Silent Struggles: Unveiling Stigma in Healthcare With Perinatal Patients on Medication for Opioid Use Disorder

Abstract

Perinatal opioid use disorder contributes significantly to the U.S. maternal health crisis. Medication for opioid use disorder (MOUD) improves maternal and neonatal outcomes, yet stigma remains a barrier to care for pregnant patients. This qualitative study examined stigma experienced by perinatal patients on MOUD and its impact on healthcare engagement using the Health Stigma and Discrimination Framework. Semi-structured interviews were conducted with 15 patients receiving integrated perinatal and addiction care in Philadelphia, Pennsylvania, between October 2023 and April 2025. Participants were aged 24–40 years; 47% identified as Black and 53% as White. Thematic analysis identified key drivers of stigma including societal judgments of parental fitness, fear of state involvement, and provider knowledge gaps regarding MOUD. Stigma manifested as inadequate pain management, fear of custody loss, and reduced care-seeking behaviors. Findings underscore the need for provider education and policy reform to reduce punitive responses to MOUD use in pregnancy.

Introduction

The prevalence of perinatal opioid use disorder (OUD) has been rising since 2010 and contributes to the current maternal health crisis in the United States (Hirai et al., 2021). Deaths related to overdose account for 16% of all pregnancy-associated deaths, with a maternal mortality ratio of 12–14 per 100,000 live births (Bruzelius & Martins, 2022; Han et al., 2024). In addition to maternal death, perinatal OUD is associated with negative fetal outcomes including increased odds of intrauterine growth restriction, preterm birth, and fetal loss (Maeda et al., 2014).

Treatment with medications for opioid use disorder (MOUD), such as buprenorphine or methadone, is the standard of care for OUD in pregnancy (“Committee Opinion No. 711,” 2017). MOUD is associated with improved treatment retention rates, lower unprescribed opioid use, and a reduction in peripartum overdoses (National Academies of Science, 2019). Pregnant patients on MOUD see additional improved neonatal and maternal outcomes including improved birth weight, increased prenatal visits, and lower rates of premature delivery (Johnson, 2019; Krans et al., 2021).

Despite the clear benefits of treatment, pregnant patients on MOUD experience significant stigma, which can lead to decreased healthcare and MOUD use and worsened maternal and neonatal outcomes (Stangl et al., 2019; Tsuda-McCaie & Kotera, 2022). Women with OUD experience more stigma than men with OUD, and the potential for fetal harm from substance use during pregnancy further fuels negative perceptions of pregnant patients with OUD (Tsuda-McCaie & Kotera, 2022). This stigma contributes to existing MOUD treatment gaps in pregnancy, with only 38% of pregnant patients with OUD receiving MOUD, compared with the national average of 50% among all people with OUD (Khachikian et al., 2022). Though prior studies have established stigmatization, there is lack of research connecting drivers, facilitators, and manifestations of stigma to perinatal health outcomes for those with OUD.

Our aim in this study was to elucidate these complicated connections for birthing people in treatment for OUD during pregnancy. To do so, we are the first to adapt the Health Stigma and Discrimination Framework to conceptualize the process of stigmatization in healthcare-related interactions for pregnant people on MOUD and the impacts of stigma manifestation on health outcomes.

Materials and Methods

We conducted semi-structured interviews of pregnant and postpartum individuals receiving care in a perinatal substance use treatment clinic exploring the process of stigmatization in health care settings. The study was approved by the University of Pennsylvania Institutional Review Board and followed the Consolidated Criteria for Reporting Qualitative Research (Tong et al., 2007).

Our study was guided by the Health Stigma and Discrimination Framework, which was developed to conceptualize components of the stigmatization process and their impacts on health outcomes. The framework identifies the drivers and facilitators of stigma. Drivers are the underlying person-level beliefs and attitudes that create stigmatizing behaviors while facilitators are broader system and society-level influences that either enable or hinder the stigmatization process. These drivers and facilitators manifest into stigma experiences that influence care outcomes (Stangl et al., 2019; Weber et al., 2021).

