Impact of policies on pregnant individuals using drugs: A narrative synthesis review of treatment, health care access, and outcomes

Abstract

Amid the opioid epidemic and racial disparities in maternal and child health, there is increasing interest from clinicians, patients, and policymakers in understanding how state policies impact pregnant individuals using drugs, particularly regarding healthcare access and outcomes. This narrative synthesis examines the types of policies affecting this population and their consequences on maternal and child health. Following PRISMA guidelines, we reviewed 408 studies, selecting 28 relevant articles to assess the prevalence and effects of punitive laws targeting pregnant individuals using drugs. The review reveals an increase in punitive policies over time, such as considering substance use as child abuse, mandatory reporting with positive toxicology tests, and cannabis-related regulations, including restrictions on breastfeeding. However, the findings are mixed regarding neonatal abstinence syndrome (NAS) and mandatory reporting. Some studies show a rise or decrease in NAS following punitive policy changes, while others suggest that such policy changes may lead to lower rates of provider reporting. The fear of being reported may discourage some pregnant individuals from seeking prenatal care due to increased stigma. Other studies report confusion about mandatory reporting procedures and providers’ concerns about damaging patient trust. Policies sanctioning incarceration of pregnant individuals using substances also increase out-of-state births, potentially endangering both mothers and infants. This study highlights the harmful, unintended consequences of various policies and discusses interventions and future research directions.

Introduction

The opioid epidemic and persistent racial inequities in maternal and child health outcomes have intensified the focus on the intersection of drug policy and healthcare access (Bridges, 2019; West et al., 2023). Overdose deaths, now a leading cause of pregnancy-associated mortality, have contributed to recent increases in maternal morbidity and mortality in the U.S., underscoring the urgency of addressing these intersecting crises (Han et al., 2024). For pregnant and postpartum individuals who use drugs, the impact of punitive state policies—such as child maltreatment laws, mandatory reporting laws, and the criminalization of prenatal drug use—on healthcare access and outcomes is of particular concern (Bruzelius et al., 2024; L. M. Madden et al., 2022; West et al., 2023). These laws generally fall into three categories: criminalizing policies that treat prenatal substance use as a prosecutable offense; mandated reporting laws that compel healthcare providers to notify child protective services; and civil child welfare policies that classify substance use during pregnancy as grounds for custody loss, even without criminal charges (NIAAA, 2009). The federal Child Abuse Prevention and Treatment Act (CAPTA) was enacted in 1974 and requires providers to notify the state of any substance-exposed newborns (Lloyd et al., 2019). CAPTA was amended in 2016 by the Comprehensive Addiction and Recovery Act (CARA) to include additional substances that potentially impact child development, to define the ‘plan of safe care’ (POSC) to include treatment for both infant and birthing parent, and to require that states oversee follow-up and data collection on substance-exposed newborns (Punch & Taylor, 2021). These federal efforts are intended to address the harms the opioid epidemic has had on families and young children. However, states vary in their policies and programs regarding how prenatal substance use is viewed and addressed. The clinical guidelines from the American College of Obstetricians and Gynecologists (ACOG) recommends for supportive, evidence-based care—including universal screening, brief intervention, referral to treatment, and medications for addiction—rather than punitive or mandatory reporting approaches (Committee on Obstetric Practice., 2017; Faherty et al., 2020; Gonzalez-Fiol & Fardelmann, 2024). While some states have programs that are aligned with the clinical guidelines, more than half of states define prenatal substance use as child abuse or neglect under child-welfare statutes and/or require prenatal substance use to be reported as suspected child abuse to child protective services (CPS) (McCourt et al., 2022; NIAAA, 2009). Unfortunately, even use of clinically recommended medications for opioid use disorder (MOUD) (Krans et al., 2021), such as methadone and buprenorphine, during pregnancy can lead to inappropriate referrals to child welfare agencies (Work et al., 2023).

These policies, intended to protect children and deter drug use during pregnancy, may inadvertently create barriers to accessing necessary healthcare services, increasing the adverse effects (e.g., overdoses) of prenatal substance use in perinatal populations, negatively impacting admissions to specialized substance use treatment programs for pregnant women, worsening perinatal outcomes, and further exacerbating health disparities (Atkins & Durrance, 2020; Faherty et al., 2020; Harp & Bunting, 2020; Hilliard et al., 2023; Tabatabaeepour et al., 2022).

Recent studies highlight those punitive measures can discourage pregnant individuals from seeking prenatal care or disclosing their substance use to healthcare providers due to fear of legal consequences and loss of child custody (Harp & Bunting, 2020; Oni et al., 2022; Stone, 2015; Toquinto et al., 2020; Wolfson et al., 2021; Woodruff et al., 2021). This reluctance can lead to inadequate prenatal care, poorer health outcomes for both the mother and the child (including adverse events, such as overdoses), and perpetuation of health inequities, particularly among marginalized racial and ethnic groups who are already disproportionately affected by the recent opioid crisis (Austin et al., 2022; King et al., 2024; Toquinto et al., 2020; Woodruff et al., 2021).

Despite adverse findings, policies concerning pregnant and postpartum individuals who use drugs have remained unchanged, with an increasing number of states adopting punitive measures. However, these punitive approaches have unintended consequences, especially amid the current opioid crisis (Bruzelius & Martins, 2022). Choi et al. (2021) revealed that in states with punitive policies targeting pregnant individuals who use drugs, the effectiveness of Medicaid expansion in facilitating access to medication for opioid use disorder was significantly reduced (Choi et al., 2021). While the opioid epidemic has received considerable attention in recent years, pregnant individuals may use a variety of substances, including alcohol, stimulants, cannabis, and tobacco, all of which can adversely affect pregnancy outcomes (Cook et al., 2017; Keegan et al., 2014; Minnes et al., 2011; Viteri et al., 2015). Among commercially insured pregnant women, Tabatabaeepour and colleagues (2022) found that punitive policies were associated with significant reductions in the proportion of pregnant females receiving psychosocial services for substance use disorder (SUD) and first-line opioid medication treatment (e.g., methadone), both of which are recommended by The ACOG as part of a pregnant individual’s opioid treatment plan, and that opioid overdoses increased by 45% in states with criminalizing policies only––the strongest type of punitive policy.

