“Just be there”: desired partner behaviors among pregnant people living with opioid use disorder, a qualitative study

Abstract

Objectives:

Elicit how partners impact pregnant people’s experience living with opioid use disorder (OUD) during pregnancy and summarize participant recommendations to improve partner support from people engaged in treatment for OUD during pregnancy.

Methods:

In this qualitative study, we completed 20 in-depth interviews in pregnant people with OUD at an outpatient clinic in Tennessee. We employed inductive and deductive coding based on a relationship intimacy model and thematic analysis to elicit their perspectives, attitudes, and experiences that shaped desired partner behaviors during their pregnancy. We placed our findings in a modified relationship intimacy model of couple adaptation to stigmatized health conditions. Finally, we summarized interviewed participants’ recommendations on how to best educate and involve their partners.

Results:

Our analysis generated 24 codes and five themes. Previous lived experience and interpersonal factors influenced participants’ experiences with relationship-enhancing and relationship-compromising behaviors. They also reported that positive, or relationship-enhancing behaviors, could mitigate some of their negative intrapersonal feelings such as self-stigma. Participants agreed that partners should display emotional intelligence and empathy, provide supportive logistic and physical behaviors, and be open to improve. Participants also suggested that partners be equipped with information about expected physiological changes during pregnancy, supportive behavior examples, and information about treatment OUD.

Conclusion:

Additional input from pregnant people and partners in future projects can build on these findings and guide the creation and assessment of comprehensive interventions to improve care for pregnant people with OUD.

Introduction

Partner attitudes and behaviors can impact a pregnant person’s mental and physical wellbeing. Supportive partners can positively influence pregnant peoples’ decision to initiate and adhere to antenatal care appointments, medications, and give birth in a hospital.^1–9 For pregnant people with substance use disorders, partners can encourage treatment uptake and adherence.^2–5,10,11 Partner involvement, including attending antenatal care appointments and completion of couples counseling, is associated with lower risks of preterm birth, low birth weight, and infant mortality.^12–14

Concerns about engaging an unsupportive partner in care, however, persist. For example, unsupportive partners may increase depressive symptoms in pregnant people or perpetuate interpersonal violence.¹⁵ For people with opioid use disorder (OUD), an unsupportive partner can result in increased substance use and treatment refusal or abandonment,^11,16 which also increases the likelihood of the negative sequelae of active opioid use during pregnancy such as birth defects, preterm birth, and maternal or fetal death.¹⁷ Preliminary evidence suggests that engaging non-pregnant partners in treatment is feasible for pregnant people with OUD.² To center pregnant peoples’ attitudes towards partner involvement in pregnancy care, we interviewed pregnant people with OUD to elicit how their partner impacts their experience living with OUD during pregnancy and what they wanted from their partner during pregnancy.

Methods

Study Sites

Interviews were conducted at an outpatient clinical site associated with an academic medical center in Nashville, Tennessee. We recruited women from an antenatal care clinic that specializes in caring for women living with medication-assisted treatment for OUD (Firefly). Firefly (Tennessee’s maternal opioid misuse model clinic) cares for people with substance use disorder during pregnancy and one year following pregnancy. Firefly provides comprehensive care that includes prenatal care, OUD treatment, peer support, group therapy, integrated social work, psychiatric, and pediatric providers, and postpartum care. Firefly has daily clinics and follows between 100-150 patients at a time, half of whom are pregnant and half of whom postpartum.

Recruitment

Pregnant adults (≥ 18 years old) with OUD attending Firefly for antenatal care were eligible to participate. By virtue of being enrolled in care at Firefly, all participants were enrolled in medication-assisted treatment for OUD. We excluded postpartum individuals since we plan to use these data to develop educational materials, and eventually interventions, for pregnant people. We approached 43 of 58 eligible participants at Firefly from February 2 to April 16, 2021. We recruited and consented 20 participants. We excluded two participants, one of whom was postpartum, the other of whom was mistakenly interviewed with their partner in the room.

Interviews

We initially planned to conduct 20-40 interviews until we reached data saturation – presumed after 20 women in this population based on the literature,^18,19 although we were prepared to interview up to 40 women if needed. We collaborated with Firefly to ensure that semi-structured interview questions would not inadvertently stigmatize participants. In line with best practices, interviews began with general questions to build rapport (Table 1).¹⁸ We then elicited participants’ ideal vision of partner support versus a description of actual support received from their partner during pregnancy. Our questions were further informed by the conceptual models described in the next section.

