Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome

Treatment and decriminalization of the mother-infant dyad in perinatal opioid use disorder

Treatment of perinatal opioid use disorder should center the mother-infant dyad, the needs of both entities, and preservation of the relationship. The criminalization of pregnancy and substance use in pregnancy through punitive policies and legislation and the involvement of the family policing system are in direct opposition to compassionate, person-centered care and lead to worse maternal and neonatal outcomes. In this chapter, we review the history and ongoing criminalization of pregnancy and perinatal substance use disorder, explore carcerality as a barrier to dyadic care that disproportionately targets Black, Brown, and Indigenous birthing individuals, and propose solutions to decriminalize care based in abolition medicine and reproductive justice frameworks.

Reporting Perinatal Substance Use to Child Protective Services: Obstetric Provider Perspectives on the Impact on Care

Objective: To understand obstetric provider perspectives on child protective services (CPS)-mandated reporting requirements and how they affect care for pregnant and postpartum patients with opioid use disorder (OUD). Methods: Key informant interviews were conducted virtually with obstetricians, nurse practitioners, and social workers caring for obstetric patients (n = 12). Providers were asked about their experience as mandated reporters working with patients with OUD. Transcripts were independently coded by two staff, and content analysis was used to identify themes. Results: Our analysis resulted in six thematic areas, including CPS-mandated strengths, concerns related to CPS reporting requirements, implementation of mandates, supporting patients after CPS report, communication between stakeholders, and the impact on care. Providers noted that the fear of CPS involvement causes some patients to delay or not engage in care. Other patients are hesitant to accept medications for OUD for fear of CPS involvement. The inconsistencies in how reporting mandates are applied and how CPS handles cases make communication about the policies challenging for providers and create anxiety for patients. Conclusions: The results of this study indicate that mandated reporting requirements and the potential for CPS involvement are perceived to have minimal positive effects on perinatal individuals with OUD and may negatively affect patients and their care. Clinicaltrials.gov number: NCT04240392.

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.

Factors associated with medications for opioid use disorder (MOUD) treatment success during the pregnancy and postpartum periods: A scoping review

BACKGROUND

Medications for opioid use disorder (MOUD) are a crucial intervention for pregnant and postpartum individuals with opioid use disorder (OUD). However, there is paucity of data on the factors associated with MOUD treatment success in this population. This scoping review aimed to evaluate factors associated with MOUD success during the pregnancy and postpartum period.

METHODS

We completed a structured search of MEDLINE, CINAHL, PsycINFO, Web of Science, and ProQuest databases. Eligible studies included a metric of success in outpatient treatment in the pregnancy and postpartum period and were conducted in the United States after the Food and Drug Administration's approval of buprenorphine in 2002. Reviewers independently screened studies for inclusion and extracted data. The primary outcome was treatment success (i.e., treatment adherence, abstinence from illicit opioids, or retention in care) during pregnancy and up to 12 months postpartum.

RESULTS

Data from 15 studies were included. Medications included methadone, naltrexone and buprenorphine (mono or combination therapy). High daily dose of buprenorphine as mono or combination therapy, early initiation and longer duration of MOUD were associated with treatment success. Legal involvement, homelessness, and rural residency were negatively associated with treatment success. There were no differences in outcomes of individuals receiving telemedicine versus in-person care.

CONCLUSION

We identified several factors associated with MOUD treatment success among individuals with OUD during the pregnancy and postpartum periods. These factors may help guide future research and inform the development and adaptation of interventions tailored to better meet the needs of this key population.

Association of prenatal substance exposure and the development of the amygdala, hippocampus, and parahippocampus

CONTEXT

Prenatal substance exposure (PSE) can lead to various harmful outcomes for the developing fetus and is linked to many emotional, behavioral, and cognitive difficulties later in life. Therefore, examination of the relationship between the development of associated brain structures and PSE is important for the development of more specific or new preventative methods.

OBJECTIVES

Our study's primary objective was to examine the relationship between the physical development of the amygdala, hippocampus, and parahippocampus following prenatal alcohol, tobacco, and prescription opioid exposure.

METHODS

We conducted a cross-sectional analysis of the Adolescent Brain and Cognitive Development (ABCD) Study, a longitudinal neuroimaging study that measures brain morphometry from childhood throughout adolescence. Data were collected from approximately 12,000 children (ages 9 and 10) and parents across 22 sites within the United States. Prenatal opioid, tobacco, and alcohol use was determined through parent self-report of use during pregnancy. We extracted variables assessing the volumetric size (mm3) of the amygdala, hippocampus, and parahippocampal gyrus as well as brain volume, poverty level, age, sex, and race/ethnicity for controls within our adjusted models. We reported sociodemographic characteristics of the sample overall and by children who had PSE. We calculated and reported the means of each of the specific brain regions by substance exposure. Finally, we constructed multivariable regression models to measure the associations between different PSE and the demographic characteristics, total brain volume, and volume of each brain structure.

RESULTS

Among the total sample, 24.6% had prenatal alcohol exposure, 13.6% had prenatal tobacco exposure, and 1.2% had prenatal opioid exposure. On average, those with prenatal tobacco exposure were found to have a statistically significant smaller parahippocampus.

CONCLUSIONS

We found a significant association between prenatal tobacco exposure and smaller parahippocampal volume, which may have profound impacts on the livelihood of individuals including motor delays, poor cognitive and behavioral outcomes, and long-term health consequences. Given the cumulative neurodevelopmental effects associated with PSE, we recommend that healthcare providers increase screening rates, detection, and referrals for cessation. Additionally, we recommend that medical associations lobby policymakers to address upstream barriers to the effective identification of at-risk pregnant individuals, specifically, eliminating or significantly reducing punitive legal consequences stemming from state laws concerning prenatal substance use.

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.

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.

The Relationship Between Workplace Drug Policies, Opioid Misuse, and Psychological Distress: Evidence From the 2020 National Survey on Drug Use and Health

Background: This study, using a nationally representative dataset of the U.S. workforce, examines how punitive workplace drug policies relate to opioid use/misuse and psychological distress. Methods: The sample included adults aged ≥18 years who participated in the National Survey on Drug Use and Health and were employed in 2020. Hierarchical multivariate logistical models were constructed to address the research questions. Results: The weighted, design-based estimates indicate that of 147 831 081 workers, 3.38% reported misusing opioids in the last 12 months. Having a punitive workplace policy was associated with higher rates of opioid use/misuse among workers aged ≤ 34 compared to their same-aged counterparts in nonpunitive workplaces, and among workers identifying as Black, Indigenous, or Person of Color who also experienced severe psychological distress the past year. Conclusion: Some employers may think drug testing policies are net-beneficial to worker well-being; these findings indicate such policies may interact in harmful ways with psychological distress.

