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Health Affairs' Rob Lott interviews Margaret Sieger of the University of Kansas Medical Center about her recent paper that reviews how Connecticut's novel prenatal substance exposure policy was associated with declining Child Protective Services reports and foster placements.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rob Lott (00:00):
Hello, and welcome to A Health Podicy. I'm your host,
(00:04):
Rob Lott. Untreated substanceuse disorder in pregnancy is a
long standing and persistentpublic health concern. That's
the first line of a new paper inthe July issue of Health
Affairs, and it spotlights acomplicated question. What are
(00:28):
our responsibilities as asociety to the parties involved
when it comes to untreatedsubstance use disorder in
pregnancy?
One responsibility, of course,is to the pregnant person to
help them get support andtreatment they might need. One
is to the future newborn toensure they have a healthy and
(00:48):
thriving parent and family thatcan provide the love and care
they need. And one is to thecaregivers, the doctors, the
clinicians, and the policymakersto ensure that they have the
guidance and tools they need toprovide the care and treatment
that's compassionate, just andrighteous. Is it possible for
(01:12):
public policy to honor all ofthose responsibilities and
goals? That's the subject oftoday's health policy.
I'm here with Doctor. MargaretLloyd Seger, an associate
professor at the University ofKansas School of Medicine in the
Department of Population Health.She and her coauthors wrote the
paper whose first line I justshared with you. It was just
(01:36):
published in the July issue ofHealth Affairs, and its title is
also one of its main findings.Connecticut's novel prenatal
substance exposure policy isassociated with declining CPS
reports and foster placements.
Doctor. Margaret Lloyd Seger,thank you so much for joining
(01:57):
us.
Margaret Sieger (01:58):
I'm so excited to be here.
Rob Lott (02:00):
All right, let's just dive right in. Let's start with
a little background. What do wecurrently know about substance
use disorder during pregnancy?How widespread is it? And what
sort of typically happens in asituation where that's the case?
Margaret Sieger (02:16):
Yeah. Great question. It's a little bit
tough to answer because we areoccasionally talking about any
substance use, and then othertimes we're talking about
substance use disorder. So ifwe're talking about substance
use, between five and fifteenpercent of pregnant women use
substances, including alcoholand cannabis at some point after
(02:40):
learning that they're pregnant.Nationally, self reported use in
pregnancy rose to a recent peakin 2022 to over nine percent of
pregnant women self reportingsubstance use in pregnancy.
Now we also know, however, thatpersisting in substance use in
pregnancy can be an indicationthat there is a substance use
(03:03):
disorder, and substance usedisorders, including at higher
severities, are more commonamong pregnant people who
continue using substances versusthe general population. But
short answer is somewherebetween five and fifteen
percent. We did some earlieranalyses of Connecticut's
approach in order to essentiallycount the number of people who
(03:27):
were using substances, and itwas eight percent of births had
substance exposure at some pointin pregnancy.
Rob Lott (03:34):
Okay. And you just mentioned that we sort of
reached a peak during was itduring COVID? And I'm curious,
do you have a sense, is that anincrease in self reporting or an
increase in use or in sort ofprevalence of the disorder? And
are we able to extricate thosetwo things from each other?
Margaret Sieger (03:53):
Yeah. That is a really good question as well. So
I think the answer is both.Substance use among everyone in
The US increased secondary toCOVID. The peak was actually in
2022 though, which is sort of acouple of years.
It wasn't 2020. It wasn't the,you know, months when we were
all in lockdown, and we did seesubstance use, including among
(04:14):
women, including among women ofchildbearing age increase. But
the most recent peak was in thelast couple of years. I think
cannabis legalization, I don'tthink there is evidence that
cannabis legalization has animpact on use in pregnancy. I
think that's related to changesin the perceptions of safety
(04:38):
around legalization, safer bothsocially, but also physically
safer.
As something becomes legal,people assume it's safer to use.
So I think it's both. We've seenmore use because there have been
changes in policy, but then alsothe effects of COVID on
isolation, mental health, andpeople using substances to cope
(05:02):
with those issues. However, wesaw in 2023 a decline in the
proportion of pregnant peopleusing substances. These data all
come from the National Survey onDrug Use and Health, which is a
population based study usingrepresentative sampling
approaches, but they only talkto between six and seven hundred
(05:24):
pregnant people a year.
So, you know, we areextrapolating based on a really
small percentage of respondents.
Rob Lott (05:31):
Got it. Understood. Okay. Against that backdrop, can
you say a little bit about theroles and responsibilities
historically of health careproviders caring for pregnant
women and newborns If and whenthey learn of a substance use
disorder, what does the law saythey have to do? What do our
(05:54):
sort of ethics and ourprinciples imply their various
responsibilities might be?
