Arrests of and forced interventions on pregnant women in the United States, 1973-2005: implications for women's legal status and public health

Pregnant and Postpartum People with Substance Use Disorders: Understanding the Obstetrical Care Provider' s Roles and Responsibilities

Peripartum individuals with substance misuse are a high-risk population that challenge clinicians and child welfare specialists alike. Federal legislation was updated in 2016 with the Comprehensive Addiction Recovery Act (CARA) to improve care via expanded screening and treatment referrals for peripartum women with substance misuse. The implementation of CARA requires providers to update their policies and procedures in order to meet the requirements outlined by this legislation. As this is a new process, this paper reviews the new administrative reporting and safety planning requirements relevant to obstetrical care providers and provides examples of best practice for different clinical scenarios. Given the variable state laws, confidentiality concerns, influence of stigma and health inequities on substance use treatment, and the fragmented healthcare system, implementation of CARA will challenge obstetric, pediatric, and mental health care providers along with child welfare services. All entities involved must work together to create effective and efficient protocols to address the CARA requirements. Health systems must also evaluate and update methods and interventions to assure that policies improve family stability and well-being.

Developments in Nursing Practice to Address Substance Use in the Perinatal Period

Since 1972, the year of the inaugural issue of Journal of Obstetric, Gynecologic, & Neonatal Nursing, substance use during pregnancy has remained a public health concern in the United States. This concern is currently exacerbated by factors such as the opioid and stimulant use crisis and widening health and social inequities for many women and families. The purposes of this historical commentary are to describe trends in the perception of women with substance use disorder and their infants and related sociolegal implications and to trace the evolution of related nursing practice and research during the past 50 years. We provide recommendations and priorities for practice and research, including further integration of support for the mother-infant dyad, cross-sectoral collaborations, and equity-oriented practices and policies.

Mothers Who Use Drugs: Closing the Gaps in Harm Reduction Response Amidst the Dual Epidemics of Overdose and Violence in a Canadian Urban Setting

Objectives. To identify key gaps in overdose prevention interventions for mothers who use drugs and the paradoxical impact of institutional practices that can increase overdose risk in the context of punitive drug policies and a toxic drug supply. Methods. Semistructured interviews were conducted with 40 women accessing 2 women-only, low-barrier supervised consumption sites in Greater Vancouver, British Columbia, Canada, between 2017 and 2019. Our analysis drew on intersectional understandings of structural, everyday, and symbolic violence. Results. Participants' substance use and overdose risk (e.g., injecting alone) was shaped by fear of institutional and partner scrutiny and loss (or feared loss) of child custody or reunification. Findings indicate that punitive policies and institutional practices that frame women who use drugs as unfit parents continue to negatively shape the lives of women, most significantly among Indigenous participants. Conclusions. Nonpunitive policies, including access to safe, nontoxic drug supplies, are critical first steps to decreasing women's overdose risk alongside gender-specific and culturally informed harm-reduction responses, including community-based, peer-led initiatives to maintain parent-child relationships. (Am J Public Health. 2022;112(S2):S191-S198. https://doi.org/10.2105/AJPH.2022.306776).

Social Construction of Target Populations: A Theoretical Framework for Understanding Policy Approaches to Perinatal Illicit Substance Screening

Perinatal illicit substance use is a nursing and public health issue. Current screening policies have significant consequences for birthing individuals and their families. Racial disparities exist in spite of targeted and universal screening policies and practices. Thus, new theoretical approaches are needed to investigate perinatal illicit substance use screening in hospital settings. The purpose of this analysis is to evaluate the social construction of target populations theory in the context of perinatal illicit substance use screening. Using the theoretical insights of this theory to interrogate the approaches taken by policy makers to address perinatal illicit substance use and screening provides the contextual framework needed to understand why specific policy tools were selected when designing public policy to address these issues. The analysis and evaluation of this theory was conducted using the theory description and critical reflection model.

Racial and Ethnic Differences in Urine Drug Screening on Labor and Delivery

INTRODUCTION

This study evaluates racial and ethnic differences in urine drug screening and patient consent to urine drug screening at a single tertiary care center.

METHODS

We conducted a retrospective cohort study of all deliveries at a single tertiary care center from January 1, 2015 to December 31, 2019. Medical records were queried for demographic data, performance of urine drug screening, commonly used diagnoses that prompted screening, documentation of patient consent, and result of screen. Associations between these outcomes were then assessed using Chi-square analysis and logistic regression.

RESULTS

During the study period, 685 of 9953 (6.9%) of patients had a urine drug screen performed. Non-Hispanic Black patients comprised 33.6% of patients receiving screening, but only 16.6% of the total population. Of examined indications for urine drug screening, only insufficient prenatal care and trauma differed significantly between groups. After adjusting for commonly used diagnoses prompting screening, non-Hispanic black patients were significantly more likely to have urine drug screening performed (OR 2.0, 95% CI 1.6-2.4). Non-Hispanic Black and Hispanic patients were not significantly more likely to have a positive screen result when compared to Non-Hispanic White patients. Consent to urine drug screening was poorly documented (only 11.7% of patients had documented consent). This did not differ significantly between the major racial or ethnic groups.

CONCLUSION

Non-Hispanic Black and Hispanic patients experience differences in urine drug screening during admission for delivery that cannot be solely explained by differences in incidence of diagnoses that typically trigger screening. Documentation of patient consent to urine drug screening is poor.

