Services for Perinatal Patients with Opioid Use Disorder: A Comprehensive Baltimore City-wide 2023 Assessment

Services for Perinatal Patients with Opioid Use Disorder: A Comprehensive Baltimore City-wide 2023 Assessment | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Services for Perinatal Patients with Opioid Use Disorder: A Comprehensive Baltimore City-wide 2023 Assessment Jessica Alison Ratner, Jennifer H Kirschner, Brittney Spencer, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4365589/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Oct, 2024 Read the published version in Addiction Science & Clinical Practice → Version 1 posted 8 You are reading this latest preprint version Abstract Background Overdose is a leading cause of maternal mortality; in response, maternal mortality review committees have recommended expanding substance use disorder (SUD) screening, improving collaboration between obstetric and SUD treatment providers, and reducing fragmentation in systems of care. We undertook an analysis of the perinatal SUD treatment landscape in Baltimore, Maryland in order to identify barriers to treatment engagement during pregnancy and the postpartum period and guide system improvement efforts. Methods We conducted a survey of seven birthing hospitals, 31 prenatal care practices, and 108 SUD treatment providers in Baltimore from April-June 2023. Organizations were asked to quantify care for perinatal patients with opioid use disorder (OUD) as well as about screening, service availability, referral practices, and support needed to improve care. Results Sixty-one percent of the 145 contacted organizations responded. Birthing hospitals reported caring for pregnant persons with OUD with greater frequency than prenatal care practices or SUD treatment programs. Most birthing hospitals and prenatal care practices reported screening for OUD at intake, but the minority reported using validated tools. Service availability varied by type of organization and type of service. In general, prenatal care practices offered the fewest number of SUD-related services. Most SUD treatment programs that offered buprenorphine or methadone to the general population also offered these medications to pregnant patients. Withdrawal management for comorbid alcohol/benzodiazepine use disorders during pregnancy was more limited. The majority of birthing hospitals and prenatal care practices reported offering neither direct naloxone distribution nor prescriptions. Few SUD treatment programs offered tailored services for perinatal patients or for parents of young children, and many programs do not permit children onsite. Respondents reported high levels of interest in education and consultative support on SUD treatment in pregnancy within obstetric settings and on pregnancy-related medical concerns within SUD programs. Conclusions This project provides a comprehensive picture of services available for treatment of perinatal OUD in a major US city. Results have served as a guide for ongoing citywide system improvement efforts by our project team and offer a model for other jurisdictions hoping to strengthen services for perinatal OUD and reduce maternal mortality. Health services public health maternal mortality overdose opioid use disorder pregnancy Figures Figure 1 BACKGROUND Overdose is a leading cause of maternal mortality in the United States ( 1 – 4 ) and the most common cause of maternal death in the state of Maryland ( 5 ) and the city of Baltimore (unpublished data). Nationwide, death due to overdose during pregnancy or within the first year postpartum has nearly doubled during recent years, driven by rising overdoses related to synthetic opioids and stimulants ( 6 – 8 ). The postpartum period, particularly 6 months or more after delivery, is the highest risk time for fatal overdose ( 7 , 9 ). Standard of care for opioid use disorder (OUD) in pregnancy includes medications (i.e., buprenorphine or methadone) ( 10 – 12 ). Medication for OUD (MOUD) is associated with increased retention in substance use disorder (SUD) treatment and reductions in overdose as well as increased prenatal care utilization, lower rates of preterm birth and low birth weight, and maintenance of custody ( 9 , 13 – 16 ). Longer duration of treatment with MOUD during pregnancy increases postpartum treatment retention ( 13 , 16 – 18 ). However, roughly half of pregnant patients with OUD do not receive MOUD, and fewer than two thirds of those who receive treatment in pregnancy remain in treatment postpartum ( 19 – 22 ). Many barriers limit access to and engagement in OUD treatment for this population, including lack of service availability during pregnancy, siloing of obstetric and SUD services, fear of legal consequences/custody loss, comorbid mental health conditions, stigma, and feelings of guilt/shame ( 12 , 23 – 28 ). Treatment discontinuation and overdose risk may be particularly high postpartum due to added factors of loss of insurance coverage, competing demands of caring for a new family, and, in some cases, custody loss ( 28 – 30 ). Through review of fatal maternal overdose cases, maternal mortality review committees (MMRCs) offer insight into potential avenues to improve outcomes for this population. Common themes among MMRC recommendations both nationwide and locally in Maryland and Baltimore have included: promotion of standardized screening for SUD during pregnancy; increasing comfort among obstetric providers in caring for patients with SUD and among SUD providers in caring for patients during pregnancy; improving navigation supports and reducing fragmentation within systems of care; anti-stigma training for providers and the broader community; and adoption of family-friendly policies/practices across organizations ( 5 , 30 , 31 ). Public health departments and other governmental and quasi-governmental agencies can play a vital role in addressing barriers to treatment and reducing overdose mortality among perinatal patients through policies and programming that focus on these MMRC priority areas. Motivated by the rate of maternal overdose deaths in Baltimore as well as local MMRC recommendations, our project team, a public health-academic partnership, aimed to assess availability of services within the local health care system for pregnant and postpartum people with OUD. The project’s ultimate goal was to identify system strengths and gaps, as well as avenues for quality improvement and collaboration to reduce maternal overdose mortality. METHODS To ensure comprehensive assessment of services available to pregnant and postpartum patients with OUD in Baltimore, the project team developed a systematic outreach list that included a wide range of healthcare organizations with potential contact with this population. Organizational categories were defined as: ( 1 ) birthing hospitals, ( 2 ) prenatal care practices, and ( 3 ) SUD treatment providers. The SUD treatment provider category was divided into the following sub-categories: (a) opioid treatment programs (OTPs), (b) office-based buprenorphine providers (OBOT), (c) residential programs, (d) state-certified recovery residences, (e) withdrawal management or stabilization programs, and (f) syringe services programs (SSPs). Individual institutions, organizations, and programs (hereafter, referred to as “organizations”) were identified using lists of certified programs maintained by city and state health departments and the local behavioral health authority. For categories for which no list was available (i.e., OBOT, withdrawal management programs), the project team generated a list of known organizations based on their local experience. Several programs known to the project team as providing services to this population but missing from maintained lists were added to the outreach list. Using either listed or publicly available contact information, project team members reached out to each organization to identify an appropriate respondent and confirm their contact information. Organizations (except birthing hospitals) were asked to identify a medical or administrative leader who could answer questions about service availability, common referrals, and barriers to care for pregnant individuals with SUD. Birthing hospitals were asked to identify the lead social worker in their obstetrics unit. Organizations no longer in operation, incorrectly included on initial lists (e.g., reporting no prenatal care offered), or identified as serving men-only during the initial contact confirmation process were removed from the outreach list. Programs for whom no individual respondent could be identified were also removed. A survey instrument was developed to assess each organization’s substance used-related service availability, common referrals and partners, and barriers/needs to care effectively for pregnant and postpartum patients with OUD. The project team drafted survey questions based on their prior experience (a) providing clinical care to and assessing availability of services for this population and (b) with qualitative and quantitative survey design. Questions were piloted with multiple health professionals for clarity. The final survey was programmed into and distributed via REDCap (Research Electronic Data Capture), a secure, web-based software platform designed to support data capture for research and quality improvement ( 32 ). Specific questions asked of each organization were determined by a skip pattern based on the organization’s self-identified “primary mission(s)” (“services for individuals with substance use disorder,” “outpatient prenatal care,” and/or “hospital-based obstetrics”). See Fig. 1 for a detailed list of topics covered by survey questions. The project team implemented a systematic strategy to ensure broad reach and maximize response rates. Initial outreach to all organizations was conducted by email. Respondents identified during the contact confirmation phase were asked to complete the survey or forward to a more appropriate respondent. The survey instrument was preceded by language informing respondents that the survey was voluntary, would take ten minutes to complete, and would not collect personal health information. Participants were given the option to confidentially provide their name and work contact information for possible follow-up. Respondents were not compensated for participation. Up to four additional attempts at contact were made over a two-month period by either email or phone before marking non-response. All data was collected from April-June 2023. For analysis, descriptive statistics (i.e., frequencies) were calculated using REDCap reports and Excel. Several organizations were included in more than one category–for example, a SUD treatment program on both the residential and certified-recovery residency lists. Responses for these organizations were included only once in analyses for main organizational categories (e.g., SUD programs) but were included in analyses for each of the applicable sub-categories (e.g., residential and recovery residences). Missing values were limited as the survey primarily utilized forced-choice questions including a “don’t know/unsure” answer option. The Johns Hopkins School of Medicine institutional review board deemed this project to be quality/systems improvement work and, thus, exempt from review. RESULTS Among the 145 organizations that were contacted, 89 responded, comprising 61% of the total sample. Response rates varied by organization type, with responses from 100% of the seven contacted birthing hospitals (n = 7), 65% of the 31 contacted prenatal care practices (n = 20), and 58% of the 108 contacted substance use-related services programs (n = 63; sum of three categories exceeds total N due to one program listed in both prenatal care and SUD categories). Among SUD programs, response rates ranged from 24% of recovery residences to 100% of withdrawal management/stabilization units. Table 1 Frequency of Caring for Pregnant Patients with OUD Always Row % (n) Frequently Row % (n) Sometimes Row % (n) Rarely Row % (n) Never Row % (n) Unsure Row % (n) Birthing Hospitals (n = 7) 28.2% ( 2 ) 42.9% ( 3 ) 28.2% ( 2 ) 0 0 0 Prenatal Care Practices (n = 20) 20.0% ( 4 ) 15.0% ( 3 ) 30.0% ( 6 ) 35.0% ( 7 ) 0 0 SUD Programs (n = 63)* 6.3% ( 4 ) 12.7% ( 8 ) 33.3% ( 21 ) 34.9% ( 22 ) 7.9% ( 5 ) 4.8% ( 3 ) OBOT (n = 12) 0 25.0% ( 3 ) 16.7% ( 2 ) 50.0% ( 6 ) 8.3% ( 1 ) 0 OTP (n = 21) 4.8% ( 1 ) 19.0% ( 4 ) 52.4% ( 11 ) 23.8% ( 5 ) 0 0 SSPs (n = 7) 0 0 28.6% ( 2 ) 28.6% ( 2 ) 14.3% ( 1 ) 28.6% ( 2 ) Residential (n = 12) 0 8.3% ( 1 ) 25.0% ( 3 ) 50.0% ( 6 ) 8.3% ( 1 ) 8.3% ( 1 ) Recovery Residence (n = 8) 37.5% ( 3 ) 0 25.0% ( 2 ) 12.5% ( 1 ) 25.0% ( 2 ) 0 Withdrawal Management(n = 6) 0 16.7% ( 1 ) 33.3% ( 2 ) 50.0% ( 3 ) 0 0 *Total N for SUD programs is less than sum of subcategories due to several programs falling into multiple categories. Organizations were asked to indicate the frequency with which they provided care for pregnant patients with OUD on a five-point Likert scale, ranging from “always” to “never” (Table 1 ), as well as the average number of pregnant patients with OUD treated per month. Birthing hospitals reported caring for