By Clarissa Donnelly-DeRoven
In 2003, Congress enacted the Keeping Children and Families Safe Act. The new law was intended to strengthen programs that prevent child abuse and neglect, including improved training for child welfare workers and better connections between social service departments and community mental health agencies.
Included in its 33 pages is the mandate that each state create a process to identify infants exposed to drugs in-utero and intervene in some way. But, nearly 20 years later, that hasn’t happened.
“There’s been tons of policy [and] federal dollars spent on ‘how can we identify these infants?’,” said Dolly Byrd, the director of clinical research at the Mountain Area Health Education Center, or MAHEC.
“The problem is, there are no standardized best practice recommendations or guidelines,” she said. “Individual hospitals or hospitals within a health system are then left to identify their own protocol for how they’re going to test these women, identify these at-risk newborns, and then treat appropriately.”
Identifying infants exposed to substances — both legal and illicit — is critical because they might experience neonatal abstinence syndrome, which resembles drug withdrawal in adults.
These babies might be irritable, cry excessively, and generally be more difficult to console. Treatment includes administering drugs to help quell the symptoms and encouraging the mom to stay with her newborn as a comfort, to console, nurse and swaddle them.
Byrd recently published a study that investigated the different drug screening practices implemented in labor and delivery units across hospitals in the southeastern U.S., including North Carolina. In the study, about 80 percent of hospitals that responded said they have a formalized drug testing process. But, that means 20 percent don’t.
“Unfortunately, what that often means, is that they are testing women based on provider or maybe nurse clinical suspicion,” she said, “which then opens up a whole lot of opportunity to increase stigma and bias towards what’s already a historically marginalized population.”
In the survey, about 18 percent of the hospitals reported that they tested all pregnant patients for drugs, while about 14 percent said testing only happened if a clinician was suspicious that a patient might be using drugs. But the vast majority — about 61 percent — tested patients based on certain criteria, such as not receiving any prenatal care or having a history of substance use.
Byrd found significant gaps in the training clinicians received on how to implement these policies. About 30 percent of survey respondents, for example, said their hospital hadn’t communicated with them at all about the drug test policies. Also, only half of the respondents said that if their patient tested positive for substances, they “always” or “most of the time” sent the tests out for a second confirmation, which is considered best practice.
About half of the respondents indicated that they “never” or only “sometimes” referred pregnant patients who tested positive for drugs to treatment resources.
Since there aren’t standard guidelines, Byrd expected to find wide variability. What surprised her though, was something else: more than 50 percent of the labor and delivery units said they did not obtain consent from their patients before conducting a drug test; other respondents said consent for drug testing was implied by the general consent to treatment form that patients sign when they enter the hospital.
“I cannot imagine another area of the hospital where you would come in for a procedure, or an intervention, that you would not sign a specific consent,” Byrd said.
Also, in contrast to the other parts of this study, there actually are guidelines from the American College of Obstetricians and Gynecologists for this: when conducting a drug test on a patient, get consent.
All this points to areas where providers can improve their care of pregnant people with substance use disorders, Byrd said.
“How well are we as providers verbally screening our patients throughout their prenatal care?” she said. If providers wait to screen for drugs until somebody is in labor, “We’ve missed the boat at that point. If we could treat patients earlier in their pregnancy, we would have more optimal neonatal infant outcomes.”
Part of the issue in this kind of preventative care likely has to do with provider discomfort. If a patient says yes, they are using drugs, many doctors and nurses don’t know what to say. A program at MAHEC, Project CARA, helps providers learn how to navigate these conversations.
“You need to respond to them in a way that acknowledges their vulnerability for sharing,” Byrd said. “That doesn’t further stigmatize or traumatize their use, because I think a lot of times what historically has happened is a lot of women disclosed, and then they feel shunned.”