Reduce Stigma for Pregnant People with SUDs

Introductory Paragraph

Pregnant women with a substance use disorder (SUD) may face feelings of shame and guilt. These feelings are reinforced by stigma. Such barriers are amplified for pregnant women who are in recovery and who may have difficulty in managing challenges with childcare, social service involvement, and access to care. Reducing stigma and perception surrounding pregnancy and SUDs will reduce the barrier to access to care.

Key Information

SAMSHA defines recovery as “a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.” SAMSHA lists health, home, purpose, and community as essential dimensions of support for a life in recovery. Stigma is a barrier in recovery. When a person with substance use disorder finally reaches out for help, he or she is often met with responses that are less than helpful or are judgmental and this is often the result of stigma. Many examples of stigma are not overt and are more subtle. Stigma comes in the form of language used, pity, disdain, silence, or rejection. Persons with mental health and substance use problems are exposed to an array of stigma components that interact to endanger their mental health. These components include stereotypes, prejudice, and discrimination.

Studies have shown that people with substance use disorder experience labeling, shame, and rejection from family members, friends, teachers, co-workers, supervisors, and health care professionals. This stigma can get in the way of the support that people in recovery need -- especially those in early recovery. Outside stigma can become internalized, leading people in recovery to embody and adopt inaccurate beliefs about themselves due to their exposure to external stigmatizing forces. Women have different experiences with SUD both biologically as well as culturally, as they are seen as caregivers and mothers. Barriers and challenges include:

• Women are at highest risk for developing SUDs during reproductive years
• Polysubstance use is common
• Unintended pregnancy rate among women with SUD is ~80%
• Substance use in pregnancy connected to many complications/negative health outcomes for mom & baby
• As many as 70% of women entering addiction treatment have children and primary responsibility for children
• Family responsibilities can interfere with regular attendance in treatment sessions including challenges with childcare
• Hesitancy to seek treatment for fear of legal action or legal issues including child protective services
• Covid-19 made barriers to access to care more challenging
• Transportation issues
• Past trauma may impact stigma and reaching out for care

Other areas of stigma for pregnant women with SUDs include those seeking medication-assisted treatment and those with HIV or other infectious diseases. Educating providers and communities about pregnancy and substance use can assist with reducing harm and facilitate pregnant women getting access to care and services.

Relevant Research

• This qualitative study used interviews to explore common factors that motivate pregnant women with SUD to seek comprehensive care during pregnancy and common hesitations and barriers to treatment.

• This guideline titled "Substance Use Disorder Treatment in Pregnant Adults," contains an extensive review of the literature. It was developed by the New York State Department of Health AIDS Institute in order to establish a statewide standard of care. The goal of the guideline was to ensure that healthcare providers in New York are aware of and able to provide appropriate options for SUD treatment during pregnancy.

• This article provides recommendations specific to expanding and improving treatment care for pregnant women with opioid use disorder.

Impactful Federal, State, and Local Policies

The National Academy for State Health Policy has published a document titled, "State Options for Promoting Recovery among Pregnant and Parenting Women with Opioid or Substance Use Disorder." This provides information on funding streams for state initiatives.

Policies surrounding pregnant women with SUD vary from state to state. These state-level policy variations include:

• Reporting and testing requirements
• Standards for child abuse
• Grounds for civil commitment
• Targeted program created
• Pregnant people given priority access in general programs
• Pregnant people protected from discrimination in publicly funded programs

The Guttmach Institute provides a state-by-state index of policies on substance use during pregnancy. This index currently reveals the following:

• 24 states and the District of Columbia consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and 3 states consider it grounds for civil commitment.
• 25 states and the District of Columbia require health care professionals to report suspected prenatal drug use, and 8 states require them to test for prenatal drug exposure if they suspect drug use.
• 19 states have either created or funded drug treatment programs specifically targeted to those who are pregnant, and 17 states and the District of Columbia provide pregnant people with priority access to state-funded drug treatment programs.
• 10 states prohibit publicly funded drug treatment programs from discriminating against pregnant people.

Available Tools and Resources

• SAMHSA's Addiction Technology Transfer Center Network (ATTC) has published "Anti-Stigma Toolkit: A Guide to Reducing Addiction-Related Stigma." It has also created a Powerpoint presentation that can be downloaded titled, "Reducing Stigma in Pregnant & Parenting Women with Substance Use Disorder."

• Safe Project has a Wiki page titled "Reduce Stigma" that has more information and links to a variety of resources.

• The From Research to Recovery Town Hall brings together speakers from across the country to address mental health, substance use and other facets of behavioral and emotional health. One example includes this YouTube titled “Gender & Use, Misuse, Treatment and Recovery," by Dr. Mishka Terplan, MD, MPH, Professor of Obstetrics and Gynecology and Psychiatry and the Associate Director of Addiction Medicine at Virginia Commonwealth University. It addresses how developing addiction to opioids and other drugs vary across gender, and how expectations impact the conception of treatment and stigma around use.

Promising Practices

Safe Project No Shame Pledge

Distorted perceptions Take the Pledge to end Stigma

'Colorado'. The Special Connections Project provides gender-responsive treatment for pregnant and parenting women who are Medicaid-eligible to maximize the chance of a healthy birth. They provide postpartum treatment services in order to maintain gains made during pregnancy. Special Connections providers offer pregnancy risk assessments, care coordination services, group counseling sessions, individual counseling sessions, health education groups, and residential SUD treatment in a women-only setting.

Maryland. "Refocus: Look Again" is a public education campaign from On Our Own of Maryland’s Anti-Stigma Project. It is designed to challenge misconceptions and assumptions associated with mental health and substance use. Their goal is to foster change through awareness and dialogue about the real and damaging impact of stigma. An example iof their online content is an Aanti-stigma interview with Adina Weissman titled, "Medicated Assisted Treatment and Pregnancy."