Evaluating a Multi-pronged Initiative to Decrease Racial and Ethnic Inequities in the Identification of Maternal Substance Use: Successes, Challenges, and Lessons Learned

Abstract Racial and ethnic disparities in prenatal substance use screening and subsequent referrals to child protective services (CPS) persist, despite similar rates of substance use across populations. The Basic Obstetric Addiction Screen (BOAS) Initiative was implemented in 2021 at two birthing facilities within a large medical system to address these inequities through a standardized, non-biased screening process. This study evaluated the initiative using a RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, analyzing electronic health record data, social work referrals, and qualitative feedback from healthcare providers and patients. Between January 2022 and November 2023, 99% of 21,342 pregnant patients were screened, with 0.45% screening positive. Among those screening positive, 71.9% were referred to social work. Qualitative analysis revealed six key themes: honesty requires fostering trust and addressing fear; BOAS implementation improved screening inequities, but they are still perceived to exist; BOAS is acceptable, EHR integration and a clinical champion facilitated its adoption; opinions vary on the best way to identify substance use; implementation was successful, but concerns exist; and many factors influence sustainability. Findings indicate that the BOAS Initiative is well-received by both patients and clinicians, with near-universal screening compliance and successful integration across both participating birthing facilities. The initiative demonstrated strong potential to reduce biased toxicology testing and unnecessary child CPS referrals.