Rural Postpartum Women With Substance Use Disorders

"They just looked at me like I was human": The experiences of parenting women and providers with substance use disorder treatment

BACKGROUND

The current US addiction treatment system does not effectively meet the needs of pregnant and parenting women with substance use disorder (SUD). The aim of this research was to identify barriers and facilitators to engagement and retention in SUD residential treatment for pregnant and parenting women. This research was part of a co-design process to collaboratively create a more patient-centered long-term residential program.

DESIGN AND METHODS

The study conducted semi-structured individual interviews with both parenting women with lived experience (WWLE) in residential SUD treatment and SUD treatment providers. Interviews aimed to elicit participants' experiences either receiving or providing care. The study team analyzed data in NVivo-12 using a deductive codebook based on the six principles of trauma informed care (TIC).

RESULTS

We conducted a total of 32 interviews (WWLE =13, SUD providers =19). The study identified four major themes: 1) peer relationships provide inspiration and diminish shame; 2) providing individuals safe space to stumble in recovery creates opportunities for growth and builds self-efficacy; 3) reasonable, clear boundaries create a structured, protective environment for early recovery; 4) nonjudgmental connections facilitate engagement and build trust. We identified small pivotal moments along the continuum of care that showed how the elements in the four themes enhanced engagement and retention in treatment. These interactions, along the care continuum, are either structural (workflow process) or relational (interpersonal).

CONCLUSION

This research increases understanding of the interplay of the structural and relational barriers and facilitators to engagement and retention in treatment. These seemingly minor positive or negative interactions along the care continuum are pivotal to fully operationalizing TIC and optimizing women's engagement in treatment. Improvement strategies that integrate the voices of WWLE and collaboratively co-design a more patient-centered system are critical steps to improving engagement in SUD treatment and more equitable SUD treatment services.

Patient and Provider Perspectives on Processes of Engagement in Outpatient Treatment for Opioid Use Disorder: A Scoping Review

Effective treatment for opioid use disorder (OUD) is available, but patient engagement is central to achieving care outcomes. We conducted a scoping review to describe patient and provider-reported strategies that may contribute to patient engagement in outpatient OUD care delivery. We searched PubMed and Scopus for articles reporting patient and/or provider experiences with outpatient OUD care delivery. Analysis included: (1) describing specific engagement strategies, (2) mapping strategies to patient-centered care domains, and (3) identifying themes that characterize the relationship between engagement and patient-centered care. Of 3,222 articles screened, 30 articles met inclusion criteria. Analysis identified 14 actionable strategies that facilitate patient engagement and map to all patient-centered care domains. Seven themes emerged that characterize interpersonal approaches to OUD care engagement. Interpersonal interactions between patients and providers play a pivotal role in encouraging engagement throughout OUD treatment. Future research is needed to further evaluate promising engagement strategies.

Strategies and Adaptations to an Integrated Substance Use and Infant Mental Health Treatment Program During COVID-19

The COVID-19 pandemic resulted in increased parenting stress and substance use. At the same time that mental health and social service needs increased, access to services, including among those receiving treatment, decreased due to stay-at-home orders. Few programs were equipped or prepared to translate their interventions to a virtual format at the start of the pandemic. There is a critical need to identify effective adaptations to substance use and family-focused treatment during the COVID-19 pandemic. Effective program adaptations have continued relevance for the expansion of access to family-focused addiction services beyond the pandemic itself, particularly for rural or other hard to reach populations. Seventy-three semi-structured interviews were conducted with the five agencies participating in the implementation of the In-Home Recovery Program (IHRP), an in-home, substance use disorder (SUD) treatment program. Using a rapid analysis approach two coders analyzed interviews for recurring concepts and themes. Facilitators for adapting services included: (1) the introduction of virtual toxicology screens, (2) helping parents access technology, (3) assisting parents with non-identified children to decrease their stress, and (4) anticipating reoccurrences of substances during the pandemic. Barriers to adapting services included: (1) engaging young children in virtual treatment, (2) privacy, and (3) engaging in telehealth with parents experiencing domestic violence or reoccurrence of substances. Findings reveal virtual substance use treatment is possible. Facilitators to adaptation such as providing access to technology and virtual toxicology screens demonstrate the feasibility and acceptability of utilizing telehealth interventions for substance use. Barriers to adaptations were primarily related to the infant mental health component. Telehealth is likely not appropriate for children below the age of five. Individual sessions focusing on caregiving, rather than dyadic treatment may be more suitable to virtual formats.

