Substance Use During Pregnancy - Reducing Stigma of Treatment
July 28, 2022
Opioid use disorder (OUD) during pregnancy contributes to maternal death and poor birth outcomes. Although prenatal care can reduce these effects, pregnant individuals may delay care due to concerns about stereotyping and stigmatizing by providers. The relationship between a physician and their patient may also be strained by mandated reporting of substance use to law enforcement or social services, and related fears of parent-child separation and criminalization. Such fears may present additional barriers to receiving prenatal care.
In this episode, Joseph Kanter, the current state health official of Louisiana, and Amy Ladley, Program Manager for the Louisiana Perinatal Quality Collaborative, discuss Louisiana’s approach to reducing stigma and fears of criminalization around opioid use in pregnant and postpartum individuals. They also highlight the importance of partnerships in these efforts.
- Joseph M. Kanter, MD, MPH, State Health Officer, Louisiana Department of Health, Office of Public Health
- Amy Ladley, Program Manager, Louisiana Perinatal Quality Collaborative
- Stigma Reinforces Barriers to Care for Pregnant and Postpartum Women with Substance Use Disorder
- Supporting Pregnant and Postpartum Women with Opioid Use Disorder: An Infographic Series
- Opioid Use Disorder Toolkit: Supporting the Public Health Response in Maternal, Child and Adolescent Health
ASTHO thanks the Center for Disease Control and Prevention for its support of this episode of Public Health Review.
This is Public Health Review. I'm Robert Johnson.
On this episode: how an independent organization in Louisiana keeps its partners focused on the needs of pregnant and postpartum people struggling with opioid use.
But it's an independent, legislatively-created commission that authorized our Perinatal Quality Collaborative, so that allows the collaborative to speak with a more independent voice.
We're not clipboard people; so, I can't write you a ticket, I can't get you in trouble. But what I can do is equip you with the tools and the confidence and the support to not only do what's best in terms of the evidence base, but do what's best for your facility staff, your patients, and your community.
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.
Today, we examined the Louisiana Perinatal Quality Collaborative and how it brings partners to the table, even if they don't always agree on the best way to help pregnant and postpartum people dealing with opioid use.
Dr. Amy Ladley manages the collaborative for Louisiana's Department of Public Health. She's along later to talk about the early results of an initiative not yet a year old.
But first, we hear from Louisiana state health officer Dr. Joseph Kanter about the importance of partnerships and a collaborative organized to work with all partners, even when there are disagreements over the response.
Well, I think the structure of our collaborative has been a real strong point for us. It's specifically authorized by a legislative-enabling commission called the Louisiana Commission on Perinatal Care and Prevention of Infant Mortality, a commission for which the Louisiana Department of Health helps provide supporting services. But it's an independent, legislatively-created commission that authorized our Perinatal Quality Collaborative, so that allows the collaborative to speak with a more independent voice than it would if it was solely run directly under the health department.
And in that independent voice, it's easier to bring in stakeholders. It's easier to bring in law enforcement. It's easier to bring in people who have perspectives that are not always the same as the health department's perspective.
But on the stigma issue, we've been able to find good common ground. I mean, certainly as the opioid epidemic has become more prolific, it's not hard to do because most people now know someone that's been affected by it, and in that you're able to find agreement upon stigma.
So, you know, we've put the message out there, but I think our stakeholders at the table have been much more effective at driving that message home within their communities and within their membership groups than we would ever have been if we tried to do it on our own.
How important has the collaborative been to the work you're doing on behalf of this community in Louisiana?
I think it's been instrumental. I'm happy the way that it was set up because having it be not directly under the auspice of the department—but with close connections and with staffing support from the department—allows it at the same time to be aligned with our mission, to be attuned to where the department is going to be attuned to, where available resources are, and simultaneously speak with an independent voice, gather stakeholders in an independent fashion, and in that derives power so it becomes its own entity.
It becomes not just an appendage of the health department, and that's allowed it to gain credibility and bring people to the table that I don't think would have come to the table as easily had it just been another programmatic office within the health department.
