Three years after Colorado stopped requiring doctors to report newborns who tested positive for drugs as possible child abuse victims, the number of families referred to child protective services for prenatal drug use is down 25% — but hospitals are still learning how best to support new mothers battling addiction.

Previously, if a child tested positive for a controlled substance at birth, the state considered it evidence of abuse. Hospitals weren’t required to test birthing parents or newborns, but many thought they were, or at least that it was a standard part of care, said Amber Johnson, a nurse midwife and director of quality improvement at the Colorado Perinatal Care Quality Collaborative.

“It’s a pretty radical change,” she said.

In 2020, the Colorado legislature narrowed the definition of child abuse via drug exposure, so providers now only need to report if the child suffered negative effects from drug use and their parents might not be able to meet their basic needs. It exempted children affected by substances their mothers took under a doctor’s direction, meaning women treating opioid addiction with methadone or buprenorphine no longer had to fear being reported.

A workgroup with the Colorado Attorney General’s Office that proposed the change in state law said the goal was to keep families together, when children could be safe with their birth parents, and to encourage mothers to get drug treatment, reducing their risk of overdose and their babies’ risk of health problems.

Overdose and suicide are the top causes of death for pregnant women and those who recently gave birth in the state.

Reports of infants exposed to drugs prenatally in Colorado increased about 7% from 2020 to 2021, before dropping by 25% over the next two years, to 1,468 reports in 2023, according to data from the state Department of Human Services.

Most providers working in birthing facilities don’t know that the law changed, though, and they may still report families based solely on a drug test, said Dr. Christine Gold, a pediatric hospitalist at University of Colorado Hospital. Facilities also vary in how they decide whether to drug-test parents and how equipped they are to offer help to families dealing with addiction, she said.

“If you go to hospital X or Y or Z, you could be treated completely differently,” she said.

In October, hospitals received a new set of guidelines on perinatal drug testing from the coalition Supporting Perinatal Substance Use Prevention, Recovery and Treatment in Colorado, known as SUPPORT Colorado. The guidelines, which are voluntary, emphasize that providers should always get the patient’s consent before drug-testing, and perform tests only when the results will make a difference in the parent’s or baby’s care.

For example, if a patient says they don’t use substances but has symptoms consistent with withdrawal, the guidelines suggest it might make sense to test so the provider has an idea of what they took and can better manage it, Johnson said. Even then, though, the provider should discuss testing with the patient to avoid creating mistrust, she said.

The American College of Obstetricians and Gynecologists recommends screening all pregnant patients for substance use disorder by asking them questions. Some providers misinterpret that to mean they should do a urine drug test with every patient, said Dr. Kaylin Klie, a family practice and addiction medicine physician in Denver. But drug tests aren’t as straightforward as many people think, she said: heartburn drugs can trigger a false positive for methamphetamine, which would stay in a patient’s medical record.

“It’s putting people in a position where they have this information they’re compelled to act on,” even if the information isn’t accurate, she said.

Most doctors come from relatively privileged communities and struggle to understand that patients skip prenatal care because of fear their children will be taken away, Klie said. Children of color and those from low-income families are more likely to be part of an abuse investigation than white and more affluent children, according to nationwide data.

While many people think babies and toddlers are too young to experience negative effects from being separated from their parents, taking them away puts extra stress on the brain in an important developmental window, she said.

Parents “are making a reasonable choice to try to avoid detection unless we make a change, where labor and delivery units are seen as a safe haven,” she said.

Making prenatal care a safe environment for people with substance use disorders also increases the odds that they will pursue medication treatment, which makes them more likely to succeed in quitting illicit opioids, Klie said. Babies can develop neonatal abstinence syndrome when their mothers use methadone or buprenorphine during pregnancy, but it doesn’t appear to cause long-term harm, she said.

“The benefit of having a healthy, sober parent is greater than the possibility or even the reality of some withdrawal symptoms after birth,” she said. “We really miss the bigger picture of how people develop.”

Since the law changed, providers have had to make a mental shift from “mandatory reporter” to “mandatory responder” in some cases, said Don Stader, executive director of the Colorado Naloxone Project. In the past, the provider’s responsibility ended with reporting to the state. Now, while they aren’t legally required to work with the patient to get them into treatment and to plan so the newborn has a safe environment, that’s the clear best practice, he said.

Colorado, like other states, doesn’t have specific guidelines about what a plan of safe care should include, though one is in the works, said Rachael Duncan, program director for Maternal Overdose Matters Plus, which works with hospitals to start medication treatment for opioid addiction during the labor and delivery hospitalization. Ideally, they’d designate a sober caregiver, ensure families store any drugs safely and check that they have needed items, such as car seats, she said. But hospital staff may not have the time to go over that many things, or know where to send parents for resources.

“I don’t think that hospitals are positioned well to carry that out,” she said. “What that looks like from facility to facility can be wildly different.”

An additional difficulty is that hospital stays for childbirth are getting shorter, Duncan said. Patients with uncomplicated vaginal births sometimes only stay one or two days, and not every hospital has a social worker on staff during nights and weekends, she said.

“That’s a very short time for a team to pull together all the resources someone might need,” she said.

While policies are changing, providers need more training on stigma and bias so they can better help families struggling with addiction, Klie said. The expectation that women will be able to quit addictive substances for the sake of their babies isn’t always a realistic one, and judging those who can’t pushes them away from care they need, she said.

“Pregnancy is a motivator for a lot of people to make all kinds of health improvements,” she said. “But pregnancy is not a cure for medical or mental health disorders.”

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