Biopsychosocial contexts of timely and adequate prenatal care utilization among women with criminal legal involvement and opioid use disorder.

OBJECTIVE: Pregnant women with criminal legal involvement and opioid use disorder (CL-OUD) living in non-urban regions may be at risk for complex biomedical, psychological, and social barriers to prenatal care and healthy pregnancy. Yet, limited research has explored prenatal care utilization patterns among this subpopulation. This study describes the biopsychosocial factors of pregnant women with a history of criminal legal involvement and opioid use disorder (CL-OUD) associated with timely prenatal care initiation and adequate prenatal care utilization (APNCU). METHODS: Analyses were conducted on a subsample of medical record data from an observational comparative effectiveness study of medication treatment models for pregnant women with diagnosed opioid use disorder (OUD) who received prenatal care in Northern New England between 2015 and 2022. The subsample included women aged ≥ 16 years with documented criminal legal involvement. Analyses included χ2, Fisher exact tests, and multiple logistic regression to assess differences in timely prenatal care and APNCU associated with biopsychosocial factors selected by backwards stepwise regression. RESULTS: Among 317 women with CL-OUD, 203 (64.0%) received timely prenatal care and 174 (54.9%) received adequate care. Timely prenatal care was associated with having two or three prior pregnancies (aOR 2.37, 95% CI 1.07-5.20), receiving buprenorphine at care initiation (aOR 1.85, 95% CI 1.01-3.41), having stable housing (aOR 2.49, 95% CI 1.41-4.41), and being mandated to court diversion (aOR 4.06, 95% CI 1.54-10.7) or community supervision (aOR 2.05, 95% CI 1.16-3.63). APNCU was associated with having a pregnancy-related medical condition (aOR 2.17, 95% CI 1.27-3.71), receiving MOUD throughout the entire prenatal care period (aOR 3.40, 95% CI 1.45-7.94), having a higher number of psychiatric diagnoses (aOR 1.35, 95% CI 1.07-1.70), attending a rurally-located prenatal care practice (aOR 2.14, 95% CI 1.22-3.76), having stable housing (aOR 1.94, 95% CI 1.06-3.54), and being mandated to court diversion (aOR 3.11, 95% CI 1.19-8.15). CONCLUSION: While not causal, results suggest that timely and adequate prenatal care among women with CL-OUD may be supported by OUD treatment, comorbid indications for care, stable access to social resources, and maintained residence in the community (i.e., community-based alternatives to incarceration).

Implementation of State Laws Giving Pregnant People Priority Access to Drug Treatment Programs in the Context of Coexisting Punitive Laws.

BACKGROUND: In response to increased prenatal drug use since the 2000s, states have adopted treatment-oriented laws giving pregnant and postpartum people priority access to public drug treatment programs as well as multiple punitive policy responses. No prior studies have systematically characterized these state statutes or examined implementation of state priority access laws in the context of co-existing punitive laws. METHODS: We conducted legal mapping to examine state priority access laws and their overlap with state laws deeming prenatal drug use to be child maltreatment, mandating reporting of prenatal drug use to child protective services, or criminalizing prenatal drug use. We also conducted interviews with 51 state leaders with expertise on their states' prenatal drug use laws to understand how priority access laws were implemented. RESULTS: Thirty-three states and the District of Columbia have a priority access law, and more than 80% of these jurisdictions also have one of the punitive prenatal drug use laws described. Leaders reported major barriers to implementing state priority access laws, including the lack of drug treatment programs, stigma, and conflicts with punitive prenatal drug use laws. CONCLUSIONS: Our results suggest that state laws granting pregnant and postpartum people priority access to drug treatment programs are likely insufficient to significantly increase access to evidence-based drug treatment. Punitive state prenatal drug use laws may counteract priority access laws by impeding treatment seeking. Findings highlight the need to allocate additional resources to drug treatment for pregnant and postpartum people.

Development and Implementation of State and Federal Child Welfare Laws Related to Drug Use in Pregnancy.

