In 2020, 8.3% of women who were pregnant reported the use of illicit drugs (including the misuse of prescribed medications or the use of cannabis, cocaine, heroin, hallucinogens, inhalants, or methamphetamine), 10.6% reported using alcohol, and 5.0% reported binge alcohol use during the month prior. 1 Following the declaration of COVID-19 as a public health emergency and the enactment of stay-at-home orders in March 2020, substance use and drug overdose deaths increased among the general population. Reference Czeisler, Lane and Petrosky2,3 From 2017-2020, pregnancy-associated overdose mortality also increased from 6.56-11.85 per 100 000 women, with the increase in 2020 more pronounced than previous years.Reference Bruzelius and Martins 4 In addition, evidence suggests that women who are pregnant and adults with substance use disorder (SUD) are at a higher risk for severe COVID-19 outcomes. 5 With 2 known risk factors for adverse outcomes, it is very important that women who are pregnant with SUDs receive uninterrupted routine health care during a global pandemic. 5 Pregnant women with SUDs are often marginalized and regularly experience stigma and barriers to treatment.Reference Terplan, McNamara and Chisolm 6 It is estimated that only about 13% of women who are pregnant and in need of SUD treatment ultimately receive treatment during pregnancy, and women who use substances encounter greater challenges accessing perinatal care than those without a known SUD.Reference Martin, Scialli and Terplan 7 , Reference Nidey, Kair and Wilder 8 There is a critical gap in knowledge about the impact of the COVID-19 pandemic on access to care for women who are pregnant and postpartum and use substances.
In the US, new care delivery methods were employed to avoid significant gaps in SUD treatment during the pandemic. As stay-at-home orders were issued and facilities deemed “nonessential” temporarily closed, SUD treatment facilities were deemed essential and were encouraged to transition to telehealth or intensive outpatient services. 9 The Substance Abuse and Mental Health Services Administration (SAMHSA), the US Drug Enforcement Administration (DEA), and the US Department of Health and Human Services (HHS) issued guidance to temporarily allow buprenorphine induction during a telehealth visit and permanently waived the federal requirement for clinicians to submit a Notice of Intent (X-waiver) to prescribe buprenorphine. 9,10 The removal of this waiver increased the number of clinicians legally able to prescribe medications for opioid use disorder (MOUD). 9,10 Additionally, while the dispensing of methadone treatment for opioid use disorder (OUD) is tightly regulated and has historically required in-person treatment, SAMHSA instituted emergency flexibilities to allow for take-home methadone protocols.Reference Alexander, Stoller and Haffajee 11 , 12 Despite these policy and practice changes, people receiving SUD treatment may still have experienced disruptions in care related to facility closures and programs diverting personnel and financial resources to treat COVID-19-related illnesses. Reference Alexander, Stoller and Haffajee11,Reference Kumar, Janmohamed and Nyhan13 Moreover, the shifts in telehealth flexibilities and MOUD prescribing were not designed with the unique substance use and SUD treatment needs of pregnant and postpartum women in mind. Reference Frazer, McConnell and Jansson14,Reference Choi, Rosenbloom and Stein15 We surveyed pregnant and postpartum women who reported substance use and interviewed clinicians who treat this population to capture key lessons learned. These findings can inform future practices, including telehealth and flexible prescribing policies, to ensure women who use substances during the perinatal period receive appropriate care during future public health emergencies. In addition, this information can inform future efforts to utilize telehealth as part of routine care, as outlined in the 2024 National Strategy for Maternal Mental Health and the accompanied Report to Congress. 16,17
Methods
The Centers for Disease Control and Prevention (CDC) collaborated with the Research Triangle Institute International (RTI) to conduct a mixed methods study with surveys and interviews. Data collection occurred from October 2021-January 2022. This study was deemed research exempt by RTI’s Institutional Review Board, received a waiver from the Federal Government’s Office of Management and Budget’s Paperwork Reduction Act, and was conducted in a manner consistent with applicable federal law and center policy (e.g., 45 CFR part 46.102.l.2; 21 CFR part 56; 42 USC §241.d; 5 USC §552a; 44 USC §3501 et seq).
