Maternity providers’ moral experiences addressing maternal drug use

Abstract

Background

Addressing drug use among pregnant and postpartum women is complicated by the social, ethical, and legal interplay between maternal and child needs. The moral experiences of providers as they care for this population are poorly understood. The purpose of this review is to synthesize the qualitative literature on the moral experiences of prescribing maternity providers managing the care of pregnant and postpartum women who use drugs (PPWUD), specifically focused on drug testing and child welfare reporting decisions.

Methods

The Hunt and Carnevale (2011) bioethics framework was used to define moral experience as “a person’s sense that values that he or she deem important are being realized or thwarted in everyday life.” A systematic search of PubMed, PsycINFO, and CINAHL resulted in 31 eligible articles. Study quality was assessed using the Critical Appraisal Checklist for Qualitative Research from the Joanna Briggs Institute (2015). Thematic narrative analysis was used to synthesize results and identify themes.

Findings

Overall, maternity providers’ experiences were characterized by ethical conflicts influenced by provider-level and policy-level factors. Even when endorsing patient autonomy and parental rights, no maternity providers endorsed continued maternal substance use that placed the fetus or child at significant risk. Structural constraints within healthcare systems and punitive laws were cited as significant barriers to providing optimal care to PPWUD. Biased drug testing protocols and some child welfare reporting policies created ethical conflict by placing maternity providers’ relationship with their patients in opposition to their legal and ethical responsibility to report child maltreatment.

Implications

More rigorous characterization of these moral experiences is needed to support the development of provider-level interventions and policy-level changes as maternity providers care for both mothers and children impacted by drug use.

Introduction

Drug use and substance use disorders (SUDs) carry significant moral implications and social stigmatization. ¹ Pregnant and postpartum women who use drugs (PPWUD) face additional stigma since drug use is often viewed as a violation of a woman’s maternal responsibility to care for her child.^2,3 Since the rise of the opioid epidemic in the early 2000s, the medical community in the United States (US) has gradually shifted the language of addiction from “moral choice” to “disease.” ⁴ In the wake of the War on Drugs era of the 1980s, drug policies addressing SUDs have vacillated on the spectrum of criminal justice-focused to the public health-focused approaches. ⁵ Criminal and civil policies addressing maternal substance use remain predominantly punitive and criminal justice-focused in the US, ⁶ despite the association of these approaches with negative maternal and child outcomes.^7–13

Clinical decisions for pregnant and postpartum patients using illicit or non-prescribed drugs are complicated by ethical and legal considerations for both mothers and their children.^14–16 Research surveys of healthcare providers in the early 2000s reveal a wide range of opinions on regulations about drug screening in pregnancy ¹⁴ and labeling drug use as a form of “child abuse” for the purposes of removing a child from custody. ¹⁷ Mandatory reporting for child abuse, particularly in the context of maternal substance use, can create conflicts for providers who are forced to weigh their relationship with the mother as their patient against their moral responsibility to make judgments about the her ability to care for her child. ¹⁸ As legally mandated reporters of child abuse, providers are faced with difficult decisions about maternal drug testing and alerting child welfare services when caring for PPWUD. ¹⁹ Particularly in the US, drug testing and reporting decisions made by providers who care for these women can lead to child custody loss, criminal charges, involuntary commitment, or even incarceration.^6,20

Hunt and Carnevale define a moral experience as “a person’s sense that values that he or she deem important are being realized or thwarted in everyday life. This includes a person’s interpretations of a lived encounter, or a set of lived encounters, that fall on spectrums of right-wrong, good-bad or just-unjust” (p. 659). ²¹ Due to the intimate nature of the patient–provider relationship and the significant role providers play in moderating or exacerbating poor health outcomes for their patients, understanding the moral experiences of providers as they care for PPWUDs is essential to better support providers in delivering effective care to this vulnerable population. This review is a synthesis of qualitative literature on the moral experiences of providers managing the care of PPWUDs, particularly with respect to drug testing and child abuse reporting decisions.

