Reducing Maternal Morbidity and Mortality With Pre-and-Postnatal Substance Use Disorder Screening
In Massachusetts, approximately 20 percent of deaths during pregnancy or within one year of pregnancy are related to substance use. And yet, care during pregnancy often does not include screening for substance use disorders. Recognizing this need, the Obstetrics and Gynecology Department at Boston Medical Center has implemented universal substance use disorder screening for pregnant and postpartum women, with the aim of decreasing maternal overdose and improving infant outcomes.
“There’s a push in Massachusetts – and nationally – to do a better job of serving and identifying prenatal patients with substance use disorders, and early identification and treatment leads to better outcomes for both mother and baby,” says Ronald Iverson, MD, MPH, vice chair of Obstetrics and director of Quality Improvement and Safety. “This is part of a larger effort to provide systematic approaches to major causes of maternal morbidity and mortality.”
Previously, a nurse in OB/GYN would do a phone intake for prenatal patients, asking about using drugs or alcohol. However, the department found that this process was insufficient for identification of patients with substance use disorder, and follow-up for connection to treatment was inconsistent. Therefore, a universal screening process was put in place to ensure all patients get the treatment they need.
Patients are screened three times – at their first prenatal visit, their mid-pregnancy visit at 24-30 weeks, and their first postpartum visit. At the prenatal and postpartum visits, patients are given the written screening form when they check in, and answers are entered into Epic by the medical assistant; at the mid-pregnancy visit, the screening is given directly by the medical assistant. Since the program was fully implemented in April 2019, over 90 percent of eligible patients have been screened.
“We’ve heard worries that the questions are going to turn patients away or offend them, but the fact that over 90 percent of patients who are asked to fill out the form do so shows that they understand why we’re asking these questions,” says Iverson. “It also indicates that our patients feel safe answering the questions.”
If a patient answers yes to any questions on the screen – including if anyone around them has problems with drugs and/or alcohol, not just their own use – the provider will do a brief intervention, which is to have a discussion with the patient to learn more. They’ll then decide on next steps with the patient, based on the patient’s individual needs and risk factors.
Those next steps might include check-ins between provider and patient, a meeting with a social worker, or a direct connection to other programs such as Project RESPECT, which provides treatment to pregnant women with substance use disorders, or treatment closer to home.
“Screening is about being able to begin a conversation to assess risk,” says Elise Petersen Memmo, MPH, MSW, LICSW, lead quality improvement specialist in the Department of Obstetrics and Gynecology. “If a patient is at risk, we’re able to build on the strong foundation that BMC already had in caring for pregnant women with SUD through our RESPECT clinic.”
The ultimate goal is to have patients who need it in a treatment program, so that when they have their baby, they’ll have a system already set up to care for them through the postpartum period. This goal recognizes the fact that women with substance use disorders who are not in treatment have the highest risk of maternal morbidity and mortality prenatally and in the postpartum period.
Screening is one component of a larger opioid use disorder “bundle” that focuses on pregnant and postpartum women and aims to reduce morbidity and mortality related to substance use and to improve infant outcomes. The bundle, which Iverson helped develop, is part of the Alliance for Innovation in Maternal Health (AIM) effort to provide systematic approaches to major causes of maternal morbidity and mortality.
Other components of the opioid use disorder bundle – which will be implemented over several years – include improving continuity of care and educating staff and providers on opioid use disorders and the particular needs of pregnant and postpartum women. Currently, BMC has created workgroups to look at how to best educate staff, what systems are already in place for continuity of care and how they can be improved, and how to best measure improvements in maternal morbidity and mortality.
Along with these workgroups, the OB/GYN team is working with community health centers and community organizations to extend the screening and figure out how to best serve prenatal and postpartum women in their populations. They’ve also started a series of staff education on substance use disorders and trauma-informed care, so that all staff members in OB/GYN are prepared to take care of patients with substance use disorders.