Margaret Sieger (05:59):
States policies dictate that. There is one
federal policy that saysanything about substance use in
pregnancy, and it is CAPTA, theChild Abuse Prevention and
Treatment Act, which in 2003added language about prenatal
substance exposure, which gaverise to the policy in
Connecticut that we researched.But in terms of those immediate
(06:21):
responses on whether you make areferral to child welfare or not
is dictated by state policies.Taking it a little more
granular, there are alsohospitals that operate their own
policies that are oftentimesmore conservative than the state
policy. But nonetheless, in overhalf of states, prenatal
(06:45):
substance exposure, whetherdocumented through toxicology,
self report, there's variationsin that as well.
Also variations depending on thetype of substance, whether there
are co occurring safetyconcerns, those all come into
play, but it's state policy thatsays something in, again, in
over 50% of states, there issome type of mandate to report
(07:08):
prenatal substance exposure.That's changed over time in that
it has increased dramaticallyover time. So Massachusetts was
the first state to have amandated reporting policy. That
happened totally independent ofany federal policy in 1974. It
was only a few states thereafterfor a long time until the crack
cocaine epidemic, quote,unquote, that increased to about
(07:31):
a quarter of states, a littlemore until the early two
thousands, jumped again, andthen we saw another jump in
02/2016.
Those last two are a reflectionof changes in federal policy. In
terms of sort of ethics of care,there are huge debates ranging
from, you know, anecdotally,I've heard of judges
(07:53):
incarcerating pregnant women forusing substances as a, you know,
dramatic and extreme effort toprevent the fetus from being
exposed. Best practices now areabout screening for substance
use, so asking verbal questionsto try and understand if there's
substance use, doing some typeof brief intervention and a
(08:17):
referral to treatment whenneeded. So we definitely don't
wanna stick our heads in thesand, and I think that's
something that in reaction toreally punitive approaches, some
providers will just ignore theissue entirely. That also, I
think, misses the mark becausethese are people who need help.
(08:40):
And we you know, in order toprovide that help, we have to
know what's going on. So that'sjust my take, though.
Rob Lott (08:47):
Sure. So I I it's a real tightrope, I think. Right?
I'm imagining the folks whomaybe wrote the initial
Massachusetts law aboutmandatory reporting were
thinking of the newborn and feltlike if we know that there's
this risky situation, the bestthing is to make sure that we
(09:10):
let the authorities know and letthem intervene. But you also
alluded to sort of punitiveapproaches and I think we know,
have learned over the years thatpunitive approaches can backfire
and actually make matters worse.
And so I'm curious, what do weknow sort of from the evidence
(09:31):
about the consequences ofsomething like mandatory
reporting or something like CPSreporting? How does that
typically affect outcomes, Iguess would be the ultimate
question. What are thedownstream consequences of
something like that?
Margaret Sieger (09:50):
Yeah. That's a very insightful comment. And I
agree. I think most of thesepolicies were passed with good
intentions of how do we helpthese families. And there have
been a number of unintendedconsequences ranging from things
that would seem very obvious,like a lot more referrals to
(10:11):
child welfare, a lot morechildren brought into foster
care, exacerbation of racedisparities to the disadvantage
of non Hispanic black families.
But things that seem even lessobvious, more unintended, less
maternal use of prenatal care,less maternal access to
(10:32):
substance use treatment inpregnancy, less access to
medications for opioid usedisorder in pregnancy, more
overdose deaths in states thathave really punitive policies.
So the in broad strokes, theimpact is that a very punitive
environment results in motherswith untreated substance use
disorders hiding from anyone whomight be able to do anything
(10:56):
about you know, you to use anyof these punitive actions
against them, and then they notonly don't access prenatal care,
but they don't access substanceuse treatment. So we have people
coming to deliver infants inhigher acuity states, higher
acuity situations than might bethe case if we used a more
(11:19):
supportive approach throughoutthe pregnancy.
Rob Lott (11:22):
Okay. Well, that's a great segue then for you perhaps
to tell us a little bit aboutthe policy in Connecticut that
they implemented there in 2019.What are the circumstances that
allowed for this change? Whatmotivated it? And how is it
different from what's going onin other states?
Margaret Sieger (11:41):
So I'm gonna give you some history. This is
maybe too much history. But likeI mentioned, in the early two
thousands, in 02/2003, the ChildAbuse Prevention and Treatment
Act, which was originally passedin 1974 and is just a very broad
it's a 75 page piece oflegislation. It covers all
different aspects of childwelfare practice. It funds all
(12:05):
sorts of things ranging fromchild abuse prevention efforts,
training with the workforce,research, and stipulates a lot
of different things that statesare responsible for in their
child welfare systems.
In 02/2003, the policy wasrevised to include that states
(12:26):
had a basically, a requirementto identify infants affected by
prenatal substance abuse. Thatwas in quotes. And that was I
think it was actually illegaldrug abuse is what the 2003
legislation said and develop aplan of safe care. It was two
sentences in this 75 page pieceof legislation, so most states
(12:48):
didn't change their practice inresponse to that federal policy
change. Then in 02/2010, thelanguage was again revised to in
addition to infants affected by,quote, unquote, illegal drug
abuse, they added fetal alcoholspectrum disorder.