Justice for Incarcerated Moms Act of 2021: Reflections and recommendations

In the last five decades, the number of women behind bars in the United States has risen exponentially. It is now estimated that there are nearly 58,000 admissions of pregnant people—disproportionately women of color—to jails and prisons each year. Recognizing the urgency and consequences of mass incarceration on pregnant people, their families, and communities, House Resolution 948: Justice for Incarcerated Moms Act of 2021 was introduced to Congress as a part of the Black Maternal Health Momnibus. The Justice for Incarcerated Moms Act aims to improve health care and promote dignity for incarcerated pregnant and parenting people through an array of policies and oversight. In this article, we review and reflect on the components of this bill within their broader public health and reproductive justice contexts. We close with recommendations for policymakers and professionals committed to promoting equity and justice for pregnant and postpartum incarcerated people.

Substance Use in Pregnancy: Identifying Stigma and Improving Care

This review examines the impact of stigma on pregnant people who use substances. Stigma towards people who use drugs is pervasive and negatively impacts the care of substance-using people by characterizing addiction as a weakness and fostering beliefs that undermine the personal resources needed to access treatment and recover from addiction, including self-efficacy, help seeking and belief that they deserve care. Stigma acts on multiple levels by blaming people for having a problem and then making it difficult for them to get help, but in spite of this, most pregnant people who use substances reduce or stop using when they learn they are pregnant. Language, beliefs about gender roles, and attitudes regarding fitness for parenting are social factors that can express and perpetuate stigma while facilitating punitive rather than therapeutic approaches. Because of stigmatizing attitudes that a person who uses substances is unfit to parent, pregnant people who use substances are at heightened risk of being screened for substance use, referred to child welfare services, and having their parental rights taken away; these outcomes are even more likely for people of color. Various treatment options can successfully support recovery in substance-using pregnant populations, but treatment is underutilized in all populations including pregnant people, and more knowledge is needed on how to sustain engagement in treatment and recovery activities. To combat stigma when working with substance-using pregnant people throughout the peripartum period, caregivers should utilize a trauma-informed approach that incorporates harm reduction and motivational interviewing with a focus on building trust, enhancing self-efficacy, and strengthening the personal skills and resources needed to optimize health of the parent-baby dyad.

Caring for Parturients with Substance Use Disorders

Parturients with substance use disorder require expertise to manage the complexity of intoxication, withdrawal, and chronic use as well as ensure adequate analgesia throughout labor. Opioid use disorder in pregnancy has increased more than 4-fold in the past decade, with a 50-fold geographic variability that now dwarfs other substance use in this population. Understanding not only the medical but also the public health and criminal justice implications of substance use disorder is essential to providing optimal care to this at-risk population.

Datafied Pregnancies: Health Information Technologies and Reproductive Governance in Turkey

Since the early 2000s, Turkey has been going through a dynamic period of health reforms where the global push toward health statistics has converged with the state's pronatalist concerns over declining birth rates. Reproductive behaviors are now monitored via health information technologies such as centralized databases. The World Health Organization and the Turkish Ministry of Health celebrate these technologies as essential steps toward evidence-based health care delivery. The everyday realities of these technologies, however, are more complicated, especially for nurses and their patients. Drawing on ethnographic fieldwork in state-run health clinics in Istanbul, this article demonstrates how these data-driven health technologies build on nurses' gendered care labor and increase surveillance on urban poor and/or ethnoracially minoritized communities. In doing so, I argue that the datafication of reproduction operates as a particular mode of "reproductive governance" (Morgan and Roberts 2012) that reflects and reproduces existing social hierarchies and inequalities.

Health care and social justice implications of incarceration for pregnant people who use drugs

The experiences of and care for pregnant, incarcerated people with substance use disorders represent a convergence of numerous clinical, historical, racialized, legal, and gendered factors. Understanding how these forces shape how they became enmeshed in the criminal legal system as well as the context of the care they do or do not receive while in custody is essential for promoting equitable maternal health care. In this review, we describe the prevalence of SUD among pregnant people behind bars, the health care landscape of incarceration, access to treatment for opioid use disorder for incarcerated pregnant and postpartum people, and nuances of providing such treatment in an inherently coercive setting. Throughout, we highlight the ways that the child welfare system and mass incarceration in the U.S. have had a unique and discriminatory impact on pregnant and parenting people, and have done so in distinctly racialized ways. Situating the clinical care of incarcerated pregnant people who use drugs in this context sheds light on fundamental social justice and health care intersections.

"They went down that road, and they get it": A qualitative study of peer support worker roles within perinatal substance use programs

BACKGROUND

Perinatal substance use programs employ multidisciplinary teams to support women who use drugs through pregnancies and parenting, with some programs expanding to include peer support workers with lived experience of parenting and substance use. Research has shown peer support to enhance care in substance use treatment; however, little research exists that examines this model of support within perinatal substance use programs. We explore the current and potential role of peer support workers within perinatal substance use programs, from the perspectives of mothers accessing these programs.

METHODS

We conducted focus groups with 20 mothers enrolled in three perinatal substance use programs serving the greater Vancouver area, including two community-based programs that employed peer workers and an acute care maternity ward that did not. We recorded focus groups, had them professionally transcribed, and analyzed them thematically.

