Prenatal Substance Use Policies And Infant Maltreatment Reports

Prenatal opioid use disorder and child protective service involvement: Does consistent treatment matter?

BACKGROUND

Infants born to individuals with opioid use disorder (OUD) often face greater scrutiny from child protective services (CPS), particularly in states like Wisconsin that mandate reporting for prenatal substance exposure. While consistent medication for opioid use disorder (MOUD) is recommended to stabilize the prenatal environment, such mandatory reporting policies may discourage seeking treatment.

METHODS

This research used Wisconsin's linked administrative data to estimate associations between prenatal OUD diagnosis and CPS involvement, focusing on variation therein by MOUD treatment consistency.

RESULTS

Of the 258,828 Medicaid-covered singleton births from 2010 to 2019, 6091 (2.4 %) were to individuals with OUD. Among these, 2349 (38.6 %) received high consistency treatment (defined as receiving MOUD for 5 or more consecutive months before the birth), 701 (11.5 %) had moderate consistency treatment (2-4 consecutive months), 660 (10.8 %) underwent intermittent treatment (<2 consecutive months), and 2381 (39.1 %) were untreated. Logistic regressions show that OUD diagnosis was associated with elevated risk of CPS referrals and removals within 30 days post-birth. The presence of other co-occurring substance use and mental health disorders was associated with additional increases in these risks. Though individuals receiving MOUD treatment had higher referral risk compared to untreated, those who received moderately and highly consistent treatment faced lower removal risk relative to those with intermittent treatment. Notably, the high consistency treatment group exhibited the lowest referral and removal rates across all treatment groups.

CONCLUSION

These findings underscore the need to promote high consistency MOUD treatment among pregnant individuals with OUD by clarifying its benefits and mitigating concerns regarding CPS involvement.

Early parent-child interaction and home environments of children exposed prenatally to opioids: A comparison of biological mothers and out-of-home caregivers

Children born to mothers with opioid use disorder (OUD) are at increased risk of maltreatment and out-of-home care (OOHC) placement. This study examines the parent-child interaction quality and home environments of 92 New Zealand children with prenatal opioid exposure (OE) and 106 non-opioid-exposed (NE) children. Experiences for those in maternal care versus OOHC were of particular interest. Biological mothers completed a lifestyle interview during late pregnancy/at birth. At 18 months, parent-child interaction observations, maternal/primary caregiver interviews, and the Home Observation for Measurement of the Environment were completed during a home visit. At age 4.5, children underwent developmental assessment. By 18 months, 20% of OE children were in OOHC. Mothers with OUD who were younger, less cooperative, and had increased polysubstance use during pregnancy were more likely to have lost custody of their child. OE children in their mother's care experienced less positive parenting and lower-quality home environments than NE children. OE children in OOHC had similarly resourced environments to NE children, yet experienced lower levels of parental warmth and responsiveness. Early parenting predicted child cognition, language, and behavior 3 years later, underscoring the critical importance of supporting the parenting and psychosocial needs of OE children's parents/caregivers to improve long-term outcomes.

State Child Abuse and Mandated Reporting Policies for Prenatal Substance Use and Congenital Syphilis Case Rates: United States, 2018-2022

Objectives. To estimate the association of state policies that define prenatal substance use as child abuse and mandate that health care professionals report prenatal substance use to child protective services with congenital syphilis case rates. Methods. We used 2018 to 2022 US data on congenital syphilis case notifications to the National Notifiable Diseases Surveillance System. We conducted linear regression with a generalized estimating equation approach to compare congenital syphilis case rates in states with a child abuse policy only, a mandated reporting policy only, and both polices to rates in states with neither policy. Results. After adjustment for confounders, the rate of congenital syphilis cases was, on average, 23.5 (95% confidence interval = 2.2, 44.8) cases per 100 000 live births higher in states with both a child abuse policy and a mandated reporting policy for prenatal substance use than in states with neither policy. Rates were similar in states with a child abuse policy only and a mandated reporting policy only compared to states with neither policy. Conclusions. The combination of state child abuse policies and mandated reporting policies for prenatal substance use potentially contributes to higher congenital syphilis case rates. (Am J Public Health. 2025;115(4):566-574. https://doi.org/10.2105/AJPH.2024.307951).