this population with greater frequency (71.4% always or frequently) than prenatal care practices (35.0% always/frequently) or SUD programs (19.0% always/frequently). Among SUD programs, OTPs and recovery residences reported more frequently caring for this population, with only 23.8% of OTPs and 37.5% of recovery residences selecting “rarely” or “never.” Most birthing hospitals reported treating 10–20 pregnant patients per month with OUD, whereas the majority of PNC practices and SUD programs reported treating five or fewer. Table 2 OUD and Pregnancy Screening Practices Birthing Hospitals (n = 7) Column % (n) Prenatal Care Practices (n = 20) Column % (n) SUD Programs (n = 63) Column % (n) Assess for OUD at intake 100% ( 7 ) 95.0% ( 19 ) N/A With informal verbal/written screening 57.1% ( 4 ) 65.0% ( 13 ) N/A With validated verbal/written tool 28.6% ( 2 ) 45.0% ( 9 ) N/A With urine toxicology 85.7% ( 6 ) 60.0% ( 12 ) N/A With urine toxicology only 14.3% ( 1 ) 0 N/A Assess for pregnancy at intake N/A N/A 85.7% (54) With urine pregnancy test N/A N/A 60.3% ( 38 ) Table 2 shows reported screening practices. Birthing hospitals and PNC practices were asked whether and how they screen for OUD at intake for services. Almost all responding organizations reported screening for OUD; most reported using urine toxicology (85.7% of birthing hospitals, 60.0% of PNC practices) and informal verbal/written screening (57.1% of birthing hospitals, 65.0% of PNC practices). One birthing hospital reported using only urine toxicology to screen for OUD. SUD programs were asked about whether and how they screen for pregnancy at intake. While 85.7% of programs assessed pregnancy status, only 60.3% utilized urine pregnancy tests. Urine pregnancy testing was most frequently reported by OTPs (100%), withdrawal management programs (83.3%), and residential programs (80.0%). Table 3 SUD-Related Service Availability During Pregnancy Birthing Hospitals (n = 7) Prenatal Care Practices (n = 20) SUD Programs (n = 63)* Available Column % (n) Available Column % (n) Available Column % (n) Unavailable to pregnant patients only Column % (n) Unavailable to all patients Column % (n) Buprenorphine initiation 57.1% ( 4 ) 25.0% ( 5 ) 66.7% (42) 6.3% ( 4 ) 22.2% ( 14 ) Buprenorphine maintenance 100% ( 7 ) 35.0% ( 7 ) 69.8% (44) 6.3% ( 4 ) 22.2% ( 14 ) Methadone initiation 57.1% ( 4 ) 0 47.6% ( 30 ) 3.2% ( 2 ) 47.6% ( 30 ) Methadone maintenance 100% ( 7 ) 0 55.6% ( 35 ) 3.2% ( 2 ) 39.7% ( 25 ) Naltrexone initiation 42.9% ( 3 ) 10.0% ( 2 ) 34.9% ( 22 ) 11.1% ( 7 ) 50.8% ( 32 ) Naltrexone maintenance 57.1% ( 4 ) 10.0% ( 2 ) 36.5% ( 23 ) 9.5% ( 6 ) 49.2% ( 31 ) Withdrawal management – alcohol/benzos 71.4% ( 5 ) 10.0% ( 2 ) 34.9% ( 22 ) 4.8% ( 3 ) 57.1% ( 36 ) Withdrawal management – opioids 71.4% ( 5 ) 0 38.1% ( 24 ) 7.9% ( 5 ) 49.2% ( 31 ) Brief intervention (SBIRT) 100% ( 7 ) 50.0% ( 10 ) 68.9% (44) 1.6% ( 1 ) 25.4% ( 16 ) Peer recovery support 100% ( 7 ) 25.0% ( 5 ) 74.6% (47) 1.6% ( 1 ) 23.8% ( 15 ) Non-peer treatment linkage services 71.4% ( 5 ) 40.0% ( 8 ) 91.9% (57) 0 3.2% ( 2 ) Individual SUD counseling 0 25.0% ( 5 ) 85.2% (52) 1.6% ( 1 ) 14.3% ( 9 ) Group SUD counseling 0 15.0% ( 3 ) 74.6% (47) 1.6% ( 1 ) 22.2% ( 14 ) Naloxone – direct distribution 14.3% ( 1 ) 10.0% ( 2 ) 69.8% (44) 3.2% ( 2 ) 42.9% ( 27 ) Naloxone – providing prescriptions 42.9% ( 3 ) 35.0% ( 7 ) 50.8% ( 32 ) 3.2% ( 2 ) 42.9% ( 27 ) Naloxone – prescribe OR distribute 42.9% ( 3 ) 35.0% ( 7 ) 84.1% (53) 3.2% ( 2 ) 12.7% ( 8 ) Other harm reduction services (e.g., providing sterile supplies) 14.3% ( 1 ) 5.0% ( 1 ) 34.9% ( 22 ) 1.6% ( 1 ) 58.7% ( 37 ) *SUD program columns do not always add up to 100%, as programs could mark “Unsure/Don’t Know” Birthing hospitals and PNC practices were asked to indicate the availability of specific SUD-related services; SUD programs were asked to specify whether these services were available to all patients, pregnant patients only, non-pregnant patients only, or unavailable to all patients (Table 3 ). Regarding medications for opioid use disorder (MOUD), all birthing hospitals reported capacity to continue buprenorphine and methadone for patients taking these medications at the time of admission, but fewer (57%) reported that MOUD initiation was available. Thirty-five percent of PNC practices reported offering buprenorphine maintenance, while only 25% offered buprenorphine initiation. Most SUD programs that offered buprenorphine or methadone reported availability to all patients regardless of pregnancy status, with some notable exceptions. In particular, 76% of responding OTPs reported offering buprenorphine, and none of these programs limited this service based on pregnancy status. One of the 21 responding OTPs reported that their program did not offer methadone during pregnancy. In addition, of the five withdrawal management programs that offered buprenorphine initiation/maintenance to the general population, one of these programs denied initiation and one denied both initiation and maintenance to pregnant people. Four withdrawal management programs offered methadone maintenance and two offered methadone initiation overall; none of these programs limited methadone based on pregnancy status. SUD programs were asked to indicate whether they required obstetrics evaluation prior to initiating MOUD–60.4% reported requiring no obstetric evaluation, 4.2% required ultrasound, 18.8% required outpatient obstetric evaluation, 2.1% required inpatient hospitalization, and 18.8% were unsure. Withdrawal management services were less widely available than MOUD, with more organizations offering opioid than alcohol/benzodiazepine withdrawal management. Five of seven birthing hospitals reported offering management of opioid and alcohol/benzodiazepine withdrawal. Only 10% of PNC practices offered opioid withdrawal management, and none offered alcohol/benzodiazepine withdrawal management. Among SUD programs, two of five withdrawal management programs offering alcohol/benzodiazepine withdrawal management reported restricting this service to non-pregnant patients only. Linkage to treatment via SBIRT (i.e., screening, behavioral intervention and referral to treatment), peer recovery support, and/or non-peer treatment linkage services was most widely available at birthing hospitals and SUD programs. Among PNC practices, only half conducted SBIRT, 25% offered peer recovery support, and 40% offered non-peer treatment linkage. Harm reduction services, including naloxone provision, were less often available at birthing hospitals and prenatal care practices than at SUD programs. Nearly two-thirds of birthing hospitals and PNC practices reported neither prescribing nor distributing naloxone, whereas only 16% of SUD programs reported neither service. Other harm reduction services (e.g., distribution of sterile supplies) were reported by 35% of SUD programs but only 14% of birthing hospitals and 5% of PNC practices. Table 4 Availability of Family-Focused Practices and Policies Within SUD Programs Services for perinatal patients^ Row % (n) Services for parents # Row % (n) Housing available during pregnancy Row % (n) Children allowed onsite w/ legal guardian Row % (n) SUD Programs Overall (n = 63)* 19% ( 12 ) 14.3% ( 9 ) 44.4% ( 28 ) 44.4% ( 28 ) OBOT (n = 12) 16.7% ( 5 ) 8.3% ( 1 ) 8.3% ( 1 ) 50.0% ( 6 ) OTP (n = 21) 23.8% ( 5 ) 9.5% ( 2 ) 23.8% ( 5 ) 57.1% ( 12 ) SSPs (n = 7) 14.3% ( 1 ) 14.3% ( 1 ) 28.6% ( 2 ) 57.1% ( 4 ) Residential (n = 12) 16.7% ( 2 ) 16.7% ( 2 ) 91.7% ( 11 ) 16.7% ( 2 ) Recovery Res (n = 8) 25.0% ( 2 ) 25.0% ( 2 ) 87.5% ( 7 ) 50.0% ( 4 ) Withdrawal (n = 6) 0 16.7% ( 2 ) 66.7% ( 4 ) 0 * Total N for SUD programs is less than sum of subcategories due to several programs falling into multiple categories. ^ Defined as “pregnant or within 1 year of birth, termination, or pregnancy loss.” # Defined as “individuals with children under age 5.” To assess specific focus on the perinatal population as well as family-friendliness, SUD programs were asked several questions about tailored services (Table 4 ). The minority of programs reported having specialized services for perinatal patients or for parents. Among the programs offering inpatient/residential level services, 92% of residential programs, 88% of recovery residences, and 67% of withdrawal management units reported offering housing to pregnant patients. Children were allowed on-site more often among outpatient programs (50% OBOT, 57% OTP, 57% SSPs) than inpatient programs (none of the withdrawal management programs, 17% residential, 50% recovery residences). Table 5 Information/Resources Needed by Organizations to Better Serve Perinatal Patients with OUD Birthing Hospitals (n = 7) Column % (n) Prenatal Care Practices (n = 20) Column % (n) SUD Programs (n = 63) Column % (n) Education on meds for OUD in pregnancy 57.1% ( 5 ) 30.0% ( 6 ) 36.7% ( 22 ) Education on other SUD treatment in pregnancy 85.7% ( 6 ) 35.0% ( 7 ) 43.3% ( 26 ) Education on pregnancy-related medical concerns 85.7% ( 6 ) 25.0% ( 5 ) 46.7% ( 28 ) Specialist consultation for SUD tx in pregnancy 85.7% ( 6 ) 40.0% ( 8 ) 38.3% ( 23 ) Specialist consultation for pregnancy-related medical concerns 57.1% ( 4 ) 5.0% ( 1 ) 43.3% ( 26 ) Increased availability of specific resources for patients 85.7% ( 6 ) 30.0% ( 6 ) 41.7% ( 25 ) Support for implementation for clinical workflows or policies 42.9% ( 3 ) 5.0% ( 1 ) 13.3% ( 8 ) Onsite sexual health services provided by external partner 28.6% ( 2 ) 5.0% ( 1 ) 23.3% ( 14 ) Onsite SUD treatment services provided by external partner 57.1% ( 4 ) 15.0% ( 3 ) 13.8% ( 8 ) Ability to distribute naloxone to individuals directly 14.3% ( 1 ) 0 16.7% ( 10 ) Respondents were asked “What information or resources would enable your organization to better serve this population?”; answer options included resources potentially available through the city health department or community partners (Table 5 ). Availability of resources for patients was among the top four responses for all three organization categories (86% birthing hospitals, 30% PNC practices, 42% SUD programs). Education/specialist consultation related to MOUD and other SUD treatment were among the most commonly endorsed by birthing hospitals and PNC practices. Conversely, education/specialist consultation on pregnancy-related medical concerns was among the most commonly endorsed by SUD treatment programs. DISCUSSION This project provides a broad look at obstetric and SUD-related services available to pregnant and postpartum patients with SUD in Baltimore, Maryland. To our knowledge, it is the first comprehensive, cross-disciplinary assessment of perinatal OUD service availability in a major US city. Overall, our results show that most birthing hospitals in Baltimore often care for perinatal patients with OUD, but the majority of PNC practices and SUD programs in the city care for this population less frequently. This imbalance may be driven by several factors including the greater number of PNC and SUD programs available to patients relative to birthing hospitals, preferential referral to specialty outpatient programs, lack of patient engagement in care prior to delivery, and/or underdiagnosis/lack of identification of SUD in the outpatient setting. Additionally, our data show considerable variability in screening practices and in service availability (both by type of organization and by type of service). Birthing hospitals and SUD programs generally provide more SUD-related services than PNC practices. MOUD and linkage to treatment are generally more available than withdrawal management and harm reduction services. Our data demonstrate a lack of consistent validated SUD screening, availability of MOUD, and naloxone accessibility in prenatal/obstetric settings, representing significant missed opportunities for treatment engagement and overdose prevention. While most birthing hospitals and PNC practices reported screening in some way for OUD, organizations frequently utilized informal screening and/or urine toxicology. Notably, our results show minimal improvement in the decade since prior statewide assessment demonstrated that a minority of obstetric settings used validated substance use screening tools, considered standard of care by many professional and governmental organizations ( 10 – 12 , 33 ). Informal approaches may lack reliability and introduce potential for bias, and urine toxicology may be used punitively ( 34 – 36 ). Additionally, while all birthing hospitals reported the ability to continue MOUD for patients, two of seven birthing hospitals and three-quarters of PNC practices do not initiate MOUD. Perhaps most notably, around two-thirds of responding birthing hospitals and PNC practices reported not offering any naloxone to patients. While most SUD programs offering MOUD reported no restrictions related to pregnancy status, our data reveal several potential barriers to treatment engagement. About a quarter of SUD programs reported requiring obstetric evaluation prior to MOUD initiation, which may be an obstacle to the OUD stabilization needed to facilitate engagement in prenatal care. Additionally, few programs offer tailored services that can increase the