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Our policies punish pregnant people for getting treatment for addiction. It doesn't have to be this way
As pediatric clinicians and public health researchers, we know that parental health is one of the strongest predictors of child health. When we care for babies in their first days of life, we spend hours with their parents to ensure they feel ready to care for their newborn after leaving the hospital. However, for parents with substance use disorders — past or present — eager preparations for these joyful first moments often go hand-in-hand with anxieties about being reported to the Department of Children and Families (DCF).
The federal Child Abuse Prevention and Treatment Act requires that all states collect data on newborns “affected by” parental substance use or withdrawal symptoms from prenatal drug exposure. These regulations are handled differently between and within states. Historically, most birthing hospitals across the country, including in Massachusetts, have interpreted state and federal law by filing DCF reports of suspected abuse or neglect in any case of prenatal substance exposure — including the use of prescribed medications for opioid use disorder (MOUD).
MOUD, including methadone and buprenorphine, are the cornerstone of expert-recommended, family-centered treatment for patients who want to stop using illicit or non-prescribed opioids. These medications support patients entering and maintaining recovery by significantly reducing cravings, withdrawal symptoms and risk of overdose or death. MOUD also improves newborn health outcomes; its use during pregnancy is associated with increased completion of recommended pediatric check-ups and lower risk of being admitted to the hospital within the first year of life.
Access to effective treatment helps promote family and child health and reduces the risk of harm. With this in mind, experts, including the director of the National Institute for Drug Abuse, have advocated that parental use of prescribed MOUD and prescribed opioids for pain management should not automatically trigger a DCF report for abuse or neglect. Emerging research supports this shift and has identified multiple policy levers we can pull to decouple DCF reporting from substance use treatment. As a result, some hospitals and states have begun updating their reporting guidelines and policies to better support family health.
In the wake of an ongoing U.S. maternal mortality crisis, encouraging pregnant people with substance use disorders to get treatment is crucial. Nationally, drug overdoses are a top cause of preventable death during and immediately after pregnancy. Among pregnant and postpartum women aged 35 to 44 years, drug overdoses tripled from 2018-2021, resulting in the deaths of 1,457 women. The Biden-Harris administration identified substance use treatment as a key policy priority. In a 2022 report, the administration explicitly agreed that “having a [substance use disorder] in pregnancy is not, by itself, child abuse or neglect.” The current status quo of categorically mandated DCF reporting for all prenatal substance exposure fails to reflect this nuance.
Some clinicians and policymakers presume that mandatory reporting is necessary to protect children and deter pregnant people from using drugs. Yet, existing evidence suggests a contrary narrative: the threat of DCF reporting may worsen family health. Pregnant people who deliver in states with harsher reporting policies are less likely to receive sufficient prenatal and postpartum care. And babies born in states with punitive policies are actually more likely to need opioid withdrawal treatment, which prolongs their birth hospitalizations and costs our healthcare system hundreds of millions of dollars every year. A recent Massachusetts-based study showed that some pregnant parents even stopped taking their MOUD due to fear of DCF investigation.
Vague guidance regarding what it means for infants to be “affected by” parental substance use has also created excuses for inaction, leading to variable and racially disparate reporting patterns between hospitals. Updating state and federal laws and clarifying institutional guidelines can help overcome these persistent problems. In 2019, Connecticut became the first state to divert anonymized prenatal substance exposure reports away from DCF for infants without safety concerns identified by their multidisciplinary medical team. Our hope is that birth hospitals and state governments, including those in Massachusetts, will do the same.
We recently published a study of 3,658 Massachusetts newborns that supports the effectiveness and safety of trauma-informed and individually tailored approaches to safety assessment and reporting. In 2021, Boston Medical Center (BMC) adopted new clinical guidelines advising clinicians to report suspected abuse or neglect only when there are tangible concerns about a parent’s ability to safely care for their child, rather than automatically filing DCF reports for all cases of prescribed opioid or MOUD use. Our statewide analysis showed that this shift reduced mandated DCF reporting at BMC by nearly half without negative impacts on length of hospitalization for the newborn or custody at discharge.
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In the wake of an ongoing U.S. maternal mortality crisis, encouraging pregnant people with substance use disorders to get treatment is crucial.
These initial results from BMC are promising and offer the first published evaluation of an institution-level policy change. If DCF reporting is limited to instances where clear protective concerns are identified by multidisciplinary teams — rather than based on categorical mandates — we can de-stigmatize prenatal and postpartum substance use treatment, conserve limited state resources and reduce unnecessary and intrusive DCF investigations. For example, the Massachusetts Department of Children and Families’ most recent annual report indicates that investigators had “reasonable cause to believe” maltreatment may have occurred in less than half of intake reports filed for substance-exposed newborns, reflecting a sizable opportunity to target investigative resources more efficiently.
Destigmatizing prenatal and postpartum substance use treatment is long overdue. Amidst rising overdose deaths among pregnant people, Massachusetts must advance legislation and regulations that are evidence-based, protect children and minimize harm to families. We urge state senators to join our neighboring states by advancing H.4758, which the House of Representatives unanimously passed this June. Section 19 of this bipartisan bill would clearly codify into law that prenatal substance exposure alone does not require mandatory reporting. Massachusetts would also create a dual-reporting pathway for prenatal substance exposure, like Connecticut, to separate anonymized notifications for collection of public health data and connection to community resources from identifiable child abuse/neglect reports to DCF. At the federal level, the SAFE in Recovery Act introduced by Sen. Ed Markey would end DCF reporting mandates for prenatal exposure to prescribed MOUD nationwide.
Mass General Brigham — our state’s largest health system — recently announced that it will follow BMC’s lead by establishing clear guidelines to end automatic reporting in the absence of child safety concerns. Other health systems across the country should, too.
Pregnant people should not be forced to choose between taking highly effective medications and avoiding being reported to DCF. To protect children and families alike, it is time to adopt institutional, state and federal policies that decouple evidence-based treatment from mandated DCF reporting.
Rohan Khazanchi, MD, MPH, is an internal medicine and pediatrics resident physician at Brigham & Women’s Hospital, Boston Children’s Hospital, and Boston Medical Center, and a research affiliate at the François-Xavier Bagnoud Center for Health and Human Rights at Harvard University.
Elizabeth Egan, MPH, LICSW, is a clinical social worker in the Department of Pediatrics at Boston Medical Center.
Heather Hsu, MD, MPH, is a pediatric hospitalist and health services researcher at Boston Medical Center and Assistant Professor of Pediatrics at the Chobanian and Avedisian School of Medicine at Boston University.