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This article was written by Sadaf Kazi, PhD. Scientists from MedStar Health Research Institute are working to improve the health of mothers and babies in Washington, D.C., by helping providers, patients, and community leaders understand the scope and impact of opioid, stimulant, and other substance use disorders during pregnancy.
Opioid, stimulant, and other substance use disorders (SUD) are a severe risk factor for pregnancy complications for the baby and the birthing patient. Nationally, about 5 percent of patients use one or more addictive substances during pregnancy. According to a study by D.C.'s Maternal Mortality Review Committee, while Black birthing people account for 50% of live births in the District, they make up 90% of the city's birth-related deaths. Many factors contribute to the complex problem of maternal morbidity and mortality, and our team is investigating the role of SUD in this problem.
One of the most pressing health needs in D.C. is to reduce disparities and challenges that birthing patients face, such as substance use. MedStar Health Research Institute is working on an initiative to understand SUD in pregnancy and develop strategies to protect the health of mothers and babies.
The initiative uses surveys, interviews, and data from electronic health records to gather insights from patients and providers about how to improve conversations about SUD and streamline effective, empathetic care for pregnant and parenting patients. Our researchers are using these insights to improve how we care for pregnant and parenting patients who experience challenges associated with SUDs.
Improving detection of SUD during pregnancy.
Our work began in 2021 with an electronic survey of healthcare practitioners at several Washington, D.C. sites to explore how often they care for pregnant and parenting patients with SUD. The goal was to understand current screening and treatment practices and seek their perspectives on opportunities to improve existing protocols.
Researchers then conducted semi-structured interviews with patients, caregivers, providers, and community leaders to collate their experiences with SUD in pregnancy and gather suggestions for improving access to and delivery of treatment.
One crucial finding was physician understanding of SUD prevalence in pregnant patients. Providers estimated few of their patients used substances while pregnant. But many patients we spoke with reported opioid use while pregnant.
Because providers anticipate that very few patients use substances during pregnancy, most do not conduct universal screening for SUD. Instead, they may discuss it only if patients bring it up or show signs of a SUD or withdrawal. This is problematic because patients might be reluctant to discuss substance use because of shame and guilt, and fear of losing custody of their other children.
Further, providers also expressed challenges in connecting patients to treatment centers that can appropriately manage patients’ SUD during pregnancy. The result is treatment gaps, leaving patients and their pregnancies at risk.
When providers screen patients, they typically use a validated questionnaire. Patients with or at risk of SUD are usually given information about how substance use harms the fetus. Then, they are referred to other providers for psychotherapy and medication.
However, many patients do not have access to reliable transportation or consistent childcare. Further, SUD is a chronic condition requiring long-term treatment. Treatment occurs in residential treatment programs and specialized outpatient clinics over a period of weeks to months to years, and may be characterized by periods of relapse. However, patients may not have the financial resources needed to seek and maintain SUD treatment.
While there are gaps in the screening process, providers have expressed their desire to improve the system. In many cases, that begins with empathetic conversations with patients to better understand factors contributing to SUD, communication about available treatment opportunities, and providing support for patients’ socioeconomic needs that may complicate treatment.
Improving screening from all perspectives.
This initiative worked to gain perspective from four primary groups of stakeholders. Over the course of the project, we conducted in-depth interviews with 19 patients, 15 caregivers, 10 community organizers and health policy experts, and 12 healthcare providers to obtain a nuanced understanding of the problem from different perspectives.
When asked via interviews why they began using substances, most patients cited pain management and coping with grief or psychosocial problems.
Many patients reported disclosing their substance use to their doctor during pregnancy—independently or with family members' encouragement. They had positive intentions, such as getting the best care or being concerned that using substances could negatively affect the pregnancy.
However, most patients described negative experiences while being screened for SUD. They reported feeling judged, insecure, guilty, and shamed in their healthcare interactions around SUD.
