What’s Working (or Not) in State Policies for Substance Use During Pregnancy
Substance use during pregnancy (or “prenatal substance use”) is becoming more common. Overdose and substance-related suicide are the leading preventable causes of maternal mortality, and prenatal substance use can increase the risk of miscarriage, birth defects, developmental disabilities, preterm birth, low birth weight, and decreased school readiness. State policy approaches to prenatal substance use vary widely, and mounting evidence indicates that treatment-oriented approaches are associated with better outcomes for children and families. This blog presents three categories of state policy approaches, with examples, and offers evidence on their effectiveness, based on available literature and correspondence with an addiction medication professional.
Broadly, states focus on 1) maximizing access to addiction treatment; 2) requiring health care providers to identify and, if needed, refer cases of prenatal substance use for treatment and/or child welfare involvement; or 3) immediately involving child welfare and/or law enforcement—or a mix of all three. The table below outlines example policies for each category and lists the number of states with each policy. Overall, state policy has increasingly turned to child welfare and law enforcement approaches to prenatal substance use. For example, three states now consider fetuses to be children, adding law enforcement implications for prenatal substance use.
Three categories of state policy responses to prenatal substance use
Policies that involve child welfare and/or law enforcement
- Prenatal substance use is considered child abuse (25 states).
- Prenatal substance use is considered a crime or grounds for involuntary commitment (7 states).
*Testing of the pregnant person and/or the newborn
Data show that certain policies are associated with positive and negative outcomes. For example, in states that consider prenatal substance use to be a crime, the policy is associated with a 45 percent increase in overdose deaths among pregnant women, following implementation of this criminalization. Among all policies that involve child welfare and/or law enforcement, data suggest these policies are associated with no decrease in prenatal substance use, less use of prenatal care and addiction treatment, a 10-18 percent increase in babies born exposed, and more children entering foster care.
In contrast, policies that fund treatment for prenatal substance use are associated with a 45 percent decrease in overdose deaths for pregnant women, and those that prioritize treatment access in cases of prenatal substance use are associated with more prenatal care use and healthier birth outcomes.
Research indicates that policies that require health care providers to test for prenatal substance use can foster inequitable treatment. For example, Black mothers can be more likely to be screened for substance use, regardless of patient history, and are no more likely to test positive than White mothers.
For additional perspective, we reached out to Dr. Anne Pylkas, MD, an addiction medicine physician. Dr. Pylkas said:
“I think the general consensus among treatment providers … is that we need to create better systems to support mothers with substance use disorder, both before and after birth, and that using legal/child protection consequences should be the option of last resort to protect the child. Obviously, the more we can engage mothers with treatment on their own terms, the better the outcomes will be, for both mother and child.”
State approaches to prenatal substance use vary widely and data show that certain policies are associated with either worse or better outcomes. Now that opioid settlement dollars are providing states a windfall, leaders must decide what to invest in. We hope their decisions are guided by achieving the best outcomes for children and families.
Author: Georgia Society of Addiction Medicine
ASAM/GSAM Chapter Engagement Manager