Medication for Opioid Use Disorder and Treatment Retention Among Pregnant Individuals

Importance

Treatment retention for pregnant individuals with opioid use disorder (OUD) is critical, especially during the high-potency synthetic opioid (HPSO) era. Current data on the relationship between medication for opioid use disorder (MOUD) receipt in specialty substance use treatment facilities and retention are needed for this population.

Objective

To examine the association between MOUD inclusion in treatment and 6-month treatment retention among pregnant individuals with OUD in publicly funded specialty treatment facilities during the HPSO era.

Design, Setting, and Participants

This cross-sectional study pooled data from January 1, 2015, to December 31, 2021, from the Treatment Episode Data Set-Discharges, a national dataset managed by the Substance Abuse and Mental Health Services Administration that tracks annual discharges from state-licensed, publicly funded substance use treatment facilities. Individuals who were pregnant at the time of admission, reported an opioid (heroin, nonprescription methadone, or other opiates and synthetics) as their primary substance, and were discharged from ambulatory, nonintensive outpatient facilities were included. Data were analyzed November 2023 to April 2024.

Exposure

MOUD inclusion in a treatment episode.

Main Outcomes and Measures

The main outcome was treatment retention (length of stay >6 months vs ≤6 months). To account for the nonrandom assignment to MOUD, inverse probability of treatment-weighted logistic regression models were estimated adjusting for sociodemographics; substance use, mental health, and treatment history; treatment admission-related variables; census division; state policy characteristics; and year fixed effects.

Results

Of 29 981 treatment episodes, most involved individuals aged 25 to 34 years (19 106 [63.7%]). Approximately two-thirds of 29 071 episodes in the final analysis (19 884 [68.4%]) included MOUD across all study years. From 2015 to 2021, MOUD inclusion in treatment episodes increased by 9.1 percentage points, from 65.0% to 74.1%. Treatment episodes with MOUD were associated with greater odds of 6-month treatment retention compared with those without MOUD (adjusted odds ratio, 1.86 [95% CI, 1.72-2.01]). This finding translated to an estimated 14.2 percentage point greater adjusted probability of 6-month retention among treatment episodes with MOUD (43.1%) vs those without it (28.9%).

Conclusions and Relevance

In this cross-sectional study of treatment episodes from ambulatory, nonintensive facilities, MOUD inclusion among pregnant individuals was associated with significant improvements in treatment retention. However, retention remained low during the HPSO era. These findings underscore the importance of MOUD in improving OUD-related outcomes in this high-risk population.

A Narrative Review of Congenital Syphilis in the United States: Innovative Perspectives on a Complex Public Health and Medical Disease

ABSTRACT

Over the past 2 decades, congenital syphilis cases have risen 11-fold in the United States. Although disparities across geography, race, and ethnicity exist, lack of timely screening or treatment is identified in 88% of cases nationally. Congenital syphilis is a public health and medical problem rooted in systematic and societal structural determinants of health and health care limitations. Early syphilis in pregnancy leads to congenital syphilis if untreated in 50% to 70% of cases, with risk for fetal demise, and among survivors, congenital anomalies, organ damage, and central nervous system disease. Prevention of congenital syphilis lies in early detection and treatment in pregnant persons. In this narrative review, we describe the evolving epidemiology of syphilis and congenital syphilis, highlighting unique aspects among women. We explore the role of novel screening and treatment strategies, public health policy, and medical considerations in terms of congenital syphilis prevention. Readers of this review will understand congenital syphilis as a complex public health and medical disease that can be prevented through innovative and coordinated strategies in public health policy, expanded screening, and research opportunities.