The challenges associated with substance use are further compounded by longstanding health inequities disproportionately impacting Black and Indigenous mothers and infants (Bradley et al., 2024; Edmonds, 2022; Schiff et al., 2024). Prior research has found these populations experience significantly higher rates of maternal mortality, preterm birth, and infant mortality compared to their White counterparts (Choi, Stein, et al., 2022; Choi et al., 2023; Habersham et al., 2024; Ragsdale et al., 2024). These disparities are driven by systemic factors such as structural racism, social determinants of health, and inequitable access to quality healthcare, rather than individual choices or behaviors alone (Crear-Perry et al., 2021; Jegede et al., 2024; Knight, 2020; Montalmant & Ettinger, 2024).

This manuscript examines the impact of state policies on healthcare access and outcomes for pregnant individuals using drugs. We explore the implementation of priority access laws alongside punitive measures and analyze their collective influence on the availability and quality of drug treatment services. Through this review, we aim to provide insights that inform policy decisions and promote equitable healthcare for pregnant individuals affected by substance use disorders.

Methods

Search strategy and selection criteria

We conducted a systematic search and screening process consistent with PRISMA guidelines to identify peer-reviewed studies examining perinatal substance use surveillance, toxicology testing, and related outcomes (Page et al., 2021). We conducted a comprehensive search of the following databases: PubMed, Scopus, and Web of Science. We additionally searched Google Scholar for grey literature. The search strategy included terms related to laws or policies, pregnancy, and drug use. Example keywords include criminalization laws, mandated reporting policies, pregnancy, pregnant women, drug, substance use disorder, addiction, and substances. The example search query is provided in Supplemental Material 1. Our review includes studies published through December 2023, which reflects the timeframe during which the literature search and analysis were conducted. Studies published after this period were not included due to the timeline of data synthesis and manuscript preparation.

Studies were included if they met the following inclusion criteria: (i) studies published in English; (ii) studies examining laws and policies that target pregnant individuals using drugs; (iii) studies reporting on the prevalence and/or impact of these laws; (iv) peer-reviewed articles or reports; and (v) studies based in the United States. The exclusion criteria include: (i) reviews or non-original articles; (ii) studies not focused on policies or laws related to pregnant individuals who use drugs. The PRISMA flowchart, showing the number of studies included at each phase, is provided in Supplemental Material 2.

Of the 409 studies screened by title and abstract, 372 were excluded for not meeting inclusion criteria—primarily due to lack of relevance. The remaining 28 studies were included for analysis to examine variation in policies and their impact on pregnant individuals who use drugs. At least two reviewers reviewed each abstract. Any discrepancies during the screening phase were resolved by a third author. The coding team consisted of individuals with PhD and MS degrees, with interdisciplinary expertise in addiction health services research, social work, anthropology, and sociology. All team members had prior training in qualitative research methods and participated in additional study-specific training on coding procedures. Coding was conducted under supervision to ensure consistency and analytic rigor throughout the process.

Data extraction and analysis: narrative synthesis

Thematic analysis is a qualitative research method used to identify, analyze, and report patterns, or themes, within data. It is particularly useful in synthesizing qualitative data for systematic reviews, allowing for a deeper understanding of the subject matter by highlighting recurring themes across multiple studies (Thomas & Harden, 2008). For this review, initially, researchers familiarized themselves with the data by thoroughly reading all the included studies and noting initial ideas, including the policies well-known to impact individuals who use substances during pregnancy. Data from included studies were extracted into a structured template capturing study design, population characteristics, policy context, and key findings. We then applied a narrative synthesis approach to analyze and integrate findings across heterogeneous study designs (Popay et al., 2006). We conducted a thematic analysis using an iterative, team-based approach. We coded the data to identify themes, patterns, and key features across the dataset, such as variations in policies and studied outcomes, to organize the data into meaningful categories. We collated similar codes into potential themes, including how different policies influence health and service outcomes, and developed an initial thematic map to visualize the direction of the findings. To describe patterns of association, we classified study findings as showing beneficial, adverse, or mixed impacts. This mapping process helped refine our understanding of how themes fit together and guided further analysis. The team reviewed and refined the analysis to ensure they accurately reflect the coded data and the overall dataset, ensuring validity. Then, we drafted the analytic narrative and data extracts, contextualizing the analysis in relation to existing literature.

Results

Overview of included articles

Of 409 articles screened, 28 studies were selected for inclusion. Summary details are shown in Table 1. Most studies were published in 2022 (n=8) and 2023 (n=5), indicating increased research in this topic in recent years. There were also several older studies from the late 1990s and early 2000s. 23 studies have been published after the implementation of CARA in 2016. The most commonly used datasets were administrative datasets like vital records, claims data, child maltreatment reports, and the NCANDS Child Files. A few studies also utilized legal databases, interviews, and medical records. The studies examined diverse populations and units of analysis to investigate the impacts of prenatal substance use policies. The units of analysis included state-years, rates (e.g., neonatal abstinence syndrome, child maltreatment reports per 1,000 infants), and cases or individuals (e.g., infants, person-infant pairs). A few studies also reported on surveys of key stakeholders like physicians and CPS directors to understand policy implementation and frontline experiences. Additionally, some qualitative studies conducted interviews with individuals impacted by the policies, such as pregnant women with OUD, to explore their perspectives and lived experiences. Only one study reported on hospital-level policies, and no studies examined local government–level regulations (Gross et al., 2022).

Table 1.

