Postpartum and addiction recovery of women in opioid use disorder treatment: A qualitative study

Abstract

Background:

Postpartum is a highly vulnerable time for women with opioid use disorder (OUD). Our primary objective was to identify patient and provider reported aspects of the pregnancy to postpartum transition that impact recovery progress for postpartum women receiving medication for opioid use disorder (MOUD).

Methods:

This qualitative study consisted of semi-structured interviews with postpartum women in OUD treatment (n = 12) and providers (n = 9) at an outpatient addiction clinic. Interviews were transcribed and analyzed using an editing style approach to report themes and quotes.

Results:

Patients and providers identified different themes that both promote and challenge recovery during the postpartum transition. These comprised of clinical factors, including MOUD, neonatal opioid withdrawal syndrome (NOWS) and pain associated with labor and delivery as well as psychosocial factors, such as role of a support system, mental health aspects of anxiety and depression causing mood changes, stigma and mistrust among healthcare providers and child welfare.

Conclusions:

Patients receiving MOUD and their providers identified multiple aspects unique to the postpartum transition that substantially strengthen and/or oppose OUD recovery. These aspects impacting recovery include factors specific to the receipt of MOUD treatment and those not specific to MOUD, yet tied to the postpartum state. Overall, these findings provide insight into areas for future research focused on identifying opportunities to promote recovery-oriented care for families affected by OUD.

Introduction

Postpartum is a time of vulnerability as women face multiple stressors.¹ For women with opioid use disorder (OUD), the interplay between these ‘Fourth Trimester’ stressors on top of those related to addiction² may contribute to overdose now being a leading cause of postpartum mortality.^3,4 A recent mixed methods study of pregnant and parenting women with OUD found that uncertainty, fear, and lack of awareness about aspects such as parenting, child welfare involvement, and mental health are common themes leading to overdose.⁵ Further, having an infant treated for neonatal opioid withdrawal syndrome (NOWS) may be associated with an increased risk of postpartum overdose, including for women on medication for OUD (MOUD) during the month of delivery.⁶

Evidence-based OUD treatment for pregnant and postpartum women includes MOUD (buprenorphine, methadone) with wrap-around services; this comprehensive approach decreases overdose risk and improves outcomes.⁷ However, OUD treatment continuation rates after delivery are poor⁸ and overdose risk remains.⁶ Motivators and challenges to substance use disorder treatment entry during pregnancy have been explored.² Data focused on postpartum OUD treatment and recovery is much more limited, especially research beyond the immediate post delivery period. For example, there is pau-city of literature to assess patient-reported priorities for OUD treatment through the postpartum period.

Further, the mother-infant dyad affected by OUD requires specialized care by a multi-disciplinary team.⁷ These providers commonly follow families longitudinally throughout the perinatal period. Therefore, they have valuable insight into the aspects of treatment and healthcare systems that promote or inhibit continued treatment engagement and optimal outcomes. To our knowledge, no study has evaluated provider perspectives on how to optimize postpartum treatment and recovery care for women with OUD.

The primary objective of this qualitative study was to explore patient and provider reported aspects of the postpartum transition that impact recovery progress among women in treatment for OUD with a focus on parenting efficacy. This study is an important step toward improving person-centered, recovery-oriented OUD care plans for the mother-infant dyad tailored to the postpartum state.

Materials and methods

This study was approved by the Virginia Commonwealth University (VCU) Institutional Review Board. This is a secondary data analysis from an ongoing study to develop and test a patient education tool focused on NOWS and the postpartum transition.

Recruitment

We recruited 12 postpartum women receiving OUD treatment at the VCU OB MOTIVATE program which provides integrated prenatal, postpartum and addiction care. This program is a component of the VCU Multidisciplinary Outpatient Addictions (MOTIVATE) clinic which opened in 2017 and provides outpatient substance use disorder treatment for over 500 adults yearly, with approximately 90% receiving treatment for OUD with buprenorphine. MOTIVATE is designated by state Medicaid services as a “preferred office-based opioid treatment center.” MOTIVATE is affiliated with a safety net health system with most patients referred by a provider (e.g., inpatient consults). On site addiction medicine providers come from multiple specialties, ranging from psychiatry to emergency medicine.