(13:08):
So now states have to respond toinfants affected by those two
categories and still develop aplan of safe care. Again, we now
have an additional phrase addedto two sentences, but it's a
very small piece of thelegislation, and there's not
much in the way of carrot orstick to mandate that states
start doing this. But in02/2016, this policy was again
(13:32):
revised. The word illegal wasslashed. So now it's just any
drug abuse.
This was done to respond to theopioid epidemic when a lot of
substance use disorders andsubstance use in pregnancy were
to prescription medications. Andbecause it was part of the
federal response to the opioidepidemic, there was a lot more
(13:55):
focus on it. There was morepolitical will, and there was
also more funding attached toimplement these elements, which
include and, again, I'm gonnaquote the federal policy
notification to child protectionof the occurrence of these
infants being born and thedevelopment of a plan of safe
care that addresses the healthand substance use disorder
(14:15):
treatment needs of the affectedcaregiver and infant. So that
policy, as it changed in02/2016, in addition to, again,
the political will, Connecticutwas particularly impacted by the
opioid epidemic, and additionalfunding was released to help
states implement these CAPTAprovisions. That was the
backdrop.
That's what led to thesechanges. So these changes in
(14:37):
Connecticut were done to beresponsive to changes in this
federal CAPTA legislation. Partof the challenge, I've already
named a couple of challengeswith the brevity of the its
inclusion in this federallegislation is that it's very
broad, and states have been ableto implement all sorts of
(14:57):
different things, interpretingthe word notification to mean a
mandated report to childwelfare, have changed their
definitions of child abuse andneglect to include infants
affected by prenatal substanceexposure and have mandated that
a plan of safe care accompany achild welfare system response.
That would be the sort of most,quote, unquote, punitive end of
(15:18):
the spectrum. Connecticut didsomething completely innovative,
which is that they interpretedthat notification to be
something totally different froma mandated report.
And the way the legislation iswritten, it doesn't require that
the child welfare system learnthe identity of any of these
families, just that anotification be submitted.
(15:41):
Presumably, if you use a publichealth approach to anything, you
want to document the incidenceof a disease or the incidence of
a condition. So this is used forsort of public health
surveillance rather than for,you know, surveilling individual
families. And so they developedthis notification portal where
(16:03):
providers submit de identifiedinformation about the occurrence
of the birth that has prenatalsubstance exposure and then
develop that plan of safe care,which Connecticut calls a family
care plan, develop that outsidethe context of the child welfare
system. So it's typicallydeveloped by the hospital social
worker at the time of delivery.
(16:24):
Another real strength ofConnecticut's implementation is
that from day one, their adultmental health and substance use
treatment authority was veryinvested in the policy's
development and implementation,wanted it to be done in a way
that wouldn't expose mothers whowere using medications for
opioid use disorder to anyincreased punishment or even
(16:47):
perceived punitive reaction fromthe child welfare system. So
they have been very engaged intraining their workforce on
developing family care plans andimplementing them with pregnant
patients who are usingmedications for opioid use
disorder. So now Connecticut hasyeah. They have this brand new
(17:09):
pathway. If there are childwelfare concerns, and I think we
can talk about this in a minute,if there are child welfare
concerns, there's still amechanism so that you can refer
them to the child welfaresystem.
But if there are no abuse orneglect concerns, the family has
a family care plan, they'reconnected to services, they're
(17:29):
connected to treatment, nowConnecticut is simply
documenting the occurrence ofthe birth, again, for public
health surveillance purposes,identify where in the state
there are unmet needs aroundsubstance use treatment, things
like that, trends in substanceuse and pregnancy to inform
prevention approaches. Theycollect those data, they report
(17:53):
it to the federal government,and the family, you know, leaves
the hospital with their familycare plan, hopefully to never
come in contact with childwelfare unnecessarily.
Rob Lott (18:02):
Fair enough. Well, that's a really straightforward
description of a really bigchange. I wanna hear a little
more about what you've foundwhen you studied the effects of
that change. We'll do that,after this quick break. And
(19:09):
we're back.
I'm here with doctor MargaretLloyd Seger, and we're talking
about Connecticut's, novelprenatal substance exposure
policy. So just a moment ago,you told us all about the new
approach. What did you learnabout its impact during the
first couple years ofimplementation?
Margaret Sieger (19:29):
Yeah, we learned that it is having an
effect such that fewer infantsare being referred and screened
in to child welfare after thepolicy and of infants who do get
referred and screened in to thechild welfare system, fewer of
those babies are going intofoster care. I actually was
(19:51):
concerned that referrals wouldgo up after the policy just
because now providers needed torespond to every infant with
prenatal substance exposure. Weknew that awareness of prenatal
substance exposure couldincrease perceptions of risk to
infants. So just due to theincreased salience of the topic
and the notification portalasked some safety screening
(20:14):
questions to ensure that infantsthat need to get a referral.