Summary of Individual Studies

Title	Last name of first author	Publication Year	Policy variables of interest
Perinatal substance abuse: the impact of reporting infants to child protective services (MacMahon, 1997)	MacMahon	1997	• Interpreting a positive drug test as prima facie evidence of child endangerment, leading to allegations of child neglect against the mother and interruption of maternal custody
National survey of the states: policies and practices regarding drug-using pregnant women Chavkin, Breitbart, et al. (1998)	Chavkin	1998	• Maternal toxicology defined as abuse/neglect by law vs. agency • Neonatal toxicology defined as abuse/neglect • Mandatory drug or alcohol testing of pregnant women vs. neonates • Mandatory reporting of positive toxicology • Mandatory reporting of positive toxicology for neonatesPractice of reporting toxicology • Mandatory treatment for pregnant women vs. women with children
Identifying substance abusing delivering women: consequences for child maltreatment reports (Albert et al., 2000)	Albert	2000	• California SB2669: identification of substance abusing delivering women
The effect of legal and hospital policies on physician response to prenatal substance exposure (Mendez et al., 2003)	Mendez	2003	• Legislation or Case Law on PSE • Child Abuse Mandates • Toxicology Screens
Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome (Faherty et al., 2019)	Faherty	2019	• Punitive policies: Policies by which substance use during pregnancy is criminalized, considered grounds for civil commitment, or considered child abuse or neglect • Reporting policies: Policies that mandate the reporting of suspected prenatal substance use to relevant authorities
Evaluation of State-Mandated Reporting of Neonatal Abstinence Syndrome — Six States, 2013–2017 (Jilani, 2019)	Jilani	2019	• Statutes and regulations that explicitly name “neonatal abstinence syndrome” in states’ disease and conditions reporting laws
Substance use disorder treatment admissions and state-level prenatal substance use policies: Evidence from a national treatment database (Kozhimannil et al., 2019)	Kozhimannil	2019	• Punitive policies • Reporting policies • Prenatal substance use related policies (n=8) were created into a composite score
State policies targeting alcohol use during pregnancy and alcohol use among pregnant women 1985–2016: evidence from the Behavioral Risk Factor Surveillance System (Roberts et al., 2019)	Roberts	2019	• Punitive policies include Civil Commitment; Child Protective Services Reporting Requirements; and Child Abuse/ Neglect • Supportive policies include Mandatory Warning Signs; Priority Substance Abuse Treatment; Reporting Requirements for Data and Treatment Purposes; and Prohibitions on Criminal Prosecution
State Policies That Treat Prenatal Substance Use As Child Abuse Or Neglect Fail To Achieve Their Intended Goals (Atkins & Durrance, 2020)	Atkins	2020	• Policies that treat prenatal substance use as child abuse or neglect
Association Between State-Level Criminal Justice–Focused Prenatal Substance Use Policies in the US and Substance Use–Related Foster Care Admissions and Family Reunification (Sanmartin et al., 2020)	Sanmartin	2020	• Policies criminalizing prenatal substance use • Policies considering prenatal substance use as child abuse under child welfare laws
Estimating the impact on initiating medications for opioid use disorder of state policies expanding Medicaid and prohibiting substance use during pregnancy (Choi et al., 2021)	Choi	2021	• Policies considering prenatal substance use as child abuse under child welfare laws
Association of state child abuse policies and mandated reporting policies with prenatal and postpartum care among women who engaged in substance use during pregnancy (Austin et al., 2022)	Austin	2022	• A child abuse policy only • Mandated reporting policy only • Both policies
Association between U.S. state prenatal drug use laws and child welfare reporting in Alabama, Maryland and Utah (Bandara et al., 2022)	Bandara	2022	• Utah’s 2012 maltreatment law • Alabama’s 2013 simultaneous maltreatment law and criminalization law • Maryland’s 2014 reporting law
Association between punitive policies and neonatal abstinence syndrome among Medicaid-insured infants in complex policy environments (Faherty et al., 2022)	Faherty	2022	• Punitive: Substance use in pregnancy is criminalized, considered grounds for civil commitment, or considered child abuse or neglect • Testing: Policies requiring health care providers to test pregnant women with suspected prenatal substance use • Reporting: Mandated reporting of suspected prenatal substance use to authorities • Targeted programs: Policies requiring states to offer targeted treatment programs for pregnant and postpartum women • Priority access: Policies requiring priority access to SUD treatment for pregnant women • Prohibiting discrimination: Policies prohibiting publicly-funded treatment programs from discriminating against pregnant patients
Patient caught breastfeeding and instructed to stop: an empirical ethics study on marijuana and lactation (Gross et al., 2022)	Gross	2022	• Hospital policy on prenatal cannabis use during breastfeeding
Evaluation of State-Led Surveillance of Neonatal Abstinence Syndrome - Six U.S. States, 2018–2021 (Jilani et al., 2022)	Jilani	2022	• Laws mandating NAS case reporting that explicitly named “neonatal abstinence syndrome” in disease and conditions reporting laws
Prenatal substance use policies and infant maltreatment reports (Maclean et al., 2022)	Maclean	2022	• Punitive: Substance use in pregnancy is criminalized, considered grounds for civil commitment, or considered child abuse or neglect • Testing: Policies requiring health care providers to test pregnant women with suspected prenatal substance use • Reporting: Mandated reporting of suspected prenatal substance use to authorities
Pregnant women and opioid use disorder: examining the legal landscape for controlling women's reproductive health (L. M. Madden et al., 2022)	Madden	2022	• Child abuse grounds for civil commitment • Reporting • Testing
Prenatal substance use policies and newborn health (Meinhofer et al., 2022)	Meinhofer	2022	• Stronger prenatal substance use policies encompass punitive policies that may criminalize prenatal substance use, while priority treatment policies prioritize access to treatment for pregnant women with substance use disorders
Relationship between mandatory warning signs for cannabis use during pregnancy policies and birth outcomes in the Western United States (Roberts et al., 2022)	Roberts	2022	• Mandatory Warning Signs for cannabis during pregnancy (MWS-cannabis)
Impact of prenatal substance use policies on commercially insured pregnant females with opioid use disorder (Tabatabaeepour et al., 2022)	Tabatabaeepour	2022	• Punitive prenatal substance use policies including criminalizing prenatal substance use or defining it as child maltreatment
Implementation of State Laws Giving Pregnant People Priority Access to Drug Treatment Programs in the Context of Coexisting Punitive Laws (White et al., 2023)	White	2023	• Child Maltreatment Laws: These laws classify prenatal drug use as child maltreatment • Mandatory Reporting Laws: These laws require healthcare providers to report diagnosed or suspected prenatal drug use to Child Protective Services (CPS) • Criminalization Laws: These laws criminalize prenatal drug use
The Implementation of the Tennessee Fetal Assault Law and Its Association With Out-of-State Births Among Residents of Tennessee (Choi et al., 2023)	Choi	2023	• Tennessee Fetal Assault Law (TFAL) implementation in April 29th 2014 to Jun 30 2016
Three-Year Custody Outcomes Among Infants Investigated by Child Protection Systems for Prenatal Substance Exposure in California (Reddy et al., 2023)	Reddy	2023	• California policies documenting alleged maltreatment
Association of Pregnancy-Specific Alcohol Policies With Infant Morbidities and Maltreatment (Roberts et al., 2023)	Roberts	2023	9 state-level pregnancy policy variables • Reporting Requirements for CPS • Reporting Requirements for Assessment/Treatment • Reporting Requirements for Data • Mandatory Warning Signs • Child Abuse/Neglect • Limits on Criminal Prosecution • Civil Commitment • Priority Treatment for Pregnant Women Only Priority Treatment for Pregnant Women and Women with Children)
An Implementation Evaluation of the Comprehensive Addiction Recovery Act (CARA) Policy in New Mexico (Sharp et al., 2023)	Sharp	2023	• CARA, passed in 2016 federally. In New Mexico, it was passed in 2019 and includes the following provisions: (1) require a hospital social worker or nurse to create the plan of safe care with the family after an infant is born and before discharge, for all newborns with a substance exposure (both illicit and non-illicit); (2) send the plans of safe care to New Mexico Children, Youth and Families Department and the New Mexico Department of Health; (3) require managed care organizations (MCOs)— or Children’s Medical Services for uninsured families— to provide care coordination for families with a plan of safe care; and (4) ensure that substance use in pregnancy should not, by itself, be considered a reason for a mandatory child abuse report.
Substance Use-Associated Infant Maltreatment Report Rates in the Context of Complex Prenatal Substance Use Policy Environments (Stritzel, 2023)	Stritzel	2023	• Punitive Policies:  o Defining substance use during pregnancy as child abuse under civil child welfare statutes  o Requiring healthcare professionals to report suspected substance use during pregnancy  o Requiring healthcare professionals to test for suspected prenatal drug exposure • Supportive/Access-Promoting Policies:  o Creating drug treatment programs specifically targeted to pregnant individuals  o Protecting pregnant individuals from discrimination in state-funded drug treatment programs  o Providing priority access to drug treatment programs for pregnant individuals
Prescribed and Penalized: The Detrimental Impact of Mandated Reporting for Prenatal Utilization of Medication for Opioid Use Disorder (Work et al., 2023)	Work	2023	• Mandated reporting requirements

