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Nurses Association (ANA) believes the threat of prosecution hinders nurses from providing care to women who seek it.17
LEGAL PERSPECTIVE
Mandatory reporting of opiate exposed infants can be used as a proxy for local prevalence of maternal opioid use. It may lead to interventions by law enforcement or social services. Legislative action toward maternal opiate use is variable between states, and is creating disparities in care and intervention.18,19 Some state policies regarding testing and reporting of mothers and infants with opiate exposure are more punitive, focusing primarily on
the safety of the child, whereas others are more preventative and consider the health and well-being of the pregnant woman and her newborn. Testing and reporting policies can vary even within states.20 Mandatory reporting, therefore, exposes women and infants to very disparate outcomes, depending on where they live, and how local and state laws are interpreted and enforced.
A recent report from the Guttmacher Institute gives a national perspective of state laws. Eighteen states consider substance use in pregnancy to be child abuse and three consider it grounds for civil commitment. Eighteen states require health care workers to report suspected abuse to the state and four mandate testing of pregnant women.18 A myriad of other laws exist in counties and well as who is mandated to report and when are not consistent or clear. The potential negative effects that may occur as a result of the legal actions taken against prenatal drug abusers are many. These negative effects may include, but are not limited
to avoidance of prenatal care, constitutional infringements, discrimination, poor prison conditions, and ineffectiveness of punitive measures.5
The punitive approach is aimed at cost reduction and social well- being. Nationally costs of all infant drug exposure total between $71 million and $113 million per year, but in particular, treatment for infant opiate exposure is extremely costly.20 However, legal action has many negative unintended consequences. ACOG states “deterring women from seeking care is detrimental to women and infants; seeking care should not expose a woman
to civil or criminal proceedings which put her and baby at risk of incarceration and separation.”3 ACOG also points out that it cannot be assumed that a pregnant woman who does not receive treatment does not want it, as availability of targeted substance abuse treatment for pregnant women is limited to 19 states, with only 12 giving pregnant women priority access to treatment.3,18 Delaware neither gives pregnant women priority access nor
protects pregnant women from discrimination in publicly funded programs.18
PROFESSIONAL RESPONSE
The National Perinatal Association opposes criminal prosecution of women who abuse substances while pregnant, as there is no evidence that this helps the mother or infant.21 The American Society of Addiction Medicine (ASAM) supports treatment rather than criminalization as incarceration may hurt the health of the mother and fetus, and may not address efforts toward long-term recovery.22 In January of 2015 the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) released a position statement, which while endorsing a nurses’ responsibility to follow the law, opposes incarceration or punitive legal action against women due to substance abuse in pregnancy.23
WORKING TOGETHER
The national extent of maternal opioid abuse and resulting NAS is not clear, and it is variable around the country. Programs
aimed at quantifying NAS as a diagnosis, looking at trends in geographic areas, and in differing populations are needed. Young et al. concluded we may be missing an opportunity to increase the impact of policy on the issue of substance use in pregnancy, and that solutions require public and private entities to work together to address how we serve families. Additionally, there is opportunity for partnerships to identify where differences exist in policy goals versus implementation of local laws.19

the potential to provide data to drive interventions and to

epidemic to individuals and society. Programs such as this are underway in Tennessee and Florida, the results of which are pending.24,25,26 Screening and reporting should be viewed as part of a larger issue of policy and practice interventions for individuals and families. In Tennessee, public health partners in both the public and private sector are using reporting results to enact local prevention strategies.26 Which mechanism to use for screening, where to collect and house the data, and how
the data are used are all questions that need to be addressed. Currently in Delaware screening via urine, meconium, and more recently, umbilical cord tissue has been used based on hospital system policy. All have potential downsides however
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Del Med J | April 2016 | Vol. 88 | No. 4