Stigma Experienced by Perinatal Women with Opioid Dependency in the United States: A Qualitative Meta-Synthesis

Stigma is a barrier to accessing care and treatment for perinatal women with pain and opioid dependency, resulting in increased maternal/neonatal morbidity and mortality, prolonged neonatal hospitalizations, and increased healthcare-related costs. This theory-generating qualitative meta-synthesis includes 18 qualitative research reports and describes the stigma-related experiences of perinatal women with opioid dependency. A model emerged consisting of cyclical yet pivotal care points, facilitators/deterrents of stigma, and stigma experiences including infant-associative stigma. Findings of this qualitative meta-synthesis include the following: (a) Perinatal stigma experiences may prevent women from accessing care; (b) Infant-associative stigma may influence the woman to deflect stigma from her infant onto herself; and (c) There is the risk of mothers withdrawing their infants from healthcare to protect from future anticipated stigma. Implications reveal ideal time points to enact healthcare interventions to reduce perinatal stigma experiences and its consequences on maternal/child health and wellness.

Challenges in Accessing Mental Health Care during Pregnancy and Postpartum in Rural Montana

PURPOSE

Postpartum depression is a well-known maternal health care concern. For women using substances or experiencing underlying mental health conditions, incidence of postpartum depression is higher than that of the general population. The purpose of this study was to identify barriers and facilitators associated with seeking mental health care among women with substance use disorder or mental health concerns.

STUDY DESIGN AND METHODS

Qualitative methods using interviews were conducted via the narrative inquiry approach. Women receiving care at a clinic in rural Montana and reporting substance use or mental health concerns were referred to the research team by the care manager. Participants were at least 18 years of age, English speaking, and pregnant or within 12 months postpartum at time of referral.

RESULTS

Twenty-five women met inclusion criteria and were referred for potential study participation. Seven women were interviewed. Four themes on family history, stigmatization, lack of postpartum depression awareness, and isolation were identified.

CLINICAL IMPLICATIONS

Our findings provide a better understanding of barriers and facilitators to seeking mental health care during pregnancy and postpartum among women living in rural areas with mental health concerns or perinatal substance use. An environment where opportunities for women to receive mental health care in a location that is free of stigma and judgment, while understanding the effects of familial trauma and limited or inconsistent social support, is essential to promote optimal outcomes.

Collaborative care programs for pregnant and postpartum individuals with opioid use disorder: Organizational characteristics of sites participating in the NIDA CTN0080 MOMs study

INTRODUCTION

Pregnant individuals with substance use disorders face complex issues that may serve as barriers to treatment entry and retention. Several professional organizations have established recommendations on comprehensive, collaborative approaches to treatment to meet the needs of this population, but information on real-world application is lacking. Sites participating in the NIDA CTN0080 "Medication treatment for Opioid use disorder in expectant Mothers (MOMs)"-a randomized clinical trial of extended release compared to sublingual buprenorphine among pregnant and postpartum individuals (PPI)-were selected, in part, because they have a collaborative approach to treating PPI with opioid use disorder (OUD). However, organizational differences among sites and how they implement expert recommendations for collaborative care could impact study outcomes.

METHODS

Prior to study launch at each of the 13 MOMs sites, investigators used the Pregnancy and Addiction Services Assessment (PAASA) to collect information about organizational factors. Input from a team of addiction, perinatal, and economic evaluation experts guided the development of the PAASA. Investigators programmed the PAASA into a web-based data system and summarized the resultant site data using descriptive statistics.

RESULTS

Study sites represented four US census regions. Most sites were specialty obstetrics & gynecology (OB/GYN) programs providing OUD services (n = 9, 69.2 %), were affiliated with an academic institution (n = 11, 84.6 %), and prescribed buprenorphine in an ambulatory/outpatient setting (n = 11, 84.6 %); all sites offered access to naloxone. Sites reported that their population was primarily White, utilized public insurance, and faced numerous psychosocial barriers to treatment. Although all sites offered many services recommended by expert consensus groups, they varied in how they coordinated these services.

CONCLUSIONS

By providing the organizational characteristics of sites participating in the MOMs study, this report assists in filling the current gap in knowledge regarding similar programs providing services to PPI with OUD. Collaborative care programs such as those participating in MOMs are uniquely positioned to participate in research to determine the most effective models of care and to determine how research can be integrated into those clinical care settings.

Multidimensional assessment of access to medications for opioid use disorder across urban and rural communities: A scoping review

BACKGROUND

The majority of patients with opioid use disorder do not receive medications for opioid use disorder (MOUD), especially in rural areas. The patient-centered access to healthcare framework posits access as a multidimensional phenomenon impacted by five healthcare system and five patient ability dimensions. Interventions to improve local MOUD treatment outcomes require an understanding of how these dimensions differ across urban and rural communities. This scoping review sought to systematically appraise the literature on MOUD access across urban and rural communities (i.e., rurality) in the US using the patient-centered access framework.

METHODS

We performed a scoping review of 1) electronic databases, 2) grey literature, and 3) correspondence with content experts (March 2021). We included articles specifying the study sample by rurality and examining at least one dimension of access to MOUD. The analysis and qualitative synthesis of study results examined study characteristics and categorized key findings by access dimensions.

RESULTS

The search produced 3963 unique articles, of which 147 met inclusion criteria. Among included studies, 96% (142/147) examined healthcare system dimensions of access while less than 20% (25/147) examined any of the five dimensions of patient ability. Additionally, 49% (72/147) of studies compared access dimensions by rurality. Across studies, increasing rurality was associated with fewer available MOUD services, but little was known about geographic variation in other critical dimensions of access.

