The Prevalence and Impact of Substance Use Disorder and Treatment on Maternal Obstetric Experiences and Birth Outcomes Among Singleton Deliveries in Massachusetts

"If We Didn't Have Our Babies, We Wouldn't Be Here Right Now": A Qualitative Exploration of New Motherhood While Navigating Substance Use Disorder Recovery

BACKGROUND

Postpartum women with substance use disorder (SUD) are at heightened risk of adverse health outcomes problems. The current understanding of early motherhood while managing SUD is poorly understood, as the transitional period following delivery has been a neglected area within research. This qualitative study examined how postpartum women balance new motherhood while navigating early recovery from SUDs.

METHODS

The primary aim was to elicit individual experiences in the context of maternal functioning (social support, psychological well-being, infant care, self-care, mother-child interaction, management, and adjustment). In 2023, we purposefully recruited a sample of postpartum women receiving residential services for SUD (N = 22) and conducted semi-structured individual interviews. Interviews were audio-recorded and transcribed verbatim, and codes were analyzed using deductive and subsequent inductive analysis to identify themes unique to each functioning domain among postpartum women with SUDs.

RESULTS

Participants were predominately white (81%), single (86%), and between 20 and 40 years of age and were the primary caregivers for their children, and half were less than 3 months postpartum. Balancing infant care and self-care was cited as a significant challenge. Several participants expressed a need for more early parenting support and assistance in navigating social services and life after leaving residential treatment. Pregnancy catalyzed entering and remaining in treatment while remaining engaged in recovery and sustaining sobriety was a form of self-care. The social network gained as part of the treatment was frequently described as crucial for new moms to care for their children while navigating early recovery.

CONCLUSIONS

This study highlights the importance of exploring the postpartum experience and needs among postpartum people in SUD recovery. Maintaining recovery through sustainable sobriety was considered a form of self-care, indicating that the postpartum period is a critical point in both a mother's life and a unique intervention point for postpartum women with SUD.

Maternal Chronic Physical Conditions and Alcohol and Substance Use Disorders in the Preconception and Perinatal Periods

Background: Chronic physical conditions (CPC) and alcohol and substance use disorders (SUD) frequently co-occur, but this has not been examined perinatally. We explored the combined effects of CPC and prepregnancy SUD on perinatal SUD-related adverse events and outpatient care. Materials and methods: This population-based study comprised 77,474 people with and 664,751 without CPC with a birth in Ontario, Canada, 2013-2020. We measured the prevalence of prepregnancy SUD in both groups. We then calculated adjusted relative risks (aRR) of: (1) SUD-related adverse events (toxicity resulting in acute care use/death, or other SUD-related acute care use) and (2) outpatient care for SUD between conception and 365 days postpartum, comparing individuals with prepregnancy CPC and SUD (CPC + SUD), and those with CPC or SUD alone, to those with neither condition. Finally, adjusted relative excess risk due to interaction (aRERI) was calculated to quantify excess risk of the outcomes associated with CPC + SUD, wherein RERI > 0 indicated positive interaction. Results: aRRs of perinatal SUD-related adverse events were 26.79 (95% confidence interval [CI]: 23.12, 31.04) for people with CPC + SUD, 22.09 (95% CI: 19.59, 24.91) for SUD alone, and 2.01 (95% CI: 1.78, 2.27) for CPC alone-each relative to neither condition. There was evidence of positive interaction for CPC + SUD (aRERI: 3.69, 95% CI: 1.13, 6.46). Similar elevated aRRs were observed for perinatal outpatient care for SUD, but without a positive interaction for people with CPC + SUD. Conclusion: As people with both CPC and SUD have the highest risk of perinatal SUD-related adversity, they may need greater preconception and perinatal support.

Weighing Risks and Benefits: Patient Perceptions on Using Medications for Opioid Use Disorder During and After Pregnancy

BACKGROUND

Opioid use disorder (OUD) among pregnant and postpartum persons has increased in the last 20 years and poses risks to both birthing parent and fetus/child. Medication for opioid use disorder (MOUD) can reduce these risks, yet engagement is limited among pregnant and postpartum persons with over half discontinuing in the postpartum year. Little research has explored pregnant and postpartum persons' reasons for using MOUD in pregnancy and decisions around (dis)continuing after childbirth. We sought to gain a deeper understanding of the reasons pregnant and postpartum persons use MOUD in pregnancy and motivations for continued use or discontinuation postpartum.

METHODS

Individual interviews (n = 4) and focus groups (2 focus groups with total n = 6) were conducted with 10 participants with OUD aged 18 to 45 years who were currently pregnant (50%) or postpartum (50%) and had been treated with MOUD. Interviews and focus groups were transcribed, and a codebook was iteratively created using thematic analysis.

RESULTS

Five themes and 7 subthemes emerged within 2 domains representing experiences with MOUD during pregnancy (domain 1) and postpartum (domain 2). Participants were highly motivated toward MOUD in pregnancy for the benefits to themselves and their unborn children but acknowledged several drawbacks including the possibility of fetal/neonatal withdrawal. Reasons for MOUD use postpartum shifted toward improving maternal mental health and parenting. Several participants anticipated eventually tapering MOUD within the postpartum year as they no longer saw a distinct need for it.

CONCLUSION

Despite perceived risks, pregnant and postpartum persons with OUD have many motivations to use MOUD during pregnancy that may shift in the postpartum period. Our findings underscore the importance of education and shared decision-making and emphasize the need for leveraging pre- and postnatal motivation for MOUD during these conversations and throughout course of treatment.

Maternal and Neonatal Risk Factors Associated with Positive Toxicology Results

The incidence of substance use disorder (SUD) during pregnancy continues to increase; however, the identification of SUD is challenging. The significance of individual risk factors and their association with toxicology is contentious. To identify maternal and neonatal risk factors associated with positive toxicology results for nonprescribed substance use during pregnancy.This retrospective study included pregnant persons and their infants, who were screened for predetermined risk factors for SUD during pregnancy. The toxicology test results of pregnant persons' urine and infants' urine, meconium/umbilical cord were correlated with risk factors.Maternal risk factors (history of prepregnancy or current SUD, on medication for opioid use disorders, insufficient prenatal care, sexually transmitted and blood-borne infections) and neonatal risk factors (neonatal opioid withdrawal syndrome, intrauterine growth restriction) showed a correlation with toxicology results.Combining maternal and neonatal risk factors with toxicology testing may accurately identify SUD in pregnancy. · Minimal prenatal care can be associated with positive infant toxicology.. · Intrauterine growth restriction/small for gestational age can be associated with positive infant toxicology.. · Combined maternal and infant testing is more sensitive at detecting prenatal substance use..

Predictors of Participation in Prenatal Substance Use Assessment, Counseling, and Treatment Among Pregnant Individuals in Prenatal Settings Who Use Cannabis

OBJECTIVES

Assessment and counseling are recommended for individuals with prenatal cannabis use. We examined characteristics that predict prenatal substance use assessment and counseling among individuals who screened positive for prenatal cannabis use in prenatal settings.

METHODS

Electronic health record data from Kaiser Permanente Northern California's Early Start perinatal substance use screening, assessment, and counseling program was used to identify individuals with ≥1 pregnancies positive for prenatal cannabis use. Outcomes included completion of a substance use assessment and among those assessed, attendance in Early Start counseling only or Addiction Medicine Recovery Services (AMRS) treatment. Predictors included demographics and past-year psychiatric and substance use disorder diagnoses evaluated with GEE multinomial logistic regression.

RESULTS

The sample included 17,782 individuals with 20,398 pregnancies positive for cannabis use (1/2011-12/2021). Most pregnancies (80.3%) had an assessment. Individuals with Medicaid, anxiety, depression and tobacco use disorders, compared to those without, had higher odds and those with greater parity, older age (≥35) and in later trimesters, had lower odds of assessment. Among 64% (n = 10,469) pregnancies needing intervention based on assessment, most (88%) attended Early Start counseling only or AMRS (with or without Early Start). Greater parity and later trimester assessment was associated with lower odds, while Medicaid was associated with higher odds of Early Start counseling. Nearly all diagnosed psychiatric and substance use disorders were associated with higher odds of AMRS treatment.

CONCLUSIONS

A comprehensive prenatal substance use program engaged most pregnant individuals with prenatal cannabis use in substance use assessment and counseling. Opportunities to improve care gaps remain.

