Barriers to Care for Pregnant Women Seeking Substance Use Disorder Treatment

Abstract

The number of pregnant women who are using opioids during pregnancy and the number of pregnant women seeking treatment for opioid use disorder during pregnancy have increased dramatically in the past decade. Over 90% of substance-using adults delay or do not receive treatment for their substance use disorder, and slightly less than half of pregnant substance-using women receive recommended treatment—medication-assisted treatment (MAT). Pregnant women and their newborns are particularly vulnerable to the adverse consequences of addiction and substance use, including opioid exposure. Substance use, which includes the use and misuse of tobacco, alcohol, opioids, and other psychoactive and stimulant substances (with or without a prescription), is now the leading cause of maternal mortality nationally. In the state of Maryland, recent estimates suggest that substance use results in approximately five deaths annually—approximately 15% of total maternal deaths in 2014. Little research has evaluated barriers to accessing healthcare services in marginalized low-income women particularly in cities such as Baltimore, Maryland, which are most impacted by the crisis of substance use. There remain critical gaps in access to care for pregnant substance-using women and in the knowledge of trajectories of substance use in this population. The dearth of evidence can, in part, be explained by the lack of emphasis on identifying and addressing the complexity of disparities—such as those due to racism, poverty, stigma, and education—that inform trajectories of addiction and dispossess vulnerable pregnant women of necessary healthcare. Furthermore, current research on treatment is limited in its generalizability. I reviewed the literature on barriers to care of substance-using pregnant women and share the findings here. In addition, I sought to elicit the experiences, beliefs, and attitudes of healthcare providers and current and former substance-using pregnant women in Baltimore, Maryland, which affected their engagement with the healthcare system. I employed qualitative research methods via an iterative process of in-depth interviews to gather the depth and breadth of these women’s experiences. This preliminary work in a sample of respondents found that among the key drivers for disengagement or lack of engagement with the healthcare system are fear of engagement with child social services agencies and lack of education around substance use treatment among care providers which pronounces the perceived stigma associated with care. Women expressed feelings of being “judged” for their decisions and even mistreated while in the care of health providers—encounters that adversely impacted their well-being. Feelings of disrespect and of “not being heard” permeate experiences of pregnant women seeking care. Finally, lack of access to healthcare services and providers are pervasive among women seeking care. In order to mitigate the impact of the substance use disorder crisis among women, it is necessary to develop targeted context-specific interventions to improve care for this population and to address, explicitly, racism in the practice of institutions and healthcare providers that further entrench healthcare inequalities. These interventions need to be mindful of the layers of legal and clinical implications for women attempting to seek care. In addition, focused attention should be paid to underlying mental health issues and social, structural, and political determinants of health, including lack of stable housing, which often precede or co-occur with substance use.

Questions for Thought and Discussion

• 1. Define stigma. What are two specific ways stigma can reflect structural racism and inequalities at the societal level?

• 2. From the perspective of healthcare providers, do you feel that mandated reporting supports care for pregnant women who are substance users? Why or why not?

• 3. What are some barriers to care for pregnant women who are substance users? In what ways are these barriers unique to pregnant women compared to nonpregnant women?

• 4. How does racism play a role in preventing substance-using women from seeking care? How is racism embedded in institutions of care and our healthcare policies and practices?

• 5. In what ways does criminalizing substance use impact access to care and health outcomes? Be specific in identifying particular laws and policies that explicitly or by extension lead to criminalization.

Glossary of Terms

Substance use

The utilization and consumption of substances (with prescription or without prescription) or illicit substances that are associated with varying degrees of adverse maternal or fetal health. These include alcohol, tobacco, opioids, and other substances.

Criminalization

The prohibition of substance use resulting in involvement of law enforcement or the state’s legal and social services apparatus broadly.

Addiction

According to the American Society of Addiction Medicine (ASAM), addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences (ASAM).