Some hospitals are changing their response when babies are born exposed to drugs
Upon delivery, Puccio’s doctors were legally mandated to report her to the Massachusetts Department of Children and Families for child abuse and neglect because she was taking methadone, a medication prescribed by her doctor to aid in her recovery from an opioid use disorder.
Puccio had known this would happen. She had gotten prenatal care at a clinic that specialized in treating pregnant people with substance use disorders, and workers there had warned her about the reporting mandate in Massachusetts. Even so, she said, the emotional toll was immense.
Puccio says she barely slept for five days after delivery out of fear that officials would take her newborn away.
Puccio and her doctors had prepared a plan for safe care outlining that safe housing, formula, diapers, and other basic needs of the infant would be met at home, so the fight to keep custody of her child was relatively short. The Department of Children and Families closed the case against her in 90 days, but most others are not so lucky, she said.
Drug overdoses are one of the main causes of preventable death among pregnant and postpartum women in the United States. Overdose deaths among this population increased 81% between 2017 and 2020 — resulting in the deaths of more than 1,200 pregnant and postpartum women in 2020.
Yet limited resources and stigma prevent pregnant women who struggle with substance use from seeking or accessing care. Those who do seek care and start taking medications to assist their recovery are often reported to welfare services for child abuse and neglect under legal mandate.
But in some hospitals, the response is changing.
Massachusetts’ largest health care system announced last week that it will no longer report suspected abuse or neglect to state welfare officials simply because a baby is born exposed to drugs. Rather, a report will be triggered only if there is reasonable cause to believe that the infant is “suffering or at imminent risk of suffering physical or emotional injury.”
Multidisciplinary care teams who know the family well will meet to determine if there are any concerns about the child not having their basic physical needs met or emotional needs met. If there are concerns, a report to child welfare services will still be triggered. However, if those concerns are not present, then exposure to substances on its own will not trigger a report.
The system’s approach reflects a growing consensus that punitive approaches to substance use during pregnancy lead to worse medical outcomes for both parent and child and inflict disproportionate harm on families.
Change is afoot at many levels. Health systems have implemented new drug testing and reporting protocols like those Mass General Brigham announced last week. States have revised laws to divert substance-exposed infants who are not under threat of abuse or neglect away from the child welfare system. Others have legislation pending that would shield mothers who are taking prescribed medications to treat substance use disorder from child welfare investigations.
At the federal level, the Biden-Harris administration acknowledged that “having substance use disorder in pregnancy is not, by itself, child abuse or neglect” in a report published in 2022.
And a federal bill called the SAFE in Recovery Act seeks to require consent for toxicology screening of the mother and block states from requiring notification of child welfare officials if the mother is taking a drug in accordance with the recommendations of the prescribing practitioner and the health care provider has no other reason to suspect that the child is in imminent danger.
Substance use during pregnancy is linked to negative health outcomes for both the mother and the fetus, according to the US Centers for Disease Control and Prevention. And untreated substance use disorder is a risk factor for child maltreatment.
However, that does not mean substance use equals maltreatment. More than 21 million children in the United States live with a parent who misuses substances. Not all of those children experience abuse or neglect and need child welfare intervention.
The landscape of child abuse prevention laws and its interpretations varies significantly across states and hospital systems, experts say.
At the federal level, child abuse prevention laws passed in 1974 mandated that child welfare agencies receive notification when an infant was born affected by “illegal drugs”. The Comprehensive Addiction and Recovery Act removed the word “illegal” from the law in 2016 to mandate notification of authorities anytime a newborn is affected by “drugs”, legal or illegal.
This one-word change is why the law now applies to medication-assisted treatments, such as the methadone Puccio was taking. Theoretically, it could apply to any medication that a pregnant person is taking that affects the infant.
The federal children’s bureau has clarified that a “notification” of drug exposure is not the same as a “report” of child abuse and neglect. However, many states have passed their own laws that equate the two.
Although these policies desire to protect children, research shows that they achieve the opposite effect.
“In states where there are punitive policies, including mandated reporting, birthing people are less likely to access prenatal care, less likely to use medications for opioid use disorder, less likely to use psychotherapy services and less likely to really connect with any health care provider in pregnancy,” she said.
This leads to worse health outcomes for both the baby and the parent.
Medication-assisted treatments like methadone and Suboxone are safe and medically recommended to treat opioid use disorder during pregnancy, according to the American College of Obstetricians and Gynecologists.
In March, the federal Substance Abuse and Mental Health Services Administration issued an advisory about the safety of these treatments during pregnancy and breastfeeding. It also identified that one of the main barriers to seeking care, especially for people of color, is the fear of consequences in states with mandatory reporting.
When used appropriately, medication for opioid use disorder in pregnancy is associated with positive effects on the mom and the baby. Because the medications are opioids, the baby may demonstrate some withdrawal symptoms at birth, but best practices have been developed to manage those symptoms effectively.
In states where mandatory reporting practices are in place, parents like Puccio who take these medications are automatically reported for child abuse and neglect. Although not all of these reports lead to the removal of the infant from the parent’s care, the involvement of child welfare services is traumatizing in and of itself and can derail confidence in recovery.
The consequences of punitive policies toward substance use during pregnancy have been especially damaging for families of color and of low socioeconomic status. Inconsistencies in testing and reporting protocols lead to a lot of subjective decision-making that results in significant disparities in outcomes.
Research shows that Black and poor pregnant women are more likely to be screened for drug use during pregnancy and referred to child welfare services than White or wealthier pregnant women, even though women of all races use substances during pregnancy at similar rates. Black children are overrepresented in the child welfare system and Black parents whose infants were placed in foster care are less likely to be reunified with their child, according to a White House report.