Date of Award

5-1-2024

Language

English

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

College/School/Department

Department of Public Administration and Policy

Dissertation/Thesis Chair

Erika Martin

Committee Members

Lucy Sorensen

Subject Categories

Public Policy

Abstract

In the United States (US), state-level policies are critical structural determinants of maternal and infant health outcomes. State policies profoundly affect prenatal care utilization and pregnancy outcomes, particularly among marginalized pregnant persons with stigmatized health conditions. In this three-paper dissertation, I focus on two closely interrelated policies that aim to address significant public health concerns in the US: prenatal syphilis screenings and the criminalization of prenatal substance use. My research revolves around two central questions: First, do these policies effectively improve the pregnancy outcomes of high-risk populations, or do they cause unintended consequences? Second, if challenges in policy design and implementation hinder improving pregnancy outcomes, what are these challenges? In Paper 1, through descriptive analyses using disease surveillance data, I find a decline in the effectiveness of state-level prevention efforts for mother-to-child syphilis transmission (i.e., congenital syphilis (CS)) using a measure of percent of cases averted. Significant disparities exist between states demonstrating high versus low performance in CS prevention. In Paper 2, I focus on the prenatal syphilis screening policy, which I identify as critical in CS prevention from findings in Paper 1. I conduct qualitative interviews to understand the barriers and facilitators of policy adoption and implementation of prenatal syphilis screening. Results suggest that negative social constructions of pregnant persons with syphilis and politics of reproduction profoundly affect state policy changes and implementation strategies. Furthermore, to navigate these challenges, public health officials are exploring various policy instruments to promote prenatal syphilis screening. In Paper 3, I delve into another policy that emerged as a major barrier to the implementation of the prenatal syphilis screening policy in Paper 2: the criminalization of prenatal substance use. Employing a quasi-experimental design, I examine whether such criminalization leads to negative policy feedback effects and prompts health system avoidance among the target population. Findings suggest that criminalization has not significantly improved prenatal care utilization, maternal health, and birth outcomes at the population level. In addition, I find that it disproportionately reduces prenatal care utilization and harms birth outcomes among non-Hispanic Black, Hispanic, and Medicaid beneficiaries, the groups most likely to be targeted. Collectively, my dissertation highlights that current state policies on maternal and infant health among marginalized pregnant persons are based on negative social constructions and stereotypes. These policies have not effectively achieved their intended goals; instead, they have resulted in negative feedback effects that disempower the target group, leading to system avoidance that may spill over to neighboring policy areas. Such negative constructions and the associated political environment significantly constrain policy changes and implementation, hindering desired policy outcomes.

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