relevance and accessibility of treatment for pregnant patients or for parents of young children. While most residential programs and recovery residences did report accepting patients during pregnancy, far fewer allow children onsite. (Of note, the higher rate of permitting children among recovery residences in our sample [50%] may be inflated by the low response rate among recovery residences and overrepresentation of programs specifically catering to this population.) Even among outpatient SUD providers, only about half permit children to accompany parents to treatment. These limits likely lead to a significant loss of treatment options after delivery for many patients given competing childcare responsibilities ( 12 , 28 ). Withdrawal management services for the perinatal population were also a notable gap within the Baltimore landscape. With regards to OUD, several of the dedicated withdrawal management/stabilization programs surveyed indicated denying buprenorphine management to pregnant patients when it was otherwise available to the general population. Alcohol/benzodiazepine withdrawal management, a critical service to facilitate safe cessation of these substances, was also unavailable in many locations, including SUD programs overall and particularly among PNC practices. This lack of availability may in part be due to the fact that these services, particularly for cases of severe withdrawal, often merit inpatient-level monitoring; however, even two of seven birthing hospitals and two of five alcohol/benzodiazepine withdrawal management programs reported denying this service during pregnancy. Among the most commonly endorsed needs by respondents were education/specialist consultation on SUD treatment in pregnancy within obstetric settings and on pregnancy-related medical concerns within SUD programs. These endorsements mirror MMRC recommendations to increase PNC and SUD provider comfort caring for patients with perinatal OUD and to reduce silos between these disciplines ( 5 , 30 , 31 ). Despite the limited availability of naloxone for overdose reversal among birthing hospitals and PNC practices, very few endorsed that they would benefit from the ability to distribute naloxone directly to patients. Lack of interest in providing this service may reflect an unawareness of the prevalence of overdose during the perinatal period as well as the potential benefit of directly distributed naloxone, compared with prescribed naloxone, in accessibility and reduction of overdose deaths ( 37 – 39 ). Overall, our results highlight strengths and weaknesses within the landscape of perinatal SUD services in Baltimore and potential avenues for quality improvement. Within Baltimore, results from this project have served as a critical guide to our team’s ongoing capacity building efforts citywide. In particular, dissemination of results to multiple local professional organizations/networks and mortality review committees has offered the opportunity for education about maternal overdose mortality as well as potential ways to strengthen care for this population. Additionally, results have enabled the project team to identify and conduct targeted outreach and technical assistance to organizations that were either already providing care to this population or had the potential to fulfill an unmet need; 88 clinicians across 10 SUD treatment and/or prenatal care organizations have been engaged thus far. Depending on specific organization needs, outreach offerings have included provider education on standards of SUD care in pregnancy, promotion of population-specific community resources (e.g., case management, legal support, doula care), supported linkage to obstetric resources, and longitudinal consultation on development of population-specific programming. While this landscape assessment is specific to Baltimore City, the patterns identified may be relevant more broadly. This project may serve as a model for other jurisdictions interested in better understanding their local landscape and strengthening services for patients using opioids during pregnancy and the postpartum period. Data from our project should be interpreted in light of both its strengths and limitations. Our assessment was unique in its comprehensiveness–both due to the broad multidisciplinary sample of organizations included as well as the range of topics addressed. Additionally, our systematic contact confirmation and outreach efforts yielded a strong response rate of 61%. However, not all organizations providing services to pregnant patients with OUD in Baltimore City are represented in this data. Some SUD-related organizations or providers, particularly those providing more informal care (such as non-certified recovery residences or individual buprenorphine prescribers outside of larger SUD-focused practices), may not have been captured by our outreach lists. For a small number of organizations on the initial outreach lists, our team was unable to identify individual respondents, leading to their exclusion. Additionally, those organizations with greater focus on this specialized population likely had a higher response rate, which may artificially increase the reported rate of service availability. Importantly, reported service availability may not accurately reflect true access to services, quality of care provided, and/or the patient experience receiving care. All of these factors may result in lower actual accessibility of services than is represented in our data. CONCLUSIONS This project provides an extensive picture of health services available for perinatal OUD across birthing hospitals, prenatal care practices, and SUD treatment programs in Baltimore, Maryland. Results have illuminated strengths as well as gaps in the landscape of care available and have served to guide ongoing citywide system improvement efforts by our project team, including targeted outreach and technical assistance to organizations providing SUD treatment and/or prenatal care to patients with perinatal SUD. As the first known citywide, multidisciplinary service assessment to be published in the literature, this project offers a model for other jurisdictions hoping to strengthen perinatal health services for patients with OUD and reduce maternal mortality. Abbreviations ASAM: American Society of Addiction Medicine MMRC: maternal mortality review committee MOUD: medication for opioid use disorder OBOT: office-based buprenorphine treatment OTP: opioid treatment program OUD: opioid use disorder PNC: prenatal care SBIRT: screening, brief intervention and referral to treatment SSP: syringe services program SUD: substance use disorder Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This project was supported by the Centers for Disease Control and Prevention’s Overdose Data to Action (OD2A) funding, provided to the Baltimore City Health Department by the Maryland Department of Health. Authors contributions JR conceptualized the project, drafted the survey instrument, supervised outreach to organizations, compiled and analyzed the data, and drafted the manuscript. JK was a major contributor to project planning, survey editing, and data interpretation. BS contributed to project planning. MT provided mentorship and support in project conceptualization, survey editing, and data interpretation. All authors read, edited, and approved the final manuscript. Acknowledgements The authors would like to acknowledge the Baltimore City Health Department (BCHD) interns who assisted in outreach and survey collection efforts including Hameenat Adekoya, Rachel Cohen, Sergine Quenum, and Kimberly Sanchez. Authors’ information JR is an internist, pediatrician, and addiction medicine specialist at Johns Hopkins School of Medicine, who receives funding from BCHD for consulting on perinatal SUD. JK works in the BCHD Bureau of Maternal and Child Health, leading Baltimore’s Prenatal/Postpartum Behavioral Health Network since late 2015. JK holds an MSPH in Health Education & Health Communication and has previously worked for Baltimore’s behavioral health authority and at a harm reduction organization. BS serves as the Director of Opioid Overdose Prevention at BCHD, where she has managed and coordinated all overdose-related work within the agency since 2018. She has nearly 20 years of experience working in healthcare, directly with communities as a case manager and as an administrator. MT is an OB/GYN and Addiction Medicine physician. He is Medical Director of Friends Research Institute in Baltimore, Maryland. References Trost S, Beauregard J, Chandra G, Njie F, Berry J, Harvey A, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019. Centers for Disease Control and Prevention. 2022;16:2017–9. Fuchs JR, Schiff MA, Coronado E. Substance Use Disorder-Related Deaths and Maternal Mortality in New Mexico, 2015–2019. Matern Child Health J. 2023 Dec 1;27:23–33. Kountanis JA, Roberts M, Admon LK, Smith R, Cropsey A, Bauer ME. Maternal deaths due to suicide and overdose in the state of Michigan from 2008 to 2018. Am J Obstet Gynecol MFM. 2023 Feb 1;5(2). Austin AE, Naumann RB, DiPrete BL, Geary S, Proescholdbell SK, Jones-Vessey K. Pregnancy-associated homicide, suicide and unintentional opioid-involved overdose deaths, North Carolina 2018–2019. Injury Prevention. 2024 Jan 9;1–7. Maryland Maternal Mortality Review Program. Maryland Maternal Mortality Review: 2020 Annual Report [Internet]. 2021. Available from: https://health.maryland.gov/phpa/mch/Pages/mmr.aspx Han B, Compton WM, Einstein EB, Elder E, Volkow ND. Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic. JAMA Psychiatry [Internet]. 2024;81(3). 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Available from: https://store.samhsa.gov/shin/content//SMA18-5054/SMA18-5054.pdf American College of Obstetricians and Gynecoloigists. ACOG Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstetrics and gynecology. 2017;130(2):e81–94. American Society of Addiction Medicine. Public Policy Statement on Substance Use and Substance Use Disorder Among Pregnant and Postpartum People [Internet]. 2022 [cited 2024 Apr 21]. Available from: https://www.asam.org/advocacy/public-policy-statements/details/public-policy-statements/2022/10/12/substance-use-and-substance-use-disorder-among-pregnant-and-postpartum-people Schauberger CW, Borgert AJ, Bearwald B. Continuation in Treatment and Maintenance of Custody of Newborns After Delivery in Women With Opioid Use Disorder. J Addict Med. 2020;14(2):119–25. Hall MT, Wilfong J, Huebner RA, Posze L, Willauer T. Medication-assisted treatment improves child permanency outcomes for opioid-using families in the child welfare system. J Subst Abuse Treat [Internet]. 2016;71:63–7. Available from: http://dx.doi.org/10.1016/j.jsat.2016.09.006 Satcher MF, Bruce ML, Goodman DJ, Lord SE. Biopsychosocial contexts of timely and adequate prenatal care utilization among women with criminal legal involvement and opioid use disorder. BMC Public Health [Internet]. 2023;23(1):1–14. Available from: https://doi.org/10.1186/s12889-023-15627-6 Krans EE, Kim JY, Chen Q, Rothenberger SD, James AE, Kelley D, et al. Outcomes associated with the use of medications for opioid use disorder during pregnancy. Addiction. 2021;116(12):3504–14. Schiff DM, Nielsen TC, Hoeppner BB, Terplan M, Hadland SE, Bernson D, et al. Methadone and Buprenorphine Discontinuation among Postpartum Women with Opioid Use Disorder. Am J Obstet Gynecol [Internet]. 2021; Available from: https://doi.org/10.1016/j.ajog.2021.04.210 Wilder C, Lewis D, Winhusen T. Medication assisted treatment discontinuation in pregnant and postpartum women with opioid use disorder. Drug Alcohol Depend [Internet]. 2015;149:225–31. Available from: http://dx.doi.org/10.1016/j.drugalcdep.2015.02.012 Schiff DM, Nielsen T, Hoeppner BB, Terplan M, Hansen H, Bernson D, et al. Assessment of Racial and Ethnic Disparities in the Use of Medication to Treat Opioid Use Disorder Among Pregnant Women in Massachusetts + Supplemental content. JAMA Netw Open [Internet]. 2020;3(5):205734. Available from: https://jamanetwork.com/ Krans EE, Kim JY, James AE, Kelley D, Jarlenski MP. Medication-assisted treatment use among pregnant women with opioid use disorder. Obstetrics and Gynecology. 2019 May 1;133(5):943–51. Xu KY, Jones HE, Schiff DM, Martin CE, Kelly JC, Carter EB, et al. Initiation and Treatment Discontinuation of Medications for Opioid Use Disorder in Pregnant People Compared with Nonpregnant People. Obstetrics and Gynecology. 2023;141(4):845–53. Short VL, Hand DJ, MacAfee L, Abatemarco DJ, Terplan M. Trends and disparities in receipt of pharmacotherapy among pregnant women in publically funded treatment programs for opioid use disorder in the United States. J Subst Abuse Treat [Internet]. 2018;89(April):67–74. Available from: https://doi.org/10.1016/j.jsat.2018.04.003 Bedrick BS, O’Donnell C, Marx CM, Friedman H, Carter EB, Stout MJ, et al. Barriers to accessing opioid agonist therapy in pregnancy. Am J Obstet Gynecol MFM [Internet]. 