Prenatal drug use criminalization and health system avoidance: Evidence from births in Alabama, South Carolina, and...

States are increasingly adopting legislation that explicitly criminalizes drug use during pregnancy. Evidence from Tennessee suggests such policies may lead to increases in health system avoidance, yet prior research has not explored this relationship in other contexts. We examined whether explicit criminalization policies in Alabama, South Carolina, and Tennessee were associated changes in prenatal care and facility-based delivery at the population-level.

Outcome data were derived from birth certificate records aggregated to the county-year-level between 1989 and 2019. Primary outcomes included the prevalence of any prenatal care and facility-based delivery, while secondary outcomes captured dimensions of prenatal care quality, specifically timeliness (i.e., first trimester initiation) and adequacy (i.e., completed number of recommended visits). We used two-way fixed effects models to test associations, also controlling for co-occurring policy changes and other time-varying confounders.

State adoption of an explicit prenatal drug criminalization was associated with 4396.29 fewer births per 100,000 receiving any prenatal care (95 % Confidence Interval [CI]: -6176.07, -2616.51). Additionally, criminalization was associated with 1847.99 fewer facility-based deliveries (CI: -3688.29, -7.69), though some estimates were imprecise across several sensitivity analyses. We observed no clear changes in the prevalence of timely (-1328.43; [CI: -3108.21, 451.36]) or adequate (-792.21; [CI: -2571.99, 987.58]) prenatal care following criminalization, though decreases in timeliness were suggested.

We found that policies explicitly criminalizing prenatal drug use were associated with some reductions in prenatal care and facility-based delivery, suggesting that such punitive approaches may be associated with health system avoidance.