(97) Timeouts May Reduce Unnecessary Child Welfare Reports for Substance Exposed Newborns

Background & Introduction: Advocates and scholars describe the child welfare system as “ground zero for the war on drugs"1. The majority of child welfare reports on newborns are made due to concerns for substance use in pregnancy, and these reports comprise a significant source of children entering the system2. Black, Indigenous, and People of Color (BIPOC) families are disproportionately involved in the child welfare system, frequently for substance use concerns, despite data demonstrating BIPOC families are not more affected by substance use than others.
In 2023, Black children in San Francisco were 16 times more likely to have child welfare investigations and 29 times more likely to enter foster care than white children3. Responding to these inequities, a multidisciplinary task force at San Francisco General Hospital interrogated the hospital’s role in reporting newborns, and developed and implemented a multidisciplinary time-out process prior to reporting newborns to child welfare. This intervention’s goal was to slow down the decision-making process, a known evidence-based approach to reduce bias, decrease unnecessary reports, and increase transparency around child welfare reporting4.
To our knowledge, this is the first timeout process applied to child welfare reporting. In this study, we describe the development, implementation, and early outcomes of this intervention.

Methods: The Pediatric and Perinatal Equity Taskforce, including OBGYNs, pediatricians, family medicine physicians, midwives, nurses, and social workers developed a timeout process, piloted it, and iteratively incorporated feedback from birth center team members in 2021-2022. Any care team member with concerns about potential harm to a newborn could call a timeout. The inpatient social worker would gather multidisciplinary care team members, facilitate the timeout, and complete a timeout form. The form included documenting reasons for the timeout, team members present, the birthing person’s strengths and barriers to parenting, the birthing person’s current support and opportunities for additional support, biases that may be at play in the decision-making process, and whether a child welfare report was made.
This study included all birthing people and their babies who had a timeout (as identified by completion of the timeout form) at San Francisco General Hospital from January to December, 2023. We reviewed individuals’ timeout forms and medical records. We extracted demographics, psychosocial characteristics, substance use, child welfare reporting, and disposition of the newborn (discharge with the birth parent(s) or not). We compared these findings with the limited data available on child welfare reporting from 2019, prior to introduction of the timeout.

Results: From January 1st to December 31st, 2023, 48 birthing people at the San Francisco General Hospital Family Birth Center had a documented timeout, out of 1,193 total births in the same time period (4% of total births). The average age among birth parent study participants was 32 years-old, 96% of whom (46/48) were primarily English-speaking. Forty-eight percent of individuals with a timeout were white, 27% Black, 13% Hispanic/Lantinx, 4% Pacific Islander, 4% multiracial, and 4% other racial/ethnic identities. Ninety-four percent of individuals (n=45) had ongoing substance use documented as a reason for the timeout, of whom 38% had co-use of opioids, stimulants, and/or alcohol noted (17/45); 29% (n=14) had opioid use; and 29% (n=14) had stimulant use. Approximately two-thirds had housing insecurity (69%, n=33), and one third had active intimate partner violence (27%, n=13).
The timeout process resulted in 38 child welfare reports (38/48, 79%), of whom 37 were substance-exposed newborns (37/38, 97%). These reports were made for white (21/38, 55%), Black (9/38, 24%), Hispanic/Latinx (5/38, 13%), American Indian (1/38, 3%), other racial/ethnic identities (1/38, 3%), and Pacific Islander (1/38, 3%) birthing people.
Of the child welfare reports made, 10 resulted in newborns being mandated to be separated from their birth parents. All of these mandated separations (10/10, 100%) were in birthing people with documented substance use, of whom 5 birthing people were white (50%), 3 were Hispanic/Latinx (30%), 1 was Black (10%), and 1 was Pacific Islander (10%).
In 2019 (prior to timeout development and prior to the COVID pandemic), at the same Birth Center, there were 33 child welfare reports made on substance-exposed newborns out of 1,062 births (3% of total births) and 17 family separations (17/1062, 2%). After implementation of the timeout process in 2023, there were 37 child welfare reports made on substance-exposed newborns out of 1,193 births (3% of total births), and 10 family separations (10/1193, 1%; p=.09 when compared to 2019).

Conclusion & Discussion: In an urban safety-net hospital, a novel timeout process utilized prior to child welfare reporting was used in 3% of births–the vast majority of which were affected by substance use. This timeout process prevented 10 child welfare reports (21% of cases which had a timeout).
The timeout process did not seem to magnify inequities and did not privilege white families, as 48% of timeouts were held for white birthing people, 55% of reports were made for white birthing people, and 50% of mandated separation were in white birthing people. The smaller numbers in other racial/ethnic groups made comparisons impractical, but trends do not suggest obvious emerging inequities.
This study did not aim to make robust comparisons across years due to the limited availability of historical child welfare reporting data, significant events (the COVID pandemic) which affected reporting, and practice changes around the care of families affected by substance use. Nevertheless, our results suggest that the timeout process did not increase child welfare reports, and may have contributed to fewer family separations.

References: 1) Sangoi, L. (2020, June). “Whatever they do, I’m her comfort, I’m her protector.” How the foster system has become ground zero for the U.S. drug war. https://bds.org/assets/files/MFPDrugWarFosterSystemReport.cleaned.pdf.

2) National Center on Substance Abuse and Child Welfare, Prevalence of parental alcohol or drug abuse as a condition associated with removal. National Center on Substance Abuse and Child Welfare, (available at https://ncsacw.acf.hhs.gov/research/child-welfare-statistics/interactive-statistics-series/1-2-prevalence-aod-removal/).

3) Webster, D., Lee, S., Dawson, W., Magruder, J., Exel, M., Cuccaro-Alamin, S., Putnam-Hornstein, E.,Wiegmann, W., Saika, G., Courtney, M., Eastman, A.L., Gomez, A., Guo, S., Zhang, A., Carrera, Y.,Dua, A., Berwick, H., Lu, F., Hoerl, C., Yee, H., Gonzalez, A., Gomez Hernandez, F., Ensele, P.,Nevin, J., & Michel, J. (2025)CCWIP reports. Retrieved Jan 09,2025, from University of California at Berkeley California Child Welfare Indicators Project website.

4) Linn S, Lawley SD, Karamched BR, Kilpatrick ZP, Josić K. Fast decisions reflect biases, slow decisions do not. ArXiv [Preprint]. 2024 Jan 2:arXiv:2401.00306v2. Update in: Phys Rev E. 2024 Aug;110(2-1):024305. doi: 10.1103/PhysRevE.110.024305. PMID: 38259347; PMCID: PMC10802676.

5) Schiff DM, Stoltman JJK, Nielsen TC, et al. Assessing Stigma Towards Substance Use in Pregnancy: A Randomized Study Testing the Impact of Stigmatizing Language and Type of Opioid Use on Attitudes Toward Mothers With Opioid Use Disorder. J Addict Med. 2021;Publish Ahead of Print. doi:10.1097/ADM.0000000000000832