2020;2(4):100225. Available from: https://doi.org/10.1016/j.ajogmf.2020.100225 Patrick SW, Richards MR, Dupont WD, McNeer E, Buntin MB, Martin PR, et al. Association of Pregnancy and Insurance Status with Treatment Access for Opioid Use Disorder. JAMA Netw Open. 2020;3(8):1–12. Angelotta C, Weiss CJ, Angelotta JW, Friedman RA. A Moral or Medical Problem? The Relationship between Legal Penalties and Treatment Practices for Opioid Use Disorders in Pregnant Women. Women’s Health Issues [Internet]. 2016;26(6):595–601. Available from: http://dx.doi.org/10.1016/j.whi.2016.09.002 Benningfield M. Opioid Dependence during Pregnancy: Relationships of Anxiety and Depression Symptoms to Treatment Outcomes. Addiction. 2012;107(0 1):74–82. Mattocks KM, Clark R, Weinreb L. Initiation and Engagement with Methadone Treatment among Pregnant and Postpartum Women. Women’s Health Issues [Internet]. 2017;27(6):646–51. Available from: https://doi.org/10.1016/j.whi.2017.05.002 Apsley HB, Brant K, Brothers S, Harrison E, Skogseth E, Schwartz RP, et al. Pregnancy- and parenting-related barriers to receiving medication for opioid use disorder: A multi-paneled qualitative study of women in treatment, women who terminated treatment, and the professionals who serve them. Womens Health (Lond). 2024;20:1–12. Campbell J, Matoff-Stepp S, Velez ML, Cox HH, Laughon K. Pregnancy-Associated Deaths from Homicide, Suicide, and Drug Overdose: Review of Research and the Intersection with Intimate Partner Violence. J Womens Health. 2021;30(2):236–44. Smid MC, Schauberger CW, Terplan M, Wright TE. Early lessons from maternal mortality review committees on drug-related deaths—time for obstetrical providers to take the lead in addressing addiction. Am J Obstet Gynecol MFM [Internet]. 2020;2(4):100177. Available from: https://doi.org/10.1016/j.ajogmf.2020.100177 Maryland Maternal Mortality Review Program. Maryland Maternal Mortality Review: 2019 Annual Report [Internet]. 2020. Available from: https://health.maryland.gov/phpa/mch/Documents/MMR/MMR_2019_AnnualReport.pdf Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform [Internet]. 2019;95(April):103208. Available from: https://doi.org/10.1016/j.jbi.2019.103208 Miller C, Lanham A, Welsh C, Ramanadhan S, Terplan M. Screening, Testing, and Reporting for Drug and Alcohol Use on Labor and Delivery: A Survey of Maryland Birthing Hospitals. Soc Work Health Care. 2014;53(7):659–69. Chin JM, Chen E, Wright T, Bravo RM, Nakashima E, Kiyokawa M, et al. Urine drug screening on labor and delivery. Am J Obstet Gynecol MFM. 2022;4(6):100733. Winchester ML, Shahiri P, Boevers-Solverson E, Hartmann A, Ross M, Fitzgerald S, et al. Racial and Ethnic Differences in Urine Drug Screening on Labor and Delivery. Matern Child Health J. 2022;26(1):124–30. Siegel MR, Cohen SJ, Koenigs K, Woods GT, Schwartz LN, Sarathy L, et al. Assessing the clinical utility of toxicology testing in the peripartum period. Am J Obstet Gynecol MFM. 2023;5(7). Irvine MA, Oller D, Boggis J, Bishop B, Coombs D, Wheeler E, et al. Estimating naloxone need in the USA across fentanyl, heroin, and prescription opioid epidemics: a modelling study. Lancet Public Health. 2022;7(3):e210–8. Hardin J, Seltzer J, Galust H, Deguzman A, Campbell I, Friedman N, et al. Emergency Department Take-Home Naloxone Improves Access Compared with Pharmacy-Dispensed Naloxone. J Emerg Med. 2023;66(4):E457–62. Rao IJ, Humphreys K, Brandeau ML. Effectiveness of Policies for Addressing the US Opioid Epidemic: A Model-Based Analysis from the Stanford-Lancet Commission on the North American Opioid Crisis. The Lancet Regional Health - Americas [Internet]. 2021;3:100031. Available from: https://doi.org/10.1016/j.lana.2021.10 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Oct, 2024 Read the published version in Addiction Science & Clinical Practice → Version 1 posted Reviews received at journal 10 Jun, 2024 Reviews received at journal 23 May, 2024 Reviewers agreed at journal 20 May, 2024 Reviewers agreed at journal 18 May, 2024 Reviewers invited by journal 17 May, 2024 Editor assigned by journal 13 May, 2024 Submission checks completed at journal 04 May, 2024 First submitted to journal 03 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4365589","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":298584924,"identity":"54328611-7f7e-46ed-ab47-dc1a112f552c","order_by":0,"name":"Jessica Alison Ratner","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvklEQVRIiWNgGAWjYBACxgYIzcPPcAZIsRGnBaxLRrKBWC0wi2wMDvAQqYV59uHnjwsq7vEYHzx7gOFD2WEirOhLM2yecaaYx+zAuQTGGeeI0dLDYNjM25YA1HLGgJm3jSgt7B+bef8l8Bg3ALX8JU4LD9CWhgQeAwagFkYitRTO5jmWwCMBdNjBnnPphLUY9rBv+MxTk2DPP+OM4YMfZdZEaGmAsSQOMBwgrB4I5OEs/gbcqkbBKBgFo2BkAwAEJjrkJmNmgwAAAABJRU5ErkJggg==","orcid":"","institution":"Johns Hopkins School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Jessica","middleName":"Alison","lastName":"Ratner","suffix":""},{"id":298584925,"identity":"6a677286-7e76-44e6-9ae2-d2e07a0520da","order_by":1,"name":"Jennifer H Kirschner","email":"","orcid":"","institution":"Baltimore City Health Department","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"H","lastName":"Kirschner","suffix":""},{"id":298584926,"identity":"164738d8-9d28-4c37-9d73-56b233d706ea","order_by":2,"name":"Brittney Spencer","email":"","orcid":"","institution":"Baltimore City Health Department","correspondingAuthor":false,"prefix":"","firstName":"Brittney","middleName":"","lastName":"Spencer","suffix":""},{"id":298584927,"identity":"70ed0e86-3c34-43e4-ac87-7945129f0c95","order_by":3,"name":"Mishka Terplan","email":"","orcid":"","institution":"Friends Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Mishka","middleName":"","lastName":"Terplan","suffix":""}],"badges":[],"createdAt":"2024-05-03 18:40:47","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4365589/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4365589/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13722-024-00507-0","type":"published","date":"2024-10-15T15:58:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56409044,"identity":"c1ec8ad6-25cb-4717-9a5e-3a6f83a83608","added_by":"auto","created_at":"2024-05-13 19:52:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":260131,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4365589/v1/abc7324cd89e959ffadef370.png"},{"id":67149102,"identity":"86a1de76-29fe-45e4-beb0-48a98b65f9e5","added_by":"auto","created_at":"2024-10-21 16:11:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1162673,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4365589/v1/dc978c45-355a-40a4-a81a-f942e4a1207b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Services for Perinatal Patients with Opioid Use Disorder: A Comprehensive Baltimore City-wide 2023 Assessment","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eOverdose is a leading cause of maternal mortality in the United States (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and the most common cause of maternal death in the state of Maryland (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) and the city of Baltimore (unpublished data). Nationwide, death due to overdose during pregnancy or within the first year postpartum has nearly doubled during recent years, driven by rising overdoses related to synthetic opioids and stimulants (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The postpartum period, particularly 6 months or more after delivery, is the highest risk time for fatal overdose (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStandard of care for opioid use disorder (OUD) in pregnancy includes medications (i.e., buprenorphine or methadone) (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Medication for OUD (MOUD) is associated with increased retention in substance use disorder (SUD) treatment and reductions in overdose as well as increased prenatal care utilization, lower rates of preterm birth and low birth weight, and maintenance of custody (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Longer duration of treatment with MOUD during pregnancy increases postpartum treatment retention (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, roughly half of pregnant patients with OUD do not receive MOUD, and fewer than two thirds of those who receive treatment in pregnancy remain in treatment postpartum (\u003cspan additionalcitationids=\"CR20 CR21\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Many barriers limit access to and engagement in OUD treatment for this population, including lack of service availability during pregnancy, siloing of obstetric and SUD services, fear of legal consequences/custody loss, comorbid mental health conditions, stigma, and feelings of guilt/shame (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR24 CR25 CR26 CR27\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Treatment discontinuation and overdose risk may be particularly high postpartum due to added factors of loss of insurance coverage, competing demands of caring for a new family, and, in some cases, custody loss (\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThrough review of fatal maternal overdose cases, maternal mortality review committees (MMRCs) offer insight into potential avenues to improve outcomes for this population. Common themes among MMRC recommendations both nationwide and locally in Maryland and Baltimore have included: promotion of standardized screening for SUD during pregnancy; increasing comfort among obstetric providers in caring for patients with SUD and among SUD providers in caring for patients during pregnancy; improving navigation supports and reducing fragmentation within systems of care; anti-stigma training for providers and the broader community; and adoption of family-friendly policies/practices across organizations (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePublic health departments and other governmental and quasi-governmental agencies can play a vital role in addressing barriers to treatment and reducing overdose mortality among perinatal patients through policies and programming that focus on these MMRC priority areas. Motivated by the rate of maternal overdose deaths in Baltimore as well as local MMRC recommendations, our project team, a public health-academic partnership, aimed to assess availability of services within the local health care system for pregnant and postpartum people with OUD. The project\u0026rsquo;s ultimate goal was to identify system strengths and gaps, as well as avenues for quality improvement and collaboration to reduce maternal overdose mortality.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eTo ensure comprehensive assessment of services available to pregnant and postpartum patients with OUD in Baltimore, the project team developed a systematic outreach list that included a wide range of healthcare organizations with potential contact with this population. Organizational categories were defined as: (\u003cspan\u003e1\u003c/span\u003e) birthing hospitals, (\u003cspan\u003e2\u003c/span\u003e) prenatal care practices, and (\u003cspan\u003e3\u003c/span\u003e) SUD treatment providers. The SUD treatment provider category was divided into the following sub-categories: (a) opioid treatment programs (OTPs), (b) office-based buprenorphine providers (OBOT), (c) residential programs, (d) state-certified recovery residences, (e) withdrawal management or stabilization programs, and (f) syringe services programs (SSPs). Individual institutions, organizations, and programs (hereafter, referred to as \u0026ldquo;organizations\u0026rdquo;) were identified using lists of certified programs maintained by city and state health departments and the local behavioral health authority. For categories for which no list was available (i.e., OBOT, withdrawal management programs), the project team generated a list of known organizations based on their local experience. Several programs known to the project team as providing services to this population but missing from maintained lists were added to the outreach list.\u003c/p\u003e\n\u003cp\u003eUsing either listed or publicly available contact information, project team members reached out to each organization to identify an appropriate respondent and confirm their contact information. Organizations (except birthing hospitals) were asked to identify a medical or administrative leader who could answer questions about service availability, common referrals, and barriers to care for pregnant individuals with SUD. Birthing hospitals were asked to identify the lead social worker in their obstetrics unit. Organizations no longer in operation, incorrectly included on initial lists (e.g., reporting no prenatal care offered), or identified as serving men-only during the initial contact confirmation process were removed from the outreach list. Programs for whom no individual respondent could be identified were also removed.