Although pregnancy is an exciting time for most women, it can also be scary and unsettling for women who use and misuse substances. These women and their unborn babies are at high risk for poor maternal outcomes. Potential obstetrical complications associated with opioid use during pregnancy include preterm labor, preeclampsia, miscarriage, fetal growth restriction, and fetal death (American Society of Addiction Medicine [ASAM], 2020). Further, the health needs of these women may be exacerbated by malnourishment and interpersonal violence. Newborns exposed to opioids before birth face prematurity, low birthweight, and withdrawal from the opioid due to exposure during the pregnancy.
Christian nurses can serve as shepherds to these women, demonstrating compassion, concern, care, and expertise. This article provides foundational information and evidence-based standards that support the collaboration of community professionals in providing healthcare and treatment options for the woman with opioid use disorder (OUD) to promote the family unit remaining together, support bonding, and encouraging lactation/breastfeeding.
A VULNERABLE POPULATION
A vulnerable population is defined as a group of individuals with an increased risk or susceptibility to adverse health outcomes (Culvert, 2018). The Centers for Disease Control and Prevention (CDC, 2021) includes the following characteristics of vulnerable populations: communication challenges, difficulty accessing medical care, maintaining independence, requiring constant supervision, and accessing transportation. Based on this definition and characteristics, women with OUD and their newborns are a vulnerable population. These individuals experience health disparities: access to care, living at or below the poverty line, lack of insurance, and food insecurities (CDC, 2021; Healthy People, 2020). Illicit drugs, such as heroin, are increasingly being used during pregnancy.
Neonatal abstinence syndrome (NAS) is a term for newborns who withdraw from any substance taken by the mother during pregnancy. A new term created specifically for newborns exposed to opioids in utero is neonatal opioid withdrawal syndrome (NOWS). "Neonatal opioid withdrawal is one of the most common results of intrauterine opioid exposure, with an incidence of 75-90 percent in exposed infants" (Piccotti et al., 2019, p. 160). Infants exposed to opioids before birth face negative outcomes: a higher risk of preterm birth, low birthweight, and the effects of NOWS. According to Piccotti et al. (2019), these newborns will, upon delivery, no longer receive that substance, leading potentially to NOWS. Although exposed in utero, a newborn may experience a generalized multisystem syndrome that affects the central and autonomic nervous systems and the gastrointestinal tract (Clark & Rohan, 2015; Jones et al., 2012; McQueen & Murphy-Oikonen, 2016; Yazdy et al., 2015).
A national study revealed a fivefold increase in the incidence of NAS/NOWS between 2004 and 2014, from 1.5 cases per 1,000 hospital births to 8.0 cases per 1,000 hospital births (Winkelman et al., 2018). During the same period, hospital costs for NAS/NOWS births increased from $91 million to $563 million, after adjusting for inflation (Winkelman et al., 2018). (See Table 1.)
The American College of Obstetrics and Gynecology (ACOG, 2021) recommends universal screening for substance use during comprehensive obstetrical care, beginning at the first prenatal visit. Also recommended is that newborns delivered to women using opioids receive careful monitoring postdelivery. Additionally, ACOG (2021) states, "...a coordinated multidisciplinary approach without criminal sanctions had the best chance of helping infants and families" (p. 1), supporting the benefit of an interprofessional approach to care.
Screening, brief interventions, and referral to treatment (SBIRT) is a term used in the ACOG committee report that "...is an evidence-based practice used to identify, reduce, and prevent problematic use and dependence on alcohol or other substances" (2021, p. 3). SBIRT includes
* Screening: assessing the severity of substance use and identifying the appropriate level of treatment
* Brief Intervention: increasing sight and awareness regarding substance use and motivation toward behavioral change
* Referral to Treatment: providing those identified as needing more extensive treatments with access to specialty care (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021, para 1).
For the pregnant woman with OUD, bringing a new life into the world creates an opportunity for significant lifestyle changes, starting with the first prenatal visit. An interprofessional approach brings in experts from healthcare areas, human services, and the judicial system to work collaboratively with the woman to keep the family unit together, supporting breastfeeding, bonding, parenting skills, job skills, housing, and food securities.
