University of Southern California Dissertations and Theses

Stigma-free pregnancy: a recruitment and retention strategy for healthcare systems to engage pregnant women with substance use disorder in collaborative care

(USC Thesis Other)

Stigma-free pregnancy: a recruitment and retention strategy for healthcare systems to engage pregnant women with substance use disorder in collaborative care

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content Running head: STIGMA-FREE PREGNANCY
Stigma-Free Pregnancy:
A recruitment and retention strategy for healthcare systems to engage pregnant women
with Substance Use Disorder in collaborative care
by
Christina Crow Cruz, DSW, LCSW
Capstone Project
In Partial Fulfillment for the Degree
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work
University of Southern California
August 2020
STIGMA-FREE PREGNANCY 2
Acknowledgements
My journey to become a Doctor of Social Work has been inspired and supported by so
many, and this accomplishment is not mine alone. First and foremost, I would like to thank my
family for their patience, love, and encouragement, without which none of this would be
possible. To my family and friends in Haiti and the Dominican Republic—you inspired me to
find the field of Social Work in the first place, and to do better for those around me. I will be
forever grateful to my colleagues and peers in Cohort 7 and the journey that we shared. Finally,
thank you to my USC professors and mentors. A special thank you to Dr. Nadia Islam, Dr. Ron
Manderscheid, Dr. Diandra Bremond, Dr. Eric Rice, Dr. Harry Hunter, Dr. Monica Jolles-Perez,
Dr. Robin Kay-Wicker, Dr. Feuerborn, Dr. Nithya Muthuswamy, Jane James, JD, and Stephanie
Wander, MBA.
STIGMA-FREE PREGNANCY 3
Abstract
The Grand Challenge of Closing the Healthcare Gap encourages a population health
approach, focusing on the most marginalized populations to improve health across the healthcare
continuum. The proposed innovation, the “Stigma-Free Pregnancy Program, focuses on pregnant
women with Substance Use Disorder (SUD), who face multiple barriers to care, including
stigma, fear of child welfare involvement and criminalization, as well as other access issues such
as transportation, child care, and geographical barriers. Increasing access to care for this
vulnerable population will improve maternal and fetal health outcomes, reduce the risk for child
maltreatment, neglect, and future risk for substance abuse, and decrease healthcare costs.
The “Stigma-Free Pregnancy” program is a recruitment and retention strategy for
healthcare systems to engage pregnant women with SUD in collaborative care. It utilizes a
community-based settings approach, interpersonal relationships, contingency management,
technology, and psychoeducation to increase access to care and early intervention and decrease
feelings of stigma. The proposed innovation will incorporate evidence-based and research-based
best practice approaches to preventative care and harm reduction strategies and connect women
with services early in their pregnancies. The innovation utilizes the logic of normative change
and will be embedded within a larger healthcare system, shifting the onus of compliance to care
from the women with SUD to the healthcare system. This innovation is low-cost, highly scalable,
and easily modifiable to adapt to different geographic regions.
STIGMA-FREE PREGNANCY 4
Executive Summary
The Link Between the Grand Challenge and Problem Within the Grand Challenge
The Grand Challenge of Closing the Health Gap includes initiatives for Health Equity
and Strengthening Healthcare Systems. Obtaining health equity necessitates confronting the root-
causes of issues, focusing on prevention and upstream interventions, and addressing inequalities,
particularly among the most marginalized populations. Disparities in access to healthcare
compound intergenerational disadvantage, and the disadvantage is directly correlated with
chronic poor health outcomes (Walters et al., 2016). This Grand Challenge postulates that social
determinants of health have a more significant impact on population health than availability and
quality of medical care (Brown et al., 2017). The Grand Challenge of Closing the Health Gap
advocates for a population health approach to cultivate improved community health. Fong,
Lubben, and Barth (2018) endorse a community settings-based approach that involves
collaboration across sectors and strengthening healthcare systems by fostering innovation in
primary care settings, supporting initiatives to increase access to healthcare, and by developing
an interdisciplinary workforce.
