Equity in Policies Regarding Urine Drug Testing in Infants

EDITORS’ NOTE

We are thrilled to introduce a new series, “EDI case series,” focused on examining and eliminating inequities in the neonatal health care setting. Disparities in birth outcomes for non-white infants have been recognized for decades, but solutions to close this gap remain elusive. We, at NeoReviews, believe that discussions about disparities and inequities in health care, lack of representation, and unconscious bias are an essential first step toward enacting actionable change at the institution level and the health care system level. We want to use our platform to disseminate educational content and ignite discussion and change. This innovative series was envisioned by Drs Kathryn Paul, Daria Murosko, Joanna Parga-Belinkie, and Diana Montoya-Williams, who have used this series in a conference-based format within their own institution. In collaboration with this inspiring team, we have adapted this to a written format in an effort to reach a wider multidisciplinary audience caring for neonates. In this case-based series, authors aim to:

• Review key literature

• Invite expert opinions

• Define terminology related to health inequities

• Provide tools and methods for readers to translate this new knowledge to foster change in their care practices and own institutions

INTRODUCTION

This piece represents a new case in a recurring series to examine health inequities within newborn medicine. Although the cases are curated from real experiences within a specific institution, the overarching themes are universal. This series is a vehicle to bring these difficult and important conversations to any unit that provides newborn care. It offers opportunities to reflect and consider individual, team, and institutional practices and ultimately, to deliver more equitable care to our patients and their families. Throughout the piece, the reader is asked to pause and reflect on their personal practices and potential biases. Perspective-taking exercises such as these have been shown to reduce implicit bias.(1) In some instances, we have also shared our own reflections, as authors, to model perspective-taking, recognizing that our personal opinions may or may not resonate with the reader. These prompts can also be discussed within teams. In addition to our voices, you will also read commentary from a national expert in the field. We close with suggestions for activities clinicians can undertake after reading through this case.

Meet the expert: Wanda D. Barfield, MD, MPH, FAAP is a board-certified neonatologist with over 25 years of clinical experience, and the Director for the Division of Reproductive Health within the Centers for Disease Control and Prevention in Atlanta, GA. She has led efforts to ensure optimal equitable health for pregnant women and their infants. She is a Professor of Pediatrics with the Uniformed Services University, and an Adjunct Assistant Professor of Pediatrics at Emory University School of Medicine. She is also a retired Assistant Surgeon General (Rear Admiral) in the US Public Health Service.

CASE PRESENTATION

A 3-day-old growth-restricted infant was born at 34 weeks and 5 days’ gestation via vaginal delivery after an unstoppable preterm labor. The birth parent, who identified as a mother, is a 22-year-old, unmarried black woman, who had appropriate prenatal care. She has a history of generalized anxiety disorder managed with benzodiazepines as needed. She reports taking her prescribed benzodiazepines only 3 to 4 times during her pregnancy. She does not report use of alcohol, tobacco, or other substances. Prenatal laboratory test results are unremarkable, and there were no complications during the pregnancy. Rupture of membranes occurred 4 hours before delivery. The infant initially required 2 minutes of positive pressure ventilation for respiratory insufficiency and was admitted to the Neonatal Intensive Care Unit on continuous positive airway pressure without supplemental oxygen requirement. The infant is now receiving a trial of lower respiratory support, and nasogastric feedings with maternal breast milk, as available.

Today, the infant is fussy and intermittently jittery, especially during nursing care, but also when not being touched. The infant’s neurologic examination findings are otherwise unremarkable and the infant settles with holding. The infant does not have any fever or other concerns for sepsis. A glucose level is checked and within normal limits. Given the prenatal exposure to benzodiazepines, the medical team elects to send a urine drug screen overnight, as is allowed by this particular state’s laws.

When the mother comes into the unit, she notices her infant has cotton balls in the diaper. She asks the nurse about this, and the nurse informs her that the medical team has ordered a urine toxicology screen for the infant to determine if the baby is “withdrawing from drugs.” The mother has not been informed of this plan and asks to speak to the infant’s physician.

Perspective Taking and Reflection

• Put yourself into the perspective of the infant’s birth parent. If you found that your infant was being tested for substance exposure without your knowledge, how might you feel?

  Author perspective (Dr. Daria Murosko [DM], who identifies as a white, cis woman): I might feel betrayed and confused. This is especially true because I had been open about the prescribed medications I used in pregnancy, and I would feel like my words were not trusted. I would feel judged, like the doctors thought I had done something to harm my baby. I’d wonder if it were the medicine for my anxiety that caused this, but why would my doctors give me a medicine that could hurt my baby? And if my baby was having issues because of the medicine, I’d also wonder why no one had mentioned this possibility to me before my baby was born?

• How might this scenario be different if the birth parent was white?

