1
|
Schiff DM, Li WZM, Work EC, Goullaud L, Vazquez J, Paulet T, Dorfman S, Selk S, Hoeppner BB, Wilens T, Bernstein JA, Diop H. Multiple marginalized identities: A qualitative exploration of intersectional perinatal experiences of birthing people of color with substance use disorder in Massachusetts. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 163:209346. [PMID: 38789329 DOI: 10.1016/j.josat.2024.209346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/29/2024] [Accepted: 03/01/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals. METHODS Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development. RESULTS The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination. CONCLUSION Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.
Collapse
Affiliation(s)
- Davida M Schiff
- Division of General Academic Pediatrics, MassGeneral for Children, 125 Nashua St. Suite 860, Boston, MA 02114, United States of America; Division of Newborn Medicine, MassGeneral for Children, Boston, MA, 02114, United States of America.
| | - William Z M Li
- Harvard Medical School, Boston, MA, United States of America
| | - Erin C Work
- University of California, Schools of Public Health and Social Welfare, Los Angeles, CA, United States of America
| | - Latisha Goullaud
- Institute for Health and Recovery, Watertown, MA, United States of America
| | | | - Tabhata Paulet
- Rutgers New Jersey Medical School, Newark, NJ, United States of America
| | - Sarah Dorfman
- Division of General Academic Pediatrics, MassGeneral for Children, 125 Nashua St. Suite 860, Boston, MA 02114, United States of America
| | - Sabrina Selk
- National Network of Public Health Initiatives, Washington, DC, United States of America
| | - Bettina B Hoeppner
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, United States of America
| | - Timothy Wilens
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, United States of America
| | - Judith A Bernstein
- Division of Community Health Sciences, Boston University School of Public Health, Boston, MA, United States of America
| | - Hafsatou Diop
- Massachusetts Department of Public Health, Boston, MA, 02108, United States of America
| |
Collapse
|
2
|
Williams A, Little SE, Bryant AS, Smith NA. Mode of Delivery and Unplanned Cesarean: Differences in Rates and Indication by Race, Ethnicity, and Sociodemographic Characteristics. Am J Perinatol 2024; 41:834-841. [PMID: 35235955 DOI: 10.1055/a-1785-8843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE We aimed to examine the relationship of sociodemographic variables with racial/ethnic disparities in unplanned cesarean births in a large academic hospital system. Secondarily, we investigated the relationship of these variables with differences in cesarean delivery indication, cesarean delivery timing, length of second stage and operative delivery. STUDY DESIGN We conducted a retrospective cohort study of births >34 weeks between 2017 and 2019. Our primary outcome was unplanned cesarean delivery after a trial of labor. Multiple gestations, vaginal birth after cesarean, elective repeat or primary cesarean delivery, and contraindications for vaginal delivery were excluded. Associations between mode of delivery and patient characteristics were assessed using Chi-square, Fisher exact tests, or t-tests. Odds ratios were estimated by multivariate logistic regression. Goodness of fit was assessed with Hosmer Lemeshow test. RESULTS Among 18,946 deliveries, the rate of cesarean delivery was 14.8% overall and 21.3% in nulliparous patients. After adjustment for age, body mass index (BMI), and parity, women of Black and Asian races had significantly increased odds of unplanned cesarean delivery; 1.69 (95% CI: 1.45,1.96) and 1.23 (1.08, 1.40), respectively. Single Hispanic women had adjusted odds of 1.65 (1.08, 2.54). Single women had increased adjusted odds of cesarean delivery of 1.18, (1.05, 1.31). Fetal intolerance was the indication for 39% (613) of cesarean deliveries among White women as compared to 63% (231) of Black women and 49% (71) of Hispanic women (p <0.001). CONCLUSION Rates of unplanned cesarean delivery were significantly higher in Black and Asian compared to White women, even after adjustment for age, BMI, parity, and zip code income strata, and rates of unplanned cesarean delivery were higher for Hispanic women self-identifying as single. Racial and ethnic differences were seen in cesarean delivery indications and operative vaginal deliveries. Future work is urgently needed to better understand differences in provider care or patient attributes, and potential provider bias, that may contribute to these findings. KEY POINTS · Racial, ethnic, and socioeconomic differences exist in the odds of unplanned cesarean.. · Indications for unplanned cesarean delivery differed significantly among racial and ethnic groups.. · There may be unmeasured provider level factors which contribute to disparities in cesarean rates..
