Costs associated with policies regarding alcohol use during pregnancy: Results from 1972-2015 Vital Statistics

The Relationship Between Alcohol Availability and Drink-Driving Policies and Admissions to Substance Use Disorder Treatment During Pregnancy

OBJECTIVE

Pregnancy-specific alcohol policies are widely adopted yet have limited effectiveness and established risks. It is unknown whether general population alcohol policies are effective during pregnancy. This study investigated associations between general population policies and alcohol treatment admission rates for pregnant people specifically.

METHOD

Data are from the Treatment Episodes Data Set-Admissions and state-level policy data for 1992-2019 (n = 1,331 state-years). The primary outcome was treatment admissions where alcohol was the primary substance, and the secondary outcome included admissions where alcohol was any substance. There were five policy predictors: (a) government spirits monopoly, (b) ban on Sunday sales, (c) grocery store sales, (d) gas station sales, and (e) blood alcohol concentration (BAC) laws. Covariates included poverty, unemployment, per capita cigarette consumption, state and year fixed effects, and state-specific time trends.

RESULTS

In models with alcohol as the primary substance, prohibiting spirits sales in grocery stores (vs. allowing heavy beer [>3.2% alcohol by volume] and spirits) had lower treatment admission rates (incidence rate ratio [IRR] = 0.88, 95% CI [0.78, 0.99], p = .028). States with BAC laws at .10% (vs. no law) had higher treatment admission rates (IRR = 1.24, 95% CI [1.08, 1.43], p = .003). When alcohol was any substance, prohibiting spirits sales in grocery stores (vs. allowing heavy beer and spirits) was again associated with lower treatment admission rates (IRR = 0.89, 95% CI [0.80, 0.98], p = .021), but there was no association for BAC laws.

CONCLUSIONS

Restrictions on grocery store spirits sales and BAC laws were associated with lower and higher alcohol treatment admission rates among pregnant people, respectively, suggesting that general population alcohol policies are relevant for pregnant people's treatment utilization.

Understanding the effects of alcohol policies on treatment admissions and birth outcomes among young pregnant people

BACKGROUND

This study examines whether state-level alcohol policy types in the United States relate to substance use disorder treatment admissions and birth outcomes among young pregnant and birthing people.

METHODS

We used data from the Treatment Episode Data Set: Admissions (TEDS-A) and Vital Statistics birth data for 1992-2019. We examined 16 state-level policies, grouped into three types: youth-specific, general population, and pregnancy-specific alcohol policies. Using Poisson and logistic regression, we assessed policy effects for those under 21 (aged 15-20) and considered whether effects differed for those just over 21 (aged 21-24).

RESULTS

Youth-specific policies were not associated with treatment admissions or preterm birth. There were statistically significant associations between family exceptions to minimum legal drinking age (MLDA) policies and low birthweight, but findings were in opposite directions across possession-focused and consumption-focused (MLDA) policies and did not differentially apply to people 15-20 versus 21-24. Most pregnancy-specific policies were not associated with treatment admissions, and none were significantly associated with birth outcomes. A few general population policies were associated with improved birth outcomes and/or increased treatment admissions. Specifically, both government spirits monopolies and prohibitions of spirits and heavy beer sales in gas stations were associated with decreased low birthweight among people 15-20 and among people 21-24. Effects of Blood Alcohol Concentration (BAC) limits varied by age, with slight reductions in adverse birth outcomes among people 15-20, as BAC limits get stronger, but slight increases for those 21-24. Although treatment admissions rates across ages were similar when BAC limits were in place, treatment admissions were greater for pregnant people 21-24 than for 15-20 when there were no BAC limits.

CONCLUSIONS

General population policies also appear effective for reducing the adverse effects of drinking during pregnancy for young people, including those under 21. Policies that target people based on age or pregnancy status appear less effective.

