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Schiff DM, Li WZM, Work EC, Goullaud L, Vazquez J, Paulet T, Dorfman S, Selk S, Hoeppner BB, Wilens T, Bernstein JA, Diop H. Multiple marginalized identities: A qualitative exploration of intersectional perinatal experiences of birthing people of color with substance use disorder in Massachusetts. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 163:209346. [PMID: 38789329 DOI: 10.1016/j.josat.2024.209346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/29/2024] [Accepted: 03/01/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals. METHODS Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development. RESULTS The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination. CONCLUSION Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.
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Affiliation(s)
- Davida M Schiff
- Division of General Academic Pediatrics, MassGeneral for Children, 125 Nashua St. Suite 860, Boston, MA 02114, United States of America; Division of Newborn Medicine, MassGeneral for Children, Boston, MA, 02114, United States of America.
| | - William Z M Li
- Harvard Medical School, Boston, MA, United States of America
| | - Erin C Work
- University of California, Schools of Public Health and Social Welfare, Los Angeles, CA, United States of America
| | - Latisha Goullaud
- Institute for Health and Recovery, Watertown, MA, United States of America
| | | | - Tabhata Paulet
- Rutgers New Jersey Medical School, Newark, NJ, United States of America
| | - Sarah Dorfman
- Division of General Academic Pediatrics, MassGeneral for Children, 125 Nashua St. Suite 860, Boston, MA 02114, United States of America
| | - Sabrina Selk
- National Network of Public Health Initiatives, Washington, DC, United States of America
| | - Bettina B Hoeppner
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA 02114, United States of America
| | - Timothy Wilens
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, United States of America
| | - Judith A Bernstein
- Division of Community Health Sciences, Boston University School of Public Health, Boston, MA, United States of America
| | - Hafsatou Diop
- Massachusetts Department of Public Health, Boston, MA, 02108, United States of America
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Martinez NG, Roberts SCM, Achu-Lopes RA, Samura TL, Seidman DL, Woodhams EJ. Reconsidering the use of urine drug testing in reproductive settings. Am J Obstet Gynecol MFM 2023; 5:101206. [PMID: 37871695 DOI: 10.1016/j.ajogmf.2023.101206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 10/25/2023]
Abstract
The urine drug test is ubiquitous within reproductive healthcare settings. Although the test can have evidence-based use for a patient and clinician, in practice, it is often applied in ways that are driven by bias and stigma, do not correctly inform decisions about clinical aspects of patient care, and cause devastating ripple effects through social and legal systems. This paper proposes a framework of guiding questions to prompt reflection on (1) the question the clinical team is trying to answer, (2) whether a urine drug test answers the question at hand, (3) how testing benefits compare with the associated risks, (4) a more effective tool for clinical decision-making if the urine drug test does not meet the standards for use, and (5) individual and institutional biases affecting decision-making. We demonstrate the use of this framework using 3 common uses of the urine drug test within abortion care and labor and delivery settings.
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Affiliation(s)
- Noelle G Martinez
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (Dr Martinez).
| | - Sarah C M Roberts
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Oakland, CA (Dr Roberts)
| | - Rachel A Achu-Lopes
- Department of Anesthesia, Boston Medical Center, Boston University School of Medicine, Boston, MA (Dr Achu-Lopes)
| | - Tirah L Samura
- Los Angeles County Department of Health Services, Harbor-University of California Los Angeles Medical Center, Los Angeles, CA (Dr Samura); Los Angeles County Department of Health Services, Martin Luther King, Jr. Outpatient Center, Los Angeles, CA (Dr Samura)
| | - Dominika L Seidman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA (Dr Seidman)
| | - Elisabeth J Woodhams
- Department of Obstetrics & Gynecology, Boston Medical Center, Boston University School of Medicine, Boston, MA (Dr Woodhams)
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West BS, Choi S, Terplan M. In our responses to the overdose epidemic, we cannot forget pregnant and postpartum people. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 120:104153. [PMID: 37572587 DOI: 10.1016/j.drugpo.2023.104153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/10/2023] [Accepted: 07/27/2023] [Indexed: 08/14/2023]
Abstract
In 2021, there were over 100,000 drug overdose deaths in the United States (US). Death rates have increased faster among women than men, particularly among Black and Indigenous people. Although drug overdose is a leading cause of pregnancy-associated deaths, birthing people are rarely emphasized in discussions of overdose and research and services remain limited. Data show increases in drug use and deaths among women of child-bearing age, with risks continuing in the postpartum period. Harms experienced by birthing people who use drugs occur in the context of broader inequities in maternal morbidity and mortality that lead to disparate reproductive health outcomes. Shared structural antecedents (e.g. intersecting sexism and racism, stigma, and punitive policies) underlie overlapping epidemics of overdose and maternal morbidity and mortality. Here we discuss the unique challenges placed on birthing people who use drugs and make recommendations on how to mitigate harms by improving access to and delivery of quality care and addressing unjust policies and practices. We highlight the need for integrated health services, clearer guidelines rooted in equity, and the need for changes to policy and practice that support rather than punish. To better serve individuals and families impacted by substance use, we need multilevel solutions that advance gender equity and racial justice to reshape and/or dismantle the systems that undergird oppression.
