Description of the Problem Our Project Seeks to Solve: Northern New England (Maine, New Hampshire, and Vermont) has among the highest rates of opioid dependence in the United States, with prevalence highest and growing among those between the ages of 18 and 35 years. This region also has among the highest rates of opioid-related deaths in the United States, with a disproportionately high rate among pregnant women with opioid use disorder. In northern New England, 5–8 percent of newborns have mothers with an opioid use disorder (OUD), greatly increasing the risk of poor outcomes, including preterm birth and long-term hospitalization for neonatal withdrawal and other newborn complications. For pregnant women with OUD, medication-assisted treatment (MAT) significantly reduces these risks. However, it is sometimes difficult for pregnant women to find MAT providers. As a result, many maternity care providers have begun to prescribe MAT in their own practices. Other practices have maintained the long-standing evidence-based standard of care: referral of patients with OUD to specialty MAT treatment programs. Most pregnant women with OUD have other psychosocial needs, ranging from lack of housing and untreated mental health conditions to a need for parenting education and support. There is variability among practices in terms of the types of other services provided to patients, whether the practice has integrated MAT or relies on referral.
Although pregnancy is a time when women are highly motivated to start MAT, many women are also likely to discontinue MAT postpartum due to loss of insurance coverage, difficulty transitioning to another provider, loss of motivation for treatment, or competing demands on time and resources as a new parent. The challenge for patients, providers, and other stakeholders is to understand the relative advantage of the two MAT models (receiving MAT as part of maternity care or at a specialty program) for improving key outcomes for baby and mother. A second challenge is to understand the relative contributions of onsite services, such as mental health care, care coordination, and parenting education, to improved outcomes. This question is important to patients and families that may have a choice of where they receive their maternity care. It is even more important in rural areas, such as northern New England, where obstetric practices and specialty care services are limited. Patients, providers, and other stakeholders need guidance in choosing the optimal models for building new programs to provide maternity care for women with OUD.
Intended Outcomes: We will focus on outcomes identified by pregnant and parenting women with opioid use disorder and their maternity care providers as important. The study will compare the outcomes of women receiving prenatal care in practices that provide MAT with those of women receiving care in practices that refer MAT to specialty care. We will study the following outcomes important to women and their care team: experience of care, depression and anxiety, quality of life, pregnancy and complications, maintenance of child custody, infant treatment for neonatal withdrawal, illicit opioid and other substance use abstinence, and maternal MAT treatment engagement during pregnancy and early postpartum. At as result of our study we hope to answer two key questions for pregnant women with opioid use disorder: (1) Is there a clear benefit to me and my baby from receiving prenatal services in practices that provide MAT rather than practices that refer patients to specialty providers? (2) What services will help most to support my long-term recovery?
Why This Project Is Important to Patients: Maternity care providers are striving to identify the most effective ways to provide the best care and support to their patients with opioid use disorder, to improve outcomes for both mothers and their infant children. Payers are looking to identify the best ways to use resources to address the growing opioid epidemic that is ravaging the northern New England region and other rural areas throughout the country. Women are looking for ways to get the care they need to promote the health of their infants, and ways to maintain recovery to maintain custody of their infants. Through the comparison of real-world experiences of these two models of MAT within maternity care practices, we will gain insight into what types of services are associated with the best outcomes for mothers and babies. This knowledge will help patients, providers, policy makers, state Medicaid officials, and other stakeholders work together to design effective programs.
How Patients and Stakeholders Will Make This Project Successful: Patients and stakeholders will be the drivers of success in this study. We are partnering with patients and providers in 21 practices providing maternity care in rural, semirural, and semiurban areas across the three northern New England states to ensure that our study reflects the diversity of our region. We are using a patient-centered, participatory approach to the study whereby patients and stakeholder partners will be active collaborators in all phases of the study, including prestudy planning, conducting the study, assisting in analysis and interpretation of study results, production of dissemination materials, and participation in sharing of study results to their networks. Our patient and stakeholder partners, along with a study advisory committee, will ensure that the study produces results that are relevant, meaningful, and actionable in terms of impacting practice and policy related to the effective care of women with opioid use disorders and their infants.
Other Health Services Interventions
Training and Education Interventions
*All proposed projects, including requested budgets and project periods, are approved subject to a programmatic and budget review by PCORI staff and the negotiation of a formal award contract.