Mutual Mistrust: The multilayered experiences at the intersection of healthcare and early parenting among mothers with opioid use disorder

Abstract

Objective:

Explore the early parenting experiences among a cohort of postpartum individuals with opioid use disorder (OUD) both during and after the delivery hospitalization to identify areas of intervention to strengthen bonding and attachment.

Methods:

Semi-structured qualitative interviews with recently pregnant people with OUD assessed parenting needs, supports, and goals in the context of the demands of addiction treatment and early motherhood. Probes explored the relationship between early parenting experiences, addiction, and recovery, and enabling factors and barriers to mother-infant bonding. Interviews were completed between 2019-2020. A constant comparative methods approach was utilized for codebook development and analysis.

Results:

Twenty-six women completed interviews a mean of 10.1 months postpartum. Twenty-four women were receiving methadone or buprenorphine treatment at delivery for OUD. Four interrelated themes emerged. Women experienced: 1) increased surveillance from healthcare workers who doubted their parenting ability; 2) a desire for a “normal” early parenting experience that was not disrupted by increased medical monitoring and surveillance; 3) complex and intersecting identities of being both a mother and a person in recovery; and 4) the importance of support from and advocacy by clinicians and peers to developing maternal confidence and connection.

Conclusion:

Interventions are needed to improve the early parenting experiences of opioid-exposed mother-infant dyads, to address the mutual mistrust between health care providers and parents, and to provide additional supports to families. Promotion of positive attachment and parental self-efficacy should be prioritized over increased surveillance and scrutiny to sustain maternal recovery trajectories into early childhood and foster family well-being.

Introduction

The period after delivery is a critical time for the mother-infant dyad. Early bonding and positive attachment during this period have been associated with improved infant social-emotional development, executive functioning in toddlerhood, long-term mental health and resilience of children and later mother-infant bonding.^1–3 Additionally, early maternal-infant attachment is important for promoting maternal mental health, decreasing the risk of postpartum depression, and enabling mothers to develop their parental identity.^4,5 Yet parental stress and disruptions in care during the newborn period, such a critically ill infant requiring care in the neonatal intensive care unit or having a prolonged delivery hospitalization, can alter parenthood identity formation and affect relationship building between a mother and infant.^6–8

For mother-infant dyads impacted by opioid use disorder (OUD), the immediate postpartum period can be a time of care disruption and increased stress.^9–11 Infants with in-utero exposure to opioids are at risk for neonatal opioid withdrawal syndrome (NOWS), a set of transient and treatable neurologic and gastrointestinal signs that may require additional monitoring and treatments.¹² Despite strong desires to connect with their newborns, parents often report guilt watching their infants display symptoms of withdrawal (particularly when due to exposure to medications to treat OUD including buprenorphine and methadone), experience conflict with care teams around infant care and feeding decisions, feel stigmatized during the process of NOWS assessments and care, and fear the consequences of child welfare involvement after delivery.^{13–15 16}Further, negative experiences in hospital settings for those experiencing medical complications from drug use have been associated with distrust of the healthcare system among women with substance use disorder (SUD).¹⁷

In 2021, the highest rate of opioid-related overdose deaths were reported amidst the ongoing opioid epidemic,^18,19 contributing to a sharp rise in pregnancy-associated deaths in the postpartum year.²⁰ There is a need to examine the experiences of mothers with OUD during the critical time directly following delivery and after hospital discharge to identify opportunities to enhance parent-infant bonding, maximize parental ability to implement non-pharmacologic supports recommended for infants at risk for NOWS, and promote optimal family relationships and well-being. Prior research has examined the perspectives of clinicians and parents of infants being treated for NOWS^11,21,22 and our prior qualitative work highlighted how mandated reporting by hospital personnel to child protective services can negatively impact maternal trust in healthcare.¹⁶ However, there are few studies examining how addiction, recovery, and motherhood collide with stigma and mothers’ lack of trust in the health care system. Elucidating this intersection is necessary to develop interventions to best support families and promote engagement in care during the early postpartum period for opioid-exposed dyads. The aim of this qualitative study was to explore the early parenting experiences among a cohort of postpartum women with OUD both during and after the delivery hospitalization.

