Improving Assessment, Treatment, and Understanding of Pregnant Women With Opioid Use Disorder: The Importance of Life Context

"I am busy enough…": Navigating challenges experienced by Medicaid providers serving pregnant people living with substance use disorders in Alabama

PURPOSE

Perinatal substance use is a clinical and public health concern. The purpose of the study was to understand the perspectives and experiences of perinatal healthcare providers serving pregnant people who receive Medicaid and are living with a substance use disorder.

DESIGN AND METHODS

We conducted a secondary data analysis of the responses from perinatal healthcare providers who completed a survey to assess the state of Alabama's capability to effectively identify and treat individuals with substance use disorder. We analyzed short answer responses using consensus coding.

FINDINGS

Nine-hundred and ninety-five Medicaid providers completed the survey, 36 of the respondents identified that they were employed in an obstetric practice. Health insurance limitations, a lack of time and resources, and limited treatment options were the primary barriers indicated in the participants' responses.

CONCLUSIONS

Structural and health system barriers negatively impact the capacity of perinatal healthcare providers in Alabama to serve pregnant people who receive Medicaid and are living with a substance use disorder.

CLINICAL RELEVANCE

Perinatal healthcare providers need educational opportunities, training, and up-to-date resources to provide supportive, comprehensive care programming for perinatal populations with substance use disorders.

Saving time, signaling trust: Using the PROMOTE self-report screening instrument to enhance prenatal care quality and therapeutic relationships

OBJECTIVES

Comprehensive screening of psychosocial vulnerabilities and substance use in prenatal care is critical to promote the health and well-being of pregnant patients. Effective implementation of new screening procedures and instruments should be accompanied by an in-depth investigation to assess their feasibility and impact on care delivery.

METHODS

In 2020, following implementation of the Profile for Maternal and Obstetric Treatment Effectiveness (PROMOTE) an innovative self-report screening instrument developed for outpatient prenatal clinics in the U.S., we conducted individual interviews and focus groups with twenty-two midwives, nurse practitioners, and obstetric residents focused on the PROMOTE and its impacts on care delivery. We used interpretive description for the qualitative analysis of the interviews.

RESULTS

Five themes were identified: Guiding Time Efficiently: "The Time I Don't Have," Preventing Missed Care, Signaling Trustworthiness, Establishing Trauma-Informed Foundations, and Promoting "Honest" Patient Disclosure.

CONCLUSION

Interviews suggest that patient completion of the PROMOTE before the medical encounter helps reduce previously reported barriers, is more time-effective, and makes history-taking easier. It also facilitates the patient-provider relationship.

INNOVATION

Findings offer insight into the breadth and depth of clinical impact resulting from the PROMOTE, and provide guidance for the implementation of such tools to optimize health outcomes.

Missingness patterns in a comprehensive instrument identifying psychosocial and substance use risk in antenatal care

BACKGROUND

Psychosocial vulnerabilities (e.g. inadequate social support, financial insecurity, stress) and substance use elevate risks for adverse perinatal outcomes and maternal mental health morbidities. However, various barriers, including paucity of validated, simple and usable comprehensive instruments, impede execution of the recommendations to screen for such vulnerabilities in the first antenatal care visit. The current study presents findings from a newly implemented self-report tool created to overcome screening barriers in outpatient antenatal clinics.

METHODS

This was a retrospective chart-review of 904 women who completed the Profile for Maternal & Obstetric Treatment Effectiveness (PROMOTE) during their first antenatal visit between June and December 2019. The PROMOTE includes the 4-item NIDA Quick Screen and 15 additional items that each assess a different psychosocial vulnerability. Statistical analysis included evaluation of missing data, and exploration of missing data patterns using univariate correlations and hierarchical clustering.

RESULTS

Three quarters of women (70.0%) had no missing items. In the entire sample, all but four PROMOTE items (opioid use, planned pregnancy, educational level, and financial state) had < 5% missing values, suggesting good acceptability and feasibility. Several respondent-related characteristics such as lower education, less family support, and greater stress were associated with greater likelihood of missing items. Instrument-related characteristics associated with missing values were completing the PROMOTE in Spanish or question positioning at the end of the instrument.