The problem within the Grand Challenge of Closing the Health Gap is that pregnant
women with Substance Use Disorder (SUD) are choosing to forgo prenatal care, including
substance abuse and mental health treatment, due to punitive laws, fear of criminalization and
child welfare involvement, stigma by the healthcare providers, and other access barriers to
healthcare. In the Journal of Health Politics, Policy, and Law, Paltrow and Flavin (2013)
demonstrated that punitive laws and policies inform public and provider opinions of pregnant
women with SUD. Paltrow and Flavin (2013) reviewed more than 400 cases from 1973 to 2005
in which women’s pregnancies were cause to deny them their physical liberties. These findings
STIGMA-FREE PREGNANCY 5
contest standard public rhetoric that criminalizing pregnant women promotes the health and well-
being of women and their unborn babies, but instead deters them from pursuing care, weakening
attempts to improve maternal and fetal health and public health.
Stigmatizing pregnant women with SUD, by placing the onus of full "compliance" to care
on this population by healthcare providers needs to end so that pregnant women with SUD do not
fear accessing prenatal care, substance use treatment, and mental health treatment during
pregnancy. Providers need to recognize that substance use is not a flaw in character but rather a
consequence of multiple factors, including but not limited to trauma and abuse, particularly for
this population. This issue requires more focused and coordinated efforts by healthcare systems,
primary care clinics, individual providers, and community social service agencies to improve
existing resources, develop new resources, remove barriers to accessing healthcare, and
ultimately close the healthcare gap for pregnant women with SUD. The proposed innovation is a
multiphasic community-based early intervention program supporting pregnant women to access
care during pregnancy. The innovation addresses the healthcare gap for pregnant women with
SUD who are forgoing care.
The Purpose of the Program Within a Larger Conceptual Framework
The purpose of the “Stigma-Free Pregnancy” program is to introduce a recruitment and
retention strategy, managed by healthcare systems, to engage pregnant women with SUD into
comprehensive care and retain them in care to improve maternal and fetal health outcomes and
disrupt the cycle of family violence. The social-ecological framework examines the individual
and their relationships with others, organizations, and the community at five stages: 1)
Individual; 2) Interpersonal; 3) Community; 4) Organizational; and 5) Public Policy (Lumen
Candela, 2020). In this program, pregnant women with SUD and community agencies and
STIGMA-FREE PREGNANCY 6
providers will gain knowledge about SUD and the effects on maternal and fetal health. Providers
will take responsibility to establish interpersonal relationships with pregnant women with SUD
through psychoeducation, outreach, motivational interviewing, and a Trauma-Informed Care
approach. The healthcare system will establish community-based partners to reach more
vulnerable people and show that they are taking responsibility to impact population health
positively. Providers and staff will do outreach in the community at community-based agencies.
Data collected through the evaluation process can be utilized to affect programs and policies.
The framework also utilizes the logic of normative change, shifting the onus of accessing care
from women with SUD to healthcare systems and finding innovative approaches to improve
population health for marginalized populations.
The Problem’s Tie to Policy and Practice
New policies, legislation, acts, and practice recommendations identify substance use
during pregnancy as an issue and support intervention and treatment programs. In 2015,
President Obama signed the Protecting Our Infants Act (POIA) into law, which was meant to
support efforts in maternal opioid use and improve treatment for infants with Neonatal
Abstinence Syndrome (NAS) and public health initiatives to decrease opioid use and subsequent
neonatal withdrawal. In 2016, Obama signed the Comprehensive Addiction and Recovery Act
(CARA) to address the opioid epidemic across the continuum of care, from prevention to
recovery, and expanded access for treatment for mothers and outreach initiatives for NAS (Bortz,
2017). The 21st Century CURES Act (2016) created a task force by the Food and Drug
Administration with research focused on lactating and pregnant women, including risk, exposure,
and mechanisms of therapy (U.S. Food and Drug Administration, n.d.). The focus should be to
STIGMA-FREE PREGNANCY 7
support women from becoming dependent and supporting pregnant women with SUD with
sufficient coverage through Medicaid and access to services and care.
