Complex decision-making of people's use of opioid agonist therapy during pregnancy: Troubling the concept of ‘non-compliance’

Clinical guidelines strongly recommend that pregnant people with opioid use disorder be offered Opioid Agonist Therapy (OAT); however, access to and retention in substance use services are influenced by a multitude of factors. We conducted 25 semi-structured qualitative interviews with pregnant and recently pregnant people who used opioids or OAT before their pregnancy. Participants were recruited from various health and social services, through social media and by word of mouth. For analysis, we used a voice-centred relational method; each transcript was read four times looking for different levels of influence in participants' stories (i.e., individual, interpersonal, societal). The participant's narratives highlighted how they navigated the expectations of 'good patient' and 'good mother.' We identified four trajectories of OAT use during pregnancy: two that represent 'compliance' and two that represent 'non-compliance.' While compliant patients used OAT out of concern for the health of their fetus and because it was medically recommended, the decision to not use OAT occurred in the context of weighing multiple, not only medical risks. Based on past experiences navigating health and social services, some participants made potentially medically risky decisions to avoid negative interactions with health and social care. Our results underscore that health and social service delivery is shaped by paternalistic measures aimed at controlling the behaviour of pregnant people who use drugs and reinforce the need for alternative approaches beyond control to foster more inclusive, supportive, and empathetic support for women who use drugs.