Factors cited (n)	Recommendations
Patient/family	Mental health (14) Substance use (13) Childhood trauma (5) Chronic disease (4) Delay in seeking care (4) unstable housing (3) Adherence to treatment plan or medications (2) social support/isolation (1)	None – recommendations at other levels support patients and families.
Health care professional	Quality of care (8)	Primary prevention • Establish standards of care for prescribers including: check controlled substance database, co-prescribe naloxone with opioids, limit number of pills prescribed Secondary prevention • Naloxone kits to women and their families for individuals with substance use disorder, risky substance use, history of overdose or chronic opioid prescriptions Perinatal mental health and addiction health care professional education • Implement use of standardized and validated prenatal and postpartum screening for both mental health and substance use • Include firearm access in mental health and substance use risk assessment • Education about risks of maternal destabilization, relapse and maternal death in setting of tapering pharmacotherapy (methadone, buprenorphine) or psychotropic medications in pregnancy or postpartum • Increase obstetrical, pediatric and emergency room health care professionals’ understanding and use of SBIRT framework including resources for mental health and drug treatment referrals, crisis team and suicide risk response • Increase health care professional awareness and skills in trauma informed care • Educate out of hospital health care professionals (i.e. direct entry midwives, birth center midwives) on mental health and substance use screening and treatment
Facility	Lack of standardized policy and procedures (4)	Inpatient and outpatient obstetrical and mental health facilities • Improved coordination of case among health care professionals, access to records and follow-up for missed appointments for women with mental health and substance use concerns • Clear referral networks for mental health and substance use specialists • Facility protocols to reduce opioids prescribing after routine vaginal delivery • Improved coordination between obstetrical and pediatric health care professionals Prison/jail • Continuation of pharmacotherapy and psychiatric medication during incarceration and upon release • More frequent monitoring of isolated inmates, standardize monitoring policies across jails re: reasons for isolation, monitoring of isolated inmates, inmates on suicide watch • Improved cultural competency training regarding LGBTQ issues in jail/prison • Naloxone provision upon release
Community	Cultural (3) Environmental (2) Legal (1)	• Expansion of inpatient substance use treatment in rural and frontier locations • Provide support for family victims of suicide (similar to support provided for victims of crime) • Increase use of peer support and recovery coaches • Improve availability of naloxone (like availability of automated external defibrillator) • Medical license boards address stigma regarding individuals with substance use among healthcare health care professionals • Educate public on disposal of excess medications including narcotics • Educate public on removing access to firearms from people with mental health issues
Systems of care	Coordination of care (11) Barriers to care (3) communication (2) Referral (1) Outreach (1)	• Department of Child and Family Services coordinate maternal follow up for 1 year postpartum, particularly if child(ren) are removed from custody • Expand case management and care coordination for women with substance use and mental health conditions • Provide in-home services for women with mental health and substance use • increased awareness and resources for healthcare health care professionals with SUD • Extend pregnancy Medicaid coverage for one year postpartum • Fund and establish perinatal psychiatric unit • Fund and establish maternal mental health hotline