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.

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 pertinent data reflecting the problem of prenatal SUDs.

• 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.

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. The following reflects non-prosecutorial risk factor data indicating categories of being high risk to use substances while pregnant:

• 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 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. 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), and
• reduced frequency of prenatal care.

Impacts on the fetus are vast and vary by the specific substance. Consuming alcohol, however minor the amount, increases the baby’s risk of Fetal Alcohol Syndrome, preterm birth, teratogenicity, neurodevelopmental 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

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

Virginia.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. 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 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. 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

• Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). This brief delineates an official position statement against reporting requirements that 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.

• New England’s SBIRT-based Prenatal Screening Outline. This provides recommended tools, how to align them with SBIRT, a process map, examples, billing/coding guides, brief intervention guide, and treatment referral plan.

• 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 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 would allow us to understand the true prevalence of Perinatal Substance Use and NAS.