Barriers to women's disclosure of and treatment for substance use during pregnancy: A qualitative study

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.

Assessment of substance exposures in nail clipping samples: A systematic review

BACKGROUND

Studies of prenatal substance exposure often rely on self-report, urine drug screens, and/or analyses of blood or meconium biomarkers. Accuracy of these measures is limited when assessing exposure over many weeks or months of gestation. Nails are increasingly being considered as a matrix from which to assess substance exposure. This systematic review synthesizes data on the validity of detecting alcohol, nicotine, cannabis, and opioid from nail clippings, with an emphasis on prenatal exposure assessment.

METHODS

The systematic review was conducted using PRISMA 2020 guidelines. Seven databases were searched with keywords relevant to the four substances of interest. Results were summarized grouping manuscripts by the exposure of interest with focus on accuracy and feasibility.

RESULTS

Of 2384 papers initially identified, 35 manuscripts were included in our qualitative synthesis. Only a few studies specifically looked at pregnant individuals or mother-child dyads. Across the four substances, many studies demonstrated a dose-response relationship between exposure and concentration of analytes in nails. Nail assays appear to detect lower level of exposure compared to hair; however, sample insufficiency, especially for multi-substance assays, remains a limitation.

CONCLUSIONS

Based on the reviewed studies, nail clippings are an acceptable and potentially preferable matrix for the evaluation of these four prenatal substances when sampling frequency and/or study design necessitates assessment of past exposures over an extended period. Nails have the advantage of infrequent sampling and minimal invasiveness to assess a broad exposure period. Future studies should examine validity of analytes in toenail versus fingernail clippings.

Marijuana Use among Pregnant and Nonpregnant Women of Reproductive Age, 2013-2019

BACKGROUND

Marijuana is the most commonly used federally illicit substance among reproductive-age women in the United States. Updated information on marijuana use in this population can inform clinical and public health interventions.

METHODS

Data from the 2013-2019 National Survey on Drug Use and Health was used to report weighted prevalence estimates of marijuana use in the past month, past 2-12 months, and past year among women aged 18-44 years with self-reported pregnancy status. Bivariate analyses and general linear regression models with Poisson distribution using appropriate survey procedures identified factors associated with past-year marijuana use by pregnancy status.

RESULTS

Among pregnant women, 4.9% (95% confidence interval [CI]: 4.1-5.6) reported marijuana use in the past month, 10.4% (95% CI: 9.3-11.5) in the past 2-12 months, and 15.2% (95% CI: 13.9-16.6) in the past year. Among nonpregnant women, 11.8% (95% CI: 11.5-12.0) reported marijuana use in the past month, 7.8% (95% CI: 7.6-8.0) in the past 2-12 months, and 19.5% (95% CI: 19.2-19.9) in the past year. After adjusting for sociodemographic characteristics, past-year marijuana use was 2.3-5.1 times more likely among pregnant, and 2.1 to 4.6 times more likely among nonpregnant women who reported past-year tobacco smoking, alcohol use, or other illicit drug use compared to those reporting no substance use.

CONCLUSIONS

Pregnant and nonpregnant women reporting marijuana use, alone or with other substances, can benefit from substance use screening and treatment facilitation.

Substance use among pregnant women in NSW prisons

INTRODUCTION AND AIMS

Little is published about pregnant women in custody. Existing data on the prevalence of substance use among incarcerated pregnant women or their needs are scant. This study sought to determine the prevalence and characteristics of women with substance use histories who present to prison pregnant in New South Wales (NSW), Australia.

DESIGN AND METHODS

A retrospective review of prison medical health records was completed for pregnant women entering New South Wales custodial settings between January 2020 and June 2021.

RESULTS

We identified 158 prison receptions among 141 pregnant women (median age 28 years [IQR 25-33 years]), 42 % identified as Aboriginal or Torres Strait Islander. Eighty four percent of the women (n = 119) reported recent use of one or more than one substance and 36 % had injected drugs. The most commonly used substances were (meth)amphetamine (60 %), cannabis (40 %) and opioids (28 %). We found discrepancies between drug problems self-reported at reception screening on entry to prison and self-reported drug use collected during the subsequent drug and alcohol specialist assessment while incarcerated. Most (88 %) women described their current pregnancy as unplanned and half (52 %) were unaware they were pregnant before incarceration.

