Drugs and having babies: an exploration of how a specialist clinic meets the needs of chemically dependent pregnant women

Women and opioid use disorder treatment: A scoping review of experiences, use of patient-reported experience measures, and integration of person-centred care principles

BACKGROUND

Patient-reported experience measures (PREMs) are an important aspect of assessing and improving women's experiences of person-centred care during treatment for Opioid Use Disorder (OUD). This scoping review aimed to 1) examine the extent, type, and characteristics of evidence regarding women's OUD treatment experiences, and 2) describe the extent to which PREMs and person-centred care principles are incorporated within research methods.

METHODS

Following Joanna Briggs Institute guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we conducted a scoping review to identify peer-reviewed articles on women's OUD treatment experiences. Data were extracted from 39 included studies and synthesised based on study design, method of assessment/analysis (including use of PREMs), key findings, and the integration of person-centred care principles.

RESULTS

Analysis of included studies revealed a predominance of qualitative research focused on women's experiences of pharmacological OUD treatment (methadone and/or buprenorphine) in Western countries. Women in these studies reported predominantly negative or mixed experiences of treatment. Few studies used validated PREMs and there was a lack of direct assessment or focus on recognised person-centred care principles. However, common categories of outcomes/findings identified in results across studies broadly aligned with person-centred care principles (e.g., fast access to reliable healthcare, effective treatment by trusted professionals), emphasising their applicability to women's experiences of treatment.

CONCLUSIONS

Although there has been an increased focus on women's experiences of treatment for OUD in recent years, results highlighted room for improvement regarding the systematic and comprehensive assessment of women's experiences across different contexts. Given the often negative or mixed experiences reported by women, an increased focus on assessing service provision through a person-centred care lens (including utilising PREMs) may allow for service improvements or adaptations targeted towards the needs and experiences of women.

Healthcare experiences of pregnant and postnatal women and healthcare professionals when facing child protection in the perinatal period: A systematic review and Critical Interpretative Synthesis

BACKGROUND

The perinatal period is known as time of transition and anticipation. For women with social risk factors, child protection services may become involved during the perinatal period and this might complicate their interactions with healthcare providers.

AIM

To systematically review and synthesise the existing qualitative evidence of healthcare experiences of women and healthcare professionals during the perinatal period while facing child protection involvement.

METHODS

A systematic search of databases (Web of Science, MEDLINE, EMBASE, PsychINFO, CINAHL, ASSIA, MIDIRS, Social Policy and Practice and Global Health) was carried out in January 2023, and updated in February 2024. Quality of studies was assessed using the Critical Appraisal Skills Programme. A Critical Interpretative Synthesis was used alongside the PRISMA reporting guideline.

RESULTS

A total of 41 studies were included in this qualitative evidence synthesis. We identified three types of healthcare interactions: Relational care, Surveillance and Avoidance. Healthcare interactions can fluctuate between these types, and elements of different types can coexist simultaneously, indicating the complexity and reciprocal nature of healthcare interactions during the perinatal period when child protection processes are at play.

CONCLUSIONS

Our findings provide a novel interpretation of the reciprocal interactions in healthcare encounters when child protection agencies are involved. Trust and transparency are key to facilitate relational care. Secure and appropriate information-sharing between agencies and professionals is required to strengthen healthcare systems. Healthcare professionals should have access to relevant training and supervision in order to confidently yet sensitively safeguard women and babies, while upholding principles of trauma-informed care. In addition, systemic racism in child protection processes exacerbate healthcare inequalities and has to be urgently addressed. Providing a clear framework of mutual expectations between families and healthcare professionals can increase engagement, trust and accountability and advance equity.

Targeted health and social care interventions for women and infants who are disproportionately impacted by health inequalities in high-income countries: a systematic review

BACKGROUND

Disadvantaged populations (such as women from minority ethnic groups and those with social complexity) are at an increased risk of poor outcomes and experiences. Inequalities in health outcomes include preterm birth, maternal and perinatal morbidity and mortality, and poor-quality care. The impact of interventions is unclear for this population, in high-income countries (HIC). The review aimed to identify and evaluate the current evidence related to targeted health and social care service interventions in HICs which can improve health inequalities experienced by childbearing women and infants at disproportionate risk of poor outcomes and experiences.

