September 19, 2022

Prenatal and postpartum care for those who engage in substance use during pregnancy is more likely to be delayed or inadequate in states with policies that consider substance use in pregnancy to be child abuse or that require health care providers to report substance use during pregnancy to child welfare agencies.

New research from the UNC Gillings School of Global Public Health suggests that these punitive policies, which run contrary to the guidance of leading health organizations, may contribute to reductions in receipt of essential care among a population of people who are already deterred from seeking care due to the stigma surrounding substance use, particularly substance use during pregnancy.

Prenatal substance use is associated with an increased risk of preterm birth, reduced birthweight, and maternal morbidity and mortality, making it important for pregnant people engaging in substance use to receive early and consistent care. Health care providers can connect pregnant people to evidence-based substance use disorder treatment, including programs offering medication for opioid use disorder, and to harm reduction services to promote healthy outcomes and prevent harms. But pregnant people may be less likely to receive prenatal and postpartum care if they are afraid of legal consequences, including loss of infant custody.

Dr. Anna Austin

Dr. Anna Austin

“The primary argument for implementing these types of policies is that the threat of punishment will deter people from using substances during pregnancy,” explained Anna Austin, PhD, who is co-author on the study and assistant professor of maternal and child health at the Gillings School. “However, we have repeatedly seen that punitive responses to substance use, including substance use during pregnancy, do not result in improved outcomes and often cause additional harm. This study adds to existing qualitative research indicating that pregnant people with substance use delay or avoid prenatal care due to fears of detection and loss of infant custody and prior experiences of stigma in health care encounters.”

Dr. Becky Naumann

Dr. Becky Naumann

Lizzy Simmons

Elizabeth Simmons

In the study, published today in JAMA Pediatrics, Austin, Assistant Professor Becky Naumann, PhD, and doctoral student Lizzy Simmons, MPH, found that in states with a mandated reporting policy, a child abuse policy or both policies, women who engaged in substance use during pregnancy began prenatal care later in pregnancy than those in states without such policies.

They also found that women in states with a child abuse policy only, a mandated reporting policy only or both policies were respectively 17.6%, 6.4% or 5.2% less likely to receive adequate prenatal care. Women in states with these policies were also 8.7%- 12.4% less likely to have a postpartum health care visit in the 4-6 weeks after birth.

The study used data collected between 2016-2019 from the Pregnancy Risk Assessment Monitoring System survey in 23 states.

Importantly, the study identified a higher percentage of births to Black non-Hispanic women in states with a child abuse policy, a mandated reporting policy, or both policies, suggesting that these policies may exacerbate the effects of structural racism and longstanding racial inequities in maternal health, substance use disorder treatment and child welfare involvement.

“These results highlight the critical importance of supportive, non-stigmatizing policies and practices that reduce barriers to services, care and treatment for pregnant people who use substances,” Austin explained. “Public health professionals and policymakers should partner with people who use substances to better understand these barriers and develop policies and practices that will be effective in reducing them.”

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