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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Podicy. I'm your host, Rob Lott. Untreated substance use disorder in pregnancy is a long standing and persistent public health concern. That's the first line of a new paper in the July issue of Health Affairs, and it spotlights a complicated question. What are our responsibilities as a society to the parties involved when it comes to untreated substance use disorder in pregnancy?
Rob Lott:One responsibility, of course, is to the pregnant person to help them get support and treatment they might need. One is to the future newborn to ensure they have a healthy and thriving parent and family that can provide the love and care they need. And one is to the caregivers, the doctors, the clinicians, and the policymakers to ensure that they have the guidance and tools they need to provide the care and treatment that's compassionate, just and righteous. Is it possible for public policy to honor all of those responsibilities and goals? That's the subject of today's health policy.
Rob Lott:I'm here with Doctor. Margaret Lloyd Seger, an associate professor at the University of Kansas School of Medicine in the Department of Population Health. She and her coauthors wrote the paper whose first line I just shared with you. It was just published in the July issue of Health Affairs, and its title is also one of its main findings. Connecticut's novel prenatal substance exposure policy is associated with declining CPS reports and foster placements.
Rob Lott:Doctor. Margaret Lloyd Seger, thank you so much for joining us.
Margaret Sieger:I'm so excited to be here.
Rob Lott:All right, let's just dive right in. Let's start with a little background. What do we currently know about substance use disorder during pregnancy? How widespread is it? And what sort of typically happens in a situation where that's the case?
Margaret Sieger:Yeah. Great question. It's a little bit tough to answer because we are occasionally talking about any substance use, and then other times we're talking about substance use disorder. So if we're talking about substance use, between five and fifteen percent of pregnant women use substances, including alcohol and cannabis at some point after learning that they're pregnant. Nationally, self reported use in pregnancy rose to a recent peak in 2022 to over nine percent of pregnant women self reporting substance use in pregnancy.
Margaret Sieger:Now we also know, however, that persisting in substance use in pregnancy can be an indication that there is a substance use disorder, and substance use disorders, including at higher severities, are more common among pregnant people who continue using substances versus the general population. But short answer is somewhere between five and fifteen percent. We did some earlier analyses of Connecticut's approach in order to essentially count the number of people who were using substances, and it was eight percent of births had substance exposure at some point in pregnancy.
Rob Lott:Okay. And you just mentioned that we sort of reached a peak during was it during COVID? And I'm curious, do you have a sense, is that an increase in self reporting or an increase in use or in sort of prevalence of the disorder? And are we able to extricate those two things from each other?
Margaret Sieger:Yeah. That is a really good question as well. So I think the answer is both. Substance use among everyone in The US increased secondary to COVID. The peak was actually in 2022 though, which is sort of a couple of years.
Margaret Sieger:It wasn't 2020. It wasn't the, you know, months when we were all in lockdown, and we did see substance use, including among women, including among women of childbearing age increase. But the most recent peak was in the last couple of years. I think cannabis legalization, I don't think there is evidence that cannabis legalization has an impact on use in pregnancy. I think that's related to changes in the perceptions of safety around legalization, safer both socially, but also physically safer.
Margaret Sieger:As something becomes legal, people assume it's safer to use. So I think it's both. We've seen more use because there have been changes in policy, but then also the effects of COVID on isolation, mental health, and people using substances to cope with those issues. However, we saw in 2023 a decline in the proportion of pregnant people using substances. These data all come from the National Survey on Drug Use and Health, which is a population based study using representative sampling approaches, but they only talk to between six and seven hundred pregnant people a year.
Margaret Sieger:So, you know, we are extrapolating based on a really small percentage of respondents.
Rob Lott:Got it. Understood. Okay. Against that backdrop, can you say a little bit about the roles and responsibilities historically of health care providers caring for pregnant women and newborns If and when they learn of a substance use disorder, what does the law say they have to do? What do our sort of ethics and our principles imply their various responsibilities might be?
Margaret Sieger:States policies dictate that. There is one federal policy that says anything about substance use in pregnancy, and it is CAPTA, the Child Abuse Prevention and Treatment Act, which in 2003 added language about prenatal substance exposure, which gave rise to the policy in Connecticut that we researched. But in terms of those immediate responses on whether you make a referral to child welfare or not is dictated by state policies. Taking it a little more granular, there are also hospitals that operate their own policies that are oftentimes more conservative than the state policy. But nonetheless, in over half of states, prenatal substance exposure, whether documented through toxicology, self report, there's variations in that as well.
