Impact of policies on pregnant individuals using drugs: A narrative synthesis review of treatment, health care access, and outcomes.

Amid the opioid epidemic and racial disparities in maternal and child health, there is increasing interest from clinicians, patients, and policymakers in understanding how state policies impact pregnant individuals using drugs, particularly regarding healthcare access and outcomes. This narrative synthesis examines the types of policies affecting this population and their consequences on maternal and child health. Following PRISMA guidelines, we reviewed 408 studies, selecting 28 relevant articles to assess the prevalence and effects of punitive laws targeting pregnant individuals using drugs. The review reveals an increase in punitive policies over time, such as considering substance use as child abuse, mandatory reporting with positive toxicology tests, and cannabis-related regulations, including restrictions on breastfeeding. However, the findings are mixed regarding neonatal abstinence syndrome (NAS) and mandatory reporting. Some studies show a rise or decrease in NAS following punitive policy changes, while others suggest that such policy changes may lead to lower rates of provider reporting. The fear of being reported may discourage some pregnant individuals from seeking prenatal care due to increased stigma. Other studies report confusion about mandatory reporting procedures and providers' concerns about damaging patient trust. Policies sanctioning incarceration of pregnant individuals using substances also increase out-of-state births, potentially endangering both mothers and infants. This study highlights the harmful, unintended consequences of various policies and discusses interventions and future research directions.