Supporting perinatal individuals with opioid use disorder and their newborns experiencing neonatal abstinence syndrome: impressions from patients and healthcare providers

Abstract

Background:

Facilitating maternal-newborn involvement and care is critical for improving outcomes for perinatal individuals receiving opioid agonist therapy (OAT) and newborns experiencing Neonatal Abstinence Syndrome (NAS). Comprehensive education strategies are needed to prepare pregnant individuals receiving OAT for navigating the perinatal period.

Objectives:

Identify facilitators to successful care of perinatal individuals receiving OAT and newborns experiencing NAS via interviews with perinatal individuals and healthcare providers. The goal of identifying this information is to inform a future educational tool development.

Methods:

Ten perinatal individuals receiving OAT and ten healthcare providers participated in interviews conducted via phone or video conference using semi-structured, open-ended questions. Data were analyzed separately for the two groups and later merged across samples using a qualitative descriptive content analysis approach to identify themes.

Results:

Under the overarching theme of empowerment to improve outcomes for perinatal women, four themes arose from perinatal and provider interviews: 1) Preparation for Child Protective Services (CPS) involvement, 2) Healthcare providers shape experience through stigma and support 3) Caring for newborns with NAS, and 4) Managing health and resources during postpartum.

Conclusion:

Perinatal participants emphasized the importance of self-advocacy while navigating healthcare and social systems. Providers highlighted the importance of communicating expectations to empower patients. Education is needed for pregnant individuals receiving OAT on what to expect during pregnancy and postpartum, as well as for providers to help them optimally support their perinatal patients receiving OAT.

Introduction

Perinatal opioid use and neonatal abstinence syndrome

In 2019, 4.6 million women reported prescription opioid misuse and 5.8% of pregnant women endorsed past month illicit drug use (1,2). From 2010 to 2017, rates of maternal opioid-related diagnoses in the U.S. rose 131% (1,3). Related, Neonatal Abstinence Syndrome (NAS) rose 82% nationally. NAS is characterized by alterations of the central nervous system, gastrointestinal tract, and/or autonomic nervous system (e.g., feeding difficulties, increased irritability, and tremors) (4-7). NAS may occur following chronic in utero substance exposure, most often opioids (e.g., illicit or prescribed including opioid agonist therapy [OAT]) (4,5,8). NAS severity can be compounded by prenatal polysubstance use, comorbid psychiatric illnesses, and external circumstance stressors (9). NAS symptoms may also challenge maternal-newborn bonding, particularly for women with substance use disorders that may have difficulty responding to their newborn’s cues (10). Establishing support for non-pharmacological modalities and family-centered care are essential for improving maternal newborn outcomes.

Family-Centered NAS care

Between 12% –80% of neonates exposed to opioids develop NAS that requires hospitalization and pharmacotherapy (11-14). Although there is consensus on first-line pharmacological agents, there is considerable variation in treatment regimens for newborns with NAS (11,15,16). Emerging literature supports developing care standards that focus on nonpharmacological, family-centered modalities that emphasize the mother-newborn dyad and address environmental and social factors (14,17-19). Therefore, successful care modalities include support not only for the newborn, but also for the perinatal individual by teaching recognition of NAS clinical signs and responses to newborn cues, as well as emotional support for maternal wellbeing and referral to postpartum resources (20).

Barriers to perinatal education and outcomes

Few published perspectives exist regarding the barriers perinatal women in treatment for opioid use disorder (OUD) face in receiving support and education on NAS-specific care and preparation for delivery and postpartum (21-23). Publications incorporating both perinatal and provider perspectives on effective NAS and perinatal care are lacking. The few existing studies surveying perinatal women receiving OAT report that pregnant individuals are often underprepared for the perinatal experience prior to having a baby (21-23). While most hospitals offer some form of non-pharmacological intervention for newborns (18), there are no standardized educational platforms to promote both non-pharmacological strategies for newborns and standardized education, support, and resources for the perinatal individual.

