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Abstract

Although the United States has safe haven laws, which allow mothers to safely relinquish their babies to designated safety points, rates of infant mortality remain significantly higher in the United States than other similarly developed countries. The current study is seeking to explore the state-level association between safe haven laws and infant mortality in the United States utilizing a legal epidemiological approach. Several sources of publicly available data were combined to examine the state-level association between safe haven laws and rates of infant mortality. A backward stepwise regression was used to determine whether certain safe haven laws significantly predicted rates of infant mortality, while controlling for demographic variables. After controlling for demographic variables including rates of health insurance and poverty, safe haven laws stating that only the mother can relinquish a child, laws that protect parents from criminal liability, and laws requiring the provider to provide legal information and referrals were associated with infant mortality, with the total model accounting for 70.1% of variance in infant mortality. These results have important implications for policymakers considering the reform of the safe haven laws. It is especially important to evaluate the effectiveness and origins of safe haven laws in the wake of the overturn of Roe v. Wade. Future studies should longitudinally examine how changes in safe haven laws lead to changes in rates of infant mortality.

Keywords

safe haven infant mortality legal epidemiology health policy public health

Introduction

Rates of infant mortality remain significantly higher in the United States than in other similarly developed countries (Douthard et al., 2021; MacDorman et al., 2014). In fact, infant mortality rates in the United States are three-to-four times higher than Hong Kong, Singapore, and Finland, and 31 to 51% higher than Canada and England. Although rates of infant mortality have decreased in recent decades, the United States’ decline in infant mortality has lagged behind other similarly developed countries, with the United States ranked 12th lowest in infant mortality worldwide in 1960 and 31st in 2015 (Singh & Stella, 2019). Research has shown that racial disparities in infant mortality in the United States have persisted for over a century, such that mortality rates for Black, Latinx, and Native American/Alaska Native infants remain significantly higher than rates for White and Asian infants (Singh & Stella, 2019). In fact, rates of infant mortality in the first 27 days following birth were 151% higher for Black infants than their White counterparts in 2017 (Singh & Stella, 2019). Among the leading causes of infant mortality are congenital malformations, complications associated with low birthweight and short gestation periods, maternal complications, sudden infant death syndrome, and unintentional injuries (Driscoll & Ely, 2020).

In addition to these leading causes, the high rate of infant mortality may be reflective, in part, of larger policy issues regarding maternal and infant welfare in the United States. For example, research has shown that laws that criminalize substance use during pregnancy have unintended negative effects on mother’s health outcomes (Lester et al., 2004; Thomas et al., 2024). Another policy that may impact rates of infant mortality in the United States is safe haven laws. In reaction to reported increases of infant abandonment and highly publicized cases of infanticide, all 50 states have passed various versions of safe haven laws, which provide a place for infants to be safely relinquished (Bartels, 2012). In 1999, Texas passed the first safe haven law; safe haven laws received bipartisan support across the U.S. and were quickly adopted, with 15 states adopting safe haven laws in 2000 and all 50 states by 2008 (Bartels, 2012). Safe haven laws were originally enacted to address infant abandonment and provide mothers with a safe method of relinquishing their infants, with the ultimate objective of preserving infant health and preventing infanticide (Infant Safe Haven Laws, 2022). This sentiment was supported across political lines and by advocates for and against abortion rights (Oaks, 2015) While safe haven laws originally received bipartisan support, legal scholars have argued that safe haven laws have been offered as an alternate to abortion as part of anti-abortion “culture of life” rhetoric, despite the fact that these laws were not originally designed for this purpose (Oaks, 2015; Sanger, 2007).