Prenatal opioid exposure, neonatal abstinence syndrome diagnosis, and child welfare involvement

BACKGROUND

Neonatal abstinence syndrome (NAS), or withdrawal from prenatal opioid exposure at birth, can trigger a referral to child protective services (CPS). However, there is some evidence of selection into NAS diagnosis because NAS screening is not universal. Such referrals may protect the infant, help connect the mother to services, or cause harm.

OBJECTIVE

To study the relation between prenatal opioid exposure, NAS diagnosis, and CPS involvement during the (early) neonatal period.

PARTICIPANTS AND SETTING

We analyzed data (N = 236,868 Medicaid-covered live births) from the Wisconsin Administrative Data Core using linked birth records, Medicaid claims, CPS records, and benefit/earnings data from 2010 to 2018.

METHODS

We identified opioid exposure using Medicaid claims and CPS investigations within 7 and 28 days of life. We estimate linear probability models with and without the inclusion of NAS diagnosis and interactions of prenatal opioid exposure and NAS diagnosis.

RESULTS

Prenatal opioid exposure is positively associated with CPS involvement, but after controlling for NAS diagnosis, exposure to opioid medications used to treat pain (non-MOUD) or opioid use disorder (MOUD) are not statistically significantly associated with CPS investigations, whereas illicit opioid exposure is associated with increased CPS investigations. Fully interacted models suggest that, for infants diagnosed with NAS, non-MOUD and MOUD exposure are protective and reduce the likelihood of CPS involvement.

CONCLUSIONS

Understanding the type of opioid exposure during pregnancy, NAS diagnosis, and access to treatment OUD is important for referrals to child welfare agencies.

Pre-natal and post-natal screening and testing in neonatal abstinence syndrome

The way we enact screening for substance use during pregnancy within our healthcare systems can work by decreasing stigma, promoting engagement, and supporting people with reaching the end of their pregnancy in a manner where the newborn can be well supported. The way we enact biochemical specimen toxicology testing for substance use during pregnancy and in newborns contributes to increased stigma, disengagement from care, and potential continuation of uncontrolled substance use up until delivery such that the newborn may not be able to be well supported in the family environment. These effects are inequitably distributed, leading to worse outcomes for families of color and families living in poverty. Serial screening with a validated questionnaire starting at the first prenatal visit and continuing through the delivery hospitalization should occur and be followed up with service connections and substance use disorder diagnosis and treatment. Newborn toxicology testing as a diagnostic tool for risk of withdrawal or the etiology of potential withdrawal symptoms represents a failure in the effectiveness of compassionate communication by healthcare providers with the birthing person. Given the current level of evidence of clinical utility and the inequitable consequences specific to these tests, they are rarely needed.

Substance Use-Associated Infant Maltreatment Report Rates in the Context of Complex Prenatal Substance Use Policy Environments

State responses to substance use during pregnancy have included policies designed to increase access to substance use treatment as well as punish such substance use. Prior research has found that punitive policies are associated with increased rates of child maltreatment reporting, but it is unclear if the presence of punitive-promoting policies also moderate the association between access-promoting polices and maltreatment reports. Using data from the National Child Abuse and Neglect Data System and state-level fixed effects models, this study investigates how interactions between access-promoting and punitive prenatal substance use policies are associated with rates of substance use-associated maltreatment reports among infants. In states with punitive policies, access-promoting policies were associated with smaller decreases in these reports than in states without punitive policies. In some cases, access-promoting policies were associated with greater increases in these reports when punitive policies were also present than when only one type of policy was adopted. Interactions between prenatal substance use policies may result in unintended and counterproductive consequences for maternal and child health and the child welfare system.