"Someone is there with you through this [pregnancy] that isn't seeing you through a negative lens": Considerations for integrating doula referrals into opioid treatment programs

INTRODUCTION

Pregnancy-associated mortality involving opioids represents a significant public health issue. Limited social support is a known factor, contributing to a more complex recovery and a greater risk for relapse and overdose. Community-based doulas have been used in other marginalized populations yet are under-studied among pregnant and parenting persons with Opioid Use Disorder (OUD). Therefore, we aimed to investigate the perspectives of Opioid Treatment Program (OTP) clinical staff and community doulas about doula support for persons with perinatal OUD to 1) describe the perceived utility of doula support and 2) identify structural considerations for integrating doula support at an OTP.

METHODS

This study conducted focus groups and utilized domains of the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Purposive sampling recruited 10 participants (5 doulas, 5 OTP staff: 1 clinical director, two counselors, one nurse, and one Community Health Worker) from an OTP program and a Philadelphia Department of Public Health Community Doula Support Program (CDSP). One focus group was held for doula staff, and two focus groups were held for OTP clinical staff. Thematic analytic procedures were used to analyze data using NVivo and an interdisciplinary coding team.

RESULTS

Five key themes were identified from the focus group data: 1) Role of advocacy in the court system, 2) Need for collaborative care, 3) Use of doulas to de-stigmatize healthcare experiences, 4) Impact of doula support on recovery, 5) Considerations to integrating doula referrals into OTPs.

CONCLUSION

Perinatal doula support among persons with OUD is perceived as beneficial by critical stakeholders to advocate in healthcare and legal systems, de-stigmatize healthcare experiences, and promote recovery engagement. The implementation recommendations outlined may guide other OTPs looking to integrate doula support to improve maternal outcomes associated with opioid use.

Maternal mental disorders and neonatal outcomes: Danish population-based cohort study

BACKGROUND

Previous studies have indicated associations between maternal mental disorders and adverse birth outcomes; however, these studies mainly focus on certain types of mental disorders, rather than the whole spectrum.

AIMS

We aimed to conduct a broad study examining all maternal mental disorder types and adverse neonatal outcomes which is needed to provide a more complete understanding of the associations.

METHOD

We included 1 132 757 liveborn singletons born between 1997 and 2015 in Denmark. We compared children of mothers with a past (>2 years prior to conception; n = 48 646), recent (2 years prior to conception and during pregnancy; n = 15 899) or persistent (both past and recent; n = 10 905) diagnosis of any mental disorder, with children of mothers with no mental disorder diagnosis before the index delivery (n = 1 057 307). We also considered different types of mental disorders. We calculated odds ratios and 95% CIs of low birthweight, preterm birth, small for gestational age, low Apgar score, Caesarean delivery and neonatal death.

RESULTS

Odds ratios for children exposed to past, recent and persistent maternal mental disorders suggested an increased risk for almost all adverse neonatal outcomes. Estimates were highest for children in the 'persistent' group for all outcomes, with the exception of the association between persistent maternal mental disorders and neonatal death (odds ratio 0.96, 0.62-1.48).

CONCLUSIONS

Our study provides evidence for increased risk of multiple adverse neonatal outcomes among children of mothers with mental disorders, highlighting the need for close monitoring and support for women with mental disorders.

Scarce perinatal social support for women with OUD: Opportunities for doula services

PROBLEM

Persons with opioid use disorder (OUD) often lack social support, which is associated with improved recovery outcomes.

BACKGROUND

In the last two decades, the rate of opioid use disorder (OUD) among pregnant people has quadrupled.

QUESTION

This study aimed to describe the prenatal and postpartum social support networks and needs of persons with OUD and assess perceived acceptability of community-based social supports such as doulas.

METHODS

This mixed methods study utilized quantitative and qualitative data to understand social support structures and needs. Data was collected through surveys -demographics and social mapping; Adverse Childhood Experiences (ACE) tool; Connor Davidson Resilience 25-item (CDRS-25) scale- and a semi-structured interview. A total of 34 participants from a single urban opioid treatment program consented to participate.

FINDINGS

Participants were on average 34.9 years old, White (64.7%), and unemployed (91.2%). Participants described small perinatal social support networks, which decreased in size from the prenatal to postpartum period. Only half (52.9%) reported adequate prenatal and postpartum social support. Doulas and peer recovery support specialists were perceived as valuable in perinatal health, social support, and recovery domains, with interest in doulas seen particularly amongst those with fewer reported supports.

DISCUSSION

The scarcity of prenatal and postpartum social support among persons with OUD is critical to address, given the increased risk of relapse during the postpartum period which has implications for the maternal child dyad.

CONCLUSION

Due to multiple disparities in prenatal and postpartum social support (small networks, inadequate support), doulas represent a trusted community-based support to be integrated into healthcare teams to address maternal morbidity/mortality associated with opioid use.

Perceptions of Primary Care Among Women in Treatment for Opioid Use Disorder: A Qualitative Study

BACKGROUND

Underutilization of primary care and receipt of preventive health services have been reported among women with opioid use disorder. The aim of this study was to describe perceptions of primary care among women in treatment for opioid use disorder.

METHODS

Between May and June 2022, 27 women who were receiving treatment for opioid use disorder from one opioid treatment program participated in this study. Participants completed one data collection session which involved a brief questionnaire followed by a semi-structured interview. Participants were asked questions about their overall experience with primary care as well as perceived facilitators and barriers to primary care utilization and quality. Interview transcripts were analyzed using an inductive thematic approach.

RESULTS

Three themes emerged from the interviews within the domain of "Facilitators to Primary Care," including: (1) coordination of care, (2) continuity of care, and (3) relationship with health care providers. Four themes emerged from the interviews within the domain of "Barriers to Primary Care," including: (1) perceived judgment from health care providers, (2) childcare needs, (3) issues related to location, and (4) issues related to time.

CONCLUSION

Approaches to primary care that help alleviate barriers to care and highlight the aspects of care that are valued may improve quality and utilization of care, thus enhancing the health and well-being of a vulnerable population.

Racial and Ethnic Disparities Among Pregnancies with Substance Use Disorder: Impact on Perinatal Outcomes

Objective: To examine racial/ethnic disparities in severe maternal morbidity (SMM) and adverse pregnancy outcomes (APOs) among pregnant patients with substance use disorder (SUD) compared to individuals without SUD. Materials and Methods: We conducted a cross-sectional analysis of inpatient hospitalizations of pregnant people from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) from 2016 to 2019. ICD-10 codes were used to identify the frequency of SMM and/or APO between those with and without SUD by race/ethnicity. Multilevel logistic regression analyses were performed to identify the effect of race/ethnicity as an independent predictor and as an effect modifier of SMM and APO in patients with SUD. Results: From 2,508,259 hospitalizations, SUD was identified in 6.7% admissions with the highest rate in White patients (8.2%) followed by Black (7.7%) and Hispanic (2.2%) patients. Rate of SMM and APO were increased in patients with SUD in all racial/ethnic groups compared to those without SUD, increasing by 1% and 10%, respectively. Among all patients, Black race was an independent predictor of SMM (adjusted odds ratio [aOR] 2.09; 95% confidence interval [CI]: 2.05-2.13) and APO (aOR 1.58; 95% CI: 1.56-1.59). Hispanic ethnicity was also an independent risk factor for predicting SMM (aOR 1.40; 95% CI: 1.37-1.43). Among Hispanic patients, SUD was associated with an ∼90% increased likelihood of SMM and APO. Conclusion: Although higher rates of SMM and APO are seen among hospitalizations of pregnant people with SUD, racial/ethnic disparities also exist among this population. This warrants further attention and presents an opportunity for intervention and for addressing the root causes of racial and ethnic disparities.

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.

Chronic Opioid Treatment Arrests Neurodevelopment and Alters Synaptic Activity in Human Midbrain Organoids

Understanding the impact of long-term opioid exposure on the embryonic brain is critical due to the surging number of pregnant mothers with opioid dependency. However, this has been limited by human brain inaccessibility and cross-species differences in animal models. Here, a human midbrain model is established that uses hiPSC-derived midbrain organoids to assess cell-type-specific responses to acute and chronic fentanyl treatment and fentanyl withdrawal. Single-cell mRNA sequencing of 25,510 cells from organoids in different treatment groups reveals that chronic fentanyl treatment arrests neuronal subtype specification during early midbrain development and alters synaptic activity and neuron projection. In contrast, acute fentanyl treatment increases dopamine release but does not significantly alter gene expression related to cell lineage development. These results provide the first examination of the effects of opioid exposure on human midbrain development at the single-cell level.

Performance of Phenotype Algorithms for the Identification of Opioid-Exposed Infants

OBJECTIVE

Observational studies examining outcomes among opioid-exposed infants are limited by phenotype algorithms that may under identify opioid-exposed infants without neonatal opioid withdrawal syndrome (NOWS). We developed and validated the performance of different phenotype algorithms to identify opioid-exposed infants using electronic health record data.