Quantitative study findings

The studies covered a wide range of outcomes related to substance use treatment access, child welfare involvement, birth and infant health, maternal health, ongoing substance use, and policy implementation experiences (n= 23). The quantitative results show mixed findings in terms of the impact of policies on neonatal abstinence syndrome (NAS) and reporting outcomes (Table 2). While some studies suggest an increase or decrease in NAS following punitive policy implementation (Faherty et al., 2022; Faherty et al., 2019; Meinhofer et al., 2022), more studies are needed to understand the mechanisms underlying how it affects the detection of NAS. Studies have reported that reduced mandated reporting by healthcare providers may be attributed to heightened stigma perception resulting from the laws (Work et al., 2023), provider distrust of child protective services, and confusion about reporting procedures (Albert et al., 2000; Mendez et al., 2003). Additional consequences of punitive policies include an increase in out-of-state births (Choi et al., 2023) and a decrease in the receipt of prenatal and postpartum care, deterring pregnant individuals from seeking substance use treatment during pregnancy (Austin et al., 2022). These policies include considering substance use as child abuse, mandated reporting with positive toxicology testing, incarcerating individuals during pregnancy, and cannabis-related regulations, including prohibiting breastfeeding when using cannabis (Table 3).

Table 2.

Example of outcome measures used in policy research

Outcome measures	Specific outcome measures	Policy measure	Findings
Healthcare utilization and treatment admissions	Proportion of pregnant admissions in the criminal justice system(Kozhimannil et al., 2019)	State policies on prenatal substance use	Positive association with policy implementation across treatment, criminal justice, and reporting, consistent across demographics
	Maternal narcotic exposure(Atkins & Durrance, 2020)	Policies treating prenatal substance use as abuse/neglect	No significant effect was found
	Substance use treatment admissions(Atkins & Durrance, 2020)	States prohibiting substance use during pregnancy	Reduced treatment admissions
	Medications for opioid use disorder(Choi et al., 2021; Tabatabaeepour et al., 2022)	States prohibiting substance use during pregnancy	Decrease in methadone (30%) services; Increase in MOUD use by 1.5% percentage points in states prohibiting substance use during pregnancy vs. use by 15.3% by year 2 in states not prohibiting after Medicaid expansion
	Opioid prescriptions(Tabatabaeepour et al., 2022)	Policies funding targeted SUD treatment for pregnant women vs. punitive policies	No significant effect was found
	Opioid overdoses(Tabatabaeepour et al., 2022)	Tennessee Fetal Assault Law	Increase in opioid overdoses by 45%
	Prenatal care utilization(Meinhofer et al., 2022)	"stronger" punitive prenatal substance use policy, prenatal substance use is treated more severely	Decrease in the number of women seeking prenatal care in the state each year (n=270).
Birth outcomes	Birthweight (low)(Meinhofer et al., 2022; Roberts et al., 2022)	Punitive prenatal substance use policy	No significant effect was found
	Gestation (Meinhofer et al., 2022; Roberts et al., 2022)	Punitive prenatal substance use policy	No significant effect was found
	Preterm birth (Roberts et al., 2022)	Mandatory Warning Signs for cannabis during pregnancy	Increase in preterm birth
	Neonatal Abstinence Syndrome(Atkins & Durrance, 2020; Faherty et al., 2019; Jilani, 2019; Meinhofer et al., 2022)	Punitive prenatal substance use policy	No significant effect was found short or long term (2 studies); Increase neonatal abstinence syndrome
Child maltreatment and welfare	Rate of infant maltreatment reports(Maclean et al., 2022)	Punitive prenatal substance use policy	Increase in substantiated infant maltreatment reports by 19 percent
	Substantiated reports with mother as alleged perpetrator(Maclean et al., 2022)	Punitive prenatal substance use policy	Increase in substantiated reports in which the mother is the perpetrator by 38 percent
	Infant foster care entry(Maclean et al., 2022)	Punitive prenatal substance use policy	Increase in infant foster care entry rates by 19–22 percent and infant foster care entries for parental substance use or neglect by 22–27 percent
	Child removal in first year of life with drug use as causal contributor(L. M. Madden et al., 2022)	Punitive prenatal substance use policy including testing	Increase in child removals due to neonatal opioid withdrawal syndrome with the growth in OUD
Substance use	Alcohol use (including binge drinking)(Roberts et al., 2019)	Supportive and punitive policy environments	Increase in odds of any alcohol use during pregnancy, but not with binge or heavy drinking