CONCLUSIONS

These findings highlight the high prevalence of substance use in incarcerated pregnant women and that many women are unaware of their pregnancy prior to incarceration. Findings emphasize the importance of timely and appropriate drug and alcohol assessment and treatment to minimize harm for both the mother and foetus and also underscore the urgent need for enhanced access to contraception for these women.

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.

Academy of Breastfeeding Medicine Clinical Protocol #21: Breastfeeding in the Setting of Substance Use and Substance Use Disorder (Revised 2023)

Background: The Academy of Breastfeeding Medicine (ABM) revised the 2015 version of the substance use disorder (SUD) clinical protocol to review the evidence and provide updated literature-based recommendations related to breastfeeding in the setting of substance use and SUD treatments. Key Information: Decisions around breastfeeding are an important aspect of care during the peripartum period, and there are specific benefits and risks for substance-exposed mother-infant dyads. Recommendations: This protocol provides breastfeeding recommendations in the setting of nonprescribed opioid, stimulant, sedative-hypnotic, alcohol, nicotine, and cannabis use, and SUD treatments. Additionally, we offer guidance on the utility of toxicology testing in breastfeeding recommendations. Individual programs and institutions should establish consistent breastfeeding approaches that mitigate bias, facilitate consistency, and empower mothers with SUD. For specific breastfeeding recommendations, given the complexity of breastfeeding in mothers with SUD, individualized care plans should be created in partnership with the patient and multidisciplinary team with appropriate clinical support and follow-up. In general, breastfeeding is recommended among mothers who stop nonprescribed substance use by the time of delivery, and they should continue to receive ongoing postpartum care, such as lactation support and SUD treatment. Overall, enhancing breastfeeding education regarding substance use in pregnancy and lactation is essential to allow for patient-centered guidance.

"It's a proactive intervention instead of a reactive one": measuring facilitators and barriers regarding readiness to implement a treatment program for infants with neonatal opioid withdrawal syndrome

BACKGROUND

Managing Abstinence in Newborns (MAiN) is an evidence-based, cost-saving approach to caring for infants at risk of developing neonatal opioid withdrawal syndrome (NOWS). MAiN provides medication management in combination with education and is being implemented in hospitals across South Carolina (SC). This expansion of MAiN throughout the state includes educational training for providers on managing NOWS symptomology and evaluation support for data collection and analysis. This evaluation assessed the readiness of hospitals to implement MAiN by identifying potential barriers and facilitators to early program adoption.

METHODS

We used the Consolidated Framework for Implementation Framework (CFIR) to guide the evaluation. As part of the ongoing evaluation of MAiN implementation, brief, structured interviews were conducted with healthcare providers (n = 82) at seven hospitals between 2019 and 2022 to learn more about perceived barriers and facilitators to implementation readiness. Two coders independently reviewed all transcripts and used deductive thematic analysis to code qualitative data using Atlas.ti Web using the established CFIR codebook.

RESULTS

We identified barriers and facilitators to implementing MAiN in all five CFIR domains. Providers identified MAiN as an evidence-based, patient-centered model with the flexibility to adapt to patients' complex needs. Specific champions, external support, alignment with providers' personal motivation, and an adaptable implementation climate were identified as facilitators for implementation readiness. Barriers included a lack of consistent communication among hospital providers, minimal community resources to support patients and families after discharge, and a lack of provider buy-in early in implementation.

CONCLUSIONS

Key barriers and facilitators of MAiN implementation readiness were identified at seven participating hospitals throughout SC. Communication, staff and hospital culture and climate, and internal and external resource were all reported as essential to implementation. These findings could inform the MAiN program expansion in hospitals across SC.

Stigma Experienced by Rural Pregnant Women with Substance Use Disorder: A Scoping Review and Qualitative Synthesis

Identification and recognition of experiences of rural pregnant women with substance use disorder is needed to inform public policy and medical training. This paper reviews and qualitatively synthesizes literature exploring the experiences of this population. Embase, PubMed, and Web of Science were used to identify literature through August 2022 using the search terms, such as pregnancy, substance use or abuse, stigma, and rural. Cited and citing research were also considered. Exclusion criteria included articles that failed to consider rural pregnant women's perspectives on stigma experienced, included potential confounds, occurred outside of the United States or Canada, and were published before January 2000. Nine articles met the inclusion criteria. Data were synthesized by the listed authors and assessed for common themes. A review of the articles revealed three common themes: stigma occurs in community settings, stigma occurs in healthcare settings, and comprehensive care is important to ensure appropriate support to this population. Stigma as a barrier seems to improve when women have strong social support and access to comprehensive care networks. Addressing this stigma through programs, such as peer social guidance and comprehensive health centers, may provide appropriate support to pregnant, rural women with SUD to further navigate their health needs.