RESULTS

Participants characterized peer support workers as extending and complementing informal care practices already occurring within programs, including mother-to-mother support with breastfeeding, childcare, and system navigation. Integrating peer workers shifted care relations and practices in ways that participants found beneficial. Participants emphasized how support workers with similar social locations and life experiences-beyond just their substance use-helped to foster trust and safety for mothers in the program. Indigenous mothers discussed the importance of having Indigenous support workers whose practice is grounded in their cultures and experiences under colonization. Participants ascribed an aspirational status to peer support workers, conveying that it was motivational to see other mothers working in the program, and described the role as a means of maintaining connection and community. However, some expressed concerns about managing professional-personal boundaries and being emotionally "triggered" by the work.

CONCLUSION

This study evidences benefits of employing peer support workers within perinatal substance use programs, while also indicating the need for organizational processes to ensure that peer staff are integrated equitably and supported adequately.

Reproductive Rights and Women's Mental Health: Essential Information for the Obstetrician-Gynecologist

Reproductive health care is crucial to women's well-being and that of their families. State and federal laws restricting access to contraception and abortion in the United States are proliferating. Often the given rationales for these laws state or imply that access to contraception and abortion promote promiscuity, and/or that abortion is medically dangerous and causes a variety of adverse obstetric, medical, and psychological sequelae. These rationales lack scientific foundation. This article provides the evidence for the safety of abortion, for both women and girls, and encourages readers to advocate against restrictions.

Barriers and Motivators to Opioid Treatment Among Suburban Women Who Are Pregnant and Mothers in Caregiver Roles

Women of childbearing age who misuse opioids are a particularly vulnerable population, and their barriers to treatment are unique because of their caregiver roles. Research on treatment for opioid use generally draws from urban and rural areas. This study fills a gap in research that focuses on barriers and motivators to opioid treatment in suburban areas. The aim of this study was to give voice to suburban pregnant women and mothers caring for children while using opioids. Ethnographic methods were used for recruitment, and 58 in-depth interviews were analyzed using a modified grounded theory approach. Barriers to medication-assisted treatment (MAT) included stigma, staff attitudes, and perceptions the women had about MAT treatment. Barriers associated with all types of treatment included structural factors and access difficulties. Relationships with partners, friends, family, and providers could be barriers as well as motivators, depending on the social context of the women’s situation. Our findings suggest increasing treatment-seeking motivators for mothers and pregnant women by identifying lack of resources, more empathetic consideration of social environments, and implementing structural changes to overcome barriers. Findings provide a contemporary understanding of how suburban landscapes affect mothers’ treatment-seeking for opioid dependence and suggest the need for more focus on emotional and structural resources rather than strict surveillance of women with opioid dependence who are pregnant or caring for children.

Women of Childbearing Age and Fetal Alcohol Spectrum Disorder Prevention: A Position Paper

It is the position of the International Nurses Society on Addictions that all nurses, in all settings, should be prepared to provide care to patients with alcohol use problems, especially for women of childbearing age.

Circumstances of overdose among suburban women who use opioids: Extending an urban analysis informed by drug, set, and setting

BACKGROUND

Opioid overdoses are primarily discussed by the pharmacological properties of the drugs used. Research shows that other factors such as the social/physical environment and the mental/emotional states can have an impact on overdose events. Ataiants and colleagues (2020) used Zinberg's "drug, set, and setting" framework to identify circumstances surrounding overdose experiences of street-involved women in Philadelphia. The aim of this paper is to extend their analysis to a diverse sample of suburban women who experienced overdoses.

METHODS

The mixed-methods design consisted of ethnographic fieldwork, in-depth interviews, and brief surveys with 32 suburban women who use opioids. Inductive theoretical reasoning and constant comparative analysis facilitated themes emerging within the "drug, set, and setting" framework.

RESULTS

Eighteen out of 32 women identified "drug" as the primary factor involved in their overdose events. Major themes were an inability to identify the synthetic opioid fentanyl, lack of knowledge or control over how much to use, poly-substance use, and an insufficient understanding of risks. Eleven out of 32 women linked "set" to their overdose experiences. Themes included emotional trauma, such as death of a child, child custody issues, and mental health conditions, such as depression. Six out of 32 women associated "setting" with one of their overdose experiences. Themes were related to being with friends or partners that used, and having recently been released from treatment or incarceration.

CONCLUSION

Findings show similar themes found among an urban sample, adding insight on the need for effective overdose interventions targeted for suburban populations. The opioid crisis is not confined to the cities, and neither should services aimed at addressing opioid overdose. The knowledge provided here can help policy makers support female-centered harm reduction services not only in urban areas but also in the suburbs.

Perspectives on self-managed abortion among providers in hospitals along the Texas-Mexico border

BACKGROUND

Following self-managed abortion (SMA), or a pregnancy termination attempt outside of the formal health system, some patients may seek care in an emergency department. Information about provider experiences treating these patients in hospital settings on the Texas-Mexico border is lacking.

METHODS

The study team conducted semi-structured interviews with physicians, advanced practice clinicians, and nurses who had experience with patients presenting with early pregnancy complications in emergency and/or labor and delivery departments in five hospitals near the Texas-Mexico border. Interview questions focused on respondents' roles at the hospital, knowledge of abortion services and laws, perspectives on SMA trends, experiences treating patients presenting after SMA, and potential gaps in training related to abortion. Researchers conducted interviews in person between October 2017 and January 2018, and analyzed transcripts using a thematic analysis approach.

