Prescription Drugs in Pregnancy and Childbirth

Summary

In restoring an Instagram video of a woman describing her experience with prescription fentanyl during childbirth, the Oversight Board recommends Meta take steps to ensure correct enforcement of existing medical exceptions to policies covering illicit drugs, and further protection of the free expression rights around sharing pregnancy and maternal health information.

Why This Matters

Social media is a vital source of pregnancy and maternal health information globally for people seeking guidance and peer support, including sharing their experiences with prescription drugs. Overenforcement of Meta’s community standards on drug-related maternal health content is a widely documented problem that suppresses well-intentioned personal storytelling and maternal health advocacy. At the same time, there has been a worldwide proliferation of drug use and trafficking. In the United States, where this case originates, there is an opioid crisis. Illicit fentanyl use is the primary driver of overdose deaths in the country, and moderating content related to illegal drugs is a serious concern for platforms.

About the Case

In February 2026, an Instagram user posted a 20-second video and caption describing the side effects she experienced from several types of prescription drugs used to treat nausea and vomiting during her pregnancy. She also described her experience with pain relief medication, including fentanyl, which was clinically administered during labor. In the post, she said that fentanyl is “on my permanent no list” because the drug made her confused. The video features imagery with memes and short, humorous movie clips representing how each medication affected her during her pregnancy.

After automatic detection and multiple, separate human reviews, Meta removed the post under its Restricted Goods and Services policy, which prohibits content that admits to personal use of “high-risk drugs,” including fentanyl, unless there is acknowledgement of or reference to recovery, treatment or other assistance to combat usage. In addition, Meta applied a strike and a time-based feature limit to the user’s account.

The user appealed Meta’s decision to the Board. When the Board brought the case to Meta’s attention, the company determined that the decision to remove the post was an error, noting that the Restricted Goods and Services policy allows exceptions for admitting to the use of a prescription drug, which fentanyl can also be. Meta restored the post and reversed the strike on the user’s account, although the post remains restricted to adults and is ineligible for recommendation.

Key Findings

The Board finds that the video in this case did not violate the Restricted Goods and Services policy because the reference to fentanyl falls under the policy exceptions for posting about prescription drugs in a medical context. Although fentanyl is listed as a “high-risk” drug under the policy, and posts can be removed if referencing fentanyl in an illicit context, discussing the medical merits of the drug when it is prescribed is allowed.

The Board also finds that restricting the content in this case to users over 18-years-old and making it ineligible for recommendation is inconsistent with Meta’s human rights responsibilities, specifically the freedom of users, including minors, to seek and receive health-related information.

The case raises serious concerns about accuracy in enforcing the Restricted Goods and Services policy, a point the Board has made repeatedly in past cases. Multiple human reviewers assessed the content and did not reach the correct conclusion. The Board notes that human reviewers are interpreting policies too rigidly, without fully taking into account the wider context. There is a further concern that the guidelines reviewers are following are insufficiently clear for them to make correct decisions based on context.

The Board also has concerns about the impact erroneous account restrictions can have on people and organizations that advocate for reproductive and maternal health globally on social media. The Board calls on Meta to include global reproductive and maternal health organizations in the Sensitive Entity Secondary Review system that currently gives additional protections to journalists, rights defenders and dissidents. It also urges Meta to conduct a global audit to determine the extent to which enforcement of the Restricted Goods and Services policy is disproportionately removing maternal health-related content.

The Oversight Board’s Decision

The Board overturns Meta's original decision to take down the content. The content should have been left up without the age-gating restriction and should not have been made non-recommendable.

The Board recommends that Meta:

• Clarify the Restricted Goods and Services Community Standard to state expressly that admissions of personal use of a drug administered by medical professionals - including substances otherwise designated high-risk - are treated under the prescription drug allowance.
• Align internal guidance and external language of the Restricted Goods and Services policy to clarify that admissions of use of high-risk drugs do not violate the policy in all cases when those drugs also exist in pharmaceutical form, such as fentanyl. Meta should ensure that these policy materials consistently emphasize the role of medical context in determining which form of a drug is at issue, and that, with respect to internal guidance, reviewers are empowered to consider medical context when distinguishing between different types of drugs. The internal guidance should also clarify what signals indicate medical context.
• Ensure that global reproductive and maternal health organizations are deemed eligible for enrollment as part of the broader set of entities protected for human rights reasons in the Sensitive Entity Secondary Review system.
• Audit global enforcement of the Restricted Goods and Services Community Standard against content discussing the medical use of drugs, publish category-level error rates broken down by region, country or language, and assess whether errors fall disproportionately on reproductive, maternal and women's health content. This audit should also assess the impact of the standard's 18+ years age restriction on the ability of under-18-year-old users to access health information relevant to them.