Potential participants were identified using convenience sampling during clinical team meetings, and eligibility was confirmed by medical record review. To be eligible, they had to be receiving MOUD, were 18 years or older, spoke English, and have given birth within the past twelve months. Women were approached in the clinic by a female research assistant (TA) not involved in clinical care, and informed consent was obtained. To further ensure trust in confidentiality, no patient information was obtained, and participants were informed that their data would be anonymous.

For the provider interviews, purposive sampling was used to recruit providers in obstetrics, addiction medicine, and pediatrics as well as nurses and social workers who have experience working with families affected by OUD. They were emailed study information to gauge their interest in participating in the study. They were not involved in the direct care of the patient study participants. Nine providers (n = 2 OBGYN-Addiction Medicine providers, n = 2 Pediatric providers, n = 3 nurses, n = 1 behavioral health counselor, n = 1 social worker) completed the semi-structured interviews. All providers were affiliated with programs in Virginia that care for families affected by OUD; some of the providers were employed by the MOTIVATE clinic (behavioral health counselor, nurse and social worker).

Semi-structured interviews

The interview guide (Supplementary Appendix 1) was created by a multidisciplinary team (Obstetric, Pediatric and Addiction providers) based on a conceptual model of parenting self-efficacy.^9,10 Examples of questions asked to start discussions included, “Learning more about what topics when you were pregnant would have helped you feel more confident in your knowledge about withdrawal in your baby and skills in how to best care for your baby?” (patient interview) and “Learning about which of the following would help make care-givers more confident in their ability to care for their baby after he/she is born and being monitored for withdrawal?” (provider interview).

Interviews were conducted in a private space by the same research assistant (TA) trained in qualitative data collection and took 20–30 min for completion. Interviews were audio-recorded. They were semi-structured and designed to allow participants to tell their story in their own terms. Patient participants received $20. Interviews were de-identified and labeled only with a study ID in addition to a job title for providers.

Analysis

Interviews were transcribed verbatim into Microsoft word. Data analysis occurred concurrently with data collection. Transcriptions were inductively analyzed using the “editing style” approach.¹¹ The first step in this process involves “immersing” oneself in the participants’ world to understand and interpret their experiences. This was accomplished by repeatedly re-reading the interviews and making notes in the margins, writing memos, and assigning codes in order to illuminate patterns and relationships that help to bring forth greater understanding of the data. The transcriptions were entered into Atlas.ti version 8 (Atlas.ti GmbH, Berlin, Germany) for coding and frequency analysis. Coding was conducted independently by two investigators TA and BT. They adjudicated discrepancies in coding through discussion and modified codes as necessary to incorporate their interpretations with guidance from CEM. Themes and subthemes were derived. Quotations were selected that best identified each theme.

Results

Due to heightened risk for social desirability bias secondary to the sensitive nature of the survey and interview topics, no individual participant information was collected. However, demographics of OB MOTIVATE clinic patients receiving MOUD from July 2019 to February 2020 (data collection timeframe) include: mean age 30.3 years, 66% non-Hispanic White, 34% African-American, mean gravida 4.06, mean parity, 2.32, 100% with at least one psychiatric co-morbidity diagnosis, receiving buprenorphine (90%), 87% with Medicaid, 10% uninsured, and 3% with private insurance.

Major Patient Interview Themes

Twelve postpartum (<12 months after delivery) women completed the semi-structured interviews (100% participation rate). We describe our thematic map in Figure 1 to summarize the patient responses highlighting the factors that promote and challenge recovery from their perspectives. We created this map after identifying the critical data segments from the interviews and using an iterative process of specific key words and phrases to capture the relationships and patterns within the qualitative data. Three themes were observed: 1) Factors promoting recovery; 2) Factors challenging recovery; 3) Factors both promoting and challenging recovery. Table 1 describes the patient themes with frequency counts and representative quotations. Supplementary Appendix 2 describes additional quotations that contributed to the coding framework.

Figure 1.

Thematic map used to generate the themes and subthemes for the patient and provider interviews.

Table 1.

Patient interview themes with frequency counts and representative quotations.

