Pregnancy-related mortality (defined as the death of a women during pregnancy or within one year of the end of pregnancy due to a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of pregnancy) increased from 7.2 deaths per 100,000 live births in 1987 to 17.6 deaths in 2019 (Pregnancy Mortality Surveillance System, Centers for Disease Control and Prevention, 2023). From 2017 to 2019, the leading cause of pregnancy-related death according to Maternal Mortality Review Committees (MMRCs) at 22.7 % was mental health conditions such as deaths of suicide, overdose/poisoning related to substance use disorder, and other deaths related to a mental health condition including substance use disorder (Trost et al., 2022). The significant increase in pregnancy-related deaths and associated infant health outcomes, has elicited a public health response to address the opioid crisis among pregnant and postpartum people (Patrick & Schiff, 2017; White, Ray-Griffith, & Coker, 2023).

From 2010 to 2017, diagnoses of opioid use disorder (OUD) increased from 3.5 cases to 8.2 cases per 1000 delivery hospitalizations (Hirai, Ko, Owens, Stocks, & Patrick, 2021). A corresponding increase occurred in diagnoses of neonatal abstinence syndrome (NAS) from 4.0 to 7.3 cases per 1000 hospital births during the same period (Hirai et al., 2021). The Comprehensive Addiction and Recovery Act of 2016, S. 524, 114th Cong. (2016) reauthorized the funding of initiatives related to residential treatment and recovery services for pregnant people, and development of plans of safe care for infants and caregivers. Screening, treatment, and provision of evidence-based care can reduce negative outcomes for pregnant and postpartum people with OUD (Ko et al., 2020) and infants with substance use withdrawal resulting in a broad diagnosis of NAS (Finnegan, Kron, Connaughton, & Emich, 1975) or, more specifically, neonatal opioid withdrawal syndrome (NOWS) (Jilani et al., 2021; Patrick, Barfield, & Poindexter, 2020; Picotti et al., 2019).

To support states in implementing systems changes to address OUD among pregnant and postpartum people and infants prenatally exposed to substances, in 2018, the Centers for Disease Control and Prevention (CDC) partnered with the Association of State and Territorial Health Officials (ASTHO) to invite state participation in the Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative (OMNI) Learning Community (LC; referred to as the OMNI LC). Fifteen state teams participated in the OMNI LC from October 2018 through August 2021. State teams were composed of state health officials or their designees, state Medicaid medical directors, state maternal and child health directors, state behavioral health or alcohol and drug abuse program directors, and clinical providers. State teams developed action plans with goals to improve capacity to meet the needs of pregnant and postpartum people, infants, and families affected by the opioid crisis (Kroelinger et al., 2019). Though the OMNI LC consisted of six areas of focus described elsewhere (see Kroelinger et al., 2019), the two focus areas most frequently identified among participating states were access to and coordination of quality services and provider awareness and training (Kroelinger et al., 2019; Kroelinger et al., 2020). Access to and coordination of quality services was defined as the assessment of eligibility and availability of services to aid in treatment, referral, or recovery efforts, coordination of quality care, and integration of ancillary services (Kroelinger et al., 2019). Provider awareness and training included guidance and education for providers on treatment protocols and guidelines to standardize care, screen and refer for treatment, and increase familiarity with clinical or social service resources and relevant state-specific laws and policies (Kroelinger et al., 2019).

Prescribing recommended medications for OUD (MOUD), such as methadone or buprenorphine, can support provision of a collaborative care model by providers, delivery hospitals, and health systems when addressing the needs of pregnant and postpartum people (Ecker et al., 2019). Screening, brief intervention, and referral to treatment (SBIRT) is a strategy recommended by clinical organizations to identify OUD, with MOUD offered to improve maternal and infant health outcomes (ACOG, 2017; Ecker et al., 2019). The development of protocols within delivery hospitals can facilitate the identification, referral, and treatment of OUD among birthing people and infants who are prenatally exposed to substances at the time of delivery (Babor et al., 2017). These protocols may also include training and monitoring the clinical provision of MOUD including a thorough history of substance use and a review of the Prescription Drug Monitoring Program with patients prior to prescribing (Babor, Del Boca, & Bray, 2017; ACOG, 2017).

At the time when the OMNI LC was implemented, the current federal regulations required that providers obtain special certification (a “waiver”) to dispense “medication-assisted treatment” (US Food and Drug Administration, Controlled Substances Act, 21 U.S.C. § 823, n.d.). In late 2020, a change in practice guidelines through Federal Register Notice [86 FR 22439] removed the waiver requirement and allowed eligible providers who possess an active Drug Enforcement Administration (DEA) prescriber’s license to prescribe and treat up to 30 patients for OUD (US Department of Health and Human Services [HHS], 2021). In late 2022, Congress enacted the legislation, removing requirements for health care providers to provide a separate DEA waiver to dispense medication for substance use disorder maintenance treatment or detoxification (US Food and Drug Administration, Mainstreaming Addiction Treatment Act of 2021, U.S.C. § 823 amendment S.445, n.d.). Though the amended waiver policy and legislation removed process-related barriers and increased the number of providers eligible who provide MOUD, continued provider trainings for screening, referral, and treatment of pregnant and postpartum people with OUD remain important for supporting the unique needs of this population (ACOG, 2017; Cleary et al., 2021).

