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Martinez NG, Seidman DL, Briscoe H, Hayes CM, Ojukwu EI, Paltin D, Roberts SCM. Patients, colleagues, systems, and self: Exploring layers of physician emotions in caring for pregnant people who use substances and their newborns. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 164:209432. [PMID: 38857826 DOI: 10.1016/j.josat.2024.209432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/24/2024] [Accepted: 06/04/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Pregnant people who use substances experience significant stigma, including in healthcare settings, where physicians make high-stakes decisions about treatment plans, resource allocation, and even a person's ability to parent. Previous psychology research has demonstrated the influence of emotions on decision-making, as well as on the development and expression of stigma. Yet the specific content of physician emotions, as well as approaches to processing these emotions, has been relatively under-examined. We sought to better understand the emotional experiences of physicians who practice in safety-net labor and delivery/inpatient settings to inform strategies to facilitate more humanizing, equitable care. METHODS From March 2021 to June 2022, the study team conducted semi-structured interviews with 24 San Francisco Bay Area-based physicians (obstetrics-gynecology, pediatrics, family medicine) caring for pregnant people who use substances and/or their newborns. We used deductive and inductive coding and identified themes regarding the nature, etiology, and processing of physician emotions. RESULTS Physicians described experiencing a range of emotions related to interpersonal (patients, colleagues), systems-level, and internal dynamics. Emotions such as anger, sadness, frustration, and helplessness resulted from their deep care and empathy for patients, witnessing stigmatizing colleague behaviors, disagreement with punitive systems, and recognition of their own limitations in effecting change. Few participants identified strategies for processing these emotions, and several described efforts to disengage from their emotional experience to preserve their sense of well-being and professionalism. CONCLUSIONS Physicians caring for pregnant people who use substances and their newborns experienced intense, multi-layered emotions. This study posits that additional efforts to support physician emotional processing and structural competency could improve healthcare experiences and outcomes for pregnant people who use substances.
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Affiliation(s)
- Noelle G Martinez
- VA San Diego Healthcare System, 3350 La Jolla Village Drive, La Jolla, CA 92161, United States of America; Department of Family and Community Medicine, University of California, San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110, United States of America.
| | - Dominika L Seidman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110, United States of America
| | - Heather Briscoe
- Department of Pediatrics, University of California, San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110, United States of America
| | - Crystal M Hayes
- School of Social Work, Sacred Heart University, 5151 Park Avenue, Fairfield, CT 06825, United States of America
| | - Ekene I Ojukwu
- San Quentin Rehabilitation Center, 100 Main Street, San Quentin, CA 94964, United States of America
| | - Dafna Paltin
- San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology, 6363 Alvarado Court, Suite 102/103, San Diego, CA 92120, United States of America
| | - Sarah C M Roberts
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, 1330 Broadway Street, Suite 1100, Oakland, CA 94612, United States of America
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Reddy J, Palmer L, Putnam-Hornstein E. Three-Year Custody Outcomes Among Infants Investigated by Child Protection Systems for Prenatal Substance Exposure in California. Matern Child Health J 2023; 27:94-103. [PMID: 37256517 PMCID: PMC10692263 DOI: 10.1007/s10995-023-03690-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVE Infants affected by prenatal alcohol and drug use are more likely to be removed from parental custody than those in the general population, although it is unclear whether their custody outcomes differ from infants investigated by child protection systems (CPS) for other reasons. This analysis seeks to compare trajectories of involvement and custody outcomes among infants investigated by CPS with and without documentation of prenatal substance exposure (PSE). METHOD We used vital birth records linked to administrative CPS records to examine the timing of system involvement and 3-year custodial outcomes among investigated infants with and without identified PSE. We defined PSE according to documentation on the state's standardized hotline screening form, which CPS completes upon referral for alleged maltreatment. We estimated the likelihood a child was in nonparental custody at age 3 by specifying multivariable generalized linear models, adjusted for covariates available in the birth record. RESULTS In our sample of 22,855 infants investigated by CPS in 2017 in California, more than 26% had documentation of PSE. These infants experienced an accelerated timeline of system penetration and were 2.2 times as likely to be in nonparental placement at age 3. DISCUSSION PSE confers an independent risk of custody interruption among infants investigated by CPS. The younger age of these infants, complexity of parental substance use, and potential misalignment of administrative permanency timelines with parental recovery all suggest the need for increased research, policy, and programmatic interventions to serve this vulnerable population.
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Affiliation(s)
- Julia Reddy
- Gillings School of Global Public Health, University of North Carolina, 412 Rosenau Hall, Chapel Hill, NC, 27599, USA.
| | - Lindsey Palmer
- The Pennsylvania State University, 133 Health and Human Development Building, University Park, PA, 16802, USA
| | - Emily Putnam-Hornstein
- School of Social Work, University of North Carolina at Chapel Hill, Tate-Turner-Kuralt Building, 325 Pittsboro St, Chapel Hill, NC, 27599-3550, USA
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Martinez NG, Roberts SCM, Achu-Lopes RA, Samura TL, Seidman DL, Woodhams EJ. Reconsidering the use of urine drug testing in reproductive settings. Am J Obstet Gynecol MFM 2023; 5:101206. [PMID: 37871695 DOI: 10.1016/j.ajogmf.2023.101206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 10/25/2023]
Abstract
The urine drug test is ubiquitous within reproductive healthcare settings. Although the test can have evidence-based use for a patient and clinician, in practice, it is often applied in ways that are driven by bias and stigma, do not correctly inform decisions about clinical aspects of patient care, and cause devastating ripple effects through social and legal systems. This paper proposes a framework of guiding questions to prompt reflection on (1) the question the clinical team is trying to answer, (2) whether a urine drug test answers the question at hand, (3) how testing benefits compare with the associated risks, (4) a more effective tool for clinical decision-making if the urine drug test does not meet the standards for use, and (5) individual and institutional biases affecting decision-making. We demonstrate the use of this framework using 3 common uses of the urine drug test within abortion care and labor and delivery settings.
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Affiliation(s)
- Noelle G Martinez
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Martinez).
| | - Sarah C M Roberts
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, CA (Dr Roberts)
| | - Rachel A Achu-Lopes
- Department of Anesthesia, Boston Medical Center, Boston University School of Medicine, Boston, MA (Dr Achu-Lopes)
| | - Tirah L Samura
- Los Angeles County Department of Health Services, Harbor-University of California Los Angeles Medical Center, Los Angeles, CA (Dr Samura); Los Angeles County Department of Health Services, Martin Luther King, Jr. Outpatient Center, Los Angeles, CA (Dr Samura)
| | - Dominika L Seidman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA (Dr Seidman)
| | - Elisabeth J Woodhams
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston University School of Medicine, Boston, MA (Dr Woodhams)
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Landis RK, Stein BD, Griffin BA, Saloner BK, Terplan M, Faherty LJ. Disparities in Perinatal and Emergency Care Receipt Among Women With Perinatal Opioid Use Disorder in Medicaid, 2007 to 2012. J Addict Med 2023; 17:654-661. [PMID: 37934525 PMCID: PMC10759200 DOI: 10.1097/adm.0000000000001199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
OBJECTIVES This study aimed to better understand receipt of perinatal and emergency care among women with perinatal opioid use disorder (OUD) and explore variation by race/ethnicity. METHODS We used 2007-2012 Medicaid Analytic eXtract (MAX) data from all 50 states and the District of Columbia to examine 6,823,471 deliveries for women 18 to 44 years old. Logistic regressions modeled the association between (1) OUD status and receipt of perinatal and emergency care, and (2) receipt of perinatal and emergency care and race/ethnicity, conditional on OUD diagnosis and controlling for patient and county characteristics. We used robust SEs, clustered at the individual level, and included state and year fixed effects. RESULTS Women with perinatal OUD were less likely to receive adequate prenatal care (adjusted odds ratio [aOR], 0.45; 95% confidence interval [CI], 0.44-0.46) and attend the postpartum visit (aOR, 0.46; 95% CI, 0.45-0.47) and more likely to seek emergency care (aOR, 1.48; 95% CI, 1.45-1.51) than women without perinatal OUD. Among women with perinatal OUD, Black, Hispanic, and American Indian and Alaskan Native (AI/AN) women were less likely to receive adequate prenatal care (aOR, 0.68 [95% CI, 0.64-0.72]; aOR, 0.86 [95% CI, 0.80-0.92]; aOR, 0.71 [95% CI, 0.64-0.79]) and attend the postpartum visit (aOR, 0.85 [95% CI, 0.80-0.91]; aOR, 0.86 [95% CI, 0.80-0.93]; aOR, 0.83 [95% CI, 0.73-0.94]) relative to non-Hispanic White women. Black and AI/AN women were also more likely to receive emergency care (aOR, 1.13 [95% CI, 1.05-1.20]; aOR, 1.12 [95% CI, 1.00-1.26]). CONCLUSIONS Our findings suggest that women with perinatal OUD, in particular Black, Hispanic, and AI/AN women, may be missing opportunities for preventive care and comprehensive management of their physical and behavioral health during pregnancy.