Collapse
Affiliation(s)
- Alexandria Williams
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General, Boston, Massachusetts
| | - Sarah E Little
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Allison S Bryant
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Massachusetts General, Boston, Massachusetts
| | - Nicole A Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| |
Collapse
|
3
|
Habersham LL, Bianco AT, Kudrich CJ, Woolfolk CL, Stern TA, Stone JL, Hurd YL. An institutional intervention on toxicology testing reduces inequities during the birthing hospitalization. Am J Obstet Gynecol 2024; 230:e47-e48. [PMID: 38070698 DOI: 10.1016/j.ajog.2023.11.1254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 11/30/2023] [Indexed: 01/11/2024]
Affiliation(s)
- Leah L Habersham
- Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574.
| | - Angela T Bianco
- Icahn School of Medicine at Mount Sinai, New York, NY 10029-6574
| | | | | | - Toni A Stern
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Yasmin L Hurd
- Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
4
|
Lijewski VA, Aldrich H, Straub HL. The Impact of Social Vulnerability on Substance Use Detection Practices in Pregnancy. Am J Perinatol 2024. [PMID: 38503303 DOI: 10.1055/s-0044-1782686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
This study aimed to synthesize current literature regarding the impact of social vulnerability on pregnancy-related substance use detection in the United States and highlight disparities in substance use detection practices. Clinicaltrials.gov, Google Scholar, PubMed (includes MEDLINE), and Cochrane Library databases were searched using the following Medical Subject Headings (MeSH): (["pregnancy" or "prenatal"] AND ["substance use screening" or "urine toxicology testing" or "toxicology testing" or "urine drug screening" or "CRAFFT" or "4P's" or "4P's Plus" or "NIDA Quick Screen" or "DAST-10" or "SURP-P" or "WIDUS"], AND ("bias" or "disparities" or "social vulnerability"]). The search included systematic reviews, prospective and retrospective studies, randomized controlled trials, case studies, and qualitative and quantitative research from January 2014 through November 2023. Selected literature was limited to studies published in English, which included a study population of either pregnant individuals or pregnancy health care providers in the United States, and that were focused on inequities in pregnancy substance use detection. Using Covidence, three authors screened abstracts, and two screened full articles for inclusion. The included studies were evaluated for quality of evidence using the mixed methods appraisal tool. The search yielded 4,188 manuscripts; 37 were eligible for full review. A total of 18 manuscripts were included based on the relevancy of the topic. The most common social vulnerability domain identified was minority status (17/18), followed by socioeconomic status (11/18), household characteristics (8/18), and housing type (1/18). Social vulnerability plays a role in substance use detection among pregnant individuals. Most notably, race and ethnicity, age, and public insurance lead to increased rates of detection, though most individual factors need to be studied in greater depth. This study was registered with PROSPERO (PROSPERO ID CRD42022352598), the International Prospective Register of Systematic Reviews. KEY POINTS: · Socially vulnerable pregnant individuals are more likely to receive substance use screening or urine toxicology testing.. · Race, ethnicity, age, and insurance influence substance use detection disparities.. · More research is needed to understand how other characteristics influence disparities in substance use detection..
