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, 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. Further, 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. 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. 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 is 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. The following is a sample of data reflecting the problem of prenatal SUDs.

• The most common substances used during pregnancy reported by the CDC include opioids, alcohol, marijuana, and tobacco, each carrying its own risks.
• Of the women who drink while pregnant, 40% also use one or more other substance, the highest of which is tobacco.
• 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.

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 young age. Most available data are taken from enacted policies, discussed below, that are meant to deter prenatal substance use but instead promote maternal prosecution. The following categories were derived from non-prosecutorial data and indicate high risk factors for substances during pregnancy:

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

Impact of Perinatal Substance Use. Prenatal habits are vital to the healthy development of the baby and the maintained health of the mother. Alcohol and drug use during pregnancy have 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. One list of the potential negative consequences of substance use for mothers includes:

• psychosocial decline (stress, reduced social support, partner violence, isolation, financial/legal troubles, self harm)
• physical issues (vascular complications, infections, bodily trauma)
• reduced frequency of prenatal care.

Impacts on the fetus are vast and vary by the specific substance. Even minor amount of alcohol consumption increase the baby’s risk of Fetal Alcohol Syndrome, preterm birth, teratogenicity, neurological developmental disorders, miscarriage, and stillbirth. Fetal Alcohol Syndrome impacts the baby’s physical growth and appearance, along with its emotional, behavioral, and cognitive health. Exposure to illicit drugs may have the following consequences:

• 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 automatic nervous system symptoms
• congenital heart malformations
• abnormal physical developments

Postnatal impacts on the mother and baby extend beyond physio-social consequences. Mothers who use substances throughout pregnancy are at an increased risk of having the child removed from their care after birth. These child removals have been shown to lead to an increase in maternal drug use and mental health complications, especially in Black and Indigenous women. Those who do retain custody of their infants and continue substance abuse are at risk of atypical maternal-infant bonding and attachment, which is linked to adverse child outcomes.

Ethical Considerations (Privacy versus Safety). There is 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 avoid seeking prenatal care, which is detrimental in its own right. There are substantial barriers to prenatal substance abuse treatment which have lasting consequences for the mother and baby. Since 2000, the number of states that criminalize prenatal substance use has more than doubled, with 25 states plus D.C. classifying it as child abuse, and the same amount has medical reporting requirements. These laws had the intention of deterring prenatal substance use, but have instead had severe adverse effects. With so few states offering pre-or postnatal drug treatment programs as an alternative to prosecution due to liability issues, many mothers have instead reported self-isolation and avoidance of both prenatal medical appointments and substance use treatments. Substance-using pregnant women who, “do receive prenatal care experience more positive birth outcomes and have greater opportunities for other health-promoting interventions than women who do not receive care.” However, the majority of pregnant substance-using women who receive appropriate care and intervention are older, white women with private health insurance that are less likely to be reported, creating significant disparities. 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. This lack of medical care and intervention of untreated prenatal substance use can lead to a 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 the SAFE Wiki titled “Expand Perinatal Treatment and Support for People with SUDs” for examples of states that have adopted successful legal policy that focus on pre-natal and post-natal SUD treatment to avoid infant removal and punitive action.

Relevant Research

Kaiser Permanente's Early Start program is an integrated model of substance abuse intervention for pregnant women. In this study, 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). The program included:

• Universal screening of all pregnant women
• No mandated reporting for toxicology
• Mental health provision apart from obstetric care
• Use of video conferencing and telephone to provide care to immediate and remote care

Documented successes included:

• Decrease in morbidity for mothers and babies
• Cost benefits
• Reduction of all barriers to care, including in prenatal care

This study compared the accuracy of three screening tools for prenatal substance use:

• 4P’s Plus
• NIDA Quick Screen-ASSIST
• SURP-P scales

In an evaluation of 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.

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

This study documents the role of screening, brief intervention, and referral to treatment in the perinatal period. The following screening instruments were evaluated:

• 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

The key conclusions were:

• 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 nonjudgmental and open-ended
• Urine toxicology should not be used in place of screening

This study emphasizes the last point above. It addresses the implementation of universal urine drug screening upon admission to labor and delivery. It sought to establish the reliability of urine drug screening (UDS) in pregnant women and to determine if it has value in universal screening efforts. Results showed there are a high number of false positives, making the tool unreliable and potentially harmful as a universal screening tool. It is recommended to use UDS only in high-risk cases.

Impactful Federal, State, and Local Policies

U.S. Supreme Court. A 2001 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." This ruling seeks to protect pregnant women’s right to medical privacy and prevent unwarranted search and seizure of a vulnerable population. 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.

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 and treatment, have basic needs met, and are connected with all available resources.

Virginia.Every state and different hospitals within states have their own policies regarding universal versus risk-based prenatal drug screening and what to do if the mother tests positive. In Virginia, it is a legal requirement for all practitioners to implement routine medical history protocol to screen all pregnant women. If their history is positive for substance use, the results are not admissible in any criminal proceedings and the women 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. 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. The DSS of Virginia has a guidebook that covers legalities, obligations, recommended evidence-based screening tools, and Plan of Safe Care.

Available Tools & Resources

SAFE Project:

• See the wiki titled "Expand SBIRT in Maternity Care Clinics" for more detailed information on the use of the SBIRT tool for mother's and their pregnancies as a method to prevent/intervene in substance use disorders.

Additional Tools & Resources:

• Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). This brief delineates an official position statement against reporting requirements which result in incarceration or other punitive legal actions against women because of a substance abuse disorder in pregnancy -- while at the same time supporting universal screening to facilitate early identification and treatment of substance use.

• Indiana Perinatal Quality Improvement Collaborative (IPQIC). This website includes guidance documents generated by the Hospital Levels of Care Task Force.

• ProPublica and World Population Review. Both of these resources provide state-by-states policy and consequences regarding screening/positive prenatal substance use.

Promising Practices

• The American College of Obstetricians and Gynecologists (ACOG) has a position statement on SUD in Pregnancy. ACOG endorses the value of universal screening in addition to treatment and resource provision in lieu of punitive action. They recommend federal and state policies focus on prioritizing the health of the mother and baby by: expanding postnatal Medicaid coverage to 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. Their recommended prenatal screening tool is the Alcohol, Smoking, and Substance Involvement Screening Test.

• InterCommunity Health Network of Oregon conducted a universal prenatal screening pilot. This 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 had 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 (ISDH). In response to the high rate of opioid prescriptions, the Indiana General Assembly charged 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. In 2016, 26 of 89 Indiana Birthing Hospitals took part in this pilot screening program. ISDH noted that universal screening in a non-punitive environment would allow us to understand the true prevalence of perinatal substance use and NAS. ISDH established a task force which provided a standard clinical definition of NAS, stating that the infant must be symptomatic, have two or three consecutive modified Finnegan scores equal to or greater than a total of 24, and either a positive toxicology test OR a maternal history with a positive verbal screen or toxicology test.