Methods

Theoretical framework

We used Hunt and Carnevale’s moral experience framework, defined above, to guide this review. Conceptualization of ethical issues in practice has often narrowly focused on constraints or problems causing moral distress, moral dilemmas, or moral injury to healthcare providers.^21–23 While this work is important, Hunt and Carnevale’s moral experience framework expands traditional definitions of “moral” to include scenarios beyond those widely recognized as “right” or “wrong” and focuses on the “social worlds” in which individuals live and work and how they ascribe meaning to their experiences. ²¹ This might include scenarios that create moral uncertainty or on the other hand, moral well-being. This broadened definition allowed for the deepest, most inclusive conceptualization of the ethical issues that maternity providers navigate as they make decision about the care of pregnant or postpartum patients who use drugs, including decisions that may not lead to moral distress or moral dilemma.

Eligibility criteria

The sampling frame for this review is prescribing maternity providers who manage the care of pregnant and/or postpartum women who use drugs, including those diagnosed with an SUD. These are encompassed by physicians, nurse practitioners, physician associates, and midwives, including post-licensure resident physicians or those in training fellowships. Since these providers have the prescriptive authority and scope of practice necessary to manage SUD treatment plans for these women (including ordering drug tests, reporting prenatal drug use, and referring patients to social work or child welfare), understanding their unique perspective when caring for this patient population is critical. ²⁴ While papers that focused solely on healthcare professionals or prelicensure students who did not directly manage the care plans of pregnant and postpartum women who use drugs (i.e., nurses and social workers) were excluded, articles with mixed samples of healthcare providers (e.g., physicians, nurse practitioners, and nurses) were included with the perspectives of prescribing providers prioritized in analysis.

Geographic setting of the studies was limited to highly resourced English-speaking countries such as the US, Canada, Australia, and Western Europe. Due to differences in legal and healthcare systems even among these Western societies, studies in the US were given priority in the synthesis, especially related to themes surrounding legal issues (i.e., mandated reporting and criminal prosecution) and healthcare system structures (i.e., insurance and reimbursement).

Included were peer-reviewed research studies published in English between 2000 and 2024 which examined the moral experiences of maternity providers when caring for PPWUDs. Excluded were studies that focused on pregnant or postpartum patient populations who only used alcohol or smoked nicotine, as the intent was to focus on the ethical issues related to women using “illicit” or criminalized substances. Non-peer-reviewed sources, literature reviews, commentaries, editorials, dissertations, and other gray literature were initially reviewed but excluded due to low quality.

Search strategy

A systematic search of PubMed, PsycINFO, and CINAHL databases was conducted in January 2022 with the assistance of a biomedical librarian and subsequently updated in November 2024. As described above, Hunt and Carnevale’s concept of “moral experience” ²¹ was used to guide the selection of initial search terms, which encompassed terms related to values, stigmas, moral beliefs, judgments, ethical conflicts, or moral distress. Key search terms were chosen to restrict studies to (1) ethical or moral issues specifically related to drug screening/testing or child welfare reporting, faced by (2) prescribing healthcare providers caring for (3) pregnant or postpartum women using drugs. The full Boolean search strategy is outlined in Appendix A. Reference lists from articles selected for inclusion were manually searched to identify other relevant sources not discovered through database search.

Study selection and data extraction

The PRISMA 2020 Flow Diagram ²⁵ was used to document the methodical process of article review and inclusion (see Appendix B). Sources were initially reviewed by title and abstract. Articles which could not be clearly excluded from these initial criteria based on title or abstract alone were reviewed in full text. To ensure a full grasp of our phenomenon, we completed full-text review of the articles before excluding any articles based on date of publication (prior to 2000), study design (quantitative), or substance type (alcohol or nicotine, only).

Data analysis and synthesis

The data analysis and synthesis approach were consistent with the thematic narrative synthesis method for reviews of the literature. ²⁶ After selection of final sources, all relevant texts and quotations from each study were organized into a table and read line-by-line. Connecting words and phrases with shared meaning across studies allowed for descriptive themes to emerge, which were further synthesized into the analytical themes and domains of moral experience described in the narrative format below. Study characteristics and themes identified were organized in the final table (see Appendix C).

Quality appraisal

Each article was assessed using the Critical Appraisal Checklist for Qualitative Research from the Joanna Briggs Institute. ²⁷ The tool consists of 10 items regarding the congruence of philosophical perspectives, methodology, data collection and analysis, researcher bias, ethics, and interpretation of results, with possible scores ranging from 0 to 10. Total scores for each study are the additive of affirmative answers to the 10-item checklist; negative answers or lack of clarity about an item were scored with zero. Quality scores are included for each paper in Appendix C.

