Navigating opioid use disorder treatment for pregnant and parenting people: composite narratives for policy action

Opioid use in pregnancy and the postpartum period in the United States has continued to rise. There are significant barriers to accessing evidence-based treatment and appropriate wrap-around services for pregnant and postpartum individuals and their families. These challenges sit at the intersection of multiple incongruent and fragmented systems, including criminal justice, child welfare, childcare, health insurance, and physical and behavioral health treatment. To support and improve outcomes for this population, with their unique medical and social complexities, we seek to understand how individuals access Medication for Opioid Use (MOUD), barriers to MOUD treatment, and how the policy environment supports or hinders care delivery and recovery. To understand this, we use in-depth interviews with interest-holders from across a mid-Atlantic state with a county-administered system, including prenatal care providers, county-level administrators, treatment programs, and pregnant and parenting people. From these interviews, we develop composite narratives that merge and share findings through the lens of four separate perspectives: an obstetrician, a director of a treatment organization, a local government official, and a parenting person who experiences opioid use disorder. We map these narratives onto the World Health Organization’s Commission on Social Determinants of Health to illustrate the mechanisms for achieving positive health outcomes and demonstrate opportunities for policy engagement. The narratives highlight the social and structural determinants of health and illustrate the policy barriers that prevent pregnant and postpartum people with opioid use disorder from accessing care. We highlight policies that govern criminal justice and substance control, child welfare, and childcare systems, as well as policies related to health insurance and treatment center operations. This paper articulates how substance use care for pregnant and postpartum people and their families is distinctly different from substance use disorder care for other populations. Efforts to improve outcomes for this population must consider the policy environment, stigma, and the structural determinants of health.