Table 1.

In-depth Interview Questions

1) How are you today?

2) How old are you?

3) What is your race and ethnicity?

4) How many weeks pregnant are you?

5) How many children do you have?

6) Tell me about your experience with addiction/living with HIV. When did it start? How much does your partner know?

a. If patient has opioid use disorder

i. How did you use opiates? (Probes: injection, pills, inhalation, smoking)

ii. Have you ever been in treatment for opioid use disorder? If so, what types of treatment and how many times?

7) Have you disclosed your current treatment plan to your partner?

a. If so, what was their reaction?

b. If not, why not?

8) Who do you live with at home?

a. Probes: are you living with your children?

9) Describe your relationship with your partner and the father of the baby.

a. Probes: husband, wife, boyfriend, girlfriend, living together, living apart, etc.

10) Imagine a woman in a hypothetical, perfect relationship. What sort of support should her partner give her during her pregnancy?

a. Probes: financial, emotional, logistical (e.g., transportation), couple-based HIV testing.

11) In what ways does your partner support you?

a. Probes: financial, emotional, logistical (e.g., transportation), accompaniment to health facility.

12) Tell me about some of the ways you would like your partner to support you more?

13) Can you tell me about anything your partner does that makes it difficult to attend antenatal care visits or adhere to treatment? How do you overcome these challenges?

14) What strategies have you tried to increase the support you receive from your partner? Have any of them been effective?

a. Probes: talking with their family, having a friend talk with them, talking with them directly, withholding affection/giving more affection.

15) Would you be open to sessions to improve your relationship with your partner during pregnancy?

16) Do you think that your partner would be open to sessions to improve their relationship with you during pregnancy?

Eligible women who consented to participate in the study and be digitally recorded were interviewed in a private room or, if easier for the participants’ schedule, we set up a Zoom^® interview at a mutually agreeable time. Participants were interviewed alone, or, in a few cases, interviewed with young children in the room. All adults that accompanied participants to antenatal visits were asked to leave the room for the duration of the interview. Participants received a $20 Walmart^® gift card for their time. Interview duration (13-35 minutes) depended on two factors: 1) a pregnant person’s interest in sharing details about their life, and 2) additional scheduled clinical appointments (laboratory, ultrasound, other provider appointments) after the interviews.

Authors DES and MES conducted all interviews. Interviews were transcribed and de-identified prior to analysis. As we interviewed participants, we listened to interviews and verified third-party transcriptions to familiarize ourselves with the data and assess for data saturation, which we reached after recruiting 20 participants.

Analysis

There are several conceptual models that seek to explain how chronic illness and trauma influence relationship dynamics.^20–24 We adapted Manne and Badr’s (2008), conceptualizing partner psychosocial adaptation to cancer, to framing partner behaviors among those living with OUD.²⁰ Their model combines components of several individual-level and dyadic relationship dynamic models to account for the complexities of individual expectations and behaviors and the interplay between diagnosis, relationship characteristics, and individual personalities.²⁰

Deductive themes from Manne and Badr’s model included relationship-compromising behaviors and relationship-enhancing behaviors.²⁰ Relationship-compromising behaviors included partner unwilling to seek treatment or actively using, current trauma, criticism, emotional suppression, guilt, and shame, whereas relationship-enhancing behavior codes included partner in treatment or non-user status, self-disclosure, emotional responsiveness, and partner engagement. After repeated reading using thematic analysis principles and independent coding in MAXDA^®,²⁵ DES and MES collaboratively generated a total of 24 deductive and inductive codes across five themes (Table 2). The final framework had > 85% inter-rater reliability after five meetings.

Table 2.