Collapse
Affiliation(s)
- Virginia A Lijewski
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado
| | - Heather Aldrich
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado
| | - Heather L Straub
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado
| |
Collapse
|
5
|
Cohen S, Nielsen T, Chou JH, Hoeppner B, Koenigs KJ, Bernstein SN, Smith NA, Perlman N, Sarathy L, Wilens T, Terplan M, Schiff DM. Disparities in Maternal-Infant Drug Testing, Social Work Assessment, and Custody at 5 Hospitals. Acad Pediatr 2023; 23:1268-1275. [PMID: 36754165 DOI: 10.1016/j.acap.2023.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVE To evaluate for disparities in peripartum toxicology testing among maternal-infant dyads across a hospital network and subsequent child protective services (CPS) involvement. METHODS Retrospective chart review of 59,425 deliveries at 5 hospitals in Massachusetts between 2016 and 2020. We evaluated associations between maternal characteristics, toxicology testing, and child welfare involvement with disproportionality risk ratios and hierarchical logistical regression. RESULTS Toxicology testing was performed on 1959 (3.3%) dyads. Younger individuals and individuals of color were more likely to be tested for cannabis use or maternal medical complications compared to white non-Hispanic individuals. Among those without a substance use disorder, age <25 (adjusted odds ratio [aOR] 2.81; 95% confidence interval [CI], 2.43-3.26), race and ethnicity (non-Hispanic Black (aOR 1.80; 95% CI, 1.52-2.13), Hispanic (aOR 1.23; 95% CI, 1.05-1.45), mixed race/other (aOR 1.40; 95% CI, 1.04, 1.87), unavailable race (aOR 1.92; 95% CI, 1.32-2.79), and public insurance (Medicaid [aOR 2.61; 95% CI, 2.27-3.00], Medicare [aOR 13.76; 95% CI, 9.99-18.91]) had increased odds of toxicology testing compared to older, white non-Hispanic, and privately insured individuals. The disproportionality ratios in testing were greater than 1.0 for individuals under 25 years old (3.8), Hispanic individuals (1.6), non-Hispanic Black individuals (1.8), individuals of other race (1.2), unavailable race (1.8), and individuals with public insurance (Medicaid 2.6; Medicare 10.6). Among dyads tested, race and ethnicity was not associated with CPS involvement. CONCLUSIONS Peripartum toxicology testing is disproportionately performed on non-white, younger, and poorer individuals and their infants, with cannabis use and medical complications prompting testing more often for patients of color than for white non-Hispanic individuals.
Collapse
Affiliation(s)
- Samuel Cohen
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass; Department of Pediatrics, Boston Medical Center (S Cohen), Boston, Mass.
| | - Timothy Nielsen
- Children's Hospital Westmead Clinical School, Faculty of Medicine and Health, University of Sydney (T Nielsen), Sydney, Australia
| | - Joseph H Chou
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass
| | - Bettina Hoeppner
- Department of Psychiatry, Harvard Medical School (B Hoeppner and T Wilens), Boston, Mass
| | - Kathleen J Koenigs
- BWH/MGH Integrated Residency Program in Obstetrics and Gynecology (KJ Koenigs and N Perlman), Boston, Mass
| | - Sarah N Bernstein
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Biology, Massachusetts General Hospital (SN Bernstein), Boston, Mass
| | - Nicole A Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital (NA Smith), Boston, Mass
| | - Nicola Perlman
- BWH/MGH Integrated Residency Program in Obstetrics and Gynecology (KJ Koenigs and N Perlman), Boston, Mass
| | - Leela Sarathy
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass
| | - Timothy Wilens
- Department of Psychiatry, Harvard Medical School (B Hoeppner and T Wilens), Boston, Mass
| | | | - Davida M Schiff
- MassGeneral Hospital for Children (S Cohen, JH Chou, L Sarathy, and DM Schiff), Boston, Mass
| |
Collapse
|
6
|
Siegel MR, Cohen SJ, Koenigs K, Woods GT, Schwartz LN, Sarathy L, Chou JH, Terplan M, Wilens T, Ecker JL, Bernstein SN, Schiff DM. Assessing the clinical utility of toxicology testing in the peripartum period. Am J Obstet Gynecol MFM 2023; 5:100963. [PMID: 37030508 DOI: 10.1016/j.ajogmf.2023.100963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Toxicology testing is frequently used as a means of gathering objective data about substance use in pregnancy, but little is known about the clinical utility of testing in the peripartum setting. OBJECTIVE This study aimed to characterize the utility of obtaining maternal-neonatal dyad toxicology testing at the time of delivery. STUDY DESIGN We performed a retrospective chart review of all deliveries in a single healthcare system in Massachusetts between 2016 and 2020, and identified deliveries with either maternal or neonatal toxicology testing at delivery. An unexpected result was defined as a positive test for a nonprescribed substance that was not known on the basis of clinical history, self-report, or previous toxicology testing within a week of delivery, excluding results for cannabis. We evaluated the characteristics of maternal-infant dyads with unexpected positive results, unexpected positive results by rationale for testing, changes in clinical management after an unexpected positive test, and maternal outcomes in the year after delivery using descriptive statistics. RESULTS Of the 2036 maternal-infant dyads with toxicology tests performed during the study period, there were 80 (3.9%) with an unexpected positive result. Diagnosis of substance use disorder with active use in the last 2 years was the clinical rationale for testing that yielded the greatest number of unexpected positive results (10.7% of total tests ordered for this rationale). Inadequate prenatal care (5.8%), maternal use of medication for opioid use disorder (3.8%), maternal medical indications such as hypertension or placental abruption (2.3%), history of substance use disorder in remission (1.7%), or maternal cannabis use (1.6%) yielded lower rates of unexpected results compared with a recent substance use disorder (within the last 2 years). Solely on the basis of findings from unexpected test results, 42% of dyads were referred to child protective services, 30% of dyads had no documentation of maternal counseling during delivery hospitalization, and 31% did not receive breastfeeding counseling after an unexpected test; 22.8% had monitoring for neonatal opioid withdrawal syndrome. Postpartum, 26 (32.5%) were referred to substance use disorder treatment, 31 (38.8%) attended a postpartum mental health visit, and only 26 (32.5%) attended a postpartum visit. Fifteen individuals (18.8%) were readmitted in the year after delivery, all for substance-related medical complications. CONCLUSION Unexpected positive toxicology results at delivery were uncommon, particularly when tests were sent for frequently used clinical rationales for testing, suggesting a need to revisit guidelines surrounding appropriateness of indications for toxicology testing. The poor maternal outcomes in this cohort highlight a missed opportunity for maternal connection to counseling and treatment in the peripartum period.