Stakeholder response and practices	Clinician reaction to prenatal substance exposure(Mendez et al., 2003)	Punitive prenatal substance use policy including testing	Physicians are inclined to act in response to suspected prenatal substance use in some manner, regardless of their policy environment, and their actions are fairly evenly distributed between punitive and patient-centered approaches
	CPS directors reporting prenatal substance reporting procedures (Chavkin, Breitbart, et al., 1998)	Prenatal substance reporting procedures	Increase in services for pregnant women, women with children, and those who are HIV positive, with some programs prioritizing these groups over others like prisoners. increase in local control accompanied by reductions in local funding for substance use and child protective services
	Plans of safe care reporting(Sharp et al., 2023)	CARA (requiring plan of safe care, managed care to provide care coordination, and ensure that substance use during pregnancy by itself is not considered a mandatory report	Providers and birthing facilities are not consistently reporting infants exposed to substances in-utero; 40% of newborns with Medicaid and an ICD-10 code for substance exposure do not have a plan of safe care

Table 3.

Example policies studied and example states

Policies, laws, practices involving prenatal substance use	Description	States
Criminalization Laws (e.g., Tennessee Fetal Assault Law (TFAL)) (Atkins & Durrance, 2020; Choi et al., 2023; Faherty et al., 2022; Meinhofer et al., 2022; Roberts et al., 2019; Roberts et al., 2023; Sanmartin et al., 2020; Tabatabaeepour et al., 2022; White et al., 2023)	State level policy that criminalizes prenatal substance use, treating it as a punishable offense, often resulting in legal consequences such as incarceration or termination of parental rights.	TN, AL
Child Abuse Prevention and Treatment Act (CAPTA) (Choi et al., 2021; Mendez et al., 2003; Roberts et al., 2023; Sanmartin et al., 2020; White et al., 2023)	Federal law that mandates states to adopt various child abuse policies and procedures to be eligible for federal funding	All
Child Maltreatment Laws (Albert et al., 2000; Atkins & Durrance, 2020; Chavkin, Wise, & Elman, 1998; Faherty et al., 2019; Kozhimannil et al., 2019; Maclean et al., 2022; MacMahon, 1997; L. M. Madden et al., 2022; Reddy et al., 2023; Sanmartin et al., 2020; Stritzel, 2023; White et al., 2023)	State-level policies that classify prenatal substance use as child abuse and/or maltreatment, potentially leading to legal interventions and protective measures for the child.	AL, AZ, AR, CO, DC, FL, IL, IN, IA, KY, LA, MN, MO, NV, ND, OH, RI, SC, SD, TX, UT, VA, WA, WI (2023) (Lynn M Madden et al., 2022; NIAAA, 2009)
Mandatory Reporting Laws (Austin et al., 2022; Bandara et al., 2022; Chavkin, Wise, & Elman, 1998; Faherty et al., 2022; Maclean et al., 2022; L. M. Madden et al., 2022; Roberts et al., 2023; Stritzel, 2023)	State-level policies requiring healthcare providers to report diagnosed or suspected prenatal substance use to Child Protective Services (CPS)	AK, AZ, AR, CA, CT, DE, GA, IN, IA, KS, LA, ME, MD, MA, MI, MO, MT, NV, NJ, OK, RI, SD, UT, VA, WI (2024) (NIAAA, 2009)
Requiring health care providers to test pregnant women who use substances (Maclean et al., 2022; L. M. Madden et al., 2022; Stritzel, 2023)	State-level policies requiring healthcare providers to test for prenatal substance use	IN, IA, KY, LA, MN, ND, RI, SD (2023) (Lynn M Madden et al., 2022; NIAAA, 2009)
Mandatory Warning Signs (Roberts et al., 2019; Roberts et al., 2022)	State level policies requiring point-of-sale warnings (e.g., cannabis, alcohol) during pregnancy, aiming to inform and potentially deter substance use among pregnant individuals.	AZ, CO, OR, WA (2024) (NIAAA, 2009)
CARA-related policies regarding plans of safe care reporting (Sharp et al., 2023)	Federal policy that mandates the development and implementation of plans of safe care for infants exposed to substances prenatally, ensuring appropriate follow-up care and support for both the infant and the family.	All
State-Mandated Reporting of Neonatal Abstinence Syndrome (NAS) (Jilani, 2019)	State level policies mandating neonatal abstinence NAS case reporting	AZ, FL, GA, KY, TN, VA
Hospital policy on prenatal substance use (cannabis) use during breastfeeding (Gross et al., 2022)	Hospital level policy that prompts clinicians to discourage or prohibit breastfeeding for those whose cannabis use was detected in pregnancy	N/A

Footnote: We include example policies and states examined in the reviewed studies. States are listed as described in each paper; when not specified, we identified policy coverage based on available sources. Policy updates and state-level variations can be found in the National Institute on Alcohol Abuse and Alcoholism (NIAAA) Alcohol Policy Information System (APIS) <https://alcoholpolicy.niaaa.nih.gov>. Although these policies may evolve over time, the information presented here reflects the most recent updates available at the time of writing.