Based on those questions, I wasworried that the rates of
reports were gonna go up.
And what we in fact saw is thatthe rates of reports relative to
the number of infants who areborn has gone down to the tune
of seven percent per month overthe course of the policy. The
(20:35):
similarly, the proportion ofinfants that go into foster care
has gone down four percent permonth since the policy was
passed.
Rob Lott (20:44):
Oh, wow. So when you say per month, are you saying
that from January to February,it went down seven percent and
then from February to March, itwent down another seven percent
and so on and so on?
Margaret Sieger (20:57):
Yes. On average over the study period. There are
fluctuations, but that is theaverage change on an, again,
aggregated average monthlybasis. Mhmm.
Rob Lott (21:08):
Wow. That's that's sounds pretty significant to me.
Can you talk a little bit aboutsort of how well targeted these
improvements may be? Earlier youalluded to there being avenues
still in place to get peoplehelp if they need it or or put
protections into place if theyneed it? What does that look
(21:30):
like in this case?
Margaret Sieger (21:32):
Our study doesn't directly address that
question. The fact that fewerinfants are going into foster
care is encouraging. It would bereally concerning if we saw a
reduction in referrals, but thenall of these babies were
suddenly going into foster care.We would be concerned that maybe
some of those middle riskinfants were not getting
(21:53):
connected to any services, andwe didn't see that. So that's
encouraging.
But again, our study doesn'taddress much beyond that initial
referral. We are going to be inthe future looking at the extent
to which this approach protectsfamilies from a referral later
in infancy and even later inearly childhood. We know that
(22:17):
under one is the highest risktime for any type of child
maltreatment and any type ofreferral to the child welfare
system. So we were looking atthe newborn hospitalization, and
we're gonna look through twelvemonths to understand how the
policies impacted infants laterin infancy. The fact that the
(22:37):
approach integrates that safetyscreener to me is improving the
targeting, that the system haschanged such that people aren't
going to providers aren't goingto be making a referral to child
welfare out of, quote, anabundance of caution because
there's this new screeningprocess kind of built in before
(23:00):
a referral is even made thatasks asks providers to think
critically about whether thesubstance use rises to a level
that creates concerns aroundchild safety or other concerns
for child abuse or neglect.
I do know anecdotally thatConnecticut's child welfare
system has been screening in aneven higher proportion of
(23:22):
referrals, meaning that peoplearen't making those referrals
that don't warrant attention orthey've been doing so less so.
So I think it's increasing theprecision, but that will be the
you know, that's just myhypothesis. To be determined.
Yeah. Exactly.
Rob Lott (23:38):
Okay. Well, you know, when when I hear you talk, when
I read the paper, this seemslike a a good story, good news
that we're sort of implementinga policy that's having
beneficial impact, at least fromour initial study of it. If I'm
a policymaker anywhere otherthan Connecticut, I'm thinking,
(24:00):
Oh, can we do this inMassachusetts or Ohio or
California or North Dakota? Howeasy could someone in those
shoes make this kind of change?Why and if so, why haven't we
already done it?
Margaret Sieger (24:17):
Yeah. That's a great question. We are actually
I'm working with my partners inConnecticut to write up the
story of the process by whichConnecticut implemented this
approach. So I think there's alot of people who have the same
exact question. And the shortanswer is that it was not easy.
The longer version of thatanswer is that it is totally
(24:41):
doable. Well, where there is awill, there is a way. So my
first point of advice, whichcomes directly from my, you
know, conversations with folkson the ground in Connecticut, is
that developing, building aninterprofessional working group
is step one. You have to havechild welfare, treatment, and
(25:06):
hospitals at the table. Becausein order for this to work well,
those three pillars need to bein place.
Where states have gone awry isnot bringing hospitals to the
table, not bringing the adultsubstance use treatment
providers to the table, andimplementing something that is
essentially just a replica ofthe status quo, child welfare
doing child welfare, which isgreat, but it's not gonna move
(25:29):
in the direction of aninnovative approach. So that is
ground zero is bringing thosepartners to the table. And
Connecticut has also invested alot in they built the system.
The notification system wasengineered specifically for the
implementation of this policy.They have been you know, people
(25:50):
have been putting a lot of skinin the game, to implement this
policy both from the childwelfare system and the adult
substance use treatment system.
So if a state or county isinterested in doing this, it is
absolutely doable. There has tobe the political will to do it
because it's gonna take a lot ofpeople coming to the
Rob Lott (26:08):
table. Great. Well, yeah. That too. Well, thank you
so much.
This is perhaps a good spot forus to wrap up. Really appreciate
your work on this issue and for,your time here today. Thanks for
joining us.
Margaret Sieger (26:25):
Thanks so much.
Rob Lott (26:27):
And for our listeners, thanks for tuning in. If you
enjoyed this episode, pleaseleave a review, share it with a
friend, hit that subscribebutton and tune in next week.