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Affiliation(s)
- Rachel K Landis
- From the RAND Corporation, Arlington, VA (RKL, BAG); RAND Corporation, Pittsburgh, PA (BDS); Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (BKS); Friends Research Institute, Baltimore, MD (MT); RAND Corporation, Boston, MA (LJF); and Department of Pediatrics, Maine Medical Center, Portland, ME (LJF)
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Edwards F, Roberts SC, Kenny KS, Raz M, Lichtenstein M, Terplan M. Medical Professional Reports and Child Welfare System Infant Investigations: An Analysis of National Child Abuse and Neglect Data System Data. Health Equity 2023; 7:653-662. [PMID: 37786528 PMCID: PMC10541941 DOI: 10.1089/heq.2023.0136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2023] [Indexed: 10/04/2023] Open
Abstract
Background Medical professionals are key components of child maltreatment surveillance. Updated estimates of reporting rates by medical professionals are needed. Methods We use the National Child Abuse and Neglect Data System (2000-2019) to estimate rates of child welfare investigations of infants stemming from medical professional reporting to child welfare agencies. We adjust for missing data and join records to population data to compute race/ethnicity-specific rates of infant exposure to child welfare investigations at the state-year level, including sub-analyses related to pregnant/parenting people's substance use. Results Between 2010 and 2019, child welfare investigated 2.8 million infants; ∼26% (n=731,705) stemmed from medical professionals' reports. Population-adjusted rates of these investigations stemming doubled between 2010 and 2019 (13.1-27.1 per 1000 infants). Rates of investigations stemming from medical professionals' reports increased faster than did rates for other mandated reporters, such as teachers and police, whose reporting remained relatively stable. In 2019, child welfare investigated ∼1 in 18 Black (5.4%), 1 in 31 Indigenous (3.2%), and 1 in 41 White infants (2.5%) following medical professionals' reports. Relative increases were similar across racial groups, but absolute increases differed, with 1.3% more of White, 1.7% of Indigenous, and 3.1% of Black infants investigated in 2019 than 2010. Investigations related to substance use comprised ∼35% of these investigations; in some states, this was almost 80%. Discussion Rates of child welfare investigations of infants stemming from medical professional reports have increased dramatically over the past decade with persistent and notable racial inequities in these investigations.
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Affiliation(s)
| | - Sarah C.M. Roberts
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Oakland, California, USA
| | | | - Mical Raz
- University of Rochester, Rochester, New York, USA
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Cohen S, Nielsen T, Chou JH, Hoeppner B, Koenigs KJ, Bernstein SN, Smith NA, Perlman N, Sarathy L, Wilens T, Terplan M, Schiff DM. Disparities in Maternal-Infant Drug Testing, Social Work Assessment, and Custody at 5 Hospitals. Acad Pediatr 2023; 23:1268-1275. [PMID: 36754165 DOI: 10.1016/j.acap.2023.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE To evaluate for disparities in peripartum toxicology testing among maternal-infant dyads across a hospital network and subsequent child protective services (CPS) involvement. METHODS Retrospective chart review of 59,425 deliveries at 5 hospitals in Massachusetts between 2016 and 2020. We evaluated associations between maternal characteristics, toxicology testing, and child welfare involvement with disproportionality risk ratios and hierarchical logistical regression. RESULTS Toxicology testing was performed on 1959 (3.3%) dyads. Younger individuals and individuals of color were more likely to be tested for cannabis use or maternal medical complications compared to white non-Hispanic individuals. Among those without a substance use disorder, age <25 (adjusted odds ratio [aOR] 2.81; 95% confidence interval [CI], 2.43-3.26), race and ethnicity (non-Hispanic Black (aOR 1.80; 95% CI, 1.52-2.13), Hispanic (aOR 1.23; 95% CI, 1.05-1.45), mixed race/other (aOR 1.40; 95% CI, 1.04, 1.87), unavailable race (aOR 1.92; 95% CI, 1.32-2.79), and public insurance (Medicaid [aOR 2.61; 95% CI, 2.27-3.00], Medicare [aOR 13.76; 95% CI, 9.99-18.91]) had increased odds of toxicology testing compared to older, white non-Hispanic, and privately insured individuals. The disproportionality ratios in testing were greater than 1.0 for individuals under 25 years old (3.8), Hispanic individuals (1.6), non-Hispanic Black individuals (1.8), individuals of other race (1.2), unavailable race (1.8), and individuals with public insurance (Medicaid 2.6; Medicare 10.6). Among dyads tested, race and ethnicity was not associated with CPS involvement. CONCLUSIONS Peripartum toxicology testing is disproportionately performed on non-white, younger, and poorer individuals and their infants, with cannabis use and medical complications prompting testing more often for patients of color than for white non-Hispanic individuals.
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Affiliation(s)
- Samuel Cohen
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass; Department of Pediatrics, Boston Medical Center (S Cohen), Boston, Mass.
| | - Timothy Nielsen
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney (T Nielsen), Sydney, Australia
| | - Joseph H Chou
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass
| | - Bettina Hoeppner
- Department of Psychiatry, Harvard Medical School (B Hoeppner and T Wilens), Boston, Mass
| | - Kathleen J Koenigs
- BWH/MGH Integrated Residency Program in Obstetrics and Gynecology (KJ Koenigs and N Perlman), Boston, Mass
| | - Sarah N Bernstein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital (SN Bernstein), Boston, Mass
| | - Nicole A Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital (NA Smith), Boston, Mass
| | - Nicola Perlman
- BWH/MGH Integrated Residency Program in Obstetrics and Gynecology (KJ Koenigs and N Perlman), Boston, Mass
| | - Leela Sarathy
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass
| | - Timothy Wilens
- Department of Psychiatry, Harvard Medical School (B Hoeppner and T Wilens), Boston, Mass
| | | | - Davida M Schiff
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass
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Olsavsky AK, Chirico I, Ali D, Christensen H, Boggs B, Svete L, Ketcham K, Hutchison K, Zeanah C, Tottenham N, Riggs P, Epperson CN. Maternal Childhood Maltreatment, Internal Working Models, and Perinatal Substance Use: Is There a Role for Hyperkatifeia? A Systematic Review. Subst Abuse 2023; 17:11782218231186371. [PMID: 37476500 PMCID: PMC10354827 DOI: 10.1177/11782218231186371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 06/16/2023] [Indexed: 07/22/2023]
Abstract
The parent-infant relationship is critical for socioemotional development and is adversely impacted by perinatal substance use. This systematic review posits that the mechanisms underlying these risks to mother-infant relationships center on 3 primary processes: (1) mothers' childhood maltreatment experiences; (2) attachment styles and consequent internal working models of interpersonal relationships; and (3) perinatal substance use. Further, the review considers the role of hyperkatifeia, or hypersensitivity to negative affect which occurs when people with substance use disorders are not using substances, and which drives the negative reinforcement in addiction. The authors performed a systematic review of articles (published 2000-2022) related to these constructs and their impact on mother-infant relationships and offspring outcomes, including original clinical research articles addressing relationships between these constructs, and excluding case studies, reviews, non-human animal studies, intervention studies, studies with fewer than 30% female-sex participants, clinical guidelines, studies limited to obstetric outcomes, mechanistic/biological studies, and studies with methodological issues precluding interpretation. Overall 1844 articles were screened, 377 were selected for full text review, and data were extracted from 157 articles. Results revealed strong relationships between mothers' childhood maltreatment experiences, less optimal internal working models, and increased risk for perinatal substance use, and importantly, all of these predictors interacted with hyperkatifeia and exerted a marked impact on mother-infant relationships with less data available on offspring outcomes. These data strongly support the need for future studies addressing the additive impact of maternal childhood maltreatment experiences, suboptimal internal working models, and perinatal substance use, with hyperkatifeia as a potential moderator, and their interacting effects on mother-infant socioemotional outcomes.
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Affiliation(s)
- Aviva K. Olsavsky
- University of Colorado School of Medicine, Aurora, CO, USA
- Children’s Hospital Colorado, Aurora, CO, USA
| | - Isabella Chirico
- SUNY Downstate Health Sciences University College of Medicine, Brooklyn, NY, USA
| | - Diab Ali
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Hannah Christensen
- University of Colorado School of Medicine, Aurora, CO, USA
- Children’s Hospital Colorado, Aurora, CO, USA
| | - Brianna Boggs
- University of Colorado School of Medicine, Aurora, CO, USA
- Children’s Hospital Colorado, Aurora, CO, USA
| | - Lillian Svete
- University of Colorado School of Medicine, Aurora, CO, USA
- University of Kentucky College of Medicine, Louisville, KY, USA
| | | | - Kent Hutchison
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Charles Zeanah
- Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Paula Riggs
- University of Colorado School of Medicine, Aurora, CO, USA
- Children’s Hospital Colorado, Aurora, CO, USA
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Schoneich S, Plegue M, Waidley V, McCabe K, Wu J, Chandanabhumma PP, Shetty C, Frank CJ, Oshman L. Incidence of Newborn Drug Testing and Variations by Birthing Parent Race and Ethnicity Before and After Recreational Cannabis Legalization. JAMA Netw Open 2023; 6:e232058. [PMID: 36884249 PMCID: PMC9996400 DOI: 10.1001/jamanetworkopen.2023.2058] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
IMPORTANCE Thirty-seven US states and the District of Columbia mandate reporting newborns with suspected prenatal substance exposure to the state, and punitive policies that link prenatal substance exposure to newborn drug testing (NDT) may lead to disproportionate reporting of Black parents to Child Protective Services. The impact of recreational cannabis legalization on racial disproportionality in NDT is unknown. OBJECTIVES To examine variations in the incidence and results of NDT by birthing parent race and ethnicity, variables associated with variation, and changes after statewide legalization of recreational cannabis. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was conducted from 2014 to 2020 with 26 366 live births to 21 648 birthing people who received prenatal care at an academic medical center in the Midwestern United States. Data were analyzed from June 2021 to August 2022. EXPOSURES Variables included birthing parent age, race, ethnicity, marital status, zip code, insurance type, prenatal and newborn diagnoses codes, and prenatal urine drug test orders and results. MAIN OUTCOME AND MEASURES The primary outcome was an NDT order. Secondary outcomes were substances detected. RESULTS Among 26 366 newborns of 21 648 birthing people (mean [SD] age at delivery, 30.5 [5.2] years), most birthing parents were White (15 338 [71.6%]), were non-Hispanic (20 125 [93.1%]), and had private insurance coverage (16 159 [74.8%]). The incidence of NDT ordering was 4.7% overall (1237 newborns). Clinicians ordered more NDTs for Black compared with White newborns (207 of 2870 [7.3%] vs 335 of 17 564 [1.9%]; P < .001) when the birthing parent had no prenatal urine drug test, a presumably low-risk group. Overall, 471 of 1090 NDTs (43.3%) were positive for only tetrahydrocannabinol (THC). NDTs were more likely to be positive for opioids in White compared with Black newborns (153 of 693 [22.2%] vs 29 of 308 [9.4%]; P < .001) and more likely to be positive for THC in Black compared with White newborns (207 of 308 [67.2%] vs 359 of 693 [51.8%]; P < .001). Differences remained consistent after state recreational cannabis legalization in 2018. Newborn drug tests were more likely to be positive for THC after legalization vs before legalization (248 of 360 [68.9%] vs 366 of 728 [50.3%]; P < .001) with no significant interaction with race and ethnicity groups. CONCLUSIONS AND RELEVANCE In this study, clinicians ordered NDTs more frequently for Black newborns when no drug testing was done during pregnancy. These findings call for further exploration of how structural and institutional racism contribute to disproportionate testing and subsequent Child Protective Services investigation, surveillance, and criminalization of Black parents.