Policy Points Over the past several decades, states have adopted policies intended to address prenatal drug use. Many of these policies have utilized existing child welfare mechanisms despite potential adverse effects. Recent federal policy changes were intended to facilitate care for substance-exposed infants and their families, but state uptake has been incomplete. Using legal mapping and qualitative interviews, we examine the development of state child welfare laws related to substance use in pregnancy from 1974 to 2019, with a particular focus on laws adopted between 2009 and 2019. Our findings reveal policies that may disincentivize treatment-seeking and widespread implementation challenges, suggesting a need for new treatment-oriented policies and refined state and federal guidance. CONTEXT: Amid increasing drug use among pregnant individuals, legislators have pursued policies intended to reduce substance use during pregnancy. Many states have utilized child welfare mechanisms despite evidence that these policies might disincentivize treatment-seeking. Recent federal changes were intended to facilitate care for substance-exposed infants and their families, but implementation of these changes at the state level has been slowed and complicated by existing state policies. We seek to provide a timeline of state child welfare laws related to prenatal drug use and describe stakeholder perceptions of implementation. METHODS: We catalogued child welfare laws related to prenatal drug use, including laws that defined child abuse and neglect and established child welfare reporting standards, for all 50 states and the District of Columbia (DC), from 1974 to 2019. In the 19 states that changed relevant laws between 2009 and 2019, qualitative interviews were conducted with stakeholders to capture state-level perspectives on policy implementation. FINDINGS: Twenty-four states and DC have passed laws classifying prenatal drug use as child abuse or neglect. Thirty-seven states and DC mandate reporting of suspected prenatal drug use to the state. Qualitative findings suggested variation in implementation within and across states between 2009 and 2019 and revealed that implementation of changes to federal law during that decade, intended to encourage states to provide comprehensive social services and linkages to evidence-based care to drug-exposed infants and their families, has been complicated by existing policies and a lack of guidance for practitioners. CONCLUSIONS: Many states have enacted laws that may disincentivize treatment-seeking among pregnant people who use drugs and lead to family separation. To craft effective state laws and support their implementation, state policymakers and practitioners could benefit from a treatment-oriented approach to prenatal substance use and additional state and federal guidance.

Promoting community stakeholder engagement in research on treatment for pregnant women with opioid use disorder.

Aim: Community stakeholder engagement in research (CSER) can improve research relevance and efficiency as well as prevent harmful practices, particularly for vulnerable populations. Despite potential benefits, researchers lack familiarity with CSER methods. Methods: We describe CSER strategies used across the research continuum, including proposal development, study planning and the first years of a comparative effectiveness study of care for pregnant women with opioid use disorder. Results: We highlight successful strategies, grounded in principles of engagement, to establish and maintain stakeholder relationships, foster bidirectional communication and trust and support active participation of women with opioid use disorder in the research process. Conclusion: CSER methods support research with a disenfranchised population. Future work will evaluate the impact of CSER strategies on study outcomes and dissemination.

Community stakeholder engagement in research on treatment for pregnant women with opioid use disorder builds and maintains stakeholder relationships, fosters communication and trust and supports active patient participation.

Integrated vs nonintegrated treatment for perinatal opioid use disorder: retrospective cohort study.

BACKGROUND: Pregnant women with opioid use disorder and their infants often experience worse perinatal outcomes than women without opioid use disorder, including longer hospitalizations after delivery and a higher risk for preterm delivery. Integrated treatment models, which combine addiction treatment and maternity care, represent an innovative approach that is widely endorsed, however, limited studies have compared the outcomes between integrated and standard, nonintegrated programs from real-world programs. OBJECTIVE: This study aimed to evaluate the perinatal and substance use outcomes for pregnant women with opioid use disorder receiving coordinated, colocated obstetrical care and opioid use disorder treatment (integrated treatment) and to compare it with those of women receiving obstetrical care and opioid use disorder treatment in distinct programs of care (nonintegrated treatment). STUDY DESIGN: In this observational, retrospective cohort study, we abstracted the perinatal and opioid use disorder treatment data from the records of pregnant women with opioid use disorder (n=225) who delivered at a rural, academic medical center from 2015 to 2017. The women either received integrated (n=92) or nonintegrated (n=133) opioid use disorder treatment and obstetrical care. Using inverse probability weighted regression models to adjust for a potential covariate imbalance, we evaluated the impact of the treatment model on the risk for preterm delivery and positive meconium or umbilical cord toxicology screens. We explored whether the number of obstetrical visits mediated this relationship by using a quasi-Bayesian Monte Carlo algorithm. RESULTS: Women receiving integrated treatment were less likely to deliver prematurely (11.8% vs 26.6%; P<.001) and their infants had shorter hospitalizations (6.5±4.8 vs 10.7±16.2 days). Using a robust inverse probability weighted model showed that receiving integrated treatment was associated with a 74.7% decrease in the predicted probability of preterm delivery (average treatment effect, -0.19; standard error, 0.14; P<.001). There were no differences in the risk for a positive meconium or umbilical cord toxicology screen, a marker for second and third trimester substance use, between women receiving integrated treatment and those receiving coordinated treatment (29.4% vs 34.6%; P=.41), however, integrated treatment was associated with significantly lower rates of positive maternal urine toxicology screens at the time of delivery (35.9% vs 74.4%; P<.001). CONCLUSION: Among a cohort of rural pregnant women with opioid use disorder, receiving integrated obstetrical care and opioid use disorder treatment was associated with a reduced risk for preterm birth, a lower risk for positive maternal urine toxicology screen at the time of delivery, and shorter infant hospitalization. This relationship was mediated by the number of obstetrical visits attended during pregnancy, suggesting that increased engagement with obstetrical care through integration of services may contribute to improved perinatal outcomes.