\u003c/p\u003e\n\u003cp\u003eA survey instrument was developed to assess each organization\u0026rsquo;s substance used-related service availability, common referrals and partners, and barriers/needs to care effectively for pregnant and postpartum patients with OUD. The project team drafted survey questions based on their prior experience (a) providing clinical care to and assessing availability of services for this population and (b) with qualitative and quantitative survey design. Questions were piloted with multiple health professionals for clarity. The final survey was programmed into and distributed via REDCap (Research Electronic Data Capture), a secure, web-based software platform designed to support data capture for research and quality improvement (\u003cspan\u003e32\u003c/span\u003e). Specific questions asked of each organization were determined by a skip pattern based on the organization\u0026rsquo;s self-identified \u0026ldquo;primary mission(s)\u0026rdquo; (\u0026ldquo;services for individuals with substance use disorder,\u0026rdquo; \u0026ldquo;outpatient prenatal care,\u0026rdquo; and/or \u0026ldquo;hospital-based obstetrics\u0026rdquo;). See Fig. 1 for a detailed list of topics covered by survey questions.\u003c/p\u003e\n\u003cp\u003eThe project team implemented a systematic strategy to ensure broad reach and maximize response rates. Initial outreach to all organizations was conducted by email. Respondents identified during the contact confirmation phase were asked to complete the survey or forward to a more appropriate respondent. The survey instrument was preceded by language informing respondents that the survey was voluntary, would take ten minutes to complete, and would not collect personal health information. Participants were given the option to confidentially provide their name and work contact information for possible follow-up. Respondents were not compensated for participation. Up to four additional attempts at contact were made over a two-month period by either email or phone before marking non-response. All data was collected from April-June 2023.\u003c/p\u003e\n\u003cp\u003eFor analysis, descriptive statistics (i.e., frequencies) were calculated using REDCap reports and Excel. Several organizations were included in more than one category\u0026ndash;for example, a SUD treatment program on both the residential and certified-recovery residency lists. Responses for these organizations were included only once in analyses for main organizational categories (e.g., SUD programs) but were included in analyses for each of the applicable sub-categories (e.g., residential and recovery residences). Missing values were limited as the survey primarily utilized forced-choice questions including a \u0026ldquo;don\u0026rsquo;t know/unsure\u0026rdquo; answer option. The Johns Hopkins School of Medicine institutional review board deemed this project to be quality/systems improvement work and, thus, exempt from review.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAmong the 145 organizations that were contacted, 89 responded, comprising 61% of the total sample. Response rates varied by organization type, with responses from 100% of the seven contacted birthing hospitals (n\u0026thinsp;=\u0026thinsp;7), 65% of the 31 contacted prenatal care practices (n\u0026thinsp;=\u0026thinsp;20), and 58% of the 108 contacted substance use-related services programs (n\u0026thinsp;=\u0026thinsp;63; sum of three categories exceeds total N due to one program listed in both prenatal care and SUD categories). Among SUD programs, response rates ranged from 24% of recovery residences to 100% of withdrawal management/stabilization units.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of Caring for Pregnant Patients with OUD\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlways\u003c/p\u003e \u003cp\u003eRow % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequently\u003c/p\u003e \u003cp\u003eRow % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSometimes\u003c/p\u003e \u003cp\u003eRow % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRarely\u003c/p\u003e \u003cp\u003eRow % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003cp\u003eRow % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eUnsure\u003c/p\u003e \u003cp\u003eRow % (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBirthing Hospitals (n\u0026thinsp;=\u0026thinsp;7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.2% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.9% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.2% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePrenatal Care Practices (n\u0026thinsp;=\u0026thinsp;20)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20.0% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30.0% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e35.0% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSUD Programs (n\u0026thinsp;=\u0026thinsp;63)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.3% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.7% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.3% (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.9% (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.9% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.8% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOBOT (n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.7% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOTP (n\u0026thinsp;=\u0026thinsp;21)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.8% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.0% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e52.4% (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.8% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSSPs (n\u0026thinsp;=\u0026thinsp;7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.6% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.6% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.6% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidential (n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.0% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecovery Residence (n\u0026thinsp;=\u0026thinsp;8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.5% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25.0% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12.5% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25.0% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWithdrawal Management(n\u0026thinsp;=\u0026thinsp;6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33.3% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e*Total N for SUD programs is less than sum of subcategories due to several programs falling into multiple categories.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOrganizations were asked to indicate the frequency with which they provided care for pregnant patients with OUD on a five-point Likert scale, ranging from \u0026ldquo;always\u0026rdquo; to \u0026ldquo;never\u0026rdquo; (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), as well as the average number of pregnant patients with OUD treated per month. Birthing hospitals reported caring for this population with greater frequency (71.4% always or frequently) than prenatal care practices (35.0% always/frequently) or SUD programs (19.0% always/frequently). Among SUD programs, OTPs and recovery residences reported more frequently caring for this population, with only 23.8% of OTPs and 37.5% of recovery residences selecting \u0026ldquo;rarely\u0026rdquo; or \u0026ldquo;never.\u0026rdquo; Most birthing hospitals reported treating 10\u0026ndash;20 pregnant patients per month with OUD, whereas the majority of PNC practices and SUD programs reported treating five or fewer.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eOUD and Pregnancy Screening Practices\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBirthing Hospitals (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrenatal Care Practices (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSUD Programs (n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAssess for OUD at intake\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95.0% (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith informal verbal/written screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.1% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.0% (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith validated verbal/written tool\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.6% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45.0% (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith urine toxicology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.7% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.0% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith urine toxicology only\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAssess for pregnancy at intake\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.7% (54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWith urine pregnancy test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60.3% (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows reported screening practices. Birthing hospitals and PNC practices were asked whether and how they screen for OUD at intake for services. Almost all responding organizations reported screening for OUD; most reported using urine toxicology (85.7% of birthing hospitals, 60.0% of PNC practices) and informal verbal/written screening (57.1% of birthing hospitals, 65.0% of PNC practices). One birthing hospital reported using only urine toxicology to screen for OUD. SUD programs were asked about whether and how they screen for pregnancy at intake. While 85.7% of programs assessed pregnancy status, only 60.3% utilized urine pregnancy tests. Urine pregnancy testing was most frequently reported by OTPs (100%), withdrawal management programs (83.3%), and residential programs (80.0%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSUD-Related Service Availability During Pregnancy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBirthing Hospitals (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrenatal Care Practices (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eSUD Programs (n\u0026thinsp;=\u0026thinsp;63)*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAvailable\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAvailable\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAvailable\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUnavailable to pregnant patients only\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnavailable to all patients\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuprenorphine initiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.1% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.7% (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.3% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.2% (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBuprenorphine maintenance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.0% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69.8% (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.3% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.2% (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethadone initiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.1% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.6% (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.2% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e47.6% (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethadone maintenance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55.6% (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.2% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e39.7% (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaltrexone initiation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.9% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.9% (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11.1% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.8% (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaltrexone maintenance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.1% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.5% (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.5% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49.2% (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithdrawal management \u0026ndash; alcohol/benzos\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.4% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.9% (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.8% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e57.1% (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithdrawal management \u0026ndash; opioids\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.4% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.1% (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.9% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49.2% (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrief intervention (SBIRT)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.0% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.9% (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25.4% (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeer recovery support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74.6% (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23.8% (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-peer treatment linkage