CONCLUSIONS

The vast majority of studies examined healthcare system dimensions of MOUD access and few studies made comparisons by rurality or prioritized the patient's perspective, limiting our understanding of how access differs by rurality in the US. As COVID-19 spurs novel changes in MOUD delivery, this inadequate multidimensional understanding of MOUD access may impede the tailoring of interventions to local needs. There is an urgent need for mixed-methods and community-engaged research prioritizing the patient's perspective of MOUD access by rurality.

REGISTRATION

Open Science Framework (https://osf.io/wk6b9/).

Factors Associated with Maternal Engagement in Infant Care When Mothers Use Substances

Introduction

Mothers who use substances can play a key role in the treatment and care of their infants. However, challenges exist to engaging these mothers in the care of their infant. The purpose of this study was to identify factors associated with maternal engagement in infant care when mothers are experiencing substance use disorders.

Materials and Methods

A systematic search was conducted using the databases of CINAHL, APA PsycINFO, and PubMed along with a manual search of Google Scholar between the years of 2012 and 2022. Studies were included if they were (1) original qualitative research; (2) published in English; (3) peer reviewed; (4) from the perspective of mothers who use substances or nurses; (5) included descriptions of interactions between mothers who use substances and their infants during postpartum care, and/or in the nursery or neonatal intensive care unit; and (6) conducted in the United States. The studies were assessed for quality and validity using 10 criteria from the Joanne Briggs Institute critical appraisal checklist for qualitative research.

Results

Findings from 22 qualitative studies were synthesized using a thematic synthesis approach and revealed 3 overarching themes that included 7 descriptive subthemes that identified factors to maternal engagement. The seven descriptive subthemes included: (1) Attitudes Toward Mothers Who Use Substances; (2) Knowledge on Addiction; (3) Complicated Backgrounds; (4) Emotional Experiences; (5) Managing Infant Symptoms; (6) Model of Postpartum Care; and (7) Hospital Routines.

Discussion

Participants described stigma from nurses, complex backgrounds of mothers who use substances, and postpartum models that influenced mothers' engagement in infants' care. The findings suggest several clinical implications for nurses. Nurses should manage their biases and approach mothers who use substances in a respectful manner, increase their knowledge of issues and care related to addiction in the perinatal period, and promote family-centered approaches to care.

Conclusion

The findings of 22 qualitative studies described factors associated with maternal engagement in mothers who use substances that were integrated using a thematic synthesis method. Mothers who use substances have complex backgrounds and experience stigma which can negatively impact their engagement with their infants.

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

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

Exclusive Breastfeeding in the Northwest: Disparities Related to Race/Ethnicity and Substance Use

BACKGROUND AND OBJECTIVES

Mothers who are Black, Indigenous, and people of color (BIPOC) are disproportionately impacted by substance use in pregnancy and less likely to breastfeed. Our objectives were to assess relationships between substance use in pregnancy and exclusive breastfeeding at discharge (EBF) and race/ethnicity and EBF, and determine the extent to which substance use influences the relationship between race/ethnicity and EBF.

METHODS

This is a retrospective cohort study of term mother-infant dyads using 2016 to 2019 data from a Northwest quality improvement collaborative, Obstetrical Care Outcomes Assessment Program. Stepwise and stratified multivariable logistic regression analyses were conducted to determine associations between independent variables consisting of characteristics, including maternal race/ethnicity and substance use, and the dependent variable, EBF.

RESULTS

Our sample consisted of 84,742 dyads, 69.5% of whom had EBF. The adjusted odds of EBF for non-Hispanic Black and Hispanic mothers were half, and for American Indian/Alaska Native mothers two-thirds, that of White mothers (aOR [95% CI]: 0.52 [0.48, 0.57], 0.51 [0.48, 0.54], 0.64 [0.55, 0.76], respectively). Substance use did not mediate the association between race/ethnicity and EBF, but it modified the association. Among those reporting nicotine or marijuana use, Hispanic mothers were half as likely as White mothers were to exclusively breastfeed. Other factors associated with a lower likelihood of EBF included public or no insurance, rural setting, C-section, NICU admission, and LBW.

CONCLUSIONS

Disparities in EBF related to race/ethnicity and substance use were pronounced in this study, particularly among Hispanic mothers with nicotine or marijuana use.

Descriptions of Maternal Mortality From Nurses Who Practice in Perinatal Settings

OBJECTIVE

To explore nurses' descriptions of maternal mortality when caring for women in the perinatal period in Indiana.

DESIGN

A qualitative descriptive approach was used to produce nurses' descriptions of maternal mortality.

SETTING/PARTICIPANTS

Convenience sample of 16 nurses recruited from the Indiana Section of the Association of Women's Health, Obstetric and Neonatal Nurses.