Prolonged detection of urine norfentanyl in individuals enrolled in a medication for opioid use disorder in pregnancy and postpartum program: a case series

BACKGROUND

Although urine drug testing can have vast legal and social ramifications, its interpretation during pregnancy and after birth remains not well understood. Fentanyl metabolism is altered by an individual's genetics, history of opioid use, and liver function. However, little is known about the clearance of fentanyl or its primary metabolite, norfentanyl, in the peripartum period.

OBJECTIVE

We sought to identify and describe cases of delayed urine norfentanyl clearance in the pregnancy and postpartum period within our institution.

STUDY DESIGN

This study described 3 cases of delayed urine norfentanyl clearance in pregnant and postpartum individuals in a colocated obstetrics, postpartum, and addiction medicine program. This program included prescriptions for medication for opioid use disorder and weekly urine drug testing with fentanyl immunoassay with reflex confirmation testing with liquid chromatography-tandem mass spectrometry for positive results with a limit of detection of 2.5 ng/mL.

RESULTS

Low levels of norfentanyl (<16.3 ng/mL) were detected in urine 294 days, 126 days, and 231 days after the last fentanyl use. Patient self-reported abstinence was supported by consistently negative urine fentanyl levels throughout the collection period, compliant weekly urine drug tests that were otherwise only positive for buprenorphine, and negative fentanyl and norfentanyl in umbilical cord toxicology.

CONCLUSION

Despite compliance in a medication for opioid use disorder program, the presence of norfentanyl in urine has significant consequences on the maternal-child dyad in the postpartum period. Caution should be used when using low levels of norfentanyl to determine an individual's abstinence, as it can lead to further discrimination against women in medication for opioid use disorder programs.

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.

Popular media misinformation on neonatal abstinence syndrome, 2015-2021

BACKGROUND

As the overdose crisis unfolded, narratives mischaracterizing neonatal abstinence syndrome (NAS) as "addicted babies" with echoes to the "crack babies" panic proliferated in mainstream media. his study examines NAS misinformation dynamics and characteristics over a seven-year period.

METHODS

Based on a comprehensive query, Media Cloud was used to compile mainstream media content relating to NAS between 2015 and 2021. Articles were redundantly coded on key parameters such as speakers represented, publication source, and scientific accuracy.

RESULTS

Of the 348 articles meeting search criteria, 264 (76 %) featured misinformed narratives, 70 (20 %) featured informed narratives, and 14 (4 %) featured both informed and misinformed content. Most frequent misinformation elements related to misrepresentation of babies as "addicted" at birth and exaggeration of NAS symptomatology and long-term harms. Least represented voices were people most affected, with just 11 (2 %) featuring mothers who used opioids prepartum.

DISCUSSION

Since misinformation contributes to punitive legal responses and harms patient care, efforts to prevent, monitor, and address inaccurate and stigmatizing narratives are essential to improving policy and practice.

Scoping review: mapping clinical guidelines and policy documents that address the needs of women who are dependent on drugs during the perinatal period

BACKGROUND

Women who use or are in treatment for drug use during the perinatal period often have complex needs and presenting comorbidity. Women who use opioids during pregnancy, and their infants, experience poor outcomes. Drug use by women during pregnancy is a public health priority. This scoping review aimed to (1) map clinical guidelines, treatment protocols and good practice guidance across the UK for women who use or are in treatment for drug use during the perinatal period, (2) identify recommended best practice across health and social care for optimising outcomes and reducing inequalities for these women and (3) identify potential gaps within guidance.

METHODS

We followed the Joanna Briggs International (JBI) guidance on scoping reviews and PRISMA Scr extension. A registered protocol, containing a clear search strategy, inclusion, and exclusion criteria was adhered to. Reviewers double screened 25%, discussing disagreements. Data were extracted using a predefined template and charted in tables. Recommendations for best practice were organised around agreed categories.

RESULTS

Of 968 documents screened, 111 met the inclusion criteria. The documents included UK-wide, national, regional, and organisational policy documents. They varied in the degree they were relevant to women who use or are in treatment for drug use during the perinatal period, the settings to which they applied, and their intended users. Most were created without patient or public involvement and lacked any clear evidence base. Overall, documents recommended an integrated model of care with a lead professional, clear referral pathways and information sharing between agencies. Guidance suggested referrals should be made to specialist midwives, drug, and social care services. A holistic assessment, inclusive of fathers / partners was suggested. Recent documents advocated a trauma-informed care approach. Opioid substitution therapy (OST) was recommended throughout pregnancy where required. Potential gaps were identified around provision of support for women postnatally, especially when their baby is removed from their care.

CONCLUSIONS

This synthesis of recommended practice provides key information for practitioners, service providers and policy makers. It also highlights the need for guidelines to be evidence-based, informed by the experiences of women who use or are in treatment for drug use during the perinatal period, and to address the support needs of postnatal women who have their babies removed from their care.

Addressing Perinatal Opioid Use at a Local Health Department in Florida

PURPOSE

Perinatal substance use disorders (SUDs) remain an urgent public health concern in the United States and are associated with increased maternal and infant morbidity and mortality. Establishing holistic prenatal care among this population allows for engaging or re-engaging the pregnant population in appropriate medical care, including treatment for SUD.

DESCRIPTION

The Florida Department of Health in Citrus County (DOH-Citrus) noticed an increase in SUD among their pregnant population and developed a pilot program that incorporates Medication for Opioid Use Disorder (MOUD) and mental health services during routine prenatal care appointments.

ASSESSMENT

Since the launch of the pilot program, DOH-Citrus has provided prenatal programs with buprenorphine assistance to 23 members of the community.

