Navigating substance use disorder can be especially difficult for those who are pregnant. As reported in InvestigateWest, state data shows that mental health conditions and substance use disorder were the leading causes of pregnancy-related deaths in Oregon from 2018 to 2021. And a study from OHSU found that the rate of opioid use during pregnancy has more than doubled over the last decade.
Those with substance use disorder are often reluctant to seek prenatal care due to stigma around their addiction, and drug treatment centers often turn away pregnant patients due to potential health risks. Efforts like Project Nurture and Nurture Oregon aim to integrate behavioral health and perinatal care by connecting pregnant clients with peer support, social services and other resources.
Diana Smith is the clinical lead for Project Nurture at Legacy Health. Sarah Bovee is a perinatal peer mentor and doula for Project Nurture. They join us to talk about providing simultaneous perinatal care and treatment for substance use disorder.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. As we heard not long ago in a conversation with InvestigateWest reporter Kaylee Tornay, Oregon data shows that mental health conditions and substance use disorder were the leading causes of recent pregnancy-related deaths. Meanwhile, a study from OHSU found not long ago that the rate of opioid use during pregnancy has more than doubled over the last decade. But people with substance use disorders are often reluctant to seek prenatal care due to stigma around their addiction, and drug treatment centers often turn away pregnant patients due to potential health risks. Efforts like Project Nurture and Nurture Oregon aim to address this by combining behavioral health and perinatal care. Diana Smith is a certified nurse midwife who works for Project Nurture. Sarah Bovee is a peer mentor and doula for Project Nurture. They both join me now. It’s great to have both of you on Think Out Loud.
Diana Smith: Thanks so much. Happy to be here.
Miller: Sarah, first, my understanding is you have four children ranging in age from four to 26, and from what I’ve read, their births were very different, depending on what had been going on in your life at the time and in particular whether or not you were in active addiction in those times. Can you tell us about your most recent pregnancy? First of all, what was your prenatal care like?
Sarah Bovee: In 2020, I got pregnant. It was during COVID, so it was hard for me to access prenatal care during that time, but also in my active addiction, it made it even harder. The stigma internally and stigma externally made it really hard for me to access those supports.
Miller: What prevented you from accessing support and what were your fears, maybe, for what would happen if you went in for a prenatal care visit?
Bovee: Well, for one, just the active addiction challenges, of just being able to get to a clinic, of knowing that I’m in the midst of my addiction to opiates at that time, and that it was just hard for me to stop and just the shame around all of that. I was able to access prenatal care when I had support, when I had connected with a harm reduction doula in Seattle.
Miller: What were your hopes, given all that, for what your birth would be like?
Bovee: Personally, because I had been through the system before and had also had a significant time in recovery and jumping through the hoops of the child welfare system and succeeding, I knew that this was an opportune time for me to be able to access the medical care that I needed. That didn’t mean that I wasn’t afraid, but I knew that if I accessed those resources and I did the next indicated step and did what was best for my child, that I’d be able to parent.
Miller: Can you tell us about the birth?
Bovee: I showed up there at the hospital, and I had my baby, and afterwards I experienced some stigma that ended up in some after birth trauma, that left me in the hospital for 21 days. During that time, I was connected to treatment. I was connected to addiction medicine providers. They stabilized me on buprenorphine. But the experience was scary, to say the least. I did share a lot about it in other settings and in that article that you referenced.
Miller: And the gist is that, from your perspective, the symptoms you were experiencing immediately post-birth were not taken seriously in your mind because you were just seen as an addict, as opposed to somebody who was dealing with a serious medical situation? And then enough time went by that it became more serious, because health care professionals, in your telling, didn’t take your actual medical concerns seriously? Is that a fair way to summarize it?
Bovee: Yeah, I felt some pressure and had brought that to the attention of my care team, and they thought that I was experiencing withdrawal symptoms, even though I knew that’s not what I felt. I was also put on a higher dose of Suboxone than I should have been. It made me very sedated and I was left for 45 minutes, which led to further harm.
