Improving Access to Care for Pregnant and Postpartum People with Opioid Use Disorder

Editor’s Note: In light of the sharp increase in pregnancy and postpartum deaths linked to opioid use disorder (OUD),¹ the American Medical Association (AMA) and Manatt Health have developed a set of recommendations for state policymakers to improve access to care for pregnant and postpartum people with OUD, focusing several strategies on improving care for justice-involved pregnant and postpartum individuals.

The recommendations were informed by relevant research findings, interviews with physicians and other experts and an analysis of federal, state and local policies. The report also includes examples of numerous state- and community-based best practices in use throughout the country. Click here to download a free copy of the full report.

In a new webinar with frontline clinicians and policymakers, the AMA and Manatt Health will discuss the recommendations in depth and highlight state- and community-based best practices. Click here to register for the free webinar. 

In recent years, opioid-related overdoses have become a leading cause of death during pregnancy and the postpartum period, with mortality rates rising more than 80% between 2017 and 2020.^2,3,4 This increase exacerbates a mounting maternal mortality and morbidity crisis and underscores the critical need to improve access to care for pregnant and postpartum people with OUD.⁵ Left untreated, OUD during pregnancy can have severe medical and social consequences. It can destabilize a pregnancy and contribute to adverse outcomes such as low birth weight, preterm labor and fetal distress and demise.⁶ It can also increase the likelihood of newborns being separated from their families at birth, raising the risk of trauma to the mother and harms to the newborn.⁷

Fortunately, there are effective treatments for pregnant people with OUD. In particular, access to medications for OUD (MOUD)—including buprenorphine and methadone—has been demonstrated to help improve the health outcomes of both pregnant people and their babies.

Despite the clear benefit of MOUD, pregnant people continue to face significant barriers to accessing it; only 50–60% of pregnant people in the United States receive MOUD.^8,9 Racial, ethnic and geographic disparities heighten access challenges, reducing treatment rates even further for certain populations.^10,11 Stigma related to perinatal OUD is pervasive and discourages many people from seeking any prenatal care. While all people with OUD face stigma, pregnant and postpartum people bear an even greater burden—they are assumed to be unfit parents, and their OUD is often treated as a basis for automatic removal of their child.¹² They may even face criminal charges for using medication to treat their OUD even though MOUD is strongly recommended under clinical guidelines.

Another challenge faced by physicians and pregnant people is the uncertainty about what federal and state laws may require. Federal law requires health care providers to notify the state if they are involved in the treatment or delivery of a substance-affected infant. However, federal law does not require automatic reporting to child welfare agencies, since an infant may be substance-affected for a variety of reasons, including that their parent is receiving MOUD. ^13,14 While some states have adopted policies generally supporting treatment, more than 20 states and the District of Columbia have adopted punitive policies in excess of federal law, requiring providers to report the pregnant or postpartum person for alleged child abuse even if the person is receiving MOUD under a physician’s supervision.

Incarcerated pregnant and parenting people have even worse access to care, as many jails and prison systems do not—or will not—provide MOUD. A 2022 survey of jails across the country found that MOUD was available during pregnancy at only 60% of jails. Among the systems that did provide MOUD, a majority (near 55%) discontinued treatment following delivery through practices ranging from “abrupt cessation” in the hours after a person delivers their baby to tapering of medication.¹⁵

Recommendations to Improve Access to Care for Pregnant and Postpartum People with Opioid Use Disorder  

The AMA’s and Manatt’s research revealed five key policy recommendations that would improve outcomes for pregnant and postpartum people, their newborns and their families: 

• Recommendation #1: State policies should make clear that MOUD is the standard of care for OUD in pregnancy and should be available for all pregnant people throughout the prenatal, peripartum and postpartum periods.
• Recommendation #2: State policies should ensure that pregnant and postpartum people with OUD are not punished for receiving MOUD and, instead, should be supported with family care plans.
• Recommendation #3: Data collection and state partnerships should be improved to help support equitable access to treatment for all pregnant and postpartum people with OUD and their families.
• Recommendation #4: Correctional facilities and judicially-supervised diversion programs should provide all justice-involved people, including pregnant and postpartum individuals, with access to FDA-approved MOUD and universal screening for OUD.
• Recommendation #5: Prior to release from jail or prison, all incarcerated individuals, including pregnant people, should receive Medicaid coverage and access to prerelease services, including detailed reintegration planning, medical referrals and linkages to essential services, such as childcare, housing and employment.

Conclusion

The escalating rise of opioid-related overdose morbidity and mortality among pregnant and postpartum people with OUD demands that state policymakers act urgently to improve access to care in both community and carceral settings. While some states have started to take a nonpunitive, public health approach to improve access to care, opportunities for improvement exist. Policymakers can use a variety of legislative and non-legislative approaches to eliminate barriers to care for pregnant and postpartum people with SUD regardless of their carceral status. The effectiveness of these measures rests on collaboration between policymakers, health care professionals, law enforcement, CPS agencies, advocates and pregnant and postpartum people to expand access to evidence-based care and enhance opportunities and outcomes for pregnant and postpartum individuals, newborns and families.

