Key takeaways:
- Standardized, algorithm-based screening reduces liability risk compared to discretionary testing driven by implicit bias, and ACOG does not recommend universal urine toxicology testing at delivery.
- Screening criteria must be based on clinical evidence rather than demographic proxies such as late prenatal care entry or limited prenatal visits, which cluster with race and perpetuate existing disparities.
- Institutions do not need an iPad-based platform to reduce testing disparities—any protocol that avoids demographic triggers and applies uniform clinical criteria can achieve meaningful equity gains.
Institutions seeking to reduce racial disparities in urine toxicology testing at delivery do not need a sophisticated digital tool to make meaningful progress—but they do need a protocol grounded in clinical criteria rather than demographic proxies, according to Mariam Naqvi, MD, associate professor of obstetrics and gynecology at Cedars-Sinai Medical Center.
Having previously addressed the disparity data and the implementation experience behind her institution's iPad-based screening program,1 Naqvi turned to the broader question of how departments can act on these findings—and what pitfalls to avoid.
On the question of liability, Naqvi reframed the risk calculus entirely. Discretionary testing based on implicit bias, she argued, exposes clinicians to far greater risk than a standardized protocol.
"When we're testing people based on some piece of bias—just kind of deciding at whim—I think that's actually a lot worse," she said. "By standardizing the testing, if anything, it's protecting us." She also challenged the premise of urine toxicology testing itself, noting that it is an imperfect test that cannot characterize the duration or severity of substance use, the timing of last use, or parenting capacity.
"It's not a surrogate for how good of a parent someone is going to be," she said. "We don't screen arbitrarily for any other medical condition in pregnant women."
For departments looking to act immediately, Naqvi outlined 2 concrete steps. The first applies to institutions still using universal urine toxicology testing—a practice ACOG does not recommend.
"If your institution is still doing that, discontinuing that practice would be the first quick and easy thing," she said. The second is establishing any form of standardized, criteria-based screening, regardless of the platform.
"It doesn't have to be iPad-based, it doesn't have to have all the bells and whistles," she said. "As long as what you're doing is standardized—meaning that you're screening patients based on A, B, and C criteria—and really avoiding things like poor prenatal care or late entry to care or other demographic variables."
Naqvi added, "When we screen using those demographic variables, we are going to still test the same populations that are vulnerable to bias. Because we know that race and demographics do cluster in this country—when we screen by those things, particularly for drug testing, it's going to just perpetuate the cycle."
The distinction between evidence-based clinical triggers and demographic surrogates, she emphasized, is the central design principle that determines whether a screening program reduces or reinforces existing disparities.
Reference:
1. Naqvi M, Tavakoli A, Thrift CS, et al. Impact of a substance use screening program on racial disparities in urine toxicology testing. Pregnancy. 2026;2(2):e70247. doi:10.1002/pmf2.70247