Trends in U.S. State Alcohol and Other Drug Use During Pregnancy Policies from 2016 to 2020: Policymaking in the Comprehensive Addiction and Recovery Act Era

Background: Prior to the U.S. Comprehensive Addiction and Reovery Act of 2016 (CARA) , policymaking on alcohol and drug use during pregnancy was more concentrated on alcohol than drug use policy - although the overlap between the two types of policy was high. Further, the highest levels of legislative activity were requirements to report pregnant women who used alcohol or other drugs and child abuse/neglect policy.

Methods: This research brief uses rigorous legal epidemiology methodology to explore state policy activity on alcohol and other drug use during pregnancy after the U.S. Comprehensive Addiction and Recovery Act of 2016 (CARA) amended the 2010 Child Abuse Prevention and Treatment Act Reauthorization (CAPTA).

Results: Since CARA, policymaking has been more concentrated on drug policy than alcohol policy, although the overlap between the two is still high. Further, since CARA, states have concentrated policy activity on priority treatment for drugs and reporting requirements.

Conclusions: Even though CARA does not require reporting for the purposes of child welfare investigations, several states adopted such requirements during these years.

Relationships Between Alcohol Policies and Infant Morbidities and Injuries

INTRODUCTION

Previous research has found that policies specifically focused on pregnant people's alcohol use are largely ineffective. Therefore, the purpose of this study is to analyze the relationships between general population policies regulating alcohol physical availability and outcomes related to pregnant people's alcohol use, specifically infant morbidities and injuries.

METHODS

Outcome data were obtained from Merative MarketScan, a longitudinal commercial insurance claims data set. Policy data were obtained from the National Institute on Alcohol Abuse and Alcoholism's Alcohol Policy Information System, the National Alcohol Beverage Control Association, and Liquor Handbooks and merged using policies in effect during the estimated year of conception. Relationships between state-level policies regulating sites, days/hours, and government monopoly of liquor sales and infant morbidities and injuries were examined. Analyses used logistic regression with individual controls, fixed effects for state and year, state-specific time trends, and SEs clustered by state. The study analysis was conducted from 2021 to 2023.

RESULTS

The analytic sample included 1,432,979 infant-birthing person pairs, specifically people aged 25-50 years who gave birth to a singleton between 2006 and 2019. A total of 3.1% of infants had a morbidity and 2.1% of infants had an injury. State government monopoly on liquor sales was associated with reduced odds of infant morbidities and injuries, whereas gas station liquor sales were associated with increased odds of infant morbidities and injuries. Allowing liquor sales after 10PM was associated with increased odds for infant injuries. No effect was found for allowing liquor sales in grocery stores or on Sundays.

CONCLUSIONS

Findings suggest that limiting alcohol availability for the general population may help reduce adverse infant outcomes related to pregnant people's alcohol use.

Associations between alcohol taxes and varied health outcomes among women of reproductive age and infants

OBJECTIVE

No studies have examined whether alcohol taxes may be relevant for reducing harms related to pregnant people's drinking.

METHOD

We examined how beverage-specific ad valorem, volume-based, and sales taxes are associated with outcomes across three data sets. Drinking outcomes came from women of reproductive age in the 1990-2020 US National Alcohol Surveys (N = 11 659 women $\le$ 44 years); treatment admissions data came from the 1992-2019 Treatment Episode Data Set: Admissions (N = 1331 state-years; 582 436 pregnant women admitted to treatment); and infant and maternal outcomes came from the 2005-19 Merative Marketscan® database (1 432 979 birthing person-infant dyads). Adjusted analyses for all data sets included year fixed effects, state-year unemployment and poverty, and accounted for clustering by state.