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Affiliation(s)
- Brooke S West
- Columbia University School of Social Work, United States.
| | - Sugy Choi
- Department of Population Health, New York University Langone Health, United States
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Siegel MR, Cohen SJ, Koenigs K, Woods GT, Schwartz LN, Sarathy L, Chou JH, Terplan M, Wilens T, Ecker JL, Bernstein SN, Schiff DM. Assessing the clinical utility of toxicology testing in the peripartum period. Am J Obstet Gynecol MFM 2023; 5:100963. [PMID: 37030508 DOI: 10.1016/j.ajogmf.2023.100963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Toxicology testing is frequently used as a means of gathering objective data about substance use in pregnancy, but little is known about the clinical utility of testing in the peripartum setting. OBJECTIVE This study aimed to characterize the utility of obtaining maternal-neonatal dyad toxicology testing at the time of delivery. STUDY DESIGN We performed a retrospective chart review of all deliveries in a single healthcare system in Massachusetts between 2016 and 2020, and identified deliveries with either maternal or neonatal toxicology testing at delivery. An unexpected result was defined as a positive test for a nonprescribed substance that was not known on the basis of clinical history, self-report, or previous toxicology testing within a week of delivery, excluding results for cannabis. We evaluated the characteristics of maternal-infant dyads with unexpected positive results, unexpected positive results by rationale for testing, changes in clinical management after an unexpected positive test, and maternal outcomes in the year after delivery using descriptive statistics. RESULTS Of the 2036 maternal-infant dyads with toxicology tests performed during the study period, there were 80 (3.9%) with an unexpected positive result. Diagnosis of substance use disorder with active use in the last 2 years was the clinical rationale for testing that yielded the greatest number of unexpected positive results (10.7% of total tests ordered for this rationale). Inadequate prenatal care (5.8%), maternal use of medication for opioid use disorder (3.8%), maternal medical indications such as hypertension or placental abruption (2.3%), history of substance use disorder in remission (1.7%), or maternal cannabis use (1.6%) yielded lower rates of unexpected results compared with a recent substance use disorder (within the last 2 years). Solely on the basis of findings from unexpected test results, 42% of dyads were referred to child protective services, 30% of dyads had no documentation of maternal counseling during delivery hospitalization, and 31% did not receive breastfeeding counseling after an unexpected test; 22.8% had monitoring for neonatal opioid withdrawal syndrome. Postpartum, 26 (32.5%) were referred to substance use disorder treatment, 31 (38.8%) attended a postpartum mental health visit, and only 26 (32.5%) attended a postpartum visit. Fifteen individuals (18.8%) were readmitted in the year after delivery, all for substance-related medical complications. CONCLUSION Unexpected positive toxicology results at delivery were uncommon, particularly when tests were sent for frequently used clinical rationales for testing, suggesting a need to revisit guidelines surrounding appropriateness of indications for toxicology testing. The poor maternal outcomes in this cohort highlight a missed opportunity for maternal connection to counseling and treatment in the peripartum period.
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Affiliation(s)
- Molly R Siegel
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein).
| | - Samuel J Cohen
- Department of Pediatrics, Boston Medical Center, Boston, MA (Dr Cohen)
| | - Kathleen Koenigs
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | - Gregory T Woods
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | | | - Leela Sarathy
- Division of Newborn Medicine, Massachusetts General Hospital for Children, Boston, MA (Dr Sarathy and Dr Chou)
| | - Joseph H Chou
- Division of Newborn Medicine, Massachusetts General Hospital for Children, Boston, MA (Dr Sarathy and Dr Chou)
| | | | - Timothy Wilens
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, Boston, MA (Dr Wilens)
| | - Jeffrey L Ecker
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | - Sarah N Bernstein
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston, MA (Dr Siegel, Dr Koenigs, Dr Woods, Dr Ecker, and Dr Bernstein)
| | - Davida M Schiff
- Division of General Academic Pediatrics, Massachusetts General Hospital for Children, Boston, MA (Dr Schiff)
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Test or Talk. Obstet Gynecol 2022; 140:150-152. [DOI: 10.1097/aog.0000000000004884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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