Differential Effects of Pregnancy-Specific Alcohol Policies on Drinking Among Pregnant Women by Race/Ethnicity

Racial and ethnic disparities in psychological care for individuals with FASD: a dis/ability studies and critical race theory perspective toward improving prevention, assessment/diagnosis, and intervention

Fetal alcohol spectrum disorders (FASD) are among the most common neurodevelopmental disorders and substantially impact public health. FASD can affect people of all races and ethnicities; however, there are important racial and ethnic disparities in alcohol-exposed pregnancy prevention, assessment and diagnosis of FASD, and interventions to support individuals with FASD and their families. In this article we use the Dis/Ability Studies and Critical Race Theory (Dis/Crit) framework to structure the exploration of disparities and possible solutions within these three areas (prevention, diagnosis, intervention). Dis/Crit provides a guide to understanding the intersection of dis/ability and race, while framing both as social constructs. Following the Dis/Crit framework, the systemic, historical, and contemporary racism and ableism present in psychological care is further discussed. We aim to elucidate these racial and ethnic disparities within the fields of psychology and neuropsychology through the Dis/Crit framework and provide potential points of action to reduce these disparities.

Equitable Policies Need Equitable Practices: Alcohol- and Substance-Exposed Pregnancy as a Case Study

There is clear need for more effective public health policies. Coupled with calls for more effective policies, increasing demand to address public health disparities experienced by systemically marginalized and historically oppressed groups emphasizes the long-standing need for policies that improve public health equity. Such need is highlighted when examining public health issues such as alcohol- and substance-exposed pregnancy (ASEP): Current policies are ineffective at reducing ASEP, and marginalized groups experience disproportionately lower benefits and higher negative consequences as a result of such policies. Powerful strategies to develop more effective policies that can account for the complexity of such issues, such as systems science methods (SSMs), are becoming popular. However, current best practices for such methods often do not emphasize the additional efforts that will be required to develop equitable, not just effective policies. Using ASEP as an example of a crucial complex issue requiring new policy, we suggest additional steps to include in SSM projects for developing more effective policies that will also help stakeholders determine high-equity policies to reduce health disparities. These steps include modeling structural differences experienced by marginalized groups via systemic racism and oppression, incorporating existing cultural and community sources of strength and resilience as key areas for policy development, and evaluating the sustainability of policies as a dimension of efficacy. We also discuss using community-based participatory approaches as a framework for all SSM processes to ensure that policy development itself is grounded in equitable shared decision-making for marginalized individuals.

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

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

CONTEXT

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Racial and ethnic disparities in birth Outcomes: A decomposition analysis of contributing factors

This study seeks to quantify and rank the contribution of selected factors to the observed racial/ethnic disparities in low-birth-weight births (LBWBs) and preterm births (PTBs). Based on vital statistics data on births to primiparous women and characteristics of mothers in the State of Nebraska during the period of 2005 to 2014 (n = 93,375), unadjusted and adjusted odds ratios were estimated to examine the association between selected variables and the odds of having LBWBs or PTBs. Fairlie decomposition analysis was performed to quantify the contribution of each selected factor to racial/ethnic differences in LBWB and PTB rates. The prevalence of PTBs was 9.1% among non-Hispanic White (NHW) women, as compared to 12.8% among non-Hispanic Black (NHB) women and 10.6% among Hispanic women. The corresponding prevalence of LBWBs in the three groups were 5.9%, 11.9%, and 7.2%, respectively. The higher educational attainment among NHW women, relative to NHB women accounted for 10% of the observed difference in LBWB rate between the two groups. Health insurance coverage was the second most important factor accounting for the observed disparities in birth outcomes. Addressing socioeconomic disadvantages in NHB and Hispanic women would be important for them to narrow their gaps with NHW women in LBWB and PTB prevalence. More research is needed to identify key factors leading to the disparities in birth outcomes between NHW and NHB women.

Health decisions amidst controversy: Prenatal alcohol consumption and the unequal experience of influence and control in networks

Individuals avoid stigma by looking to members of their networks for guidance on how to behave. Health controversies complicate this process by exposing people to inconsistent norms, influence, and control within their networks. To understand this process, we meld perspectives on networks and social psychology. Using the case of light/moderate drinking during pregnancy, we examine how people make health decisions in the face of controversy. Through in-depth interviews with first-time pregnant individuals and their health care providers, we reveal that individuals' decisions about controversial health behaviors depend on 1) the consistency of the influence and control they encounter, 2) their status relative to enforcers, and 3) the strength of their ties to enforcers. These processes give people from higher social positions more power to resist influence and control. These findings illuminate how medical recommendations and public health interventions should account for the unequal experience of influence and control within networks.