Survey
Respondents were eligible to complete the survey if they met the screening criteria for 1 of the following groups:
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• Pregnant: The respondent reported being pregnant at the time of screening and using alcohol (any alcohol use), tobacco, marijuana (hereafter referred to as cannabis, not including cannabidiol oil), or an illicit substance (i.e., cocaine, heroin, hallucinogens, inhalants, or methamphetamine) while pregnant; misusing a prescription medication while pregnant (i.e., use of a prescription medication in any way not directed by a clinician, including opioid pain relievers, benzodiazepines, sleeping pills, stimulants, or other prescribed medications); or receiving treatment or counseling for alcohol or substance use in the past year.
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• Postpartum: The respondent reported having delivered a baby in the past 1-3 months and using alcohol (any alcohol use), tobacco, cannabis, or an illicit substance during the pregnancy, misusing a prescription medication while pregnant, or receiving treatment or counseling for alcohol or substance use in the past year.
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• Non-perinatal: The respondent was not pregnant or not less than 3 months postpartum when completing the screener and reported alcohol use that was classified as heavy drinking (for women, consuming 8 or more drinks per week) or binge drinking (for women, consuming 4 or more drinks at a time), use of tobacco, cannabis, or an illicit substance, misuse of a prescription medication during the past 30 days, or receiving treatment or counseling for alcohol or substance use in the past year.
The focus of this analysis is on the perinatal period, so this report only includes the responses from participants who reported being pregnant or postpartum. Survey respondents were recruited through advertisements on Facebook and Instagram. Two campaigns were implemented: one for recruiting pregnant and postpartum women via imagery and language related to pregnancy, and the other for recruiting women who were not pregnant or postpartum via imagery and language not specific to pregnancy. Each campaign included a variety of advertisements that were rotated depending on performance metrics. Women who clicked on the advertisement were taken to a website to complete an eligibility screener; based on this, they were then invited to complete the survey. To avoid selection bias, the eligibility screener included questions on a variety of topics (e.g., substance use, exercise, sleeping, etc.) so that respondents did not know the inclusion criteria when completing the screener. Survey participation was voluntary, and respondents could skip questions per their discretion. A $15 digital gift card was offered as incentive for completing the entire survey.
The survey included questions on access and barriers to health care (including specific questions on prenatal and postpartum care), mental health, substance use, and SUD treatment. Because the questions for pregnant and postpartum respondents were designed to inquire about experiences during the time the respondent was pregnant, we have combined these results.
Key Informant Interviews
Structured key informant interviews were conducted with practicing clinicians who indicated a relevant primary area of practice in the US and taking care of an average of at least 1 pregnant or postpartum woman per week who uses substances. Clinician recruitment was conducted through communications sent out by CDC clinical partners to their networks, including the American Academy of Family Physicians; American College of Nurse-Midwives; American Congress of Obstetricians and Gynecologists (ACOG); American Psychiatric Association; American Society on Addiction Medicine; Association of Women’s Health, Obstetric and Neonatal Nurses; and National Association of Nurse Practitioners in Women’s Health. Announcements about the study were distributed by email and through online organizational message boards and listservs. Clinicians who were interested in participating were directed to complete an online study screener. Eligible respondents were then contacted by RTI to schedule a 30-minute interview. Participation was voluntary and the clinicians could skip any questions during the interview per their discretion. A $75 digital gift card was offered as incentive for completing the interview.
The interview guide included questions that focused on changes clinicians made to their practice due to COVID-19, and the challenges and opportunities these changes created. In addition, the guide included questions about impacts on the availability of SUD treatment and other resources to which they typically refer their patients, changes to their clinical practice, and lessons learned for future public health emergencies.