Codebook

Theme	Code	Definition	Examples
Previous Lived Experience	Correctional institutions	Reported interactions with correctional institutions such as law enforcement, child protective services, etc.	“[Relapsing] led to a whole lot of legal [trouble] (sic) because I got kicked out of the halfway house…Then that violated me with my probation and all kinds of stuff, just like I said, like it can be going so perfectly well, and then just something happens.” (29-year-old)
	Treatment history	Reported previous attempts to engage (successfully or unsuccessfully) in treatment for substance use	“[Treatment] really just depends on the facility and the employees, and I mean it depends on everything about the place, cause, yeah at first when I started getting, like into treatment, it was people were in it just for the money…other places genuinely care if you leave right that moment and do what you say you’re going to do.” (28-year-old)
	Outside support	Reported outside support (or lack thereof) from family and friends	“I don’t really have no family there [back home] or anything. I have a sister there, but she’s in addiction. So, I can’t put myself in that situation and stay with her, because I’ll be right back in addiction. So, I don’t do that” (28-year-old)
	Economic situation	Financial situation, whether positive or negative	“It’s and then, like, because of the eviction, it’s hard for me to find an apartment.” (39-year-old)
Intrapersonal Factors	Self-stigma	Using self-stigmatizing words (e.g., “clean”) or internalized negative social expectations about substance use	“You know, I know I got myself into this, but it’s difficult to live with because you don’t want to tell anybody, you don’t want to be sick, you don’t want to miss work, you don’t want to hurt, you don’t want to think about, “What if I got arrested or what if I go to jail?” You know, and all this kind of stuff. So, it’s just, it’s a lot of stress, but that’s part of what got me to here.” (36-year-old)
	Trauma history	Reported trauma (physical, sexual, emotional) prior to current relationship. Does not include medical diagnoses except for traumatic injuries	“Like mental, physical, sexual abuse, in the past life.” (22-year-old)
	Physical comorbidities	Reported physical comorbidities (e.g., pain, immune conditions, etc.)	“When I was 21…My back was bothering me. And at that point, opioids were not that big of a deal. So, they just wrote a prescription for hydrocodone. I think they were 10, 15 milligrams or something, but I had three a day. So, they wrote me 90 for the month…” (30-year-old)
	Psychiatric comorbidities	Reported psychiatric comorbidities (e.g., bipolar disorder, depression, anxiety, etc.) including other drug use	“ I get to the point to where I’ve got PTSD so bad that I can’t even go into a grocery store without panicking. (32-year-old)
	HIV or substance use origin	When the participant first started using substances	“[My young children] died within a year of each other. And uh, I ended up on drugs. It wasn’t to get high. It was more of a coping mechanism, um, to keep me, uh, to where I felt like I could be a part of society.” (32-year-old)
Relationship Compromising Behaviors	Partner unwilling to seek treatment or actively using	Current partner having comorbid untreated substance use and/or HIV or introducing participant to substances	“I didn’t really understand what addiction was until I met my fiancé. And he opened my eyes to a lot, and I was like, “Oh.” And we got lost together, but he found himself and then I just kind of kept going.” (35-year-old)
	Current trauma	Current partner actions that constitute physical, sexual, or emotional trauma	“I tried to telling the father of my child that I needed to go to rehab, and he was not having it. He said the only way I would leave him would be in a body bag. So I had to like sneak out and leave while he was asleep one night.” (32-year-old)
	Criticism	Intentional unsupportive reactions, such as criticizing how a partner is dealing with opioid use	“lately he, he has asked me, because sometimes my medicine makes my blood pressure a little low, so I get sleepy and he thinks I’m nodding out or something. And I’m like, “No, you don’t understand.” (22-year-old)
	Emotional Suppression	Lack of engagement from either partner such as lack of actions to reduce the partner’s upset and/or burden	“he’s not the type that sits and will tell you that he’s hurting or something’s bothering him. He just keeps it all bottled up.” (28-year-old)
	Guilt	Expressing regret about how the participant has treated themselves or others in the past given substance use	“I feel like I’ve traumatized his world [telling him about my drug use]” (22-year-old with OUD).
	Shame	Expressing trepidation about how others (partners, family members, etc.) might view participants substance use	“He did not even want me to go to the doctor and get on the Suboxone or Subutex whenever I was pregnant with her because he was like “No, you’re not doing that. You need to just quit.” I’m like “It’s not that simple. Like, I can’t just quit.” Being pregnant, like, I was scared that if I did that I would miscarry or something. Like something would go wrong and all this.” (30-year-old)
Relationship Enhancing Behaviors	Partner treated, uninfected, or not using	Partner with comorbid treated substance use and in care or partner without substance use disorder	“He…as soon as I found out I was pregnant, he also quit using. We’re addicts together. And when I found out I was pregnant, I stopped and a little bit after he found out I was pregnant, he stopped.” (24-year-old)
	Self-disclosure	Disclosure of concerns and feeling specifically regarding living with opioid use disorder	“we just sat down as a family and I had to come clean to everybody. And he just happened to be one of the people that…you know, I mean, everybody stood beside me, which is awesome. You know, he could’ve walked away very easily.” (30-year-old)
	Emotional responsiveness	Partner makes participant feel understood, cared for, and accepted	“He makes me feel worthy.” (32-year-old)
	Partner engagement	Engaging in behaviors aimed at sustaining or enhancing the relationship, may come from either partner	“He’s been to every doctor’s appointment, whether it’s just a regular checkup, just to go in there and be like, “Hey, how are you feeling?” You know, and he’s just very present and there and involved.” (20-year-old)
Desired Partner Behaviors	Emotional intelligence	Partner’s ability to proactively perform supportive care including, but not limited to, self-awareness, social awareness, self-management, and relationship management	“Involved…concerned, asking questions. I’ve even had this conversation with him. Like, you know, “I feel like I’m not asking you to do a lot, but all I would need is you to ask me, ‘How is it going? How’s everything going?’” …Just try and be involved, try and understand, try and care.” (30-year-old)
	Empathy	Partner’s ability to make participant feel like they understand the participants feelings and make them feel heard and seen when prompted	“I’m not telling him everything that’s going on, and he says he understands, but I just wish he’d gotten more of an understanding, and he’d feel exactly how I feel.” (22-year-old)
	Supportive behaviors	Engaging in behaviors that make it possible for participant to be in treatment (including financial support, transportation, childcare, etc.)	“Oh, well, as far as helping, I mean, if she also had three kids and, you know, all of that, helping with the kids, taking care of the house, you know, things like that. Making it easier on the, making easier on her, basically. Not feeling like there’s so much to do because he’s taking care of it. So yeah, that would be perfect.” (29-year-old)
	Soothing physical behaviors	Engaging in behaviors that sooth the pregnant partner such as foot rubs, back rubs, etc.	“they should be fully supportive and rub my feet every night, which I don’t get…” (28-year-old).
	Openness to improve	Engaging in or willingness to engage in behaviors that show partner openness to learn how to be more supportive	“Priorities [have] got to change. Like, ‘Yes, you need to work and make money and stuff, but you also need to be home by five o’clock so you can have some dinner and some family time’” (27-year-old).