Thank you everyone. Thanks forlistening. If you enjoyed
today's episode, I hope you'lltell a friend about a health
(26:47):
policy.
Hello, and welcome to A Health Podicy. I'm your host,
(00:04):
Rob Lott. Untreated substanceuse disorder in pregnancy is a
long standing and persistentpublic health concern. That's
the first line of a new paper inthe July issue of Health
Affairs, and it spotlights acomplicated question. What are
(00:28):
our responsibilities as asociety to the parties involved
when it comes to untreatedsubstance use disorder in
pregnancy?
One responsibility, of course,is to the pregnant person to
help them get support andtreatment they might need. One
is to the future newborn toensure they have a healthy and
(00:48):
thriving parent and family thatcan provide the love and care
they need. And one is to thecaregivers, the doctors, the
clinicians, and the policymakersto ensure that they have the
guidance and tools they need toprovide the care and treatment
that's compassionate, just andrighteous. Is it possible for
(01:12):
public policy to honor all ofthose responsibilities and
goals? That's the subject oftoday's health policy.
I'm here with Doctor. MargaretLloyd Seger, an associate
professor at the University ofKansas School of Medicine in the
Department of Population Health.She and her coauthors wrote the
paper whose first line I justshared with you. It was just
(01:36):
published in the July issue ofHealth Affairs, and its title is
also one of its main findings.Connecticut's novel prenatal
substance exposure policy isassociated with declining CPS
reports and foster placements.
Doctor. Margaret Lloyd Seger,thank you so much for joining
(01:57):
us.
Margaret Sieger (01:58):
I'm so excited to be here.
Rob Lott (02:00):
All right, let's just dive right in. Let's start with
a little background. What do wecurrently know about substance
use disorder during pregnancy?How widespread is it? And what
sort of typically happens in asituation where that's the case?
Margaret Sieger (02:16):
Yeah. Great question. It's a little bit
tough to answer because we areoccasionally talking about any
substance use, and then othertimes we're talking about
substance use disorder. So ifwe're talking about substance
use, between five and fifteenpercent of pregnant women use
substances, including alcoholand cannabis at some point after
(02:40):
learning that they're pregnant.Nationally, self reported use in
pregnancy rose to a recent peakin 2022 to over nine percent of
pregnant women self reportingsubstance use in pregnancy.
Now we also know, however, thatpersisting in substance use in
pregnancy can be an indicationthat there is a substance use
(03:03):
disorder, and substance usedisorders, including at higher
severities, are more commonamong pregnant people who
continue using substances versusthe general population. But
short answer is somewherebetween five and fifteen
percent. We did some earlieranalyses of Connecticut's
approach in order to essentiallycount the number of people who
(03:27):
were using substances, and itwas eight percent of births had
substance exposure at some pointin pregnancy.
Rob Lott (03:34):
Okay. And you just mentioned that we sort of
reached a peak during was itduring COVID? And I'm curious,
do you have a sense, is that anincrease in self reporting or an
increase in use or in sort ofprevalence of the disorder? And
are we able to extricate thosetwo things from each other?
Margaret Sieger (03:53):
Yeah. That is a really good question as well. So
I think the answer is both.Substance use among everyone in
The US increased secondary toCOVID. The peak was actually in
2022 though, which is sort of acouple of years.
It wasn't 2020. It wasn't the,you know, months when we were
all in lockdown, and we did seesubstance use, including among
(04:14):
women, including among women ofchildbearing age increase. But
the most recent peak was in thelast couple of years. I think
cannabis legalization, I don'tthink there is evidence that
cannabis legalization has animpact on use in pregnancy. I
think that's related to changesin the perceptions of safety
(04:38):
around legalization, safer bothsocially, but also physically
safer.
As something becomes legal,people assume it's safer to use.
So I think it's both. We've seenmore use because there have been
changes in policy, but then alsothe effects of COVID on
isolation, mental health, andpeople using substances to cope
(05:02):
with those issues. However, wesaw in 2023 a decline in the
proportion of pregnant peopleusing substances. These data all
come from the National Survey onDrug Use and Health, which is a
population based study usingrepresentative sampling
approaches, but they only talkto between six and seven hundred
(05:24):
pregnant people a year.
So, you know, we areextrapolating based on a really
small percentage of respondents.
Rob Lott (05:31):
Got it. Understood. Okay. Against that backdrop, can
you say a little bit about theroles and responsibilities
historically of health careproviders caring for pregnant
women and newborns If and whenthey learn of a substance use
disorder, what does the law saythey have to do? What do our
(05:54):
sort of ethics and ourprinciples imply their various
responsibilities might be?
