Babies Suffer Under Punitive Policies for Maternal Drug Use

Policies that punish pregnant women for disclosing substance use disorder (SUD) can have negative consequences for infants, according to a cross-sectional study.

In an analysis of eight states with varying degrees of reporting policies for maternal SUD, those that classified it as child abuse, considered it grounds for civil commitment, or otherwise criminalized it had significantly higher rates of neonatal abstinence syndrome (NAS) than those without such policies, reported Laura Faherty, MD, MPH, of the RAND Corporation in Boston, and colleagues.

Compared to the year before states enacted their policies, those that enacted punitive measures for maternal SUD saw rates of NAS significantly increase during year 1 of implementation (adjusted odds ratio [aOR] 1.25, 95% CI 1.06-1.46, P=0.007) as well as beyond 1 year (aOR 1.33, 95% CI 1.17-1.51, P<0.001), indicating that the policy had an immediate and sustained impact, the researchers wrote in JAMA Network Open. No significant increase was seen in states that only enacted reporting policies.

From 2003 to 2014, 46 neonates were born with NAS per 10,000 births in states without punitive policies. In comparison, those with punitive policies had 57 infants born with NAS per 10,000 births the first year a punitive policy was enacted and 60 per 10,000 births the year after implementation.

"We think these punitive policies are pushing women into the shadows," Faherty told MedPage Today. "We're very concerned they've stigmatized women with the chronic condition of addiction and there is data to show these policies discourage women from getting prenatal care and SUD treatment that they really need both to keep themselves healthy and to ensure the best possible start to their babies' lives."

This is an opportunity for policymakers to focus their energies towards preventative approaches to SUD treatment, which could include things like responsible opioid prescribing to women of childbearing age, providing access to family planning, and addressing women's behavioral health needs throughout the life course -- not just in pregnancy, Faherty added.

Currently, 23 states have enacted policies that consider substance use in pregnancy child abuse or neglect, and 25 require clinicians to report suspected drug use to child protection services (CPS). Additional laws -- like the Comprehensive Addiction and Recovery Act -- require state reporting of neonatal substance exposure, but this reporting is not synonymous to reports of child abuse or neglect.

In this study, no association was found between the rate of NAS and policies that require clinicians to report suspected substance use to CPS, which the authors hypothesized may be a result of increased physician-patient conversations that lead to treatment.

While the authors of an accompanying commentary agreed that "policies that force pregnant women into hiding" need to be replaced with policies that facilitate access to treatment, they disagreed that the lack of an association with clinician reporting was driven by fewer women disengaging with healthcare.

The majority of women in these scenarios may not distinguish between policies that define maternal substance use as child abuse and those that report substance use to CPS, wrote Bonny Whalen, MD, of the Children's Hospital at Dartmouth-Hitchcock in Lebanon, New Hampshire, and colleagues.

They noted that in prior studies, the majority of women report not disclosing their disorder for fear they will lose custody of their child, and they may still refrain from doing so if they know providers are required to report it to the state.

Whalen and co-authors said that instead, they suspect the lack of an association "was the result of an atmosphere of stigma about substance use by pregnant women that existed before and after enactment," and that "most state policies are based on a foundational perception of women who use drugs as unfit to parent their children, whether or not punitive laws are in place."

The commentators also noted that using NAS reduction as the primary outcome in this study is "problematic" because treatment for maternal SUD can result in NAS, but also improves outcomes for both mothers and infants.

"[This makes] the presence of NAS diagnosis a nonspecific measure, as it does not differentiate exposure to non-prescribed drugs vs maternal [opioid use disorder] treatment," Whalen and colleagues wrote.

Faherty said she does not believe the association was primarily driven by NAS treatment with methadone or buprenorphine because pregnant women face many barriers to SUD treatment.

"Overall, one in seven infants lived in counties that even have substance use treatment programs specifically designed for pregnant and postpartum women," Faherty said.

Study Details, Further Findings

For the study, the researchers linked NAS and SUD rates from national datasets in the following states, from the following years: Arkansas, 2004-2009; Arizona, 2003-2013; Colorado, 2003-2014; Kentucky, 2007-2014; Massachusetts, 2005-2014; Maryland, 2003-2014; Nevada, 2003-2014; and Utah, 2009-2014.

In total, 4,567,963 infants were included in the analysis, 23,377 (0.5%) of whom had NAS. Infants born with NAS compared with those who were not were more likely to be non-Hispanic white (71.7% vs 51.2%), publicly insured (81.4% vs 40.9%), and to be born preterm (18.5% vs 8.4%), the authors reported. Infants born in areas with high rates of unemployment and with SUD treatment programs for women were also more likely to be born with NAS.

The main limitations to the study, the researchers said, are that the findings from the eight states included may not be nationally generalizable and that the authors could not determine how these policies were implemented. Misclassification of NAS was also a possibility, as was a general increasing number of diagnoses due to increased attention from policy makers.

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