The Methodology Employed to Address the Project’s Aims
The methodology guiding the “Stigma-Free Pregnancy” program addresses the stated
problem because the healthcare system is taking responsibility for community outreach, inviting
women into care, and allowing pregnant women with SUD to establish trust, rapport, and care
with providers in safe settings. The community-based settings approach, leveraging technology,
contingency management, interpersonal relationships, psychoeducation, and early intervention
for harm reduction, is supported as best-practice by the literature. This program will be replicable
nationally, and a program manual for the "Stigma-Free Pregnancy" program has been created to
support diffusion and replication. Success will be measured by an increase in women being
recruited and enrolled in this program, retention in care, and a reduction in the number of child
welfare referrals due to infants testing positive for substances at the time of birth.
Summary of Aims for Project Implementation and Future Action Steps
The project has goals on the individual, system, and macro levels. The primary goals of
this project are to recruit, enroll, and retain pregnant women with SUD into care and build
resiliency throughout pregnancy so that they are not only less likely to test positive for
substances at the time of delivery, but are also more likely to maintain sobriety. System goals are
to train designated staff from medical systems and community agencies on Trauma-Informed
Care, Motivational Interviewing, and substance use during pregnancy to provide best-practice
recommended care and reduce stigma. Macro goals are to decrease substance use during
pregnancy, thus reducing the risk of child abuse, neglect, and future substance use, and
disrupting the cycle of family violence. There will also be significant cost savings to the
STIGMA-FREE PREGNANCY 8
taxpayers in the short term and long-term. Data can be used to inform population and community
health programs as well as child-welfare programs and policy. At least two state representatives
are to be involved in the promotion of this program. St. Luke’s Regional Medical Center, in
Boise, ID, has been identified as a healthcare system with potential interest in implementation
and evaluation of the program. The program has been reviewed by several stakeholders within
the healthcare system and the next step is to run a pilot program in Ada and Canyon counties,
where about 83% of the anticipated population will deliver their babies in the State of Idaho
(Division of Public Health, 2018). The program will be expanded to the rest of the system the
following year.
Potential Implications Beyond a Local Context
Illicit substance use during pregnancy is a national problem in the United States. Data
suggests that about 5% of pregnant women use illicit substances during pregnancy (Havens et al.,
2008). According to the U.S. Department of Health and Human Services and SAMHSA (2009),
every year between 400,000 and 440,000 infants are affected by prenatal substance exposure,
and the trend is growing. The literature overwhelmingly identifies stigma by healthcare providers
as the primary barrier to accessing care. The "Stigma-Free Pregnancy" program is highly
scalable because 1) the problem exists nationally; 2) evidence-based best practice approaches
support early intervention and a collaborative care model; 3) healthcare systems are uniquely
poised and able to take responsibility for community health initiatives; 4) the program leverages
technology to reduce feelings of stigma and make care more accessible; 5) it is a low-cost
program, and 6) contingency management has shown to be effective for retention in short-term
substance use treatment programs. Federal policies and funding also support initiatives to
prevent drug use, treatment, and recovery among pregnant women.
STIGMA-FREE PREGNANCY 9
Conceptual Framework
Statement of Problem
The problem within the Grand Challenge of Closing the Health Gap is that pregnant
women with Substance Use Disorder (SUD) are choosing to forgo prenatal care, including
substance abuse and mental health treatment, due to punitive laws, fear of criminalization and
child welfare involvement, stigma by the healthcare providers, and other access barriers to
healthcare including transportation, childcare, and employment.
Literature and Practice Review of Problem and Innovation
Although the United States' population accounts for approximately 5% of the world's
population, 80% of the world's opioids are used in the United States (Bortz, 2017), and opioid
use by pregnant women mirrors that of the general population. According to The National
Survey of Drug Use and Health (2002-2006), only 20% of the women who needed treatment had
access to it. Of the programs accepting federal funding for substance abuse treatment, only
17.5% had programs designed for pregnant women's unique needs (Terpaln et al., 2012). With
Medicaid expansion, there may be more options for funding; however, there remains a need for
programs designed to support the unique needs of pregnant women in their treatment and
recovery to limit exposure and encourage harm reduction.