Statistical Analyses
Analyses of survey data were conducted using SPSS (v25). To examine associations between types of substance use and health care outcomes, some substances were combined into 2 categories: polysubstance use (i.e., report of using more than 1 of the substances listed) and misuse of prescription medications (i.e., opioid pain relievers, benzodiazepines, sleeping pills, stimulants, or other prescribed medications). To examine telehealth satisfaction, a composite of 11 items scored from 1 (strongly disagree)-5 (strongly agree) was developed, and t tests of independent groups (equal variances assumed) were used to test these scores.
Interviews were transcribed and coded using NVivo. A codebook was developed based on the interview guide and notes. Two coders independently analyzed the transcriptions and met to resolve any identified coding discrepancies. Thematic analyses were completed to identify emerging themes.
Results
Survey
In this convenience sample, 302 respondents who reported being either pregnant or postpartum completed the survey. Of these, 22 (7.3%) respondents did not appropriately complete an attention-check question (i.e., a question asking the respondent to select option D) used as a data quality flag to ensure respondents were taking time to read and respond to each question, reducing the sample to 280 (210 pregnant and 70 postpartum).
Demographics
Most respondents identified as White (n = 228; 81.4%), followed by Black or African American (n = 46; 16.4%) and Asian (n = 14; 5.0%); additionally, 13.9% of respondents identified as Hispanic (n = 39) (Table 1). Most respondents reported having less than a bachelor’s degree (n = 248; 88.6%) and 3/4 indicated their annual household income was less than $45 000 (n = 210; 75.0%). The most common health insurance indicated by respondents was Medicaid (n = 200; 71.4%).
Survey of pregnant and postpartum women: demographics
* Not mutually exclusive
Substance Use and Treatment
The most used substances during pregnancy were cannabis (n = 172; 61.4%), tobacco (n = 140; 50.0%), and alcohol (n = 105; 37.5%) (Table 2). Nearly 1 in 10 respondents (n = 26; 9.3%) reported using methamphetamine during pregnancy. The most frequently reported prescription drugs misused were opioids (n = 61; 21.8%), sleeping pills (n = 41; 14.6%), and benzodiazepines (n = 36; 12.9%). When asked to report their substance use frequency during their pregnancy, over 1/4 reported using substances daily (n = 81; 28.9%) and 1/5 reported using substances 1-5 times per week (n = 59; 21.1%). Over half of respondents reported polysubstance use, or the use of more than 1 substance (n = 150; 53.6%). More than half of the respondents (n = 55; 52.4%) reported their alcohol use increased since the start of the pandemic (Table 2). Nearly half reported that their substance use increased (n = 109; 46.6%), and 38.8% (n = 40) reported an increase in prescription drug misuse.
Survey of pregnant and postpartum women: reported substances used and substance use disorder treatment
a Report of using more than 1 substance
* Not mutually exclusive
One-third of respondents reported being diagnosed with a SUD (n = 97; 34.6%) (Table 3) and receiving SUD treatment in the past year (n = 102; 36.4%) (Table 2). Among the respondents who received SUD treatment, the most common substances for which they were treated included tobacco (n = 42; 41.2%), alcohol (n = 40; 39.2%), cannabis (n = 31; 30.4%), and prescription opioids (n = 28; 27.5%). One-third of respondents who received SUD treatment reported receiving MOUD (n = 32; 31.4%) (Table 2).
