Association of State Child Abuse Policies and Mandated Reporting Policies With Prenatal and Postpartum Care Among Women Who Engaged in Substance Use During Pregnancy

Abstract

Importance: Some states have implemented policies that consider substance use during pregnancy as child abuse and require mandated reporting of substance use during pregnancy. Implications of these policies for health care receipt among pregnant people who engage in substance use are unknown.

Objective: To examine the association of state child abuse policies and mandated reporting policies with prenatal and postpartum care among women who engaged in substance use during pregnancy.

Design, setting, and participants: In this cross-sectional study, data from the 2016-2019 Pregnancy Risk Assessment Monitoring System survey were analyzed. The study population included 4155 women from 23 states who reported substance use during pregnancy. Data were analyzed between August and November 2021.

Exposures: Delivery in a state with a child abuse policy only (n = 6), a mandated reporting policy only (n = 4), both policies (n = 7), or neither policy (n = 5). One state switched from a mandated reporting policy only to having both policies.

Main outcomes and measures: Month of gestation at prenatal care initiation (ie, months 1-10, with a higher number of months indicating later initiation), receipt of adequate prenatal care, and receipt of a postpartum health care visit 4 to 6 weeks after delivery. Sample characteristics were calculated using unweighted frequencies and weighted percentages and means. Associations of state policies with the outcomes were examined using generalized linear regression with generalized estimating equations, adjusting for potential confounders and accounting for the complex sampling design of the Pregnancy Risk Assessment Monitoring System survey.

Results: The study sample included 4155 women who reported substance use during pregnancy; 33.9% of these women delivered in states with a child abuse policy only, 16.4% in states with a mandated reporting policy only, 32.9% in states with both policies, and 16.8% in states with neither policy. Overall, 14.7% of women were Black, 69.0% were White, and 64.6% were aged 18 to 29 years at delivery. Women who delivered in states with a child abuse policy only, mandated reporting policy only, or both policies initiated prenatal care at a later month of gestation (β = 0.44 [95% CI, 0.10-0.78], 0.32 [95% CI, 0.04-0.59], and 0.40 [95% CI, 0.09-0.72], respectively) and had a lower likelihood of adequate prenatal care (risk ratio, 0.85 [95% CI, 0.79-0.91], 0.94 [95% CI, 0.87-1.01], and 0.95 [95% CI, 0.89-1.03], respectively) and a postpartum health care visit (risk ratio, 0.89 [95% CI, 0.82-0.96], 0.89 [95% CI, 0.80-0.98], and 0.92 [95% CI, 0.83-1.02], respectively) compared with women who delivered in states with neither policy.

Conclusions and relevance: The results indicate that state child abuse policies and mandated reporting policies are associated with reduced receipt of prenatal and postpartum care among women who engage in substance use during pregnancy.

Figure 1.. Mean Difference in Month of Gestation at Prenatal Care Initiation by State Prenatal Substance Use Policies

^aAmong 4155 births to women who reported substance use during pregnancy. ^bAdjusted for maternal age, education, race and ethnicity, per capita household income, pregnancy intention, mental health prior to pregnancy, and experiences of violence prior to pregnancy and for state-level Presumptive Eligibility for Medicaid, Expanded Family Planning under Medicaid, Medicaid expansion, priority access to substance use disorder treatment for pregnant people, targeted substance use disorder treatment programs for pregnant people, medical marijuana legalization, and number of obstetricians/gynecologists per 100 000 female population.

Figure 2.. Risk Ratios (RRs) Comparing Adequacy of Prenatal Care by State Prenatal Substance Use Policies

^aAmong 4155 births to women who reported substance use during pregnancy. ^bRR, 0.85 (95% CI, 0.79-0.91). ^cRR, 0.94 (95% CI, 0.87-1.01). ^dRR, 0.95 (95% CI, 0.89-1.03). ^eAdjusted for maternal age, education, race and ethnicity, per capita household income, pregnancy intention, mental health prior to pregnancy, and experiences of violence prior to pregnancy and for state-level Presumptive Eligibility for Medicaid, Expanded Family Planning under Medicaid, Medicaid expansion, priority access to substance use disorder treatment for pregnant people, targeted substance use disorder treatment programs for pregnant people, medical marijuana legalization, and number of obstetricians/gynecologists per 100 000 female population.

Figure 3.. Risk Ratios (RRs) Comparing Receipt of a Postpartum Health Care Visit by State Prenatal Substance Use Policies

^aAmong 4155 births to women who reported substance use during pregnancy. ^bRR, 0.89 (95% CI, 0.82-0.96). ^cRR, 0.89 (95% CI, 0.80-0.98). ^dRR, 0.92 (95% CI, 0.83-1.02). ^eAdjusted for maternal age, education, race/ethnicity, per capita household income, pregnancy intention, mental health prior to pregnancy, and experiences of violence prior to pregnancy and state-level Presumptive Eligibility for Medicaid, Expanded Family Planning under Medicaid, Medicaid expansion, priority access to substance use disorder treatment for pregnant people, targeted substance use disorder treatment programs for pregnant people, medical marijuana legalization, and number of obstetricians/gynecologists per 100 000 female population.