Purpose: How society should perceive and respond to the use of alcohol, tobacco and other drugs (ATOD) during pregnancy is a recurring public policy issue with conflicting and intensely held views. These frameworks reflect different social constructions of the issue: clinical, public health, child maltreatment, and limited state intervention. Legislation is one marker of how social problems are constructed, whether or not laws are fully implemented. The goal of this study was to determine current legislative approaches across the 50 states that provide a policy framework for state funding and practices with regard to pregnancy and ATOD. Questions include the degree to which legislation reflects clinical, public health, child welfare or criminal justice perspectives, what drugs and behaviors are of concern, how states cluster on relevant dimensions and the implications of these patterns for policy-making, advocacy, and health care and other practice.

Methods: Statutes that addressed some aspect of pregnancy and ATOD use were identified through the Lexus/Nexus State Capital Database. Component elements were coded by the perspectives represented and then by type of policy or activity. Tables were constructed for each discrete category, and codes were developed to reflect the major topical areas within each table. These codes were then entered in a composite table that depicted patterns of statutes across all categories, by state. An additional table was constructed to indicate which substances were of concern in each statute.

Results: Public health approaches include statements of values, collection of anonymous data to determine prevalence and guide programming, various kinds of preventive activities, early case-finding and treatment. Child maltreatment approaches identify drug use as a risk for neglect and abuse and mandate a number of actions when this is detected. Approaches that allow for limited state intervention authorize various actions when other public health measures have not been effective. Ten states have no relevant statutes while six espouse a public health approach but with limited programming. Thirteen states combine a public health philosophy with a number of active programs and five allow for conditional state intervention within a public health philosophy. Ten states have statutes with (often conflicting) mixtures of public health, child maltreatment and limited state intervention, and six have statutes that only focus on child maltreatment philosophy and interventions. Statutes with a child maltreatment framework are more likely to focus primarily on illicit drugs.

Implications: States have very disparate statutes with regard to pregnancy and ATOD. Half have one or more statutes reflecting a public health perspective but these are variable in their scope and focus. Statutes are not consistent within many states, and a significant number of states have apparently not addressed this issue at all legislatively. Further work is needed to determine whether and how these statutes are being implemented, trends over time, and what forces led to particular legislation. Even if not enforced, these statutes are available to guide funding and practice should they be invoked and reflect the views of influential policy makers.