Despite limited funding and availability of resources, many programs utilize research and
evidence-based best practice approaches, and innovative programs do provide support to
pregnant women with SUD. One example of these programs is the Early Start program created
by Kaiser Permanente in Northern California. This program offers wrap-around services,
including prenatal care, substance use treatment, and mental health treatment to this population
in over forty outpatient clinics. The program has proven to have a positive impact on maternal
STIGMA-FREE PREGNANCY 10
and fetal health outcomes as well as showing significant long-term cost savings related to
substance use during pregnancy (Green & Conway, 2018).
Internationally, Portugal has been successful in reducing their drug-induced death rates
through policy and outreach programs. In the 1990s, Portugal had a massive drug epidemic, but
in 2001 the government decriminalized the consumption of drugs (Bajekal, 2018). Crescer, a
state-funded Portuguese NGO, developed a strategy for harm reduction using community
outreach teams (Crescer, 2017). Crescer utilizes harm reduction interventions in order to increase
knowledge and adherence to treatment as well as to decrease feelings of social isolation.
Establishing relationships with pregnant women allows the team to provide permanent
psychosocial support as well as to make referrals for health care and treatment while taking in to
account individual, social, familial, cultural, and environmental factors for each woman (M.
Santos, personal communication, July 4, 2019). Drug-induced death rates in Portugal are now
one-fiftieth of the United States’ (Bajekal, 2018).
Innovations in technology have also been developed to support this population. The Best
Beginnings app, based in the United Kingdom, partners with the Health Department, health
professionals, and parents to provide resources and education on parenting, substance use,
mental health issues, and positive development (Best Beginnings, n.d). The “text4baby” app is
available in many states and offers basic information on questions regarding pregnancy and
substance use (text4baby, 2017). Depending on the state, the Department of Health and
Welfare/Health and Human Services and SAMHSA also have information on substance use
during pregnancy and offer resources for obtaining funding for treatment, although their lists are
not comprehensive.
STIGMA-FREE PREGNANCY 11
Other evidence-based programs supporting chemically dependent pregnant women
include the Parent-Child Assistance Program (PCAP), the Children and Recovering Mothers
(CHARM) collaborative, peer-to-peer recovery specialists, public campaigns, residential
treatment programs, and supplemental funding for recovery programs. Other efforts by counties,
cities, and healthcare systems include the use of mobile health units to increase access to
healthcare, with mixed outcomes. A few states have supplemented funding sources for Women’s
Recovery programs to provide additional support for this population (Steiner, 2017). There are
residential treatment programs that are specifically designed for women to stay with their
children and allow children to stay with their mothers overnight (SAMHSA, 2009). Contingency
management of short duration has also been shown to be effective in improving adherence to
substance use treatment programs (Hutchinson et al., 2012) and may be useful for recruiting
women into programs to access care throughout their pregnancy. Even with these attempts to
close the healthcare gap for pregnant women with SUD, challenges remain. An on-going issue is
how to recruit pregnant women with SUD into programs to access needed care, and retain them
in care for maximum benefit and increased resiliency.
Social Significance
According to the U.S. Department of Health and Human Services and SAMHSA (2009),
every year between 400,000 and 440,000 infants are affected by prenatal substance exposure,
and the trend is growing. In 2015 the Substance Abuse and Mental Health Services
Administration (2016) found that approximately 109,000 women reported using illicit substances
while pregnant. Havens et al. (2008) found that women who utilized illegal drugs were about
eight times less likely to seek prenatal care than women who did not use substances. It is
recognized that the majority of women who receive treatment for substance use have a history of
STIGMA-FREE PREGNANCY 12
trauma and about a quarter of those women have been diagnosed with Post Traumatic Stress
Disorder (Wong, Ordean, & Kahan, 2011). Per Mclafferty et al., (2016), 75% of pregnant
women with Substance Use Disorder identify punitive laws as the main barrier to accessing care.
One of the most cited barriers to care, following stigma, is the fear of criminal repercussions and
child welfare involvement. Law enforcement, criminal justice agencies, and the child welfare
system are typically reactive and have little investment in preventative programs. Mclafferty et
al., (2016) found that 35% of states regarded fetal exposure to substances in-utero as child abuse,
and in some states, women can lose custody of their children and face criminal charges.