The needed standardized education for perinatal individuals with OUD is multilayered and includes not only neonatal and maternal medical support but also education on the complex social and legal landscapes for this population. Indeed, consistent themes that emerge in existing published literature surveying perinatal individuals with OUDs are perinatal individuals’ reported lack of clarity around how to access resources, wanting more transparency, support, education, and preparation when navigating the health, social, and legal systems, and relatedly, reported fears of Child Protective Services (CPS) involvement (21-24). Families report significant negative experiences with CPS services (23,25) and because there is considerable inconsistency in conditions that qualify for CPS notification depending on provider, hospital, county, and state interpretation, pregnant patients are increasingly confused about what constitutes the need for CPS reporting and what this may mean for their family (23). Providers who care for perinatal women with OUD and NAS affected infants must adhere to varying legal reporting requirements regarding potential child abuse when serving this population, yet health professionals are often underprepared to successfully treat and fully support this population (26,27). Providers face educational and logistical barriers when attempting to provide evidence-based care to perinatal patients with OUD, such as lack of or insufficient training in opioid prescribing practices, and lack of education regarding empowering and non-stigmatizing communication with patients (26-29). In addition, perinatal individuals receiving OAT report how negative interactions and judgmental attitudes within the healthcare system are adversely impacting their experience in treatment and during delivery (22,23,30-33). These adverse impacts extend to their ability to successfully breastfeed and bond with their newborn (22,34). Perinatal individuals receiving OAT report lower rates of breastfeeding in large part due to lack of support and education posed by hospital policies (34). Therefore, the postpartum period is a critical time of increased risk for OAT discontinuation (35).

Perinatal individuals are at a vulnerable time when attempting to utilize resources either for their own care or for their newborns experiencing NAS (20,30). To optimize positive maternal-newborn outcomes, perinatal individuals need to learn effective NAS caregiving strategies and prepare for how to best navigate the perinatal period physically, emotionally, and legally while they are pregnant, yet standardized strategies for pregnant individuals are lacking (14,30,36). Input is needed both from the lived experience of perinatal women with OUD and healthcare providers with expertise in successfully treating perinatal women with OUD and NAS affected infants. This study addresses these gaps by incorporating perspectives and experiences of both groups to inform the future development of an educational intervention designed for pregnant individuals receiving OAT.

Objective

The objective of this study was to determine how to best prepare pregnant individuals receiving OAT to care for themselves and their newborns that may experience NAS during the perinatal period, from the perspective of perinatal women with OUD and healthcare providers. This was done with the goal of identifying necessary information to be included in educational interventions that will prepare pregnant individuals for the perinatal period and caring for a newborn with NAS.

Methods

Perinatal patients from OAT programs in Washington State, and NAS providers participated in semistructured phone or videoconference interviews between November 2020 and January 2021. Participants were asked about their perspectives and experiences related to perinatal NAS and maternal care (see Table 1 for interview guide) with the goal of informing development of an educational tool. Recruitment flyers were distributed to two OAT programs to recruit perinatal participants. NAS providers were recruited from existing partnerships with perinatal healthcare providers and local hospitals. Participants received a $25 Amazon e-gift card after the interview. Inclusion criteria for perinatal participants were 1) pregnant individual currently in OAT or postpartum individual currently in OAT with experience caring for a NAS-affected newborn; 2) ≥ 18 years of age; and 3) ability to speak and understand English. Inclusion criteria for NAS providers were 1) NAS provider (broadly defined as those providing any health or social services to perinatal populations) with experience in infant NAS care; 2) ≥ 18 years of age; and 3) ability to speak and understand English. The university’s Institutional Review Board deemed this study exempt from review.

Table 1.

Interview guides for NAS providers and perinatal participants.

After a verbal and power point description of the draft intended topics to be included in the educational platform for pregnant women receiving OAT was provided and participants had a chance to ask questions, we asked the following questions:

NAS Providers Interview Guide

1. What do you think of the topics?

2. Do the topics cover all necessary information about maternal care and care for Neonatal Abstinence Syndrome?

3. Are any topics missing from this list?

4. Do you think pregnant/postpartum women could use it with relative ease?

• What challenges do you foresee for perinatal women to using it?

• Was there any unclear information in any of the module topics? Please give examples if you can.

5. Do you think this would help at risk women to care for a baby with Neonatal Abstinence Syndrome after birth?

• If yes, how? If no, what could improve it?

6. What do you think we should add to this study? what topics are missing that are important to highlight?

7. Any additional thoughts/suggestions about the modules?

Perinatal Women Interview Guide

1. Tell us about your pregnancy, delivery, and postpartum experience while receiving opioid treatment.

2. What do you think of the topics?

3. Are any topics missing from this list?

4. Do you think you could use it with relative ease?

• What challenges do you foresee to using it?