Themes	n = Mentions (Participants)	Quotations
Factors promoting recovery	62(12)
Maternal fetal/infant attachment	21(10)	“just comfort your baby as much as you can keep her close to you. Hold your baby if you are breastfeeding. I felt that is good thing.”
Strong support system for recovery	12(7)	“It’s been really helpful for me to have that because I know I have 6 people right now who I could call if something was wrong.”
Parenting support	3(3)	“More so the recovery focus with the new baby the emotions, hormones being all crazy, definitely being prepared for any postpartum [depression] is very important to talk about.”
OUD treatment engagement, including medications	33(12)	“Just the fact that there is this program and how it works and how the treatment works and medications.”
Factors challenging recovery	86(12)
Parenting stress	42(12)	“you can’t be just like oh my god you have to do it and oh my god I am responsible for this happening to my baby because of the choices I made in my life.”
Stigma (substance use, medication for OUD)	13(6)	“there is a stigma with suboxone and methadone. And overcoming those stigmas is a pain in the butt.”
Pain associated with labor and delivery	7(4)	“And this time I was on suboxone and I was so terrified they couldn’t give me pain meds but then it came out and I find out you can. And I was so stressed out about that” .
Mood (depression, anxiety)	9(6)	“I was very depressed which is not good obviously when you are pregnant. And then like I had moments of being very anxious and then I would use again.”
NOWS	45(12)	“I felt really prepared. It was more so I had a guilty complex that she would have withdrawals. That was like a mental thing, I think my baby is going to withdraw and it’s my fault.”
Factors promoting and challenging recovery	29(12)
Role of child welfare	29(12)	“Because they are going to get involved when suboxone is involved because you think that you are doing the right thing and you know but they still have to get involved because it still is substance.” “I always thought CPS hated me and is the enemy, and this time I kinda realized they were helping me… I feel like they want you to do good.”

Patient theme 1: Patient reported factors promoting recovery

Patient subtheme 1a: Maternal fetal/infant attachment.

Women highlighted bonding with their infants as beneficial for their recovery. One participant remarked “Just comfort your baby as much as you can, keep her close to you. Hold your baby if you are breastfeeding. I felt that is good thing.” Overall, participants discussed the recovery benefits gained from employing strategies to strengthen attachment such as breastfeeding, skin to skin, comforting their infants, holding them and swaddling. Another participant gave advice for mothers about how to foster attachment with their infants: “I would say always, just always be around your baby. The skin to skin is very important … you can bond with your baby. Just always having a positive mindset about it - like your baby is ok, you are going to get through that time.”

Patient subtheme 1b: OUD treatment engagement, including medications.

Collectively, participants stated that being in an OUD treatment program and receiving MOUD were critical components of their recovery progress. One participant explained “Just the fact that there is this program and how it works and how the treatment works and medications.” They discussed benefits of MOUD, including the ability to focus on parenting without being overwhelmed by cravings and withdrawal symptoms. Another participant mentioned “You know just the Suboxone really helped; it is like a miracle drug and … you don’t think about getting high … You think about things that you need to. My major stress right know is maintaining everything that I have got; So it’s like about getting a job and stuff and that’s what I am stressed about. I don’t wake up thinking I need to get high. I wake up thinking I got to do this today.”

Patient subtheme 1c: Parenting support.

Participants discussed the importance of parenting support for infant care and their own wellness. As one participant described “It’s been really helpful for me to have that because I know I have 6 people right now who I could call if something was wrong.” They highlighted how identifying who would provide postpartum assistance with infant care before delivery made their postpartum transition less stressful.

Patient subtheme 1d: Strong support system for recovery.

Many participants discussed the need to have a strong recovery-focused support system during the postpartum period. One participant mentioned that “More so the recovery focus with the new baby, the emotions, hormones being all crazy, definitely being prepared for any postpartum [depression] is very important to talk about. “ Participants explained how just knowing they had people they could contact at any time, who could provide recovery support, was critical during this stressful time.

Patient theme 2: Patient reported factors challenging recovery

Patient subtheme 2a: NOWS.

The challenging factor to recovery most commonly reported was NOWS. The feeling of guilt that they were responsible for their infants having withdrawal was widespread. One participant stated that “I felt really prepared. It was more so I had a guilt complex that she would have withdrawals. That was like a mental thing, l think my baby is going to withdraw and it’s my fault.” Further, participants described concerns about not being able to identify NOWS signs and symptoms, confusion regarding NOWS medications and treatments, and not understanding the timeline of infant recovery and the different roles providers play delivering infant care. As one participant described “I think a lot of moms want to know how long is the baby going to be in the hospital cause it’s not just if they don’t have to have medicine, they still need have to be there longer to be watched, which can seem scary because you get discharged and your baby doesn’t - so explain that upfront, instead you having to find that out after your baby is born that you are going to be discharged without your baby.”