Safe haven laws vary by state in terms of who may relinquish the infant, where the infant may be relinquished, and how old the infant is at the time of relinquishment. Some state safe haven statutes protect certain parties, including medical providers and/or parents, from potential liability, while other states do not protect parties from potential criminal and civil liability, thus criminalizing those parties if relinquishment is not conducted according to the statutory requirements (Infant Safe Haven Laws, 2022). This aspect of criminalization has important implications for the relationship between motherhood and the law. Some scholars argue that laws regarding child and maternal welfare may stigmatize mothers who deviate from the societal “motherhood” norm (Roberts, 1993). For example, research has shown that laws that criminalize prenatal substance use tend to have negative effects on the mother’s health and decrease the likelihood of the mother seeking assistance (Lester et al., 2004; Thomas et al., 2024). It is important to note that many safe have laws require that a relinquished baby be “unharmed,” and thus parents may be hesitant to relinquish babies who have been exposed to substances out of fear of facing legal consequences. Further research is needed to understand the impact of safe haven policies that criminalize mothers on the health of mothers and their children.

For years, legal scholars have offered critiques of safe haven laws, arguing that safe haven laws were an emotional response to high-profile cases of infanticide and were not properly researched before being enacted, and, therefore, do not address the root problems of infant abandonment and infant mortality (Racine, 2005). Legal scholars have argued that safe haven laws may make citizens feel like crime and infant harm is being prevented, rather than offering concrete, evidence-based solutions (Hammond et al., 2010). Moreover, safe haven laws have been criticized for ignoring racial, cultural, and socioeconomic issues that impact women’s reasons for relinquishment, as well as the complex needs of mothers during their pregnancy (Biehl, 2002; Oaks, 2015).

Although a goal of safe haven laws is to ensure the safety of infants and reduce infant mortality, few studies have analyzed the association between safe haven laws and infant mortality. There are no national datasets aimed at understanding the use of safe havens in the United States, as most states do not mandate data collection on the number of infants surrendered to safe havens (Bartels, 2012). Worldwide, there has been a call for more robust, long term data collection to understand the use of safe haven laws and the potential relationship between safe haven laws on rates of infant mortality (Bartels, 2012). In one of the few studies examining the efficacy of safe haven laws, Wilson and colleagues compared infant homicide rates in the United States from 1989–1998 to 2008–2017 to determine whether rates had changed after the enactment of safe haven laws across the United States; results revealed a 66.7% decrease in infant homicides from 1989–1998 to 2008–2017 (Wilson et al., 2020). The authors also examined whether the age limit of legal relinquishment predicted rates of infant homicide, and found that there was not a significant association between age limit of legal relinquishment and rates of infant homicide (Wilson et al., 2020). In response to these results, the Centers for Disease Control and Prevention called states to evaluate the effectiveness of safe haven laws in preventing infant homicides, and to consider other programs and policies that could reduce rates of infant homicides by providing economic support, affordable childcare, and skill-building for young parents (Wilson et al., 2020).

As these laws vary significantly by state, research is needed to understand what elements of safe haven laws, if any, predict infant mortality, including who may relinquish the infant, where the infant may be relinquished, and how old the infant is at the time of relinquishment. We utilize a legal epidemiological approach to examine the state-level association between specific elements of safe haven laws and rates of infant mortality in the United States, adding to the literature by including elements of safe haven laws beyond just those that establish age limits.