In their own words: a qualitative study of factors promoting resilience and recovery among postpartum women with opioid use disorders.

BACKGROUND: Opioid use disorder (OUD) is associated with substantial morbidity and mortality for women, especially during the perinatal period. Opioid overdose has become a significant cause of maternal death in the United States, with rates highest in the immediate postpartum year. While pregnancy is a time of high motivation for healthcare engagement, unique challenges exist for pregnant women with OUD seeking both substance use treatment and maternity care, including managing change after birth. How women successfully navigate these barriers, engage in treatment, and abstain from substance use during pregnancy and postpartum is poorly understood. The aim of this study is to explore the experiences of postpartum women with OUD who successfully engaged in both substance use treatment and maternity care during pregnancy, to understand factors contributing to their ability to access care and social support. METHODS: We conducted semi-structured, in-depth interviews with postpartum women in sustained recovery (n = 10) engaged in a substance use treatment program in northern New England. Interviews were analyzed using grounded theory methodology. RESULTS: Despite multiple barriers, women identified pregnancy as a change point from which they were able to develop self-efficacy and exercise agency in seeking care. A shift in internal motivation enabled women to disclose need for OUD treatment to maternity care providers, a profoundly significant moment. Concurrently, women developed a new capacity for self-care, demonstrated through managing relationships with providers and family members, and overcoming logistical challenges which had previously seemed overwhelming. This transformation was also expressed in making decisions based on pregnancy risk, engaging with and caring for others, and providing peer support. Women developed resilience through the interaction of inner motivation and their ability to positively utilize or transform external factors. CONCLUSIONS: Complex interactions occurred between individual-level changes in treatment motivation due to pregnancy, emerging self-efficacy in accessing resources, and engagement with clinicians and peers. This transformative process was identified by women as a key factor in entering recovery during pregnancy and sustaining it postpartum. Clinicians and policymakers should target the provision of services which promote resilience in pregnant women with OUD.

Treating perinatal opioid use disorder in rural settings: Challenges and opportunities.

Perinatal opioid use disorder (OUD) is a life-threatening condition that significantly impacts women in rural areas. Medication assisted treatment (MAT) is the recommended treatment but can be difficult to access. Pregnant women may initially present for treatment of OUD in the emergency department, on labor and delivery units, or in an office setting, each of which presents unique challenges. Initiation of MAT in the appropriate setting, based on accurate assessment of gestational age, is a centrally important component of care for perinatal OUD. However, initiating treatment may present challenges to providers who lack experience treating this disorder. Vermont and New Hampshire are predominantly rural states which have focused on expanding MAT access for pregnant women using two different approaches to integrating treatment with maternity care.

Findings from a novel approach to publication guideline revision: user road testing of a draft version of SQUIRE 2.0.

