Identifying Areas to Improve Care and Support Parent-Child Relationships From the Perspective of Pregnant and Parenting People in Recovery

Abstract

Objectives:

Opioid use during pregnancy is a critical public health concern that has given rise to significant treatment needs throughout the perinatal period. The purpose of this study was to gather perspectives of pregnant and parenting individuals in recovery from opioid use disorder (OUD) to better understand their needs and identify ways to improve care and support parenting.

Methods:

We conducted semi-structured interviews with 18 pregnant and postpartum people receiving medication for opioid use disorder (MOUD) at an outpatient buprenorphine clinic. The coding team developed a codebook using both inductive and deductive methods that was applied to all interviews. Key topics and trends were identified using thematic analysis.

Results:

Four themes emerged from participants’ reflections on their experiences with health care as pregnant and parenting people in recovery: (1) need for support with parenting, (2) concerns about MOUD, (3) difficulty accessing resources, and (4) value of peer support and options for receiving information.

Conclusions:

There is a need to prioritize support with parenting, understanding MOUD, and accessing basic needs to better prepare pregnant and early postpartum individuals for parenting in recovery from OUD. It is also important to incorporate peer support into services to better support pregnant and parenting people in recovery.

Opioid use disorder (OUD) among pregnant individuals has increased 333% over the past 15 years,¹ which has resulted in significant treatment needs for parents and their young children. While pregnancy often serves as a motivator to seek treatment for OUD,^2,3 medication for opioid use disorder (MOUD) is underutilized during pregnancy, and the risk of OUD treatment discontinuation increases significantly after birth.⁴ Low MOUD use and treatment engagement during the perinatal period are associated with an increased risk of overdose, with the highest prevalence occurring between 7 and 12 months postpartum.⁵ Parents with OUD frequently face obstacles to engagement with treatment services such as stigma, fear of child welfare involvement, and logistical barriers, including transportation and insurance coverage, which can jeopardize recovery. There is a critical need to better support parents in recovery.

Pregnant people in recovery frequently report disrespectful, inconsistent care⁶; invalidating and stigmatizing relationships with providers³; and a lack of gender-responsive, equitable care.⁷ In one study, 60% of pregnant and parenting individuals with a substance use disorder (SUD) reported fear of prejudicial treatment,⁶ and many studies have identified social stigma as a barrier to treatment access and engagement.^3,7 Fears related to mandated reporting guidelines, social services involvement, loss of child custody, and neonatal opioid withdrawal syndrome (NOWS) are also barriers to treatment engagement.^3,6-8 In many cases, pregnant individuals experience feelings of guilt, hesitancy, and anxiety about receiving MOUD for fear of NOWS, expressing a desire to protect their infants from harm.^3,7 Internalized guilt and anxiety may be exacerbated when parents face infant care challenges associated with NOWS, including increases in crying, loose stools and diaper rash, and difficulties with feeding and sleeping. In past qualitative research, some parents with OUD noted feeling unprepared for birth and parenting and emphasized a desire for programs that offer evidence-based support from trusted sources around preparing to deliver and care for an infant with NOWS symptoms.⁹

It is imperative to understand the lived experiences of pregnant and parenting individuals in recovery to better meet their needs and support them in meeting their parenting goals. Not all parents with OUD have difficulty parenting, yet many express feelings of judgment and bias from others about their parenting and have expressed a need for more compassionate support.^2,8,10,11 Prior research demonstrates that access to MOUD improves outcomes for perinatal people with OUD. Thus, as a pivotal care point for people in recovery,^12,13 clinics that provide MOUD are promising locations to offer support around parenting. The implementation of parenting interventions through outpatient medication management clinics is an important area in need of further study. A patient-centered understanding of the gaps in access to prenatal programs to support parenting can inform the development of strengths-based, destigmatized interventions by identifying the ways in which pregnant and parenting people in recovery would like to be supported. We previously published a concept paper introducing a novel prenatal adaptation of an evidence- and strengths-based parenting intervention (Family Check-Up-Prenatal) tailored to support pregnant people with OUD.¹⁴ In the present study, we present the preliminary data collected to support the adaptation and better understand the perspectives of pregnant people with OUD.