Speaking of that, it seems to have had a lot of success in a fairly short period of time. Would you agree with that?
I think it has. I think there's no doubt here what the challenge is. And for decades really, Louisiana has ranked bottom of perinatal outcomes and the opioid epidemic has complicated that, so it has been a clear recognition of the need for a broad-based intervention like this. And this has dovetailed closely with other maternal mortality work that's ongoing. There's a clear recognition that we need to be working together to help improve maternal outcomes. So, I think, you know, the buy-in, it was easier to obtain because that's the environment here.
To be certain, the work is far from over, and, you know, it's difficult to measure success when you're relatively fresh in this, as I think we still are. But I'm very encouraged by the acceptance of—I'm very encouraged by the breadth of the stakeholders that have come to the table, and the experience for us so far is that people are working together. And so, I'm optimistic that we'll continue to make progress here, particularly because of the people that we have at the table with us.
Were you thinking you would get that kind of reaction when you were putting this together?
You know, we had hope for it, but I don't think it was a given. And, you know, the politicization of this issue makes it more challenging to bring stakeholders to the table like this.
And look, to be frank, there are obvious disagreements. There's disagreements about the extent to which these conditions should be criminalized. There's disagreements about the extent to which care practices should be dictated legislatively. And those are really thorny issues to work through.
I think, you know, what I'm proud of is that the commission here has worked through that and kept stakeholders at the table and the programs in place right now, and the initiatives and the laws in place are better than they would have been otherwise had we not been able to keep people at the table and work through those issues.
So, you know, a lesson to other states, I think—as states grapple with very challenging issues surrounding potential criminalization and the role of police in perinatal-opioid addiction and so forth—is whatever you do, stay at the table and keep your law enforcement partners at the table because whatever happens at the end of the day, it's going to be better for moms and families in their state if the public health department remains an actively engaged partner in that.
How do politics impact this work?
Yeah, these issues are often highly politicized, and that becomes challenging. There's absolutely no question about that.
You know, oftentimes these cases become sensationalized and as the opioid epidemic has grown, it's affected more and more people. This issue usually comes up once or twice a legislative session for us. I feel that's not much different than other states' experiences as well. You're trying to work through that. You're trying to always come back to the medicine, to the signs of it. You try and give personal examples where they can be helpful. You try and emphasize that opioid addiction is a medical disease, it's a treatable disease, and there's good evidence-based practices that can be employed that genuinely improve outcomes.
I think the more and more that you share that, you help steer the conversation to interventions that are productive in this. That doesn't mean that you get there 100% of the time, and this remains a politicized issue. But the more the public health is at the table, providing a good pedestrian friendly synopsis of the evidence—and the evidence at this point is robust, and the treatments are excellent and much more available than they have been in times past—that the more that public health is at the table providing that expert perspective and doing so in a way that's understandable to legislators and the public alike, I think the more that you can steer work here towards productive endeavors.
What do you think your colleagues might learn from your experience with the collaborative?
I think the structure of the collaborative here is worth looking into because it's proven to be beneficial to us. Again, it's called for through a legislatively-enabled commission that requires a lot of supportive services from the Department of Health, but it's not solely driven by us. So, it allows the Collaborative to maintain alliance with what the department is doing and awareness of the resources that are available, but to speak independently. It also allows the communications between the Collaborative and hospitals and other agencies to have some degree of protection that it wouldn't have had to been directly communicated with the department.
So, people have trust in the Collaborative, there's buy-in. There's hopefully longevity that will persist beyond political administrations and it becomes really a force of its own, not just another programmatic wing of a department. I think that structure has proved beneficial and strategic for us, particularly in a politicized climate like we have in many places in the country on this issue.
Dr. Amy Ladley is a political communicator who found her way into public health and now, among other things, manages the Louisiana Perinatal Quality Collaborative. She's excited about the progress the organization has made in a very short time, bringing hospitals and others together to address stigma and treatment for pregnant and postpartum people dealing with opioid use.