• Was there any unclear information in any of the module topics? Please give examples if you can.

5. Do you think this would help you care for a baby with Neonatal Abstinence Syndrome after birth?

If yes, how? If no, what could improve it?

6. What do you think we should add to this study? what topics are missing that are important to highlight?

7. Any additional thoughts/suggestions about the modules?

Data analysis and procedures

Interviews lasted 30–60 minutes and were conducted by two researchers (EB and OB). Participants were enrolled until saturation was reached for each group, once new data no longer offered further distinctive information. Interviews were either digitally audio-recorded, transcribed, and de-identified by a professional transcriptionist (n = 10 perinatal participants and 4 healthcare providers) or extensive notes were taken during the interview (n = 6 of the healthcare providers whose interviews could not be recorded due to an error). While we only present direct quotes from the n = 4 audio-recorded providers, these concepts were described by all providers.

A descriptive qualitative content analysis approach, based on recommendations by Schreier (37-39), was used to analyze interview data first within each participant group, and then across both perinatal and provider participants. In this approach, common themes were identified in the transcripts to provide definitions and details of the most prominent ideas in the participants’ responses. Our approach was primarily inductive, allowing the data to drive the building of the coding frame through its placement into categories and subcategories. However, we did also engage concept-driven analysis, to a lesser extent, as we followed our predetermined structured interview guide during the interview process (this guide was developed by researcher EB based on her topic expertise). We allowed the interview guide’s structure to direct both the conversation during our meetings and our conceptualization of the participants’ responses throughout development of the main categories during analysis. We met five times as a group to refine our main- and sub-categories and to develop the themes. During group meetings, main- and sub-categories were discussed with supported examples and quotes, and eventually were either altered or excluded. Participant quotes were then coded solely into one main category (i.e., quotes were not duplicated across main categories). Reliability was addressed by having each researcher initially review the data prior to meeting, and then comparing consistency of agreement between the researchers (39). Our analysis team began by conducting parallel coding of transcripts, and then discussed and refined codes using consensus coding (40). Validity was addressed by considering the applicability of the themes when compared to the participants’ responses and through iterative reflection by each of the analysts to ensure that the categories developed adequately represented the concepts in the research questions of interest. An audit trail throughout the analytic process detailed decisions and next steps. Themes across the two samples were similar, while reflecting distinctions based on professional roles of providers and lived experiences of perinatal individuals. Therefore, themes will be presented together across the two samples.

Results

Participant characteristics

Perinatal participants were pregnant or postpartum individuals enrolled in one of two Washington State OAT programs from which we recruited our sample. We screened 11 perinatal patients and successfully scheduled 10 interviews. Nine participants were postpartum (ranging from 6 weeks to 9 months), and one participant was pregnant. Five perinatal participants were receiving buprenorphine+naloxone and five were receiving methadone. Providers consisted of 10 health professionals with experience in addiction medicine and providing services to perinatal women with OUD and/or newborns experiencing NAS. We contacted 12 providers for participation, and ten agreed to schedule interviews. Providers included two registered nurses; one nurse practitioner; three OBGYN practitioners, one pediatrician; and three neonatologists. No other demographic information was collected from participants.

Qualitative descriptive themes

An overarching theme of empowerment to improve outcomes for perinatal women described perinatal participants advocating for themselves and their newborn, while navigating healthcare and social services landscapes, as well as the providers educating and empowering women on what to expect during pregnancy and postpartum for the mother-newborn dyad. Four themes arose across the perinatal and provider participants’ data (Figure 1) and contributed to the overarching theme. The overarching theme is reflected in the following quotes by both groups and these sentiments were threaded throughout the four themes:

Figure 1.

Participant Themes. Overarching theme of empowerment to improve outcomes for perinatal women supported by four themes.

I really had to advocate for myself and pour my heart out to a couple of doctors. And they really helped me out after that. But I would just say encourage moms – to advocate for themselves.

#3, perinatal participant

I think you can’t control the context of what people are going through. Their history of trauma or a drug provider. What you can provide is objective information that would be empowering to them. […] I would provide the data and the education.

#14, provider

Theme 1: preparation for CPS involvement

Perinatal participants described experiences with CPS:

Anyone in a case where they’re pregnant and they’re using or they’re in some kind of treatment, CPS is gonna be involved. And that’s the biggest fear for every woman – every mother.