CONCLUSION

A growing number of local health departments (LHDs) provide harm reduction supplies, overdose prevention education, and local resources for treatment and other life-saving services. In many communities, LHDs are typically the most accessible sources of public health information and health care services. By framing the pilot program as a prenatal care center that incorporates SUD treatment as the prescribed standard of care, DOH-Citrus has implemented a holistic model for treating SUD and reducing barriers while improving continuity of care. LHDs are uniquely positioned to implement harm reduction strategies that address perinatal SUDs, treatment, and recovery within maternal and child health populations. As a health department located in a state without expanded Medicaid and with high rates of uninsured people, this pilot program has the potential to be replicated in other states facing similar challenges.

Nursing as total institution

Healthcare under the auspices of late-stage capitalism is a total institution that mortifies nurses and patients alike, demanding conformity, obedience, perfection. This capture, which resembles Deleuze's enclosure, entangles nurses in carceral systems and gives way to a postenclosure society, an institution without walls. These societies of control constitute another sort of total institution, more covert and insidious for their invisibility (Deleuze, 1992). While Delezue (1992) named physical technologies like electronic identification badges as key to understanding these societies of control, the political economy of late-stage capitalism functions as a total institution with no cohesive, centralized, connected material apparatus required. In this manuscript, we outline the ways in which the healthcare industrial complex demands nurse conformity and how that, in turn, operationalizes nurses in service to the institution. This foundation leads to the assertion that nursing must foster a radical imagination for itself, unbound by reality as it presently exists, in order that we might conjure more just, equitable futures for caregivers and care receivers alike. To tease out what a radical imagination might look like, we dwell in paradox: getting folks the care they need in capitalist healthcare systems; engaging nursing's deep history to inspire alternative understandings for the future of the discipline; and how nursing might divest from extractive institutional structures. This paper is a jumping-off place to interrogate the ways institutions telescope and where nursing fits into the arrangement.

Demographics, Birth Parameters, and Social Determinants of Health Among Opioid-Exposed Mother-Infant Dyads Affected by Neonatal Abstinence Syndrome in Pennsylvania, 2018-2019

OBJECTIVES

To characterize demographics, birth parameters, and social determinants of health among mother-infant dyads affected by neonatal abstinence syndrome (NAS) in Pennsylvania.

METHODS

We linked 2018-2019 NAS surveillance data to birth record data using probabilistic methods and then geospatially linked to local social determinants of health data based on residential address. We generated descriptive statistics and used multivariable mixed-effects logistic regression to model the association between maternal characteristics, birth parameters, social determinants of health, and NAS.

RESULTS

In adjusted models maternal age > 24, non-Hispanic white race/ethnicity, low educational attainment, Medicaid as payor at delivery, inadequate or no prenatal care, smoking during pregnancy, and low median household income were associated with NAS. We found no significant associations between NAS and county-level measures of clinician supply, number of substance use treatment facilities, or urban/rural designation.

CONCLUSIONS FOR PRACTICE

This study characterizes mother-infant dyads affected by NAS using linked non-administrative, population data for Pennsylvania. Results demonstrate a social gradient in NAS and inequity in prenatal care receipt among mothers of infants with NAS. Findings may inform implementation of state-based public health interventions.

Prenatal Substance Exposure and Neonatal Abstinence Syndrome: State Estimates from the 2016-2020 Transformed Medicaid Statistical Information System

INTRODUCTION

Estimating Neonatal Abstinence Syndrome (NAS) and prenatal substance exposure rates in Medicaid can help target program efforts to improve access to services.

METHODS

The data for this study was extracted from the 2016-2020 Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) Research Identifiable Files (RIF) and included infants born between January 1, 2016 and December 31, 2020 with a either a NAS diagnosis or prenatal substance exposure.

RESULTS

Between 2016 and 2020, the estimated national rate of NAS experienced a 18% decline, while the estimated national rate of prenatal substance exposure experienced a 3.6% increase. At the state level in 2020, the NAS rate ranged from 3.2 per 1000 births (Hawaii) to 68.0 per 1000 births (West Virginia). Between 2016 and 2020, 28 states experienced a decline in NAS births and 20 states had an increase in NAS rates. In 2020, the lowest prenatal substance exposure rate was observed in New Jersey (9.9 per 1000 births) and the highest in West Virginia (88.1 per 1000 births). Between 2016 and 2020, 38 states experienced an increase in the rate of prenatal substance exposure and 10 states experienced a decline.

DISCUSSION

Estimated rate of NAS has declined nationally, but rate of prenatal substance exposure has increased, with considerable state-level variation. The reported increase in prenatal substance exposure in the majority of US states (38) suggest that substances other than opioids are influencing this trend. Medicaid-led initiatives can be used to identify women with substance use and connect them to services.

The Effect of Maternal Adverse Childhood Experiences (ACEs) on Substance Use During Pregnancy

OBJECTIVES

To analyze adverse childhood experiences (ACEs) among mothers of newborns referred to a hospital's child protection team (CPT) for suspected substance exposure. Researchers hypothesized that a higher prevalence of these mothers have ≥ 4 ACEs than female counterparts in the general population. The study team also explored whether associations existed between type of maternal ACEs and substance use in pregnancy.

METHODS

Retrospective review of infant referrals to the CPT in the 3 years after adding an ACEs questionnaire to the consultation process. Bivariate analyses and multivariate logistic regression models examined associations between prenatal substance use and maternal ACEs prevalence, controlling for demographics.

RESULTS

Data from 222 infants (four sets of twins) and 218 mothers were analyzed. Half (50.0%) the infants had withdrawal symptoms. Most (67.0%) women had positive toxicology screens, while 85.0% reported prenatal substance use. Half (50.9%) the mothers reported ≥ 4 ACEs and these individuals had significantly higher odds of cannabinoid use [adjusted odds ratio (aOR), 3.7; 95%CI 2.0, 6.9, p < 0.001) than those with < 4 ACEs. A significant association was found between substance use and ACEs in the household challenges category (p = 0.03), especially parental separation/divorce (p < 0.001).

CONCLUSIONS FOR PRACTICE

As hypothesized, a higher prevalence of mothers referred to the CPT had ≥ 4 ACEs than women in the general population (50.9% vs. 15.2%), and a large proportion had used substances while pregnant. Routine prenatal ACEs screening and universal, nonpunitive toxicology testing of infants and mothers at birth may provide opportunities for intervention while reducing the transgenerational impact of ACEs.