Ethical Considerations

This study was approved by the Vanderbilt University Medical Center Institutional Review Board (IRB #202145). All participants provided written informed consent. If any participants shared information with the interviewers that may have impacted their clinical care, that information was shared (with their consent) with the clinical team.

Results

The 27 participants had a median age of 30 years (interquartile range [IQR] 28-32), a median gestational age of 29 weeks (IQR 13-37), most self-identified as White (n = 18, 90%), and a plurality had one living child or stepchild (n = 9, 45%) (Table 4). Participants described their partners as a fiancé (n = 5, 25%), boyfriend (n = 5, 25%), husband (n = 3, 15%), partner (n = 3, 15), and other (n = 4, 20%), where “other” included father of the baby (but not in a relationship) or ex-partners. Employing codes and themes from Manne and Badr’s relationship imtimacy model of couple adaptation to cancer we developed an adapted thematic map of relationship intimacy model of couple to stigOUD (Figure 1).²⁵

Table 4.

Participant Characteristics (n = 27)

	n (%) or median (IQR)
Median age (years)	30 (28-32)
Self-identified race/ethnicity
White	18 (90)
Other*	2 (10)
Partner status
Husband	3 (15)
Fiance	5 (25)
Partner	3 (15)
Boyfriend	5 (25)
Other	4 (20)
Median gestational age (weeks)	29 (13-37)
Number of living children/stepchildren
0	3 (15)
1	9 (45)
2	3 (15)
3+	5 (25)

^*de-identified as “other” to protect participant privacy

Figure 1.

A conceptual model of pregnant partner desired behaviors during pregnancy

Previous Lived Experiences and Intrapersonal Factors

Previous lived experiences and intrapersonal factors influenced how participants frames relationship-compromising, relationship-enhancing, and desired partner behaviors. Participants reported sources of trauma (previous partners, family members, the criminal justice system, the medical system, accidents, etc.) often coincided with their initial substance use and contributed to continued substance use/inhibited their ability to start or continue treatment. Participants also noted multiple barriers to care (lack of social support, financial difficulties, stigma within the health system). Participants who were current or recent substance users and, in general, had lower expectations of their partners (further elaborated below) than participants who had been in recovery for longer.

