Disparities in the Continuum of Care for Pregnant People Diagnosed with Substance Use Disorder

"Critically, although most women reported receiving substance use screening, only 1 in 10 women who met SUD [Substance Use Disorder] criteria received SUD treatment in the past year. The significant drop-off between SUD screening and receipt of treatment underscores a structural gap in the perinatal addiction care continuum (i.e., care coordination, referral infrastructure, and follow-up practices). Although universal screening is widely promoted as the essential starting point for identifying pregnant women with a SUD,19,18 little is known about what happens after screening and before treatment initiation, and few studies have evaluated whether efforts to promote universal screening are effective in actually identifying pregnant women in need of treatment services and successfully connecting them to those services.53,54 Study findings suggest that screening alone is insufficient.53,54 While screening alone did not significantly predict treatment engagement, a provider-initiated conversation about alcohol treatment options and/or a discussion about drug use was associated with a tenfold increase in treatment engagement, making it one of the strongest observed predictors of care entry. The magnitude of this association likely reflects multiple, overlapping factors. For example, initiating these conversations may itself promote greater recognition of a SUD. Alternatively, or in addition to this, pregnant women engaging in such discussions with their providers may themselves already be more ready to seek treatment and might have even initiated the conversation about treatment options.55 Finally, discussions about treatment with healthcare providers may have been experienced by pregnant women as supportive, helping to reduce the stigma associated with SUDs, and clarifying available pathways to care.56

"These results suggest that follow-up conversations and coordination of services are necessary for improving treatment linkage to SUD treatment for pregnant women with SUDs. While research has supported the effectiveness of universal screening, brief intervention, and referral to treatment (SBIRT) as a strategy for connecting screening practices to subsequent engagement in treatment, practical barriers often interrupt its implementation in prenatal settings.54 Importantly, while Medicaid reimburses for the use of SBIRT, this does not ensure consistent or effective implementation, and further training may have limited impact on provider implementation in the absence of larger system-level support.57 Regardless of the payer, barriers to the implementation of the screening of substance use are well documented; these include limited time and competing priorities during prenatal visits, lack of training and support for healthcare professionals, and discomfort in discussing substance use during pregnancy.54 Addressing these barriers will require increased focus on workflow redesign (e.g., creating time for follow-up conversations), strengthened workforce training and supports (e.g., continuing education on perinatal SUD), and an effort to promote greater accessibility and availability of culturally and gender-responsive care.58,59

"Equally important are coordinated follow-up models that actively link patients to care through integrating obstetric care with behavioral health service delivery.54 The majority of research on behavioral health integration has focused on primary care, but integrated behavioral health in obstetric settings also has significant evidence.60,61 Research on such models has found that integrating obstetric and behavioral health teams creates a system-level infrastructure with swift follow-up after positive substance perinatal substance use screens, clear communication between the care team, streamlined referrals to treatment, and the necessary ancillary support for the perinatal population (e.g., telehealth, transportation assistance).54 In all, 12 states have implemented similar approaches, demonstrating growing recognition that what occurs after screening, rather than screening alone, ultimately determines treatment access and continuity of care.57 Taken together, these findings point to the disparities observed in the continuum of care from screening to treatment engagement are best understood as system-, organizational-, and policy-level barriers within perinatal care delivery, rather than individual-level shortcomings of pregnant women or their healthcare providers."