Reimagining Supportive Approaches at the Intersection of Mandatory Reporting Policies for the Mother-Infant Dyad Affected by Substance Use

BACKGROUND

As rates of substance use during pregnancy persist, the health and optimal development of infants with prenatal substance exposure remain a key priority. Nurses are tasked with identifying and reporting suspected cases of child maltreatment, including abuse and neglect, which is often assumed to be synonymous with substance use during pregnancy. While policies aimed at protecting infants from child abuse and neglect are well intentioned, literature regarding the short- and long-term social and legal implications of mandatory reporting policies is emerging.

PURPOSE

In this article, we explore the intersections between the condition of substance use in pregnancy and policies related to mandatory reporting.

METHODS

We provide an overview of historical and current trends in mandatory reporting policies for nurses related to substance use in pregnancy and related ethical and social implications for mother-infant dyads.

RESULTS

Nurses often function at the intersection of healthcare and social services, underscoring the important role they play in advocating for ethical and equitable care for both members of the mother-infant dyad affected by substance use.

IMPLICATIONS FOR PRACTICE AND RESEARCH

We offer recommendations for practice including the integration of respectful care and family-centered support for the mother-infant dyad affected by substance use. Cross-sectoral collaborations, inclusive of the family, are important to the advancement of evidence-based and equity-focused research, advocacy, and policy initiatives to support familial preservation and reduce mother-infant separation.

Pre-COVID Trends in Substance Use Disorders and Treatment Utilization During Pregnancy in West Virginia 2016-2019

Introduction: Access to prenatal care offers the opportunity for providers to assess for substance use disorders (SUDs) and to offer important treatment options, but utilization of treatment during pregnancy has been difficult to measure. This study presents pre-COVID trends of a subset of SUD diagnosis at the time of delivery and related trends in treatment utilization during pregnancy. Materials and Methods: A retrospective cohort design was used for the analysis of West Virginia Medicaid claims data from 2016 to 2019. Diagnosis of SUDs at the time of delivery and treatment utilization for opioid use disorder (OUD) and non-OUD diagnosis during pregnancy across time were the principal outcomes of interest. This study examined data from n = 49,398 pregnant individuals. Results: Over the 4-year period, a total of 2,830 (5.7%) individuals had a SUD diagnosis at the time of delivery. The frequency of opioid-related diagnoses decreased by 29.3%; however, non-opioid SUD diagnoses increased by 55.8%, with the largest increase in the diagnosis of stimulant use disorder (30.9%). Treatment for OUD increased by 13%, but treatment for non-opioid SUD diagnoses during pregnancy declined by 41.1% during the same period. Conclusions: Interventions enacted within West Virginia have improved access and utilization of treatment for OUD in pregnancy. However, consistent with national trends in the general population, non-opioid SUD diagnoses, especially for stimulants, have rapidly increased, while treatment for this group decreased. Early identification and referral to treatment by OB-GYN providers are paramount to reducing pregnancy and postpartum complications for the mother and neonate.

The Hypocritical Oath? Unintended Consequences of Prenatal Substance Use Policies and Considerations for Health Care Providers

Prenatal substance use (PSU) is a serious perinatal health issue in the United States with consequential health effects. To address this issue and protect children from the detrimental effects of substance exposure during pregnancy, the US government amended the Child Abuse Prevention and Treatment Act to provide funding to states with protocol to notify child protective services of PSU cases and develop treatment plans for affected families. Although well-intentioned, this statute resulted in diverse inter- and intrastate interpretations and implementation of PSU regulations nationwide, ultimately leading to mass confusion about who the policy applies to and when it should be applied. PSU policies are largely punitive in nature, which has led to null or adverse effects on perinatal outcomes. Treatment-prioritizing policies present hope for supporting birthing parents who use substances; however, their potential benefits are obstructed by fear and confusion instilled by coexisting punitive policies, stigma of disclosing substance use during pregnancy, variable or lack of screening methods, and insufficient knowledge about PSU health risks and counseling methods. Precis: Punitive prenatal substance use policies may result in adverse perinatal outcomes. Treatment-oriented protocols and legislation should be prioritized.