Patient subtheme 2b: Mood (depression, anxiety).

Participants described worsening depression and anxiety after delivery and its detrimental effects on both their recovery and ability to parent. One participant described that “I was very depressed which is not good obviously …. And then I had moments of being very anxious and then I would use again.” Common exacerbations of mood were related to infant care. Another participant explained that “Of course I was getting anxious about what was going to happen and I googled it - about what was going to happen - and I freaked myself out. It would have been a little better if I had that conversation”.

Patient subtheme 2c: Pain associated with labor and delivery.

Participants described how the anticipation and experience of pain associated with labor and delivery increases stress. Some participants also stated they felt unprepared for the birthing process, particularly for how pain would be managed. One participant mentioned that: “The scary part to me is if you are on Suboxone and if you need pain medicine for a C-section or anything you need pain medicine for. I did not understand that they could still give you pain medicine even if you are on Suboxone. I didn’t know you could have pain meds while on Suboxone.”

Patient subtheme 2d: Parenting stress.

Descriptions of how stress related to parenting negatively impacts recovery were prevalent. One participant described it as “You can’t be just like oh my god you have to do it and oh my god I am responsible for this happening to my baby because of the choices I made in my life.” Specific stressors included NOWS, lack of knowledge about the trajectory of infant care in the hospital, coping with guilt, lack of parenting support, and the persistent demands of being a parent in addition to other life responsibilities. One participant described her stressors in comparison to her experiences with prior pregnancies, “That was a main thing for me is I was very detached while I was using and I wasn’t able to prepare myself the way I should have for bringing a child to this world … I did the bare minimum of what it took to do what you are supposed to do when you are pregnant. I didn’t make a lot of prenatal appointments I didn’t have a baby shower because I did not want to be around my friends and family … Then having to watch my child going through the withdrawal when she came in to this world and then me being on Suboxone and not having to go through that was also very hard. Now I am sober and getting that attachment, and now I have to watch her being sick and I am not - is really hard for me also. It sucks.”

Patient subtheme 2e: Stigma (substance use, medication for OUD).

Most participants discussed the powerful negative impacts of stigma on their recovery during pregnancy and the postpartum period. One participant explained “There is a stigma with suboxone and methadone. And overcoming those stigmas is a pain in the butt.” Participants described prior and recent experiences being stigmatized by healthcare providers, family, friends, child welfare and the general community. Another participant expressed “I wish I could have known everything else that you could have known. I wish I could have known that I could go to a doctor and say that I am a drug addict. I wanted to share some of that in group. I was addicted in my pregnancy with him. I was scared to ask for help”.

Patient theme 3: Patient reported factors both promoting and challenging recovery

Patient subtheme 3a: Role of child welfare.

Most participants described child welfare involvement as a barrier to their recovery, while some highlighted it as a facilitator. Participants described how they anticipated a child protective services referral after delivery (Virginia has a mandatory reporting policy) but reported frustration and stress regarding not knowing what to expect after the initial reporting. One participant mentioned “They are going to get involved when suboxone is involved - you think that you are doing the right thing and you know [you are], but they still have to get involved because it still is substance.” Participants reported this increased stress stemmed from the heterogeneity in how cases are handled across counties/cities, leaving them feeling unprepared for these upcoming interactions with child welfare. For example, one participant explained, “I think one thing I struggled with is not knowing just what I was about to experience … Each county is different … and I know a lot of people - they don’t want to be honest with their case worker because they think the more that you tell them the worse it is going to be.” Conversely, other participants described how their child welfare workers provided support postpartum. Some also mentioned the added benefits of building a good rapport with their case workers. One participant stated “I always thought CPS hated me and is the enemy, and this time I kinda realized they were helping me … I feel like they want you to do good.”

