Introduction

The postpartum period is a critical transition for women with substance use disorders (SUD) and is characterized by significant physiologic, social and emotional change. Often referred to as the “fourth trimester,” the postpartum period is traditionally defined as the 6–8-week period after delivery of the baby due to resolution of the physiological effects of pregnancy on maternal organ systems during this time [1]. However, because of the profound social, emotional and economic impact that pregnancy and childbirth have on many women, the postpartum transition is currently thought of as lasting up to 12 months after delivery [2].

Pregnancy is often characterized as a window of opportunity to provide preventative health care services. In contrast, the postpartum period presents multiple challenges and represents a period of unique vulnerability for women with SUD. Stresses associated with parenting, increased financial demands, limited resource availability and sleep deprivation can be overwhelming for women that often have limited social support [3]. Postpartum depression and anxiety, incomplete transitions from obstetric to primary care providers and loss of pregnancy-related insurance eligibility after delivery place women at significant risk of relapse and treatment discontinuation. Therefore, efforts to enhance care coordination among providers and increased attention to the complex psychiatric, social and environmental factors faced by women with SUD during the postpartum period can dramatically improve outcomes for this particularly vulnerable population [4].

Substance Use, Relapse and Treatment Discontinuation

Pregnancy is associated with a reduction in substance use for the majority of women [5]. Over half of women who report pre-pregnancy tobacco use quit smoking prior to their first prenatal appointment [6]. Likewise, 90 percent of women abstain from alcohol use and 70–100 percent of women abstain from other substances including cannabis, prescription opioids, and cocaine during pregnancy [7, 8]. Time to abstinence during pregnancy is shortest for alcohol followed by cocaine, cannabis, and cigarettes, with most women achieving abstinence by the second trimester. When all substances are evaluated concurrently, over 80 percent of women discontinue the use of at least one substance during pregnancy [9].

Conversely, women often resume substance use in the postpartum period. According to the National Survey on Drug Use and Health (NSDUH), binge alcohol (10.0 percent vs. 1.0 percent), cigarette (20.4 percent vs. 13.9 percent), and cannabis use (3.8 percent vs. 1.4 percent) are significantly higher among women during the first 3 months postpartum when compared to the third trimester of pregnancy [5]. Resumption of substance use can occur rapidly as approximately half of women who quit smoking during pregnancy, resume within the first 2 weeks postpartum [10]. Women with opioid use disorder (OUD) who are on medication-assisted treatment (MAT) are also at significantly increased risk of treatment discontinuation in the postpartum period. In an evaluation of over 200 women with OUD on methadone, the estimated probability of methadone discontinuation before 6 months postpartum was 56 percent [11].

Postpartum relapse carries a heightened risk of overdose and overdose death. In contrast to global trends, the maternal mortality rate is increasing in the United States, related in part to the opioid epidemic [12]. From 2002 to 2011, the maternal mortality rate for substance use and overdose exceeded that of any obstetric cause (hemorrhage, emboli, preeclampsia, or sepsis) [13]. In Maryland, substance use and overdose was the leading cause of maternal death in 2015, with all deaths but one occurring in the postpartum period [14]. For this reason naloxone co-prescribing and overdose awareness education should be a routine part of postpartum care for women with OUD.

Multiple reasons may exist for resumption of substance use and treatment discontinuation in the postpartum period. First, the frequency and intensity of maternal health care utilization decreases significantly after pregnancy. Frequently, women with SUD receive a combination of care from prenatal care, SUD treatment and sometimes primary care providers. After delivery, women transition from seeing their obstetric care provider every week during the end of the third trimester to a single visit 4–6 weeks after delivery. There is a recalibration of health care providers following delivery and, as a result, the pediatrician is the health care provider that many women most frequently encounter postpartum. Second, communication is often limited, especially postpartum, between obstetricians and other health care providers, and between the inpatient and outpatient settings. Third, the traditional SUD treatment system is typically not designed to accommodate both women and their children. Only 40 percent of SUD treatment facilities in the United States offer any women-centered programming, 15 percent offer specific services for pregnant and postpartum women, and only 8 percent offer childcare [15]. Addressing some of these barriers to continued care may help prevent treatment discontinuation, relapse and overdose death, prolong abstinence and support recovery.

Pain Management

Adequate control of pain in the immediate postpartum period can be challenging for women with OUD. Among women with OUD, acute pain is often underestimated and undertreated [16]. Furthermore, patients with a long history of OUD, including those who are prescribed methadone and/or buprenorphine, frequently have increased pain sensitivity and chronic hyperalgesia, especially after cesarean delivery [17]. In one small study, women who used methadone during their pregnancy required 70 percent more morphine milligram equivalents of opioids to adequately control their pain compared to women without OUD [17, 18]. Likewise, in another evaluation, women who used buprenorphine during pregnancy required 47 percent more opioids for pain control compared to those not on buprenorphine [19].