Perinatal Quality Collaboratives (PQCs) are state or multi-state networks of multidisciplinary teams of clinical providers and other public health professionals implementing quality improvement (QI) initiatives statewide in hospitals and other facilities to equitably improve reproductive and infant health care and outcomes (Gupta, Donovan, & Henderson, 2017; Henderson et al., 2018). PQCs are uniquely positioned to identify gaps in health care processes and affect change at the facility and state level by reducing clinical practice variation and implementing clinical best practices (Henderson et al., 2018). PQCs also facilitate communication between clinicians and other public health professionals, collaborative learning, and the implementation of QI initiatives to achieve systems-level changes (Gupta et al., 2017; Henderson et al., 2018).

From September 2019 to September 2021, the CDC supported PQCs in 12 states and the National Network of PQCs (The National Institute of Children’s Health Quality, n.d.) to address OUD among birthing people and their newborns (Centers for Disease Control and Prevention, n.d.; Centers for Disease Control and Prevention, 2023). With this support, PQCs were required to provide training that increased the number of providers with waivers to prescribe MOUD. However, PQCs had the option to implement additional activities, including: 1) provider trainings on screening for OUD; stigma, bias, and trauma-informed care; or treatment and identification of opioid-exposed newborns; 2) protocol development to standardize care and increase referral plans for local and community support in participating delivery hospitals; or 3) strategies to increase the number of pregnant and postpartum people with OUD receiving recommended screening and linkages to evidence-based care and resources.

The CDC supported multiple activities as part of an overarching strategy to improve outcomes for pregnant and postpartum people with OUD and infants prenatally exposed to substances. This study analyzed data from two sources implemented in the overarching strategy during the same time frame to synthesize separate, yet complimentary efforts across many states. Reported data include summarized barriers and facilitators identified by OMNI LC state teams to increase access to and coordination of quality services and to improve provider awareness and training. Additionally, this study describes complementary QI activities implemented by PQCs. Both the OMNI LC and statewide PQCs worked to address OUD among birthing people at the state level and demonstrate ways in which public health and clinical providers can collaborate to affect change for those at higher risk of OUD. Presenting data from both sources offers a detailed description of activities within a state co-occurring in different systems: statewide in public health programming and clinically at delivery facilities.

An evaluation team consisting of scientists and other public health professionals from the CDC, ASTHO, and the University of Illinois Chicago (UIC) collected and analyzed data. This descriptive study synthesizes: 1) qualitative data extracted from 15 OMNI LC state action plans; 2) excerpts from qualitative interviews conducted with OMNI LC state teams; and 3) quantitative data derived from quarterly project performance monitoring reports (PPMRs) from the 12 CDC-funded PQCs. Analysis of the state action plans was completed by the CDC and ASTHO, interviews were conducted and analyzed by UIC, and PQC reports were collected and analyzed by the CDC. State participation varied by project and states participating in the OMNI LC and states with CDC-funded PQCs did not have complete overlap; therefore, the two initiatives were evaluated separately. We deidentified data from each source, analyzed independent of the other sources, and summarized separately, i.e., findings from the OMNI LC are reported separately from findings from the PQCs.

This project was determined to be public health practice and did not require Institutional Review Board (IRB) approval from the CDC and was determined exempt from IRB approval by UIC.

Partner engagement and coordination of integrated services was identified as a barrier to accessing quality care for OUD by state teams; all of which indicated a lack of coordination between clinical providers, delivery hospitals, and other ancillary providers to deliver comprehensive, integrated support services for pregnant and postpartum people, their infants, or their families (Table 1). The next major theme highlighted barriers to provider awareness, training, and service capacity. Examples include insufficient numbers of trained providers actively prescribing MOUD, insufficient numbers of in-patient treatment beds, unsustainable support programs, and provider bias toward persons with OUD. The insurance eligibility, coverage, and reimbursement theme included limited Medicaid eligibility and coverage periods up to 60 days postpartum which impacted continuity of care; and states identified a need for standardized billing codes to support optimal Medicaid and private insurance reimbursement for screening, treatment, and ancillary support services. Lastly, a lack of universal protocols, including those for identifying and screening for OUD, referring to treatment, and reporting to law enforcement or child protective services (CPS) were identified as barriers to accessing coordinated treatment and influenced patient willingness to seek treatment due to fear of negative consequences.

