“Instead of just a drive by”: Clinician and birthing person perspectives on consent for toxicology testing during pregnancy

Abstract

Introduction

Although state, federal, and professional guidelines stipulate the need for informed consent for toxicology testing during pregnancy, consent is often inadequately obtained. The objective of this study was to explore birthing person and obstetric clinician experiences with consent for toxicology testing during pregnancy.

Methods

Semi‐structured qualitative interviews were conducted with 25 obstetric clinicians and 15 birthing persons who had toxicology testing performed during their delivery hospitalization. Interviews assessed clinical decision‐making around toxicology testing, perceptions of testing utility, as well as consent and communication practices. Transcripts were then double‐coded and analyzed using thematic analysis.

Results

Three primary themes were identified. First, information disclosure during consent conversations for toxicology testing deviated from normative standards for informed consent in obstetrics. Second, barriers to adequate information provision included clinicians’ limited knowledge of and discomfort with the test's risks, the infrequency of testing in clinical practice, and birthing peoples’ discomfort asking questions within the physician–patient power hierarchy. Third, birthing people felt unable to decline testing due to fears of child protective services involvement and perceived pressure from clinicians to undergo testing.

Conclusion

While both birthing people and clinicians identified challenges related to appropriate information provision during consent conversations, birthing people critically underscored a lack of voluntariness related to their fears of child protective services and experiences of pressure from clinicians to consent to testing. As a result, consent practices failed to adhere to normative standards for informed consent within obstetrics, which undermined patient autonomy.

1. INTRODUCTION

Although professional organizations recommend universal substance use screening for pregnant people using a validated instrument, toxicology testing remains a routinely employed method for identifying substance use during pregnancy [1, 2, 3]. The punitive legal and social consequences of toxicology testing during pregnancy are well‐established and differentially enacted across racial, ethnic, and socioeconomic (SES) groups, with Black and low SES individuals more likely to be tested, reported to child protective services (CPSs), and have their parental rights terminated [4, 5, 6, 7, 8].

In recognition of these potential harms, major professional organizations have established guidelines stipulating the need for consent prior to toxicology testing during pregnancy [1, 9, 10]. Consistent with bioethical principles for informed consent in clinical care [11], the American College of Obstetricians and Gynecologists (ACOG) defines the normative standards for consent for toxicology testing as including “the medical indication for the test, information regarding the right to refusal and the possibility of associated consequences for refusal, and discussion of the possible outcome of positive test results” [12]. Beyond the ethical imperative to protect the rights of birthing people, consent for toxicology testing during pregnancy is also federally mandated [13].

Despite this consensus, consent practices for toxicology testing during pregnancy remain inconsistent [14]. Only a minority of hospitals report having guidelines requiring consent [15, 16, 17], and retrospective studies in Massachusetts and California revealed that verbal consent for peripartum toxicology testing was documented in only 29% and 35% of cases, respectively [18, 19]. While qualitative studies have explored the consent process for other obstetric procedures [20, 21, 22, 23, 24, 25], as well as birthing person perspectives on toxicology testing more broadly [26, 27], only one study has explored clinician perspectives on consent for peripartum toxicology testing [28]. To date, no studies have specifically examined both birthing person and obstetric clinician perspectives on consent for peripartum toxicology testing—an essential triangulation that is critical for understanding the dynamics shaping these encounters that can have profound consequences for families. Toward this end, we aimed to describe birthing persons’ and obstetric clinicians’ experiences with consent for toxicology testing during pregnancy.

2. MATERIALS AND METHODS

This analysis draws on data collected as part of a qualitative study examining clinician and patient experiences with birthing person and newborn toxicology testing, which included interviews with birthing people as well as obstetric and pediatric clinicians. A companion paper focused on newborn toxicology testing has been published [29]. This analysis focused on birthing person toxicology testing, which is wholly original and not based upon data published elsewhere.