Methods

Procedure

Publicly available state-level data was combined from several data sources including: (1) Children Welfare Information Gateway’s List of State Statutes of Infant Safe Haven Laws as of 2021 (Infant Safe Haven Laws, 2022); (2) Center for Disease Control and Prevention state-level data on infant mortality rates per 100,000 live births in the United States in 2021 (Infant Mortality Rates by State, 2021); and (3) U.S. Census state-level estimates of race, poverty levels, percent of state that is rural, and health insurance rates from 2010 to 2019 (Explore Census Data, 2020). All variables were continuous, with the exception of the state-level coding of safe haven laws, which were coded 1 for the presence of the law and 0 for the lack of the law based upon categorizations published by the Children’s Bureau of the Administration for Children and Families. Elements of safe haven laws included in the initial analyses were: (1) whether there is a right to reclaim the infant; (2) whether the safe haven personnel are required to provide legal information and referrals to the relinquisher; (3) the number of days after birth that an infant can be relinquished; (4) whether either parent may relinquish the infant; (5) whether only the mother may relinquish the infant; (6) whether an agent of the parent may relinquish the infant; (7) whether someone with legal custody can relinquish the infant; (8) whether the law specifies who can relinquish the infant; (9) whether the infant can be relinquished to a hospital; (10) whether the infant can be relinquished to a fire department; (11) whether the infant can be relinquished to law enforcement; (12) whether the infant can be relinquished to a church; (13) whether there is immunity from liability for providers; (14) whether parents can remain anonymous; (15) whether parents are protected from criminal liability; (16) whether the provider must ask for medical information when an infant is relinquished; (17) whether an infant can be left in a newborn safety device (also known as a “baby box”); and (18) whether emergency medical personnel responding to 911 calls may accept an infant. Data from all 50 states were included in the analyses.

Data Analysis

A hierarchical multiple regression was performed in SPSS to examine the state-level association between safe haven laws and infant mortality in 2021. Each state was entered as a separate row in the SPSS dataset. Due to the exploratory nature of the study, a backwards stepwise approach was utilized to select the most salient correlate variables to control for in the first step of the regressions while reducing the likelihood of overfitting the model with variables not contributing to the variance in infant mortality. The backwards stepwise regression began with a full, saturated model that included all potential demographic variables informed by extant literature, including race, poverty level, percent of state that is rural, and health insurance rates. Next, variables that contributed the least amount of variance were removed one-by-one to find a reduced model that best explained the data. The threshold for removing variables was p = .10. In the second step of the model, the state-level policies described above were included.

Results

The backwards stepwise approach revealed a final regression model which controlled for state-level percent of the population that falls below the poverty line, percent of the population with no health insurance, and percent of the population that has Medicaid insurance, which accounted for 53.2% of variance in infant mortality (Table 1). In order to determine which legal variables to include in the second step of the model, another backwards stepwise approach was used, which revealed a final regression model that included presence of a law in which parents remain anonymous when relinquishing a child to a safe haven (p = .082), presence of a law in which only the mother may relinquish the child (p = .005), presence of a law in which either parent may relinquish the child (p = .094), presence of a law in which parents are protected from criminal liability (p = .018), presence of a law in which the provider must provide legal information and referrals (p = .024), and the number of days after birth that a child can be relinquished at a safe haven (p = .088). Thus, the second step of the model (including percent of the population that falls below the poverty line (β = 1.136), percent of the population with no health insurance (β = −.344), and percent of the population that has Medicaid insurance (β = −.767), presence of a law in which parents remain anonymous when relinquishing a child to a safe haven (β = .169), presence of a law in which only the mother may relinquish the child (β = .318), presence of a law in which either parent may relinquish the child (β = .182), presence of a law in which parents are protected from criminal liability (β = −.236), presence of a law in which the provider must provide legal information and referrals (β = .241), and the number of days after birth that a child can be relinquished (β = −.173)) predicted 70.1% of variance in infant mortality. See Table 2 for a list of states with each safe haven law that was significant in our analysis. The addition of the legal variables in the second step of the model led to a significant change in R² (F (9,40) = 10.44, p < .001).

Table 1.

Regression analyses examining the impact of safe haven laws on infant mortality

Predictors	Β	R ²
Step 1:
Percent below poverty line	1.074***	.532***
Percent with no health insurance	−.305*
Percent with medicaid	−.6.83***
Step 2:
Percent below poverty line	1.136***	.701***
Percent with no health insurance	−.344*
Percent with medicaid	−.767***
Safe haven law: Number of days after birth that child may be relinquished	−.173
Safe haven law: Parents remain anonymous	.169
Safe haven law: Parents are protected from criminal liability	−.236*
Safe haven law: Only mother may relinquish	.218**
Safe haven law: Either parent may relinquish	.182
Safe haven law – Provider must provide legal information and referrals	.241*

***p < .001, **p < .01, *p < .05, N = 50.

Table 2.

