The Opioid Epidemic and Maternal Health: Three Opportunities for Change
Opioid use disorder in pregnancy has increased dramatically across the country in the last decade, bringing with it increased health risks for mothers and babies. Mothers who don’t receive treatment are facing increased pregnancy complications, including increased risk for preterm births and low birth rates, and ultimately, more families are being separated, whether by needed social services or the tragic loss of a parent.
“These numbers oblige us to seize every opportunity to support families affected by the opioid crisis,” says NICHQ Chief Health Officer Elizabeth Coté, MD, MPH. “Each encounter a potential mother has with a care system—whether during gynecological care and screening, prenatal care and delivery, postpartum care or well child visits—is an opportunity for advocacy and change. Each encounter is a new chance, a potential moment for change that conveys hope.”
Improving these encounters is one area of focus for the National Network of Perinatal Quality Collaboratives (NNPQC), funded by the Centers for Disease Control and Prevention. NICHQ serves as the coordinating center for the NNPQC , which provides quality improvement expertise to state-based PQCs, helping them drive change in maternal and infant health outcomes across the country. Many of the PQCs in the network have identified opioid use disorder as a critical opportunity for improvement.
Below, we’re sharing ideas from NNPQC faculty experts—Ron Iverson, MD, MPH; Mike Marcotte, MD; Moira Crowley, MD; and Elisha Wachman, MD—on improving three potential encounters at three early stages of motherhood. Improving these interactions, especially for at-risk mothers, translates to more opportunities to help families when they are in crisis and in most need of additional aid.
In giving these families better support and more chances to make a change, public health professionals can better address the opioid epidemic and its damaging effects on maternal and infant health.
Prenatal opportunities: Screening and intervention
A woman’s first prenatal visit is a critical opportunity to screen for opioid use disorder. When the visit is managed well, a care provider can identify a mother’s addiction severity, offer initial information on the risks of continued illicit drug use, advise on next steps, and connect her with the supports she needs to heal (e.g., Medication-Assisted Treatment (MAT) providers, psychiatric care, social workers and local resources). However, without this supportive and compassionate approach, such screenings may be underutilized and ineffective.
“Women may feel nervous or uncomfortable bringing up their substance use,” says Iverson, the director of labor and delivery at Boston Medical Center (BMC). “It’s our job to be proactive about the screening and sensitive about how we respond. Establishing an initial rapport with these families, and acknowledging their unique experiences, brings needed trust.”
Similarly, says Iverson, care providers should never appear caught off guard when a mother discloses her opioid use. Acting surprised or judgmental can leave mothers feeling even more uncomfortable, making them less likely to trust recommendations or follow-up with concerns. Developing a standard plan for intervention helps ensure that providers are always prepared to give relevant, actionable and, perhaps most importantly, judgement-free advice.
Opportunities post-delivery: Empowering caregivers
After delivery, opioid-exposed newborns are often taken to intensive care for pharmacologic treatment, leaving mothers feeling alienated from their babies’ care.
“Rather than inspire change, this approach risks telling a new mother that she’s not capable of caring for her child,” explains Wachman, attending neonatologist at BMC. “We need to instead empower mothers as the primary treatment for their new babies. We can teach them how to console their babies, how to be a constant source of comfort and care.”
When care teams empower mothers on behalf of their own health and the health of their children, they improve long-term outcomes for families, all while helping babies recover at a faster rate. According to Wachman, this “nonpharmacologic” treatment approach—including rooming-in and breastfeeding, if not contraindicated—supports infant recovery and has reduced the length of stay and need for pharmacologic treatment in infants with neonatal abstinence syndrome by half at BMC.
Supporting mothers as caregivers also means being honest about their own treatment. This transparency helps realistically prepare mothers for recovery while establishing a foundation of trust between them and the healthcare system.
