COVID-19 and the Fourth Trimester

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson. On this episode: pregnant people in crisis; how isolation during the pandemic leaves new families at risk; and what it will take to help them recover.

DR. KRISTINA BOX:
When you're in treatment during pregnancy, your body kind of loses that tolerance to the drugs that you were using. And then if you start to use again—oftentimes in that postpartum period—you don't have that same tolerance built up; and so, your risk is higher to overdose.

DR. MISHKA TERPLAN:
So, I think public health has a real central role to play in general, and in particular when we're talking about pregnancy, postpartum, and substance use.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today: another pandemic crisis, this one impacting pregnant people or new parents battling pandemic-related isolation—maybe even depression—and how all of it can lead to substance use and overdose. The numbers from 2020 are not good. It's believed at least 90,000 people died last year from an overdose—an upsetting record largely blamed on COVID-19. Our guests on this episode are thinking about the pregnant people or new parents who are part of that number, and ways to help those still fighting look forward to a better future for themselves and their families.

Dr. Mishka Terplan is a nationally-recognized expert in the care of pregnant and parenting people with substance use disorder. He's along shortly to talk about stigma.

But first, we hear from Dr. Kristina Box, an OB-GYN and state health commissioner for Indiana.

BOX:
When we speak specifically of pregnant individuals and women that are in that fourth trimester—which is really the postpartum period—the pandemic has been isolating for all of us; so, it's certainly been isolating for our pregnant patients and our postpartum patients.

While they're pregnant—early on, there may not have been a vaccine available; and of course the vaccine, when it first came out, had not really been studied very well in pregnant women. So, there was a lot of hesitation about taking the vaccine at that time.

And the postpartum period is a particularly difficult time for women anyway, minus a pandemic, because they are more isolated, they're facing a lot of changes in their life, some anxieties about the baby and how the baby's doing, and lots of lack of sleep, which can significantly impact a woman's ability to kind of manage through some of the changes that they have to accept at that point in time.

So, there's been a higher risk for—just like in the general population—depression, anxiety, and substance use disorder.

JOHNSON:
And some of that leads to overdose.

BOX:
Absolutely. And, you know, in general, a pregnant woman is much more likely, while she's pregnant, to reach out and accept help, and to get into treatment for her substance use disorder. And then their risk—even in a non-pandemic time—is higher for relapse in that postpartum period.

When they're pregnant, they want to do everything they can to try to prevent causing any issues with their unborn child. And then, the stresses, and the frustrations, and trying to go back to work, and the changes in their life, and their lack of sleep—oftentimes, they will see a relapse in that postpartum period, especially that first year.

JOHNSON:
Have there been more of these challenges during the pandemic?

BOX:
For sure. I mean, in general, across the United States and certainly here in Indiana, we have seen more overdoses throughout the pandemic; and, unfortunately, I know that that has included also our pregnant and postpartum population.

When you're in treatment during pregnancy, your body kind of loses that tolerance to the drugs that you were using. And then if you start to use again—oftentimes in that postpartum period—you don't have that same tolerance built up; and so, your risk is higher to overdose.

JOHNSON:
How, then, can you deal with that as a public health official? Are there any strategies you can employ? Are there any programs or policies that can be put in place that could help?

BOX:
I think that, number one, you have to reduce the stigma associated with saying, "I have a substance use disorder issue." We need to normalize that as healthcare professionals and as a society; to say substance use disorder—just like having diabetes or high blood pressure—is an underlying medical disorder that needs to be treated. We need to recognize that a lot of those substance use disorders are treating underlying anxiety and depression, and actually evaluate and identify those underlying mental health issues that are a problem.

When we look at our maternal mortality review—the state of Indiana has been doing a very thorough review since 2018; so, we've looked at 2018 and 2019. Fully a third or more of our pregnancy-associated deaths have been in women, and pregnant women or postpartum women. And when we look at significant contributing causes, substance use disorder was present in over 50% of those pregnancy-associated deaths. So, what you do then, as a state, is you look at what things could make a difference going forward.

One of those is expanding postpartum coverage for a full year after that woman delivers, because we know that's their time that they're at highest risk. And if you come off your postpartum Medicaid coverage, for instance, at six weeks or eight weeks, you may lose access to your medication-assisted therapy and your counseling and support systems that you need at that time.