Major Provider Interview Themes

The provider interviews resulted in three themes: 1) Factors promoting recovery; 2) Factors challenging recovery; and 3) Factors promoting and challenging recovery. Figure 1 includes the map summarizing the subthemes and themes that characterize provider responses. Table 2 describes the provider themes with frequency counts and representative quotations. Supplementary Appendix 3 depicts additional quotations that contributed to the coding framework.

Table 2.

Provider interview themes with frequency counts and representative quotations.

Themes	n = Mentions (Participants)	Quotations
Factors promoting recovery	20(9)
Engagement in an OUD treatment program	2(2)	“Individual and group therapy can be very beneficial. This is a difficult time and getting as much support can be very helpful.”
Parenting support	7(6)	“For example, if they have someone to watch the baby that they trust when they want to take a 20 min nap and want to get some rest. They need to identify this person during the pregnancy.”
Receiving patient centered compassionate care	8(6)	“Also something that we try as nurses is to be there for the mom while they are caring for the baby not getting rest, and we are aware of this situation and we are ready to help.”
Strong peer recovery support system	3(2)	“ I would say the importance of building your support network… if there can be someone saying something about postpartum depression. Saying right after you have a baby this is going to be a really tough time. Just like trying to normalize this”
Factors challenging recovery	66(9)
Lack of information about NOWS, including its assessments and provider roles	21(9)	“Somehow they need to be educated on what is normal and what is not normal for babies. For example, babies can scream and cry and that can be normal and not surrounding NAS”.
Mental health	4(3)	“These moms are definitely at higher risk of postpartum depression and there is a lot of guilt too because they feel responsible for what is happening with their baby.”
Misinformation informing expectations for pain and medication management postpartum	4(3)	“You want to do tough love with the actual love. Tough love, hey listen you don’t need opioids after vaginal delivery. However, the love part, is hey if you’re in pain, your pain will be treated.”
Mistrust of healthcare providers	7(4)	“Yeah and they do think that physicians are working with the social workers as spies. So that kind of inhibits the provider patient relationship.”
Parenting stress, especially regarding NOWS	24(9)	“Moms are scared you know, but we have to do our best to reassure them.”
Stigma (substance use, medication for OUD)	6(5)	“Because they all try to wean down [on buprenorphine or methadone]. Or they need a dose increase and they don’t do it and then they relapse. Because they think it’s going to be helpful [for NOWS]”
Factors promoting and challenging recovery	26(9)
Role of child welfare	26(9)	“Hands down moms are 100% most worried about CPS [child protective services].” “I would say the main thing CPS is concerned with is that, they are compliant with treatment, have a safe place to live, have what they need for their baby. And to assess what their support system is like.”

Provider theme 1: Provider reported factors promoting recovery

Provider subtheme 1a: Engagement in an OUD treatment program.

Providers emphasized the value of being in OUD treatment and peer recovery groups through the postpartum period. One provider mentioned that “Individual and group therapy can be very beneficial. This is a difficult time and getting as much support can be very helpful.”

Provider subtheme 1b: Parenting support.

Providers detailed how having adequate parenting support, especially after hospital discharge, is vital for recovery. They emphasized how providers can deliver this parenting support through education about NOWS, breastfeeding, infant health expectations, and strategies to bond with their infants. One provider described “For example, if they have someone to watch the baby that they trust when they want to take a 20 min nap and want to get some rest. They need to identify this person during the pregnancy.”

Provider subtheme 1c: Receiving person centered compassionate care.

Providers elaborated on the importance of providing patient centered compassionate care by delivering NOWS education in a non-judgmental manner and explaining their role on the care team. They reflected on how having a positive patient-provider relationship can have added benefits of strengthening women’s parenting confidence as well as their engagement in OUD treatment. One provider mentioned “Also something that we try as nurses is to be there for the mom while they are caring for the baby not getting rest, and we are aware of this situation and we are ready to help.”

Provider subtheme 1d: Strong peer recovery support system.

Providers elaborated on the significant recovery and mood benefits (i.e., for women with postpartum depression) that come with being able to share difficulties with peers who have shared similar experiences. One provider stated that “ I would say the importance of building your support network … if there can be someone saying something about postpartum depression. Saying right after you have a baby this is going to be a really tough time. Just like trying to normalize this.”

Provider theme 2: Provider reported factors challenging recovery

Provider subtheme 2a: Lack of information about NOWS including its assessments and provider roles.

