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HOSPITALS GAVE PATIENTS MEDS DURING CHILDBIRTH, THEN REPORTED THEM
FOR POSITIVE DRUG TESTS  
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Shoshana Walter
December 11, 2024
The Marshall Project
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_ Mothers were reported after they were given medications used
routinely for pain or in epidurals, to reduce anxiety or to manage
blood pressure during cesarean sections. _

Victoria Villanueva sits outside of her home in West Lafayette,
Indiana, in November 2024. Doctors gave her morphine to ease the pain
of contractions during the birth of her first child in 2017. The
hospital drug tested her daughter’s first bowel movement, Ash Dye
for The Marshall Project

 

Amairani Salinas was 32 weeks pregnant with her fourth child in 2023
when doctors at a Texas hospital discovered that her baby no longer
had a heartbeat. As they prepped her for an emergency cesarean
section, they gave her midazolam, a benzodiazepine commonly prescribed
to keep patients calm. A day later, the grieving mother was cradling
her stillborn daughter when a social worker stopped by her room to
deliver another devastating blow: Salinas was being reported to child
welfare authorities. A drug test had turned up traces of
benzodiazepine — the very medication that staff had administered
before wheeling her into surgery.

For Victoria Villanueva, pregnant with her first child, the drug
detected in her baby’s system was morphine. Villanueva had arrived
at an Indiana hospital at 41 weeks to have her labor induced. To ease
the pain of her contractions, doctors gave her narcotics. A day later,
a social worker told the new mother: The baby’s meconium — or
first bowel movement — had tested positive for opiates. Now, instead
of bonding with her baby, Villanueva shook with fear that her newborn
could be taken away. “I didn’t even know how to function,” she
recalled.

What happened to Salinas and Villanueva are far from isolated
incidents. Across the country, hospitals are dispensing medications to
patients in labor, only to report them to child welfare authorities
when they or their newborns test positive for those very same
substances on subsequent drug tests, an investigation by The Marshall
Project and Reveal has found.

The positive tests are triggered by medications routinely prescribed
to millions of birthing patients in the U.S. every year. The drugs
include morphine or fentanyl for epidurals or other pain relief,
anxiety medications, and two different blood pressure meds prescribed
for C-sections.

In a time of increasing surveillance and criminalization of pregnant
women
[[link removed]] since
the end of Roe v. Wade, the hospital reports have prompted calls to
the police, child welfare investigations and even the removal of
children from their parents.

The reporting for this story included interviews with two dozen
patients and medical professionals, and a review of hundreds of pages
of medical and court records. Some spoke about cases on condition of
anonymity because the custody of children is at stake.

In New York, a mother with no history of drug use lost custody of her
toddler and newborn for five months after she tested positive for
fentanyl that the hospital had given her in her epidural. In Oklahoma,
when a mother tested positive for meth, sheriff’s deputies removed
her newborn and three other children. They were held in foster care
for 11 days, until a confirmation test proved that the culprit was a
heartburn medication the hospital had given the patient.

By the time of Villanueva’s hospital stay in 2017, researchers and
doctors had known for years that medications can rapidly pass from
mother to baby, causing positive drug test results. Two tests from
Villanueva’s prenatal visits, and another test done right before she
went into labor, all showed the mother had no drugs in her system. The
morphine given to Villanueva for her contractions was documented in
her medical records. But the staff reported her to the state child
welfare agency anyway, hospital records show.

[A White woman, wearing glasses and a red dress, holds one of her
children as she stands in front of her house. Her other two children,
who are standing beside her, are eating strawberries.]

Villanueva and her children share strawberries outside their home in
West Lafayette, Indiana, in November 2024. Ash Dye for The Marshall
Project

Marion General Hospital in Indiana did not respond to requests for
comment. Brian Heinemann, a spokesperson for the Indiana Department of
Child Services, declined to comment on Villanueva’s case, but said
policy has since changed to ensure that drug screen results alone are
not used to substantiate an allegation of abuse or neglect.

Kimberly Walton, a spokesperson for the Texas Health Resources system,
declined to answer questions about Salinas’ case, but said that
doctors order drug tests if there is a concern about patient health,
and that they are required “to report suspected illegal drug use
that could endanger the health or safety of a child.”

Hospital drug testing of pregnant women, which began in the 1980s and
spread rapidly during the opioid epidemic, was intended in part to
help identify babies who might experience withdrawal symptoms and need
extra medical care. Federal law requires hospitals to alert child
welfare agencies anytime such babies are born. But a previous
investigation by The Marshall Project and Reveal
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that the relatively inexpensive, pee-in-a-cup tests favored by many
hospitals are highly susceptible to false positives, errors and
misinterpretation — and many hospitals have failed to put in place
safeguards that would protect patients from being reported over faulty
test results.

