Illicit Substance Use, Pregnancy, and Perinatal Screening Practices

Introduction: Perinatal illicit substance use is a critical public health issue because of the potential health implications for the birthing individual and fetus. While the specific substances used over time has changed (e.g., crack cocaine, heroin, methamphetamines, opioids, and marijuana), concern for the health of the birthing individual and fetus, as well as, creating mechanisms to monitor perinatal substance use has remained constant. In an attempt to address perinatal illicit substance use, several policies at the federal, state, and institutional levels have been developed and implemented. These policies typically include universal screening or targeted/risked-based screening and can be completed via questionnaire, verbal interview, or biological specimen toxicology. In addition, these policies and practices are often disproportionately used against birthing individuals of color and those living in low-resourced communities. The purpose of this dissertation is to investigate perinatal illicit substance screening practices at the institutional level (i.e., hospitals).Research Question and Aims: What are the implicit purposes of perinatal illicit substance screening in the postpartum period. The specific aims of this dissertation are to: (1) describe the implicit purpose(s) of perinatal illicit substance screening in the postpartum setting from the perspective of healthcare workers, (2) to explore the perceived influences of illicit substance screening in the postpartum setting on the birthing individual, and (3) identify possible alternatives to perinatal illicit substance screening in the postpartum period. Methods & Procedures: This qualitative study was designed as a critical ethnography within the contexts of the social construction of a target population theory. Participants were recruited from birthing hospitals located in the United States. A purposive sample of 36 healthcare workers providing care to birthing individuals in the acute care intrapartum and postpartum periods were recruited. Data were collected using semi-structured interviews, participant observations, interdisciplinary team meeting observations both in person and virtually, and field notes. Summary of the Findings: A theoretical analysis of the social construction of target populations theory in the context of perinatal illicit substance use screening was conducted to better understand state level policy approaches taken to address perinatal illicit substance screening. The social construction of target populations provided the framework needed to understand why specific punitive and/or supportive policy tools were selected when designing public policy. In describing the implicit purposes of illicit substance screening in the acute care postpartum period from the perspective of healthcare workers, eight themes emerged from the data: connecting patients with resources; assessing risk/safety; managing care; engaging with social service agencies; surveillance; reinforcing institutional racism; preventing government intervention; and fulfilling a legal, moral, or ethical duty. These themes were categorized as either the perceived, interpreted, or implied purpose and helped to uncover instances of institutional racism and institutional bias in screening. In describing the perceived influences of perinatal illicit substance screening, most healthcare stakeholders reported that perinatal illicit substance screening was subject to both provider bias and institutional racism. The subsequent outcome(s) of such screening as reported by participants included institutional surveillance, child separation, and the criminalization of birthing individuals. The implicit purposes and perceived influences focused on institutional (i.e., hospital) illicit substance screening policies. While participants expressed the utility of some screening, the harmful effects of screening and the lack of resources available to address substance use cannot be ignored. Unlike previous studies exploring perinatal illicit substance screening, the majority (n=31, 86%) of participants were registered nurses, nurse midwives, and advanced practice nurses. Lastly, this study addresses gaps in existing research by focusing on the postpartum period and examining the purpose of screening. In conclusion, the discovery of such a broad range of implicit purposes ranging from supportive to punitive coupled with punitive perceived influences suggest that the risk for harm associated with perinatal illicit substance screening in the postpartum period does not outweigh the potential benefits. That said, the routine use of perinatal illicit substance screening should be eliminated and stakeholders identify concrete situations in which screening should occur