Margaret Sieger (05:59):
States policies dictate that. There is one
federal policy that saysanything about substance use in
pregnancy, and it is CAPTA, theChild Abuse Prevention and
Treatment Act, which in 2003added language about prenatal
substance exposure, which gaverise to the policy in
Connecticut that we researched.But in terms of those immediate
(06:21):
responses on whether you make areferral to child welfare or not
is dictated by state policies.Taking it a little more
granular, there are alsohospitals that operate their own
policies that are oftentimesmore conservative than the state
policy. But nonetheless, in overhalf of states, prenatal
(06:45):
substance exposure, whetherdocumented through toxicology,
self report, there's variationsin that as well.
Also variations depending on thetype of substance, whether there
are co occurring safetyconcerns, those all come into
play, but it's state policy thatsays something in, again, in
over 50% of states, there issome type of mandate to report
(07:08):
prenatal substance exposure.That's changed over time in that
it has increased dramaticallyover time. So Massachusetts was
the first state to have amandated reporting policy. That
happened totally independent ofany federal policy in 1974. It
was only a few states thereafterfor a long time until the crack
cocaine epidemic, quote,unquote, that increased to about
(07:31):
a quarter of states, a littlemore until the early two
thousands, jumped again, andthen we saw another jump in
02/2016.
Those last two are a reflectionof changes in federal policy. In
terms of sort of ethics of care,there are huge debates ranging
from, you know, anecdotally,I've heard of judges
(07:53):
incarcerating pregnant women forusing substances as a, you know,
dramatic and extreme effort toprevent the fetus from being
exposed. Best practices now areabout screening for substance
use, so asking verbal questionsto try and understand if there's
substance use, doing some typeof brief intervention and a
(08:17):
referral to treatment whenneeded. So we definitely don't
wanna stick our heads in thesand, and I think that's
something that in reaction toreally punitive approaches, some
providers will just ignore theissue entirely. That also, I
think, misses the mark becausethese are people who need help.
(08:40):
And we you know, in order toprovide that help, we have to
know what's going on. So that'sjust my take, though.
Rob Lott (08:47):
Sure. So I I it's a real tightrope, I think. Right?
I'm imagining the folks whomaybe wrote the initial
Massachusetts law aboutmandatory reporting were
thinking of the newborn and feltlike if we know that there's
this risky situation, the bestthing is to make sure that we
(09:10):
let the authorities know and letthem intervene. But you also
alluded to sort of punitiveapproaches and I think we know,
have learned over the years thatpunitive approaches can backfire
and actually make matters worse.
And so I'm curious, what do weknow sort of from the evidence
(09:31):
about the consequences ofsomething like mandatory
reporting or something like CPSreporting? How does that
typically affect outcomes, Iguess would be the ultimate
question. What are thedownstream consequences of
something like that?
Margaret Sieger (09:50):
Yeah. That's a very insightful comment. And I
agree. I think most of thesepolicies were passed with good
intentions of how do we helpthese families. And there have
been a number of unintendedconsequences ranging from things
that would seem very obvious,like a lot more referrals to
(10:11):
child welfare, a lot morechildren brought into foster
care, exacerbation of racedisparities to the disadvantage
of non Hispanic black families.
But things that seem even lessobvious, more unintended, less
maternal use of prenatal care,less maternal access to
(10:32):
substance use treatment inpregnancy, less access to
medications for opioid usedisorder in pregnancy, more
overdose deaths in states thathave really punitive policies.
So the in broad strokes, theimpact is that a very punitive
environment results in motherswith untreated substance use
disorders hiding from anyone whomight be able to do anything
(10:56):
about you know, you to use anyof these punitive actions
against them, and then they notonly don't access prenatal care,
but they don't access substanceuse treatment. So we have people
coming to deliver infants inhigher acuity states, higher
acuity situations than might bethe case if we used a more
(11:19):
supportive approach throughoutthe pregnancy.
Rob Lott (11:22):
Okay. Well, that's a great segue then for you perhaps
to tell us a little bit aboutthe policy in Connecticut that
they implemented there in 2019.What are the circumstances that
allowed for this change? Whatmotivated it? And how is it
different from what's going onin other states?
Margaret Sieger (11:41):
So I'm gonna give you some history. This is
maybe too much history. But likeI mentioned, in the early two
thousands, in 02/2003, the ChildAbuse Prevention and Treatment
Act, which was originally passedin 1974 and is just a very broad
it's a 75 page piece oflegislation. It covers all
different aspects of childwelfare practice. It funds all
(12:05):
sorts of things ranging fromchild abuse prevention efforts,
training with the workforce,research, and stipulates a lot
of different things that statesare responsible for in their
child welfare systems.
In 02/2003, the policy wasrevised to include that states
(12:26):
had a basically, a requirementto identify infants affected by
prenatal substance abuse. Thatwas in quotes. And that was I
think it was actually illegaldrug abuse is what the 2003
legislation said and develop aplan of safe care. It was two
sentences in this 75 page pieceof legislation, so most states
(12:48):
didn't change their practice inresponse to that federal policy
change. Then in 02/2010, thelanguage was again revised to in
addition to infants affected by,quote, unquote, illegal drug
abuse, they added fetal alcoholspectrum disorder.