Safe Haven Laws by State

Type of law	States with that law	N
Law that parents are protected from criminal liability	AK, AZ, CA, CT, FL, GA, HI, ID, IL, IA, KS, KY, LA, MD, MA, MN, MO, MT, NE, NV, NM, NC, ND, OH, OK, PA, RI, SC, SD, TN, TX, VT, WA, WI	34
Law that only mother may relinquish child	GA, MD, MN, TN	4
Law that provider must provide legal information and referrals	CT, DC, DE, HI, IL, KY, LA, MI, MT, NM, ND, OH, OK, RI, SC, TN, WA, WI	18

Discussion

Rates of infant mortality are significantly higher in the United States than in other similarly developed countries. In fact, the United States ranks 26 out of 29 Organization of Economic Cooperation and Development (OECD) nations for rates of infant mortality (MacDorman et al., 2014). While safe haven laws were created to reduce cases of infanticide and other infant deaths, there has been no research that has examined the impact of the specific elements of safe haven laws (i.e., who may relinquish the infant, where the infant may be relinquished, and how old the infant is at the time of relinquishment) on rates of infant mortality to our knowledge (Bartels, 2012). Thus, the goal of our study was to examine the state-level association between specific elements of safe haven laws and rates of infant mortality.

Results revealed that, when controlling for percent of the state’s population with no health insurance, percent of the population with Medicaid insurance, and percent of the population that falls below the poverty line, the presence of 3 elements of state safe haven laws were associated with infant mortality, with the full model predicting 70.1% of the variance in infant mortality. Utilizing a backwards stepwise approach allowed for the inclusion of 18 elements of state-level safe haven laws in the analysis, and revealed that the elements of the safe haven law that most significantly predicted infant mortality were laws regarding who is permitted to relinquish a child, parental criminal liability, and whether the medical provider must provide legal information and legal referrals, rather than where the infant can be relinquished. Specifically, results revealed that states with laws stating that only the mother may relinquish, that do not protect parents from criminal liability, and that require medical providers to provide legal information and legal referrals had higher rates of infant mortality.

Further research is needed to understand the mechanism by which these elements of safe haven laws are related to higher rates of infant mortality. One possible explanation is that laws that limit who may relinquish a child and laws that do not provide protection from criminal liability deter parents from relinquishing their infants. Future research should explore the mechanism by which these laws may be barriers to the use of safe havens. Specifically, no research has examined the impacts of criminalization on utilization of safe havens, although research has revealed the negative impacts of criminalizing related acts, such as prenatal substance use (Atkins & Durrance, 2020; Lester et al., 2004). It is possible that the criminalization of parents who use safe haven laws may deter mothers from safely relinquishing their infants, leading to increased rates of infant mortality; however, further research is needed to explore the relationship. Future research can also examine whether policies that decriminalize use of safe haven laws and increase access to medical care for the mother and baby could improve rates of infant mortality by reducing labor and birth risks.

Results of the current study also revealed that states with laws requiring that healthcare providers provide referrals and legal information to parent(s) utilizing safe havens had higher rates of infant mortality. One possible explanation of this relationship is the vast differences in the types of referrals and legal information required by each state statute, with some states offering substantial counseling and case management (WA Rev. Code § 13.34.360), and others only providing a pamphlet for the parent(s) (CT Gen. Stat. §§ 17a-58; 17a-59). Differences in the types of referrals and information offered may contribute to differing rates of mortality in the corresponding state. Future studies should explore the impact of specific types of referrals and information.

