Associations between Women's Race/Ethnicity, Self-Reported Substance Use and Health Care Providers' Screening for Substance Use during Pregnancy

Background/Purpose: Expanding liberalization of cannabis laws and changing social norms have implications for prenatal substance use. Professional organizations recommend universal screening for substance use during pregnancy, yet provider screening varies in practice partially due to differing prenatal substance use laws that mandate reporting to child protective services. Despite estimates suggesting lower prenatal substance use among Black and Hispanic women than white women, Black and Hispanic women are overrepresented in referrals to child protective services. However, findings to date have been compiled across datasets, may not be comparable, and are insufficient to understand the relationships between women’s race/ethnicity, substance use, and provider screening practices. Using data on representative samples of new mothers, we examined the associations between women’s race/ethnicity and self-reported substance use and, separately, their reporting of whether health care providers screened for substance use during prenatal care visits.

Methods: We used the 2016-2020 Pregnancy Risk Assessment Monitoring System, an annual survey administered by the Centers for Disease Control and Prevention to samples of women who recently delivered and resided in 28 states and DC. The primary exposure was women’s race/ethnicity (Black, Hispanic, white). Outcomes were women’s self-reported cannabis and cigarette use during pregnancy and alcohol use within the past 2 years as well as women’s reports of whether health care providers screened prenatally for drugs (defined as marijuana, cocaine, crack, meth), cigarettes, and alcohol. All outcomes were dichotomized. We conducted logistic regression models to examine the associations between race/ethnicity and prenatal substance use, and subsequently, with provider screening for substance use. Covariates included women’s age, education, marital status, insurance status, when prenatal care started, parity, and survey year.

Results: Of 84,256 respondents in the 4-year period, 5.4% of women reported using cannabis prenatally and 83.4% reported that health care providers screened for drug use during prenatal visits. In adjusted models, Black (Odds Ratio 0.63; 95% CI 0.55, 0.72) and Hispanic (0.30; 0.25, 0.37) women were less likely to report using cannabis than white women, but were more likely (1.21; 1.10, 1.33 and 1.27; 1.14, 1.40, respectively) to report being screened by providers for drug use. Overall, 9.2% of women reported using cigarettes prenatally and 96.0% reported that providers screened for smoking. Black women were less likely to report smoking than white women (0.24; 0.22, 0.27), and less likely to report being screened for smoking (0.80; 0.68, 0.94). Overall, 71.7% of women reported using alcohol in the past 2 years and 95.3% reported that providers screened for alcohol. Black (0.49; 0.45, 0.53) and Hispanic (0.67; 0.61, 0.71) women were less likely to report alcohol use than white women, but there were no differences in screening for alcohol.

Conclusions/Implications: Despite Black and Hispanic women being less likely to use substances prenatally than white women, they were more likely to report that providers screened for drug use. These findings suggest that racial bias in screening may perpetuate the overrepresentation of minoritized children in the child welfare system. Health care systems mandating universal screening for substance use could mitigate these inequities.