Study Site and Sample

The study was conducted in Philadelphia, Pennsylvania between October 2023 and April 2025. We recruited participants from a university-affiliated outpatient clinic that provides collocated perinatal care and MOUD treatment services with buprenorphine. Patients were eligible for recruitment if they were at least 18 years of age, spoke English as their primary language, and were pregnant or within one year postpartum.

In Philadelphia, Child Protective Services (CPS) is housed in the Department of Human Services (DHS) and is under the supervision of the Office of Children and Families. It is the department that investigates allegations of child abuse and neglect, including prenatal substance use, and decides which cases are brought to Family Court for determination of child custody on either a temporary or permanent basis (DHS, 2025). In Pennsylvania, like many other states, all cases of Neonatal Abstinence Syndrome (NAS) where neonates demonstrate symptoms of withdrawal due to in utero exposure of opioids or benzodiazepines including both MOUD and unprescribed medications should be reported based on mandatory reporting guidelines (DHS, 2019). While not all DHS reports lead to opening of investigations or cases against families, Philadelphia has the highest rate of child removal among the ten largest cities in the United States (NCCPR, 2025).

Interviews

The interview-guide was developed using the Health Stigma and Discrimination Framework and iteratively adapted throughout the study as new themes were identified (Stangl et al., 2019). Prompts explored patient perceptions of their healthcare experiences throughout pregnancy and postpartum, barriers and facilitators to care, and how interactions between the healthcare team and participants may impact future health behaviors. Two members of the study team (RS and NB) conducted interviews by phone. All participants were compensated with a $25 electronic payment upon completion of the interview. Interviews were recorded and transcribed verbatim.

Analysis

To develop the codebook, the authors (RS, NBH) used a hybrid inductive-deductive approach where some themes were predetermined based on the conceptual framework and other themes emerged during the analysis (Timmermans & Tavory, 2012). Each interview was coded by two coders (RS, NBH, MM), with high interrater reliability (Cohen’s k = 0.76), and coding discrepancies were resolved through consensus with the research team. We collected participant characteristics by self-report at the time of the interview and from the electronic medical record.

Results

Study Sample

Fifteen women ranging in age from 24 to 40 years participated in the study (Table 1). Seven participants identified as non-Hispanic Black, and eight participants identified as non-Hispanic White. Three participants were primigravida and the others were multigravida with between two and six living children. Fifty-three percent of participants were established on MOUD prior to their most recent pregnancy and the rest started or restarted MOUD during their most recent pregnancy. All patients were pregnant or within one year of pregnancy at the time of the interview.

Table 1.

Demographics

	n	%
Total	15	100
Age
20–29	5	33%
30–39	9	60%
40–49	1	7%
Race
White	8	53%
Black	7	47%
Ethnicity
Hispanic	0	0%
Non-Hispanic	15	100%
Living children
0–1	3	20%
2–3	9	60%
4–5	2	13%
≥6	1	7%
Stable on buprenorphine-naloxone	8	53%
Started or restarted buprenorphine-naloxone	7	47%

Findings

Participants disclosed a diverse range of stigmatizing healthcare encounters throughout their perinatal course. Several factors were identified as drivers, facilitators, and manifestations of stigma within the adapted Health Stigma and Discrimination Framework. Figure 1 demonstrates application of this framework to the specific experiences of pregnant patients on MOUD.

Figure 1.

Adapted Health Stigma Discrimination Framework

Drivers & Facilitators

Participants identified (1) health practitioner prejudice and lack of knowledge around MOUD use during pregnancy and (2) participant fear that MOUD use in pregnancy will result in state (CPS) notification and intervention as key drivers of stigma. Facilitators of stigma were identified as (1) health system and patient power imbalances, (2) societal expectations for mothering, and (3) mandatory state (CPS) notification for pregnant people on MOUD.

Drivers

Participants repeatedly shared experiencing negative perceptions from providers about MOUD use during pregnancy as a driver of stigma. Providers questioned the moral acceptability of MOUD use during pregnancy equating it to another form of addiction, labelling participants as unfit to parent.