services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.4% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.0% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.9% (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.2% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual SUD counseling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e85.2% (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14.3% (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup SUD counseling\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74.6% (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.2% (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaloxone \u0026ndash; direct distribution\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e69.8% (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.2% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.9% (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaloxone \u0026ndash; providing prescriptions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.9% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.0% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.8% (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.2% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.9% (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNaloxone \u0026ndash; prescribe OR distribute\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.9% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.0% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e84.1% (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.2% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12.7% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther harm reduction services (e.g., providing sterile supplies)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.9% (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.6% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58.7% (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e*SUD program columns do not always add up to 100%, as programs could mark \u0026ldquo;Unsure/Don\u0026rsquo;t Know\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBirthing hospitals and PNC practices were asked to indicate the availability of specific SUD-related services; SUD programs were asked to specify whether these services were available to all patients, pregnant patients only, non-pregnant patients only, or unavailable to all patients (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Regarding medications for opioid use disorder (MOUD), all birthing hospitals reported capacity to continue buprenorphine and methadone for patients taking these medications at the time of admission, but fewer (57%) reported that MOUD initiation was available. Thirty-five percent of PNC practices reported offering buprenorphine maintenance, while only 25% offered buprenorphine initiation.\u003c/p\u003e \u003cp\u003eMost SUD programs that offered buprenorphine or methadone reported availability to all patients regardless of pregnancy status, with some notable exceptions. In particular, 76% of responding OTPs reported offering buprenorphine, and none of these programs limited this service based on pregnancy status. One of the 21 responding OTPs reported that their program did not offer methadone during pregnancy. In addition, of the five withdrawal management programs that offered buprenorphine initiation/maintenance to the general population, one of these programs denied initiation and one denied both initiation and maintenance to pregnant people. Four withdrawal management programs offered methadone maintenance and two offered methadone initiation overall; none of these programs limited methadone based on pregnancy status. SUD programs were asked to indicate whether they required obstetrics evaluation prior to initiating MOUD\u0026ndash;60.4% reported requiring no obstetric evaluation, 4.2% required ultrasound, 18.8% required outpatient obstetric evaluation, 2.1% required inpatient hospitalization, and 18.8% were unsure.\u003c/p\u003e \u003cp\u003eWithdrawal management services were less widely available than MOUD, with more organizations offering opioid than alcohol/benzodiazepine withdrawal management. Five of seven birthing hospitals reported offering management of opioid and alcohol/benzodiazepine withdrawal. Only 10% of PNC practices offered opioid withdrawal management, and none offered alcohol/benzodiazepine withdrawal management. Among SUD programs, two of five withdrawal management programs offering alcohol/benzodiazepine withdrawal management reported restricting this service to non-pregnant patients only.\u003c/p\u003e \u003cp\u003eLinkage to treatment via SBIRT (i.e., screening, behavioral intervention and referral to treatment), peer recovery support, and/or non-peer treatment linkage services was most widely available at birthing hospitals and SUD programs. Among PNC practices, only half conducted SBIRT, 25% offered peer recovery support, and 40% offered non-peer treatment linkage.\u003c/p\u003e \u003cp\u003eHarm reduction services, including naloxone provision, were less often available at birthing hospitals and prenatal care practices than at SUD programs. Nearly two-thirds of birthing hospitals and PNC practices reported neither prescribing nor distributing naloxone, whereas only 16% of SUD programs reported neither service. Other harm reduction services (e.g., distribution of sterile supplies) were reported by 35% of SUD programs but only 14% of birthing hospitals and 5% of PNC practices.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAvailability of Family-Focused Practices and Policies Within SUD Programs\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eServices for perinatal patients^\u003c/p\u003e \u003cp\u003eRow % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eServices for parents\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRow % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHousing available during pregnancy\u003c/p\u003e \u003cp\u003eRow % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChildren allowed onsite w/ legal guardian\u003c/p\u003e \u003cp\u003eRow % (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSUD Programs Overall (n\u0026thinsp;=\u0026thinsp;63)*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3% (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.4% (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44.4% (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOBOT (n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.7% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOTP (n\u0026thinsp;=\u0026thinsp;21)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.8% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.5% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.8% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.1% (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSSPs (n\u0026thinsp;=\u0026thinsp;7)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.6% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.1% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidential (n\u0026thinsp;=\u0026thinsp;12)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.7% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e91.7% (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.7% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecovery Res (n\u0026thinsp;=\u0026thinsp;8)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.0% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e87.5% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.0% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWithdrawal (n\u0026thinsp;=\u0026thinsp;6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.7% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e66.7% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003e* Total N for SUD programs is less than sum of subcategories due to several programs falling into multiple categories.\u003c/p\u003e \u003cp\u003e^ Defined as \u0026ldquo;pregnant or within 1 year of birth, termination, or pregnancy loss.\u0026rdquo;\u003c/p\u003e \u003cp\u003e# Defined as \u0026ldquo;individuals with children under age 5.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo assess specific focus on the perinatal population as well as family-friendliness, SUD programs were asked several questions about tailored services (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The minority of programs reported having specialized services for perinatal patients or for parents. Among the programs offering inpatient/residential level services, 92% of residential programs, 88% of recovery residences, and 67% of withdrawal management units reported offering housing to pregnant patients. Children were allowed on-site more often among outpatient programs (50% OBOT, 57% OTP, 57% SSPs) than inpatient programs (none of the withdrawal management programs, 17% residential, 50% recovery residences).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInformation/Resources Needed by Organizations to Better Serve Perinatal Patients with OUD\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBirthing Hospitals (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrenatal Care Practices (n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSUD Programs (n\u0026thinsp;=\u0026thinsp;63)\u003c/p\u003e \u003cp\u003eColumn % (n)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation on meds for OUD in pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.1% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.0% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.7% (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation on other SUD treatment in pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.7% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.0% (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.3% (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation on pregnancy-related medical concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.7% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.0% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.7% (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist consultation for SUD tx in pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.7% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.0% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.3% (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialist consultation for pregnancy-related medical concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.1% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43.3% (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncreased availability of specific resources for patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.7% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.0% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.7% (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupport for implementation for clinical workflows or policies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.9% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.3% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnsite sexual health services provided by external partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.6% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.0% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e23.3% (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnsite SUD treatment services provided by external partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.1% (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0% (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.8% (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbility to distribute naloxone to individuals directly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.3% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.7% (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRespondents were asked \u0026ldquo;What information or resources would enable your organization to better serve this population?\u0026rdquo;; answer options included resources potentially available through the city health department or community partners (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Availability of resources for patients was among the top four responses for all three organization categories (86% birthing hospitals, 30% PNC practices, 42% SUD programs). Education/specialist consultation related to MOUD and other SUD treatment were among the most commonly endorsed by birthing hospitals and PNC practices. Conversely, education/specialist consultation on pregnancy-related medical concerns was among the most commonly endorsed by SUD treatment programs.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis project provides a broad look at obstetric and SUD-related services available to pregnant and postpartum patients with SUD in Baltimore, Maryland. To our knowledge, it is the first comprehensive, cross-disciplinary assessment of perinatal OUD service availability in a major US city.