Methods

Study Design

This ancillary study drew from a qualitative study investigating modifiable factors, facilitators, and barriers to using medications to treat opioid use disorder (MOUD) in the perinatal period.¹⁶

The Behavioral Model for Vulnerable Populations²³ and the Ecological Model of Health Behavior²⁴ were adapted to inform our interview guide development, described in more detail previously.¹⁶ Questions were developed to explore the experiences of mothers in OUD treatment during and following the delivery hospitalization, including monitoring for NOWS in the infant, child protective services reporting, and other communication with healthcare providers. We aimed to assess parenting needs, supports, resources and goals in the context of the demands of OUD treatment and early motherhood. Probes explored participants’ experiences parenting with OUD, their personal response to any signs or symptoms of withdrawal in their infant, perceptions of interactions with their infant’s healthcare team, enabling factors and barriers to mother-infant bonding, parenting resources and supports available and any unmet needs, and the relationship between early parenting experiences, addiction, and recovery. The guide was reviewed by a peer recovery coach with lived experience and iteratively updated throughout the interview process, with the final questions and probes included in the Supplement. The CoreQ-32 checklist was utilized to assure quality (see Supplement).²⁵ The Mass General Brigham Institutional Review Board reviewed and approved this study.

Participants, Recruitment, and Data Collection

Eligible participants included those with a diagnosis of OUD who delivered a live birth within three years prior to the study. Individuals were largely identified through medical record review of enrolled patients at a multidisciplinary clinic caring for pregnant and postpartum people with OUD and their children in Boston, MA where one author provides clinical care (DMS). Additional recruitment efforts included the use of flyers, word-of-mouth, and snowball sampling.²⁶

Interviews occurred between 10/2019-12/2020 and lasted 30-90 minutes, with a median time of 44 minutes. Interviews were completed by a trained female research coordinator who previously worked in the multidisciplinary substance use clinic. Interviews were completed initially in person, and then via telephone during the COVID-19 pandemic. Participants received a $40 gift card for renumeration plus reimbursement for travel costs and childcare. All interviews were audio-recorded, transcribed verbatim by a professional transcription service, and deidentified for analysis. Recruitment continued until thematic saturation occurred.

Data Analysis

Our team used a constant comparative methods approach, utilizing an iterative process of reviewing data collected, analyzing codes, and updating interview questions in a contemporaneous and ongoing fashion in order to develop and refine themes in the data.^27,28 Four investigators (DMS, ECW, JAB, KDM) independently reviewed transcripts and iteratively generated a codebook of nodes and sub-nodes, until no new codes were identified. NVivo Qualitative software was used to evaluate all transcripts using the coding scheme developed. Two independent coders (ECW, SM) then performed a content analysis of all transcripts, reviewing any discrepancies (the final kappa coefficient was 0.93) and monitoring for saturation.²⁹ The study team met frequently to interpret the findings and discuss emerging themes.

Results

There were 26 individuals who completed interviews (out of 31 approached), all identified as female. Interviews were conducted a mean of 10.1 months from delivery. The demographic characteristics of the participants have been described previously (Table 1).¹⁶ In addition to the current delivery, 19 of women had previous deliveries. At time of interview, 20 participants had custody of some or all of their children. With their most recent delivery, 12 participants experienced child removal at some point between birth and when the interview took place, with 6 of those subsequently experiencing reunification. We identified four interrelated themes, detailed below and in Table 2.

Table 1.

Participant demographics.