METHODS

We developed phenotype algorithms for the identification of opioid-exposed infants among a population of birthing person-infant dyads from an academic health care system (2010-2022). We derived phenotype algorithms from combinations of 6 unique indicators of in utero opioid exposure, including those from the infant record (NOWS or opioid-exposure diagnosis, positive toxicology) and birthing person record (opioid use disorder diagnosis, opioid drug exposure record, opioid listed on medication reconciliation, positive toxicology). We determined the positive predictive value (PPV) and 95% confidence interval for each phenotype algorithm using medical record review as the gold standard.

RESULTS

Among 41 047 dyads meeting exclusion criteria, we identified 1558 infants (3.80%) with evidence of at least 1 indicator for opioid exposure and 32 (0.08%) meeting all 6 indicators of the phenotype algorithm. Among the sample of dyads randomly selected for review (n = 600), the PPV for the phenotype requiring only a single indicator was 95.4% (confidence interval: 93.3-96.8) with varying PPVs for the other phenotype algorithms derived from a combination of infant and birthing person indicators (PPV range: 95.4-100.0).

CONCLUSIONS

Opioid-exposed infants can be accurately identified using electronic health record data. Our publicly available phenotype algorithms can be used to conduct research examining outcomes among opioid-exposed infants with and without NOWS.

Neonatal outcomes of pregnant women attending integrated and standard substance use treatment programs in Ontario, Canada

BACKGROUND

Substance use in pregnancy raises concern given its potential teratogenic effects. Given the unique needs of parenting people and the potential impact for developing children, specialized substance use treatment programs are increasingly being implemented for this population. Substance use treatment is associated with more positive neonatal outcomes compared with no treatment, however treatment models vary limiting our understanding of key treatment components/modelsFew studies have explored the influence of treatment model type (i.e., integrated treatments designed for pregnant clients compared with standard treatment models) and no studies have examined the influence of treatment model on neonatal outcomes using Canadian data.

METHOD

We conducted a population-based cohort study of clients who were pregnant when initiating integrated (n = 564) and standard (n = 320) substance use treatment programs in Ontario, Canada.

RESULTS

Neonatal outcomes did not significantly differ by treatment type (integrated or standard), with rates of adverse neonatal outcomes higher than published rates for the general population, despite receipt of adequate levels of prenatal care. While this suggests no significant impact of treatment, it is notable that as a group, clients engaged in integrated treatment presented with more risk factors for adverse neonatal outcomes than those in standard treatment. While we controlled for these risks in our analyses, this may have obscured their influence in relation to treatment type.

CONCLUSION

Findings underscore the need for more nuanced research that considers the influence of client factors in interaction with treatment type. Pregnant clients engaged in any form of substance use treatment are at higher risk of having children who experience adverse neonatal outcomes. This underscores the urgent need for further investment in services and research to support maternal and neonatal health before and during pregnancy, as well as long-term service models that support women and children beyond the perinatal and early childhood periods.

Social Determinants Associated with Substance Use and Treatment Seeking in Females of Reproductive Age in the United States

Introduction: Females of reproductive age (FoRA; 15-49 years) are the demographic most likely to be diagnosed with a substance use disorder. Preventative treatment prior to or during pregnancy is critical. Stigma and social inequities can delay access to care. There is limited research examining social determinants of health (SDoH) and how they are related to substance use and treatment seeking in this demographic. Methods: We analyzed the 2016-2019 data from the United States National Survey on Drug Use and Health using multivariable logistic regression models. Statistically significant variables were conceptually linked to the Office of Disease Prevention and Health Promotion's (ODPHP's) SDoH framework's five domains. Results: From a total sample of 1,477,336 (weighted) pregnant people and 39,600,523 (weighted) FoRA, substance use was reported by 879,209 (2.14% [95% confidence interval = 2.13-2.15]). Pregnancy status was not associated with substance use or treatment seeking. Past-month substance use was associated with high educational attainment, an annual income <$20,000, a history of criminality, low religiosity, and having health insurance. Past-month treatment-seeking behavior was associated with older age, an annual income >$20,000, a history of criminality, and greater religiosity. Behavioral health support seeking in the past month was associated with some college education. Higher depression severity was associated with all the three models. Conclusions: Using the ODPHP's SDoH framework, we begin to elicit critical connections that can describe substance use and treatment-seeking practices in FoRA. We encourage additional research to inform public health, health care, behavioral health, and other support service programming.

Maternal Perspective of Inpatient Methadone Initiation: Opportunities to Increase Retention in Treatment

OBJECTIVES

Recent trends demonstrate increases in the rates of opioid use among pregnant and parenting women. Treatment for pregnant people with opioid use disorder (OUD) includes medications for OUD, like methadone, as well as comprehensive support services. Still, inpatient treatment engagement is suboptimal and treatment drop out is common. There is little research examining the maternal perspective of the inpatient methadone initiation experience. The primary aim of this qualitative methods study was to explore patient experience and perspective of the inpatient methadone initiation period.

METHODS

All participants were recruited from a single urban university affiliated hospital and OUD treatment program. Data were collected from 30 maternal participants in OUD treatment about their inpatient methadone initiation experience while pregnant using semistructured interviews. Thematic analyses were conducted using an inductive approach after an iterative process of code development and application among a multidisciplinary team of 3 coders. Validity was accounted for through 2 participant feedback interviews and study team review and discussion of findings.

RESULTS

Four themes emerged from the maternal interview data: (1) Barriers to Inpatient Methadone Initiation, (2) Facilitators to Inpatient Methadone Initiation, (3) Transition From Hospital Inpatient to Outpatient or Residential OUD Treatment Services, and (4) Opportunities for Enhanced Clinical Support.

CONCLUSION

Maternal participants reported multiple barriers and facilitators to inpatient care during methadone initiation, highlighting opportunities for improvement to effectively engage pregnant individuals in treatment.

Group prenatal care for pregnant women with opioid use disorder: Preliminary evidence for acceptability and benefits compared with individual prenatal care

INTRODUCTION

The effectiveness of group prenatal care (G-PNC) compared with individual prenatal care (I-PNC) for women with opioid use disorder (OUD) is unknown. The objectives of this study were to (1) assess the acceptability of co-locating G-PNC at an opioid treatment program and (2) describe the maternal and infant characteristics and outcomes of pregnant women in treatment for OUD who participated in G-PNC and those who did not.

METHODS

This was a retrospective cohort study of 71 women (G-PNC n = 15; I-PNC n = 56) who were receiving treatment for OUD from one center and who delivered in 2019. Acceptability was determined by assessing the representativeness of the G-PNC cohorts, examining attendance at sessions, and using responses to a survey completed by G-PNC participants. The receipt of health services and healthcare use, behaviors, and infant health between those who participated in G-PNC and those who received I-PNC were described.

RESULTS

G-PNC was successfully implemented among women with varying backgrounds (e.g., racial, ethnic, marital status) who self-selected into the group. All G-PNC participants reported that they were satisfied to very satisfied with the program. Increased rates of breastfeeding initiation, breastfeeding at hospital discharge, receipt of the Tdap vaccine, and postpartum visit attendance at 1-2 weeks and 4-8 weeks were observed in the G-PNC group compared with the I-PNC group. Fewer G-PNC reported postpartum depression symptomatology.

CONCLUSION

Findings suggest that co-located G-PNC at an opioid treatment program is an acceptable model for pregnant women in treatment for OUD and may result in improved outcomes.

Breastfeeding Intention, Knowledge, and Attitude of Pregnant Women in Treatment for Opioid Use Disorder

OBJECTIVE

The objective of this study was to describe breastfeeding intention, knowledge, and attitude, and sources of infant feeding information during the prenatal period among a cohort of pregnant women in treatment for opioid use disorder (OUD).

STUDY DESIGN

Pregnant women who were receiving treatment for OUD and in the third trimester completed a questionnaire that measured demographic characteristics, infant feeding intentions, breastfeeding beliefs and attitudes, and sources of breastfeeding information. Frequency counts and percentages and means and standard deviations were used to describe data.

RESULTS

Sixty-five women completed the survey. Three-fourths reported some intention to breastfeeding. While attitudes around breastfeeding were generally positive, less than half of respondents knew the recommendations and infant health benefits of breastfeeding.

CONCLUSION

Prenatal programs for women in treatment for OUD should consider addressing patient-reported concerns and gaps in knowledge regarding the benefits of and recommendation for breastfeeding.

KEY POINTS

· Breastfeeding has unique benefits for mother-infant dyads affected by maternal OUD.. · Breastfeeding decisions are influenced by maternal psychosocial factors (e.g., knowledge and attitudes), however, such factors have not been previously assessed in women in treatment for OUD.. · Results indicate that attitudes around breastfeeding are positive but knowledge gaps exist..

