Impact of a Multidisciplinary Program on Pregnancies Affected by Opioid Use Disorder

Introduction
The incidence of opioid use disorder (OUD) among pregnant women has significantly increased in the last 2 decades, and is now the second leading cause of pregnancy related deaths1. Now complicating 1-2% of pregnancies, OUD is associated with an increased risk of maternal and neonatal complications including fetal growth restriction, preterm birth, and neonatal abstinence syndrome2. To address some of the unique challenges associated with caring for this population, we created a multidisciplinary program to provide coordinated prenatal care for women with OUD. The aim of this study is to evaluate the impact of this program on adequacy of prenatal care and pregnancy outcomes.
Methods
This is a retrospective cohort study of women with OUD who delivered at our institution between 3/1/18 and 12/31/19 who were offered referral to the Connections Program (CP) and had at least one prenatal visit. In addition to seeing an obstetrician for routine prenatal care, women in the CP were seen by a case manager and a recovery specialist. The primary outcome was adequacy of prenatal care, as assessed by the Kotelchuck Index, a validated index focusing on two elements of prenatal care: how early care was initiated and the percentage of expected visits attended3. Adequate care was defined as initiating care by 16 weeks gestation and attending at least 80% of expected visits. Secondary outcomes included rates of medication-assisted treatment (MAT), rehabilitation, drug relapse, obstetrical and neonatal outcomes, and postpartum follow-up.
Results
100 women met inclusion criteria: 79 women opted to participate in the CP (“CP group”) and 21 declined (“no-CP group”). There was no difference in baseline characteristics between groups. At the time of referral to CP, 42% of women were actively using or had used opioids within the last 6 months, and polysubstance abuse rates were high in both groups. There was no difference in adequacy of prenatal care between the CP and no-CP groups (53.2 vs 38.1% adequate care, p=0.45). Women in the CP group were more likely to use MAT (73.4% vs 38.1%, p=0.01) and attend rehabilitation (75% vs 28.6%, p=0.003) than those in the no-CP group. There was no difference in relapse rates, pregnancy outcomes, or neonatal outcomes. Neonates of women in the CP group were more likely to have a meconium drug screen positive for MAT (70.9 vs 38.1%, p=0.009), reflecting higher use of MAT in that group. There was a trend towards higher postpartum visit attendance in the CP group (86.1 vs 66.7%, p=0.06).
Conclusions
Our study found no significant difference in adequacy of prenatal care for women with OUD followed in a multidisciplinary program, although this may be due to our small sample size. However, participation in the program was associated with higher use of MAT and rehabilitation services, which have been shown to be effective therapies for treatment of opioid use disorders, and may improve long term maternal outcomes. Given the scope of the opioid crisis, future studies should continue to explore treatment strategies to improve pregnancy outcomes for women with OUD.

References: 1. Goldman-Mellor, Sidra, et al. “Maternal Drug-Related Death and Suicide Are Leading Causes of Postpartum Death in California.” American Journal of Obstetrics and Gynecology, vol. 221, no. 5, 2019
2. ACOG Committee Opinion No. 524: Opioid abuse, dependence, and addiction in pregnancy. Obstetrics And Gynecology. 2012;119(5):1070-1076.
3. Kotelchuck, M. “The Adequacy of Prenatal Care Utilization Index: Its US Distribution and Association with Low Birthweight.” American Journal of Public Health, vol. 84, no. 9, 1994, pp. 1486–1489., doi:10.2105/ajph.84.9.1486.