*Case summaries provide an overview of cases and do not have precedential value.

Full Case Decision

1. Case Description and Background

The Board selected this case to address overenforcement of the Restricted Goods and Services Community Standard against health-related content. Civil society organizations have documented the impact of this overenforcement on users’ ability to share reproductive and maternal health information on social media platforms. Social media has become a significant source of health information globally, including for pregnant women seeking guidance and peer support. The increase in maternal health information being shared on social media has also coincided with a worldwide proliferation of drug use and trafficking. In the U.S., where this case originates, there is an opioid crisis, with illicit fentanyl now the primary driver of overdose deaths in the country. Drug-related content is therefore a serious and legitimate concern for platforms that host health-related speech.

The case involves a 20-second video posted on Instagram in February 2026. In the video and accompanying caption, the user describes the side effects she experienced from several types of prescription drugs used to treat nausea and vomiting during pregnancy, including Bonjesta, Phenergan, and Zofran. She also described her experience with pain relief medication, including fentanyl, which she said was clinically administered during her labor and is now “on my permanent no list” because the drug made her confused. She reported that, while under the influence of fentanyl, she accused her husband of “trying to kill her.” She stated that an epidural was the only intervention that brought her relief. The video features imagery with memes and short, humorous movie clips representing how each medication affected the user during her pregnancy.

Following automated detection and multiple human reviews that occurred sequentially, Meta removed the post under its Restricted Goods and Services Community Standard, which prohibits content that admits to personal use of “high-risk drugs,” including fentanyl, without acknowledgement of or reference to recovery, treatment or other assistance to combat usage. Each human reviewer independently determined the content violated this community standard. After removing the content, Meta applied a strike and a time-based feature limit to the user’s account. The user appealed the content removal decision to Meta. Following another human review, Meta upheld its original decision to take it down.

The user appealed Meta's decision to the Board. When the Board brought the case to Meta's attention, the company determined that its original decision to remove the post was an error. Meta stated that its policy permits content containing admission of use of prescription drugs, although the content is restricted to adults aged 18 years or older and is ineligible for recommendation to other users. Because Meta also classifies fentanyl as a prescription drug, it restored the post in line with this policy and reversed the strike.

Civil society organizations have documented inconsistencies in the enforcement of Meta’s Restricted Goods and Services Community Standard against reproductive and maternal health content. The non-profit organization the Electronic Frontier Foundation’s (EFF) Stop Censoring Abortion project reported that the Restricted Goods and Services policy was the most common reason Meta gave for removing reproductive health content within the available data. EFF contends that Meta enforces the policy against posts that provide factual or educational content, even when those posts make no attempt to buy, sell, trade or solicit pharmaceutical drugs. The project’s findings concern enforcement against content with abortion-related information specifically, which EFF acknowledges is “just one facet of reproductive healthcare.” Moreover, this research is based on a qualitative analysis of user-submitted experiences rather than comprehensive data from Meta on enforcement of the Restricted Goods and Services policy. EFF contends that the “findings apply to the broader healthcare context” around reproductive rights and has called on Meta to provide greater transparency about the reasons for its enforcement actions (PC-32680). In response to a media report about the removal and restriction of reproductive health content and accounts in January 2025, Meta described some of the incidents detailed as “overenforcement.”

The Center for Intimacy Justice, a non-profit organization promoting equality around people's intimate lives and wellbeing, found that all 60 women's health organizations it studied experienced ad rejections on Meta's platforms, with half suspended from advertising. Similarly, a 2025 white paper by CensHERship, an advocacy group addressing bias in women's health content, and The Case for Her, a financial portfolio addressing women's health issues, reported that 95% of women's health creators surveyed experienced content removal or restriction, while more than half reported self-censoring to avoid negative consequences (see also PC-32682). Some researchers have separately documented that drug-related platform policies can suppress harm reduction and health information generally, with community guidelines erroneously interpreting such material as promotion of drug use and sales.