Collapse
Affiliation(s)
- Molly R Siegel
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein).
| | - Samuel J Cohen
- Department of Pediatrics, Boston Medical Center, Boston, MA (Dr Cohen)
| | - Kathleen Koenigs
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | - Gregory T Woods
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | | | - Leela Sarathy
- Division of Newborn Medicine, Massachusetts General Hospital for Children, Boston, MA (Dr Sarathy and Dr Chou)
| | - Joseph H Chou
- Division of Newborn Medicine, Massachusetts General Hospital for Children, Boston, MA (Dr Sarathy and Dr Chou)
| | | | - Timothy Wilens
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, MA (Dr Wilens)
| | - Jeffrey L Ecker
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | - Sarah N Bernstein
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | - Davida M Schiff
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Dr Schiff)
| |
Collapse
|
7
|
Siegel MR, Mahowald GK, Uljon SN, James K, Leffert L, Sullivan MW, Hernandez SJ, Gray JR, Schiff DM, Bernstein SN. Fentanyl in the labor epidural impacts the results of intrapartum and postpartum maternal and neonatal toxicology tests. Am J Obstet Gynecol 2022:S0002-9378(22)02185-8. [PMID: 36427599 DOI: 10.1016/j.ajog.2022.11.1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/30/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND A positive urine fentanyl toxicology test may have considerable consequences for peripartum individuals, yet the extent to which fentanyl administration in a labor epidural may lead to such a positive test is poorly characterized. OBJECTIVE This study aimed to quantify the extent to which neuraxial fentanyl in labor neuraxial analgesia can lead to a positive peripartum maternal or neonatal urine toxicology test. STUDY DESIGN We performed a prospective cohort study of pregnant participants planning a vaginal delivery with neuraxial analgesia. Participants with a history of substance use disorder, hypertension, or renal or liver disease were excluded. A urine sample was collected before initiation of neuraxial analgesia, each time the bladder was emptied during labor, and up to 4 times postpartum. Neonatal urine was collected once. Urine fentanyl testing was performed using 2 common toxicology testing methods, namely immunoassay and liquid chromatography with tandem mass spectrometric detection. RESULTS A total of 33 maternal-infant dyads yielded a total of 178 urine specimens. All maternal specimens were negative for fentanyl using liquid chromatography with tandem mass spectrometric analysis and immunoassay before initiation of neuraxial analgesia. Intrapartum, 26 of 30 (76.7%) participants had positive liquid chromatography with tandem mass spectrometry results for fentanyl or its metabolites, and 12 of 30 (40%) participants had positive immunoassay results. Postpartum, 19 of 21 (90.5%) participants had positive liquid chromatograph with tandem mass spectrometric results, and 13 of 21 (61.9%) had a positive immunoassay result. Of the 13 neonatal specimens collected, 10 (76.9%) were positive on liquid chromatography with tandem mass spectrometry analysis, the last of which remained positive 29 hours and 50 minutes after delivery. CONCLUSION Neuraxial fentanyl for labor analgesia may lead to positive maternal and neonatal toxicology tests at various times after epidural initiation and cessation and at different rates depending on the testing method used. Caution should be used in interpreting toxicology test results of individuals who received neuraxial analgesia to avoid false assumptions about nonprescribed use.