METHODS

Twelve databases searched for studies across all HICs, from any methodological design. The search concluded on 8/11/22. The inclusion criteria included interventions that targeted disadvantaged populations which provided a component of clinical care that differed from standard maternity care.

RESULTS

Forty six index studies were included. Countries included Australia, Canada, Chile, Hong Kong, UK and USA. A narrative synthesis was undertaken, and results showed three intervention types: midwifery models of care, interdisciplinary care, and community-centred services. These intervention types have been delivered singularly but also in combination of each other demonstrating overlapping features. Overall, results show interventions had positive associations with primary (maternal, perinatal, and infant mortality) and secondary outcomes (experiences and satisfaction, antenatal care coverage, access to care, quality of care, mode of delivery, analgesia use in labour, preterm birth, low birth weight, breastfeeding, family planning, immunisations) however significance and impact vary. Midwifery models of care took an interpersonal and holistic approach as they focused on continuity of carer, home visiting, culturally and linguistically appropriate care and accessibility. Interdisciplinary care took a structural approach, to coordinate care for women requiring multi-agency health and social services. Community-centred services took a place-based approach with interventions that suited the need of its community and their norms.

CONCLUSION

Targeted interventions exist in HICs, but these vary according to the context and infrastructure of standard maternity care. Multi-interventional approaches could enhance a targeted approach for at risk populations, in particular combining midwifery models of care with community-centred approaches, to enhance accessibility, earlier engagement, and increased attendance.

TRIAL REGISTRATION

PROSPERO Registration number: CRD42020218357.

Implementation barriers and enablers of midwifery group practice for vulnerable women: a qualitative study in a tertiary urban Australian health service

Background

Maternity services have limited formalised guidance on planning new services such as midwifery group practice for vulnerable women, for example women with a history of substance abuse (alcohol, tobacco and other drugs), mental health challenges, complex social issues or other vulnerability. Continuity of care through midwifery group practice is mostly restricted to women with low-risk pregnancies and is not universally available to vulnerable women, despite evidence supporting benefits of this model of care for all women. The perception that midwifery group practice for vulnerable women is a high-risk model of care lacking in evidence may have in the past, thwarted implementation planning studies that seek to improve care for these women. We therefore aimed to identify the barriers and enablers that might impact the implementation of a midwifery group practice for vulnerable women.

Methods

A qualitative context analysis using the Consolidated Framework for Implementation Research was conducted at a single-site tertiary health facility in Queensland, Australia. An interdisciplinary group of stakeholders from a purposeful sample of 31 people participated in semi-structured interviews. Data were analysed using manual and then Leximancer computer assisted methods. Themes were compared and mapped to the Framework.

Results

Themes identified were the woman’s experience, midwifery workforce capabilities, identifying “gold standard care”, the interdisciplinary team and costs. Potential enablers of implementation included perceptions that the model facilitates a relationship of trust with vulnerable women, that clinical benefit outweighs cost and universal stakeholder acceptance. Potential barriers were: potential isolation of the interdisciplinary team, costs and the potential for vicarious trauma for midwives.

Conclusion

There was recognition that the proposed model of care is supported by research and a view that clinical benefits will outweigh costs, however supervision and support is required for midwives to manage and limit vicarious trauma. An interdisciplinary team structure is also an essential component of the service design. Attention to these key themes, barriers and enablers will assist with identification of strategies to aid successful implementation. Australian maternity services can use our results to compare how the perceptions of local stakeholders might be similar or different to the results presented in this paper.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08633-8.

A qualitative meta-synthesis of pregnant women's experiences of accessing and receiving treatment for opioid use disorder

ISSUES

Addressing opioid use disorder (OUD) among pregnant women is of growing importance, and substance use treatment positively impacts outcomes for mother and baby. Understanding substance use treatment experiences is important to improve access, and retention, and no review or synthesis of research addressing the treatment experiences of pregnant women exists.

APPROACH

Thus, a qualitative meta-synthesis was conducted, which investigated the psychological motivators and barriers of pregnant women with OUD trying to access treatment and their perceptions of treatment.

KEY FINDINGS

A total of 3844 articles were retrieved from the literature search. Nine articles met eligibility criteria, were appraised, then synthesised using a comparative thematic approach. Four themes: (i) Embodied Experiences; (ii) Institutional Pressures; (iii) Social Context; and (iv) Reconstructing Selves; indicate that women with OUD are motivated to engage in treatment to pursue the safety and custody of the unborn baby and to pursue and enact the changes necessary to claim 'normal' parenthood status. Pregnant women describe psychological and relational barriers to engaging in treatment, including anxieties about the baby's health, fears of authorities' involvement, stigma and experiencing relationships with treatment providers as constrictive or invalidating.