U.S. State rates of newborns reported to child protection at birth for prenatal substance exposure

BACKGROUND

In the U.S., the opioid epidemic has revitalized national attention to newborns with prenatal substance exposure (PSE). These newborns and their caregivers have specific health and treatment needs and frequently interact with multiple systems, including child protection systems (CPS).

METHODS

This study calculated rates of newborns (less than 15 days old) reported to CPS per 1,000 births due to PSE by state and year using data from the National Child Abuse and Neglect Data System (NCANDS). Given the lack of a clear definition of PSE reports in the data, we calculated rates using three different definitions. To examine the relationship between different state laws regarding the mandated reporting of PSE and PSE reports rates, we used panel data analysis.

RESULTS

Rates of newborn reports more than doubled between 2011 and 2019. There was extensive state variability of rates including some states that were consistently more than 100 % greater than and others consistently more than 150 % less than the annual national mean. Reporting rates were not associated with state requirements to report PSE, but were positively associated with rates of diagnosed neonatal abstinence syndrome.

CONCLUSION

State-level inconsistencies in identification, reporting, and CPS responses prevent a clear understanding of the scope of the affected population and service needs.

Trends in prenatal prescription opioid use among Medicaid beneficiaries in Wisconsin, 2010-2019

OBJECTIVE

To examine changes in prenatal opioid prescription exposure following new guidelines and policies.

STUDY DESIGN

Cohort study of all (262,284) Wisconsin Medicaid-insured live births 2010-2019. Prenatal exposures were classified as analgesic, short term, and chronic (90+ days), and medications used to treat opioid use disorder (MOUD). We describe overall and stratified temporal trends and used linear probability models with interaction terms to test their significance.

RESULT

We found 42,437 (16.2%) infants with prenatal exposure; most (90.5%) reflected analgesic opioids. From 2010 to 2019, overall exposure declined 12.8 percentage points (95% CI = 12.1-13.1). Reductions were observed across maternal demographic groups and in both rural and urban settings, though the extent varied. There was a small reduction in chronic analgesic exposure and a concurrent increase in MOUD.

CONCLUSION

Broad and sustained declines in prenatal prescription opioid exposure occurred over the decade, with little change in the percentage of infants chronically exposed.

"Instead of just taking my baby, they could've actually given me a chance": Experiences with plans of safe care among birth parents impacted by perinatal substance use

BACKGROUND

Federal legislation mandates healthcare providers to notify child protective service (CPS) agencies and offer a voluntary care plan called a "plan of safe care" (POSC) for all infants born affected by prenatal substance use. While POSCs aim to provide supportive services for families impacted by substance use, little is known about birth parents' perceptions and experiences.

OBJECTIVE

To examine birth parents' perceptions and experiences regarding POSC.

PARTICIPANTS AND SETTING

Parents offered a POSC in Philadelphia in the prior year were included.

METHODS

This is a qualitative interview study. Participants were recruited from birth hospitals and community-based programs with telephone consent and interview procedures. Transcripts were analyzed using an inductive, grounded theory approach to identify content themes.

RESULTS

Twelve birth parents were interviewed (30.7 % of eligible, contacted individuals). Fear of CPS involvement and stigma were common. Some birth parents reported that the increased scrutiny related to POSCs negatively impacted their attitudes toward healthcare providers and medications for opioid use disorder (MOUD). While parents found the consolidated resource information helpful, many did not know how to access services. Finally, parents desired more individualized plans tailored to their unique family needs.

CONCLUSIONS

Stigma, confusion, and fear of CPS involvement undermine the goal of POSCs to support substance-exposed infants and birth parents. Providers serving this population should be transparent regarding CPS notifications, provide compassionate, non-stigmatizing care, and offer coordination services to support engagement after discharge. Policymakers should consider separating POSCs from CPS to avoid exacerbating fear and mistrust.