RESULTS

Most of the 54 participants interviewed said that the care provided to SMA patients was, and should be, the same as for patients presenting after miscarriage. The majority had treated a patient they suspected or confirmed had attempted SMA; typically, these cases required only expectant management and confirmation of pregnancy termination, or treatment for incomplete abortion. In rare cases, further clinical intervention was required. Many providers lacked clinical and legal knowledge about abortion, including local resources available.

CONCLUSIONS

Treatment provided to SMA patients is similar to that provided to patients presenting after early pregnancy loss. Lack of provider knowledge about abortion and SMA, despite their involvement with SMA patients, highlights a need for improved training.

Non-pharmacological care for opioid withdrawal in newborns

BACKGROUND

The prevalence of substance use, both prescribed and non-prescribed, is increasing in many areas of the world. Substance use by women of childbearing age contributes to increasing rates of neonatal abstinence syndrome (NAS). Neonatal opioid withdrawal syndrome (NOWS) is a newer term describing the subset of NAS related to opioid exposure. Non-pharmacological care is the first-line treatment for substance withdrawal in newborns. Despite the widespread use of non-pharmacological care to mitigate symptoms of NAS, there is not an established definition of, and standard for, non-pharmacological care practices in this population. Evaluation of safety and efficacy of non-pharmacological practices could provide clear guidance for clinical practice.

OBJECTIVES

To evaluate the safety and efficacy of non-pharmacological treatment of infants at risk for, or having symptoms consistent with, opioid withdrawal on the length of hospitalization and use of pharmacological treatment for symptom management. Comparison 1: in infants at risk for, or having early symptoms consistent with, opioid withdrawal, does non-pharmacological treatment reduce the length of hospitalization and use of pharmacological treatment? Comparison 2: in infants receiving pharmacological treatment for symptoms consistent with opioid withdrawal, does concurrent non-pharmacological treatment reduce duration of pharmacological treatment, maximum and cumulative doses of opioid medication, and length of hospitalization?

SEARCH METHODS

We used the standard search strategy of Cochrane Neonatal to search CENTRAL (2019, Issue 10); Ovid MEDLINE; and CINAHL on 11 October 2019. We also searched clinical trials databases and the reference lists of retrieved articles for randomized controlled trials (RCTs), quasi-RCTs, and cluster trials.

SELECTION CRITERIA

We included trials comparing single or bundled non-pharmacological interventions to no non-pharmacological treatment or different single or bundled non-pharmacological interventions. We assessed non-pharmacological interventions independently and in combination based on sufficient similarity in population, intervention, and comparison groups studied. We categorized non-pharmacological interventions as: modifying environmental stimulation, feeding practices, and support of the mother-infant dyad. We presented non-randomized studies identified in the search process narratively.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used the GRADE approach to assess the certainty of evidence. Primary outcomes in infants at risk for, or having early symptoms consistent with, opioid withdrawal included length of hospitalization and pharmacological treatment with one or more doses of opioid or sedative medication. Primary outcomes in infants receiving opioid treatment for symptoms consistent with opioid withdrawal included length of hospitalization, length of pharmacological treatment with opioid or sedative medication, and maximum and cumulative doses of opioid medication.

MAIN RESULTS

We identified six RCTs (353 infants) in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated between 1975 and 2018. We identified no RCTs in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. The certainty of evidence for all outcomes was very low to low. We also identified and excluded 34 non-randomized studies published between 2005 and 2018, including 29 in which infants at risk for, or having symptoms consistent with, opioid withdrawal participated and five in which infants receiving opioid treatment for symptoms consistent with opioid withdrawal participated. We identified seven preregistered interventional clinical trials that may qualify for inclusion at review update when complete. Of the six RCTs, four studies assessed modifying environmental stimulation in the form of a mechanical rocking bed, prone positioning, non-oscillating waterbed, or a low-stimulation nursery; one study assessed feeding practices (comparing 24 kcal/oz to 20 kcal/oz formula); and one study assessed support of the maternal-infant dyad (tailored breastfeeding support). There was no evidence of a difference in length of hospitalization in the one study that assessed modifying environmental stimulation (mean difference [MD) -1 day, 95% confidence interval [CI) -2.82 to 0.82; 30 infants; very low-certainty evidence) and the one study of support of the maternal-infant dyad (MD -8.9 days, 95% CI -19.84 to 2.04; 14 infants; very low-certainty evidence). No studies of feeding practices evaluated the length of hospitalization. There was no evidence of a difference in use of pharmacological treatment in three studies of modifying environmental stimulation (typical risk ratio [RR) 1.00, 95% CI 0.86 to 1.16; 92 infants; low-certainty evidence), one study of feeding practices (RR 0.92, 95% CI 0.63 to 1.33; 49 infants; very low-certainty evidence), and one study of support of the maternal-infant dyad (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). Reported secondary outcomes included neonatal intensive care unit (NICU) admission, days to regain birth weight, and weight nadir. One study of support of the maternal-infant dyad reported NICU admission (RR 0.50, 95% CI 0.13 to 1.90; 14 infants; very low-certainty evidence). One study of feeding practices reported days to regain birth weight (MD 1.10 days, 95% CI 2.76 to 0.56; 46 infants; very low-certainty evidence). One study that assessed modifying environmental stimulation reported weight nadir (MD -0.28, 95% CI -1.15 to 0.59; 194 infants; very low-certainty evidence) and one study of feeding practices reported weight nadir (MD -0.8, 95% CI -2.24 to 0.64; 46 infants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

We are uncertain whether non-pharmacological care for opioid withdrawal in newborns affects important clinical outcomes including length of hospitalization and use of pharmacological treatment based on the six included studies. The outcomes identified for this review were of very low- to low-certainty evidence. Combined analysis was limited by heterogeneity in study design and intervention definitions as well as the number of studies. Many prespecified outcomes were not reported. Although caregivers are encouraged by experts to optimize non-pharmacological care for opioid withdrawal in newborns prior to initiating pharmacological care, we do not have sufficient evidence to inform specific clinical practices. Larger well-designed studies are needed to determine the effect of non-pharmacological care for opioid withdrawal in newborns.