_{¹ Bruzelius E, Martins SS. US Trends in Drug Overdose Mortality Among Pregnant and Postpartum Persons, 2017-2020. JAMA. 2022.}

_{² Ibid.}

_{³ Trost SL, Beauregard J, Njie F, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017–2019. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2022.}

_{⁴ Campbell J, Matoff-Stepp S, Velez ML, Cox HH, Laughon K. Pregnancy-Associated Deaths from Homicide, Suicide, and Drug Overdose: Review of Research and the Intersection with Intimate Partner Violence. J Womens Health (Larchmt). 2021 Feb;30(2):236-244. doi: 10.1089/jwh.2020.8875. Epub 2020 Dec 8. PMID: 33295844; PMCID: PMC8020563.}

_{⁵ Hoyert DL. Maternal Mortality Rates in the United States, 2021. NCHS Health E-Stats. 2023.DOI: https://dx.doi.org/10.15620/cdc:124678.}

_{⁶ Harter K. Opioid use disorder in pregnancy. Ment Health Clin. 2019 Nov 27;9(6):359-372. doi: 10.9740/mhc.2019.11.359. PMID: 31857932; PMCID: PMC6881108.}

_{⁷ "When Reimagining Systems Of Safety, Take A Closer Look At The Child Welfare System", Health Affairs Blog, October 7, 2020. DOI: 10.1377/hblog20201002.72121.}

_{⁸ Short VL, Hand DJ, MacAfee L, Abatemarco DJ, Terplan M. Trends and disparities in receipt of pharmacotherapy among pregnant women in publically funded treatment programs for opioid use disorder in the United States. J Subst Abuse Treat. 2018 Jun;89:67-74. doi: 10.1016/j.jsat.2018.04.003. Epub 2018 Apr 6. PMID: 29706175.}

_{⁹ Krans EE, Kim JY, James AE 3rd, Kelley D, Jarlenski MP. Medication-Assisted Treatment Use Among Pregnant Women With Opioid Use Disorder. Obstet Gynecol. 2019 May;133(5):943-951. doi: 10.1097/AOG.0000000000003231. PMID: 30969219; PMCID: PMC6483844.}

_{¹⁰ Gao YA, Drake C, Krans EE, Chen Q, Jarlenski MP. Explaining Racial-ethnic Disparities in the Receipt of Medication for Opioid Use Disorder during Pregnancy. J Addict Med. 2022 Nov-Dec 01;16(6):e356-e365. doi: 10.1097/ADM.0000000000000979. PMID: 35245918; PMCID: PMC9440158.}

_{¹¹ Opioid Use Disorder and Treatment Among Pregnant and Postpartum Medicaid Enrollees. The Kaiser Family Foundation, September 2023.}

_{¹² Schiff, Davida M., MD, MSc; Stoltman, Jonathan JK, PhD; Nielsen, Timothy C., MPH; Myers, Sara, BA; Nolan, Moira, BA; Terplan, Mishka, MD, MPH; Patrick, Stephen W., MD, MPH, MS; Wilens, Timothy E., MD; Kelly, John, PhD. Assessing Stigma Towards Substance Use in Pregnancy: A Randomized Study Testing the Impact of Stigmatizing Language and Type of Opioid Use on Attitudes Toward Mothers With Opioid Use Disorder. Journal of Addiction Medicine 16(1):p 77-83, January/February 2022 | DOI: 10.1097/ADM.0000000000000832.}

_{¹³ The distinction between a confidential “notification” to the state that a health care professional was involved in the delivery of a newborn exposed to substances can be separate and distinct from a “report” to a child protective services agency. The AMA strongly supports that state and federal child protection laws be amended so that pregnant people with substance use and substance use disorders are only reported to child welfare agencies when protective concerns are identified by the clinical team, rather than through automatic or mandated reporting of all pregnant people with a positive toxicology test, positive verbal substance use screen or diagnosis of a substance use disorder.}

_{¹⁴ See, generally, FAQ from the Administration for Children and Families, U.S. Department of Health and Human Services. Available at https://www.acf.hhs.gov/cwpm/public_html/programs/cb/laws_policies/laws/cwpm/policy_dsp.jsp?citID=350#:~:text=CAPTA%20requires%20that%20the%20health,a%20Fetal%20Alcohol%20Spectrum%20Disorder. Last accessed October 19, 2023.}

_{¹⁵ Sufrin C, Kramer CT, Terplan M, et al. Availability of Medications for the Treatment of Opioid Use Disorder Among Pregnant and Postpartum Individuals in US Jails. Journal of the American Medical Association Netw Open. 2022;5(1):e2144369. doi:10.1001/jamanetworkopen.2021.44369.}