The pharmaceutical drugs described in the video in this case are widely used in pregnancy and childbirth. The combination of doxylamine and pyridoxine (e.g., Bonjesta) is recommended by the American College of Obstetrics and Gynecology as first-line pharmacologic therapy for nausea and vomiting during pregnancy, with Phenergan and Zofran among the alternatives commonly prescribed when first-line treatment is insufficient. Pharmaceutical fentanyl is a Schedule II controlled substance in the U.S., meaning that it has high potential for abuse yet also accepted medical uses. It is routinely administered during labor: neuraxial (epidural or spinal) analgesia is the most common method of labor pain control in the U.S., used by more than 70% of those undergoing vaginal delivery, and fentanyl is a standard component of epidural mixtures. Fentanyl can also be used in labor as an intravenous or patient-controlled analgesia where an epidural is contraindicated or declined. In the video in this case, fentanyl is described as being used in this second sense — that is, as an analgesia administered separately from the epidural. The World Health Organization (WHO) recommends parenteral opioids, including fentanyl, for healthy pregnant women requesting pain relief during labor.

2. User Submissions

The person who posted the video appealed on the grounds that her video shared her personal experience with commonly prescribed medications used in pregnancy and labor for educational purposes, and did not promote or encourage the use of any drug - noting that she in fact stated she would not choose fentanyl for herself in the future. She explained that her audience consists mainly of mothers and women preparing for pregnancy or childbirth, and that open, firsthand discussion of pain management options supports informed decision-making and informed consent, reduces stigma around discussing birth experiences and helps women advocate for themselves in medical settings. She asked that her content be reviewed in the context of education, personal storytelling and maternal health advocacy.

3. Meta’s Content Policies and Submissions

I.Meta’s Content Policies

The Restricted Goods and Services Community Standard aims to “encourage safety and deter potentially harmful activities” while also allowing discussions “advocating for or concerning the use of pharmaceutical drugs in the context of medical treatment, including discussion of physical or mental side effects.”

Under this policy, Meta removes content that admits to personal use of high-risk drugs “without acknowledgement of or reference to recovery, treatment or other assistance to combat usage.” A “note” in this section of the policy says that “debating or advocating for the legality or discussing scientific or medical merits of high-risk drugs is allowed. This includes news and public service announcements.” Meta lists fentanyl in the policy’s definition of high-risk drugs.

Meta has a policy line in the Restricted Goods and Services Community Standard for content that “includes admission or consumption of prescription drugs.” For such content, it restricts visibility to adults 18 years of age and older, and this content is also ineligible for recommendation on Meta’s platforms, including Instagram.

II. Meta’s Submissions

After the Board selected the case, Meta reversed its decision and restored the content - with restricted visibility and ineligibility for recommendations - because the conditions for the policy lines related to content that “includes admission or consumption of prescription drugs,” and not high-risk drugs, were met.

Meta said that, under the Restricted Goods and Services Community Standard, fentanyl is a high-risk drug that can also be considered a prescription drug depending on context. In this case, Meta said that the “content describes the use of prescription drugs only” and that it “clearly gives an account of the use of prescribed pharmaceutical fentanyl during labor, which is a medical context.”

In situations where there is overlap between high-risk and prescription drugs, Meta’s internal guidance aims to help reviewers distinguish between content that admits to prescription drug use and content that admits to high-risk drug use. Meta said that reviewers “may consider indicators of a medical context.” Meta’s internal definition of “medical context” under the Restricted Goods and Services policy provides a non-exhaustive list of references that could be relevant for determining that context. In addition, Meta provides internal guidance for determining the absence of a medical context when evaluating content that involves an admission of use of prescription drugs.

Because of the discrepancy between multiple human reviews and Meta’s final decision, the Board asked whether Meta expects an at-scale reviewer following the above internal guidance to reach the policy application deemed correct by the company’s subject matter experts. Meta said that an at-scale reviewer following internal guidance may not come to the same conclusion as subject matter experts. Meta explained this was because of internal guidance to reviewers. Meta said that, following internal guidance, at-scale reviewers may remove content mentioning a high-risk drug even when indications of medical content may exist. Such removals occur because, according to Meta, the high-risk classification takes precedence over a mention of a prescription drug. According to Meta, assessing content that mentions a high-risk drug that is also prescribed by medical professionals and assessing whether there is sufficient medical context in that content is challenging. The Board offers its own analysis of the clarity and accessibility of this guidance below.

When asked about the tradeoffs that led to the decision to age-gate the content and make it ineligible for recommendation under the Restricted Goods and Services policy, Meta recognized that there “may be tension between protecting minors from drug-related content and preserving access to health information - including about maternal and reproductive health.” The company noted that content “debating or advocating for the legality or discussing scientific or medical merits of prescription drugs” is allowed and would be accessible to minors.