RESULTS

Models yield no robust significant associations between taxes and drinking. Increased spirits ad valorem taxes were robustly associated with lower rates of treatment admissions [adjusted IRR = 0.95, 95% CI: 0.91, 0.99]. Increased wine and spirits volume-based taxes were both robustly associated with lower odds of infant morbidities [wine aOR = 0.98, 95% CI: 0.96, 0.99; spirits aOR = 0.99, 95% CI: 0.98, 1.00] and lower odds of severe maternal morbidities [wine aOR = 0.91, 95% CI: 0.86, 0.97; spirits aOR = 0.95, 95% CI: 0.92, 0.97]. Having an off-premise spirits sales tax was also robustly related to lower odds of severe maternal morbidities [aOR = 0.78, 95% CI: 0.64, 0.96].

CONCLUSIONS

Results show protective associations between increased wine and spirits volume-based and sales taxes with infant and maternal morbidities. Policies that index tax rates to inflation might yield more public health benefits, including for pregnant people and infants.

Preserving Families of Children in Child Welfare with Fetal Alcohol Spectrum Disorders: Challenges and Opportunities

The mission of child welfare is to ensure children's safety, permanency, and well-being. It is also charged with preserving and strengthening families and with avoiding the removal of children who can be kept at home safely. This paper addresses some of the challenges in meeting these concurrent goals in work with children prenatally exposed to alcohol and their families. Current child welfare practices are unlikely to identify prenatal alcohol exposure or children with fetal alcohol spectrum disorders (FASD). Yet if this exposure is identified when families come into contact with child welfare, a jurisdiction's laws and safety and risk assessment processes may lead to unnecessary removal of children from their homes, particularly for Black and American Indian/Alaska Native families. Drawing from research and discourse in the field, strategies are described that could help the child welfare system care for children who may be impacted by FASD while preserving their families. A crucial strategy is partnering with key child and family service providers to identify and respond to FASD.

Associations between state-level general population alcohol policies and drinking outcomes among women of reproductive age: Results from 1984 to 2020 National Alcohol Surveys

BACKGROUND

Policies specific to alcohol use during pregnancy have not been found to reduce risks related to alcohol use during pregnancy. In contrast, general population alcohol policies are protective for the general population. Here, we assessed whether US state-level general population alcohol policies are related to drinking outcomes among women of reproductive age.

METHODS

We conducted secondary analyses of 1984-2020 National Alcohol Survey data (N = 13,555 women ≤44 years old). State-level policy exposures were government control of liquor retail sales, heavy beer at gas stations, heavy beer at grocery stores, liquor at grocery stores, Sunday off-premise liquor sales, and blood alcohol concentration (BAC) driving limits (no law, 0.10 limit, 0.05-0.08 limit). Outcomes were past 12-month number of drinks, ≥5 drink days, ≥8 drink days, and any DSM-IV alcohol abuse/dependence symptoms. Regressions adjusted for individual and state-level controls, clustering by state, and included fixed effects for survey month and year.

RESULTS

Allowing Sunday off-premise liquor sales versus not was related to having 1.20 times as many drinks (95% CI: 1.01, 1.42), 1.41 times as many ≥5 drink days (95% CI: 1.08, 1.85), and 1.91 times as many ≥8 drink days (95% CI: 1.28, 2.83). BAC limits of 0.05-0.08 for driving versus no BAC limit was related to 0.51 times fewer drinks (95% CI: 0.27, 0.96), 0.28 times fewer days with ≥5 drinks (95% CI: 0.10, 0.75), and 0.20 times fewer days with ≥8 drinks (95% CI: 0.08, 0.47).

CONCLUSIONS

US state-level policies prohibiting Sunday off-premise liquor sales and BAC limits of 0.05-0.08 for driving are related to less past 12-month overall and heavy drinking among women 18-44 years old.

Association of Pregnancy-Specific Alcohol Policies With Infant Morbidities and Maltreatment

Importance

Research has found associations of pregnancy-specific alcohol policies with increased low birth weight and preterm birth, but associations with other infant outcomes are unknown.

Objective

To examine the associations of pregnancy-specific alcohol policies with infant morbidities and maltreatment.

