I read an interesting and depressing article in the Journal of Addiction Medicine (May/June 2022) by Davis et al. It was about access to treatment for pregnant women in states with laws preventing discrimination against them. The study sought to find out if such laws made a difference and assured more access to care than in states without such laws.
As my readers know, using medications for opioid use disorder (MOUD) is the standard of care for people with opioid use disorder, and is particularly recommended for pregnant patients with opioid use disorder. This is because of proven benefits not only to the mom, but also to the infant. Moms on MOUD are less likely to have complications and more likely to have heathy full-term babies.
There’s no evidence that avoiding MOUD during pregnancy decreases the risk of withdrawal in newborns, as some have falsely claimed. This sentence is directed to the backward obstetricians in Tennessee, except apparently, they don’t do much reading, or they’d already know this by now.
Anyway, back to the study. This was a “secret shopper” type of study, where the study’s authors called treatment programs, posing as prospective patients. These simulated patients said either that they were not pregnant or were four months pregnant. They made calls to programs in states that have laws forbidding providers from refusing to treat pregnant patients, and in states without such laws. The study sought to see if treatment is more accessible to pregnant women in states with laws forbidding discrimination.
They called opioid treatment programs and office-based buprenorphine programs in ten states. Four states had laws preventing discrimination due to pregnancy: Kentucky. Missouri, Tennessee, and West Virginia. Study authers also called providers in six other states: Florida, Massachusetts, Michigan, North Carolina, Virginia, and Washington, where there are no such laws.
All callers said they had either Medicaid or private insurance.
In both groups of states, non-pregnant callers were significantly more likely to get appointments than pregnant callers.
In states with a law mandating treatment access for pregnant patients, the non-pregnant callers got appointments 75% of the time, and pregnant patients only 60% of the time. In states without a law mandating treatment access for pregnant patients, 73% of non-pregnant patients and 62% of pregnant patients were able to get an appointment.
The study was done in 2019, so COVID wasn’t a confounding factor.
Office-based buprenorphine prescribers were significantly more likely to turn down pregnant patients than opioid treatment programs. In fact, at opioid treatment programs, pregnant and non-pregnant patients got appointments at the same rate.
So why don’t laws prohibiting pregnancy discrimination work?
I have some ideas, and so do the authors of this study.
The authors think providers might not know about these laws prohibiting discrimination, or if they do know, have never seen the laws enforced. These providers may not think they will get into any trouble for turning down a pregnant patient.
They also point out that the relevant laws only apply to providers who accept Medicaid for payment. Many OBOT (office-based opioid treatment) programs don’t participate in the Medicaid. I think this is because of low reimbursement rates and administrative hassles.
I also think most providers don’t like to treat pregnant women. They make us nervous. The actual physical treatment is more complicated, and more ethical issues arise. What if we precipitate withdrawal with the first dose of buprenorphine and the patient has a miscarriage? It takes more time and energy to coordinate with an obstetrician, who may disapprove of buprenorphine use in pregnant women. For example, in Tennessee, buprenorphine providers say many OBs don’t want their pregnant patients on buprenorphine OR methadone. Will that lead to a contentious relationship between the OB and the OBOT physician?
And what if the pregnant woman refuses to go to the OB once she’s started on buprenorphine? Will the buprenorphine prescriber be blamed for a bad outcome if there’s no prenatal care except what she gets in the OBOT office?
I think these thoughts enter the average OBOT provider’s brain when faced with a new pregnant patient.
Things get even more complicated when we consider that some of these states have laws against drug use during pregnancy. In these states, instead of approaching drug use in pregnancy as a public health issue, they view it as a crime.
According to Guttmacher Institute (https://www.guttmacher.org/state-policy/explore/substance-use-during-pregnancy ), at present twenty-four states and the District of Columbia consider drug use during pregnancy to be child abuse, and three consider it grounds for civil commitment. Twenty-five states and D.C. require healthcare professionals to report suspected prenatal drug use.
Lawmakers sometimes say the reasons they pass these laws is to push pregnant women into getting help and getting treatment for their substance use disorders. Except that, as this study shows, it’s harder for pregnant women to get into treatment than non-pregnant, even with laws meant to increase their access.
Opioid use disorder treatment providers might not want to get in a situation where they are mandated to report a pregnant patient who isn’t doing well in treatment.
Imagine you are a woman with a substance use disorder and you just found out you’re pregnant. If you live in a state with laws criminalizing drug use during pregnancy, you might fear your doctor will report you if you seek medical care, assuming the doctor detects your drug use. Would you go to the doctor for prenatal care? Would you try to get treatment assistance? If you tried to get help and were turned down repeatedly, what would you do?
With abortion becoming far more difficult to obtain in many states, I suspect most pregnant women in these states will try to carry on as best they can during the pregnancy, without prenatal care, and hope for the best at delivery.
Medically, this is the worst option.
The maternal mortality rate in the U.S. is 17 deaths per 100,000 live births, which isn’t as good as all other high-income countries, but at least we have fewer maternal deaths than Turkey, Chile, and Mexico. This dismal data isn’t due to drug use alone, but to lack of available health care, among other factors. [1]
Infant mortality rates in the U.S. aren’t anything to brag about either, with most recent data showing we have 5 deaths per 1000 live births. That’s far worse that countries like Norway, Japan, and Singapore, but on par with countries such as Uruguay, Serbia, and the Slovak Republic. Even the Russian Federation and Cuba had better infant mortality rates than the U.S. did in 2020. [2]
Maybe it’s time we re-thought our healthcare system and our drug laws for pregnant women. And maybe if laws are passed to improve access for pregnant women, they should be implemented with the kind of support that makes providers eager to treat them.
Janaburson's Blog 
Posted by William Taylor on August 16, 2022 at 6:34 am
Doctors don’t know what they’re missing! Treating a pregnant patient for OUD, followed by delivery of a healthy baby to a healthy mom, is one of the most satisfying experiences in medical practice.
Posted by Kristan Hilchey on November 7, 2022 at 2:11 pm
I know that there are regulations for ALL addiction treatment providers that require them to make pregnant women their 1st priority for intake. I thought that was a SAMSHA regulation-but maybe its only a state rule? Pregnant women are moved to the top of waiting lists and given any available intake–even if it means cancelling an appointment with another patient. How is it that providers are actually turning pregnant women away in other states? Unless patients start to fight for their rights, we will continue to see rules and laws broken or ignored.