Drug testing after delivery ‘disproportionately targets’ Black, marginalized women

Key takeaways:

• Women who were Black, publicly insured, uninsured or single had a higher likelihood of drug testing after delivery.
• None of the women had consent for drug testing documented in medical records.

Black, single, publicly insured and uninsured women are disproportionately targeted by current risk factor-based toxicology policies in the labor and delivery department after birth, according to study findings published in O&G Open.

ACOG recommends screening for substance use be universal, not risk factor-based, and use a validated questionnaire instead of a urine drug test. However, screening questionnaires are not routinely used and urine drug tests are sent when patients have certain risk factors such as limited prenatal care, according to the researchers.

“Drug testing patients based on risk factors such as limited prenatal care or housing status disproportionately targets patients who are already marginalized — Black patients, low-income patients and uninsured or underinsured patients,” Arienne Malekmadani, MD, a maternal health fellow at Scripps Health in San Diego, told Healio. “These tests can have significant negative consequences for the parent and newborn and should be ordered in the labor and delivery setting for clear clinical indications only and with a patient’s informed consent.”

Malekmadani and colleagues conducted a retrospective cohort study using data from 20,084 women who gave birth in a regional hospital system from 2020 to June 2022. In a manual chart review, researchers identified whether urine drug testing was performed and as well as patient age, race, marital status, insurance status, ZIP code, gestational age, BMI and delivery mode. Researchers assessed the association of race, insurance status, marital status and median income with drug testing likelihood.

Overall, 6.2% of women were drug tested, of which 11.3% tested positive. None of the women had consent for drug testing documented in medical records.

Compared with women of other racial groups, white women had the highest (16.6%) and Hispanic patients had the lowest (9.3%) rate of positive drug test results. Limited or no prenatal care was the most common indication for drug testing (48.7%), followed by obstetric and medical indications (28.5%).

Most (67.9%) positive results were reported to child welfare services.

When accounting for the effects of race, ethnicity, income, insurance status and marital status, researchers observed significant associations with a higher likelihood of undergoing drug testing among women with:

• Black race (OR = 1.78; 95% CI, 1.23-2.59);
• public insurance (OR = 1.59; 95% CI, 1.18-2.15);
• no insurance (OR = 1.45; 95% CI, 1.09-1.93); and
• single marital status (OR = 2.79; 95% CI, 2.29-3.39).

“My hope is that this study, along with the growing body of evidence demonstrating inequities in urine drug testing pregnant patients, helps inform clinical practice and hospital policy. I would like to see hospitals have clear policies that outline the few situations in which a urine drug test could provide clinically relevant information,” Malekmadani told Healio. “These should be clinical situations, such as acutely altered mental status, difficult to control pain or resistant hypertension, in which the drug test result would inform patient care. Importantly, these policies should also require patients’ informed consent prior to testing.”

For more information:

Arienne Malekmadani, MD, can be reached at [email protected].