#6, perinatal participant

A lot of people have issues with CPS, but they can also be very supportive.

#10, perinatal participant

Providers spoke about educating patients on CPS involvement and stigma:

Every provider should be talking about child welfare involvement.

#14, provider

Although it is experienced as stigmatizing, it is not the provider who is saying that the patient needs a Plan of Safe Care ‘cause they’re an unsafe person. It’s actually the federal role, and we’re just doing our best to use it in a good way.

#11, provider

Theme 2: healthcare providers shape experience through stigma and support

Perinatal participants described instances of help and judgment from healthcare providers:

Every time I relapsed and needed to come back, they were sure to answer the phone for me and call me back and tell me to come on back. They didn’t look down on me. They didn’t treat me terrible. Everybody was so understanding.

#5, perinatal participant

There’s a little bit of judgment and stigmatism [sic] passed – But I was in extreme pain. […] And I just wish that they’d been a little less judgmental toward me.

#9, perinatal participant

Some of the nurses like let me do skin-on-skin, but other ones were not – they weren’t very nice.

#7, perinatal participant

I know that some women experienced – some hospital policy was that if you, had a UA that was dirty, you couldn’t breastfeed. But that wasn’t the case with me. They encouraged me to breastfeed.

#4, perinatal participant

Providers spoke about self-guilt in patients, judgment from other providers, and preparing patients to navigate experiencing stigma::

I’ve just interviewed so many women now in treatment, and they all have – they have these negative experiences. And for the most part, it comes from people who are supposed to care for them the most. So, it’s so evident that there’s such a gap from the provider’s side.

#14, provider

I think some of them are so – there’s a lot of guilt.

#12, provider

Prepare them for experiencing stigma and prejudice, at least in a manner that hopefully is not, scary to them, but to prepare them.

#11, provider

Theme 3: caring for newborns with NAS

Perinatal participants talked about general newborn care such as gentle care, skin-to-skin contact, swaddling and feeding techniques, and long-lasting crying:

How do I swaddle her? Um, what do I do for bottles? What do I do for her crib? What is a safe sleeping situation for my daughter? What’s a not safe situation for my daughter? How to comfort her and how to console her.

#1, perinatal participant

Perinatal participants spoke about preparing for and recognizing NAS-related symptoms and understanding how newborns are evaluated for NAS:

Knowing what could possibly go on and happen if my daughter was addicted to opiates. That she would be shaking. That she would go through the same things that I’ve been through when I haven’t had the dope. Knowing what to do in case my child was experiencing withdrawals and knowing that if she was to experience withdrawals, she would be put on a low dose of very strong opiates to assist her in the withdrawals, if needed. That made a huge difference for me.

#1, perinatal participant

And I know they have a different way that they score the withdrawal symptoms.

#8, perinatal participant

Providers described information to prepare pregnant woman regarding newborn NAS care like NAS scoring systems, and effects of other substances on NAS symptoms and care:

I do take time to forewarn them that their baby is probably going to have withdrawal symptoms and talk about Eat, Sleep, Console.

#12, provider

I think you’re – you’re right not to focus too much on one scoring system.

#14, provider

How to communicate to them that even if you did something other than just methadone – especially if you did something other than methadone – it’s really important to pay attention to what your baby is telling you over the first three months.

#13, provider

Providers also noted non-pharmacological care for treating NAS symptoms and the role of maternal presence, as well as preparing women for the possibility of pharmacotherapy:

I think really emphasizing the importance of maternal presence is really big. The best care for neonatal opioid withdrawal is the mother. That it’s skin-to-skin. It’s breastmilk if possible. It’s her presence and engagement with her baby.

#11, provider

I think focusing on nonpharmacologic care and interventions that they can do to respond to what their infant is doing – can be really useful. To sort of warn – not warn them but make them know that they may require pharmacotherapy. It’s not a failure.

#14, provider

Theme 4: managing health and engaging with resources during the postpartum period

Perinatal participants emphasized the importance of understanding their patient rights and described resources they found helpful during the postpartum period:

Know your rights. Because I already knew to get an attorney that was actually free, because I had a friend that went through the same thing. So having information that there are resources – and free resources to use.

#4, perinatal participant

[…] options of who you can call. Like public counsel, that you could seek out to help you.

#6, perinatal participant

I wish that I also would’ve known about a treatment center where I can bring my kids.

