Article Figures & Data
Figures
- Figure 1.
Explanatory framework of potential influences of structural racism on health care professional decision making in newborn drug testing.
CAPTA = Child Abuse and Prevention Treatment Act; CPS = child protective services; HCP = health care professional; NDT = newborn drug testing.
Tables
Characteristic No. (%) Role Certified nurse midwife 5 (17) CPS professional 4 (13) Nurse 4 (13) Physician (attending)a 12 (40) Physician (resident)b 4 (13) Social worker 1 (3) Age, y 20-29 2 (8) 30-39 10 (38) 40-49 7 (27) ≥50 7 (27) Gender identityc Woman 24 (92%) Man 2 (8%) Race/Ethnicityd Arab 1 (4) Asian 1 (4) Black/African American 3 (12) Hispanic 1 (4) Mixed 1 (4) White/Caucasian 22 (85) Years in practice 0-5 5 (19) 6-10 6 (23) 11-15 4 (15) ≥16 11 (42) Years at institution 0-5 5 (19) 6-10 11 (42) 11-15 5 (19) ≥16 4 (15) CPS = child protective services.
Note: Data from 26 of 30 participants that agreed to provide demographic information. Valid or non-missing values are used for calculation of percentages.
↵a Attending physicians: 6 in pediatrics, 3 in family medicine, 2 in obstetrics/gynecology, and 1 in pediatric medicine.
↵b Resident physicians: 2 in pediatrics, 1 in family medicine, and 1 in obstetrics/gynecology.
↵c Participants self-identified their gender identity in a short open-ended answer.
↵d Participants self-identified their race/ethnicity in a short open-ended answer and could select more than 1.
Subthemes Quotations Theme 1. Levels of racisim beyond the hospital structure contributed to higher rates of NDT for Black newborns Negative historical views of drug use in Black communities “We pretend to ourselves, we call it risk-based screening, but it automatically assumes that a woman of color is more at risk to use than others. I think it’s this long-standing implicit bias coming out of the 80s and the war on drugs. I think that there’s an implicit bias that women of color will use heavier than [White] women do and so therefore there’s an increased level of harm.” (CNM, P19) Racialized views of contemporary drug use patterns “Whether [they] are intentional or not, there are definitely associations that we make that are involuntary associating skin color and substance use. Marijuana use in particular is nearly ubiquitous, but with the patients that I take care of, I have an association in my mind with my African American patients.” (Family medicine attending, P16) Racialized poverty, barriers, and lack of access to early prenatal care “Poor Black single women and their babies are tested more frequently … maybe they have more limited prenatal care … It is just a very complex situation that doesn’t mean that your first go-to should be a drug screen.” (Nurse, P22) Drug testing is used to police Black culture, related to race discordance between staff and patients “Our staff is mainly higher socioeconomic status … and more Caucasian than not. So, I think cultural norms of interactions within a healthcare setting, and I think when families express questions differently or have different coping mechanisms people can become frustrated or think that something is going on.” (Pediatrics attending, P1) NDT is an aggression like obstetrical racism “Seeing in numbers and graphs really hits home to prenatal providers how different it is and how women of color are targeted in so many ways. We have the maternal morbidity and mortality rate and stuff but it’s all these other little—not even micro aggressions—these other aggressions like access to prenatal care and access to mental health.” (CNM, P19) Theme 2. Inconsistent hospital policies led to racialized application of state law and downstream CPS reporting State law is too ambiguous to apply “I think it would be very, very helpful to get more clarity in the state law. I almost feel like nobody has clarity including the state.” (Family medicine attending, P17) Lack of clear policy leads to bias “I’m concerned that when it’s not a streamlined set criteria and it’s more subjective that it can be used for some populations and not others, and I think that leads to bias, or is the result of bias. Which is concerning for me.” (Nurse, P22) HCPs retain discretion to not order NDT which creates inequity “If there’s a fancy [White] professor who just smokes weed every now and then … people may not order the drug screen … but that’s not equitable.” (CNM, P24) Theme 3. HCP knowledge of benefits and disproportionate harms of CPS reporting on Black families influenced their testing decision making Lack of knowledge following CPS reporting “I don’t know what happens when CPS is contacted. I know that they meet with the family, I know they do a home visit.” (Pediatrician, P2) Need for child protection when risk of PSE exists “The drug screen is more to have objective concrete data to satisfy legal aspects of things versus safety … Without that test we can’t protect the baby.” (Pediatrician, P9) Goal of sending NDT results is to protect children “My goal is to ensure that we have a safe place for