(13:08):
So now states have to respond toinfants affected by those two
categories and still develop aplan of safe care. Again, we now
have an additional phrase addedto two sentences, but it's a
very small piece of thelegislation, and there's not
much in the way of carrot orstick to mandate that states
start doing this. But in02/2016, this policy was again
(13:32):
revised. The word illegal wasslashed. So now it's just any
drug abuse.
This was done to respond to theopioid epidemic when a lot of
substance use disorders andsubstance use in pregnancy were
to prescription medications. Andbecause it was part of the
federal response to the opioidepidemic, there was a lot more
(13:55):
focus on it. There was morepolitical will, and there was
also more funding attached toimplement these elements, which
include and, again, I'm gonnaquote the federal policy
notification to child protectionof the occurrence of these
infants being born and thedevelopment of a plan of safe
care that addresses the healthand substance use disorder
(14:15):
treatment needs of the affectedcaregiver and infant. So that
policy, as it changed in02/2016, in addition to, again,
the political will, Connecticutwas particularly impacted by the
opioid epidemic, and additionalfunding was released to help
states implement these CAPTAprovisions. That was the
backdrop.
That's what led to thesechanges. So these changes in
(14:37):
Connecticut were done to beresponsive to changes in this
federal CAPTA legislation. Partof the challenge, I've already
named a couple of challengeswith the brevity of the its
inclusion in this federallegislation is that it's very
broad, and states have been ableto implement all sorts of
(14:57):
different things, interpretingthe word notification to mean a
mandated report to childwelfare, have changed their
definitions of child abuse andneglect to include infants
affected by prenatal substanceexposure and have mandated that
a plan of safe care accompany achild welfare system response.
That would be the sort of most,quote, unquote, punitive end of
(15:18):
the spectrum. Connecticut didsomething completely innovative,
which is that they interpretedthat notification to be
something totally different froma mandated report.
And the way the legislation iswritten, it doesn't require that
the child welfare system learnthe identity of any of these
families, just that anotification be submitted.
(15:41):
Presumably, if you use a publichealth approach to anything, you
want to document the incidenceof a disease or the incidence of
a condition. So this is used forsort of public health
surveillance rather than for,you know, surveilling individual
families. And so they developedthis notification portal where
(16:03):
providers submit de identifiedinformation about the occurrence
of the birth that has prenatalsubstance exposure and then
develop that plan of safe care,which Connecticut calls a family
care plan, develop that outsidethe context of the child welfare
system. So it's typicallydeveloped by the hospital social
worker at the time of delivery.
(16:24):
Another real strength ofConnecticut's implementation is
that from day one, their adultmental health and substance use
treatment authority was veryinvested in the policy's
development and implementation,wanted it to be done in a way
that wouldn't expose mothers whowere using medications for
opioid use disorder to anyincreased punishment or even
(16:47):
perceived punitive reaction fromthe child welfare system. So
they have been very engaged intraining their workforce on
developing family care plans andimplementing them with pregnant
patients who are usingmedications for opioid use
disorder. So now Connecticut hasyeah. They have this brand new
(17:09):
pathway. If there are childwelfare concerns, and I think we
can talk about this in a minute,if there are child welfare
concerns, there's still amechanism so that you can refer
them to the child welfaresystem.
But if there are no abuse orneglect concerns, the family has
a family care plan, they'reconnected to services, they're
(17:29):
connected to treatment, nowConnecticut is simply
documenting the occurrence ofthe birth, again, for public
health surveillance purposes,identify where in the state
there are unmet needs aroundsubstance use treatment, things
like that, trends in substanceuse and pregnancy to inform
prevention approaches. Theycollect those data, they report
(17:53):
it to the federal government,and the family, you know, leaves
the hospital with their familycare plan, hopefully to never
come in contact with childwelfare unnecessarily.
Rob Lott (18:02):
Fair enough. Well, that's a really straightforward
description of a really bigchange. I wanna hear a little
more about what you've foundwhen you studied the effects of
that change. We'll do that,after this quick break. And
(19:09):
we're back.
I'm here with doctor MargaretLloyd Seger, and we're talking
about Connecticut's, novelprenatal substance exposure
policy. So just a moment ago,you told us all about the new
approach. What did you learnabout its impact during the
first couple years ofimplementation?
Margaret Sieger (19:29):
Yeah, we learned that it is having an
effect such that fewer infantsare being referred and screened
in to child welfare after thepolicy and of infants who do get
referred and screened in to thechild welfare system, fewer of
those babies are going intofoster care. I actually was
(19:51):
concerned that referrals wouldgo up after the policy just
because now providers needed torespond to every infant with
prenatal substance exposure. Weknew that awareness of prenatal
substance exposure couldincrease perceptions of risk to
infants. So just due to theincreased salience of the topic
and the notification portalasked some safety screening
(20:14):
questions to ensure that infantsthat need to get a referral.
Based on those questions, I wasworried that the rates of
reports were gonna go up.
