A New Path to Child Welfare: Implementing Alternatives to CPS Reporting for Substance-Exposed Infants

Abstract

In 2022, one in five pregnant women in the United States reported using substances during the past month. Prenatal substance use results in risks for maternal and infant health, as substance use is a leading cause of maternal death and can increase risk of preterm birth, low birth weight, and stillbirth. While states have differing approaches to addressing prenatal substance use, over thirty states require healthcare providers to report infants with prenatal substance exposure to Child Protective Services (CPS). Between 2010-2019, over 250,000 substance-exposed infants were investigated by CPS following reports from healthcare providers. There is increasing evidence that policies that require CPS reporting of infants with prenatal substance exposure can deter pregnant women from seeking out prenatal care and SUD treatment. In response, several states have recently reformed their CPS reporting requirements and created an alternative notification pathway for substance-exposed infants. This pathway allows states to comply with federal CAPTA data collection requirements while preventing substance-exposed infants without additional safety concerns from being reported to CPS. Using a mixed-methods approach, this thesis is among the first to assess implementation of recent state reforms of child welfare reporting requirements for prenatal substance exposure. First, this thesis maps and categorizes each state’s CPS reporting requirements and identifies which states have adopted an alternative notification pathway. Second, this thesis conducts case studies of four different states, Connecticut, Washington, Massachusetts, and New Jersey, that are each at different stages of implementing an alternative notification pathway. I interviewed 38 healthcare providers, social workers, and state agency staff from these four states to assess the implementation process and understand how healthcare providers experienced the policy change. The mapping analysis found that 33 states require CPS reports for substance-exposed or substance-affected infants, while 17 states explicitly do not require CPS reports for these infants unless there are additional safety concerns. Additionally, 22 states have adopted an alternative notification pathway, though these pathways differ based on how notifications are submitted, whether the notification is identified, and what circumstances still require a CPS report. Stakeholder interviews revealed consensus that alternative notification pathways have the potential to reduce fear surrounding CPS reporting and increase access to care for pregnant patients with SUD. However, proper implementation of these pathways is essential to their success, including accessible training, guidance on the difference between a notification and a report, and hospital compliance enforcement mechanisms. Furthermore, interviews revealed several best practices for patient-centered CPS reporting, including collaborative decision making processes and allowing the patient to be present for the report. In conclusion, proper implementation of alternative notification pathways is essential for achieving their intended policy outcomes of increasing uptake of prenatal care and treatment for pregnant patients with SUD, while simultaneously ensuring infant safety. However, these notification pathways are only one part of how to improve maternal and infant health outcomes; these notifications must also be paired with warm hand-offs to wrap-around resources, including SUD treatment, mental health care, and other social services.