Miller: In the days that followed, or maybe even as you said, the weeks that followed, what helped you most?
Bovee: What helped me most was connecting with my care team in a way in which they’d seen that I could succeed at being a parent, connecting me with the resources I needed to fill gaps. I wanted more than anything to be in a safe place as well as to be a safe space for my child. And so, over the next 21 days, I had an addiction medicine specialist that helped me change that tape in my head. And I had other people that were there to support me and show me that there doesn’t have to be as much of a bridge between what I hope to see and what I can do.
Miller: When you say they helped you change the tape in your head, what was the tape? What was it saying?
Bovee: The tape was, “I’m not good enough. I can’t do this. I’m not going to be able to meet the expectations of child welfare.” Even though, like I said, I had been there before and I knew that this would be an opportune time, I still was hearing all of that. Especially having had the experience that I did after the birth, it led to more shame, and at one point I was like, well this is my karma for using while I was pregnant, so it took a long time to change that tape.
Miller: Is it fair to say that the stressors, the physical and the emotional pain you were dealing with in those weeks, that they might have led you back into active addiction at earlier points in your life?
Bovee: Absolutely, yes.
Miller: So in that sense it seems like a huge win and sort of an amazing thing that they didn’t this time. I guess I’m still wondering why not? What was different about this time?
Bovee: I wish I could say, because I had gotten a significant time in recovery before, but what led me back into active addiction was deaths in my family and not having the proper support around me. So I think just since then, I’ve had the proper supports around me.
I also had to experience 21 days in the hospital where, because of the stigma of me being a person in addiction, they overlooked my son’s condition of pyloric stenosis, which was actually a very organic thing that happens sometimes for babies, and they had overlooked it as if I was not feeding my child appropriately.
So CPS was involved with that, and it took 15 days before they realized that they overlooked that he had pyloric stenosis. So, even through that, I was able to not turn back to addiction. And there’s been things this time around, it’s been five years, I’m coming up on five years in recovery and a year off of buprenorphine. The things that I think have kept me here this time is just the actual support that I have and knowing how hard I fought to get here.
Miller: As I noted, Diana Smith is with us as well, a certified nurse midwife who works for Project Nurture. Diana, you’ve described yourself as a midwife who works at the intersection of addiction and reproductive health. Why did you seek this out?
Smith: Well, I had been a midwife for a number of years before I came to Portland, and I joined a practice here in town where our clinic had been chosen as a pilot site for Project Nurture, because we knew that many women who came to us for care were reporting that they were using substances and wanted access to treatment and mental health supports.
I personally have family members who have substance use disorders. My sister had struggled with use during her pregnancy and was a teen parent, and I navigated with her alongside that journey, so I was compelled to become a part of this work and really to respond to the need that I was seeing in our community. When I began doing it, I just found it to be incredibly satisfying work because substance use disorders are chronic medical conditions, that we have medications to treat them, we have therapies that work, and we need to build our support system. So within a program like Project Nurture where people get that wraparound care, we see people succeed.
Miller: It seems that pregnancy represents both a serious danger in a number of ways and also a real possibility for people who are already struggling with substance use disorder. Can you describe those two sides of it, the danger and the opportunity?
Smith: Sure. We know that untreated substance use disorder is the leading cause, along with other mental health conditions, of death during pregnancy in the year postpartum. One leading cause nationally, but also the leading cause here in our state. So it’s a complex issue.
When people are using substances, it affects their bodies physically, it has potential to affect the fetus that they’re carrying. Certainly, the stigma and bias and lack of resources prevent people from getting care. They can experience a lot of health sequelae related to poverty, living outside, infectious disease that comes with active use. Very hard on your health.
On the flip side, we’re talking about reproductive-age women, many of whom haven’t been long in their addiction and their use. They often have motivation internally, and they’re compelled to seek care. And when they’re welcomed to care, they can be very engaged in working towards recovery. And then there are pressures from the outside system. Fear of child welfare and the fear of having their family disrupted.