\u003c/p\u003e \u003cp\u003eOverall, our results show that most birthing hospitals in Baltimore often care for perinatal patients with OUD, but the majority of PNC practices and SUD programs in the city care for this population less frequently. This imbalance may be driven by several factors including the greater number of PNC and SUD programs available to patients relative to birthing hospitals, preferential referral to specialty outpatient programs, lack of patient engagement in care prior to delivery, and/or underdiagnosis/lack of identification of SUD in the outpatient setting. Additionally, our data show considerable variability in screening practices and in service availability (both by type of organization and by type of service). Birthing hospitals and SUD programs generally provide more SUD-related services than PNC practices. MOUD and linkage to treatment are generally more available than withdrawal management and harm reduction services.\u003c/p\u003e \u003cp\u003eOur data demonstrate a lack of consistent validated SUD screening, availability of MOUD, and naloxone accessibility in prenatal/obstetric settings, representing significant missed opportunities for treatment engagement and overdose prevention. While most birthing hospitals and PNC practices reported screening in some way for OUD, organizations frequently utilized informal screening and/or urine toxicology. Notably, our results show minimal improvement in the decade since prior statewide assessment demonstrated that a minority of obstetric settings used validated substance use screening tools, considered standard of care by many professional and governmental organizations (\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Informal approaches may lack reliability and introduce potential for bias, and urine toxicology may be used punitively (\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Additionally, while all birthing hospitals reported the ability to continue MOUD for patients, two of seven birthing hospitals and three-quarters of PNC practices do not initiate MOUD. Perhaps most notably, around two-thirds of responding birthing hospitals and PNC practices reported not offering any naloxone to patients.\u003c/p\u003e \u003cp\u003eWhile most SUD programs offering MOUD reported no restrictions related to pregnancy status, our data reveal several potential barriers to treatment engagement. About a quarter of SUD programs reported requiring obstetric evaluation prior to MOUD initiation, which may be an obstacle to the OUD stabilization needed to facilitate engagement in prenatal care. Additionally, few programs offer tailored services that can increase the relevance and accessibility of treatment for pregnant patients or for parents of young children. While most residential programs and recovery residences did report accepting patients during pregnancy, far fewer allow children onsite. (Of note, the higher rate of permitting children among recovery residences in our sample [50%] may be inflated by the low response rate among recovery residences and overrepresentation of programs specifically catering to this population.) Even among outpatient SUD providers, only about half permit children to accompany parents to treatment. These limits likely lead to a significant loss of treatment options after delivery for many patients given competing childcare responsibilities (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWithdrawal management services for the perinatal population were also a notable gap within the Baltimore landscape. With regards to OUD, several of the dedicated withdrawal management/stabilization programs surveyed indicated denying buprenorphine management to pregnant patients when it was otherwise available to the general population. Alcohol/benzodiazepine withdrawal management, a critical service to facilitate safe cessation of these substances, was also unavailable in many locations, including SUD programs overall and particularly among PNC practices. This lack of availability may in part be due to the fact that these services, particularly for cases of severe withdrawal, often merit inpatient-level monitoring; however, even two of seven birthing hospitals and two of five alcohol/benzodiazepine withdrawal management programs reported denying this service during pregnancy.\u003c/p\u003e \u003cp\u003eAmong the most commonly endorsed needs by respondents were education/specialist consultation on SUD treatment in pregnancy within obstetric settings and on pregnancy-related medical concerns within SUD programs. These endorsements mirror MMRC recommendations to increase PNC and SUD provider comfort caring for patients with perinatal OUD and to reduce silos between these disciplines (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Despite the limited availability of naloxone for overdose reversal among birthing hospitals and PNC practices, very few endorsed that they would benefit from the ability to distribute naloxone directly to patients. Lack of interest in providing this service may reflect an unawareness of the prevalence of overdose during the perinatal period as well as the potential benefit of directly distributed naloxone, compared with prescribed naloxone, in accessibility and reduction of overdose deaths (\u003cspan additionalcitationids=\"CR38\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOverall, our results highlight strengths and weaknesses within the landscape of perinatal SUD services in Baltimore and potential avenues for quality improvement. Within Baltimore, results from this project have served as a critical guide to our team\u0026rsquo;s ongoing capacity building efforts citywide. In particular, dissemination of results to multiple local professional organizations/networks and mortality review committees has offered the opportunity for education about maternal overdose mortality as well as potential ways to strengthen care for this population. Additionally, results have enabled the project team to identify and conduct targeted outreach and technical assistance to organizations that were either already providing care to this population or had the potential to fulfill an unmet need; 88 clinicians across 10 SUD treatment and/or prenatal care organizations have been engaged thus far. Depending on specific organization needs, outreach offerings have included provider education on standards of SUD care in pregnancy, promotion of population-specific community resources (e.g., case management, legal support, doula care), supported linkage to obstetric resources, and longitudinal consultation on development of population-specific programming. While this landscape assessment is specific to Baltimore City, the patterns identified may be relevant more broadly. This project may serve as a model for other jurisdictions interested in better understanding their local landscape and strengthening services for patients using opioids during pregnancy and the postpartum period.\u003c/p\u003e \u003cp\u003eData from our project should be interpreted in light of both its strengths and limitations. Our assessment was unique in its comprehensiveness\u0026ndash;both due to the broad multidisciplinary sample of organizations included as well as the range of topics addressed. Additionally, our systematic contact confirmation and outreach efforts yielded a strong response rate of 61%. However, not all organizations providing services to pregnant patients with OUD in Baltimore City are represented in this data. Some SUD-related organizations or providers, particularly those providing more informal care (such as non-certified recovery residences or individual buprenorphine prescribers outside of larger SUD-focused practices), may not have been captured by our outreach lists. For a small number of organizations on the initial outreach lists, our team was unable to identify individual respondents, leading to their exclusion. Additionally, those organizations with greater focus on this specialized population likely had a higher response rate, which may artificially increase the reported rate of service availability. Importantly, reported service availability may not accurately reflect true access to services, quality of care provided, and/or the patient experience receiving care. All of these factors may result in lower actual accessibility of services than is represented in our data.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003e This project provides an extensive picture of health services available for perinatal OUD across birthing hospitals, prenatal care practices, and SUD treatment programs in Baltimore, Maryland. Results have illuminated strengths as well as gaps in the landscape of care available and have served to guide ongoing citywide system improvement efforts by our project team, including targeted outreach and technical assistance to organizations providing SUD treatment and/or prenatal care to patients with perinatal SUD. As the first known citywide, multidisciplinary service assessment to be published in the literature, this project offers a model for other jurisdictions hoping to strengthen perinatal health services for patients with OUD and reduce maternal mortality.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eASAM: American Society of Addiction Medicine\u003c/p\u003e\n\u003cp\u003eMMRC: maternal mortality review committee\u003c/p\u003e\n\u003cp\u003eMOUD: medication for opioid use disorder\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOBOT: office-based buprenorphine treatment\u003c/p\u003e\n\u003cp\u003eOTP: opioid treatment program\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOUD: opioid use disorder\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePNC: prenatal care\u003c/p\u003e\n\u003cp\u003eSBIRT: screening, brief intervention and referral to treatment\u003c/p\u003e\n\u003cp\u003eSSP: syringe services program\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSUD: substance use disorder\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project was supported by the Centers for Disease Control and Prevention\u0026rsquo;s Overdose Data to Action (OD2A) funding, provided to the Baltimore City Health Department by the Maryland Department of Health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJR conceptualized the project, drafted the survey instrument, supervised outreach to organizations, compiled and analyzed the data, and drafted the manuscript. JK was a major contributor to project planning, survey editing, and data interpretation. BS contributed to project planning. MT provided mentorship and support in project conceptualization, survey editing, and data interpretation. All authors read, edited, and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the Baltimore City Health Department (BCHD) interns who assisted in outreach and survey collection efforts including Hameenat Adekoya, Rachel Cohen, Sergine Quenum, and Kimberly Sanchez.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; information\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJR is an internist, pediatrician, and addiction medicine specialist at Johns Hopkins School of Medicine, who receives funding from BCHD for consulting on perinatal SUD.\u003c/p\u003e\n\u003cp\u003eJK works in the BCHD Bureau of Maternal and Child Health, leading Baltimore\u0026rsquo;s Prenatal/Postpartum Behavioral Health Network since late 2015. JK holds an MSPH in Health Education \u0026amp; Health Communication and has previously worked for Baltimore\u0026rsquo;s behavioral health authority and at a harm reduction organization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBS serves as the Director of Opioid Overdose Prevention at BCHD, where she has managed and coordinated all overdose-related work within the agency since 2018. \u0026nbsp;She has nearly 20 years of experience working in healthcare, directly with communities as a case manager and as an administrator.\u003c/p\u003e\n\u003cp\u003eMT is an OB/GYN and Addiction Medicine physician. He is Medical Director of Friends Research Institute in Baltimore, Maryland.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTrost S, Beauregard J, Chandra G, Njie F, Berry J, Harvey A, et al. Pregnancy-Related Deaths: Data from Maternal Mortality Review Committees in 36 US States, 2017-2019. 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Available from: https://health.maryland.gov/phpa/mch/Pages/mmr.aspx\u003c/li\u003e\n\u003cli\u003eHan B, Compton WM, Einstein EB, Elder E, Volkow ND. Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic. JAMA Psychiatry [Internet]. 2024;81(3). Available from: https://pubmed.ncbi.nlm.nih.gov/37991773/\u003c/li\u003e\n\u003cli\u003eBruzelius E, Martins SS. US Trends in Drug Overdose Mortality Among Pregnant and Postpartum Persons, 2017-2020. JAMA [Internet]. 2022;328(21):2159\u0026ndash;61. Available from: https://pubmed.ncbi.nlm.nih.gov/36472602/\u003c/li\u003e\n\u003cli\u003eMargerison CE, Wang X, Gemmill A, Goldman-Mellor S. Changes in Pregnancy-Associated Deaths in the US During the COVID-19 Pandemic in 2020. JAMA Netw Open [Internet]. 2023;6(2):E2254287. Available from: https://pubmed.ncbi.nlm.nih.gov/36723945/\u003c/li\u003e\n\u003cli\u003eSchiff DM, Nielsen T, Terplan M, Hood M, Bernson D, Diop H, et al. Fatal and Nonfatal Overdose among Pregnant and Postpartum Women in Massachusetts. Obstetrics and Gynecology. 