The study borrowed from Anderson’s framework for healthcare access24,25 and focused on facilitating inhibitory and operational factors that informed the interview questions depicted in the following four domains (Figure 1): Provider perceptions of MAT; Treatment delivery; Access to resources; and Challenges/barriers. Recommendations from providers are reported in a separate section.
Provider Perceptions of MAT, Treatment delivery and Access to resources
Five central themes (Figure 1) emerged from the three domains (Perceptions of MAT, Treatment delivery, and Access to resources) and are presented in this section.
MAT is a better option for pregnant women with OUD
Mostproviders (n = 11) perceived MAT to be a better option for treatment compared to reports of immediate cessation of drug use recommended by some clinicians during pregnancy. Several providers shared the perceptions of MAT for pregnant women:
“MAT makes so much sense, and for most of them [women], it is a lifeline. It is how they survive. I think without it, they would be back to where they started” (Participant (P) 2, P8).
“Treatment with medications reduces risky behaviors, infections, and other negative factors that compromises the health of pregnant women” (P3).
Many providers (n = 6) argued that a safer and controlled environment, as well as well-established current neonatal abstinence syndrome (NAS) treatment modalities, reduced the severity of withdrawal symptoms. In one provider’s word, “withdrawal [for babies] outside of the mother is much better than withdrawal inside the mother” (P4).
Overall, many providers (n = 6) with outpatient/inpatient experience, favored buprenorphine, over methadone. Two providers shared the following statement:
“Buprenorphine was more likely to lead to successfully being able to stop use. The majority [patients], find it helpful” (P7).
“People in general on buprenorphine feel the effects of the medication less than methadone” (P5).
Most providers (n = 11) acknowledged buprenorphine was easily accessible on the streets and the likely source was from prescriptions diverted by patients in treatment.A clinic provider reported that about half of the patients on buprenorphine knew of the benefits during pregnancy and were “already getting it on the street, to manage their addiction as best as they can” (P5), prior to being started on MAT in the clinic.
Pregnancy: A time to promote MAT
This perception was widely shared by most providers (n = 10) who found pregnancy to be a motivating time for change. “Younger women who had not previously sought help for their addiction were motivated to get healthy and found in pregnancy something they want to address” (P5). Providers reported that patients believed MAT would help their babies and prevent withdrawal symptoms. One provider spoke about the potential for behavior change during this period:
“Pregnancy offered a precious opportunity to start fresh. A time when patients were the most motivated” (P7).
Integrated and co-located models can improve treatment
Recent and ongoing discussions about treatment modalities have shed light on the variability of treatment for pregnant women with OUD.32 Providers operated in practices that were linked to referral services such as medical, addictions and psychiatry specialties, as well as to programs in facilities that were separated but proximal to essential clinics throughout the university networks. Most providers (n = 10) were unclear about their practice delivery models, which were described, as “traditional collaborative,” “integrated,” “co-located,” “embedded,” or “traditional substance abuse programs.”
Providers (n = 10), uniformly described the co-located (or integrated) or “embedded” model as crucial to treatment and viewed the approach more positively than other models. To study providers, practice delivery models were not fully integrated. One outpatient provider commented that the integrated model was, “an effective strategy, not 100% co-located care, but as close as we have” (P5). The perception of most providers was that it was not enough to have a co-located model, and the most desirable approach was one that was also patient-centered.
Hospitalization and prenatal care link women to MAT and healthcare services
Hospital admissions provided an opportunity to treat at-risk women who may otherwise be lost to the healthcare system.Providers (n = 8) reported an opportunity to “catch them…” (P2) during inpatient admissions when women presented for preterm labor, withdrawal symptoms, or other conditions. Two inpatient providers commented:
“We [hospitals] are their entry into getting care. It’s the first time they were getting care, for some women (P1). They [women] are referred appropriately and not discharged without an outpatient plan to continue treatment” (P6).
Outpatient clinic providers also described prenatal visits as a “gateway” (P2) for pregnant women to access healthcare and meet prenatal objectives of engaging women during pregnancy:
“I am like the first step in their process to connect with treatment for women seeking prenatal care and who have typically been struggling with substance abuse for a long time” (P2).
Supportive services improve MAT delivery
Allproviders (n = 12) acknowledged the critical role of social workers in supporting MAT delivery initiated by waivered prescribers. One provider spoke about the work of social workers:
“In our clinic, it’s the social worker. We pretty much, the two of us, deal with the bulk of them. They [social workers] are critical for continuity of care. If we didn’t have a social worker, we couldn’t do any of this. We will work with a social worker to get them into an outpatient facility” (P3, P6).