We conducted a statewide survey of birthing hospitals and learned that stigma and bias were operating pretty freely and, like most biases, without anybody's knowledge. But particularly related to this patient population, those affected by substance use, it's particularly pernicious because the vernacular, the language of stigma, is so pervasive in how we communicate about these patient populations.
So, knowing that and understanding that we can really solve for stigma or start to build in those programmatic efforts that address stigma very early on in our work with ICSED. So, everything from webinars calls and trainings have been offered in the kind of nine-ish months we've been doing this work. But on the horizon, in the very near horizon, we have in-person hospital-based trainings in the coming months really focusing on stigma.
Did you find the same challenges within state government?
It's interesting. I think we're starting to really explore areas of partnership now that we know, like, really the landscape of all of the different systems and agencies that touch a substance-exposed dyad. What we really are trying to develop now is a series of shared trainings where we can start to move towards, I would say, a unified vocabulary, an empathetic and deliberate way of communicating about these dyads that really cross-cuts agencies with not only within the Department of Health, but within state government.
How do you know if what you're doing is working?
I think knowing if your work is working is difficult because traditional surveillance systems within public health always have a lag—you know, you're waiting for data to come in, you're waiting for finalized numbers. And when it comes to maternal mortality data in particular, there could a 18–24 month delay in knowing if your efforts are resulting in reduced maternal deaths.
So, while we monitor that surveillance—the big level, high-level surveillance—we also track individual processes that are being implemented at the facility level. So, are you screening consistently? Are you referring? Are you following up with your patients? So, creating that support system, that network of care.
Additionally, structures like are you educating your staff about different aspects of caring for this dyad? So, we monitor those structures and how they're coming into place. Policies are a really big part of that.
And I would say the last way that we kind of know—I can get the short-term and immediate whether or not our work is making a difference—is when we hear actually stories from hospitals. You know, stories where they say, "You know, six months ago, we wouldn't have done it this way," right. "Six months ago, we would have called DCFS and been like, 'Good luck.' And now we're able to have improved conversations and communication with our patients that we may have had to report to DCFS. But before that patient left, they'd already been connected to medication for opioid use disorder, you know, treatment provider or intensive outpatient therapy."
And that is where we know that change is happening. It's not change that you can calculate, right, you can't apply statistics there. But to hear those patient stories start to emerge and the increased awareness and empathy and identification that's occurring at the hospital level, that is kind of an engine for continuing to lean into this work.
The other big topic is health equity. How does that figure into the work you do with people in this community?
Equity and health disparities are really baked into every initiative of the LaPQC. So, regardless of whether we're talking about our ICSED initiative or our initiatives focused on breastfeeding or perinatal outcomes and other drivers of maternal mortality and morbidity, equity is really the first thing we tackle when we're building an initiative. It's a really big part of our strategic approach and has been from the very beginning.
So, we really try to pull together a constellation of changes for our hospitals that are evidence-based, right, and that we have a roadmap that other states have done a really exceptional job implementing changes or doing QI programs through their perinatal quality collaborative.
But then we have to understand what's going on in Louisiana. And that means taking a deep dive into surveillance. It means asking questions and really listening and trying to get qualitative data points to inform a targeted health equity approach. And for this initiative, it really is about understanding where stigma and bias come from, how that materializes in clinical interactions, and also equipping hospitals to understand disparities and to measure them.
How are the hospitals in Louisiana responding to the collaborative?
I think change is hard, but what I will say that the LaPQC does really well is build relationships to meet hospitals and hospital systems where they are. When I started this position three and a half years ago, there was a lot of uncertainty about the Perinatal Quality Collaborative and the state kind of coming in and trying to unpack processes and change decision-making. And I think what it did require was sort of a attitude reset, not only in the part of kind of how we do this work, but hospitals themselves to realize that we can be trusted partners in this work rather than the adversaries.