Relationship compromising behaviors

Partner unwilling to seek treatment or actively using

Participants explained how their partner’s substance use impacted their ability to abstain from opiates or fueled their addiction. One explained, “…as long as he is actively using while I’m pregnant, it would be fine for me to use because that’s still benefits him and his addiction” (28-year-old). Another elaborated, criticizing their partner in the process:

The father of my child would let me use, would bring it to me to use, but then would talk to me about how worthless I was for using after giving it to me…But he continued giving it to me. (32-year-old)

Current trauma

Some participants also described ongoing trauma in their relationship. One participant reported:

I tried telling the father of my child that I needed to go to rehab, and he was not having it. He said the only way I would leave him would be in a body bag. So, I had to like sneak out and leave while he was asleep one night. He made me felt like I was just nothing. I just felt like I didn’t exist…He said in his world, he’d maybe kill off my family. I wasn’t allowed to talk to nobody. I literally had to run away from him. (32-year-old)

Criticism

Partners were noted to have used a participant’s substance use history to demean them or dissuade them from seeking treatment. One participant reported that their partner frequently references the stereotype that people with OUD engage in transactional sex. They explained that he likes to, “…make a little joke, like: ‘You slept with everybody, but I’m the only one that ever got you pregnant’” (28-year-old).

Another reported that their partner, “…did not even want me to go to the doctor and get on the Suboxone or Subutex whenever I was pregnant with her [child] because he was like ‘No, you’re not doing that. You need to just quit’” (30-year-old).

Disengagement

Disengagement, where either partner does not engage emotionally with the other, was the most common relationship compromising behavior. One participant described their partner as “…not the type that sits and will tell you that he’s hurting or something’s bothering him. He just keeps it all bottled up” (28-year-old).

A different participant used the same metaphor to describe themselves, “I’m horrible with communication. Like, I don’t know why, but I am. I’ll just keep it all bottled up until I explode…” (20-year-old).

Guilt

Participants reported guilt about their substance use and how they acted while actively using opioids. One explained:

I became homeless, I slept outside, I went without food, you know, I’ve stolen things, I’ve broken into people’s houses, and it’s just not something good to do…I feel bad. I already feel guilty for my past, you know, so it makes me feel bad, but it is part of me. (28-year-old)

Other participants expressed guilt associated with sharing their substance use history with their partners. One explained, “I feel like I’ve traumatized his world [telling him about my drug use]” (22-year-old).

Shame

Participants also reported profound shame, often related to how they thought their partners or other people may react to learning about their substance use. One participant explained the enhanced anticipated stigma they experienced:

Especially someone else that’s pregnant, because the stigma on being pregnant and addicted is still so, like, controversial, whatever the word is. And it just shouldn’t be, because it’s, it’s a really crappy feeling. You want to stop, it’s not that you don’t love your kids, but you just don’t know how…I’ve been a closet addict. No one’s known. (35-year-old)

Another reported that they did not seek treatment initially because, “I kept seeing all these articles about these moms getting their kids taken away and going to jail…” (30-year-old).

Relationship enhancing behaviors

Partner treated, uninfected, or not using

Participants reported how helpful it was to have a never-user partner or a partner in treatment. One participant explained:

He’s never used drugs or been an addict or anything like that. I think that has been really good, support wise…having him be the sober person is really, I guess, good for me to just see that you know, you can live like that.” (30-year-old)

Self-disclosure

Some participants reported that, until recently, their partner had not been fully in the loop regarding their substance use. One participant elaborated on their positive experience disclosing their substance use to their partner:

Yeah, so he knew that I had a prescription. I don’t think he knew how bad it had gotten…because I kind of hid what was really going on because I was afraid, you know, of losing him…[but he] stood beside me, which is awesome. (30-year-old)

Emotional responsiveness

Participants reported that feeling heard strengthened their relationships and made them feel loved. One participant elaborated that their partner’s responsiveness validates them:

He’s pushed me to being where I am here [in treatment]. He pushed me into therapy and being on [sertraline] has drastically helped my anxiety. I don’t know, he’s always just, just there. He’s always understanding. Even if I act like a psycho, he’s like, “It’s all right. It’s okay, I love you.” (35-year-old)

Partner engagement

In addition to emotional support, participants appreciated financial support and help with housework, childcare, and doctors’ appointments. There were also examples of participants who reported different standards of partner engagement, likely reflecting previous relationships with poor partner engagement. One participant reported that the father of the baby had recently married someone else but was still seeing her occasionally, described engagement as “He texts me every day whenever he can” (39-year-old).