  DM: I think a white birth parent may be given the benefit of the doubt. Perhaps drug use might not be the first diagnosis on the differential if the infant had been fussy and jittery and the birth parent was white, married, older, or some combination of those characteristics. We often construct differential diagnostic lists for societally minoritized people differently, given our assumptions about who uses drugs. I also wonder if a white birth parent might have been informed about the test before it was sent or have been involved in the decision-making process.

  Dr Wanda Barfield (WB): It is important to note that as pediatricians and neonatal clinicians, we are interacting not only with our patients, but their parent(s). Families of color (black, American Indian, and Alaska Native, Hispanic, Native Hawaiian/other Pacific Islander) experience high rates of mistreatment by health care professionals during pregnancy, birth, and the postpartum period. The most common experiences of mistreatment included verbal abuse, stigma and discrimination, and delays and refusals in care. (2) For example, pregnant women who declined prenatal care were substantially more likely to report perceived discrimination during the childbirth hospitalization. (3) Perceived discrimination may create valid reasons for a parent’s desire to decline care or seek care at another facility. Unfortunately, parents who decline care may be labeled “problem parents.”

Case Objectives

• Describe how racism acts across multiple levels of our society, within the medical system in general, and within newborn medicine in particular.

• Articulate the historical context unfairly linking substance use and black people and the persistent influence on contemporary stereotypes.

• Identify opportunities to address racial disparities in urine toxicology testing in our individual practices and within our medical system.

Key Terms

• Structural racism: “Macro-level conditions (eg, residential segregation and institutional policies) that limit opportunities, resources, power, and well-being of individuals and populations based on race/ethnicity and other statuses.” (4)

• Personally mediated racism: Prejudice and discrimination, where prejudice means differential assumptions about the abilities, motives, and intentions of others according to their race, and discrimination means differential actions toward others according to their race. (5)

• Stereotype: “A standardized mental picture that is held in common about members of a group that represents an oversimplified opinion, attitude, or unexamined judgment, without regard to individual difference.” (6)

• Implicit bias: An example of personally mediated racism, whereby “learned stereotypes and prejudices operate automatically, and unconsciously, when interacting with others. Also referred to as unconscious bias.” (7)

• Health inequities: “Differences in health status and mortality rates across population groups that are systemic, avoidable, unfair, and unjust. These differences are rooted in social and economic injustice, and are attributable to social, economic, and environmental conditions in which people live, work, and play.” (8)

DISCUSSION OF RELEVANT LITERATURE

Historical Context

Since the 1980s, substance use has been unfairly associated with people who are black. (9) The popular press at that time highlighted the increasing prevalence of crack-cocaine use in predominantly urban, impoverished, and black neighborhoods. Those struggling with addiction were labeled as “junkies” and “users.” The Washington Post described children of people who used crack as “a bio-underclass, a generation of physically damaged cocaine babies whose biologic inferiority is stamped at birth.”(10) These stereotypes animated the “War on Drugs,” manifesting as the systemic incarceration of black men for drug-related offenses at 13 times the rate of white men, even though rates of drug use were similar between black and white men. (11) Black men were also more likely to be incarcerated for possession of smaller amounts of substances or incarcerated significantly longer for similar offenses. (12) This stands in stark contrast today with the response to the more recent opioid overdose crisis, which initially affected white individuals, and those who use drugs are more often met with an emphasis on treatment and rehabilitation, as opposed to a more punitive approach, including incarceration, that dominated drug policy in the past.(12)(13)(14)

The systematic differential treatment of black individuals with respect to substance use disorder and the criminal justice system is an example of structural racism. The War on Drugs and mass incarceration has had reverberating impacts on urban black communities, physically separating family members, and limiting educational achievement and economic opportunities for those convicted. Moreover, the stereotype of an individual who struggles with addiction as black, poor, and urban has been engrained into our mainstream culture, and affects our unconsciously held assumptions about who is more likely to be using drugs. (4)

Health care professionals are not immune to stereotypes associating substance use with black individuals. In one experiment, after health care professionals were primed with subliminal images of black men, they reacted more quickly to diseases that were stereotypically associated with black individuals, which included substance abuse. (15) When presented with clinical vignettes featuring adults with chronic pain, health care professionals ranked black patients at higher risk of abuse and misuse compared with white patients, even when there were no red flag symptoms for abuse. (16) The authors speculated that these stereotypes—even if they were not consciously articulated by the physicians—could, in part, explain the well-documented disparities in undertreatment of pain in black patients. (17)

WB: Recognizing the historical contributors to health disparities is only the very first step in effecting change. One cannot use learning about the past as a means of not thinking about the future. Just because these issues stemmed from past actions, it does not mean they don’t still exist with the same intensity today. So instead of a “Wow, that was not great, glad we are past that” mentality, we have to adopt a “How is this manifesting today?” mentality and continue to think about incremental change over time to achieve equity in care and outcomes.