2.1. Setting

Participants were recruited between December 2021 and October 2022 from an academic medical center (AMC) and a community hospital (CH) in the Boston metropolitan area, both with an affiliated outpatient multidisciplinary perinatal substance use disorder program and part of a single hospital network. Both hospitals are located in a region with a high opioid‐related overdose burden characterized by early introduction of fentanyl into the illicit drug supply and a recent rise in non‐prescribed stimulant use. Both hospitals employed a risk‐based toxicology testing policy. In November 2021, the AMC transitioned from a policy that required verbal consent for birthing person toxicology testing to one requiring written consent, while the CH did not explicitly require consent for birthing person testing (Table S1). The state mandatory reporting statute stipulated that clinicians must make CPS referrals when they have “reasonable cause to believe that a child is suffering physical or emotional injury resulting from…physical dependence upon an addictive drug at birth” [30]. Hospital policy at both sites followed state‐provided practice recommendations to interpret this statute as mandating CPS reporting for positive birthing person toxicology tests for nonprescribed substances due to substance use disorder or alcohol use disorder or prescribed medications for opioid use disorder (MOUD).

2.2. Participant eligibility and recruitment

Birthing people over 18 years old who underwent toxicology testing or whose infant underwent toxicology testing during their delivery admission within the past year were recruited via convenience and purposive sampling. Eligible birthing people were identified in the electronic medical record and were approached during their delivery admission or postpartum visit by a member of their clinical team and subsequently contacted by study staff by telephone if interested in participating. Eight eligible birthing people declined to participate, while ten expressed initial interest in participating but subsequently could not be reached.

Eligible clinician participants included OB/GYN and family medicine trainees and physicians, and certified nurse midwives (CNMs) who had ordered toxicology testing on a birthing person during their delivery admission within the past year were recruited via convenience and purposive sampling. Study staff contacted eligible clinician participants via email up to two times. No clinician participants explicitly declined participation; however, no response was received from 42 clinicians.

All participants were remunerated for their time. Verbal informed consent was obtained. This study was approved by our institution's Institutional Review Board.

2.3. Data collection and analysis

Standardized interview guides were developed in collaboration with clinicians with experience in pediatrics and obstetrics and informed by prior research on perinatal toxicology testing. Birthing person interviews explored experiences with toxicology testing throughout pregnancy, including consent and communication practices. Clinician interviews explored clinical decision‐making, perceptions of testing utility, and consent and communication practices. Both guides were field‐tested prior to use. Semi‐structured interviews were conducted by telephone or video teleconference by one investigator (L.N.S.), at the time a medical student with Master's‐level training in qualitative methods, who identifies as a cisgender white woman. The interviewer had no related patient care responsibilities, had no prior relationships with study participants, and disclosed that she was a medical student. Interviews were audio‐recorded with field notes, transcribed verbatim, and deidentified for analysis. Recruitment was stopped at 15 birthing people and 25 obstetric clinicians, based on when no novel codes emerged. These sample sizes were typical for the range at which thematic saturation is usually reached [31].

Interview transcripts were analyzed with Dedoose software using an inductive thematic analysis approach [32]. Two investigators (L.N.S and E.J.Y) reviewed the transcripts for each participant type and developed a birthing person codebook with 23 main codes and a clinician codebook with 27 main codes, which were then reviewed by the larger study team (L.N.S., E.J.Y., D.M.S., S.N.B.). The codebooks were then tested on seven transcripts for each participant type and refined until reaching sufficient inter‐rater agreement, which was defined as greater than 70% agreement between coders across main codes. Once the codebook was finalized, all interview transcripts were re‐coded and any discrepancies were resolved via consensus. Thematic analysis was then conducted separately for each participant type by reviewing excerpted data grouped by code and identifying key themes and concepts. Once this first phase of analysis was completed for each participant type, preliminary themes from each participant type related to consent for testing, the clinician–patient relationship, and mandatory reporting were discussed at a team meeting, and revised themes were generated with a specific focus on areas of tension and alignment between each participant type.

A demographic survey was administered to birthing person participants following the interview, which included gender, race, ethnicity, education level, and health insurance type. Obstetric clinician participants were asked during interviews about their role, practice setting, and years in practice. Finally, medical records of birthing person participants were reviewed for documentation of consent, defined as any documentation indicating that verbal or written consent was obtained for toxicology testing.