Collapse
Affiliation(s)
- Molly R Siegel
- Departments of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA.
| | | | - Sacha N Uljon
- Pathology, Massachusetts General Hospital, Boston, MA
| | - Kaitlyn James
- Departments of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA
| | - Lisa Leffert
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT
| | - Mackenzie W Sullivan
- Departments of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA
| | - Susan J Hernandez
- Departments of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA
| | - Jessica R Gray
- Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Davida M Schiff
- Division of General Academic Pediatrics, Massachusetts General Hospital, Boston, MA
| | - Sarah N Bernstein
- Departments of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
8
|
Urine Drug Screening for Isolated Marijuana Use in Labor and Delivery Units. Obstet Gynecol 2022; 140:607-609. [PMID: 36083598 DOI: 10.1097/aog.0000000000004930] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 06/23/2022] [Indexed: 01/05/2023]
Abstract
Isolated marijuana use is frequently used as an indication for urine drug screening in labor and delivery units. We aimed to identify the results of urine drug screening in a labor and delivery unit for isolated marijuana use. This retrospective cohort study reviewed data from patients admitted for delivery at an urban academic center from January 1, 2020, to December 31, 2020. Patients undergoing urine drug screening for isolated marijuana use were more likely to be younger (median age 25 vs 29 years, P <.001), more often Black (adjusted odds ratio [aOR] 2.58, 95% CI 1.94-3.41), and more likely to have public insurance (aOR 1.54, 95% CI 1.21-1.95). A few (5/338, 1.5%) urine drug screening tests performed for isolated marijuana use were positive for substances besides marijuana. Most patients (177/197, 89.8%) with a urine drug screening test result that was positive for marijuana were reported to the state child abuse hotline. The utility of isolated marijuana use as a criterion for urine drug screening thus appears limited in benefit but rife with inequitable potential to harm.
Collapse
|
9
|
Koenigs KJ, Chou JH, Cohen S, Nolan M, Liu G, Terplan M, Cummings BM, Nielsen T, Smith NA, Distefano J, Bernstein SN, Schiff DM. Informed consent is poorly documented when obtaining toxicology testing at delivery in a Massachusetts cohort. Am J Obstet Gynecol MFM 2022; 4:100621. [PMID: 35354087 DOI: 10.1016/j.ajogmf.2022.100621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/09/2022] [Accepted: 03/23/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Positive toxicology testing at delivery can have enormous consequences for birthing persons and their families, including charges of child abuse or neglect and potential loss of custody for the birthing parent. Therefore state and national guidelines stipulate that, clinicians must obtain consent before toxicology testing at delivery. OBJECTIVE This study aimed (1) to determine clinician documentation of patient consent for peripartum toxicology testing and (2) to characterize the extent to which patient and hospital characteristics were associated with documented consent. STUDY DESIGN This was a retrospective cohort of individuals who underwent toxicology testing within 96 hours of delivery between April 2016 and April 2020 at 5 affiliated hospitals across Massachusetts. Medical records were reviewed for documentation of clinician intent to obtain maternal toxicology, testing indication, verbal consent to testing, and child protective services involvement. Hierarchical multivariable logistic regression was used to examine the association between patient and hospital characteristics and documentation of verbal consent. RESULTS Among 60,718 deliveries, 1562 maternal toxicology tests were obtained. Verbal consent for testing was documented in 466 cases (29.8%). Documented consent was lacking across most demographic groups. Consent was no more likely to be documented when a report was filed with child protective services and less likely in cases where the birthing parent lost custody before discharge (P=.003). In our multivariable model, consent was least likely to be documented when a maternal complication (abruption, hypertension, preterm labor, preterm premature rupture of membranes, or intrauterine fetal demise) was the indication for testing (adjusted odds ratio, 0.46; 95% confidence interval, 0.28-0.76). Verbal consent was twice as likely to be documented in delivery hospitals with established consent policies (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.37). CONCLUSION Consent for toxicology testing at delivery seemed to be infrequently obtained on the basis of clinician documentation. Provider education and hospital policies for obtaining informed consent are needed to protect the rights of birthing individuals.
