Racial Disparities Arise From Inconsistent Newborn Drug Screening Policy

A study out of the University of Michigan found that the absence of a clear policy for newborn drug screening, physician bias, and institutional racism led to the emergence of racial disparities in drug testing rates for Black newborns.

This latest research, published in JAMA Network Open, examined more than 26,000 births from 2014 to 2020 at the University of Michigan Health, comparing drug testing rates among various racial and ethnic groups. Additionally, the researchers aimed to investigate whether there were any changes in newborn drug testing patterns following the legalization of recreational cannabis in Michigan in 2018.

The likelihood of a clinician requesting a drug test showed racial inequities for Black newborns as they were higher than for newborns from any other racial or ethnic group, except for the period between 2016 and 2020, during which they were only comparable to the multiracial group.

The study findings showed that a newborn drug test was placed for 11.3 percent of Black newborns and 4.2 percent of White newborns. Moreover, urine tests were conducted for 9.1 percent of Black participants, 4.5 percent of White participants, and 8 percent of multiracial participants.

In the unadjusted model, White newborns were 24 percent less likely to have a drug test ordered than Black newborns. Meanwhile, White birthing individuals were more likely to have a positive drug test. Said otherwise, Black babies are more likely to be drug tested, even though White babies are the ones more likely to be positive for one.

The under-testing of White newborns might result from clinician bias, potentially causing missed opportunities to identify and address opioid use disorder, according to Lauren Oshman, MD, MPH, the senior author of the study and an associate professor of family medicine at the University of Michigan Medical School.

“In the absence of a newborn drug screening policy, we saw inconsistencies in how and when clinicians ordered drug tests for newborns at low risk of prenatal drug exposure,” Oshman said. “We measured drug testing rates before and after cannabis legalization to see if the change in law improved or worsened these inequities and found it didn’t appear to make any difference.”

Among all racial and ethnic groups, positive newborn drug tests increased following the legalization of cannabis, increasing from 50 to 69 percent. Roughly two out of five newborn drug tests were positive solely for THC, with Black newborns more likely to test positive than White newborns.

According to Oshman, this increase mirrors national trends of rising cannabis use during pregnancy, with up to 12 percent of individuals reporting usage in the first trimester between 2016 and 2017.

Even though there isn't enough evidence to suggest that cannabis use during pregnancy increases the risk of child abuse, states mandate a Child Protective Services (CPS) report for newborns testing positive for THC.

On the other hand, prenatal exposure to nicotine, which has been proven to result in poorer health outcomes for babies, doesn't require the same reporting.

In 37 states and the District of Columbia, clinicians must report suspected prenatal drug use to the state. The American College of Obstetricians and Gynecologists is against criminalizing substance use during pregnancy and opposes using newborn biological testing as an indirect indicator of child abuse or neglect.

“It is incumbent upon medical institutions to identify racial inequities that occur as a result of their policies, or lack thereof, and processes. We can’t change what we don’t measure,” said study coauthor Justine Wu, MD, MPH, an assistant professor of family medicine at the U-M Medical School. “We can’t move forward without self-reflection to stop practices that perpetuate structural and obstetrical racism, followed by thoughtful, community-engaged solutions to promote health equity.”

In light of these racial disparities, Michigan Medicine implemented a new clear policy to assist clinicians in decision-making on whether a drug test is warranted. In the past, the decision was left to clinicians, leaving room for racial bias.

Within this new process, clinicians will evaluate if a baby shows symptoms of withdrawal or, if at the time of birth, a birthing person answers “yes” to the question of whether they’d used drugs during pregnancy.

The authors emphasized that introducing a standardized policy is only the initial step. They noted that the hospital plans to monitor data on a monthly basis to determine if the implemented changes lead to positive outcomes.

“Our leaders, doctors, researchers, nurses and staff are all committed to reducing biases in the health system that may lead to inequitable applications of laws and negatively impact treatment and care,” Oshman said. “We hope this type of research helps other health systems explore how their policies or state policies may influence inequities affecting patient care and outcomes.”