Strengthening the System Supporting Perinatal People with Substance Use Disorder in the Midwest Using Group Model Building

INTRODUCTION

Providing comprehensive, evidence-based care to perinatal people with substance use disorders (SUD) requires multi-stakeholder collaboration and alignment. The National Maternal and Child Health Workforce Development Center facilitated a system-strengthening process with the Midwest substance use in pregnancy (SUPper) club, a regional collaborative of health care providers, state public health agencies, and community-rooted organizations.

METHODS

Facilitators led a 2 day group model building (GMB) workshop with 20 participants and two semi-structured interviews. Workshop participants were invited to complete an evaluation.

RESULTS

Two primary trends were identified as priorities for change: (1) Birthing people's perception/experience of stigma and (2) The Midwest SUPper Club's reach and influence. Three causal loop diagrams (CLDs) were created to capture the interconnected dynamics of the Midwest perinatal SUD system: (1) the influence of stigma on maternal and infant health outcomes, (2) the role of clinic, organizational, and state policies, and (3) the impact of workforce education and evidence-based practices on care. From the CLDs, four priorities for action emerged: (1) align and promote shared mental models across stakeholders, (2) expand education and training opportunities for the perinatal SUD workforce, (3) strengthen systems infrastructure to support care navigation for patients and providers, and (4) collaboratively identify evidence-based practices that meet regional needs. All evaluation respondents reported that the workshop supported the development of a shared mental model.

DISCUSSION

The GMB process strengthened collaboration and advanced strategic planning for the SUPper Club. GMB can be further utilized among diverse stakeholders across MCH systems to create shared mental models and accelerate collaborative planning efforts.

Can umbilical cord testing add to maternal urine drug screen for evaluation of infants at risk of neonatal opioid withdrawal syndrome?

OBJECTIVE

This study evaluated maternal urine drug screen (UDS) at delivery and umbilical cord drug testing and its association with neonatal opioid withdrawal syndrome (NOWS) diagnosis and severity following opioid exposed pregnancy.

METHODS

A retrospective chart review of 770 mother-infant dyads at five birthing hospitals in the United States Appalachian region for a five-year period was performed. Variables of interest included dyad demographics, results of maternal UDS at delivery and umbilical cord drug testing, and three neonatal outcomes: NOWS diagnosis, pharmacologic treatment administered for NOWS, and length of hospital stay (LOS) of the newborn.

RESULTS

Opioid-positivity was between 8.5% and 66.3% based on maternal UDS at delivery or umbilical cord testing. Odds of NOWS diagnosis and increased infant LOS was best associated with opioid detection in maternal UDS alone (OR = 5.62, 95% CI [3.06, 10.33] and OR = 8.33, 95% CI [3.67, 18.89], respectively). However, odds of pharmacologic treatment for NOWS was best associated with opioid detection in both maternal UDS and umbilical cord testing on the same dyad (OR = 3.22, 95% CI [1.14, 9.09]).

CONCLUSION

Maternal UDS is a better option compared to umbilical cord testing for evaluation of opioid-exposed infants and risk of NOWS diagnosis and increased infant LOS.

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.

Impacts of intergenerational substance use and trauma among black women involved in the criminal justice system: A longitudinal analysis

INTRODUCTION

Intergenerational substance use and trauma disproportionately impact racialized women. Yet, how these factors impact outcomes in women involved in the criminal justice system is understudied.

METHODS

Using data from 443 participants in the Black Women in a Study of Epidemics, we assessed the impact of intergenerational substance use and trauma on participant drug use and open Child Protective Services (CPS) cases over 18 months. In repeated-measures logistic regression, intergenerational substance and trauma were independent variables, while participants' drug use at each follow-up and any open CPS case (s) served as separate dependent variables. Models were adjusted for criminal justice involvement, age, marital status, education, childhood guardian, number of children, and prior year homelessness.

RESULTS

On average, participants were aged 35 years, 64 % had never married, and 44 % were raised by both parents. Two-thirds of women (67 %) reported intergenerational substance use (≥1 parent and/or grandparent with alcohol/drug problems), while only 13 % reported intergenerational trauma. Each increase in the number of parents/grandparents with drug/alcohol problems was associated with 30 % increased odds of participants' drug use (aOR 1.30, 95 % CI: 1.07,1.57) and 40 % increased odds of having an open CPS case (aOR 1.40, 95 % CI: 1.11, 1.78). The association of intergenerational trauma and CPS cases was attenuated with sociodemographic/contextualizing factors.

CONCLUSIONS

Intergenerational substance use and trauma are associated with negative outcomes. Our findings highlight the need for substance use treatment to address the pervasive generational effects of substance use and trauma faced by racialized women in the criminal justice system.

Clinician views on reporting pregnant and birthing patients who use alcohol and/or drugs to child welfare

BACKGROUND

Multiple health professional associations have expressed concern with policies that require clinician reporting of pregnant people's substance use to child welfare, including that reporting negatively affects patient outcomes and the patient-provider relationship. However, research has shown that clinicians continue to report pregnant and birthing patients at high rates.

OBJECTIVE

This study aimed to explore clinician views on reporting pregnant and birthing patients who use alcohol or drugs during pregnancy to child welfare and whether there are patterns in the types of decisions that clinicians agree with, disagree with, or feel conflicted about.

STUDY DESIGN

In-depth interviews were conducted with 37 hospital-based clinicians (13 obstetrics and gynecology physicians, 12 emergency medicine physicians, 10 family medicine physicians, and 2 advance practice registered nurses) in the United States. The participants discussed one or more patient cases where they or someone else on the care team had to decide whether to report that patient to child welfare related to their use of alcohol or drugs during pregnancy. Cases were categorized on the basis of whether the participant agreed, disagreed, or was conflicted by the reporting decision in that case. Patterns were explored by patient-level factors, provider specialty, and whether the participant perceived that the decision was influenced by a state or hospital policy.

RESULTS

A total of 53 patient cases (average 2 per interview) were identified. The participants typically described cases where they agreed with the decision to report or believed there was no other option than reporting. These cases typically involved patients who used nonprescribed opioids during pregnancy, were experiencing factors (eg, unstable housing and untreated mental health disorders) in addition to substance use, and/or left the hospital against medical advice without their infant. Moreover, some participants, mostly obstetricians and gynecologists, described cases where they felt conflicted about or disagreed with the decision to report. These cases typically involved pregnant patients using cannabis and patients reported because of hospital and/or state policy. Only 1 participant described a case where they disagreed with the decision to not report.