The Board asked questions on, among others, the Restricted Goods and Services Community Standard, internal guidelines for enforcing that policy at scale and Meta’s rationale for different enforcement mechanisms, such as age-gating and non-recommendability of content. Meta responded to all the questions.

4. Public Comments

The Board received five public comments that met the terms for submission. Four of the comments were submitted from the U.S. and Canada, and one from Europe. To read public comments submitted with consent to publish, click here.

The submissions covered the following themes: systemic overenforcement against women’s health content; impacts of enforcement of the Restricted Goods and Services policy on educational and experiential content; chilling effects and self-censorship; impacts of enforcement actions beyond removal (such as account-level penalties, demotion and recommendation-removal) on users; and calls for context-sensitive enforcement of women’s health content.

In August 2026, the Board consulted with representatives of reproductive health and services non-governmental organizations (NGOs). This discussion focused on the impacts of Meta’s enforcement practices on the NGOs’ ability to serve those who turn to them for information. Participants stressed the importance of WHO-approved information as an authoritative baseline, recommended consulting medical experts to improve human review of health-related content and accounts, and called for increased consistency and transparency in how policies that impact health-related content are applied across languages, regions and countries.

5. Oversight Board Analysis

This case highlights the tension between users’ freedom of expression, especially when discussing health-related matters, and Meta’s responsibility to protect users from harms related to illicit drugs. The case falls within the Board’s Gender strategic priority.

The Board analyzed Meta’s decision in this case against the company's content policies, values and human rights responsibilities. The Board also assessed the implications of this case for Meta’s broader approach to content governance.

5.1 Compliance With Meta’s Content Policies

I. Content Rules

The Board finds that the content does not violate the Restricted Goods and Services Community Standard. While the video includes a description of the use of several prescription drugs, including fentanyl, which Meta also deems a high-risk drug, that description makes clear the use occurred entirely within a medical context. The caption clearly identifies the video as occurring within the context of pregnancy and labor, references the pregnancy condition hyperemesis, and describes a labor of approximately 48 hours from induction to delivery. Clinicians administered the fentanyl during labor, alongside other prescribed medications used to treat nausea and vomiting in pregnancy. The policy permits, with age restriction and ineligibility for recommendation, content that admits to personal use of prescription drugs. Pharmaceutical fentanyl administered under clinical supervision during childbirth falls within that allowance.

Moreover, the post contains no attempt to buy, sell, trade, donate, gift or ask for fentanyl. It also does not speak positively about, encourage or provide instructions for its illicit use. To the contrary, the user rates fentanyl poorly and places it on her "permanent no list," citing adverse effects including confusion and paranoia, conveyed through a movie clip depicting its negative impact on her mental state. Even if the user had spoken positively about fentanyl, removing the content would not comply with the Restricted Goods and Services policy because the speech occurs in a medical context and clearly refers to pharmaceutical fentanyl.

The user's statement to the Board confirms what the content itself makes evident: her purpose was “educational and experiential,” sharing firsthand experience not as authoritative medical guidance but to help reduce stigma around discussing pain management and to “empower women with information so they can advocate for themselves.”

II. Enforcement Action

This case raises serious concerns about accuracy in enforcing the Restricted Goods and Services Community Standard, especially considering that multiple reviewers assessed the content and none reached the correct policy application as determined by both the Board and the company’s subject matter experts.

The Board has repeatedly pushed Meta for content to be reviewed more holistically at-scale, rather than making assessments based on isolated parts of the content (see, among others, Wampum Belt and Poem About Political Protest in Argentina). The enforcement history in this case suggests that at-scale reviewers are given a checklist that can be interpreted too formulaically, with violations dependent on singular elements. In this case, it was the admission of fentanyl use that led to removal of the post, without any consideration of the context in which that use occurred.

The Board is especially concerned that some sections of the internal guidelines conflict with each other. Some sections instruct reviewers to remove content even with clear pregnancy or medical context. Other sections allow for consideration of such context. In addition, internal guidance states that in the case of such conflict, the high-risk category should lead to removal. Yet treating high-risk classification as effectively dispositive, notwithstanding the policy’s exceptions for medical contexts, reads that exception out of the policy in practice. This discrepancy raises questions about whether at-scale reviewers are even permitted to conduct the kind of basic contextual analysis required for accurate enforcement in cases like this one. It is unclear whether, despite the existence of a policy exception involving medical contexts, an at-scale reviewer would ever find this content non-violating given the current reviewer guidance. Even Meta acknowledged that a reviewer following internal guidance “may not come to the same conclusion as subject matter experts.”