Margaret Sieger:Also variations depending on the type of substance, whether there are co occurring safety concerns, those all come into play, but it's state policy that says something in, again, in over 50% of states, there is some type of mandate to report prenatal substance exposure. That's changed over time in that it has increased dramatically over time. So Massachusetts was the first state to have a mandated reporting policy. That happened totally independent of any federal policy in 1974. It was only a few states thereafter for a long time until the crack cocaine epidemic, quote, unquote, that increased to about a quarter of states, a little more until the early two thousands, jumped again, and then we saw another jump in 02/2016.
Margaret Sieger:Those last two are a reflection of changes in federal policy. In terms of sort of ethics of care, there are huge debates ranging from, you know, anecdotally, I've heard of judges incarcerating pregnant women for using substances as a, you know, dramatic and extreme effort to prevent the fetus from being exposed. Best practices now are about screening for substance use, so asking verbal questions to try and understand if there's substance use, doing some type of brief intervention and a referral to treatment when needed. So we definitely don't wanna stick our heads in the sand, and I think that's something that in reaction to really punitive approaches, some providers will just ignore the issue entirely. That also, I think, misses the mark because these are people who need help.
Margaret Sieger:And we you know, in order to provide that help, we have to know what's going on. So that's just my take, though.
Rob Lott:Sure. So I I it's a real tightrope, I think. Right? I'm imagining the folks who maybe wrote the initial Massachusetts law about mandatory reporting were thinking of the newborn and felt like if we know that there's this risky situation, the best thing is to make sure that we let the authorities know and let them intervene. But you also alluded to sort of punitive approaches and I think we know, have learned over the years that punitive approaches can backfire and actually make matters worse.
Rob Lott:And so I'm curious, what do we know sort of from the evidence about the consequences of something like mandatory reporting or something like CPS reporting? How does that typically affect outcomes, I guess would be the ultimate question. What are the downstream consequences of something like that?
Margaret Sieger:Yeah. That's a very insightful comment. And I agree. I think most of these policies were passed with good intentions of how do we help these families. And there have been a number of unintended consequences ranging from things that would seem very obvious, like a lot more referrals to child welfare, a lot more children brought into foster care, exacerbation of race disparities to the disadvantage of non Hispanic black families.
Margaret Sieger:But things that seem even less obvious, more unintended, less maternal use of prenatal care, less maternal access to substance use treatment in pregnancy, less access to medications for opioid use disorder in pregnancy, more overdose deaths in states that have really punitive policies. So the in broad strokes, the impact is that a very punitive environment results in mothers with untreated substance use disorders hiding from anyone who might be able to do anything about you know, you to use any of these punitive actions against them, and then they not only don't access prenatal care, but they don't access substance use treatment. So we have people coming to deliver infants in higher acuity states, higher acuity situations than might be the case if we used a more supportive approach throughout the pregnancy.
Rob Lott:Okay. Well, that's a great segue then for you perhaps to tell us a little bit about the policy in Connecticut that they implemented there in 2019. What are the circumstances that allowed for this change? What motivated it? And how is it different from what's going on in other states?
Margaret Sieger:So I'm gonna give you some history. This is maybe too much history. But like I mentioned, in the early two thousands, in 02/2003, the Child Abuse Prevention and Treatment Act, which was originally passed in 1974 and is just a very broad it's a 75 page piece of legislation. It covers all different aspects of child welfare practice. It funds all sorts of things ranging from child abuse prevention efforts, training with the workforce, research, and stipulates a lot of different things that states are responsible for in their child welfare systems.
Margaret Sieger:In 02/2003, the policy was revised to include that states had a basically, a requirement to identify infants affected by prenatal substance abuse. That was in quotes. And that was I think it was actually illegal drug abuse is what the 2003 legislation said and develop a plan of safe care. It was two sentences in this 75 page piece of legislation, so most states didn't change their practice in response to that federal policy change. Then in 02/2010, the language was again revised to in addition to infants affected by, quote, unquote, illegal drug abuse, they added fetal alcohol spectrum disorder.