Reporting of methods and results was completed using the Consolidated Criteria for Reporting Qualitative Research [33].

3. RESULTS

We enrolled 25 clinicians (19 OB/GYNs and 6 CNMs) and 15 birthing people (see Table 1). Interviews ranged from 24 to 68 min (mean 50 min). Among clinician participants, four were trainees, mean years in practice was 16.5 years, and 64% practiced in an AMC while 36% practiced in a CH. Among birthing person participants, mean age was 32.6 years, 93% identified as white, and 67% had at least some college education. Of the 15 birthing person participants, 14 had urine toxicology testing sent at delivery; among them, nine (64.3%) had no documentation of verbal or written consent in their medical record.

TABLE 1.

Birthing person and clinician participant characteristics.

Characteristics	n (%) or mean (range)
Birthing person participants (N = 15)
Age	32.6 (22‐42)
Days from delivery when interviewed	49.8 (19–121)
Race
American Indian/Alaska Native	1 (7%)
White	14 (93%)
Ethnicity
Non‐Hispanic or Latina	15 (100%)
Sexual orientation
Heterosexual	14 (93%)
Other	1 (7%)
Relationship status
Single	2 (13%)
Partnered, not living with partner	6 (40%)
Living with partner	3 (20%)
Married	4 (27%)
Highest educational attainment
Less than high school	1 (7%)
High school/equivalent	4 (27%)
Some college	6 (40%)
College graduate/higher	4 (27%)
Housing status
Room, apartment, house that I own or rent	9 (60%)
Residential treatment program	2 (13%)
With family or friends	4 (27%)
Insurance type
Public	11 (73%)
Private	4 (27%)
Clinician Participants (N = 25)
Clinician type
Obstetrician/gynecologist	19 (76%)
Nurse midwife	6 (24%)
Years in practice
Resident or fellow	4 (16%)
<10 years	7 (28%)
10–20 years	8 (32%)
>20 years	6 (24%)
Practice setting
Academic medical center	16 (64%)
Community hospital	9 (36%)

Our analysis revealed three primary themes: (1) limited information disclosure during consent conversations deviates from normative expectations of communication around indications for testing, consequences of refusal, and outcomes after a positive test; (2) diverse barriers exist to adequate information provision, with clinicians emphasizing their limited knowledge of risks due to the infrequency of testing in clinical practice and birthing people underscoring their discomfort asking questions during consent conversations stemming from a power asymmetry; and (3) birthing people feel unable to decline testing due to fears of CPS involvement and perceived pressure from clinicians to undergo testing.

3.1. Theme 1: “Instead of just a drive by”—Deviation from normative standards for information disclosure

When obtaining consent for toxicology testing, clinicians presented toxicology testing as a routine part of obstetric care aimed at providing the best possible care to birthing people and their infants. While many clinicians reported discussing testing indication, they rarely addressed the right to decline testing or the benefits and risks of testing, including the consequences of a positive result (Table 2, Quote 1). Importantly, clinicians commented on the relatively limited scope of information shared when obtaining consent for toxicology testing compared with other obstetric procedures:

TABLE 2.

Summary of themes, subthemes, and illustrative quotations.