BACKGROUND: The Standards for Quality Improvement Reporting Excellence (SQUIRE) Guideline was published in 2008 (SQUIRE 1.0) and was the first publication guideline specifically designed to advance the science of healthcare improvement. Advances in the discipline of improvement prompted us to revise it. We adopted a novel approach to the revision by asking end-users to 'road test' a draft version of SQUIRE 2.0. The aim was to determine whether they understood and implemented the guidelines as intended by the developers. METHODS: Forty-four participants were assigned a manuscript section (ie, introduction, methods, results, discussion) and asked to use the draft Guidelines to guide their writing process. They indicated the text that corresponded to each SQUIRE item used and submitted it along with a confidential survey. The survey examined usability of the Guidelines using Likert-scaled questions and participants' interpretation of key concepts in SQUIRE using open-ended questions. On the submitted text, we evaluated concordance between participants' item usage/interpretation and the developers' intended application. For the survey, the Likert-scaled responses were summarised using descriptive statistics and the open-ended questions were analysed by content analysis. RESULTS: Consistent with the SQUIRE Guidelines' recommendation that not every item be included, less than one-third (n=14) of participants applied every item in their section in full. Of the 85 instances when an item was partially used or was omitted, only 7 (8.2%) of these instances were due to participants not understanding the item. Usage of Guideline items was highest for items most similar to standard scientific reporting (ie, 'Specific aim of the improvement' (introduction), 'Description of the improvement' (methods) and 'Implications for further studies' (discussion)) and lowest (<20% of the time) for those unique to healthcare improvement (ie, 'Assessment methods for context factors that contributed to success or failure' and 'Costs and strategic trade-offs'). Items unique to healthcare improvement, specifically 'Evolution of the improvement', 'Context elements that influenced the improvement', 'The logic on which the improvement was based', 'Process and outcome measures', demonstrated poor concordance between participants' interpretation and developers' intended application. CONCLUSIONS: User testing of a draft version of SQUIRE 2.0 revealed which items have poor concordance between developer intent and author usage, which will inform final editing of the Guideline and development of supporting supplementary materials. It also identified the items that require special attention when teaching about scholarly writing in healthcare improvement.

A Multidisciplinary Approach to the Treatment of Co-occurring Opioid Use Disorder and Posttraumatic Stress Disorder in Pregnancy: A Case Report.

Perinatal opioid use disorders negatively impact maternal and neonatal outcomes and are a public health problem of increasing severity. More than half of women with a substance use disorder have a history of posttraumatic stress disorder that, if not adequately addressed, can impede substance use disorder treatment. This case report describes complexities in the treatment of a pregnant woman with opioid use disorder and posttraumatic stress disorder and reviews the psychotherapeutic and pharmacologic approaches available to treat these co-occurring disorders in pregnancy. This case demonstrates the importance of early screening and intervention for co-occurring posttraumatic stress disorder in pregnant women who use substances in a closely coordinated, multidisciplinary approach to improve outcomes for women and their infants.

Treating tobacco use disorder in pregnant women in medication-assisted treatment for an opioid use disorder: a systematic review.

Smoking is associated with adverse effects on pregnancy and fetal development, yet 88-95% of pregnant women in medication-assisted treatment for an opioid use disorder smoke cigarettes. This review summarizes existing knowledge about smoking cessation treatments for pregnant women on buprenorphine or methadone, the two forms of medication-assisted treatment for opioid use disorder indicated for prenatal use. We performed a systematic review of the literature using indexed terms and key words to capture the concepts of smoking, pregnancy, and opioid substitution and found that only three studies met search criteria. Contingency management, an incentive based treatment, was the most promising intervention: 31% of participants achieved abstinence within the 12-week study period, compared to 0% in a non-contingent behavior incentive group and a group receiving usual care. Two studies of brief behavioral interventions resulted in reductions in smoking but not cessation. Given the growing number of pregnant women in medication-assisted treatment for an opioid use disorder and the negative consequences of smoking on pregnancy, further research is needed to develop and test effective cessation strategies for this group.

Screening for substance abuse in women's health: a public health imperative.

Alcohol and drug use is a significant public health problem with particular implications for the health and safety of women. Women who abuse these substances are more likely to have untreated depression and anxiety and are at higher risk for intimate partner violence, homelessness, incarceration, infectious disease, and unplanned pregnancy. Substance abuse during pregnancy places both mother and fetus at risk for adverse perinatal outcomes. Data regarding the prevalence of substance abuse in women are conflicting and difficult to interpret. On the clinical level, strong arguments exist against routine urine drug testing and in favor of the use of validated instruments to screen women for drug and alcohol use both in primary women's health care and during pregnancy. A number of sex-specific screening tools are available for clinicians, some of which have also been validated for use during pregnancy. Given the risks associated with untreated substance abuse and dependence in women, the integration of drug and alcohol screening into daily clinical practice is imperative. This article reviews screening tools available to providers in both the prenatal and primary women's health care settings and addresses some of the challenges raised when women screen positive for drug and alcohol abuse.