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Kirsten Puccio gave birth to her daughter in August 2020, a moment she had been dreading for months.
After giving birth, Puccio's doctors were authorized to report her to the Massachusetts Department of Children and Families for child abuse and neglect because she was taking methadone, a drug prescribed by her doctor to help her recover from opioid use disorder.
Puccio knew this would happen. She received prenatal care at a clinic that specializes in treating pregnant women with substance use disorders, and staff there warned her about reporting obligations in Massachusetts. Still, she says, the emotional toll was immense.
“Following doctor's orders and doing what is medically recommended, they are primarily punished,” she says. “No matter how hard you work, how strong your recovery is, how good positive things you're doing, you're still going to get reported for abuse and neglect.”
Puccio said she slept for five days after the birth, fearing the authorities would take her newborn away.
“I was in fight or flight mode my whole pregnancy,” she said. “When I was born, I was shocked because I knew I had to fight to keep my baby.”
Puccio and her doctors had developed a safe care plan that stipulated that safe housing, formula, diapers and other basic infant needs would be met at home, so the battle for custody of her son was relatively short. The Department of Children and Families closed the case against her within 90 days, but most others aren't so lucky, she said.
Drug overdose is one of the main reasons. Preventable death Among pregnant and postpartum women in the United States. Overdose deaths have increased in this population 81% Between 2017 and 2020 – caused death More than 1,200 Pregnant and postpartum women in 2020.
Christmas Limited resources And stigma prevents pregnant women struggling with substance abuse from seeking or receiving care. People like Puccio, who seek care and start taking drugs to help them recover, are often reported to child abuse and neglect services under legal jurisdiction.
But in some hospitals, the response is changing.
Mass General Brigham, Massachusetts' largest health care system; announced Last week, he announced that he would not report suspected abuse and neglect to government welfare authorities just because a child was born exposed to drugs. Instead, the report is triggered only when there is reasonable cause to believe that an infant is “in pain or very close to pain.” Physical or emotional harmHe said.
Multidisciplinary care teams who know the family closely meet to determine if there is concern that the child is not meeting their basic physical needs (such as food, shelter, and clothing) or their emotional needs (such as stimulation and stimulation). A report to Child Welfare Services is still triggered if there are concerns, said Dr. Sarah Wakeman, senior medical director of substance use disorders at Mass General Brigham. But if those concerns don't exist, then exposure to the substance itself won't trigger a report, she said.
“It's trying to conflate this idea of drug exposure as equivalent to abuse or neglect,” Wakeman said.
The systems approach reflects consensus that punitive approaches to substance use during pregnancy result in worse medical outcomes for parents and children and disproportionately harm families of color and families of lower socioeconomic status.
“In most cases, the needs of the parent and the child are perfectly aligned, and supporting the family unit is the best intervention for child well-being and family well-being,” Wakeman said.
Change is happening on many levels. Health systems like Yale New Haven Children's Hospital and Boston Medical Center have implemented new drug testing and reporting protocols, as Mass General Brigham announced last week.
States like Connecticut, New Mexico, Washington and Colorado have reformed laws to keep at-risk infants out of the child welfare system. Others, like Massachusetts, have Pending legislation Protects mothers who take prescription drugs to treat substance use disorders from child welfare screenings.
At the federal level, the Biden-Harris administration has acknowledged that “substance use disorders during pregnancy are not in themselves child abuse or neglect.” Report Published in 2022.
and federal draft law Safety recovery lawBy Senator Edward J. Markey et al announced in October that it would require consent for the mother to undergo a toxicology test — not currently common — and states would not require notification to child welfare officials if the mother is taking drugs “based on the recommendations of a pharmacist” and the health care provider has no other reason to suspect the child is in imminent danger.
Markey b News release. “Substance use disorder treatment makes parents and children safer, not less.”
Laws and definitions vary.
Drug use during pregnancy is associated with adverse health outcomes for both the mother and the fetus. US Centers for Disease Control and Prevention. And untreated substance use disorders put children at risk of harm; A large percentage of children who enter the welfare system because of reports of abuse and neglect have a parent with a substance abuse problem, said Dr. Margaret Lloyd Seeger, an associate professor of social work at the University of Connecticut.
But that doesn't mean drug addiction is the same as violence, she said.
In the year According to the US Department of Health and Human Services, by 2022, more than 21 million children in the United States will live with a parent who abuses substances. Report. All of these children have experienced abuse or neglect and are in need of child welfare intervention, Lloyd Seeger said.
The landscape of child abuse prevention laws and their interpretations vary widely across states and hospital systems, experts say.
At the federal level, Child abuse prevention laws In the year Passed in 1974, it mandated that child welfare agencies be notified when a child is born affected by “illegal drugs.” of Comprehensive Addiction and Recovery ActKnown as CARA, the word “illegal” was removed from the law in 2016 to mandate reporting to authorities any time a newborn child is “under the influence of drugs,” legal or illegal.
This one-word change is why the law now applies to drug-assisted treatments, such as the methadone Puccio was taking. In theory, it could apply to any drug a pregnant woman takes that could harm the baby, including anti-seizure drugs and antidepressants, Wakeman said.
It has a federal children's office Explained. A “report” of drug exposure is not the same as a “report” of child abuse and neglect. However, many states have passed their own laws that equate the two; Massachusetts was among the first to do so in the 1970s, Lloyd Seeger said.
Although these policies are in the interest of protecting children, according to Lloyd Seeger, Research It shows that they get the opposite result.
“In states with punitive policies, including mandated reporting, women who give birth are less likely to receive prenatal care, less likely to use medication for opioid use disorder, less likely to use psychiatric services, and less likely to interact with any health care provider during pregnancy.” she said.
This leads to worse health outcomes for both the baby and the parents, says Lloyd Seeger.
Medication-assisted treatments such as methadone and Suboxone (containing buprenorphine and naloxone) are safe and medically recommended for treating opioid use disorder during pregnancy. American College of Obstetricians and Gynecologists.
In March, the federal Substance Abuse and Mental Health Services Administration issued advice on the safety of these treatments during pregnancy and breastfeeding. Also, one of the barriers to seeking care, especially for people of color, is fear of repercussions in states with mandatory reporting.
“When used appropriately, opioid use disorder medication during pregnancy is associated with many positive effects on both mother and baby,” said Lloyd Seeger. “Longer pregnancies, higher birth weights, better adherence to treatment during pregnancy, more frequent prenatal care – both better health and mental health.”
Because the drugs are opioids, the baby may show some withdrawal symptoms at birth, such as irritability, convulsions, and feeding problems, but Eat, sleep, console According to Lloyd Seeger, a method has been developed to effectively control the symptoms.
In states with mandatory reporting practices, parents like Puccio who take these drugs are immediately reported for child abuse and neglect. Although not all of these reports result in the infant being removed from parental care, the involvement of child welfare services can be traumatic in itself and undermine confidence in recovery, Lloyd Seeger said.
Dr. Sharon Ostfeld-Jones, assistant professor of clinical pediatrics and internal medicine at Yale School of Medicine, said, “The psychological impact of losing custody is more traumatic than the death of a child.”
Punitive policies regarding drug use during pregnancy are particularly harmful to families of color and low socioeconomic status. Inconsistencies in testing and reporting protocols lead to many subjective decisions that lead to large differences in outcomes, Ostfeld-Jones said.
Research Although women of different races use similar amounts of substances during pregnancy, black and poor pregnant women are more likely to be screened for drug use during pregnancy and referred to child welfare services than white or wealthier pregnant women. Black children in the child welfare system and black…