The Effects of Opioid Use during Pregnancy on Infant Health and Well-Being

AuthorJessica Pac,Christine Durrance,Lawrence Berger,Deborah B. Ehrenthal
Published date01 September 2022
Date01 September 2022
106 ANNALS, AAPSS, 703, September 2022
DOI: 10.1177/00027162231154338
The Effects of
Opioid Use
Pregnancy on
Infant Health
and Well-Being
We estimate the causal effects of infants’ exposure to
opioids in utero on their health at birth and on the
likelihood that their parents will be the subjects of sub-
sequent reports to child protective services. We use
administrative data on 259,723 infants born to 176,224
mothers enrolled in Medicaid between 2010 and 2019.
Results suggest that an infant experiencing withdrawal
symptoms after birth or needing admission to intensive
care is strongly associated with prenatal opioid expo-
sure, and that this effect is concentrated among those
whose mothers used illicit opioids or were undergoing
medication-assisted opioid treatments in their first and
third trimesters. Prenatal opioid exposure is also associ-
ated with referrals of parents to child protective ser-
vices and with being born preterm, low birthweight, or
small for gestational age. We find smaller effects among
infants exposed to prescription opioids, but these
effects are not trivial, supporting current recommenda-
tions to balance the potential for infant adverse effects
with the benefits of pain management during
Keywords: prenatal opioid exposure; medication-
assisted treatment; opioids; fetal develop-
ment; infant health; child protective
services; in utero
The U.S. is witnessing an increase in opioid
use among pregnant people,1 as evidenced
by an 83 percent increase in neonatal absti-
nence syndrome (NAS) between 2010 and
2017 (Hirai et al. 2021). NAS is a condition in
which a newborn exhibits withdrawal symp-
toms after birth, and it is often associated with
Jessica Pac is an assistant professor at the University of
Wisconsin–Madison Sandra Rosenbaum School of
Social Work. Jessica’s research examines the impact of
public policies on child maltreatment and other forms
of domestic violence, infant and maternal health, and
human capital. Jessica holds a PhD with concentrations
in economics and social policy from Columbia
University School of Social Work and a master’s degree
in public administration with a concentration in social
policy from Cornell University.
substance use (typically opioid use) during pregnancy. In 2019, estimates suggest
that 7 percent of women were prescribed opioids during pregnancy and that 21
percent of them indicated misuse of those opioids during pregnancy (Ko et al.
2020). Moreover, diagnoses of opioid use disorder (OUD) among mothers at
delivery increased by 131 percent between 2010 and 2017. A large and growing
body of economic literature has identified the disparate health effects of opioid
use on adults, but, for the most part, this literature does not attend to the effects
of opioid exposure among infants and children. Most of the evidence from the
medical literature documenting the short-term physical and neurological effects
of in utero opioid exposure among children is correlational in nature (Corsi et al.
2020; Jantzie et al. 2020). Although these estimated effects are consistent, the
causal effect of in utero opioid exposure on short- and long-term health and well-
being remains unknown. Given the mounting empirical evidence demonstrating
that adulthood health and well-being are determined in part by the fetal environ-
ment and health at birth (Almond and Currie 2011; Almond, Currie, and Duque
2018), researchers anticipate that any short-term causal effects might translate
into disparities in health and human capital later in life (Nygaard et al. 2015;
Odegaard, Pendyala, and Yelamanchili 2021).
The aim of this study is to investigate the causal impact of in utero opioid
exposure on infant health and well-being at birth. Specifically, we investigate
whether there are causal effects of opioid exposure during critical periods of
pregnancy on infant health at birth, including the diagnosis of NAS, birthweight,
Christine Durrance is an associate professor in the La Follette School of Public Affairs at the
University of Wisconsin–Madison. She is the research colead for the Collaborative for
Reproductive Equity and an affiliate at the Institute for Research on Poverty. An economist by
training, her work is concentrated in health economics and policy, with focal areas in substance
use; maternal, infant, and reproductive health; and competition policy.
Lawrence Berger is associate vice chancellor for research in the social sciences, Vilas
Distinguished Achievement Professor in the Sandra Rosenbaum School of Social Work, and
past director of the Institute for Research on Poverty at the University of Wisconsin–Madison.
