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    1 Comment for this article
    The negative effects of punitive policies
    Frederick Rivara, MD, MPH | University of Washington
    This study should be required reading for state legislators and maternal and child health advocates. It shows that punitive policies for substance abuse during pregnancy are totally counterproductive and harmful.
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open
    Original Investigation
    November 13, 2019

    Association of Punitive and Reporting State Policies Related to Substance Use in Pregnancy With Rates of Neonatal Abstinence Syndrome

    Author Affiliations
    • 1RAND Corporation, Boston, Massachusetts
    • 2School of Medicine, Boston University, Boston, Massachusetts
    • 3RAND Corporation, Arlington, Virginia
    • 4RAND Corporation, Santa Monica, California
    • 5Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
    • 6Mildred Stahlman Division of Neonatology, Vanderbilt University, Nashville, Tennessee
    • 7Vanderbilt Center for Child Health Policy, Nashville, Tennessee
    • 8Department of Health Policy, Vanderbilt University, Nashville, Tennessee
    • 9RAND Corporation, Pittsburgh, Pennsylvania
    • 10School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
    JAMA Netw Open. 2019;2(11):e1914078. doi:10.1001/jamanetworkopen.2019.14078
    Key Points español 中文 (chinese)

    Question  Are state punitive or reporting policies related to substance use during pregnancy associated with rates of neonatal abstinence syndrome (NAS)?

    Finding  In this repeated cross-sectional study of nearly 4.6 million births in 8 states, policies that criminalized substance use during pregnancy, considered it grounds for civil commitment, or considered it child abuse or neglect were associated with significantly greater rates of NAS in the first full year after enactment and more than 1 full year after enactment. Policies requiring reporting of suspected prenatal substance use were not associated with rates of NAS.

    Meaning  Policy makers seeking to reduce NAS rates may wish to consider approaches favored by public health experts that focus on primary prevention.


    Importance  Despite the rapidly changing policy environment regarding substance use during pregnancy, information is lacking on the association of state policies with neonatal abstinence syndrome (NAS).

    Objective  To determine if punitive or reporting state policies related to substance use during pregnancy are associated with NAS rates.

    Design, Setting, and Participants  This repeated cross-sectional study used retrospective, difference-in-difference analysis of live births in the State Inpatient Databases from 8 US states in varying years between January 1, 2003, and December 31, 2014. States without punitive or reporting policies were compared with states with policies before and after policy enactment using logistic regression models adjusted for individual and county-level factors and state and year fixed effects. Analyses were conducted from April 10, 2019, to July 30, 2019.

    Exposures  Time since enactment of state policies related to substance use in pregnancy, county-level rurality and unemployment, and presence of specialized treatment programs for pregnant and postpartum women in a county.

    Main Outcome and Measures  Rates of NAS.

    Results  Among 4 567 963 live births, 23 377 neonates (0.5%) received a diagnosis of NAS. Among neonates with NAS, 3394 (14.5%) lived in counties without any treatment programs specifically for pregnant and postpartum women, 20 323 (86.9%) lived in metropolitan counties, and 8135 (34.8%) lived in counties in the highest unemployment quartile. In adjusted analyses among neonates in states with punitive policies, odds of NAS were significantly greater during the first full calendar year after enactment (adjusted odds ratio, 1.25; 95% CI, 1.06-1.46; P = .007) and more than 1 full year after enactment (adjusted odds ratio, 1.33; 95% CI, 1.17-1.51; P < .001). After regression adjustment, the annual NAS rate was 46 (95% CI, 43-48) neonates with NAS per 10 000 live births in states without punitive policies; 57 (95% CI, 48-65) neonates with NAS per 10 000 live births in states with punitive policies during the first full year after enactment; and 60 (95% CI, 56-65) neonates with NAS per 10 000 live births in states with punitive policies in effect for more than 1 full year. There was no association between reporting policies and odds of NAS.

    Conclusions and Relevance  In this repeated cross-sectional analysis of 8 states, states with punitive policies were associated with greater odds of NAS immediately and in the longer term, but there was no association between NAS and states with reporting policies.