MEASUREMENTS

Semistructured phone interviews were conducted, and participants were asked to explain their experiences related to maternal mortality. This information, which was summarized using content analysis, provided data related to nurses' descriptions of maternal mortality when caring for women in the perinatal period.

RESULTS

Analysis revealed three main themes that explain nurses' descriptions of maternal mortality: When It Comes to Maternal Mortality: Out of Sight Is Out of Mind, Nurses Express Detachment From Their Role in Preventing Maternal Mortality, and Experience With Maternal Mortality or a Near-Miss Event Is a Turning Point for Nurses.

CONCLUSION

Nurses who have limited experience with maternal mortality and who approach the issue in a detached manner may miss opportunities to provide health education to women in the perinatal period. Nurses need education on substance use disorders in the perinatal period, guidance on how to support women in the postpartum period, and support for coping with death and dying in the perinatal period.

Listening to women and pregnant and postpartum people: Qualitative research to inform opioid use disorder treatment for pregnant and postpartum people

Background

The diagnosis of Opioid Use Disorder (OUD) during pregnancy has increased 2-to-5-fold over the past decade and barriers to treatment are significant. Technology-based solutions have the potential to overcome these barriers and deliver evidence-based treatment. However, these interventions need to be informed by end-users. The goal of this study is to gain feedback from peripartum people with OUD and obstetric providers about a web-based OUD treatment program.

Methods

Qualitative interviews were conducted with peripartum people with OUD (n = 18) and focus groups were conducted with obstetric providers (n = 19). Feedback from these interviews informed the development of text message-based screening, brief phone-based intervention and referral to treatment program, called Listening to Women and Pregnant and Postpartum People (LTWP). Once developed, further qualitative interviews with peripartum people with OUD (n = 12) and obstetric providers (n = 21) were conducted to gather feedback about the LTWP program.

Results

Patients reported that a relationship with a trusted provider is paramount for treatment engagement. Providers reported that time constraints and complex patient needs prohibit them from treating OUD and that evidence-based Screening, Brief Intervention and Referral to Treatment (SBIRT) are not implemented effectively in routine prenatal care. Neither patients nor providers were enthusiastic about our web-based intervention for OUD; thus, results were used to guide the development of LTWP to improve implementation of SBIRT during prenatal care.

Conclusions

End-user informed, technology-enhanced SBIRT has the potential to improve the implementation of SBIRT during routine prenatal care, and in turn, improve maternal and child health.

A Scoping Review of Computer-Based and Telecommunication Technology Interventions to Address Drug and Alcohol Misuse and Smoking in Women

BACKGROUND

Computer-based and telecommunication technology has become increasingly common to address addiction among women. This review assessed the effect of technology-based interventions on substance misuse, alcohol use, and smoking outcomes among women.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR) guideline was used to conduct the scoping review. Four databases (PubMed, Web of Science, PsycINFO, and Scopus) were used to search for peer-reviewed articles published in English on computer-based and telecommunication technology use to address substance misuse, alcohol use, and smoking among women.

RESULTS

A total of 30 articles were selected after the final full-text review from the U.S., England, Japan, and the Netherlands. The types of technology used in the interventions included computer software (standalone or web-based), mobile applications, video calling, phone, and text messaging. Intervention outcomes included alcohol and other substance misuse reduction as polysubstance misuse (n = 5), smoking cessation (n = 10), substance misuse reduction only (n = 6), and alcohol use reduction only (n = 9). The populations reached included women who were pregnant (n = 13), postpartum (n = 4), or non-pregnant (n = 14) ranging from adolescent to adulthood. Interventions that targeted polysubstance misuse showed statistically significant reductions (p < .05).

CONCLUSION

Although effective in reducing alcohol and other substance misuse, mixed findings were identified for other outcomes targeting a single substance. Technology-based interventions might maximize their effects by targeting polysubstance misuse and addressing associated contextual issues in the form of a computer-delivered module(s).

Developments in Nursing Practice to Address Substance Use in the Perinatal Period

Since 1972, the year of the inaugural issue of Journal of Obstetric, Gynecologic, & Neonatal Nursing, substance use during pregnancy has remained a public health concern in the United States. This concern is currently exacerbated by factors such as the opioid and stimulant use crisis and widening health and social inequities for many women and families. The purposes of this historical commentary are to describe trends in the perception of women with substance use disorder and their infants and related sociolegal implications and to trace the evolution of related nursing practice and research during the past 50 years. We provide recommendations and priorities for practice and research, including further integration of support for the mother-infant dyad, cross-sectoral collaborations, and equity-oriented practices and policies.

Rural Patient Experiences of Accessing Care for Chronic Conditions: A Systematic Review and Thematic Synthesis of Qualitative Studies

PURPOSE

Access to health care is a long-standing concern for rural patients; however, administrative measures fail to capture the subjective patient experience of accessing health care. The purpose of this review was to synthesize the qualitative literature on patient and caregiver experiences of accessing health care services for chronic disease management among US residents of rural areas.