Margaret Sieger:So now states have to respond to infants affected by those two categories and still develop a plan of safe care. Again, we now have an additional phrase added to two sentences, but it's a very small piece of the legislation, and there's not much in the way of carrot or stick to mandate that states start doing this. But in 02/2016, this policy was again revised. The word illegal was slashed. So now it's just any drug abuse.
Margaret Sieger:This was done to respond to the opioid epidemic when a lot of substance use disorders and substance use in pregnancy were to prescription medications. And because it was part of the federal response to the opioid epidemic, there was a lot more focus on it. There was more political will, and there was also more funding attached to implement these elements, which include and, again, I'm gonna quote the federal policy notification to child protection of the occurrence of these infants being born and the development of a plan of safe care that addresses the health and substance use disorder treatment needs of the affected caregiver and infant. So that policy, as it changed in 02/2016, in addition to, again, the political will, Connecticut was particularly impacted by the opioid epidemic, and additional funding was released to help states implement these CAPTA provisions. That was the backdrop.
Margaret Sieger:That's what led to these changes. So these changes in Connecticut were done to be responsive to changes in this federal CAPTA legislation. Part of the challenge, I've already named a couple of challenges with the brevity of the its inclusion in this federal legislation is that it's very broad, and states have been able to implement all sorts of different things, interpreting the word notification to mean a mandated report to child welfare, have changed their definitions of child abuse and neglect to include infants affected by prenatal substance exposure and have mandated that a plan of safe care accompany a child welfare system response. That would be the sort of most, quote, unquote, punitive end of the spectrum. Connecticut did something completely innovative, which is that they interpreted that notification to be something totally different from a mandated report.
Margaret Sieger:And the way the legislation is written, it doesn't require that the child welfare system learn the identity of any of these families, just that a notification be submitted. Presumably, if you use a public health approach to anything, you want to document the incidence of a disease or the incidence of a condition. So this is used for sort of public health surveillance rather than for, you know, surveilling individual families. And so they developed this notification portal where providers submit de identified information about the occurrence of the birth that has prenatal substance exposure and then develop that plan of safe care, which Connecticut calls a family care plan, develop that outside the context of the child welfare system. So it's typically developed by the hospital social worker at the time of delivery.
Margaret Sieger:Another real strength of Connecticut's implementation is that from day one, their adult mental health and substance use treatment authority was very invested in the policy's development and implementation, wanted it to be done in a way that wouldn't expose mothers who were using medications for opioid use disorder to any increased punishment or even perceived punitive reaction from the child welfare system. So they have been very engaged in training their workforce on developing family care plans and implementing them with pregnant patients who are using medications for opioid use disorder. So now Connecticut has yeah. They have this brand new pathway. If there are child welfare concerns, and I think we can talk about this in a minute, if there are child welfare concerns, there's still a mechanism so that you can refer them to the child welfare system.
Margaret Sieger:But if there are no abuse or neglect concerns, the family has a family care plan, they're connected to services, they're connected to treatment, now Connecticut is simply documenting the occurrence of the birth, again, for public health surveillance purposes, identify where in the state there are unmet needs around substance use treatment, things like that, trends in substance use and pregnancy to inform prevention approaches. They collect those data, they report it to the federal government, and the family, you know, leaves the hospital with their family care plan, hopefully to never come in contact with child welfare unnecessarily.
Rob Lott:Fair enough. Well, that's a really straightforward description of a really big change. I wanna hear a little more about what you've found when you studied the effects of that change. We'll do that, after this quick break. And we're back.
Rob Lott:I'm here with doctor Margaret Lloyd Seger, and we're talking about Connecticut's, novel prenatal substance exposure policy. So just a moment ago, you told us all about the new approach. What did you learn about its impact during the first couple years of implementation?
Margaret Sieger:Yeah, we learned that it is having an effect such that fewer infants are being referred and screened in to child welfare after the policy and of infants who do get referred and screened in to the child welfare system, fewer of those babies are going into foster care. I actually was concerned that referrals would go up after the policy just because now providers needed to respond to every infant with prenatal substance exposure. We knew that awareness of prenatal substance exposure could increase perceptions of risk to infants. So just due to the increased salience of the topic and the notification portal asked some safety screening questions to ensure that infants that need to get a referral. Based on those questions, I was worried that the rates of reports were gonna go up.
