Racial Disparities in Newborn Drug Testing After Implementation of Question-Based Screening for Prenatal Substance Use

Abstract

OBJECTIVE: To examine the association of universal question-based screening for prenatal substance use on racial inequities in prenatal and newborn drug testing. METHODS: We conducted a retrospective cohort study of 32,802 live births of patients receiving prenatal care at an academic medical center in the midwestern United States from 2014 to 2022, before and after implementation of question-based screening in 2018. Primary outcomes included prenatal and newborn drug test orders. Logistic regression models using a generalized estimating equation framework assessed associations with question-based screening and results, birthing parent age, race, ethnicity, marital status, and insurance type. Charts of patients who indicated difficulties stopping substance use were audited for guideline-directed care. RESULTS: A total of 12,725 of 14,992 pregnant people (85.3%) received question-based screening. Implementation of question-based screening was associated with a decrease in prenatal urine test orders (5.0% [95% CI, 4.6–5.3%] before implementation, 3.1% [95% CI, 2.8–3.4%] after implementation; P<.001), with Black birthing parents having the largest reduction in prenatal urine drug testing (10.3% [95% CI, 9.0–11.7%] before implementation, 4.9% [95% CI, 3.9–5.9%] after implementation). However, rates of newborn drug testing did not change (4.7% [95% CI, 4.4–5.0%] before implementation, 4.5% [95% CI, 4.2–4.8%] after implementation; P=.46), and clinicians continued to order significantly more newborn drug tests for newborns of Black birthing parents compared with other race and ethnicity groups. CONCLUSION: Implementation of question-based screening for substance use in pregnancy was associated with decreased prenatal urine drug testing but no change in overall newborn drug testing or racial inequities in newborn drug testing for Black birthing people. Further policy efforts are warranted to improve substance use treatment and to eliminate racial inequities in punitive policies such as newborn drug testing and subsequent child protective services reporting.