We have, here in Indiana, an amazing Indiana perinatal quality improvement collaborative that has really done a fabulous job dealing with neonatal syndrome, which are the results of opioid use disorder in newborn babies. And with perinatal substance use disorder, we have actually developed a substance use disorder NAS toolkit. That is rolled out into over 75 of our 85 delivering hospitals.

The governor has been very supportive of this. And a couple of years ago, in legislation, we actually mandated that every person that sees a pregnant woman or a pregnant person in early pregnancy is mandated to screen for substance use disorder, and then to either treat them or to refer them for treatment for that.

You also, as a society or community, want to set up programs that give women access to resources and support throughout their pregnancy in that first year postpartum. So, we have a program called My Healthy Baby that basically attaches women to a family support person—which would be also a home visitor—that can support them throughout the pregnancy, make sure they have access to all the resources that they need, and to treatment them for their substance use disorder and care.

FSSA—Family Social Services Administration—has a new program called Pregnancy Promise program. That gives increased or enhanced Medicaid support through our managed care entities here in the state so that we can make sure that women are being followed up as to whether they're making their appointments for the counseling therapy substance use disorder, that they have access to keep a roof over their head, and for food for their family, and to keep their lights turned on. Making sure that all of that is available, those resources, so that we can decrease those stresses that might make it a higher risk for them to relapse.

And then, lastly—and I think probably most importantly—we have a whole campaign here in the state called Know the O facts, which is kind of know the opioid facts. And that's around the stigma of opioid use disorders specifically, and kind of educating the general population—and also our providers across the state—about that importance of being engaged with substance use disorder.

We have ECHO programs that actually train our obstetrical providers across the state to give medication-assisted therapy to their patients throughout pregnancy and postpartum period.

JOHNSON:
I wanted to talk a little more about stigma—you've mentioned it a few times already. How do you make it easier for someone to explain a problem they're having or an issue that they're dealing with when they're in front of a provider? Is there a way that public health can be helpful there?

BOX:
I think having social media things, and advertisements, hotlines that people can call to get help so that they know this is kind of a normalized thing, that we know it's a problem and it's an issue, and we're trying to provide you resources for that.

As a provider, just the fact that I screen somebody for depression or I screen them for substance use disorder somewhat normalizes that. The woman actually feels, "You know what, my doctor actually cares about this. Maybe I can share this with her, that I'm struggling with depression or anxiety," or, "I have a problem with alcohol use that I'm not able to control when I'm pregnant or postpartum," or opioid use disorder, whatever that is. I think just opening that conversation helps to normalize that as part of, "We screen all of our patients for this; and if you have a problem, please share it with me so that I can engage with you and we can partner together so that you can have the best outcome for your pregnancy."

JOHNSON:
Obviously, the pandemic has upended every facet of life. How much damage has it done in this area?

BOX:
So, it's done a huge amount of damage.

If you think about anybody with substance use disorder, what they need is connection; they need direct connection to human beings that they know care about them, that are there for them, and oftentimes just that healing touch. So, the pandemic has separated all of us from that. Even those individuals who don't struggle with substance use disorder or depression or anxiety have struggled from that throughout this pandemic.

So, we needed to work extra hard to make sure that these women were still connected to care. But throughout the pandemic, especially early, on many of these programs shut down because many of the offices and the clinics shut down.

Now, the good news is a lot of this is very, very accessible through telemedicine, and the type of counseling and therapy that is needed can be done, you know, over a computer or a phone. But the problem is it doesn't make up for, again, that human touch and that human connection that a lot of us need. So, do I think things will improve after this pandemic has gone? Most assuredly. I think the great news is that people will once again be able to have family in the delivery room with them. Women now go home postpartum; and they're warned about having too many people in to see the baby and, if they do come in, washing their hands; and wearing a mask; and warned about not going out into crowded areas.

And so, it has really limited those Mommy and Me groups and those family groups that bring postpartum women together for kind of that support system that we all need after we've just had our first, second, third babies.

JOHNSON:
It's left us with a lot of ground to make up.

BOX:
Absolutely. I believe that when we look back—unfortunately, I believe our maternal mortality will go up through the years of 2020 and 2021. And that's heartbreaking to think about that.

