Interprofessional Care Models for Pregnant and Early-Parenting Persons Who Use Substances: A Scoping Review

Patient Enrollment and Continuity of Care within Programs

We reviewed the articles for patient enrollment criteria for each program and if there were referral processes. Enrollment and referral processes are important for patient accessibility and decision makers as they plan programs and identify costs. The inclusion criteria for pregnant individuals who use substances to participate in the reported programs during the prenatal period varied from substance abstinence [35] to program attendance that endorsed a harm reduction approach [5343741]. The TIDES program had 97% of their patients enter the program voluntarily and attributed the voluntary participation to the success of the program [35]. Programs such as the Collaborative Outreach and Adaptable Care at Hallmark Health (COACHH) program identified that there are challenges enrolling patients and measuring their program outcomes [33]. The pathway by which patients were engaged by or accepted into the other programs was not available.

Continuity of care for perinatal individuals that spans the continuum of pregnancy, birth, and postpartum is ideal to develop trusting relationships between patient and provider. We identified 6 programs that reported Provider continuity of care across the continuum inclusive of the birth period. The Center for Addiction and Pregnancy (CAP) program provided 24-hour midwifery coverage for the birth experience [20]. Oversight of labour and delivery coverage was not detailed by the other 5 programs. The CAP program was the only program that reported the inclusion of residential care for 5–7 days [20]. The residential care in the CAP program was followed by outpatient programming that included group education on obstetrical care, substance use, occupational therapy, family, relapse prevention, family planning, parenting, and lactation.

We determined that variances existed in length of services for postpartum care provided by the eleven programs analyzed in this scoping review. The care interval ranged from 6 weeks to 18 months postpartum. The WANDA’s program providers reported that they link patients to appropriate follow up care in the community before they discharge patients at 3 months postpartum [38]. The importance of a handoff to other care providers postpartum was likewise emphasized by some of the program leaders interviewed in Schiff and colleagues qualitative research study [40].

Co-location of Services

Co-location of services is an attempt to address the barriers of access to services and promote consultation and care from different providers in one site. All eleven publications reported varying multiple services offered in the same physical space. The identified benefits of co-location of services included decreased barriers to access and care providers being able to meet and discuss care planning [203441]. Study participants in the programs reviewed identified the significant benefits of having basic needs of food, clothing, housing, and care for women’s health, substance use, trauma, child welfare, and/or children’s health services co-located as impactful to their pregnancy and postpartum health and care experiences [53340]. Co-location of services can facilitate the wraparound approach for pregnant individuals who use substances focusing on social determinants of health, with provision of primary, prenatal, perinatal, and mental health services [5].

Most of the studies reviewed also discussed the establishment and importance of partnerships with community agencies located outside of their programs. Emphasis was placed on the importance of trusting partnerships and agreements when a recommended prenatal or postpartum service is not co-located [3435]. McKinney and colleagues identified the importance of the interprofessional care teams’ interface and advocacy with the legal system in keeping families together [36]. Rutman and colleagues acknowledged that despite the importance and need of partnerships with housing, income assistance, Indigenous cultural programming, infant development, and legal services not all programs have these partnerships developed [5].

Interprofessional Care Team Roles

The interprofessional care teams consisted of 4 to 15 members in differing roles. The obstetrician was represented on all eleven of the interprofessional care teams in the publications reviewed. McKinney and colleagues described the obstetrician’s role as the provider responsible for coordinating care and ensuring appropriate referral to other care [36]. Additional team members identified in the programs reviewed included midwifery, nurse practitioner, patient navigator, pharmacy, nutritionist, childcare providers, dental hygienist, cultural liaison, art therapist, music therapist, and spiritual care provider. The importance of multidisciplinary team meetings was emphasized by a few of the authors to enhance coordinated care [3536]. North American program leaders for perinatal individuals who use substances (n = 23) were interviewed in Schiff et al.’s phenomenological study [40]. They reported on the immense potential for furthering integrated care as a necessity, highlighting the requirements for changes in infrastructure, staffing, and loosening of the bonds of siloed maternal, infant, and addictions care in many settings [40]. Pregnant individuals who choose who they interact with on the interprofessional care team reported the positive impact related to patient experience and their autonomy [535].