CONCLUSION

The participants agreed with most, but not all, child welfare reporting decisions. When participants disagreed or felt conflicted with reporting decisions, these feelings were almost entirely related to decisions to report, which, in some cases, were prompted by hospital or state policies. Policies may prompt reporting that exceeds what clinicians believe is appropriate.

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.

Polysubstance Use in Pregnancy: Surveillance, Interventions, and Next Steps

Substance use during pregnancy increases risk for a wide range of adverse maternal and neonatal health outcomes. Polysubstance use is common among people who use substances during pregnancy; however, the risks of combined substance exposures during pregnancy are poorly understood. In this report, we provide an overview of the activities of the Centers for Disease Control and Prevention (CDC) and partners and identified gaps related to (1) surveillance, (2) routine screening, and (3) prevention of polysubstance use during pregnancy. Efforts by CDC and other partners to reduce polysubstance use during pregnancy can improve the health of pregnant people and their infants and children.

The Fall of Roe v. Wade : The Addiction Specialist's Role in Championing Reproductive Rights

Reproductive age-pregnant individuals who use substances are disproportionately impacted by the US Supreme Court reversal of Roe v. Wade . Because of historic and ongoing discrimination against pregnant individuals who use substances, this group is at high risk for inadequate pregnancy options counseling and lack of access to safe and legal abortions. Fetal rights laws set a concerning precedent that further criminalize and penalize substance use in pregnancy. As addiction specialists, we have the professional responsibility to champion the reproductive freedoms of pregnant individuals who use substances. There are several ways that addiction specialists can uphold the reproductive rights of patients on an individual, state, and federal level, including the following: incorporate reproductive healthcare into addiction practices, help those seeking abortion navigate barriers, partner with perinatal healthcare clinicians to provide evidence-based addiction treatment during pregnancy, and support decriminalization and destigmatization of substance use, especially in pregnancy.

Office-Based Management of Perinatal Substance Use and Substance Use Disorder for the General Obstetrician-Gynecologist

This is a review of substance use and substance use disorder in pregnancy, intended for the generalist obstetrician-gynecologist. Herein, the authors discuss legal considerations, outline definitions, review screening tools, introduce special considerations and harm reduction, caution the use of urinary toxicology testing, and touch on the screening, brief intervention, and referral to treatment model. Furthermore, the authors provide a brief overview of the prevalence, maternal and neonatal risks, and treatment approaches for commonly used substances.

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.

Interventions to Support Engagement in Addiction Care Postpartum: Principles and Pitfalls

There is a fundamental disconnect between the optimal management of addiction in general and care delivery in pregnancy and postpartum. Addiction is a chronic condition requiring some degree of management across the life course. Yet, in the US, reproductive care is episodic and centers more on pregnancy than at other stages of the reproductive life course. Pregnancy is prioritized in access to insurance as almost all pregnant people are Medicaid eligible but access ends at varying points postpartum. This results in a structural mismatch: the episodic management of the chronic condition of addiction only within gestational periods. Though people with substance use disorder (SUD) may access care in pregnancy, treatment attrition is common postpartum. Postpartum is a time of increased vulnerabilities where insurance churn and newborn caretaking responsibilities collide in a context of care withdrawal from the health system and health providers. In part in consequence, return to use, SUD recurrence, overdose, and overdose death are more common postpartum than in pregnancy, and drug deaths have become a leading cause of maternal deaths in the US. This review addresses interventions to support engagement in addiction care postpartum. We begin with a scoping review of model programs and evidence-informed interventions that have been shown to increase continuation of care postpartum. We then explore the realities of contemporary care through a review of clinical and ethical principles, with particular attention to harm reduction. We conclude with suggestions of strategies (clinical, research, and policy) to improve care postpartum and highlight potential pitfalls in the uptake of evidence-based and person-centered services.

Addressing stigma within the dissemination of research products to improve quality of care for pregnant and parenting people affected by substance use disorder

Substance use disorders are a common and treatable condition among pregnant and parenting people. Social, self, and structural stigma experienced by this group represent a barrier to harm reduction, treatment utilization, and quality of care. We examine features of research dissemination that may generate or uphold stigmatization at every level for pregnant and parenting individuals affected by substance use disorder and their children. We explore stigma reduction practices within the research community that can increase uptake of evidence-based treatment programs and prevent potential harm related to substance use in pregnant and parenting people. The strategies we propose include: (1) address researcher stereotypes, prejudice, and misconceptions about pregnant and parenting people with substance use disorder; (2) engage in interdisciplinary and transdisciplinary collaborations that engage with researchers who have lived experience in substance use; (3) use community-based approaches and engage community partners, (4) address stigmatizing language in science communication; (5) provide contextualizing information about the social and environmental factors that influence substance use among pregnant and parenting people; and (6) advocate for stigma-reducing policies in research articles and other scholarly products.

A qualitative exploration of the eight dimensions of wellness in opioid use disorder recovery during the postpartum period

Background

Recovery from opioid use disorder (OUD) during the perinatal period has unique challenges. We examined services for perinatal women with OUD using the Substance Abuse and Mental Health Services Administration (SAMHSA) eight dimensions of wellness (DoW), which reflect whole person recovery.

Methods

We enrolled professionals from the Southwestern United States who work with people with OUD during the perinatal period. Semi-structured in-depth interviews were conducted from April to December 2020. Participants were shown the DoW diagram (emotional, social, environmental, physical, financial, spiritual, occupational, intellectual) and asked to share how their clinic/agency addresses each DoW for perinatal people with OUD. Responses were transcribed and coded by two researchers using Dedoose software.

Results

Thematic analysis revealed ways professionals (n = 11) see how the services they provide fit into the DoW. This included: the need to provide mothers emotional support with a nonjudgmental approach, groups providing social support; guidance on nutrition, self-care, and a focus on the mother/infant dyad; assistance with employment and activities of daily living; parenting education; connecting mothers with resources and grants; providing a variety of spiritual approaches depending on the desire of the mother; and navigating the interpersonal environment as well as the physical space.

