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December 2022 (Volume 100)
Quarterly Article
Alexander D. McCourt
Sarah A. White
Sachini Bandara
Theo Schall
Daisy J. Goodman
Esita Patel
Beth McGinty
Jun 29, 2026
Jun 25, 2026
Mental Health and Substance Use Challenges
Back to The Milbank Quarterly
Policy Points:
Context: Amid increasing drug use among pregnant individuals, legislators have pursued policies intended to reduce substance use during pregnancy. Many states have utilized child welfare mechanisms despite evidence that these policies might disincentivize treatment-seeking. Recent federal changes were intended to facilitate care for substance-exposed infants and their families, but implementation of these changes at the state level has been slowed and complicated by existing state policies. We seek to provide a timeline of state child welfare laws related to prenatal drug use and describe stakeholder perceptions of implementation.
Methods: We catalogued child welfare laws related to prenatal drug use, including laws that defined child abuse and neglect and established child welfare reporting standards, for all 50 states and the District of Columbia (DC), from 1974 to 2019. In the 19 states that changed relevant laws between 2009 and 2019, qualitative interviews were conducted with stakeholders to capture state level perspectives on policy implementation.
Findings: Twenty-four states and DC have passed laws classifying prenatal drug use as child abuse or neglect. Thirty-seven states and DC mandate reporting of suspected prenatal drug use to the state. Qualitative findings suggested variation in implementation within and across states between 2009 and 2019 and revealed that implementation of changes to federal law during that decade, intended to encourage states to provide comprehensive social services and linkages to evidence-based care to drug-exposed infants and their families, has been complicated by existing policies and a lack of guidance for practitioners.
Conclusions: Many states have enacted laws that may disincentivize treatment seeking among pregnant people who use drugs and lead to family separation. To craft effective state laws and support their implementation, state policymakers and practitioners could benefit from a treatment-oriented approach to prenatal substance use and additional state and federal guidance.
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