Social workers described engagement opportunities with the healthcare team beyond prenatal appointments, such as, screening and assessing new/returning pregnant women, coordinating referrals, locating resources, providing psychosocial support, building relationships, and working closely with local/state agencies to identify suitable programs and services.
All providersn = 12) spoke about the diminishing support women with OUD on maintenance MAT received post-pregnancy. Providers described postpartum support as a critical time when women were already overwhelmed with the care of newborns and were therefore at risk of relapsing.
“Women worried about managing their recovery in the context of parenting. Relapse is about two issues: removing the motivator of doing something for their babies… and visitation with providers that occurred weekly in the third trimester…. I worry about the moms once the baby is here and the attention goes away…our ability to help in the postpartum period…is particularly worrisome” (P7).
Another provider concluded, “You don’t stop being an important person when you are not pregnant anymore” (P1).
Challenges and barriers
Overall four themes emerged in relation to provider/health systems (2) and patient factors (2), when providers were asked about challenges and barriers to MAT delivery (Figure 1).
Lack of provider knowledge, inadequate training, and inconsistent treatment guidelines
Most providers (n = 8) found inpatient medical residents lacked knowledge of current MAT information and updated guidelines for clinical decision making, often “citing old research” (P9). Inpatient providers (n = 4), reported feeling inadequately prepared to screen and assess the increasing number of pregnant women with OUD on admissions and did not “necessarily feel comfortable” (P7, P9) counseling women without adequate MAT training. Treatment guidelines were reported to be inadequate or absent for post-operative cesarean sections and immediate postpartum because of unresolved MAT concerns. One provider added:
“We don’t have written protocols in place. It is an issue when the recommendations can change. Tell us what to do! We want to do the right thing. We want to treat the pain, but not in a way that risks relapse. But then there can be contradictory recommendations given to us” (P7).
Lack of follow-up and inadequate coordination
For women on MAT maintenance, inpatient providers (n = 5) complained that there was “no good plan for follow up and coordination” (P5) with prescribing practitioners whose patients were on MAT. Attempts to communicate with these practitioners during inpatient admissions to determine the right dosage was time-consuming and frustrating when patients did not have prescriber contact information. Similar frustrations were also expressed by outpatient providers (n = 5) by the following comments:
“A lot of them [providers] are very busy, so getting someone to call back and confirm their dose can take too long. A provider would have to seek out notes from other providers, to confirm medication dosages” (P7, P12).
A few providers (n = 3) found methadone clinics were less forthcoming with information-sharing and one provider added that the clinics “lacked real coordination with goals for treatment.”
Lack of external support/resources
Among the challenges and barriers, providers identified two main themes related to patient factors which impeded treatment. The first factor is the lack of external and additional support and resources for pregnant women with OUD.Most providers (n = 8) stated MAT delivery was impacted by limited childcare, transportation, and housing. Providers called transportation a major barrier that affected appointments, work, attendance, timeliness, child visitation/child custody and therefore, treatment.
“We don’t have a good way of addressing a lot of other psychosocial needs they have like helping with transportation” (P5).
“I think we forget sometimes how hard it can be to get across town if you don’t have a car. If you’re trying to bring along a toddler, or you need to go check in with your probation officer or have to provide a document you can’t produce…. Every time I hear about some of the things our clients deal with, I’m amazed they’re ever there” (P7).
Providers (n = 9) complained about lack of access to residential placement facilities and programs for MAT patients. Few programs existed, particularly for pregnant women with children, and those with a critical need such as the homeless or women living with another drug user. Social workers who coordinate MAT delivery summed up their efforts to locate residential services as beleaguered by:
“Availability, geography, insurance, and transportation… Barriers related to availability of services are the most frustrating… Because when I have a woman who’s willing and able and covered, to not be able to place her in treatment is very frustrating” (P2, P12).
A few providers familiar with the justice system (n = 3), expressed concerns about MAT access and the criminal justice system. They reported a system that lacked clear guidelines and avenues to communicate with providers and women about MAT resulting in inadequate or no access to MAT for incarcerated pregnant women as reported in the following comment by one provider:
“The courts don’t understand when they [women] are on their medication, what the levels are, and might make judgements about the appropriate dose rather than talk to the individual or doctor” (P8).
Stigma, shame, and guilt
The second major patient factor revealed the theme of stigma, shame, and guilt which providers considered to be barriers to effective MAT delivery. Providers (n = 5) reported that women often felt stigmatized by healthcare professionals. Stigma was a barrier to treatment and women were fearful of being discovered to be utilizing MAT and may be the biggest barrier as noted in the following provider comments:
“For the people I see who are on it [MAT], to take care of their kid, but they don’t want to have to be on it and they don’t want their children to know they are on it. I have one client whose sisters are on treatment; methadone and she goes over to watch the kids in the car when they go to pick up the medications. They feel very stigmatized of being on it [MAT] and needing it” (P3).
