"Instead of just a drive by": Clinician and birthing person perspectives on consent for toxicology testing during pregnancy.

Introduction: Although state, federal, and professional guidelines stipulate the need for informed consent for toxicology testing during pregnancy, consent is often inadequately obtained. The objective of this study was to explore birthing person and obstetric clinician experiences with consent for toxicology testing during pregnancy. Methods: Semi-structured qualitative interviews were conducted with 25 obstetric clinicians and 15 birthing persons who had toxicology testing performed during their delivery hospitalization. Interviews assessed clinical decision-making around toxicology testing, perceptions of testing utility, as well as consent and communication practices. Transcripts were then double-coded and analyzed using thematic analysis. Results: Three primary themes were identified. First, information disclosure during consent conversations for toxicology testing deviated from normative standards for informed consent in obstetrics. Second, barriers to adequate information provision included clinicians' limited knowledge of and discomfort with the test's risks, the infrequency of testing in clinical practice, and birthing peoples' discomfort asking questions within the physician-patient power hierarchy. Third, birthing people felt unable to decline testing due to fears of child protective services involvement and perceived pressure from clinicians to undergo testing. Conclusion: While both birthing people and clinicians identified challenges related to appropriate information provision during consent conversations, birthing people critically underscored a lack of voluntariness related to their fears of child protective services and experiences of pressure from clinicians to consent to testing. As a result, consent practices failed to adhere to normative standards for informed consent within obstetrics, which undermined patient autonomy.