Disparities in Maternal-Infant Drug Testing

The US Child Abuse and Prevention Treatment Act (CAPTA) requires that all states have policies in place to identify newborns exposed to substances.  At the present time, 37 states and the District of Columbia require clinicians to report suspected prenatal drug use to the state.  According to the Guttmacher Institute, 25 states and the District of Columbia consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and five states consider it grounds for civil commitment.

The American College of Obstetricians and Gynecologists (ACOG) strongly recommends that women who are pregnant or planning to conceive should abstain from alcohol, tobacco and recreational drugs during pregnancy; however, ACOG opposes the criminalization of substance use during pregnancy and the use of toxicologic testing of newborns as a proxy for child abuse or neglect.  Of great concern is the fact that previous studies have documented that clinicians are more likely to report Black parents to Child Protective Services (CPS) for prenatal substance use than their White counterparts. This disparity has been observed in settings using either selective or universal screening despite similar prevalence rates of drug use in the two groups.

In a recent retrospective chart review, Mass General researchers including Davida Schiff, MD, Medical Director of the MGH HOPE Clinic, as well as Bettina Hoeppner, PhD and Timothy Wilens, MD from the Department of Psychiatry, have evaluated for disparities in peripartum toxicology testing among maternal-infant dyads and subsequent child protective services (CPS) involvement across five Massachusetts hospitals.

Evident Disparities in Toxicology Testing at Birth

The analysis included 59,425 deliveries between 2016 and 2020. The researchers observed that toxicology testing was performed on 1959 (3.3%) mother-infant dyads. Younger individuals and individuals of color were more likely to be tested for cannabis use than white non-Hispanic individuals. 

In women without a documented substance use disorder, the following factors were associated with increased likelihood of toxicology testing:

• Younger age (under 25 years, adjusted odds ratio [aOR] 2.81; 95% CI, 2.43-3.26),
• Race and ethnicity: non-Hispanic Black (aOR 1.80; 95% CI, 1.52-2.13), Hispanic (aOR 1.23; 95% CI, 1.05-1.45), mixed race/other (aOR 1.40; 95% CI, 1.04, 1.87), unavailable race (aOR 1.92; 95% CI, 1.32-2.79),
• Public insurance (Medicaid aOR 2.61; 95% CI, 2.27-3.00 or Medicare aOR 13.76; 95% CI, 9.99-18.91) 

Among the mother-infant pairs tested, race and ethnicity was not associated with child protective services involvement.

The current study is consistent with previous reports from other hospital networks and indicates that peripartum toxicology testing is disproportionately performed on non-white, younger, and poorer individuals and their infants, with cannabis use and medical complications prompting testing more often for patients of color than for white non-Hispanic individuals.

Can We Do Better in Determining Who Should Be Drug Tested?

While the primary goals of toxicology testing at birth are to guide clinical treatment of the mother and newborn and to ensure the safety and well-being of the child, toxicology testing in this setting can have far-reaching consequences, including the introduction of child welfare surveillance into the family’s life, loss of parental custody and criminal charges. It is of great concern that this study and others have documented that peripartum toxicology testing is disproportionately performed on non-white, younger, and publicly insured mothers and their infants.  Although the current study from Massachusetts does not indicate that race or ethnicity was associated with referral to Child Protective Services, other studies from other states have indicated that clinicians are more likely to report Black parents to CPS for prenatal substance than white parents.

Guidelines outlining the indications for peripartum toxicology testing are often unclear and inconsistent, a factor that may contribute to racial inequities in testing.While targeted testing based on clinical presentation and maternal risk factors for substance use disorders has been advocated, this study suggests that testing for certain indications may disproportionately affect specific groups.  To minimize this sort of bias and to provide more equitable care, the authors suggest that toxicology testing decision aids could be incorporated into the electronic medical record, so that providers must indicate specific indications for testing prior to requesting toxicology testing.  They note that further study is also needed to better understand the clinical utility of toxicology testing to ensure equitable care for the most marginalized patients.

This research was carried out in collaboration with Samuel Cohen, Timothy Nielsen, Joseph H Chou, Kathleen J Koenigs, Sarah N Bernstein, Nicole A Smith, Nicola Perlman, Leela Sarathy, and Mishka Terplan.

Cohen S, Nielsen T, Chou JH, Hoeppner B, Koenigs KJ, Bernstein SN, Smith NA, Perlman N, Sarathy L, Wilens T, Terplan M, Schiff DM. Disparities in Maternal-Infant Drug Testing, Social Work Assessment, and Custody at 5 Hospitals. Acad Pediatr. 2023 Feb 7: S1876-2859(23)00014-1.