The Board is also concerned that the enforcement error in this case recurs on ground it has covered before. In Promoting Ketamine for Non-FDA Approved Treatments, the Board recommended that Meta clarify in the Restricted Goods and Services Community Standard that admissions of pharmaceutical drug use are allowed where use occurs in a supervised medical setting, and that the company define that setting through indicators such as reference to a diagnosis or the presence of medical staff. Meta initially declined this recommendation, citing concerns that such requirements would unduly restrict discussion of pharmaceutical drugs. Meta later reopened this recommendation and attributed additions to the policy rationale allowing for discussions about “pharmaceutical drugs in the context of medical treatment, including discussion of physical or mental side effects” to the recommendation. However, the present case shows the cost of leaving the boundaries of a “medical context” undefined in the policy itself and associated enforcement guidelines. In this case, it was beyond clear that the pharmaceutical drug was being used in the context of medical treatment, but the content was nonetheless removed. The Board reiterates its recommendation to better define the indicators used to confirm whether the use of a drug occurs in a medical context.

5.2 Compliance With Meta’s Human Rights Responsibilities

The Board finds that while keeping the content up on the platform is consistent with Meta’s human rights responsibilities, the use of age restrictions and the non-recommendable outcome is not.

Freedom of Expression (Article 19 ICCPR)

Article 19 of the International Covenant on Civil and Political Rights (ICCPR) provides for broad protection of expression. This right includes “freedom to seek, receive and impart information and ideas of all kinds.” The United Nations (UN) Committee on Economic, Social and Cultural Rights makes clear that “access to health-related education and information” is a critical part of the right to health enshrined in Article 12 of the International Covenant on Economic, Social and Cultural Rights ( General Comment No. 14, para. 11). As the Board has noted in prior decisions, social media companies should respect freedom of expression around pharmaceutical and non-medical drugs (see, Promoting Ketamine for Non-FDA Approved Treatments, Sri Lanka Pharmaceuticals,Asking for Adderall).

When restrictions on expression are imposed by a state, they must meet the requirements of legality, legitimate aim, and necessity and proportionality (Article 19, para. 3, ICCPR). These requirements are often referred to as the “three-part test.” The Board uses this framework to interpret Meta’s human rights responsibilities in line with the UN Guiding Principles on Business and Human Rights, which Meta itself has committed to in its Corporate Human Rights policy. The Board does this both in relation to the individual content decision under review and what this says about Meta’s broader approach to content governance. As the UN Special Rapporteur on freedom of expression has stated, although “companies do not have the obligations of governments, their impact is of a sort that requires them to assess the same kind of questions about protecting their users' right to freedom of expression” ( A/74/486, para. 41).

I. Legality (Clarity and Accessibility of the Rules)

The principle of legality requires rules limiting expression to be accessible and clear, formulated with sufficient precision to enable an individual to regulate their conduct accordingly (General Comment No. 34, para. 25). Additionally, these rules “may not confer unfettered discretion for the restriction of freedom of expression on those charged with [their] execution” and must “provide sufficient guidance to those charged with their execution to enable them to ascertain what sorts of expression are properly restricted and what sorts are not” (ibid). The UN Special Rapporteur on freedom of expression has stated that when applied to private actors’ governance of online speech, rules should be clear and specific (A/HRC/38/35, para. 46). People using Meta’s platforms should be able to access and understand the rules, and content reviewers should have clear guidance regarding their enforcement.

The Board finds that the Restricted Goods and Services policy is clear in allowing “discussions of ... pharmaceutical drugs in the context of medical treatment, including discussion of physical and mental side effects.” However, the Board has legality concerns with the fact that this statement occurs in the policy rationale without clear and operational criteria as to what is permitted on the platform under this line of the policy rationale. The policy rationale should be codified in its operable rules to avoid confusion for users and content moderators.

The policy clearly prohibits content admitting personal use of “high-risk drugs.” It just as clearly permits content acknowledging use of “pharmaceutical drugs,” with the restrictions on age and recommendability discussed above. Fentanyl falls within both the prohibited and permitted categories: Meta designates it a high-risk drug, yet it is a prescription medication that medical professionals routinely administer, including during labor. The public-facing policy does not tell users which classification applies when the two overlap. Representatives of reproductive health and services NGOs told the Board that their experiences of navigating the Restricted Goods and Services policy often left them confused as to what the policy prohibits and permits. They said the policy should be clearer on what kinds of speech constitute awareness-raising around the use of particular drugs in medical contexts, and that enforcement of the policy should not presume that such content encourages use of or attempts to buy or sell drugs.