Providers described how the lack of understanding about NOWS leads to stress which negatively impacts recovery. They described patients being overwhelmed by not knowing about NOWS scoring systems, signs and symptoms, the role of providers in infant care, NOWS medications and non-pharmacologic treatment options. One provider mentioned “Somehow they need to be educated on what is normal and what is not normal for babies. For example, babies can scream and cry and that can be normal and not surrounding NAS”.

Provider subtheme 2b: Mental health.

Providers described the negative impacts of depression and anxiety on recovery. They also elaborated on the high prevalence of underdiagnosis of these conditions. One provider stated “ These moms are definitely at higher risk of postpartum depression and there is a lot of guilt too because they feel responsible for what is happening with their baby.”

Provider subtheme 2c: Misinformation informing expectations for postpartum pain management.

Providers agreed that misinformation related to pain management during and after delivery is another stressor. Specifically, providers reported that many women have heightened anxiety about their expected pain with cesarean delivery due to the lack of awareness about the effectiveness of and indications for pain medications (e.g., opioids, epidural). One provider explained “Moms they need to know that we will treat their pain … Moms think people are going to think they are drug seeking. And we just need them to know if they are going to have a surgery, we are going to treat their pain. But just like anyone who gets a vaginal delivery, we just give them ibuprofen. And were not signaling anyone out you know, we just don’t give opioids for vaginal delivery in general.”

Provider subtheme 2d: Mistrust of healthcare providers.

Providers across specialties clearly identified mistrust as a significant barrier to the patient-provider relationship, leaving providers feeling incapable of being able to positively support women in their recovery. One provider mentioned “They do think that physicians are working with the social workers as spies. So that kind of inhibits the provider patient relationship.” Providers also strongly emphasized the importance of prenatal anticipatory education to reduce mistrust.

Provider subtheme 2e: Parenting stress, especially regarding NOWS.

All providers identified the substantial worry women describe when caring for their infants at risk of NOWS. One provider explained that: “Moms are scared you know, but we have to do our best to reassure them.” The providers reported women being overwhelmed by this stress which impeded their efficacy to ask questions about their infants’ health. Providers also described the heightened anxiety women display due to the fear of infant separation by child welfare and the anxiety related to safety of breastfeeding while receiving MOUD. One provider described how to address this: “Somehow they need to be educated on what is normal and what is not normal for babies. … So all of these things are going to soothe baby. So your heartbeat, your scent, your voice, breastfeeding. … So you’re talking about empowering moms. So if you let them know that they are most powerful thing to soothe baby, more than anything else, if you can sort of extrapolate that- if you can hone in on that, you can make it big deal.”

Provider subtheme 2f: Stigma (substance use, medication for OUD).

Providers detailed the negative impacts of stigma on women in recovery. Providers described how women self-taper MOUD during pregnancy and postpartum due to fear of NOWS, child welfare involvement and stigma from family. One Provider stated “Because they try to wean down [on buprenorphine or methadone]. Or they need a dose increase and they don’t do it and then they relapse. Because they think it’s going to be helpful [for NOWS].” One provider gave advice on how to address this: “I would say the idea of using a non-judgmental approach … and talking about evidence and science that supports using Suboxone because moms are going to hear a lot negative stuff about it … people who don’t know are going to say a lot of mean and hurtful things about it. So I think that anything that can help them to know that the medical field supports them and has science behind it.”

Provider theme 3: Provider reported factors both promoting and challenging recovery

Provider subtheme 3a: Role of child welfare.

Providers shared important insights into the role of child welfare, especially during the postpartum period. They described how many women have strong negative perceptions about child welfare. One provider mentioned that “Hands down moms are 100% most worried about CPS [child protective services].” The providers felt that it was crucial to educate women prenatally about the stated goal of child welfare which is family safety. In doing so, providing education about the different roles hospital social workers, addiction counselors, and child protective services play is critical. Another provider explained “I would say the main thing CPS is concerned with is that, they are compliant with treatment, have a safe place to live, have what they need for their baby. And to assess what their support system is like.” Providers described frustration regarding the heterogeneity in how child welfare cases are handled across counties/cities, yet they also described the positive support case workers can bring to postpartum women in recovery.