Results

Thirty-one articles from 29 distinct studies met eligibility criteria.^28–58 All studies were quality graded as moderate to high quality, and none were excluded to ensure a thorough and robust representation of the current state of science. Two mixed methods studies^33,37 were identified from which only the qualitative portions were extracted and included in this analysis.

As detailed in Appendix C, two-thirds of the 29 distinct studies (n = 19) examined moral experience among mixed specialties of maternity providers (physicians, midwives, NPs, and PAs), and a few (n = 12) also included nurses, social workers, or other healthcare workers in the larger sample of maternity providers. Less common were samples of only midwives (n = 7) or physicians (n = 3). No studies were solely focused on the perspective of NPs or PAs practicing in obstetrics. Over two-thirds (n = 20) of studies were conducted in the US, and nearly one quarter (n = 7) focused specifically on the care of women with an opioid use disorder (OUD). Moral experiences reported by maternity providers were driven by ethical tensions arising from (a) the intra- or interpersonal provider level as well as (b) the external or systemic policy level.

Provider-level factors

Moral experiences within the provider-level domain were characterized by perceived intra- and interpersonal tensions between (1) the maternity provider’s values/beliefs and the patient’s values/behaviors; (2) moral judgments and clinical judgments about “problematic” maternal drug use; and (3) the prioritization of maternal autonomy and parental rights balanced with the prioritization of fetal and/or child safety.

Values, beliefs, and behaviors

Personal beliefs and values about drug use, pregnancy, and motherhood were routinely described by providers as they navigated clinical decision-making for PPWUDs.^{29,32–36,38,40–42,44,47–49,51,54–58} Several studies described providers separating personal beliefs and values about substance use and motherhood from the norms they accepted for PPWUDs in clinical practice. For example, two papers from Canadian settings^29,49 captured this struggle when providers made personal decisions about their own pregnancies. Providers in both studies described how they either struggled with and/or reconciled their own views of motherhood with the dissonant views and behaviors of their pregnant or postpartum patients who redefined “good” mothering for themselves in the context of active drug use. Benoit and colleagues ²⁹ described providers creating a divide between their personal beliefs and clinical practice to “maintain their private ethic and image of appropriate maternal behavior while still striving to provide care in a non-judgmental way” (p. 256) for patients who did not meet these standards.

Despite holding normative or traditional personal beliefs about substance use and motherhood, several providers believed that allowing pregnant or postpartum women to define “problematic” substance use for themselves would increase treatment engagement and sustain recovery. ²⁹ It was unclear how this balanced tension played out in the clinical setting. However, one provider noted that she took leave from her job while pregnant because this tension between the choices she made for her own pregnancy with the choices she saw her pregnant patients making was too distressing for her. ⁴⁹ Some providers espoused belief in the “disease model” of addiction as an effective way to approach substance use on an institutional or policy level^40,54,55; however, these discussions tended to lack an operationalized definition in the clinical setting. Many providers struggled to functionally apply this view in clinical practice,^29,49 emphasizing instead the relational/behavioral aspects of addiction and leveraging the strengths and personal agency of their patients.^49,55

Judgments and stigma

Another recurrent theme reported was providers struggling between making moral judgments about the woman’s substance use and making clinical judgments about her care.^{29,32–36,38,44–49,51,52,54–58} The distinction between clinical judgment and moral judgment (i.e., stigma) was not always well defined. For example, Nichols and colleagues ⁴⁹ found that, among providers, “‘judgment’ was used with both a negative and neutral connotation” (p. 28) to describe both stigmatizing attitudes as well as clinical assessments. Many providers had difficulty defining what was considered “problematic” substance use in pregnant or postpartum women, which the authors concluded was “likely to be a reflection of the social, legal, and moral ambiguity within which maternal substance use occurs” (p. 255). ²⁹ Some vacillated between “moral outrage” over the impact of a woman’s substance use on her child and supporting the mother within the “line of professionalism that you have to walk” (p. 4). ⁵⁴ Others spoke about leveraging the moral judgments about “good motherhood” as a successful strategy to promote clinical outcomes and recovery among the women, stating that it “reinforced treatment as a redemptive act on the path to ‘good mothering’” (p. 31). ⁴⁹ Woolhouse and colleagues ⁵⁷ described this constant moral/clinical leveraging as a “delicate dance of deciding when to back off and when to push forward” (p. 247) based upon their patients’ receptivity and capacity.