In some cases examined by The Marshall Project, doctors and social
workers did not review patient medications to find the cause of a
positive test. In others, providers suspected a medication they
prescribed could be the culprit, but reported patients to authorities
anyway.

“How much harm to birthing people are we willing to allow? Our
patients are being harmed until we can get our act together,” said
Dr. Davida Schiff, whose hospital network, Mass General Brigham in New
England, instituted a new policy this year that directs providers to
drug test patients, with their consent, only when medically necessary.
The new policy also halted automatic reporting of positive test
results. Hospitals have a responsibility to address the testing
problems, she said. “The hospitals are at fault. The clinicians are
at fault. Our policies are at fault.”

The risks from giving medications to birthing patients and then
testing them for illicit substances have been well documented. A 2022
study [[link removed]] by researchers at
Massachusetts General Hospital found that 91% of women given fentanyl
in their epidurals tested positive for it afterward. Other studies
[[link removed]] have found that mothers
can quickly pass these medications onto their babies. A baby’s
positive drug test “cannot and should not be used to identify
fentanyl drug abuse in mothers,” said Athena Petrides, the lead
researcher of one of the studies at Brigham and Women’s Hospital in
Boston.

Despite these warnings, hospitals often lack policies requiring
providers to review a patient’s records to see what medications they
received before reporting them to authorities. Mandatory reporting
laws protect doctors from liability for reports made “in good
faith,” even if they turn out to be wrong. And toxicologists and
doctors say many doctors lack the time and expertise needed to
adequately interpret drug test results.

“It’s not something routinely taught in medical school or even
residency,” said Dr. Tricia Wright, an OB-GYN and professor at
University of California, San Francisco Medical Center who specializes
in substance use disorders in pregnancy. “It’s all up to
individuals who make their own interpretations.” Wright helped
change the policy at her hospital, one of the country’s leading
teaching facilities, to direct doctors not to drug test patients
unless medically necessary.

While drug tests can help pediatricians determine how to treat an
infant who may experience withdrawal symptoms, many OB-GYNs say that
positive drug test results do not generally inform the mother’s
medical care, so they have little reason to dwell on them.

Instead, at many hospitals, it is social workers — responsible for
contacting child welfare agencies — who are more likely to pay
attention to drug test results. Some hospitals require social workers
to automatically file a report for any positive test, while other
facilities first perform an assessment to determine whether a parent
might be a risk to the baby.

But hospital social workers are often overworked, said Kylie Haines,
who manages a program for pregnant women with opioid use disorder at
Vanderbilt University Medical Center, one of the top maternity
teaching hospitals in the nation. Social workers generally have even
less training than doctors on drug testing, and little authority to
question test results, she said. Investigating the cause of a positive
drug test is not considered part of their job.

“We’re not medical providers,” said Haines, a licensed social
worker herself. “We can’t interpret drug screens.”

The timing of the tests can also make it tricky to interpret them. In
theory, the best time to take a urine sample for drug testing is when
a patient arrives at the hospital, before receiving medications. But
it is common for hospitals to test urine samples taken from a birthing
patient’s catheter bag, or to request a urine sample after
medications have already been administered, providers said.

Newborn drug tests can add another layer of complexity. While urine
tests can detect potential drug use over a period of days, testing the
baby’s meconium can uncover illicit substances going back months.
Meconium tests are widely considered to be the gold standard for
newborn drug testing because they can indicate potential drug use
earlier in pregnancy, a possible sign of addiction.

But in some cases, there is no way to tell whether a baby’s positive
test was caused by a medication the hospital dispensed or a substance
the mother used earlier. Nor do such tests tell providers how much or
how frequently a person may have used drugs — for example, if a
patient used substances in the past but stopped when she realized she
was pregnant. “You actually don’t know,” said Schiff. “Which
is kind of a mess.”

Medications such as morphine or fentanyl have led some patients to get
flagged as opioid users. Ephedrine and phenylephrine, medications for
low blood pressure that are commonly prescribed during C-sections,
have caused false positives for meth. The Marshall Project also found
that women were questioned over positive drug tests after hospitals
gave them sedatives such as benzodiazepines or barbiturates.

When women are flagged by a positive drug test result, other aspects
of their lives can quickly come under suspicion. Medical conditions or
birth complications that can be associated with addiction — such as
high blood pressure, a placenta that separates before birth or a
premature birth — may mistakenly be viewed as further evidence that
a pregnant patient used drugs. Through the lens of a positive drug
test, even something as innocuous as missing some prenatal
appointments becomes potential evidence that a mother is a risk to her
baby. And patients who had traumatic experiences giving birth may
suddenly find themselves under threat.

