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

 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

Promising Practices for Standardized Screening

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.

Sources

1. [1]
2. [2]