Health care provider decision making on reporting prenatal substance use
July 8, 2022
Discussions of alcohol and/or drug use during pregnancy often focus on the harms cause by the substance use. But research shows that policies and health care practices adapted in response also cause harm. Two practices that contribute to those harms are reporting of pregnant people’s substance use to Child Protective Services (CPS) and those that define substance use during pregnancy as child abuse or neglect.
The federal Child Abuse Prevention and Treatment Act requires healthcare providers to notify CPS about births affected by a pregnant person’s substance use, and more than half of states have policies that require reporting and/or define use during pregnancy as child abuse or neglect. There are significant racial inequities in reporting, with healthcare providers reporting Black newborns to CPS or health authorities up to 4-10 times more often than they report white newborns. These policies lead pregnant people to disengage from prenatal care physically and emotionally and can contribute to increased preterm birth and low birthweight.
Health professional associations have raised concerns that reporting requirements related to substance use during pregnancy get in the way of their ability to provide care and treatment, yet there is little momentum to change these policies. Researchers from ANSIRH conducted in-depth interviews with hospital-based healthcare providers to understand factors that contribute to their decision making related to reporting people’s substance use to government health authorities, police or CPS.
They found that individual, interpersonal, organizational and policy-level factors influence providers’ decision making. While there were a range of perceptions and experiences about whether reporting decisions are a physician or a social worker responsibility, it’s clear that hospital-based physicians do play roles in reporting decision for individual patients and in changing hospital policies. They generally believe that reporting can have negative consequences for the pregnant or birthing person, the baby, and parent/baby relationships, but they also believe that not reporting will lead to a baby being harmed or possibly dying. This fear of what could happen if they don’t report was intense and appears influenced by anecdotes and experiences rather than evidence about how common these cases were or whether reporting meaningfully decreased risks.
Some providers also viewed and experienced their decision making as constrained by hospital and state policy and the possibility that any decision not to report could be overridden by anyone else in the hospital. Individual reporting decisions are unlikely to change unless policies change, or hospitals provide clarification if providers are misinterpreting requirements as more stringent than they are.
Public health policies, including those related to pregnant people’s substance use, should be based in the best available evidence. Research has not found that state policies requiring CPS reporting have a public health benefit. These requirements, especially combined with policies that define substance use during pregnancy as abuse or neglect, just serve to increase reporting and more involvement in the child welfare system. They also serve as a barrier to prenatal care, limiting opportunities for support to promote patients’ health.
Hospitals and states need new policies that create and sustain supportive conditions where people who use substances, their children and families can thrive. Several providers in the study mentioned racism as something they noticed and navigated in relation to reporting decisions, reflecting the racial inequities in reporting. Efforts to reduce reporting inequities by standardizing hospital protocols haven’t worked and may just ingrain the racism present prior to those changes. The healthcare system needs broader efforts to address racism in general as well as specifically around policies for pregnancy and alcohol or drug use. Many of the factors that influenced reporting pregnant and birthing people are outside of the control of individual physicians and require social, structural, and policy changes.
“If we report these patients they won’t come in when they’re using these substances and they won’t seek care – either prenatal care or care for substance abuse disorder – because there may be legal ramifications of coming to seek care.” – Family Medicine physician, midwest