METHODS

Study Design and Sampling

From May 2021 to July 2022, we recruited pregnant people (We did not ask participants about their gender identity and therefore used gender-neutral language throughout both to acknowledge the importance of inclusivity and because we do not know the gender identities of our participants.) in Western Pennsylvania who identified as being in recovery. Recovery can be defined in many ways. In the present study, we defined recovery as a self-reported history of OUD and current enrollment in a clinic providing MOUD and other supportive services. Recruitment occurred through an outpatient substance use treatment clinic that provides MOUD and recovery support services (ie, case management and peer recovery support), within a large tertiary care birthing hospital. Eligible participants were invited to enroll in a study exploring the need for and acceptability of prenatal parenting programs, which were not yet available at the time of the study (participants in the present study were not actively participating in a parenting program). Rather, data from this study and ongoing studies on our team are being used to inform an adaptation of the evidence-based parenting intervention “Family Check-Up” based on the experiences of parenting people in recovery (ie, Family Check-Up-Prenatal). Clinic staff handed out flyers with study information. If patients were interested, they reached out on their own or elected to have clinic staff share their contact information with the study team.

Among 25 individuals approached for participation, 18 (72%) agreed to a one-time qualitative interview. Those who did not participate were either not able to be reached or declined to participate when we spoke with them. Interviews ranged from 20 to 40 minutes in length, and participants were paid $25. Most participants (Table 1) were 28–36 years old (n= 15; 83.3%), self-identified as white (n= 16; 88.9%), and had a total household income < $10,000 (n= 7; 38.9%). Among participants, 15 (83%) were pregnant and 3 (17%) were within 2–3 weeks postpartum. All participants were pregnant at the time of recruitment and were initially scheduled to complete their interviews while pregnant. Three participants delivered before the date of the scheduled interview, and we chose to follow up with them postpartum to complete the interview. Over half (55.5%) had children before their current pregnancy.

TABLE 1.

Demographic Characteristics of Participants

Characteristic	n (%)
Age
22–24	1 (5.6)
25–27	2 (11.1)
28–30	9 (50.0)
31–33	4 (22.2)
34–36	2 (11.1)
Weeks gestation
1–13	1 (5.6)
14–27	2 (11.1)
28–42	12 (66.7)
Postpartum	3 (16.7)
Ethnicity
Non-Hispanic or Latino	18 (100.0)
Race
Black or African American	1 (5.6)
White	16 (88.9)
Other (Biracial- Black, White)	1 (5.6)
Romantic relationship
Yes	15 (83.3)
Number of dependents
0	8 (44.4)
1	4 (22.2)
2–3	6 (33.3)
Total household income
< $10,000	7 (38.9)
$10,000–$39,000	5 (27.8)
> $39,000	4 (22.2)
Unsure/ don’t know	2 (11.1)
Highest level of education
Some high school	4 (22.2)
High school/ GED	7 (38.9)
Trade/ technical/ vocational training /associate’s degree	4 (22.2)
Some college credit, no degree	3 (16.7)
Student/ took educational courses in the past year
Yes	2 (11.1)
Employment status
Employed full-time (30–40 h per week)	3 (16.7)
Employed part-time ( < 30 h per week)	3 (16.7)
Unemployed, looking for a job	10 (55.5)
Other*	2 (11.1)

N=18.

^*Self-employed, own business with fiancé.

Data Collection

Before the semi-structured interview, participant sociodemographic information and experiences with opioid use were collected. The interview guide consisted of both closed- and open-ended questions (Table 2) to explore participants’ experiences as parents in recovery. A peer recovery specialist and a board-certified OBGYN who specializes in addiction medicine reviewed the interview guide. This study was approved by the institutional review board at the University of Pittsburgh. Participants consented to sharing their de-identified data in research reports and were aware that de-identified quotes may be used.

TABLE 2.