Conclusions

There are opportunities to expand the treatment and services provided to women with OUD during the perinatal period within all eight DoWs. Additional research is needed to identify effective strategies to incorporate these components into patient-centered, holistic care approaches.

Nurses as Disciplinary Agents of the State: Ethical Practice and Mandatory Reporting in the United States

This article reviews legislative initiatives that mandate nurses to report patients, families, and clinicians to law enforcement. Most recently, these laws target transgender and gender diverse (TGD) youth and people seeking abortion. In this article, we examine the ethics of such laws through professional ethical codes. Furthermore, through a biopolitical lens, we critically analyze examples of nurses' participation in complying with laws that harm patients. Finally, we discuss the damage these laws have on the nursing profession and assert the necessity of a resituating of professional ethics that considers the complexity of nursing care amidst increasingly blatant state-sanctioned violence.

A National Portrait of Public Attitudes toward Opioid Use in the US: A Latent Class Analysis

BACKGROUND

Opioid overdose rates have steadily been increasing in the United States (US) creating what is considered an overdose death crisis. The US has a mixture of public health and punitive policies aimed to address opioid use and the overdose crisis, yet little is known about public opinion relating to opioid use and policy support. Understanding the intersection of public opinion about opioid use disorder (OUD) and policy can be useful for developing interventions to address policy responses to overdose deaths.

METHODS

A national sample of cross-sectional data from the AmeriSpeak survey conducted from 27 February 2020 through 2 March 2020 was analyzed. Measures included attitudes toward OUD and policy beliefs. Latent class analysis, a person-centered approach, was used to identify groups of individuals endorsing similar stigma and policy beliefs. We then examined the relationship between the identified groups (i.e., classes) and key behavioral and demographic factors.

RESULTS

We identified three distinct groups: (1) "High Stigma/High Punitive Policy", (2) "High Stigma/Mixed Public Health and Punitive Policy", and (3) "Low Stigma/High Public Health Policy". People with higher levels of education had reduced odds of being in the "High Stigma/High Punitive Policy" group.

CONCLUSION

Public health policies are most effective in addressing OUD. We suggest targeting interventions toward the "High Stigma/Mixed Public Health and Punitive Policy" group since this group already displays some support for public health policies. Broader interventions, such as eliminating stigmatizing messaging in the media and redacting punitive policies, could reduce OUD stigma among all groups.

Implementation of State Laws Giving Pregnant People Priority Access to Drug Treatment Programs in the Context of Coexisting Punitive Laws

BACKGROUND

In response to increased prenatal drug use since the 2000s, states have adopted treatment-oriented laws giving pregnant and postpartum people priority access to public drug treatment programs as well as multiple punitive policy responses. No prior studies have systematically characterized these state statutes or examined implementation of state priority access laws in the context of co-existing punitive laws.

METHODS

We conducted legal mapping to examine state priority access laws and their overlap with state laws deeming prenatal drug use to be child maltreatment, mandating reporting of prenatal drug use to child protective services, or criminalizing prenatal drug use. We also conducted interviews with 51 state leaders with expertise on their states' prenatal drug use laws to understand how priority access laws were implemented.

RESULTS

Thirty-three states and the District of Columbia have a priority access law, and more than 80% of these jurisdictions also have one of the punitive prenatal drug use laws described. Leaders reported major barriers to implementing state priority access laws, including the lack of drug treatment programs, stigma, and conflicts with punitive prenatal drug use laws.

CONCLUSIONS

Our results suggest that state laws granting pregnant and postpartum people priority access to drug treatment programs are likely insufficient to significantly increase access to evidence-based drug treatment. Punitive state prenatal drug use laws may counteract priority access laws by impeding treatment seeking. Findings highlight the need to allocate additional resources to drug treatment for pregnant and postpartum people.

The Implementation of the Tennessee Fetal Assault Law and Its Association With Out-of-State Births Among Residents of Tennessee

INTRODUCTION

This study analyzed the association between the implementation of the Tennessee Fetal Assault Law (TFAL), which allowed prosecutors to incarcerate people who used substances during pregnancy, and out-of-state births among residents of Tennessee.

METHODS

The main data source is vital records on singleton births in hospitals to people aged 15-44 years during the period January 2010 to June 2016. We include data from 33 states and the District of Columbia where birth certificate data are comparable over this time period. The statistical significance of the difference in outcomes observed before and after TFAL implementation was tested using a difference-in-differences analysis between Tennessee and the comparison group.

RESULTS

After TFAL implementation, the odds of having an out-of-state birth increased by 13% for residents of Tennessee (odds ratio, 1.13; 95% confidence interval, 1.09-1.16) relative to residents of the comparison states. When we adopted different thresholds for travel distances to the birth hospital, the odds of residents of Tennessee having an out-of-state birth more than 75 miles away increased by 17% (odds ratio, 1.17; 95% confidence interval, 1.13-1.21) after TFAL implementation.

CONCLUSION

The results of this study suggest that the implementation of a policy allowing incarceration of people who use substances during pregnancy is associated with an increase in out-of-state births, potentially putting pregnant people and their infants at greater risk.

Predictors of the Rate of Illicit Fentanyl Metabolism in a Cohort of Pregnant Individuals

INTRODUCTION

Illicit fentanyl use is growing in the United States, including among pregnant persons. Despite the prevalence of illicit fentanyl in the drug supply, the pharmacokinetics of fentanyl remains understudied, especially for pregnant individuals. The variability of fentanyl pharmacokinetics influences detection of fentanyl in urine samples, the results of which can have significant legal consequences. For pregnant and parenting individuals, these legal consequences may include termination of parental rights.

METHODS

Through this medical-legal lens, we conducted a retrospective cohort analysis using the electronic medical records of women receiving integrated prenatal care and substance use disorder treatment. A total of 420 medical records were reviewed and 112 individuals who had a positive fentanyl immunoassay and met the selection criteria were included. Metabolic ratios (level of norfentanyl/level of fentanyl) were calculated for each study individual. A linear regression analysis was used to determine if the following physiologic factors were predictors of the rate of fentanyl metabolism: hepatic function, renal function, body mass index, medication dosage, gestational age, and maternal age.

RESULTS

Results indicated that advanced maternal age predicted a slower conversion of fentanyl to norfentanyl, whereas increased gestational age predicted a faster conversion.