Moral judgments captured by discriminatory attitudes and prejudicial treatment of patients were mostly noted through grounded theory observation and field notes taken at conferences, ⁴⁹ rather than direct report from providers themselves. Providers often spoke about enacted stigma perpetrated by other providers and generally denounced this treatment.^{30–33,44,54} However, Nichols and colleagues noted that some providers may believe that stigma experienced by their patients was simply “perceived” due to prior mistreatment rather than acknowledging ways they may be enacting stigma on their patients. ⁴⁹

While many noted examples of stigmatizing patients with “moral” judgment, hostility, or unflattering stereotypes, one study noted that to avoid judgmental treatment and overcompensate for their discomfort with this population, some providers treated patients with hesitancy and uncertainty or were overly kind, which was just as distancing as other manifestations of stigma. ⁴⁹ When addressing strategies to combat stigma, many providers noted the importance of establishing trust with women by treating them “where they’re at” (p. 247) ⁵⁷ and respecting them as valued fellow humans.^54,55,57 One provider noted that, to address stigma, it was important “to know and to listen to their stories of pain…without judging them…so that they feel that…they are a human being…who is worthwhile.” ⁵⁷

In multiple studies, providers reported significant discomfort over the disparities and discrimination in drug testing and child welfare reporting practices toward poor and racial minority women, linking moral judgments with clinical biases.^{34,38,44,45,52,58} Public insurance (Medicaid) was used as a proxy for socioeconomic status and considered a risk factor prompting drug screening. ⁴⁵ One midwife who worked across different settings noted that “poor women get toxed,” or drug-tested, more frequently. ³⁵ Providers in Chicago who worked at private hospitals described the opioid crisis as likely undetected among their privately insured, majority white patient population due to lack of routine drug testing because “OBs feel like their patients don’t do that and we all obviously know that’s not the case.” ⁴⁵ Another provider noted: “When there’s a white woman that looks to be middle or upper class, and we’re like where did you get prenatal care, and she’s pushin’ a [baby] out, she’ll be like ‘I don’t know…some group, I don’t know.’ And we’re like ‘okay, okay…we’ll get your records later.’ And if it’s…a black teenager, and she’s like I don’t know. Then it’s like ‘hmm…get the test’.” ⁴⁵ Black providers in this study, specifically, expressed frustration about these perceived racial differences in drug testing. ⁴⁵ Selective and subjective methods of assessing risk and choosing to drug test were believed to translate into racial disparities in child welfare reporting.^45,52,58

Some providers mentioned that they attempted to combat stigma of substance use disorders by normalizing risk prevention strategies, such as drug testing, by presenting them in a nonjudgmental manner and characterizing it as a routine part of prenatal care, with one stating: “[We tell] them this is part of their care just as much as taking their blood pressure … it’s something they have to do, not to make them feel guilty.” ³⁴ However, another study cited this approach to normalize drug testing as routine “like a syphilis screen” was problematic when implications of a positive test were unexplained and the framing of drug testing as neutral masked the social and legal risks. ⁴⁵

Rights and risks

The legal and ethical balance between the bodily autonomy and parental rights of the woman and safety of her child was perhaps the most common source of ethical conflict reported across studies.^{28,29,32,36,38,41–46,49,51,52,58} One provider summarized: “It’s a balancing act, right?” (p. 256). ²⁹ Some providers defined substance use as problematic when it impaired the woman’s ability to care for herself or her child’s well-being ²⁹ ; several midwives further defined it as impairing the woman’s ability to recognize dangers to herself and, thereby, her child either from drug use itself or other situational harms (e.g., an abusive partner). ⁴⁶ One provider expressed this tension, stating: “It’s a tricky issue because you want to protect the baby for sure, but it’s such a contentious issue because it’s [substance use] criminalized… and on the flipside is separation of mother and baby, and then the flipside is the baby’s well-being” (p. 261). ³⁸ Even when believing in the woman’s right to terminate a pregnancy, no providers in Benoit and colleagues’ study ²⁹ were comfortable endorsing a woman’s continuation of substance use that put either the fetus or infant at significant risk of harm or death.