In 2023, Salinas was still in a haze of grief after delivering her
stillborn baby when she learned she would be reported to child welfare
authorities. Salinas had no idea the hospital had given her the
benzodiazepine for which she tested positive and denied using the
medication. She had also tested positive for Delta-9, a legal
hemp-derived product, which she said she had bought at the grocery
store. But soon, Salinas found herself under a monthslong
investigation, trying to fight off paralyzing depression while
processing her grief and caring for her other children.

[A photo illustration shows a tearsheet of a medical record stating
that a patient was administered midazolam. ]

Amairani Salinas tested positive for midazolam, the same medication
her hospital record shows she had received there hours earlier.   
  Photo illustration by The Marshall Project. Courtesy of Amairani
Salinas

“I still have three live children. They still need to eat. They
still need to get up for school. They still need their mom,” Salinas
recalled thinking as she was being questioned.

Officials closed the case about four months later as
“unsubstantiated.” But it wasn’t until a year later that Salinas
read through her medical records with a Marshall Project reporter and
discovered the cause of the positive test.

Marissa Gonzales, a spokesperson for the Texas Department of Family
and Protective Services, declined to discuss Salinas’ case, citing
confidentiality laws.

Salinas said she wondered why child welfare workers weren’t spending
their time investigating allegations of actual child abuse. “Why are
you giving your attention to this person who’s a good mom, who
hasn’t done anything, instead of a child who may actually be in
danger?”

In recent years, studies have found that drug tests aren't necessarily
the best way to identify someone with a substance use problem — a
simple screening questionnaire is also effective. Leading medical
groups advise hospitals to use questionnaires instead of universal
drug tests. But hospital drug testing — and reporting — of labor
and delivery patients remains ubiquitous.

In at least 27 states, hospitals are required by law to alert child
welfare agencies about a positive test or a potential exposure to the
baby. But not a single state requires hospitals to confirm test
results before reporting them. Hospitals routinely contact authorities
without ordering confirmation tests or waiting to receive the results.

Not every state explicitly requires reporting a positive test, but
many hospitals do so anyway. In 2022 alone, more than 35,000 babies
were reported to child welfare authorities as substance-exposed,
federal data shows, with no guarantee that the underlying test results
were accurate.

“The system is primed for a report,” said Dr. Mishka Terplan, an
OB-GYN in Maryland and a leading researcher on substance use disorders
during pregnancy. “To slow it down, or to stop it, takes effort.”

The consequences of a faulty drug test can be especially severe for
people with histories of addiction, who are less likely to be believed
when they protest that the positive test was caused by a hospital
medication. In this environment, a patient’s word is often pitted
against a single drug test, and it’s up to an individual doctor,
nurse or social worker to decide whether to ferret out the truth.

Lisa Grisham, a nurse in Arizona, recalled the case of a patient in
recovery for opioid use disorder who tested positive for fentanyl. The
woman insisted that another nurse had given her the medication during
labor, even though it was not listed in her hospital records. Grisham,
the director of a hospital program for substance-exposed infants at
Banner University Medical Center in Tucson, took it upon herself to
investigate and eventually tracked down the nurse, who confirmed the
patient’s explanation.

“It makes me sick to think of all the moms that have come through
and said they don't use fentanyl and we don’t believe them,”
Grisham said.

Villanueva was just 18, newly married and still working on her GED
when she gave birth to her first baby. As a child, she had been taught
to be honest with medical providers. So during hospital admission, she
told a nurse that she had briefly experimented with drugs such as
marijuana and acid when she was 15 years old. She hadn’t used drugs
since, she said.

When she was admitted, Villanueva took a drug test that came back
negative for any illicit substances — the same result as the two
drug tests from her prenatal appointments. Then she received medicine
to induce labor, and her contractions began. They were so painful,
Villanueva recalled, that she was relieved when a nurse told her she
was giving her morphine.

The day after Villanueva gave birth, an investigator with the Indiana
Department of Child Services arrived. The hospital had informed the
agency about Villanueva’s “history of drug use,” according to
medical records. Without her knowledge, Villanueva said, the hospital
also sent her daughter’s meconium for testing, which found the
morphine.

Villanueva was certain that her hospital records would prove she had
received morphine, and she was right. The drug test results even
stated, “Drugs administered during labor and delivery may be
detected in meconium.”

But even after the investigator received the hospital records,
Villanueva said, the agency required her to submit to more drug tests
and allow inspections of her home. Finally, after several weeks, the
agency closed the case, Villanueva recalled.

Only after the investigators were out of her life did Villanueva feel
that she could finally revel in her baby’s birth and allow herself
to be happy.

“I couldn’t even really enjoy properly my child being born,” she
recalled. “Until after the fact, when they were gone.”

_Shoshana Walter
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staff writer for The Marshall Project, working on investigations._

_Additional reporting by Weihua Li
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Rodriguez Calderón
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Carter
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Odom_

_This article was published in partnership with Reveal News
[[link removed]], Mother Jones
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* motherhood
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* drug tests
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* babies
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* hospitals
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