Semi-structured Interview Guide

During this pregnancy, what questions have been on your mind about parenting your new baby?
a. Have you asked these questions to your doctor or other provider?
i. If no, what are some of the reasons why you have not asked these questions?
ii. If yes, what has it been like to ask these questions?
We do not currently have services available for women but are curious what you think we should provide. Before the baby arrives, would you be interested in learning more about and/or getting help with any of the following? (the interviewer invited the participant to elaborate on their yes or no answer)
What it might be like to have a baby born with opioid dependence	Y/N
Breastfeeding	Y/N
Bonding with your infant	Y/N
Infant soothing/calming techniques	Y/N
Safe sleep practices	Y/N
Parenting skills	Y/N
Your own well-being (eg, stress, relationship/partner support, depression, anxiety)	Y/N
Anything else?	Specify
For the above topics, how would you like to learn about them? (the interviewer invited the participant to elaborate on their yes or no answer)
Reading material	Y/N
Personal assistance (eg, one-on-one sessionswith a counselor)	Y/N
Both	Y/N
If available, would you be interested in a parenting program focused on parenting and bonding with your new baby that started during pregnancy?
a. If yes, what types of things should the program cover?
b. If they said maybe, “what kept you from saying yes?”
c. If they said no, “We would like to hear more about why you arenot interested. (give time to respond) Are there any barriers toengaging in such a program or worries or concerns that you have?”
Now I would like you to describe what you imagine your relationship will be with your baby in 5 words or phrases.
Thinking back to when you were a child, tell me about a memory of a time when you were little when you felt especially loved, understood or safe.
a. Is there anything about this/these memories that you would like your child/children to experience with you?

Interviews were conducted in a manner that emphasized participant openness, comfort, and honesty; the interviewer opened the interview by stating their positionality (ie, their background and why they were conducting the research study). Each interview was conducted by phone in a private location. The interviewer was not previously known to participants nor a part of the clinic at the time of the study. Before beginning the interview, participants were reminded of the voluntary nature and that participation (or not) would not adversely affect their services at the clinic.

Data Analysis

All interviews were transcribed and uploaded into NVivo (version 14). C.K., J.S., and K.L.G.-H. created a codebook based on a subset of transcripts that included both deductive and inductive codes. The only deductive code was about interest in a predetermined list of intervention topics. All other codes were developed inductively, meaning they were created without a priori ideas of what codes might emerge. All transcripts were independently coded by C.K. and J.S., who met weekly to review coding, discuss any new or emerging codes, and make updates to the codebook. There were very few discrepancies between coders and when discrepancies did occur, they were fully adjudicated. C.K., J.S., and K.L. G.-H. performed an analysis of themes and patterns following an analytic induction approach, where we analyzed deduced propositions of the parenting needs and challenges of people in recovery, alongside searching for new ideas and information based on lived experiences.¹⁵ Key topics and patterns across the interviews were organized by theme.

RESULTS

Four themes emerged from participants’ reflections on their experiences as pregnant and parenting people in recovery: (1) need for support with parenting, (2) concerns about MOUD, (3) difficulty accessing resources, and (4) value of peer support and options for receiving information. Additional quotations and their corresponding codes can be found in Table 3.

TABLE 3.