Contemporary Implications

Currently, the American College of Obstetricians and Gynecologists (ACOG) recommends universal screening for substance use in all pregnant women using a validated verbal questionnaire. (18) These recommendations are af-firmed by the American Academy of Pediatrics (AAP). (19)(20) Of note, these guidelines are particularly focused on opioid use, though the screening tools presented also capture the use of prescribed psychotropic medications (such as benzodiazepines) that might be associated with infant withdrawal symptoms. (21) The use of psychotropic medications during pregnancy should be identified and discussed; however, practice guidelines strongly advocate for the provision of such medications to effectively support birth parents’ mental health and avoid risks of untreated mental illness to the fetus and infant. (22)

Both ACOG and AAP recommend against routine biochemical testing for illicit substances, partially due to prior work demonstrating racial inequities in which patients undergo these types of screening. (18)(20) Black mothers and their infants, particularly those who are younger, unmarried, or unemployed are 1.5 to 2 times more likely to be screened than white dyads. (22)(23) However, race has not been shown to be associated with higher odds of positive findings on toxicology testing. (22) Black infants were significantly more likely to undergo biochemical evaluation for cocaine exposure than white infants, regardless of whether they met specific non–race-based screening criteria. (24) The authors concluded that, despite established screening guidelines, patients’ race still factored into the decision to perform biochemical testing for substance exposure (23); this observation has been corroborated by other studies. (25)(26)

The recent legalization of cannabis for nonmedical and medical use in 18 and 38 US states, respectively (ncsl.org/research/health/state-medical-marijuana-laws.aspx) has also introduced new challenges for potential perpetuation of racism and implicit bias in toxicology testing. A study from Washington found that black birth parents had the highest rates of toxicology testing of any racial group, and that this disparity in testing widened after legalization (though the number of birth parents testing positive did not). (26) Maternal cannabis use was most frequently cited as the indication for wide biochemical testing (that included opioids and cocaine) in black birth parents, even though cannabis use was legal in the state during the study period. (23) These findings highlight how personally mediated racism and implicit biases perpetuate racial stereotypes that can have a direct impact on the decision to conduct biochemical testing, and may affect care and erode trust between parents and clinicians.

For new birth parents and infants in particular, biochemical toxicology testing may have severe implications for length of stay, medical intervention, and even custodial determination. In 24 states and the District of Columbia, substance use during pregnancy is considered child abuse, potentially leading to criminal implications for birth parents. (27) If black dyads are disproportionately tested, they are disproportionately burdened with the adverse outcomes of those results, leading to health care disparities and inequities within the criminal justice system. Evidence suggests that black birth parents who use substances are more likely than their white counterparts to be reported to child protective services. (28)(29) Given these realities, the decision to conduct toxicology testing—even if the result is negative—may alter the outcomes for a family, or irrevocably damage the trust a family has in their care team.

WB: Throughout my experience leading staff in NICUs and as a health equity researcher with interest in neonatal opioid withdrawal syndrome (NOWS), I have witnessed the impact of racism on both individual and structural levels within hospitals. However, we need more data describing the outcomes of opioid use disorder on maternal-infant dyads and how these outcomes may differ by race and/or ethnicity. In a recent study of nearly 2,000 women at one tertiary facility, 6.9% of women underwent drug screening and although non-Hispanic black women represented 16.6% of the population, they received 33.6% of drug screening (2 times more likely than non-Hispanic white women); the non-Hispanic black women had the same rate of positive screening results as non-Hispanic white women. In a scoping review of over 2,000 articles, Schiff et al found few studies evaluating racial/ethnic disparities among maternal-infant dyads affected by opioid use disorder with no information on the role of structural racism. (30) The authors note the importance of future research to assess racial/ethnic inequities across the spectrum of substance use disorders through thoughtful data collection.

CONCLUSION

The societal framing of and response to the crack cocaine epidemic of the 1980s is likely evidence of structural racism, due to the large inequities it created within the criminal justice system, and the downstream effects on individual and familial health, educational outcomes, economic attainment, and community disruption. Stereotypes of black people contribute to both conscious and unconscious bias regarding who is more likely to use drugs and may be one explanation for why health professionals inequitably evaluate black infants for substance exposure compared with white infants. Biochemical toxicology testing in infants, regardless of outcome, can have a profound impact on families both immediately and in the long-term, thus contributing to race-specific health inequities.

Moving Forward

Health professionals can take individual actions and work within their multidisciplinary teams to address their implicit biases (Table). Actively recruiting, supporting, and promoting black providers from training to positions of leadership can help increase diverse perspectives and potentially improve outcomes. (32) At the institutional level, leadership in all roles can commit to making changes that address structural racism. In addition, the use of standardized approaches and protocols helps to ensure consistent and equitable treatment for every patient every time. (33) Support for parents and families can and should start outside the NICU and within communities. As pediatric clinicians, we all have important roles to play in connecting with community individuals, leaders, and organizations that serve families. In addition, we have an opportunity to raise the bar for quality improvement initiatives by understanding the drivers of disparities to focus our efforts on these core issues.