We just need to get right back to doing the programs that we know were working, and continuing to expand those programs and make sure that all women in the state of Indiana and across the nation have access to this kind of care.

JOHNSON:
Like Dr. Box, Dr. Mishka Terplan is a trained OB-GYN who also plays a key role in helping several national organizations develop health policy. He's published more than 100 peer-reviewed articles on topics like addiction medicine, drug use in pregnancy, and stigma.

TERPLAN:
Stigma—it's a really interesting term. It comes from stigmata, the mark of the wounds of the crucifixion of Christ. It's really a mark of otherness, of deviation from norms—norms of gender, norms of profession, norms of motherhood. And in many ways, stigma, you know, is a mark of otherness and can be seen as a quote unquote "them" problem.

Stigma is really important to talk about, but it's connected also to discrimination and prejudice because that reflects how we treat other people. And whereas stigma is a "them" problem, discrimination and prejudice are "us" problems, and that's something we can do something about. So, people who use drugs during pregnancy—as well as postpartum—you know, experience discrimination and prejudice from healthcare providers, from payers, from society at large, and it certainly impedes care.

On the individual level, you know, people who use drugs who are pregnant or postpartum might be reluctant, you know, to seek care due to previous poor experiences with healthcare providers. When they access care, they might fear disclosure. And that fear is legitimate because sharing information, sharing vulnerabilities about substances, with people in power can lead to, you know, involvement of state agencies such as child welfare, which could lead to removal of the children from the home.

And then, I think within treatment context, people who are in treatment. One thing that happens in pregnancy is we marshal many public health resources during the first three trimesters—you know, there's payment for prenatal care, visits increase in frequency as birth approaches to weekly visits. And then, it all kind of falls off: there can be health insurance realignments; there's suddenly, you know, childcare needs that weren't there like during pregnancy always; and care, you know, that healthcare system recedes a little bit from a weekly presence that had been there before for the pregnant person.

And then, there's, like, certain kind of policy perspectives or institutions that come into play—as I mentioned, child welfare and child welfare responses. And at each of those levels—at the individual, in treatment or not treatment, and within public health and public policy—stigma and discrimination and prejudice exist, and play out oftentimes negatively for the health of the postpartum person.

JOHNSON:
So many challenges to unwind while trying to have a baby, and then care for one when maybe you don't know how to do that—that's an issue for anybody, no matter what their condition is. How do you start to work through all of this?

TERPLAN:
Well, I think it's important, you know, to try to set everybody up for success. And that begins, you know, even before pregnancy, but certainly should be part of prenatal care. And it's, you know, trying to assess what is the universe of needs that a mother-to-be has and is going to have, and how can we best meet and support that? What are existing resources in the community? How can we connect them to that?

You know, on the clinical level, we oftentimes do this when somebody is pregnant. You know, their baby's going to need a pediatrician, so we make an introduction, right, you know, between the, you know, pediatrician-to-be to the, you know, pregnant person at this moment in time. And we do this within the healthcare space, but we don't necessarily do this in the universe of what are called sort of social or structural determinants—to a large extent because healthcare providers don't always know what those resources are.

So, very good tools that some institutions or some clinics have utilized are, you know, linking peer services, you know, expanding the scope and knowledge base of social workers, and using patient navigators to help connect people to that which they need after delivering.

JOHNSON:
We expect the clinicians, the providers, to be in the middle of this, and maybe even sometimes first responders. But how do public health people fit into the equation?

TERPLAN:
Ideally, public health is, you know, that which stitches everything together. It goes from, you know, direct patient care to working on, you know, policies and procedures, to linkages between traditional spaces, to, you know, healthcare policy and payment itself. So, I think public health has a real central role to play in general, and in particular when we're talking about pregnancy, postpartum, and substance use.

Examples of ways that public health and public health agencies can support people postpartum. One I mentioned previously, the example of peer services; so, peers, people with lived experience, sometimes people in recovery—there's a shifting definitions, to some extent, as to what a peer is—and creating and supporting multidisciplinary teams that are inclusive of people with lived experience. And that means more than, you know, reimbursement—although that's important and agencies have a strong role in advocating, actually, for more equitable reimbursement for peer services and increasing, as I mentioned, access to other things.