Exploring the conceptualisation and study of freebirthing as a historical and social phenomenon: a meta-narrative review of diverse research traditions

Freebirthing is a clandestine practice whereby women intentionally give birth without healthcare professionals (HCPs) present in countries where there are medical facilities available to assist them. Women who make this decision are frequently subjected to stigma and condemnation, yet research on the phenomenon suggests that women's motivations are often complex. The aim of this review was to explore how freebirth has been conceptualised over time in the English-language academic and grey literature. The meta-narrative methodology employed enables a phenomenon to be understood within and between differing research traditions, as well as against its social and historical context. Our research uncovered nine research traditions (nursing, autobiographical text with birthing philosophy, midwifery, activism, medicine, sociology, law and ethics, pregnancy and birth advice, and anthropology) originating from eight countries and spanning the years 1957-2018. Most of the texts were written by women, with the majority being non-empirical. Empirical studies on freebirth were usually qualitative, although there were a small number of quantitative medical and midwifery studies; these texts often focused on women's motivations and highlighted a range of reasons as to why a woman would decide to give birth without HCPs present. Motivations frequently related to women's previous negative maternity experiences and the type of maternity care available, for example medicalised and hospital-based. The use of the meta-narrative methodology allowed the origins of freebirth in 1950s America to be traced to present-day empirical studies of the phenomenon. This highlighted how the subject and the publication of literature relating to freebirth are embedded within their social and historical contexts. From its very inception, freebirth aligns with the medicalisation of childbirth, the position of women in society, the provision of maternity care and the way in which women experience maternity services.

Care for Incarcerated Pregnant People With Opioid Use Disorder: Equity and Justice Implications

With the simultaneous rise in maternal opioid use disorder (OUD) and the incarceration of pregnant people in the United States, we must ensure that prisons and jails adequately address the health and well-being of incarcerated pregnant people with OUD. Despite long-established, clear, and evidence-based recommendations regarding the treatment of OUD during pregnancy, incarcerated pregnant people with OUD do not consistently receive medication treatment and are instead forced into opioid withdrawal. This inadequate care raises multiple concerns, including issues of justice and equity, considerations regarding the legal and ethical obligations of the provision of health care, and violations of the medical and legal rights of incarcerated people. We offer recommendations for improving care for this often-ignored group.

Opioid use disorder incidence and treatment among incarcerated pregnant women in the United States: results from a national surveillance study

BACKGROUND AND AIMS

The established standard care in pregnancy is medication for opioid use disorder (MOUD); however, many institutions of incarceration do not have MOUD available. We aimed to describe the number of incarcerated pregnant women with opioid use disorder (OUD) in the United States and jails' and prisons' MOUD in pregnancy policies.

DESIGN

Epidemiological surveillance study of 6 months of outcomes of pregnant, incarcerated women with OUD and cross-sectional survey of institutional policies.

SETTING

United States.

PARTICIPANTS

Twenty-two state prison systems and six county jails.

MEASUREMENTS

The number of pregnant women with OUD admitted and treated with methadone, buprenorphine or withdrawal; policies on provision of MOUD and withdrawal in pregnancy.

FINDINGS

Twenty-six per cent of pregnant women admitted to prisons and 14% to jails had OUD. One-third were managed through withdrawal. The majority who were prescribed MOUD were on methadone (78%, prisons; 81%, jails), not buprenorphine. While most sites (n = 18 prisons, n = four jails) continued pre-incarceration MOUD in pregnancy, very few initiated in custody (n = four prisons; n = two jails). Two-thirds of prisons and three-quarters of jails providing MOUD in pregnancy discontinued it postpartum.

CONCLUSIONS

In this sample of US prisons and jails, one-third required pregnant women with opioid use disorder to go through withdrawal, contrary to medical guidelines. More women were prescribed methadone than buprenorphine, despite the fewer regulatory barriers on prescribing buprenorphine. Most sites stopped medication for opioid use disorder postpartum, signaling prioritization of the fetus, not the mother. Pregnant incarcerated women with opioid use disorder in the United States frequently appear to be denied essential medications and receive substandard medical care.

Advancing Reproductive Justice to Close the Health Gap: A Call to Action for Social Work

Reproductive justice is an intersectional social movement, theory, and praxis well aligned with social work's mission and values. Yet, advancing reproductive justice-the right to have children, to not have children, to parent with safety and dignity, and to sexual and bodily autonomy-has not been a signature area of scholarship and practice for the field. This article argues that it is critical for social work to advance reproductive justice to truly achieve the grand challenge of closing the health gap. The article starts by discussing the history and tenets of reproductive justice and how it overlaps with social work ethics. The authors then highlight some of the ways by which social workers have been disruptors of and complicit in the oppression of individuals, families, and communities with regard to their reproductive rights and outcomes. The article concludes with a call to action and recommendations for social work to foreground reproductive justice in research, practice, and education efforts by centering marginalized voices while reimagining the field's pursuit of health equity.

