Association for Public Policy Analysis & Management

During the mid-1980s, at the height of the American crack cocaine epidemic, states first introduced legislation to address the potential consequences of illegal drug use among pregnant women. For example, maternal cocaine use is associated with premature membrane rupture and placental abruption, which may lead to early gestation and poor infant health outcomes. By January 2000, 48 states and the District of Columbia had enacted prenatal substance abuse policies.

While most states prioritized non-punitive policies, such as targeted substance abuse treatment for pregnant women, other states amended civil child welfare laws to define drug use during pregnancy as child abuse. In addition, three states enacted civil commitment laws; between 1973 and 2005, more than 400 pregnant women were arrested or forced to receive medical treatment due to illegal drug use.

State legislatures continue to debate civil and criminal penalties for illegal drug use during pregnancy due to increasing trends in opioid use among pregnant women. In 2014, Tennessee became the first state to criminalize drug use during pregnancy. Although qualitative research suggests that punitive policies deter women from receiving medical care during pregnancy, very little is known about the impact of these punitive policies on birth outcomes and maternal health behaviors.

I use the variation in prenatal substance abuse policy implementation across states from 1985 to 2000 to study the impact of punitive policies on birth outcomes and on maternal health behaviors. I analyze birth certificate and infant death records from the National Vital Statistics System as well as substance abuse treatment admissions from the Treatment Episode Data Set. I estimate event study and difference-in-differences models, focusing on amendments to state civil child welfare laws, while controlling for potentially confounding characteristics.

I find robust evidence of negative effects of punitive prenatal substance abuse policies on birth weight, early gestation, and prenatal care use—especially among younger white mothers (aged 15-24) and older black mothers (aged 25-44). The results of this study have important implications for public policy responses to the growth in maternal opioid use and neonatal abstinence syndrome.