#9, perinatal participant

Perinatal participants also emphasized the importance of staying in opioid treatment:

Be willing to soak in every resource possible and take every resource possible. And, follow through with treatment.

#2, perinatal participant

I just feel like there should be like a very big stress on like, yes, the importance of staying in treatment.

#4, perinatal participant

Providers emphasized maternal care, staying in opioid treatment, and postpartum follow-up and health screenings:

Caring for your baby is critically important, so we have to take care of you, too. And so self-care for the mom is super important around that. Like being in the hospital is stressful.

#11, provider

You could provide some mom focused things on maternal treatment, too – that provide positive reassurance or positive reinforcement about her engagement in treatment and what it might mean for her infant’s outcome.

#14, provider

They should always have a two-week postpartum visit. You know? And a phone call at one week at least.

#11, provider

One thing would be hepatitis C testing and HIV testing

#14, provider

Discussion

This study explored perspectives of perinatal individuals receiving OAT and healthcare providers who care for perinatal individuals with OUD and newborns affected by NAS with the goal of detailing necessary information to be included in an educational tool for this population. Under the overarching theme of empowerment to improve outcomes for perinatal women, four themes arose across the perinatal and provider data consisting of preparing for CPS involvement, providers shaping experience through stigma and support in healthcare, caring for newborns with NAS, and managing health and resources during postpartum. While the four themes described distinct areas, the overarching theme was threaded throughout them. Perinatal participants emphasized the importance of empowering self-advocacy while navigating the healthcare and social systems, and providers highlighted the importance of communicating expectations in an empowering way. This was reflected in all four themes. For example, while the theme of caring for newborns with NAS described different aspects of NAS-specific and general newborn care, threaded through it was the theme of empowerment. While this theme spanned several aspects of newborn care, with perinatal participants focusing more on general newborn care and providers noting more NAS symptom specific newborn care, it became apparent that the main goal of including this information on newborn care is preparing perinatal patients receiving OAT and empower them to advocate for themselves. In another example, the theme of managing health and engaging with resources during the postpartum period spanned topics such as the importance of staying in OUD treatment, as well as stressing maternal postpartum self-care and connecting with appropriate community resources during postpartum. Perinatal participants emphasized the need to be informed of their rights and seek appropriate resources during the postpartum period such as legal aid and housing and treatment programs that allow for newborns. Providers stressed the importance of caring for the mother and not just her newborn by focusing information on postpartum health screenings and maternal self-care. Threaded throughout this was the overarching theme that emphasized self-advocacy for perinatal patients and communicating expectations in an empowering way from providers.

In the theme of Providers shape experience through stigma and support in healthcare, perinatal participants recounted experiencing stigma in their current or past healthcare setting and noted how healthcare providers have a strong capacity to impact their overall experience for better or for worse. Providers spoke extensively about how they often see self-blame and guilt from their patients. They also spoke about preparing them to navigate experiencing stigma in healthcare. Providers emphasized that any information presented to pregnant women receiving OAT should empower them to know their rights as they navigate their pregnancies through the healthcare and legal systems. These sentiments align with research showing that pregnancy can be a potentially pivotal moment in individuals’ lives that can transform their life trajectory and can be aided by treatment induction and appropriate social supports (30). If perinatal individuals are empowered at these critical moments, they will be better equipped to seek out resources and persevere with treatment. Hence, empowering pregnant individuals with OUDs, and equipping them with the necessary resources and tools to self-advocate and successfully navigate the perinatal period has the potential to substantially improve maternal-newborn outcomes in high-risk populations.

