Punitive drug laws may deter prenatal care and hospital-based delivery

October 29, 2025 — States that explicitly criminalize prenatal drug use may unintentionally discourage pregnant people from seeking essential medical care, according to new research from Columbia University Mailman School of Public Health. The study is the first to empirically test whether fear of legal repercussions leads some people with drug use disorders to give birth outside healthcare settings to avoid hospital drug testing. The findings are published in Social Science & Medicine.

“Comprehensive perinatal care is crucial for healthy pregnancy outcomes, yet people who use drugs are significantly less likely to receive it,” said Emilie Bruzelius, a postdoctoral fellow in Epidemiology at Columbia Mailman School, and first author. “Our findings suggest that criminalizing prenatal drug use may worsen this gap by driving avoidance of healthcare services.”

The researchers examined more than 124 million births across 83,300 county-years and found that explicit prenatal drug criminalization policies were associated with reductions in prenatal care and facility-based deliveries. For example, states adopting such policies saw declines in overall and first-trimester care initiation. In particular, there were on average 4,396 fewer births per 100,000 with any prenatal care in criminalization states relative to non-criminalization states.  Additionally, criminalization was associated with 1,848 fewer facility-based deliveries.

Over the past decade, a growing number of states have enacted pregnancy-related substance use laws. Some, including Tennessee, South Carolina, and Alabama -- the focus of this study -- have gone further by directly designating prenatal drug use as a felony or misdemeanor offense.

“These laws were often originally intended to encourage treatment by including provisions to exempt those already in care from prosecution,” according to Silvia Martins, MD, PhD, professor of Epidemiology at Columbia Mailman School, and senior author. “However, emerging evidence suggests the opposite effect—fewer treatment admissions, less prenatal care, and more births occurring outside healthcare facilities.”

The authors note that healthcare avoidance in response to legal risk mirrors behaviors seen in other contexts—such as among immigrants fearing deportation. They warn that such avoidance carries serious health consequences, particularly for high-risk pregnancies.

“Formal laws do make a difference, and efforts to repeal these types of laws would go a long way to better support maternal and neonatal health,” Bruzelius said. “Future research should pinpoint which policies most discourage care and guide reforms that protect, rather than punish, pregnant people.”

Co-authors include Seth Prins and Lisa Bates, Columbia Mailman School; Karen Underhill, Cornell Law School; and Marian Jarlenski, University of Pittsburgh School of Public Health.

The study was supported by the National Institute on Drug Abuse (T32DA031099, R01DA053745).

The authors report no financial conflicts of interest.

Columbia University Mailman School of Public Health

Founded in 1922, the Columbia University Mailman School of Public Health pursues an agenda of research, education, and service to address the critical and complex public health issues affecting New Yorkers, the nation and the world. The Columbia Mailman School is the third largest recipient of NIH grants among schools of public health. Its nearly 300 multi-disciplinary faculty members work in more than 100 countries around the world, addressing such issues as preventing infectious and chronic diseases, environmental health, maternal and child health, health policy, climate change and health, and public health preparedness. It is a leader in public health education with more than 1,300 graduate students from 55 nations pursuing a variety of master’s and doctoral degree programs. The Columbia Mailman School is also home to numerous world-renowned research centers, including ICAP and the Center for Infection and Immunity. For more information, please visit www.mailman.columbia.edu.