Primary theme	Subtheme	Illustrative quotation
Theme 1: Deviation from normative standards for information disclosure
	Risk disclosure	1I say, 'It would be really helpful in this case if we could get a sample of your urine and do a toxicology screen; would you donagree to that?' And if they say 'yes', then we take it. But I don't usually say to them, 'The implications are that if this is positive, you're going to see the social worker afterwards. Your baby's going to go to the NICU and will be monitored for three days'. You just can't go down all of those worlds. (Clinician 9)
	Noninvasiveness/lack of physical risk	2It's less informative. I think it's pretty much more straightforward because there's no ramifications of it as far as harming a patient physically. I think more ramifications maybe emotionally, but you don't have to go into your risk of bleeding, your risk of infection, your risk of fever, your risk of this and that. And it's interesting that we don't consent them for your risk of being involved legally. (Clinician 13) 3We don't think of it as a major intervention. I don't think we appreciate the repercussions, and we frequently are a lot of times, we're assuming it's going to be negative. So we don't think about the implications of a positive [result]. (Clinician 20) 4I don't think we talk through as clearly like, what are the sequelae of each possible outcome of this? So whereas I can talk to someone about like a bowel injury during repeat C section, and like, what would happen, what are the next steps, and that's like, routinely part of my spiel, I don't have that information. I can't tell them, like when this comes back for, you know, positive for whatever substance, I don't know what that pathway looks like. And I've seen it play out in different ways, but I can't tell you how this is gonna affect custody, you know, your need for treatment and documented treatment. (Clinician 15)
	Lack of transparency from clinicians	5I think that they should be up front about it and just say, “We are going to be drug testing you.” If they are gonna be sharing the results with [CPS] or anybody, I think they should say that up front and not be sneaky about it, and just be kind about it. Like, “We're not doing this to hurt you. We're doing this for the benefit of the baby, for the benefit of you.” Just not make you feel like a piece of shit. (Birthing Person 13) 6It just made me feel like they didn't think it was important to tell me and that it was sneaky. When they said it, they didn't even tell me that it was taken. They said that it was clear. They didn't say like, “Oh, we drug tested you.” They said, “Oh, your test came back clear.” (Birthing Person 2)
	Information desired by birthing people	In body of text
Theme 2: Barriers to information provision for clinicians and birthing people
	Lack of frequency	In body of text
	Lack of training	7I can't remember a time where I was in the room and a more senior person walked through a consent for tox testing. And like if you think about it for any other procedure—that would be absurd. I just have no model and that feeling of being ill‐equipped to carry out a conversation and not knowing enough. And literally any question the patient asks, I feel like there's a deferral. (Clinician 15)
	Lack of knowledge of testing risks	8I'm not sure I'm giving patients the full risks and benefits, the way you consent for something else. You know, I think I do have gaps in my knowledge as to what even happens. I think sometimes what I hear about what happens with [CPS] and babies and patients and stuff is stuff that someone told me like three years ago. And now that we're talking about it, I'm not really sure what happens to the babies? Like, how invasive is the stuff the peds does, like what does it mean? I know that [CPS] has to be involved…So yeah, there's a challenge with consent. (Clinician 11) 9I definitely had to be the biggest advocate for me and him. I definitely shouldn't have had to play that role as hard as I did to get answers. I think they lack a lot of knowledge about these types of situations because some even told me straight upfront that they don't know an answer.‘’ (Birthing Person 8)
	Discomfort discussing testing risks	10What am I going to say if it's positive, you're going to lose control of your baby? Like, no. What I try to say is, “If it's positive, it'll be useful for us to know, because we can take care of you and your baby better.” Yeah, so I try to make it all positive. (Clinician 18) 11I don't want the patient to view me as the police. Because I'm not or I don't want to be, and I worry that she may perceive me that way. (Clinician 12)
	Perceived power asymmetry	12You don't want to come off as if you are hiding something or give them any reason to suspect you for anything, so I just gave them whatever they wanted. I felt like if I asked any questions that it would come off as suspicious. (Birthing Person 10) 13I just was like, “Okay, okay.” For every single one of these times this has ever been asked of me, I have never once said why. Because again, I feel like if I—which is just me—but I feel like if I'm asking, then it makes me defensive and therefore noncooperative…I feel like I have to be the model patient. (Birthing Person 5)
Theme 3: Illusory voluntariness in consent practices
	Inability to decline due to fears of CPS involvement	14I should've said no to everything— but I was afraid if I said that it would look like I was hiding something, and [CPS] would open a case because I was being noncompliant. I did what I—trying to just be as compliant and easy to make everything just go, “Oh, okay. Open, close.” (Birthing Person 14) 15I felt like, again, exonerating evidence is better than saying no and then having it trigger some sort of who knows what. Maybe then they would have sent someone in to talk to me, or maybe that would have triggered CPS…I didn't really even weigh the possibility [of saying no]. I didn't say I wouldn't because I had no interest in saying no because I wanted the exculpatory evidence. (Birthing Person 5)
	Clinician concern about CPS/documentation of negative toxicology testing	16No matter what, declining a urine toxicology screen seems like it's a negative thing. (Clinician 2) 17I think there's this feeling that, or at least I've heard this, I don't know if it's true—that for people that have a history of substance use disorder, having urine toxicology during the pregnancy that demonstrates that they're taking their Suboxone or methadone and not anything else is helpful from a DCF perspective, because [CPS] has to be involved when these patients are delivering. So it would help to protect these patients when they deliver. (Clinician 11)
	Perceived pressure from clinicians to undergo testing	18I wouldn't give it to them. She said if I didn't give her a urine, it was going to come back on me really bad. I ended up giving the urine, because I ended up getting into an argument with her over it. I don't remember, I think I dumped it. If I didn't dump it, I know I had said to her I didn't feel comfortable. She was very adamant, if you don't produce urine, that's going to look like you're hiding something. (Birthing Person 6) 19I didn't feel like I had a choice. I knew that I did, just from previous conversations with my OB. She warned me that they're going to come to you with this…but it was intimidating… It was like—it felt as if she was questioning my character. (Birthing Person 10)