Collapse
Affiliation(s)
- Kathleen J Koenigs
- Brigham and Women's Hospital/Massachusetts General Hospital Integrated Residency Program in Obstetrics and Gynecology, Boston, MA (Dr Koenigs)
| | - Joseph H Chou
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff)
| | - Samuel Cohen
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff)
| | - Moira Nolan
- Massachusetts General Hospital, Boston, MA (Ms Nolan)
| | - Gina Liu
- Harvard Medical School, Boston, MA (Ms Liu)
| | | | - Brian M Cummings
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff)
| | - Timothy Nielsen
- Faculty of Medicine and Health, Children's Hospital Westmead Clinical School, University of Sydney, Sydney, Australia (Mr Nielsen)
| | - Nicole A Smith
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA (Dr Smith)
| | - Joseph Distefano
- Boston University School of Public Health, Boston, MA (Mr Distefano)
| | - Sarah N Bernstein
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Bernstein)
| | - Davida M Schiff
- Division of Newborn Medicine, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Drs Chou, Cohen, Cummings, and Schiff).
| |
Collapse
|
10
|
Giuliani E, Townsel CD, Jiang L, Leplatte-Ogini DJ, Caldwell MT, Marsh EE. Emergency Department Utilization for Substance Use Disorder During Pregnancy and Postpartum in the United States (2006-2016). Womens Health Issues 2022; 32:586-594. [PMID: 35660347 DOI: 10.1016/j.whi.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We aimed to better understand emergency department (ED) use, admission patterns, and demographics for substance use disorder in pregnancy and postpartum (SUDPP). METHODS In this longitudinal study, the United States Nationwide Emergency Department Sample was queried for all ED visits by 15- to 50-year-old women with a primary diagnosis defined by International Classification of Diseases, 9th or 10th edition Clinical Modification, codes of SUDPP between 2006 and 2016. Patterns of ED visit counts, rates, admissions, and ED charges were analyzed. RESULTS Annual national estimated ED visits for SUDPP increased from 2,919 to 9,497 between 2006 and 2016 (a 12.4% annual average percentage change), whereas admission rates decreased (from 41.9% to 32.0%). ED visits were more frequent among women who were 20-29 years old, using Medicaid insurance, in the lowest income quartile, living in the South, and in metropolitan areas. Compared with the proportion of ED visits, 15- to 19-year-olds had significantly lower admission rates, whereas women with Medicaid and in the lowest income quartile had higher admission rates (p < .001). Opioid use, tobacco use, and mental health disorders were most commonly associated with SUDPP. The ED average inflation-adjusted charges for SUDPP increased from $1,486 to $3,085 between 2006 and 2016 (7.1% annual average percentage change; p < .001), yielding total annual charges of $4.02 million and $28.53 million. CONCLUSIONS Despite the decrease in admissions, the number and charges for ED visits for SUDPP increased substantially between 2006 and 2016. These increasing numbers suggest a continuous need to implement preventive public health measures and provide adequate outpatient care for this condition in this population specifically.
Collapse
Affiliation(s)
- Emma Giuliani
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Courtney D Townsel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan.
| | - Li Jiang
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | | | - Martina T Caldwell
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Erica E Marsh
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
11
|
Kravitz E, Suh M, Russell M, Ojeda A, Levison J, McKinney J. Screening for Substance Use Disorders during Pregnancy: A Decision at the Intersection of Racial and Reproductive Justice. Am J Perinatol 2021; 40:598-601. [PMID: 34891192 DOI: 10.1055/s-0041-1739433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Improve racial equity with routine universal drug screening / Study Design: Commentary on the medicolegal and social history of the United States and the field of obstetrics and gynecology regarding drug screening policy / Results: Critical aspects to inform an equitable drug screening policy include (1) racial bias and stigma related to substance use, (2) the legislative history surrounding substance use during pregnancy, (3) the relationship between substance use and mass incarceration which disproportionately affects persons of color, (4) propensity toward punitive measures for Black mothers with substance use, including termination of parental rights, (5) the role of the medical field in fostering mistrust among our patients / Conclusion: new practices in screening for substance use during pregnancy are needed. KEY POINTS · Increasing demand for racial justice warrants reframing the issue of urine drug screening.. · The current legal constructs continue to disproportionately impact women of color.. · Routine verbal screening can replace urine drug screening and diminish implicit biases..