Philadelphia Department of Health Doula Support Program: Early Successes and Challenges of a Program Serving Birthing People Affected by Substance Use Disorder

PURPOSE

Maternal substance use and deaths due to overdoses are increasing nationwide. Evidence suggests that the rate of resumed substance use, and fatal and non-fatal overdose is greatest in the first year after birth, particularly around six months postpartum, compared to other parts of the perinatal period. Doula care has been linked to improvements in perinatal health and outcomes.

DESCRIPTION

In response to the opioid epidemic, the Philadelphia Department of Public Health developed and implemented the Doula Support Program (DSP), with a focus on one year of postpartum care for birthing people with a substance use disorder (SUD). In this paper, we describe the program and its formation and report on the early challenges and successes of the program implementation, based on information we received from program founders and managers in a group interview.

ASSESSMENT

Early successes of the program include partnering with local community-based programs to recruit and retain doulas, supplementing traditional doula education with perinatal SUD-specific trainings, and maximizing client referrals by collaborating with local organizations and treatment centers that serve birthing people with SUD. Client retention, however, has proven to be challenging, especially during the COVID-19 pandemic.

CONCLUSION

The DSP continues to grow, and lessons learned will facilitate program improvements. The goal of this paper is to outline the development and launch of the DSP and to act as a model for other state and local health departments interested in providing doula care for birthing people with SUD.

Substance use during pregnancy and risk of postpartum depression: a systematic review and meta-analysis

Introduction

Postpartum depression (PPD) is a prevalent mental health condition affecting women globally within the first year following childbirth. Substance use during pregnancy has been associated with an increased risk of developing PPD, but the evidence remains inconclusive. This meta-analysis aims to comprehensively assess the effects of different substances on PPD risk, exploring potential modifiers and confounding factors.

Objectives

To examine the proportion of PPD among substance users during pregnancy, compared to non-users, and investigate the specific risk associated with different substances (tobacco, alcohol, and non-specified substance use/multiple substance use).

Methods

A systematic literature search was conducted from inception to November 2022 using the Web of Science database (Clarivate Analytics), incorporating Web of Science Core Collection, the BIOSIS Citation Index, the KCI-Korean Journal Database, MEDLINE®, the Russian Science Citation Index, the SciELO Citation Index, and the Cochrane Central Register of Reviews, and Ovid/PsycINFO databases. Inclusion criteria comprised original studies with pregnant women, using validated depression scales and substance use reporting.

Results

Among the 26 included studies, encompassing 514,441 women, the pooled prevalence of PPD among substance users during pregnancy was 29% (95% CI 25-33). Meta-analyzes revealed an overall odds ratio (OR) of 3.67 (95% CI 2.31-5.85, p < 0.01) indicating a significantly higher risk of PPD among substance users compared to non-users. Subgroup analyzes demonstrated a higher risk for women with non-specified or multiple substance use (OR 4.67, 95% CI 2.59-8.41; p < 0.01) and tobacco use (OR 4.01, 95% CI 2.23-7.20; p < 0.01). Alcohol use showed a trend toward higher risk that did not reach statistical significance (OR 1.88, 95% CI 1.00-3.55; p = 0.051).

Conclusion

This meta-analysis provides evidence of an increased risk of PPD among pregnant substance users, particularly those using multiple substances or tobacco. However, caution is needed in interpreting the association with alcohol use due to its non-significant result.

Systematic review registration

This study protocol was registered at PROSPERO (registration number: CCRD42022375500).

Maternal and Neonatal Outcomes in Women with Metabolic Syndrome and Substance Use Disorder

INTRODUCTION

Metabolic syndrome amplifies the risk of gestational diabetes, preeclampsia, and preterm labor in pregnant women. Similarly, women with substance use disorder have worsened obstetric and birth outcomes. Despite these two conditions being major healthcare disparities in Appalachia, the health outcomes of this cohort have not been studied thus far. This study looks at the health outcomes of this cohort.

METHOD AND RESULTS

In this retrospective cohort study, we analyzed 27,955 mothers who delivered at Cabell Huntington Hospital between January 2010 and November 2021. We implemented Chi-square tests to determine the associations and multiple logistic regression methods for comparison after controlling for other factors, and found that MetS, together with SUD, significantly increases the risk as well as the number of pregnancy complications such as gestational diabetes (p-value < 0.001), preeclampsia (p-value < 0.001), premature rupture (p-value < 0.001), preterm labor (p-value < 0.001), and newborn disorder (p-value < 0.001) compared to the women who had none or had either MetS or SUD alone.

CONCLUSION

Women with both metabolic syndrome and substance abuse had worsened pregnancy and neonatal outcomes compared to women with metabolic syndrome or SUD alone. In conclusion, analysis of all the variables is crucial to strategically planning and implementing health interventions that will positively influence the health outcome of the pregnant woman as well as the child.

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.

Written exposure therapy for treatment of perinatal PTSD among women with comorbid PTSD and SUD: A pilot study examining feasibility, acceptability, and preliminary effectiveness

OBJECTIVE

This pilot open trial examined the feasibility, acceptability, and preliminary effectiveness of Written Exposure Therapy (WET), a 5-session evidence-based intervention for posttraumatic stress disorder (PTSD) during pregnancy. Participants were pregnant women with comorbid PTSD and substance use disorder (SUD) receiving prenatal care in a high risk obstetrics-addictions clinic.

METHODS

A total of 18 participants with probable PTSD engaged in the intervention, and 10 completed the intervention and were included in outcome analyses. Wilcoxon's Signed-Rank analyses were used to evaluate PTSD and depression symptoms and craving at pre-intervention to post-intervention and pre-intervention to the 6-month postpartum follow-up. Engagement and retention in WET and therapist fidelity to the intervention manual were used to assess feasibility. Quantitative and qualitative measures of patient satisfaction were used to assess acceptability.

RESULTS

PTSD symptoms significantly decreased from pre-intervention to post-intervention (S = 26.6, p = 0.006), which sustained at the 6-month postpartum follow-up (S = 10.5, p = 0.031). Participant satisfaction at post-intervention was high. Therapists demonstrated high adherence to the intervention and excellent competence.

CONCLUSIONS

WET was a feasible and acceptable treatment for PTSD in this sample. Randomized clinical trial studies with a general group of pregnant women are needed to expand upon these findings and perform a full-scale test of effectiveness of this intervention.

Impact of an Asynchronous Training for the Early Intervention and Childcare Workforce Addressing the Developmental Impact of the Opioid Crisis on Young Children

OBJECTIVES

The US opioid epidemic contributes to a growing population of children experiencing neonatal abstinence syndrome (NAS) and adverse childhood experiences (ACEs). A review of the developmental impacts of the opioid crisis highlights that both prenatal exposure to teratogens and ACEs can result in developmental delay and disabilities. Training for the early intervention/early childhood (EI) systems is needed to enable them to meet the needs of this growing population.

METHODS

To address this, an IRB-approved online training on best practices for NAS, developmental monitoring and referral, and trauma-informed care was created for Ohio EI providers who provided informed consent to participate. The feasibility of utilizing an online training was assessed. Knowledge on opioid addiction, NAS, ACEs, and early intervention provider characteristics were collected for 2973 participants.

RESULTS

Within 6 months, the training reached providers in all Ohio counties and seventeen other states. 57% of providers reported caring for one or more children with a caregiver who has confirmed opioid use. 31% reported these children had experienced four or more ACEs. Providers' ACEs awareness was moderately associated with their experiences with prenatally-exposed youth. There was a significant increase in knowledge following training. Differences in post-training knowledge differed only by county-level opioid death rates, where those providers with low-medium opioid death rates reported more awareness of children with prenatal opioid exposure compared to participants who lived in a county with medium and medium-high opioid death rates.

CONCLUSIONS

Online-training is feasible for closing gaps in the early intervention system.

Usability and acceptability testing of a Plan of Safe Care in a mobile health platform

Purpose

Women who are pregnant or parenting while recovering from substance use disorder (SUD) are at risk for insufficient recovery support. With the federal mandate, implementation has been left to each state for the Plan of Safe Care (POSC), leading to challenges in providing comprehensive care coordination and meeting federal reporting requirements.

