The Alabama Supreme Court decision: Will it make delivering appropriate health care to pregnant women more difficult?

Photo of Alabama Supreme Court building

The Alabama Supreme Court recently decided that pregnant women can be prosecuted under a law intended to protect children from methamphetamine labs. Much of the resulting discussion has focused on the implications for “personhood” and on other instances in which women have been punished and prosecuted for their behavior while pregnant. Outrage at these prosecutions, and concern about the slippery slope they open up for abortion and for other behaviors pregnant women may engage in, are certainly appropriate responses. However, it is also important to ask: What are the implications of this decision for delivering recommended health-based interventions to pregnant women who use drugs?

While the evidence isn’t conclusive, there is some suggestion that prenatal care-based interventions—such as screening, brief intervention, and referral to treatment for drug use (also known collectively as SBIRT)—may help women have healthier babies. Many (but not all) leading national health organizations recommend SBIRT. Two key ingredients are necessary, however, for SBIRT to even have a chance of working:

  • First, pregnant women who use drugs need to go to prenatal care.
  • And second, they need to trust their prenatal health care providers.

Research my colleagues and I conducted suggests that the Alabama Supreme Court decision has implications for each of these ingredients.

In our research, we interviewed women who used drugs during pregnancy about barriers to prenatal care. While most of the women we interviewed did get at least some prenatal care, a variety of reasons led women to delay prenatal care entry and skip prenatal care appointments. Among these reasons was fear that attending prenatal care would lead to punishment. And the punishment that women feared most was being reported to Child Protective Services (CPS) and having their children removed. A few women also reported fear that going to prenatal care would lead to them going to jail.

Women’s fears of being reported to CPS weren’t surprising. At the time we conducted this research in a California county, a little less than 1% of newborns in the county were being reported to CPS due to maternal drug use. That women reported fear of going to jail, however, was somewhat more surprising. Prosecutions for drug use during pregnancy are not as common, especially in the western part of the United States. But if prosecutions become more common and punishments “stick,” it seems fair to anticipate that women’s fears of being prosecuted will increase and that fewer pregnant women who use drugs will attend prenatal care.

The second necessary ingredient—that women trust their prenatal health care providers enough to disclose and talk honestly about their drug use—is also threatened by the Alabama decision. Many pregnant women using drugs already do not trust their prenatal care providers. Research shows that they expect that providers who find out about their drug use will, at the very least, judge them—and worse, may report them to CPS. It is reasonable to assume that trust will be eroded even further if it becomes more common for women to be prosecuted for information about their drug use that health care providers obtain from them or from their newborn.

This is not to say that SBIRT for pregnant women using drugs is a silver bullet, or that there is sufficient evidence to say that it definitively improves birth outcomes, reduces maternal drug use during and after pregnancy, or reduces the need for CPS involvement. But if women don’t show up for care, and don’t disclose their drug use to providers out of fear of prosecution, then health-care based interventions to help reduce drug use don’t even have a chance of working.

For this reason, the Alabama Supreme Court decision should concern anyone—especially public health and health care professionals—interested in improving outcomes for children born to women who use drugs during pregnancy. Laws like this can be expected to make providing high-quality and appropriate health care to all pregnant women—both women carrying pregnancies to term and women wanting to terminate pregnancies—more and more difficult.

Photo of Alabama Supreme Court building courtesy Jimmy Emerson via creative commons license.

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