Design, Setting, and Participants

This retrospective cohort study used outcome data from Merative MarketScan, a national database of private insurance claims. The study cohort included individuals aged 25 to 50 years who gave birth to a singleton between 2006 and 2019 in the US, had been enrolled 1 year before and 1 year after delivery, and could be matched with an infant. Data were analyzed from August 2021 to April 2023.

Exposures

Nine state-level pregnancy-specific alcohol policies obtained from the National Institute on Alcohol Abuse and Alcoholism's Alcohol Policy Information System.

Main Outcomes and Measures

The primary outcomes were 1 or more infant injuries associated with maltreatment and infant morbidities associated with maternal alcohol consumption within the first year. Logistic regression, adjusting for individual-level and state-level controls, and fixed effects for state, year, state-specific time trends, and SEs clustered by state were used.

Results

A total of 1 432 979 birthing person-infant pairs were included (mean [SD] age of birthing people, 32.2 [4.2] years); 30 157 infants (2.1%) had injuries associated with maltreatment, and 44 461 (3.1%) infants had morbidities associated with alcohol use during pregnancy. The policies of Reporting Requirements for Assessment/Treatment (adjusted odds ratio [aOR], 1.28; 95% CI, 1.08-1.52) and Mandatory Warning Signs (aOR, 1.18; 95% CI, 1.10-1.27) were associated with increased odds of infant injuries but not morbidities. Priority Treatment for Pregnant Women Only was associated with decreased odds of infant injuries (aOR, 0.83; 95% CI, 0.76-0.90) but not infant morbidities. Civil Commitment was associated with increased odds of infant injuries (aOR, 1.26; 95% CI, 1.08-1.48) but decreased odds of infant morbidities (aOR, 0.57; 95% CI, 0.53-0.62). Priority Treatment for Pregnant Women and Women With Children was associated with increased odds of both infant injuries (aOR, 1.12; 95% CI, 1.00-1.25) and infant morbidities (aOR, 1.08; 95% CI, 1.03-1.13). Reporting Requirements for Child Protective Services, Reporting Requirements for Data, Child Abuse/Neglect, and Limits on Criminal Prosecution were not associated with infant injuries or morbidities.

Conclusions and Relevance

In this cohort study, most pregnancy-specific alcohol policies were not associated with decreased odds of infant injuries or morbidities. Policy makers should not assume that pregnancy-specific alcohol policies improve infant health.

Relationship between mandatory warning signs for cannabis use during pregnancy policies and birth outcomes in the Western United States

As U.S. states legalize recreational cannabis, some enact policies requiring Mandatory Warning Signs for cannabis during pregnancy (MWS-cannabis). While previous research has found MWS for alcohol during pregnancy (MWS-alcohol) associated with increases in adverse birth outcomes, research has not examined effects of MWS-cannabis. This study uses Vital Statistics birth certificate data from June 2015 - June 2017 in seven western states and policy data from NIAAA's Alcohol Policy Information System and takes advantage of the quasi-experiment created by Washington State's enactment of MWS-cannabis in June 2016, while nearby states did not. Outcomes are birthweight, low birthweight, gestation, and preterm birth. Analyses use a Difference-in-Difference approach and compare changes in outcomes in Washington to nearby states in the process of legalizing recreational cannabis (Alaska, California, Nevada) and, as a secondary analysis, nearby states continuing to criminalize recreational cannabis (Idaho, Montana, Wyoming). Birthweight was -7.03 g lower (95% CI -10.06, -4.00) and low birthweight 0.3% higher (95% CI 0.0, 0.6) when pregnant people were exposed to MWS-cannabis than when pregnant people were not exposed to MWS-cannabis, both statistically significant (p = 0.005 and p = 0.041). Patterns for gestation, -0.014 weeks earlier (95% CI -0.038, 0.010) and preterm birth 0.2% higher (95% CI -0.2, 0.7), were similar, although not statistically significant (p = 0.168 and 0.202). The direction of findings was similar in secondary analyses, although statistical significance varied. Similar to MWS-alcohol, enacting MWS-cannabis is associated with an increase in adverse birth outcomes. The idea that MWS-cannabis provide a public health benefit is not evidence-based.

