Stigmatization of Pregnant Individuals with Opioid Use Disorder

The reproductive justice framework

Reproductive justice (RJ) represents the basic human right to maintain personal bodily autonomy, to have or not have children, and to parent children in safe and sustainable communities.¹³ For individuals with SUD, these innate rights are often violated.^12,13 As such, we critically analyzed the impact of stigma on the reproductive rights of pregnant/parenting individuals with OUD.¹³ RJ is an ideal framework for this exploration because RJ is a combination of a Human Rights Framework and Black Feminist Theory, both of which evaluate all civil and reproductive issues.¹³

The philosophical underpinnings of RJ also acknowledge the broader social, cultural, political, and economic context that influences the development and presence of stigma by evaluating the historical nuances of the oppression which are perpetuated by societal discriminatory mindsets and institutions.¹³In this secondary analysis of an existing qualitative data set, we explore the perceptions and experiences of stigma among pregnant and parenting individuals with OUD using the three major tenets of the RJ framework as categories for characterizing stigmatizing behaviors.

Data collection and analysis

In the original study, participants were asked to describe their experience of either return to opioid use or overdose during the perinatal period. Interviews took place in a small private office space or room within a community treatment center. Probe questions were used during the individual interviews to ensure richness of data; however, participants primarily guided the discussions. Questions included: (1) Tell me about the patterns of drug use before and during your pregnancy, (2) Describe patterns of drug use the year following the birth of your baby, and (3) Can you describe events and circumstances surrounding your return to opioid use or overdose?

Interview data were transcribed verbatim by a professional transcription company, and demographic information, used to describe the sample (Table 1), was collected at the end of each interview. Participants were debriefed immediately following interviews, and all were compensated $20 for their time. Directed content analysis, guided by the RJ framework, was used to reexamine the data to allow themes to emerge with the goal of answering our research question specific to stigma.

In addition, we sought to address trustworthiness through criticality, authenticity, integrity, and credibility.¹⁵ Audit trails documenting each aspect of the study and analyses enhanced criticality. We ensured authenticity using member checking; participants were asked clarifying questions following their interviews to confirm accuracy of their interview data. Integrity was accomplished through participant consent after full explanation of the study purpose, process, and procedures. Finally, all data for this secondary analysis were reviewed with the research team for confirmation of the interpretation, which ensured credibility.¹⁵ Collectively, this body of work contributes greatly to our understanding of the experiences of stigma for pregnant individuals with OUD.

Tenet 3: the right to parent in safe and sustainable environments

Historically, the nation's reform and punishment systems rest on concepts of corporal punishment, public humiliation, religious penalties, financial sanctions, and forced servitude to pay off one's debt.²⁴ Consequently, these concepts perpetuate the health, legal, and child welfare system, to enforce punitive measures against individuals who use substances.²⁶ One person described how parents with OUD get automatically judged from society, which limited their environments of social support:

I think that's where we fall short on not only our support, but out there in the community because we're automatically going to be judged. And that's the first thing, and that's the wrong thing. Only one person is supposed to judge, not [our neighbors].

The participants repeatedly described how the punitive mindsets of broader society prevented them from supporting themselves and their children. They described that having limited job opportunities due to the presence of criminal records associated with their OUD. The stigma and labeling from prior convictions led them to resort to illegal activity for means of survival. One person described the challenge of securing legitimate employment and returning to illegal activities to provide for themself and their child:

It's hard. They say they hire felons. I went to [an employer] for an interview. The manager said, “I can't wait to work with you, come for training.” And then they send me a letter in an e-mail saying, “sorry, we can't hire you because of your background.” Even though it was seven years ago, they will not hire you because of your background. I didn't wanna be doing that [illegal] stuff.

Social judgment, blame, and stereotypes that individuals with OUD encounter are inherently dangerous and serve to perpetuate stigma.²³ Several of the participants described judgment as a recurring theme during their interactions with the health care, CPS, and judicial system. As such, the perceived judgment interfered with the parent's attempts to interact with and raise their children in an environment that felt safe and free from stigma. One participant described how a judge involved in their child welfare case stigmatized them because of their OUD and poverty. They believed that their children were taken away from them because they were poor. They described how the loss of their children eventually led to their relapse:

[The judge] basically, after I did all of my services, he told me that I wouldn't be able to support my children financially and he didn't believe in recovery, so he took my children, and eventually I relapsed.