Punitive legal responses to prenatal drug use in the United States: A survey of state policies and systematic review of their public health impacts

BACKGROUND

Punitive legal responses to prenatal drug use may be associated with unintended adverse health consequences. However, in a rapidly shifting policy climate, current information has not been summarized. We conducted a survey of U.S. state policies that utilize criminal or civil legal system penalties to address prenatal drug use. We then systematically identified empirical studies evaluating these policies and summarized their potential public health impacts.

METHODS

Using existing databases and original statutory research, we surveyed current U.S. state-level prenatal drug use policies authorizing explicit criminalization, involuntary commitment, civil child abuse substantiation, and parental rights termination. Next, we systematically identified quantitative associations between these policies and health outcomes, restricting to U.S.-based peer-reviewed research, published January 2000-December 2022. Results described study characteristics and synthesized the evidence on health-related harms and benefits associated with punitive policies. Validity threats were described narratively.

RESULTS

By 2022, two states had adopted policies explicitly authorizing criminal prosecution, and five states allowed pregnancy-specific and drug use-related involuntary civil commitment. Prenatal drug use was grounds for substantiating civil child abuse and terminating parental rights in 22 and five states, respectively. Of the 16 review-identified articles, most evaluated associations between punitive policies generally (k = 12), or civil child abuse policies specifically (k = 2), and multiple outcomes, including drug treatment utilization (k = 6), maltreatment reporting and foster care entry (k = 5), neonatal drug withdrawal syndrome (NDWS, k = 4) and other pregnancy and birth-related outcomes (k = 3). Most included studies reported null associations or suggested increases in adverse outcome following punitive policy adoption.

CONCLUSIONS

Nearly half of U.S. states have adopted policies that respond to prenatal drug use with legal system penalties. While additional research is needed to clarify whether such approaches engender overt health harms, current evidence indicates that punitive policies are not associated with public health benefits, and therefore constitute ineffective policy.

Estimating the incidence of substance exposed newborns with child welfare system involvement

BACKGROUND

Prenatal substance use can have negative health consequences for both mother and child and may also increase the likelihood of child welfare involvement. The rate of newborns with substance exposure has increased dramatically. As of 2016, federal law requires notification of all infants to child welfare agencies so that a plan of safe care can be developed and referrals to services can be offered.

OBJECTIVE

Child welfare agencies have not historically collected consistent, systematic data identifying substance exposed newborns. We utilized a unique strategy to identify substance exposed newborns with child welfare involvement.

PARTICIPANTS & SETTING

We used data from the National Child Abuse & Detection System (NCANDS) which captures N = 3,189,034 unique child protective services investigations for children under the age of 1 between 2004 and 2017.

METHODS

We calculated the incidence of substance exposed newborns investigated by child welfare agencies and compared with other administrative data on prenatal substance exposure. We also analyzed this rate by infant demographic characteristics (race/ethnicity, sex, rurality).

RESULTS

Between 2004 and 2017, approximately 13 % of infants reported to child protective services were likely reported because of substance exposure at birth, and the rate of substance exposed newborns with child welfare involvement increased from 3.79 to 12.90 per 1000 births, an increase of 240 %, over this period.

CONCLUSIONS

Understanding the extent of the substance use crisis for child welfare involvement is important for policymakers to support children and families.

A Different Vision: Centering Love Not Punishment for Families Affected by Substance Use

Improving maternal and child outcomes requires us to understand and deconstruct our country's historically punitive policies toward pregnant and parenting people who use drugs. We also must build a new system that centers wellness in partnership with individuals directly affected by these policies. From a maternal and child health (MCH) perspective, wellness is defined as parent-infant dyads living in supportive, preserved, and loving families with access to the resources needed for optimal health. To achieve wellness and positive outcomes, all individuals must have equitable access to a full continuum of culturally and linguistically effective, geographically available, evidence-informed, non-punitive, and welcoming health and social services that prioritize family preservation. In addition, to attain transformative and equitable outcomes, advocates for families affected by substance use must focus on implementing and evaluating services and continuously monitoring disaggregated data to ensure inequities are eliminated.

Pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA

AIMS

We examined relationships between pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA.

METHODS

We merged state-level policy and treatment admissions data for 1992-2019. We aggregated data by state-year to examine effects of nine pregnancy-specific alcohol policies on the number of admissions of pregnant women where alcohol was reported as the primary, secondary, or tertiary substance related to the treatment episode (N = 1331). We fit Poisson models that included all policy variables, state-level controls, fixed effects for state and year, state-specific time trends, and an offset variable of the number of pregnancies in the state-year to account for differences in population size and fertility.

RESULTS

When alcohol was reported as the primary substance, civil commitment [incidence rate ratio (IRR) 1.45, 95% CI: 1.10-1.89] and reporting requirements for assessment and treatment purposes [IRR 1.36, 95% CI: 1.04-1.77] were associated with greater treatment admissions. Findings for alcohol as primary, secondary, or tertiary substance were similar for civil commitment [IRR 1.31, 95% CI: 1.08-1.59] and reporting requirements for assessment and treatment purposes [IRR 1.21, 95% CI: 1.00-1.47], although mandatory warning signs [IRR 0.84, 95% CI: 0.72-0.98] and priority treatment for pregnant women [IRR 0.88, 95% CI: 0.78-0.99] were associated with fewer treatment admissions. Priority treatment findings were not robust in sensitivity analyses. No other policies were associated with treatment admissions.

CONCLUSIONS

Pregnancy-specific alcohol policies related to greater treatment admissions tend to mandate treatment rather than make voluntary treatment more accessible, raising questions of ethics and effectiveness.

Medical Professional Reports and Child Welfare System Infant Investigations: An Analysis of National Child Abuse and Neglect Data System Data

Background

Medical professionals are key components of child maltreatment surveillance. Updated estimates of reporting rates by medical professionals are needed.

Methods

We use the National Child Abuse and Neglect Data System (2000-2019) to estimate rates of child welfare investigations of infants stemming from medical professional reporting to child welfare agencies. We adjust for missing data and join records to population data to compute race/ethnicity-specific rates of infant exposure to child welfare investigations at the state-year level, including sub-analyses related to pregnant/parenting people's substance use.

Results

Between 2010 and 2019, child welfare investigated 2.8 million infants; ∼26% (n=731,705) stemmed from medical professionals' reports. Population-adjusted rates of these investigations stemming doubled between 2010 and 2019 (13.1-27.1 per 1000 infants). Rates of investigations stemming from medical professionals' reports increased faster than did rates for other mandated reporters, such as teachers and police, whose reporting remained relatively stable. In 2019, child welfare investigated ∼1 in 18 Black (5.4%), 1 in 31 Indigenous (3.2%), and 1 in 41 White infants (2.5%) following medical professionals' reports. Relative increases were similar across racial groups, but absolute increases differed, with 1.3% more of White, 1.7% of Indigenous, and 3.1% of Black infants investigated in 2019 than 2010. Investigations related to substance use comprised ∼35% of these investigations; in some states, this was almost 80%.

Discussion

Rates of child welfare investigations of infants stemming from medical professional reports have increased dramatically over the past decade with persistent and notable racial inequities in these investigations.

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.

Development and Implementation of State and Federal Child Welfare Laws Related to Drug Use in Pregnancy

Policy Points Over the past several decades, states have adopted policies intended to address prenatal drug use. Many of these policies have utilized existing child welfare mechanisms despite potential adverse effects. Recent federal policy changes were intended to facilitate care for substance-exposed infants and their families, but state uptake has been incomplete. Using legal mapping and qualitative interviews, we examine the development of state child welfare laws related to substance use in pregnancy from 1974 to 2019, with a particular focus on laws adopted between 2009 and 2019. Our findings reveal policies that may disincentivize treatment-seeking and widespread implementation challenges, suggesting a need for new treatment-oriented policies and refined state and federal guidance.