Health care provider decision-making around prenatal substance use reporting

BACKGROUND

Recent research has found that harms related to alcohol and/or drug (AOD) use during pregnancy are not limited to those associated with use itself; harms also result from policies and health care practices adopted in response, including reporting to Child Protective Services (CPS). This study sought to understand factors that influence health care providers' reporting practices.

METHODS

We conducted 37 semi-structured interviews with hospital-based obstetricians/gynecologists, family medicine physicians, and emergency department physicians, focused on experiences with reporting pregnant/birthing people with AOD to government authorities. We deductively applied an implementation science framework, the Theoretical Domains Framework (TDF) to identify the relevant domains and then inductively coded within domains to identify sub-themes.

RESULTS

Most participants saw reporting as someone else's job, primarily social workers. While a few participants associated reporting with increased connection to services, many participants expressed awareness of negative consequences associated with reporting. Nonetheless, participants were much more concerned about potential harms to the baby associated with not reporting and expressed considerable anxiety about these harms occurring if a report was not made. While a few participants described making reporting decisions themselves, most described interpersonal, hospital-level, and state policy-level factors that constrained their decision-making.

CONCLUSIONS

Many of the factors that influence physician decision-making in reporting pregnant/birthing people who use AOD to CPS are outside the control of individual physicians and require social, structural, and policy changes. Those that are individual-focused involve intense emotions and thus are unlikely to be influenced by solely didactic cognitive-focused trainings.

Dismantling the legacy of failed policy approaches to pregnant people's use of alcohol and drugs

Most U.S. states have one or more pregnancy-specific alcohol or drug policies. However, research evidence indicates that some of these policies lead to increases in adverse birth outcomes, including low-birthweight and preterm birth. We offer explanations for why these ineffective policies related to pregnant people's use of alcohol and drugs in the U.S. exist, including: abortion politics; racism and the 'War on Drugs'; the design and application of scientific evidence; and lack of a pro-active vision. We propose alternative processes and concepts to guide strategies for developing new policy approaches that will support the health and well-being of pregnant people who use alcohol and drugs and their children. Processes include: involving people most affected by pregnancy-specific alcohol and drug policies in developing alternative policy and practice approaches as well as future research initiatives. Additionally, we propose that research funding support the development of policies and practices that bolster health and well-being rather than primarily documenting the harms of different substances. Concepts include accepting that policies adopted in response to pregnant people's use of alcohol and drugs cause harms and working to do better, as well as connecting to efforts that re-envision the child welfare system in the U.S.

The Presence and Consequences of Abortion Aversion in Scientific Research Related to Alcohol Use during Pregnancy

Recent research has found that most U.S. state policies related to alcohol use during pregnancy adversely impact health. Other studies indicate that state policymaking around substance use in pregnancy—especially in the U.S.—appears to be influenced by an anti-abortion agenda rather than by public health motivations. This commentary explores the ways that scientists’ aversion to abortion appear to influence science and thus policymaking around alcohol and pregnancy. The three main ways abortion aversion shows up in the literature related to alcohol use during pregnancy include: (1) a shift from the recommendation of abortion for “severely chronic alcoholic women” to the non-acknowledgment of abortion as an outcome of an alcohol-exposed pregnancy; (2) the concern that recommendations of abstinence from alcohol use during pregnancy lead to terminations of otherwise wanted pregnancies; and (3) the presumption of abortion as a negative pregnancy outcome. Thus, abortion aversion appears to influence the science related to alcohol use during pregnancy, and thus policymaking—to the detriment of developing and adopting policies that reduce the harms from alcohol during pregnancy.