Qualitative Themes, Codes, and Representative Quotes

Theme	Code	Representative Quotes
Need for support with parenting
Interest in or need for support/parenting/parenting skills in general		“Well just you know simple things, I feel like there is a lot of basic knowledge that I do not know but need to know.” (Participant 13)
		“I feel like everyone needs parenting skills because everyone was raised different, my mom was great, but I did not learn the best parenting skills from her.” (Participant 16)
Interest in or need for support/parenting/bonding		“Yeah, I would have liked more about that [infant bonding] other than just tik toks that I watch. A lot of people know the basics maybe but there is more to learn, and our parents do not always teach us.” (Participant18)
		“It’s [support with bonding] definitely important because you know, a lot of the times the hospitals keep the baby… and the mother won’t get to stay… so, you know that bonding process gets cut into.” (Participant 2)
Interest in or need for support/parenting/infant care and soothing		“I guess [support with] just the basics of what to do what you bring them home, like feeding and sleeping, how much sleep they are supposed to get. ” (Participant 18)
		“Like swaddling, that I should probably learn.” (Participant 13)
Interest in or need for support/parenting/safe sleep practices		“Yes, I went through parenting classes before, but you can never learn too much about it. That SIDS thing, I am pretty scared of that.” (Participant 8)
		“I know a lot of people who put toys or blankets in the crib with the baby, a lot of people are not educated on that topic [safe sleep practices].” (Participant 7)
Thoughts about self as parent/self-doubt		“My first baby is very picky. Did I do something wrong with [my first child] with regards to food? Maybe I have more knowledge this time, but I am still scared and feel like it’s my first.” (Participant 11)
		“I think I’ll be an average parent because I am still learning. My daughter is happy, that gives me confidence but little things or maybe big things I slack on-I am hard on myself. I think I could do more with her.” (Participant 11)
		“I have been questioning myself, just whether I am going to be the best mom I can.” (Participant 9)
Concerns about MOUD
Concerns about current pregnancy/effect of MOUD/at birth		“Lots of questions about being on methadone, how things are going to go at birth, will he go through withdrawal?” (Participant 9)
		“How hard the withdrawal would be for her, that’s really what was on my mind.” (Participant 17)
Concerns about current pregnancy/effect of MOUD/ breastfeeding		“Is breastfeeding best whenever you have a child born on methadone?” (Participant 2)
		“I was nervous about it [MOUD] being in the breastmilk.” (Participant 5)
Interest in or need for support/parenting/breastfeeding		“I was wondering if I will be able to breastfeed [on MOUD].” (Participant 13)
		“I do not think that I can [breastfeed] being on Methadone.” (Participant 9)
Difficulty accessing resources
Interest in or need for support/basic needs/housing		“Yeah, that’s a big thing [housing]. Cause I’m here trying to do the right thing and I’m facing homelessness and I’m about to pop in what, two and a half months with nothing figured out.” (Participant 3)
Interest in or need for support/basic needs/supplies for baby		“[It would help to have] a list of resources like where to get baby furniture, clothing, and supplies… and diapers.” (Participant 6)
		“I guess [support with] where to find baby furniture, and like getting connected with community baby showers.” (Participant 13)
Interest in or need for support/basic needs/WIC		“Maybe [support with] how to get WIC.” (Participant 6)
Value of peer support and options for receiving information
Receiving support and information about pregnancy and parenting/importance of information coming from a peer		“It’s a lot easier for me to speak to other girls that have went through it [pregnancy and parenting in recovery].” (Participant 2)
		“I think it [advice and education around pregnancy and parenting in recovery] would be better personally- my personal opinion is if it’s somebody that has experienced it.” (Participant 2)
Receiving support and information about pregnancy and parenting/format/peer		“I go to narcotics anonymous, so a lot of the women that are mothers there have gone through what I’ve gone through, whether it’s using while pregnant or… been on maintenance. I have a lot of resources with narcotics anonymous, that these women have been there to support me and help me out with any questions that I have.” (Participant 5)
		“Everybody’s different, but it would be nice to hear how other people dealt with their stuff that actually had to deal with it” (Participant 2)
		“It is good to have support from other mothers.” (Participant 7)
		“[I’d like] Socializing with other moms who are in the same situation, like a mommy and me class or some sort of group thing.” (Participant 15)
		“[Peer recovery specialist] explained all this stuff to me, and I can ask her any questions that I want and she’s there- every time I go in for my appointment, she’s there. So I can ask her questions whenever I need to, and it’s really helpful cause she’s helped me with a lot of questions about like, breastfeeding while I’m on maintenance and you know if the baby’s gonna be dependent on the suboxone.” (Participant 5)
Receiving support and information about pregnancy and parenting/format/ one-on-one		“I try to google everything but there’s nothing out there for what I need. So getting information I need from the clinic or meeting with someone would be helpful.” (Participant 15)
		“I would prefer one on one sessions.” (Participant 10)
Receiving support and information about pregnancy and parenting/format/reading materials		“When you get a bunch of pamphlets it’s a lot and you might not read it.” (Participant 14)
		“People learn different ways, I just prefer reading, but both [personal assistance & reading materials] can be helpful.” (Participant 16)

MOUD indicates medications for opioid use disorder; SIDS, sudden infant death syndrome; WIC, women, infants, and children.