Survey of pregnant and postpartum women: patient health characteristics, access, and barriers to health care
a Composite score of 11 satisfaction items scored from 1 to 5 (1 = Strongly disagree, 5 = Strongly agree).
b M = mean or average value
c SD = standard deviation or how many values deviate from the mean
* Not mutually exclusive
Barriers to Health Care
All respondents experienced pandemic-related barriers to routine health care services. Over half of respondents reported skipping a preventive health care visit (n = 150; 53.6%) and 40.4% (n = 113) said they were unable to schedule a non-prenatal medical appointment because of the pandemic (Table 3). Additionally, 1/3 of respondents skipped a recommended medical test, vaccine, or treatment (n = 100; 35.7%) and over a quarter skipped or did not fill a prescription (n = 83; 29.6%). Over half of respondents reported delaying prenatal care due to the pandemic (n = 156; 55.7%). Regarding SUD treatment, 37.3% (n = 38) of respondents experienced delays or disruptions. Over 1/3 reported canceling their own SUD treatment appointment (n = 39; 38.2%) and 1/4 had their clinician cancel an appointment (n = 26; 25.5%). Nearly one-half of respondents transitioned to telehealth services for their SUD treatment due to COVID-19 (n = 47; 46.1%).
Telehealth Satisfaction
Most respondents reported at least 1 telehealth visit during the pandemic (n = 200; 71.4%) (Table 3). The top reasons for their most recent telehealth visit included mental health (n = 54; 27.0%), prenatal/postpartum care (n = 36; 18.0%), and SUD treatment (n = 24; 12.0%). The telehealth satisfaction score among respondents was generally positive (M = 3.97, SD = 0.82). About half of respondents (n = 97; 48.5%) preferred a combination of in-person and telehealth visits, while some respondents preferred in-person services (n = 75; 37.5%).
Key Informant Interviews
Twenty-five clinicians participated in the interviews. Among the interviewees, 20 (80%) identified as female and 5 (20%) identified as male. Most reported being White (n = 19; 76%). Half of the clinicians practiced in the South (n = 12; 48%), 6 (%) in the Midwest, 4 (16%) on the West Coast, and 3 (12%) in the Northeast. Half of the clinicians specialized in obstetrics and gynecology (n = 13; 52%), followed by addiction medicine (n = 7; 28%), primary care (n = 3; 12%), midwifery (n = 1; 4%), and addiction psychiatry (n = 1; 4%) (Table 4).
Clinician key informant interview characteristics
a Asian and White
Telehealth Practices
All clinicians reported implementing telehealth either exclusively or through a combined in-person and telehealth approach in response to the pandemic. Among those who employed a combined approach, in-person visits were determined by the type of medical care being provided, such as fetal heartrate monitoring or buprenorphine initiation. Most clinicians said they were more likely to use telehealth services for SUD treatment than for delivery of routine prenatal care. Clinicians who provided both group and individual SUD counseling to patients believed telehealth worked better for individual counseling.
Clinicians outlined several challenges implementing telehealth, including technological issues for patients such as lack of access to a computer, smart phone, or stable internet connection. At times patients reported privacy concerns and concerns that family members or other people might be in listening proximity.
“Not only people who lack technology or were in a rural area, lacked broadband access, just basic stuff to even be able to participate in telehealth, but also people who lived in congregate settings where they couldn’t have any privacy.” (Nurse Midwife, OB/GYN)
By nature, telehealth visits do not allow for detailed physical exams and specific testing (e.g., ultrasounds for prenatal care visits, drug screening for SUD treatment, etc.). Some clinicians also raised concerns that the quality of care might be less due to the inability to comprehensively assess the patient through telehealth as compared to an in-person visit. At the beginning of the pandemic, a few clinicians reported telehealth billing was initially a concern, however most reimbursement issues resolved over time.
All clinicians noted that increased telehealth utilization facilitated improved health care access for patients, especially patients in rural areas. It also allowed for increased care retention due to higher attendance for telehealth visits and the ability to offer telehealth as an alternative modality to remain in SUD treatment if in-person visits were not possible, especially for patients without reliable transportation or who would need childcare to attend the in-person appointment.