Methods

This research tests the usability and acceptability of a POSC platform, called SAFE4BOTH, which combines a mobile health (mHealth) app for use by mothers with substance use disorder (MSUD) with a web-based case management system for use by stakeholders to reduce the issue of fragmented postnatal maternal and infant care. The platform was designed to enable access to services, improve reporting task workflow, and assist in improving interactions between mothers and service providers.After applying a user-centered design approach, the usability and acceptability of the SAFE4BOTH platform were evaluated using focus groups, interviews, and a System Usability Scale (SUS). The evaluation involved four staff members from a Medication for Addiction Treatment clinic (comprising of three case management workers and one peer counselor), four state employees of the Delaware Division of Family Services, and 20 mothers with MSUD who had delivered infants in need of a POSC.Features tested in the SAFE4BOTH platform included a secure, web-based POSC, a contingency management-based reward system, a micro-learning library, a resources locator, a chat messaging and videoconferencing system, a directory for contact management, a QR code reader, use of an appointment compliance system engaging geofencing, and an enhanced calendar. Family services and treatment center staff accessed SAFE4BOTH from their laptops or tablets, and MSUD accessed SAFE4BOTH from their phones.

Results

Family services staff, treatment center staff, and MSUD participants rated SAFE4BOTH as usable and acceptable with average System Usability Scale scores of 68.1 (SD 8.5), 92.5 (SD 11.73), and 78.4 (SD 12.5) (respectively).

Conclusion

The platform was judged both usable and acceptable by all three target populations (family services staff, treatment center staff, and MSUD). Further studies are planned to explore the efficacy of longitudinally supporting the mother's recovery and the infant's healthy development.

Principles of care for pregnant and parenting people with substance use disorder: the obstetrician gynecologist perspective

Substance use in pregnant and parenting persons is common, yet still underdiagnosed. Substance use disorder (SUD) is one of the most stigmatized and undertreated chronic medical conditions, and this is exacerbated in the perinatal period. Many providers are not sufficiently trained in screening or treatment for substance use, so gaps in care for this population persist. Punitive policies towards substance use in pregnancy have proliferated, lead to decreased prenatal care, do not improve birth outcomes, and disproportionately impact Black, Indigenous, and other families of color. We discuss the importance of understanding the unique barriers of pregnancy-capable persons and drug overdose as one of the leading causes of maternal death in the United States. We highlight the principles of care from the obstetrician-gynecologist perspective including care for the dyad, person-centered language, and current medical terminology. We then review treatment of the most common substances, discuss SUD during the birthing hospitalization, and highlight the high risk of mortality in the postpartum period.

Effects of Recent Medicaid Expansions on Infant Mortality by Race and Ethnicity

INTRODUCTION

The purpose of this study is to examine year-by-year effects of the 2014 Affordable Care Act Medicaid expansion on infant mortality by race and ethnicity over the first 6 years.

METHODS

Publicly available 2011-2019 Multiple Cause of Death data were extracted in October and analyzed by November 2021. A difference-in-differences event-study design compared infant mortality changes in states that expanded in 2014 to nonexpansion states.

RESULTS

In the main model, the 2014 Medicaid expansions were associated with a statistically significant decline in Black infants' mortality in 2018 and 2019 by 1.19 (95% CI= -2.27, -0.12) and 1.35 (95% CI= -2.45, -0.26) deaths per 1,000 live births, respectively. There was also a decline in mortality for Hispanic infants in 2015-2019, including by 0.8 (95% CI= -1.25, -0.36) and 1.28 (95% CI= -1.88, -0.68) deaths per 1,000 live births in 2015 and 2019, respectively. Overall, infant mortality declined by 0.37 (95% CI= -0.70, -0.05) deaths per 1,000 live births in 2019.

CONCLUSIONS

The study adds evidence on the association of the Affordable Care Act Medicaid expansions with a decline in mortality of Black and Hispanic infants. The findings shed light on the importance of examining year-by-year effects over multiple years.

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.

Facilitating treatment initiation and reproductive care postpartum to prevent substance-exposed pregnancies: A randomized bayesian pilot trial

BACKGROUND

For non-treatment-seeking women who use substances during pregnancy, immediately postpartum may be an optimum time for intervention. Our study tested a novel, brief, hospital-initiated, adaptive motivational interviewing plus acceptance and commitment therapy (MIACT) intervention to facilitate treatment initiation and reproductive planning postpartum among mothers who used substances during pregnancy.

METHODS

Mothers (N = 64) with an infant admitted to a neonatal intensive care unit were enrolled if they or their infant tested positive for an illicit substance at delivery or had a documented positive drug screen during pregnancy. A parallel group, randomized controlled design assigned participants to MIACT or conventional care (CC), with assessments at week 2 and 4 during treatment and follow-up at 2 and 6 months post treatment. Bayesian generalized linear modeling was used to evaluate outcomes as a function of treatment.

RESULTS

Results indicated that during treatment the MIACT group demonstrated an 84% probability of benefit relative to CC with regard to initiating treatment (RR=1.5), however the effect was not seen at follow-up. MIACT was also associated with an increased probability of attending a postpartum obstetrics visit (RR=1.4), and receiving contraception during treatment and at both follow-ups, with posterior probabilities of 96% or higher and relative risks ranging from 1.5 to 5.1 at varying timepoints. Substance use rates for the MIACT versus CC were higher at follow-up.

CONCLUSIONS

Brief, hospital-initiated interventions can assist postpartum mothers who use substances to enter treatment and obtain contraception in order to reduce future substance-exposed pregnancies.

Emergency Department Utilization for Substance Use Disorder During Pregnancy and Postpartum in the United States (2006-2016)

OBJECTIVES

We aimed to better understand emergency department (ED) use, admission patterns, and demographics for substance use disorder in pregnancy and postpartum (SUDPP).

METHODS

In this longitudinal study, the United States Nationwide Emergency Department Sample was queried for all ED visits by 15- to 50-year-old women with a primary diagnosis defined by International Classification of Diseases, 9th or 10th edition Clinical Modification, codes of SUDPP between 2006 and 2016. Patterns of ED visit counts, rates, admissions, and ED charges were analyzed.

RESULTS

Annual national estimated ED visits for SUDPP increased from 2,919 to 9,497 between 2006 and 2016 (a 12.4% annual average percentage change), whereas admission rates decreased (from 41.9% to 32.0%). ED visits were more frequent among women who were 20-29 years old, using Medicaid insurance, in the lowest income quartile, living in the South, and in metropolitan areas. Compared with the proportion of ED visits, 15- to 19-year-olds had significantly lower admission rates, whereas women with Medicaid and in the lowest income quartile had higher admission rates (p < .001). Opioid use, tobacco use, and mental health disorders were most commonly associated with SUDPP. The ED average inflation-adjusted charges for SUDPP increased from $1,486 to $3,085 between 2006 and 2016 (7.1% annual average percentage change; p < .001), yielding total annual charges of $4.02 million and $28.53 million.

CONCLUSIONS

Despite the decrease in admissions, the number and charges for ED visits for SUDPP increased substantially between 2006 and 2016. These increasing numbers suggest a continuous need to implement preventive public health measures and provide adequate outpatient care for this condition in this population specifically.

Association of prenatal substance use with prenatal and postpartum care: Evidence from the Pregnancy Risk Assessment Monitoring System, 2016-2019

The objective of this study was to build on existing qualitative research to estimate the association of prenatal substance use with prenatal and postpartum care. We used data from the 2016-2019 Pregnancy Risk Assessment Monitoring System for 9 states. We conducted adjusted linear regression to compare month of gestation of first prenatal visit and adjusted logistic regression to compare receipt of adequate prenatal care and a postpartum healthcare visit among women who reported prenatal use of any opioids, prescription opioids, marijuana, and illicit drugs to those who did not report use of each substance. Women who reported prenatal use of any opioids (Risk Difference(RD) = 0.16; 95% Confidence Interval (CI) = 0.04, 0.28), prescription opioids (RD = 0.16; 95% CI = 0.04, 0.28), marijuana (RD = 0.25; 95% CI = 0.10, 0.41) and illicit drugs (RD = 0.52; 95% CI = 0.09, 0.95) initiated prenatal care later than those who did not report use of each substance. Women who reported prenatal use of any opioid (Odds Ratio (OR) = 0.82; 95% CI = 0.68, 1.00), prescription opioids (OR = 0.84; 95% CI = 0.69, 1.02), marijuana (OR = 0.59; 95% CI = 0.48, 0.73) and illicit drugs (OR = 0.29; 95% CI = 0.20, 0.42) were less likely to receive adequate prenatal care. Women who reported prenatal use of any opioid (OR = 0.82, 95% CI = 0.65, 1.04), prescription opioids (OR = 0.83; 95% CI = 0.66, 1.05), marijuana (OR = 0.65; 95% CI = 0.51, 0.82) and illicit drugs (OR = 0.47; 95% CI = 0.30, 0.72) had a lower likelihood of a postpartum visit than those who did not report use of each substance. Results indicate potential intervention points for pregnant women who use substances.