Miller: How would you describe overall the relationship between perinatal or maternal care and the behavioral healthcare worlds right now in general? I know there’s a lot of different versions of this, but broadly, what do you see?
Smith: Well, I think the systems have set us up to be very siloed. Pregnancy healthcare happens over in physical healthcare – OB-GYNs, midwives that are really experts in reproductive health. And then we’ve got our addiction medicine specialists and behavioral health counselors that operate in our systems of behavioral healthcare. And often they’re not working together and communicating across the system. So you have folks in treatment settings and behavioral health who feel really scared and unprepared to take care of pregnant people.
Miller: What are the reasons that they’re scared? What have you heard?
Smith: Just general knowledge gaps. Like, “We don’t know what to do,” they’re worried that maybe they would do inadvertent harm, or they don’t know if the medications or treatments that they use are safe to use during pregnancy.
They also just don’t have the resources that they need, like not every addiction treatment center has an infrastructure to bring families in. So for people who are parents and have young children, ideally, the family would stay together and those young children would come with the parents into that treatment setting.
Miller: But that’s rare.
Smith: There are a limited number of beds, yeah,
Miller: So that’s more in the behavioral health side. What about on the OB or midwife side? What do you hear in terms of their general understanding of, awareness of, and ability to deal with or help people through substance use disorder?
Smith: I think many people did not receive formal education on substance use disorder in their training. So there’s a knowledge gap. And then there is unintentional and also overt stigma and bias against people who use drugs, and sometimes an attitude of like, “That’s just not what we do here.” And I think with good collaboration, we really do need more addiction medicine specialists and people trained with those expertises that can partner then with our reproductive health specialists and provide that dual care.
But there’s also a lot we can do as OB providers and midwives to learn about addiction and at least have an open mind and a welcoming attitude and a science-based understanding of the disease so that we can connect people with the treatment that they need.
Miller: If you’re just tuning in, I’m talking right now with Sarah Bovee and Diana Smith. Diana Smith is a midwife who works at the intersection of addiction and reproductive health. Sarah Bovee is a peer mentor and doula now for Project Nurture. Sarah, what does your daily work entail now, as a doula and peer mentor for Project Nurture?
Bovee: It’s all over the place, because I meet clients where they’re at, whether that be at the hospital where they’ve arrived for the first time to have their baby, or whether it be that they’ve established prenatal care within our midwifery office, or sitting alongside them through intensive outpatient groups that our CADC facilitates.
It’s a lot of meeting people where they’re at with non-judgment, and letting my story or my experiences also help guide them and teach them how to advocate for themselves and be consistent with compassion and help them build their autonomy.
Miller: What are specific ways that you draw on your own experience as you’re helping them? I guess what I’m wondering is, what does it mean to you to be a peer mentor?
Bovee: It’s healing for me. It’s healing for them. It’s a mutual healing. I’ve been in dark places, but then I’ve also made it out of those dark places and have had success, and I feel like everybody deserves that and everybody deserves dignity. And so, as I watch somebody else heal through their journey, it also heals me.
Miller: Just last week we talked to a reporter who had done a pretty deep dive into the nationwide issue of women being referred to law enforcement post-birth after positive drug tests. How much does the fear of either being arrested or losing your children prevent expecting mothers from seeking care, whether prenatal care or support for substance use disorder in the first place? I’m wondering how much the people you’re talking to don’t seek care because they’re afraid of what might happen if they do?
Bovee: I think it depends on how early we’re able to get to them and pair them with support. I meet people sometimes that have been connected to us through outreach, where they currently are living in homeless camps, and they have so much fear about child welfare because of maybe past involvement that makes it to where they end up not even being able to access our supports, no matter how many times I reach out. So there’s a lot of fear around that.
It’s the way that the system treats a person, and by the system, I mean all the systems that a person with addiction has to navigate, whether that be medical or child welfare. The way that they hold space for a person with non-judgment and let them have autonomy in the choices that they make, it really dictates the trajectory of where that person is able to go as a parent and the healing that they’re able to access.
