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A Call for Reform: Treating Pregnant and Postpartum Women with Substance Use Disorder

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By Dr. Philip Moore, Chief Medical Officer at Gaudenzia

National Patient Recognition Week (NPRW) is observed in the U.S. from February 1 to 7 each year. The annual observance emphasizes patient care and satisfaction while serving as a time for hospital administrators to take stock of policies and procedures. While NPRW focuses on all patients, there are specific patient populations that face higher instances of stigma, discrimination, and negative health outcomes resulting from harmful policies and practices. One such population is pregnant and postpartum women with substance use disorder (SUD).

As one of the nation’s first SUD treatment providers to offer programming specifically tailored to meet the needs of pregnant women and women with children, Gaudenzia, Inc. strongly supports the recommendations set forth in the American Society of Addiction Medicine’s (ASAM) public policy statement on Substance Use and Substance Use Disorder Among Pregnant and Postpartum People.

Adopted in October 2022, ASAM’s statement outlines problematic legislation, misguided policies, and practices that harm pregnant and postpartum women and children affected by SUD. The statement notably underscores the need to shift away from punitive approaches that perpetuate barriers to SUD treatment access, including the fear of prosecution, child separation, and stigmatization.

With a long-established history as pioneers in the treatment of pregnant and parenting women, Gaudenzia can attest that pregnant and postpartum women with SUD are one of the most stigmatized subpopulations of substance users. Understanding that substance use disorder is exactly that — a disorder and not a moral failing — is crucial to recognizing how and why punitive approaches to SUD treatment cause significant harm to affected individuals and their families. For that reason, we appreciate ASAM’s actionable recommendations with the goal of improving health and treatment outcomes for pregnant and postpartum women and their children, with a focus on the perinatal period.

Consistent with ASAM’s recommendations, Gaudenzia strongly supports:

1. Adopting Payment Models that Support Family-Centered SUD Treatment Services

As an agency that operates 10 residential SUD programs where children can accompany their mothers to treatment, Gaudenzia strongly supports the adoption of payment models that allow SUD treatment providers to meet the unique needs of pregnant and postpartum women and their families. A lack of appropriate childcare and fear of losing custody of children remain among the top reasons why pregnant and postpartum women do not access traditional SUD treatment services. According to the Medicaid and CHIP Payment and Access Commission (MACPAC), only about 2% of Medicaid-funded residential treatment beds permit children. This presents a significant barrier to women who wish to enter and complete treatment while preserving relationships with their children.    

Increasing funding for, and access to, residential treatment services that permit children to live on premises while their mothers receive treatment is crucial to improving both short- and long-term outcomes for women and their children. As ASAM deftly notes, the majority of CAPTA funds are currently directed toward maintaining children outside of the home, rather than supporting treatment programs that work to preserve the family unit. This occurs despite evidence that children subjected to family separation have worse long-term outcomes, and that child removal is associated with higher relapse rates, parental overdose, and higher rates of post-traumatic stress disorder (PTSD) in parents.

2. Expanding Postpartum Medicaid Coverage to Reduce Treatment Discontinuation and Overdose Death

Another salient point in ASAM’s statement touches on the prevalence of treatment discontinuation and overdose deaths during the postpartum period. Medicaid coverage provided during the perinatal period traditionally expires 60 days after birth, while a lack of childcare presents a significant barrier to SUD treatment access and engagement during the postpartum period.

While we applaud Pennsylvania, Maryland, and Delaware — all states within our footprint — on expanding postpartum Medicaid coverage, we support ASAM’s recommendation that all states should expand Medicaid and the Children’s Health Insurance Program (CHIP) to provide 12 months of coverage for postpartum care.

3. Clarifying the Federal Child Abuse Prevention and Treatment Act’s (CAPTA) Definition of “Affected By” for Infants Prenatally Exposed to Substances

ASAM’s statement highlights a problematic lack of clarity in the 1974 federal Child Abuse Prevention and Treatment Act (CAPTA). The legislation provides funding to states to mitigate child abuse and neglect. To receive funds, states must, among other requirements, implement policies that address the needs of newborn infants “affected by” prenatal drug exposure or withdrawal symptoms.

As CAPTA does not define parameters for “affected by,” interpretations at the state and institutional levels vary widely, leading to inequitable policies and practices. In many hospitals, this includes unnecessary restrictions that interrupt or separate the parent-newborn dyad after birth, inequitable surveillance, and punitive room searches that can result in damaging legal implications for patients. 

Conflating substance use or a positive toxicology result, often obtained without patient consent, with child neglect or abuse can lead to extremely damaging outcomes for parents and children alike. Some states interpret CAPTA’s reference to “withdrawal symptoms” in infants as inclusive of situations involving legally prescribed opioid agonist medications. This is highly problematic, as a patient participating in medication-assisted treatment (MAT) at the time of birth may be reported and subjected to child separation or legal ramifications despite actively engaging in treatment.

In alignment with ASAM’s recommendations, amending the language in CAPTA for clarity and adopting universal policies that promote access to ethical, equitable, and evidence-based care at state and institutional levels is integral to improving health outcomes for women and children.

Lastly, Gaudenzia cannot ignore the implications of limiting or erasing bodily autonomy for individuals who can get pregnant. With estimates that up to 86% of pregnancies in women who use substances are unintentional, the decision to overturn Roe v. Wade and resulting abortion bans drastically and disproportionately impact pregnant women who use substances — particularly pregnant and postpartum women of color. We stand with ASAM’s statement that clinicians and patients must be able to make clinical decisions without legislative interference, and that pregnant women must always have fair and equitable access to life-saving medical care.    

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