Interprofessional Care Provider Characteristics

Many of the programs in the eleven articles indicated they were built on non-judgmental care, trusting relationships, and relational care. However, these characteristics are not well described with coinciding actionable approaches. McKinney and colleagues refer to a non-stigmatizing approach being necessary to promoting better outcomes with child welfare [36]. Mitchell et al. described the non-judgemental attitude as important to give the clients increased confidence and self-esteem, allowing questions to be asked, and being inviting to make decisions [37]. Shared-decision making was central to two of the programs (COACHH & T-CUP) as clients benefit when they decide what care providers, they need to be successful in the program [3339]. Respect and positivity were other characteristics identified and not further described. Since it is well reported that significant barriers for pregnant individuals who use substances to engage or return for care are stigmatization, judgment, and fear the care provider characteristics identified make sense. Table 3 identifies the care characteristics of the program providers.

Improved Maternal and Neonatal Outcomes

Overall, the programs reported beneficial outcomes when pregnant individuals who use substances engaged in specialized care with an interprofessional care team. Major findings included increased prenatal engagement, decreased substance use, and increased mother-baby togetherness/custody (see Table 1). Qualitative data from Mitchell and colleagues’ study reported on patients signals of change such as decreasing substance use and safer substance use [37]. Patients of the TIDES program and T-CUP program self-reported on abstinent opioid use during the postpartum period of the programs [3539].

Many of the publications reported on the improved neonatal outcomes related to decreased preterm deliveries and decreased neonatal intensive care admissions [20353839]. The success of this was correlated with care providers from their programs fostering the newborn and mother relationship and advocating to keep women and their newborns together. The TIDES program emerged when North Carolina was spotlighted for opioid use and significant concerns with child placement in foster care [35]. The TIDES program was designed to avoid foster care placement and 100% of program participants (n = 57) had full custody of their newborns following completion of the program. The COACHH program reported that clients in their program had positive interactions with the Department of Children and Families and secure housing [33]. There is a lack of long-term outcomes for patients reported in the reviewed literature.

Discussion

Given the rise of substance use throughout the perinatal care continuum there is a need to have specialized programs staffed with interprofessional care providers. The importance of multi-sector, multi-service wraparound programming and partnership approach is evident amongst the literature reviewed. When there is a wide range of services provided and pregnant individuals who use substances can choose what services and care providers they interact with, a person and women centered approach is honored [5]. Studies reviewed in this scoping review were inclusive of an obstetrician, however, many settings may not have obstetrical resources. Perinatal expertise can be provided by other primary care providers such as midwifery and family practice physicians. The existing programs highlight positive maternal and neonatal outcomes promoting the need for them to scale and spread across the health care systems. When the services are offered and co-located, this results in pregnant individuals who use substances having increased engagement with the health care system.

Despite the number of growing programs and interest in program development for perinatal individuals who use substances, attention to a low barrier referral process into programs is required. Overcoming complex health care systems and limiters such as abstinence to promote successful referral and engagement must be addressed [36]. Partnership between care providers and agencies to promote care engagement is essential to prevent missed care opportunities that improve maternal and newborn outcomes [2636]; the interprofessional care programs reviewed highlighted the increased engagement during the prenatal period. With a commitment to meeting the needs of pregnant through postpartum individuals who use substances, program leaders need to evaluate what services should be offered, how to foster relationships among the care team and with external community partners. A decision about who will be employed on the interprofessional care team also needs to be considered. Resource constraints along with the high demand for substance use programs and detoxification programs are likely a reality in many settings throughout the world. Given the current context and strains in many healthcare systems utilizing existing care models and evidence-based approaches rather than creating new ones is sensible.