Collapse
Affiliation(s)
- Elizabeth Kravitz
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michelle Suh
- Department of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Matthew Russell
- Department of Psychiatry and Behavioral Science, Baylor College of Medicine, Houston, Texas
| | - Andres Ojeda
- Department of Psychiatry and Behavioral Science, Baylor College of Medicine, Houston, Texas
| | - Judy Levison
- Department of Maternal Fetal Medicine, Baylor College of Medicine, Houston, Texas
| | - Jennifer McKinney
- Department of Maternal Fetal Medicine, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
12
|
Perlman NC, Cantonwine DE, Smith NA. Racial differences in indications for obstetric toxicology testing, and relationship of indications to test results. Am J Obstet Gynecol MFM 2021; 4:100453. [PMID: 34352428 DOI: 10.1016/j.ajogmf.2021.100453] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/15/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite illicit substance use in pregnancy occurring across all demographic groups, minority and lower income pregnant and delivering patients tend to undergo testing at a higher rate than their counterparts. National guidelines for indications do not exist, and ordering of toxicology testing may be applied inequitably. OBJECTIVE To evaluate whether any documented indications in a large cohort of patients were associated with a positive toxicology test, and whether indications for urine toxicology testing were applied consistently to different demographic groups. STUDY DESIGN Retrospective cohort study reviewing pregnant and delivering patients who underwent toxicology testing on obstetric units at one institution from 5/30/2015 to 12/31/2018. Age, race, marital status, median income of residential zip code, indications for testing, and test result were collected for each patient by individual chart review. Indications included preterm complications (preterm prelabor rupture of membranes or preterm labor), abruption or hypertension, reported substance use, fetal complications, maternal complications, and none. Multivariate logistic regression models were analyzed for association between indication and test result, and for likelihood of marijuana as the sole positive test result. Logistic regression was used to evaluate the relationship of indication for testing with maternal race. RESULTS Among 20,274 births, 551 patients underwent toxicology testing during the study period. No indication for drug toxicology testing was associated with a positive result except reported current or prior substance use. Compared to White patients, Black and Hispanic women were 4.26 (95%CI: 2.55, 7.09) and 5.75 (95%CI: 2.89, 11.43) times more likely to have toxicology testing for an indication other than reported substance use. Of all patients with positive tests (n=194), 48% tested positive for marijuana only. CONCLUSIONS Compared to their White counterparts, Black and Hispanic pregnant and delivering patients may be more frequently toxicology tested for indications less clearly associated with illicit substance use. Absence of evidence- based guidelines for toxicology testing on obstetrics units risks inequitable care and stigmatization of patient groups.
Collapse
Affiliation(s)
- Nicola C Perlman
- Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital.
| | - David E Cantonwine
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, and Harvard Medical School
| | - Nicole A Smith
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, and Harvard Medical School
| |
Collapse
|
13
|
Jarque P, Roca A, Gomila I, Marchei E, Tittarelli R, Elorza MÁ, Sanchís P, Barceló B. Role of Neonatal Biomarkers of Exposure to Psychoactive Substances to Identify Maternal Socio-Demographic Determinants. BIOLOGY 2021; 10:biology10040296. [PMID: 33916618 PMCID: PMC8067052 DOI: 10.3390/biology10040296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/29/2021] [Accepted: 04/01/2021] [Indexed: 11/16/2022]
Abstract