Forgoing healthcare is related to a higher risk for poor maternal and fetal health
outcomes. Being exposed to substances in–utero is associated with increased risk of being
subjected to child abuse and intimate partner violence, as well as developing substance abuse
issues later in life. Research has found that children are almost five times more likely to be
abused and nine times more likely to be neglected during childhood if their parents use
substances (Daley et al., 2016). Per Parolin et al. (2016), being exposed to drugs in-utero is also a
direct predictor of future substance abuse by 29% as an adolescent and by 45% as an adult. A
study by Oei (2018) found that children who were treated for Neonatal Abstinence Syndrome
(NAS) after birth were “21 times more likely to be hospitalized during childhood for assaults,
injuries, and maltreatment and three times more likely to die before the age of twelve” than other
children (Oei, 2018, p 26). The facts are clear that prenatal substance exposure is a contributing
factor to the generational deficits of child maltreatment and substance abuse.
There is a false assumption that people with SUD have the choice to use or not and that
pregnant women should have the ability to choose to discontinue use and seek necessary care.
Roughly 2.1 million people are struggling with opioid addiction in the United States. According
STIGMA-FREE PREGNANCY 13
to recent studies, many of these people are women of childbearing age, and 90% of pregnancies
in this population were not intended. Opioid use by pregnant women is on the rise, most notably
in rural areas, where use increased by over 600% between 2004 and 2013 (The New York Times,
2018). Rates of Neonatal Abstinence Syndrome (NAS) imitate patterns of overdose deaths,
which occur at higher rates in disadvantaged and rural counties (Patrick et al., 2019). Pregnant
women with SUD are still viewed as perpetrators by society, even though there is an increased
understanding that addiction is an illness. Women with substantial trauma histories are about
twelve times more likely to use substances than women who do not have a history of trauma
(O’Brian & Phillips, 2011). The general public and many providers do not understand that SUD,
trauma, and other mental health diagnoses are often co-occurring issues.
Two of the most significant impacts on society are the short-term and long-term costs
associated with in-utero substance exposure. According to The Economist (2015), prescription
opiate use increased over the past ten years by 400%, and the number of babies who were born
affected by opioids increased by 500%. It cost $731 million to provide care for those infants in
2009, and in 2012 the cost of care rose to $1.5 billion, of which 80% was paid for by Medicaid
(The Economist, 2015). In contrast, nationally, only 37% of births are paid for by Medicaid
(SAMHSA, 2009). Although it is difficult to quantify, there is also a substantial lifetime
financial impact related to prenatal substance exposure beyond the cost incurred at the time of
delivery. Long term costs include, but are not limited to, treatment of chronic health issues,
including psychological and behavioral health, special education, early interventions, residential
treatment programs and institutional costs, juvenile and criminal justice system costs,
expenditures for child welfare and foster care, entitlement payments, and cost of substance abuse
treatment across generations (O’Brien & Phillips, 2011). If a fraction of what is being spent
STIGMA-FREE PREGNANCY 14
paying for the consequences of the issue of substance exposure during pregnancy were spent on
prevention and early intervention programs, there would be significant cost savings to society in
both the short and long term.
Conceptual Framework with Logic Model Showing Theory of Change
The “Stigma-Free Pregnancy” innovation follows the logic of normative change to
identify a behavior that holds a problem in place, and disrupts it to subvert the social norm. In
this case, the norm is that medical providers should only work with pregnant women with SUD if
they are first compliant with prenatal care and substance use treatment programs. This norm
comes from the culture of victim-blaming and lack of recognition that the women was, or is, also
likely a victim of abuse herself. Compliance also assumes a choice and ignores barriers to access,
including stigma on the part of healthcare providers and office staff, and fear of criminalization.
This program shifts the onus of compliance to care from pregnant women with SUD to
healthcare systems. The Social-Ecological framework is also utilized to examine the interactions
of the individual, their relationships with others, organizations, community, and policies (Lumen
Candela, 2020).
As previously stated, the problem is that pregnant women with SUD are forgoing prenatal
care, including substance use and mental health treatment, primarily due to stigma and fear.
Recruitment into care and retention in care need to be improved, and Healthcare systems need to
shift the onus of "compliance to care" off of the women and take responsibility for improving
population health. The “Stigma-Free Pregnancy” Program’s mission is to improve access to
healthcare for pregnant women with SUD through a community-based settings approach.