While not accessible to users, Meta’s internal guidelines clarify that medical context is one of the signals reviewers may consider when determining whether content that involves admission of use refers to a prescription drug. This is especially important for content involving fentanyl, which has a dual status as a widely used pharmaceutical drug for pain management and an illegally manufactured drug. As discussed above, the Board is concerned that “medical context” continues to be a vague and ill-defined term in Meta’s external policies and internal enforcement guidance (see Promoting Ketamine for Non-FDA Approved Treatments and Asking for Adderall) that does not, in its current form, support reviewers in differentiating between fentanyl’s illicit and licit uses. The Board reiterates its recommendation to better define the indicators used to confirm whether the use of a drug occurs in a medical context.

Even if medical context is accurately determined, the Board is concerned that contradictions within the internal guidelines to the Restricted Goods and Services policy make such carveouts impracticable. Some instructions indicate that it is possible for reviewers to consider policy exceptions for medical context, and others require reviewers to remove content despite a clear medical context when an admission of high-risk drug use is present. Contradictions in the internal guidelines create confusion for reviewers and are counter to the policy rationale in the public-facing policy, which recognizes the importance of the platform for people using firsthand experience to draw attention to the physical and mental side effects of common pharmaceutical drugs used in pregnancy and childbirth.

To ensure that this type of content is protected, as well as similar content from other health-related contexts, the Board recommends that Meta align its internal guidance and external language of the Restricted Goods and Services policy to clarify that admissions of use of high-risk drugs are not violative when such drugs also exist in pharmaceutical form, such as fentanyl, and when the reference is to use in a medical context, subject to a prescription. Meta should ensure that these policy materials consistently emphasize the role of medical context in determining which form of a drug is at issue in content, and that, with respect to internal guidance, reviewers are empowered to consider medical context when distinguishing between whether a reference to particular drugs is permissible or not.

II. Legitimate Aim

Any restriction on freedom of expression should also pursue one or more of the legitimate aims listed in Article 19, para. 3 of the ICCPR. Meta has a responsibility to ensure its rules comply with the principle of legitimacy (A/HRC/38/35, para. 45). As emphasized in the Asking for Adderall and Promoting Ketamine for Non-FDA Approved Treatments, the Restricted Goods and Services Community Standard, by addressing the risks of drug abuse among users, serves the legitimate aim of protecting public health. It also protects the rights of others, including the right to health and the right to information about health-related matters.

III. Necessity and Proportionality

Under ICCPR Article 19(3), necessity and proportionality requires that restrictions on expression “must be appropriate to achieve their protective function; they must be the least intrusive instrument amongst those which might achieve their protective function; they must be proportionate to the interest to be protected” (General Comment No. 34, para. 34).

The Board has previously recognized the serious harms associated with drug-related content on Meta’s platforms, and the role the Restricted Goods and Services policy plays in protecting users from those harms (see Promoting Ketamine for Non-FDA Approved Treatments). Research confirmed the severity of the fentanyl crisis: illicitly manufactured fentanyl is the primary driver of overdose deaths in the U.S.. However, these harms arise from illicit manufacture, sale and unsupervised use - not from clinical administration of pharmaceutical fentanyl, which is a routine, WHO-recommended component of pain management in labor and delivery around the world.

In this post, the admission of fentanyl use clearly described medication administered by clinicians during the user’s labor, as part of an account intended to inform other women preparing for childbirth. The Board finds no direct or immediate connection between the content and the possibility of harm, so removal was not necessary.

The Board has previously recognized the importance of protecting children from age-inappropriate and potentially harmful content, and has endorsed age restriction as a proportionate measure where content poses genuine risks to younger users while retaining value for adults (see India Sexual Harassment Video). Meta's interest in limiting minors' exposure to drug-related content is legitimate, particularly in the context of the fentanyl crisis: adolescents face acute risks from illicitly manufactured fentanyl, and platforms have served as a channel through which counterfeit pills reach young people.