IMPLICATIONS

Identity theory's concepts of identity verification, closed environments and master status identities illuminate the findings. Implications include recognising the salience of bodily experiences, providing medication-assisted treatment support groups and promoting validating relationships in treatment using strengths-based approaches.

CONCLUSIONS

Pregnant women face unique psychological challenges in accessing and engaging in substance use treatment for OUD.

Facilitators and barriers to substance-free pregnancies in high-income countries: A meta-synthesis of qualitative research

BACKGROUND

Previous studies have associated substance use (alcohol, illicit drugs and smoking) to negative pregnancy outcomes, including higher risk of stillbirth.

AIM

This study aims to identify facilitators and barriers reported by women to remain substance free during pregnancy.

METHODS

A systematic search was conducted in six databases from inception to March 2019 and updated in November 2020. Qualitative studies involving pregnant or post-partum women, from high-income countries, examining women's experiences of substance use during pregnancy were eligible. Meta-ethnography was used to facilitate this meta-synthesis.

FINDINGS

Twenty-two studies were included for analysis. Internal barriers included the perceived emotional and social benefits of using substances such as stress coping, and the associated feelings of shame and guilt. Finding insensitive professionals, the lack of information and discussion about risks, and lack of social support were identified as external barriers. Furthermore, the social stigma and fear of prosecution associated with substance use led some women to conceal their use. Facilitators included awareness of the health risks of substance use, having intrinsic incentives and finding support in family, friends and professionals.

DISCUSSION

Perceived benefits, knowledge, experiences in health care settings, and social factors all play important roles in women's behaviours. These factors can co-occur and must be considered together to be able to understand the complexity of prenatal substance use.

CONCLUSION

Increased clinical and community awareness of the modifiable risk factors associated with substance use during pregnancy presented in this study, is necessary to inform future prevention efforts.

Developing a model of care for substance use in pregnancy and parenting services, Sydney, Australia: Service provider perspectives

INTRODUCTION

The absence of a clear model of care for services supporting pregnant women and mothers with substance use disorders has impeded opportunities to build an evidence base for the effectiveness of these services. Previous research has typically focused on the needs of pregnant women or mothers, as two distinct groups. This paper explores service providers' perceptions of key components of a model of care, extending from perinatal care to community-based support for up to 17 years post-delivery. A model of care is outlined and feasibility factors affecting implementation are highlighted.

METHODS

Qualitative methods were adopted as a first step to informing development of the model of care. Semi-structured in-depth interviews were conducted with thirty-eight staff providing a range of substance use in pregnancy and parenting services (SUPPS) in hospital and community-based agencies, in a metropolitan health district in Sydney, Australia. Interview data was entered into NVivo and analysed using constant comparative methods.

RESULTS

Guiding principles for the model of care included integrated care, harm reduction and person-centredness. Practice approaches integral to the model of care were promoting engagement with women, flexible service provision, trauma-informed care, and continuity of care. Feasibility factors influencing implementation of the model of care included fragmentation or siloing of the service network and workforce sustainability.

CONCLUSIONS

A harm reduction approach was crucial for promoting engagement of women with SUPPS, particularly child protection services. A greater focus on providing ongoing community-based support for mothers also has the potential to achieve sustainable positive outcomes for women and children. Implementation of the SUPPS model of care could be undermined by threats to integration of service delivery and continuity of care. Further research is needed to explore consumer perspectives and inform the model of care as a framework for evaluation.

Diagnosing uncertainty, producing neonatal abstinence syndrome

The use of alcohol and other drugs during pregnancy is understood to be an important public health problem. One way in which this problem is expressed and responded to is via the identification and treatment of neonatal abstinence syndrome (NAS). In this article, we demonstrate how the processes of anticipating, identifying and responding to NAS are characterised by significant uncertainty among parents and health and social care practitioners. We draw on interviews with 16 parents who had recently had a baby at risk of NAS, and multidisciplinary focus groups with 27 health and social care professionals, held in Scotland, UK. NAS, and drug use in pregnancy, is a fraught and complex arena. Parents in the UK who use opioids risk losing custody of children, and must navigate a high degree of surveillance, governance and marginalisation. We suggest that considering NAS as a social diagnosis, further informed by Mol's political ontology of 'multiple' bodies/diseases, may help to produce clinical and social responses to uncertainty which avoid, rather than promote, further marginalisation of parents who use drugs. One such response is to develop a culture of relationship-based care which empowers both service providers and service users to challenge existing practice and decision-making.

