The Government's Involvement in Prenatal Drug Testing May Be Toxic

A Comparison of Two Statewide Datasets to Understand Population Prevalence of Substance Use in Pregnancy: Findings and Considerations for Policy & Research

Mental health conditions including substance use disorder are the leading cause of pregnancy-related deaths in the U.S. Unfortunately, fears of child protective services' involvement interfere with maternal self-disclosure of substance use in pregnancy. Seeking to identify more mothers with substance use disorder in pregnancy or at delivery, and responsive to changes to the federal Child Abuse Prevention and Treatment Act (CAPTA), Connecticut requires hospital personnel to submit a deidentified notification to CPS for all newborns with prenatal substance exposure. However, it is unknown whether this approach aligns with maternal self-report on substance use. For the present study, we compared population parameters derived from CAPTA notifications submitted between March-December 2019 with parameters derived from self-report data on substance use in pregnancy from mothers who gave birth during the same timeframe. Results revealed that three times as many mothers self-reported any alcohol or drug use in pregnancy compared to the rate measured with CAPTA notifications. Compared to mothers who self-reported drug use in the third trimester, CAPTA notifications were made for statistically similar rates of Black mothers but half the self-reported rate of White and Hispanic mothers. This disparity reflects that CAPTA notifications were made for twice as many Black mothers as White or Hispanic. Although CAPTA notifications are not punitive in nature, this disparity reveals that the public health aims of this policy are not yet achieved.

Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic

Importance

Knowledge about characteristics of US pregnancy-associated decedents is needed to guide responses.

Objective

To examine individual sociodemographic characteristics and residing county's health care resources and socioeconomic factors among pregnancy-associated overdose decedents in comparison with obstetric decedents and overdose decedents who were not pregnant in the past year.

Design, Setting, and Participants

This cross-sectional, exploratory study included 1457 pregnant and postpartum overdose decedents, 4796 obstetric decedents, and 11 205 nonpregnant overdose decedents aged 10 to 44 years from 2018 to 2021. Data were analyzed August 2023.

Exposures

Decedents from the 2018-2021 Multiple Cause of Death Files linked to the 2021 Area Health Resources Files and the 2018-2021 County Health Rankings data at the county level.

Main Outcomes and Measures

Pregnancy-associated deaths were defined as deaths during pregnancy or within 1 year of pregnancy termination. This study focused on unintentional drug overdoses or drug overdoses with undetermined intent involving the most common psychotropic drugs of misuse.

Results

From 2018 to 2021, across the pregnancy-postpartum continuum, pregnancy-associated overdose mortality ratios consistently increased among women aged 10 to 44 years. Mortality ratio more than tripled among pregnant and postpartum women aged 35 to 44 years from 4.9 (95% CI, 3.0-8.0) per 100 000 mothers aged 35 to 44 years with a live birth in January to June 2018 to 15.8 (95% CI, 12.3-20.4) in July to December 2021 (average semiannual percentage changes, 15.9; 95% CI, 8.7-23.6; P < .001). Compared with pregnant obstetric decedents, pregnant overdose decedents had increased odds of being aged 10 to 34 years (75.4% vs 59.5%; range of odds ratios [ORs], 1.8 [95% CI, 1.3-2.5] for ages 10 to 24 years to 2.2 [95% CI, 1.7-2.8] for ages 25 to 34 years), being non-college graduates (72.1% vs 59.4%; range of ORs, 2.7 [95% CI, 1.7-4.3] for those with some college education to 3.9 [95% CI, 2.4-6.1] for those with less than high school education), being unmarried (88.0% vs 62.1%; OR, 4.5; 95% CI, 3.7-6.0), and dying in nonhome, non-health care settings (25.9% vs 4.5%; OR, 2.5; 95% CI, 1.8-3.6) and were associated with decreased odds of dying in health care settings (34.7% vs 77.6%; range of ORs, 0.1 [95% CI, 0.1-0.1] for those who died in hospital inpatient settings to 0.4 [95% CI, 0.3-0.6] for those who died in hospital outpatient/emergency room settings).

Conclusions and Relevance

From 2018 to 2021, the mortality ratio more than tripled among pregnant and postpartum women aged 35 to 44 years, consistent with increases in overdose mortality across US populations. Most pregnancy-associated overdose deaths occurred outside health care settings, indicating the need for strengthening community outreach and maternal medical support. To reduce pregnancy-associated overdose mortality, evidence-based interventions are urgently needed at individual, health care, local, and national levels, along with nonpunitive approaches incentivizing pregnant and postpartum women to seek substance use disorder treatments.

Reconsidering the use of urine drug testing in reproductive settings

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.

Substance Use-Associated Infant Maltreatment Report Rates in the Context of Complex Prenatal Substance Use Policy Environments

State responses to substance use during pregnancy have included policies designed to increase access to substance use treatment as well as punish such substance use. Prior research has found that punitive policies are associated with increased rates of child maltreatment reporting, but it is unclear if the presence of punitive-promoting policies also moderate the association between access-promoting polices and maltreatment reports. Using data from the National Child Abuse and Neglect Data System and state-level fixed effects models, this study investigates how interactions between access-promoting and punitive prenatal substance use policies are associated with rates of substance use-associated maltreatment reports among infants. In states with punitive policies, access-promoting policies were associated with smaller decreases in these reports than in states without punitive policies. In some cases, access-promoting policies were associated with greater increases in these reports when punitive policies were also present than when only one type of policy was adopted. Interactions between prenatal substance use policies may result in unintended and counterproductive consequences for maternal and child health and the child welfare system.

