Perinatal Substance Use and the Documentation of Stigmatizing Language in Clinical Notes

Background: Patients with substance use disorders (SUD) experience bias from clinicians when receiving pregnancy care. Stigmatizing language documented in electronic health records is a marker of clinician bias and it can reinforce inequitable care practices. Objective: The purpose of this study was to examine the associations between substance use and stigmatizing language documented in clinical notes from the birth hospitalization. Methods: This was a cross-sectional study of electronic health record data from patients 20 weeks gestation admitted to labor and birth at two urban hospitals between 2017-2019 (N=19,094). We identified patients with SUD through ICD-10 codes and natural language processing (NLP)-based keyword searches. We employed an NLP algorithm to identify four categories of stigmatizing language in clinical narratives. We conducted multivariable logistic regression and calculated adjusted odds ratios and 95% confidence intervals for each stigmatizing language category. Results: Approximately 1.5% of patients had a documented SUD. Patients with SUD had higher odds of any stigmatizing language compared to patients without SUD. Patients with SUD also had higher odds of language representing marginalized language/identities and difficult patient categories. There were no significant differences in the unilateral/authoritarian language category between patients with and without SUD. Discussion: Patients with SUD were more likely to have stigmatizing language documented by clinicians during labor and birth. Findings underscore the need for clinician training on person-centered language, and the implementation of abolitionist approaches to reduce the stigmatization of patients with SUD.