How do state policies on alcohol use affect pregnant women and infants?

It is well known that if women drink while they are pregnant, they increase the chances that children may be affected by alcohol, including a broad range of serious defects referred to as Fetal Alcohol Spectrum Disorder. Many states have enacted laws aimed at pregnant women intended to reduce these risks. But do the laws have the intended effects? A new, first of its kind study helps answer that question.

Approximately 21% of pregnant women in the United States report that they used some alcohol during pregnancy and approximately 3% reporting binge drinking (defined as 4 or more drinks on at least one occasion). States have adopted a variety of policies in recent decades to try to reduce alcohol use by pregnant women. The policies included in this study were:

• Mandatory warning signs posted in locations where alcoholic beverages are sold, as well as healthcare facilities where pregnant women receive treatment.
• Priority treatment for pregnant women and women with children, which makes access to substance abuse treatment for pregnant and postpartum women who abuse alcohol priority.
• Reporting requirements for data and treatment purposes, which specify either mandated or discretionary reporting of suspicion of or evidence of alcohol use or abuse by women during pregnancy to either Child Protective Services or a health authority.
• Prohibitions on criminal prosecution, which prohibits use of the results of medical tests, such as prenatal toxicology tests, as evidence in the criminal prosecutions of women who may have caused harm to a fetus or a child.
• Civil commitment, which is mandatory involuntary commitment of a pregnant woman to either treatment or protective custody of the state for the protection of a fetus from exposure to alcohol.
• Reporting requirements for child protective services purposes, and child abuse/child neglect. This topic addresses the legal significance of a woman’s conduct prior to birth of a child and of damage caused in utero and, in some cases, define alcohol use during pregnancy as child abuse or neglect.

These policies have a variety of rationales. Policies such as mandatory signage are designed to inform women about possible dangers of alcohol; some policies, such as priority treatment, are designed to expedite substance abuse treatment for pregnant women so they are not on waiting lists than can be longer than the term of pregnancy. Other policies punish women for drinking while pregnant. The intent of these policies was likely to deter pregnant women from drinking, but researchers have found that they might have the unintended effect of making women avoid prenatal care to evade detection of their alcohol use.

The researchers analyzed birth certificate data from 148,048,208 births in the United States between 1972 and 2013. The data examined from the birth certificates included whether the infant had a low birthweight, was a premature birth (before 37 weeks), whether the woman used prenatal care, whether she used prenatal care late in her pregnancy, and whether the infant had a normal Apgar score (which is a method to quickly summarize the health of a newborn).

The results of the analysis that compared births to the state of the law in each U.S. state showed that six of the eight policies were significantly associated with birth outcomes. The other two had no significant effects. Unfortunately, all of the significant effects of these laws were in the direction of worse outcomes. The laws included mandatory warning signs, child abuse and neglect laws, civil commitment laws, prohibition of criminal prosecution, reporting requirements and priority treatment for pregnant women. Interestingly, the mandatory warning signs had the most effects. Women who lived in a state that requires these signs were more likely to have infants with low birthweight and to deliver prematurely. They were less likely to receive appropriate prenatal care and were less likely to have infants who had normal Apgar scores.

The study authors concluded that these laws, which were intended to reduce alcohol related birth problems, appear to have the reverse effect. Women in states with these laws appear to be reluctant to seek prenatal care and in this way, their babies are put at greater risk.

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