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Affiliation(s)
| | - Melissa Plegue
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Victoria Waidley
- Department of Family Medicine, University of California, San Diego
| | - Katharine McCabe
- Reilly Center for Science, Technology, and Values, University of Notre Dame, South Bend, Indiana
| | - Justine Wu
- Department of Family Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - P. Paul Chandanabhumma
- Department of Family Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Carol Shetty
- Department of Family Medicine, University of Michigan, Ann Arbor
| | | | - Lauren Oshman
- Department of Family Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
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Cohen A, Vakharia SP, Netherland J, Frederique K. How the war on drugs impacts social determinants of health beyond the criminal legal system. Ann Med 2022; 54:2024-2038. [PMID: 35852299 PMCID: PMC9302017 DOI: 10.1080/07853890.2022.2100926] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There is a growing recognition in the fields of public health and medicine that social determinants of health (SDOH) play a key role in driving health inequities and disparities among various groups, such that a focus upon individual-level medical interventions will have limited effects without the consideration of the macro-level factors that dictate how effectively individuals can manage their health. While the health impacts of mass incarceration have been explored, less attention has been paid to how the "war on drugs" in the United States exacerbates many of the factors that negatively impact health and wellbeing, disproportionately impacting low-income communities and people of colour who already experience structural challenges including discrimination, disinvestment, and racism. The U.S. war on drugs has subjected millions to criminalisation, incarceration, and lifelong criminal records, disrupting or altogether eliminating their access to adequate resources and supports to live healthy lives. This paper examines the ways that "drug war logic" has become embedded in key SDOH and systems, such as employment, education, housing, public benefits, family regulation (commonly referred to as the child welfare system), the drug treatment system, and the healthcare system. Rather than supporting the health and wellbeing of individuals, families, and communities, the U.S. drug war has exacerbated harm in these systems through practices such as drug testing, mandatory reporting, zero-tolerance policies, and coerced treatment. We argue that, because the drug war has become embedded in these systems, medical practitioners can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and by becoming engaged in policy reform efforts. KEY MESSAGESA drug war logic that prioritises and justifies drug prohibition, criminalisation, and punishment has fuelled the expansion of drug surveillance and control mechanisms in numerous facets of everyday life in the United States negatively impacting key social determinants of health, including housing, education, income, and employment.The U.S. drug war's frontline enforcers are no longer police alone but now include physicians, nurses, teachers, neighbours, social workers, employers, landlords, and others.Physicians and healthcare providers can play a significant role in promoting individual and community health by reducing the impact of criminalisation upon healthcare service provision and engaging in policy reform.
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Affiliation(s)
- Aliza Cohen
- Department of Research and Academic Engagement, Drug Policy Alliance, New York, NY, USA
| | - Sheila P Vakharia
- Department of Research and Academic Engagement, Drug Policy Alliance, New York, NY, USA
| | - Julie Netherland
- Department of Research and Academic Engagement, Drug Policy Alliance, New York, NY, USA
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Murosko D, Paul K, Barfield WD, Montoya-Williams D, Parga-Belinkie J. Equity in Policies Regarding Urine Drug Testing in Infants. Neoreviews 2022; 23:788-795. [PMID: 36316251 PMCID: PMC10044569 DOI: 10.1542/neo.23-10-e788] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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
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Perron BE, Victor BG, Ryan JP, Piellusch EK, Sokol RL. A text-based approach to measuring opioid-related risk among families involved in the child welfare system. CHILD ABUSE & NEGLECT 2022; 131:105688. [PMID: 35687937 DOI: 10.1016/j.chiabu.2022.105688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The public health significance of the opioid epidemic is well-established. However, few states collect data on opioid problems among families involved in child welfare services. The absence of data creates significant barriers to understanding the impact of opioids on the service system and the needs of families being served. OBJECTIVE This study sought to validate binary and count-based indicators of opioid-related maltreatment risk based on mentions of opioid use in written child welfare summaries. DATA AND PROCEDURES We developed a comprehensive list of terms referring to opioid street drugs and pharmaceuticals. This terminology list was used to scan and flag investigator summaries from an extensive collection of investigations (N = 362,754) obtained from a state-based child welfare system in the United States. Associations between mentions of opioid use and investigators' decisions to substantiate maltreatment and remove a child from home were tested within a framework of a priori hypotheses. RESULTS Approximately 6.3% of all investigations contained one or more opioid use mentions. Opioid mentions exhibited practically signficant associations with investigator decisions. One in ten summaries that were substantiated had an opioid mention. One in five investigations that led to the out-of-home placement of a child contained an opioid mention. CONCLUSION This study demonstrates the feasibility of using simple text mining procedures to extract information from unstructured text documents. These methods provide novel opportunities to build insights into opioid-related problems among families involved in a child welfare system when structured data are not available.
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Affiliation(s)
- Brian E Perron
- University of Michigan, School of Social Work, 1080 S. University Avenue, Ann Arbor, MI 48109, United States of America.
| | - Bryan G Victor
- Wayne State University, School of Social Work, 5447 Woodward Avenue, Detroit, MI 48202, United States of America
| | - Joseph P Ryan
- University of Michigan, School of Social Work, 1080 S. University Avenue, Ann Arbor, MI 48109, United States of America
| | - Emily K Piellusch
- University of Michigan, School of Social Work, 1080 S. University Avenue, Ann Arbor, MI 48109, United States of America
| | - Rebeccah L Sokol
- Wayne State University, School of Social Work, 5447 Woodward Avenue, Detroit, MI 48202, United States of America
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12
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Challenges in Perinatal Drug Testing. Obstet Gynecol 2022; 140:163-166. [DOI: 10.1097/aog.0000000000004808] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/17/2022] [Indexed: 11/26/2022]
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13
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Karr AJ, Rayens MK, Scott LK. Neonatal abstinence syndrome: Effectiveness of targeted umbilical cord drug screening. J Perinatol 2022; 42:1038-1043. [PMID: 35810246 DOI: 10.1038/s41372-022-01457-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/24/2022] [Accepted: 06/30/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study sought to determine if targeted drug screening of newborns was effective in identifying a positive drug test result. STUDY DESIGN This was a retrospective cross-sectional study. A total of 340 infants met criteria for drug screening. Sensitivity and specificity were used to evaluate each of the potential risk factors in terms of their ability to predict a positive drug test result. Two-sample t-tests were used to compare differences in Finnegan scores between babies with a positive drug test result and those with a negative one. RESULT The risk factor with the highest sensitivity was maternal history of drug use. The difference in the Finnegan scores between groups was statistically significant. CONCLUSION The risk factors associated with this study were not very sensitive. The only way to identify all infants at risk of NAS is to standardize the screening process and apply to all infants.
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Affiliation(s)
- Alecia J Karr
- Division of Neonatology, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA. .,Baptist Hardin Health, Elizabethtown, KY, USA. .,University of Kentucky College of Nursing, Lexington, KY, USA.
| | - Mary Kay Rayens
- University of Kentucky College of Nursing, Lexington, KY, USA
| | - Leslie K Scott
- University of Kentucky College of Nursing, Lexington, KY, USA
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14
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Affiliation(s)
- Daniel Grossman
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco
| | | | - Deborah Grady
- Department of Medicine, University of California, San Francisco.,Deputy Editor, JAMA Internal Medicine
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15
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Koenigs KJ, Chou JH, Cohen S, Nolan M, Liu G, Terplan M, Cummings BM, Nielsen T, Smith NA, Distefano J, Bernstein SN, Schiff DM. Informed consent is poorly documented when obtaining toxicology testing at delivery in a Massachusetts cohort. Am J Obstet Gynecol MFM 2022; 4:100621. [PMID: 35354087 DOI: 10.1016/j.ajogmf.2022.100621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Positive toxicology testing at delivery can have enormous consequences for birthing persons and their families, including charges of child abuse or neglect and potential loss of custody for the birthing parent. Therefore state and national guidelines stipulate that, clinicians must obtain consent before toxicology testing at delivery. OBJECTIVE This study aimed (1) to determine clinician documentation of patient consent for peripartum toxicology testing and (2) to characterize the extent to which patient and hospital characteristics were associated with documented consent. STUDY DESIGN This was a retrospective cohort of individuals who underwent toxicology testing within 96 hours of delivery between April 2016 and April 2020 at 5 affiliated hospitals across Massachusetts. Medical records were reviewed for documentation of clinician intent to obtain maternal toxicology, testing indication, verbal consent to testing, and child protective services involvement. Hierarchical multivariable logistic regression was used to examine the association between patient and hospital characteristics and documentation of verbal consent. RESULTS Among 60,718 deliveries, 1562 maternal toxicology tests were obtained. Verbal consent for testing was documented in 466 cases (29.8%). Documented consent was lacking across most demographic groups. Consent was no more likely to be documented when a report was filed with child protective services and less likely in cases where the birthing parent lost custody before discharge (P=.003). In our multivariable model, consent was least likely to be documented when a maternal complication (abruption, hypertension, preterm labor, preterm premature rupture of membranes, or intrauterine fetal demise) was the indication for testing (adjusted odds ratio, 0.46; 95% confidence interval, 0.28-0.76). Verbal consent was twice as likely to be documented in delivery hospitals with established consent policies (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.37). CONCLUSION Consent for toxicology testing at delivery seemed to be infrequently obtained on the basis of clinician documentation. Provider education and hospital policies for obtaining informed consent are needed to protect the rights of birthing individuals.