Validity and Reliability of the Modified Attitudes About Drug Use in Pregnancy Scale

OBJECTIVE

To contemporize the Attitudes About Drug Abuse in Pregnancy questionnaire, keep the length of the modified scale brief to promote use, and test the psychometric properties of the modified scale among perinatal nurses.

DESIGN

Cross-sectional survey.

SETTING

Four hospitals in the Midwestern United States.

PARTICIPANTS

Registered nurses who worked in perinatal units (N = 440).

METHODS

We collected data from participants using survey methods. Seven experts in perinatal substance use research and clinical care informed scale modifications. We used a split-sample design involving maternal-newborn units (labor, postpartum) and newborn-focused units (NICU, pediatrics). We evaluated construct validity using factor analysis and reliability using Cronbach's alpha. We tested for differences between units using analysis of variance and Tukey's post hoc honest significant difference test of pairwise differences.

RESULTS

The final modified scale included 13 items that loaded on one factor and showed internal consistency reliability in both samples (α = .88-.91). We found a statistically significant difference in mean score between NICU and pediatric units; however, the absolute difference was small and likely not clinically significant.

CONCLUSIONS

The Modified Attitudes About Drug Use in Pregnancy scale has initial evidence for validity and reliability, was updated to reflect current terminology in the field, and is a pragmatic tool for use in research.

Differences in outpatient, emergency, and inpatient use among pregnant women with a substance-related diagnosis

BACKGROUND

As a vulnerable population, pregnant women with a substance-related diagnosis (ie, substance use, misuse, or dependence) may use healthcare disproportionately.

OBJECTIVE

The primary goal of this study was to evaluate the differences in the use of outpatient clinical visits, emergency department visits, and inpatient days in the hospital among women with and without a substance-related diagnosis during the antepartum period.

STUDY DESIGN

This retrospective study retrieved electronic health record data on women (age, 18-44 years) who delivered a single live birth or stillbirth at ≥20 weeks of gestation from April 1, 2012, to September 30, 2019. Imbalance in measured maternal sociodemographic and obstetrical characteristics between women with and without a substance-related diagnosis was attenuated using propensity score matching on key demographic characteristics (eg, age), yielding a matched 1:1 sample. Unadjusted and adjusted logistic regressions models were used to determine the association between a substance-related diagnosis and outpatient visits, emergency visits, and inpatient days.

RESULTS

From the total sample (n=16,770), the matched cohort consisted of 1986 deliveries. Of these, most were White (51.0%), or mixed or of some other race (31.1%). The mean age was 29.8 (standard deviation, 5.6). A substance-related diagnosis was identified in 993 women (50%) because of matching. Women with a substance-related diagnosis were more likely to have ≤10 outpatient visits than women without a substance-related diagnosis (adjusted odds ratio, 1.81 [95% confidence interval, 1.44-2.28]; P<.0001). Alcohol-, opioid-, and stimulant-related diagnoses were independently associated with ≤10 outpatient visits (adjusted odds ratio, 3.16 [95% confidence interval, 1.67-6.04]; P=.0005; adjusted odds ratio, 3.02 [95% confidence interval, 1.79-5.09]; P<.0001; adjusted odds ratio, 2.18 [95% confidence interval, 1.39-3.41]; P=.0007, respectively). Women with a substance-related diagnosis were more likely to have ≥1 emergency visit than women without a substance-related diagnosis (adjusted odds ratio, 1.36 [95% confidence interval, 1.00-1.85]; P<.0001). Opioid-, stimulant-, and nicotine-related diagnoses were independently associated with ≥1 emergency visit (adjusted odds ratio, 2.28 [95% confidence interval, 1.09-4.77]; P=.0287; adjusted odds ratio, 2.01 [95% confidence interval, 1.07-3.78]; P=.0301; adjusted odds ratio, 3.38 [95% confidence interval, 1.90-6.02]; P<.0001, respectively). Women with a substance-related diagnosis were more likely to have ≥3 inpatient days than women without a substance-related diagnosis (adjusted odds ratio, 1.69 [95% confidence interval, 1.07-2.67]; P=.0256). Opioid-, stimulant-, and nicotine-related diagnosis were independently associated with ≥3 inpatient days (adjusted odds ratio, 3.52 [95% confidence interval, 1.42-8.75]; P=.0067; adjusted odds ratio, 3.51 [95% confidence interval, 1.31-9.34]; P=.0123; adjusted odds ratio, 2.74 [95% confidence interval, 1.11-6.73]; P=.0285, respectively).

CONCLUSION

Women with a substance-related diagnosis during the antepartum period who delivered a single live birth or stillbirth at ≥20 weeks of gestation were experiencing fewer outpatient visits, more emergency department visits, and more inpatient days than women without a substance-related diagnosis. The type of substance-related diagnosis (eg, alcohol, opioids, stimulants, or nicotine) was associated with different patterns of healthcare use. The results from this study have reinforced the need to identify substance-related diagnoses in pregnant women early to minimize disproportionate healthcare service utilization through intervention and treatment.

Substance Use and Utilization of Prenatal and Postpartum Care

OBJECTIVES

Prenatal and postpartum care for women with substance use is important due to increased risk of poor health outcomes. The influence of substance use on perinatal care utilization is not well characterized, especially postpartum care. The objective of this study was to examine the effect of substance use during pregnancy on prenatal and postpartum care utilization in a nationally representative sample and to identify maternal characteristics associated with inadequate prenatal and postpartum care among women with substance use.

METHODS

Pregnancy Risk Assessment Monitoring System data (2016-2018) from 8 states were used for this study. Logistic regression models adjusted for complex survey weights and confounder variables were used to estimate the odds of not receiving adequate prenatal care and postpartum care. Weighted Rao-Scott chi-square tests were used to examine maternal characteristics associated with care utilization among women who reported substance use during pregnancy.

RESULTS

The study included 15,131 women, with 5.3% who reported illicit substance use during pregnancy. In multivariable models, substance use was associated with an increase in the odds of not receiving adequate prenatal care (OR 1.69, CI 1.32, 2.17) and not receiving postpartum care (OR: 1.47, CI 1.10, 1.95). Among women who reported substance use, depression and smoking status were associated with not receiving adequate prenatal or postpartum care.

CONCLUSIONS

Substance use during pregnancy is independently associated with disparities in prenatal and postpartum care access. Future studies are needed to identify how barriers lead to care inequalities and importantly, to identify strategies to improve care utilization.

Comparing Childhood Characteristics of Adopted and Non-adopted Individuals Deceased by Suicide

OBJECTIVE

Across the globe more than 35,000 children a year are adopted by non-relatives, and some studies suggest that adopted individuals may be more vulnerable to developing mental disorders. To map the differences in suicide risk factors in adopted and non-adopted individuals, this study will compare the development of mental disorders as well as life events occurring before the age of 18 for both adopted and non-adopted individuals deceased by suicide.

METHODS

This study included 13 adopted and 26 non-adopted individuals deceased by suicide as well as 26 non-adopted living control individuals. Cases were taken from a data bank created over the last decade by researchers of [our institution] comprising a mixture of 700 suicide cases and living control individuals aged from 14 to 84. Adopted and non-adopted individuals deceased by suicide; adopted individuals deceased by suicide and non-adopted living control individuals were each compared on Axis I and II disorders, early life events, and burdens of adversity.

RESULTS

Results show significant differences, with a higher rate of Attention Deficit Hyperactivity Disorder, mental health comorbidity and Cluster C personality disorders among adopted individuals. Furthermore, adopted individuals have higher adversity scores prior to the age of 15.

CONCLUSION

This study underlines the fact that adoptive families need to be supported throughout adoption. Health care professionals need specialized training on this matter, and the psychological challenges adopted individuals face need to be treated at the earliest juncture.

Doula engagement and maternal opioid use disorder (OUD): Experiences of women in OUD recovery during the perinatal period

BACKGROUND

Pregnant women who have substance use disorders (SUDs) are at increased risk of preterm birth, fetal mortality, and inadequate prenatal care and have higher rates of childhood trauma than their counterparts without SUDs. Doulas have been utilized with other vulnerable populations who experience trauma to increase perinatal healthcare utilization, provide emotional support, and improve birth outcomes. The objective of the current study was to examine, in women with opioid use disorder (OUD), perceptions of working with a doula in the perinatal period.

METHODS

Eligible participants were ≥ 18 years old, in OUD treatment, and were pregnant or recently delivered (child ≤ 3 months of age). Semi-structured interviews were used to collect tacit data on the woman's experience working with a doula during the perinatal period. All one-hour interviews were conducted over the phone and transcribed verbatim by a HIPAA compliant transcription service. Transcripts were reviewed independently by 4 coders using open coding procedures, constant comparative method of grounded theory, and inductive thematic analysis. Demographic data and history of childhood trauma information (Adverse Childhood Experiences Tool) were collected with a phone survey prior to the interview.