Given these challenges, special attention needs to be placed on adequate pain relief in the immediate postpartum period. Nonpharmacological interventions including abdominal binders, sitz-baths and analgesic sprays should be used as first-line therapy followed by acetaminophen and anti-inflammatory medications, such as ibuprofen or ketorolac, for postpartum pain control. However, for those with inadequate pain control with these agents, short-acting opioids may be used in addition to continuation of maintenance doses of buprenorphine and methadone [20]. If women with OUD continue to require additional opioids for adequate pain relief, they should be prescribed the lowest effective dose of short-acting opioids for short durations, in accordance with the CDC opioid prescribing guidelines [21]. Judicious use of opioids combined with a prioritization of nonpharmacologic interventions and nonopioid medications can help promote compassionate, patient-centered care while protecting against opioid misuse.

Breastfeeding

Breastfeeding and breastmilk may play a particularly beneficial role for women with OUD and their infants due to associations with decreased neonatal abstinence syndrome (NAS) severity, increased maternal confidence and enhanced maternal–child attachment [22–26]. In 2013, the American Academy of Pediatrics (AAP) emphasized the importance of breastfeeding for mothers on methadone or buprenorphine regardless of maternal dose. Despite recommendations, less than half of women who receive methadone pharmacotherapy breastfeed their infants after delivery. Even among women who breastfeed, up to 60 percent stop within 6 days of delivery [27]. However, OUD treatment programs that incorporate intensive prenatal and postpartum lactation counseling and support have shown far better breastfeeding initiation rates – 76 percent among women on buprenorphine [28]. In Guidelines for Breastfeeding and the Drug-Dependent Woman, breastfeeding recommendations for women with SUDs are clearly outlined [29]. Breastfeeding is not recommended for mothers who are actively using illicit drugs due to rapidly fluctuating levels of drug exposure.

Contraception and Reproductive Health Care

Unintended pregnancy is common among women with SUDs [30, 31]. Over 86 percent of women with OUD report having an unintended pregnancy compared to 45 percent of the US population [30, 32]. Women with OUD also report a higher prevalence of rapid, repeat pregnancies with approximately one-third of women reporting six or more pregnancies [31]. In a survey of 183 women enrolled in opioid treatment programs, approximately half reported having their first pregnancy under the age of 18 and 57 percent of women reported ever having had an abortion, a rate that is twice that of the general population [31].

In evaluations of contraceptive use patterns of sexually active women with OUD, only 26–55 percent report using any form of contraception, despite the majority not wanting to get pregnant [31, 33–36]. When contraceptive method choice is evaluated, the majority of women report using condoms as their predominant form of contraception, with less than 10 percent reporting the use of high effective contraceptive methods also known as long acting reversible contraception (LARC) [33]. A lack of awareness about the effectiveness of different contraceptive methods, inadequate prenatal contraceptive counseling, and failure to provide highly effective contraceptive options in the immediate postpartum period are significant barriers to reducing unintended pregnancy in this population [37].

Pregnancy and the immediate postpartum period provide unique opportunities to provide comprehensive family planning counseling, education and services [38–40]. Enhanced patient engagement during pregnancy with both prenatal and SUD treatment providers can facilitate education and counseling regarding the effectiveness of available contraceptive methods, the importance of consistent condom use to prevent sexual transmitted infection and pregnancy planning. Long acting reversible contraception (LARC) such as intrauterine devices (IUDs) and subdermal implants are safe and highly effective in reducing the incidence of unintended pregnancy in all populations and should be encouraged over other methods due to significantly greater continuation rates when used for postpartum contraception [41, 42]. To further reduce the risk of unplanned pregnancy, immediate post-placental IUD placement or insertion of implants prior to discharge should also be considered [43]. Given that less than half of women enrolled in MAT programs attend the traditional postpartum appointment approximately 4–6 weeks after delivery emphasizes the importance of contraceptive planning and LARC utilization in the immediate postpartum period [44].

Postpartum Mood Disorders

Women with SUD are more vulnerable to develop postpartum depression due to the high prevalence of co-occurring psychiatric disorders, limited social support, low self-esteem, and increased stress [45]. Emotional, physical and sexual abuse, which are also common among women with SUD, have also been consistently associated with an increased risk of postpartum depression [46]. The strongest risk factor for postpartum depression is a history of depression and the prevalence of co-occurring mood disorders such as depression, anxiety, bipolar disorder and posttraumatic stress disorder (PTSD) among women with OUD is estimated between 65 and 73 percent [47, 48]. Women with OUD and a co-occurring mood disorder are also at greater risk of adverse SUD treatment outcomes including both relapse and MAT discontinuation [48].