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Affiliation(s)
- Kathleen J Koenigs
- Brigham and Women's Hospital/Massachusetts General Hospital Integrated Residency Program in Obstetrics and Gynecology, Boston, MA (Dr Koenigs)
| | - Joseph H Chou
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff)
| | - Samuel Cohen
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff)
| | - Moira Nolan
- Massachusetts General Hospital, Boston, MA (Ms Nolan)
| | - Gina Liu
- Harvard Medical School, Boston, MA (Ms Liu)
| | | | - Brian M Cummings
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff)
| | - Timothy Nielsen
- Faculty of Medicine and Health, Children's Hospital Westmead Clinical School, University of Sydney, Sydney, Australia (Mr Nielsen)
| | - Nicole A Smith
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA (Dr Smith)
| | - Joseph Distefano
- Boston University School of Public Health, Boston, MA (Mr Distefano)
| | - Sarah N Bernstein
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Bernstein)
| | - Davida M Schiff
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff).
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16
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English F, Greyson D. "You still have that fear": Policy constraints on informed decision making about legalized cannabis use during pregnancy and lactation. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 106:103774. [PMID: 35772267 DOI: 10.1016/j.drugpo.2022.103774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Cannabis is the most commonly used drug during pregnancy, excluding alcohol and tobacco, in the United States. Cannabis consumption during pregnancy is increasing along with greater legal and social acceptance. METHODS We conducted a qualitative content analysis of 23 in-depth interviews with pregnant and lactating people in Massachusetts, a state that legalized cannabis for adult use in 2016. Our aim was to explore how policy constrains or facilitates people's ability to make informed decisions about cannabis use during pregnancy and lactation. Our analysis was conducted using an ecosocial approach, recognizing that the implementation and interpretation of cannabis policy can be understood at multiple levels, which interact with each other and shape the health and experiences of individuals. Additionally, this analysis was informed by a harm reduction approach in which we acknowledge the complexity surrounding cannabis use during pregnancy and lactation, while attempting to identify ways to reduce potentially harmful consequences. RESULTS Findings revealed that, despite the legal status of cannabis, there continues to be a lack of clarity for pregnant and lactating people regarding the legal implications of cannabis use. Inconsistent state and institutional policies about drug testing of mothers and newborns leave a cloud of fear hanging over the experiences of people who use cannabis and inhibit their ability to obtain expert advice from healthcare providers. CONCLUSION Decision makers in public and institutional policy should work to clarify and update policies regarding substance use during pregnancy following legalization of a new substance, and ensure that pregnant and lactating people are afforded the same legal protections as the general population.
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Affiliation(s)
- Faith English
- Department of Health Promotion and Policy 325 Arnold House, School of Public Health & Health Sciences, University of Massachusetts Amherst, 715 North Pleasant St. Amherst, MA, 01003, USA.
| | - Devon Greyson
- Department of Communication N308 Integrative Learning Center 650 N. Pleasant St. University of Massachusetts Amherst, Amherst, MA, 01003, USA.
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McCabe K. Criminalization of Care: Drug Testing Pregnant Patients. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2022; 63:162-176. [PMID: 34794355 DOI: 10.1177/00221465211058152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
This article reveals how law and legal interests transform medicine. Drawing on qualitative interviews with medical professionals, this study shows how providers mobilize law and engage in investigatory work as they deliver care. Using the case of drug testing pregnant patients, I examine three mechanisms by which medico-legal hybridity occurs in clinical settings. The first mechanism, clinicalization, describes how forensic tools and methods are cast in clinical terminology, effectively cloaking their forensic intent. In the second, medical professionals informally rank the riskiness of illicit substances using both medical and criminal-legal assessments. The third mechanism describes how gender, race, and class inform forensic decision-making and criminal suspicion in maternal health. The findings show that by straddling both medical and legal domains, medicine conforms to the standards and norms of neither institution while also suspending meaningful rights for patients seeking care.
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18
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Austin AE, Gest C, Atkeson A, Berkoff MC, Puls HT, Shanahan ME. Prenatal Substance Exposure and Child Maltreatment: A Systematic Review. CHILD MALTREATMENT 2022; 27:290-315. [PMID: 33550839 DOI: 10.1177/1077559521990116] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
State and federal policies regarding substance use in pregnancy, specifically whether a notification to child protective services is required, continue to evolve. To inform practice, policy, and future research, we sought to synthesize and critically evaluate the existing literature regarding the association of prenatal substance exposure with child maltreatment. We conducted a comprehensive electronic search of PubMed, Web of Science, PsycInfo, CHINAL, Social Work Abstracts, Sociological Abstracts, and Social Services Abstracts. We identified 30 studies that examined the association of exposure to any/multiple substances, cocaine, alcohol, opioids, marijuana, and amphetamine/methamphetamine with child maltreatment. Overall, results indicated that substance exposed infants have an increased likelihood of child protective services involvement, maternal self-reported risk of maltreatment behaviors, hospitalizations and clinic visits for suspected maltreatment, and adolescent retrospective self-report of maltreatment compared to unexposed infants. While study results suggest an association of prenatal substance exposure with child maltreatment, there are several methodological considerations that have implications for results and interpretation, including definitions of prenatal substance exposure and maltreatment, study populations used, and potential unmeasured confounding. As each may bias study results, careful interpretation and further research are warranted to appropriately inform programs and policy.
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Affiliation(s)
- Anna E Austin
- 359831Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, NC, USA
| | - Caitlin Gest
- 359831Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Alexandra Atkeson
- 359831Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
| | - Molly C Berkoff
- Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, NC, USA
| | - Henry T Puls
- Department of Pediatrics, Children's Mercy Kansas City and School of Medicine, University of Missouri-Kansas City, NC, USA
| | - Meghan E Shanahan
- 359831Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, NC, USA
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19
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Peddireddy SR, Austin AE, Gottfredson NC. Factors contributing to level and type of child welfare involvement following prenatal substance exposure: A scoping review. CHILD ABUSE & NEGLECT 2022; 125:105484. [PMID: 35032823 DOI: 10.1016/j.chiabu.2022.105484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 12/14/2021] [Accepted: 01/03/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND An understanding of factors contributing to variation in child welfare outcomes in cases of prenatal substance exposure (PSE) can help identify gaps in research and practice and guide state and agency policy. OBJECTIVE To summarize the evidence base and identify critical gaps in the literature, we conducted a scoping review regarding individual- and institutional-level factors associated with child welfare decision-marking across the service continuum and caregivers' perceptions of child welfare involvement in cases of PSE. PARTICIPANTS AND SETTING The sample included peer-reviewed studies based in the United States. METHODS We conducted a comprehensive search of four databases for studies investigating 1) sociodemographic, behavioral, policy, or other factors contributing to variation in child welfare outcomes and 2) maternal, family, or provider perceptions of the child welfare process in cases of PSE. We followed an established methodological framework for conducting scoping reviews. RESULTS Of the 23 articles included in the review, 20 explored variation in decision-making across the child welfare services continuum and three examined caregivers' perceptions of child welfare involvement. At the institutional level, provider characteristics, such as agency capacity, were linked to specific child welfare outcomes including reports and removals. At the individual level, factors such as socioeconomic status, race, and substance type were also associated with outcomes across the service continuum. CONCLUSIONS Child welfare agencies use an unsystematic approach in addressing PSE, contributing to a variation in child welfare outcomes and potentially allowing for bias. This review highlights a need for increased resources and guidance for caseworkers.
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Affiliation(s)
- Snigdha R Peddireddy
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr., Chapel Hill, NC 27599, USA; Department of Behavioral, Social, and Health Education Sciences, Emory University Rollins School of Public Health, 1518 Clifton Rd., Atlanta, GA 30322, USA
| | - Anna E Austin
- Department of Maternal and Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr., Chapel Hill, NC 27599, USA
| | - Nisha C Gottfredson
- Department of Health Behavior, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr., Chapel Hill, NC 27599, USA.