I think the consent for other things is a bit more robust. In terms of talking about risks of testing, I wouldn't say we're very detailed at describing the possibility of a false positive test, or the social or legal implications of a positive test, whereas for a procedure we're obviously covering the risks and benefits in more detail than we do with toxicology. It's more of a getting permission to do the test. (Clinician 20)

For several clinicians, this difference appeared to be related to their perception of toxicology testing as a non‐invasive intervention that lacked the risks more commonly discussed for obstetric procedures, such as bleeding and infection (Table 2, Quotes 2–4).

This departure from normative standards for consent was not only observed by clinicians, but also by birthing people, who expressed a strong desire for a more thorough consent conversation:

I guess maybe, instead of just a drive‐by, ‘Hey, we're gonna do this, is that okay?’ actually explain why they're doing it…When you get a flu vaccine, they give you a handout that says this is what we're doing, here are the ingredients in it. Something like here's a handout consent form for what we're doing, why we're doing it, and making sure that you're okay with it and what happens when we get the results back. (Birthing Person 12)

Many birthing people also reported relying on additional information from peers or prior childbirth experiences to inform their decisions around toxicology testing, and nearly all underscored the need for greater transparency from their clinicians, particularly those from whom consent was never obtained (Table 2, Quote 6). Specifically, birthing people desired additional information about indications for testing, test characteristics (e.g., substances tested for, turnaround time, and window of detection), their right to decline testing, the sequelae of a positive test result, and how test results would be shared with CPS (Table 2, Quote 5).

3.2. Theme 2: “I just don't think I have the mental script for it”—Barriers to information provision for clinicians and birthing people

The most frequently cited challenges to obtaining consent for toxicology testing included limited knowledge of and discomfort discussing the risks of toxicology testing, the infrequency with which toxicology testing is ordered in clinical practice, and lack of training in obtaining consent for such testing (Table 2, Quote 8). Eight clinicians felt that obtaining consent for toxicology testing was particularly difficult because they do it so infrequently:

It's just not been the kind of thing that is part of my day‐to‐day practice so I think it falls by the wayside more easily. It's already a challenging topic, and so when you don't practice with something, and it's infrequent, it's also uncomfortable, and that makes it extra hard…I just don't think I have the mental script for it in the same way. (Clinician 5)

This lack of a “mental script” for obtaining consent was also a concern among trainees, who cited lack of training, rather than infrequency, as a key barrier (Table 2, Quote 7). Clinicians also reported limited knowledge of the sociolegal sequelae of a positive test result, preventing them from being able to appropriately counsel birthing people on the risks of testing. Others, who possessed more knowledge about the risks of testing, described significant unease discussing them with birthing people:

I think that the negative implications are so vast and…the change in clinical management is so narrow—that all it does is have a negative effect on the patient who's getting the urine drug [test]. I think that's the hardest part about it. It's hard to really spin much positive except for the fact that it provides me information. (Clinician 2)

Clinicians’ lack of knowledge and discomfort regarding the consequences of a positive test result appeared to be related; several clinicians explicitly described distancing themselves from actions taken following a positive test result, namely reporting to CPS, because they felt it violated their professional identity as advocates for birthing people (Table 2, Quotes 10 and 11).