Sociocultural aspects of drug dependency during early pregnancy and considerations for screening: Case studies of social networks and structural violence

OBJECTIVE

To contribute in closing the current gap in literature that holistically examines sociocultural influences on perinatal drug dependency. This article draws from social network theory and structural violence to qualitatively consider the contextual components of addiction and substance use during pregnancy, which purposefully moves away from situating this issue from solely being within the contexts of pathologized disorders or products of social inequalities.

DESIGN

Face-to-face semi-structured interviews with drug-dependent pregnant women identified during a reproductive environmental health consultation.

SETTING

Interviews were conducted at a university hospital in southeastern Spain between October 2015 and June 2016.

PARTICIPANTS

10 pregnant women with confirmed perinatal substance use and/or drug dependency.

FINDINGS

The sociocultural perspective offers a useful lens by which providers can understand the reasons for initial substance use and progress of multi-drug dependency as way of individually tailoring intervention strategies for expecting mothers. This perspective draws from the frameworks of social network analysis (SNA) and structural violence to dialectically examine drug dependency in this unique patient population not to be solely an individual occurrence, but rather a combination of macro and micro-level factors at play.

KEY CONCLUSIONS

The sociocultural approach in examining maternal health allows for the holistic exploration of the already taboo and symbolically paradoxical phenomenon of drug dependency in pregnant women.

IMPLICATIONS FOR PRACTICE

The "Hoja Verde" and similar perinatal screening methods that comprehensively assess for the potential of environmental risks can be a key instrument in the practice of preventing developmental issues of children as early as pregnancy and into adolescence.

Midwifery student's perceptions of caring for substance-using pregnant women

AIM

To identify undergraduate and postgraduate student midwives' attitudes towards women using licit and illicit substances during pregnancy.

BACKGROUND

Literature shows that globally, substance misuse during pregnancy is growing rapidly. Women who use substances during their pregnancy have specific healthcare needs and require midwives to demonstrate positive attitudes to improve appointment compliance and treatment completion.

METHODS

A cross-sectional quantitative survey design was used. A total of 42 surveys were retained for full data analysis.

FINDINGS

Of the 42 participants, 22 were undergraduate midwifery students and 20 were postgraduate midwifery students. The results revealed that both undergraduate and postgraduate students had positive attitudes towards women who used substances during pregnancy. Specifically, postgraduate students, with 1-2 years' experience looking after pregnant women, had the most positive attitudes towards substance use in pregnancy.

CONCLUSION

This study revealed that undergraduate and postgraduate midwifery students have positive attitudes towards women who misuse illicit and licit substances, which is important for providing quality care upon qualification as a registered midwife. It is essential that midwifery students, who will go on to qualify as registered midwives, are non-judgmental and positive to ensure adequate antenatal care and regular antenatal attendance so maternal and fetal wellbeing can be better managed.

Midwives' attitudes towards pregnant women using substances: Informing a care pathway

OBJECTIVE

The purpose of this study was to identify midwives' attitudes towards women using substances during pregnancy, which informed the development of an integrated care pathway for the provision of optimal care.

METHODS

A mixed methods research design was used, that included an online survey via the online survey tool Qualtrics™ which collected quantitative data, and interviews and focus groups were used to collect qualitative data.

FINDINGS

Participants held a positive or neutral view towards women who used substances during pregnancy, and the participants had an empathetic perception of the issue of substance use within pregnancy, believing that women were using substances due to the environment and circumstances that they lived in, and that they had been raised and socialised in.

CONCLUSION

Caring for women during pregnancy with substance misuse issues is complex and requires coordination and multidisciplinary care. Midwives have the capacity to provide sensitive midwifery care but require the framework to ensure women needing additional resources during pregnancy receive the services available and specific to their needs. The midwives in this study were supportive of developing an integrated care pathway to allow for collaborative care, and to enable a specialised midwifery approach.