However, age restriction must be assessed against the content being restricted, and the post in this case presents none of the risks that justify limiting minors' access. It contains no promotion, glamorization or facilitation of drug use; it is a first-person account of clinically administered medication that clearly refers to pharmaceutical fentanyl. Restricting it to adults does not shield minors from harm. Rather, it withholds from them experience-based health information. Where official guidance on medications in pregnancy is variable and sometimes conflicting, firsthand accounts of prescription drugs - whether positive or negative - can play an important role in informing decision-making. The account in this case was negative, but a positive assessment would serve the same function. As the Board has discussed elsewhere (see Claimed COVID Cure and Removal of COVID-19 Misinformation policy advisory opinion), wide-ranging input on health-related matters can coexist with WHO-approved information serving as an authoritative baseline.

This analysis is consistent with the Board’s findings in Promoting Ketamine for Non-FDA Approved Treatments, in which the Board overturned Meta’s decision to leave up a user’s Instagram post discussing their experience using ketamine. While ketamine also can have medical and illicit uses, that case concerned paid, branded content promoting a drug’s effects, which the Board found did not sufficiently demonstrate that the ketamine use described had occurred under medical supervision. The content at issue in this case is materially different: it is unpaid, personal experience, and the medical context of the drug use it describes is clear and undisputed.

The information shared in the case content has particular value for some adolescents, including, as discussed above, users under 18-years-old who are pregnant and who face labor and its pain-management decisions, and for whom the Convention on the Rights of the Child ( Article 24) recognizes a right of access to health information (General Comment No. 20, para. 47). More broadly, fentanyl poses a distinct and growing danger to adolescents, who face rising overdose deaths driven largely by counterfeit pills rather than increased drug use. Public health researchers emphasize that teenagers have an urgent need to access information about fentanyl's different uses and associated risks. A firsthand account of the drug's effects in a medical context is the kind of content from which adolescents stand to benefit, not the kind from which they require protection. The Board therefore finds that restricting this content to users over 18-years-old was neither necessary nor proportionate.

The Board also finds that in this case coupling the age restriction with exclusion from recommendation surfaces is an unnecessary additional restriction on freedom of expression. Social media plays a significant role in how women share and seek maternal health information, and the user stated that her purpose was to reduce stigma around discussing pain management and to help women advocate for themselves in medical settings. The Board is concerned that by making this content non-recommendable, Meta ignores the value of the platform for those preparing for pregnancy and childbirth and ultimately undermines the purpose of its own policy allowance for admitting prescription drug use. Content of this kind can often reach its audience through recommendation surfaces. Excluding it from those surfaces confines it to existing followers, imposing a substantial restriction on reach. The public comments received in this case document that such suppression has been applied to women's health content without notice, explanation or recourse, and contributes to widespread self-censorship among health creators and educators (PC-32680; PC-32682).

The Board has previously found that excluding awareness-raising content from recommendation was not a necessary or proportionate restriction on freedom of expression (see, most recently, Posts Condemning Bus Harassment), and has recommended decoupling the non-recommendable function from other enforcement actions for other policies . As further outlined in Eating Disorder Awareness Posts, Meta's systems should not impede awareness-raising content from reaching its intended audiences. That concern is particularly applicable here, where the intended audience of mothers and women preparing for childbirth is precisely the audience excluded by the non-recommendable enforcement action.

The Board is further concerned by the account-level consequences of erroneous enforcement in this case. The strike applied to the user's account resulted in a time-based feature limit. Because the content was restored only after the Board selected the case, the user served the penalty in full. She was punished, in effect, for sharing her experience of prescribed medical care. The interference was not reversed in time to be remedied, reflecting a failure the Board has previously identified: where content-level enforcement triggers account-level measures, appeals must be reviewed promptly enough for reversal to be meaningful (see Asking for Adderall). These consequences can be far-reaching when enforcement impacts organizational accounts. For health organizations, educators and advocates - including those serving women on sensitive issues such as reproductive health and sexual violence - feature limits and suspensions can sever contact with the communities that depend on them, in some documented cases cutting off critical services overnight (PC-32680).

Restrictions also carry the potential for reputational harm. In discussions with the Board, stakeholders shared that a suspended account can appear illegitimate, damaging trust in the underlying health service and compounding the stigma that such organizations work to reduce. To address the impacts of overenforcement on such organizations, the Board recommends that Meta ensure they are deemed eligible and enrolled as part of the broader set of entities protected for human rights reasons in the Sensitive Entity Secondary Review system. This follows from recommendations in the Board's policy advisory opinion on Meta’s cross-check program (see, in particular, recommendations 4 and 7) that called on Meta to differentiate between users who merit additional protection from a human rights perspective and those included in the Sensitive Entity Secondary Review system for business reasons. The Board identified journalists, rights defenders and dissidents as categories for enrollment. The Board recommends that Meta ensure global reproductive and maternal health organizations are included in the broader set of entities enrolled for human rights reasons.

