Multiple marginalized identities: A qualitative exploration of intersectional perinatal experiences of birthing people of color with substance use disorder in Massachusetts.

INTRODUCTION: Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals. METHODS: Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development. RESULTS: The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination. CONCLUSION: Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.

Limited Utility of Toxicology Testing at Delivery for Perinatal Cannabis Use.

OBJECTIVES: To describe the characteristics of individuals undergoing toxicology testing at delivery for a sole indication of cannabis use and to evaluate the rate of unexpected positive toxicology testing results among this cohort. METHODS: This retrospective cohort study included dyads with a maternal history of cannabis use who underwent peripartum toxicology testing between 2016 and 2020 at 5 birthing hospitals in Massachusetts. We collected information on maternal demographic characteristics and toxicology test results and reviewed records of dyads with unexpected positive results to identify additional social risk factors and clinical outcomes. RESULTS: Of 60 608 live births reviewed, 1924 dyads underwent toxicology testing, including 614 (31.9%) for a sole indication of cannabis use. Significantly greater percentages of patients in the cannabis cohort were <25 years old (32.4% vs 6.1% of the birthing population, P <.001), non-Hispanic Black (32.4% vs 8.1%, P < .001), Hispanic or Latino (30.5% vs 15.5%), American Indian/Alaskan (0.7% vs 0.1%), and publicly insured (39.9% vs 15.6%, P <.001). Eight of the 614 dyads (1.3%) had an unexpected positive toxicology test result, including 2 (0.3%) unexpectedly positive for opioids. Seven dyads (1.1%) had false positive test results for unexpected substances. Only 1 test result changed clinical management; a urine test positive for opioids prompted monitoring (but not medication) for neonatal opioid withdrawal syndrome. CONCLUSIONS: Toxicology testing of patients for a sole indication of cannabis use, without other risk factors, may be of limited utility in elucidating other substance use and may exacerbate existing disparities in perinatal outcomes.