CONTEXT

Amid increasing drug use among pregnant individuals, legislators have pursued policies intended to reduce substance use during pregnancy. Many states have utilized child welfare mechanisms despite evidence that these policies might disincentivize treatment-seeking. Recent federal changes were intended to facilitate care for substance-exposed infants and their families, but implementation of these changes at the state level has been slowed and complicated by existing state policies. We seek to provide a timeline of state child welfare laws related to prenatal drug use and describe stakeholder perceptions of implementation.

METHODS

We catalogued child welfare laws related to prenatal drug use, including laws that defined child abuse and neglect and established child welfare reporting standards, for all 50 states and the District of Columbia (DC), from 1974 to 2019. In the 19 states that changed relevant laws between 2009 and 2019, qualitative interviews were conducted with stakeholders to capture state-level perspectives on policy implementation.

FINDINGS

Twenty-four states and DC have passed laws classifying prenatal drug use as child abuse or neglect. Thirty-seven states and DC mandate reporting of suspected prenatal drug use to the state. Qualitative findings suggested variation in implementation within and across states between 2009 and 2019 and revealed that implementation of changes to federal law during that decade, intended to encourage states to provide comprehensive social services and linkages to evidence-based care to drug-exposed infants and their families, has been complicated by existing policies and a lack of guidance for practitioners.

CONCLUSIONS

Many states have enacted laws that may disincentivize treatment-seeking among pregnant people who use drugs and lead to family separation. To craft effective state laws and support their implementation, state policymakers and practitioners could benefit from a treatment-oriented approach to prenatal substance use and additional state and federal guidance.

Impact of prenatal substance use policies on commercially insured pregnant females with opioid use disorder

INTRODUCTION

States' approaches to addressing prenatal substance use are widely heterogeneous, ranging from supportive policies that enhance access to substance use disorder (SUD) treatment to punitive policies that criminalize prenatal substance use. We studied the effect of these prenatal substance use policies (PSUPs) on medications for opioid use disorder (OUD) treatment, including buprenorphine, naltrexone, and methadone, psychosocial services for SUD treatment, opioid prescriptions, and opioid overdoses among commercially insured pregnant females with OUD. We evaluated: (1) punitive PSUPs criminalizing prenatal substance use or defining it as child maltreatment; (2) supportive PSUPs granting pregnant females priority access to SUD treatment; and (3) supportive PSUPs funding targeted SUD treatment programs for pregnant females.

METHODS

We analyzed 2006-2019 MarketScan Commercial Claims and Encounters data. The longitudinal sample comprised females aged 15-45 with an OUD diagnosis at least once during the study period. We estimated fixed effects models that compared changes in outcomes between pregnant and nonpregnant females, in states with and without a PSUP, before and after PSUP implementation.

RESULTS

Our analytical sample comprised 2,438,875 person-quarters from 164,538 unique females, of which 13% were pregnant at least once during the study period. We found that following the implementation of PSUPs funding targeted SUD treatment programs, the proportion of opioid overdoses decreased 45% and of any OUD medication increased 11%, with buprenorphine driving this increase (13%). The implementation of SUD treatment priority PSUPs was not associated with significant changes in outcomes. Following punitive PSUP implementation, the proportion receiving psychosocial services for SUD (12%) and methadone (30%) services decreased. In specifications that estimated the impact of criminalizing policies only, the strongest type of punitive PSUP, opioid overdoses increased 45%.

CONCLUSION

Our findings suggest that supportive approaches that enhance access to SUD treatment may effectively reduce adverse maternal outcomes associated with prenatal opioid use. In contrast, punitive approaches may have harmful effects. These findings support leading medical organizations' stance on PSUPs, which advocate for supportive policies that are centered on increased access to SUD treatment and safeguard against discrimination and stigmatization. Our findings also oppose punitive policies, as they may intensify marginalization of pregnant females with OUD seeking treatment.

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.