Integrating OB/GYN and Substance Use Disorder (SUD) Care

Policy opportunities, implementation challenges, and care delivery approaches for providing integrated care to pregnant and postpartum women with SUD

Over the past two decades, the United States has experienced a public health crisis related to substance use disorders (SUDs), spurred in part by the ongoing opioid epidemic. This crisis affects individuals from all walks of life, including pregnant and postpartum individuals. During 1999 and 2014, the national prevalence of opioid use disorders among women hospitalized for childbirth more than quadrupled. 

Maternal SUDs can have damaging and far-reaching impacts on birth outcomes, quality of life, and health care costs related to increased hospital costs and length of stay. Rising rates of maternal SUD have particularly affected state Medicaid programs, which pay for 45% of all births nationwide.

Pregnancy is a known critical period for addressing SUD. Women may be more receptive during pregnancy to ceasing or reducing substance use or seeking treatment for SUD, and they are more likely to have insurance coverage during pregnancy due to mandatory pregnancy-related Medicaid coverage and classification of maternity coverage as an essential benefit under the Affordable Care Act. Integrated OB/GYN and SUD services may be a viable option for link pregnant women with SUD to appropriate treatment services. However, there is little research regarding the availability and effectiveness of SUD treatment in OB/GYN settings.

To help fill this research gap, in 2019 RTI was awarded work by the Office of Assistant Secretary for Planning and Evaluation. The project aimed to describe existing models of integrated SUD and OB-GYN care, effectiveness of these models, opportunities and challenges faced by OB-GYN providers to integrate SUD services in their practices, and policies that could support scaling up of these models.
 

Comprehensive Analysis and Assessing Effectiveness of Integration

To tackle this problem, the RTI team conducted a scan of existing integrated OB/GYN and SUD program models, reviewed literature on the effectiveness of these integrated models, interviewed subject matter experts, and convened a technical expert panel.

Program Model Scan

The scan of existing program models began with a review list of programs provided by ASPE and identified through RTI’s previous work on State Policy Leavers for Expanding Family-Centered Medication-Assisted Treatment. These sources identified programs, services, collaboration of agencies, community-based support services, and funding sources. 

OB/GYN & SUD Literature Review

RTI conducted a review of peer-reviewed articles, grey literature, and Internet-based sources on integrated OB/GYN and SUD models published between 2007 and 2019. The peer-reviewed literature selected originated from journals representing disciplines including psychology, public health, OB/GYN/midwifery/perinatology, maternal and child health, women’s health, and addiction/substance abuse.

Primary Data Collection

Telephone interviews were conducted with a mix of eight researchers, providers, state officials, and professional associations. The team also convened and moderated a 15-person technical expert panel (TEP) composed of academic researchers and providers, state officials, stakeholders from non-profit organizations, and representatives of federal agencies. 

Program Models

10 established and emerging models of care were identified as meeting the definition of integrated OB/GYN and SUD care: collaborative systems of care; integrated care; screening, brief intervention, and referral to treatment (SBIRT); patient-centered teams; evidence-based models; trauma-informed care; co-located corrections treatment; reverse co-located treatment; hub-and-spoke centers; and teleconsultation and telehealth models. These models of care were categorized using the Center for Integrated Health Solutions’ Standard Framework for Levels of Integrated Health Care. Select models and example programs are depicted below.

Key Findings to Integrate Maternal & SUD Care

This project revealed promising emerging models of integrated care along the SAMHSA continuum of levels of integrated care, including the SBIRT model, the Centering Pregnancy group model, the Maternal/Pregnancy Health Home model, and the Integrated Care model. Discussions with subject matter experts identified common themes in establishing integrated care for PPW with SUD. 

1. Treatment models must allow for flexibility. Clinical experts have noted that the location of the treatment provider (obstetrics vs. addiction treatment provider) may change over the course of a woman’s reproductive health cycle. Although fully merged or integrated models of care are ideal, some women may not require intensive SUD treatment, and access to fully integrated services may not be realistic for all women, particularly those in rural areas. Telemedicine and hub-and-spoke models can help meet this need. 
2. Treatment should include both clinical and non-clinical supports. All stakeholders indicated the need to address social determinants of health within integrated care models to make treatment more successful. However, some stakeholders noted limitations in funding, and the need for providers to prioritize their core mission of clinical treatment. 
3. Services should be available for up to one year postpartum. Experts emphasized that postpartum SUD treatment is critical--women are least likely to overdose during pregnancy and most likely to overdose using opiates in the postpartum period at 7-12 months postpartum. Provision of integrated care services should continue up to a year after birth. 
4. Limited reimbursement is a key barrier to implementing and expanding integrated models of SUD and OB/GYN care. Standard maternity bundles do not include incentives for provision of SUD treatment, and many payment models do not support the essential non-clinical services that are important for PPW and their families. 
5. Additional workforce training is needed to promote knowledge and reduce provider stigma. Experts noted that there is a need for additional training in identifying SUD among women who are pregnant. The addition of addiction medicine modules to standard medical and nursing school curricula would be helpful, as would ongoing training for practicing health care professionals.

Future Directions for OB/GYN & SUD Integration

Despite the identification of several care models, there remains a notable gap in understanding their effectiveness. Limited research exists concerning the feasibility of scaling up and implementing these models on a broader scale, necessitating further investigation to ascertain the potential for expansion. Research is needed to inform effective policymaking regarding integrated OB/GYN and SUD treatment. This includes examining state policies that facilitate efficient billing and information sharing to optimize the integration process and enhance outcomes for mothers grappling with substance use disorders. Collectively, researchers, policymakers, providers, and advocates all have a role to plan in enhancing availability of integrated care and better serving affected mothers, infants, and communities.