METHODS

We searched Embase, MEDLINE, PsycInfo, CINAHL, and Scopus to identify qualitative studies published during 2010-2019. A thematic synthesis approach was used to analyze findings from included studies.

RESULTS

A total of 62 studies involving 1,354 unique participants were included. The largest share of studies (24.2%) was focused on the experience of patients with cancer, followed by behavioral health (16.1%), HIV and AIDS (14.5%), and diabetes (12.9%). We identified 4 primary analytic themes of barriers and facilitators associated with the experience of accessing health care services for chronic disease management in rural areas: (1) navigating the rural environment, (2) navigating the health care system, (3) financing chronic disease management, and (4) rural life (ie, common elements of a distinct "rural" way of thinking and behaving).

CONCLUSIONS

In this comprehensive review, we found that important cultural, structural, and individual factors influenced the rural patient's experience of health care access and use, including barriers and facilitators posed by geographic and built environments, and distinct rural mores. Our findings can inform policies and programs that both facilitate structural aspects of access and include culturally appropriate interventions.VISUAL ABSTRACT.

Perinatal OUD Treatment Provider Understandings of Rural Patients' Experiences

OBJECTIVES

To present perspectives of substance use treatment providers offering perinatal opioid use disorder (OUD) treatment in a largely rural, Appalachian region. To demonstrate the extent to which providers sought to understand their patients' experiences accessing treatment and how this understanding informed providers' approach to offering patient-centered care.

METHODS

A qualitative study combining semi-structured interviews and participant-observation with perinatal substance use treatment providers, conducted within a comprehensive program. Using purposive and opportunistic sampling with key informants (n = 10), a saturation sample was achieved. Data were analyzed using modified Grounded Theory.

RESULTS

Perinatal substance use treatment providers had a good understanding of their patients' experiences seeking treatment for opioid use disorder, including being aware of obstacles patients encountered. This understanding allowed providers to better address patients' needs in and out of the clinic.

CONCLUSIONS

Participants demonstrated a good understanding of what their largely rural, Appalachian patients experienced when attempting to access perinatal OUD treatment. This understanding may enable more patient-centered care.

Gossip and Addiction Recovery in Rural Communities

Features of rural life, such as low population density and greater distances from urban areas, could worsen the prospects of addiction recovery for rural residents. Gossip is a central feature of rural life, and studies have shown that being the target of it can worsen health and well-being. However, no previous study has focused on the impact of gossip on addiction in rural communities. The current study employed semi-structured interviews with individuals in recovery, as well as addiction providers, to create a conceptual model of the relationship between gossip and addiction recovery in a rural region of Minnesota. The conceptual model depicted a bi-directional relationship between the individual and the community and suggested that gossip transforms from negative to positive over the course of addiction, early recovery, and long-term recovery. These data demonstrate that education at both the community and individual levels could support the transition to long-term recovery.

Knowledge and Power Relations in Older Patients' Communication About Medications Across Transitions of Care

Communicating about medications across transitions of care is a challenging process for older patients. In this article, we examined communication processes between older patients, family members, and health professionals about managing medications across transitions of care, focusing on older patients' experiences. A focused ethnographic design was employed across two metropolitan hospitals. Data collection methods included interviews, observations, and focus groups. Following thematic analysis, data were analyzed using Fairclough's Critical Discourse Analysis and Medication Communication Model. Older patients' medication knowledge and family members' advocacy challenged unequal power relations between clinicians and patients and families. Doctors' use of authoritative discourse impeded older patients' participation in the medication communication. Older patients perceived that nurses' involvement in medication communication was limited due to their task-related routines. To reduce the unequal power relations, health professionals should be more proactive in sharing information about medications with older patients across transitions of care.

Alcohol and other substance use disorder recovery during pregnancy among patients with posttraumatic stress disorder symptoms: A qualitative study

Background

About 5% of women are pregnant at substance use disorder (SUD) treatment entry, and pregnant women with SUD often belong to marginalized groups experiencing social, economic, and health care barriers associated with stigma from prenatal substance use. Pregnant women in SUD treatment have high rates of trauma and posttraumatic stress disorder (PTSD). This study sought to (1) examine the lived experiences of pregnant individuals with PTSD symptoms in SUD treatment and (2) understand the roles of systematic or contextual barriers to the pursuit of prenatal abstinence.

Methods

We draw upon in-depth semi-structured interviews to examine relationships between SUD, psychological trauma/PTSD experience, social resources, and lived experiences among patients in prenatal SUD treatment with PTSD symptoms. Our sample was pregnant patients (N = 13) with prior DSM-5 Criterion A trauma and current PTSD symptoms enrolled in a comprehensive program integrating prenatal care, substance use counseling, medication for opioid use disorder and case management at three sites affiliated with an urban academic medical center in New Mexico.

Results

Using thematic analysis, four main themes identified structural forces influencing alcohol and drug use: (a) lack of access or ability to obtain resources, (b) substance use to cope with negative affect, (c) social stigma, and (d) interpersonal relationships.