Table.

Suggested activities for clinicians after reading this case

Level	Personnel Involved	Suggested Activities
Individuals	Any person caring for expectant parents and newborns (including physicians, nurses, therapists, social workers, pharmacists, etc)	Reflect on the case: Should the infant in this clinical vignette have undergone urine toxicology testing? What factors influenced the health care professional’s decision? Would you have done anything differently? Reflect on your care practices: Consider patients who you have cared for who have had toxicology testing. Who were these patients? What was the indication for testing? How might have the patient’s race influenced decisions around care? Familiarize yourself with your local county and state laws around substance use during pregnancy and referralfor Child Protective Services (see Guttmacher Institute link below). Avoid stigmatizing language Labels like “drug users” or “abusers” are stigmatizing and obfuscate the medical basis of substance use disorders. Instead, discuss use of unprescribed medications, substance exposure in pregnancy, or maternal substance use. The term “withdrawal” can be stigmatizing, especially when it is used without a known history of maternal substance use disorder. Instead, state objective symptoms (such as jitteriness or poor feeding). These symptoms have a broad differential. Characterization of withdrawal may lead to premature anchoring on an incorrect diagnosis (31).
Clinical teams	Multidisciplinary teams caring for newborns made up of various health care professionals.	Conduct a multidisciplinary huddle when a patient exposed to substances is admitted. Review the policies and procedures that apply in the particular case. Ensure that all team members are in agreement with the plan of care. Discuss how best to partner with the family Establish expectations in conjunction with parents early in the admission. Clearly outline individual responsibilities, considering the following: What is the unit standard around obtaining parental consent or assent for toxicology testing for infants? Who will communicate to families that this test is needed and how will this be documented in the medical record? Who will disclose results of testing? When is that anticipated to occur? Where does the conversation occur (ie, in the unit or a one-on-one private conversation)? Identify other needs the family may have and partner with them to optimize support during the admission (eg, breastfeeding support, rooming in, support for siblings). Reflect on the care provided, and whether it aligned with unit policies. What was each team member’s experience in caring for the family? What went well? What challenges were encountered? Was the care provided equitable? How can the team improve for all patients?
Institutions	A dedicated interdisciplinary group responsible for optimizing and improving policies around substance exposure. Members include: unit leadership, clinicians (both those caring for newborns and those caring for expecting parents), nurses, social workers, pharmacists, case managers, and family representatives and/or community council members.	Review the process for identifying substance use in expecting parents Do all parents receive screening or only some? How are parents informed about this process? What supports are offered if the birth parent screens positive? What information about newborn care is provided to birth parents who have substance use histories prior to delivery? State how withdrawal is defined Consider using a designated set of clinicalcriteria, such as this definition of opioid withdrawal. (25) Be specific about which substances trigger an observation for withdrawal. Review the policy for obtaining neonatal toxicology testing Review your state’s particular laws or guidelines regarding drug screening in newborn infants (see resource below). Ensure there are clear criteria for obtaining a test that are based on objective findings. Assess if infant testing is necessary if birth parent screening was negative. Clearly outline protocols for required steps if biochemical testing is positive Define what constitutes a positive screen. Will marijuana be included in the positivity definition? If yes, to what end? If no, should it be removed from the test? Publicize your policies for expectant parents and staff Provide in-depth education for all staff members If staff have not already had antiracism training, consider introducing this topic to anchor understanding and buy-in related to substance use protocols. Track toxicology testing in the unit Include the indication, patient demographics (including race, ethnicity, and preferred language), and test outcome. Compare these to the demographics of your whole unit. Is there a difference in who is tested? Are patients of color overrepresented or underrepresented in the group who is tested? Are proportions of positive tests aligned with the racial and ethnic composition of the total population and the population tested?

Further Reading

Below, we outline suggested reading. Please note that extensive resources for institutional best practices are publicly available (examples provided below).

• State specific laws: guttmacher.org/state-policy/explore/substance-use-during-pregnancy

• History of discriminatory treatment of black Americans in the criminal justice system: vera.org/downloads/publications/for-the-record-unjust-burden-racial-disparities.pdf

• California Maternal Quality Care Collaborative (cmqcc.org/resources-toolkits/toolkits/mother-baby-substance-exposure-initiative-toolkit)

American Board of Pediatrics Neonatal-Perinatal Content Specification.

• Know the issues in the organization of perinatal care (e.g., regionalization, transport, practice guidelines, benchmarking data, quality improvement).