So, I think our ongoing joke within the LA PQC is that we may be in the Department of Health, but we're not the Department of Health. We're not clipboard people, so I can't write you a ticket, I can't get you in trouble. But what I can do is equip you with the tools and the confidence and the support to not only do what's best in terms of the evidence base, but do what's best for your facility staff, your patients, and your community.
And that's why we're here. That's been a really important piece of this, is creating that trusting relationship to move this work forward.
Would you say the collaborative is growing in the hospitals?
I would say so. You know, we have four initiatives within the LaPQC, and there are 49 birthing hospitals in the state of Louisiana, and 47 of them are participating in at least one initiative of the LaPQC. So, that means that at least one of our quality improvement activities touches about 98% of deliveries in Louisiana.
And I think that for the majority of our hospitals, there's no mandate for participation at the moment. So, I would like to think that they are staying with us because of the support that we offer and the relationships that we've built. And we also have quality improvement designations, but we're not paying them to do this. And so, they show up and they show up for us, but more importantly, they show up for their patients in their communities.
Did you model this collaborative after another program in another state, or is this something that was built from scratch there in Louisiana?
An excellent question. I would say it's a little bit of both.
The perinatal quality collaborative model is known and sort of deeply rooted and known to be effective. Every single perinatal quality collaborative is organized a little bit differently in terms of not only sort of where it's housed administratively, but who staffs it and how they operate.
So, I think that we had early on kind of taken a basic understanding of what a perinatal quality collaborative is and how to run it, you know, using some of the standard models, and then really taking a step back and saying, "What can we do to make this work more efficiently and more effectively in Louisiana?" Every state is different and states like New York and Illinois, and California do incredible perinatal quality collaborative work—but at the end of the day, they're not Louisiana. And so, where do we see things that are specific to Louisiana that we have to incorporate, have to acknowledge? And that's been really important for us.
So, we do some weird things in Louisiana. Like, we do a lot of work all at the same time, which other states traditionally might have a single initiative running at one. So, an individual hospital may only be working on one constellation of best practices sort of actively, and maybe in maintenance mode with some others. And we try to cram as much quality improvement into a single initiative as possible because we find that doing that creates a really wonderful momentum and ways to capitalize on the building of relationships across initiatives and across care teams. And I think that's one way where we do things a little bit individually in Louisiana.
Public health people across the states and territories are listening to this conversation right now, so I wonder what about this collaborative might work for them?
I really think one thing we do very well—in addition to centering equity, right, starting with equity in all of our work—but programmatically one thing we do really well is meeting teams where they are.
We create—for example, we partner with teams to create customized quarterly action plans for their quality improvement work. We learn about their individual system and facility and community barriers and the things that make those communities in those hospitals special, and we try to amplify those things and we try to address barriers very specifically and really trying to meet our hospital teams where they are. That is a really important way to model how hospitals and care teams can continue to meet patients where they are and meet communities where they are.
In the end, how important is the collaborative in opioid use among pregnant and postpartum people?
In Louisiana, maternal mortality attributed to overdose has increased significantly just in terms of our surveillance data. Overdose is one of the leading causes of pregnancy-associated, but not -related, deaths. And we anticipate—particularly from what we know about the pandemic and its impact on substance use—is that that trend will continue to be present and, if anything, increase.
PQCs are really great because they create infrastructure for a systems and culture change. And I think what we've learned in the pandemic is that stability of processes can change. It doesn't matter how, like, amazing you're doing with a process at a hospital if half of your staff has COVID or has been reassigned to a COVID unit, if those processes aren't heavily ingrained, if they're not patient-centered—particularly as it relates to things like identifying and caring for substance exposed dyads—then you can set yourself back years and years.
And so, really the Perinatal Quality Collaborative is exceptional because it puts itself in a position to be able to create stable and sustainable change. And that's, I think, where we can create our greatest impact for these dyads.
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This show is a production of the Association of State and Territorial Health Officials. For Public Health Review, I'm Robert Johnson. Be well.