CONCLUSIONS

Variations in fentanyl metabolism in pregnancy highlight the importance of clinician vigilance when interpreting fentanyl rests results, especially for individuals with advancing maternal age. In such cases, clinician caution and advocacy may prevent unwarranted and unjust removal of a child from maternal custody.

Infants, children, and youth in foster care with prenatal substance exposure: a synthesis of two scoping reviews

Background: Infants, children, and youth in foster care have frequently experienced prenatal substance exposure (PSE), neglect, and maltreatment as well as disruptions in their relationships with families. They also have great capacity for overcoming early adversities. In this synthesis of two previously conducted scoping reviews, we aimed to identify and describe literature that identifies a range of interventions that support the health and development of this population. Methods: This review integrates and extends two previously conducted scoping reviews, one focusing on infants and one focusing on children and youth, to synthesize themes across these developmental stages. The Joanna Briggs Institute scoping review methodology was employed for the current and previous reviews. A three-step search strategy identified published studies in the English language from January 2006 to February 2020. Results: One-hundred and fifty-three sources were included in this review. Four themes were identified: (1) early screening, diagnosis, and intervention; (2) providing theoretically grounded care; (3) supporting parents and foster care providers; and (4) intersectoral collaboration. Conclusion:Infants, children, and youth with PSE are overrepresented in foster care. Child welfare system planning should take a multi-sectoral approach to addressing the cumulative needs of this population and their care providers over developmental ages and stages. Although research remains limited, early screening, diagnosis, and developmentally and fetal alcohol spectrum disorder-informed intersectoral interventions are critical for optimizing outcomes.

Reducing Prenatal Alcohol Exposure and the Incidence of FASD: Is the Past Prologue?

PURPOSE

This narrative review summarizes and synthesizes the clinical trials and randomized clinical trials that evaluated selected and targeted approaches to reducing preconception and prenatal alcohol exposure (PAE) and alcohol-exposed pregnancy (AEP) since 2011.

SEARCH METHODS

A professional hospital librarian completed the primary search using strategies specified within this review, resulting in 94 records returned in PubMed, Ovid MEDLINE, Clinical Key, the World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. The author completed two supplementary literature searches.

SEARCH RESULTS

From the total of 238 records returned from the three searches, 217 records were eliminated. Elimination reasons included other medical problem (119); duplicate entry (34); no content/results (23); secondary analysis (16); focus on effects of PAE (9); treatment of childhood fetal alcohol spectrum disorders (FASD) (6); maternal risk factors (3); and other (7). The remaining 21 studies were included with four overarching themes: (1) case management efforts (n = 4); (2) preconception efforts to reduce AEP (n = 5); (3) motivational interviewing and screening, brief intervention, and referral to treatment (n = 2); and (4) use of technology to deliver the intervention (n = 10).

DISCUSSION AND CONCLUSIONS

Case management and home visits did not appear to have strong current empirical support. Study limitations included small sample sizes and no comparison groups, whereas larger efforts did not demonstrate definitive advantages to justify this intensive approach. The studies of preconception efforts, all based on the Project CHOICES approach, had similar outcomes, with the reduction in AEP risk largely due to improved contraception in women of childbearing age who were sexually active and drank alcohol but were not pregnant. It is unknown whether these women refrained from alcohol use when they became pregnant. Two studies of motivational interviewing to reduce prenatal alcohol use did not demonstrate the efficacy of the intervention. Both were small, with less than 200 pregnant women combined; moreover, the study samples had low baseline levels of alcohol use, allowing little opportunity for improvement. Finally, studies evaluating the impact of technological approaches to reducing AEP were reviewed. These exploratory investigations had small sample sizes and provided preliminary evaluations of techniques such as text messages, telephone contact, computer-based screening, and motivational interviewing. The potentially promising findings may inform future research and clinical efforts. Future directions may include research to address the limitations of the evidence to date and should reflect the complexities of FASD that include the biological and social context associated with prenatal alcohol use.

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.

Novel Implementation of State Reporting Policy for Substance-Exposed Infants

BACKGROUND

The Child Abuse Prevention and Treatment Act's provisions concerning hospitalist and child protective services response to infants with prenatal substance exposure (IPSE) were revised in 2016 to address the impact of the opioid epidemic. In 2019, Connecticut unveiled a statewide hospital reporting infrastructure to divert IPSE without safety concerns from CPS using a deidentified notification to CPS and a plan of safe care (POSC). Connecticut is the first state to implement a separate, deidentified notification system.

METHODS

We used notification and birth data to determine rates per 1000 births. We employed multinomial logistic regression to understand factors associated with 3 mutually exclusive outcomes: (1) diversion with POSC, (2) report with POSC, or (3) report without POSC.

RESULTS

During the first 28 months of policy implementation, hospitalists submitted over 4700 notifications (8% of total Connecticut births). Over three-quarters (79%) of notifications included marijuana exposure, and 21% included opioid exposure. Fewer than 3% included alcohol exposure. Black mothers were disproportionally overrepresented among notifications compared with the state population, and all other race groups underrepresented. Over half of identified IPSE were diverted. Type of substance exposure was the strongest predictor of outcome, controlling for maternal age and race group.

CONCLUSIONS

Connecticut Child Abuse Prevention and Treatment Act diverted IPSE without provider safety concerns away from child protective services. Substance exposure type was associated with the dyad's outcome at hospital discharge. Nonuniversal screening practices may contribute to racial disproportionality in implementation.

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.

"You have to take this medication, but then you get punished for taking it:" lack of agency, choice, and fear of medications to treat opioid use disorder across the perinatal period

INTRODUCTION

Medications to treat opioid use disorder (MOUD) during pregnancy and in the postpartum period remain underutilized. A need exists to enhance our understanding of modifiable factors, facilitators, and barriers to MOUD utilization and adherence in the perinatal period to improve maternal and child outcomes.

METHODS

The study conducted semi-structured qualitative interviews with recently pregnant people with opioid use disorder (OUD) to explore experiences as a pregnant and/or parenting person with OUD, perceptions of enabling factors and barriers to treatment utilization, incentivizing factors for maintaining adherence, and acceptability of ongoing supports to sustain treatment adherence. The study team used constant comparative methods to analyze transcripts and develop the codebook. The team double coded the transcripts, with an overall kappa coefficient of 0.88.

