Mass General Brigham has prioritized Substance Use Disorder care and Maternal Child Health as two of four prioritized health conditions in its United Against Racism efforts.
In Massachusetts, Black and Hispanic birthing people are less likely to receive medications to treat opioid use disorder during pregnancy and less likely to stay on these medications in the year after delivery. Additionally, maternal mortality rates continue to rise across all racial and ethnic groups, but remain the highest for Black birthing people.
One way that Mass General Brigham is striving to address inequities in substance use disorder (SUD) care is by creating a systemwide policy to ensure a standardized and equitable approach to toxicology testing and child protective services reporting for pregnant people and their infants, aligned with national practice guidelines.
The goal is to reduce barriers to treatment for substance use disorder that have disproportionately impacted patients of color, while prioritizing practices that support the safety and wellbeing of families impacted by SUD.
In the Q&A below, Davida Schiff, MD, expands on her recently published study in the Journal of Substance Use and Addiction Treatment (JSAT) that sought to better understand the experiences of pregnant people of color with substance use disorder and find ways to overcome them.
Dr. Schiff is a general academic pediatrician, addiction medicine physician, and health services researcher at Mass General for Children. She is focused on improving care for families impacted by SUD.
She is the Director of Perinatal and Family-based SUDs Care at Massachusetts General Hospital, where she founded the HOPE Clinic, a multidisciplinary program for pregnant and parenting people with substance use disorder.
What was the purpose of your study?
DS: The aim of this study was to identify key drivers impacting the perinatal and delivery experiences for people of color with substance use disorder in Massachusetts to identify opportunities for hospital-based teams to address care gaps and inequities.
We prioritized using qualitative methods to elevate the voices of individuals with lived experience, including the use of peers as interviewers and an advisory board that had equal representation from academic “experts” and individuals with lived expertise.
Can you expand on existing racial inequities in pregnant people with substance use disorder?
DS: Our prior research has highlighted that Black and Hispanic birthing people in Massachusetts are less likely to receive medications to treat opioid use disorder during pregnancy, and less likely to stay on these medications after pregnancy.
Too often, studies on pregnant people and infants did not even examine for differences by race and ethnicity for substance use disorder.
Our study used qualitative methods to hear from women directly and better understand what may contribute to those disparities.
Can you explain the child welfare guidelines related to substance use in Massachusetts and why some have been problematic?
DS: In Massachusetts, most hospitals were following guidance from many years ago from the Department of Children and Families that recommended filing a report of abuse or neglect at the time of birth when a substance-exposed newborn is delivered, even if that exposure is due only to a prescribed medication to treat opioid use disorder.
Our prior qualitative work has highlighted the shame and anxiety this causes for people with substance use disorder during pregnancy leading to a desire to wean off or not start using live saving medications.
Additionally, in Massachusetts, the highest rate of disproportionality in the child protection system occurs at the time of filing, where the relative rate of filing reports for Black and Hispanic individuals is twice that of white individuals (for filings of all causes, not just substance use).
What were some of the qualitative themes identified in the study?
DS: We identified three main themes.
First, individuals of color faced increased scrutiny and mistrust from clinicians and treatment programs.
Second, greater self-advocacy was required from individuals of color to counteract stereotypes and stigma.
Third, experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination.
Participants described negative care experiences, including health care professionals treating them rudely, not believing their pain needs, coercion around contraception choices, and a belief that they would not be able to safely care for their children.
Rather than providing needed support, these clinicians stood as barriers to accessing care and resources.
What are the next steps in your research?
DS: We are working to develop a “Know your Rights” card for patients to help them advocate for themselves in the areas of inequitable care that they identified, including opportunities for patient advocates such as doulas or peers, shared decision-making conversations to discuss contraception options, and moving towards case-based rather than a mandatory reporting approach for prenatal substance exposure due to use of medications to treat addiction.
What, if any, action items can hospitals make to ensure equitable care?
DS: Participants identified a desire to have hospital staff members who looked like them at all interactions—from front desk staff to physicians.
Hospitals can also support staff in providing dedicated time to attend anti-racism and upstander training programs.
Finally, hospitals can create clinical practice guidelines that promote equitable use of toxicology testing, reporting, and shared decision-making for contraceptive counseling.
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