RESULTS

Participants' (N = 23) were 32.5 years of age (4.1 SD), with the majority Caucasian (71.4%), Non-Hispanic (71.4%) and Medicaid recipients (100%). Participants reported a mean of 5.61 (SD=2.93) adverse childhood experiences, indicating a significant trauma burden. Major themes uncovered in the interview transcripts revealed emotional and OUD recovery support provided by the doula and increased maternal health literacy and self-advocacy. The presence of a doula during labor/delivery reduced maternal perceptions of stigma they perceived from their healthcare providers.

CONCLUSION

Doula engagement was associated with perceptions of increased emotional support, health literacy and self-advocacy in maternal health among women with OUD, which is significant given this population's trauma histories. This preliminary research has significant implications for improving the health of the mother child dyad affected by maternal OUD.

Comprehensive and compassionate responses for opioid use disorder among pregnant and parenting women

Pregnant and parenting women with opioid use disorder face multiple challenges to recovery. Trauma histories, poverty, stigma and discrimination, and lack of access to treatment intersect to marginalise this population. It is important that pregnant and parenting women with opioid use disorder receive comprehensive care to improve their health, the health of their child(ren), and prevent the intergenerational transmission of opioid and other substance use disorders. For nearly 50 years the Maternal Addiction Treatment, Education, and Research program has provided an evolving and expanding range of comprehensive services for treating opioid and other substance use disorders in this population. In this review the rationale for, and processes by which, key components of a comprehensive approach are discussed. These components include patient navigation for access to care, low-barrier medications for opioid use disorder, effective trauma-responsive therapy, prenatal and well-child healthcare, and other support services that make it possible for pregnant and parenting women to engage in treatment and improve the health of the entire family. Additionally, a method for supporting staff to build resilience and reduce fatigue and burnout is discussed. These components comprise an effective model of care for pregnant and parenting women with opioid and other substance use disorders.

The association between asthma and perinatal mental illness: a population-based cohort study

BACKGROUND

Asthma is a risk factor for mental illness, but few studies have explored this association around the time of pregnancy. We studied the association between asthma and perinatal mental illness and explored the modifying effects of social and medical complexities.

METHODS

In a population-based cohort of 846 155 women in Ontario, Canada, with a singleton live birth in 2005-2015 and no recent history of mental illness, modified Poisson regression models were constructed to examine the association between asthma diagnosed before pregnancy and perinatal mental illness, controlling for socio-demographics and medical history. We explored the modifying effects of social and medical complexities using relative excess risk due to interaction. Additional analyses examined the association between asthma and perinatal mental illness by timing and type of mental illness.

RESULTS

Women with asthma were more likely than those without asthma to have perinatal mental illness [adjusted relative risk (aRR) 1.14; 95% (confidence interval) CI: 1.13, 1.16]. Asthma was associated with increased risk of diagnosis of mental illness prenatally (aRR 1.11; 95% CI: 1.08, 1.13) and post-partum (aRR 1.17; 95% CI: 1.15, 1.19) and specifically diagnoses of mood and anxiety disorders (aRR 1.14; 95% CI: 1.13, 1.16), psychotic disorders (aRR 1.20; 95% CI: 1.10, 1.31) and substance- or alcohol-use disorders (aRR 1.24; 95% CI: 1.14, 1.36). There was no effect modification related to social or medical complexity for these outcomes.

CONCLUSIONS

Women with asthma predating pregnancy are at slightly increased risk of mental illness in pregnancy and post-partum. A multidisciplinary management strategy may be required to ensure timely identification and treatment.

Telehealth for Pregnant Women With Opioid Use Disorder: A Theory-Based Approach

Pregnant women with opioid use disorder (OUD) face barriers to receiving substance use treatment and prenatal care, which can lead to adverse health outcomes. The purpose of the current article is to inform practice through the design of an innovative, nurse-led approach derived from King's Theory of Goal Attainment to care for pregnant women with OUD using telehealth technologies. The practice model encompasses King's theory using telehealth by addressing perceptions in the nurse-client interaction, establishing effective communication in nurse-client interactions, building mutual goal setting and decision making, and promoting clients' goal attainment using nurses' knowledge and skills. This theory-based approach using telehealth technologies can provide nurses the opportunity to increase effectiveness in nurse-client interactions, use evidence-based communication strategies for expanded access, and deliver safe care for pregnant women with OUD. [Journal of Psychosocial Nursing and Mental Health Services, 58(12), 13-20.].

Scoping Review of the Associations Between Perinatal Substance Use and Perinatal Depression and Anxiety

OBJECTIVE

To evaluate published literature on the associations between perinatal substance use (PSU), perinatal depression and anxiety (PDA), and known maternal-newborn outcomes.

DATA SOURCES

We conducted a systematic search of health-related databases, including PubMed, CINAHL, MEDLINE, and Embase. Search terms included maternal mental health, substance use, postpartum, opioid, alcohol, methamphetamine, addiction, dependence, pregnancy, depression, and anxiety.

STUDY SELECTION

We included English-language, peer-reviewed reports of primary research and systematic reviews that were published between 2010 and 2020 and focused on PSU and PDA. We excluded commentaries, nonsystematic reviews, and articles on maternal mental health other than PDA. Fourteen of 379 articles met the inclusion criteria.

DATA EXTRACTION

We used the Joanna Briggs Institute Review Guidelines to guide extraction of the following data: author(s), year of publication, type of study, country of origin, study sample, targeted substance(s), mental health, key findings, and recommendation(s).

DATA SYNTHESIS

In studies of PSU, researchers identified a strong association with PDA. Likewise, researchers investigating PDA found a strong association with PSU. Findings from these articles suggest an increasing risk for PSU with increasing severity of PDA, depending on the specific substances of use. Findings also indicated that women with polysubstance use have greater odds for comorbid perinatal mental health conditions. A relationship between PSU and PDA and adverse newborn outcomes, such as low birth weight, was found.

CONCLUSION

There is a paucity of published research on co-occurring PSU and PDA. However, polysubstance use appears to be associated with the greatest risk for PDA. It is essential to address PSU and PDA together to better understand the effects on maternal and infant outcomes.

Pregnancy Status is Associated With Screening for Alcohol and Other Substance Use in the Emergency Department

OBJECTIVES

Determine the rates of screening for substance use in pregnant women versus non-pregnant women attending the emergency department (ED).

METHODS

We captured all ED visits by women of childbearing age (12-50 years in our study) over a 5-year period (2012-2017) (n = 72,752) from a local community hospital. The 2742 pregnant women were then matched by ethnicity, marital status, and arrival method to 9888 non-pregnant women. We then compared rates of screening for substance use by pregnancy status stratifying by age and diagnosis.

RESULTS

The proportion of non-pregnant women who were screened for substance use was 3.66% compared to 1.90% of pregnant women, yielding an odds ratio (OR) of 1.96 (95% CI = 1.44 to 2.67). We then stratified the results by presenting complaint and age. Non-pregnant women 14 to 19 and 30 to 34 had the highest likelihood for screening (OR > 3.0). The presenting complaint showed little effect on screening.

CONCLUSION

Pregnant women were screened only 51% as often as non-pregnant women for substance use in the ED. These results are of particular concern as we continue to see a rise in substance use during pregnancy which results in an increased burden on the healthcare system and society. This study replicates a previous study showing that the rates of screening are lower for pregnant women than non-pregnant women presenting to the ED. Earlier recognition of substance use offers increased opportunities for intervention and prevention of adverse outcomes from substance use during both the current pregnancy and future pregnancies.

Risk factors for emergency room use and rehospitalization among opioid-exposed newborns in Massachusetts

OBJECTIVE

To determine the risk factors for receipt of emergency room (ER) care and rehospitalization among opioid-exposed newborns in Massachusetts.

DESIGN/METHODS

We analyzed two linked data sets from 2002 to 2010: (a) Massachusetts Pregnancy to Early Life Longitudinal Data System and (b) Massachusetts Bureau of Substance Abuse Services Management Information System. Generalized estimating equations were used to assess the independent association of maternal and infant characteristics with ER use and rehospitalization in the first year of life.