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20
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COURCHESNE-Krak NS, KEPNER W, RUBANO A, MARIENFELD C. Differences in outpatient, emergency, and inpatient use among pregnant women with a substance-related diagnosis. Am J Obstet Gynecol MFM 2022; 4:100559. [PMID: 34990875 PMCID: PMC8891059 DOI: 10.1016/j.ajogmf.2021.100559] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/15/2021] [Accepted: 12/29/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND As a vulnerable population, pregnant women with a substance-related diagnosis (ie, substance use, misuse, or dependence) may use healthcare disproportionately. OBJECTIVE The primary goal of this study was to evaluate the differences in the use of outpatient clinical visits, emergency department visits, and inpatient days in the hospital among women with and without a substance-related diagnosis during the antepartum period. STUDY DESIGN This retrospective study retrieved electronic health record data on women (age, 18-44 years) who delivered a single live birth or stillbirth at ≥20 weeks of gestation from April 1, 2012, to September 30, 2019. Imbalance in measured maternal sociodemographic and obstetrical characteristics between women with and without a substance-related diagnosis was attenuated using propensity score matching on key demographic characteristics (eg, age), yielding a matched 1:1 sample. Unadjusted and adjusted logistic regressions models were used to determine the association between a substance-related diagnosis and outpatient visits, emergency visits, and inpatient days. RESULTS From the total sample (n=16,770), the matched cohort consisted of 1986 deliveries. Of these, most were White (51.0%), or mixed or of some other race (31.1%). The mean age was 29.8 (standard deviation, 5.6). A substance-related diagnosis was identified in 993 women (50%) because of matching. Women with a substance-related diagnosis were more likely to have ≤10 outpatient visits than women without a substance-related diagnosis (adjusted odds ratio, 1.81 [95% confidence interval, 1.44-2.28]; P<.0001). Alcohol-, opioid-, and stimulant-related diagnoses were independently associated with ≤10 outpatient visits (adjusted odds ratio, 3.16 [95% confidence interval, 1.67-6.04]; P=.0005; adjusted odds ratio, 3.02 [95% confidence interval, 1.79-5.09]; P<.0001; adjusted odds ratio, 2.18 [95% confidence interval, 1.39-3.41]; P=.0007, respectively). Women with a substance-related diagnosis were more likely to have ≥1 emergency visit than women without a substance-related diagnosis (adjusted odds ratio, 1.36 [95% confidence interval, 1.00-1.85]; P<.0001). Opioid-, stimulant-, and nicotine-related diagnoses were independently associated with ≥1 emergency visit (adjusted odds ratio, 2.28 [95% confidence interval, 1.09-4.77]; P=.0287; adjusted odds ratio, 2.01 [95% confidence interval, 1.07-3.78]; P=.0301; adjusted odds ratio, 3.38 [95% confidence interval, 1.90-6.02]; P<.0001, respectively). Women with a substance-related diagnosis were more likely to have ≥3 inpatient days than women without a substance-related diagnosis (adjusted odds ratio, 1.69 [95% confidence interval, 1.07-2.67]; P=.0256). Opioid-, stimulant-, and nicotine-related diagnosis were independently associated with ≥3 inpatient days (adjusted odds ratio, 3.52 [95% confidence interval, 1.42-8.75]; P=.0067; adjusted odds ratio, 3.51 [95% confidence interval, 1.31-9.34]; P=.0123; adjusted odds ratio, 2.74 [95% confidence interval, 1.11-6.73]; P=.0285, respectively). CONCLUSION Women with a substance-related diagnosis during the antepartum period who delivered a single live birth or stillbirth at ≥20 weeks of gestation were experiencing fewer outpatient visits, more emergency department visits, and more inpatient days than women without a substance-related diagnosis. The type of substance-related diagnosis (eg, alcohol, opioids, stimulants, or nicotine) was associated with different patterns of healthcare use. The results from this study have reinforced the need to identify substance-related diagnoses in pregnant women early to minimize disproportionate healthcare service utilization through intervention and treatment.
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Affiliation(s)
- Natasia S. COURCHESNE-Krak
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, MC0957, La Jolla, CA 92093, USA
| | - Wayne KEPNER
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, MC0957, La Jolla, CA 92093, USA
| | - Amanda RUBANO
- Medicine, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Rochester, NY 14642, USA
| | - Carla MARIENFELD
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, MC0957, La Jolla, CA 92093, USA
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21
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Minkoff HL, Ecker JL. Prenatal Cannabis Use Before and During the COVID-19 Pandemic. JAMA 2022; 327:587. [PMID: 35133422 DOI: 10.1001/jama.2021.23719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Howard L Minkoff
- Department of Obstetrics and Gynecology, State University of New York Downstate Health Sciences University, Brooklyn
| | - Jeffrey L Ecker
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
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22
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Perlman NC, Cantonwine DE, Smith NA. Toxicology Testing in a Newborn ICU: Does Social Profiling Play a Role? Hosp Pediatr 2021; 11:e179-e183. [PMID: 34373267 DOI: 10.1542/hpeds.2020-005765] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE A rising incidence in maternal drug use during pregnancy has led to a concomitant rise in neonatal opioid withdrawal syndrome. Despite evidence that drug use during pregnancy affects all demographic groups equally, authors of recent studies have suggested that minority women are tested for drug use more than their counterparts. In this study, we aimed to assess whether toxicology testing of neonates was associated with maternal characteristics. METHODS Retrospective cohort study reviewing charts of neonates born at an urban academic center between January 1, 2018, and December 31, 2018, who underwent toxicology testing. Demographics from tested neonates were taken from mothers' self-reported data and compared with sociodemographics of all mothers with deliveries in 2018, including age, race, marital status, and zip code. Indication for toxicology testing as recorded by ordering clinician was also collected. There were no standardized guidelines for toxicology testing during this study period. RESULTS Of 6438 births in 2018, toxicology testing was sent on 86 neonates (1.3%). Mothers of neonates with testing were younger (P < .0001), less likely to be white (P < .0001), self-reported "single" (P < .0001), and lived in lowest income zip codes (P < .0001). Indications for testing were varied, with the most common indications including maternal substance use disorder (37%) and marijuana use (26%). CONCLUSION Maternal age, race, marital, and socioeconomic status were associated with toxicology testing on neonates, although data suggest that drug use affects all demographic groups. Current practice at our institution may overtest some groups. Evidence-based, standardized guidelines are urgently needed to reduce bias and repercussions of toxicology testing of neonates.
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Affiliation(s)
- Nicola C Perlman
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, Massachusetts
| | - David E Cantonwine
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Harvard University, Cambridge, Massachusetts
| | - Nicole A Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Harvard University, Cambridge, Massachusetts
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Perlman NC, Cantonwine DE, Smith NA. Racial differences in indications for obstetric toxicology testing, and relationship of indications to test results. Am J Obstet Gynecol MFM 2021; 4:100453. [PMID: 34352428 DOI: 10.1016/j.ajogmf.2021.100453] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/15/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite illicit substance use in pregnancy occurring across all demographic groups, minority and lower income pregnant and delivering patients tend to undergo testing at a higher rate than their counterparts. National guidelines for indications do not exist, and ordering of toxicology testing may be applied inequitably. OBJECTIVE To evaluate whether any documented indications in a large cohort of patients were associated with a positive toxicology test, and whether indications for urine toxicology testing were applied consistently to different demographic groups. STUDY DESIGN Retrospective cohort study reviewing pregnant and delivering patients who underwent toxicology testing on obstetric units at one institution from 5/30/2015 to 12/31/2018. Age, race, marital status, median income of residential zip code, indications for testing, and test result were collected for each patient by individual chart review. Indications included preterm complications (preterm prelabor rupture of membranes or preterm labor), abruption or hypertension, reported substance use, fetal complications, maternal complications, and none. Multivariate logistic regression models were analyzed for association between indication and test result, and for likelihood of marijuana as the sole positive test result. Logistic regression was used to evaluate the relationship of indication for testing with maternal race. RESULTS Among 20,274 births, 551 patients underwent toxicology testing during the study period. No indication for drug toxicology testing was associated with a positive result except reported current or prior substance use. Compared to White patients, Black and Hispanic women were 4.26 (95%CI: 2.55, 7.09) and 5.75 (95%CI: 2.89, 11.43) times more likely to have toxicology testing for an indication other than reported substance use. Of all patients with positive tests (n=194), 48% tested positive for marijuana only. CONCLUSIONS Compared to their White counterparts, Black and Hispanic pregnant and delivering patients may be more frequently toxicology tested for indications less clearly associated with illicit substance use. Absence of evidence- based guidelines for toxicology testing on obstetrics units risks inequitable care and stigmatization of patient groups.
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Affiliation(s)
- Nicola C Perlman
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital.
| | - David E Cantonwine
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, and Harvard Medical School
| | - Nicole A Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, and Harvard Medical School
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Palusci VJ, Botash AS. Race and Bias in Child Maltreatment Diagnosis and Reporting. Pediatrics 2021; 148:peds.2020-049625. [PMID: 34088760 DOI: 10.1542/peds.2020-049625] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Vincent J Palusci
- Department of Pediatrics, Grossman School of Medicine, New York University, New York, New York
| | - Ann S Botash
- Department of Pediatrics, State University of New York Upstate Medical University, Syracuse, New York
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Pflugeisen BM, Mou J, Drennan KJ, Straub HL. Demographic Discrepancies in Prenatal Urine Drug Screening in Washington State Surrounding Recreational Marijuana Legalization and Accessibility. Matern Child Health J 2020; 24:1505-1514. [PMID: 33009980 DOI: 10.1007/s10995-020-03010-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study evaluated demographic patterns related to prenatal cannabinoid urine drug screening (UDS) over a 5-year period during which recreational marijuana was legalized and became accessible in Washington State. METHODS Using electronic health record data, we performed a retrospective analysis for deliveries occurring over a 5-year period that encapsulated the transitions to marijuana legalization and legal access. For three cohorts of women delivering prior to legalization, between legalization and accessibility, and following accessibility, the UDS completion rate and screening demographic characteristics were assessed using Chi-squared tests and multivariate logistic regression. RESULTS 25,514 deliveries occurred between March 2011 and March 2016. A significantly higher percentage of women underwent UDS post-accessibility (24.5%) compared to pre-legalization (20.0%, p < 0.001). A corresponding increase was not observed in the percentage of marijuana-positive UDS in tested patients (22.7% vs. 23.3%, p = 0.86). African American women had 2.8 times higher odds than Latinas of being tested, 2.1 times higher odds than Asian women, 1.7 times higher odds than White women, and 1.4 times higher odds than women of other races (all p < 0.001). Subsidized insurance status was also strongly associated with increased likelihood of testing (aOR = 3.5, p < 0.001). CONCLUSIONS FOR PRACTICE Prenatal UDS testing patterns changed as recreational marijuana possession and accessibility became legal. Demographic discrepancies in testing reveal biases related to race and insurance status, which may be a proxy for socioeconomic status. As such discrepancies are potential contributors to health outcome disparities, it is important for providers and health care systems to examine their practices and ensure they are being appropriately, equally, and justly applied.