In our responses to the overdose epidemic, we cannot forget pregnant and postpartum people

In 2021, there were over 100,000 drug overdose deaths in the United States (US). Death rates have increased faster among women than men, particularly among Black and Indigenous people. Although drug overdose is a leading cause of pregnancy-associated deaths, birthing people are rarely emphasized in discussions of overdose and research and services remain limited. Data show increases in drug use and deaths among women of child-bearing age, with risks continuing in the postpartum period. Harms experienced by birthing people who use drugs occur in the context of broader inequities in maternal morbidity and mortality that lead to disparate reproductive health outcomes. Shared structural antecedents (e.g. intersecting sexism and racism, stigma, and punitive policies) underlie overlapping epidemics of overdose and maternal morbidity and mortality. Here we discuss the unique challenges placed on birthing people who use drugs and make recommendations on how to mitigate harms by improving access to and delivery of quality care and addressing unjust policies and practices. We highlight the need for integrated health services, clearer guidelines rooted in equity, and the need for changes to policy and practice that support rather than punish. To better serve individuals and families impacted by substance use, we need multilevel solutions that advance gender equity and racial justice to reshape and/or dismantle the systems that undergird oppression.

Principles of care for pregnant and parenting people with substance use disorder: the obstetrician gynecologist perspective

Substance use in pregnant and parenting persons is common, yet still underdiagnosed. Substance use disorder (SUD) is one of the most stigmatized and undertreated chronic medical conditions, and this is exacerbated in the perinatal period. Many providers are not sufficiently trained in screening or treatment for substance use, so gaps in care for this population persist. Punitive policies towards substance use in pregnancy have proliferated, lead to decreased prenatal care, do not improve birth outcomes, and disproportionately impact Black, Indigenous, and other families of color. We discuss the importance of understanding the unique barriers of pregnancy-capable persons and drug overdose as one of the leading causes of maternal death in the United States. We highlight the principles of care from the obstetrician-gynecologist perspective including care for the dyad, person-centered language, and current medical terminology. We then review treatment of the most common substances, discuss SUD during the birthing hospitalization, and highlight the high risk of mortality in the postpartum period.

Umbilical Cord Collection and Drug Testing to Estimate Prenatal Substance Exposure in Utah

OBJECTIVE

Our primary objective was to estimate statewide prenatal substance exposure based on umbilical cord sampling. Our secondary objectives were to compare prevalence of prenatal substance exposure across urban, rural, and frontier regions, and to compare contemporary findings to those previously reported.

METHODS

We performed a cross-sectional prevalence study of prenatal substance exposure, as determined by umbilical cord positivity for 49 drugs and drug metabolites, through the use of qualitative liquid chromatography-tandem mass spectrometry. All labor and delivery units in Utah (N=45) were invited to participate. Based on a 2010 study using similar methodology, we calculated that a sample size of at least 1,600 cords would have 90% power to detect 33% higher rate of umbilical cords testing positive for any substance. Deidentified umbilical cords were collected from consecutive deliveries at participating hospitals. Prevalence of prenatal substance exposure was estimated statewide and by rurality using weighted analysis.

RESULTS

From November 2020 to November 2021, 1,748 cords (urban n=988, rural n=384, frontier n=376) were collected from 37 hospitals, representing 92% of hospitals that conduct 91% of births in the state. More than 99% of cords (n=1,739) yielded results. Statewide, 9.9% (95% CI 8.1-11.7%) were positive for at least one substance, most commonly opioids (7.0%, 95% CI 5.5-8.5%), followed by cannabinoid (11-nor-9-carboxy-delta-9-tetrahydrocannabinol [THC-COOH]) (2.5%, 95% CI 1.6-3.4%), amphetamines (0.9%, 95% CI 0.4-1.5), benzodiazepines (0.5%, 95% CI 0.1-0.9%), alcohol (0.4%, 95% CI 0.1-0.7%), and cocaine (0.1%, 95% CI 0-0.3%). Cord positivity was similar by rurality (urban=10.3%, 95% CI 8.3-12.3%, rural=7.1%, 95% CI 3.5-10.7%, frontier=9.2%, 95% CI 6.2-12.2%, P=.31) and did not differ by substance type. Compared with a previous study, prenatal exposure to any substance (6.8 vs 9.9%, P=.01), opioids (4.7 vs 7.0% vs 4.7%, P=.03), amphetamines (0.1 vs 0.9%, P=.01) and THC-COOH (0.5 vs 2.5%, P<.001) increased.

CONCLUSION

Prenatal substance exposure was detected in nearly 1 in 10 births statewide.

"I Grew Up Amidst Alcohol and Drugs:" a Qualitative Study on the Lived Experiences of Parental Substance Use Among Adults Who Developed Substance Use Disorders Themselves

Experiencing parental substance use (PSU) has been associated with a heightened risk of developing substance use disorders (SUDs) in offspring. The primary goal of this study was to explore perspectives of adult children with lived experience of PSU who also developed SUDs themselves through first-hand experience. This study was conducted in Flanders (Belgium). A qualitative exploratory research design was applied. Seventeen semi-structured interviews were conducted with adult children of parents with SUDs (range: 29-48 years) who themselves had developed SUDs. All interviews were audio-taped and transcribed verbatim. Three overarching themes emerged through thematic analysis: 1) loneliness and neglect in childhood; 2) stigma and the self; and 3) the role of social connection in substance use and recovery. The narratives highlighted the central role of feelings of loneliness, isolation and belonging among children of parents with SUDs in childhood and adulthood. Increasing public awareness on the impact of PSU on children and accessible support is needed to overcome stigma and remove barriers to social inclusion for children of parents with SUDs. Findings may prove valuable in informing policy, program and treatment development aimed at breaking maladaptive intergenerational cycles.