“So, if your Medicaid ride doesn’t show up, if you don’t have gas money, if you have a sick kid, you can hop on a telemedicine visit and still see your clinician, still get a refill of your life-saving medication, engage in support services all while you’re at home. I think that is the biggest positive of telemedicine.” (Nurse Practitioner, OBGYN)
“Telehealth has increased the likelihood of patients showing for a new patient appointment and has definitely increased retention and care. Several [of my] patients who had scheduled with me a few different times before telemedicine was available and missed appointment – after telemedicine became available, were able to keep appointments and really engage.” (Physician, Addiction Medicine)
Telehealth visits afford the unique opportunity to gain a better understanding of the home environment, which may inform plans for care and SUD treatment. One clinician commented that challenges related to urine drug screening during the pandemic led to a revisiting of the value of requiring drug screens before initiating or changing MOUD. This clinician believed this was a positive outcome.
Changes in Substance Use Screening and MOUD
Most clinicians noted that most screening practices did not change due to the pandemic aside from the implementation of pre-screening patients by phone to decrease the amount of physical time patients spent in the clinic. Clinicians indicated that incorporating pre-screening into their practice enabled them to enhance the questions they asked to better connect with the patient and capture their substance use history to identify what care they need.
Clinicians working within methadone clinics indicated that during the pandemic they saw increases in the number of take-home methadone doses offered and increases in telehealth services. Clinicians who prescribed buprenorphine noted the biggest opportunity in buprenorphine-related care was the ability to initiate this treatment via telehealth. Some noted buprenorphine induction via telehealth improved access and retention to buprenorphine treatment among their patients. However, other clinicians shared that they would ask patients who were initiating buprenorphine to attend their visit in-person, and as soon as the clinicians felt they were stable, they would conduct their check-in appointments via telehealth.
“The waivers to allow individuals to do substance use disorder and controlled substance prescribing through telehealth was also really important, because I know that was not even possible. It’s opened up another avenue of care and lowered a barrier. And anytime we can lower a barrier to get access to treatment is a good thing.” (Physician, Addiction Medicine)
Discussion
Pregnant and postpartum women who reported using substances increased their use during the COVID-19 pandemic and most experienced barriers to care. These findings correlate with pandemic-associated increases in pregnancy-related overdose mortality and the pre-pandemic US maternal morbidity and mortality crisis.Reference Bruzelius and Martins 4 Telehealth and flexible MOUD prescribing policies expanded the opportunities for continued care, albeit with some initial challenges. In future public health emergencies, the practices used during the COVID-19 pandemic could be used to ensure unfettered access to SUD treatment. 16
When compared with 2021 nationally representative data, this analysis demonstrated higher rates of alcohol and substance use during pregnancy, with 4 times higher reported alcohol use, 5 times higher tobacco use, 8 times higher cannabis use, and 9 times higher methamphetamine use. 18 Additionally, nearly half of survey respondents reported daily or weekly substance use and 1/3 reported having an SUD. The higher alcohol and substance use as well as the high frequency of use reported in this analysis may indicate the respondents were a unique population compared with nationally representative data, or that this survey facilitated more accurate responses, given that substance use is a stigmatized subject with high social-desirability bias. The findings are consistent with reports in the literature, reinforcing the importance of maintaining perinatal access to substance use screening, treatment, and harm reduction services (e.g., syringe services programs, substance use hotlines, etc.) during public health crises. Reference Sugarman, Busch and McHugh19,Reference Shimbo, Artinian and Basile20 Additionally, findings from this study indicate more than half of the respondents reported delaying prenatal and/or postpartum care due to the pandemic, and over 1/3 reported delays in SUD treatment. This might be due to heightened concerns about one’s health risks during pregnancy, prioritization of avoiding COVID-19 over other health care needs, or reduced clinic availability during the pandemic.
