"Fear Gets in the Way" Multiple Stigmas and Discrimination in Health Settings As a Driver of Overdose Among Postpartum Women

Background and Purpose: Overdose is a leading causes of maternal morbidity and mortality, with overdose death rates peaking 7-12 months post-delivery. Racial/ethnic minorities face systemic inequities in both addiction and maternal care, which lead to substantial differences in drug-related and reproductive health outcomes. Underlying these inequities is widespread stigma and discrimination by providers within health systems against pregnant and postpartum people who use drugs. Experiences of both drug- and race-related stigma can result in limited access to and engagement in drug treatment and maternal health care, especially for people with multiple intersectional marginalized identities (i.e. racialized/ethnicized minority, low-income, other marginalized groups). In this study, we qualitatively explore how stigma and discrimination within health systems may underlie experiences of overdose for postpartum women who use opioids.

Methods: Qualitative data were collected via (a) key informant interview with 15 stakeholders working in substance use and/or maternal health, and (b) in-depth interviews with 30 postpartum women reporting recent opioid use and overdose in the New York metro area. Interviews focused on experiences with overdose and within health systems, including stigma and discrimination. Interviews were transcribed and coded, employing a modified grounded theory approach using open, axial, and selective coding procedures to identify a priori and emerging themes.

Results: Postpartum women and key informants discussed the ubiquity of stigma and discrimination within health systems towards childbearing people who use drugs. Stigma was enacted (i.e. directly experienced), anticipated (i.e. expected), and internalized (i.e., accepted negative views). These stigma experiences adversely affected substance use in ways that placed women at increased risk of overdose. Key themes emerged around disclosure of drug use and avoidance of care, both rooted in the fear of punitive responses. Experiences of poor treatment by providers led to distrust of health systems, preventing women from seeking care or disclosing substance use once in care. Women reported traumatic experiences with OB/GYN’s, in particular, who failed to give competent care by pressuring people to detox rather than supporting medications for opioid use disorder (MOUD) and spreading misinformation about MOUD. Fear of being reported to child protective services and losing custody of their children was also a major theme, which led women to avoid seeking care for themselves and their children. Participants indicated that oppressive policies and practices intersected with race-based stigma and were used to police Black and Latinx parents. Negative experiences within health systems were a major source of stress and created conditions that were more conducive to overdose, including feelings of isolation and despair, an increased need for substances and limited support for evidence-based treatment, like MOUD.

Conclusions and Implications: Provider and systems-level solutions rooted in reproductive justice are needed to address systemic inequities in drug-related maternal morbidity and mortality. Among providers, stigma reduction interventions should include training in harm reduction, addiction medicine, and trauma-informed care. Health systems must also explicitly tackle institutional racism and stigma through the development of culturally competent justice-oriented patient care, integrated systems of care, expanded access to evidence-based treatments, and policies that prioritize treatment over punishment.