Adopt Universal Screening for Pregnant People

Introductory Paragraph

With substance use disorder and the opioid epidemic rising, so is the use of prenatal substance use. While pregnancy can be exciting for others, for those with an SUD, diagnosed or not, there is an immense amount of stress added to their lives. Not only do they face negative health consequences for their unborn baby and themselves, they face public scrutiny and shame along with potential legal repercussions depending on their local and state laws. There is no current uniform protocol for substance testing among pregnant patients, with localities and hospitals patch-working their own models. They argue against universal screening on the fear that pregnant women won’t seek out or continue prenatal care out of fear of prosecution or having their child removed from their care. However, risk-based screening has been shown to lead to implicit bias, with practitioners using previous “red-flag” history information to decide if a patient is at risk for an SUD (11). A 2017 study showed that practitioners who used risk-based screening showed “as much implicit bias as the public” and the results were poor prenatal care treatment (11,12). Universal screening is a way to combat implicit bias that negatively impacts the most vulnerable pregnant women, along with early detection and treatment interventions.

Key Information

Statistical Data In order to understand the argument and basis for universal screening for pregnant women, it’s vital to know the scope of the problem. The CDC has reported that prenatal substance use is a growing concern, with 10% of pregnant women consuming alcohol regularly and 4.5% partaking in binge drinking (10). Here is a list of pertinent data reflecting the problem of prenatal SUDs (9,10)

• of the women who drink while pregnant, 40% also use one or more other substance
• 5% of pregnant women 15-44 years old reported illicit drug use
• the highest rate of substance use occurs during the first trimester, a critically vulnerable time for the baby, and decline to 1.4% by the third trimester

Risk Factors While substance abuse occurs within every demographic, there are certain risk factors that create vulnerability for use during pregnancy. It is important to note that demographic data collection is scarce, should be taken as a “minimum” amount, and is highly biased based on policies that disproportionately threaten women of color, low socioeconomic status, and of young ages. Most data available is taken from enacted policies, discussed below, that are meant to deter prenatal substance use but instead promote maternal prosecution (3,4). Cook, et al. has the most comprehensive, non-prosecutorial risk factor data indicating the following categories of being high risk to use substances while pregnant

• ages 15-24 (5)
• education level high school or below (5)
• at or below poverty level (5)
• concurrent psychiatric disorders (mood/anxiety & eating disorders most common) (5)
• history of trauma (child- or adulthood sexual/domestic/interpersonal abuse) (5)
• polysubstance use (5)
• family history of substance use (5)
• women of color and women on public health insurance had higher rates of prenatal substance use (3).

Impact of Perinatal Substance Use Prenatal health and habits are vital to the healthy development of the baby and the maintained health of the mother, and alcohol and drug use during pregnancy has many negative effects on both. Much of the research focuses on the physical effects of prenatal substance use on the fetus, but there are important impacts on the mother that must also be considered. Cook, et al. lists the potential negative consequences of substance use for mothers as: psychosocial deline (stress, reduced social support, partner violence, isolation, financial/legal troubles, self harm), physical issues (vascular complications, infections, bodily trauma), and reduced frequency of prenatal care (5). Impacts on the fetus are vast and vary by the specific substance it is subjected to. Consuming alcohol, however minor the amount, increases the baby’s risk of Fetal Alcohol Syndrome, preterm birth, teratogenicity, neurodevelopmental disorders, miscarriage, and stillbirth (5). Fetal Alcohol Syndrome impacts the baby’s physical growth and appearance, along with its emotional, behavioral, and cognitive health (6). Exposure to illicit drugs may have the following consequences (5,6)

low birth weight and growth restriction preterm birth miscarriage stillbirth sudden infant death syndrome exaggerated startles and diminished crying response neonatal withdrawal or abstinence symptoms transient central and automcatice nervous system symptoms congenital heart malformations abnormal physical developments