“I just feel like [nurses and doctors] looked at me as if I was less than or as if I was trying to harm the baby [by being on buprenorphine].” Participant 4

“It can be nerve wracking because even though you are told it doesn’t have a negative effect on your child… you feel like a bad parent, knowing okay, if it doesn’t have an effect on my kids, or can’t create an addiction for them, then why do they have to stay extra days in the hospital compared to other kids. You know, sometimes it just makes you, as a parent, you just feel like, damn I wish I could have done things a little bit differently and not feel like I’m hindering my child off the bat.” Participant 9

The lack of education about MOUD was highlighted by experiences of several participants who felt providers expressed the erroneous perception that patients on MOUD experience euphoria from their treatment and are not truly sober. Additionally, these themes were often expressed in tandem with healthcare workers marking MOUD usage as a marker for risk of recurrence of illicit use:

“The hospital once they found out I’m on [buprenorphine] all of sudden was acting like I was going to start taking [drugs] right there in the hospital…I could tell they didn’t think I was going to stay clean for my baby.” Participant 15

Participants interacted with many healthcare workers who were unaware of the role for MOUD as a long-term maintenance medication. One participant shared her unique perspective as both a patient on MOUD and a nurse who overheard colleagues discussing that patients on MOUD should not be allowed to bear children. Most participants experienced the misperception that pregnant patients on MOUD are unfit parents, manifesting in the most extreme belief that patients on MOUD should be sterilized to prevent future reproduction:

“I feel like [nurses] think, ‘she shouldn’t be getting this, or she shouldn’t be taking it.’ People put their own stigmas in their head and their beliefs. It’s really hard to wrap into words, and even just the way, you know, people look at you, it’s just... It’s like uncomfortable.… It’s not something that is easy to control, especially reading people’s history. A lot of people, even some of the nurses I work with [will say things like], ‘Oh, why does this one keep having kids? She’s on this maintenance or that maintenance [buprenorphine]. She should just be fixed [sterilized].” Participant 5

Participants described these experiences longitudinally in the prenatal, delivery, and postpartum spaces. Relatedly, participants would say that these experiences made them fearful to continue getting prescribed buprenorphine, or that clinics unfamiliar with perinatal MOUD would stop providing buprenorphine, leaving participants in the lurch:

“I’ve had to get them [buprenorphine] off the streets because once they [buprenorphine clinic] found out I was pregnant say that they couldn’t give me them no more… they think if you pregnant you can’t take them and it put me in a hard decision.” Participant 13

Facilitators

Participants also identified an unequal power distribution between them and healthcare providers, which created a fear of retaliation during their prenatal, labor, and postpartum care if they were to offend providers by advocating for themselves:

“The whole time I’m in the hospital I can’t say anything. I need water, I’m in pain, I need my medicines, I know if I piss them off, I’m going to suffer… I already worry what they think of me because of my history and the nurses and doctors they control what happens to me while I’m there.” Participant 13

Many shared that protocols for neonatal opioid withdrawal syndrome monitoring were not explained as being universal or part of healthcare. Rather, participants thought it was due to punishment or discrimination:

“My daughter was in the hospital for 5 days. They acted like her birth weight was like really, really, really low. You know, I’ve heard of a lot of kids that were smaller than her. I felt like they were holding her hostage in the hospital. It was just a bad experience all around inside of the hospital. The nurses were good, but just the fact of that they kept saying, well she’s on the suboxone. She had it in her system. I knew she had it in her system because I was told that I should continue to take it… It just felt like they were holding me hostage because of it and my daughter.” Participant 4

Additionally, participants expressed that societal expectations of mothering were embedded in all aspects of their care, and these expectations did not include birthing people with a history of OUD. These facilitators were voiced to be external and internal forces that impeded participants ability to advocate for themselves in healthcare settings.

CPS, the department in Pennsylvania that includes Child Welfare and determines if parents can maintain custody of their children, was mentioned both as driver and facilitator for stigma. Many participants described a all-consuming fear of CPS involvement, especially those with past CPS experiences:

“The whole time [in prenatal care] and the hospital I’m thinking [CPS is] going to come... It took over the whole experience. Like, I should be happy about the pregnancy and baby… instead I’m thinking how everything I do is gonna be reported to [CPS]… it takes over.” Participant 14

They described that this fear pervaded every healthcare-based decision they made from what they expressed during appointments, the labs they choose to complete, and the treatment decisions they made. Particularly, the majority of participants described a disconnect between inpatient and outpatient care where they were told they were doing well on the outpatient side but then had a CPS report filed in the inpatient setting:

“I knew in the hospital they were going to call them [CPS], you know, you can tell. The way they look, the questions they ask over and over again… they didn’t think I could take care of the baby… it didn’t matter that I had everything ready, that I was doing good… they [the hospital staff] didn’t think I was going to do a good job.” Participant 10

State notification of pregnant people on MOUD due to conservative interpretation of state legislation also facilitated prejudices experienced during care, (Crime of Victims Act: Act 51, 2017) and indeed, participants often felt frustrated or betrayed that being engaged in MOUD flagged them for involvement with CPS:

“This year I’m on [buprenorphine], and hopefully everything goes good. But, there is a downfall in it too because just because you are on suboxone, they call the state on you… I don’t feel good about it because you’re doing what you gotta do, and it’s a medicine that they prescribed to you, so I don’t see why, you know, they make it so positive and everything, but then there is faults to it as well… But, there are some times that I still, in my head, wish that I didn’t go the doctors at first until I got off [buprenorphine] because it’s, you know, it’s a big fear of, the state stepping in and trying to intervene.” Participant 6

“It feels like a trap… the doctors, the nurses, everyone in the clinic told me to take it [buprenorphine] because it was good for me and the baby. But once I got to the hospital, it kind of, it really felt like they thought I was trying to hurt my baby by taking it [buprenorphine]. You know, why else would they call [CPS] on me?” Participant 12

Stigma Experiences

Stigma manifested in a variety of healthcare experiences during the perinatal course. Three of the most significant stigma experiences for participants were: (1) internalized stigma, whereby participants accepted negative societal conceptions and devaluation of themselves, (2) inadequate pain management during the peripartum period, and (3) unfair government intervention in child custody after delivery.

Internalized stigma manifested for participants as feelings of guilt related to prior substance use and the subsequent exposure of their fetuses to MOUD with ongoing treatment during pregnancy. One participant described a feeling of self-hatred and culpability for needing to be on MOUD while another questioned her own parental fitness. Participants described the process of internalization as they sensed and heard these prejudices from healthcare workers. As a result, many felt that they were setting their children up for disadvantages in life even before birth due to being exposed to MOUD or due to being raised by someone with OUD and its potential disruptive effects:

“I have a lot of guilt around actually even having to take this medication. I was getting an injection every month [injectable buprenorphine], but I really had a lot of guilt still… Most of the time we hate ourselves. It’s not like something that we want to do as crazy as that sounds. Once you are in the throes of it, you are kind of owned by the addiction and you do whatever it tells you to do because you can’t stop the cycle unless you get help. Most of the time you feel just as shitty, if not more, than people might think.” Participant 5

Stigma also manifested as a lack of appropriate medications and pain management during labor, delivery, and postpartum:

“They have to ask you in the hospital if you in pain, but they didn’t believe me when I said [the pain] was a 10. I had issues after the surgery, it hurt so bad, and didn’t matter, they thought I just wanted drugs. I knew they were trying to not give me any.” Participant 15

Participants shared not receiving even the routine opioid medications, let alone the increased dosing needed for those on MOUD, after cesarean deliveries and perceived judgment from nursing when receiving pain medications due to their histories of substance use:

“They didn’t want to give me any pain medication at all… I’ve had nurses physically go out of their way to try and not, especially when it comes to pain control, to try and not give you what the doctor ordered. Specifically nurses. They feel like they know best, and I’m a nurse, right. I feel like they think, ‘She shouldn’t get be getting this, or she shouldn’t be taking it.” Participant 5

Finally, participants described discontinuation of MOUD during labor and delivery by healthcare practitioners resulting in withdrawal symptoms. These stigmatizing experiences were voiced as being due to healthcare workers lack of knowledge about pain management in the setting of MOUD, beliefs that people with histories of OUD should not have access to opioids, and general discomfort caring for people with OUD leading to avoidance of interactions.