While the four themes were similar between the perinatal and provider participants, the perspectives within each theme differed in content, reflecting each group’s lived and professional experiences. For example, both groups discussed the importance of preparing pregnant individuals receiving OAT for CPS involvement. While some perinatal participants noted negative experiences and trauma incurred from CPS, others discussed positive experiences. Providers also expressed the ability of CPS involvement to potentially cause trauma to their patients and the need to empower women to understand their rights and responsibilities to maximize chances of taking their child home. The emphasis on preparing this perinatal population for CPS involvement is a consistent theme that has emerged in other literature surveying perinatal individuals. A recent study interviewing 27 perinatal patients receiving OAT in rural U.S. found that most individuals were concerned about the potential involvement of social services during delivery and postpartum, that they wanted more information on delivery preparation and more support and education from providers (23). Similar findings regarding fear of CPS involvement, stigma in the healthcare setting, wanting additional support and information from providers, and requesting additional education on navigating the health care and social support systems during pregnancy and postpartum was noted in other recent studies surveying perinatal patients engaged in OAT in the U.S (21,22). This theme of CPS involvement is likely to be even more pronounced in marginalized communities. While published literature including perspectives and experiences of perinatal women from diverse ethnic and racial backgrounds with OUD are explicitly lacking (41), we know that women of color are disproportionally and unjustly affected by punitive policies and inequitable access to substance use and mental health treatment (42). For example, Black women are significantly more likely than women of other races to be reported to CPS by healthcare providers suspecting perinatal substance use. This CPS involvement in turn leads to adverse health outcomes such as increased drug use and mental health problems (43). Perinatal Native American women are also excessively affected by criminalization laws and limited access to substance use treatment (44). Additionally, a recent study found significant racial and ethnic disparities in access and use of medication for OUD treatment in pregnancy (45). Punitive legal policies, stigma and racial discrimination in healthcare, and inadequate social support are some of the identified obstacles to treatment in perinatal women of color with OUD (45).

Providers in this study described gaps not only in patient education, but also in provider education. Providers noted often feeling unprepared for how to speak to perinatal patients receiving OAT, being mindful of bias and stigma when interacting with perinatal individuals who have OUD and wanting to maximize benefit through appropriate resource referral for their patients. The literature indicates that both perinatal individuals and providers need more education regarding NAS-specific care and navigating the perinatal period to optimize care and outcomes for perinatal patients with OUD and their newborns (21-23,46). These topics brought up by both providers and perinatal participants of needing more information and support while they navigate the healthcare system and empowering patients, are easily framed through the shared decision making (SDM) model. SDM is a medical decision-making method that encompasses both healthcare providers and patients discussing evidence-based options when faced with the need to make health related decisions. Imperative to the SDM is the notion of patients being offered all pertinent information and feeling supported to consider the different medical options to truly achieve informed decisions (47,48). Indeed, the four themes that perinatal participants and providers in this study described can be contextualized as reflecting SDM: in perinatal participants expressing the importance of self-advocacy while navigating healthcare and social services landscapes, the need for more support, and in how healthcare providers shape their outcomes and experiences; and the providers emphasizing the importance of educating and empowering women on what to expect during pregnancy and postpartum for improved mother-newborn outcomes. These sentiments expressed by the participants in our study echo the key takeaway from the SDM model of providers and patients working together to achieve informed medical decisions.

Strengths, limitations and future directions

The primary strength of this study is capturing the experiences and perceptions of perinatal individuals receiving OAT with lived experience of navigating the health and social systems and caring for a newborn with NAS. We were also able to describe perceptions and recommendations for optimizing education of this population from providers in diverse professions and work settings.

To protect confidentiality and increase recruitment efforts, we did not collect identifying and demographic information on our participants, and this limits our description of the sample. Our goal was to understand the experience of perinatal women with OUD regarding their own and their infant’s NAS care and providers’ expertise in caring for these populations to obtain feedback on what information should be included in the educational tool we are developing for this population. Because demographic information beyond a participant being in the perinatal period and receiving OAT treatment for OUD was not needed to meet project goals, we decided against collecting other demographic information. This was done to decrease burden and risk of deterring perinatal participants from participating in the study. Collecting demographic information on our perinatal participants would have added to the strength of this study, especially when published literature on the experiences of marginalized populations with OUDs treatment is lacking, and would have likely impacted our interview questions and as a result, the development and interpretation of data. Our perinatal sample reflects those living and receiving treatment in Washington State which may hinder generalizability of the findings. However, our themes map on to those of similar studies, lending support to the shared experiences perinatal individuals receiving OAT face in the U.S. As provider data were collected via two methods (extensive note taking and recorded interviews), we cannot provide direct quotes for six provider participants. However, interview notes were included in the data analyses and these perspectives are reflected in the results.

Comprehensive education is needed both for pregnant individuals receiving OAT regarding what to expect during pregnancy and postpartum for the mother-newborn dyad, as well as for providers to help them optimally support perinatal individuals receiving OAT. This type of education has the potential to optimize outcomes of newborns with NAS and improve perinatal outcomes by encouraging perinatal treatment adherence and psychological well-being. Future research should focus on developing evidence-based education geared both for pregnant individuals receiving OAT, as well as for providers that serve this population.