Interviews with key informants from OMNI LC state teams provided additional context for several barriers identified in the state action plans. For example, state team members discussed the need to train more clinicians participating in the statewide PQCs to provide MOUD and to encourage and support previously trained providers who are actively prescribing MOUD.

State teams discussed how stigma toward pregnant and postpartum people with OUD impacted access to and coordination of quality care, indicating a need for provider trainings to reduce bias and discrimination. As one state team member said,

Please see Supplemental Table 1 for additional qualitative excerpts supporting study findings.

All states listed facilitators for improved access to and coordination of quality care grouped through qualitative analysis into the themes of partner engagement and the coordination of integrated services; provider awareness, training, and service capacity; insurance eligibility, coverage, and reimbursement; and universal screening, treatment, and referral protocols for persons with OUD. Partner engagement and the coordination of integrated services included facilitators such as improving communication between prenatal clinics and birthing hospitals to aid standardized practices; disseminating research, policies, and plans of safe care among clinical providers and other partners; mapping the availability of providers trained to provide MOUD; and implementing policies to integrate behavioral health into medical settings (Table 2). Most states identified approaches to build provider awareness, training, and service capacity including coordinated buprenorphine trainings to increases the number of providers trained to prescribe MOUD, and implicit bias trainings for clinicians and other public health professionals to reduce bias, stigma, and discrimination toward perinatal patients with OUD. Next, states highlighted facilitators for insurance eligibility, coverage, and reimbursement such as standardizing definitions, protocols for insurance coding and billing to optimize reimbursement for SBIRT and expanding Medicaid coverage beyond the 60-day postpartum period. Lastly, states identified facilitators for improving universal screening, treatment, and referral for OUD, such as implementing standard definitions and protocols in birthing hospitals and other clinical settings for evidence-based identification, screening, and treatment referral. Some states developed universal protocols for the notification of CPS and/or the referral to support services or other ancillary programs offered through CPS.

Facilitators for improving access to quality care via the strategies listed above were discussed during state team evaluation interviews. Consistent with data derived from the action plans, analysis of OMNI LC state team qualitative excerpts described facilitators such as the coordination of clinical care, particularly following discharge, and the implementation of evidence-based protocols for screening, referral, and treatment.

OMNI LC state teams discussed implementing protocols to identify, screen, and refer pregnant and postpartum people with OUD to treatment. For example, one team shared how delivery hospitals are implementing OUD-specific protocols as a primary facilitator for the screening of OUD:

Some states expressed how clear and consistent protocols could facilitate appropriate pain management for birthing people with OUD and described collaboration with PQCs to increase the number of delivery hospitals with OUD-specific pain management protocols in place. One state team shared,

All 12 CDC-funded PQCs worked statewide to increase the number of providers with waivers to prescribe or dispense buprenorphine to treat pregnant and postpartum people, which included hosting their own waiver trainings or encouraging participation in national OUD treatment training courses. Other types of PQC-hosted trainings were optional, including provider trainings on screening for OUD; stigma, bias, and trauma-informed care; and MOUD and/or behavioral treatment for OUD (Table 3).

All CDC-funded PQCs reported increases in hospital participation in PQC QI initiatives to address OUD from baseline (September 2019) to end of project (September 2021; Table 4). Nine of the 12 PQCs implemented protocols in participating delivery hospitals for pregnant and postpartum people with OUD and opioid exposed newborns. Six PQCs reported on activities to increase the number of hospitals providing recommended screening and OUD treatment resources post-discharge.

This study had several limitations. First, the data collected, and findings presented were from two different sources. While some states provided data for both sources, not all state teams participated in the OMNI LC or in the CDC-supported PQC opioid QI initiatives or activities. The findings provided by both projects are complementary and overlap, addressing state-identified barriers to patient access to services. Second, findings are limited to participating states and the results are not generalizable to all states in the U.S. However, these findings can inform other states in the planning of programmatic activities for pregnant and postpartum people with OUD and their infants. Third, data collected through interviews or self-reporting may have been affected by response bias as state teams were interviewed in groups rather than individually. Fourth, state action plans varied in level of detail and required some interpretation; though the qualitative analysis protocol employed included consensus-based decision-making to limit over-interpretation. Fifth, not every PQC was required to implement all OUD initiative activities in participating hospitals. The study had no specific requirements for identifying which participating hospital submitted reported data on each metric, potentially introducing reporting bias. Last, the pandemic restricted travel and in-person gatherings, which impacted the OMNI LC in-person meetings, delivery of the provider trainings, and resource commitments by participating states for clinical and non-clinical activities. While the shift to virtual formats may have allowed more people to participate in meetings and trainings because of the lack of travel necessity, the pandemic also required shifts in staffing or funding resources, and activities may have been paused or scaled down to support response activities. PQCs reported challenges with hospital participation, staffing, and data reporting due to the pandemic.