Birthing people also cited lack of clinician knowledge as a barrier to informed consent; two shared that their clinical teams were unable to provide basic information about toxicology testing when asked (Table 2, Quote 9). More frequently, though, birthing people reflected on their discomfort asking questions during consent conversations, fearing that doing so would make their clinical teams suspicious. This hesitation was demonstrative of a broader and significant power imbalance in the clinician‐patient relationship:

We're just so programmed to just go with what doctors and people above us, so to speak, tell us. You know? I'm a little person here, so I just do what I'm told…I never put into thought whether I should be upset or put more thought into if my privacy's being violated in any way. I just assumed that that's what I need to do. (Birthing Person 14)

This power asymmetry also appeared to underpin the decision of some birthing people to consent to toxicology testing as a means of proving their abstinence to their healthcare team (Table 2, Quotes 12 and 13).

3.3. Theme 3: “I didn't feel like I had a choice”—Illusory voluntariness in consent practices

Both birthing people and clinicians underscored a broader concern regarding birthing people's lack of voluntariness when providing consent for toxicology testing at the time of delivery (Table 2, Quotes 14 and 15). Most birthing people shared that they did not feel they could decline testing—even when the option was explicitly offered to them—due to concerns about CPS involvement:

I was so scared about even the possibility of a case being open. Like what if I say something wrong, and the [CPS] worker thinks I'm suspicious, or what if my husband talks too much…I felt like I couldn't say no because of…what could happen, and what if this was the only thing hinging on them not opening a case. (Birthing Person 15)

Notably, while many clinicians perceived birthing people as having autonomy to decline testing, a minority of clinicians recognized the constraints on birthing people's voluntariness:

It's inappropriate, and I think borders on illegal in a lot of circumstances. And that may sound dramatic, but if we're saying we need to be consenting this patient for this test, which I do strongly believe, I think the consents that we're doing are not appropriate. And they're not true consents—I don't think the patient feels empowered to say no. (Clinician 15)

Clinicians also shared birthing people's concerns that declining toxicology testing could have negative consequences with respect to CPS involvement and described a practice of ordering toxicology testing when the result was expected to be negative so that it could serve as supportive documentation for birthing people at risk of future CPS investigation (Table 2, Quotes 16 and 17). According to several birthing people, however, these concerns led clinicians to pressure them to consent to toxicology testing, with birthing people reporting experiences ranging from receipt of subtle encouragement to undergo testing to intense pushback after refusing testing. (Table 2, Quotes 18 and 19).

4. DISCUSSION

Our study highlights critical gaps in how consent for peripartum toxicology testing is obtained and the consequent threat to patient autonomy. Both birthing people and clinicians agreed that the scope of information provided during consent conversations was limited, particularly surrounding risk disclosure. Clinicians cited limited knowledge, inexperience, and discomfort discussing the risks of testing as the major drivers of incomplete consent conversations. For birthing people, this important exchange of information was further compromised by a power asymmetry that prevented them from asking questions and compelled them to undergo testing due to fear of CPS involvement and pressure from their clinicians, revealing a notable lack of voluntariness characterizing their consent experiences.

A key strength of our study is the inclusion of both clinician and birthing person perspectives, which, when analyzed together, reveal the chasm between clinician intent and the impact on birthing people. For example, clinicians frequently reported a perception that documentation of negative toxicology testing is beneficial for birthing people who might be investigated by CPS and expressed a strong desire to shield birthing people from the non‐clinical consequences of toxicology testing. At the same time, birthing people reported feeling like they were being asked to prove their innocence to clinical teams and felt pressure to undergo testing, even when the purpose was to document negative test results. In this way, clinicians’ purported advocacy on behalf of birthing people may inadvertently threaten the voluntary nature of the consent process.