A significant benefit of telehealth is the ability to bridge potential gaps and overcome challenges in accessing health care services.Reference Sugarman, Busch and McHugh 19 The interviewed clinicians noted that incorporating telehealth into their medical practice reduced barriers for patients related to transportation and improved overall retention rate. While the survey respondents tended to prefer in-person or a combined in-person/virtual medical visit, fewer reported having skipped a prenatal telehealth appointment than a prenatal in-person appointment. Given that prenatal visits require more physical exams to monitor the progress of the pregnancy and overall health – and patients usually find comfort in fetal monitoring through in-person visits – it is understandable that more respondents preferred in-person appointments. Innovative prenatal care solutions such as home blood pressure monitoring, drop-in fetal heartrate monitoring, and coordinating laboratory/immunization-only visits with other care are also important considerations for future public health crises. Reference Shmerling, Hoss and Malam21,Reference Aziz, Zork and Aubey22 Health care providers may utilize a combination of telehealth and in-person visits when providing care to their perinatal patients to continue addressing barriers during and after a global pandemic.
However, there might still be hesitancy among some patients and clinicians about fully embracing telehealth, especially during pregnancy and with SUD treatment. Additional training for clinicians who treat this population may help promote best practices for telehealth by proving clear guidelines for remote SUD treatment and clear benefits of remote care for women who are pregnant. Patients and clinicians could benefit from additional education about the commonly performed face-to-face prenatal and SUD services and the evidence-base for these practices; for example, blood pressure can be monitored successfully at home, and urine toxicology is not recommended for improving outcomes during SUD treatment. Reference Shimbo, Artinian and Basile20,Reference Terplan, Martin and Premkumar23 Given findings from this study that 1 in 4 respondents reported prescription opioid misuse and 1 in 20 reported heroin use, preserving access to MOUD, including the provision of naloxone (i.e., an overdose reversal drug), and other harm reduction services appears important during future public health emergencies. Reference Bruzelius and Martins4,24 Additionally, the relaxation of MOUD-related policies, such as removing the requirement for an X-waiver for clinicians to prescribe buprenorphine and allowing more methadone takeaway doses, are important changes that have been sustained. 10
This study is subject to limitations. First, these data are not nationally representative and do not reflect the experiences of all pregnant and postpartum women who use substances or clinicians providing SUD treatment. The sample sizes of respondents who used certain types of substances were small; therefore, we could not examine unique characteristics of health care and SUD treatment access for substances individually. We also surveyed women who were pregnant after the time when most stay-at-home orders were lifted (May of 2020), and across multiple waves of the COVID-19 pandemic (characterized by the predominant circulating SARS-CoV-2 variant). Therefore, findings might not be applicable to the challenges and opportunities experienced by women who were pregnant and used substances earlier in the pandemic.
Conclusion
Women who reported substance use during and after pregnancy reported increased substance use during the COVID-19 pandemic, while at the same time experiencing substantial barriers to ongoing care. Strategies used to mitigate barriers and gaps in care included the use of telehealth and removal of the X-waiver for buprenorphine prescriptions. Despite these efforts, survey respondents still experienced barriers to consistent care. Findings from this study highlight the need for innovative solutions to address the medical needs of pregnant and postpartum women who use substances during public health crises.
CDC Disclaimer
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Replication Statement
Analyses were conducted by using SPSS (v25) by Elizabeth Adams. Data were replicated by Caitlin Green.
Author contribution
CRediT author statement: Caitlin Green: Writing – Original Draft, Conceptualization, Validation. Amy Board: Writing – Review & Editing, Validation, Claudia Squire: Investigation, Methodology, Formal Analysis. Elizabeth T. Adams: Investigation, Formal Analysis . Shin Y. Kim: Conceptualization, Methodology, Supervision. Jill A. Brown: Investigation. Peyton Williams: Investigation. Raahina Malik: Investigation. Kara Polen: Methodology, Writing – Review & Editing. Suzanne M. Gilboa: Supervision, Writing – Review & Editing. Kathryn Miele: Methodology, Supervision, Writing – Review & Editing.
Funding statement
This work was completed through a contract between CDC and RTI International.
Competing interests
The authors have no conflicts to disclose.
