Punitive Laws on Substance Use in Pregnancy May Do More Harm Than Good

U.S. states are increasingly adopting legislation to address substance use among pregnant and postpartum individuals. However, a new study by researchers at Columbia University's Mailman School of Public Health finds that punitive laws are largely ineffective and may actually harm those they aim to protect. These laws can undermine trust between patients and clinicians and disproportionately affect lower-income women and women of color—groups already facing systemic barriers to care.

The study, published in the New York State Bar Association Journal, is among the first to analyze how different legal strategies influence outcomes for pregnant people who use substances. Many policies focus on deterrence and isolated behavior, rather than connecting people to harm reduction services, addiction treatment, or comprehensive healthcare. “Modernizing this area of law is critical to improving outcomes for pregnant people, their infants, and families,” said Silvia Martins, MD, PhD, senior author and professor of Epidemiology at Columbia Mailman School. “There is an urgent need for evidence-based regulation.”

The U.S. maternal mortality rate—about 22 deaths per 100,000 live births—is one of the highest among peer nations and disproportionately affects women of color. More than 80 percent of deaths among pregnant people may be preventable, and mental health and substance use are important contributing factors. While U.S. states have rarely imposed criminal penalties for drug use during pregnancy, many states have enacted legislation to categorize prenatal drug use as child abuse or neglect.

The researchers reviewed 14 state Maternal Mortality Review Committees (2008–2017), examining how states use laws, prosecutions, and court decisions to address substance use in pregnancy. They categorized laws as either punitive—relying on threats of punishment to deter drug use—or prosocial, which prioritize access to care and harm reduction. “Prosocial laws are more likely to recognize the complex, socially influenced nature of substance use,” said Martins, who is also director of the Substance Use Epidemiology Unit at the Columbia Mailman School.

Approximately 11 percent of maternal deaths with known causes were related to mental health, and more than two-thirds involved people with current or past substance use. “Substance use during pregnancy is linked to complications including severe morbidity, lack of prenatal care, domestic violence, and parenting challenges,” observed Emilie Bruzelius, postdoctoral fellow in epidemiology and co-author of the study.

“Many U.S. states have undertaken legislation with the goal of minimizing harms related to prenatal substance use,” Martins noted. “But to truly improve outcomes, we need a comprehensive understanding of how legal strategies interact and how they may affect the lives of pregnant people and their families—and the evidence shows that punitive approaches may be doing more harm than good.”

Co-authors are Kristen Underhill, Cornell Law School; and Weill Cornell Medical College; Megan E. Marziali, Sam D. Gardner, and Emilie Bruzelius, Columbia Mailman School; and Morgan Philbin, UC San Francisco School of Medicine.

The study was supported by the National Institutes of Health (grant DA053745).