And what we in fact saw is thatthe rates of reports relative to
the number of infants who areborn has gone down to the tune
of seven percent per month overthe course of the policy. The
(20:35):
similarly, the proportion ofinfants that go into foster care
has gone down four percent permonth since the policy was
passed.
Rob Lott (20:44):
Oh, wow. So when you say per month, are you saying
that from January to February,it went down seven percent and
then from February to March, itwent down another seven percent
and so on and so on?
Margaret Sieger (20:57):
Yes. On average over the study period. There are
fluctuations, but that is theaverage change on an, again,
aggregated average monthlybasis. Mhmm.
Rob Lott (21:08):
Wow. That's that's sounds pretty significant to me.
Can you talk a little bit aboutsort of how well targeted these
improvements may be? Earlier youalluded to there being avenues
still in place to get peoplehelp if they need it or or put
protections into place if theyneed it? What does that look
(21:30):
like in this case?
Margaret Sieger (21:32):
Our study doesn't directly address that
question. The fact that fewerinfants are going into foster
care is encouraging. It would bereally concerning if we saw a
reduction in referrals, but thenall of these babies were
suddenly going into foster care.We would be concerned that maybe
some of those middle riskinfants were not getting
(21:53):
connected to any services, andwe didn't see that. So that's
encouraging.
But again, our study doesn'taddress much beyond that initial
referral. We are going to be inthe future looking at the extent
to which this approach protectsfamilies from a referral later
in infancy and even later inearly childhood. We know that
(22:17):
under one is the highest risktime for any type of child
maltreatment and any type ofreferral to the child welfare
system. So we were looking atthe newborn hospitalization, and
we're gonna look through twelvemonths to understand how the
policies impacted infants laterin infancy. The fact that the
(22:37):
approach integrates that safetyscreener to me is improving the
targeting, that the system haschanged such that people aren't
going to providers aren't goingto be making a referral to child
welfare out of, quote, anabundance of caution because
there's this new screeningprocess kind of built in before
(23:00):
a referral is even made thatasks asks providers to think
critically about whether thesubstance use rises to a level
that creates concerns aroundchild safety or other concerns
for child abuse or neglect.
I do know anecdotally thatConnecticut's child welfare
system has been screening in aneven higher proportion of
(23:22):
referrals, meaning that peoplearen't making those referrals
that don't warrant attention orthey've been doing so less so.
So I think it's increasing theprecision, but that will be the
you know, that's just myhypothesis. To be determined.
Yeah. Exactly.
Rob Lott (23:38):
Okay. Well, you know, when when I hear you talk, when
I read the paper, this seemslike a a good story, good news
that we're sort of implementinga policy that's having
beneficial impact, at least fromour initial study of it. If I'm
a policymaker anywhere otherthan Connecticut, I'm thinking,
(24:00):
Oh, can we do this inMassachusetts or Ohio or
California or North Dakota? Howeasy could someone in those
shoes make this kind of change?Why and if so, why haven't we
already done it?
Margaret Sieger (24:17):
Yeah. That's a great question. We are actually
I'm working with my partners inConnecticut to write up the
story of the process by whichConnecticut implemented this
approach. So I think there's alot of people who have the same
exact question. And the shortanswer is that it was not easy.
The longer version of thatanswer is that it is totally
(24:41):
doable. Well, where there is awill, there is a way. So my
first point of advice, whichcomes directly from my, you
know, conversations with folkson the ground in Connecticut, is
that developing, building aninterprofessional working group
is step one. You have to havechild welfare, treatment, and
(25:06):
hospitals at the table. Becausein order for this to work well,
those three pillars need to bein place.
Where states have gone awry isnot bringing hospitals to the
table, not bringing the adultsubstance use treatment
providers to the table, andimplementing something that is
essentially just a replica ofthe status quo, child welfare
doing child welfare, which isgreat, but it's not gonna move
(25:29):
in the direction of aninnovative approach. So that is
ground zero is bringing thosepartners to the table. And
Connecticut has also invested alot in they built the system.
The notification system wasengineered specifically for the
implementation of this policy.They have been you know, people
(25:50):
have been putting a lot of skinin the game, to implement this
policy both from the childwelfare system and the adult
substance use treatment system.
So if a state or county isinterested in doing this, it is
absolutely doable. There has tobe the political will to do it
because it's gonna take a lot ofpeople coming to the
Rob Lott (26:08):
table. Great. Well, yeah. That too. Well, thank you
so much.
This is perhaps a good spot forus to wrap up. Really appreciate
your work on this issue and for,your time here today. Thanks for
joining us.
Margaret Sieger (26:25):
Thanks so much.
Rob Lott (26:27):
And for our listeners, thanks for tuning in. If you
enjoyed this episode, pleaseleave a review, share it with a
friend, hit that subscribebutton and tune in next week.
Thank you everyone. Thanks forlistening. If you enjoyed
today's episode, I hope you'lltell a friend about a health
(26:47):
policy.
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