Rooming-in and loss of child custody: Key factors in maternal overdose risk

Addiction recently published a research report on maternal and infant characteristics associated with maternal opioid overdose in the year following delivery¹. We commend and support Nielsen et al. for drawing attention to the increased risk of maternal overdose in the first year post-partum and associated risk factors. We believe that two major potential risk factors for overdose were overlooked in the aforementioned study: lack of rooming-in and loss of child custody. The authors mention shame and stigma associated with neonatal withdrawal and loss of child custody as possible contributors to post-partum overdose. We believe these factors have a profound impact on maternal and neonatal outcomes, and have the potential to independently affect overdose risk.

We provide integrated care in Vancouver, Canada at Sheway, an interdisciplinary outpatient program specializing in the care of mothers and their families who use substances, and at Fir Square, the peripartum unit at British Columbia Women’s Hospital that practices rooming in and supports women to parent. In our clinical experience, giving mothers the opportunity to room-in and parent their baby is a powerful motivator to engage in treatment for substance use that is putting them at high risk for overdose.

Rooming-in, the practice of caring for mother and newborn together in the same room immediately from birth, is supported as standard practice by JAMA Pediatrics and the Canadian Pediatric Association for newborns of substance-using women^2,3. Rooming-in is well supported by the literature and is associated with decreased severity and duration of neonatal abstinence syndrome (NAS), decreased NICU admissions, shorter hospital stays, increased likelihood of breastfeeding during the hospital stay, decrease in loss of child custody, and no increase in readmission rates or hospital adverse events^4–8. A population-based cohort study of 13,577 mothers in Canada and England found that mothers who had babies with NAS had an all-cause mortality rate 11–12 times greater than the control group in 10 years following delivery¹⁴. Given that a growing body of literature suggests rooming in can reduce NAS scores, and that higher NAS scores are associated with an increased risk of maternal overdose, we believe rooming in should be considered a critical factor in future analyses looking at risk for maternal overdose¹.

Although more research is needed, studies looking at loss of child custody show increase in the rates of substance use, mental illness, trauma, criminal activity and mortality which further reduces the chance of parenting in the future, fuelling the cycle of addiction and trauma^9–13. When a mother loses custody of her baby, she is at high risk of relapse given the trauma of that experience and loss of the chance to be a parent. This is why we believe that loss of child custody could be independently associated with overdose.

It is critical that perinatal addiction research considers the potential profound impact of rooming in and child custody so that there is evidence to support the necessary health system changes to keep families together and potentially reduce the risk of maternal overdose and death.