CONCLUSIONS AND IMPLICATIONS

Conducting a comprehensive screening of theoretically and clinically meaningful vulnerabilities in an outpatient setting is feasible. Study findings will inform modifications of the PROMOTE and subsequent digitisation.

Maternal-infant bonding for the opioid exposed dyad: A rodgers' evolutionary concept analysis

AIM

This concept analysis aimed to offer insight into how opioid exposure affects the quality and construction of the maternal-infant bond.

BACKGROUND

Maternal-infant bonding can be influenced by maternal opioid use disorder and the neonatal intensive care unit environment. Many interventions for mothers with opioid use disorder focus on enhancing parental skills, but often the emotional and relational features of the maternal-infant bond have been overlooked.

DATA SOURCE

Literature from Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PubMed, and PsycINFO published from January 2011 to June 2021 using "attachment theory," "mother-infant attachment," "maternal-infant bonding," "neonatal opioid withdrawal syndrome," and "neonatal abstinence syndrome" as key terms.

REVIEW METHODS

Rodgers' method of concept analysis was used to determine the antecedents, attributes, and consequences of maternal-infant bonding.

RESULTS

The key attributes of bonding for the opioid-exposed mother-infant dyad are engaged mothering, recognition of risk, affection, and respectful maternity care. The antecedents are closeness, selflessness, and purposeful touch. The consequences are sobriety, custody, love, and security.

"A good mother": Impact of motherhood identity on women's substance use and engagement in treatment across the lifespan

BACKGROUND

Women are underrepresented in substance use disorder (SUD) treatment. Interpersonal and structural factors affect women's access to SUD treatment, but limited research evaluates how motherhood is a potential barrier and facilitator to engagement in SUD treatment. We focus on women from young to middle adulthood, and capture women's identities as mothers, caretakers, and grandmothers, outside of pregnancy and the postpartum period.

METHODS

Study staff conducted twenty qualitative interviews with women in SUD treatment to assess experiences with SUD treatment, in which motherhood emerged as a key theme. Twelve women then participated in four focus groups centered on motherhood. The study audio-recorded and transcribed interviews, and two independent authors analyzed interviews, followed by group consensus.

RESULTS

Most women identified their children and responsibilities as mothers and caretakers as important motivators to accessing SUD treatment. Motherhood was also a barrier to treatment, in that women feared losing child custody by disclosing substance use and few residential programs accommodate women with children. Multiple women expressed guilt about their substance use, sensing that it contributed to perceived abandonment or separation from their children. Reunification was important to SUD recovery.

CONCLUSION

Women with SUD who are mothers experience specific barriers to treatment engagement and recovery. Women need SUD treatment programs that address these interpersonal and structural factors across the lifespan.

Conceptualizing stigma in contexts of pregnancy and opioid misuse: A qualitative study with women and healthcare providers in Ohio

BACKGROUND

Women with histories of opioid misuse face drug-related stigma, which can be amplified during pregnancy. While women are often blamed for their drug use and urged to change, the social contexts that create and reinforce stigma are largely unchallenged. Drawing on a multidimensional model of stigma, we examine how stigma manifested across women's pregnancy journeys to shape access and quality of care.

METHODS

We triangulate in-depth interviews with 28 women with histories of opioid misuse who were pregnant or recently gave birth and 18 healthcare providers in Ohio. Thematic analysis examined how stigma operates across contexts of care.

RESULTS

Providers represented physicians, nurses, social workers, counselors, and healthcare administrators. Among 28 women, average age was 30 (range: 22-41) and 79 % were White. Most women used prenatal medication-assisted treatment (MAT), including Suboxone (n = 19) or methadone (n = 8), and 15 were pregnant. Evidence of stigma emerged across healthcare contexts. Structural stigma encoded barriers to care in insurance practices and punitive drug treatment, while enacted stigma manifested as mistreatment and judgment from providers. Unpredictability of an infant diagnosis of neonatal abstinence syndrome (NAS), even when women were "doing everything right" by using MAT, perpetuated anticipated stigma from fear of loss of custody and internalized stigma among women who felt guilty about the diagnosis. Providers recognized the harmful effects of these stigmas and many actively addressed it.