Policy and program planners need to advocate for resources and share the positive impacts for the pregnant person, family, and community when an interprofessional care approach is integrated into the health care system. The discourse to obtaining non-judgmental care among pregnant individuals who use substances is challenging. Persons are often framed with the double stigma of being a substance user or “addict,” along with the perception as a parent-to-be lacking maternal commitment in the eyes of society [44]. Advocacy is required to reconsider that narrative, as substance use (or lack thereof) does not define parental capacity. Care providers working with pregnant individuals who use substances are in a precarious position as they navigate the patient-provider confidential relationship with the role of mandatory reporting for child abuse and neglect. Patients may perceive a dual loyalty; providers scope should be transparent with the patient before and after communication with child welfare [17]. Stigma associated with substance use or “addiction stigma” is thought to exacerbate the structural and individual level barriers to treatment and care [45]. Intersectional stigma exists among pregnant individuals who use substances; the stigma is a result of the dynamic interaction of multiple marginalized social identities [46]. Therefore, incorporating the components of trauma informed care and harm reduction are vital in facilitating safe access [417]. When organizations do not enact policies to provide nonjudgmental, trauma informed, and culturally grounded approaches, the result can lead to decreased prenatal care [5]. Cultural care inclusive of individuals perspectives align with a wraparound approach by viewing cultural engagement as healing [4243]. When someone has experienced stigma and a negative health care interaction, they are less likely to engage in care, for any reason again [46]. The consequences of shame-based barriers such as stigmatization can be grave for both the parent and newborn. The programs that identified the importance of a nonjudgmental approach did not provide a nuanced approach to enact being nonjudgmental.

Providers who care for pregnant individuals who use substances had a philosophy of care that demonstrated commitment to the population. Based on the literature reviewed, there is limited description of how patients perceive care provider characteristics in the health care setting. Further exploration of the impact of approaches taken by the care providers that are nonjudgmental, trusting, relational, respectful, and positive could provide insight into provider training. Care providers have reported that they have not received specialized or adequate education and training in substance use [14]. Training for healthcare professionals is still in the early adoption stages when it comes to care for persons with substance use disorders [36]. The programs analyzed in this scoping review did not discuss the education and training that their interprofessional care team possessed to work in the programs. Nathoo et al. acknowledges that many Canadian programs have taken their own initiative to provide training for health professionals on substance use and pregnancy [26] but measurements on impact related to patient outcomes and providers knowledge and attitudes is not reported.

Gaps in the Literature

Research in this area is already limited by under-reporting likely related to the stigmas related to substance use during pregnancy and inconsistent screening. Quantifying outcomes directly related to the programs for substance use among pregnant persons has been a challenge [3339]. This scoping review was limited to programs published in the literature for this population and the search terms’ limits. Many of the publications reported on the perspectives of program employees [40] and a volunteer sampling approach was taken with patients [534]. Studies have yet to identify the relative contribution of program components (care provider make up) and provider characteristics that contribute to positive perinatal outcomes.

Much of the published literature provides overviews of the programs without statistically significant or comparative evidence. Marcellus et al. has highlighted the need for evaluation indicators to move away from using abstinence as a measure of success [47]. Ordean and Kahan’s retrospective study identified that there are many confounding factors in their data analysis including baseline severity of addiction and level of functioning [39]. Finding the right quantitative outcome measurements is noted as difficult; instead, success has been measured in qualitative terms for many programs.

Qualitative interviewing with program providers and participants is a guided approach to facilitate sharing of experiences and perspectives. It is possible that participants will not have shared all aspects and perspectives related to their experiences. The existing literature and the publication reviewed in the scoping review highlighted the importance of care provider characteristics as non-judgmental, trusting, and relational from the provider perspective. However, a significant gap in the literature is the patients’ perspectives on what provider characteristics are important and what they look like in practice. The nuances of these relationships remain unknown. Patient perspectives and patient engaged research are key to the success of programs. Thus, patient perspectives need to be further explored by researchers.