Providers in one study compared pregnant patients refusing drug testing to “pleading the fifth,” or the constitutional right against self-incrimination. ⁴⁵ Even when informed of the possible risks of a positive result, the option to decline drug test is virtually non-existent since women who refuse the drug test are assumed to be using drugs. Some providers encouraged their patients who were stable in recovery to use negative drug tests as “proof” of their parental fitness during child welfare investigation after delivery, even while recognizing the discriminatory or punitive use of drug testing itself. ³⁵

While acknowledging the potential negative effects of reporting drug use to child welfare, providers did not view child welfare services as wholly negative but instead recognized child welfare case workers’ evaluations of parental capacity and connections to services as an essential, if imperfect, means of ensuring child safety.^38,43,51,58 In one study, US hospital-based physicians caring for pregnant women reported more concern about potential harms to the baby associated with not reporting and expressed considerable anxiety about these harms occurring if a report was not made, with one stating: “The risks of not reporting are danger to the child…The child could die” (p. 6). ⁵¹

In an Australian study, one midwife described her prioritization of care for women whose children were removed by child welfare, stating: “Our midwife role is to support the woman. Before [child removal] we focus on the wellbeing of the mother and the baby and once the baby’s been removed, we transition to the well-being of the mother” (p. e8). ⁴¹ When children were removed (frequently related to drug use), midwives in this study reported that they felt guilty, helpless, and like they had betrayed the midwife–mother relationship. ⁴² They described this experience as the most distressing in clinical practice and internalized more than joyful experiences. One midwife said, “At the end of my shift I just went home and cried myself to sleep. I was pouring with sadness for that woman” (p. 1107). ⁴² Even when they believed the decision was in the best interest of the baby, their struggling to reconcile both their own and the mothers’ emotions caused significant professional and moral distress. ⁴²

Policy-level factors

Providers also described significant policy-level factors that defined their moral experiences caring for their patients. These influences were largely cited as (1) federal regulations, state laws, and institutional policies or practices guiding drug testing and mandated reporting; and (2) healthcare system structures that constrained or impeded the providers’ decision-making or ability to provide, what they believed, the best care to their patients. Many providers reported significant frustration and distress within these contexts, although some reported leveraging these laws or polices to help motivate behavior change in their patients.

Laws and practices

Laws, regulations, and institutional policies and practices addressing prenatal drug use were met with conflicted yet largely negative reactions from providers.^{28,30–32,34–36,40,41,43–45,47,48,51,52,54,58} When asked directly, most providers agreed that treating substance use as a criminal violation was not helpful in the care of their pregnant patients, and were in favor of public health approaches to maternal drug use and more supportive policies to increase resources for their patients.^{29,31,32,38,44,54} Providers noted that criminalization and mandated child abuse reporting policies created mistrust between themselves and their patients.^{30,32,43,44,52} A provider in Washington state spoke about stigma surrounding state-mandated referrals to child welfare services for community support resources (i.e., Plans of Safe Care), saying: “Although it is experienced as stigmatizing, it is not the provider who is saying that the patient needs a Plan of Safe Care ‘cause they’re an unsafe person. It’s actually the federal role, and we’re just doing our best to use it in a good way” (p. 600). ³⁰

In other studies, some providers were bothered that the risk categorization of drug use in pregnancy was largely based upon legal rather than medical consideration, particularly when developing drug testing and reporting protocols within hospital systems.^28,45 One physician stated:

Why aren’t you testing for SSRIs? Why aren’t you testing for protein, for tobacco? … The number one cause of preventable cognitive impairment in this country is in-utero alcohol exposure. Why aren’t you looking for this? And they’re like: “oh, because that’s legal.” … you’re showing me that their primary programmatic intent is law enforcement or administrative law, or something like that. But it’s not medical. (p. 170) ⁴⁵

Although not recommended or considered ideal, most maternity providers reported low concern over the medical impact of cannabis in pregnancy,^{28,32,35,36,38,45,58} with one noting that “anything above marijuana takes priority.” ³⁶ However, some providers in Pennsylvania discussed with patients the illegal status of cannabis and used child welfare reporting policies to motivate patients to stop using marijuana during pregnancy.^36,38

While drug testing was routinely discussed as the role of the maternity provider, one study among hospital-based physicians across the US found that many viewed the act of child welfare reporting more the responsibility of social workers, although the initial decision to involve social workers remained with the providers and decision to report were often informed by their input. ⁵¹ One physician in another study echoed this theme, stating:

I have no way of knowing how to evaluate if that infant is safe to leave the hospital with that mother. And I don’t want to have to assess that. I want no part of it. I have no idea how to go about figuring that out. And I would want somebody with a lot more skill and experience to be able to come and talk to the mother to kind of figure that out with her. (p. 170-1) ⁴⁵

