(73) Racial Inequity in Newborn Drug Testing Despite Universal Prenatal Substance Use Screening

Background & Introduction: Risk-based biological testing for prenatal substance use is associated with disproportionate reporting of Black families to the child welfare system. The American College of Obstetrics and Gynecology (ACOG) recommends universal question-based screening with a validated tool. Despite this, there are very few studies that have accessed system implementation of such screening recommendations. The primary aim of this study is to evaluate the implementation of universal verbal screening during prenatal care on the frequency and racial disparity of prenatal and newborn drug testing. A secondary aim was to understand the outcome of positive substance use screens on brief interventions and treatment.

Methods: This retrospective cohort study includes 32,802 live births between July 2014 and July 2022 who received prenatal care at an academic health system in the Midwestern US that adopted a universal verbal substance use screening in May 2018. Primary outcomes included prenatal or newborn drug test orders. Demographic data included birthing parent age, self-reported race and ethnicity, marital status, insurance type, and zip code. Prenatal substance use screening was done with the free version of the validated 4Ps tool. Chart reviews were performed for patients who reported struggling to stop using substances to evaluate assessment, brief intervention, and referral to treatment.

Results: After implementation, 12725 (85.3%) of pregnant people received verbal screening with a standard questionnaire. Most birthing parents were White (72%), non-Hispanic (93%) and had private insurance (73%). Prior to implementation of the verbal screening, 10.3% of Black birthing parents had a prenatal urine drug test. After implementation, testing rates for Black birthing parents dropped to 4.9%. Among White birthing parents, implementation of the screening program was associated with a smaller reduction in prenatal drug testing from 4.7% to 3.1%. Rates of newborn drug testing, on the other hand, did not change significantly. Among Black birthing parents, newborn drug testing rates changed from 11.2% to 9.1% post-implementation. In chart reviews of 39 patients who reported struggling to stop using substances, 17 (43.6%) were mislabeled and represented either substance use by the parent of the pregnant person or had no additional documentation indicating active substance use. Of individuals who reported struggling to stop using drugs or alcohol, 45.% were using cannabis in isolation. Of the birthing parents reporting difficulty stopping cannabis, only 60% received a brief intervention as defined as conversations understanding motivation to use and intention to quit or documented discussion of health risks.

Conclusion & Discussion: Universal implementation of verbal substance use screening during prenatal care reduced racial disparities in prenatal drug testing while newborn drug testing rates remained unchanged. Clinician responses to patients struggling with substance use were variable, particularly for patients using cannabis. This study demonstrates both the promise and insufficiency of using universal question-based substance use screening to resolve racial disparities in prenatal and newborn drug testing. Additionally, there is a clear need to standardize and incorporate evidence-based treatment for prenatal substance use with particular focus on cannabis use.

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