Conclusions

Despite receiving high-quality integrated prenatal and SUD care, these pregnant patients with PTSD symptoms in SUD treatment still experienced substantial social and structural hurdles to achieving abstinence during pregnancy.

Nurses' Descriptions of Interactions When Caring for Women With Perinatal Substance Use Disorders and Their Infants

The purpose of this review is to describe health care interactions between nurses and women with perinatal substance use disorders, including interactions with their infants from the perspective of the nurses. Findings from 11 qualitative inclusion articles were synthesized using a metasummary approach. The majority of articles showed that nurses experience problematic interactions when providing care to women with perinatal substance use disorders and their infants, although some results indicated that some nurses engage in interactions that are assuring. Six types of conflictual interactions were identified: inadequate care, distressing, condemning, deficient knowledge, rejecting, and dissatisfying. Two types of therapeutic interactions were identified: compassionate and supportive. The findings underscore the importance of managing stigma, enhancing knowledge of the science of addiction processes, and promoting best practices when caring for this population.

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.].

Creating a Lactation-Friendly Learning Environment for Medical Students and Residents: A Northern Canadian Perspective

Background: Lactation is a normal postpartum physiological process that can continue in excess of 3 years and is often the sole nutritional source for infants in the first 6 months of life. Breastfeeding not only provides infant nutrition, but also facilitates maternal-infantile bonding. Lactating mothers separated from their children face multiple challenges in finding and accessing appropriate spaces and time for milk expression. Maternal employment is a great barrier to breastfeeding and accordingly has led to multiple advancements in the area of breastfeeding policy. One example of a policy is the Baby-Friendly Initiative. This initiative focused on breastfeeding promotion, support, and protection. However, the impact of such campaigns on lactating medical students and residents is thought to be low. Furthermore, breastfeeding rates differ vastly according to geographic locations in North America. Trends indicate decreased rates of breastfeeding in northern rural areas in comparison with southern urban counterparts. This highlights the need for increased protection, support, and creation of safe-lactation spaces for all working mothers including medical students and residents, and especially those in rural areas. Goals: To review challenges of breastfeeding as a medical trainee and delineate the creation of a lactation policy for medical learners and residents. Methodology: We conducted a literature review of breastfeeding policy and experiences of breastfeeding while in the learning environment. Results: Challenges of breastfeeding in medical school and residency include the complex, high-paced medical working environment where taking breaks or time off is often difficult. Few medical schools across North America have any breastfeeding policy. Conclusion: The Northern Ontario School of Medicine's lactation policy serves as a possible solution to the barriers medical students and residents face when breastfeeding in the academic environment. This policy creates lactation-friendly medical learning spaces through the entitlement of dedicated space and time for milk expression.

Nurses' Approaches to Pain Management for Women With Opioid Use Disorder in the Perinatal Period

OBJECTIVE

To identify how nurses approach pain management for women with opioid use disorder (OUD) in the perinatal period from the perspectives of nurses and women.

DESIGN

A secondary analysis of data from a qualitative descriptive study on the development of trust between nurses and women who use substances during the perinatal period.

SETTING

We interviewed the woman participants in a private conference room at a residential treatment center, and we interviewed the nurse participants over the phone.

PARTICIPANTS

Four women from a residential treatment center in the rural U.S. Midwest and nine nurses who were members of a local Midwestern Chapter of the Association of Women's Health, Obstetric and Neonatal Nurses.

METHODS

We used semistructured individual interviews, and participants were asked to describe positive, negative, and typical interactions they had with the other group to identify factors that helped or hindered the formation of trust. In the course of the interviews, four of the women and nine of the nurses described interactions centered on pain management. This information, which we summarized using content analysis, provided data related to the approaches to pain management that nurses use for women with opioid use disorder in the perinatal period.

RESULTS

Analysis showed that nurse participants used five approaches to pain management: Promoting Nonopioid Pain Management Strategies; Trying to Give Pain Medications on Time; Doubting or Judging Women; Withholding, Delaying, or Resisting Giving Pain Medications; and Responding to Women's Hostility.

CONCLUSION

Nurses should confront biases related to opioid use during pregnancy and receive training on how to manage aggressive behavior during the provision of maternity care.

Meeting the Challenge of Perinatal Care in Rural Communities

The complexities of providing quality perinatal care within rural communities provide significant challenges to providers and policy makers. Provision of healthcare in rural communities is challenging on individual as well as community-based levels. A quality improvement lens is applied to consider key challenges that pertain to patients, providers, place, and policy. Potential solutions from a provider perspective include nurse-midwifery care and inclusion of advanced practice providers in a variety of specialties in addition to creating care models for registered nurses to practice at the top of their scope. To enhance access in the rural place, telehealth and coordination activities are recommended. Finally, policy approaches such as Perinatal Care Collaboratives, Area Health Education Centers, and enhanced financial resources to eliminate socioeconomic disparities will enhance perinatal care in rural communities.