2018;132(2):466\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eSubstance Abuse and Mental Health Services Administration. Clinical guidance for treating pregnant and parenting women with opioid use disorder and their infants [Internet]. Vol. (SMA), HHS Publication. 2018. Available from: https://store.samhsa.gov/shin/content//SMA18-5054/SMA18-5054.pdf\u003c/li\u003e\n\u003cli\u003eAmerican College of Obstetricians and Gynecoloigists. ACOG Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstetrics and gynecology. 2017;130(2):e81\u0026ndash;94. \u003c/li\u003e\n\u003cli\u003eAmerican Society of Addiction Medicine. Public Policy Statement on Substance Use and Substance Use Disorder Among Pregnant and Postpartum People [Internet]. 2022 [cited 2024 Apr 21]. 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BMC Public Health [Internet]. 2023;23(1):1\u0026ndash;14. Available from: https://doi.org/10.1186/s12889-023-15627-6\u003c/li\u003e\n\u003cli\u003eKrans EE, Kim JY, Chen Q, Rothenberger SD, James AE, Kelley D, et al. Outcomes associated with the use of medications for opioid use disorder during pregnancy. Addiction. 2021;116(12):3504\u0026ndash;14. \u003c/li\u003e\n\u003cli\u003eSchiff DM, Nielsen TC, Hoeppner BB, Terplan M, Hadland SE, Bernson D, et al. Methadone and Buprenorphine Discontinuation among Postpartum Women with Opioid Use Disorder. Am J Obstet Gynecol [Internet]. 2021; Available from: https://doi.org/10.1016/j.ajog.2021.04.210\u003c/li\u003e\n\u003cli\u003eWilder C, Lewis D, Winhusen T. Medication assisted treatment discontinuation in pregnant and postpartum women with opioid use disorder. Drug Alcohol Depend [Internet]. 2015;149:225\u0026ndash;31. Available from: http://dx.doi.org/10.1016/j.drugalcdep.2015.02.012\u003c/li\u003e\n\u003cli\u003eSchiff DM, Nielsen T, Hoeppner BB, Terplan M, Hansen H, Bernson D, et al. Assessment of Racial and Ethnic Disparities in the Use of Medication to Treat Opioid Use Disorder Among Pregnant Women in Massachusetts + Supplemental content. JAMA Netw Open [Internet]. 2020;3(5):205734. Available from: https://jamanetwork.com/\u003c/li\u003e\n\u003cli\u003eKrans EE, Kim JY, James AE, Kelley D, Jarlenski MP. Medication-assisted treatment use among pregnant women with opioid use disorder. Obstetrics and Gynecology. 2019 May 1;133(5):943\u0026ndash;51. \u003c/li\u003e\n\u003cli\u003eXu KY, Jones HE, Schiff DM, Martin CE, Kelly JC, Carter EB, et al. Initiation and Treatment Discontinuation of Medications for Opioid Use Disorder in Pregnant People Compared with Nonpregnant People. Obstetrics and Gynecology. 2023;141(4):845\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eShort VL, Hand DJ, MacAfee L, Abatemarco DJ, Terplan M. Trends and disparities in receipt of pharmacotherapy among pregnant women in publically funded treatment programs for opioid use disorder in the United States. J Subst Abuse Treat [Internet]. 2018;89(April):67\u0026ndash;74. Available from: https://doi.org/10.1016/j.jsat.2018.04.003\u003c/li\u003e\n\u003cli\u003eBedrick BS, O\u0026rsquo;Donnell C, Marx CM, Friedman H, Carter EB, Stout MJ, et al. Barriers to accessing opioid agonist therapy in pregnancy. Am J Obstet Gynecol MFM [Internet]. 2020;2(4):100225. Available from: https://doi.org/10.1016/j.ajogmf.2020.100225\u003c/li\u003e\n\u003cli\u003ePatrick SW, Richards MR, Dupont WD, McNeer E, Buntin MB, Martin PR, et al. Association of Pregnancy and Insurance Status with Treatment Access for Opioid Use Disorder. JAMA Netw Open. 2020;3(8):1\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eAngelotta C, Weiss CJ, Angelotta JW, Friedman RA. A Moral or Medical Problem? The Relationship between Legal Penalties and Treatment Practices for Opioid Use Disorders in Pregnant Women. Women\u0026rsquo;s Health Issues [Internet]. 2016;26(6):595\u0026ndash;601. Available from: http://dx.doi.org/10.1016/j.whi.2016.09.002\u003c/li\u003e\n\u003cli\u003eBenningfield M. Opioid Dependence during Pregnancy: Relationships of Anxiety and Depression Symptoms to Treatment Outcomes. Addiction. 2012;107(0 1):74\u0026ndash;82. \u003c/li\u003e\n\u003cli\u003eMattocks KM, Clark R, Weinreb L. Initiation and Engagement with Methadone Treatment among Pregnant and Postpartum Women. Women\u0026rsquo;s Health Issues [Internet]. 2017;27(6):646\u0026ndash;51. Available from: https://doi.org/10.1016/j.whi.2017.05.002\u003c/li\u003e\n\u003cli\u003eApsley HB, Brant K, Brothers S, Harrison E, Skogseth E, Schwartz RP, et al. Pregnancy- and parenting-related barriers to receiving medication for opioid use disorder: A multi-paneled qualitative study of women in treatment, women who terminated treatment, and the professionals who serve them. Womens Health (Lond). 2024;20:1\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eCampbell J, Matoff-Stepp S, Velez ML, Cox HH, Laughon K. Pregnancy-Associated Deaths from Homicide, Suicide, and Drug Overdose: Review of Research and the Intersection with Intimate Partner Violence. J Womens Health. 2021;30(2):236\u0026ndash;44. \u003c/li\u003e\n\u003cli\u003eSmid MC, Schauberger CW, Terplan M, Wright TE. Early lessons from maternal mortality review committees on drug-related deaths\u0026mdash;time for obstetrical providers to take the lead in addressing addiction. Am J Obstet Gynecol MFM [Internet]. 2020;2(4):100177. Available from: https://doi.org/10.1016/j.ajogmf.2020.100177\u003c/li\u003e\n\u003cli\u003eMaryland Maternal Mortality Review Program. Maryland Maternal Mortality Review: 2019 Annual Report [Internet]. 2020. Available from: https://health.maryland.gov/phpa/mch/Documents/MMR/MMR_2019_AnnualReport.pdf\u003c/li\u003e\n\u003cli\u003eHarris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O\u0026rsquo;Neal L, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform [Internet]. 2019;95(April):103208. Available from: https://doi.org/10.1016/j.jbi.2019.103208\u003c/li\u003e\n\u003cli\u003eMiller C, Lanham A, Welsh C, Ramanadhan S, Terplan M. Screening, Testing, and Reporting for Drug and Alcohol Use on Labor and Delivery: A Survey of Maryland Birthing Hospitals. Soc Work Health Care. 2014;53(7):659\u0026ndash;69. \u003c/li\u003e\n\u003cli\u003eChin JM, Chen E, Wright T, Bravo RM, Nakashima E, Kiyokawa M, et al. Urine drug screening on labor and delivery. Am J Obstet Gynecol MFM. 2022;4(6):100733. \u003c/li\u003e\n\u003cli\u003eWinchester ML, Shahiri P, Boevers-Solverson E, Hartmann A, Ross M, Fitzgerald S, et al. Racial and Ethnic Differences in Urine Drug Screening on Labor and Delivery. Matern Child Health J. 2022;26(1):124\u0026ndash;30. \u003c/li\u003e\n\u003cli\u003eSiegel MR, Cohen SJ, Koenigs K, Woods GT, Schwartz LN, Sarathy L, et al. Assessing the clinical utility of toxicology testing in the peripartum period. Am J Obstet Gynecol MFM. 2023;5(7). \u003c/li\u003e\n\u003cli\u003eIrvine MA, Oller D, Boggis J, Bishop B, Coombs D, Wheeler E, et al. Estimating naloxone need in the USA across fentanyl, heroin, and prescription opioid epidemics: a modelling study. Lancet Public Health. 2022;7(3):e210\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eHardin J, Seltzer J, Galust H, Deguzman A, Campbell I, Friedman N, et al. Emergency Department Take-Home Naloxone Improves Access Compared with Pharmacy-Dispensed Naloxone. J Emerg Med. 2023;66(4):E457\u0026ndash;62. \u003c/li\u003e\n\u003cli\u003eRao IJ, Humphreys K, Brandeau ML. Effectiveness of Policies for Addressing the US Opioid Epidemic: A Model-Based Analysis from the Stanford-Lancet Commission on the North American Opioid Crisis. The Lancet Regional Health - Americas [Internet]. 2021;3:100031. Available from: https://doi.org/10.1016/j.lana.2021.10\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"addiction-science-and-clinical-practice","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ascp","sideBox":"Learn more about [Addiction Science \u0026 Clinical Practice](https://ascpjournal.biomedcentral.com/)","snPcode":"13722","submissionUrl":"https://submission.nature.com/new-submission/13722/3","title":"Addiction Science \u0026 Clinical Practice","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health services, public health, maternal mortality, overdose, opioid use disorder, pregnancy","lastPublishedDoi":"10.21203/rs.3.rs-4365589/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4365589/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOverdose is a leading cause of maternal mortality; in response, maternal mortality review committees have recommended expanding substance use disorder (SUD) screening, improving collaboration between obstetric and SUD treatment providers, and reducing fragmentation in systems of care. We undertook an analysis of the perinatal SUD treatment landscape in Baltimore, Maryland in order to identify barriers to treatment engagement during pregnancy and the postpartum period and guide system improvement efforts.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e We conducted a survey of seven birthing hospitals, 31 prenatal care practices, and 108 SUD treatment providers in Baltimore from April-June 2023. Organizations were asked to quantify care for perinatal patients with opioid use disorder (OUD) as well as about screening, service availability, referral practices, and support needed to improve care.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSixty-one percent of the 145 contacted organizations responded. Birthing hospitals reported caring for pregnant persons with OUD with greater frequency than prenatal care practices or SUD treatment programs. Most birthing hospitals and prenatal care practices reported screening for OUD at intake, but the minority reported using validated tools. Service availability varied by type of organization and type of service. In general, prenatal care practices offered the fewest number of SUD-related services. Most SUD treatment programs that offered buprenorphine or methadone to the general population also offered these medications to pregnant patients. Withdrawal management for comorbid alcohol/benzodiazepine use disorders during pregnancy was more limited. The majority of birthing hospitals and prenatal care practices reported offering neither direct naloxone distribution nor prescriptions. Few SUD treatment programs offered tailored services for perinatal patients or for parents of young children, and many programs do not permit children onsite. Respondents reported high levels of interest in education and consultative support on SUD treatment in pregnancy within obstetric settings and on pregnancy-related medical concerns within SUD programs.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis project provides a comprehensive picture of services available for treatment of perinatal OUD in a major US city. Results have served as a guide for ongoing citywide system improvement efforts by our project team and offer a model for other jurisdictions hoping to strengthen services for perinatal OUD and reduce maternal mortality.\u003c/p\u003e","manuscriptTitle":"Services for Perinatal Patients with Opioid Use Disorder: A Comprehensive Baltimore City-wide 2023 Assessment","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-13 19:52:17","doi":"10.21203/rs.3.rs-4365589/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2024-06-11T03:11:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-23T18:27:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"172830564852220156096762628438623727520","date":"2024-05-20T14:27:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329974117852826429576113442825921811820","date":"2024-05-18T13:21:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-17T21:50:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-13T17:47:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-04T04:07:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"Addiction Science \u0026 Clinical Practice","date":"2024-05-03T18:38:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"addiction-science-and-clinical-practice","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ascp","sideBox":"Learn more about [Addiction Science \u0026 Clinical Practice](https://ascpjournal.biomedcentral.com/)","snPcode":"13722","submissionUrl":"https://submission.nature.com/new-submission/13722/3","title":"Addiction Science \u0026 Clinical Practice","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c6d3c8d2-8da4-4620-9689-e0949ee063d6","owner":[],"postedDate":"May 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T16:04:30+00:00","versionOfRecord":{"articleIdentity":"rs-4365589","link":"https://doi.org/10.1186/s13722-024-00507-0","journal":{"identity":"addiction-science-and-clinical-practice","isVorOnly":false,"title":"Addiction Science \u0026 Clinical Practice"},"publishedOn":"2024-10-15 15:58:00","publishedOnDateReadable":"October 15th, 2024"},"versionCreatedAt":"2024-05-13 19:52:17","video":"","vorDoi":"10.1186/s13722-024-00507-0","vorDoiUrl":"https://doi.org/10.1186/s13722-024-00507-0","workflowStages":[]},"version":"v1","identity":"rs-4365589","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4365589","identity":"rs-4365589","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}