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. Early identification of substance use allows for early intervention and treatment which minimizes potential harms to the mother and her pregnancy. Unfortunately, there is no current uniform protocol for substance testing among pregnant patients, with localities and hospitals patch-working their own models. Some people argue against universal screening because of the belief that pregnant people won’t seek out or continue prenatal care out of fear of prosecution or having their child removed from their care. However, selective screening based on “risk factors” perpetuates stigma and misses most people with problematic use. 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. Along with early detection and treatment interventions, universal screening is a way to combat implicit bias that negatively impacts the most vulnerable pregnant people.

Key Information

Statistical Data. In order to understand the case for universal screening for pregnant people, 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 people 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 people who drink while pregnant, 40% also use one or more other substance, the highest of which is tobacco.
• 5% of pregnant people 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 use 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.

Women who were exposed to adverse childhood experiences (ACEs) and are socioeconomically vulnerable have a greater risk of using illicit substances, tobacco, and alcohol. White pregnant people are more likely to use tobacco when compared to black and Hispanic populations. During pregnancy, Black people are more likely to use illicit substances when compared to Hispanics and white people. This data shows that prenatal substance use is present among multiple races and ethnicities. Therefore, medical providers and public health professionals should intervene by identifying all people at risk for developing or continuing substance use during pregnancy.

People with psychiatric comorbidities are at a higher risk of using multiple substances during pregnancy. A study on the results of the National Survey of Drug Use and Health (NSDUH) showed that people who experienced a major depressive episode within the last year were more likely to engage in alcohol and tobacco use during pregnancy when compared to pregnant people who abstained from substances. The study also found that environmental stressors and lack of consistent prenatal care were correlated with worsening maternal and fetal outcomes. The World Health Organization (WHO) recommends engaging people in prevention efforts to improve mental health before becoming pregnant since mental health issues are a risk factor for developing a substance use disorder.

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 people 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 people who do receive prenatal care experience more positive birth outcomes and have greater opportunities for other health-promoting interventions than people who do not receive care. However, the majority of pregnant substance-using people who receive appropriate care and intervention are older, white, and with private health insurance that are less likely to be reported, creating significant disparities. people 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.

Primary Prevention The implementation of thorough screening and education in primary care settings for all females of reproductive age, not just those who are currently pregnant, could drastically impact the occurrence of prenatal substance use. Since about half of all pregnancies are unplanned, many people could be using alcohol or other substances without knowing they are pregnant. Physicians can provide broad education on the risks of using substances and the possibility of unknowingly becoming pregnant while continuing to use. Early detection and intervention for substance use during childbearing age can offer an opportunity for people to take necessary precautions such as contraception or abstaining from substance use if there is a chance of becoming pregnant. Medical providers and public health officials can increase education about the effects of substances and the associated risks. Women, in general, have unique risks pertaining to alcohol, tobacco, and illicit substance use when compared to males. For example, the National Center for Addiction and Substance Abuse (CASA) reports the following facts for women when compared to men:

• Greater impairment after drinking the same amount of alcohol;
• Accelerated development of alcohol-related problems;
• Greater susceptibility to the development of alcohol-related medical disorders;
• Increased asthma attacks;
• Becoming addicted to nicotine at lower levels of use;
• Greater impairment of lung functioning;
• Greater difficulty quitting smoking;
• Greater susceptibility to brain damage from heavy use of Ecstasy;
• Greater likelihood of hospitalization from nonmedical use of pain medications;
• Moderate to heavy alcohol consumption increases risks for breast cancer;
• Increased risk of female infertility;

Along with all of these harmful impacts of substance use on women in general, substance use also places women of reproductive age at a heightened risk for unplanned pregnancy. Medical provider training and improved local support for prevention in this area could potentially reduce the number of people who knowingly or unknowingly become pregnant and expose their unborn children to substances. Physicians can also screen and empower people who use substances to seek treatment or take precautions so as to not become pregnant through the use of contraceptives.

Screening, Brief Intervention, and Referral to Treatment (SBIRT). The goal of SBIRT is to identify individuals who are unaware that their behaviors are putting them at risk for developing more serious issues. With feedback and support from medical providers, these individuals have the opportunity to make an informed decision and change their current behavior or to seek treatment if needed. If a patient is deemed “moderate” or “high risk” or having “problematic use” the provider can provide a brief intervention and referral for treatment. SBIRT can be implemented with minimal time and effort on behalf of the provider. The impact SBIRT has on the patient is invaluable and helps to connect patients who need education and referral to treatment. The objectives of SBIRT are directly applicable to the use in maternity care and include:

• Educate people about the risks of alcohol and other drugs
• Make people aware of their use and whether it may be creating health risks for them
• Decrease general use so as to reduce the societal risk and burden of the effects of overuse
• Identify individuals who have dependence and provide rapid access to care

Screening consists of the provider asking a series of questions that can help to identify where patients fall along a continuum of substance use, not merely just “addicted” or “non-addicted.” SBIRT’s model of substance use has six categories:

• abstinence
• experimental use
• social use
• binge use
• abuse
• substance use disorder

Relevant Research

Kaiser Permanente's Early Start program is an integrated model of substance use intervention for pregnant people. In this study, pregnant people 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 people
• 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 people. 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 people 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 people 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 people “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 people'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 people. If their history is positive for substance use, the results are not admissible in any criminal proceedings and the people 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 Program" for more detailed information on the Screening, Brief Intervention, and Referral to Treatment (SBIRT) tool used as an prevention/early intervention method at screening for substance use in the general population.

• 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 people because of a substance use 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.

• 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.

• 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.