Qualitative study findings

Eight of the studies incorporated qualitative methods into their methodology. Six of these studies included semi-structured interviews (Bandara et al., 2022; Chavkin, Breitbart, et al., 1998; Jilani, 2019, 2022; White et al., 2023; Work et al., 2023), and two studies included content analysis of existing documentation (medical records and meeting reports) (Gross et al., 2022; Sharp et al., 2023). Five of these studies included quantitative methodology as well, specifically, survey data and existing administrative datasets. Only one of the studies that included interviews had people with lived experience (recent history of pregnancy and SUD) as interview participants; the other studies focused on people in leadership roles in the areas of healthcare services, SUD treatment, CPS, law enforcement, advocacy, and state-level policy. In terms of the policy recommendations made by the articles’ authors, two papers recommended increased funding and restructuring of SUD treatment services and additional relevant services needed by the target population. Four papers called for more standardized definitions, procedures, and guidelines related to substance use in the perinatal population.

Qualitative studies reported that lack of dedicated resources was a consistent barrier to policy implementation, especially in rural areas, that hindered implementation of supportive policies like CARA and priority access laws (Sharp et al., 2023; White et al., 2023). White and colleagues (2023) also mentioned that most priority access laws were unfunded mandates, limiting their impact. Across states, policies such as mandated reporting of prenatal substance exposure (Bandara et al., 2022; Work et al., 2023) and NAS surveillance (Jilani, 2019, 2022) have been introduced with the intent of improving child health outcomes. However, punitive laws—such as criminalization statutes or child maltreatment designations for drug use in pregnancy—frequently conflict with more treatment-oriented policies like priority access to care (White et al., 2023). This misalignment undermines policy effectiveness, as fear of CPS deters many pregnant individuals from seeking care (Sharp et al., 2023; Work et al., 2023). Moreover, limited or nonexistent dedicated funding for implementing supportive policies such as Plans of Safe Care has further constrained the reach of well-intentioned reforms (Sharp et al., 2023).

Thematic findings

Historical context

Among the earlier studies (n = 8; published late 1990s–2015), the focus was on punitive, detection-oriented state laws, such as fetal assault statutes, mandatory reporting requirements, and defining prenatal drug exposure as child abuse. These studies provide historical context for current reforms, illustrating the development of enforcement patterns, provider attitudes, and disparities in reporting practices.

Post-CARA publications

Among the studies included in our review, 18 publications encompassed data that overlapped with the year of CARA implementation, 2016. However, two of these studies only included data up to 2016, making it difficult to assess the immediate impact of the policy. Only one study directly analyzed the effects of CARA (Sharp et al., 2023), while three additional studies included data collected only after 2016, providing limited insight into post-CARA trends (Austin et al., 2022; Gross et al., 2022; Reddy et al., 2023).

Structural barriers

At the organizational level, healthcare and child welfare systems face substantial structural and operational challenges in implementing these policies. Providers often work within fragmented systems lacking training, guidance, or infrastructure to effectively and consistently respond to substance use during pregnancy. Reporting systems vary by state, are frequently unclear, and impose administrative burdens on already stretched providers (Bandara et al., 2022; Jilani, 2019, 2022). Organizational policies sometimes reinforce punitive responses, as seen in hospital documentation that uses stigmatizing language or restricts breastfeeding based on marijuana exposure (Gross et al., 2022). While some innovations, such as co-located prenatal care and substance use treatment or expanded family-centered care beds, show promise (White et al., 2023), they are often insufficient to meet population needs and unevenly distributed across geography, particularly in rural areas (Sharp et al., 2023).

Stigma and trust

Papers consistently revealed that people who use substances during pregnancy face stigma, fear, and conflicting information that impact both their health behaviors and engagement with care. Many perceive mandated CPS reporting as unjust and discriminatory, especially when it includes clinician-prescribed medications like MOUD (Work et al., 2023). Anticipation of surveillance contributes to stress, deters disclosure, and can disrupt family well-being (Sharp et al., 2023; Work et al., 2023). Conflicting messages between healthcare providers and CPS further complicate treatment decisions, leaving individuals caught between medical advice and fear of legal consequences. These experiences are compounded for marginalized populations who already face disproportionate scrutiny in healthcare and child welfare systems, highlighting how structural and interpersonal stigma converge to undermine trust and access to care (Gross et al., 2022; White et al., 2023).

Racial disparities

Only a few studies examined the impact of these polices on racial disparities, explicitly. First, one study found that after Tennessee’s fetal assault law was implemented, more non-Hispanic Black and uninsured residents gave birth out of state (Choi et al., 2023). Another paper showed that non-Hispanic White children had higher parental reunification rates than non-Hispanic Black children, but both groups had lower reunification rates in states with criminal justice–focused prenatal substance use policies (Sanmartin et al., 2020). Other studies highlighted potential associations between the legal context of the states and racial/ethnic demographic patterns. For example, states with child abuse or mandated reporting policies had higher rates of births to non-Hispanic Black women, suggesting these policies may worsen racial disparities in maternal care, SUD treatment, and child welfare involvement (Austin et al., 2022). A similar study found that states with more prohibitive policies toward treating pregnant clients with opioid use disorder had higher proportions of Black pregnant women compared to less restrictive states (Choi et al., 2021).