Desired partner behaviors

Emotional intelligence

Most participants reported wanting their partner to proactively support them and display emotional intelligence in their relationship. One participant described their hypothetical perfect partner as someone who is:

Involved…concerned, asking questions. I’ve even had this conversation with him. Like, you know, “I feel like I’m not asking you to do a lot, but all I would need is you to ask me, ‘How is it going? How’s everything going?’” …Just try and be involved, try and understand, try and care. (30-year-old)

Another participant had some more specific requirements given their situation:

I mean, if she also had three kids and, you know, all of that, helping with the kids, taking care of the house, you know, things like that. Making it easier on the, making easier on her, basically. Not feeling like there’s so much to do because he’s taking care of it…that would be perfect. (29-year-old)

Empathy

Participants were also keen on their partners having the ability to empathize with them. One participant explained:

Sometimes I wish he understood more that pregnancy is very, very rough. Like, I don’t think he understands, like, how rough it really is or how hard pregnancy really is. (20-year-old)

Another explained that the importance of having an empathetic partner during pregnancy and beyond:

I guess it would go for as far as not being pregnant, too, emotionally being involved, act like…being compassionate, caring, and genuine, actually caring and actually genuinely being concerned and interested in what is going on and how it’s going with everything…that would definitely be it [the ideal relationship]. (30-year-old)

Supportive behaviors

Participants reported that they would like financial and logistic support in addition to emotional support from their partners. One participant captured the sentiments of the group, explaining that an ideal partner would also:

…Definitely go to appointments with her when he can…helping out around the house is always nice, making sure that she has everything that she needs, you know, is taken care of…Financial support would be good…and I assume that when you get really big, when you’re pregnant that it’s probably hard to drive, so yeah, transportation support’s probably good too. (36-year-old)

Soothing physical behaviors

Participants also reported that they would love more soothing physical behaviors from their partners, with one explaining, “they should be fully supportive and rub my feet every night, which I don’t get…” (28-year-old).

Openness to improve

Finally, participants described their ideal partners as someone open to improve both themselves and their relationship. One participant described how important it is for partners to be open to adapt, “Priorities [have] got to change. Like, ‘Yes, you need to work and make money and stuff, but you also need to be home by five o’clock so you can have some dinner and some family time’” (27-year-old).

Suggestions for partner engagement

Participants also had several suggestions about what types of resources should be available for pregnant people and their partners to support and strengthen their relationship. First, some participants reported that it’s important to educate partners on the changes they can expect during pregnancy, particularly with the context of OUD with one explaining, “you are constantly changing [physically and emotionally] and then you add the addiction in with it” (28-year-old).

While most participants were open to couples’ sessions, many reported that their partners might not be due to work schedules or general discomfort with sharing their feelings with people outside their relationship. Participants did express interest in educational materials, such as pamphlets, brochures, videos, and websites, that they could use to educate their partner on pregnancy and their underlying OUD. Participants’ suggestions are summarized in Table 2.

Discussion

There is evidence that pregnant people who experience and/or anticipate criticism or abuse from their current or recent partners are at an increased risk of return to substance use or disengagement with care, during and after pregnancy.^26,27 Among our participants who reported criticism and abuse, their partners shamed them with references to events linked to their past drug use, such as transactional sex and sexual health status. In addition to partner-induced stigma, participants reported feeling internalized shame and guilt about their drug use stemming from social norms and legal statutes, such as state laws that incarcerate people for substance use during pregnancy, that undermine pregnant people’s health.^28–30 While our participants were too homogeneous to consider additional potential contributors to their experienced and anticipated stigma (e.g., race, ethnicity, class, occupation, etc.), intersectional stigma is likely at play in this population and warrants intensive further study to improve care and outcomes among pregnant people with OUD.^30–32

Previous interventions during pregnancy have found that pregnant people were open to partner-based interventions and that partner behavior impacted each other’s outcomes during pregnancy.^9,33 Our participants agreed that partners should be present and engaged during and after pregnancy.³⁴ Our participants also wanted their partners to be proactive in providing empathetic emotional, physical, and logistic support during and after pregnancy.³⁴ This included understanding and supporting the physiologic changes that accompany pregnancy and helping with childcare and transportation. Finally, participants desired partners who wanted to learn to be a better spouse and parent, acknowledging that they and their partners could do a better job of communicating their feelings to each other.

