The US Child Abuse and Prevention Treatment Act (CAPTA) requires that each one states have policies in place to discover newborns exposed to substances.  This present day, 37 states and the District of Columbia require clinicians to report suspected prenatal drug use to the state.  In keeping with the Guttmacher Institute, 25 states and the District of Columbia consider substance use while pregnant 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 ladies who’re pregnant or planning to conceive should abstain from alcohol, tobacco and recreational drugs while pregnant; nevertheless, ACOG opposes the criminalization of substance use while pregnant and using toxicologic testing of newborns as a proxy for child abuse or neglect.  Of great concern is the proven fact that previous studies have documented that clinicians usually tend 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 within the two groups.

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

Disparities in Toxicology Testing at Birth

The evaluation 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 prone to be tested for cannabis use than white non-Hispanic individuals. 

In women and not using a documented substance use disorder, the next aspects were related to 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], Medicare [aOR 13.76; 95% CI, 9.99-18.91]) 

Among the many mother-infant pairs tested, race and ethnicity was not related to child protective services involvement.

The present 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.

While the first goals of toxicology testing at birth are to guide clinical treatment of the mother and newborn and to make sure the security and well-being of the kid, toxicology testing on this setting can have far-reaching consequences, including the introduction of kid welfare surveillance into the family’s life, lack of parental custody and criminal charges. It’s of great concern that this study and others have documented that peripartum toxicology testing is disproportionately performed on non-white, younger, and publicly insured moms and their infants.  Although the present study from Massachusetts doesn’t indicate that race or ethnicity was related to referral to Child Protective Services, other studies from other states have indicated that clinicians usually tend to report Black parents to CPS for prenatal substance than white parents.

Guidelines outlining the indications for peripartum toxicology testing are sometimes unclear and inconsistent, an element that will contribute to racial inequities in testing.While targeted testing based on clinical presentation and maternal risk aspects for substance use disorders has been advocated, this study suggests that testing for certain indications may disproportionately affect specific groups.  To attenuate this type of bias and to offer more equitable care, the authors suggest that toxicology testing decision aids may very well be incorporated into the electronic medical record, in order that providers must indicate specific indications for testing prior to requesting toxicology testing.  They note that further study can be needed to raised understand the clinical utility of toxicology testing to make sure equitable take care of essentially the most marginalized patients.

Ruta Nonacs, MD PhD

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.