The results have important implications for policymakers who wish to address the prevalence of infant mortality in the United States. There is a need for more systematic data collection regarding the use of safe havens, and policymakers can advocate for laws requiring the collection of data recording how often safe havens are used and by whom. The systematic collection of data would also allow researchers to examine potential disparities in the use of safe havens, and identify barriers that might hinder their use. Furthermore, systematic data collection could include data on the implementation of safe haven laws, which would allow for research to examine potential gaps in the law and current practices.

Legal scholars have identified the lack of education and resources to promote awareness of safe haven laws as a key issue in the effectiveness of safe haven laws in the United States (Bartels, 2012). Mothers may be more likely to relinquish infants if they knew that these laws existed, but public education has been practically nonexistent and women are often unaware of the laws or how to use a safe haven (Lacci, 2006; Trossman, 2006). Previous research has suggested that mothers are most likely to seek information from health professionals and online health resources, and that 90% of expectant mothers preferred to consult more than one information resource before making a decision (Mahony et al., 2022). Future studies can examine the role of education and promoting awareness of safe haven laws on the use of safe havens and the effectiveness of safe haven laws in reducing rates of infant mortality and infant homicide. It is especially important to consider who is utilizing safe haven laws in order to more effectively disseminate information about these laws. Additionally, other studies have suggested that mothers who illegally abandon or kill babies are on average 19 years old, single, no longer involved with the baby’s father, and concealed their pregnancy (Lacci, 2006). Policies can then focus on disseminating information about safe havens to these populations who are most vulnerable to infant mortality.

Understanding the impact of state haven laws and their policy implications are especially important in recent months, as safe havens have been suggested, by Supreme Court Justice Amy Coney Barrett in the oral arguments in Dobbs v. Jackson Women’s Health Organization, as a way of alleviating the “burdens of parenting” and “obligations of motherhood” that will likely increase in wake of Roe v. Wade being overturned. It is evident that the connection between safe haven laws and abortion has been used in the conversation surrounding reproductive rights, making it even more important that safe haven laws are understood by researchers and policymakers alike. Safe haven laws were originally adopted with the purpose of reducing infant abandonment and infant homicide; they were not adopted to replace abortions or serve as an alternate option for women who cannot access abortion (Sanger, 2006). In fact, women who are unable to get an abortion usually will not utilize safe havens or elect to place their infants up for adoption (Foster, 2020). While there is a need for future research that examines the efficacy of safe haven laws, it is important to note that safe haven laws are only one piece of a larger puzzle that must be considered when considering women’s choices and reproductive justice.

The current study serves as a preliminary look at the association between state-level safe haven laws and rates of infant mortality, and there are limitations to the study’s cross-sectional design. Future studies should utilize a longitudinal approach to determine how changes in safe haven laws lead to changes in infant mortality. Additionally, this study examines state-level trends rather than the individual impact of safe haven laws on parents’ decisions to utilize safe haven services. Future studies can examine individuals’ experience utilizing safe havens and the barriers which may prevent their use on an individual level rather than a state level. The use of state-level data also limits the statistical power for analyses, and thus results may not capture the full impact of the safe haven laws on infant mortality, especially for certain components of safe haven laws that are present in few states. Since there is currently no dataset that systematically tracks rates of infanticide in the United States (Johnson & Mondor, 2025), the current study utilized infant mortality as the outcome variable rather than infanticide; efforts should be made to improve data collection practices around infanticide and future research should examine the relationship between safe haven laws and infanticide. Finally, it is important to note that infant deaths due to abandonment represent a minute portion of infant mortality; future research can examine safe haven laws in the context of other policy drivers of infant mortality, such as structural racism and policies that limit access to health care and contraception.

Footnotes

ORCID iD

Kathryn A. Thomas

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This publication was made possible by CTSA Grant Number UL1 TR001863 from the National Center for Advancing Translational Science (NCATS), a component of the National Institutes of Health (NIH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NIH.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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The State-Level Association Between Safe Haven Laws and Rates of Infant Mortality in the United States