Feeding Infants with Neonatal Abstinence Syndrome: Finding the Sweet Spot

PURPOSE

The purpose of this study is to learn how caregivers who are expert in feeding infants with neonatal abstinence syndrome (NAS) successfully feed these infants during withdrawal.

DESIGN/SAMPLE

Focus group methodology was used to gather information from self-identified experts from three large regional NICUs. Twelve NICU nurses and speech therapists participated in open-ended, recorded discussions. Detailed flip chart notes were taken, reviewed, and verified by the participants before the group ended.

RESULTS

Four major themes emerged verified by the participants: (1) optimal medication management, (2) follow the baby's cues, (3) calm and comfortable, and (4) nurture the relationship. Participants reported using both common and creative techniques. Keeping the infant calm was crucial to being successful, as well as maintaining good control of withdrawal signs. Feeding the infant facing away from them to avoid eye contact was used, as well as vertical rocking, continuous butt patting, bundling, "shhing" sound, and a novel feeding position.

Mothers with substance and alcohol abuse-support through pregnancy and early infancy

This article is about the support given to pregnant women and mothers, at an antenatal and child welfare team in Gothenburg (Sweden), specialised on working with mothers who abuse alcohol and/or other substances. The study consists of interviews with 17 women. The aim of the article is to account for how the women experienced the support they got and how they perceived the impact. The results show the importance for the staff of finding the balance between control and support and of creating a non-judgmental attitude in order to build trusting relationships with the women. The organization of the MBHV-team is a prerequisite for the staff to be able to design support based on an assessment of the mother's whole situation.

Psychiatric Co-Morbidities in Pregnant Women with Opioid Use Disorders: Prevalence, Impact, and Implications for Treatment

Purpose of Review

This review seeks to investigate three questions: What is the prevalence of comorbid psychiatric diagnoses among pregnant women with opioid use disorder (OUD)? How do comorbid psychiatric illnesses impact pregnant women with OUD? And how do comorbid psychiatric illnesses affect the ability of pregnant women with OUD to adhere to and complete OUD treatment?

Recent Findings

Based on this literature review, 25–33% of pregnant women with OUD have a psychiatric comorbidity, with depression and anxiety being especially common. However, of the 17 studies reviewed only 5 have prevalence rates of dual diagnosis in pregnant women with OUD as their primary outcome measures, their N’s were typically small, methods for determining psychiatric diagnosis were variable, and many of the studies were undertaken with women presenting for treatment which carries with its implicit selection bias. Of the women enrolled in treatment programs for SUD, those with psychiatric comorbidity were more likely to have impaired psychological and family/social functioning than those without psychiatric comorbidity. Greater severity of comorbid psychiatric illness appears to predict poorer adherence to treatment, but more research is needed to clarify this relationship with the psychiatric illness is less severe.

Summary

While cooccurrence of psychiatric disorders in pregnant women with opioid use disorder appears to be common, large population-based studies with validated diagnostic tools and longitudinal assessments are needed to obtain definitive rates and characteristics of cooccurring illnesses. Integrated prenatal, addiction, and psychiatric treatment in a setting that provides social support to pregnant patients with OUD is most effective in maintaining women in treatment. More research is still needed to identify optimal treatment settings, therapy modalities, and medication management for dually diagnosed pregnant women with OUD.

Making a Difference: The Experiences of Midwives Working With Women Who Use Illicit Drugs

AIM:This article describes the experiences of midwives who choose to work with pregnant women who use illicit drugs.

BACKGROUND:Pregnant women who use illicit drugs present complex challenges for those who choose to work with them. Society’s views on illicit drug use fluctuate from acceptance and harm minimization to reprimand and retribution.

METHOD:Qualitative interviews were conducted between June and August 2009 with 12 Australian midwives. A thematic analysis method informed by hermeneutic phenomenology was applied to interpret this data to explicate lived experiences and gain deeper understanding and meanings of this phenomenon.

FINDINGS:Three major themes encapsulated the experience: making a difference, making partnerships, and learning to let go. The focus of this article, “making a difference,” included two subthemes of “working on the margins” and “transition and transformation.” The midwives were both rewarded and challenged by the needs of women who use illicit drugs and by the systems in which they worked.

CONCLUSIONS:The midwives acknowledged that their aspirations “to make a difference” was not always sufficient when working with women who use illicit drugs. They also require the establishment of maternity services that are compassionate and accessible, including woman–care provider partnerships and continuity of the care environments.