CPS-related experiences were not only drivers and facilitators of stigma but also experiences of stigma themselves. The confusion, anger, and trauma related to government involvement in child custody was described by one patient who had experienced CPS both as a child and as a parent:

“I had asked the doctor if they thought I should stop the [buprenorphine] because I was pregnant. I didn’t want the baby to come out with dependency, and I didn’t want [CPS] involved. I was told, ‘No, don’t stop it. It’s fine. There are studies that it is safe and bla bla bla... when I went to the hospital I felt like everything that I was told... I felt like... wasn’t a lie, but it kind of slapped me in the face. [CPS] ended up getting called… It made me very upset. I was a product of [CPS] myself when my sister passed away when I was 8… it was bad… It made me feel like basically the whole world was coming down. I didn’t know what they were going to do.” Participant 4

She described the traumatic effects of forced child separation, CPS home visits, and foster care interactions as spaces for internalized, perceived, and experienced stigma.

Many participants stated that interactions with CPS workers were filled with stigmatizing language and beliefs, including the beliefs that those with a history of OUD are not fit to parent, that MOUD is a form of addiction, and that recovery is not possible:

“I don’t feel like she [CPS worker] wanted to, she never helped. I could tell what she was thinking, rolling her eyes, anything I said she didn’t believe… She didn’t want to help, she didn’t want me to have my baby… Every time I met with her, and you have to meet with them all the time, she was looking for any reason to tell something negative to the judge.” Participant 14

These experiences bled into other aspects of life, with family and friends using CPS involvement as proof they were bad mothers:

“…my family was waiting for it. Once they [CPS] came my mom jumped to take my baby, it’s like, you know, she can’t let go my past, what I did… no matter what. I’m not the person I used to be… It’s like she [mom] and the [CPS worker] were working together to make it seem like I was the old me when I’ve worked really hard to get past all that. Like I know I’ve worked hard not going back to drugs, but when you see your own family treating you like that… you start to think, maybe I deserve it.” Participant 11

This stigma related to CPS involvement compounded the internalized stigma and guilt that participants experienced.

Health Outcomes

The manifestations of stigma through the experiences outlined above impacted health outcomes through (1) the limited availability of safe and accepting prenatal care options, (2) low uptake of adequate MOUD dosing, (3) plans to avoid MOUD in future pregnancies, and (4) low attendance at healthcare appointments.

The stigma experiences in healthcare settings led participants to limit care to the locations where they perceived receiving high quality care without prejudice. These locations were at times hours away from their residences. Stigma experiences, especially with CPS, also negatively impacted willingness to attend prenatal visits. Those who had used unprescribed opioids during pregnancy were concerned about the impact of positive urine drug testing (UDT) on retaining custody of children. As a result, many would skip appointments if they did not identify an urgent need to see a physician:

“Like when I was pregnant last time, I didn’t want to go because they use your urines... they don’t use it against you... but it’s a paper trail. It always follows you, you know. So you try to, like, avoid it. You know, you feel good. I feel like I’m good pregnancy wise, the baby is good, so I don’t have to go.” Participant 6

All stigma experiences influenced MOUD uptake during pregnancy and plans for use of MOUD in future pregnancies. Due to stigma manifestations and fear of harming their fetuses, some participants reported reducing their MOUD dose on their own to try to limit fetal exposure to the medication, despite counseling during prenatal care about the safety of MOUD. These suboptimal doses led some participants to experience withdrawal, cravings, or use, and multiple patients reported significant suffering because of this. These same stigma experiences influenced desire for future MOUD use as well, with some participants reporting hesitation about continuing MOUD during future pregnancies:

“I would say [going into withdrawal] was because of me. I was kind of in denial. I didn’t really want to take the suboxone, you know, while I was pregnant... because of everything that had happened last time” Participant 7

“I guess the next time I get pregnant, if there is a next time, I’m not going to take the suboxones. I don’t feel like the experience I went through at the hospital is worth taking them, to be honest with you.” Participant 4

CPS involvement was specifically referenced as the biggest reason for plans to discontinue MOUD in future pregnancies. Participants explained the ambivalence they felt taking MOUD: on one hand being informed of the parental and fetal health benefits, but on the other hand having traumatic state involvement after delivery due to treatment with MOUD. These inconsistencies eroded future trust in healthcare providers. Many participants felt that if they had kept using substances and never sought care, or purchased buprenorphine off the street to facilitate their own treatment, they may have never been identified or reported to CPS. For most, despite understanding and experiencing the benefits of buprenorphine during pregnancy, the fear of possible loss of custody outweighed the advantages of treatment:

“One thing I know is that taking the strips [buprenorphine] is the worst thing that I did during that pregnancy. If I had just not taken them, or taken them from the streets, then they [CPS] would have never been involved. If I ever have another baby, even if the strips are helping, I know I have to stop taking them because I can’t deal with [CPS] again… it will kill me.” Participant 12

Discussion

This study identified important dimensions of the stigmatization of pregnant patients with OUD in healthcare settings. Negative perceptions and lack of knowledge about MOUD in pregnancy by healthcare providers and patient fear of CPS involvement were identified as key drivers of stigma. Unequal power dynamics between patients and the healthcare system, societal expectations for mothering, and mandatory CPS notification for prescribed MOUD use were identified as facilitators of stigma. Stigma experiences including internalized stigma related to conceptions of parental fitness, poor treatment during delivery, and CPS proceedings, impacted participants willingness to seek and use MOUD in future pregnancies.

State involvement in determination of child custody for patients on MOUD functioned as a driver, facilitator, and stigma experience itself at personal and institutional levels. This impacted the care seeking behaviors of patients and their perceptions of the acceptability of treatment, expanding upon prior studies on the negative impact of state policing of parenthood on healthcare behaviors broadly (Colvin & Howard, 2022; Ostrach & Leiner, 2019). Our findings add to this literature by demonstrating that while these policies in Pennsylvania were intended to protect children, they have led to unintended consequence of reducing care-seeking and incentivize pregnant patients towards suboptimal care. Additionally, studies have demonstrated that the child welfare system is marred with discrimination (Hina & Aryeh, 2022; Roberts, 2022).^, Families of color, Black families especially, are more likely to be reported to child welfare and more likely to have their children removed from their custody than White families (Dettlaff & Boyd, 2020). While our study was not designed to detect differences in experience by racial identity, future work should apply intersectionality frameworks to the Health Stigma and Discrimination Framework to determine how racial discrimination intersects with state agencies involved in custody determination (Bauer et al., 2021; Crenshaw, 1997).

Unlike other chronic medical conditions where parents may be in a state of poorly controlled or well controlled health, the stigma inherent to substance use prevents providers and patients from viewing OUD and MOUD in the same way. While changing social norms to decrease prejudice against pregnant patients with MOUD is challenging, this research demonstrates some clear areas for intervention to decrease the drivers, facilitators, and manifestations of stigma. Clinics and hospitals must expand education provided to perinatal healthcare professionals about MOUD in antenatal, perinatal, and postnatal care spaces. Research from the nursing literature has demonstrated that increasing nurses’ knowledge about OUD has the potential to change the perspectives from which they care for patients and lead to care that both nursing and patients identify as more compassionate (Bernier & Barroso, 2024). As nurses typically spend the most time with patients during hospitalizations, their knowledge, and the attitudes and perspectives derived from this knowledge, significantly impact nursing care (Bernier & Barroso, 2024). Additionally, studies have shown educational interventions such as critical reflection techniques, structured educational sessions, and direct contact with people with lived experience with SUD can improve attitudes of medical students towards people with SUD (Hartman et al., 2025; Livingston et al., 2012). In inpatient settings with frequently rotating staff, these strategies can be incorporated through brief standardized educational modules, onboarding trainings, or recurring unit-based educational sessions that can reach new staff as they rotate through clinical services.

Importantly, participants did not uniformly describe negative experiences with health care providers. Several individuals reported supportive, respectful care from clinicians, particularly in settings with greater familiarity with MOUD in pregnancy. However, because the purpose of this analysis was to characterize experiences of stigma and their implications for care engagement, the themes presented here focus on stigmatizing interactions described by participants. These findings should therefore not be interpreted as suggesting that stigma is universal among health care providers.

