Incidence of Newborn Drug Testing and Variations by Birthing Parent Race and Ethnicity Before and After Recreational Cannabis Legalization

Abstract

Importance: Thirty-seven US states and the District of Columbia mandate reporting newborns with suspected prenatal substance exposure to the state, and punitive policies that link prenatal substance exposure to newborn drug testing (NDT) may lead to disproportionate reporting of Black parents to Child Protective Services. The impact of recreational cannabis legalization on racial disproportionality in NDT is unknown.

Objectives: To examine variations in the incidence and results of NDT by birthing parent race and ethnicity, variables associated with variation, and changes after statewide legalization of recreational cannabis.

Design, setting, and participants: This retrospective cohort study was conducted from 2014 to 2020 with 26 366 live births to 21 648 birthing people who received prenatal care at an academic medical center in the Midwestern United States. Data were analyzed from June 2021 to August 2022.

Exposures: Variables included birthing parent age, race, ethnicity, marital status, zip code, insurance type, prenatal and newborn diagnoses codes, and prenatal urine drug test orders and results.

Main outcome and measures: The primary outcome was an NDT order. Secondary outcomes were substances detected.

Results: Among 26 366 newborns of 21 648 birthing people (mean [SD] age at delivery, 30.5 [5.2] years), most birthing parents were White (15 338 [71.6%]), were non-Hispanic (20 125 [93.1%]), and had private insurance coverage (16 159 [74.8%]). The incidence of NDT ordering was 4.7% overall (1237 newborns). Clinicians ordered more NDTs for Black compared with White newborns (207 of 2870 [7.3%] vs 335 of 17 564 [1.9%]; P < .001) when the birthing parent had no prenatal urine drug test, a presumably low-risk group. Overall, 471 of 1090 NDTs (43.3%) were positive for only tetrahydrocannabinol (THC). NDTs were more likely to be positive for opioids in White compared with Black newborns (153 of 693 [22.2%] vs 29 of 308 [9.4%]; P < .001) and more likely to be positive for THC in Black compared with White newborns (207 of 308 [67.2%] vs 359 of 693 [51.8%]; P < .001). Differences remained consistent after state recreational cannabis legalization in 2018. Newborn drug tests were more likely to be positive for THC after legalization vs before legalization (248 of 360 [68.9%] vs 366 of 728 [50.3%]; P < .001) with no significant interaction with race and ethnicity groups.

Conclusions and relevance: In this study, clinicians ordered NDTs more frequently for Black newborns when no drug testing was done during pregnancy. These findings call for further exploration of how structural and institutional racism contribute to disproportionate testing and subsequent Child Protective Services investigation, surveillance, and criminalization of Black parents.

Figure 1.. Newborn Drug Testing Incidence Over Time, by Birthing Parent Race and Ethnicity

Newborn drug testing incidence was significantly higher for Black newborns compared with White and Asian newborns in all years, newborns in the combined group (those self-reporting as American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and other race) for all years except 2014 and 2019, and Hispanic newborns in all years except 2014. Testing prevalence was significantly higher for White newborns compared with Asian newborns in all years, the combined group in 2020, multiracial newborns in 2014 and 2015, and Hispanic newborns in 2015. Multiracial includes patients self-reporting as 2 or more race options. Hispanic includes patients self-reporting as Hispanic ethnicity, regardless of race selection.

Figure 2.. Newborn Drug Testing Rates by Birthing Parent Race and Ethnicity and by Prenatal Urine Drug Test Order and Result

The combined group includes patients self-reporting as American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, Asian, and other race. Illicit substances include amphetamines, buprenorphine without prescription, cannabinoids, cocaine, methamphetamines, methadone without prescription, opiates, and oxycodone, which were typically nonprescribed controlled substances. Barbiturates and benzodiazepines were not included in this analysis because these were typically prescribed (legal) controlled substances. ^aSignificantly higher than White (P < .001), combined (P < .001), multiracial (P < .001), and Hispanic (P < .001) newborns. ^bSignificantly lower than Black (P < .001) and White (P < .001) newborns.

Figure 3.. Newborn Drug Test Results by Substance and Birthing Parent Race and Ethnicity

The combined group includes patients self-reporting as American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and other race. Multiracial includes patients self-reporting as 2 or more race options. Opioids include morphine, oxymorphone, codeine, oxycodone, and hydrocodone. Stimulants include amphetamines, cocaine, and methamphetamine. ^aSignificantly higher than Black newborns (P < .001). ^bSignificantly higher than White newborns (P < .001).