His research focuses on the ways in which economic resources, sociodemographic characteris-
tics, and public policies affect parental behaviors and child and family well-being.
Deborah B. Ehrenthal is director of the Social Science Research Institute and professor of
Biobehavioral Health at Pennsylvania State University. She was the founding director of the
University of Wisconsin–Madison Prevention Research Center, focused on improving the
health of low-income women, infants, and families. Her research is focused on the social and
healthcare factors that shape health of over the life course.
NOTE: We thank HeeJin Kim for excellent research assistance. Jessica Pac was lead author on
this article. The other three authors contributed equally to all aspects of the article. The
authors of this article are solely responsible for the content therein. The authors would like to
thank the Wisconsin Department of Health Services and the Wisconsin Department of
Children and Families for the use of data for this analysis, but these agencies do not certify the
accuracy of the analyses presented. We gratefully acknowledge National Institutes of Health
(NIH) support to complete this work (NIH R01 #HD102125-01, MPIs Berger and Ehrenthal)
and the institutional support provided by the Institute for Research on Poverty and the Social
Science Research Institute at the Pennsylvania State University.
gestational age, APGAR (Appearance, Pulse, Grimace, Activity, and Respiration)
score, admissions of newborns to neonatal intensive care units (NICUs), and
reports to child protective services (CPS) within seven days of birth. To perform
these analyses, we use linked administrative data from birth records, Medicaid
claims, and CPS for Medicaid-covered births in Wisconsin between 2010 and
2019. We leverage within-mother/across-sibling variation in the timing and intensity
of narrowly defined exposures to prescribed opioids, including both medication-
assisted treatment (MAT) used in treatment of OUD, and non-MAT opioid anal-
gesics, as well as an innovative measure to approximate illicit opioid use.
The opioid epidemic generates massive societal costs. One estimate is that the
costs reached $1 trillion in 2017 (Maclean et al. 2021), and another study suggests
that such costs are likely underestimated (Bifulco and Shybalkina, this volume).
It is likely that external, supply-side factors gave rise to the initial surges in wide-
spread opioid use, but mounting evidence suggests that physician prescribing
behavior has fueled the epidemic (Alpert et al. 2019; Arteaga and Barone 2021;
Currie and Schwandt 2021). MAT and non-MAT opioids are Food and Drug
Administration (FDA)–approved for use during pregnancy. Yet medical research
has documented correlations between fetal opioid exposure and diminished
health at birth in both animal and human studies (Brogly et al. 2021; Ko et al.
2021; Nørgaard, Nielsson, and Heide-Jørgensen 2015; Reddy et al. 2017; Yazdy,
Desai, and Brogly 2015). A central challenge is that opioid use is not random.
Women who use opioids during pregnancy might be more likely than those with-
out opioid use to live in highly polluted areas, to delay prenatal care, or to experi-
ence higher rates of stress (Conradt, Crowell, and Lester 2018). As these factors
similarly affect health at birth (Aizer, Stroud, and Buka 2015; Nilsson 2017) and
are likely correlated with opioid use, failure to observe and account for them will
plausibly overstate the estimated effects of opioids in utero.
This study is motivated by the paucity of causal evidence that rigorously
accounts for differences across mothers and infants, including those that may not
be observed in existing data. Prior economic work identifies the probability of any
exposure to opioids during the entire pregnancy period, making comparisons
across women in either counties or states with varying levels of predicted expo-
sure. To the extent that individual-level controls fully capture confounding fac-
tors vis-à-vis variation in opioid use and birth outcomes, the resulting estimates
can be suggestive of causal effects. However, this is a strong assertion. We find
that, including mother fixed effects in regression models (comparing siblings)
results in attenuating cross-mother comparisons by 55 to 80 percent. This sug-
gests that unobserved heterogeneity in maternal characteristics, health, or
human capital endowments is spatially correlated with birth outcomes. In this
study, we improve on the existing literature by adopting narrowly defined meas-
ures of opioid exposure by type (MAT, non-MAT, and illicit) during critical peri-
ods in pregnancy. By making comparisons in opioid exposure effects across
siblings in maternal fixed-effects estimations, our estimates are less prone to bias
due to unobserved heterogeneity between mothers.

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