Need for Support with Parenting

All participants expressed interest in receiving support with parenting and developing their parenting skills. One participant explained, “You can never learn enough. I have done some parenting classes, but I am always ok with doing more. Learning hands on from experience is best, but any parenting classes and books are helpful too. You can never get enough of that” (participant 8). Many participants identified parenting as a learning process, sharing, “I feel like I’m probably gonna be a pretty average parent? I’m gonna go above and beyond to do anything I need to do, but I still—this is all gonna be a learning process because it’s my first kid, so I don’t know how it’s gonna completely turn out” (participant 5). Several participants who already had children reflected on past parenting experiences that led to insecurities. One participant shared, “I really hurt my other children when I was in my active addiction and so I have a fear that, you know… Am I a good enough mother? Am I gonna be able to provide for this baby better than I did for my children?” (participant 4). In addition, several participants expressed self-doubt as parents alongside a desire to learn, saying “I doubt myself constantly, but I really try my best” (participant 18). All participants shared an interest in growing their parenting skills, and several identified worries about parenting, emphasizing the need for greater support.

Concerns about MOUD

Many participants shared questions and concerns about MOUD during pregnancy, such as, “I did not know… even if taking [buprenorphine] while being pregnant was safe” (participant 18). Several participants also expressed a desire to learn more about MOUD. One participant stated, “I’ve had a lot of questions really, cause my first child wasn’t born on methadone, or anything, so one of my biggest things is just learning more about being pregnant on methadone” (participant 2). Many participants had questions about breastfeeding while taking MOUD, as well, asking “Is [breastfeeding] safe for the baby, is it helpful for withdrawal? With my first, I refused because I was scared and worried she would be hurt. With this baby, I am giving her breastmilk because I learned there is not enough [medication] in the milk to harm her” (participant 17).

Participants also expressed concerns about caring for an infant with exposure to MOUD. Several raised concerns about NOWS. One participant worried, “Due to withdrawal she might be uncomfortable” (participant 14). When asked about infant care and soothing, many participants expressed interest in support, saying, “That would…be important too because from my understanding, they’re very fussy being born on methadone” (participant 2). Overall, most participants had questions about MOUD during pregnancy, including concerns about breastfeeding and potential effects on infant health.

Difficulty Accessing Basic Needs

Several participants expressed a need for more support with basic necessities. A couple of participants reported challenges finding housing, sharing, “Oh man, my main problem has been the housing issue. Like when I was pregnant with my daughter, I had a house and I had everything together. How am I going to do it without having a house, is it going to be ok?” (participant 16).

Many participants also expressed difficulties obtaining infant supplies. One shared, “I do not really make very much money and have not been able to buy many things… I really need a stroller, changing table, crib” (participant 13). Another identified transportation access as a challenge, stating, “Most people do not have transportation. Many cannot drive or do not have a driver’s license so getting to things can be really hard” (participant 18). Several participants requested help with accessing support programs, namely the Supplemental Nutrition Program for Women, Infants, and Children (WIC), asking for support with “finding resources like WIC” (participant 7). Overall, participants identified difficulties obtaining a variety of necessities, including housing, transportation, and infant supplies.

Value of Peer Support and Options for Receiving Information

Participants reflected on ideal resources for support throughout the perinatal period, sharing their preferences for receiving information and highlighting the benefits of peer support. Participants expressed the importance of options for educational materials to accommodate differences in learning styles and time commitments. One participant explained, “I think everybody’s independently different. Their lifestyles are different, they got different things going on in their life, and people learn different. The way I learn might not be the way you learn” (participant 4). Several participants prefer personal assistance, like individual sessions with a counselor, sharing, “I like one-on-one…I learn better whenever somebody explains something to me” (participant 2). Other participants prefer the flexibility of reading materials, explaining, “I think reading material is the best thing for me… It’s rough having so many appointments and easier to do it on my own” (participant 9). A few participants, however, find reading materials to be less helpful, “great to have, but it’s easier when someone can sit down with you. It makes you feel like you have more support that way. Booklets could be overwhelming and confusing” (participant 7).

Although participants were not asked directly about peer support as a format for receiving information, appreciation for peer support services came up frequently in the interviews. Participants emphasized the value of connecting with individuals who have lived experience. A couple of participants reported a preference to learn from someone who is in recovery themselves, sharing, “You know I don’t really wanna take advice from somebody that hasn’t experienced it” (participant 2). Several participants also explained how they appreciate hearing the thoughts of other parents in recovery. One participant stated, “I like to hear other women’s experiences and what their opinions are” (participant 8).

In addition, multiple participants identified certified peer recovery specialists as important resources for education and support. Of note, the clinic from which participants were referred had a certified recovery specialist on staff, and participants often referred to her by name, which we have replaced with “peer recovery specialist.” One participant stated, “[Peer recovery specialist] has been wonderful so far. It’s a little hard with what I have been through before, but she makes it relatively easy, so I know what I am in for” (participant 15). Another participant was more receptive to learning about MOUD from the peer recovery specialist than other professionals at the recovery center (eg, social workers, nurses):

“[Peer recovery specialist] wasn’t the first person to come into my room, it was somebody else who came in there twice and I was like ‘no, get out…’—I’m not getting on anything while I’m pregnant… and then, when she came in, she just sat down with me and my significant other and… explained everything to me and she literally made it… so much easier for me to just ask her any questions”

(participant 5).

Overall, participants emphasized the importance of having options for receiving information to accommodate differences and identified peer support as an important resource, sharing how connecting with peers made them feel more comfortable to learn and prepare for parenting in recovery.

DISCUSSION

Our findings indicate that pregnant and parenting people with OUD are interested in support with developing parenting skills and confidence, understanding MOUD, and accessing basic needs. Our participants also identified that peer support can modify many concerns and help them navigate their recovery as parents. These findings are consistent with previous qualitative evaluations among pregnant and parenting individuals with OUD, which highlight the need for educational interventions and the power of peer support.^16-19 Our study has expanded on these findings by providing additional knowledge regarding the concerns and hopes of pregnant and parenting individuals in recovery and how they would like to receive information.

Past parenting experiences and concerns about a lack of knowledge around parenting often manifested selfdoubt, with many participants expressing worries about their parenting abilities alongside an eagerness to learn and aspirations to be their best. To address parenting concerns among women with substance use disorders, one study evaluated the effects of a parenting skills training program and found that parenting knowledge improved after parenting training was incorporated into comprehensive substance use treatment.¹⁶ However, the intervention was largely focused on parenting skills pertaining to caring for an infant with neonatal opioid exposure and did not provide ongoing support in the postpartum period. Given the stress of parenting, persistent fear of child welfare involvement, and higher rates of return to use in the latter half of the postpartum period, it is important that parenting support be initiated prenatally and continue throughout the postpartum period. Furthermore, our findings support the notion that the perinatal period is a window of enhanced motivation for behavior change, particularly maintaining recovery and improving parenting.

Concerns about the use of MOUD during pregnancy were common among participants. Many raised questions about the safety of MOUD while pregnant and breastfeeding. Participants also expressed concern about infant care and soothing for neonates with in-utero exposure to MOUD. Through focus groups, one study found that women desire more information regarding how MOUD affects their pregnancy, infant, and breastfeeding.⁹ To improve knowledge of neonatal abstinence syndrome (NAS; now referred to as neonatal opioid withdrawal syndrome, NOWS), another study piloted an education intervention among pregnant women enrolled in a clinic providing MOUD. Participants perceived that the intervention effectively prepared them for the early postpartum period; however, there was no statistically significant difference between knowledge before and after the intervention.¹⁷ Thus, although information about NOWS and preparing for the postpartum period may be welcomed and beneficial, perinatal people in recovery may benefit from additional support rooted in a framework of behavior change and motivational interviewing to better prepare parents for making the changes they want to make in their parenting.