Artificial Wombs and the Ectogenesis Conversation: A Misplaced Focus? Technology, Abortion, and Reproductive Freedom

Bioethics scholarship considering the possibility of gestating an embryo to full term in an artificial womb (ectogenesis) often overstates the capacities of current technologies and underestimates the barriers to the development of full ectogenesis. Moreover, this debate causes harm by (1) neglecting more immediate problems in the development of artificial wombs, (2) treating abortion as a “problem with a technological solution,” bolstering anti-abortion rhetoric, and (3) presuming the stability of women’s reproductive rights. The ectogenesis conversation must consider anticipated uses of the technology (neonatal intensive care) and acknowledge the immediate context (recognizing abortion as essential healthcare and existing reproductive inequities).

Ferguson v. City of Charleston Redux: Motivated Reasoning and Coercive Interventions in Pregnancy

Criminalization of perinatal substance use disorder and other coercive interventions in pregnancy (such as forced cesarean delivery or involuntary hospitalization for bed rest) directly affect the well-being of children and their families and, potentially, of all women of reproductive capacity. Untenable legal and policy approaches that occasion such incursions not only persist but affect a growing number of women. They are antithetical to healthy pregnancies, healthy children, and healthy families; they have the potential to reduce prenatal care seeking, divert attention and resources away from critical mental health and maternal and child support services, and epigenetically affect maternal and infant bonding. Punitive and coercive interventions contravene long-established guidance by professional associations that advocate for public health approaches and ethical frameworks to guide practice. Harmful policies persist because of motivated reasoning by clinicians, members of the judiciary, and ill-informed legislators who rely on personal experience and anecdote rather than evidence to fashion policy. Compounding the problem are inadequate substance use treatment resources and professional associations that choose not to hold their members accountable for violating their ethical obligations to their patients. Pediatricians must advocate for the cessation of coercive interventions within their institutions and their larger communities. All health care professionals should collaborate at the local, state, and national level to provide policymakers and legislators with data emphasizing the negative effects of punitive and coercive policies aimed at pregnant women and their children.

Imprisoning Pregnant and Parenting Women: A Focus on Social Justice, Equal Rights, and Equality

The mass incarceration of pregnant and parenting women is a serious problem in the United States. African American women and other women of color are most burdened by mass incarceration. This article outlines the problems with health care delivery in correctional facilities. It is argued that correctional facilities are not the place for pregnant and parenting women. A policy focus is needed that takes a public health approach. There are promising alternative policies that integrate a public health approach, improve treatment outcomes for women, and provide an alternative to incarceration. This problem is discussed through the lens of the Grand Challenges for Social Work. Alternative policies and programs are recommended that align with a public health approach and directly target the pathways for imprisonment. This issue requires a call for policy action to challenge the inequality and social justices inherent in this problem. The grand challenges offer a blueprint in which to develop effective policy approaches.

Reviewing the womb

Throughout most of human history women have been defined by their biological role in reproduction, seen first and foremost as gestators, which has led to the reproductive system being subjected to outside interference. The womb was perceived as dangerous and an object which husbands, doctors and the state had a legitimate interest in controlling. In this article, we consider how notions of conflict surrounding the womb have endured over time. We demonstrate how concerns seemingly generated by the invisibility of reproduction and the inaccessibility of the womb have translated into similar arguments for controlling women, as technology increases the accessibility of the female body and the womb. Developments in reproductive medicine, from in vitro fertilisation (IVF) to surrogacy, have enabled women and men who would otherwise have been childless to become parents. Uterus transplants and 'artificial wombs' could provide additional alternatives to natural gestation. An era of 'womb technology' dawns. Some argue that such technology providing an alternative to 'natural' gestation could be a source of liberation for female persons because reproduction will no longer be something necessarily confined to the female body. 'Womb technology', however, also has the potential to exacerbate the labelling of the female body as a source of danger and an 'imperfect' site of gestation, thus replaying rudimentary and regressive arguments about controlling female behaviour. We argue that pernicious narratives about control, conflict and the womb must be addressed in the face of these technological developments.

Obstetric and Pediatric Provider Perspectives on Mandatory Reporting of Prenatal Substance Use

OBJECTIVE

In many states, health care providers are legally required to report pregnant women who use substances, or infants affected by prenatal substance use, to child welfare authorities. The objective of this study was to characterize obstetric and pediatric providers' perceptions of and experiences with policies requiring mandatory reporting of prenatal substance use to child welfare authorities.

METHODS

We conducted a qualitative interview study among 20 obstetric and pediatric providers to elicit participants' perspectives about and experience with current policy requiring mandatory reporting of prenatal substance use. Two investigators used an iterative content analysis approach to code interview transcripts and identify themes.

RESULTS

Study participants included obstetrician/gynecologists (N = 7), midwives (N = 5), and pediatricians (N = 8). Providers noted that implementation of the policy was often targeted and that targeted screening can be biased. Most providers reported that they incorporated information about mandatory reporting policies into patient counseling about substance use. They described not knowing what happens to patients after mandatory reporting and concerns regarding unintended consequences. Providers indicated that changes are needed to improve outcomes for patients and their families and suggested increased research into best practices, more funding for social services, and eliminating the policy altogether.

CONCLUSIONS

Health care providers expressed concern about the targeted screening process used to identify women with substance use whose children are reported to child welfare authorities. Most providers believed that mandatory reporting processes could be modified in ways that would support the health of women and children.

"Bed Bugs and Beyond": An ethnographic analysis of North America's first women-only supervised drug consumption site

BACKGROUND

Attention to how women are differentially impacted within harm reduction environments is salient amidst North America's overdose crisis. Harm reduction interventions are typically 'gender-neutral', thus failing to address the systemic and everyday racialized and gendered discrimination, stigma, and violence extending into service settings and limiting some women's access. Such dynamics highlight the significance of North America's first low-threshold supervised consumption site exclusively for women (transgender and non-binary inclusive), SisterSpace, in Vancouver, Canada. This study explores women's lived experiences of this unique harm reduction intervention.

METHODS

Ethnographic research was conducted from May 2017 to June 2018 to explore women's experiences with SisterSpace in Vancouver's Downtown Eastside, an epicenter of Canada's overdose crisis. Data include more than 100 hours of ethnographic fieldwork, including unstructured conversations with structurally vulnerable women who use illegal drugs, and in-depth interviews with 45 women recruited from this site. Data were analyzed in NVivo by drawing on deductive and inductive approaches.

FINDINGS

The setting (non-institutional), operational policies (no men; inclusive), and environment (diversity of structurally vulnerable women who use illegal drugs), constituted a space affording participants a temporary reprieve from some forms of stigma and discrimination, gendered and social violence and drug-related harms, including overdose. SisterSpace fostered a sense of safety and subjective autonomy (though structurally constrained) among those often defined as 'deviant' and 'victims', enabling knowledge-sharing of experiences through a gendered lens.

CONCLUSION

SisterSpace demonstrates the value and effectiveness of initiatives that engage with socio-structural factors beyond the often narrow focus of overdose prevention and that account for the complex social relations that constitute such initiatives. In the context of structural inequities, criminalization, and an overdose crisis, SisterSpace represents an innovative approach to harm reduction that accounts for situations of gender inequality not being met by mixed-gender services, with relevance to other settings.

Reproductive Justice Disrupted: Mass Incarceration as a Driver of Reproductive Oppression

We describe how mass incarceration directly undermines the core values of reproductive justice and how this affects incarcerated and nonincarcerated women.Mass incarceration, by its very nature, compromises and undermines bodily autonomy and the capacity for incarcerated people to make decisions about their reproductive well-being and bodies; this is done through institutionalized racism and is disproportionately done to the bodies of women of color. This violates the most basic tenets of reproductive justice-the right to have a child, not to have a child, and to parent the children you have with dignity and in safety.By undermining motherhood and safe pregnancy care, denying access to abortion and contraception, and preventing people from parenting their children at all and by doing so in overpoliced, unsafe environments, mass incarceration has become a driver of forms of reproductive oppression for people in prison and jails and in the community.

Pain, Opioids, and Pregnancy: Historical Context and Medical Management

Women are being disproportionately affected by the opioid crisis, including during pregnancy. Pain and other vulnerabilities to addiction differ between men and women. Management of opioid use disorder should be gender informed and accessible across the lifespan. During pregnancy, care teams should be multidisciplinary to include obstetrics, addiction, social work, anesthesia, pediatrics, and behavioral health. Pain management for women with opioid use disorder requires tailored approaches, including integration of trauma-informed care and addressing psychosocial needs. Thus, coordinated continued care by obstetric and addiction providers through pregnancy into postpartum is key to supporting women in recovery.

A conceptual framework for understanding iatrophobia

OBJECTIVE

Iatrophobia - fear of doctors, medical care, or the medical care system - is common among patients and can negatively impact their health-seeking behaviors and relationships with health care professionals. Despite this, academic literature on iatrophobia often fails to explore its nuanced causes.

METHODS

We establish a conceptual framework of iatrophobia, categorizing sources of fear that may create barriers to accessing medical care, and recommend a research agenda to address this phenomenon and understand its role in medical care.

RESULTS

The framework includes three categories of determinants of iatrophobia: patient fear of illness and the medical exam, patient fear of physician reaction, and patient fear related to barriers to care. These categories represent influences from individual to more system-related factors associated with the physician-patient relationship. Research examining iatrophobia should focus on understanding its prevalence, how patients cope with their fear, discussing iatrophobia in the physician-patient encounter, the sociopolitical contribution to iatrophobia, and how iatrophobia can be reduced.

CONCLUSIONS

Iatrophobia can be categorized into three primary domains, but it remains poorly understood.

PRACTICE IMPLICATIONS

A more thorough understanding of iatrophobia will help to contextualize its role amid other barriers to care and patient health outcomes.

Policy perceptions of US state public health and child and family services regarding maternal opioid use and neonatal exposure

OBJECTIVE

To explore how state legislatures and departments of health are responding to the public health and economic issues of increases in opioid use disorder and the impact on pregnant women and infants.

DESIGN

The design was a non-experimental descriptive study using a mixed methods survey research approach.

SETTING

Electronic and telephone survey of individuals from state departments of health associated with departments of behavioral health and substance use, or child and family services.

PARTICIPANTS

Fifty-two respondents employed by individual state departments of health and child and family services.