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Affiliation(s)
- Bethann M Pflugeisen
- Institute for Research & Innovation, MultiCare Health System, 314 Martin Luther King Jr. Way, Suite 402, Tacoma, WA, 98405, USA.
| | - Jin Mou
- Institute for Research & Innovation, MultiCare Health System, 314 Martin Luther King Jr. Way, Suite 402, Tacoma, WA, 98405, USA
| | - Kathryn J Drennan
- Division of Maternal-Fetal Medicine, University of Rochester, Rochester, NY, USA
| | - Heather L Straub
- Division of Maternal-Fetal Medicine, University of Colorado, Aurora, CO, USA
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Dreyer BP. Racial/Ethnic Bias in Pediatric Care and the Criminalization of Poverty and Race/Ethnicity-Seek and Ye Shall Find. JAMA Pediatr 2020; 174:751-752. [PMID: 32421176 DOI: 10.1001/jamapediatrics.2020.1033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Benard P Dreyer
- Department of Pediatrics, New York University Grossman School of Medicine, New York, New York
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Abstract
OBJECTIVE In many states, health care providers are legally required to report pregnant women who use substances, or infants affected by prenatal substance use, to child welfare authorities. The objective of this study was to characterize obstetric and pediatric providers' perceptions of and experiences with policies requiring mandatory reporting of prenatal substance use to child welfare authorities. METHODS We conducted a qualitative interview study among 20 obstetric and pediatric providers to elicit participants' perspectives about and experience with current policy requiring mandatory reporting of prenatal substance use. Two investigators used an iterative content analysis approach to code interview transcripts and identify themes. RESULTS Study participants included obstetrician/gynecologists (N = 7), midwives (N = 5), and pediatricians (N = 8). Providers noted that implementation of the policy was often targeted and that targeted screening can be biased. Most providers reported that they incorporated information about mandatory reporting policies into patient counseling about substance use. They described not knowing what happens to patients after mandatory reporting and concerns regarding unintended consequences. Providers indicated that changes are needed to improve outcomes for patients and their families and suggested increased research into best practices, more funding for social services, and eliminating the policy altogether. CONCLUSIONS Health care providers expressed concern about the targeted screening process used to identify women with substance use whose children are reported to child welfare authorities. Most providers believed that mandatory reporting processes could be modified in ways that would support the health of women and children.
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Sanjuan PM, Pearson MR, Fokas K, Leeman LM. A mother's bond: An ecological momentary assessment study of posttraumatic stress disorder symptoms and substance craving during pregnancy. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2020; 34:269-280. [PMID: 31829665 PMCID: PMC7064398 DOI: 10.1037/adb0000543] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Pregnant women with substance use disorder (SUD) comprise an underserved population with complex treatment needs, including complications from trauma histories and comorbid psychological disorders. Using ecological momentary assessment, we examined momentary fluctuations in posttraumatic stress disorder (PTSD) symptoms, prenatal bonding, and substance craving, among pregnant women in SUD treatment who had a history of trauma. We hypothesized that (a) PTSD symptoms and prenatal bonding would each be associated with substance craving and (b) PTSD symptoms would be negatively associated with prenatal bonding, and this would at least partially account for the association between PTSD symptoms and substance craving (i.e., indirect effect). Participants (n = 32) were on average 27.1 weeks pregnant (SD = 5.27), 27.8 years old (SD = 4.54), and predominantly Hispanic/Latina (66%). At the within subjects level, higher momentary ratings of PTSD symptoms were associated with lower quality (but not intensity of preoccupation) of prenatal bonding, which in turn was associated with greater craving. Lower quality of prenatal bonding partially mediated the positive association between PTSD symptoms and craving, which remained strong after accounting for prenatal bonding. Our results provide some preliminary support for considering interventions aimed at stabilizing or decreasing PTSD symptoms and stabilizing or increasing prenatal bonding to reduce substance craving and, thus, the risk of perinatal substance use among women with SUD and trauma histories. (PsycINFO Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
| | | | - Kathryn Fokas
- Center on Alcoholism, Substance Abuse, and Addictions
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Mark K, Pierce E, Joseph D, Crimmins S. Interaction with the justice system and other factors associated with pregnant women's self-report and continuation of use of marijuana. Drug Alcohol Depend 2020; 206:107723. [PMID: 31765856 DOI: 10.1016/j.drugalcdep.2019.107723] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 11/05/2019] [Accepted: 11/05/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Marijuana use in pregnancy is common and self-report of use to healthcare providers is variable. This study evaluates the relationship between prior interaction with the justice system as well as other factors associated with self-report and continuation of use of marijuana in pregnancy. METHODS This retrospective cohort study included women with a positive urine toxicology test for marijuana at their initial prenatal visit. Prior interaction with the judicial system was determined by querying a publicly available database. Those who did and did not self-report use were compared using chi square and Fisher's exact test for analysis of categorical variables and t test for comparison of means. A logistic regression was performed to determine factors related to remaining positive at the time of birth. RESULTS Of 597 women included in analysis, 308 (51.6%) self-reported use. African American women were more likely to self-report use (p = 0.02). Interaction with the justice system was not statistically predictive of self-report. Of 483 (80.9%) who had birth outcome data available, 117 (24.2%) had positive marijuana tests at the time of delivery. Women who tested positive at birth were older (27.3 v 25, p < 0.01), more likely to present later for care (p = 0.02) and more likely to have self-reported their use at their initial visit (p = 0.03). DISCUSSION Discrepancies exist between pregnant women's self-report of marijuana use and biologic testing results. Women with positive toxicology testing who self-report use may do so due to more problematic use and may benefit from enhanced interventions.
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Affiliation(s)
- Katrina Mark
- University of Maryland School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, 11 S Paca, Suite 400, Baltimore, MD, 21042, USA.
| | - Emily Pierce
- University of Maryland School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, 11 S Paca, Suite 400, Baltimore, MD, 21042, USA
| | - Dania Joseph
- University of Maryland School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, 11 S Paca, Suite 400, Baltimore, MD, 21042, USA
| | - Sarah Crimmins
- University of Maryland School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, 11 S Paca, Suite 400, Baltimore, MD, 21042, USA
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Ecker J, Abuhamad A, Hill W, Bailit J, Bateman BT, Berghella V, Blake-Lamb T, Guille C, Landau R, Minkoff H, Prabhu M, Rosenthal E, Terplan M, Wright TE, Yonkers KA. Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine. Am J Obstet Gynecol 2019; 221:B5-B28. [PMID: 30928567 DOI: 10.1016/j.ajog.2019.03.022] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Rebbe R, Mienko JA, Brown E, Rowhani-Rahbar A. Child protection reports and removals of infants diagnosed with prenatal substance exposure. CHILD ABUSE & NEGLECT 2019; 88:28-36. [PMID: 30445334 PMCID: PMC6333477 DOI: 10.1016/j.chiabu.2018.11.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/24/2018] [Accepted: 11/01/2018] [Indexed: 05/04/2023]
Abstract
BACKGROUND A frequent response for prenatal substance exposure (PSE) is intervention by child protective services (CPS). Previous research has examined differences in reports to CPS regarding PSE by substance exposure and by maternal race. However, little is known regarding the frequency of immediate removals by CPS relating to PSE and maternal race. METHODS We investigated hospital reports to CPS and CPS removals of PSE infants by using linked birth, hospital discharge, and CPS records for all children born in Washington State between 2006 and 2013 (N = 760,863). We identified PSE using diagnostic codes, calculated prevalence by substance type and maternal race, and tested for differences by interactions of race and substance using multinomial logistic regression. RESULTS Prevalence of PSE births varied by race with 8.1% of Native American, 2.8% of black, 1.9% of white, and 0.8% of Hispanic births diagnosed with PSE. Opioids was the most common type of PSE diagnosis at 48.2%. The majority of PSE infants (86.7%) were not removed by CPS but variations by substance type were observed. Of the interactions in the multinomial logistic regression model, only black infants exposed to alcohol were more likely to result in reports to CPS without removal than the referent group of white infants exposed to opioids. CONCLUSIONS Findings indicate that most infants diagnosed with PSE were not removed by CPS and minority PSE infants were not reported to CPS or removed by CPS more than white infants. Racial differences identified in the prevalence of PSE present opportunities for targeted prevention efforts.
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Affiliation(s)
- Rebecca Rebbe
- Partners for Our Children, University of Washington School of Social Work, Seattle, WA, United States.
| | - Joseph A Mienko
- Partners for Our Children, University of Washington School of Social Work, Seattle, WA, United States
| | - Emily Brown
- Seattle Children's Hospital, Seattle, WA, United States; University of Washington School of Medicine, Department of Pediatrics, Seattle, WA, United States
| | - Ali Rowhani-Rahbar
- University of Washington School of Medicine, Department of Pediatrics, Seattle, WA, United States; University of Washington School of Public Health, Department of Epidemiology, Seattle, WA, United States; Harborview Injury Prevention & Research Center, University of Washington, Seattle, WA, United States
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Historical and clinical factors associated with positive urine toxicology screening on labor and delivery. Eur J Obstet Gynecol Reprod Biol 2018; 228:261-266. [PMID: 30041147 DOI: 10.1016/j.ejogrb.2018.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 07/17/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Illicit drug use in pregnancy may lead to adverse outcomes. Although the American College of Obstetricians and Gynecologists recommends that all pregnant women be screened for substance use by questionnaire or conversation, it remains unclear how well these methods identify women with illicit drug use. Drug use may also be suspected based on clinical complications, such as fetal demise or placental abruption. There are currently no formal recommendations to guide targeted laboratory testing in women perceived to be at risk based on historical or clinical factors. Our objective was to determine which historical and clinical factors are associated with positive urine toxicology screens in women admitted to labor and delivery. STUDY DESIGN Historical cohort study of all women admitted to labor and delivery at our county hospital over a 5-year period (2010-2014). All patients underwent historical and clinical risk assessment and women perceived to be at increased risk of illicit drug use and who consented to testing had urine toxicology performed. We conducted a detailed chart review on all women with a positive test during this 5-year period and compared them to all women with a negative test in 2014, reporting values significant at a p-value of ≤0.05. RESULTS Amongst the 19,604 admissions during this period, 850 women underwent urine toxicology testing, accounting for 4.8% of all admissions. We compared the 83 women who tested positive for illicit drugs (9.8% of all women tested) to the 179 women who tested negative in 2014. Historical drug use was the factor most strongly associated with a positive test. Other historical and demographic factors associated with a positive test included single relationship status, lack of employment, lack of high school education, nulliparity and history of a prior sexually-transmitted or blood-borne infection. Regarding clinical risk factors, maternal medical complications were not associated with a positive test, and obstetrical complications, like preterm labor, were associated with a negative test. CONCLUSIONS A positive urine toxicology test was most strongly associated with maternal historical factors, especially known drug use. No clinical risk factor was associated with a positive test. The implications of our findings in guiding targeted laboratory testing are discussed.