But, at the same time, public health agencies have an authority in the public discourse around health and healthcare; and, therefore, they can also advocate to reduce barriers. They can advocate and even resist, you know, punitive measures that are in place in many states related to substance use and pregnancy.

JOHNSON:
Are there any models in play right now around the country that you like to refer to or direct people to when they're trying to get their arms around this from a public health perspective? They want to be more involved in it, they want to follow some of this advice that you've just offered here; but they don't really know how that looks or what to do next.

TERPLAN:
I'm going to answer that in a somewhat vague way—I want to pivot to talking about sort of principles and concrete measures.

So, I think it's important, you know, to walk the walk, in a way. And so, for example, there has been emphasis in combating stigma and discrimination in providing what we might call sort of anti-bias, anti-racism sorts of trainings. And those are very important to, you know, shift the dialogue and increase sort of awareness, and those can begin internally. So, I think it's really important that all agencies—as you mentioned, first responders, as well—to actually work through some of the content that is present in some of these sort of anti-bias trainings.

And a really easy place to begin, I think, is around language; making sure that the words that we use, that we speak, are inclusive, are person-centered, are supporting recovery. And that can oftentimes mean for a state agency, let's say, to look at their website, look at their publications, look at their presence and what they have said, and have that be an exercise to make the content, you know, reflective of those principles of inclusion and recovery support.

JOHNSON:
Is anyone doing that well right now?

TERPLAN:
Yeah. I mean, I don't infrequently, when I work with a particular state agency, go through some sampling of their websites; and I will say I've been sometimes quite surprised at the absence of discriminatory language. The last one I looked at was the state of Washington, and I was impressed that they had, you know, inclusive, scientifically appropriate, person-centered, you know, language almost throughout, from what I reviewed.

So, I think that that's a good place to begin; and that serves, then, as sort of a nidus for education. It's a concrete thing—words—that reflect our humanity or our lack of humanity, so becomes a way to start a conversation.

And then, on the flip side, for people who are needing of services, people are quite attuned to, you know, what somebody the other day referred to as, you know, the BS meter—that people who use drugs, people have experienced discrimination, are attuned to some of those. You know, they're almost like microaggressions that providers or systems or clinics, you know, might sometimes unintentionally—and sometimes intentionally—be disseminating.

JOHNSON:
It sounds like, though, we have a lot of work still to do in this area.

TERPLAN:
Well, without a doubt.

You know, this is where I think policy becomes very important. You know, there is a tension between: on the one hand, people like me—public health agencies, the general, you know, scientific discourse—which, you know, states that addiction is a chronic, at times recurring, medical condition best treated within the public health domain; and our drug policy, which classifies substances—some as illegal, some as legal—and for the illegal ones, there is a criminal, legal, punitive response.

And that's the big picture, and those two perspectives are in conflict with each other. It can't be a medical condition and criminalized at the same time.

JOHNSON:
Would you say the solution then starts with public health, or just involves public health?

TERPLAN:
Somewhat I don't think it matters where you start at. It's more important where you end up. And I think for change to really happen, the starting points should be heterogeneous and reflect, you know, a broad coalition of concern.

JOHNSON:
Your final thought—your final message to public health leaders who listen to these conversations that we put together for them—what would that be as it relates to this issue and where they ought to go with it in the months and years ahead?

TERPLAN:
I'm going to return to the example of peer services that I mentioned, and not in a very specific kind of way; because, to me, really what I think the most important thing is expanding the fold of people who are considered experts and people who, you know, sit at the table. And there's been increasing, both in public health clinical research and service delivery, utilization—creation and support and utilization—of things such as community advisory boards.

So, I think bringing in the voices of people who are affected by policy, who have the greatest burden of a particular, you know, public health concern; bring them to the table, support them, and listen to them. And I think that that will go far farther than a, you know, talking head, you know, ivory tower-ish expert like me; because it's really the narratives of lived experience that I think are probably the most powerful in overcoming discrimination.

JOHNSON:
Thanks for listening to Public Health Review. If you like the show, please share with your colleagues. And, if you have comments or questions, we'd like to hear from you. Email us pr@astho.org—that's PR at ASTHO dot org. Also, we'd love it if you could leave us a rating and a review—those are two great ways to give us feedback.

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This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.