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Mental Health and Substance Use Challenges (Volume 103)
Quarterly Article
Hannah L.F. Cooper
Anna L. Mullany
Snigdha Peddireddy
Simone Wien
Melvin "Doug" Livingston
Whitney S. Rice
Anne L. Dunlop
Michael R. Kramer
Madison Haiman
Lasha S. Clarke
Natalie D. Hernandez-Green
Angélica Meinhofer
Sep 23, 2026
Jun 29, 2026
Jun 12, 2026
Back to The Milbank Quarterly
Policy Points:
See all articles in the special issue, Mental Health and Substance Use Challenges Facing the United States: What Can State Policymakers Do?
Pregnant and postpartum people who use drugs (PWUDs) live at the intersection of two of the gravest public health crises currently facing the United States: epidemics of (1) maternal morbidity and mortality, and (2) substance-related harms. The United States has the highest maternal mortality rate of all high-income countries, and overdoses are a leading cause of these deaths.1, 2 State legislatures have been actively engaging with these intersecting epidemics for decades, and to date, at least 44 states have enacted laws governing substance use during pregnancy (LGSUPs).3 A growing body of research has found that LGSUPs shape health and health care use outcomes among pregnant/postpartum PWUDs, and a recent review of this research concluded that punitive LGSUPs—that is, laws employing threats and penalties for prenatal substance use—adversely affect these outcomes.4
To date, however, the LGSUP literature has amassed almost no evidence about whether and how these laws shape inequities in health and health care use outcomes among pregnant/postpartum PWUDs. This absence is striking. Large inequities exist in these outcomes along gradients of economic class and urbanicity; racial and ethnic inequities are emerging.5-13 Punitive LGSUPs disproportionately target structurally marginalized people,14-19 and professional societies and federal agencies have cautioned that this targeting sustains or exacerbates inequities.20-22
This paper seeks to foster a new line of research and interventions into LGSUP impacts on inequities in health and health care use among pregnant/postpartum PWUDs. After briefly reviewing salient epidemiologic evidence, we argue that this new line of research and interventions must include a focus on LGSUP implementation and present four recommendations to build out this evidence. We apply a broad definition of equity research. Some recommendations could be applicable to traditional equity analyses that quantify and seek to explain different distributions across subpopulations (recommendations 1, 2, and 4.) Others could illuminate pathways through which LGSUPs shape outcomes in a subpopulation known to experience high burdens of harms (recommendations 1, 2, and 3).
Bruzelius E, Martins SS. US trends in drug overdose mortality among pregnant and postpartum persons, 2017–2020. JAMA. 2022; 328(21): 2159–2161.
Maternal deaths and mortality rates per 100,000 live births. Kaiser Family Foundation. Accessed June 3, 2025. https://www.kff.org/other/state-indicator/maternal-deaths-and-mortality-rates-per-100000-live-births/
Alcohol Policy Information System. National Institute on Alcohol Abuse and Alcoholism. 2024. Accessed June 3, 2025. https://alcoholpolicy.niaaa.nih.gov/
Bruzelius E, Underhill K, Askari MS, et al. Punitive legal responses to prenatal drug use in the United States: a survey of state policies and systematic review of their public health impacts. Int J Drug Policy. 2024; 126:104380.
Admon LK, Kozhimannil KB, Rowe ME, Dalton VK, Winkelman T. Amphetamine abuse/dependence among pregnant women, United States 2003–2014 [20B]. Obstet Gynecol. 2018; 131: 24S–52S.
Admon LK, Bart G, Kozhimannil KB, Richardson CR, Dalton VK, Winkelman TN. Amphetamine-and opioid-affected births: incidence, outcomes, and costs, United States, 2004–2015. Am J Public Health (N Y). 2019; 109(1): 148–154.
Ahrens KA, Rossen LM, Burgess AR, Palmsten KK, Ziller EC. Rural–urban residence and maternal hepatitis C infection, US: 2010–2018. Am J Prev Med. 2021; 60(6): 820–830.
Giuliani E, Townsel CD, Jiang L, Leplatte-Ogini DJ, Caldwell MT, Marsh EE. Emergency department utilization for substance use disorder during pregnancy and postpartum in the United States (2006–2016). Womens Health Issues. 2022; 32(6): 586–594.
D’Souza RR, Cooper HL, Chang HH, et al. Person-centered hospital discharge data: essential existing infrastructure to enhance public health surveillance of maternal substance use disorders in the midst of a national maternal overdose crisis. Ann Epidemiol. 2024; 94: 64–71.
Cooper HL, D’Souza R, Chang H, et al. Patterns of non-fatal overdose and injection-related bacterial infections during pregnancy and the postpartum year among New York State residents. medRxiv. Preprint posted online January 22, 2025. https://doi.org/10.1101/2025.01.21.25320879.
Thornton P, Abrams R, Briller J, Geller S. Illinois Maternal Morbidity and Mortality Report: October 2018. Illinois Department of Public Health; 2020.
Friedman JR, Nguemeni Tiako MJ, Hansen H. Understanding and addressing widening racial inequalities in drug overdose. Am J Psychiatry. 2024; 181(5): 381–390.
Nidey N, Kair LR, Wilder C, et al. Substance use and utilization of prenatal and postpartum care. J Addict Med. 2022; 16(1): 84–92.
Kunins HV, Bellin E, Chazotte C, Du E, Arnsten JH. The effect of race on provider decisions to test for illicit drug use in the peripartum setting. J Womens Health (Larchmt). 2007; 16(2): 245–255.
Kerker BD, Horwitz SM, Leventhal JM. Patients’ characteristics and providers’ attitudes: predictors of screening pregnant women for illicit substance use. Child Abuse Negl. 2004; 28(2): 209–223.
Sanmartin MX, Ali MM, Lynch S, Aktas A. Association between state-level criminal justice–focused prenatal substance use policies in the US and substance use–related foster care admissions and family reunification. JAMA Pediatr. 2020; 174(8): 782–788.
Maclean JC, Witman A, Durrance CP, Atkins DN, Meinhofer A. Prenatal substance use policies and infant maltreatment reports. Health Aff (Millwood). 2022; 41(5): 703–712.
Leschied AW, Chiodo D, Whitehead PC, Hurley D. The association of poverty with child welfare service and child and family clinical outcomes. Community Work Fam. 2006; 9(1): 29–46.
Maguire-Jack K, Kim H. Rural differences in child maltreatment reports, reporters, and service responses. Child Youth Serv Rev. 2021; 120:105792.
American College of Obstetricians and Gynecologists. Committee Opinion no. 633: alcohol abuse and other substance use disorders: ethical issues in obstetric and gynecologic practice. Obstet Gynecol. 2015; 125(6): 1529–1537.
American College of Obstetricians and Gynecologists. Committee Opinion no. 711: opioid use and opioid use disorder in pregnancy. Obstet Gynecol. 2017; 130(2): e81–e94.
Volkow N. Pregnant people with substance use disorders need treatment, not criminalization. National Institute on Drug Abuse. February 15, 2023. Accessed June 3, 2025. https://nida.nih.gov/about-nida/noras-blog/2023/02/pregnant-people-substance-use-disorders-need-treatment-not-criminalization