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Context: Michigan is among 25 states that mandate health care professionals (HCPs) to report newborn drug exposure to Child Protective Services (CPS) under the US Child Abuse and Prevention Treatment Act. HCPs are more likely to report Black families to CPS for prenatal drug use than their White peers despite similar rates of drug use.1 2 CPS reports can facilitate parental drug treatment but can also lead to criminalization of substance use in pregnancy and contribute to health inequity for Black families. Objective: To examine factors associated with HCP decisions to obtain newborn drug testing (NDT) using an anti-racist and justice-informed approach. Study design and analysis: A retrospective cohort study. Setting and dataset: EHR data set from a large academic hospital in the Midwest US. Population studied: Mother-baby dyads receiving prenatal and birth care from 2014-2020. Intervention/Instrument: n/a. Outcome measures: The primary outcome was placement of an NDT order. We collected demographic data including age, race and ethnicity, marital status, insurance type, and neighborhood disadvantage score. Results: Data were available for 26,366 dyads and NDT orders were placed for 1,237 newborns. The rate of NDT ordering was 11.3% (n=359) for Black participants, the referent group for analysis. Unadjusted odds of NDT were lower for non-Hispanic White (OR 0.37, CI 0.32-0.42) than Black participants. Adjusted odds were lower for non-Hispanic White (OR 0.72, 0.57-0.91), non-Hispanic Other race (OR 0.5, CI 0.32-0.79), and Hispanic race (OR 0.4, 1.06). Of the 88% (1,090/1,237) NDTs with test results, 56% were positive for tetrahydrocannabinol, 18% for opioids, and <6% for amphetamine, cocaine, methamphetamine, and phencyclidine. There was no difference in the rate of positive drug tests across racial groups. Conclusions: Black families experience more newborn drug testing despite similar rates of positive drug tests. Interventions focused on racial inequity are urgently needed to reduce bias, overtesting, and subsequent criminalization and CPS investigation of Black birthing people. [ABSTRACT FROM AUTHOR]