Characteristic	n (%) or mean (SD)
Age, mean (SD)	33 years (4.6)
Months from delivery when interviewed, mean (range)	10.1 months (3-33.1)
Race
American Indian/Alaska Native	1 (3.8%)
Black or African American	3 (11.5%)
Mixed Race	3 (11.5%)
White	19 (73.1%)
Ethnicity
Hispanic or Latina	5 (19.2%)
Non-Hispanic or Latina	21 (80.8%)
Sexual orientation
Heterosexual	24 (92.3%)
Lesbian/Bisexual	2 (7.7%)
Relationship status
Dating/Partnered	5 (19.2%)
Single	14 (53.8%)
Living with Partner	7 (26.9%)
Married	3 (11.5%)
Highest educational attainment
Less than high school	6 (23.1%)
High school/equivalent	10 (38.5%)
Some college	8 (30.8%)
College graduate/higher	1 (3.8%)
Unknown	1 (3.8%)
Living situation
Residential treatment program/ sober house	6 (23.1%)
Room, apartment, house that I own or rent	13 (50.0%)
Shelter	1 (4.0%)
Transitional Stabilization Services	1 (3.8%)
With family or friends	4 (15.4%)
Unknown	1 (3.8%)
MOUD at delivery
Buprenorphine (Suboxone, Subutex)	16 (61.5%)
Methadone	8 (30.8%)
None	2 (7.8%)
Number of Children
More than one	19 (73%)
One child	7 (27%)
CPS filing at delivery	25 (96.2%)
CPS filing screened in for investigation (of 25 participants with filing at delivery	24 (96%)
Child removal at some point between most recent delivery and interview	12 (46.2%)
Reunification with most recent child prior to interview	6 (50%)
Previous child removal	10 (38.5%)
Custody status of all children at time of interview
No custody of infant and older children	6 (23.1%)
No custody of infant, has custody of some/all older children	1 (3.8%)
Has custody of infant, doesn’t have custody of older children	6 (23.1%)
Has custody of infant and some/all older children (if applicable)	13 (50%)

Table 2:

Themes and representative quotations

Theme	Quote
1. Mothers with OUD experienced surveillance in the period following delivery by hospital staff who doubted their parenting abilities resulting in a disruption of their trust in the medical system/hospital personnel.	“I didn’t want them to think I couldn’t handle her… They were like, “Are you okay?” And I was like, “…I’m fine.” But, you know, obviously, I was nodding off. [My nurse explained] ‘when you are tired, you have to go to sleep. You cannot hold her. She’s a newborn.’ … I explained ‘Oh, I didn’t want you to think—cause CPS… I don’t want you to say I don’t know what I’m doing.’” (Participant 25, 31-year-old Black mixed-race mother)
	“I’m white. I own my own home. I run a business…I didn’t have any relapses during my pregnancy, all of those things…I’m able to open my mouth and say, “What the h*** are you doing? This is not okay,” but you think about how many women in my position aren’t able to do that…and are basically being told like, “Oh, we know better.” Oftentimes, we believe them because we’ve had that messaging told to us over and over again. I tell the women all the time whether they’re getting high throughout their pregnancy or not, “You’re still their mother, you know what your baby needs, and they need you,” (Participant 26, 40-year-old white non-Hispanic mother)
	“I was very adamant that I wanted to just breastfeed him … a couple of the nurses were great about it, and then other nurses were just very, very horrible about. Like, ‘Oh, if you’re not here on time, if you go out to the methadone clinic in the morning and you’re not back here on time.’ I go, ‘Listen, I’m going to be.’…it got me stressed out. I started to slow down on milk production because they started feeding my son bottles, but I told them not to.” (Participant 13, 35-year-old white non-Hispanic mother)
2. Desires for a “normal” early parenting experience and recognition of parenting strengths are often disrupted by ramifications of an infant NOWS diagnosis, including prolonged hospitalization, mandatory child welfare reporting, labeling in the medical record, and monitoring for risk of developmental delay.	1. “Because you don’t get to enjoy your child being a newborn like everyone else does. I wish I had been prepared to know exactly what was going to be happening and know that I was not going to be treated like a normal mother or good mother at that… From the second I had him until he was four months old I was treated terribly … in general every single person that I came in contact with treated me in a negative light. I wish I had just been prepared for that and known that I was going to be looked at as if I was actively using the whole time.” (Participant 6, 31-year-old white non-Hispanic mother)
	2. “I was like, ‘I don’t deserve her if I made her go through all this s***.’ I really didn’t think I deserved her because I really f***** up. I was like, ‘I do not deserve this kid. Even if she comes out good, I don’t deserve her, to make her go through all this.’ They’re lookin’ at me like, ‘You wanna hurt your baby, but you won’t cry over here.’ I just felt like a monster over and over.”(Participant 3, 24-year-old Black Latina mother)
	3. “I don’t appreciate having my child be treated as if there’s something wrong with him when there isn’t. It’s a very nerve-wracking experience. I regret signing up for specialized clinics for my child that were related to addiction, because the appointments were about me instead of about my child…It’s as if I did something wrong to my kid when I didn’t. They should be treated like normal children because they are…my kid’s fine. I feel like he’s being punished for me being on [buprenorphine]” (Participant 6, 31-year-old white non-Hispanic mother)
3. Participants early parenting experiences were impacted by their dual, and sometimes competing identities and priorities, as a mother and a person in recovery.	“I always remind myself of what I want. What I want doesn’t require drugs or unhealthiness. What I want is success. What I want is a family. What I want is a life in a healthy neighborhood and a healthy way I can raise my kids so I can make of them what I wanted to be, which was a teacher, a lawyer. They could be that. I could be somethin’ even higher than what I wanted to be. I want them to be what they want. They need to know my traumas because I went through it. I want them to have their own memories, their own childhood, and grow up in a healthy way. That does not require alcohol or drugs. It doesn’t. I always remind myself of what I want. I always remind myself of a nice car, a nice apartment, nice furniture, all the good things that I like. I’m like, ‘You want that? Yeah, you got it.’ You gotta do what you gotta do.” (Participant 3, 24-year-old Black Latina mother)
	“I wasn’t prepared to be in a program. I thought that I was gonna be in my own apartment … After me being a couple months pregnant, I knew the situation, what it was gonna be. It made me nervous … because I wanted her in her own space, not with a bunch of random people that aren’t exactly the healthiest people to be around.” (Participant 11, 23-year-old Native American mother)
	“It’s like it puts a wrench in my life when it comes to my son because I wanna be all for my son and I wanna be able to do whatever he needs me to do and not say, ‘Oh, mommy has to go get her medication first. Mommy can’t do this yet ‘cause she doesn’t feel good.’ Or, ‘Mommy can’t do this yet because—we can’t go on vacation because mommy—there’s no clinic where we’re going,’ or whatever. I don’t want there ever to be a point in his life where the methadone clinic gets in the way of something that he wants or that he wants to do.” (Participant 4, 30-year-old white non-Hispanic mother)
4. Small acts of support and advocacy by clinicians and peers helps parents develop confidence and connection in the postpartum period strengthening their recovery.	1. “She had literally sent the unit a letter saying, ‘Listen, do not treat her as if she’s any different than anybody else. Don’t treat her as an addict. Don’t treat her in these ways … Do not disrespect this woman at all. Walk a day in her shoes. Don’t.’ Right then, they treated me very good.” (Participant 24, 32-year-old white non-Hispanic mother)
	2. “There’s a woman here who specifically does childcare. She had a woman drop me off a crib. She gave me a bunch of baby clothes…helping me with diapers and getting me prepared for her coming. I’m actually really glad that we came here because if we didn’t, I don’t know what I woulda done…she just got me a lot of things that I know I wouldn’t’ve been able to pay for.” (Participant 11, 23-year-old, Native American mother)

Theme 1: Mothers with OUD experienced surveillance in the period following delivery by hospital staff who doubted their parenting abilities, resulting in a disruption of parents’ trust in the medical system.