Canadian Resources on Cannabis Use and Fertility, Pregnancy, and Lactation: Scoping Review

BACKGROUND

Cannabis use among reproductive-aged Canadians is increasing, but our understanding of its impacts on fertility, pregnancy, and breast milk is still evolving. Despite the availability of many web-based resources, informed decision-making and patient counseling are challenging for expectant families and providers alike.

OBJECTIVE

We aimed to conduct a scoping review of publicly available web-based Canadian resources to provide information on the effects of cannabis on fertility, pregnancy, and breast milk.

METHODS

Following PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews), we systematically searched 8 databases between January 1, 2010, and November 30, 2020, and web pages of 71 Canadian obstetrical, government, and public health organizations. We included English resources discussing the effects of cannabis on fertility, pregnancy, breastfeeding, or the exposed fetus and infant. Epidemiological characteristics, readability, and content information were extracted and summarized.

RESULTS

A total of 183 resources met our inclusion criteria. Resources included content for public audiences (163/183, 89.1%) and health care providers (HCPs; 31/183, 16.9%). The resources were authored by national-level (46/183, 25.1%), provincial or territorial (65/183, 35.5%), and regional (72/183, 39.3%) organizations. All provinces and territories had at least one resource attributed to them. The majority (125/183, 68.3%) were written at a >10 grade reading level, and a few (7/183, 3.8%) were available in languages other than English or French. The breadth of content on fertility (55/183, 30.1%), pregnancy (173/183, 94.5%), and breast milk or breastfeeding (133/183, 72.7%) varied across resources. Common themes included citing a need for more research into the effects of cannabis on reproductive health and recommending that patients avoid or discontinue cannabis use. Although resources for providers were consistent in recommending patient counseling, resources targeting the public were less likely to encourage seeking advice from HCPs (23/163, 14.1%).

CONCLUSIONS

Canadian resources consistently identify that there is no known safe amount of cannabis that can be consumed in the context of fertility, pregnancy, and breastfeeding. Areas of improvement include increasing readability and language accessibility and encouraging bidirectional communication between HCPs and patients.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1136/bmjopen-2020-045006.

Treatment providers' perspectives on a gender-responsive approach in alcohol and drug treatment for women in Belgium

BACKGROUND

Gender inequity is a pervasive challenge to health equity on a global scale, and research shows the impact of sex and gender on substance use regarding for example epidemiology, treatment needs, treatment admission and treatment outcomes. The gender-transformative approach to action and health indicates that health interventions may maintain, exacerbate or reduce gender-related health inequalities, depending on the degree and quality of gender-responsiveness within the programme or policy. However, research shows a lack of gender-responsive initiatives in the alcohol and drug addiction field.

AIMS

The purpose of this study is to explore in depth how alcohol and drug treatment can be made more sensitive to female users' treatment needs from the perspective of service providers. Consequently, study findings can inform the development of gender-responsive treatment options and aid to a deeper understanding of how these trends are designated on the continuum of approaches to action and health in the alcohol and drug field.

METHODS

Four focus groups were organized across different regions in Belgium with a total of 43 participants, including service providers, policy makers and women who use(d) drugs.

RESULTS

The perspective of the participants on substance use prevention and treatment for female users incorporates some crucial gender-specific and gender-transformative features. Next to implementing mother-child options, a holistic approach, experts by experience and empowering women in treatment, professionals report the relevance of awareness raising campaigns targeting all levels and sectors in society. Also, recurring attention was given to the role of men in the narratives of female users.

CONCLUSION

Study findings show that the field of alcohol and drug prevention and treatment is being looked at through the lens of gender-responsiveness. However, to achieve improvement in the lives of both women and men, and hence creating more equal chances and opportunities in substance abuse treatment, the gender-transformative approach in addiction care needs to be further explored, criticized and established in practice and future research.