Harm Reduction Policies for Perinatal Substance Use Instead of Criminalization: Better Outcomes for Families
August 6, 2024
Overview
The evidence is clear that the criminalization of substance use leads to worse health outcomes for pregnant and postpartum people who use drugs (PPWUD) and their babies. Despite this evidence, many states continue to prioritize punitive measures for PPWUD. Others, however, are beginning to embrace a harm reduction approach to perinatal substance use.
The United States has long stigmatized and criminalized pregnant and postpartum people who use drugs (PPWUD) in many ways, including by taking away their freedom or their children. This approach has been informed by the “war on drugs” rather than public health evidence. In fact, the evidence is clear that the criminalization of substance use leads to worse health outcomes for both pregnant people and their babies. For example, the adoption of punitive policies adversely affects uptake of prenatal care, mean Apgar score, risk of stillbirth, and infant mortality.
Despite this evidence, many states continue to prioritize punitive measures for PPWUD. Others, however, are beginning to embrace a harm reduction approach to perinatal substance use. This approach involves meeting PPWUD where they are at and providing evidence-based services that improve outcomes for the parent, child, and society. Harm reduction service providers strive to create positive change without judgment. This is especially important during pregnancy, because stigma and racial bias can discourage pregnant people from seeking prenatal care, and prenatal care reduces the risk of adverse pregnancy outcomes.
Perinatal harm reduction strategies, such as syringe services, medications for opioid use disorder, and prenatal care for PPWUD, work. These strategies keep parents engaged in health services, improve health outcomes for pregnant people and infants, increase breastfeeding rates, and facilitate early attachment and healthy childhood development. State policies that support harm reduction measures, unlike those that criminalize and stigmatize perinatal substance use, improve the health and well-being of PPWUD and their families.
Pennsylvania offers one example. The state has allocated some of its federal Title V Maternal and Child Health block grant to the Centering Pregnancy Program (CPP). The CPP is a patient-centered model of group prenatal care. One site, Lancaster General Hospital, administers a group specifically for pregnant people with substance use disorder. In this group, a Licensed Social Worker certified in addiction counseling facilitates group prenatal care and educates the group about substance use disorder and pregnancy. Evaluations of the program have found that participants have lower rates of low birthweight and preterm birth, and higher rates of prenatal visits and breastfeeding, compared to traditional prenatal care.
Illinois has also begun to implement perinatal harm reduction measures. The state has allocated funds from federal Opioid Crisis Response grants to develop a Pregnant and Postpartum Women with Opioid Use Disorder (PPW-OUD) pilot project. The project provides family-based services to support pregnant and postpartum individuals experiencing opioid use disorder and their families. These include trauma-informed screening, referral, care coordination, family-based treatment, and recovery support such as childcare, vocational, educational, and transportation services. Participants also have access to a Doula Certified Peer Recovery Specialist, a person in active recovery with certifications in doula training, who assists a recovering mother through all phases of obstetrics and opioid use disorder recovery.
The American College of Obstetricians and Gynecologists, along with many other governmental and professional organizations, opposes policies that criminalize people for conduct alleged to be harmful to a pregnancy and recommends implementing harm reduction strategies to support the agency and autonomy of PPWUD. A holistic perinatal harm reduction approach should include making changes to health care delivery practices, addressing stigma, confronting structural racism and health inequity, repealing laws that criminalize perinatal substance use, and ensuring that PPWUD have access to syringe services, pre-exposure prophylaxis, naloxone, and medications for opioid use disorder. Allocating funding to programs that embrace harm reduction like those in Pennsylvania and Illinois is only a start, but a promising start nonetheless. Other states can look to these programs as examples of how to address perinatal substance use with evidence-based harm reduction efforts.
This post was written by Nina Shields, Legal Fellow, Network for Public Health Law — Harm Reduction Legal Project, and reviewed by Corey Davis, J.D., M.S.P.H., Director, Network for Public Health Law — Harm Reduction Legal Project.
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