While it is positive that some of our participants found outpatient providers and care settings where they felt comfortable, the limited number of these clinics restricted care options and the ability to seek care in their own communities. Furthermore, our participants highlighted that the internalized stigma mitigated by reassurance from knowledgeable outpatient providers was often undone once in the hospital to give birth. Increased transparency about inpatient and state reporting policies for patients on MOUD is vital for changing perceptions of treatment, as our participants voiced feeling penalized even when they “did everything right.” Additional research must include interventions at bridging this dire outpatient-inpatient disconnect, aimed at improving communication between these spaces to improve patient satisfaction and decrease trauma related to birth experiences. One solution would be to incorporate prenatal consultations with CPS to set expectations around delivery, in a similar manner to prenatal neonatology consults that many patients on MOUD receive about neonatal abstinence syndrome protocols for infants. Warm handoffs from any outpatient clinic to inpatient teams with patient consent must become standard of care to disrupt inpatient team bias, assumptions, and lack of perinatal MOUD knowledge. Finally, inpatient settings must acknowledge that when patients are engaged in care and doing well, CPS notifications may be harmful to parental wellbeing and confer little, if any, benefit to the child.

Some institutions have created clinics similar to our study site, which effectively collocate perinatal and addiction medicine services (Goodman et al., 2022). In these locations, all prenatal healthcare providers are educated and trained in providing affirming, evidenced-based, care for pregnant patients on MOUD. However, as identified by our participants, one barrier to this model is avoidance of appointments due to fear of inappropriate urine drug testing (UDT) results from the outpatient setting being viewed on inpatient admission and their potential consequences. In our study, inpatient services could see all UDT results from outpatient clinics connected to the institution but were unable to see outside or methadone clinic UDT results without a release and faxed request. While not identified by participants in this study, the authors have anecdotally noted some patients find that UDTs in prenatal care to be helpful to demonstrate stability in treatment at the time of delivery. Further work must focus on thoughtful integration of outpatient UDT results to inpatient settings so that not only patients from certain clinics are unfairly under increased surveillance. Solutions may include necessitating a release to view any UDT results from the antepartum period, even in outpatient settings where inpatient providers have easy access to UDT results through electronic medical records, as well as a critical appraisal of the utility of UDT for perinatal treatment surveillance.

A limitation of this study is that it draws from a small sample at a single university-affiliated clinic with collocation of prenatal and addiction services. Providers at this clinic are familiar with harm reduction principles and national guidelines related to standards of care for treatment of OUD in pregnant patients. Most patients in this study delivered at the affiliated academic hospital where providers had access to outpatient clinic notes and some physicians had expertise in perinatal addiction medicine. Patients in this study may have experienced less stigma than patients in other healthcare settings due to access to specialized providers. Conversely, they may have experienced more stigma secondary to the availability of clinic UDT results by the inpatient providers. This study also only included patients who were being treated with buprenorphine. It does not include patients on methadone, who must seek medication treatment at specific opioid treatment programs and may experience different stigma when receiving care in these spaces. Finally, this study was conducted in Philadelphia and perceptions and experiences of patients may vary based on regional differences in acceptability of MOUD in pregnancy, local laws, local drug supply, and availability of treatment.

In conclusion, our study explored multiple dimensions of stigma and its impact on care seeking and MOUD uptake among pregnant people with OUD. Our findings demonstrate opportunities for healthcare team members to support and empower patients who experience healthcare-based stigma or discrimination by providing evidence-based and nonjudgemental care for pregnant people on MOUD and by building systems to connect inpatient and outpatient care settings. Ultimately, state and hospital policies that recommend CPS reporting simply for MOUD use in pregnancy may be more harmful than beneficial for both maternal and fetal health. Thus, policies and procedures related to postpartum CPS involvement should be standardized and shared with patients antenatally to help with expectation setting to mitigate feelings of betrayal and decreased future MOUD use and perinatal care engagement.

Supplemental Material

Supplemental Material - Silent Struggles: Unveiling Stigma in Healthcare With Perinatal Patients on Medication for Opioid Use Disorder

Supplemental Material for Silent Struggles: Unveiling Stigma in Healthcare With Perinatal Patients on Medication for Opioid Use Disorder by Rebecca G. Schapiro, Karampreet Kaur, Margaret Lowenstein, Navid Roder, Nia M. Bhadra-Heintz in Journal of Drug Issues