Government agencies and professional organizations encourage prenatal health care providers to implement universal screening for alcohol and drug use in prenatal care [1
]. Some agencies/organizations promoting universal screening argue that universal screening will reduce Black-White racial disparities in reporting to Child Protective Services (CPS) at delivery [5
]. Importantly, no published research has assessed the impact of universal screening on CPS reporting disparities at delivery or explored the mechanisms through which universal screening could reduce these disparities. Understanding the impact of universal screening on CPS reporting disparities as well as the potential mechanisms through which universal screening could influence the disparities is essential as many providers begin to implement universal screening.
Understanding these possible mechanisms requires a look at screening in context of the larger system, which includes the policies and practices of providers, women, and institutions. Important points in this system are shown in Fig. .
Universal screening in prenatal care in context
Two potential mechanisms have been alluded to in discourse around universal screening. The first will be referred to as: Equitable Surveillance. The second will be referred to as: Effective Treatment.
Without explicitly stating the logic connecting universal screening to CPS reporting disparities, those arguing that universal screening will reduce disparities [5
] often cite the Pinellas County study [6
]. In this study, Chasnoff et al. found that although White and Black pregnant women used alcohol and drugs at similar rates at their first prenatal care visit, Black women were 10 times more likely than White women to be reported to health authorities at delivery. In the discussion, the authors speculate that reporting disparities exist because prenatal providers primarily screen, and thus primarily identify, Black women. Chasnoff has since proposed universal screening as a solution to these reporting disparities [7
]. The logic appears to be that universal screening will lead providers to identify more alcohol and drug use among White women during prenatal care. It follows that identifying more White women as using alcohol and drugs in prenatal care will lead providers to report more White women to CPS at delivery, thereby reducing reporting disparities. The argument is essentially that screening for alcohol and drug use in prenatal care functions as surveillance for CPS reporting at delivery. Thus, the goal of universal
screening is to create more equitable surveillance where White women are just as likely to be screened and therefore reported as Black women.
Others suggest that universal screening helps identify pregnant women needing treatment earlier in pregnancy and ensures they receive needed treatment, either Brief Interventions (BI) or formal treatment [5
]. Although unstated in the published literature, the premise underlying this argument is that providing effective treatment during the prenatal period reduces the need for and risk of CPS reporting at delivery. Reducing the number of women (including Black women) identified in prenatal care who continue to use alcohol and/or drugs through delivery will reduce the number of Black women reported at delivery, thereby reducing reporting disparities.
In addition to different perspectives on the role of screening in reducing reporting disparities, the assumptions underlying these two mechanisms differ. Equitable Surveillance
assumes that: (1) prenatal providers screen fewer White than Black women; [6
] (2) White and Black women do not differ in patterns of alcohol and drug use during the prenatal period; [6
] (3) rates of identification at delivery are disproportional to rates of use at delivery; and (4) once providers identify pregnant women as using alcohol and/or drugs, they are equally likely to report White and Black women. Effective Treatment
assumes that: (1) women identified through screening in prenatal care receive treatment; (2) there are no racial disparities in treatment receipt; (3) treatment provided to women identified through universal screening in prenatal care is effective; and (4) there are no racial disparities in treatment effectiveness.