Prenatal Care in the Context of Substance Use Disorders: Perspectives of Postpartum Women and Health Care Providers

Background: Pregnant women with Substance Use Disorders (SUDs) are in particular need of support during the prenatal period (ASAM, 2011).  However, they contend with stigma and possible punitive responses (Terplan et al, 2015), which can result in avoidance of treatment.  Prenatal care and patient-provider relationships are essential to improve health outcomes and can lead to other support, including social work (Lori et al, 2011).  Little is known about the patient-provider relationship for pregnant women with SUDs and what facilitates trust and women’s willingness to engage in care. This qualitative study uses interview data to examine prenatal care and patient-provider relationships from the perspectives of postpartum women with SUDs and providers.  The study’s analysis is informed by recognition theory (Honneth, 1992), which emphasizes acknowledging each person’s uniqueness and dignity in interpersonal relationships.  For women with SUDs, who may also be impacted by racism, sexism, classism, and stigma, being acknowledged in this way is a matter of social justice.

Methods: Semi-structured interviews were conducted with postpartum women with SUDs (n=19) and health care providers (n=10) (not matched pairs) regarding their experiences receiving and providing prenatal care.  Postpartum women (M age = 28 years) predominantly identified as White and the majority reported heroin or other opiates as their primary substance of misuse.  All prenatal care providers (M age = 47 years) identified as White women.  Providers were: 30% OB/GYNs; 40% certified nurse midwives; 30% family medicine physicians. Using a two-layered thematic analytical approach – data-driven and informed by recognition theory – this research offers a comprehensive examination of prenatal care in the context of SUDs.

Results: The majority of the women reported entering prenatal care newly motivated, worried about their babies, and with significant experiences of feeling judged.  Surprisingly, given past experiences, most of the postpartum women reported that their providers were nonjudgmental, caring, and medically informative.  The women reported that these traits facilitated connection by fostering a sense of trust and feeling comfortable.  Further, for some women, this type of treatment resulted in them feeling like they “deserve to be treated like a person.”  The majority of the providers reported approaching prenatal care with women with SUDs from a nonjudgmental and compassionate approach.  Findings from both the providers’ and the women’s data underscore the salience in acknowledging the worth and dignity of pregnant women with SUDs in not only maintaining the relationship, but also fostering confidence in the women. 

Conclusions:  Limitations include: this small qualitative study took place in the northeast with a self-selected sample of providers and postpartum women in treatment for SUDs.  However, this study may offer preliminary thoughts that some efforts by medical organizations in the northeast may have resulted in a shift in approach to care for pregnant women with SUDs.  Given the ways that pregnant women with SUDs are impacted by marginalization, future social work research should assess whether these approaches by professionals working with pregnant and parenting women with SUDs are occurring nationwide and in other settings, including in child welfare settings and SUD treatment programs.