Racial Equity in Urine Drug Screening Policies in Labor and Delivery

Importance: Black pregnant patients are significantly more likely than their White counterparts to undergo peripartum urine drug screening (UDS) and subsequent reporting to child protective services (CPS). Objective: To evaluate the association of removing isolated cannabis use and limited prenatal care as order indications, combined with clinician-facing clinical decision support, with racial parity in peripartum UDS and CPS reporting. Design, Setting, and Participants: This quality improvement study assessed 9396 pregnant patients at a single tertiary care center in a Midwestern US urban metropolitan region who delivered before (June 1, 2021, to September 31, 2022) and after (October 1, 2022, to January 31, 2024) the intervention. Exposure: Updated UDS indications combined with clinical decision support. Main Outcomes and Measures: Primary outcomes included UDS and CPS report rate by race before vs after the intervention. The secondary outcome was the rate of nonprescribed, noncannabis substance-positive UDS. Neonatal outcomes were included as balancing measures. Results: Of 9396 female patients (median [IQR] age, 29 [24-33] years; 4305 [45.8%] Black, 4277 [45.5%] White, and 814 [8.7%] other race) included in the analysis, 4639 and 4757 delivered in the preintervention and postintervention periods, respectively. There was a small but statistically significant decrease in the number of Black patients before vs after the intervention (2210 [47.6%] vs 2095 [44.0%], P =.005); there were no significant differences in other race groups, median age, or multiparity. Before the intervention, 513 (23.2%) and 228 (11.1%) Black and White patients, respectively, had UDS (P <.001) compared with 95 (4.5%) and 79 (3.6%) Black and White patients, respectively, after the intervention (P =.40). Before the intervention, an association between Black race and CPS report was observed (249 [11.3%] Black and 119 [5.8%] White patients, P <.001); there was no association between race and CPS report after the intervention (87 [4.2%] Black and 78 [3.5%] White patients, P =.67). There was no association between the intervention and the percentage of UDS results that were positive for nonprescribed, noncannabis substances (107 [2.5%] preintervention vs 88 [2.0%] postintervention; P =.14). There was no significant association between the intervention and any measured neonatal outcomes. Conclusions and Relevance: In this quality improvement study, removal of isolated cannabis use and limited prenatal care as UDS indications, coupled with clinical decision support, was associated with improved racial equity in UDS testing and CPS reporting. The intervention was not associated with a significant change in UDS positivity for nonprescribed, noncannabis substances. These findings suggest that this intervention improved equity in UDS practices without decreasing identification of clinically relevant substance use.