A new federally funded study published by the American Medical Association finds that removing isolated marijuana use as a reason to order urine drug screenings during pregnancy “was associated with improved racial parity in testing and reporting” of test results to child protective services, “with no evidence of decreased identification of non prescribed, non cannabis substances” and “no significant association between the intervention and any measured neonatal outcomes.”
The report, published on Monday in the journal JAMA Network Open, notes that urine drug screenings are often used during pregnancy to guide prenatal care. And some states require that positive results for federally illegal substances be reported to child protective services.
Authors from Washington University in St. Louis, however, suggest that the harms of that practice sometimes outweigh the benefits. Eliminating marijuana as a reason to order drug screening, they wrote, better protects families and promotes parity by “reduc[ing] racial bias in urine drug screening and reporting to child protective services without impacting the identification of clinically meaningful substance use.”
The report notes that “Black patients are significantly more likely than their White counterparts to undergo peripartum urine drug screening (UDS) and subsequent reporting to child protective services (CPS).”
Parents’ fear of a CPS report and possible loss of custody of a newborn child can get in the way of needed care, which can further exacerbate racial disparities in health.
“Fear of mandated reporting is an often-cited concern among pregnant people,” it says. “In Missouri, where Black pregnant people are 4 times more likely to die within 1 year of pregnancy than White pregnant people, reducing barriers and increasing access to safe, excellent, and equitable care is paramount.”
Data from the study come after a change in policy for urine drug screenings aimed at improving racial equity. Under the change, if “isolated cannabis use” is identified during a verbal drug screening, UDS was no longer ordered. Additionally, patients receiving limited prenatal care (LPNC) were also no longer routinely sent for urine testing.
“Removal of isolated cannabis use and limited prenatal care as UDS indications, coupled with clinical decision support, was associated with improved racial equity in UDS testing and CPS reporting.”
An electronic clinical decision support (CDS) tool also required providers to input justifications for ordering urine drug screening.
The change seemed to treat people more equally by race, reduce overall drug screenings and increase the rate of detecting other non-prescribed drugs.
“Our study found that the intervention was associated with a greater than 75% reduction in overall UDS and improved racial parity,” wrote the 12-author research team. “This reduction correlated with more than 2- and 3-fold increases in the percentage of tested patients testing positive for any non cannabis compound and non prescribed, non-cannabis compounds, respectively, and a 3-fold decrease in cannabis-only positive results.”
The team emphasized that its findings aren’t meant to condone cannabis use during pregnancy or suggest that reporting dangerous situations to child protective services isn’t important. Rather, they’re meant to encourage a better balancing of risks to parents and their children.
“We acknowledge that CPS referral may have safety benefit in some clinical situations and is certainly indicated in cases of child abuse,” authors wrote; “however, these authors would challenge the assumption that parental substance use, particularly of cannabis, which is legal in the state of Missouri, constitutes such a scenario.”
The pointed out that research into mandatory reporting to CPS “demonstrates significant potential harms associated with this practice, including incarceration, loss of custody of the newborn, involuntary commitment, and loss of housing.”
“Evidence does not support UDS for isolated cannabis use or LPNC, practices that disproportionately affect Black patients.”
The report also grants that removing isolated marijuana use “as an approved UDS order indication will naturally raise reasonable concerns about the impact of maternal cannabis use on the developing fetus.”
“Cannabis is the second-most common (after alcohol) psychoactive substance used during pregnancy. Several observational studies have reported negative associations among fetal cannabis exposure, fetal development, neonatal outcomes, and neurocognitive development,” it notes, pointing to advice from the American College of Obstetricians and Gynecologists (ACOG) that people who are pregnant or thinking about becoming pregnant should avoid cannabis use.
“Although we recognize the potential harm of in utero exposure and agree with ACOG’s position,” authors continued, “cannabis use during pregnancy in and of itself does not indicate that a person is potentially unfit to parent. Indeed, ACOG explicitly states that ‘seeking obstetric-gynecologic care should not expose a woman to criminal or civil penalties for marijuana use.’”
Not only is isolated marijuana use “poorly predictive for other substances” in drug screenings, the team argued, but it’s also not a strong indicator that people are unfit parents.
“Supporting this argument is the finding that 196 of 197 patients (>99%) who tested positive for cannabis after undergoing UDS for isolated cannabis use in a previous study were discharged home with custody of the newborn,” the report says, “suggesting that this practice has low predictive value for identifying what CPS would deem unsafe for a newborn.”
“There were no significant associations between the intervention and other patient demographics, neonatal outcomes, or neonatal substance-related withdrawal diagnoses.”
The report was funded in part by a federal grant from the National Institute on Drug Abuse (NIDA).
This past October, two other federally funded reports published by the American Medical Association also examined issues of cannabis and pregnancy. One study found that cannabis use during early pregnancy was not associated with child autism, while the other found no association with increased risk for early childhood developmental delays.
Late last year, meanwhile, a separate report from a reproductive rights organization found that pregnancy-related prosecutions were at an all-time high in the wake of the 2022 Supreme Court decision that ended the nationwide right to abortion. By far the most common criminal allegation facing pregnant people was that they used marijuana or other drugs during their pregnancies.
Rates of prosecution varied strikingly across the country, according to that study. Alabama, for example, was responsible for nearly half of the prosecutions, at 104, followed by Oklahoma at 68 and South Carolina at 10. The majority of defendants charged in pregnancy-related cases were also low income.
In Oklahoma, local news in 2022 began reporting that prosecutors there were targeting pregnant women for using medical marijuana, resulting in felony child neglect charges being filed against 26 mothers. The crime can carry up to a life prison in Oklahoma.
In 2023, NIDA Director Nora Volkow blasted the criminalization of drug use by pregnant people and new parents, arguing that the resulting stigmatization is harming families and contributing to the overdose crisis.
She said that families need “support, not criminalization.”
Then in July of last year, a state court ruled that people cannot be prosecuted for child neglect for legally using medical marijuana while pregnant.
Recently, the state’s house speaker, Rep. Anthony Moore (R), filed legislation that would make it illegal to use medical marijuana while pregnant.
As for other American Medical Association (AMA)-published research, a study late last year found that psilocybin-assisted therapy in a group of frontline clinicians during the COVID-19 pandemic “resulted in a significant, sustained reduction of symptoms of depression.”
A separate AMA-published study that received federal funding analyzed product listings on a popular marijuana advertising site and found that nearly half of all products were “flavored,” based on notes in the product descriptions. Researchers raised concerns that those flavors—along with cannabis-infused edibles, products like concentrates and merely listing retailers and products online—may make marijuana more appealing to young people.
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