As a pediatrician, I've cared for a lot of babies with neonatal abstinence syndrome (NAS), which is a withdrawal syndrome experienced by some opioid-exposed babies after birth. I've had the privilege of getting to listen to some of their mothers at the bedside, while their babies remain in the hospital being treated for their symptoms. These mothers talk about their past traumas, their struggles with addiction, and their fears of losing custody of their children. I began to wonder how various state policies related to substance use in pregnancy were impacting these families outside of the hospital walls.
I learned that since 2000, the number of states with policies that punish women for substance use during pregnancy has more than doubled. About half of all U.S. states now have these policies, which criminalize substance use in pregnancy, consider it grounds for civil commitment, or consider it child abuse or neglect.
My colleagues and I decided to study this issue because, while these policies were becoming increasingly common, we were concerned that no one knew if they even worked. Our study looked at almost 5 million births in 8 states around the United States. Some of the states enacted these policies, and some states didn't. We found that instead of being associated with lower rates of NAS, in fact, more infants were born with drug withdrawal symptoms in states with policies that punish pregnant women for substance use. This was the case both immediately after the policy was enacted, and in the longer term.
In short, our research suggests that punitive policies aren't beneficial for infants or their mothers. (This infographic shows our key findings.)
Why might this be happening? It is likely that these punitive policies are pushing women into the shadows. In other words, they stigmatize women with opioid addiction, a chronic medical condition, and discourage them from getting the prenatal care and substance use disorder treatment that they need to keep themselves healthy, ensuring the best possible start for their babies.
We'd never punish someone for having diabetes or epilepsy during pregnancy. But we treat substance use disorder as a moral failing instead of a chronic medical condition that can be managed with appropriate treatment.
We'd never punish someone for having diabetes or epilepsy during pregnancy. But we treat substance use disorder as a moral failing instead of a chronic medical condition.Share on Twitter
The fact is that the vast majority of women with substance use disorder during pregnancy struggled with their addiction before they became pregnant and will continue to battle it after the pregnancy ends.
Punishing these women pushes them away from the health care system. And if they do come into clinic, it further discourages them from openly discussing their concerns about substance use. This is not good for the mother, and it's not good for her baby.
Instead, we need to make sure that policies are in place to
- encourage responsible opioid prescribing to women of reproductive age
- address the significant behavioral health needs of women with substance use disorders, as co-occurring mental health conditions are common (PDF) among women who use substances
- ensure access to family planning that aligns with people's reproductive goals
- expand access to substance use disorder treatment for pregnant and parenting women (In 2018, only 23 percent of substance abuse treatment facilities offered programs specifically designed for pregnant and parenting women.)
- remove barriers to pregnant women with substance use disorders from getting evidence-based treatment that's tailored to their unique needs.
Every pregnant woman facing substance use disorder deserves to get the help she needs so that she and her infant have the best possible chance to thrive. Mothers and infants affected by opioids need evidence-based, family-centered, trauma-informed, and compassionate care—not punishment.
Laura Faherty is a physician policy researcher at the nonprofit, nonpartisan RAND Corporation and a general pediatrician.
This commentary originally appeared on Tennessee Justice Center on January 21, 2020. Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.