Simple Summary The rapid identification of newborns exposure to psychoactive drugs allows an appropriate clinical care. This study tried to identify maternal profiles that help to identify newborns exposed to psychoactive drugs during pregnancy. Mothers were interviewed using a questionnaire. The biomarkers of fetal exposure were measured in meconium samples. Statistical analysis was performed to identify the maternal characteristics that were most likely to be associated with drug use during pregnancy. Of a total of 372 mothers, 49 (13.2%) tested positive for psychoactive drugs use: 24 (49.0%) for cannabis, 11 (22.5%) for ethyl glucuronide, six (12.2%) for cocaine, and eight (16.3%) for more than one psychoactive substance. The maternal characteristics that most likely identify substance use during pregnancy are: maternal age < 24 years, lack of pregnancy care, single-mother families, and active tobacco smoking. The profiles of prenatal maternal exposure identified in a clinical setting can be used to request specific detection tests for identifying newborns exposed to these drugs. Abstract Background: The accurate assessment of fetal exposure to psychoactive substances provides the basis for appropriate clinical care of neonates. The objective of this study was to identify maternal socio-demographic profiles and risk factors for prenatal exposure to drugs of abuse by measuring biomarkers in neonatal matrices. Methods: A prospective, observational cohort study was completed. Biomarkers of fetal exposure were measured in meconium samples. The mothers were interviewed using a questionnaire. Univariate and multivariate logistic regression analyses were performed. Results: A total of 372 mothers were included, 49 (13.2%) testing positive for psychoactive substances use: 24 (49.0%) for cannabis, 11 (22.5%) for ethyl glucuronide, six (12.2%) for cocaine, and in eight (16.3%) more than one psychoactive substance. Mothers who consumed any psychoactive substance (29.7 ± 6.6 years) or cannabis (27.0 ± 5.7 years) were younger than non-users (32.8 ± 6.2 years, p < 0.05). Cocaine (50.0% vs. 96.9%, p < 0.05) and polydrug users (37.5% vs. 96.9%, p < 0.05) showed a lower levels of pregnancy care. Previous abortions were associated with the use of two or more psychoactive substances (87.5% vs. 37.8%, p < 0.05). Single-mother families (14.3% vs. 2.5%, p < 0.05) and mothers with primary level education (75.5% vs. 55.1%, p < 0.05) presented a higher consumption of psychoactive substances. Independent risk factors that are associated with prenatal exposure include: maternal age < 24 years (odds ratio: 2.56; 95% CI: 1.12–5.87), lack of pregnancy care (odds ratio: 7.27; 95%CI: 2.51–21.02), single-mother families (odds ratio: 4.98; 95%CI: 1.37–8.13), and active tobacco smoking (odds ratio: 8.13; 95%CI: 4.03–16.43). Conclusions: These results will allow us to develop several risk-based drug screening approaches to improve the early detection of exposed neonates.
Collapse
Affiliation(s)
- Pilar Jarque
- Department of Pediatrics, Division of Neonatology, Son Espases University Hospital, Valldemossa Road, 79, 07120 Palma de Mallorca, Spain; (P.J.); (A.R.)
- Pediatric Multidisciplinary Research Group, Balearic Islands Health Research Institute (IdISBa), Valldemossa Road, 79, 07120 Palma de Mallorca, Spain
| | - Antonia Roca
- Department of Pediatrics, Division of Neonatology, Son Espases University Hospital, Valldemossa Road, 79, 07120 Palma de Mallorca, Spain; (P.J.); (A.R.)
- Pediatric Multidisciplinary Research Group, Balearic Islands Health Research Institute (IdISBa), Valldemossa Road, 79, 07120 Palma de Mallorca, Spain
| | - Isabel Gomila
- Clinical Analysis Service, Son Llàtzer University Hospital, Manacor Road, 07198 Palma de Mallorca, Spain;
- Clinical Toxicology Research Group, Balearic Islands Health Research Institute (IdISBa), Valldemossa Road, 79, 07120 Palma de Mallorca, Spain;
| | - Emilia Marchei
- National Centre on Addiction and Doping, Istituto Superiore di Sanità, Viale Regina Elena, 299, 00161 Rome, Italy;
| | - Roberta Tittarelli
- Department of Anatomical, Unit of Forensic Toxicology, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185 Rome, Italy;
| | - Miguel Ángel Elorza
- Clinical Toxicology Research Group, Balearic Islands Health Research Institute (IdISBa), Valldemossa Road, 79, 07120 Palma de Mallorca, Spain;
- Clinical Analysis Service, Clinical Toxicology Unit, Son Espases University Hospital, Valldemossa Road, 79, 07120 Palma de Mallorca, Spain
| | - Pilar Sanchís
- Department of Chemistry, University of the Balearic Islands, Valldemossa Road, km 7.5, 07122 Palma de Mallorca, Spain;
- Research Group in Vascular and Metabolic Pathologies, Balearic Islands Health Research Institute (IdISBa), Valldemossa Road, 79, 07120 Palma de Mallorca, Spain
| | - Bernardino Barceló
- Clinical Toxicology Research Group, Balearic Islands Health Research Institute (IdISBa), Valldemossa Road, 79, 07120 Palma de Mallorca, Spain;
- Clinical Analysis Service, Clinical Toxicology Unit, Son Espases University Hospital, Valldemossa Road, 79, 07120 Palma de Mallorca, Spain
- Correspondence: ; Tel.: +34-871205000 (ext. 65476)
| |
Collapse
|