Mothers reported experiencing intense scrutiny during the immediate postpartum period because their newborn was opioid-exposed, even when they engaged in recommended addiction treatments including MOUD. One mother, who had older children, described this scrutiny and judgement around her parenting skills, which she felt she received from hospital providers due to their roles as mandated reporters to child protective services (CPS):

“They’re the ones that knew my history, and they give their insight to the CPS workers. Even the way they handled you, I felt like I was bein’ treated like I was a little kid that didn’t know what she was doing, that has to be watched all the time … It just didn’t feel good.” (Participant 14)

Participants also noted that their experiences in the hospital differed from the support that they perceive new mothers typically receive during the immediate postpartum period, with a sense that the focus was instead on inspecting their ability to provide newborn care after delivery:

“The nurse comes in and rips the curtain open and is like, ‘You cannot be sleeping in here.’ …. Their concern is are my eyes closed, right, not ‘can I get you anything? How can we support you? Are you feeling okay?’ I’m gonna tell you any mother that just went through childbirth is gonna be tired … but they don’t monitor other mothers that have had children the way they monitor women with substance use disorder.” (Participant 26)

Perceived doubt of the mother’s parenting skills by hospital staff, who believe they have both the authority and obligation to report pertinent behaviors to CPS, often resulted in participants feeling that they needed to prove their capability and worthiness as parents (Table 2; Theme 1, Quote 1). One participant reflected that this subtle but constant scrutiny can make mothers with SUD doubt their parenting skills and abilities (Theme 1, Quote 2).

Several participants also noted disagreements with hospital staff around feeding or NOWS treatment for their baby and felt as though staff did not value their perspective as parents. One mother described nursing staff giving her baby pharmacological treatment for NOWS “behind my back” (Participant 6) without discussing any concern for signs of withdrawal with her. Another participant discussed scrutiny from staff as she tried to balance her OUD treatment program requirements with breastfeeding goals and highlighted interactions with staff that she felt undermined her breastfeeding efforts (Theme 1, Quote 3).

Theme 2: Desires for a “normal” early parenting experience and recognition of parenting strengths are often disrupted by ramifications of a NOWS diagnosis, including prolonged hospitalization, mandatory child welfare reporting, labeling in the medical record, and monitoring for risk of developmental delay.

Seven participants expressed a desire to be treated like a “normal” mother rather than solely as someone who uses drugs (Theme 2, Quote 1). They identified interruptions of intimacy with their baby as particularly disruptive to mother-infant bonding after delivery. One mother described disruptions and lack of privacy while spending time with her infant who was receiving NOWS care in the special care nursery:

“I had no type of privacy with my daughter, even to rock her or nurture her or feed her. I was stuck to that chair. It was just awful. I don’t wish that on anybody … I believe that at this point, that could have been avoided if I had stopped taking the [buprenorphine]” (Participant 8)

While caring for their infants after the delivery hospitalization, participants experienced ongoing guilt and shame over the risk of NOWS, developmental disorders, and potentially stigmatizing interactions their children may face in the future. One participant recalled the immense guilt she felt for exposing her infant to substances prenatally, how this guilt affected her perception of herself as a mother and her ability to attach to her newborn, and how scrutiny from health care providers made her internalize feelings of being a bad mother and a “monster” (Theme 2, Quote 2).

Multiple interviewees also reported feeling anxiety and responsibility for the permanency and long-term impact of a “substance-exposed newborn” label or NOWS diagnosis in their child’s medical record. Their concerns centered around how such documentation could affect their child’s self-perception and perception of them as parents, as well as the potential for stigmatizing medical experiences in the future:

“It’s the very first thing in black and white on my daughter’s medical record… for the rest of her life, no matter how long I stay sober —I could be the president—and she’s gonna go to the doctor when she’s 17, and that’s gonna be on her record that her mother was on [buprenorphine] when she gave birth to her. That really bothers me.” (Participant 10)

Additionally, increased developmental monitoring of infants because of NOWS diagnosis made mothers feel as if their children were viewed differently due to their mother’s substance use disorder and/or receipt of MOUD during pregnancy. One participant described regret in accessing a specialized pediatric clinic, viewing it as potential extenders of labels and stigma from mother to child (Theme 2, Quote 3).

Theme 3: Participants’ early parenting experiences were impacted by their dual, and sometimes competing, identities and priorities, as a mother and a person in recovery.

