Table 2.

Feedback loops in the stigma and MCH outcomes model

Name of feedback loop	Feedback loop structure	Explanation of feedback loop	Participant quotations
Example		An “S” on the arrow indicates that the two connected variables move in the same direction (i.e., if the first variable increases, it triggers an increase in the second variable; if the first variable decreases, the second variable decreases). An “O” on the arrow indicates that the two variables move in opposite directions (i.e., if the first variables increases, the second variable decreases; if the first variable decreases, the second variable increases).
		This example shows that an individual/community response to increasing stress levels is to support development of coping strategies to deal with the stress. This balancing feedback loop (“B”) is striving to “control” stress and keep it at a tolerable level, and assumes that increased use of coping strategies will effectively reduce stress. Coping strategies should thus be enhanced in individuals and strengthened over time to retain this defense against stress.
R1: Perpetuation of structural and social stigma		High levels of institutional and systems-level stigmatization of perinatal substance use drives individual stigma perpetuated by people working in the prevention, treatment, and recovery community. This individual-level stigma further fuels/creates/increases structural stigma, in a reinforcing feedback loop (“R”) explaining increasing cycles of growth (or decline, if either is pushed to decrease) in inter-connected social and structural stigma.	“When our health system is unwilling to invest in perinatal addiction treatment, it does send a message to those of us in clinical care that this is not something to be prioritized during pregnancy, and further reinforces stigma.”—Obstetric Care Physician
R2: Provider stigma limits patient centered care		Social stigma limits the provider’s desire to provide patient-centered care by consciously or subconsciously acting on the belief that substance use is a choice and not a medical condition. Alternatively, a strong desire to provide patient-centered care can challenge and reduce the prevalence of social stigma.	“When they come in to deliver, for instance, the group that's on may or may not have, the same level of education, or examined their own biases, or done any of the things that we need to do to really provide quality care to these folks.”—Hospital Nursing Director of Women’s Health
B1: Poor infant health outcomes creates urgency to improve care		A lack of high-quality, patient-centered, equitable, evidence-based, and trauma-informed care negatively impacts infant health outcomes, including through increased exposure to adverse childhood experiences (ACEs). Poor infant health outcomes increase the provider/service communities focus on reducing prenatal substance exposure, including through the delivery of more equitable and evidence-based care. While this solves the problem of improving care in the short-term, it raises questions about sustaining investment and engagement in improving perinatal substance use care in the long-term.	“We focus significantly on reducing prenatal substance exposure, which is important, but we have limited guidance on how to provide evidence-based support for pregnant people and infants exposed to non-prescribed substances (i.e., a harm-reduction based model of care) and I worry that this may negatively impact patients and families in the long term.”—Maternal Fetal Medicine and Addiction Medicine Physician
R3: Interdependence of maternal and infant health outcomes		When birthing people experience positive health outcomes, including SUD and pregnancy/postpartum outcomes, their infants are more likely to experience positive outcomes, such as lower rates of preterm birth and a decreased likelihood of neonatal abstinence syndrome, among others (Patrick et al., 2017). Similarly, birthing people may experience more positive mental health outcomes as a result of a healthy newborn infant.	“When you treat the pregnant person, you are also investing in their health across their lifespan and potentially the lifespan of the infant. You cannot focus only on treatment of one without thinking of the benefits to the other. If you only treat the neonate, you forsake the health of the mother who wants to provide skin-to-skin, the mother who wants to bond, the mother who wants to breastfeed. The mother who desperately wants to get better.”—OBGYN Provider
R4: Self-stigma drives maternal health outcomes		A birthing person’s self-stigmatization and negative beliefs about their SUD and capacity for recovery can discourage engagement in perinatal and SUD care, which decreases the likelihood of positive health outcomes. Negative health outcomes can perpetuate self-stigma by reinforcing the negative beliefs a person holds about themselves and their SUD.	“Patients often already carry so much guilt and self-blame due to their substance use and substance use disorders. And when they experience a negative health outcome, it may reinforce their beliefs that they are not deserving of good things in their lives.”—OBGYN Provider
R5: Self-stigma drives infant health outcomes		Similarly to loop R4, a high level of self-stigma in the absence of perinatal and SUD care negatively influences infant health outcomes. Poor infant health outcomes reinforce self-stigma as birthing people may feel selfblame without adequate support and treatment opportunities.	“Self-stigma, shame, fear and guilt all contribute to pregnant people with SUD not engaging in prenatal care. These thoughts, emotions and feelings impact the birthing person’s health as well as infant health outcomes. It is crucial to acknowledge and educate the care team, and remind the patient, that a SUD is a disease and can be treated. It is recommended to have SUD screening for every OB patient in the prenatal setting to allow for safe, therapeutic and trauma-informed conversation about SUD during pregnancy. Reminding the patient that the care team is supportive, that there is treatment for SUD, and remaining non-judgmental can lead to patient centered goals for reduced use or abstinence to improve maternal and infant outcomes.”—OBGYN Social Worker
R6: Engagement in care improves health outcomes/encourages continued engagement		When birthing people are highly engaged in perinatal and/or SUD care and they experience positive health outcomes, they are more likely to remain engaged in future care.	“If there’s a feeling of stigma from past experiences, patients may not be seen for care and that absence of care may be associated with undesirable outcomes.”—OGBYN/Addiction Medicine Physician
R7: Family separation harms birthing peoples’ health outcomes		Family separation, whether from parental incarceration or child protective service intervention, is detrimental to maternal behavioral health and has been linked to increased substance use, further reducing the likelihood of family reunification (Harp & Oser, 2018).	“I’ve worked with parents who really want to get to where they needed to be, but they just didn’t have enough time to do it. People are going to relapse and need more support… and now all the sudden the county is pushing permanency and it sets the parents up for failure under that kind of pressure”—State Department of Health staff member
R8: Family separation harms infant health outcomes		Family separation harms infant health immediately and over the life-course through its negative impact on parent child attachment, breastfeeding, childhood behavioural health, and increased exposure to ACEs (Lander, et al., 2013). Poor infant health outcomes may increase the likelihood of continued substance use/relapse among birthing people, thus increasing rates of family separation.	“I can’t help but wonder if he’d still be the same giggly smiling kid if they would have taken him from me after birth.”—Person with lived experience of perinatal SUD