Meta acknowledged that, due to dangers associated with fentanyl, it has designed the Restricted Goods and Services policy to prioritize safety at scale. As a result, the policy may prioritize overenforcement. This approach may be necessary and proportionate for jurisdiction-specific challenges, such as the fentanyl crisis in the U.S.. However, a policy calibrated to a jurisdiction-specific challenge can have disproportionate impacts when applied uniformly to a global user base. Countries where fentanyl is not a significant public health concern, or where other prescription and non-prescription drugs present different risk profiles, may see legitimate health content restricted to address a harm that is largely absent from their own context while leaving the harms of other drugs unaddressed. Given that Meta said it has not conducted specific research into over- or under-enforcement of content related to pregnancy and/or maternal health issues, in this case the Board recommends that Meta undertake a global audit of enforcement of the Restricted Goods and Services policy and its impacts on this type of content.

Finally, the principles in this decision are not specific to women's health. Access to health information is a universal right. Users seeking or sharing firsthand accounts of medications for any condition are entitled to the same protection from erroneous enforcement. The Board's attention to the gendered dimensions of overenforcement of the Restricted Goods and Services policy reflects the evidence in this case. Public comments indicate that enforcement errors of this kind have had a significant impact on reproductive, maternal and women's health content (PC-32680 and PC-32682), a domain where open discussion already contends with longstanding stigma. Where enforcement impacts have been unevenly distributed, addressing them is not preferential treatment; it simply levels an uneven field. The measures this decision recommends would protect health-related speech for all users and attempt to correct documented imbalance in who bears the cost of overenforcement.

6. The Oversight Board’s Decision

The Board overturns Meta's original decision to take down the content. The content should have been left up without the age-gating restriction and should not have been made non-recommendable.

7. Recommendations

Content Policy

1. To ensure that discussion and awareness-raising related to prescription drugs is protected, Meta should clarify the Restricted Goods and Services Community Standard to state expressly that admissions of personal use of a drug administered by medical professionals - including substances otherwise designated high-risk - are treated under the prescription drug allowance.

The Board will consider this recommendation implemented when the language of the Restricted Goods and Services Community Standard has been updated to reflect this change.

Enforcement

2. To ensure that content admitting medical use of prescription drugs is properly enforced, Meta should align internal guidance and external language of the Restricted Goods and Services policy to clarify that admissions of use of high-risk drugs are not violative in all cases when such drugs also exist in pharmaceutical form, such as fentanyl. Meta should ensure that these policy materials consistently emphasize the role of medical context in determining which form of a drug is at issue, and that, with respect to internal guidance, reviewers are empowered to consider medical context when distinguishing between different types of drugs. The internal guidance should also clarify what signals indicate medical context.

The Board will consider this recommendation implemented when the updated internal guidance is shared with the Board.

3. To minimize the impact of potentially incorrect account-level actions on global reproductive and maternal health organizations, Meta should ensure that such groups are deemed eligible for enrollment as part of the broader set of entities protected for human rights reasons in the Sensitive Entity Secondary Review system.

The Board will consider this recommendation implemented when Meta provides evidence to the Board that reproductive and maternal health organizations are eligible and enrolled in the Sensitive Entity Secondary Review system.

Transparency

4. To ensure that its policies and enforcement practices do not disproportionately limit access to health information, Meta should audit global enforcement of the Restricted Goods and Services Community Standard against content discussing the medical use of drugs, publish category-level error rates broken down by region, country or language, and assess whether errors fall disproportionately on reproductive, maternal and women's health content. This audit should also assess the impact of the standard's 18+ years age restriction on the ability of under-18-years-old users to access health information relevant to them.

The Board will consider this recommendation implemented when Meta publishes category-level error rates surfaced by the audit and shares the full results with the Board.

*Procedural Note:

• The Oversight Board’s decisions are made by panels of five Members and approved by a majority vote of the full Board. Board decisions do not necessarily represent the views of all Members.
• Under its Charter, the Oversight Board may review appeals from users whose content Meta removed, appeals from users who reported content that Meta left up, and decisions that Meta refers to it (Charter Article 2, Section 1). The Board has binding authority to uphold or overturn Meta’s content decisions (Charter Article 3, Section 5; Charter Article 4). The Board may issue non-binding recommendations that Meta is required to respond to (Charter Article 3, Section 4; Article 4). Where Meta commits to act on recommendations, the Board monitors their implementation.

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