Several participants expressed that their children provided motivation for their unified goal of continuing to parent while remaining in recovery (Theme 3, Quote 1). Interviewees also noted that the requirements of their OUD treatment programs often competed with their parenting goals. One mother described her uncertainties about parenting in a family residential treatment program, despite knowing it was what she needed to do to support her recovery, as it differed from the optimal parenting environment for her daughter (Theme 3, Quote 2). Another participant shared her long-term concerns that logistics of her methadone treatment would restrict her ability to meet her son’s future needs and ensure typical childhood experiences (Theme 3, Quote 3).

Interviewees also discussed the importance—and challenge—of seeking help when needed. One interviewee expressed that it can be daunting to identify necessary recovery and parenting supports when first learning one is pregnant:

“Some of us don’t know how to ask for the support that we need. Some of us don’t even know the support that we need. Again, you’re askin’ us to be moms and a recovering addict in a matter of 30 seconds after a pregnancy test.” (Participant 21)

Another described the shame and difficulty she experienced while asking for support with parenting challenges, worrying that her struggles, which would be normal for any new mother, would be incorrectly attributed to her substance use disorder:

“I also think we as people that suffer from substance use disorder have this idealistic view of other parents and that they’re perfect and don’t struggle with challenges. I think normalizing challenges in parenting and nobody is the perfect parent, right.” (Participant 26)

Theme 4: Small acts of support and advocacy by clinicians and peers helps parents develop confidence and connection in the postpartum period, strengthening their recovery.

Despite the negative experiences described above, participants also shared ways in which they felt successfully supported as mothers in recovery by providers, peers, family, and community. One participant shared her experience of feeling valued and cared for through non-stigmatizing experiences with her family’s multidisciplinary care team, and the positive effect this had on her parenting:

“They make you feel like you’re a regular human being and you’re not just some addict who is now having a baby. [They] get to know us and know our backgrounds, our surroundings. It’s actually caring about us… I chose to stay [at the clinic] because it’s like a family… That is what brought to me all my confidence as a parent.” (Participant 4)

Several participants noted the positive impact of their providers advocating for them outside of their clinic purview. One interviewee described how a letter her physician wrote to the labor and delivery unit in the hospital where she gave birth improved the care she received during delivery hospitalization (Theme 4, Quote 1). Participants also noted their appreciation of support from their community and family providing material and childcare resources (Theme 4, Quote 2).

Finally, many participants identified the importance of peer support in their recovery. Several interviewees shared that both receiving and giving peer support helped them find meaning in mutually supportive relationships, bond over common lived and parenting experiences, and share information:

“When a girl needs anything, clothes or just support, I’m there. It helps me. It makes me feel like I can be a bigger person clean. I can help people. That helps me. … it makes me feel high up there. It makes me feel like I got this. You could be clean and help people.” (Participant 3)

Discussion

This exploratory analysis of the early parenting period illustrated specific challenges experienced by mothers with OUD, reporting mistrust between health care providers and patients, disruption of the “normal” parenting experience, and the at-times competing demands of parenting and addiction treatment. Participants also suggested potential avenues for intervention to improve their experiences in the health care system and simultaneously encourage their recovery and growth as new parents, including acts of support and advocacy by providers and connection with peers.

The delivery hospitalization experience was marked by participant mistrust of hospital staff who they perceived as devaluing their parenthood and engaging in heightened scrutiny of their parenting decisions. This distrust of hospital staff increased as they experienced non-normative treatment as new mothers, stigmatizing language, and exclusion from treatment decisions for their newborns.^30,31 Significantly, mandated child protective services reporting at delivery created a common stressor within the delivery hospitalization that disrupted the trust between mothers and the medical system.

Similar to prior research, mothers reported that when the infant’s medical team disregarded their input on feeding and medical decisions, it hindered their ability to exercise their parental role and judgement.^11,14,32This perceived distrust of parenting skills from medical staff led mothers to feel a need to overcompensate to prove their worthiness as parents as they recovered from childbirth. Multiple studies have indicated that parental trust in the healthcare system influences engagement with pediatric care and adherence to recommendations, and that infants with prenatal opioid exposure have lower rates of engagement with recommended pediatric care.^33–36 To optimize engagement with pediatric care, parental trust must be built with the medical system during the delivery hospitalization, including a sense that providers trust them as new parents. Measures necessary to advance the health of mothers and infants and facilitate the bridge to pediatric care include: improving interpersonal interactions with hospital staff, involving parents in medical decisions for their infants, anti-stigma education around OUD and parenting, and dismantling policies that generically unduly surveil.