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Hoerr JJ, Heard AM, Baker MM, Fogel J, Glassgow AE, Kling WC, Clark MD, Ronayne JP. Substance-exposed newborn infants and public health law: Differences in addressing the legal mandate to report. CHILD ABUSE & NEGLECT 2018; 81:206-213. [PMID: 29753200 DOI: 10.1016/j.chiabu.2018.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/23/2018] [Accepted: 04/24/2018] [Indexed: 06/08/2023]
Abstract
Prenatal exposure to illicit substances is a finding that typically requires reporting to a child protective services agency. We examine whether there is differential reporting to two public agencies, and whether it varies by race/ethnicity and region. We also study predictors of indicating a maltreatment report as credible. Data on positive neonatal toxicology reports were obtained from the Illinois Department of Public Health (IDPH) and the Illinois Department of Children and Family Services (DCFS). Variation in reporting rates by race/ethnicity and region were compared with Pearson chi-square analysis. Multivariate logistic regression examined factors related to the likelihood of DCFS indicating a report as credible for maltreatment. IDPH recorded 1838 reports of substance-exposed newborn infants while DCFS only recorded 459 reports. There was a greater percentage of whites than blacks reported to DCFS as compared to those reported to IDPH (p < 0.001). There was a greater percentage of whites than blacks found to be indicated by DCFS as compared to those reported to IDPH (p < 0.001). Infants reported in rural areas were indicated less often (OR:0.34, 95% CI:0.17-0.67, p = 0.002) than those from urban areas. In conclusion, there was variation in reporting patterns between the two agencies. To optimize health outcomes for substance-exposed newborn infants (SEIs), the law should be clarified to provide clear standards for reporting and managing SEIs. Clinicians should ensure they are acting within the confines of existing law, and should engage in an interprofessional process with a broad array of stakeholders to develop statewide drug testing and reporting protocols.
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Affiliation(s)
- Jordan J Hoerr
- Department of Pediatrics, University Hospitals, Cleveland, OH, USA
| | - Anthony M Heard
- Department of Health Social Work, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | | | - Joshua Fogel
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA; Department of Business Management, Brooklyn College, Brooklyn, NY, USA
| | - Anne Elizabeth Glassgow
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - William C Kling
- Health Policy Administration, School of Public Health, University of Illinois at Chicago, Chicago, IL, USA
| | - Maureen D Clark
- Library of the Health Sciences, University Library, University of Illinois at Chicago, Chicago, IL, USA; Department of Medical Education, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - James P Ronayne
- Department of Pediatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA.
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Wood KE, Smith P, Krasowski MD. Newborn drug testing practices in Iowa birthing hospitals. J Neonatal Perinatal Med 2017; 10:445-450. [PMID: 29286931 DOI: 10.3233/npm-16153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES Federal law mandates states to have policies and procedures to identify newborns exposed to maternal substance use during pregnancy. National guidelines for newborn drug testing are lacking; therefore, procedures are variable and determined by state law and local practices. In Iowa, maternal substance use during pregnancy is considered child abuse and must be reported.The objective of this study was to identify newborn drug testing policies and procedures among birthing hospitals in Iowa. METHODS This was a cross sectional survey of all birthing hospitals in Iowa identified via the Statewide Perinatal Care Program. An electronic survey was sent to the representative at each affiliated hospital. RESULTS Sixty-nine of 76 hospitals completed the survey for a 90.8% response rate. Newborn drug testing is ordered in 97.1% of responding hospitals with most testing 25% or less of newborns annually. The majority utilized a risk assessment tool (89.6%), although many (62.7%) also allowed for provider discretion. No hospital performed universal testing of all newborns. 86.6% of hospitals reported all positive newborn drug test results including illicit and/or prescription drugs to child protective services. 35.0% of hospitals notified mothers of the report and 45.5% offered substance abuse services and/or treatment to the mothers. CONCLUSIONS Most Iowa birthing hospitals perform newborn drug testing and report all positive test results to child protective services. The majority use risk assessment tools. Maternal notification practices and referral for substance use disorder treatment are suboptimal and represent an area for future improvement.
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Affiliation(s)
- K E Wood
- Stead Family Department of Pediatrics, University of Iowa Children's Hospital, Iowa City, IA, USA
| | - P Smith
- Iowa Statewide Perinatal Care Program, Iowa Department of Public Health, Des Moines, IA, USA
| | - M D Krasowski
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Neonatal Abstinence Syndrome and Ethical Approaches to the Identification of Pregnant Women Who Use Drugs. Obstet Gynecol 2017; 129:164-167. [DOI: 10.1097/aog.0000000000001781] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Putnam-Hornstein E, Prindle JJ, Leventhal JM. Prenatal Substance Exposure and Reporting of Child Maltreatment by Race and Ethnicity. Pediatrics 2016; 138:peds.2016-1273. [PMID: 27519445 DOI: 10.1542/peds.2016-1273] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Substance exposure is thought to contribute to reports of suspected maltreatment made to child protective services (CPS) at or shortly after birth. There are limited data, however, on whether clinicians are more likely to report black and Hispanic substance-exposed infants compared with white infants. METHODS We examined racial differences in diagnosed substance exposure and subsequent maltreatment reports by using linked birth, hospital discharge, and CPS records. Diagnostic codes were used to document substance exposure; CPS records provided information on maltreatment reports. Prevalence of infant exposure was calculated by race or ethnicity, substance type, and sociodemographic covariates. We estimated racial differences in maltreatment reporting among substance-exposed infants using multivariable models. RESULTS In a 2006 population-based California birth cohort of 474 071 black, Hispanic, and white infants, substance exposure diagnoses were identified for 1.6% of infants (n = 7428). Exposure varied significantly across racial groups (P < .001), with the highest prevalence observed among black infants (4.1%) and the lowest among Hispanic infants (1.0%). Among white and Hispanic infants, the most frequently observed substances were amphetamine and cannabis; for black infants, cannabis was the most common, followed by cocaine. After adjusting for sociodemographic and pregnancy factors, we found that substance-exposed black and Hispanic infants were reported at significantly lower or statistically comparable rates to substance-exposed white infants. CONCLUSIONS Although we were unable to address potential racial and ethnic disparities in screening for substances at birth, we found no evidence that racial disparities in infant CPS reports arise from variable responses to prenatal substance exposure.
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Affiliation(s)
- Emily Putnam-Hornstein
- Department of Children, Youth, and Families, School of Social Work, University of Southern California, Los Angeles, California; and
| | - John J Prindle
- Department of Children, Youth, and Families, School of Social Work, University of Southern California, Los Angeles, California; and
| | - John M Leventhal
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
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Jarlenski M, Tarr JA, Holland CL, Farrell D, Chang JC. Pregnant Women's Access to Information About Perinatal Marijuana Use: A Qualitative Study. Womens Health Issues 2016; 26:452-9. [PMID: 27131908 DOI: 10.1016/j.whi.2016.03.010] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 03/16/2016] [Accepted: 03/24/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Marijuana is the most commonly used illicit substance in pregnancy. Little is known about how pregnant women who use marijuana obtain and understand information about perinatal marijuana use. We conducted a qualitative study among pregnant women who had used marijuana to understand their information-seeking patterns and perceptions of usefulness of available information about perinatal marijuana use. STUDY DESIGN We conducted semistructured interviews with 26 pregnant women who were receiving prenatal care and who either disclosed marijuana use or had urine samples testing positive for marijuana. Interviews assessed women's sources of information about risks of perinatal marijuana use and perceptions regarding the usefulness of such information. Interview data were coded independently by two coders who iteratively refined the codes and reviewed transcripts for themes. RESULTS Commonly reported sources of information about perinatal marijuana use included Internet searching and anecdotal experiences or advice from family or friends. Few women reported receiving helpful information from a health care provider or social worker. Women perceived a lack of evidence about harms of perinatal marijuana use, and reported being dissatisfied with the quality of information. Most women said they desired information about the effects of perinatal marijuana use on infant health. CONCLUSIONS Women who used marijuana before or during pregnancy did not find available information about perinatal marijuana use to be useful, and sought more information pertaining to infant health and well-being. Efforts to reduce perinatal marijuana use should focus on addressing this need in both clinical and public health settings.
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Affiliation(s)
- Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.
| | - Jill A Tarr
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cynthia L Holland
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Judy C Chang
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, Pennsylvania; Departments of Obstetrics, Gynecology and Reproductive Sciences and Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Roberts SCM, Zahnd E, Sufrin C, Armstrong MA. Does adopting a prenatal substance use protocol reduce racial disparities in CPS reporting related to maternal drug use? A California case study. J Perinatol 2015; 35:146-50. [PMID: 25233193 DOI: 10.1038/jp.2014.168] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 07/23/2014] [Accepted: 08/05/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This study examined whether adopting a standardized prenatal substance use protocol (protocol) in a hospital labor and delivery unit reduced racial disparities in reporting to child protective services (CPS) related to maternal drug use during pregnancy. STUDY DESIGN This study used an interrupted time series design with a non-equivalent control. One hospital adopted a protocol and another hospital group serving a similar geographic population did not change protocols. Data on CPS reporting disparities from these hospitals over 3.5 years were analyzed using segmented regression. RESULT In the hospital that adopted the protocol, almost five times more black than white newborns were reported during the study period. Adopting the protocol was not associated with reduced disparities. CONCLUSION Adopting a protocol cannot be assumed to reduce CPS reporting disparities. Efforts to encourage hospitals to adopt protocols as a strategy to reduce disparities may be misguided. Other strategies to reduce disparities are needed.
