Six percent of people report using non-prescribed substances while pregnant1 and up to 11% of infants, more than 400,000 per year, are exposed in-utero to alcohol or non-prescribed substances.2  Amidst an ongoing opioid overdose epidemic and widespread cannabis legalization in the United States, identification of dyads with prenatal substance use is common. Toxicology testing of mother-infant dyads at delivery is used to help clinicians understand the cause of maternal clinical presentations, such as hypertension and placental abruption,3 identify pregnant individuals who would benefit from substance use disorder treatment,4 recognize infants at risk for neonatal opioid withdrawal syndrome and other substance related complications,5 help guide discussions over the potential risks and benefits to breastfeeding, and detect in-utero exposures that raise safety concerns for the infant.6 Though utilized for acute clinical and social concerns, the impact of peripartum toxicology testing reaches beyond the delivery hospitalization and can include the loss of parental custody and criminal charges.7

The American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Society of Maternal Fetal Medicine support the use of standardized questionnaires during pregnancy to identify individuals using non-prescribed substances.4,8,9 Yet explicit guidelines for toxicology testing of newborns and their mothers at delivery are lacking and as a result practice varies widely.10 Historically, provider biases, impacted by structural racism and reinforced by the “War on Drugs” have impacted the decision to test,2,4,11, 12, 13 resulting in racial inequities in the testing of pregnant individuals and neonates.14, 15, 16, 17 While targeted testing based on clinical presentation and maternal risk factors has been promoted,18 there remains a need to assess whether testing for certain indications disproportionately impacts specific groups and to investigate the persistence of disparities during the current opioid epidemic and era of cannabis legalization. Further, no studies, to our knowledge, have examined testing and test indication in a combined sample of birthing individuals and their infants and then followed them through the hospitalization to evaluate disparities in hospital social worker assessments, referral to child protective services, and the custody of the newborn at discharge.

The primary aim of this study was to evaluate the association of maternal sociodemographic characteristics with the likelihood of toxicology testing and the specific indication for that testing. Our secondary aim was to examine the extent to which these characteristics were associated with a social work assessment, a report to child protective services, and infant removal from parental custody.