Criminalizing substance use during pregnancy and parenting is not only harmful for mothers and caregivers, it’s harmful for public health at large. It’s time to make a change in how we treat pregnant women, mothers, and caregivers who use drugs. To start with, there are many misconceptions about the effects of drug use during pregnancy and parenting. For example, legal drugs like alcohol, tobacco, or common prescription drugs are often more harmful to fetuses than drugs that are currently illegal (West, 2021). Furthermore, the effects of illegal drugs can typically be treated with minimal long-term impacts on babies (West, 2021). However, the stigma associated with substance use and the fear of criminalization prevents mothers from seeking help.
Criminalizing substance use during pregnancy prevents women from getting the care they need. This includes reproductive/maternal health care and potential treatment for substance use. Punitive approaches include, but are not limited to, arrest, incarceration, and loss of parental custody (Terplan et al., 2015). These approaches are not based on scientific evidence, are applied unequally on the basis of race, and do not address the structural factors contributing to substance use disorders (SUD) during pregnancy (Terplan et al., 2015). Structural factors refer to the policies, economic systems, and institutions that produce and maintain social inequities, typically along the lines of social categories such as race/ethnicity, class status, gender identity, sexuality, and ability (Knight, 2017). Historical and intergenerational trauma, as a result of these structural factors, also contribute to SUD (West, 2021).
Rather than getting to the root of what structural factors cause pregnant women and parents to use substances, we are criminalizing the individual and causing further harm—which impacts Black families the most (West, 2021). Black families are already at risk for greater adverse health outcomes as a result of the way structural factors disproportionately impact communities of color, and because the prejudice and discrimination directed towards marginalized communities bring about unique stressors (West, 2021). In the United States, “pregnant and parenting women with ongoing substance use (prescription and/or illicit) have been specific, targeted recipients of racialized health and health-care discrimination” (Knight, 2020). That means behavior is criminalized instead of treated. In fact, policies that criminalize substance use during pregnancy have been associated with significantly higher rates of neonatal abstinence syndrome (Knight, 2020).
As a result of stigma, women and caregivers with SUD often choose to avoid seeking help or treatment “because they fear experiencing discrimination and stigma due to their substance use, and/or perceived race/ethnicity or class status, and/or because they fear that they will lose custody of their children if their substance use is revealed” (Knight, 2020). The impact of this on public health is huge: The structural stigmas perpetuated by punitive and criminalizing policies are associated with poor prenatal care and birth outcomes (Knight, 2020). As this stigma continues to be perpetuated, “public stigma and enacted stigma… become structural stigma when they become encoded in cultural norms, laws, and institutional policies” (Knight, 2020), thus impacting the rest of society.
This problem is exacerbated when considering the effects on mothers and caregivers, in addition to pregnant women. Drug usage does not indicate parental unfitness (Terplan et al., 2015). Nonetheless, society typically deems those who use drugs unfit to raise children. As a result, we cause more harm by removing children from their families. Losing parental custody often results in children being separated from their families and becoming part of the foster care system, impacting their emotional, and often physical, well-being. Additionally, this loss has a large health impact on mothers who experience this separation as traumatic (Kenny et al., 2015). In one study, women described this pain as unbearable and reported symptoms of post-traumatic stress disorder and other mental health conditions (Kenny et al., 2015). As a result, many turn to the increased use of drugs and alcohol to numb the pain, reinforcing a heightened vulnerability through increased exposure to housing instability, intimate partner violence, and sex work (Kenny et al., 2015). Parents with SUD are forced into a lose-lose situation: avoid treatment and risk the health of the baby and themselves with further substance use or get help and risk being criminalized or losing custody of the child. The latter often results in further substance use for the parent and further harm for the child.
Stigma is causing just as much, if not more, harm as the SUD themselves in its impact on public health. We should “integrate reproductive justice and harm-reduction frameworks to address productively the multiple forms of stigma that pregnant people with [SUD] experience, particularly those who are caught in webs of incarceration, criminalization, housing insecurity, and child welfare system involvement” (Knight, 2020). Switching to non-criminalizing, non-punitive policies will improve birth outcomes for pregnant women with substance use disorders (Knight, 2020)
Offering treatment and care in a supportive, non-discriminatory setting will encourage those with SUD to seek help. Policies that provide support and treatment will encourage keeping families together, rather than tearing them apart, which will have positive long-term health consequences for both parent and child. One thing is clear: in order to make real positive change for mothers and improve public health, the so-called “War on Drugs” needs to become “the War on Stigma.”
Kenny, K. S., Barrington, C., & Green, S. L. (2015). “I felt for a long time like everything beautiful in me had been taken out”: Women’s suffering, remembering, and survival following the loss of child custody. International Journal of Drug Policy, 26(11), 1158–1166. https://doi.org/10.1016/j.drugpo.2015.05.024
Knight, K. R. (2020). Structural Factors That Affect Life Contexts of Pregnant People With Opioid Use Disorders: The Role of Structural Racism and the Need for Structural Competency. Women’s Reproductive Health, 7(3), 164–171. https://doi.org/10.1080/23293691.2020.1780400
Knight, K. R. (2017). Women on the Edge: Opioids, Benzodiazepines, and the Social Anxieties Surrounding Women’s Reproduction in the U.S. “Opioid Epidemic.” Contemporary Drug Problems, 44(4), 301–320. https://doi.org/10.1177/0091450917740359
Terplan M., Kennedy-Hendricks A., & Chisolm M. S. (2015). Prenatal Substance Use: Exploring Assumptions of Maternal Unfitness. Substance Abuse: Research and Treatment, 2015-S2, 1–4. https://doi.org/10.4137/SART.S23328
West, Brooke. (2021). Session 2: It’s bigger than you—Contexts of substance use over the lifecourse. (PowerPoint presentation.) Columbia University.