CONCLUSIONS

We recommend harm reduction approaches to address the multiplicity of stigmas that women navigate in opioid misuse and pregnancy to improve healthcare experiences.

Supporting routine psychosocial assessment in the perinatal period: The concurrent and predictive validity of the Antenatal Risk Questionnaire-Revised

BACKGROUND

Australian clinical practice guidelines support comprehensive psychosocial assessment as a routine component of maternity care.

AIM

To examine the concurrent and predictive validity of the Antenatal Risk Questionnaire-Revised (ANRQ-R) when used across the perinatal period.

METHODS

Women completed the ANRQ-R and a diagnostic reference standard (SAGE-SR) in the second and third trimesters and at 3-months postpartum. ANRQ-R test performance for cut-off scores at each time-point was assessed using Receiver Operator Characteristic (ROC) analysis.

FINDINGS

Overall sample sizes were N=1166 (second trimester), N=957 (third trimester) and N=796 (3-month postpartum). 6.5%, 5.6% and 6.2% of women met SAGE-SR criteria for any depressive or anxiety disorder at these time-points ('cases'), respectively. ROC analysis yielded acceptable areas under the curve (AUC) when the ANRQ-R was used to detect current (AUC=0.789-0.798) or predict future (AUC=0.705-0.789) depression or anxiety. Using an example cut-off score of 18 or more, the ANRQ-R correctly classified 72-76% of concurrent 'cases' and 'non-cases' (sensitivity=0.70-0.74, specificity=0.72-0.76) and correctly predicted 74-78% of postnatal 'cases' and 'non-cases' (sensitivity=0.52-0.72, specificity=0.75-0.79). Completion of the ANRQ-R earlier in pregnancy yielded greater positive likelihood ratios for predicting depression or anxiety at 3-months postpartum (cut-off ≥18: second trimester=3.8; third trimester=2.2).

CONCLUSION

The ANRQ-R is a structured psychosocial assessment questionnaire that can be scored to provide an overall measure of psychosocial risk. Cut-off scores need not be uniform across settings. Such decisions should be guided by factors including diagnostic prevalence rates, local needs and resource availability.

Adverse Perinatal Outcomes Predicted by Prenatal Maternal Stress Among U.S. Women at the COVID-19 Pandemic Onset

Background

High stress prenatally contributes to poor maternal and infant well-being. The coronavirus disease 2019 (COVID-19) pandemic has created substantial stress for pregnant women.

Purpose

To understand whether stress experienced by women pregnant at the beginning of the pandemic was associated with a greater prevalence of adverse perinatal outcomes.

Methods

Pregnant women across the USA aged ≥18 years old enrolled in a prospective cohort study during the pandemic onset (T1) in April–May 2020. This report focuses on the 1,367 participants who gave birth prior to July–August 2020 (T2). Hierarchical logistic regression models predicted preterm birth, small for gestational age infants, and unplanned operative delivery from T1 stress, sociodemographic, and medical factors.

Results

After controlling for sociodemographic and medical factors, preterm birth was predicted by high prenatal maternal stress, delivering an infant small for gestational age was predicted by interpersonal violence and by stress related to being unprepared for birth due to the pandemic, and unplanned cesarean or operative vaginal delivery was predicted by prenatal appointment alterations, experiencing a major stressful life event, and by stress related to being unprepared for birth due to the pandemic. Independent of these associations, African American women were more likely than other groups to deliver preterm.

Conclusion

Pregnant women who are experiencing high stress during the COVID-19 pandemic are at risk of poorer perinatal outcomes. A longitudinal investigation is critical to determine whether prenatal maternal stress and resulting outcomes have longer-term consequences for the health and well-being of children born in the midst of the current pandemic.