Variations by Education Status in Relationships Between Alcohol/Pregnancy Policies and Birth Outcomes and Prenatal Care Utilization: A Legal Epidemiology Study

CONTEXT

Previous research finds that some state policies regarding alcohol use during pregnancy (alcohol/pregnancy policies) increase low birth weight (LBW) and preterm birth (PTB), decrease prenatal care utilization, and have inconclusive relationships with alcohol use during pregnancy.

OBJECTIVE

This research examines whether effects of 8 alcohol/pregnancy policies vary by education status, hypothesizing that health benefits of policies will be concentrated among women with more education and health harms will be concentrated among women with less education.

METHODS

This study uses 1972-2015 Vital Statistics data, 1985-2016 Behavioral Risk Factor Surveillance System data, policy data from National Institute on Alcohol Abuse and Alcoholism's Alcohol Policy Information System and original legal research, and state-level control variables. Analyses include multivariable logistic regressions with education-policy interaction terms as main predictors.

RESULTS

The impact of alcohol/pregnancy policies varied by education status for PTB and LBW for all policies, for prenatal care use for some policies, and generally did not vary for alcohol use for any policy. Hypotheses were not supported. Five policies had adverse effects on PTB and LBW for high school graduates. Six policies had adverse effects on PTB and LBW for women with more than high school education. In contrast, 2 policies had beneficial effects on PTB and/or LBW for women with less than high school education. For prenatal care, patterns were generally similar, with adverse effects concentrated among women with more education and beneficial effects among women with less education. Although associations between policies and alcohol use during pregnancy varied by education, there was no clear pattern.

CONCLUSIONS

Effects of alcohol/pregnancy policies on birth outcomes and prenatal care use vary by education status, with women with more education typically experiencing health harms and women with less education either not experiencing the harms or experiencing health benefits. New policy approaches that reduce harms related to alcohol use during pregnancy are needed. Public health professionals should take the lead on identifying and developing policy approaches that reduce harms related to alcohol use during pregnancy.

Differential Effects of State Policy Environments on Substance Use by Sexual Identity: Findings From the 2000-2015 National Alcohol Surveys

Introduction

This study explored whether structural stigma, defined by U.S. state policies related to sexual minority rights, moderated the relationship between sexual identity identity and heavy drinking, alcohol problems, and marijuana use among men and women.

Methods

Using combined data from the National Alcohol Survey (NAS) series (2000, 2005, 2010, and 2015), the sample included 11,115 men (421 sexual minority and 10,694 heterosexual) and 14,395 women (413 sexual minority and 13,982 heterosexual). State policy environment was assessed using a time-varying dichotomous indicator of comprehensive protections for sexual minorities (4-6 protections vs. limited or no protections). Gender-stratified logistic regression analyses examined the differential effect of the policy environment by sexual identity on three past-year substance use outcomes: high-intensity drinking (8+ drinks/day), any DSM-5 alcohol use disorder, and marijuana use.

Results

Among women, sexual minority status was associated with increased odds of all alcohol and marijuana use outcomes. Among men, sexual minority status was associated with decreased odds of high-intensity drinking but increased use of marijuana. Comprehensive policy protections were associated significantly decreased odds of high-intensity drinking among sexual minority men and marginally significant decreases among women.

Conclusions

Comprehensive policy protections appear to be protective for high-intensity drinking among sexual minority men and women. Findings underscore the importance of supportive policies in reducing risk of alcohol-related problems among sexual minorities.

Impact of State-Level Reproductive Health Legislation on Access to and Use of Reproductive Health Services and Reproductive Health Outcomes: A Systematic Scoping Review in the Affordable Care Act Era

INTRODUCTION

We systematically reviewed the literature to understand the associations between state-level reproductive health policies and reproductive health care outcomes and describe policy impacts on reproductive health outcomes among women aged 18 and older. We focused on research conducted after the implementation of the Patient Protection and Affordable Care Act to understand the influence of state-level policies in the context of existing federal policy.

METHODS

Standard search terms were used to search PubMed for studies published between March 10, 2010, and August 31, 2019. Studies were included that reflected original U.S.-based research testing associations between state-level policies (i.e., laws related to family planning, maternity care, and abortion) and reproductive health outcomes related to those services (e.g., prenatal care use) among adults. Reference lists of systematic reviews were searched to improve the identification of relevant studies. Studies were excluded if they were reviews, qualitative or mixed-methods studies, or descriptive studies, or if a state was not the unit of analysis. After dual review, agreement on inclusion of studies was 100%.

RESULTS

Search results returned 1,529 articles; 56 (3.59%) met the inclusion criteria for a full review based on title and abstract review. After dual independent review, eight were selected for inclusion. Two included all 50 states and Washington, DC; one included Oregon and Washington; and the remaining studies included single states (Texas, Arizona, Ohio, and Utah). One-half of the studies (n = 4) focused solely on restrictive abortion legislation. Restricting access to family planning and abortion services (e.g., mandatory waiting periods) were associated with negative outcomes (e.g., additional interventions for medication abortion). Expanding maternity care through Medicaid reform and autonomous midwifery laws were associated with positive outcomes (e.g., prenatal care use).

