New Study Finds Implementation Barriers to States’ Plans of Safe Care for Infants with Prenatal Substance Exposure

A recent study from researchers at the Rollins School of Public Health and University of Kansas Medical Center shows that nearly every U.S. state now has a policy to support infants exposed to substances before birth—but most remain difficult to access and lack clear standards for eligibility, development, and monitoring, creating implementation challenges for families affected by prenatal substance exposure.

The study, published in Hospital Pediatrics, provides the first nationwide analysis of “Plans of Safe Care” (POSCs). These are federally required policies meant to ensure that infants with prenatal substance exposure and their caregivers receive coordinated health and substance use treatment services.

"In 2016, Congress created ‘Plans of Safe Care’ in response to the rising number of pregnant women and infants affected by the opioid crisis. The goal was straightforward: strengthen connections to treatment for parents and caregivers and ensure substance-affected infants received the services they need. Nearly a decade later, however, our research shows that states have taken widely different approaches, many policies are hard to follow, and most are missing critical components that could improve outcomes for both mothers and infants,” says Stephen Patrick, MD, senior author and chair of the Department of Health Policy and Management at Rollins.

Key Findings

• As of 2024, every state except Illinois maintains some form of POSC policy—up from just 30 states five years ago. However, only 18 states had enacted POSC statutes or regulations. While considerable effort has gone into creating POSC policies, most are inconsistent regarding which parts are codified and therefore may not be effectively implemented.
• State statutes and regulations generally have more information about the beginning of the POSC process, which covers who gets a POSC and who develops it—with substantially less information about monitoring processes.
• The average accessibility rating across states was 3.3 out of 6. Thirty-one states had very low levels of accessibility of POSC policies.
• States use a dozen different terms for POSC, further complicating research and implementation.
• The current state of POSC laws makes it difficult for hospitals, clinicians, and families to effectively use them as intended. Administrative manuals can be revised without public hearings or legislative review, which prevents the opportunity to bring valuable evidence to an administrative agency’s attention. According to the study’s authors, internally developed policies are more likely to maintain the “status quo” rather than adopting upstream, interdisciplinary, and nonpunitive approaches. Additionally, inconsistent implementation in how policies are enacted across states can create confusion for providers and data inconsistencies for policymakers, limiting accountability and potentially widening disparities in care.

Why This Matters

The study proposes that a replicable and comprehensive POSC policy needs to address, at a minimum, 12 policy components of interest. This should include factors such as defining which infants qualify, outlining when plans must be created, specifying who develops and monitors each plan, and ensuring consistent data sharing and oversight across agencies.

“Although states have made considerable progress in creating POSC policies, more work is needed to ensure effective implementation. Greater transparency and standardization in state policies would ensure that all infants affected by prenatal substance exposure receive the coordinated, evidence-based care that federal law envisions,” notes first author Margaret Sieger, PhD, associate professor at the University of Kansas School of Medicine.

Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under award number R01DA056436, Patrick; K01DA058060, Lloyd Sieger.