Ethical Considerations (Privacy versus Safety) There is a lot of debate among providers of various professions as to whether substance use screening should be universal in prenatal care. Early detection and treatment is critical to protecting the health of both the baby and the mother. However, the fact that many states make prenatal substance use a punitive offense can cause women to not seek prenatal care, which is detrimental in its own right (7, 8). Women who use substances while pregnant have a great fear and mistrust of medical and treatment providers because of the risk of reporting, prosecution, and infant displacement. Those who are marginalized and do seek out treatment have little success, as their honesty often leads to criminal reporting or they are unable to find available and affordable treatment programs (9). This lack of medical care and intervention of untreated prenatal substance use can lead to greater likelihood of fetal substance dependency and ensuing fetal medical complications. It is vital to advocate and lobby for states to adopt impactful treatment policy, while also negating or varying the consequences of legal action taken against the mothers. See “Expand Perinatal Treatment and Support for Women with SUDs (During Pregnancy)” for examples of states that have adopted successful legal policy that focus on pre- and post-natal SUD treatment to avoid infant removal and punitive action.

Relevant Research

Implementing universal urine drug screening upon admission to labor and delivery”' - this study sought to establish the reliability of urine drug screening (UDS) in pregnant women and if it has value in universal screening efforts. Results showed there are a high amount of false positives, making the tool unreliable and potentially harmful as a universal screening tool. It is recommended to use UDS in high-risk cases.

Accuracy of Three Screening Tools for Prenatal Substance Use”' - this study compares the accuracy of the 4P’s Plus, NIDA Quick Screen-ASSIST, and the SURP-P scales in a population of 500 pregnant women. The,SURP-P and 4P's Plus had high sensitivity and negative predictive values, making them more ideal screening tests than the NIDA Quick Screen-ASSIST.

Implementation of a universal screening process for substance use in pregnancy”'- this study sought to implement universal substance use screening in an urban prenatal outpatient clinic. They exceeded their goal of 90% of patients being screened and found the universal process, outlined in SBIRT workflow with various evidence-based tools, allowed for greater identification of use amongst even low-risk patients. It is concluded that is a feasible model to implement but there needs to be added protocol for documenting practitioner intervention with those who had positive screenings.

In Kaiser Permanente's Early Start program, pregnant women were screened for substance abuse risk at the first prenatal visit by a self-administered questionnaire and by urine toxicology testing (with signed consent). Universal screening facilitates early identification and treatment of substance use.

Early Start: An Integrated Model of Substance Abuse Intervention for Pregnant Women - Kaiser Permanente
Overview of program:

• Universally screen all pregnant women
• No mandated reporting for toxicology
• Mental health provider apart of obstetric care
• Use video conferencing and telephone to provide care to immediate and remote care

Outcome Successes:

• Show decrease in morbidity for mothers and babies
• Cost beneficial
• Reduces all barriers to care, including in prenatal care

The role of screening, brief intervention, and referral to treatment in the perinatal period -- Tricia E. Wright, MD, MS
Method:

Screening Instruments:

• CAGE -- Cut down, Annoyed, Guilt, Eye opener
• T-ACE -- Takes, Annoyed, Cut down, Eye opener
• TWEAK -- Tolerance, Worry, Eye opener, Amnesia, Cut down
• 4Ps -- Past, Present, Parents, Partner
• NIDA Quick Screen -- Uses 3 open-ended questions regarding alcohol, tobacco, and other drugs

Key Screening Conclusions:

• Screening should be done for all pregnant women and throughout pregnancy for those at risk
• Screening can be done by a provider using a validated instrument during follow-up or by asking standardized questions during interview
• Screening must be nonjudgemental and open-ended
• Urine toxicology should not be used in place of screening