Our study revealed several novel barriers to information disclosure and autonomy when obtaining consent within obstetrics. First, conversations around consent lacked discussion of risk, even among those clinicians who reported awareness of the social and legal consequences of testing. Clinicians familiar with counseling birthing people about the physical risks associated with common obstetric procedures may be so accustomed to the association of risk with physical harm that they fail to include counseling about other varieties of risk. While this is understandable, it is precisely because of these exceptional implications that make it all the more critical for consent practices to adhere to normative standards for comprehensive informed consent within obstetrics. Finally, clinicians expressed significant unease about mandatory reporting practices for a positive toxicology test and described avoiding discussion of this possible consequence with birthing people, a dynamic described in prior studies [34, 35]. Without a thorough discussion of risk, toxicology testing is inappropriately presented as a routine, neutral part of obstetric care, an example of what McCabe et al. have termed “clinicalization,” or the use of clinical terminology to describe interventions with non‐clinical aims and consequences [28]. This resulting brevity and neutrality of consent conversations and, specifically, the limited discussion of risk, ultimately prevents birthing people from being able to appreciate the full extent of risks associated with toxicology testing, a critical component of the informed consent process.

Both birthing people and clinicians in our study possessed a shared desire for more information: birthing people were eager for increased information disclosure during consent conversations and the vast majority of clinicians wanted to be able to provide them with it. Training in how to consent birthing people for toxicology testing should, therefore, be a routine part of obstetric education, just as training in best practices for informed consent for common obstetric procedures has become standard. Such training must equip clinicians with both factual knowledge—such as which substances are tested for, the need for confirmatory testing, and in which circumstances a report to CPS is mandated—as well as communication skills to discuss sensitive issues like stigma, legal involvement, and implications for parenting [36, 37]. In parallel, hospitals should develop standardized consent procedures and patient‐facing materials to help facilitate these conversations and ensure birthing people are given real opportunities to ask questions and make informed choices. In tandem with clinician training, meaningful policy changes that decouple toxicology testing from mandatory reporting to CPS must be pursued to restore the conditions under which consent can be truly voluntary. Toward this end, at the time of publication, our hospital network has implemented a revised policy under which a positive toxicology test during pregnancy does not automatically trigger a report to CPS unless there is concern for child abuse or neglect.

Finally, our findings should be interpreted within the context of several important limitations. First, our sample included very few non‐white birthing people. Overall, the characteristics of our final sample were similar the cohort of eligible individuals our study staff was able to approach at our recruitment sites. However, this limitation is particularly important given the unique intersectional challenges birthing people of color with substance use disorder experience and the well‐established racial disparities in toxicology testing and reporting practices [7]. Second, although interviews were conducted within six months postpartum, birthing people's recollection of peripartum clinical interactions may have been subject to recall bias, potentially limiting the completeness of reported experiences. Incorporating direct observation of clinician‐birthing person communication in future studies could help validate and extend our findings. Third, given the centrality of mandatory reporting to the experiences of participants in our study and the known variation in such policies across the United States, our findings may not be generalizable to other regions. Finally, the critical role of pediatric clinicians, who are often tasked with obtaining consent for newborn toxicology testing, is absent from this discussion but was included in the larger study and published separately [29].

5. CONCLUSION

While the informed consent process has a clear role to play in promoting patient autonomy by empowering birthing people with knowledge to make informed choices about their care, our study reveals that current consent practices for peripartum toxicology testing, even in hospitals with policies and procedures to promote consent for testing during pregnancy, fall short of this ideal. Ultimately, reforms to ensure birthing person consent is obtained for toxicology testing during pregnancy [38, 39], without associated reforms to mandatory reporting policies, run the risk of creating the illusion of choice in the absence of true autonomy.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

ETHICS STATEMENT

This study was approved by the Mass General Brigham Institutional Review Board (2021P001882).

Supporting information

Supporting Information