Approximately half of women with OUD screen positive for postpartum depression, a rate significantly higher than that of the general population [49]. As a result, all providers involved in the care of pregnant and postpartum women with SUDs should screen for perinatal depression. The most widely used screening tool used to identify depression in the postpartum period is the self-administered, 10-item Edinburgh Postnatal Depression Scale which takes less than 5 minutes to complete [50]. Screening for postpartum depression should occur at least once between 4 and 8 weeks after delivery, but may be administered more frequently for women with SUD [51]. Once depression is identified, the initiation of an antidepressant medication may be warranted. In particular, selective serotonin reuptake inhibitors (SSRI’s) are safe and effective medications in the postpartum period and are compatible with breastfeeding [52].

Social Support

Support from social workers, case managers, sponsors, and peer support groups such as narcotic anonymous (NA), alcoholics anonymous (AA) is critical to providing ongoing recovery support for women with a history of SUD after delivery. Many pregnant and postpartum women with SUD are at high risk for physical, emotional and sexual violence, have unstable or lack safe, drug-free housing, do not have reliable transportation and lack the financial resources necessary to provide for themselves and their children [53]. These social and environmental stressors are often exacerbated in the postpartum period when financial and emotional demands related to parenting and childcare are realized.

Special attention should be placed on communication between providers during the transition of care from the perinatal to postpartum period. Appropriate care for women with OUD will need to move beyond the traditional biomedical model to embrace a more holistic model of care. Much of the needed care may take place beyond the walls of the clinic and hospital. As such, systems that allow for adequate referral processes, integrated care and communication between providers will facilitate the successful care of postpartum women with OUD.

Parenting

Perhaps the most important transition in the postpartum period is to the role of parent. Women with SUD face unique challenges related to caring for an infant that may need a prolonged hospitalization for complications related to prematurity and/or NAS. Once home from the hospital, chronically drug-exposed infants are more likely to have abnormal sleeping patterns, feeding difficulties and may be difficult to soothe due to overstimulation [54]. Moreover, many women with a history of SUD often have poor parental role modeling, have low self-esteem and inadequate coping mechanisms that may interfere with development of effective parenting skills [55]. In an evaluation of parenting knowledge among women in a drug treatment program, 64 percent of women wrongly believed that holding their baby when they cried would spoil them, 51 percent were not aware that holding their baby would result in less crying and 67 percent did not identify signs of infant stress [55]. In addition to limited parenting knowledge, 58 percent of women incorrectly believed that children exposed to drugs in utero were “born addicts” [55]. Women with SUD who are caring for children often feel stigmatized, which results in barriers to open conversations with pediatric providers and traditional support systems to help with parenting [56, 57]. As a result, parenting skills training and education should be an integral component of any program that provides care to pregnant and postpartum women with SUD.

Child Welfare

State civil child-welfare statutes are heterogeneous in how they classify substance use during pregnancy. Currently 23 states and the District of Columbia consider substance use in pregnancy to be child abuse and 3 states consider it grounds for civil commitment [58]. The Child Abuse Prevention and Treatment Act (CAPTA) is one of the key pieces of federal legislation guiding child protection and the mechanism through which the federal government disburses block grants for local Department(s) of Social Services for child abuse and neglect prevention. Key elements of CAPTA include (1) the identification of infants born affected by substance use, withdrawal symptoms resulting from prenatal drug exposure or Fetal Alcohol Spectrum Disorder and (2) the establishment of a “Plan of Safe Care” for infants affected [59]. The Comprehensive Addiction and Recovery Act of 2016 additionally increased States’ accountability by requiring, to the extent possible, reporting back to the federal government the number of infants identified as meeting the criteria in CAPTA and the number for whom a plan of safe care was developed. Consequentially, many states are considering legislation that would mandate notification to child protective services when these infants are born, in addition to the 7 states that currently mandate testing and the 23 states including the District of Columbia that currently mandate reporting [58]. Therefore, it is not uncommon for women with SUD to become involved with child welfare in the postpartum period which may result in child removal, maternal arrest, and the lifelong consequences of a child abuse conviction [60].

The consequence of the opioid epidemic on the child welfare system is profound. In 2014, a third of all child removals were due to parental alcohol or drug use compared to 14 percent in 1998, with the largest proportion of removals occurring during the first year [61]. While providers need to be aware of local reporting mandates and provide appropriate counseling to their patients, they should advocate for the dismantling of harmful legislation and for the expansion of treatment and associated services for women with SUD.

Conclusions

Women with SUD face many challenges in the postpartum period. In addition to the physiologic, emotional and social changes that are faced by all postpartum women, those with SUD face additional barriers to appropriate care. These include stigma and discrimination, insufficient structural support for women who have children within the existing SUD treatment system, issues with adequate pain control, barriers to appropriate contraceptive management and breastfeeding support, and child welfare interference with care. Special attention to women with SUD in the postpartum period, including increased frequency of visits, intentionality of communication between providers and education about stigma may help reduce some of these issues and help support recovery and prevent relapse. Additional research to create evidence to promote policy changes to better support postpartum women with SUD will benefit both the health of the mother and the child.