Patients suggested ways to improve screening conversations, including:
- Screening led by a female physician or sympathetic mother
- Involving a mental health professional to navigate the emotional impact of disclosing substance use during the screening
- Focusing on how to manage the significant life change of pregnancy in addition to SUD
Treatment could also be streamlined with patient input, such as:
- Increasing the consistency of appointments
- Providing educational materials around the effect of substance use during pregnancy and postpartum
- Improving access to therapists and providers specialized in SUD treatment
- Connecting patients with community-based services to manage socioeconomic needs
Our researchers also spoke with providers, caregivers, and community leaders to get a holistic understanding of successes and areas of opportunity during SUD screening and treatment.
The providers we interviewed reported that they typically conduct SUD screening on a patient's first visit. If no substance use is suspected, the screening is repeated at the patient's third-trimester visit. They also report talking with patients about social needs and whether they could benefit from wraparound services, including social work, nutrition, or legal aid.
Providers identified opportunities to improve this process to create a holistic approach to SUD treatment that includes more healthcare touch points and the logistical needs of patients. Some suggestions to improve detection and treatment of SUD included:
- Guidance about clinical, educational, and legal workflows after a positive substance use screening
- Reliable contact information for treatment facilities with available services
- Training in motivational interviewing to encourage truthful disclosures
Caregivers, such as a partner, loved one, or aide who helps patients with errands or medication reminders, can personally impact pregnant patients to disclose or seek treatment for SUD.
We spoke with caregivers who fill several roles, including attending appointments with pregnant patients, and helping the pregnant patient with chores. The caregivers reported that they could help their loved ones more if they received:
- Better training to recognize the signs of SUD
- Realistic treatment expectations about the relapsing nature of SUD
- Resources to support SUD treatment during and after delivery
Caregivers also expressed the need for and unawareness about financial resources (e.g., federal- or state-based programs and funds) to support SUD treatment during pregnancy.
Community leader and health policy expert insights.
Community leaders comprise citizens, clergy, nonprofit staff, government officials, and others who regularly interact with pregnant patients. They are often the bridge between research, citizens, and resources such as mental and physical health care, education, housing, spiritual support, and SUD treatment and recovery.
Interviewees identified opportunities to improve care for pregnant patients with SUD, such as:
- A confidential hotline to access treatment and other resources
- Improving access to childcare resources so patients can keep their healthcare appointments
- Integrated care among the patient's provider team for seamless information sharing and care delivery
Turning data into action.
Based on the survey and interview findings, the research team is designing resources for each stakeholder group to support best practices in SUD:
- Pregnant and postpartum patients: Training materials that cover health and wellness during pregnancy with a focus on the effects of substance use on a developing baby and how to access community- and healthcare-based resources to manage patient social needs.
- Caregivers: Educational materials about factors that influence the health and wellness of patients during and after pregnancy, recognizing signs and symptoms of substance use, and how to navigate the healthcare system when supporting treatment.
- Providers: Anti-bias training and conversation guides can help support empathetic care and facilitate truthful disclosures about substance use during pregnancy. Educational materials about the effects of legal and illegal substances on the health of a pregnant patient and fetus could also be developed.
- Community leaders: Opportunities for improvement include streamlined information sharing to plan and deliver care, confidential hotlines and anonymous call centers for information and care resources, childcare provision to enable residential treatment for SUD and robust community resource lists.
These materials can help close the gap between patient needs and clinical workflows to support these needs. This initiative has revealed that working with constituent groups throughout the city can bring patients and providers together to help protect the health of mothers and babies in Washington, D.C.
At MedStar Health, the D.C. Safe Babies Safe Moms program is one example of integrating health and community services to benefit the health and well-being of mothers and infants. D.C. Safe Babies Safe Moms is a partnership between MedStar Health, Community of Hope, and Mamatoto Village that addresses disparities in maternal and infant care by putting each family at the center of their care before, during, and after pregnancy. To accomplish this, MedStar Health brings together partners from the health system and the community to support birthing people and their families.
With a similarly integrated community approach, informed by patient-centered research and enlivened by committed providers and dedicated partners, we can help improve screening and treatment for SUD in pregnant and postpartum patients in Washington, D.C.
The solution begins with leaders at all levels. Recognizing the problem and committing to expanding equitable access to health care, building the community knowledge base, and designing health, social, and legal solutions to support the critical work of helping patients achieve treatment for SUD.