BENEFITS OF BREASTFEEDING
The standard of practice in the labor and delivery setting is emerging for women with OUD to initiate breastfeeding upon their baby's delivery. Breastfeeding diminishes the risk of the newborn developing NOWS and/or decreasing the signs and symptoms of withdrawal. The opioid does cross into breastmilk in small quantities, so the newborn does not experience immediate withdrawal when the umbilical cord is clamped. Breastfeeding these affected newborns remains controversial, despite evidence indicating the severity and intensity of NOWS symptoms can be reduced through this measure (Cleveland, 2016; Grossman et al., 2017; Ozyurt et al., 2018; Shan et al., 2020). Moreover, breastfeeding may not be consistently supported once the woman is discharged from the hospital. She may receive conflicting information about breastfeeding, potentially leading to the newborn's withdrawal symptoms at home.
Evidence-based research, policy statements, and practice standard recommendations support women with OUD to initiate and to continue to breastfeed. The literature indicates that this is the ideal time for the woman to continue her treatment toward sobriety and to make lifestyle changes (ACOG, 2021; ASAM, 2020, Clark, 2019: Cleveland, 2016; Reece-Stremtan et al., 2015; SAMHSA, 2021; Shan et al., 2020). Table 2 summarizes current evidence, guidelines, and recommendations for opioids and other substances women may use or misuse during pregnancy.
Regarding breastfeeding in general, women who breastfeed in the postpartum period experience decreased postpartum bleeding and more rapid uterine involution in the first weeks after delivery. During the first several months of breastfeeding, women experience decreased menstrual blood loss with the potential of delayed ovulation. Return to prepregnancy weight is easier and risk of breast cancer and ovarian cancer is decreased. Women who breastfeed have a lower risk of hip fractures and osteoporosis postmenopausally. Additionally, breastfeeding promotes bonding and attachment between the woman and her newborn. Breastmilk provides essential vitamins, minerals, and nutrients for the newborn's growth and development. The newborn's immune system, immature at delivery, is boosted by breastmilk with IgA and IgG immunoglobulins from the mother. Breastmilk also provides nutrients for human brain growth. Breastfed newborns have fewer sick days and are less likely to become obese.
Moreover, breastfeeding reduces the incidence of Type 1 and Type 2 diabetes in the child, protects against sudden infant death syndrome, and leads to significantly higher scores on development scales when compared with nonbreastfed children of the same age. Breastfed babies have reduced risks for lymphoma, leukemia, allergies, and asthma (AWHONN, 2021; Collins, 2019; McKinney et al., 2018). See Table 3.
SCOPE OF THE PROBLEM
According to the CDC's 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes report,
In 2016, an estimated 48.5 million persons in the U.S., or 18.0% of persons aged 12 years and older, reported use of illicit drugs or misuse of prescription drugs in the past year. This estimate includes the use of marijuana, cocaine (including crack), heroin, hallucinogens, inhalants, and methamphetamines, and the misuse of prescription drugs. The reported prevalence of illicit drug use in the past year by drug type was: 13.9% for marijuana, 0.4% for heroin, 1.9% for cocaine, and 0.5% for methamphetamine. The reported prevalence of prescription drug misuse by drug type was: 4.3% for prescription pain relievers, 2.1% for prescription stimulants, 2.2% for prescription tranquilizers, and 0.6% for prescription sedatives. The reported prevalence of opioid misuse (heroin use or prescription pain reliever misuse) in the past year was 4.4%. (p. 7)
The CDC (2020) notes that opioid use in women between ages 15 and 44 has been increasing. Ailes et al. (2015) reported that during 2008-2012, one in three women of childbearing age filled an opioid prescription each year. The CDC also reported that the number of women between 1999 and 2014 with OUD at labor and delivery had more than quadrupled (Haight et al., 2018). The ACOG Committee Opinion reaffirmed in October 2021, "Substance use disorders affect women across all racial and ethnic groups and socioeconomic groups and affect women in rural, urban and suburban populations" (p. 1).
Winkelman et al. (2018) reported, based on hospital birth data, that the diagnosis of NAS had increased more than fivefold between 2004 and 2014. The authors stated that by 2014, NAS had affected approximately 14.4 infants per 1,000 births, for a total of $462 million in hospital Medicaid costs.
Of opioid use among women of childbearing age, research indicates that those who obtain opioids through prescriptions may misuse the drug, may use illicit opioids such as heroin, or may use opioids (opioid agonists and/or antagonists) as part of medication-assisted treatment for OUD (Bateman et al., 2017; Butcher et al., 2018; Gomez-Pomar & Finnegan, 2018; Kraft et al., 2017; Taleghani et al., 2019). Refer to Table 5 as SDC for more details at http://links.lww.com/NCF-JCN/A90).