Difficult binds: A systematic review of facilitators and barriers to treatment among mothers with substance use disorders

BACKGROUND

The United States and Canada have observed sharp increases in substance use disorder among women of child-bearing or child-rearing age. Substance use disorder can have deleterious effects on children, families, and communities. Many evidence-based treatments exist, but engaging mothers in treatment is difficult. No recent review is available to help systems and providers understand the facilitators of and barriers to treatment for mothers.

OBJECTIVE

To systematically identify facilitators and barriers to substance use and mental health treatment for mothers with substance use disorder who are pregnant or parenting young children in the United States and Canada.

METHODS

We systematically searched the literature using five online databases and performed a gray literature search. We included studies published in the past two decades focused on parent or provider perspectives.

RESULTS

Our search identified 23 high-quality papers. The majority of papers qualitatively examined the perspectives of treatment-seeking pregnant women and mothers diverse in race/ethnicity, region, and treatment settings. Our synthesis of findings revealed the compelling and complex centrality of motherhood, which served as both a facilitator and barrier. Motherhood often interacted with relational (e.g., perceiving stigma vs. support from providers, family, friends, partners) and structural (e.g., time commitments, childcare) factors to both hinder and help engagement in treatment.

CONCLUSIONS

Our findings can help policy-makers and practitioners make tangible improvements to the financing and delivery of substance use treatment for mothers. Our review points to specific areas for future research, including an examination of the relationships between various structural factors and treatment outcomes.

"The elephant in the room;" a qualitative study of perinatal fears in opioid use disorder treatment in Southern Appalachia

BACKGROUND

Diagnoses of perinatal opioid use disorder (OUD) continue to rise in the United States. Patients and providers report obstacles to OUD treatment access. Difficulties include legal ambiguity related to Social Services notification requirements following a birth to people using opioids or in medication-assisted treatment for OUD.

METHODS

Through semi-structured interviews, participant-observation, and a focus group conducted in a mostly rural, region of the Southern United States (where perinatal OUD is more prevalent), patients' and providers' perspectives about perinatal substance use treatment were initially sought for a larger study. The findings presented here are from a subset analysis of patients' experiences and perspectives. Following ethics review and exemption determination, a total of 27 patient participants were opportunistically, convenience, and/or purposively sampled and recruited to participate in interviews and/or a focus group. Data were analyzed using modified Grounded Theory.

RESULTS

When asked about overall experiences with and barriers to accessing perinatal substance use treatment, 11 of 27 participants reported concerns about Social Services involvement resulting from disclosure of their substance use during pregnancy. In the subset analysis, prevalent themes were Fears of Social Services Involvement, Preparation for Delivery, and Providers Addressing Fears.

CONCLUSIONS

Perinatal OUD patients may seek substance use treatment with existing fears of Social Services involvement. Patients appreciate providers' efforts to prepare them for this potential reality. Providers should become aware of how their own hospital systems, counties, states, and countries interpret laws governing notification requirements. By becoming aware of patients' fears, providers can be ready to discuss the implications of Social Services involvement, promote patient-centered decision-making, and increase trust.

"I didn't want to be on Suboxone at first…" - Ambivalence in Perinatal Substance Use Treatment

OBJECTIVES

The objectives of this article are to present findings from recent qualitative research with patients in a combined perinatal substance use treatment program in Central Appalachia, and to describe and analyze participants' ambivalence about medication-assisted treatment for opioid use disorder (OUD), in the context of widespread societal stigma and judgement.

METHODS

We conducted research in a comprehensive outpatient perinatal substance use treatment program housed in a larger obstetric practice serving a large rural, Central Appalachian region. The program serves patients across the spectrum of substance use disorders but specifically offers medication-assisted treatment to perinatal patients with OUD. We purposively and opportunistically sampled patients receiving prescriptions for buprenorphine or buprenorphine-naloxone dual product, along with prenatal care and other services. Through participant-observation and semi-structured interviews, we gathered qualitative data from 27 participants, in a total of 31 interviews. We analyzed transcripts of interviews and fieldnotes using modified Grounded Theory.

RESULTS

Participants in a combined perinatal substance use treatment program value supportive, non-judgmental care but report ambivalence about medication, within structural and institutional contexts of criminalized, stigmatized substance use and close scrutiny of their pregnancies. Women are keenly aware of the social and public consequences for themselves and their parenting, if they begin or continue medication treatment for OUD.

CONCLUSIONS

Substance use treatment providers should consider the social consequences of medication treatment, as well as the clinical benefits, when presenting treatment options and recommendations to patients. Patient-centered care must include an understanding of larger social and structural contexts.

Substance Use Disorder Treatment, Perceived Need for Treatment, and Barriers to Treatment Among Parenting Women With Substance Use Disorder in US Rural Counties

OBJECTIVE

Higher rates of substance use in rural counties compared to urban counties have been well documented. Low perceived need for treatment among those with substance use disorder (SUD) has also been documented in the literature. However, not much is known about SUD treatment among parenting women in rural counties and the impact of perceived need for treatment in seeking care. Little research has also examined barriers to SUD treatment among parenting women in rural communities.

