Updated urine drug screening criteria and clinical support tools were associated with reduced racial disparities.
Reports to Child Protective Services also decreased overall with more racial parity.
Urine drug screening is controversial and Black people are generally screened at higher rates.
For peripartum urine drug screening, removing some indications and implementing a clinician-facing clinical decision support tool reduced disparities between Black and white patients, a quality improvement study found.
After the policy change, the proportion of patients who underwent urine drug screening dropped more than 75%, from a rate of 17.4% to 4% (P<0.001), reported Vahid Azimi, MD, MS, of the department of pathology and immunology at Washington University School of Medicine in St. Louis, and colleagues.
The intervention involved removing both isolated cannabis use and limited prenatal care as indications for urine drug screening, as well as implementing a mandatory electronic clinical decision support tool requiring physicians to select approved indications when ordering urine drug screening. Before this intervention, Black patients had much higher rates of urine drug screening than white patients (23.2% vs 11.1% respectively, P<0.001). Afterwards, the difference between Black and white pregnant patients was smaller (4.5% vs 3.6% respectively, P=0.40), they wrote in JAMA Network Open.
The intervention also eliminated the link between race and reporting to child protective services (CPS), which had been significantly more likely for Black patients than for white ones (11.3% Black vs 5.8% white, P<0.001) but dropped to statistical nonsignificance (4.2% Black vs 3.5% white, P=0.67). Missouri, where the study took place, requires CPS to be notified of any positive results for federally illegal and non-prescribed substances -- including cannabis, which has been legal in the state since 2022.
"These findings suggest that this intervention improved equity in [urine drug screening] practices without decreasing identification of clinically relevant substance use," the authors wrote.
Urine drug screening is controversial, in part due to potentially exacerbating racial inequalities. Despite similar rates of substance use as other groups, Black people are more likely to be subjected to urine drug screening, authors noted. The growing number of states that have legalized cannabis also complicates this testing.
Still, past studies have found that cannabis exposure has been linked to some adverse pregnancy, maternal, and pediatric outcomes. The American College of Obstetricians and Gynecologists recommends that pregnant women be screened for substance use with validated tools in early pregnancy in order to allow time to intervene and treat.
At the same time, CPS reports for substance use can lead to harms such as incarceration, losing custody or housing, and involuntary commitment.
Geoffrey Baird, MD, PhD, and Edwin Lindo, JD, both of University of Washington School of Medicine in Seattle, wrote in an accompanying editorial that this study contributes evidence that racial bias "plays a role in the creation of policies and practices determining when and how a laboratory test is requested, how its results are applied, or even how the health risks of the results are assessed."
Baird and Lindo noted the findings raise the important and complicated question of "whether cannabinoid use in pregnancy is more detrimental to parent and child than a racially inequitable policy and medical practice that tests members of one race disproportionally more than another, with associated negative consequences, such as referrals of parents and their children to CPS at double the rate depending on race." They did note that more definitive research assessing the long-term safety of cannabinoids in pregnancy is still needed.
This observational study assessed 9,396 pregnant patients (median age 29) at a single urban Midwestern tertiary care center. Of these patients, 4,639 delivered in the pre-intervention period (June 1, 2021 to Sept. 31, 2022) and 4,757 delivered during post-intervention (Oct. 1, 2022 to Jan. 31, 2024). The cohort was racially diverse with 45.8% Black, 45.5% white, and 8.7% other races. The authors noted a small but statistically significant decrease in the number of Black patients across the study period (2,210 pre-intervention and 2,095 post-intervention, P=0.005).
The primary outcomes were the urine drug screening and CPS report rate by race before and after intervention. The rate of non-prescribed, non-cannabis, substance-positive urine drug screening was the secondary outcome.
Researchers noted several limitations, including the observational and single-center design; that some criteria in the updated urine drug screening policy may be open to physician interpretation; that the simpler intervention of removing cannabis from the urine drug screening panel wasn't feasible for this study; inability to isolate cannabis versus limited prenatal care as criteria for screening; not being able to assess racial groups other than Black and white; and not having reliable socioeconomic data.
The authors suggested that future research look at long-term maternal and child outcomes from reduced CPS referrals.
author['full_name']
Rachael Robertson is a writer on the MedPage Today enterprise and investigative team, also covering OB/GYN news. Her print, data, and audio stories have appeared in Everyday Health, Gizmodo, the Bronx Times, and multiple podcasts. Follow
Disclosures
Azimi had no disclosures.
Other co-authors reported receiving grants from Pew Charitable Trusts, the Community Opioid Response and Education (CORE) Project, and BioMerieux as well as personal fees and other support from Cystic Fibrosis Foundation, Association for Diagnostics and Laboratory Medicine, Sebia, Siemens, and Werfen.
Baird reported personal fees from Avalon Healthcare Solutions and Lindo had no disclosures.
Primary Source
JAMA Network Open
Source Reference: Azimi V, et al "Racial equity in urine drug screening policies in labor and delivery" JAMA Netw Open 2025; DOI: 10.1001/jamanetworkopen.2025.0908.
Secondary Source
JAMA Network Open
Source Reference: Baird G, Lindo E "Reducing the harm of urine drug screening in pregnancy" JAMA Netw Open 2025; DOI: 10.1001/jamanetworkopen.2025.0914.