A small number of providers, who were upset by the high rate of reporting at their institutions, were involved on hospital committees and even worked in collaboration with child welfare services in their state to make reporting policies and practice more evidence-based and equitable.^28,51 However, many noted that these policies were largely informed by the legal and political priorities of hospital administrators responding to state regulations rather than specific case level considerations or outcome data.^28,51

Despite endorsing the necessity and benefits of social work or child welfare case worker involvement, many providers acknowledged the legitimate concern many women have over the involvement of child welfare and inconsistent or discriminatory decisions about child custody, even acknowledging that reporting did not always lead to increased connection to services.^43,51 Many providers incorporated warnings about mandatory reporting policies and child welfare investigation into discussions with their patients during prenatal care.^36,38 Yet, providers also expressed feeling frustrated and powerless because most had either little control over, or did not know, the outcomes for their patients after mandatory child abuse reporting and child welfare involvement.^38,44,52,58 Though they noted significant discomfort with the current policies and practices around mandatory reporting, most providers believed that some level of reporting was still necessary in many cases and that more research about both maternal and child outcomes was needed before current reporting policies should be modified.^38,58

Healthcare system structures

Providers reported frustration with structural barriers within the healthcare systems where they practiced, which prevented them from providing high-quality care to PPWUDs. These barriers included (1) a lack of resources and treatment options; (2) a lack of time to build trust and effect change; and (3) pervasive stigma in criminal justice, child welfare, and community realms.

Lack of resources

Lack of resources and treatment availability for PPWUDs was described as an overwhelming and disheartening barrier to providing optimal and comprehensive care.^{33,37,38,40,43–45,50,51,53–56,58} One physician stated that she felt “like you’re part of a system that doesn’t actually value [patients] lives, and so you can’t offer them the resources that you wish you could” (p. 6). ⁴⁴ Many other physicians in this study expressed deep sadness over the complexity of their patients’ lives and inability to address their needs; yet many reported disengaging or suppressing this empathy to preserve their own well-being, with one obstetrician stating, “I do see the sadness, but…we all just park it somewhere… or, you know, you’d get depressed” (p. 7). ⁴⁴

Providers acknowledged the dilemma between the problems with punitive policies and the inability of the current system to support treatment, stating: “[Criminalizing substance use] sets up a barrier between the provider and the woman. So it’s just part of an entire system that is dysfunctional – you know, mandatory reporting, criminalization, not enough treatment beds… I feel like it’s not a system that works right now” (p. 261). ³⁸ Some providers cited the fact that Medicaid coverage often expired within 6 to 10 weeks postpartum, which hindered the transition to long-term substance use treatment beyond this brief window.^37,40,53 One provider expressed that using drug testing and child welfare reporting to assess risk for mothers who used marijuana or medications for the treatment of opioid use disorder (MOUD) was not “an appropriate use of law or resources” because risks associated with the use of these drugs was a “known issue” (p. 169). ⁴⁵ But this provider believed it was an “appropriate use” of resources and the child abuse statutes to test or report women who use illicit drugs like heroin or cocaine. ⁴⁵ However, a midwife provider stated: “If you’ve got nothing to offer them, why identify them? I don’t believe in [drug testing] routinely, unless your program is going to help the woman and the baby, not punish her. And what are you going to do with the information?” (p. 92). ³⁵

Many acknowledged the systemic failure of the child welfare system that typically increased punitive consequences rather than referral to resources.^{35,38,43,44,51,58} Some attributed the reason for poor patient outcomes associated with punitive child welfare policies not to the policies themselves but rather to the lack of concurrent supportive resources and treatment options. One provider stated: “We’re under resourced with this [current policy]. In order to make something work, the state would have to put in enough money in order to actually support it” (p. 261). ³⁸ Another provider from the same study stated, “Should we screen more, should we screen less? ...What are the downstream implications of screening positive, and what do we offer that mother and that family? And what are the resources that we realistically have to bring to the problem? Those are the things I would want to understand before I would just decide to rewrite the law” (p. 262). ³⁸