RESULTS

The study team interviewed twenty-six women on average 10.1 months after delivery. All women had some prior experience using MOUD. Four unique themes emerged as barriers to medication utilization and adherence in the perinatal period: 1) Lack of agency and autonomy surrounding medication decisions because pregnancy or parenting status affected treatment adherence; 2) Hesitancy to use MOUD to minimize risk of newborn withdrawal; 3) Concern about increased scrutiny and potential loss of custody due to mandated child protective services reporting for opioid-exposure at delivery in Massachusetts; and 4) Perception that treatment environments, particularly methadone clinics, did not provide gender-responsive or equitable care, and standardized, inflexible visit regulations were particularly difficult to comply with in the early postpartum period.

CONCLUSIONS

Women with OUD experienced a double bind when making perinatal treatment decisions, describing pressure to use MOUD with negative consequences after delivery. Key areas for possible intervention emerged from interviews. These areas include improving uptake of shared decision-making to increase patient autonomy and agency, particularly among those in the earliest stages of recovery during pregnancy; ongoing education around perinatal MOUD safety and efficacy; detangling MOUD and neonatal withdrawal signs from mandated child protective services reporting; and improving gender-responsive and equitable care in substance use disorder treatment programs, including incorporating the utilization of home visiting services for dosing assessments and administration in the early postpartum period.

Beyond Abortion: The Consequences of Overturning Roe

The upcoming U.S. Supreme Court decision in Dobbs v. Jackson Women's Health Organization has the potential to eliminate or severely restrict access to legal abortion care in the United States. We address the impact that the decision could have on abortion access and its consequences beyond abortion care. We posit that an abortion ban would, in effect, mean that anyone who becomes pregnant, including those who continue a pregnancy and give birth to healthy newborns and those with pregnancy complications or adverse pregnancy outcomes will become newly vulnerable to legal surveillance, civil detentions, forced interventions, and criminal prosecution. The harms imposed by banning or severely restricting abortion access will disproportionately affect persons of color and perpetuate structural racism. We caution that focusing on Roe as a decision that only protects ending a pregnancy ignores the protection that the decision also affords people who want to continue their pregnancies. It overlooks the ways in which overturning Roe will curtail fundamental rights for all those who become pregnant and will undermine their status as full persons meriting Constitutional protections. Such a singular focus inevitably obscures the common ground that people across the ideological spectrum might inhabit to ensure the safety, health, humanity, and rights of all people who experience pregnancy.

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.

Prenatal substance use policies and newborn health

We study the effect of punitive and priority treatment policies relating to illicit substance use during pregnancy on the rate of neonatal drug withdrawal syndrome, low birth weight, low gestational age, and prenatal care use. Punitive policies criminalize prenatal substance use, or define prenatal substance exposure as child maltreatment in child welfare statutes or as grounds for termination of parental rights. Priority treatment policies are supportive and grant pregnant women priority access to substance use disorder treatment programs. Our empirical strategy relies on administrative data from 2008 to 2018 and a difference-in-differences framework that exploits the staggered implementation of these policies. We find that neonatal drug withdrawal syndrome increases by 10%-18% following the implementation of a punitive policy. This growth is accompanied by modest reductions in prenatal care, which may reflect deterrence from healthcare utilization. In contrast, priority treatment policies are associated with small reductions in low gestational age (2%) and low birth weight (2%), along with increases in prenatal care use. Taken together, our findings suggest that punitive approaches may be associated with unintended adverse pregnancy outcomes, and that supportive approaches may be more effective for improving perinatal health.

Motherhood, pregnancy and gateways to intervene in substance use disorder

Motherhood increases women's use of health and social services, presenting opportunities to identify and refer women with substance use disorder (SUD) to treatment. We pooled 4 years (2015-2018) of cross-sectional data from National Survey on Drug Use and Health on women of child-bearing age (18-44) in the United States (n = 64,346). (1) We compared the use of services (health, social and criminal justice involvement) by SUD and 'motherhood' (pregnant or has one or more children under 18). We used multivariable logistic regression models to estimate the association between motherhood, SUD and their interaction with the use of services. (2) We estimated the association between the use of different services and SUD treatment use among women with SUD. Among women of child-bearing age, 9.7% had SUD. Mothers who had SUD were more likely to use social services (AOR = 1.48 [95% CI: 1.22, 1.79]) and mental health services compared with non-mothers who did not have SUD (AOR = 1.40 [95% CI: 1.19, 1.65]). The following factors were associated with increased odds of receiving SUD treatment among mothers: mental health treatment utilisation (AOR = 1.94 [95% CI: 1.29, 2.93]); Medicaid coverage (AOR = 2.48 [95% CI: 1.64, 3.76]); and criminal justice involvement (AOR = 3.38 [95% CI: 1.97, 5.80]). To increase treatment access, it is important to address women's different stages in life, including how to best engage women in SUD care across different settings.

"You still have that fear": Policy constraints on informed decision making about legalized cannabis use during pregnancy and lactation

BACKGROUND

Cannabis is the most commonly used drug during pregnancy, excluding alcohol and tobacco, in the United States. Cannabis consumption during pregnancy is increasing along with greater legal and social acceptance.

METHODS

We conducted a qualitative content analysis of 23 in-depth interviews with pregnant and lactating people in Massachusetts, a state that legalized cannabis for adult use in 2016. Our aim was to explore how policy constrains or facilitates people's ability to make informed decisions about cannabis use during pregnancy and lactation. Our analysis was conducted using an ecosocial approach, recognizing that the implementation and interpretation of cannabis policy can be understood at multiple levels, which interact with each other and shape the health and experiences of individuals. Additionally, this analysis was informed by a harm reduction approach in which we acknowledge the complexity surrounding cannabis use during pregnancy and lactation, while attempting to identify ways to reduce potentially harmful consequences.

RESULTS

Findings revealed that, despite the legal status of cannabis, there continues to be a lack of clarity for pregnant and lactating people regarding the legal implications of cannabis use. Inconsistent state and institutional policies about drug testing of mothers and newborns leave a cloud of fear hanging over the experiences of people who use cannabis and inhibit their ability to obtain expert advice from healthcare providers.

CONCLUSION

Decision makers in public and institutional policy should work to clarify and update policies regarding substance use during pregnancy following legalization of a new substance, and ensure that pregnant and lactating people are afforded the same legal protections as the general population.