A 28-year-old immigrant from Ghana who was 40 weeks pregnant came to labor and delivery triage for rupture of membranes.
Upon further investigation, I learned that she received all prenatal care in Ghana, and she preserved and presented all her prenatal records in triage. The quality of the documents was poor, the physician notes handwritten and illegible, but the patient was able to discuss details and disclosed that she had an uncomplicated pregnancy. Upon further discussion with a supervisor, we obtained full admission labs as well as a urine drug screening. We discussed how urine drug screening is important in pregnant women who are late to prenatal care, miss several prenatal appointments, or have a history of drug or alcohol use.
Six months later, during my newborn rotation, I was rounding on a 1-day-old newborn boy born to a 34-year-old Caucasian female. Her prenatal records documented that she occasionally smoked cigarettes and moderately drank alcohol during her pregnancy. I opened her records but found no admission laboratory tests or urine drug screen. These experiences caused me to reflect on biases surrounding prenatal drug testing.
Determining whether to perform drug screening on pregnant patients presents an ethical dilemma. Many obstetrician-gynecologists are against universal drug screening for pregnant women due to concerns that patients won’t show up for prenatal care because they may be afraid of being prosecuted for drug use. Unfortunately, inadequate prenatal care can exacerbate pregnancy complications (preeclampsia, HELLP syndrome, etc.) and worsen health outcomes for mothers and newborns. As a result, these OB/Gyns recommend risk-based drug testing rather than universal drug testing. Risk-based screening can allow physicians and providers to identify substance abuse in pregnant women who have obvious red flags in their history; the results may help to anticipate potential challenges in newborn resuscitation and hospital course. Risk-based drug testing may lower perceived barriers to patients seeking prenatal care.
Unfortunately, risk-based testing introduces physician bias into decisionmaking, and can disproportionately target low-income, minority, and immigrant women. Simultaneously, physicians can overlook screening patients who are white and higher income, placing their infants at risk for drug withdrawal and birth defects. Universal screening has been touted by many physicians and providers because it eliminates risk for discriminatory practices, provides a basis for early detection and education of pregnant women, and directs physicians to provide resources for pregnant women to quit drug use during pregnancy.
Implicit bias is defined as an unconscious attitude or stereotype that is applied to a race, gender, or social class. This bias unconsciously affects actions and decisions toward different groups.
Unfortunately, this bias can lead to unintended consequences. A 2017 meta-analysis showed that health care professionals demonstrated as much implicit bias as the general population, and all the studies found a positive correlation between the level of implicit bias and poorer quality of care.1
Thankfully, standardized screening methods can help combat the human tendency toward implicit bias. Cincinnati, Ohio, launched a universal urine drug testing program for pregnant patients that tests both mothers and newborns.2 Participating hospitals encourage pregnant patients to consent to drug testing; in mothers who refuse, the newborn is tested instead. Mothers who test positive for substance abuse are provided information about substance abuse programs, and newborns may have a prolonged stay for monitoring and management of birth complications. After the first year of this program, 5.4% of all pregnant patients had a positive drug test on admission, and 3.2% were positive specifically for opiates. Newborns of mothers who tested positive for opiates often had prolonged hospital stays for poor feeding, irritability, and seizures. Drug testing provided information that could preemptively guide physicians and providers.
Adopting similar programs nationwide could provide resources to patients who are struggling with drug use and abuse, eliminate bias associated with risk-based testing, and help prevent and treat newborn complications associated with abuse.
Funmi Odeyomi, MD, MPH,is a first-year family medicine resident in the Department of Population Health at Dell Medical School at The University of Texas at Austin. Swati Avashia, MD, is an associate professor of population health in the Department of Internal Medicine and Pediatrics at Dell Medical School and a contributing author.
References
1. FitzGerald, C., & Hurst, S. (2017). Implicit Bias in Healthcare Professionals: A Systematic Review. BMC Medical Ethics, 18(1), 19. doi:10.1186/s12910-017-0179-8.
2. Newman, L. (2016). As Substance Abuse Rises, Hospitals Drug Test Mothers, Newborns. American Association for Clinical Chemistry: AACC. Retrieved from https://www.aacc.org/publications/cln/articles/2016/march/as-substance-abuse-rises-hospitals-drug-test-mothers-newborns.