“Tell mothers what they can expect during that first hospitalization and prepare them to talk to social services,” says Crowley, the director of neonatal ECMO at the University Hospitals Rainbow Babies and Children’s Hospital in Cleveland. “Offering mothers realistic, honest advice positions you as a trusted ally, whereas letting them get blindsided might make them resistant to care.”
Postpartum opportunities: Supporting the dyad
When mothers return home, they’re often left battling their addiction while taking on the significant additional stress of a newborn. During that first year, relapse rates spike, bringing with them dire consequences.
“In many states, accidental overdose is the leading cause of maternal death in that first year,” says Marcotte, director of quality and safety for women’s services at TriHealth in Cincinnati. “We’re losing too many mothers because they don’t have a support system. We can change that, though, by partnering with pediatricians to help support post-discharge care.”
While a mother may not follow up with her own care, she is likely to follow up with her child’s. Pediatric visits then become critical opportunities to discuss addiction treatment and needs, such as coordinating sub-specialists and social services, and directing mothers to additional community support networks. Forwarding a two-generational approach at these visits—one that prioritizes comprehensive care of the mother-child dyad—provides another critical opportunity to support families, another chance to inspire change.
“We have to remember that these families often face significant barriers to optimal health, such as trauma, poverty and access to healthcare,” says Coté. “Addiction is a chronic disease marked by relapse. But by aligning systems of care and transforming every interaction into an opportunity for change, we’ll come closer to providing these families with the wrap-around services they need to recover and heal.”
NICHQ Employee Spotlight: Chiagbanwe Enwere, NICHQ Project Analyst
As a member of NICHQ's Data Applied Research and Evaluation (DARE) team, NICHQ Project Analyst Chiagbanwe Enwere brings a unique data and equity perspective to the New York State Maternal and Child Health Collaboratives project
MCH Lead Poisoning Toolkit: Lessons on Using Data for Improvement
The Maternal and Child Environmental Health Collaborative Improvement and Innovation Network (MCEH CoIIN), a national initiative led by the Association of Maternal and Child Health Programs developed the MCH Lead Poisoning Toolkit to share innovative practices and methods that nine different state teams tested out to improve access to systems and services that address the needs for pregnant women, infants, children, and families that are exposed to lead. NICHQ provided quality improvement expertise and technical assistance for the MCEH CoIIN—offering state teams guidance on using data and measurement to determine where improvements have been made and areas that still require change. Read tips and take-aways from the three-year CoIIN for data collection and using data for Improvement.
A Physician’s Reflections on Racism and Treating Sickle Cell Disease
For NICHQ’s current and future work, I am motivated by wanting to be a better version of myself in service of others. Wondering whether my own implicit biases impacted my care of patients and families, I realize that I cannot redo past ER experiences. If I could go back, I would slow down to acknowledge and try to set my biases aside and approach patients from a personally more informed perspective. But now, I can use my past, present, and future experiences to ensure NICHQ is amplifying important lessons from this multi-year effort reflecting the compassion, care, and commitment of hundreds of dedicated professionals in pursuit of equitable, accessible, and quality healthcare for people living with sickle cell disease.
Navigating Well-Child Visits and Vaccinations during COVID-19
Well-child visits and recommended vaccinations are essential, ensuring children stay healthy and are protected from preventable diseases and illnesses such as measles, whooping cough, and seasonal flu. But, as the COVID-19 pandemic persists, data shows that fewer childhood vaccinations have been given and many children have fallen behind on their scheduled appointments. Healthcare professionals should utilize the following strategies to work with parents and caregivers to get their children caught up on missed appointments and recommended vaccinations.
Exploring a Nonbinary Approach to Health
NICHQ is not abandoning the traditional use of the terms “mother” and “maternal.” We are embracing the inclusive language of “birthing person/people” across our work. A move toward inclusive language does not force us to stop using language that so many people identify with; at its core, inclusion is about creating more space for one another. We are taking care to expand the use of these terms in our communications, on our website, in our resources, and eventually, in all our projects.