment they need.

Q: You’ve described pregnancy as a window of opportunity for helping a drug user break her addiction. What do you mean by that?

A: All women say, “I’m pregnant. I’m going to eat right, I’m going to do all the right things to make sure I have a healthy baby.” There isn’t a woman who doesn’t go through this process--and addicts are no different. They have the same instincts. They are likely to seek prenatal care, and that’s when we have our opportunity. So I’ve tried to teach young doctors that this may be our only chance to reach this woman.

Some of them are so happy to have someone who cares--who won’t be judgmental--that they will just have these dramatic outpourings of their stories. I had a woman who told me about being abandoned by her parents, having to live on the streets and work as a prostitute--this gut-wrenching tale--all while I’m giving her a Pap smear!

Q: Can you paint me a picture of the kind of woman who might come for help?

A: She began smoking cigarettes in her early teens. She also began drinking alcohol in her early teens, maybe added marijuana, then moved up the ladder to cocaine. Maybe not so often heroin, although the newest heroin is so pure that you can snort it--you don’t need to inject--so women who were afraid of needles might now use heroin. Then there are methamphetamines. But cocaine remains the drug of choice in the county.

These are women who may be using a potpourri of these drugs, and drinking as well. She’s usually been pregnant before--our women have an average of two children already.

Q: What about birth control and abortion? Do you help them with birth control?

A: Being pregnant every year is not what these women want. It’s just that when your life is in chaos, you might not remember to take your pill every day. I know a lot of women who don’t live in chaos who can’t remember.

A large number of our patients have requested sterilization. However, in California, a woman who is pregnant has to sign a consent form at least 30 days before her due date in order for the physician to tie her tubes after delivery. While the law was meant to protect women--in a population of women who don’t get prenatal care, it means they never have the opportunity to sign the consent form.

Norplant (a long-term birth-control implant) has been a godsend. Women who may not want a tubal ligation, but realize they need time to get their life in order, see five years without worrying about pregnancy as Nirvana. It helps them realize they can focus on the other issues in their life.

Q: In your experience, what are the things that work--how do you get an addict who is pregnant to stay off drugs?

A: The first thing you do is establish an environment in which these women will not be judged. Then you have to address the most basic of needs--food, shelter--things that a lot of us take for granted and that many of these women don’t have. Then there is the area of parenting. These women want to be good parents, but they have not been raised in homes where good parenting practices were evident. So they need to be taught these skills.

But without drug treatment, you won’t get anywhere. That means long-term care--and it means care for both the mother and the child. Women shouldn’t have to make what I call “Sophie’s Choice”--they shouldn’t have to choose drug treatment knowing it means their children will go into foster care. No matter how dysfunctional their life, they are going to try to keep their family together. So we had to create programs where women can take their children with them into treatment.

In the male-focused programs (for drug addiction), the goal is to get back to work--to get a job. Our goal is not necessarily to get the woman into the job force, because if she’s got several children, and she’s a single parent, it’s probably unrealistic, given the lack of child care. So our goal is to help her be the best mother she can be, and to break the cycle by parenting those children in a way that they can move into the mainstream.

Q: It’s clear that the kind of care you provide can be cost-effective. When you lobby for support, what sort of pitch do you make?

A: The difficulty is that people tend to look at their own little pot of money--they don’t look across the broad system. With prenatal programs, it’s pretty easy--you can look at the cost of the program and figure if you keep one baby out of the Natal Intensive Care Unit, you pay for your program. At Harbor, before the program, some 20% to 30% of the babies went into NICU. Now only about 5% do--that’s a huge cost saving.

After that, it gets a little more difficult. If you can keep a child out of foster care, that’s going to cost less. If you optimize the pregnancy, you save down the line in costs--like special education and criminal justice. The problem in selling this kind of treatment is that it’s front-loaded--your costs are high in the beginning and it takes a long time to see the investment pay off.

Q: Are you starting a similar program at California Hospital?

A: Yes, but it will be a little different. This program will focus on substance-abusing families--the whole family. The population I have been serving for the last several years has been mostly a female-addict-based one. The population we’ll see for this project will be different--we’re targeting the Pico-Union area. Generally, the addict-alcoholic here is not the mother, but rather the father. We see a lot of domestic violence in this population. We’ve learned a lot already about the acculturation stresses, and how the male drinking patterns change with immigration. We hope to learn a lot more about that, because it effects such a large population of people entering the United States. So there won’t be the hard-core drugs so much as alcohol.

We’ll offer intensive services over a long term, as many as five years. Which is great, because we need the time. Even in our two-year program we see families really turning around, going from chaos into having children back into the home and in a stable environment.

Q: Why do you do this? You could have an office in Beverly Hills, treat rich women and probably only work three days a week. What’s the payoff?

A: I’ve been pretty blessed throughout my life, having anything I pretty much ever wanted made available to me--so this is the pay-back. I believe in the American dream. I certainly saw it in my own family. And I know most families need someone to help. My parents worked as domestics for a couple after they came out of the camp, and when my father wanted to start a dry-cleaning business, that couple lent him money to start it. This is my own little way of also making that kind of loan to someone else.