Lack of time

Limited time with patients was cited as a barrier to establishing patient trust, which was viewed as an essential component of effective care for this population.^{33,34,37,44,47,50,56} This lack of time was noted by short clinic visits due to high patient volumes. ³⁷ Inpatient providers were limited to the few days of inpatient care for labor and delivery, ³³ but even outpatient obstetric providers viewed the 9-month window of obstetric care as too short to provide effective care and long-lasting change.^37,47 Others recognized this limited obstetric care window as a barrier to care continuity but also viewed this time as a window of opportunity to capitalize on a woman’s motivation to change and to “seize the 9-month moment,” with one stating: “This is a little tiny window [of time] … It makes a difference to talk to the women. It may not be our joy to see any change, but change may happen another time.” ³⁴

Some providers considered drug testing useful because it was a “quick” assessment of drug use in settings with limited time, ³⁴ especially when providers did not believe their patients were being forthright about drug use. ³⁷ Despite time constraints and overburdened schedules, some obstetric providers reported the desire to personally screen and refer their patients to resources rather than delegating the tasks to social workers or case management. ³⁴ Although treatment availability for pregnant patients was described by providers as “very limited,” providers in Alabama still reported prioritizing screening for substance use and referring for treatment. ³⁷

Structural stigma

Providers implicated structural stigma for undermining the care they wished to provide for their patients.^{32,39,40,43–45,47,52–54} Stigma within the systems of care related to buprenorphine and methadone, the first-line MOUDs in pregnancy, was noted by providers caring for pregnant patients with OUD in rural Appalachian communities ⁴⁰ as well as pregnant patients with OUD involved with the criminal justice system. ³⁹ Providers cited a lack of knowledge and education on the clinical necessity of these medications among child welfare workers, parole and probation officers, and judges. ³⁹ One provider stated: “Sometimes the judges don’t want to put [pregnant women] in an outpatient setting or inpatient setting, they’ll just place them in jail without knowing additional risks of doing that, not only to the mother, but also to the fetus” (p. 22). ³⁹ In another study in Virginia, providers mentioned that mandated reporting of neonatal abstinence syndrome led to some patients self-tapering their MOUDs to prevent their infant’s withdrawal and subsequent referral to child welfare after birth. ⁴³ One study among Australian midwives described these providers as the “lynch pin” helping PPWUDs navigate the complexity and biases of the healthcare system itself. ⁴⁸ Yet, providers across studies reported feeling overwhelmed and frustrated as their patients encountered structural barriers and systemic biases in care systems, particularly surrounding drug testing and child abuse reporting.^{40,43–45,48,49,52–54}

Discussion

This review of the moral experiences of maternity providers caring for PPWUDs revealed frequent instances of ethical conflict, arising from internal tension within their personal beliefs systems; interpersonal tension in clinical encounters with patients; and tension from policies, practices, and system-level pressures dictating clinical decision-making. High levels of ethical conflict, or dissonance between providers’ values or ethics and decision-making in the clinical setting,^59,60 have demonstrated downstream consequences across healthcare disciplines on provider burnout and other emotional and physical burdens, the quality of patient care provided, and patient outcomes.^61–64 These outcomes in maternity care have not yet been explored in association with the ethical conflict reported by providers in our review. Addressing this ethical conflict among maternity providers is particularly critical since these providers report burnout rates from 40% to more than 75%.^65–67

In the studies reviewed, providers reported wrestling with personal beliefs about drug use while navigating clinical decisions for their patients. Social stigma, or negative beliefs and attitudes, about drug use and addiction is a significant barrier to care for those with substance use disorders, particularly for mothers.^3,68,69 Healthcare providers, as part of society themselves, are not immune to the societal discomfort about maternal drug use and may operationalize these beliefs and value judgments when addressing drug use in their pregnant or postpartum patients.^70,71 Prior research has shown that healthcare providers across specialties hold more negative attitudes or stigmatizing views of patients with SUDs compared to patients with other mental health conditions, are less engaged with these patients, and are often avoidant or more “task-oriented” when caring for these patients. ⁷² Negative attitudes and discomfort were noted among maternity providers in our review, and distancing or disengagement was reported as a coping mechanism among physicians to reduce emotional distress. While some providers reported that stigma was pervasive among their clinical colleagues, most attributed their own emotional distress and discomfort to concerns for infant safety and the desire to mitigate the destructive effects of drug use in their patients’ lives. ⁷⁵