While participants were clear on the support they were seeking, many acknowledged that their partners lacked the knowledge about their health needs and/or skills necessary to support them. Alio et al. (2013) provides a comprehensive framework for partner-based interventions for improved pregnancy outcomes.³⁴ They suggest that providers, pregnant partners, and non-pregnant partners should all be involved in any intervention but no clear standard of care exists for such engagement. Preliminary evidence suggests that targeted partner interventions to improve communication strategies and knowledge about OUD, even among non-treatment seeking opioid using partners, increases partner retention in treatment and social support for pregnant individuals.² Pregnant women with OUD would benefit from the integration of partner education or counseling sessions into the health care appointments.

Limitations

These data are from one clinical site in Nashville, Tennessee and are therefore not completely representative of the perspectives of pregnant people with OUD about partner support in other locations or the perspectives of people who face additional structural barriers (for example, most of our participants self-identified as White so could not assess the impact of systemic racism on our findings) to healthy pregnancies. We were not able to interview pregnant people who clinic staff determined might have been emotionally triggered or retraumatized from the interviews due to recent partner experiences. Our participants, for the most part, also reported having a current partner. We therefore lacked the perspectives of pregnant people with unsupportive or no partners, however, we did elicit a breadth of perspectives from pregnant people with OUD with supportive partners. Finally, we did not specifically ask participants about their or their partners’ understanding about the neonatal or fetal impacts of neonatal opioid withdrawal syndrome and medication-assisted treatment for OUD, which could be a potent contributor to desired engagement in pregnancy care for both partners. Our findings, however, align with other research examining what pregnant people want from their partners during and after pregnancy, which suggests that future interventions, while tailored for people with OUD, may have motifs that can be adapted to pregnant people with other stigmatized health conditions.

Conclusions

We found that pregnant people wanted partners who display emotional intelligence and empathy, provide supportive logistic and physical behaviors, and are open to improve. Future interventions can build on these findings, with further input from pregnant people and their partners, to create and assess comprehensive interventions aimed at improving care and outcomes. Such interventions should recognize the movement towards recovery-oriented systems of care approach to substance use disorder for both pregnant people and their partners.³⁵ Interventions should therefore include educational and service components that address community, societal, and even policy barriers to partner engagement.^34,36 Finally, they should recognize and address barriers that impact pregnant people and their partners across various levels of their identities.^30–32 Specifically, building on this preliminary research and with further input from pregnant people, the next step is to collaboratively gather data from more geographically and ethnically diverse pregnant people and, with their consent, their partners. These data can be used to plan and assess interventions and programming aimed at strengthening recovery-oriented systems of care to productively engage partners in antenatal care to improve outcomes for pregnant people with stigmatized health conditions.

Table 3.

Suggested partner learning points for opioid use disorder and pregnancy^*

Physiological changes	During pregnancy, the following changes are normal and expected:   • Being extra tired because the body makes so much blood that the oxygen in the blood gets a little low and sometimes from changes in the lungs that make some people short of breath   • Joint pain (especially back pain) from the joints getting ready to allow the baby to come out of the uterus   • Increased urination from the uterus pushing on the bladder
Supportive behaviors	When your partner is pregnant, they may appretiate the following things to help support them and make them feel better:   • Help taking care of the children when they are tired or need to go to the doctor   • Help getting to the doctor and remembering to take any medicines   • You asking what you can do to help regularly   • Foot rubs or massages on sore muscles or areas With all of the above, and any time you want to provide support, the most important thing is to listen to them and communicate how you are feeling and what is reasonable for you both to do to help each other!
Treatment information	• Treatment is safer than risking relapse for pregnant people and the baby • If you also use opioids, it helps if you also start treatment • It’s important to take the treatment medicine every day • Sometimes people will look flushed, have trouble sleeping, and have hard or loose stools with their medicines • Please reach out to the doctor with any questions
Additional resources	• https://www.acog.org/womens-health/faqs/opioid-use-disorder-and-pregnancy • https://www.cdc.gov/pregnancy/opioids/resources.html

^*these learning points are not comprehensive and only a starting point