Prenatal Substance Use: The Effects of State Policy on Maternal and Infant Outcomes

Substance use and misuse during pregnancy can cause severe, life-long harm to the baby. According to the most recent statistics from the National Survey on Drug Use and Health (NSDUH, 2017), 8.5% of pregnant women aged 15-44 reported using illicit drugs, 11.5% reported using alcohol, and 15% reported using tobacco. One consequence of maternal substance misuse is neonatal abstinence syndrome (NAS), which is a condition of newborn withdrawal as a result of substance exposure in utero. Between 1999 and 2013, the overall incidence of NAS tripled in the United States from 1.5 cases per 1,000 births in 1999 to 6 per 1,000 births in 2013. In 2014, Tennessee was the first state to criminalize prenatal substance misuse. In other states, variation over time exists in how prenatal substance misuse is handled by the law. For example, prenatal substance misuse is treated as child abuse in many states, which could be ground for child removal or termination of parental rights. Other states require mandatory reporting or testing by health care professionals.

Using state prenatal substance misuse policy variation, and controlling for other important state substance misuse policy (e.g., prescription drug monitoring programs (PDMPs)), we investigate the effect of state-level punitive policies on outcomes for women of reproductive age, pregnant women, and newborns. Specifically, we consider the effects on (1) NAS using data from the Healthcare Cost & Utilization Project (HCUP); (2) admissions of pregnant women into substance use treatment using the Treatment Episode Admissions Dataset (TEDS); (3) reports of child maltreatment for children under the age of 1 using the National Child Abuse and Neglect Data System (NCANDS) data; and (4) foster care admissions for children under the age of 1 using the Adoption and Foster Care Analysis and Reporting System (AFCARS) data. State policy data are drawn from the Guttmacher Institute’s State Policies in Brief: Substance Abuse During Pregnancy.

Our preliminary results suggest that policies that address prenatal substance use do not reduce the incidence of NAS. Prenatal substance misuse policies do appear to increase the rate of children under the age of 1 referred to the foster care system, specifically in the case of drug use and/or neglect as the main cause. Our findings are important in the context of the continued substance misuse and opioid epidemic specifically. Without improvements in access to treatment for pregnant women, punitive prenatal substance misuse policies may have limited protective effects.