METHODS

Using a large nationally representative dataset, the study utilizes multivariable logistic regression models to estimate the differences in utilizing SUD treatment among parenting women with SUD in rural and urban counties in the United States. Role of perceived need for SUD treatment and barriers related to finance, access, and stigma are also examined.

RESULTS

Parenting women in rural counties with SUD who perceive a need for treatment have more than 90% lower odds of receiving treatment compared to those in urban counties. In addition, parenting women with SUD in rural counties have more than 50% higher odds of identifying access-related issues such as lack of openings in programs, unavailability of treatment facilities, and lack of transportation as barriers to care compared to parenting women in urban counties.

CONCLUSION

Diagnosis of SUD among parenting women is steadily increasing in rural communities. While many resources in combatting maternal SUD are being utilized, policy and programmatic responses tailored for mothers with SUD in rural communities might help increase utilization of treatment and reduce barriers to treatment.

Development and Psychometric Testing of the Nurses' Confidence Scale: Unique Families

OBJECTIVE

To develop and evaluate an instrument designed to measure the confidence of nurses in their ability to provide neutral, compassionate care to unique families in perinatal settings: the Nurses' Confidence Scale: Unique Families.

DESIGN

Prospective instrument development and psychometric study.

SETTING

Health system in the U.S. Mountain West region.

PARTICIPANTS

Convenience sample of 62 perinatal/neonatal nurses.

METHODS

We developed a two-part scale to measure the confidence of nurses in their ability to care for complex/nontraditional families, termed unique families. Part A was focused on nursing care behaviors for any unique family; Part B was focused on providing care to seven specific unique family populations. Five experts in perinatal nursing or adoption evaluated the scale's content validity. To test the psychometric properties of the scale, we used item analysis, reliability analysis, and exploratory factor analysis.

RESULTS

The content validity index was 0.82. The Cronbach's alpha coefficient estimate of internal consistency for Part A was .92. Principal component analysis resulted in two factors that explained 64% of the total variance: skills and resources (Cronbach's alpha coefficient = .89) and awareness and sensitivity (Cronbach's alpha coefficient = .87). Part B had a Cronbach's alpha coefficient of .90. Parts A and B showed a strong positive relationship with one another (r = .77). The general self-efficacy measure was strongly and positively correlated with Part A (r = .81) and moderately and positively correlated with Part B (r = .48).

CONCLUSION

The Nurses' Confidence Scale: Unique Families is a new tool with which to measure the confidence of perinatal/neonatal nurses in providing sensitive, specific care to complex/nontraditional families. Results of our psychometric evaluation supported initial acceptable reliability and validity of the scale.

Trying to Do What Is Best: A Qualitative Study of Maternal-Infant Bonding and Neonatal Abstinence Syndrome

BACKGROUND

The maternal experience of caring for and bonding with infants affected by neonatal abstinence syndrome (NAS) has not been adequately characterized.

PURPOSE

This study was designed to describe mothers' experiences of, supports for, and barriers to bonding with infants with NAS.

METHODS

Semistructured interviews were coded using computer-assisted thematic content analysis. A code co-occurrence model was used to visualize the relationships between themes.

RESULTS

Thirteen mothers of infants with NAS participated. Trying to Do What Is Best emerged as the overarching theme with which several subthemes co-occurred. Subthemes that captured mothers loving their infants and bonding, feeling supported by the infants' fathers, feeling supported in the community, and receiving information from hospital staff were associated with mothers' trying to do what is best. Barriers to trying to do what is best included feeling unsupported in the community, guilt about taking medications or substances during pregnancy, feeling judged, and infant withdrawal.

IMPLICATIONS FOR PRACTICE

Specific implications for practice may be derived from the mothers' criticisms of NAS assessment tools. Mothers highlighted the value of reassurance and education from providers and the uniquely nonjudgmental support received from peers and male coparents.

IMPLICATIONS FOR RESEARCH

There is a lack of information about maternal-infant bonding in dyads affected by NAS and factors that contribute to parental loss of custody. Qualitative, quantitative, and mixed-methods studies in diverse populations might help researchers better understand the long-term outcomes of NAS and develop interventions that decrease family separation.

Deep Vein Thromboses in Injecting Drug Users: Meanings, Bodily Experiences, and Stigma

Deep vein thromboses (DVTs) are common sequelae of injecting drugs into the groin. We explored meanings and experiences of DVTs in a group of 19 patients from the North East of England with a DVT and in treatment for opioid use. We report three themes: (a) DVT meaning making, (b) embodied experience, and (c) Stigma. Patients attributed DVTs to groin injecting, though thought other factors were also partially responsible. Medication performed both treatment and preventive functions. The most pertinent worry was amputation. Patients recognized stopping injecting as important, but it did not necessarily occur. Stigma resulted in delayed admission to hospital and feelings of isolation; support groups might alleviate the latter. Although groin injecting was undertaken partly to avoid the censure of being a drug user, ironically, a DVT led to long-standing stigmata that were discrediting signs of that exact status.