Discussion

This review highlights the evolving landscape of U.S. policies addressing prenatal substance use, from early punitive approaches to more recent reforms such as CARA. Most studies have focused on punitive policies and have shown that these policies often fail to improve health outcomes for pregnant patients and infants, and in many cases, are associated with harmful effects. Yet over time, the number of states implementing punitive policies against pregnant individuals who use substances has continued to increase. As of 2024, 28 states have policies that have legal significance for child abuse/neglect for prenatal substance use, and 42 states have mandatory reporting requirements for prenatal substance use (National Institute on Alcohol Abuse Alcoholism, 2013). Our findings reveal persistent tensions between criminalization and treatment-oriented strategies, ongoing racial and socioeconomic disparities, and substantial variability in policy implementation across states. While some progress has been made toward supportive, family-centered approaches, stigma and structural barriers continue to limit access to care and undermine maternal and infant health outcomes. In the following sections, we contextualize these findings historically, examine the harms of criminalization, explore barriers to care, and identify systemic and policy-level challenges that shape the experiences of pregnant individuals who use substances.

Historical context

As part of the “war on drugs” - era policing efforts, CAPTA was signed into law by Nixon over 50 years ago and has since contributed to increased family separations and involvement with child protective services, disproportionately impacting low-income families and communities of color (McCourt et al., 2022). These findings demonstrating racial disparities are non-trivial and are direct evidence supporting drug policy reform efforts. Disparities exist, with women of color and poor women more likely to be suspected of drug use and reported based on those suspicions (L. M. Madden et al., 2022; Roberts, 1990; Shetty et al., 2024; Stuntz, 1998). Hospitals, in particular, may under-report potential drug use by high- and middle-income white women and over-report or suspect and test low-income minority women (Azimi et al., 2025). Better mechanisms for communicating the state’s legal environment to physicians could enhance their understanding and response to legal requirements.

Recent amendments

The limited number of studies examining post-CARA periods highlights the need for further research to evaluate the policy’s impact on perinatal substance use practices and outcomes. This may be due to slow and uneven implementation of CAPTA and CARA provisions across states (Lloyd Sieger & Rebbe, 2020). Recent policy discussions reflect a growing focus on implementation fidelity, maternal treatment engagement, and the ongoing misalignment between federal guidance and state enforcement systems. Although the 2021 CAPTA reauthorization proposed additional funding, clearer guidance, and a public health–oriented approach, it has not been enacted (Sieger et al., 2021). Nevertheless, future evaluation of these proposed policy changes will be critical for understanding their potential to improve family outcomes, reduce unnecessary foster care placements, and advance equity in services for substance-exposed infants and their parents.

Although there have been efforts to implement “Plans of Safe Care”, which aim to provide comprehensive care and support to perinatal patients and their infants testing positive for substances, research has shown hesitancy among both providers and patients to enact them in practice (McCourt et al., 2022). Although Plans of Safe Care offer a potential shift away from prior notification methods that may have led to punitive outcomes, recent studies have highlighted ongoing implementation challenges. Providers and states often failed to offer adequate guidance, and policy implementation varied significantly by locality or was insufficient overall (McCourt et al., 2022).

Harms of criminalization

Consistent with prior research, our review highlights potential harms associated with a criminalization-focused approach to addressing prenatal substance use. This is similar to another review that has shown that punitive laws may discourage pregnant women from seeking treatment, resulting in fewer women engaging with services (Bruzelius et al., 2024). Given the mixed findings in the literature, our review suggests a need to reconsider automatic classification of prenatal substance use as child abuse or neglect, and to explore alternative, supportive approaches that prioritize maternal and infant health while minimizing unnecessary punitive involvement. On the one hand, these policies have created new reporting infrastructures, surveillance systems, and statutory mechanisms for data collection and service linkage (Jilani, 2019, 2022; Sharp et al., 2023). On the other, they have also produced confusion among providers, fostered mistrust between patients and institutions, and exacerbated stigma against pregnant and postpartum individuals who use substances (Bandara et al., 2022; Work et al., 2023).

Stigma and barriers to care

Fear among pregnant individuals who use drugs was a theme that resonated throughout these publications. Stigma against prenatal drug use and the use of medications for MOUD remains a significant barrier to care, operating at multiple levels and discouraging pregnant individuals from initiating and sustaining treatment. Women receiving MOUD during pregnancy often view mandatory reporting for prescribed medication treatment as unjust and deeply stigmatizing (Work et al., 2023). This stigma is reinforced by provider hesitancy to treat pregnant patients with OUD, particularly in U.S. regions hardest hit by the opioid epidemic—further exacerbating access barriers. More broadly, punitive state policies, which pregnant patients find both stigmatizing and threatening, have been found to discourage admissions to specialty SUD treatment among pregnant individuals, leading to worse perinatal health outcomes (Atkins & Durrance, 2020; Faherty et al., 2019; Kozhimannil et al., 2019; Tabatabaeepour et al., 2022). Despite policy reforms and growing emphasis on supportive, family-centered approaches, stigma and systemic barriers to care for pregnant and postpartum individuals who use substances persist, continuing to impede treatment engagement and equitable access to services (Huizinga et al., 2025).

Policy implementation and institutional challenges

At the organizational level, variability in implementation and institutional readiness plays a significant role in shaping how policies are experienced in practice. Many health departments and hospitals operate with limited infrastructure, especially in rural regions, and struggle to meet the demands of screening, reporting, treatment referral, and data management (Chavkin, Breitbart, et al., 1998; Sharp et al., 2023). Challenges such as unclear case definitions, insufficient training, and lack of care coordination contribute to inconsistent application of laws and increase provider burden (Bandara et al., 2022; Jilani, 2019). Restrictive hospital practices, such as withholding lactation support or restricting breastfeeding, compromise maternal autonomy and exacerbate power imbalances between birthing individuals and institutions (Gross et al., 2022). These practices often stem from mandatory toxicology screenings, which can automatically trigger child welfare investigations. When applied broadly and without context, these practices are harmful—particularly for marginalized groups—and may exacerbate racial disparities in health outcomes such as breastfeeding rates and infant well-being. Clinical decisions around testing and reporting should be based on an individual’s full medical context and informed consent, not driven by blanket policies that prioritize surveillance over care (Habersham et al., 2025). These policies exacerbate existing racial inequities, with a higher percentage of births to non-Hispanic Black women in states with specific child abuse policies (LaBrenz et al., 2023). Delayed or inconsistent prenatal and postpartum care among substance-using pregnant women is tied to the role of healthcare professionals as mandated reporters and caregivers' fears of losing infant custody (Choi, Rosenbloom, et al., 2022).

