The Effect of Criminalizing Illicit Drug Use in Pregnancy
January 1, 2026
By Rebecca H. Allen, MD, MPH, Editor
Synopsis: In this observational study of three states, punitive prenatal drug use policies were associated with 4,396.29 fewer births per 100,000 patients receiving any prenatal care (95% confidence interval [CI], -6,176.07, -2,616.51) and 1,847.99 fewer facility-based deliveries (95% CI, -3,688.29, -7.69).
Source: Bruzelius E, Prins SJ, Bates LM, et al. Prenatal drug use criminalization and health system avoidance: Evidence from births in Alabama, South Carolina, and Tennessee, 1989-2019. Soc Sci Med. 2025; Oct 25. doi: 10.1016/j.socscimed.2025.118716. [Online ahead of print].
The authors of this study sought to estimate the effect of prenatal drug use criminalization on the use of prenatal care and facility-based birth. Currently, three states (Alabama, South Carolina, and Tennessee) have had laws criminalizing prenatal drug use. There are concerns that criminalization policies will deter patients from seeking needed care.
The authors used data from the U.S. National Center for Health Statistics (NCHS) National Vital Statistics System (NVSS) Natality files from 1989 to 2019. The exposure was criminalization of prenatal drug use, defined as legislation or a court decision that allowed prosecutors to charge a pregnant woman with a felony or misdemeanor crime for using drugs. The following three states and time periods were subject to this criminalization: South Carolina after 1997, Alabama after 2013, and Tennessee between 2014 and 2016.
The primary outcomes were county-level prevalence of any prenatal care, defined as at least one prenatal care visit, and facility-based delivery, which was defined as birth in a hospital, clinic, or freestanding birth center rather than at home. Secondary outcomes included timely prenatal care, which was defined as prenatal care starting in the first trimester, and adequate prenatal care, which was defined as those patients who attended at least 80% of recommended prenatal care visits.
Other factors were controlled for in the analysis, including state policies that considered prenatal substance use child abuse, mandatory reporting policies that require providers to report prenatal drug use to authorities, policies supporting drug treatment for pregnant women, Medicaid expansion policies, police officers and drug treatment centers per capita, state political party, and urbanicity.
The data set included more than 124 million births. The authors found that, after controlling for other variables, an explicit criminalization policy was associated with a decrease in the prevalence of births receiving any prenatal care (-4,396.29/100,000 births; 95% confidence interval [CI], -6,176.07, -2,616.51]). Similarly, criminalization laws were associated with fewer facility-based deliveries (-1,847.99; 95% CI, -3,688.29, -7.69). For the secondary outcome, there was no strong association between criminalization and timely or adequate prenatal care.
Commentary
The authors found an association between punitive laws for prenatal drug use and a lower prevalence of prenatal care and facility-based delivery based on birth certificate data. The association is suggestive, but the authors could not determine any individual-level data regarding how many pregnant persons were using drugs and whether they were aware of the criminalization policies. Furthermore, the authors specifically focused on policies that made prenatal drug use a criminal offense, but other laws making the same behavior a civil offense or equivalent to child abuse also were in effect. Therefore, it is difficult to know which policy affected people’s behavior and adequately control for multiple policies over decades of time. Nevertheless, the analysis is indicative that punitive prenatal drug laws actually deter patients from seeking needed care.
The American College of Obstetricians and Gynecologists (ACOG) advises providers that, “Drug enforcement policies that deter women from seeking prenatal care are contrary to the welfare of the mother and fetus. Incarceration and the threat of incarceration have proved to be ineffective in reducing the incidence of alcohol or drug abuse.”1 Although prenatal care providers need to follow their state’s mandatory reporting laws, these laws are counterproductive to the physician-patient relationship. It is more important that patients feel safe coming to their prenatal care visits so that substance use disorder treatment can be initiated if indicated. This stance is supported by other medical organizations, such as the American Medical Association.2
If patients are distrustful of the medical system and fear reporting, they may not disclose prenatal drug use and may not receive the care they need. There also is evidence that pregnancy can be a motivating factor for seeking substance use disorder treatment, and women who have custody of their children are more likely to complete substance use treatment programs.3
ACOG recommends universal screening for substance use disorders in pregnancy rather than targeted screening.4 Substance use affects patients from all socioeconomic and racial groups. For those patients with opioid substance use disorder in pregnancy, there are effective options for treatment. Both methadone and buprenorphine can be used safely in pregnancy. Buprenorphine has the advantage of being prescription-based, while methadone must be dispensed in a registered opioid treatment program. Breastfeeding should be encouraged in these patients, and their neonates should be monitored for the development of neonatal abstinence syndrome.4 Treatment for opioid use disorder can improve both maternal and infant outcomes compared to no treatment. In sum, healthcare settings should be a safe space for pregnant women to obtain prenatal care and deliver regardless of whether they use illicit substances.
Rebecca H. Allen, MD, MPH, is Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, RI.
References
1. American College of Obstetricians and Gynecologists. Substance abuse reporting and pregnancy: The role of the obstetrician-gynecologist. Committee Opinion No. 473. January 2011. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2011/01/substance-abuse-reporting-and-pregnancy-the-role-of-the-obstetrician-gynecologist
2. Henry TA. Don’t criminalize pregnant patients with substance-use disorders. American Medical Association. Published July 5, 2023. https://www.ama-assn.org/health-care-advocacy/judicial-advocacy/don-t-criminalize-pregnant-patients-substance-use-disorders
3. American College of Obstetricians and Gynecologists. Alcohol abuse and other substance use disorders: Ethical issues in obstetric and gynecologic practice. Committee Opinion No. 633. June 2015. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2015/06/alcohol-abuse-and-other-substance-use-disorders-ethical-issues-in-obstetric-and-gynecologic-practice
4. American College of Obstetricians and Gynecologists. Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. August 2017. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy