Treatment for substance use disorders in pregnant women: Motivators and barriers

Substance Use-Associated Infant Maltreatment Report Rates in the Context of Complex Prenatal Substance Use Policy Environments

State responses to substance use during pregnancy have included policies designed to increase access to substance use treatment as well as punish such substance use. Prior research has found that punitive policies are associated with increased rates of child maltreatment reporting, but it is unclear if the presence of punitive-promoting policies also moderate the association between access-promoting polices and maltreatment reports. Using data from the National Child Abuse and Neglect Data System and state-level fixed effects models, this study investigates how interactions between access-promoting and punitive prenatal substance use policies are associated with rates of substance use-associated maltreatment reports among infants. In states with punitive policies, access-promoting policies were associated with smaller decreases in these reports than in states without punitive policies. In some cases, access-promoting policies were associated with greater increases in these reports when punitive policies were also present than when only one type of policy was adopted. Interactions between prenatal substance use policies may result in unintended and counterproductive consequences for maternal and child health and the child welfare system.

Factors Influencing Maternal Substance Use and Recovery in the Perinatal Period

BACKGROUND

Substance use disorders (SUD) in the perinatal period have risen dramatically over the past 2 decades. Substance use disorders can have deleterious effects on maternal-infant health. Recovery can improve quality of life but can be challenging for women with SUD in the perinatal period. It is important for health care providers to have an understanding of factors associated with maternal substance use and recovery.

OBJECTIVE

The purpose of this qualitative review was to identify factors influencing substance use and recovery in women with SUD in the perinatal period.

METHODS

A systematic search was conducted using the databases of CINAHL, PsycINFO, and PubMed along with a manual search of Google Scholar. The studies were assessed using criteria from the Joanna Briggs Institute's critical appraisal checklist for qualitative research.

RESULTS

Findings from 16 qualitative studies were synthesized. Six descriptive subthemes identifying factors influencing substance use and recovery were revealed: (1) Infant Care, (2) Stigma, (3) Social Settings Involving Substance Use, (4) Internalized Stigma and Mental Health Symptoms, (5) Addiction Concerns, and (6) Coping Abilities.

CONCLUSIONS

Participants described external and internal factors that influenced their substance use and recovery. The findings suggest health care providers refer women to residential addiction treatment, use destigmatizing language, promote access to peer services, and provide trauma-informed care.

Pregnant Women's Experiences of Seeking Treatment for Opioid Use

PURPOSE

The purpose of this study was to describe women's experiences seeking treatment for opioid use disorder during pregnancy.

STUDY DESIGN AND METHODS

This was an exploratory multi-method study to understand women's experiences seeking treatment for opioid use disorder during pregnancy using surveys and interviews. Women pregnant within the past 5 years while using opioids were recruited from a private Facebook group for mothers on medication for opioid use disorder. Members of this group assisted with the development of the survey. Descriptive statistics were used for the 18-question survey and interviews were recorded, transcribed, and analyzed for themes.

RESULTS

Twenty-one women completed an online survey, and six participated in an in-depth virtual interview about their experience. Five themes describing their experiences were identified: (1) fear of child protective services, (2) family and partner support, (3) health care providers' reactions, (4) accessing treatment centers, and (5) awareness of support services during pregnancy .

CLINICAL IMPLICATIONS

Participants reported an overall negative experience seeking treatment for opioid use disorder during pregnancy. Nurses can improve the outcomes for pregnant women with opioid use disorder by using a non-stigmatizing approach, promoting early identification, and providing information, including harm reduction education. Facilitation of resources for treatment, mother and child programs, and advocating for partner treatment can improve maternal and neonatal outcomes.

The Lived Experiences of Pregnant and Parenting Women in Recovery Toward Medication Treatment for Opioid Use Disorder

BACKGROUND

Maternal misuse of prescription opioids and illicit drugs such as, heroin and non-pharmaceutical fentanyl analogs has increased in the last 2 decades and one in 5 women reported misuse of opioids. Medications for opioid use disorder (MOUD) are recommended for treating pregnant women with opioid use disorder (OUD). MOUD is effective in reducing cravings and negative outcomes, yet treatment is underutilized and varies in integration and intensity of resources across health systems. Exploring perceptions of MOUD delivery among pregnant/parenting women promises to uncover and address the underlying challenges to treatment, a perspective that may be different for providers and stakeholders. Therefore, our main purpose is to elicit patients' experiences and perceptions of MOUD, associated access to treatment, and availability of supportive resources during pregnancy/postpartum to inform OUD treatment.

METHODS

Through a qualitative research approach we gathered data from individual interviews/focus group discussions for this pilot study. Pregnant and postpartum parenting women (n = 17) responded to questions related to perceptions of MOUD, access to treatment, and availability of social and psychosocial resources. Data were collected, transcribed, and coded (by consensus) and emerging themes were analyzed using grounded theory methodology.

RESULTS

Emerging themes revealed positive uptake and perceptions of MOUD, continuing gaps in knowledge, negative impact of stigmatization, and limited access to programs and resources. Supportive relationships from family, peers, healthcare providers and child welfare staff, and co-located services were perceived as positive motivators to recovery.

CONCLUSIONS

Through the unique lenses of women with lived experience, this study revealed several themes that can be transformative for women. Overall perceptions of MOUD were positive and likely to facilitate uptake and promote positive recovery outcomes. Bridging knowledge gaps will reduce anxieties, fears about neonatal opioid withdrawal syndrome and adverse maternal outcomes. Additionally, a deeper understanding of stigmatization and relationships can inform an integrated patient-centered approach to OUD treatment.

Patient navigation for perinatal substance use disorder treatment: A systematic review

BACKGROUND

Substance use during the perinatal period (i.e., pregnancy through the first year postpartum) can pose significant maternal and infant health risks. However, access to lifesaving medications and standard care remains low for perinatal persons who use substances. This lack of substance use disorder treatment access stems from fragmented services, stigma, and social determinants of health-related barriers that could be addressed using patient navigators. This systematic review describes patient navigation models of care for perinatal people who use substances and associated outcomes.

METHODS

We conducted a structured search of peer-reviewed, US-focused, English- or Spanish-language articles from 2000 to 2023 focused on 1) patient navigation, 2) prenatal and postpartum care, and 3) substance use treatment programs using PubMed, Scopus, PsycINFO, and CINAHL databases.

RESULTS

After meeting eligibility criteria, 17 studies were included in this review. The majority (n=8) described outpatient patient navigation programs, with notable hospital (n=4) and residential (n=3) programs. Patient navigation was associated with reduced maternal substance use, increased receipt of services, and improved maternal and neonatal health. Findings were mixed for engagement in substance use disorder treatment and child custody outcomes. Programs that co-located care, engaged patients across the perinatal period, and worked to build trust and communication with family members and service providers were particularly successful.

CONCLUSION

Patient navigation may be a promising strategy for improving maternal and infant health outcomes among perinatal persons who use substances. More experimental research is needed to test the effect of patient navigation programs for perinatal persons who use substances compared to other models of care.

Association between socioeconomic and motherhood characteristics with receiving community-based treatment services among justice-involved young female drug users: a retrospective cohort study in Taiwan

BACKGROUND

Drug-involved individuals who contact treatment services in Taiwan are mostly driven by criminal justice systems either as an alternative or adjunct to criminal sanctions for a drug offence. With a focus on justice-involved young female drug users, the present study examines the extent to which socioeconomic and motherhood characteristics are associated with receiving deferred prosecution, a scheme diverting drug offenders to community-based addiction treatment.

METHODS

We identified a cohort of 5869 women under the age of 30 arrested for using Schedule II drugs (primarily amphetamine-like stimulants) from the 2011-2017 National Police Criminal Records in Taiwan. Information concerning socioeconomic characteristics, pregnancy and live birth history, and deferred prosecution was obtained through linkage with the 2006-2019 National Health Insurance, birth registration, and deferred prosecution datasets. Multinomial logistic regression was used to evaluate the association with stratification by recidivism status.

RESULTS

Within six months of arrest, 21% of first-time offenders (n = 2645) received deferred prosecution and 23% received correction-based rehabilitation; the corresponding estimates for recidivists (n = 3224) were 6% and 15%, respectively. Among first-time offenders, low/unstable income was associated with lower odds of deferred prosecution (adjusted odds ratio [aOR] = 0.71; 95% CI: 0.58, 0.88). For recidivists, those with low/unstable income (aOR = 1.58) or unemployment (aOR = 1.58) had higher odds of correction-based rehabilitation; being pregnant at arrest was linked with reduced odds of deferred prosecution (aOR = 0.31, 95% CI: 0.13, 0.71) and correction-based rehabilitation (aOR = 0.50, 95% CI: 0.32, 0.77).

CONCLUSIONS

For the young women arrested for drug offences, disadvantaged socioeconomic conditions were generally unfavored by the diversion to treatment in the community. Childbearing upon arrest may lower not only the odds of receiving medical treatment but also correctional intervention. The criminal prosecution policy and process should be informed by female drug offenders' need for treatment and recovery.

Characterizing Multisystem Barriers to Women's Residential SUD Treatment: A Multisite Qualitative Analysis in Los Angeles

Residential substance use disorder (SUD) treatment programs are challenged by the differing values of the problem-solving court (PSC) and child welfare (CW) systems, along with communication barriers between staff. This study aimed to understand, from the viewpoints of SUD treatment providers, how divergent values and communication barriers adversely affect women's residential SUD treatment. We conducted qualitative semistructured interviews with 18 SUD treatment clinicians and six directors from four women's residential SUD treatment programs. Using a thematic analysis framework, we identified salient themes across specified codes. Analysis revealed six main themes, suggesting differing values and communication barriers across the SUD, PSC, and CW systems adversely affect the provision of SUD treatment. For differing values, three main themes emerged: (a) unaddressed trauma and fear of mental health treatment seeking; (b) perceptions of mothers with a SUD; and (c) the Adoption and Safe Families Act (ASFA) timeline as a barrier to SUD treatment provision. For communication barriers, three themes emerged: (a) inadequate communication and responsiveness with PSC and CW systems adversely affect treatment coordination, induce patient stress, and treatment disengagement; (b) lack of PSC and CW communication regarding child visitation planning adversely affects treatment motivation and retention; and (c) competing ASFA, PSC, and CW priorities and inadequate cross-system communication adversely affect treatment planning. Treatment providers face significant barriers in providing effective treatment to women simultaneously involved in the CW and PSC systems. Aligning values and addressing communication barriers, changes in policy, and enhanced cross-system training are crucial. Additionally, it is essential to reevaluate the ASFA timeline to align with the long-term treatment needs of mothers with a SUD. Further research should explore the viewpoints of patients, CW, and PSC staff to gain deeper insights into these SUD treatment barriers.

Investigating the neurobiology of maternal opioid use disorder and prenatal opioid exposure using brain organoid technology

Over the past two decades, Opioid Use Disorder (OUD) among pregnant women has become a major global public health concern. OUD has been characterized as a problematic pattern of opioid use despite adverse physical, psychological, behavioral, and or social consequences. Due to the relapsing-remitting nature of this disorder, pregnant mothers are chronically exposed to exogenous opioids, resulting in adverse neurological and neuropsychiatric outcomes. Collateral fetal exposure to opioids also precipitates severe neurodevelopmental and neurocognitive sequelae. At present, much of what is known regarding the neurobiological consequences of OUD and prenatal opioid exposure (POE) has been derived from preclinical studies in animal models and postnatal or postmortem investigations in humans. However, species-specific differences in brain development, variations in subject age/health/background, and disparities in sample collection or storage have complicated the interpretation of findings produced by these explorations. The ethical or logistical inaccessibility of human fetal brain tissue has also limited direct examinations of prenatal drug effects. To circumvent these confounding factors, recent groups have begun employing induced pluripotent stem cell (iPSC)-derived brain organoid technology, which provides access to key aspects of cellular and molecular brain development, structure, and function in vitro. In this review, we endeavor to encapsulate the advancements in brain organoid culture that have enabled scientists to model and dissect the neural underpinnings and effects of OUD and POE. We hope not only to emphasize the utility of brain organoids for investigating these conditions, but also to highlight opportunities for further technical and conceptual progress. Although the application of brain organoids to this critical field of research is still in its nascent stages, understanding the neurobiology of OUD and POE via this modality will provide critical insights for improving maternal and fetal outcomes.

Perinatal women in substance use disorder treatment: Interest in partnering with family and friends to support recovery needs

BACKGROUND

Perinatal women treated for substance use disorder (SUD) face considerable barriers to recovery that might be ameliorated through activation of community support.

OBJECTIVES

This descriptive study evaluated the presence of drug-free family and friends in the social networks of perinatal women treated for SUD. It also assessed the interest of these women to partner with network members to mobilize support across several recovery needs.

METHODS

Social network interviews were conducted with 40 pre- and post-partum women treated at the Center for Addiction and Pregnancy (CAP) in Baltimore, Maryland. These interviews also prompted participants to consider which network members to invite to the program to support recovery efforts.

RESULTS

Study participants reported that their personal social networks included 4.4 drug-free adults. An overwhelming majority (80%) of participants reported a willingness to invite at least one person to the CAP program. Participants also endorsed several opportunities for collaboration between the program and community support.

CONCLUSIONS

These findings suggest that treatment program guided activation of network support offers a testable strategy to help perinatal women reduce barriers to recovery and improve treatment outcomes.

Clinically defining the opioid-exposed birthing person and infant as a dyad to support bedside care, surveillance, and research

Introduction

An increased incidence of maternal opioid use disorder (OUD) and neonatal abstinence syndrome (NAS) has prompted recommendations supporting a dyadic approach to care for birthing persons and their infants. However, there are no consensus guidelines outlining how the dyad is clinically defined.

Methods

To examine how the opioid-exposed birthing person-infant dyad has been defined for purposes of data collection and research, a literature review applying the RAND/UCLA Appropriateness Method was conducted.

Results

The search yielded 320 abstracts, with 110 articles identified as having a dyadic focus. While no articles included a specific definition for the dyad, 33 (30%) contained a descriptive reference to the birthing person-infant dyad. Thematic analysis revealed eight recurring elements characteristic of the dyad: (1) engagement, (2) communication, (3) bonding, (4) attachment, (5) mutual responsiveness, (6) reciprocity, (7) synchrony, and (8) attunement. Integrating these elements revealed the interactional relationship between the opioid-exposed birthing person and infant as the foundational principle that defines the dyad.

Discussion

This definition shifts the focus of the opioid-exposed dyad from two individual patient populations to an interactional relationship that has broad applicability for clinical use, public health data collection, and research considerations.

Listening to Black Pregnant and Postpartum People: Using Technology to Enhance Equity in Screening and Treatment of Perinatal Mental Health and Substance Use Disorders

Perinatal mood and anxiety disorders (PMADs), perinatal substance use disorders (PSUDs), and intimate partner violence (IPV) are leading causes of pregnancy-related deaths in the United States. Screening and referral for PMADs, PSUDs and IPV is recommended, however, racial disparities are prominent: Black pregnant and postpartum people (PPP) are less likely to be screened and attend treatment compared to White PPP. We conducted qualitative interviews to better understand the experience of Black PPP who used a text/phone-based screening and referral program for PMADs/PSUDs and IPV-Listening to Women and Pregnant and Postpartum People (LTWP). We previously demonstrated that LTWP led to a significant reduction in racial disparities compared to in-person screening and referral, and through the current study, sought to identify facilitators of PMAD/PSUD symptom endorsement and treatment attendance. Semi-structured interviews were conducted with 68 Black PPP who were or had been pregnant within the last 24 months, and who either had or did not have a PMAD or PSUD. Participants were enrolled in LTWP and provided feedback on their experience. Using a grounded theory approach, four themes emerged: usability, comfort, necessity, and recommendations. Ease of use, brevity, convenience, and comfort in discussing mental health and substance use via text were highlighted. Need for a program like LTWP in Black communities was discussed, given the reduction in perceived judgement and access to trusted information and resources for PMADs/PSUDs, which may lessen stigma. These qualitative findings illuminate how technology-based adaptations to behavioral health screening and referral can reduce perceived negative judgment and facilitate identification and referral to treatment, thereby more adequately meeting needs of Black PPP.

Pre-COVID Trends in Substance Use Disorders and Treatment Utilization during Pregnancy in West Virginia 2016-2019

Introduction: Access to prenatal care offers the opportunity for providers to assess for substance use disorders (SUDs) and to offer important treatment options, but utilization of treatment during pregnancy has been difficult to measure. This study presents pre-COVID trends of a subset of SUD diagnosis at the time of delivery and related trends in treatment utilization during pregnancy. Materials and Methods: A retrospective cohort design was used for the analysis of West Virginia Medicaid claims data from 2016 to 2019. Diagnosis of SUDs at the time of delivery and treatment utilization for opioid use disorder (OUD) and non-OUD diagnosis during pregnancy across time were the principal outcomes of interest. This study examined data from n = 49,398 pregnant individuals. Results: Over the 4-year period, a total of 2,830 (5.7%) individuals had a SUD diagnosis at the time of delivery. The frequency of opioid-related diagnoses decreased by 29.3%; however, non-opioid SUD diagnoses increased by 55.8%, with the largest increase in the diagnosis of stimulant use disorder (30.9%). Treatment for OUD increased by 13%, but treatment for non-opioid SUD diagnoses during pregnancy declined by 41.1% during the same period. Conclusions: Interventions enacted within West Virginia have improved access and utilization of treatment for OUD in pregnancy. However, consistent with national trends in the general population, non-opioid SUD diagnoses, especially for stimulants, have rapidly increased, while treatment for this group decreased. Early identification and referral to treatment by OB-GYN providers are paramount to reducing pregnancy and postpartum complications for the mother and neonate.

"They just looked at me like I was human": The experiences of parenting women and providers with substance use disorder treatment

BACKGROUND

The current US addiction treatment system does not effectively meet the needs of pregnant and parenting women with substance use disorder (SUD). The aim of this research was to identify barriers and facilitators to engagement and retention in SUD residential treatment for pregnant and parenting women. This research was part of a co-design process to collaboratively create a more patient-centered long-term residential program.

DESIGN AND METHODS

The study conducted semi-structured individual interviews with both parenting women with lived experience (WWLE) in residential SUD treatment and SUD treatment providers. Interviews aimed to elicit participants' experiences either receiving or providing care. The study team analyzed data in NVivo-12 using a deductive codebook based on the six principles of trauma informed care (TIC).

RESULTS

We conducted a total of 32 interviews (WWLE =13, SUD providers =19). The study identified four major themes: 1) peer relationships provide inspiration and diminish shame; 2) providing individuals safe space to stumble in recovery creates opportunities for growth and builds self-efficacy; 3) reasonable, clear boundaries create a structured, protective environment for early recovery; 4) nonjudgmental connections facilitate engagement and build trust. We identified small pivotal moments along the continuum of care that showed how the elements in the four themes enhanced engagement and retention in treatment. These interactions, along the care continuum, are either structural (workflow process) or relational (interpersonal).

CONCLUSION

This research increases understanding of the interplay of the structural and relational barriers and facilitators to engagement and retention in treatment. These seemingly minor positive or negative interactions along the care continuum are pivotal to fully operationalizing TIC and optimizing women's engagement in treatment. Improvement strategies that integrate the voices of WWLE and collaboratively co-design a more patient-centered system are critical steps to improving engagement in SUD treatment and more equitable SUD treatment services.

Stigma and self-stigma among women within the context of the german "zero alcohol during pregnancy" recommendation: A qualitative analysis of online forums and blogs

BACKGROUND

In many countries, including Germany, it is recommended to abstain from alcohol during pregnancy to avoid harm to the baby. In this qualitative research study, analysis of online forums was conducted to explore women's perception of the German "zero alcohol during pregnancy" recommendation with regard to stigma and self-stigma.

METHODS

We used a grounded theory approach to analyze online forum discussions on alcohol use during pregnancy. Data consisted of 9 discussion threads from 5 different forums and blogs involving 115 participants in total. We used key concepts developed during analysis and the theory of stigma to interpret the posts.

RESULTS

We identified five key themes: (1) Low alcohol health literacy as a breeding ground for stigmatization; (2) The widespread assumption that maternal abstinence is a prerequisite for being considered a "good mother"; (3) Interpersonal role conflicts and a guilty conscience as a result of stigmatization or self-stigmatization; (4) Paying little attention to the role of psychosocial factors in alcohol consumption, especially regarding partner responsibility during pregnancy.; (5) Understanding the "zero alcohol during pregnancy" recommendation as a complete ban, associated with loss of autonomy.

CONCLUSION

The current method of communicating the "zero alcohol during pregnancy" recommendation may have unintended consequences. Specifically, misconceptions about the harm associated with low alcohol consumption and setting high expectations of motherhood are factors that can contribute to stigma or self-stigma and potentially undermine self-efficacy, help-seeking behavior, and overcoming the barriers to alcohol health literacy.

Intersectional disparities in outpatient alcohol treatment completion by gender and race and ethnicity

BACKGROUND

Untreated alcohol use disorder (AUD) can have negative outcomes, including premature death. Completing specialty treatment for AUD can improve economic and educational outcomes. However, there are large racial and ethnic disparities in treatment completion, and how these disparities vary intersectionally (e.g., by gender and race and ethnicity) is unknown. Recent studies suggest that not using an intersectional approach can mask important disparities. We estimated disparities in AUD nonintensive outpatient treatment completion by gender alone, race and ethnicity alone, and intersectionally in a gender-by-race-and-ethnicity model. Accurately quantifying treatment completion disparities is critical not only for understanding healthcare disparities but reducing them to advance health equity.

METHODS

Data are from SAMHSA's 2017 to 2019 Treatment Episode Dataset-Discharges for adults aged 18+ who entered nonintensive outpatient treatment primarily for alcohol (n = 559,447 episodes; 30.3% women; 63.7% White, 18.0% Black, 14.4% Hispanic/Latinx, 2.1% American Indian/Alaska Native [AIAN], 1.0% Asian/Pacific Islander). Using the rank-and-replace method, treatment completion disparities were estimated by gender, race and ethnicity, and gender-by-race-and-ethnicity due to any reason other than differences in need for treatment, consistent with the Institute of Medicine's definition of a healthcare disparity.

RESULTS

The intersectional gender-by-race-and-ethnicity model identified the widest range of disparities among all models tested. Using this model, the largest disparities were identified for minoritized women's treatment episodes. Compared to White men whose completion rate was 60.79% (95% confidence interval [CI]: 60.06, 60.98), Black, Hispanic/Latina, AIAN, and Asian-American/Pacific Islander women had treatment episode completion rates that were 12.35 (CI: 12.33, 12.37), 9.08 (CI: 9.06, 9.11), 10.27 (CI: 10.22, 10.32), and 4.87 (CI: 4.78, 4.95) percentage points lower, respectively.

CONCLUSIONS

In the United States, treatment completion rates for non-intensive outpatient alcohol treatment episodes are significantly lower for minoritized women than White men. The extent of the disparity is not apparent in univariate models, highlighting the importance of an intersectional approach to understanding disparities in the completion of non-intensive outpatient treatment for AUD.

Transit and treatment: Aligning systems to address substance use in Connecticut

OBJECTIVE

Test hypotheses that proximity to new transit improves substance use disorder treatment provider cost efficiency (i.e., economies of scale and scope).

DATA SOURCES AND STUDY SETTING

Connecticut substance uses disorder treatment providers/programs. A 2015 rapid transit line opening with 10 stations, near some providers/programs. Providers' annual operating costs from publicly available federal tax forms (2013-2018). Annual client counts, service-type (including substance use disorder and/or mental health, among others), and location data, for 50 providers and their programs, from Department of Mental Health and Addiction Services, with an unbalanced panel of 285 provider-years.

STUDY DESIGN

Economies of scale occur when the percent change in operating costs is less than the percentage change in clients. Economies of scope occur when operating costs fall as providers treat clients with multiple service needs. With our quasi-experimental, multivariate regressions approach, we test hypotheses that proximity to a new transit line enhances economies of scale and scope (i.e., lowers unit operating costs).

DATA COLLECTION/EXTRACTION METHODS

Annual provider-level operating costs merged with new transit station locations and Department of Mental Health and Addiction Services program/provider-level secondary data (locations, client counts/completions/dates, service types, and average demographics).

PRINCIPAL FINDINGS

For providers with programs within 1-mile of new transit (compared with a "control" sample beyond 1-mile of new transit), (i) a 10% increase in clients leads to a 0.12% lower operating costs per client; (ii) a 10% increase in clients completing treatment results in a 1.5% decrease in operating costs per client; (iii) a 10% increase in clients receiving treatment for multiple services causes a 0.81% lower operating costs per client; (iv) offering multiple services leads to 6.3% lower operating costs.

CONCLUSIONS

New transit proximity causes operating cost savings for substance use disorder/mental health treatment providers. System alignment may benefit transit and health care sectors.

Antenatal care of women who use opioids: a qualitative study of practitioners' perceptions of strengths and challenges of current service provision in Scotland

BACKGROUND

The increasing rise of women using opioids during pregnancy across the world has warranted concern over the access and quality of antenatal care received by this group. Scotland has particularly high levels of opioid use, and correspondingly, pregnancies involving women who use opioids. The purpose of this study was to investigate the different models of antenatal care for women using opioids during pregnancy in three Scottish Health Board Areas, and to explore multi-disciplinary practitioners' perceptions of the strengths and challenges of working with women who use opioids through these specialist services.

METHODS

Thirteen semi-structured interviews were conducted with health and social care workers who had experience of providing antenatal and postnatal care to women who use drugs across three Scottish Health Board Areas: NHS Greater Glasgow and Clyde, NHS Lothian, and NHS Tayside. Framework Analysis was used to analyse interview data. The five stages of framework analysis were undertaken: familiarisation, identifying the thematic framework, indexing, charting, and mapping and interpretation.

RESULTS

Each area had a specialist antenatal pathway for women who used substances. Pathways varied, with some consisting of specialist midwives, and others comprising a multidisciplinary team (e.g. midwife, mental health nurse, social workers, and an obstetrician). Referral criteria for the specialist service differed between health board areas. These specialised pathways presented several key strengths: continuity of care with one midwife and a strong patient-practitioner relationship; increased number of appointments, support and scans; and highly specialised healthcare professionals with experience of working with substance use. In spite of this, there were a number of limitations to these pathways: a lack of additional psychological support for the mother; some staff not having the skills to engage with the complexity of patients who use substances; and problems with patient engagement.

CONCLUSIONS

Across the three areas, there appears to be high-quality multi-disciplinary antenatal services for women who use opioids during pregnancy. However, referral criteria vary and some services appear more comprehensive than others. Further research is needed into the perceptions of women who use opioids on facilitators and barriers to antenatal care, and provision in rural regions of Scotland.

Knowledge of Maternal Mortality Risk Among Women with Substance Use Disorders during Pregnancy and Postpartum

PURPOSE

The purpose of this study was to investigate knowledge of maternal mortality risk of women with substance use disorder in the perinatal period.

STUDY DESIGN

This study was conducted using a qualitative descriptive design.

METHODS

Participants were recruited from a residential substance use treatment center in a rural Midwestern city. We used semi-structured interviews during which participants described their understanding of maternal mortality risk and their related experiences. We analyzed the transcribed interviews using content analysis to yield themes and subthemes.

RESULTS

Sixteen women participated. Three main themes were identified: Women with substance use disorder lack understanding of maternal mortality; Women with substance use disorder experience barriers to perinatal care; and Women with substance use disorder have additional risk factors for maternal mortality.

CLINICAL IMPLICATIONS

Nurses can use validated screening tools, offer brief interventions, and refer women to appropriate substance use disorder treatment and mental health resources. Nurses must educate women with substance use disorder about their risk for maternal mortality as well as the signs and symptoms of perinatal mood and anxiety disorders. Nurses should provide education about the access and use of naloxone. A non-judgmental and trauma-informed approach should be used during interactions with this population.

Grounded Theory Approach to Understand Self-Management of Opioid Recovery Through Pregnancy and Early Parenting

OBJECTIVE

To develop a theory to explain the processes women use to self-manage recovery from opioid use disorder during pregnancy, the postpartum period, and early parenting.

DESIGN

Constructivist grounded theory approach.

PARTICIPANTS

Women (N = 16) who gave birth during the past 12 months and used medication for opioid use disorder for recovery through pregnancy and the postpartum period.

METHODS

We recruited participants through seven medication-assisted treatment clinics in a mid-size Midwestern city and the surrounding suburbs and through online parenting and recovery community groups with national-based memberships. We conducted semistructured, individual audio interviews from November 2020 to July 2021. Interviews continued until we reached theoretical and meaning saturation. We used constant comparative methods during initial and intermediate coding.

RESULTS

Participants described a central process, Growing as a Healthy Dyad, that included six processes they used to self-manage recovery: Maintaining Vigilance, Performing Self-Care, Putting in the Work of Recovery, Advocating, Navigating Social Support, and Acquiring Skills and Knowledge. These processes were affected by personal and social contextual factors.

CONCLUSIONS

The grounded theory, Self-Management of Opioid Recovery Through Pregnancy and Early Parenting, can be used to explain the unique processes of self-management by women in opioid recovery and highlights the need for a strengths-based approach to caring for the maternal-infant dyad.

Advances in the Care of Infants With Prenatal Opioid Exposure and Neonatal Opioid Withdrawal Syndrome

A significant number of advances have been made in the last 5 years with respect to the identification, diagnosis, assessment, and management of infants with prenatal opioid exposure and neonatal opioid withdrawal syndrome (NOWS) from birth to early childhood. The primary objective of this review is to summarize major advances that will inform the clinical management of opioid-exposed newborns and provide an overview of NOWS care to promote the implementation of best practices. First, advances with respect to standardizing the clinical diagnosis of NOWS will be reviewed. Second, the most commonly used assessment strategies are discussed, with a focus on presenting new quality improvement and clinical trial data surrounding the use of the new function-based assessment Eat, Sleep, and Console approach. Third, both nonpharmacologic and pharmacologic treatment modalities are reviewed, highlighting clinical trials that have compared the use of higher calorie and low lactose formula, vibrating crib mattresses, morphine compared with methadone, buprenorphine compared with morphine or methadone, the use of ondansetron as a medication to prevent the need for NOWS opioid pharmacologic treatment, and the introduction of symptom-triggered dosing compared with scheduled dosing. Fourth, maternal, infant, environmental, and genetic factors that have been found to be associated with NOWS severity are highlighted. Finally, emerging recommendations on postdelivery hospitalization follow-up and developmental surveillance are presented, along with highlighting ongoing and needed areas of research to promote infant and family well-being for families impacted by opioid use.

Access to MAT: Participants' Experiences With Transportation, Non-Emergency Transportation, and Telehealth

INTRODUCTION

Access to medication assisted treatment (MAT) for opioid use disorder (OUD) in the United States is a significant challenge for many individuals attempting to recover and improve their lives. Access to treatment is especially challenging in rural areas characterized by lack of programs, few prescribers, and transportation barriers. This study aims to better understand the roles that transportation, Medicaid-funded non-emergency medical transportation (NEMT), and telehealth play in facilitating access to MAT in West Virginia (WV).

METHODS

We developed this survey using an exploratory sequential mixed methods approach following a review of current peer-reviewed literature plus information gained from 3 semi-structured interviews and follow-up discussions with 5 individuals with lived experience in MAT. Survey results from 225 individuals provided rich context on the influence of transportation in enrolling and remaining in treatment, use of NEMT, and experiences using telehealth. Data were collected from February through August 2021.

RESULTS

We found that transportation is a significant factor in entering into and remaining in treatment, with 170 (75.9%) respondents agreeing or strongly agreeing that having transportation was a factor in deciding to go into a MAT program, and 176 (71.1%) agreeing or strongly agreeing that having transportation helps them stay in treatment. NEMT was used by one-quarter (n = 52, 25.7%) of respondents. Only 13 (27.1%) noted that they were picked up on time and only 14 (29.2%) noted that it got them to their appointment on time. Two thirds of respondents (n = 134, 66.3%) had participated in MAT services via telehealth video or telephone visits. More preferred in-person visits to telehealth visits but a substantial number either preferred telehealth or reported no preference. However, 18 (13.6%) reported various challenges in using telehealth.

CONCLUSIONS

This study confirms that transportation plays a significant role in many people's decisions to enter and remain in treatment for OUD in WV. Additionally, for those who rely on NEMT, services can be unreliable. Finally, findings demonstrate the need for individualized care and options for accessing treatment for OUD in both in-person and telehealth-based modalities. Programs and payers should examine all possible options to ensure access to care and recovery.

Pregnancy- and parenting-related barriers to receiving medication for opioid use disorder: A multi-paneled qualitative study of women in treatment, women who terminated treatment, and the professionals who serve them

BACKGROUND

Women face unique barriers when seeking treatment for substance use disorders, often related to pregnancy and parenting.

OBJECTIVES

This study adds to the extant literature by elucidating the pregnancy- and parenting-related barriers women face when initiating or continuing medication for opioid use disorder, specifically.

DESIGN

This study is based on qualitative semi-structured interviews.

METHODS

Three subgroups participated in semi-structured interviews regarding their experiences (N = 42): women with current or past opioid use disorders who have used or were presently using medication for opioid use disorder, professionals working in substance use disorder treatment programs, and criminal justice professionals.

RESULTS

Three parenting-related subthemes were identified: (1) insufficient access to childcare to navigate appointments and meetings, (2) fear of losing custody of, or access to, one's children, and (3) prioritizing one's children's needs before one's own. Three subthemes were identified with regard to pregnancy as a barrier: (1) hesitancy among physicians to prescribe medication for opioid use disorder for pregnant patients, (2) limited access to resources in rural areas, and (3) difficulty navigating a complex, decentralized health system.

CONCLUSION

Systemic changes are needed to reduce pregnant and parenting women's barriers to seeking medication for opioid use disorder. These include improved childcare support at both in-patient and outpatient treatment programs, which would assuage women's barriers related to childcare, as well as their fears of losing access to their children if they spend time away from their children for treatment. An additional systemic improvement that may reduce barriers for these women is access to comprehensive, integrated care for their prenatal care, postpartum care, pediatric appointments, and appropriate substance use disorder treatment.

Supporting the implementation of written exposure therapy for posttraumatic stress disorder in an obstetrics-substance use disorder clinic in the Northeastern United States

Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the pregnant person and the fetus, including a host of physical and mental health consequences. When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms of each may exacerbate and maintain the other. Pregnancy often increases engagement in the healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD treatment to birthing people motivated to mitigate risks of losing custody of their children. This paper presents implementation process outcomes of Written Exposure Therapy (WET), a brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center. Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working (77.8%), had a high school or lower level of education (55.5%), had an annual household income less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators to implementation; and feedback on supporting uptake and sustainability of the intervention using coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N = 5]) from providers involved in trial planning and treatment delivery. Results reflected high acceptability, appropriateness, and adoption of WET. Participants described system-, provider-, and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not raise concerns about core components of the intervention. Findings suggest that WET is an appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has the potential to positively impact pregnant persons and their children.

Demographics, Birth Parameters, and Social Determinants of Health Among Opioid-Exposed Mother-Infant Dyads Affected by Neonatal Abstinence Syndrome in Pennsylvania, 2018-2019

OBJECTIVES

To characterize demographics, birth parameters, and social determinants of health among mother-infant dyads affected by neonatal abstinence syndrome (NAS) in Pennsylvania.

METHODS

We linked 2018-2019 NAS surveillance data to birth record data using probabilistic methods and then geospatially linked to local social determinants of health data based on residential address. We generated descriptive statistics and used multivariable mixed-effects logistic regression to model the association between maternal characteristics, birth parameters, social determinants of health, and NAS.

RESULTS

In adjusted models maternal age > 24, non-Hispanic white race/ethnicity, low educational attainment, Medicaid as payor at delivery, inadequate or no prenatal care, smoking during pregnancy, and low median household income were associated with NAS. We found no significant associations between NAS and county-level measures of clinician supply, number of substance use treatment facilities, or urban/rural designation.

CONCLUSIONS FOR PRACTICE

This study characterizes mother-infant dyads affected by NAS using linked non-administrative, population data for Pennsylvania. Results demonstrate a social gradient in NAS and inequity in prenatal care receipt among mothers of infants with NAS. Findings may inform implementation of state-based public health interventions.

Improving Reproductive Health Communication Between Providers and Women Affected by Homelessness and Substance Use in San Francisco: Results from a Community-Informed Workshop

OBJECTIVES

Many cisgender women affected by homelessness and substance use desire pregnancy and parenthood. Provider discomfort with patient-centered counseling about reproductive choices and supporting reproductive decisions of these women poses barriers to reproductive healthcare access.

METHODS

We used participatory research methods to develop a half-day workshop for San Francisco-based medical and social service providers to improve reproductive counseling of women experiencing homelessness and/or who use substances. Guided by a stakeholder group comprising cisgender women with lived experience and providers, goals of the workshop included increasing provider empathy, advancing patient-centered reproductive health communication, and eliminating extraneous questions in care settings that perpetuate stigma. We used pre/post surveys to evaluate acceptability and effects of the workshop on participants' attitudes and confidence in providing reproductive health counseling. We repeated surveys one month post-event to investigate lasting effects.

RESULTS

Forty-two San Francisco-based medical and social service providers participated in the workshop. Compared to pre-test, post-test scores indicated reduced biases about: childbearing among unhoused women (p < 0.01), parenting intentions of pregnant women using substances (p = 0.03), and women not using contraception while using substances (p < 0.01). Participants also expressed increased confidence in how and when to discuss reproductive aspirations (p < 0.01) with clients. At one month, 90% of respondents reported the workshop was somewhat or very beneficial to their work, and 65% reported increased awareness of personal biases when working with this patient population.

CONCLUSIONS FOR PRACTICE

A half-day workshop increased provider empathy and improved provider confidence in reproductive health counseling of women affected by homelessness and substance use.

Receipt and duration of buprenorphine treatment during pregnancy and postpartum periods in a national privately-insured cohort

Background

Research gaps exist on the use of medications for opioid use disorder (OUD) among birthing people.

Methods

This retrospective cohort study included people who underwent childbirth deliveries during 2017-2020 and had a diagnosis of OUD identified from a national private insurance claims database. Buprenorphine prescriptions received during the year before childbirth and the year after childbirth were obtained from pharmacy claims. Logistic regressions were used to estimate associations between receipt of buprenorphine and individual and state-level factors.

Results

Among a sample of 1,523 birthing people diagnosed with OUD, 540 (35.5 %) received buprenorphine during the pregnancy or postpartum periods. About half (51.5 %) of new recipients of buprenorphine received treatment for at least six months and, of those, one-third experienced a treatment interruption. The buprenorphine receipt rate differed significantly by race and ethnicity: 28.8 % of non-Hispanic Black birthing people with OUD and 22.8 % of Hispanic birthing people with OUD received buprenorphine treatment in contrast to 37.7 % of non-Hispanic white birthing people (aOR 0.53 [95 % CI 0.35-0.81] and 0.59 [95 % CI 0.37-0.96], respectively). The buprenorphine use rate increased over time from 29.7 % in 2017 to 42.9 % in 2020. Birthing people living in states with punitive policies related to substance use in pregnancy had the lowest buprenorphine use rate of 22.7 % as compared to 43.0 % in states with least restrictive policies.

Conclusion

In this national sample of privately-insured individuals, by 2020, 42.9 % of birthing people with OUD received buprenorphine treatment. Treatment discontinuation and interruptions were common in the period surrounding childbirth.

Pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA

AIMS

We examined relationships between pregnancy-specific alcohol policies and admissions to substance use disorder treatment for pregnant people in the USA.

METHODS

We merged state-level policy and treatment admissions data for 1992-2019. We aggregated data by state-year to examine effects of nine pregnancy-specific alcohol policies on the number of admissions of pregnant women where alcohol was reported as the primary, secondary, or tertiary substance related to the treatment episode (N = 1331). We fit Poisson models that included all policy variables, state-level controls, fixed effects for state and year, state-specific time trends, and an offset variable of the number of pregnancies in the state-year to account for differences in population size and fertility.

RESULTS

When alcohol was reported as the primary substance, civil commitment [incidence rate ratio (IRR) 1.45, 95% CI: 1.10-1.89] and reporting requirements for assessment and treatment purposes [IRR 1.36, 95% CI: 1.04-1.77] were associated with greater treatment admissions. Findings for alcohol as primary, secondary, or tertiary substance were similar for civil commitment [IRR 1.31, 95% CI: 1.08-1.59] and reporting requirements for assessment and treatment purposes [IRR 1.21, 95% CI: 1.00-1.47], although mandatory warning signs [IRR 0.84, 95% CI: 0.72-0.98] and priority treatment for pregnant women [IRR 0.88, 95% CI: 0.78-0.99] were associated with fewer treatment admissions. Priority treatment findings were not robust in sensitivity analyses. No other policies were associated with treatment admissions.

CONCLUSIONS

Pregnancy-specific alcohol policies related to greater treatment admissions tend to mandate treatment rather than make voluntary treatment more accessible, raising questions of ethics and effectiveness.

Integrated Supports for Women and Girls Experiencing Substance Use and Complex Needs

There is strong research to support integrated and gender-sensitive harm reduction approaches for supporting women, girls, and gender diverse people. For individuals who are pregnant, flexible and integrated treatment approaches may be especially important. In this study, we report on an integrated program in rural Canada designed to support pregnant women, girls, and gender diverse people experiencing substance use and other complex needs. Program data (N = 393) from the 2nd Floor Women's Recovery Centre (2nd Floor) at the Lakeland Centre for Fetal Alcohol Spectrum Disorder (LCFASD) was analyzed with several aims. Study goals were to (1) describe characteristics and needs of clients, (2) identify factors associated with program completion, and (3) for a subset of clients, examine resources, wellbeing, and social and behavioral outcomes after treatment. Clients (Mage = 27.4 years, range 15-64) presented at the 2nd Floor with complex medical and mental health needs, and experiences of significant socioenvironmental adversity. However, almost two-thirds (63.4%) successfully completed the program, which was more likely for clients who had stable housing at intake and a possible or confirmed diagnosis of FASD. After treatment, clients reported high levels of wellbeing, and most were connected to health care and community resources. In the year after program completion, clients who were contacted for follow-up maintained strong connection to resources and reported notable improvements in social and behavioral functioning. Many were working or volunteering, most were in stable home environments, rates of substance use and legal involvement were substantially reduced, and many clients were actively caring for their children. This study offers important findings to inform future research, practice, and policy for supporting health and wellbeing for women, children, families, and communities.

Guideline No. 443b: Opioid Use Throughout Women's Lifespan: Opioid Use in Pregnancy and Breastfeeding

OBJECTIVE

To provide health care providers the best evidence on opioid use and women's health. Areas of focus include pregnancy and postpartum care.

TARGET POPULATION

The target population includes all women currently using or contemplating using opioids.

OUTCOMES

Open, evidence-informed dialogue about opioid use will improve patient care.

BENEFITS, HARMS, AND COSTS

Exploring opioid use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Opioid use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Health care providers need to understand the effect opioids can have on pregnant women and support them to make knowledgeable decisions about their health.

EVIDENCE

A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome, and breastfeeding.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All health care providers who care for pregnant and/or post-partum women and their newborns.

TWEETABLE ABSTRACT

Opioid use during pregnancy often co-occurs with mental health issues and is associated with adverse maternal, fetal, and neonatal outcomes; treatment of opioid use disorder with agonist therapy for pregnant women can be safe during pregnancy where the risks outnumber the benefits.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Directive clinique no 443b : Opioïdes aux différentes étapes de la vie des femmes : Grossesse et allaitement

OBJECTIF

Présenter aux professionnels de la santé les données probantes concernant l'utilisation des opioïdes et la santé des femmes. Les domaines d'intérêt sont la grossesse et les soins post-partum.

POPULATION CIBLE

Toutes les femmes qui utilisent des opioïdes. RéSULTATS: Un dialogue ouvert et éclairé sur l'utilisation des opioïdes améliorera les soins aux patientes. BéNéFICES, RISQUES ET COûTS: L'exploration de l'utilisation d'opioïdes par une approche tenant compte des traumatismes antérieurs donne au professionnel de la santé et à la patiente l'occasion de bâtir une alliance solide, collaborative et thérapeutique. Cette alliance permet aux femmes de faire des choix éclairés. Elle favorise le diagnostic et le traitement possible du trouble lié à l'utilisation d'opioïdes. L'utilisation ne doit pas être stigmatisée, puisque la stigmatisation affaiblit le partenariat (le partenariat entre patiente et professionnel de la santé). Les professionnels de la santé ceus-ci doivent comprendre l'effet potentiel des opioïdes sur la santé les femmes enceintes et les aider à prendre des décisions éclairées sur leur santé. DONNéES PROBANTES: Une recherche a été conçue puis effectuée dans les bases de données PubMed et Cochrane Library pour la période d'août 2018 à mars 2023 des termes MeSH et mots clés suivants (et variantes) : opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome et breastfeeding. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les professionnels de la santé qui prodiguent des soins aux femmes et aux nouveaux-nés. RéSUMé POUR TWITTER: La consommation d'opioïdes pendant la grossesse coïncide souvent avec des problèmes de santé mentale et est associée à des conséquences néfastes pour la mère, le fœtus et le nouveau-né ; le traitement des troubles liés à la consommation d'opioïdes par agonistes peut être sûr pendant la grossesse lorsque les risques sont plus nombreux que les avantages. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Developing a Theoretically Informed Implementation Model for Telemedicine-Delivered Medication for Opioid Use Disorder: Qualitative Study With Key Informants

BACKGROUND

Telemedicine-delivered medication for opioid use disorder (TMOUD) has become more prevalent during the COVID-19 pandemic, particularly in North America. This is considered a positive development as TMOUD has the potential to increase access to evidence-based treatment for a population heavily affected by the opioid crisis and consequent rising mortality and morbidity rates in relation to opioid use disorder. Despite the increase in the use of TMOUD, there are no established service- and process-focused models to guide the implementation of this intervention.

OBJECTIVE

This study aims to develop a process- and service-focused implementation model in collaboration with key stakeholders and bring together peer-reviewed literature, practice-based knowledge, and expert opinions.

METHODS

The simple rules for evidence translation in complex systems framework was applied to guide the development of a 6-step qualitative study. The steps were definition of the scope and objectives of the model, identification of evidence, stakeholder engagement, draft model development, key informant consultation, and final model specification.

RESULTS

The final specification for the TMOUD implementation model incorporated key strategic priorities, service delivery prerequisites, service design elements, stakeholder identification and engagement, key process domains, and iterative cycles of evaluation and improvement.

CONCLUSIONS

Through stakeholder engagement and key informant consultation, we produced a process- and service-focused TMOUD implementation model. The model is modifiable to different contexts and settings while also in keeping with the current evidence base and national and international standards of high-quality opioid use disorder care.

Considerations for the provision of PTSD treatment among pregnant women with substance use histories: A clinical conceptual model based on case consultation field notes

OBJECTIVE

Increasing prevalence of substance use in pregnancy presents a public health crisis that is compounded by posttraumatic stress disorder (PTSD) comorbidity. We aimed to detail the clinical complexities of PTSD treatment provision among pregnant women with substance use histories.

METHODS

We conducted a qualitative study using clinical case consultation field notes (N = 47 meetings) which were gathered during a hybrid effectiveness-implementation pilot study of Written Exposure Therapy (WET) for PTSD among pregnant women seen in an obstetrics-SUD clinic [2019-2021]. Patient baseline survey data (N = 25) were used to characterize the sample and contextualize engagement.

RESULTS

Participants were exposed to a high number of trauma/adversity event types. There was no association between number of trauma/adversity event types and treatment response or dropout. Qualitative findings revealed clinical features relevant to PTSD treatment, including multi-system involvement; parental trauma and substance use; relevance of substance use to trauma context and posttraumatic cognitions, emotions, and behaviors; impact of trauma on experiences of pregnancy, attachment, and child rearing; limited social networks placing women at risk of ongoing violence; and experiences of substance use discrimination.

CONCLUSION

PTSD treatment among pregnant women with substance use histories is highly important to maternal-child health.

Office-Based Management of Perinatal Substance Use and Substance Use Disorder for the General Obstetrician-Gynecologist

This is a review of substance use and substance use disorder in pregnancy, intended for the generalist obstetrician-gynecologist. Herein, the authors discuss legal considerations, outline definitions, review screening tools, introduce special considerations and harm reduction, caution the use of urinary toxicology testing, and touch on the screening, brief intervention, and referral to treatment model. Furthermore, the authors provide a brief overview of the prevalence, maternal and neonatal risks, and treatment approaches for commonly used substances.

Opioid and stimulant attributed treatment admissions and fatal overdoses: Using national surveillance data to examine the intersection of race, sex, and polysubstance use, 1992-2020

BACKGROUND

We use national surveillance data to evaluate race/ethnicity by sex/gender differences and trends in substance use treatment admissions and overdose deaths involving opioid and stimulant use.

METHODS

We used data (1992-2019) from the Treatment Episode Dataset-Admissions to identify treatment admissions and the Center for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research (1999-2020) to identify overdose deaths. We assessed treatment admissions and related drug overdose deaths per 100,000 adults by sex and race/ethnicity for opioid and stimulant groups: cocaine, opioid, methamphetamines, cocaine and opioid use, cocaine and methamphetamines, and opioid and methamphetamines.

RESULTS

We found significant variations in treatment admissions and deaths by race/ethnicity and sex/gender. Cocaine-related treatment admissions and deaths were most prevalent among Non-Hispanic Black individuals over the study years, yet lower rates were evident among individuals from other racial/ethnic groups. Notably, Non-Hispanic Black men experienced larger increases in cocaine-only admissions than men of other racial/ethnic groups between 1992 and 2019. Men had higher opioid and stimulant treatment admissions and overdose deaths than women. We observed skyrocketing methamphetamine deaths among American Indian/Native Alaskan men and women from 1992 to 2019.

DISCUSSION

Steep increases in overdose deaths fueled by methamphetamines among Non-Hispanic Native Americans and cocaine among Non-Hispanic Black individuals suggest a need for more effective interventions to curb stimulant use. Variations by race/ethnicity and sex/gender also suggest interventions should be developed through an intersectionality lens.

Maternal Opioid Use Disorder and the Risk of Postneonatal Infant Mortality

Importance

The risk of serious long-term outcomes for infants born to individuals with opioid use disorder (OUD) is not fully characterized, nor is it well understood whether risks are modified by infant diagnosis of neonatal opioid withdrawal syndrome (NOWS).

Objective

To characterize the risk of postneonatal infant mortality among infants with a NOWS diagnosis or born to individuals with OUD.

Design, Setting, and Participants

The study team conducted a retrospective cohort study of 390 075 infants born from 2007 through 2018 to mothers who were enrolled in Tennessee Medicaid from 183 days prior to delivery through 28 days post partum (baseline). Maternal and infant baseline characteristics were measured using administrative claims and birth certificates, and infants were followed up from day 29 post partum through day 365 or death. Deaths were identified using linked death certificates through 2019. These data were analyzed from February 10, 2022, through March 3, 2023.

Exposure

Infant exposures included birth to an individual with OUD or postnatal diagnosis of NOWS. The study team defined a pregnant individual's OUD status (maternal OUD) as having OUD diagnosis or a maintenance medication prescription fill during baseline; this study defined NOWS as having NOWS diagnosis up to day 28. Groups were categorized by exposures as maternal OUD with NOWS (OUD positive/NOWS positive), maternal OUD without NOWS (OUD positive/NOWS negative), no documented maternal OUD with NOWS (OUD negative/NOWS positive), and no documented maternal OUD or NOWS (OUD negative/NOWS negative, unexposed).

Main Outcome and Measures

The outcome was postneonatal infant death, confirmed by death certificates. Cox proportional hazards models were used, adjusting for baseline maternal and infant characteristics, to estimate adjusted hazard ratios (aHRs) and 95% CIs for the association between maternal OUD or NOWS diagnosis with postneonatal death.

Results

Pregnant individuals in the cohort had a mean (SD) age of 24.5 (5.2) years; 51% of infants were male. The study team observed 1317 postneonatal infant deaths and incidence rates of 3.47 (OUD negative/NOWS negative, 375 718), 8.41 (OUD positive/NOWS positive, 4922); 8.95 (OUD positive/NOWS negative, 7196), and 9.25 (OUD negative/NOWS positive, 2239) per 1000 person-years. After adjustment, the risk of postneonatal death was elevated for all groups, relative to the unexposed: OUD positive/NOWS positive (aHR, 1.54; 95% CI, 1.07-2.21), OUD positive/NOWS negative (aHR, 1.62; 95% CI, 1.21-2.17), and OUD negative/NOWS positive (aHR, 1.64; 95% CI, 1.02-2.65).

Conclusions and Relevance

Infants born to individuals with OUD or with a NOWS diagnosis had an increased risk of postneonatal infant mortality. Future work is necessary to create and evaluate supportive interventions for individuals with OUD during and after pregnancy to reduce adverse outcomes.

Polysubstance use during pregnancy: The importance of screening, patient education, and integrating a harm reduction perspective

BACKGROUND

Substance use during pregnancy is associated with poor health outcomes. This study assessed substance use, polysubstance use, and use of select prescription medications during pregnancy.

METHODS

We analyzed 2019 data from the Pregnancy Risk Assessment Monitoring System in 25 United States jurisdictions that included questions on prescription medications, tobacco, and illicit substance use during pregnancy. Alcohol and electronic cigarette use were assessed during the last three months of pregnancy, and all other substances and medications were assessed throughout pregnancy. Weighted prevalence estimates and 95% confidence intervals (CIs) were calculated.

RESULTS

Nearly one-fifth of respondents who reported use of any substance reported use of at least one other substance during pregnancy. Cigarettes (8.1%; 95% CI 7.6-8.7%) and alcohol (7.4%; 95% CI 6.7-8.1%) were the most frequently reported substances, followed by cannabis (4.3%; 95% CI 3.9-4.7%). Substance use was higher among individuals who reported having depression or using antidepressants during pregnancy compared with those who did not report depression or antidepressant use. Illicit drug use prevalence was low (0.5%, 95% CI 0.4-0.7%); however, respondents reporting heroin use also frequently reported use of illicit stimulants (amphetamines: 51.7%, 95% CI 32.1-71.3% or cocaine: 26.5%, 95% CI 11.9-41.1%). Although prenatal clinician screening for alcohol and cigarette use was approximately 95%, fewer respondents (82.1%) reported being screened for cannabis or illicit substance use during pregnancy.

CONCLUSIONS

One in five individuals who reported use of any substance during pregnancy engaged in polysubstance use, highlighting the importance of comprehensive screening and evidence-based interventions including harm reduction.

Commentary on Nowakowski et al.: Bringing the participants' own words into addictions research-a win-win for patients and investigators

Bringing the participant’s own words into the design of clinical investigations, such as with qualitative and mixed methodologies, should be prioritized in addictions research across the translational science spectrum.

Sex-related differences in the prevalence of substance use disorders, treatment, and overdose among parents with young children

Introduction

Risk factors and treatment rates for substance use disorders (SUDs) differ by sex. Females often have greater childcare and household responsibilities than males, which may inhibit SUD treatment. We examined how SUD, medication for opioid use disorder (MOUD) receipt, and overdose rates differ by sex among parents with young children (<5 years).

Methods

Using deidentified national administrative healthcare data from Optum's Clinformatics® Data Mart Database version 8.1 (2007-2021), we identified parents aged 26-64 continuously enrolled in commercial insurance for ≥ 30 days and linked to ≥ 1 dependent child < 5 years from January 1, 2016-February 29, 2020. We used generalized estimating equations to estimate the average predicted prevalence of SUD diagnosis, MOUD receipt after opioid use disorder (OUD) diagnosis, and overdose by parent sex in any month, adjusting for age, race/ethnicity, state of residence, enrollment month, and mental health conditions.

Results

From 2016 to 2020, there were 2,241,795 parents with a dependent child < 5 years, including 1,155,252 (51.5%) females and 1,086,543 (48.5%) males. Male parents had a higher average predicted prevalence of an SUD diagnosis (11.1% [11, 11.16]) than female parents (5.5% [5.48, 5.58]). Among parents with OUD, the average predicted prevalence of receiving MOUD was 27.4% [26.1, 28.63] among male and 19.7% [18.34, 21.04] among female parents, with no difference in overdose rates by sex.

Conclusion

Female parents are less likely to be diagnosed with an SUD or receive MOUD than male parents. Removing policies that criminalize parental SUD and addressing childcare-related barriers may improve SUD identification and treatment.

Racial/ethnic differences in medication for addiction treatment for opioid use disorders among pregnant women in treatment facilities supported by state funds

INTRODUCTION

Medication for addiction treatment (MAT) for opioid use disorder (OUD) in pregnant women is known to improve neonatal health outcomes. Despite the benefits of this evidence-based treatment for OUD, MAT has been underutilized during pregnancy among certain racial/ethnic groups of women in the United States. The purpose of this study was to examine racial/ethnic differences and factors that affect MAT administration among pregnant women with OUD seeking treatment at publicly funded facilities.

METHODS

We used data from the 2010-2019 Treatment Episode Data Set system. The analytic sample included 15,777 pregnant women with OUD. We built logistic regression models to examine associations between race/ethnicity and MAT and determine differences and similarities in factors that may influence the use of MAT across racial/ethnic groups of pregnant women with OUD.

RESULTS

Although in this sample only 31.6 % received MAT, an increasing trend of MAT receipt has been observed during 2010-2019. Approximately 44 % of the Hispanic pregnant women received MAT, and this was significantly higher than non-Hispanic Black (27.1 %) and White (31.3 %) women. Even after adjusting for potential confounders, the adjusted odds of receiving MAT during pregnancy were lower for Black (AOR = 0.57, 95 % CI 0.44, 0.75) and White (AOR = 0.75, 95 % CI 0.61, 0.91) women compared to Hispanic women. Not being in the labor force increased the odds of receiving MAT in Hispanic women relative to their employed counterparts while homelessness or dependent living decreased the odds of MAT for White women compared to those living independently. Regardless of their racial/ethnic background, pregnant women younger than 29 years old were less likely to receive MAT relative to older women; however, if they were arrested once prior to admission to treatment, they had significantly higher odds of receiving MAT than those with no arrests. Treatment of at least 7 months was associated with a higher likelihood of MAT across all racial/ethnic groups.

CONCLUSIONS

This study highlights the underutilization of MAT, particularly among pregnant Black and White women who seek treatment for OUD in publicly funded treatment facilities. A multi-dimensional approach to MAT intervention programs is needed to increase MAT for all pregnant women and reduce racial/ethnic inequities.

An unexpected path to addiction medicine

The field of Addiction Medicine needs dedicated reproductive healthcare specialists who are motivated to move the field forward to provide optimal patient care.

Project BETTER: A Family-Centered, Technology-Delivered Intervention for Pregnant People with Opioid Use Disorder

Birthing people with opioid use disorder (OUD) face unique stressors during the transition from pregnancy to postpartum that can negatively impact the maternal-infant dyad. This study aimed to describe the development of a family-centered, technology-delivered intervention tailored to help pregnant people receiving medication for OUD (MOUD) prepare for this transition. Formative data from patients and providers identified intervention content: (1) recovery-oriented strategies for the pregnancy-to-postpartum transition; (2) guidance around caring for an infant with opioid withdrawal symptoms; and (3) preparation for child welfare interactions. The content was reviewed in successive rounds by an expert panel and modified. Pregnant and postpartum people receiving MOUD pre-tested the intervention modules and provided feedback in semi-structured interviews. The multidisciplinary expert panel members (n = 15) identified strengths and areas for improvement. Primary areas for improvement included adding content, providing more structure to help participants navigate the intervention more easily, and revising language. Pre-testing participants (n = 9) highlighted four themes: reactions to intervention content, navigability of the intervention, feasibility of the intervention, and recommendation of the intervention. All iterative feedback was incorporated into the final intervention modules for the prospective randomized clinical trial. Family-centered interventions tailored for pregnant people receiving MOUD should be informed by patient-reported needs and multidisciplinary perspectives.

Supporting pregnant and parenting women who use alcohol during pregnancy: A scoping review of trauma-informed approaches

Alcohol is legalized and used for a variety of reasons, including socially or as self-medication for trauma in the absence of accessible and safe supports. Trauma-informed approaches can help address the root causes of alcohol use, as well as the stigma around women's alcohol use during pregnancy. However, it is unclear how these approaches are used in contexts where pregnant and/or parenting women access care. Our objective was to synthesize existing literature and identify promising trauma-informed approaches to working with pregnant and/or parenting women who use alcohol. A multidisciplinary team of scholars with complementary expertise worked collaboratively to conduct a rigorous scoping review. All screening, extraction, and analysis was independently conducted by at least two authors before any differences were discussed and resolved through team consensus. The Joanna Briggs Institute method was used to map existing evidence from peer-reviewed articles found in PubMed, CINAHL, PsycINFO, Social Work Abstracts, and Web of Science. Data were extracted to describe study demographics, articulate trauma-informed principles in practice, and gather practice recommendations. Thirty-six studies, mostly from the United States and Canada, were included for analysis. Studies reported on findings of trauma-informed practice in different models of care, including live-in treatment centers, case coordination/management, integrated and wraparound supports, and outreach-for pregnant women, mothers, or both. We report on how the following four principles of trauma-informed practices were applied and articulated in the included studies: (1) trauma awareness; (2) safety and trustworthiness; (3) choice, collaboration, and connection; and (4) strengths-based approach and skill building. This review advances and highlights the importance of understanding trauma and applying trauma-informed practice and principles to better support women who use alcohol to reduce the risk of alcohol-exposed pregnancies. Relationships and trust are central to trauma-informed care. Moreover, when applying trauma-informed practices with pregnant and parenting women who use alcohol, we must consider the unique stigma attached to alcohol use.

Disparities in opioid use disorder-related hospital use among postpartum Virginia Medicaid members

INTRODUCTION

The overdose crisis is increasingly revealing disparities in opioid use disorder (OUD) outcomes by race and ethnicity. Virginia, like other states, has witnessed drastic increases in overdose deaths. However, research has not described how the overdose crisis has impacted pregnant and postpartum Virginians. We report the prevalence of OUD-related hospital use during the first year postpartum among Virginia Medicaid members in the years preceding the COVID-19 pandemic. We secondarily assess how prenatal OUD treatment is associated with postpartum OUD-related hospital use.

METHODS

This population-level retrospective cohort study used Virginia Medicaid claims data for live infant deliveries between July 2016 and June 2019. The primary outcome of OUD-related hospital use included overdose events, emergency department visits, and acute inpatient stays. Independent variables of interest were prenatal receipt of medication for OUD (MOUD) and receipt of non-MOUD treatment components in line with a comprehensive care approach (e.g., case management, behavioral health). Both descriptive and multivariate analyses were performed for all deliveries and stratified by White and Black non-Hispanic individuals to bring attention to the devastating impacts of the overdose crisis within communities of color.

RESULTS

The study sample included 96,649 deliveries. Over a third were by Black birthing individuals (n = 34,283). Prenatally, 2.5 % had evidence of OUD, which occurred more often among White (4 %) than Black (0.8 %) non-Hispanic birthing individuals. Postpartum OUD-related hospital use occurred in 10.7 % of deliveries with OUD, more commonly after deliveries by Black, non-Hispanic birthing individuals with OUD (16.5 %) than their White, non-Hispanic counterparts (9.7 %), and this disparity persisted in the multivariable analysis (Black AOR 1.64, 95 % CI 1.14-2.36). Postpartum OUD-related hospital events were less frequent for individuals receiving versus not receiving postpartum MOUD within 30 days prior to the event. Prenatal OUD treatment, including MOUD, was not associated with decreased odds of postpartum OUD-related hospital use in the race-stratified models.

CONCLUSION

Postpartum individuals with OUD are at high risk for mortality and morbidity, especially Black individuals not receiving MOUD after delivery. An urgent need remains to effectively address the systemic and structural drivers of racial disparities in transitions of OUD care through the one-year postpartum period.

Supportive alcohol policy as a key element of fetal alcohol spectrum disorder prevention

In Canada, a Four-Part Model of Fetal Alcohol Spectrum Disorder (FASD) Prevention has been developed that describes a continuum of multi-sectoral efforts, including broad awareness campaigns, safe and respectful conversations around pregnancy and alcohol use, and holistic and wraparound support services for pregnant and postpartum women with alcohol, and other health and social concerns. Supportive alcohol policy is at the centre of the four mutually reinforcing levels of prevention. The purpose of this narrative review is to describe alcohol policies related to specific levels of FASD prevention, and to consider the implications of alcohol policies on FASD prevention and women's and fetal health. The majority of the evidence focused on alcohol in pregnancy guidelines, alcohol warning labels, and knowledge and uptake of national or regional alcohol and pregnancy guidelines. Several US studies described shifts in alcohol and pregnancy policy over the 7-year period, including moves to punitive approaches that criminalize women's substance use or prompt child apprehension. This review indicates that more attention could be paid to the role of alcohol policy in FASD prevention and in promoting women's and fetal health, and that policy actions and advocacy could be important catalysts for both FASD prevention and women's health promotion. Moving forward, it is essential that alcohol policies are rooted in evidence; attend to and promote women's health including health during pregnancy; and are collaborative in order to prompt a higher standard of care, and more holistically respond to the factors that contribute to women's alcohol use during pregnancy.

Non-engagement in substance use treatment among women with an unmet need for treatment: A latent class analysis on multidimensional barriers

BACKGROUND

Women with substance use disorders experience multifaceted barriers in accessing substance use treatment. Little is known about how these barriers may aggregate. Using a person-centered approach, this study evaluates patterns of treatment barriers and the factors associated with experiencing distinct sets of barriers among women.

METHODS

Data were from the NSDUH (2015-2019). 461 adult women with an unmet need for substance use treatment in the last year reported on 14 treatment barriers. Latent class analysis examined classes of barriers; multinomial logistic regression assessed predictors of class membership.

RESULTS

Three classes were identified: just not ready to abstain (71.2%), logistical barriers and stigmatization (18.2%), and barriers across all dimensions (10.6%). Higher education (aOR:1.94, p = 0.03) and psychological distress (aOR:2.19, p = 0.02) predicted higher odds-and identifying as African American predicted lower odds (aOR:0.17, p = 0.02)-of belonging to the "Logistics and Stigma Barriers" class relative to the "Just Not Ready" class. Similarly, higher education (aOR: 2.57, p = 0.02) and having children (aOR:2.28, p = 0.03) predicted higher odds-and marriage predicted lower odds (aOR:0.22, p = 0.02)-of belonging to the "High and Diverse Barriers" class relative to the "Just Not Ready" class. Having children predicted higher odds (aOR: 2.93, p = .02), and marriage predicted lower odds (aOR:0.19, p = 0.02) of belonging to the "High and Diverse Barriers" class relative to the "Logistics and Stigma" class.

CONCLUSION

A lack of readiness to abstain, socioeconomic circumstances, and family obligations are main barriers to SUD treatment among women. Interventions incorporating motivational interviewing, family systems, and social networks are needed.

Patient and provider perspectives on barriers and facilitators to reproductive healthcare access for women experiencing homelessness with substance use disorders in San Francisco

BACKGROUND

Women experiencing homelessness with substance use disorders face unique and intersecting barriers to realizing their reproductive goals.

OBJECTIVE

This study explored the reproductive aspirations of this population, as well as the barriers to accessing reproductive services from the perspectives of affected individuals, and the healthcare providers who serve them.

DESIGN

This mixed-methods study included surveys and interviews with women experiencing homelessness with substance use disorders and healthcare providers.

METHODS

We conducted surveys and semi-structured interviews with women recruited from opiate treatment programs and homeless encampments in San Francisco, California in 2018. We also conducted interviews and focus groups with healthcare providers in reproductive health and substance use treatment settings. Interviews were recorded, transcribed, and coded. Descriptive statistics of survey results were performed.

RESULTS

Twenty-eight women completed surveys, 96% of whom reported current substance use. Ten women participated in interviews. One-third (9/28) reported desiring pregnancy in the next year; over half (16/28) reported they would be somewhat or very happy to learn they were pregnant. A majority used no contraception at last intercourse (14/28). Twenty-six healthcare providers participated in interviews (n = 15) and focus groups (n = 2). Patients and providers identified similar barriers to care access, including discrimination, logistical and financial challenges, and delayed pregnancy awareness. While providers proposed solutions focused on overcoming logistical challenges, patients emphasized the importance of transforming the healthcare environment to treat patients affected by substance use and homelessness with dignity and respect.

CONCLUSION

Women experiencing homelessness with substance use disorders face intersecting and compounding barriers to accessing reproductive health services. For patients, the impact of stigma and bias on treatment experiences are particularly salient, in contrast to logistical barriers emphasized by providers. Improving access will require structural and individual-level solutions to address stigma and create person-centered, trauma-informed, and respectful care environments.

Racial Differences in Retention in a Community-based Addiction Reduction Program Implemented by Peer Recovery Coaches for Women of Reproductive Age

To identify program characteristics that influence the retention of women of reproductive age in the Community-based Addiction Reduction program (CARE), mixed-method analyses of CARE survey data and CARE Peer Recovery Coach (PRC) narrative entries of participant encounters were performed. About 251 women were enrolled in this prospective community-based implementation science intervention. We compared survey responses by race for treatment status, treatment motivation scales, and retention in the program at intake, 2-, 6-, 9-, and 12-month follow ups using Chi-square/T-tests. Qualitative analysis of PRC narrative entries was conducted following thematic analysis and crystallization immersion analytic methods. White compared with Black women in CARE were significantly more likely to be in treatment at intake (P < .001) and more motivated to engage in recovery treatment (P < .001). However, Black women were retained longer in CARE at 2- (P < .006), 6- (P < .011), and 9- (P < .004) months. PRC narrative entries were coded, and emergent themes mapped well to the 4 types of supports provided by PRC as outlined by the Substance Abuse and Mental Health Services Administration: emotional, instrumental, informational, and affiliational. Analysis of narrative entries by race revealed that Black women were given more detailed information, communications with PRC were more encouraging and proactive in identifying and meeting needs, and PRC took a more hands-on approach when assisting and linking to resources. The inclusion of PRC as integral members of SUD recovery programs may preferentially provide Black women with SUD the opportunity to build more trusting relationships with these peer coaches, thereby increasing their participation and retention.

Facilitating Integrated Perinatal Care for Families Affected by Substance Use

Families of newborns are frequently referred to child protection systems because of parental substance use, yet many families face barriers to accessing prenatal care and substance use treatment services. Although federal legislation requires states to develop Plans of Safe Care to address families' health and substance use treatment needs, few have developed comprehensive and systematic approaches to provide perinatal support to parents and infants. In this commentary, we describe the development and initial testing of a Plan of Safe Care that engages patients and their providers in perinatal care coordination. Developed out of an in-depth analysis of current care workflows at an urban safety net health system, the Plan of Safe Care facilitates conversations with clients around delivery planning and aligns resources to support families with substance use disorders.

Treatment barriers and gender-based perceptions: Establishing gender-based treatment specialty facilities as a strategy to motivate South African young women to seek treatment for substance use disorders

South Africa alongside other low-middle-income countries have been some of the hardest hit by the substance use scourge. The study sought to identify and measure treatment barriers among young adults (18-29 years) living with substance use disorders, and then examine the role of gender in the perception of treatment barriers, with a view to establish gender-based treatment specialty facilities as a strategy to promote treatment seeking among young South African women. Quantitative method was used for this study, employing simple random sampling. Exploratory factor analysis and independent samples t-tests were used as statistical measures. The identified treatment barriers were found to have a larger effect on females than males. Women were considered less likely to utilise treatment services compared to males. Health promotion practitioners and policymakers can alleviate the situation by establishing gender-based treatment facilities. that respond better to women's needs.

Alcohol use during pregnancy and motherhood: Attitudes and experiences of pregnant women, mothers, and healthcare professionals

Alcohol is the most used substance by women of childbearing age. Alcohol exposed pregnancies can have serious consequences to the fetus, and the UK has one of the highest rates of drinking during pregnancy. Alcohol use during motherhood is also a public health concern, linked with potential harms to the woman and child. This qualitative study investigated the attitudes and experiences of pregnant/parenting women and healthcare professionals regarding maternal drinking. A semi-structured focus group and interviews were conducted in the North West of England with pregnant women, mothers, and healthcare professionals. Quantitative measures captured demographics, alcohol use, and screened for mental ill-health for pregnant women and mothers. Reflexive thematic analysis was used to analyse narratives. Findings revealed that most participants believed avoiding alcohol during pregnancy is the safest option. However, some pregnant women and mothers stated that there was insufficient evidence to demonstrate the harms of low-level drinking and that abstinence guidelines were patronising. All participants reported that low-level drinking during motherhood was acceptable. Heavy drinking was believed to pose serious harm during pregnancy and motherhood to the baby and mother, in addition to damaging relationships. Strong motives were revealed for choosing and avoiding to drink, such as coping with the difficulties of motherhood and parental responsibilities, respectively. Contradictions were found across quantitative and qualitative self-reports of consumption, reflecting potential underreporting of alcohol use. Additionally, drinking levels were discussed in extremes only (low/heavy) without considering 'grey area' drinking. Clear, consistent advice and guidelines are needed to support women in reducing their alcohol use during pregnancy and motherhood. These should include the unique potential risks regarding maternal drinking, and the harm attributable to non-clinically dependent alcohol use. The maternal participants in this study were middle-class, therefore, research is needed to capture the views and experiences of women of all socioeconomic backgrounds.