METHODS

Univariate analysis and frequency distribution of ordinal variables was completed. Thematic analysis was used to analyze free text questions and identify themes.

RESULTS

All states reported recent changes or plans to address the problem of opioid misuse in their state. Many respondents feel their state continues to lack adequate services for treatment. Some states are exploring unique methods for addressing this in a safe and timely fashion, such as moving medication-assisted treatment to primary care and expanding licensure to Primary Care Physicians (PCPs) and nurse practitioners.

CONCLUSIONS

Our findings demonstrate an increased commitment throughout the United States to enhance access to clinically appropriate treatment of substance use disorder particularly during pregnancy, consider unique methods for addressing the problem of opioid dependency, and increase education and primary prevention programs.

Long-acting reversible contraception: A route to reproductive justice or injustice

This article presents information on unintended pregnancies and the ongoing efforts of policy makers to promote long-acting reversible contraception (LARC) to reduce the numbers of such pregnancies. Also discussed is the tension between the encouragement of LARC to promote the public's interests in achieving that goal versus the need to assure that all women can decide about their bodies and reproductive needs. Our discussion includes information, primarily from the United States, on (a) risks associated with unintended pregnancies, (b) LARC devices approved in the United States (copper intrauterine devices (IUDs), hormone IUDs, and implants), (c) public and social benefits of increasing the use of LARC, (d) disadvantages and barriers to using LARC, (e) dangers of promoting LARC in unjust ways, and (f) the meaning of reproductive justice and its connection to social justice. By sharing the information with the audience of this journal, we hope that it will be integrated into clinical work and research on mental health and development. We also hope that experts in those fields will become discussants in the conversation regarding women's reproductive health and social justice that is taking place in the United States and elsewhere.

Update on Reproductive Rights and Women's Mental Health

Reproductive rights are essential to the recognition/treatment of women as full-fledged human beings/citizens. Barriers to reproductive rights pose a grave danger to women's well-being. This article explores the origins of these barriers, their nature, and their impact on mental health. The most controversial relationship is between induced abortion and mental health. Barriers, misinformation, and coercion affecting contraceptive, abortion, and pregnancy care are an ongoing danger to women's mental health and the well-being of their families. Mental health professionals are best qualified, and have an obligation, to know the facts, apply them, and provide accurate information to protect women's health.

Making the Ethnic Embryo: Enacting Race in US Embryo Adoption

How are frozen embryos donated for procreation racialized as "ethnic" subjects and what are the political implications of these enactments? Based on ethnographic research within an embryo adoption program in the United States, I examine the practices through which staff and participants produce "ethnicity" in embryos and trace its multiple permutations. Strategies used to stabilize race in embryos also disturb, fracture, and confound the bases for designating race. Analyzing race-making practices in embryo adoption reveals the interplay between practical challenges in assisted family-making practices and their wider political implications for reproductive politics.

Pregnancy Outcomes in US Prisons, 2016-2017

OBJECTIVES

To collect national data on pregnancy frequencies and outcomes among women in US state and federal prisons.

METHODS

From 2016 to 2017, we prospectively collected 12 months of pregnancy statistics from a geographically diverse sample of 22 state prison systems and the Federal Bureau of Prisons. Prisons reported numbers of pregnant women, births, miscarriages, abortions, and other outcomes.

RESULTS

Overall, 1396 pregnant women were admitted to prisons; 3.8% of newly admitted women and 0.6% of all women were pregnant in December 2016. There were 753 live births (92% of outcomes), 46 miscarriages (6%), 11 abortions (1%), 4 stillbirths (0.5%), 3 newborn deaths, and no maternal deaths. Six percent of live births were preterm and 30% were cesarean deliveries. Distributions of outcomes varied by state.

CONCLUSIONS

Our study showed that the majority of prison pregnancies ended in live births or miscarriages. Our findings can enable policymakers, researchers, and public health practitioners to optimize health outcomes for incarcerated pregnant women and their newborns, whose health has broad sociopolitical implications.

Pregnant women with opioid use disorder and their infants in three state Medicaid programs in 2013-2016

BACKGROUND

Maternal opioid use disorder (OUD) has serious consequences for maternal and infant health. Analysis of Medicaid enrollee data is critical, since Medicaid bears a disproportionate share of costs.

METHODS

This study analyzes linked maternal and infant Medicaid claims data and infant birth records in three states in the year before and after a delivery in 2014-2015 (2013-2016) examining health, health care use, treatment, and neonatal outcomes. Diagnosis and procedure codes identify OUD and other substance use disorders (SUDs).

RESULTS

In the year before and after delivery, 2.2 percent of the sample had an OUD diagnosis, and 5.9 percent had a SUD diagnosis other than OUD. Of the women with OUD, 72.8% had treatment for a SUD in the year before and after delivery, but most had none in an average enrolled month, and only 8.8% received any methadone treatment in a given month. Pregnant women with OUD had delayed and lower rates of prenatal care compared to women with other substance use disorders (SUDs). Infants of mothers with OUD did not differ from infants of mothers with other SUDs in rate of preterm or low birth weight but had higher NICU admission rates and longer birth hospitalizations. Health care costs for women with an OUD were higher than those with other SUDs.

CONCLUSIONS

There is an urgent need for comprehensive, evidence-based OUD treatment integrated with maternity care. To fill critical gaps in care, workforce and infrastructure innovations can facilitate delivery of preventive and treatment services coordinated across settings.