Pregnant, Black? Here’s Your Drug Test

Perinatal care differs by race and ethnicity, with greater disparities in care for more stigmatizing conditions such as depression and substance use, according to a retrospective study.

For example, compared with white women, Black women were less likely to receive a prenatal depression screen (OR 0.8, 95% CI 0.7-0.9) and more likely to be given a urine drug test when denying drug use (OR 1.6, 95% CI 1.3-2.0), reported Mary Byrn, PhD, RN, of Loyola University Chicago, and colleagues in Birth: Issues in Perinatal Care.

Hispanic (OR 0.6, 95% CI 0.5-0.8) and Asian (OR 0.4, 95% CI 0.2-0.9) women were less likely than white women to have a urine drug test after denying drug use.

“Our results indicate that perinatal care differs by race/ethnicity, reinforcing that racial bias, whether implicit or explicit, exists in perinatal care,” the study authors concluded.

As providers, “we have the best intentions of treating everybody the same, with the best care,” Byrn told MedPage Today. “But how do our biases and our decisions impact the outcomes and the treatments that patients get?”

One of the study’s “biggest takeaways,” Byrn said, was that areas of care and treatment without longstanding guidelines showed the most disparities.

While she and her colleagues observed few differences along racial and ethnic lines in non-discretionary guidelines-based care, they did observe racial differences in discretionary care.

There is a tendency to suggest that disparities rooted in racial bias may actually reflect differences in income or education level, Byrn said. However, by using insurance status as a proxy for socioeconomic status, the researchers found even larger disparities by race.

Among women with private insurance, Black women were more than twice as likely as white women to undergo a urine drug test after denying drug use (OR 2.11, 95% CI 1.35-3.29).

One thought is that these decisions align with a prejudice that Black people are more likely to use illicit drugs, Byrn noted, adding that, in fact, evidence indicates that Black people are not more likely to use drugs.

“Despite national surveys demonstrating a higher prevalence of illicit drug use (including marijuana use) among white relative to Black adults, providers continue to associate drug abuse with African Americans, consistent with racial stereotypes portrayed in the United States media,” the authors wrote.

A 2007 study found that while Black women in the peripartum period were more likely to be tested for drugs, “they were not more likely to be positive,” Byrn and team wrote.

In the case where a pregnant woman of any race is using drugs, “depending on [the provider’s] prejudices or preconceived notions on what that drug is and why somebody might use that, that could also impact the care that’s provided to that patient,” Byrn said.

That Black women were also less likely to be screened for prenatal depression than white women independent of insurance status, despite a 2015 recommendation for universal prenatal screening from the American College of Obstetricians and Gynecologists, is also a concern, the authors said.

“These racial disparities in care may stem from ‘strong Black woman’ stereotypes, which contribute to under-recognition and under-treatment of depression in Black women,” they added.

Hispanic and Asian women were also less likely than white women to receive prenatal depression screens (57.8% and 60.9% vs 66.4%, P=0.001).

Byrn and colleagues stressed that while they are hopeful that the new recommendation for universal prenatal screening could help address such gaps in care, continuing to examine prenatal screening prevalence is important.

In other findings, Black women were more likely than white women to receive maternal-fetal medicine (MFM) consults when indicated (40.7% vs 33.1%, P=0.002).

“We know Black women are more likely to have preterm birth and low birth weight and some have preeclampsia … so they’re more likely to be sent to an MFM consult,” Byrn said. “It’s still not giving us the outcomes that we need.”

She stressed that the study’s results underscore the importance of professional guidelines in perinatal care in ensuring equitable access to screening and testing.

Based on research, “we know that people are more likely to make decisions, or sort of act on these unintentional biases when they’re stressed, when they’re thinking fast, when they’re tired,” she said, noting that following guidelines are “a way to mitigate bias.”

However, guidelines must be written carefully to avoid unintentionally “disadvantaging certain races,” she pointed out. For example, a provider might order a urine drug screen for a patient who has had poor prenatal care. If that were written into the guideline, it could “inherently disadvantage” some individuals of one race over another.

In certain states, a positive urine drug test in a pregnant women has consequences, including jail time, Byrn noted.

Study Details

This study included 7,056 patients who delivered an infant in a large Midwestern medical center from January 2012 to September 2018; 36% were Hispanic, 34% were white, 21% were Black, and 4% were Asian. Average age was 29, 53% had private insurance, and 45% had Medicaid.

Byrn and colleagues acknowledged several limitations to their study, including that they were unable to capture instances where a patient refused care. It also did not include maternal or infant outcomes or any direct assessment of provider bias.

They also noted that the use of data from a single Midwestern medical center limits the generalizability of their results, “particularly since implicit bias appears to vary with geography,” they wrote.

The study also did not capture the provider’s race and could not determine “provider-patient race concordance,” they said.