Margaret Sieger:And what we in fact saw is that the rates of reports relative to the number of infants who are born has gone down to the tune of seven percent per month over the course of the policy. The similarly, the proportion of infants that go into foster care has gone down four percent per month since the policy was passed.
Rob Lott:Oh, wow. So when you say per month, are you saying that from January to February, it went down seven percent and then from February to March, it went down another seven percent and so on and so on?
Margaret Sieger:Yes. On average over the study period. There are fluctuations, but that is the average change on an, again, aggregated average monthly basis. Mhmm.
Rob Lott:Wow. That's that's sounds pretty significant to me. Can you talk a little bit about sort of how well targeted these improvements may be? Earlier you alluded to there being avenues still in place to get people help if they need it or or put protections into place if they need it? What does that look like in this case?
Margaret Sieger:Our study doesn't directly address that question. The fact that fewer infants are going into foster care is encouraging. It would be really concerning if we saw a reduction in referrals, but then all of these babies were suddenly going into foster care. We would be concerned that maybe some of those middle risk infants were not getting connected to any services, and we didn't see that. So that's encouraging.
Margaret Sieger:But again, our study doesn't address much beyond that initial referral. We are going to be in the future looking at the extent to which this approach protects families from a referral later in infancy and even later in early childhood. We know that under one is the highest risk time for any type of child maltreatment and any type of referral to the child welfare system. So we were looking at the newborn hospitalization, and we're gonna look through twelve months to understand how the policies impacted infants later in infancy. The fact that the approach integrates that safety screener to me is improving the targeting, that the system has changed such that people aren't going to providers aren't going to be making a referral to child welfare out of, quote, an abundance of caution because there's this new screening process kind of built in before a referral is even made that asks asks providers to think critically about whether the substance use rises to a level that creates concerns around child safety or other concerns for child abuse or neglect.
Margaret Sieger:I do know anecdotally that Connecticut's child welfare system has been screening in an even higher proportion of referrals, meaning that people aren't making those referrals that don't warrant attention or they've been doing so less so. So I think it's increasing the precision, but that will be the you know, that's just my hypothesis. To be determined. Yeah. Exactly.
Rob Lott:Okay. Well, you know, when when I hear you talk, when I read the paper, this seems like a a good story, good news that we're sort of implementing a policy that's having beneficial impact, at least from our initial study of it. If I'm a policymaker anywhere other than Connecticut, I'm thinking, Oh, can we do this in Massachusetts or Ohio or California or North Dakota? How easy could someone in those shoes make this kind of change? Why and if so, why haven't we already done it?
Margaret Sieger:Yeah. That's a great question. We are actually I'm working with my partners in Connecticut to write up the story of the process by which Connecticut implemented this approach. So I think there's a lot of people who have the same exact question. And the short answer is that it was not easy.
Margaret Sieger:The longer version of that answer is that it is totally doable. Well, where there is a will, there is a way. So my first point of advice, which comes directly from my, you know, conversations with folks on the ground in Connecticut, is that developing, building an interprofessional working group is step one. You have to have child welfare, treatment, and hospitals at the table. Because in order for this to work well, those three pillars need to be in place.
Margaret Sieger:Where states have gone awry is not bringing hospitals to the table, not bringing the adult substance use treatment providers to the table, and implementing something that is essentially just a replica of the status quo, child welfare doing child welfare, which is great, but it's not gonna move in the direction of an innovative approach. So that is ground zero is bringing those partners to the table. And Connecticut has also invested a lot in they built the system. The notification system was engineered specifically for the implementation of this policy. They have been you know, people have been putting a lot of skin in the game, to implement this policy both from the child welfare system and the adult substance use treatment system.
Margaret Sieger:So if a state or county is interested in doing this, it is absolutely doable. There has to be the political will to do it because it's gonna take a lot of people coming to the
Rob Lott:table. Great. Well, yeah. That too. Well, thank you so much.
Rob Lott:This is perhaps a good spot for us to wrap up. Really appreciate your work on this issue and for, your time here today. Thanks for joining us.
Margaret Sieger:Thanks so much.
Rob Lott:And for our listeners, thanks for tuning in. If you enjoyed this episode, please leave a review, share it with a friend, hit that subscribe button and tune in next week. Thank you everyone. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.