Implications for research, intervention development, and policy on stigma

RJ can be helpful in formulating plans to dismantle stigma that may influence health outcomes in pregnant and parenting individuals with OUD. We will now discuss ways to promote public awareness about the negative impact of stigma, advocate for health policy change, and call for an end to the marginalization of this population of individuals. We call awareness to the misconception that OUD is a criminal matter and recommend the development of policies aligned with the science that clearly states, “Addiction is a treatable, chronic, medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences.”³³

Despite current research, punitive policies are still enacted today in our legal systems.⁹ The American Medical Association Opioid Task Force (2020)³⁴ and the American Academy of Nursing³⁵ have put forth an urgent call to action to end the threat of incarceration and punitive civil actions against individuals based solely upon their history of substance use. Nurses are often at the frontlines, taking an active role in care coordination for this population. Therefore, it is critical that as health care leaders, nurses take an active stand against the harmful stigma that can jeopardize the health of parents and children.

For example, while there is no universally agreed upon treatment protocol for infants with prenatal opioid exposure, care is typically provided in a neonatal intensive care unit (NICU) where infants may experience a long hospital stay.³⁶ Symptom management usually begins with common soothing techniques used for any fussy baby, including swaddling, rocking, skin-to-skin holding, and breastfeeding.

However, due to the nature of most NICUs, infants are often separated from their mothers, which is a barrier to these recommended soothing techniques. Furthermore, if the hospital environment is such that the mother is unable to be present or feels uncomfortable visiting her infant, both the mother's capacity to engage in the care of her infant, as well as her ability to sooth and comfort her own infant, may be jeopardized.

Experts are evaluating more closely whether the NICU is the most supportive and cost-effective environment for infants with neonatal abstinence syndrome (NAS).³⁷ One alternative approach has been coined “Eat, Sleep, and Console (ESC)” which is a practical individualized model of care that can be implemented by nurses.³⁸ ESC actively engages the biological parent in their infant's care and calls for pharmacologic intervention only when needed rather than basing medication decisions on a complicated scoring system and treatment protocol.³⁹ Hospitals using the ESC model have benefited from shorter, less costly hospital stays for infants with NAS.^38,40,41 These findings further suggest that the ESC model may be a more humane and less stigmatizing approach to caring for infants with NAS.

Additional considerations include the unique gendered needs of individuals with OUD.⁴² For example, two-thirds of individuals who self-identify as women with OUD are the primary caregivers of young dependent children.⁴³ Yet, treatment and recovery support services are often not designed with the needs of parenting individuals in mind.⁹ Furthermore, some methadone clinics prohibit their clients from bringing anyone with them, to include dependent children, during daily dosing. This can serve as a significant barrier for parenting individuals in need of evidence-based treatment who have no assistance with childcare. Furthermore, few recovery residences offer beds for parents and children.⁴⁴

Emerging literature suggests that when children are present in recovery housing, all residents benefit.⁴⁵ Furthermore, when parents remain with their children while accessing treatment and recovery support services, they are more likely to complete treatment and enter long-term recovery.⁴⁵ Future care models must be more gender tailored to include the unique aspects of parenthood. Several examples of such programs include: Maternal Opiate Medical Supports Plus (MOMS+) Ohio program,⁴⁶ the Mommies Program of Texas,⁴⁷ and Casa Mia in San Antonio, Texas.⁴⁸

As a final consideration, while the majority of participants in our study self-reported as women, Hispanic/Latino, participants did not mention race and ethnicity as a dimension specifically shaping their experiences of stigma related to OUD. Nonetheless, evidence suggests that the right to parent has been neglected for individuals of color in the United States.¹³ Specifically, to be a parent of color with OUD comes with a set of social assumptions related to race that may also intersect with stigma associated with other statuses of oppressive positionality.¹³ Therefore, future studies should examine how the stigma surrounding OUD may intersect with other existing biases related to race, gender, sexuality, class, and the positionality of being a parent.¹³