Our analysis identified a perceived lack of normalcy for both mother and infant in the postpartum period as a source of distress. Previous studies have identified that new mothers’ experiences of feeling unsupported or judged can impede bonding with a newborn with NOWS and intensify the emotional and logistical challenges of parenting while in recovery.^11,37 Our participants further identified that they did not get to experience “normal” mother-infant bonding and parenting due to both the logistics of NOWS hospitalization and mandated reporting shifting staff focus from supporting the mother-infant dyad toward identifying parental failures. The perception that their children are labeled as “abnormal” due to their prenatal opioid exposure further detracts from normal bonding and even celebration of birth. For mothers who desire a breastfeeding relationship, lack of lactation support adds to perceptions of inadequacy and disruption of normalcy.

We also identified that mothers may experience anxiety and responsibility for the permanency of a NOWS diagnosis in their child’s medical record. In concordance with a previous study, despite benefits to developmental monitoring because of a NOWS diagnosis, mothers were frustrated by these extra visits, and felt that their child was being treated as “not normal.”³⁸ Parents now have increased access to medical information through online portals and open notes following the Cures Act.³⁹ It will be important to assess the optimal balance between the length of time newborn diagnoses such as NOWS are retained in the problem list for childhood developmental monitoring versus potential harms that may be caused due to stigma, negative effects of labeling, or ascribing blame for future developmental diagnoses.

Participants described how the logistics of their OUD treatment and caring for their infant caused deviations from their vision of early motherhood with their child. Prior research found that early mother-infant bonding was a stronger predictor of later mother-infant bonding compared to either maternal mental health or substance use alone.⁴⁰ Disruptions in early mother-infant bonding and increased parental stress may be modifiable factors that affect early childhood development.^2,40 Given both the enacted and internalized stigma participants experienced, novel supportive interventions that rebuild trust in health care teams may be needed prior to focusing on parental-infant attachment in order to positively impact outcomes.

Finally, participants identified many crucial avenues of support that they considered necessary to achieve their parenting and recovery goals. Interviewees felt particularly supported when healthcare providers recognized participants as whole, complex individuals learning to be mothers, rather than just someone with a SUD. In addition to the imperative for non-stigmatizing care, several interviewees discussed the positive impact of providers who advocated for their patients in other medical or legal settings. Lastly, participants in our study also described the importance of both giving and receiving peer support with other mothers in recovery, which may further serve to recognize relative strengths and bolster confidence in parenting.^41,42

Limitations

Our study had several limitations. Most participants received perinatal care at a multidisciplinary clinic that specializes in caring for families impacted by OUD where, limiting generalizability and introducing bias due to the positionality of a member of our research team also providing clinical care. Snowball sampling techniques may further introduce sampling biases. Future studies should prioritize the voices of individuals with ongoing non-prescribed opioid use and not engaged in care, a group that may be at highest risk for stigma at delivery. Additionally, our participants all lived in Massachusetts, a state that has a robust addiction treatment infrastructure but continues to mandate reporting of MOUD use at delivery to CPS, which may uniquely lead to some of the negative experiences reported.

Conclusion:

To improve maternal infant bonding and attachment, interventions that aim to strengthen the early parenting experiences of opioid-exposed dyads are need to address the mutual mistrust between health care providers and parents. Policy changes should emphasize shared decision making, improved delivery preparation, space that is more intimate for mother/infant, novel approaches to address stigma and bias with a specific perinatal focus, and critically assessing documentation practices of newborn diagnoses. To sustain recovery trajectories into early childhood, avoid child harm, and promote family well-being, small acts of support and advocacy on behalf of families may promote positive attachment and parental self-efficacy. Targeted support should thus be prioritized over non-individualized surveillance and scrutiny.