“For women there is the stigma of being seen in a drug treatment program, which a major hurdle and discouraged women from keeping appointments. Women were fearful of being discovered to be on MAT” (P1, P11).
“There is also the fear for example, if they tell other doctors or a pediatrician that they’re on it, that they might indicate they can’t take care of their kids, when they are aware they need to be on it in order to not use. There is a lot of stigma, especially for the people who use it to addiction and pain” (P3).
Providers revealed women reported feeling ashamed and concerned about negative words from healthcare providers and expressed mixed feelings about staying on MAT. One provider reported, “I hear nurses all the time say it [MAT] is replacing substance for another” (P9), although MAT was prescribed and prescribed by a provider. In another area, post-delivery providers (n = 6) stated that their patients expressed guilt about their babies and NAS. One provider shared this view:
“Part of it is guilt. They don’t want to see the baby shaking and going through withdrawal. I think probably the biggest thing that prevents them besides the mechanisms of addiction, is the shame and guilt and worry about what’s going to happen to their kids” (P8).
Overall, providers recommended four areas for improving MAT delivery and focused on recommendations to improve both provider barriers/challenges, as well as, patient factors that impeded treatment progress.
Improve patient access to resources and education
Most providers (n = 10), recommended improvements to psychosocial needs to complete MAT delivery. Availability and access to patient resources such as transportation, housing, money, support groups, parenting education and, outreach workers/recovery support personnel impacted comprehensive treatment: “Lack of safe and stable housing impacts the ability to keep custody of their children, a major stressor for women” (P8). A provider with multiple years working with pregnant women found psychosocial needs to be one of the most important factors for effective treatment, and spoke about d the importance of available resources:
“Just having more resources, more outreach, some peer recovery navigators, and having more access to more residential programs will improve treatment delivery. A peer-to-peer, like another mom who’s gone through it and is on the other side, who is in recovery and who was able to keep her kids, I think that would probably be the best help” (P5).
Another factor presented by providers (n = 8) was, access to no-cost/free educational materials from government agencies to reinforce messages about OUD, NAS and postpartum conditions. Additionally, child welfare providers, recommended anticipatory guidance teaching, “transparency and working with the parents beforehand” (P1) to reduce fears/anxieties, provide clear guidelines/expectations and prevent child removal/custody battles.
Advance an integrated “one-stop shop” model
Providers (n = 8) recommended an integrated team-based, and a patient-centered approach as the ideal model for pregnant women. Existing evidence-based integrative models appear to be effective. For women with OUD, having related services in one place as a “one-stop shop” facilitates collaboration, coordination, and seamless transitions as noted by inpatient providers:
“To have a model where the treatment is done within the OB clinic, would be simple and they might be more likely to follow through [with treatment] if they go to one place. For some women, there’s the stigma of being seen in drug treatment program that bothers them. For some, it’s just convenience, (or, they are familiar with their OB [obstetrics]), so they want to stay” (P5, P11).
Provide education and training to enhance OUD management
All providers recommended education and training to lessen provider discomfort with prescribing MAT to pregnant women. Training will reduce knowledge gaps in MAT management of pregnant women and should be embedded into a core curriculum in medical education. Providers (n = 7) reported that mentorship training with experienced MAT prescribers, such as psychiatrists, will be beneficial to prenatal providers.
“Colleagues would be more willing to obtain the waiver if they had the opportunity to practice. If I were to start in a position where I was expected to prescribe buprenorphine, I would want to spend a little time in the programs where they already do that. Just to make sure I understand all the subtleties” (P7).
Reduce stigma and promote patient-centeredness
Providers (n = 7) should be made aware of the similarities in addiction and chronic disease management during encounters and exercise more tolerance towards persons with addictions. Substance use disorders may lead to “chronic relapsing, just like diabetes and hypertension” (P11).
“No more insulin for you, is not an option offered to diabetics, after eating sweets and reaching high blood sugar levels” (P11).
Women should therefore not be punished “over a weekend of using,” at a time when the need for continued treatment is greatest. Providers should use appropriate terminology and language such as “persons with drug addiction” instead of, “a drug addict,” (P6), to reduce stigma and promote patient-centered approaches to advance patient/provider relationships as noted by one provider:
“I think the focus on the relationships is really critical, to addressing the roots of addiction, experiences of childhood trauma or addicted parents, and patients who did not grow up with a lot of support. In keeping people engaged in recovery and utilizing all the services effectively, I would say relationships are the most important part” (P5, P6).