“We Have to Keep Advocating and Helping and Doing What We Can”: Examining Perinatal Substance Use Services in the Absence of Integrated Treatment Programs

• Author: Tracy R. Nichols,Meredith R. Gringle,Amber Welborn,Amy Lee
• DOI: http://doi.org/10.1177/00220426221092771
• Published date: 01 January 2023
• Date: 01 January 2023
• Subject Matter: Articles

https://doi.org/10.1177/00220426221092771

Journal of Drug Issues

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DOI: 10.1177/00220426221092771

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Article

“We Have to Keep Advocating and

Helping and Doing What We Can”:

Examining Perinatal Substance

Use Services in the Absence of

Integrated Treatment Programs

Tracy R. Nichols1, Meredith R. Gringle1, Amber Welborn2,

and Amy Lee1

Abstract

Effective treatment of substance-exposed pregnancies requires gender-responsive care

coordinated across agencies and systems. A deeper understanding of the perspectives,

experience, and practices of professionals providing these services is needed to improve care.

This study examines service provision for perinatal substance use through the perspectives and

experiences of healthcare and social service professionals. Using a constructivist grounded theory

design, data were collected over a 7-year period. Data collection consisted of interviews and

focus groups with professionals as well as observations of professional meetings and workshops

where practices and procedures were discussed. A multi-level model of service delivery is

described. The role of affect, particularly around issues of custody, is discussed along with

structural level actions that develop in the absence of integrated treatment. Structural support

both within and across systems of care is crucial to developing coordinated and compassionate

care and to increasing engagement in care services.

Keywords

pregnancy, substance use, opioid use disorder, systems of care, integrated care

Introduction

Pregnant people who use drugs (PPWUDs) require multiple social and healthcare services due to

complexities that arise from the intersection of multiple marginalization, childbearing and rear-

ing, and comorbid conditions. Limited resources, stigma, and fear of both civil and criminal

prosecution are barriers to effective care provision (Barnett et al., 2021). Multi-faceted care is

critical for the health and well-being of both parent and child and necessitates systems of care

that are coordinated, compassionate, and responsive to the needs of PPWUDs. A robust literature

details the lived experiences of PPWUDs when accessing healthcare and social services (Adams,

1University of North Carolina Greensboro, Greensboro, NC, USA

2Beaver College of Health Science, Appalachian State University, Boone, NC, USA

Corresponding Author:

Tracy R. Nichols, Department of Public Health Education, University of North Carolina Greensboro, 437 HHP

Building, Greensboro, NC 27402-6170, USA.

Email: trnicho2@uncg.edu

092771

JODXXX10.1177/00220426221092771Journal of Drug IssuesNichols et al.

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2023, Vol. 53(1) 18–36

Nichols et al. 19

et al., 2021; Barnett et al., 2021; Wolfson et al., 2021). This literature centers parenting as both a

facilitator of and a barrier to engaging with care services (Barnett et al., 2021). Understanding the

experiences of PPWUDs is critical; however, we also need to understand perspectives and expe-

riences of care-providers and other professionals to develop effective and compassionate service

delivery.

A burgeoning literature on the experience of care-providing professionals who serve PPWUDs

reports on their feelings of frustration, anger, and burnout (Maguire et al., 2012; Murphy-Oikonen

et al., 2010; Shaw et al., 2016; Whittaker et al., 2016). Of particular concern are the tensions that

exist between professionals’ empathy for PPWUDs and their personal biases and judgments

regarding pregnancy and drug use. These biases and judgments may impact provider’s assess-

ments of a person’s fitness as a parent (Benoit et al., 2014; Geraghty et al., 2019; Nelson, 2016),

which can have repercussions both during and after PPWUDs’ engagement with care services.

Research has also highlighted institutional and systems-level practices which contribute to chal-

lenges and frustrations experienced by professionals. Identified problematic practices include

time constraints, overfilled workloads, lack of adequate funding, and a lack of cross-training

between reproductive care and addiction treatment professionals (Geraghty et al., 2019; MacAfee

et al., 2020; Shaw et al., 2016; Syversten et al., 2018; Whittaker et al., 2016). While these studies

provide important insights, most have been conducted within a specific discipline (such as mid-

wifery or nursing) or setting (such as a residential treatment facility). It is important to examine

how care is provided both within and across the complex systems of care required to meet the

needs of PPWUDs.

Essential elements of effective care for a PPWUD go beyond simply receiving prenatal care

and treatment for substance use disorders to include services that provide other mental health

treatment, educational and supportive services (such as parenting and job training), and child-

care. Additionally, services should be gender-responsive, follow trauma-informed principles, and

both conceptualize and treat the parent and infant as a dyad (Jones & Kaltenbach, 2013). In the

case of prenatal opioid use, opioid agonist therapy (OAT) is best practice (Saia et al., 2016).

Research also suggests integrated and/or co-located service provision is optimal to provide

streamlined communication, similar policies, and geographical proximity (Hubberstey et al.,

2019; Sword et al., 2009; Wright, 2019). When services are not integrated and/or site-specific,

care coordination is more challenging. It becomes imperative for professionals to develop strong

interagency relationships to create a system of services that prevents uncontrolled drug use, pro-

vides prenatal care that includes drug treatment, delivery, and discharge, offers evidence-based

birth and postpartum care, and initiates aftercare to reinforce efforts to prevent future substance-

exposed births (Syvertsen et al., 2018).

While components of evidence-based practices for perinatal substance use generally, and opi-

oid use specifically, are well documented (Jones & Kaltenbach, 2013; Saia et al., 2016), less is

known about how services are provided across these systems of care. A deeper understanding of

how care is provided within and across agencies, grounded in the perspectives of the profession-

als who provide care, can help identify leverage points for interventions to improve PPWUDs’

experiences of coordinated and compassionate care. The purpose of our study was to develop a

grounded theory of service provision for PPWUDs, with a specific focus on perinatal opioid use,

across multiple care systems in North Carolina, USA.

Perinatal Substance Use Service Provision in North Carolina

North Carolina has a long history of offering programs and providing resources for perinatal

substance use (Godwin et al., 2020). Care provision includes screening for pregnancy and/or

drug use, prenatal care delivery, addiction treatment, OAT, patient navigation, hospital-based

services for labor and delivery, and as needed, the Neonatal Intensive Care Unit (NICU).