Opioids, due to low molecular weight and lipid solubility, cross the placental barrier, exposing the fetus to the drug. The effects of fetal exposure to opioids in the womb are not well understood because clinical trials typically exclude pregnant women for ethical reasons. It is hypothesized that the drug exposure signs in the fetus are dependent on the particular drug, gestational age at birth, total fetal exposure, the amount and purity of the drugs used, length of use, maternal and infant drug metabolism, the individual kinetics of placental drug transfer, and genetic/epigenetic factors (Clark & Rohan, 2015; Gomez-Pomar & Finnegan, 2018).
OPIOIDS AND NEWBORNS
Neonatal abstinence syndrome was first described in the 1970s (McQueen & Murphy-Oikonen, 2016). Defined as a multisymptom syndrome, NAS involves a constellation of symptoms of the central nervous, gastrointestinal, autonomic nervous, and respiratory systems (Table 1). When the umbilical cord is clamped or cut, maternal opioid supply to the exposed fetus ends abruptly, leading to the development of NAS. Finnegan's Neonatal Abstinence Scoring System is often used to evaluate newborns for NAS. Based on the newborn's ability to metabolize the opioid, the timing of NAS symptoms occurs usually within the first 48 to 72 hours, but can occur as late as 7 days. Shan et al. (2020) commented, "Neonatal opioid withdrawal syndrome (NOWS) is a subset of NAS reflecting neonatal withdrawal following exposure to opioids in pregnancy" (p. 2).
When a mother is opioid-dependent, so is the newborn. Sutter et al. studies (2014) noted that 21% to 94% of infants exposed to opioids in utero will develop withdrawal signs and symptoms severe enough to need pharmacologic treatment. Medical management should begin in the antenatal period when the mother is identified as misusing or abusing opioids (Worley, 2014). By establishing this therapeutic relationship, pregnant women receive early screening for abuse, drug testing including consent, and discussion of treatment options. Withdrawal management of the newborn begins at delivery, encompassing both supportive care and medical treatment.
The U.S. Food and Drug Administration has not yet approved medications specifically for the treatment of NAS. In a foundational article, Anwar (2007) presented a literature review from a historical perspective indicating that the altered pharmacokinetics of drugs during pregnancy will affect the metabolism and elimination of the opioid in the system, resulting in longer effects on the body. Anwar further stated that breastfeeding depends on the percentage of the drug that passes through to the breastmilk, the drug's half-life, and the newborn's gestational age at birth. Butcher et al. (2018) stated that the goals of therapy are to ensure proper nutrition for growth and development, enhance the mother-newborn bonding experience, support the newborn through withdrawal, and decrease the duration of treatment and length of hospital stay.
Nonpharmacological measures are becoming more common to support the newborn through opioid withdrawal. These measures include decreasing environmental stimuli, reducing light exposure, minimizing noise, providing a calm and soothing environment, nonnutritive sucking with a pacifier, on-demand feedings, avoiding unnecessary handling, swaddling, and rocking (Gomez-Pomar & Finnegan, 2018; Ozyurt et al., 2018). Grossman et al. (2017) introduced the "Eat, Sleep, Console" model of care (as cited in Grisham et al., 2019) that evaluates the essential functions of eating and sleeping for the newborn and recommends supportive care practices. Grisham et al. (2019) stated, "Interruption in these [essential] functions indicates that the infant is unable to perform activities of daily living and is having withdrawal symptoms that require pharmacological intervention" (p. 139). (See Table 4 as SDC at http://links.lww.com/NCF-JCN/A89.)
The outcome of NAS is improved with breastfeeding and rooming-in, according to Washington and Wilson (2019). Additional supportive measures include music therapy, acupuncture, massage, use of a waterbed, and volunteers to cuddle the infant (McQueen & Murphy-Oikonen, 2016).
Historically, newborns who were exposed to opioids in utero and experienced withdrawal symptoms after delivery received pharmacological treatment for opioid withdrawal (Butcher et al., 2018; Gomez-Pomar & Finnegan, 2018; Kraft et al., 2017; Taleghani et al., 2019). Morphine, tincture of opioid, and phenobarbital have been prescribed to successfully treat NAS. More recently, methadone and buprenorphine treat NOWS when nonpharmacological measures are insufficient. (See Table 5 SDC at http://links.lww.com/NCF-JCN/A90.)