Miller: Diana, how does payment work for this, for the kinds of services that Sarah is providing or the kinds of trauma-informed practices that you want, system-wide, people to adopt?
In the end, in America, so much of healthcare comes down to, who’s going to reimburse this? At what level will this be reimbursed? Will it be reimbursed at all? This care, will insurance pay for it? Will Medicaid pay for it? What does that look like in Oregon?
Smith: This is a big barrier for our program’s sustainability and expansion. There isn’t a great reimbursement model for this complex care that is integrating behavioral health and physical healthcare and so the payment systems are siloed, just as the healthcare delivery systems are siloed.
We are working with folks across our state, both on the healthcare system side and the payer side, the CCOs, the Oregon Health Authority and the legislature to try to solve for this and come up with a value-based reimbursement that really recognizes the positive impact of the care during the pregnancy and the good health outcomes for the whole family lifelong.
Miller: You also work with the Oregon Perinatal Collaborative, which focuses more on these kinds of policy questions, as opposed to individual healthcare questions, to reduce perinatal mortality and morbidity, including from substance use disorder. What does that policy work look like right now?
Smith: Right now, a lot of the work that Oregon Perinatal Collaborative does, or the OPC, is to bring community partners together and folks from across the different sectors to do collective problem solving.
Right now, we’re working on figuring out some guidance with work groups from the Oregon Health Authority, with representation from people around the state on recommendations for how to bill for peer services like the services that Sarah provides in physical health settings, and also really advocating for Medicaid reform.
Miller: Sarah, I’m curious what message you would give to people listening right now, who are dealing with these issues themselves, dealing with pregnancy and substance use disorder right now. If you were talking directly to them, what would you say?
Bovee: That there is a way out, that there are people doing work so that you can have a safe space to heal within, so that you can parent your child if that’s what your choice is. But that, also, if you have a different idea of what it is you want that’s healthy for you, that they will support you through that too.
Miller: What would it have taken for you to hear that message at earlier points in your life? Diana, you raised your hand. You want to answer that first?
Smith: I want to speak to this common misconception that if the person were stronger, then perhaps they would have been able to achieve recovery sooner. What we really see with the disease of substance use disorders is that it’s very common for people to have multiple attempts before they get into sustained recovery. And it’s similar to folks living with diabetes or other mental health conditions, that they access care, they try it out, then they might have a stressor and return to their disease state and then recover.
So what Sarah described in her trajectory is actually pretty common. I think we need to plan for that. Not this idea that on the first try people are necessarily then going to be able to abstain for the rest of their lives, but that if we have a system that supports families to have the medications, the healthcare in place, and the supports to make sure they keep their kids safe and get back into their treatment and recovery, then they can sustain that and they’re more likely to get into long-term recovery after a few tries.
Bovee: And I echo that. Since 2004, I’ve been working on my sobriety and recovery and sustained recovery. I had eight years before and even when I went out again, I think that I’ve learned lessons from both of those times that were very imperative for me for my success now.
Miller: Diana, you mentioned families there, and I just want to, before we say goodbye, I just want to zero in on that. What would a system look like that is more attuned to family dynamics in the context of what we’re talking about here, as opposed to an individual?
Smith: Well, I think about the things that families broadly need like respite care, support in the early postpartum period, to support mental health, ensure that people are getting sleep and healthcare as they need to get through that early parenting window. Access to childcare, affordable housing, opportunities for employment, those things are really, really key.
I think we’re moving in the right direction, even within the child welfare system. That they have dedicated teams that work with families, that focus for families with addiction, that better understand that life course and are able to create individualized plans with the goal of keeping the family unified and supported and healthy and well and plans in place for when they need that added support.
Miller: Diana and Sarah, thanks so much. I appreciate your time.
Smith: Thank you.
Miller: Diana Smith is a certified nurse midwife who works for Project Nurture. Sarah Bovee is a peer mentor and doula for Project Nurture.
Note: The following transcript was transcribed digitally and validated for accuracy, readability and formatting by an OPB volunteer.
