Theses Doctoral

Evaluating the Collateral Consequences of Prenatal Drug Use Criminalization: The Paradox of Deterrence as Public Health Strategy

Bruzelius, Emilie

Criminalization, and other forms of punishment, are at the core of the current policy response to prenatal drug use in the United States (U.S.). However, evidence has repeatedly shown that interventions founded on deterrence principles—the idea that punishments deter crimes—more commonly harm rather than advance public health goals. In three aims, this dissertation examines several consequences of prenatal drug use criminalization, first, through a review of the current policy and evidence base (Chapter 2), followed by two empirical studies testing for adverse effects of state-level prenatal drug use criminalization on pregnant people’s participation in drug treatment (Chapter 3) and pregnancy care (Chapter 4).

First, in Chapter 2, the legal survey found that by 2022, nearly half of U.S. states had implemented one or more punitive policies, demonstrating that a significant number of pregnant people are vulnerable to the carceral and child custody-related implications of these laws. Moreover, the review of the corresponding literature found that while existing research consistently identified few benefits of punitive law adoption, evidence for potential negative repercussions, including on drug treatment utilization, pregnancy and birth-related outcomes, and family separation, was inconsistent, supporting the need for additional research.

In Chapter 3, analyses of national drug treatment program data from 1992 to 2019, revealed that contrary to legislative intent, prenatal drug use criminalization was associated with a decrease in pregnancy-specific drug treatment admissions. Post-criminalization declines were limited to admissions for opioid and amphetamine use in criminalization states, rather than for non- criminalized substances like alcohol, supporting the validity of the primary finding. Further, while treatment reductions appeared to be concentrated among low-income pregnant people receiving public assistance, similar reductions were not observed among pregnant people of color, in contrast to expectations.

Lastly, Chapter 4 used birth certificate information from 1989 to 2019, to investigate a potential unintended consequence of prenatal drug use criminalization—reductions in pregnancy care. Results indicated that criminalization was associated with a meaningful decrease in the prevalence of any prenatal care, and a likely, though imprecise, decrease in the prevalence of healthcare facility-based delivery. Results further suggested potential post-criminalization decreases in prenatal care timeliness, but not adequacy, measures defined in terms of the trimester of initiation and the completed number of recommended visits, respectively.

The findings from this dissertation support the hypothesis that policies criminalizing prenatal drug use discourage pregnant people from participating in drug treatment and from some types of pregnancy care. Criminalization is therefore a public health strategy that appears to be not only ineffective, but also overtly counterproductive, to the goal of preventing potential harms associated with prenatal drug use.

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More About This Work

Academic Units
Thesis Advisors
Martins, Silvia S.
Ph.D., Columbia University
Published Here
July 12, 2023