According to practice standards outlined by the American College of Obstetricians and Gynecologist, maternity providers have an ethical responsibility to notify pregnant patients with SUD of any medical or legal obligation to drug test; to make a “reasonable effort” to obtain informed consent; to protect patient autonomy and confidentiality as allowable by mandated reporting laws; and “to discourage the separation of parents from their children solely based on SUD, either suspected or confirmed.” ¹⁵ Yet, providers in our review described the pressure to weigh these professional obligations to the woman as their patient against their obligation to report maternal substance use and suspected child maltreatment as a source of notable ethical conflict. Although maternal needs and child needs were not viewed as inherently mutually exclusive, prenatal drug use was often discussed as an inherent conflict between the pregnant/postpartum patient’s autonomy and the well-being of the fetus/child requiring a delicate moral dance in decision-making for the dyad. ¹⁴

Prevailing state laws and institutional protocols, which govern provider decision-making,^73,74 are commonly cited contextual factors that drive ethical conflict across healthcare specialties.^22,61 Providers recognized that both drug testing and child welfare reporting are fraught with biases, legal issues, and punitive consequences that undermined patient trust and lead to poor outcomes for their patients. However, many also viewed drug testing and child welfare reporting as useful tools to assess “problematic” drug use among pregnant patients and to leverage their patient’s motivation to engage in drug treatment during pregnancy. Though punitive consequences broadly (i.e., child welfare involvement and child custody loss) evoked mixed responses from providers depending on the clinical scenario, criminal consequences were more broadly denounced and distressing to providers, especially when misaligned with actual medical risk level of certain drugs in pregnancy and when undermining patients’ trust. Research on the adverse consequences of criminally prosecuting mothers has been increasingly documented in the US and validates the providers’ verbalized discomfort with such laws.^10,12,13

Lack of resources, limited time with patients, and limited availability of evidence-based treatment for mothers and their children were system-level pressures that further constrained providers’ ability to care for dyads impacted by drug use. Stigma surrounding prenatal drug use on both the interpersonal patient level in the clinic setting as well as the system level further deepened disparities for PPWUDs, particularly for rural, low-income, and racial minority patients who already face barriers to care access. Stigma surrounding MOUD within communities and court systems can leave women at heightened risk for relapse and overdose in postpartum, particularly after losing child custody.^9,75 A few studies have quantified this stigma surrounding maternal drug use,^71,76 but none have examined the impact of either interpersonal or structural stigma on ethical conflicts experienced by maternity providers caring for PPWUDs.

Limitations

Given the complexity of human experience and the value frameworks through which individuals interpret the world, this review of providers’ moral experience when caring for PPWUDs is not without limitations. First, included were studies across the US, Canada, Australia, and Western Europe. Child welfare policies, healthcare systems, criminal justice systems, and cultural expressions of stigma vary across each of these regions and, therefore, likely influence the moral experiences reported. Given the differing scopes of practice and training of maternity provider types (e.g., physicians, midwives, and nurse practitioners), the lack of meaningful differentiation in their experiences limits the transferability of our findings. Yet, this analysis provides groundwork for future research comparing differences in moral experience across provider types and geographical locations.

While our initial search did identify some quantitative studies that measured beliefs of providers and stigma about SUD in pregnancy, these studies were excluded from review due to the low quality of the quantitative measures used or their limited ability to explicate the “moral experiences” behind stigmatizing beliefs. Due to the lack of good quality quantitative studies, none of the studies in our review could contextualize the degree of ethical conflict within the context of specific provider-level factors or policies environments. Future analyses characterizing the mechanisms of this phenomenon are needed to better inform future policy recommendations.

Conclusion

Maternity providers are key players in delivering high-quality, non-stigmatizing care to PPWUDs, who are at unique risk for poor health outcomes and discrimination.^77,78 Clinical care for this patient population is often complicated by legally and ethically distressing decision-making influenced by internal and external conflicts. The direct impact of this ethical conflict on provider burnout and patient outcomes remains anecdotal, yet our findings provide a strong foundation for future analyses exploring these mechanisms and effects of ethical conflict. This deeper understanding of providers’ moral experiences as they care for PPWUDs is needed to better support providers in delivering compassionate care to this vulnerable population.

Supplemental Material

Supplemental Material - Maternity providers’ moral experiences addressing maternal drug use

Supplemental Material for Maternity providers’ moral experiences addressing maternal drug use by Caroline K. Darlington, Peggy Compton, Rebecca Clark, Connie M. Ulrich in Nursing Ethics.