CONCLUSIONS

Our review identified eight studies that were largely focused on only one key aspect of reproductive health policy. Findings suggest that state-level legislation could have considerable impact on the reproductive health care that women have access to and receive, as well as the related outcomes. Research in this area remains limited. Rigorous evaluations of the relationship between the breadth of reproductive health policies and related health outcomes are needed, as is an exploration of barriers to the conduct of this type of research.

Ferguson v. City of Charleston Redux: Motivated Reasoning and Coercive Interventions in Pregnancy

Criminalization of perinatal substance use disorder and other coercive interventions in pregnancy (such as forced cesarean delivery or involuntary hospitalization for bed rest) directly affect the well-being of children and their families and, potentially, of all women of reproductive capacity. Untenable legal and policy approaches that occasion such incursions not only persist but affect a growing number of women. They are antithetical to healthy pregnancies, healthy children, and healthy families; they have the potential to reduce prenatal care seeking, divert attention and resources away from critical mental health and maternal and child support services, and epigenetically affect maternal and infant bonding. Punitive and coercive interventions contravene long-established guidance by professional associations that advocate for public health approaches and ethical frameworks to guide practice. Harmful policies persist because of motivated reasoning by clinicians, members of the judiciary, and ill-informed legislators who rely on personal experience and anecdote rather than evidence to fashion policy. Compounding the problem are inadequate substance use treatment resources and professional associations that choose not to hold their members accountable for violating their ethical obligations to their patients. Pediatricians must advocate for the cessation of coercive interventions within their institutions and their larger communities. All health care professionals should collaborate at the local, state, and national level to provide policymakers and legislators with data emphasizing the negative effects of punitive and coercive policies aimed at pregnant women and their children.

Substance Use Treatment Patient and Provider Perspectives on Accessing Sexual and Reproductive Health Services: Barriers, Facilitators, and the Need for Integration of Care

Background: Women with substance use disorders have high rates of adverse sexual and reproductive health (SRH) outcomes, including unintended pregnancy, sexually transmitted infections, and contraceptive nonuse. Little research has explored barriers and facilitators to accessing SRH services experienced by women with substance use disorders. Objectives: To investigate barriers and facilitators to accessing SRH services experienced by women with substance use disorders. To assess perspectives on integration of SRH services into substance use treatment. Methods: Twenty-nine semi-structured interviews were conducted with female patients (N = 17) and providers (N = 12) at four substance use treatment facilities in Michigan between October 2015 and January 2016. Respondents were asked about experiences accessing SRH services and perspectives on integration of SRH services into substance use treatment. Data were analyzed using the constant comparative method. Results: Patients and providers discussed barriers to accessing SRH services, including competing priorities, structural barriers, lack of knowledge on SRH services and substance use, fear of Child Protective Services and law enforcement, and stigma. Facilitators included reprioritization of SRH, accessible transportation, insurance coverage and funding for SRH services, and education and training on SRH. Finally, participants expressed support for integration of SRH services into substance use treatment. Conclusions/Importance: Understanding the barriers to accessing SRH services is essential to reducing the adverse SRH outcomes experienced by women with substance use disorders. Substance use treatment is a critical time to offer SRH services. Integration of care is a potential model for improving the SRH of women with substance use disorders.

Racial differences in the relationship between alcohol/pregnancy policies and birth outcomes and prenatal care utilization: A legal epidemiology study

OBJECTIVES

State policies regarding alcohol use during pregnancy (alcohol/pregnancy policies) have been in effect for more than 40 years. Previous research finds some policies increase adverse birth outcomes and decrease prenatal care utilization. This research examines whether effects of alcohol/pregnancy policies vary by race; the general hypothesis is that health benefits of policies are concentrated among White women and health harms of policies are concentrated among Black women.

METHODS

This study uses 1972-2015 Vital Statistics data and policy data from NIAAA's Alcohol Policy Information System and original legal research. The dataset includes more than 150 million singleton births. Outcomes are preterm birth (PTB), low birthweight (LBW), and prenatal care utilization. Logistic regression models include raceXpolicy interaction terms as main predictors, adjust for individual- and state-level controls, include fixed effects for state, year and state-specific time trends, and account for clustering by state.

RESULTS

The impact of alcohol/pregnancy policies varied by race for preterm birth, varied in a few cases for low birthweight, and generally did not vary for prenatal care utilization. The hypothesis regarding the direction of differential effects was not supported. Six policies had an adverse impact on PTB and/or LBW for White women. Findings differed for Black women; for Black women, four policies had a beneficial impact for PTB and one had an adverse impact for LBW.

CONCLUSIONS

The impact of alcohol/pregnancy policies on birth outcomes varies by race. Future research should explore why some policies appear to have opposite effects for White v. Black women.