As the number of U.S. pregnancies and child births affected by substance use disorder (SUD) has risen, so too has the need for safeguards to protect newborns and their families. To address this need, in 2016 Congress amended the Child Abuse Prevention and Treatment Act (CAPTA) to require health care providers to both report to child protective services (CPS) when a child is born to someone actively using a substance and offer the birth parent a voluntary Plan of Safe Care (POSC). 

A POSC is intended to help improve the health and safety of infants exposed to alcohol, opioids, or other illicit substances before birth. For example, a POSC might include diapers and a crib for the infant, provided by community-based organizations and public health agencies, SUD treatment, home visiting programs, and help with finding housing or transportation to appointments. 

Although all states are required to monitor the implementation of POSCs, reporting and planning procedures differ by state. The statute does not provide clear criteria for determining if an infant’s health has been impacted by a substance, which has led to wide variability in how states interpret the law and in how providers implement it. 

To better understand the perspectives of birthing parents about POSCs, LDI Senior Fellows Yuan He, Barbara Chaiyachati, Meredith Matone, and Joanne Wood conducted a qualitative interview study with birth parents who received a POSC. From a group of 29 birth parents who received a POSC in Philadelphia, the researchers conducted semi-structured interviews on the phone with 12. The interviews included open-ended questions about the trustworthiness and accessibility of POSCs as well as the services they offer participants.

The researchers found that while the requirement for providers to report prenatal substance use exposure to CPS was designed to improve the well-being of the child and family, CPS also incites fear and anger among parents and guardians over potentially losing their children. 

As a result, it can have unintended effects. For instance, the CAPTA requirement for pregnant individuals and parents to be reported to CPS if they take medications for opioid use disorder (MOUD), such as methadone and buprenorphine, may discourage its use. Despite the American College of Obstetricians and Gynecologist (ACOG) recommending it in combination with behavioral therapy, MOUD use remains low among pregnant and parenting people with SUD. 

The qualitative interviews by He and colleagues provide insights that can be harnessed to achieve CAPTA’s intended effects for infants—and reduce the concerns surrounding its implementation. To learn more about the key themes from participant responses and the study’s implications for research, clinical practice, and policy, see our Q&A with Yuan He, MD, MPH below.

What were the motivations for Congress to require safe care plans and how have they evolved?

He: Federal law first started mandating notifications to CPS and POSCs in 2003, with the goal of monitoring and supporting infants who were born affected by illegal substance abuse or withdrawal symptoms or fetal alcohol spectrum disorder. As the opioid crisis worsened and more infants were diagnosed with neonatal abstinence syndrome (NAS), new legislation was passed in 2016 to expand the definition of affected infants to include those affected by any substance, including prescribed opioids, such as medications for opioid use disorder (MOUD).

What unintended consequences have resulted from these plans and need to be addressed on the federal level?

He: Because the law requires providers to notify CPS of affected infants, health care and CPS systems have become further intertwined, especially as perceived by parents with a history of substance use disorder (SUD). Increased CPS scrutiny and involvement among birthing people with SUD exacerbates both stigma and fear of family separation, which deters them from engaging in needed health care services. To ensure that POSC and related services are truly supportive rather than punitive, they must be decoupled from CPS reporting and surveillance.

What concerns do you have about how Pennsylvania implements the required reporting and subsequent Plans of Safe Care?

He: Pennsylvania law requires health care providers to notify ChildLine, the state child abuse reporting hotline, which then directs county CPS agencies to implement plans of safe care for infants deemed to be “affected.” Ideally, plans could be offered widely to a broad range of families to support care coordination and linkages to services. But providers may worry about unnecessary CPS contact, and be more selective about which families “need” the POSC, especially since the plan may not be implemented at all if the infant is not determined to be “affected” at the state level. 

My biggest worry is that as a result, birthing people affected by SUD may be less likely to seek care, and less likely to be connected to services when they do.

What questions did you ask study participants and why did you choose them?

He: We wanted to learn about the development and implementation of POSCs from participants’ point of view so that we could explore which elements were more valued, and where their implementation and/or messaging could be improved. We asked why participants said yes or no to a plan, what services were included if they said yes, and which services they found most helpful. We also asked participants what supports they needed and desired, and where and from whom they would like to get that support.

Many eligible individuals declined to participate or did not follow through. Can you talk about this study’s unique challenges in recruiting?

He: Recruitment was challenging for multiple reasons. The postpartum period is an overwhelming and stressful time as birthing parents navigate physical, mental, and emotional changes while caring for a newborn. Birthing parents with SUD face even more challenges, with unique barriers to engagement in SUD treatment and recovery, high risks of relapse and overdose, and high rates of postpartum depression and anxiety that may further limit their interest and bandwidth to participate.

What were your key findings?

He: We found that participants experienced pervasive stigma, fear of CPS, and confusion around how best to access services. A few participants described how this changed their perceptions of providers and SUD treatment, including medications for opioid use disorder.

What recommendations do you have for federal policymakers?

He: There are a few promising approaches to decoupling notifications and POSC implementation from CPS. Federal policymakers could consider explicitly directing jurisdictions to establish distinct notification pathways and implementation approaches that live outside of CPS, for instance through public health and/or behavioral health agencies. Alternatively, protections could be established so that notifications to CPS about substance-exposed infants only contain identifying information if there is a stated concern for child abuse or neglect.

Many participants worried that the POSC process was a penalty for following medical advice and taking medications for opioid use disorder. What policy or practice changes does this suggest?

He: MOUD, such as buprenorphine and methadone, are highly effective in managing addiction to opioids, with health benefits for both the birthing parent and infant. Policymakers, health care providers, and agencies need to work together to improve uptake and maintenance of MOUD, rather than scrutinize and stigmatize its use. 

One recommendation is to more clearly define which parent-infant dyads are at higher risk and should be offered a POSC, to avoid uncertainty and confusion. Policymakers could identify which substances and types of misuse warrant a POSC, and consider excluding those who are in more stable recovery and engaged in treatment. 

As our study participants voiced, another recommendation is to ensure that POSCs are not offered with stigma, and include individualized, desired supports, such as lactation support and education for people on MOUD, in addition to linkages to SUD treatment.

Do MOUD drugs affect infants?

He: Yes. When used during pregnancy, MOUD reduces the risk of preterm birth, increases birth weight, and reduces fetal exposure to illicit opioids. MOUD is also associated with a higher risk of withdrawal symptoms after birth, e.g., neonatal abstinence syndrome (NAS) or neonatal opioid withdrawal syndrome (NOWS). While these are short-term, treatable conditions, they can be distressing to birthing people, who should be educated about the expected signs and symptoms, their monitoring and treatment, and the expected clinical course.

How can perspectives from birth parents with SUD affect practice and policy on POSC interventions?

He: Policies and programs will only reach their goals if they are grounded in the realities and lived experiences of the populations they are meant to serve. In this way, the perspectives and insights of birthing people with SUD who have experienced POSC are critical to inform how policies and practices can be improved to improve trust and outcomes for this population.

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The study, ““Instead of just taking my baby, they could’ve actually given me a chance”: Experiences with plans of safe care among birth parents impacted by perinatal substance use,” was published April 13, 2024, in Child Abuse & Neglect. Authors included Yuan He, Barbara H. Chaiyachati, Meredith Matone, Shelley Bastos, Stacey Kallem, Aasta Mehta, and Joanne N. Wood.

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