Understanding Racial and Socioeconomic Bias in Screening for Substance Use in Labor and Delivery

Educational Objectives

The goal of this program is to improve screening for substance use in labor and delivery. After hearing and assimilating this program, the clinician will be better able to:

1. Recognize racial and socioeconomic biases in screening for substance use in labor and delivery.
2. Implement recommendations for urine toxicology screening in pregnant patients.

Summary

Screening for substance use disorder (SUD): an important part of comprehensive obstetric care; a validated verbal questionnaire is recommended instead of urine toxicology screening (UTox)

Urine drug testing: limitations — false-positives and false-negatives; confirmatory testing takes several days; timing of sample collection is important; does not provide information on frequency or quantity of use or presence of SUD; indications — include unexplained altered mental status; a birthing person may desire UTox to prove adherence; studies show limited utility of UTox in identifying causes of preterm labor or placental abruption; legal status — UTox should not be used for legal or punitive purposes; in a Supreme Court ruling (2000), use of UTox in pregnant women without informed consent was deemed illegal for punitive purposes; however, most hospitals in the United States perform UTox screening based on risk factors (eg, limited prenatal care, homelessness, history of SU), and not for clinical care purposes

Racism in risk-based testing: data show risk-based testing perpetuates racism; individuals at risk for increased testing include Black women, those with low socioeconomic status and single status, and those who are unemployed; Winchester et al (2022) found that informed consent was documented in only 12% of cases

Negative consequences: higher costs; fosters mistrust of the medical system, leading to avoidance of prenatal care, prolongation of hospital stay, and separation of mother and baby; may lead to criminal prosecution; nonconsensual testing may be traumatizing to the mother; evidence shows that states with punitive policies have higher rates of neonatal abstinence syndrome (patients are less likely to seek care); racial disparities in foster care — Black children are 4-fold more likely to be placed within Child Welfare Services than White children; before they turn 18 yr of age, 1 in 7 Native American children and 1 in 9 Black children are placed in foster care; recently, racial and socioeconomic bias in substance screening leading to increased foster care removals has recently received media attention

Best practices: the American College of Obstetricians and Gynecologists and California Maternal Quality Care Collaborative have advocated best practices and clinical guidelines; universal screening for SU with a validated verbal screening tool (not UTox) is recommended; practitioners have an ethical responsibility to discourage the separation of parents from their children solely based on SUD; the purpose of toxicology testing should be to improve clinical decision-making, eg, pain management; informed consent must be obtained after explaining legal, criminal, and child welfare consequences

Toxicology policy at Scripps Health: reflects nationwide practice; UTox is part of an automatic admission order set, and the provider may not be informed; indications are primarily social (eg, homelessness, limited prenatal care, domestic violence); includes drug use ≤5 yr, not drug or alcohol abuse ≤5 yr as it is difficult to interpret; in hospitals that do not have a policy, testing is based on the provider's discretion

Retrospective cohort study at Scripps Health

Methods: the study included pregnant patients (≈20,000) who gave birth at the 4 Scripps hospitals between January 2020 and June 2022; patients were propensity-matched based on pregnancy risk and assessed for effects of race, income, and insurance on the likelihood of receiving UTox testing; a chart biopsy of randomly selected patients was also performed

Results: at Scripps Health, 6% of pregnant patients are tested for UTox, of whom 11.3% test positive; primary language was not associated with UTox; Black patients are 2.6-fold more likely than White patients to be tested for UTox, after accounting for income and insurance status; Asian race was a protective factor; patients dwelling in highest income zip codes were 33% as likely to have UTox compared with those living in lowest income zip codes, but this did not hold true when considering race and insurance status; patients with Medi-Cal were 2.2-fold more likely and uninsured patients 1.8-fold more likely to have UTox compared with privately insured patients; positive test — Hispanic and Black patients have lower rates of positive tests despite higher test rates; a larger proportion of White patients had a positive test; charts — common indications for UTox include limited prenatal care (most common), marijuana use, and history of SU prior to pregnancy; clinical factors comprised 5% of indications; indications were clearly documented in 12% of cases; informed consent was not obtained or documented

Implications: Scripps data are consistent with national data, ie, risk factors reflect racism and social determinants of health, and not true risk of SU; policy should align with current best practices and evidence

Actionable steps: include universal screening for SU with a validated verbal questionnaire incorporating 5Ps (free version of 4P's Plus); in one study, 20% of pregnant patients screened positive on 5Ps compared with 2% on UTox; the goal of screening is to support the patient; UTox should be obtained only when medically indicated or when requested by the patient or provider; document the indication for UTox; obtain informed consent from all patients; await confirmatory results for positive tests before taking action, if possible; be mindful of potential newborn discharge concerns; SUD diagnosis may not automatically equate with unsafe parenting; reporting a positive UTox to Child Protective Services is not a legal obligation in California; connect SUD patients to resources and treatment; evaluate the impact of policy changes

Readings

Chasnoff IJ, Wells AM, McGourty RF, et al. Validation of the 4P’s Plus screen for substance use in pregnancy validation of the 4P’s Plus. J Perinatol. 2007;27(12):744-748. doi:10.1038/sj.jp.7211823; Coleman-Cowger VH, Oga EA, Peters EN, et al. Comparison and validation of screening tools for substance use in pregnancy: a cross-sectional study conducted in Maryland prenatal clinics. BMJ Open. 2018;8(2):e020248. Published 2018 Feb 17. doi:10.1136/bmjopen-2017-020248; Committee opinion no. 711: opioid use and opioid use disorder in pregnancy. Obstet Gynecol. 2017;130(2):e81-e94. doi:10.1097/AOG.0000000000002235; Jarlenski M, Shroff J, Terplan M, et al. Association of race with urine toxicology testing among pregnant patients during labor and delivery. JAMA Health Forum. 2023;4(4):e230441. doi:10.1001/jamahealthforum.2023.0441; Nishino M, Giobbie-Hurder A, Hatabu H, et al. Incidence of programmed cell death 1 inhibitor-related pneumonitis in patients with advanced cancer: A systematic review and meta-analysis. JAMA Oncol. 2016;2(12):1607-1616. doi:10.1001/jamaoncol.2016.2453; Ondersma SJ, Chang G, Blake-Lamb T, et al. Accuracy of five self-report screening instruments for substance use in pregnancy. Addiction. 2019;114(9):1683-1693. doi:10.1111/add.14651; Wildeman C, Emanuel N. Cumulative risks of foster care placement by age 18 for U.S. children, 2000-2011. PLoS One. 2014;9(3):e92785. doi:10.1371/journal.pone.0092785; Winchester ML, Shahiri P, Boevers-Solverson E, et al. Racial and ethnic differences in urine drug screening on labor and delivery. Matern Child Health J. 2022;26(1):124-130. doi:10.1007/s10995-021-03258-5.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Malekmadani was recorded at SDAFP Family Medicine 2023 Update, held June 23-25, 2023, in San Diego, CA, and presented by San Diego Academy of Family Physicians. For more information about upcoming CME activities from this presenter, please visit https://sandiegoafp.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

IM703802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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