Bias Against Babies

Bias is defined as “prejudice in favor of or against one thing, person, or group compared with another, usually in a way considered to be unfair.” This topic comes up often regarding testing pregnant patients for misuse of drugs.

For example, in April 2023, JAMA reported that “Black patients, regardless of history of substance use, had a greater probability of receiving a UTT [Urine Toxicology Testing] at delivery compared with White patients and other racial groups. However, Black patients did not have a higher probability of a positive test result than other racial groups” (JAMA).

And, in February 2021, the American Journal of Obstetrics & Gynecology reported “During the study period, 685 (7.4%) patients had a urine drug test performed. Black patients made up 36% of patients receiving testing, but only 16.6% of the overall population” (AJOG).

But here’s another thing that study indicated: “Without a standardized protocol, physician-driven risk-based urine drug testing may introduce implicit bias into the care of patients.” Said another way, pregnant patients may face implicit bias when healthcare providers don’t follow a standardized protocol around testing. The simple solution for that is that providers SHOULD ALWAYS follow a standardized protocol, but even some of those can lead to bias. You know what can’t? Universal collection of umbilical cord tissue.

According to the National Library of Medicine, receipt of federal Child Abuse Prevention and Treatment Act (CAPTA) funds by states required that states “develop a plan of safe care when newborns exposed to illicit substances during pregnancy are reported by healthcare providers.” As an aside, note that CAPTA did nothing to help babies exposed to legal teratogenic substances – think alcohol and cannabis.

Anywho, some states codified the plans to provide safe care for drug-exposed neonates, and some didn’t, leaving the decision to healthcare providers…leading to bias. For those states that did codify the plans, typically the rules as to which babies get tested are along these lines: history of maternal drug use or agitated/altered mental status in the mother; no prenatal care; unexplained placental abruption; unexplained central nervous system (CNS) complications in the newborn (seizures, brain hemorrhages); symptoms of drug withdrawal in the newborn; changes in the behavioral state of the newborn (jittery, fussy, lethargic) (Drug).

If healthcare providers collect umbilical cord tissue on every single newborn, there’s no collection bias. And, because cord tissue is so easily stored after collection, it wouldn’t be tested until it’s needed, so that would also limit testing bias. Consider that babies aren’t necessarily going to exhibit unexplained central nervous system (CNS) complications like seizures, symptoms of drug withdrawal, or changes in behavior immediately after birth, while still in the hospital. “Neonatal Opioid Withdrawal Syndrome (NOWS) is a heterogeneous condition that consists of central nervous system hyperactivity, autonomic nervous system dysfunction, and gastrointestinal problems, with symptoms typically beginning within 24–72 hours after birth” (Neonatal). That means that symptoms can start over 24 hours after a baby leaves the hospital, and, what about those neonates affected by alcohol use?

Remember that these safe plans only concern themselves with illicit substances, but, according to the Minnesota Department of Health, “FASD is the most common cause of brain damage before birth (called congenital neurological deficits) and is related to alcohol intake by the mother during pregnancy” (Health).

And consider that “approximately 5 – 10% of women self-report the use of illicit drugs in pregnancy, while universal testing for illicit drugs in high-risk populations results in a significantly higher prevalence (10 – 40%) of usage than through self-reporting. […] Importantly, other substances that can have deleterious effects on the mother and infants’ health (such as nicotine and alcohol) are often used concurrently with illicit drugs” (Drug).

When healthcare providers don’t collect umbilical cord on every neonate, there’s a potential for bias. But bias against whom? If we consider that bias is “prejudice in favor of or against one thing, person, or group compared with another, usually in a way considered to be unfair,” then who is looking out for the babies? While we can all agree that bias is bad, let’s consider equity for the littlest victims. Let’s give them a fighting chance to make their healthiest way into the world.

References

https://jamanetwork.com/journals/jama-health-forum/fullarticle/2803729

https://www.ajog.org/article/S0002-9378(20)32551-5/fulltext

Drug Testing for Newborn Exposure to Illicit Substances in Pregnancy: Pitfalls and Pearls https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3139193/

https://www.health.state.mn.us/diseases/cy/fetalalcohol.html

Neonatal Opioid Withdrawal Syndrome (NOWS): A Transgenerational Echo of the Opioid Crisis

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7919394/