Punitive Policies for Substance Use in Pregnancy Tied to Worse Obstetric Care

Women who lived in states with policies that punished women for substance use during pregnancy received worse prenatal and postpartum care, according to a cross-sectional study.

Patients in states that considered substance use during pregnancy a form of child abuse, or required providers to report pregnant women who use substances, started prenatal care at a later gestational age than women who lived in states with neither policy, reported Anna Austin, PhD, of the University of North Carolina at Chapel Hill, and colleagues.

Additionally, women in states with these policies were less likely to receive adequate prenatal care, or have a postpartum visit within 4 to 6 weeks after delivery, Austin and co-authors reported in JAMA Pediatrics.

The researchers found a higher percentage of births to Black women in states with a child abuse policy (19.6%), a mandated reporting policy (16.3%), or both (15%) compared with states that had neither policy (5.9%).

A 2019 CDC report found that only two of 12 states were exploring strategies to address legal, ethical, and social factors — including child abuse and mandatory reporting policies — that affect pregnant people with substance use disorders, Austin and colleagues noted.

“Our results underscore the importance of more widespread consideration of these strategies, specifically strategies that take a more supportive, non-stigmatizing approach to addressing the needs of pregnant people who engage in substance use,” the researchers wrote.

In an accompanying editorial, Brownsyne Tucker Edmonds, MD, MPH, MS, of the Indiana University School of Medicine in Indianapolis, pointed out that the higher percentage of births to Black women in states with child abuse or mandatory reporting policies in this study raises concerns.

“Although rates of perinatal substance use are similar among Black and white women, Black as well as Indigenous women are more likely to be screened for illicit substance use in prenatal care,” Tucker Edmonds wrote, adding that this can lead to a loss of parental rights and, in some cases, incarceration.

Instead, policy efforts should focus on expanding equitable educational opportunities, increasing access to treatment, creating affordable housing, offering parental leave, and more, Tucker Edmonds suggested. As evidenced by this study, “policies driving fear, blame, and punishment appear to be drivers of greater child harm, not greater child protection,” she wrote.

Currently, 26 states and the District of Columbia have either child abuse or mandated reporting policies (or both) for women who use substances during pregnancy, Austin’s group stated. Using the Pregnancy Risk Assessment Monitoring System database, the researchers examined the relationship between these policies with prenatal and postpartum care.

They included 4,155 women over 18 who reported using prescription opioids, marijuana or synthetic marijuana, heroin, amphetamines, cocaine, tranquilizers, or hallucinogens during pregnancy between 2016 to 2019 in their analysis. They studied women in 23 states, including six states with child abuse policies, four with mandatory reporting policies, seven with both policies, five states with neither policy, and one that switched from a mandated reporting policy only to both policies in 2019.

Approximately 34% of women gave birth in states with a child abuse policy only, 16% in states with a mandatory reporting requirement only, 33% in states with both policies, and 17% in states with neither policy. Nearly 70% of participants were white, 15% were Black, and 7% were Hispanic. Most participants were 18 to 29 years old.

Women who lived in states with child abuse or mandatory reporting policies started prenatal care later than those who lived in states with neither. Those in states with child abuse policies started prenatal care at a mean gestational age of 2.6 months (95% CI 1.6-3.5); those in states with mandated reporting policies started at 2.4 months (95% CI 1.7-3.2). Women in states with neither policy started at 2.1 months (95% CI 1.3-3.0).

Women in states with child abuse policies (risk ratio [RR] 0.85, 95% CI 0.79-0.91), mandatory reporting policies (RR 0.85, 95% CI 0.79-0.91), or both (RR 0.95, 95% CI 0.89-1.03) were less likely to receive adequate prenatal care.

Child abuse policies (RR 0.89, 95% CI 0.82-0.96), mandatory reporting policies (RR 0.89, 95% CI 0.80-0.98), or both (RR 0.92, 95% CI 0.83-1.02) were also associated with lower odds of receiving a postpartum health care visit.

Austin and colleagues noted that the data they used on substance use relied on self-reported information by pregnant patients between 2 and 6 months postpartum, which may have limited their findings. Additionally, they were unable to analyze prenatal and postpartum care by type of substance.

The researchers also acknowledged that, although many states implement similar policies around substance use during pregnancy, there is variation in state-by-state laws which may have influenced results.