kiddos, and to ensure that if parents need additional help and resources that we are able to get them additional help and resources to have a family thrive.” (Pediatrician, P3) CPS provides resources “CPS does do a one-time visit strictly whether or not this mother has appropriate resources and doesn’t need additional help in taking care of their child. To some degree [CPS is] supposed to be more like a resource safety net for helping mom and baby.” (Pediatrics attending, P26) Substance exposure alone does not merit opening a case against the family “Substance exposure, in and of itself is not a reason for us to investigate. So also, you know when those mandated reporters typically call me, and we have to dig and ask more questions and see if there’s some other neglect tied to it.” (CPS professional, P10) No permanent CPS record for isolated substance exposure “When we all have isolated marijuana use—and no other issues—all CPS does is investigate but they don’t open an actual case. So, in the scheme of things, there’s nothing on this record under CPS for this family.” (Social worker, P7) CPS creates mistrust “It feels like to me that [a CPS report is] mostly a punitive thing that then ties up the medical community into more mistrust of the medical community which happens more because of history in Black and brown communities of having some level of mistrust of doctors.” (Family medicine attending, P18) Risk of CPS reporting creates unsafe system for Black people to disclose drug use “[Black] people are taught that we have to wear a certain mask when we come into health care and that there are certain things [like drug use] that we should not bring up and … certain things that you know you’re going to be treated badly for.” (CNM, P24) CPS can reduce harm by providing resources instead of opening an investigation “Instead of putting them into our system where we don’t know what could potentially happen as they move through, we actually go the other route and give them those preventive services. And so that we’re only bringing the people in who truly are suspected of abuse and neglect.” (CPS professional, P10) CNM = certified nurse midwife; CPS = child protective services; HCP = health care professional; NDT = newborn drug testing; PSE = prenatal substance exposure.
SUPPLEMENTAL APPENDIX IN PDF FILE BELOW
Supplemental Appendix. Structural Racism in Newborn Drug Testing: Healthcare and Child Protective Professional Perspectives Interview Guide
- 271-SupplementalAppendix.pdf -
PDF FILE
- 271-SupplementalAppendix.pdf -
VISUAL ABSTRACT IN PNG FILE BELOW
- ChandanabhummaVisualAbstract.png -
PNG file
- ChandanabhummaVisualAbstract.png -
PLAIN-LANGUAGE SUMMARY OF ARTICLE
Original Research
Structural Racism and Inconsistent Hospital Policies Result in Health Care Professionals Disproportionately Testing Black Newborns for Prenatal Drug Exposure
Background and Goal:Black birthing parents and their newborns disproportionately experience newborn drug testing for prenatal substance exposure by health care professionals. This practice contributes to Child Protective Services reporting, family separation, and termination of parental rights. This qualitative study, conducted at the University of Michigan in Ann Arbor, MI, explored knowledge, attitudes, and experiences of health care professionals and Child Protective Services professionals regarding the influence of structural racism on inequities in newborn drug testing practices.
Study Approach:This qualitative analysis is the third qualitative phase of a larger antiracist, justice-informed, community-engaged, multiphase mixed methods study. For this phase, researchers conducted semi-structured interviews between May 2021 and October 2022 with 30 physicians, midwives, nurses, social workers, and Child Protective Services professionals. Researchers also conducted inductive, reflexive thematic analysis, using elements of the Levels of Racism Framework, the Theoretical Domains Framework, and the Public Health Critical Race Praxis.
Main Results:Researchers identified three primary themes: (A) Levels of racism beyond the hospital structure contributed to higher rates of drug testing of Black newborns; (B) Inconsistent hospital policies led to racialized application of state law and downstream Child Protective Services reporting; and (C) health care professionals’ knowledge of the benefits and disproportionate harms of Child Protective Services reporting on Black families influenced their testing decision making.
Why It Matters:Health care professionals recognized structural racism as a driver of disproportionate newborn drug testing, but their beliefs, lack of knowledge, and skill limitations were barriers to dismantling power structures impeding systems-level change.
There will be an accompanying Annals of Family Medicine Podcast episode in which lead authors and researchers, Dr. Carol Shetty and Dr. Lauren Oshman, discuss this important study in detail. The episode will be accessible on July 22nd at 5 PM here.
Visual Abstract:
