Stop Testing Black Babies!

• pediatrics
• racism in medicine
• qualitative methods
• disparities in health
• health care
• infant drug testing

This issue of Annals of Family Medicine contains an informative and compelling qualitative study on newborn drug testing (NDT) to detect prenatal substance abuse and its disproportionate use on Black newborns entitled, “Structural Racism in Newborn Drug Testing: Perspectives of Health Care and Child Protective Services Professionals.”¹ The authors interviewed 30 health care (HCP) and child protective services (CPS) professionals to determine the attitudes and perceptions of those who either ordered the newborn drug test or those who dealt with the consequences of those tests. After qualitative analysis, 3 themes emerged: (1) levels of racism beyond the hospital structure contributed to higher rates of drug testing of Black newborns, (2) inconsistent hospital policies led to racialized application of state law and downstream CPS reporting, and (3) HCP knowledge of the benefits and disproportionate harms of CPS reporting on Black families influenced their testing decision making. These themes recognize important points, principally that structural racism plays a role in the disproportionate testing of Black babies. Subjects also felt that their lack of knowledge about child protective services affected their use of the newborn drug test and the subsequent reporting of a positive result. In addition, policies were inconsistent across hospitals, indicating a need for a governing policy from a higher level.

In this editorial, physicians with expertise in racism, trained in OB/GYN, urogynecology, medicine/pediatrics, allergy/immunology and family medicine share their perspectives on this critical issue. We call the reader’s attention to Table 2 of the manuscript, which shares the subthemes from the interview data. To inform the first theme, the subthemes of “negative historical views of drug use in Black communities” and “racialized views of contemporary drug use patterns” reveal that Black race and drug use in pregnancy are seen as equivalent. Health professionals are not immune to stereotypes regarding drug use and Black families.² While this may not be the view of all health care providers, it is essential that physicians and researchers disprove this societal narrative with data revealing that drug use in pregnancy is no different between Black and non-Black birthing parents.^2,3 Some studies on opiate use show that in Black women, substance use is less than in the non-Black population.³

In addition, the subtheme “newborn drug testing is an aggression like obstetrical racism” highlights that newborn drug testing, like other medical practices, has been weaponized against Black families. Newborn drug testing, coupled with the disproportionate referral to child protective services with a positive NDT, becomes more destructive for Black families.^2,4 This can remove children from the home, affect mothers and caretakers, siblings and grandparents, and have an intergenerational traumatic effect.

The lack of consistent hospital and state policies regarding the use of this test enables the weaponization of NDT. A telling subtheme of theme 2, “lack of clear policy leads to bias,” shows that there is something that we can do now. Newborn drug testing is not currently recommended by the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), or American College of Obstetricians and Gynecologists (ACOG) to detect drug exposure in newborns.² The recommendations clearly state that drug screening should be performed with a questionnaire of the mother/birthing parent.³ Perhaps heeding the guidelines more strictly can eliminate some of this bias. A policy that requires universal screening, if thought to be valid, coupled with a mandatory reporting of all positive tests to CPS or its state equivalent nationally, can mitigate the weaponization of NDT. Any required NDT needs funding, supportive resources, and equitable treatment for all patients in case of a positive screen. Providers who use NDT to detect prenatal substance exposure in that environment could then help the mother with substance use. Currently, NDT is testing babies to confirm stereotypes under the guise of protecting newborn babies from their parents.

Child protective services may be more punitive to Black families,⁴ as evidenced in the subtheme of the third theme, “CPS creates mistrust.” Positive action has been taken in recent years to change CPS from being seen as punitive to supporting families with resources and treatments necessary to prevent undue separation of families. Child Protective Services in many states has changed its name to Child and Family Services to de-emphasize the punitive connotation of child protective services. The Substance Abuse Disorder and Family Engagement (SAFE) in Recovery Act proposed by Senator Markey from Massachusetts is a step in the right direction,⁵ providing the supports listed above at the national level.

We applaud the authors of this study for their illumination of these crucial points. Read the article to learn more about how structural racism interferes with the delivery of health care to Black parents and families. Black babies and families face structural racism from birth, and the article gives excellent guidance on how to mitigate this damage. Structural racism perpetuates the correctly placed mistrust by Black patients against health systems in the United States. Still, because of this critical study, we have a path forward to mitigate its effects.

• Received for publication June 4, 2024.
• Accepted for publication June 4, 2024.

• © 2024 Annals of Family Medicine, Inc.