RESULTS

Four thousand and five hundred and twenty-four maternal-infant dyads affected by OUD were included in the analysis. In adjusted analysis, risk factors for receipt of ER care included Hispanic ethnicity (aOR 1.63 [95% CI 1.30-2.05]), lower education levels (aOR 1.54-1.69 [95% CI 1.12-2.31]), nonprivate insurance (aOR 1.44 [95% CI 1.11-1.86]), and presence of maternal chronic conditions (aOR 1.14 [95% CI 1.01-1.29]). Risk factors for rehospitalization included prematurity (aOR 1.44 [95% CI 1.14-1.82]), low birthweight (aOR 2.02 [95% CI 1.63-2.49]), and nonprivate insurance (aOR 1.58 [95% CI 1.13-2.22]). Prolonged infant birth hospitalization was protective against both ER use (aOR 0.84 [95% CI 0.73-0.96]) and rehospitalization (aOR 0.63 [95% CI 0.53-0.75]).

CONCLUSIONS

Clinical and sociodemographic characteristics are risk factors for receipt of ER care and rehospitalization among opioid-exposed newborns in Massachusetts.

Adverse childhood experiences are associated with illicit drug use among pregnant women with middle to high socioeconomic status: findings from the All Our Families Cohort

Background

Adverse childhood experiences (ACEs) are associated with illicit drug use among pregnant women who are socioeconomically vulnerable. While it is assumed that the impact of ACEs on illicit drug use in pregnancy is reduced among women with higher socioeconomic status (SES), this assumption is not well tested in the literature. The objective of this study was to examine the impact of maternal ACEs on illicit drug use in a community-based sample of pregnant women with middle to high SES.

Methods

This study is a secondary analysis of a prospective cohort study that collected data from 1660 women during and after pregnancy in Calgary, Canada between 2008 and 2011 using mailed surveys. Illicit drug use in pregnancy was self-reported by women at 34–36 weeks gestation. An established scale examined maternal ACEs before 18 years. Logistic regression models and 95% confidence intervals tested associations between maternal ACE scores and illicit drug use in pregnancy.

Results

Overall, 3.1% of women in this predominantly married, well-educated, middle and upper middle income sample reported illicit drug use in pregnancy. Women with 2–3 ACEs had more than a two-fold increase, and women with 4 or more ACEs had almost a four-fold increase in illicit drug use in pregnancy, relative to women with 0–1 ACEs after adjustment for confounders. Exposure to child abuse was more consistently associated with illicit drug use in pregnancy than exposure to household dysfunction in childhood.

Conclusions

Maternal ACEs were common and associated with a moderate increase in the odds of illicit drug use in pregnancy among Canadian women with middle to high SES.

Diagnosis and treatment of substance use disorder among pregnant women in three state Medicaid programs from 2013 to 2016

Substance use disorder (SUD) during pregnancy increases risks of adverse outcomes for mothers and children. Because Medicaid covers about half of all births and maternal SUD is a costly problem, describing the timing of enrollment and health care that Medicaid-enrolled pregnant women with SUDs receive is critical to understanding gaps in the timeliness and specificity of SUD diagnosis and treatment for pregnant women with SUDs. We used linked maternal and infant Medicaid claims and enrollment data and infant birth records from three states (n=72,086 mother-infant dyads) to estimate the share of sample women diagnosed with a specified SUD (e.g., opioid use disorder) before or during the birth month, with a specified SUD after the birth month, and with only an unspecified SUD diagnosed (e.g., drug use disorder complicating pregnancy). We also examined the timing of first observed Medicaid enrollment, SUD diagnosis and treatment, and maternal and infant costs. In the 24 months surrounding birth, 3.6% of women had a specified SUD diagnosis first observed before or during the birth month, 1.7% had a specified SUD diagnosis first observed after the birth month, and 6.0% had an SUD diagnosis that was not specified. Most women with a specified SUD diagnosis were enrolled in Medicaid before or early in pregnancy and initiated prenatal care in the first or second trimester, yet nearly one-third of these women received their specified SUD diagnosis after the birth month. Less than two-thirds of women with a specified SUD diagnosis received any SUD treatment during the study period (59.9% among those identified before or during the birth month and 63.1% among those observed after the birth month), and women with an unspecified SUD were about half as likely to get treatment (28.6%). Among treated women, more than two-thirds had the first observed treatment in the same month as their first observed SUD diagnosis. Findings point to a critical need for interventions as well as substantial opportunities to improve the identification of substance use-related needs and provision of treatment among women who birth in Medicaid. Changes in Medicaid and other public policy to reduce disincentives for pregnant and parenting women to report substance use during medical visits and to increase providers' abilities and motivation to equitably screen for as well as treat women with SUDs before, during, and after pregnancy could improve outcomes for mothers and their children. Improvements in SUD diagnosis would also improve prevalence estimates of specific types of SUD, which could contribute to better Medicaid policies aimed at prevention and treatment.

Factors Affecting Contraception Access and Use in Patients With Opioid Use Disorder

Maternal opioid use disorder increased > 4-fold from 1999 to 2014 and is associated with poor maternal and fetal outcomes. Women with opioid use disorder are at 2 to 3 times greater risk for unintended pregnancy than the general population and may face additional barriers to accessing and effectively using contraception compared to women without opioid use disorder, particularly highly effective long-acting reversible contraception. Additionally, women with opioid use disorder tend to use less effective forms of contraception such as condoms alone. Barriers to contraceptive access include patient misconceptions or knowledge gaps regarding reproductive health and family planning, cost, intimate partner violence, fear of criminalization, difficulty accessing care, comorbid health conditions, and health care provider misconceptions or practice limitations. Strategies that may assist women with opioid use disorder in achieving their family planning goals include colocation of family planning services within opioid treatment facilities, optimization of patient care services to minimize the need for costly and/or time consuming follow-up, increasing provider education and awareness of best practices in family planning and opioid use disorder treatment, and providing patient-centered family planning education and counseling. Additional research is needed to identify and develop strategies that empower women who use opioids to effectively access and use their preferred contraceptive method.

A review of the pharmacogenomics of buprenorphine for the treatment of opioid use disorder

As the opioid epidemic continues to grow across the United States, the number of patients requiring treatment for opioid use disorder continues to climb. Although medication-assisted treatment presents a highly effective tool that can help address this epidemic, its use has been limited. Nonetheless, with easier dosing protocols (compared to the more complex dosing required of methadone due to its long and variable half-life) and fewer prescribing limitations (may be prescribed outside the setting of federally approved clinics), the increase in buprenorphine use in the United States has been dramatic in recent years. Despite buprenorphine's demonstrated efficacy, patient-specific factors can alter the response to the medications, which may lead to treatment failure in some patients. Clinical characteristics (sex, concurrent medications, and mental health comorbidities) as well as social determinants of health (housing status, involvement with the criminal justice system, and socioeconomic status) may impact treatment outcomes. Furthermore, a growing body of data suggests that genetic variations can alter pharmacological effects and influence therapeutic response. This review will cover the available pharmacogenomic data for the use of buprenorphine in the management of opioid use disorders. Pharmacogenomic determinants that affect opioid receptors, the dopaminergic system, metabolism of buprenorphine, and adverse events are discussed. Although much of the existing data comes from observational studies, clinical research is ongoing. Nevertheless, the development of pharmacogenomic-guided strategies has the potential to reduce opioid misuse, improve clinical outcomes, and save healthcare resources.

A Novel 4D Ultrasound Parenting Intervention for Substance Using Pregnant Women in Finland: Participation in Obstetric Care, Fetal Drug Exposure, and Perinatal Outcomes in a Randomized Controlled Trial

Objectives

The aim of the study was to explore the effect of a new prenatal intervention on participation in obstetric care, fetal drug exposure, and perinatal outcomes among substance using pregnant women in Finland.

Methods

The participants were 90 women referred to a hospital obstetric outpatient clinic due to current or recent substance use. The intervention group (n = 46) was offered three interactive ultrasounds at 24, 30 and 34 gestational weeks and a pregnancy diary accompanied by three prenatal infant mental health consultations. The intervention elements were designed to enhance parental mentalization and prenatal attachment. A randomized control group (n = 44) design was used. All participants were offered treatment-as-usual in the obstetric tertiary setting. Medical record data and meconium toxicology were analyzed.

Results

The retention rate in the whole sample was 89%. Retention was higher in the intervention group (96% vs. 82%, p < 0.05), of which 74% attended all three ultrasound sessions. However, the pregnant women in the intervention group participated less often in all the scheduled obstetric standard care visits (59% vs. 83%, p = 0.02). Fetal drug exposure and perinatal outcomes were similar in both groups. Within the whole sample, 13% of the neonates were preterm, 12% small for gestational age and 7% had exposure to drugs.

Conclusions for Practice

Retention in the intervention was very good. Watching the fetus with parenting focus seemed to motivate these high-risk women. Interestingly, the pregnant women in the intervention group tended to prefer the intervention sessions to the routine care. Clinical implications of this finding are discussed.

Trial Registry

The trial registration number in ClinicalTrials.gov: NCT03413631.