Evidence for Supportive Prenatal Substance Use Policies

Punitive approaches may be associated with unintended adverse pregnancy outcomes.

By Bonnie Tse

June 29, 2022

Pregnant Woman in White Top and Blue Denim Jeans

Photo by Pavel Danilyuk.

Increased prevalence of illicit substance use during pregnancy in the past decade has renewed national attention to prenatal substance use policies (PSUPs).

Currently, there are punitive policies that criminalize drug use during pregnancy or define prenatal substance use as child maltreatment in child welfare statutes. If newborns are found to have prenatal exposure to substances or are born with neonatal abstinence syndrome, these states may charge the pregnant person with substance use disorder with child abuse or terminate their parental rights.

In contrast, states that adopt supportive policies provide pregnant women with priority access to substance use disorder treatment programs, as well as create or fund targeted substance use disorder treatment programs for pregnant women. Supportive treatments are recommended by American College of Obstetricians and Gynecologists to build trust and connections with the health care systems.

Some prenatal substance use policies date back to the 1980s, when states adopted measures that were intended to reduce adverse maternal and newborn health outcomes during the crack cocaine epidemic. Despite the limited body of research assessing the effectiveness of these policies, PSUPs have grown more punitive over time.

New publications authored by CHERISH Research Affiliates Angélica Meinhofer, Catherine Maclean, Ali Jalali, and Shashi Kapadia, and CHERISH investigators Yuhua Bao and Jake Morgan evaluate the effectiveness of PSUPs on newborn health and analyze the impact of PSUPs on maternal outcomes among populations with opioid use disorder. The findings from these studies provide evidence that punitive PSUPs are potentially harmful and supportive PSUPs can have positive effects.

Prenatal Substance Use Policies and Infant Maltreatment Reports

takeaway of study

Authors Catherine Maclean, Allison Witman, Christine Piette Durrance, Danielle N. Atkins, and Angélica Meinhofer led a study to examine the effects of punitive and priority treatment prenatal substance use policies on infant maltreatment reports. The authors used differences-in-differences and quasi-experimental methods to analyze maltreatment reports from the National Child Abuse and Neglect Data System (NCANDS). Published in Health Affairs, the authors arrived at three key findings:

  • Punitive prenatal substance use policies increased total infant maltreatment reports by 19% and substantiated infant maltreatment reports by 33.3% during the study period.
  • Punitive prenatal substance use policies increased infant maltreatment reports in which the mother was the perpetrator across nearly all racial and ethnic groups.
  • There is no evidence that priority treatment prenatal substance use policies affected infant maltreatment reports.

The study offers several policy implications with renewed emphasis on strengthening families, improving the well-being of both mothers and infants, and accentuating supportive evidence-based services to address prenatal substance use.

Catherine Maclean, PhD, is an associate professor at Temple University.

Angélica Meinhofer, PhD, is an assistant professor of population health sciences at Weill Cornell Medicine.

Yuhua Bao, PhD, is an associate professor of population health sciences at Weill Cornell Medicine.

Prenatal Substance Use Policies and Newborn Health

Published in Health Economics, Angélica Meinhofer, Johanna Catherine Maclean, Allison Witman, and Yuhua Bao suggest supportive approaches may be more effective for improving perinatal health. Their study found that:

  • Neonatal drug withdrawal syndrome increased by 10% to 18% following the implementation of a punitive policy that criminalizes prenatal substance use, or defines prenatal substance exposure as child maltreatment in child welfare statutes or as grounds for termination of parental rights.
  • Priority treatment policies, measures that grant pregnant women priority access to substance use disorder treatment programs, are associated with small reductions in low gestational age (2%) and low birth weight (2%), along with increases in prenatal care use.

This study strengthens previous qualitative studies and leading medical organizations’ stances to oppose punitive PSUPs. Further research is needed to understand the impact of PSUPs using different outcomes and subpopulations and provide evidence-based approaches for improving pregnancy outcomes for perinatal populations affected by substance use disorder.

Impact of Prenatal Substance Use Policies on Commercially Insured Pregnant Females with Opioid Use Disorder

Published in the Journal of Substance Abuse Treatment, Nadia Tabatabaeepour, Jake Morgan, Ali Jalali, Shashi Kapadia, and Angélica Meinhofer found that supportive approaches may improve health outcomes among commercially insured pregnant females with opioid use disorder while punitive prenatal substance use policies may worsen health outcomes.

The authors used commercial claims data to study maternal outcomes including medications for opioid use disorder (MOUD) treatment; psychosocial services for substance use disorder (SUD) treatment; opioid prescriptions; and opioid overdoses among commercially insured pregnant females with opioid use disorder. Their study had three key findings:

  • The proportion of any MOUD increased 11% and the proportion of opioid overdoses decreased 45% following the adoption of PSUPs creating or funding targeted SUD treatment programs.
  • SUD treatment priority PSUPs were not associated with statistically significant changes in maternal outcomes or increased dispensing of OUD medications.
  • Punitive PSUPs were associated with statistically significant reductions in the proportion of pregnant females receiving psychosocial services for SUD and methadone.

Additionally, psychotherapy (12%) and methadone (30%) services decreased following punitive PSUP implementation. Opioid overdoses also increased by 45% in states with criminalizing policies only. Altogether, the study lends new evidence to fund supportive PSUPs that improve access to treatment and medications for opioid use disorder.

Photo of Jake Morgan

Jake Morgan, PhD, is a research assistant professor in the Department of Health Law, Policy, and Management at the Boston University School of Public Health.

Ali Jalali

Ali Jalali, PhD, MA, is an assistant professor of population health sciences at Weill Cornell Medicine.

Shashi Kapadia, MD, MS, is an infectious diseases physician and health services researcher at Weill Cornell Medicine.

The studies were supported by funding from the Robert Wood Johnson Foundation, Gerber Foundation, and National Institute on Drug Abuse. The study, “Prenatal Substance Use Policies and Newborn Health,” was published in Health Economics on April 20, 2022; “Prenatal Substance Use Policies and Infant Maltreatment Reports,” was published in Health Affairs in May 2022; and, “Impact of prenatal substance use policies on commercially insured pregnant females with opioid use disorder,” was published in the Journal of Substance Abuse Treatment on May 10, 2022.