Dave Miller: This is Think Out Loud on OPB. I’m Dave Miller. Over a recent six-year period, women who’ve recently given birth were referred to police more than 70,000 times for allegedly using illegal drugs during pregnancy, but that is surely an undercount. It represents available data from only 21 states, including Oregon. As reported by the Marshall Project, these cases can involve drug tests that are difficult to read or are simply wrong. Meanwhile, in Oregon and 12 other states, child welfare agencies automatically report any positive test results to authorities. Shoshana Walter is a staff writer and investigative reporter for The Marshall Project. She joins us now. It’s great to have you on the show.
Shoshana Walter: Thanks so much for having me, Dave.
Miller: Can you tell us the story first of Ayanna Harris-Rashid, a South Carolina woman who had her third child in 2021?
Walter: Absolutely. So, Ayanna was living in South Carolina at the time that she was pregnant with her son, and like a lot of women, she experienced severe pregnancy nausea and pain. And the medications that doctors recommended she take just were not effective for her. So to ease those symptoms, she took legally purchased CBD gummies during her pregnancy. She didn’t know, like a lot of women, that she would be drug tested when she gave birth. And the drug tests that hospitals use often cannot distinguish between a legal marijuana or hemp product, like a CBD gummy, versus something that is illegal under state law.
So when she went into the hospital to give birth, she and her son tested positive for marijuana. The hospital forwarded that positive test result to child welfare authorities, and child welfare authorities then automatically forwarded that report to police. And just a couple months after giving birth, Ayanna was in bed, breastfeeding her newborn son. She was scrolling on her phone when she got a call from law enforcement and was told that she had to turn herself in immediately on a felony charge of child neglect. She was arrested, strip searched, put in a cold and crowded jail cell, and faced up to 10 years in prison simply for taking legal CBD gummies during her pregnancy.
Miller: The charges against her were eventually dropped, but how was she affected by that whole ordeal?
Walter: Yeah, the charges were dropped, and she was relieved about that. But the experience just has led to this never ending trauma, the memory of her son’s birth has been forever tarnished by this experience of being arrested and strip searched shortly after delivering her child.
Miller: I mentioned the topline from your analysis that over the course of six years, parents in at least 70,000 cases in 21 states were referred to law enforcement over allegations of substance use during pregnancies. It doesn’t mean that they were necessarily arrested like Harris-Rashid. What’s the range of what can happen after people are referred to law enforcement?
Walter: In some states it’s almost like a matter of administrative routine. A police officer or prosecutor will receive a report and they’ll either discard it or file it away. It really just depends on where you live in the United States, and in some states, when police receive these reports they will sometimes accompany child welfare workers to the hospital or a parent’s home to investigate or interview the parent. And in many cases we found, police will actually rely on that report to make an arrest. So depending on where you live, you could be interrogated, arrested, jailed, and even prosecuted based on a single positive drug test result.
Miller: What were you able to learn about what’s been happening in Oregon?
Walter: Oregon is one state that actually does not require hospitals to report positive drug tests. So the numbers there are smaller than other states. We found the overall number of cases in Oregon were 101 over four years. You compare that to a state like Minnesota, there were 9,000 reports forwarded to law enforcement in a six-year period. So the overall numbers in Oregon are pretty small compared to some other states. But Oregon is one of 13 states that automatically refers every single one of these reports to law enforcement. That includes cases that might be based on an erroneous drug test result.
Miller: I want to hear more about those erroneous results in just a second, but what does federal law require?
Walter: Federal law only requires that a hospital notify child welfare authorities whenever they identify a newborn that was allegedly exposed to substances in the womb. And that’s so child welfare authorities can then make sure that the family has a plan in place, that they can refer that family to services they might need for that newborn who may have extra medical needs due to that substance exposure. What federal law does not require is a a child abuse or neglect investigation or a referral to law enforcement. There is absolutely nothing in federal law that requires that.
Miller: All right, so some states are going well past what’s required under federal law. What are the ostensible reasons for this? What’s potentially at stake for these babies?