Furthermore, the program from which participants were recruited provides counseling about MOUD and its effects on the infant and emphasizes the safety and benefits of the medications. However, it is clear that participants were eager for more information and still had concerns despite receiving information. This continued concern may be due to the high stakes parents perceive in taking MOUD given the known reality in our state and many others that child welfare will be consulted at birth even for those taking their prescribed MOUD.¹⁰ Future policylevel work is gravely needed to eliminate stigmatizing and unfairly just policies around mandated reporting for prenatal use of MOUD.

Difficulties finding housing, accessing reliable transportation, and gathering infant supplies were identified as sources of stress for many participants. Participants also highlighted the need for information about accessing these resources and how to sign up for support programs like WIC and other local organizations offering free or low-cost resources. A qualitative study among pregnant and parenting people with OUD demonstrated similar challenges, finding inadequate access to social services and difficulty obtaining housing after discharge from inpatient treatment or incarceration.⁶ Thus, it is important that programs designed for parents in recovery not only include information about programs to support basic needs but also provide support and build motivation around accessing basic needs.

Participants identified valuable sources of support and preferred formats for receiving information about pregnancy and parenting, including peer support services, one-on-one assistance, and reading materials. Preferences varied among participants, who emphasized the value of options to accommodate differences in time availability and learning styles. Participants also communicated a preference to learn from peers and an appreciation for opportunities to connect with someone who had experience taking MOUD during pregnancy and parenting while in recovery from OUD. The treatment center from which participants were recruited²⁰ was spoken about as a positive health care experience, attributed to the staff and peer recovery specialists. One study evaluating experiences with peer support specialists among postpartum women with OUD demonstrated that peer support positively impacts recovery and that women with OUD feel a greater sense of trust with peer providers.¹⁹ Another study evaluated a virtual peer support group among people with SUD and found that peer support reduced mental health symptoms and helped participants develop coping mechanisms, including meditation, spiritual practices, and reaching out to peers.²⁰ Future work should more deeply explore the trust that exists with peers and how systems and providers can incorporate more individuals with lived experiences into the care of pregnant and parenting individuals in recovery and learn from this trust to build better health care systems and experiences.

Limitations

In this study, all participants were recruited from the same outpatient recovery center for people in recovery, and our sample consisted of individuals with similar demographic backgrounds regarding race and ethnicity. These factors limit the generalizability of the findings, especially given the known racial and ethnic inequities in access to and use of MOUD.^21,22 Our findings may not generalize to postpartum people. Although our goal was to understand the needs and experiences of pregnant people to aid in the adaptation of a prenatal parenting program, future studies would benefit from examining the experiences of postpartum people to understand needs and challenges across the perinatal period. In our current work, we are completing a study that follows pregnant people with OUD from pregnancy through 12 months postpartum through a series of 5 qualitative interviews during and after pregnancy to capture lived experiences across the transition to parenthood. Another limitation is that this study did not involve individuals with lived experience of OUD in the coding process or analysis, which may limit the validity of our findings.

CONCLUSIONS

Opioid use during pregnancy is a critical public health concern, raising significant treatment needs throughout the perinatal period for both parents and their children. The lived experiences of pregnant and postpartum people in recovery highlight important areas of focus to improve care and better support parents with OUD. Health care providers and services should incorporate or provide support with parenting to help individuals develop their parenting skills and build self-confidence. Our findings suggest that offering education about MOUD in pregnancy and connection to resources to improve access to basic needs are also important to prepare for the postnatal period. Finally, there is a need to more thoroughly incorporate peer recovery specialists at all levels of care to better support pregnant and parenting individuals in recovery.