Support for breastfeeding of newborns exposed to opioids in utero is detailed in practice briefs and clinical protocols from the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, 2021) and the Academy of Breastfeeding Medicine (Cleveland, 2016). Other research has supported breastfeeding to minimize the symptoms of NAS, slow the withdrawal process, and decrease the length of hospitalization for these newborns (McQueen & Murphy-Oikonen, 2016). Breastfeeding also promotes bonding between the mother with her newborn when accompanied by rooming-in and supportive care measures (McQueen & Murphy-Oikonen, 2016).
NURSING RECOMMENDATIONS
Women who use and misuse opioids during pregnancy often are more willing to consider a lifestyle change when bringing a new life into the world. Nurses can collaborate in an interprofessional approach-private healthcare providers, the local public health department, human service providers, and the judicial system-to improve the family unit's success, with a comprehensive educational program and toolkit based on evidence-based research for the community agencies that support women and their newborns (King, 2021).
Community agencies should work together to support this change as women return to the community after the birth. This is an ideal time to explore how to keep the mother and newborn together by supporting bonding, lactation, and the family unit. It is becoming the standard of practice to allow women with OUD to participate in the care of their newborns through breastfeeding, as this diminishes the risk of NOWS as long as the woman continues the OUD treatment regime established during pregnancy.
APPLYING A BIBLICAL WORLDVIEW
Conscience conflicts and hesitations are common in relation to supporting women with OUD to parent their newborns. "Faith-based practitioners working with pregnant clients on opioid maintenance may find value conflicts even more arduous as they attempt to balance potential competing beliefs related to faith and practice" (Watson et al., 2019, p. 72). Christian nurses can benefit from reflection on their worldview and how it aligns with Jesus' perspective: that each person God created has innate value. Some nurses may find deep reflection helpful, as suggested by Cone (2015). Reflecting on Scripture and God's view of persons can enable Christian nurses to love others as God loves them, leading to a course of action as change agents for women with OUD and their newborns.
Vulnerable women need guidance from Christian nurses as they transition to sobriety while gaining a biblical image of themselves as mothers. Psalm 139:13-16 is a fitting text to share with women wanting to reframe their lives and futures:
For you created my inmost being; you knit me together in my mother's womb.
I praise you because I am fearfully and wonderfully made; your works are wonderful, I know that full well. My frame was not hidden from you when I was made in the secret place when I was woven together in the depths of the earth. Your eyes saw my unformed body; all the days ordained for me were written in your book before one of them came to be. (NIV)
Christian nurses have significant opportunity to influence the woman with OUD and her newborn to continue breastfeeding; nurses also function as shepherds to influence community health professionals in supporting these new mothers. In this shepherding role, nurses emulate Christ through demonstrating compassion, concern, and unconditional love.
Further, the local church community can offer support for women with OUD and their newborns. Faith communities can endeavor to increase awareness in their communities about the OUD crisis. Nurses can empower churches with medical and scientific evidence that breastfeeding for women with OUD is safe and supports the well-being of both parent and child. Finally, faith communities can collaborate with community professionals to connect women with avenues of support.
CONCLUSION
God's design is for relationship; we demonstrate our alignment with God's design by caring for and nurturing the vulnerable among us, imitating how Jesus cared for those around him while he was on earth. Practicing evidence-based care to encourage breastfeeding for women with OUD and engaging other healthcare and community professionals in this effort improves the outcomes for the new mother and her child. Connecting with women in need with love, support, and grace in both words and actions is a major contribution of the church to the community it serves, fulfilling the directive in Galatians 6:2: "Carry each other's burdens, and in this way you will fulfill the law of Christ" (NIV).
Web Resources
* Perinatal Substance Exposure Task Force: At a Glance: Perinatal Provider Toolkit https://todayisfor.me/wp-content/uploads/2021/04/Perinatal-Provider-At-A-Glance.
* Health Resources and Services Administration: Caring for Women with Opioid Use Disorder: A Toolkit for Organizational Leaders and Providers https://www.hrsa.gov/sites/default/files/hrsa/Caring-for-Women-with-Opioid-Disor
* Substance Abuse and Mental Health Services Administration: Clinical Guidance For Treating Pregnant And Parenting Women With Opioid Use Disorder And Their Infants https://store.samhsa.gov/sites/default/files/d7/priv/sma18-5054.pdf
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