Impactful Federal, State, and Local Policies

A 2001 U.S. Supreme Court Ruling states that hospital workers cannot perform a drug test on pregnant women, “without their informed consent or a valid warrant if the purpose is to alert the police to a potential crime,” (13). This ruling seeks to protect pregnant women’s right to medical privacy and prevent unwarranted search and seizure of a vulnerable population (14). It also solidifies the ethical role that practitioners have in informing patients of their constitutional rights when it comes to privacy and protections, while making it clear to law officials that they aren’t to recruit hospitals in the collection of evidence without a valid warrant (15). The Child Abuse Prevention and Treatment Act - CAPTA requires that all infants who are substance-exposed at any point of the pregnancy/birth have a Plan of Safe Care that addresses the needs of both the baby and their mother. This plan is not for prosecution but to ensure that the baby and mother receive education, treatment, have basic needs met, and be connected with all available resources (16). States Every state, and even hospitals within each state, have their own policy regarding universal versus risk-based prenatal drug screening and what to do if the mother tests positive. Here are two resources for state-by-states policy and consequences regarding screening/positive prenatal substance use: https://worldpopulationreview.com/state-rankings/states-that-drug-test-newborns https://projects.propublica.org/graphics/maternity-drug-policies-by-state Virginia It is a legal requirement for all practitioners in Virginia to implement routine medical history protocol to screen all pregnant women. If their history is positive for substance use, the results shall not be admissible in any criminal proceedings and they should be properly counseled and referred for treatment. Mothers must provide informed consent before a urine or blood sample can be screened for substances or HIV (16). However, health care providers are required to report suspected child abuse/neglect to the appropriate channels, and infants who have been exposed to substances fall into this caveat (16). The DSS of Virginia has put out this guidebook that covers legalities, obligations, recommended evidence-based screening tools, and Plan of Safe Care (16): https://www.dss.virginia.gov/files/division/dfs/mandated_reporters/cps/resources_guidance/Perinatal_Substance_Use_Promoting_Healthy_Outcomes.pdf

Available Tools & Resources

Validated Screening Tools Quick Sheet (IPQIC-SBIRT) - https://www.in.gov/health/laboroflove/files/Validated-Screening-Tools-Final.pdf New England’s SBIRT-based Prenatal Screening Outline - provides recommended tools, how to align them with SBIRT, a process map, examples, billing/coding guides, brief intervention guide, and treatment referal plan http://www.nnepqin.org/wp-content/uploads/2018/03/03.-SBIRT-for-Substance-Use-During-Pregnancy_REV-03.15.18.pdf

Promising Practices for Standardized Screening

• ACOG SUD in Pregnancy Position Statement: ACOG endorses the value of universal screening in addition to treatment and resource provision enliu of punitive action. They recommend federal and state policies focus on prioritizing the health of the mother and baby by: expanding postnatal Medicaid coverage and include SUD/mental health screening, treatment, and services; providing access to MAT; providing adequate postpartum psychosocial, SUD, and relapse support and treatment; enforcing safe prescribing practices, and increasing focus on curbing prenatal alcohol and tobacco use (17). Their recommended prenatal screening tool is the Alcohol, Smoking, and Substance Involvement Screening Test (16).
• Final Report and Evaluation of the Universal Prenatal Screening Pilot conducted by the InterCommunity Health Network of Oregon (18) - this pilot program aimed to establish referral processes; train various medical/birthing professionals on screening tools; implement standardized, universal screening using the 5Ps; implement consented urine testing; and provide medical clinics with public health literature (related to SUD during pregnancy and breastfeeding). They educated clinics on warm-handoff procedures to encourage open communication between patient, doctor, and services. The project has success in reducing provider stigma, creating a more inviting and safe environment for the patient, increasing access to prenatal SUD treatment, and opening the dialogue around the benefits of universal screening as a tool for prevention and treatment, rather than prosecution.

Indiana State Department of Health

In 2014, because of the high rate of opioid prescriptions, the Indiana General Assembly charged the Indiana State Department of Health (ISDH) to: develop a standard clinical definition of NAS and a standardized process of identifying it, identify the resources hospitals need to do this, and then establish a voluntary pilot program with hospitals to implement this standardized NAS identification. As of 2016, 26 of 89 Indiana Birthing Hospitals are taking part in this pilot screening program

  To understand and address perinatal substance use, accurate data needed to be collected through standardized screening and testing:

• When any pregnant arrives at the hospital for delivery, hospital personnel conduct a standardized and validated verbal screening regarding substance use.
• Any woman with a positive verbal screen at any point during pregnancy, including at presentation for delivery, is requested to consent to a urine toxicology screening.
• Babies whose mothers had a positive verbal screen or toxicology screen, or babies whose mothers did not consent to the toxicology screen will be tested for evidence of maternal substance use using the infant’s umbilical cord.
  • Note: Umbilical cord testing, not meconium stool, was used on all infants.
• Babies also have modified Finnegan scoring initiated to observe for signs and symptoms of NAS.

ISDH noted that universal screening in a non-punitive environment would allow us to understand the true prevalence of Perinatal Substance Use and NAS.

See Improve Identifying and Data Collecting on NAS for more information on defining, testing, and reporting data about NAS.