Discussion

Similar to qualitative findings of pregnant women,^2,12 we found that postpartum women receiving MOUD face a host of medical, social and psychological stressors after delivery. However, patients and providers are able to simultaneously identify recovery strengthening aspects of the postpartum transition, such as engagement in MOUD treatment and having a strong recovery support system. Our findings illustrate pathways for health systems to take a multi-disciplinary, patient-centered approach to improve the quality of OUD treatment and recovery support services for pregnant and postpartum women.¹³

Participants described the negative impacts of stigma on postpartum recovery progress consistent with existing qualitative literature among non-pregnant¹⁴ and pregnant¹⁵ women receiving MOUD. Stigma has been identified as a significant barrier to substance use disorder treatment entry.¹⁶ Our findings expand the existing call to eradicate stigma¹⁶ to include postpartum women receiving MOUD. Given the complexities surrounding the intersections between pregnancy and substance use, future interventions targeting stigma could include providers across fields (e.g., OBGYN, pediatrics, nursing, social work) and incorporate interventions focused on pregnant and parenting women.

A common theme challenging recovery was mood. Patients described how depression and anxiety impede parenting and lead to postpartum substance use recurrence as a coping mechanism. Providers described how they witness the guilt associated with NOWS fueling women’s negative mood symptoms. Maternal depression impedes attachment,¹⁷ which can have negative child development and behavioral outcomes.¹⁸ Addressing mental health is critical in optimizing outcomes for the mother-infant dyad affected by OUD.

Patient and provider participants discussed the prevalent inaccurate postpartum pain management expectations among women receiving MOUD and how this results in increased anxiety. They described women being fearful of not being provided adequate pain relief and having trauma from prior experiences of poor pain control. Prior work has demonstrated that pain may be correlated with substance use recurrence,^15,19 but how pain associated with labor and delivery impacts postpartum OUD recovery remains unclear. Altogether, quality improvements focused on improving prenatal pain education for women with OUD that incorporate recovery-oriented approaches could be studied further.

An interesting finding was the conflicting impacts child welfare had on recovery of postpartum women in OUD treatment, similar to prior research.²⁰ Some patients in our study discussed how their child welfare case workers promoted recovery progress, such as when they provided assistance (e.g., rent, infant supplies) during difficult times. However, providers described mistrust as a prominent barrier to the patient-provider relationship as well as to patients’ engagement in OUD treatment and NOWS care. They detailed how the etiology of this mistrust is complex, but a major contributing factor is the negative perceptions of child welfare held by these women. Similar to prior qualitative work,¹⁵ patients described being hesitant to ask providers questions if it related to their substance use due to fear of child welfare. These issues need to be addressed as the impacts of the uncertainty women perceive about child welfare’s actions can be drastic (e.g., overdose).⁵ Both child welfare and healthcare providers caring for the mother-infant dyad affected by OUD state they have the same overarching goals, to ensure families are safe and that they have the necessary resources to provide infant care, but their actions are not being universally perceived in this positive manner. Our findings highlight the need for more research into how child welfare and health organizations can effectively improve patient-centered care coordination systems through pregnancy into postpartum for families affected by OUD.

Our study has strengths and weaknesses. First, the study is a secondary data analysis. Thus, the interview guides were designed to address the parent study’s primary objective. However, interview questions were open-ended to allow themes to emerge naturally. Further, social desirability bias is likely given the sensitive nature of the topics covered. We took multiple measures to mitigate this bias. For example, recruitment, consent and interviews were conducted by a research assistant not involved in patient care. Also, we did not gather patient identifying information in line with previous literature highlighting the benefit of patient anonymity to decrease underreporting about sensitive subjects.²¹ Lastly, our results have limited generalizability. Patients and providers were both engaged in a comprehensive care program for pregnant and parenting women with substance use disorders at a large academic center in an urban-suburban setting. Thus, our findings may not apply to populations with smaller clinical programs and/or rural areas. However, our limitation to women in OUD treatment (versus women with untreated OUD) was intentional, as this patient population is unique in its health service utilization and needs.

Findings from this study provide insight into how to take steps toward improving the quality of recovery-oriented care for postpartum women in treatment for OUD. Overall, we build upon the evidence base guiding health systems in the provision of person-centered, trauma-informed, compassionate care tailored to the unique needs of the mother-infant dyad affected by OUD.²²