(104) Child Custody Loss and Prenatal Engagement in Pregnant Women With Substance Use

Background & Introduction: Policies surrounding maternal-infant dyad separation in the setting of substance use disorder (SUD) ostensibly aim to promote child safety and deter future substance use. However, child custody loss has been associated with an increased risk of subsequent substance-exposed pregnancies, highlighting need for better characterization of prior custody loss as it relates to prenatal care (PNC) engagement and substance use (SU) during subsequent pregnancies. Existing studies offer conflicting evidence, with some suggesting increased SU and reduced treatment engagement following Child Protective Services (CPS) involvement, while others demonstrate no reduction in treatment participation. In qualitative studies, people having lost child custody report both traumatization that might render prenatal engagement difficult as well as motivation to change life circumstances that might strengthen prenatal engagement. We aimed to evaluate the association between prior child custody loss/CPS involvement and subsequent PNC engagement, degree of polysubstance use, and plan to parent.

Methods: Retrospective observational analysis of pregnant individuals presenting for PNC between 2023–2025 at an integrated perinatal/SUD clinic. Eligible participants had ≥ 1 prior live birth, a complete intake form, and available delivery data. SU and social information from standardized intake forms, PNC attendance, missed visits, and postpartum follow-up were abstracted from the electronic medical record. The primary exposure was any self-reported prior child custody loss or CPS involvement. The co-primary outcomes included three measures of PNC engagement, defined by 1) ratio of attended PNC visits to the expected number of visits between intake and delivery based on standard schedules; 2) ratio of recorded no-show visits to the same expected number; and 3) attending a postpartum evaluation within 12 weeks. Polysubstance use was defined as the number of substances used within one month prior to intake, including illicit substances, alcohol, tobacco, and marijuana. Multivariable linear and logistic regressions models were fit for each outcome, including the three prenatal engagement measures, polysubstance use, and plan to parent. We used covariates of housing status, maternal age, race, insurance status, partner involvement, and prior care at this clinic, with polysubstance as an additional covariate in models for which PNC engagement was the outcome.

Results: Among 185 eligible participants, 66 (34.7%) reported prior child custody loss or CPS involvement. Of these, 53 reported custody loss (28%), 7 reported CPS involvement without custody loss (3.7%), 4 reported CPS involvement with unclear custody status (2.1%), and 4 reported adoption (2.1%). Compared with participants without prior custody loss, those with prior custody loss were significantly less likely to be stably housed (56.1% vs 75.6%, p = 0.006). Maternal age, race, insurance status, partner involvement, and prior care at this clinic did not differ significantly across exposure groups. In unadjusted regression models, prior custody loss was not associated with PNC attendance (B = 0.08, 95% CI −0.06 to 0.22), no-show-to-expected visit ratios (B = 0.02, 95% CI −0.03 to 0.07), attendance at a postpartum evaluation within 12 weeks (OR 1.06, 95% CI 0.57 to 1.98), polysubstance use (B = 0.21, 95% CI −0.22 to 0.63), or plan to parent (OR 1.52, 95% CI 0.66 to 3.51). In adjusted analyses, prior child custody loss was not associated with PNC attendance (B = 0.08, 95% CI −0.07 to 0.22), no-show-to-expected visit ratios (B = 0.01, 95% CI −0.04 to 0.06), attendance at a postpartum evaluation within 12 weeks (OR 1.09, 95% CI 0.56 to 2.13), polysubstance use (B = 0.17, 95% CI −0.27 to 0.62) or plan to parent (OR = 2.08, 95% CI 0.79 to 5.44). In the same adjusted models, greater polysubstance use was independently associated with lower PNC attendance (B = −0.07, 95% CI −0.12 to −0.03), higher no-show-to-expected visit ratios (B = 0.02, 95% CI 0.01 to 0.04), and greater odds of postpartum evaluation within 12 weeks (OR 1.34, 95% CI 1.07 to 1.68). In the same models, prior receipt of care at this specialized perinatal SUD clinic was associated with fewer substances used in the month prior to intake (B = −0.53, 95% CI −1.03 to −0.03).

Conclusion & Discussion: Among pregnant individuals with SUD receiving care in a specialized perinatal SUD clinic, prior child custody loss was not independently associated with PNC engagement, postpartum follow-up, substance use, or plan to parent. However, higher polysubstance use was correlated with lower PNC attendance, greater no-shows, and higher odds of postpartum visit attendance. Prior receipt of care at this clinic was associated with a lower degree of polysubstance use, suggesting that engagement with specialized perinatal services may be associated with improved SUD clinical outcomes. Limitations include a relatively small sample, reliance on a self-reported, heterogeneous measure of custody loss/CPS involvement (which could include individuals whose parenting arrangement did not include separation), lack of data on timing between pregnancies, and lack of data on the salience of custody loss for each patient. Furthermore, individuals with severe consequences of CPS involvement may be less likely to present for PNC in a future pregnancy. Together, these results suggest that among pregnant people who present for PNC in a subsequent pregnancy, prior child custody loss or CPS involvement may have limited impact on the degree of current polysubstance use or engagement in subsequent PNC.

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