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Affiliation(s)
- S C M Roberts
- Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Oakland, CA, USA
| | - E Zahnd
- Public Health Institute, Oakland, CA, USA
| | - C Sufrin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - M A Armstrong
- Division of Research, Kaiser Permanente, Oakland, CA, USA
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Jaques SC, Kingsbury A, Henshcke P, Chomchai C, Clews S, Falconer J, Abdel-Latif ME, Feller JM, Oei JL. Cannabis, the pregnant woman and her child: weeding out the myths. J Perinatol 2014; 34:417-24. [PMID: 24457255 DOI: 10.1038/jp.2013.180] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 11/23/2013] [Accepted: 12/12/2013] [Indexed: 11/09/2022]
Abstract
To review and summarise the literature reporting on cannabis use within western communities with specific reference to patterns of use, the pharmacology of its major psychoactive compounds, including placental and fetal transfer, and the impact of maternal cannabis use on pregnancy, the newborn infant and the developing child. Review of published articles, governmental guidelines and data and book chapters. Although cannabis is one of the most widely used illegal drugs, there is limited data about the prevalence of cannabis use in pregnant women, and it is likely that reported rates of exposure are significantly underestimated. With much of the available literature focusing on the impact of other illicit drugs such as opioids and stimulants, the effects of cannabis use in pregnancy on the developing fetus remain uncertain. Current evidence indicates that cannabis use both during pregnancy and lactation, may adversely affect neurodevelopment, especially during periods of critical brain growth both in the developing fetal brain and during adolescent maturation, with impacts on neuropsychiatric, behavioural and executive functioning. These reported effects may influence future adult productivity and lifetime outcomes. Despite the widespread use of cannabis by young women, there is limited information available about the impact perinatal cannabis use on the developing fetus and child, particularly the effects of cannabis use while breast feeding. Women who are using cannabis while pregnant and breast feeding should be advised of what is known about the potential adverse effects on fetal growth and development and encouraged to either stop using or decrease their use. Long-term follow-up of exposed children is crucial as neurocognitive and behavioural problems may benefit from early intervention aimed to reduce future problems such as delinquency, depression and substance use.
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Affiliation(s)
- S C Jaques
- Department of Newborn Care, Royal Hospital for Women, Randwick, NSW, Australia
| | - A Kingsbury
- Mater Miseriacordiae Health Service Brisbane, Mater Mothers' Hospital, South Brisbane, QLD, Australia
| | - P Henshcke
- Mercy Women's Hospital, Heidelberg, Melbourne, VIC, Australia
| | | | - S Clews
- The Langton Centre, Surry Hills, NSW, Australia
| | - J Falconer
- The Langton Centre, Surry Hills, NSW, Australia
| | - M E Abdel-Latif
- The Centenary Hospital for Women and Children, Canberra, ACT, Australia
| | - J M Feller
- 1] The Sydney Children's Hospital, Randwick, NSW, Australia [2] School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia
| | - J L Oei
- 1] Department of Newborn Care, Royal Hospital for Women, Randwick, NSW, Australia [2] School of Women's and Children's Health, University of New South Wales, Randwick, NSW, Australia
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Pan IJ, Yi HY. Prevalence of hospitalized live births affected by alcohol and drugs and parturient women diagnosed with substance abuse at liveborn delivery: United States, 1999-2008. Matern Child Health J 2013; 17:667-76. [PMID: 22688539 PMCID: PMC4521396 DOI: 10.1007/s10995-012-1046-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To describe prevalence trends in hospitalized live births affected by placental transmission of alcohol and drugs, as well as prevalence trends among parturient women hospitalized for liveborn delivery and diagnosed with substance abuse problems in the United States from 1999 to 2008. Comparison of the two sets of trends helps determine whether the observed changes in neonatal problems over time were caused by shifts in maternal substance abuse problems. This study independently identified hospitalized live births and maternal live born deliveries from discharge records in the Nationwide Inpatient Sample, one of the largest hospital administrative databases. Substance-related diagnosis codes on the records were used to identify live births affected by alcohol and drugs and parturient women with substance abuse problems. The analysis calculated prevalence differences and percentage changes over the 10 years, with Loess curves fitted to 10-year prevalence estimates to depict trend patterns. Linear and quadratic trends in prevalence were simultaneously tested using logistic regression analyses. The study also examined data on costs, primary expected payer, and length of hospital stays. From 1999 to 2008, prevalence increased for narcotic- and hallucinogen-affected live births and neonatal drug withdrawal syndrome but decreased for alcohol- and cocaine-affected live births. Maternal substance abuse at delivery showed similar trends, but prevalence of alcohol abuse remained relatively stable. Substance-affected live births required longer hospital stays and higher medical expenses, mostly billable to Medicaid. The findings highlight the urgent need for behavioral intervention and early treatment for substance-abusing pregnant women to reduce the number of substance-affected live births.
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Affiliation(s)
- I-Jen Pan
- CSR Incorporated, Arlington, Virginia
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Paltrow LM, Flavin J. Arrests of and forced interventions on pregnant women in the United States, 1973-2005: implications for women's legal status and public health. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2013; 38:299-343. [PMID: 23262772 DOI: 10.1215/03616878-1966324] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
In November 2011, the citizens of Mississippi voted down Proposition 26, a "personhood" measure that sought to establish separate constitutional rights for fertilized eggs, embryos, and fetuses. This proposition raised the question of whether such measures could be used as the basis for depriving pregnant women of their liberty through arrests or forced medical interventions. Over the past four decades, descriptions of selected subsets of arrests and forced interventions on pregnant women have been published. Such cases, however, have never been systematically identified and documented, nor has the basis for the deprivations of liberty been comprehensively examined. In this article we report on 413 cases from 1973 to 2005 in which a woman's pregnancy was a necessary factor leading to attempted and actual deprivations of a woman's physical liberty. First, we describe key characteristics of the cases and the women, including socioeconomic status and race. Second, we investigate the legal claims made to justify the arrests, detentions, and forced interventions. Third, we explore the role played by health care providers. We conclude by discussing the implications of our findings and the likely impact of personhood measures on pregnant women's liberty and on maternal, fetal, and child health.
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Abstract
Prenatal substance abuse continues to be a significant problem in this country and poses important health risks for the developing fetus. The primary care pediatrician's role in addressing prenatal substance exposure includes prevention, identification of exposure, recognition of medical issues for the exposed newborn infant, protection of the infant, and follow-up of the exposed infant. This report will provide information for the most common drugs involved in prenatal exposure: nicotine, alcohol, marijuana, opiates, cocaine, and methamphetamine.
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Development of the Drug-Exposed Infant Identification Algorithm (DEIIA) and Its Application to Measuring Part C Early Intervention Referral and Eligibility in Massachusetts, 1998–2005. Matern Child Health J 2012; 17:1567-75. [DOI: 10.1007/s10995-012-1157-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Wood JN, Pecker LH, Russo ME, Henretig F, Christian CW. Evaluation and referral for child maltreatment in pediatric poisoning victims. CHILD ABUSE & NEGLECT 2012; 36:362-9. [PMID: 22571909 DOI: 10.1016/j.chiabu.2012.01.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 01/16/2012] [Accepted: 01/23/2012] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Although the majority of poisonings in young children are due to exploratory ingestions and might be prevented through improved caregiver supervision, the circumstances that warrant evaluation for suspected maltreatment and referral to Child Protective Services (CPS) are unclear. Therefore the objective of this study was to determine the percentage and characteristics of young poisoning victims who were evaluated for child maltreatment by the hospital team (social work and/or child protection team) and/or referred to CPS. METHODS Retrospective study of poisoning victims<6 years old seen at an urban children's hospital from 2006 to 2008. Logistic regression was performed to evaluate the associations between the outcomes (evaluation for maltreatment by hospital team and/or referral to CPS) and predictor variables (demographics and circumstances, type and severity of poisoning). RESULTS Among 928 poisonings, 41% were from household products, 20% from over-the-counter drugs, 7% from prescription narcotics/sedatives, 29% from other prescription drugs, and ≤ 1% each from ethanol, illicit drugs, or other substances. Most children were asymptomatic (69%) or stable (28%); 3% were critically ill. Only 13% were evaluated by the hospital team and 4% were referred to CPS. Demographic characteristics were not associated with referral to CPS. Higher clinical severity was associated with increased referral (p<0.001). Compared to poisonings with over-the-counter drugs, referrals were more likely for poisonings with ethanol and prescription narcotics/sedatives, but not other prescription drugs or household products (p<0.001). All illicit drug poisonings and 44% of ethanol poisonings were referred. The majority of referrals to CPS were for concerns for illicit drugs, poor supervision or multiple forms of maltreatment; 6% were secondary to concerns for intentional poisoning. CONCLUSIONS Evaluations and referrals to CPS for maltreatment are uncommon in young poisoning victims. Referrals occurred consistently for illicit drugs but not ethanol. Although referrals were more likely for higher severity poisonings, it is unclear if the severity of poisoning is associated with the level of supervisory neglect or a marker of ongoing risk to the child. These findings suggest the need to identify risk factors for ongoing harm and the development of clinical guidelines used to determine which poisoning victims should be referred to Child Protective Services.
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Affiliation(s)
- Joanne N Wood
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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