Introduction. High quality substance abuse treatment for women reduces related health costs. Punitive state legal responses to maternal substance use may serve as a barrier for women seeking treatment. South Carolina has been one of the most punitive states for women of reproductive age since the Whitner v. State decision (1997) established substance use during pregnancy as an act of child abuse. The purpose of this study was to examine the impact of this decision on substance abuse treatment avoidance, length of stay, and criminal justice referral.

Methods. A dataset of SC women admitted to publicly funded treatment centers from 1993 to 2007 (N=101,169) was analyzed using descriptive and multivariate statistics. Logit models testing the relationship between type of treatment and client characteristics were analyzed for the entire sample. Dummy variable regression analyses were conducted to test for differences between average annual counts of admissions, referrals, and type of treatment post-Whitner as compared to pre- Whitner for women compared with men (N=240,622) and subgroups of women at higher- and lower-risk for arrest.

Results. For the entire sample, women who were unemployed (OR=8.339, p<.0001) or referred by the criminal justice system (OR=2.805, p<.0001) had a higher likelihood of receiving short-term treatment. Following the decision, higher-risk group differences existed by race (p=.0004), psychological diagnosis (p<.0001), and employment ( p=.0177) for the number of admissions/individual referrals (indicators of treatment avoidance). Fewer than 4.0% of women were served in a long-term setting, and higher-risk group treatment differences existed by race ( p=.0182), poverty region (p=.0002), and psychological diagnosis (p=.0036). Fewer employed (p=.0291), non-poverty region (p=.0002), and more educated women ( p=.0429) were referred by the criminal justice system.

Conclusions. Women with client characteristics associated with arrest potentially avoided substance abuse treatment and received less intensive care post-Whitner as compared to pre-Whitner. Additionally, women of higher socioeconomic status were less likely to be referred by the criminal justice system post-Whitner. Given this differential treatment between higher- and lower-risk group women, it is recommended that state policy makers enact a less punitive, more treatment-oriented policy to decrease discrimination by increasing access to treatment for historically disadvantaged women in SC.