Federal funding and support gaps

The current allocation of federally-directed funds, such as those provided through CAPTA, raises important concerns about the priorities in how these funds are utilized. While CAPTA aims to address child welfare needs, a significant portion of its funding is often directed toward creating and maintaining surveillance systems rather than directly supporting services for children and families (Murray & Granger, 2023). While the study did not directly examine federal funding allocations, our findings highlight systemic gaps in support for vulnerable children and families. In light of these gaps, we suggest that shifting the focus of federal investments from surveillance-oriented approaches toward more supportive services, such as mental health care, housing assistance, and educational programs, could enhance the effectiveness of interventions and reduce the need for child welfare involvement (Osterling & Austin, 2008). Policy changes that promote a more equitable distribution of resources may help address root causes and improve long-term outcomes for families. To truly make a difference, more must be done to guarantee that federal funds are allocated to services and supports that foster long-term well-being rather than perpetuating systems of monitoring and control.

Treatment system limitations

Of equal concern, addiction treatment programs have not adapted to meet the evolving needs of pregnant individuals experiencing poverty (Haney, 2010; King et al., 2024). Reporting procedures often target MOUD, despite being clinician-prescribed, reflecting societal attitudes toward motherhood and substance use. Mandated reporting policies harm families by causing trauma through investigations of parental fitness and prioritizing child protection over maternal and family well-being. Fear of CPS involvement affects treatment decisions and access to care for pregnant individuals who use substances (Stone, 2015). MOUD treatment decisions should be uncoupled from CPS reporting to ensure safety and improve health outcomes for maternal-infant dyads.

Limitations

This review followed a systematic search consistent with PRISMA guidelines, but the synthesis used a narrative, thematic approach due to heterogeneity in study designs and outcomes. Although this review provides a summary of the literature and aggregate findings at a larger scale encompassing both quantitative and qualitative results, it is not without challenges; the analysis is subjective and relies heavily on the researchers’ interpretation, which can introduce bias. One potential limitation of this review is the risk of publication bias, as studies with statistically significant or novel findings are more likely to be published, potentially skewing the results. However, we did not find evidence that punitive policies have resulted in positive outcomes for pregnant women or infants. Another limitation of this study is the quality of evidence, particularly in terms of internal validity. The analysis may have a small sample size, which could affect the robustness of the findings, and measurement errors may influence the accuracy of the results. Additionally, external validity may be a concern, as the populations studied may not be fully generalizable or comparable to other groups. Many existing studies also fail to examine how “competing” policies interact with one another, such as how Medicaid expansion, harm reduction, and housing-first policies might moderate the effects of more punitive policies. This lack of consideration for policy interactions may limit the broader applicability and understanding of the results. We included articles published prior to the CARA to capture the full scope of policy evolution affecting pregnant individuals who use drugs. While some findings reflect policies that have since changed, including earlier studies allows for a comparison of policy impacts over time. The limited number of studies examining post-CARA periods underscores the need for further research to evaluate the policy’s impact on perinatal substance use practices and outcomes. Another limitation is the lack of clear definitions for laws and policies, which complicates measurement and comparison. Recent studies have noted the methodological challenges this poses for policy research (Barsky et al., 2025). Additionally, this review focused primarily on legal factors, which may not fully capture the broader social determinants that influence outcomes for pregnant individuals using drugs, such as socioeconomic status, access to healthcare, and social support systems. We may not be able to capture the full heterogeneity of these co-varying factors across states (Aleksanyan et al., 2025). A key limitation is the difficulty of observing variation in policy enforcement. Research shows that enforcement often disproportionately harms people of color and those from low socioeconomic backgrounds, highlighting the need to interpret policy impacts through an equity lens (Brownson et al., 2021; Gilson et al., 2006). These unexamined factors could contribute to a more nuanced understanding of the issue and should be considered in future research. Finally, while our analysis did not specifically examine the influence of the current administration on federal funding allocation, recent policy shifts may impact priorities and resource distribution. Future studies should explore how such changes affect service delivery and outcomes for pregnant individuals affected by substance use.

Conclusion

Punitive policies targeting prenatal substance use persist despite evidence showing limited benefits and considerable harms. These policies exacerbate stigma, create barriers to care, and contribute to racial and socioeconomic inequities, while supportive interventions remain unevenly implemented. Addressing challenges in tailoring de-implementation strategies to specific contexts is strongly advised. Substance use during pregnancy should not automatically be defined as child abuse or trigger maltreatment reporting without evidence of actual child abuse or neglect. We suggest future research to focus on understanding within-state differences, as many local entities are involved in the decision-making processes after CPS is involved. Clinicians should focus on service delivery rather than surveillance for CPS, providing concrete assistance and supportive interventions for families affected by SUD. Future studies should focus on local contexts, as local policies significantly impact outcomes yet are often overlooked. We propose a transparent, inclusive, and socially informed policy approach centered on harm reduction, engaging interdisciplinary experts and community members, especially marginalized groups and frontline providers, in interpreting evidence and shaping care for individuals who use substances during pregnancy (Ezell et al., 2024). This approach can improve scientific integrity and social trust, leading to more equitable and effective health guidance.

Clinical Impact Statement.

Punitive policies targeting pregnant individuals using drugs may worsen healthcare access, increase stigma, and compromise maternal and child health. This review highlights their unintended consequences, including inconsistent effects on neonatal abstinence syndrome and reduced healthcare engagement due to provider distrust. Policies permitting incarceration also drive out-of-state births, posing additional risks. Findings underscore the need for supportive, evidence-based approaches that prioritize care over punishment to improve maternal and infant outcomes.

Positionality statement:

Mindful that our identities can influence our approach to science (Roberts, et al. 2020), the authors wish to provide the reader with information about our backgrounds. With respect to gender, when the manuscript was drafted, five authors self-identified as women and one authors as men. With respect to race, three authors self-identified as white, one as Black, and two as East Asian.