Exploring Physicians' Perceptions of Social Workers in Mandated Reporting of Substance Use during Pregnancy

Background and purpose

Hospitals are frequently sites of pregnancy criminalization, or state intervention that restricts people’s reproductive self-determination because of their pregnant status via law enforcement and/or child protective services (CPS) involvement. Pregnancy criminalization often involves cases of substance use during pregnancy. Social workers are routinely called upon to provide resources and support to individuals in these contexts and may be engaged in decision making about reporting to the state. Hospital-based social workers often work in multidisciplinary care teams including physicians. In the context of such teams, understanding how physicians—who frequently hold the most power in such settings—perceive social workers and their role in mandated reporting, is essential.

Methods

In March-July 2021, we conducted semi-structured interviews with 37 hospital-based physicians in three specialties (obstetrics-gynecology, family medicine, emergency medicine) from across the US to better understand physicians’ decision making around mandated reporting of substance use in pregnancy. The interview guide addressed decision making around reporting pregnant and birthing people to CPS or law enforcement, collaboration with social workers in this process, and perceptions of social workers’ role in mandated reporting. Interviews were audio-recorded and transcribed verbatim. We used reflexive thematic analysis. We developed a codebook based on preliminary themes identified within transcript excerpts flagged for mentions of social workers from the initial analysis. We coded five transcripts using Dedoose coding software, revised the codebook, and applied it to the remaining transcripts. Then, we reviewed our codes to identify initial themes and reviewed, refined and renamed them as a team to ensure they appropriately captured respondent narratives.

Results

Many respondents worked in settings with protocols that allow or require them to either defer mandated reporting to social workers or include social workers in the decision-making process. However, perception that social workers are overly enthusiastic about mandated reporting and urine toxicology screens during labor and delivery, as well as disagreement about social workers’ decisions to report in these scenarios, emerged as important themes. Many respondents also demonstrated a general lack of understanding and/or unconfirmed assumptions regarding the course of action after making a referral to social workers for substance use in pregnancy. Finally, there was a dominant perception that social workers believe mandated reporting leads to positive interventions in the context of substance use in pregnancy—and disagreement with this belief among many respondents.

Conclusions and Implications

These findings suggest that physicians’ perceptions of mandated reporting of substance use in pregnancy and social workers’ role may differ from social workers’ perceptions and values. This may point to discipline-level disagreements about providers’ responsibilities towards pregnant and birthing people, and the role of CPS and other government authorities in these scenarios. Future research with hospital-based social workers regarding mandated reporting in these contexts is needed to illuminate the extent to which social workers feel adequately prepared and able to use discretion in ways that affirm and support people’s reproductive self-determination and dignity, and the ways their level of preparation and broader issues of power in multidisciplinary teams impact collaboration with physicians.