BOSTON—In the United States, federal legislation mandates that all states track data on all newborns who have been exposed to substances during pregnancy and ensure that a plan of Safe Care is created for each family. Yet each state manages those regulations differently.
In Massachusetts, the Department of Children and Families (DCF) has issued guidance that any prenatal substance exposure—including exposure to medications for opioid use disorder (MOUD)—is an indication to file a report for alleged child abuse/neglect upon the birth of the child.
MOUD including methadone and buprenorphine are effective treatments that bind to opioid receptors and reduce cravings and withdrawal symptoms. They decrease non-prescribed opioid use and reduce the risk of overdose. Yet when used in pregnancy as the recommended treatment, health care workers in Massachusetts are required to file a report to CPS.
This creates a dilemma for pregnant individuals with OUD—do they continue their prescribed treatments and risk the intervention of state services, or stop taking MOUD during pregnancy, which can increase the risk of relapse or overdose and impact the health of mother and child?
A team of researchers led by Davida M. Schiff, MD, director of Perinatal and Family Based Substance Use Disorders Care at Massachusetts General Hospital, conducted a study to learn more about the impact of these regulations on pregnant and postpartum individuals with OUD. Their findings were recently published in the Maternal and Child Health Journal.
Schiff and colleagues interviewed 26 individuals with OUD who delivered a baby in the past three years.
Those who received MOUD during pregnancy described the mandated state reporting process as "discriminatory, unjust and stigmatizing."
Participants also experienced intense anxiety and stress knowing that they would be reported to CPS upon delivery. One felt pained to be identified as a "child abuser," while others worried they would be separated from their children. Some were treated like unfit mothers by healthcare workers and state staff.
Participants said the state-mandated reporting policy also had a direct impact on their medical decisions—one individual who had been taking MOUD for two years prior to becoming pregnant decided to stop treatment during pregnancy for fear of being reported.
Based on these interviews, Schiff and colleagues believe that uncoupling OUD treatment decisions from mandated reporting during the perinatal period (pregnancy and postpartum) is essential.
"Other states in New England—New Hampshire, Vermont, Connecticut, and Rhode Island—do not have an automatic filing with CPS when newborns have been exposed to medications in-utero," says Schiff, who is also an assistant professor of Pediatrics at Harvard Medical School.
"Under the current policy [in Massachusetts], women who are stable and in long-term recovery for OUD are potentially subject to the same reporting and scrutiny that is required for a child who has been physically or sexually abused," says Schiff.
Although prenatal MOUD exposure can result in neonatal opioid withdrawal syndrome, the condition is transient and treatable, Schiff says.
"Newborns with a physical dependence to either methadone or buprenorphine are treated and supported in the same manner as newborns who are dependent on other medications their mothers took during pregnancy, such as insulin," she explains. "We don't report women whose newborns require special treatment from being exposed to insulin to treat gestational diabetes. But that's what we are doing when a pregnant woman receives MOUD."
The current policy doesn't require notifications for other prescribed medications that can have an impact on fetal and infant health, such as benzodiazepines for anxiety and SSRIs for depression, notes first author Erin Work, who is currently completing a master's degree in public health and social welfare at University of California, Los Angeles. "The fact that medications for opioid use disorder are singled out in this policy speaks to the stigma against women with a history of substance use disorder as unfit mothers."
The policy also discriminates against women, adds Work. "Fathers who are using either prescribed or non-prescribed substances are not subject to the same mandated reporting as women receiving MOUD."
The research by MGH investigators was prompted by Massachusetts legislators, who asked for data that demonstrates that the state's current reporting policies are harmful to women and families. Two bills concerning newborns affected by in-utero substance exposure are scheduled to be discussed in a joint hearing in July.
Co-authors include Timothy Wilens, Shelly Greenfield, Kate Macmillan, Jessica Gray, Mishka Terplan, Serra Muftu, Nicole Bell, Julia Reddy, and Judith Bernstein.
This study was supported by the National Institute on Drug Abuse K23DA048169
About the Massachusetts General Hospital
Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The Mass General Research Institute conducts the largest hospital-based research program in the nation, with annual research operations of more than $1 billion and comprises more than 9,500 researchers working across more than 30 institutes, centers and departments. In July 2022, Mass General was named #8 in the U.S. News & World Report list of "America's Best Hospitals." MGH is a founding member of the Mass General Brigham healthcare system.