Walter: A baby who’s been exposed chronically to substances in the womb definitely could face challenges that other babies do not face. They may experience withdrawal symptoms, they may experience developmental delays or physical disabilities. The science on that is a little unclear depending on what substance you’re looking at. So these babies, there’s definitely a medical need to identify them and to make sure that they have services that they might need to deal with these challenges.
But also what we’ve learned from decades of research is that mothers and babies fare better when they’re allowed to remain together. The best form of treatment for withdrawal symptoms in a newborn is to have that newborn remain with his or her mother, to have that newborn breastfeed, have skin-to-skin contact. So policies that lead to these automatic removals of children or automatic investigations and arrests are really not in the best interest of the mother or the baby.
Miller: Were you able to find out if every newborn in any given state is given a drug test or if these tests are unevenly applied?
Walter: Yeah. Drug testing policies vary hospital to hospital. It’s totally different depending on where you go to give birth. Some hospitals might drug test every single pregnant person who comes in to give birth, while others have more specific criteria. Some pieces of criteria I heard are, if the parent has limited prenatal care, if they have hypertension, if they have tattoos or bad teeth, those are some of the reasons a hospital might choose to drug test someone.
Then oftentimes it’s a subjective decision; a nurse or a medical provider may just decide, oh, this person looks or seems suspicious, we should drug test them. And what, again what studies have shown is that there are significant race and class disparities in who is getting drug tested. Black women, Hispanic women, Native American women, low-income women are far more likely to be drug tested when they go in to give birth. They’re far more likely to be investigated, and they’re less likely to reunite with their children once removed.
Miller: Just how reliable are these tests?
Walter: Most hospitals that drug test are relying on urine drug screens that have very high false positive results – about up to 50% – and they’re very easy to misinterpret. So, earlier we were talking about Ayanna. Most of these tests cannot differentiate between a legal CBD or hemp product and an illegal form of marijuana or cannabis. And I’ve seen again and again, women who were reported to authorities over positive tests triggered by poppy seeds, by common over-the-counter medications like heartburn meds, from blood pressure medication, even from the fentanyl in their epidurals. All of these substances can trigger false positives on these tests and lead to a report to authorities that has significant consequences for parents.
Miller: Some of the people that you talked to made a connection between the Dobbs decision that overturned Roe v. Wade and these referrals to police. What’s that connection that you heard about?
Walter: Yeah, so in many states, there are now a lot of legal rulings that have helped establish this notion of fetal personhood, and many of those cases are built on cases involving the arrest of women over allegations of drug use during pregnancy. So these reports of positive drug tests to child welfare authorities and then to the police have really significant implications for cases involving fetal personhood. They’re a significant part of the pipeline that is leading to women, actively today in the United States, getting arrested and prosecuted for using substances during their pregnancies.
Miller: Do you have any advice for what people should be thinking about or doing before they go to a hospital to give birth?
Walter: Yes, and I want to say too, as a mother, I had this firsthand experience. So what I’m suggesting is something I’ve had to go through myself, but I would highly recommend that if you’re expecting or planning a pregnancy, talk to your medical provider and ask what your hospital’s policy is on drug testing. I think fortunately, we have these stories from The Marshall Project that can be helpful in asking your medical provider. I remember when I asked, these didn’t exist yet and so my question was kind of met with suspicion.
But I think now that we have these stories, I would suggest women go to their doctors, send a link to these stories and say, I want to know what the hospital does, where I’m going to be giving birth. And if the hospital does drug test, what criteria do you use to determine who to drug test, and what kind of follow-up testing do you do after a positive screen? Is there confirmation testing? Is there someone who can interpret it accurately, who might know the difference between a false-positive and a legitimately positive result? And then if you have this positive result, what do you do with it? Who do you share it with? Does it go to child welfare? Does it go to law enforcement? I think women and pregnant people have the right to know what medical care they’re going to receive and how that information will be shared.
Miller: Shoshana, thanks very much.
Walter: Thanks so much for having me. I appreciate it.
Miller: Shoshana Walter is a staff writer and an investigative reporter for The Marshall Project.
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