Mobile County Metro Jail on July 14, 2016

The interior of a local jail in Alabama. Women incarcerated in jail for drug use during pregnancy may not receive services to stabilize their pregnancies. (Sharon Steinmann/ssteinmann@al.com)

(Sharon Steinmann)

Raven West's first child was almost 10 months old when authorities arrested the 23-year-old Pleasant Grove woman for using drugs during her pregnancy with the girl.

West and her newborn tested positive for opiates at birth in July 2015, results a social worker reported to police, according to court records. Authorities issued a warrant in October, but didn't make an arrest for more than six months.

By the time she was booked, West was pregnant again, due in less than six months and still consumed by addiction to prescription drugs and heroin. As her pregnancy became more obvious, so did her legal problems. After she missed a hearing in August 2016, a judge sent her back to the Bessemer jail - which offers little in the way of drug treatment - even for pregnant opioid addicts who typically require medication and close observation.

Heroin use during pregnancy carries many risks for babies, but quitting cold turkey can be just as dangerous. The physical shock of drug withdrawal, and the violent sickness it causes, can trigger miscarriage in the early months and preterm labor later on. For this reason, addiction specialists treat opioid abuse in pregnancy as an urgent medical condition and move moms-to-be to the front of the line for scarce treatment spots.

Alabama gives pregnant moms priority placement in drug treatment centers, but the state also has the nation's harshest laws punishing those who use drugs during pregnancy. At least 500 women have been charged with felony chemical endangerment of a child since prosecutors began applying the 2006 meth lab law to women who use drugs during pregnancy. Addiction experts argue that putting women in jail can also put therapy out of reach - and West's case shows just how hard it can be to treat women during criminal punishment.

At issue, particularly for pregnant women, is access to medication such as buprenorphine and methadone, which stabilize cravings and withdrawal but aren't usually available in jail.

Some sheriffs and district attorneys say they can use chemical endangerment charges as leverage to get women into treatment, but that didn't happen for West or Alexandra Laird, another Pleasant Grove woman charged twice for chemical endangerment after using heroin. A judge ordered Laird back to jail in September after she admitted using heroin during pregnancy, but her treatment team at UAB refused to release her due to concerns about the adequacy of care at the Bessemer jail.

In a letter submitted on behalf of Laird's defense team, Sarah Harkless, director of substance abuse treatment and development for the Alabama Department of Mental Health, wrote that jails aren't designed for drug treatment, especially for pregnant women.

"This is especially relevant to pregnant women with opioid addictions who require ongoing medical evaluation, monitoring and maintenance on appropriate medication" Harkless wrote. "Jails are not equipped to provide this level of medical care."

West, who has been incarcerated in the Bessemer jail since November, granted an interview during visiting hours in January. Despite spending much of her pregnancy behind bars, she said no one suggested treatment until a judge noticed her bulging stomach just a few weeks before her due date.

"Nobody ever said anything about treatment until I was eight months pregnant," West said.

Suzanne Muir, associate director for UAB Substance Abuse Programs, said drug treatment resources are scarce for people without private insurance and the system is difficult to navigate without assistance. Alabama spends a minimal amount on public drug treatment programs - just enough to qualify for federal funds and not nearly enough to provide treatment to a growing number of opioid addicts. Although there are services available, Alabama is not one of 19 states that have created publicly-funded substance abuse programs specifically geared toward pregnant women, according to the Guttmacher Institute.

"It can be very difficult to find out where to go for help," Muir said.

Despite Alabama's crackdown on drug use during pregnancy, the number of babies born dependent on drugs keeps rising. An analysis of claims submitted to Blue Cross Blue Shield of Alabama showed the number of claims more than doubled from 63 to 132 between 2014 and 2016, according to spokeswoman Koko Mackin. Babies dependent on opioids must be weaned over weeks or months and can cost as much as five times more than a normal newborn to treat in the hospital, Mackin wrote in an email.

Many medical and civil liberties groups oppose Alabama's punitive approach to drug use during pregnancy. In 2011, the American Congress of Obstetricians and Gynecologists urged its members to fight such laws.

"Incarceration and the threat of incarceration have proved to be ineffective in reducing the incidence of alcohol and drug abuse," the opinion read.

Tennessee passed a law against fetal assault aimed at pregnant women who use opioids in 2014. But the law was allowed to expire two years later following reports of women avoiding hospitals during labor for fear of arrest.

Pleasant Grove sits in a pocket of post-industrial Jefferson County that has been hit particularly hard by heroin and prescription drug addiction.

Pleasant Grove Police Lt. Danny Reid said law enforcement agencies all over the area have noticed sharp increases in heroin-related crime, including chemical endangerment. Rates of heroin use have sharply increased among young women between the ages of 18 and 25, according to the U.S. Centers for Disease Control and Prevention.

"Whether it's the women using during pregnancy or the number of overdoses, yeah, we're seeing more of it," Reid said.

West said her drug use started with marijuana and prescription pills, before she got hooked on cheap heroin flooding the Birmingham area. West finally received a release to treatment in October, but said she felt uncomfortable at the rehab facility, which is located near burned out houses in a high-crime area. She walked out less than a day after she arrived.

"Maybe it would have been better if they sent me earlier," she said.

According to court records, she consumed Xanax and Lortab less than 24 hours later.

She used heroin the day after that, and went into labor on her third day out of jail, according to court records. Her unborn son was still kicking when she used, according to documents, but stopped before West delivered. He came into the world stillborn at Princeton Baptist Medical Center, a 7-pound infant who never took a breath.

Authorities filed more felony charges against West, contending that heroin use killed her baby - a charge that carries up to 99 years in prison. West said her doctor found blood clots on her placenta, a common cause of stillbirth that could be unrelated to drug use. The district attorney's office in Bessemer did not return calls seeking comment and would not release the autopsy report, citing the ongoing investigation.

Unable to make $30,000 bond, West returned to jail in November, grieving her baby's loss and suffering withdrawal.

Nancy Rosenbloom, director of legal advocacy for National Advocates for Pregnant Women, said the number of arrests in Alabama, and the length of prison sentences, far outpaces any other state.

"We see more cases every week from Alabama," she said. "It really is extraordinary even in the US today the fervor with which they are going after pregnant women."

Rosenbloom said research shows that incarceration is less effective than treatment - which women won't receive if they avoid doctors and hospitals for fear of arrest. The opioid epidemic - which has struck many white rural communities - has improved understanding about the disease of addiction, Rosenbloom said, but increasing sympathy doesn't extend to pregnant women.

"Again and again, addiction medicine specialists and neonatologists all say that affordable and confidential and effective health care is the answer," she said. "Our concern of course is that as this law in Alabama is used more and more, it's harming women and their families."

West wouldn't be the first woman in Alabama sentenced to prison after a stillbirth. The first woman to challenge her conviction for chemical endangerment at the Alabama Supreme Court spent three years behind bars after the death of her son, born several months premature in 2008. West could face decades in prison, a prospect unthinkable to the young woman who said she is still grieving for her son.

"Are they really going to send a woman who just lost her baby to prison?" West asked.