Expected outcomes are increased awareness and access to care, improved provider skills, lower
healthcare cost, improved recruitment and retention in care, better patient-provider relationships
STIGMA-FREE PREGNANCY 15
and satisfaction, increased availability of resources, greater data volumes, enhanced prevention
programs, improved health outcomes, decreased substance use, child maltreatment, and intimate
partner violence, and reduced feelings of stigma. Some key assumptions are that there will be
buy-in from healthcare leadership and stakeholders, women with SUD will access community-
based agencies and seek care based on the innovation, the target population will have access to
technology, and fidelity will be maintained. External factors to consider are the political climate,
changing policies, laws, and community perceptions, COVID-19 and other healthcare crisis,
child welfare and law enforcement reactions, funding sources, staff turnover, and buy-in from
leadership, community-based agencies, and providers. For the complete Logic Model, See
appendix A.
Problems of Practice and Innovative Solutions
Proposed Innovation and Its Effect on the Grand Challenge
The “Stigma-Free Pregnancy” Program addresses the gap in healthcare for women who
are using illicit drugs during pregnancy, and in particular, those who are forgoing care because of
fear, stigma, and other access issues. Through primary and secondary research, it was identified
that there is a void in the current knowledge base as to how to recruit pregnant women with SUD
into programs so that they receive appropriate care (see Appendix B). The "Stigma-Free
Pregnancy" strategy is a multiphasic early intervention approach for healthcare systems aimed at
recruiting and retaining pregnant women with SUD into a collaborative care program during
their pregnancies. The phases include: 1) Training; 2) Preparation; 3) Recruitment; 4)
Enrollment; 5) Retention; and 6) Evaluation. See Appendix D for Phases of Implementation. The
goals of the program are to increase access to healthcare for pregnant women with SUD through
a community-based settings approach, improve maternal and fetal health outcomes, and disrupt
STIGMA-FREE PREGNANCY 16
the cycle of abuse. The objectives of this system approach include improving community
partnerships and collaboration between services, establishing positive interpersonal relationships
between providers and pregnant women with SUD, creating a comprehensive continuum of care
by addressing other access issues, improving provider knowledge and skill related to trauma-
informed care and SUD, recruiting more women into care, retaining women in care, increasing
the resiliency of women to avoid relapse, and reducing incidences of abuse and child welfare
involvement.
The proposed early intervention program reflects best practice approaches, is research-
based, and is in alignment with Fong, Lubben, and Barth (2018) who, in the Grand Challenges
for Social Work and Society, suggest cultivating innovative strategies in primary care settings,
promoting complete access to healthcare, and developing interdisciplinary workforces in
healthcare settings. Research overwhelmingly identifies stigma and fear as the primary barrier to
accessing care (McLafferty et al., 2016). Research also shows that most women who continue to
use illicit drugs during pregnancy also have a trauma history and co-occurring mental health
diagnoses (Wong, Ordean, & Kahan, 2011). Best practice suggests early intervention during
pregnancy and harm reduction strategies to reduce the effects of in-utero substance exposure on
the fetus as well as the pregnant woman (Patrick & Schiff, 2017). The competitive advantage of
this innovation is that it is a low-cost, scalable program that will transform the way that pregnant
women with SUD are recruited and retained in care, thus closing the healthcare gap and
improving population health outcomes across generations.
Views of Key Stakeholders
There are multiple stakeholders involved in the problem of drug use during pregnancy,
including pregnant women and their families, healthcare systems, medical providers, community
STIGMA-FREE PREGNANCY 17
services agencies, politicians, taxpayers, law enforcement and criminal justice agencies, and
child welfare. Public rhetoric is polarized concerning illicit drug use during pregnancy, either
acknowledging addiction as a complex issue that involves trauma and mental health
comorbidities, or believing that women can and should choose to stop using drugs and
criminalization is justified if they do not abstain. These perspectives tend to inform public and
provider attitudes and direct women's decisions to pursue or forgo treatment and care.
Overwhelmingly, women who continue to use illicit drugs while pregnant report trauma
histories and co-occurring mental health diagnoses (Wong, Ordean, & Kahan, 2011) and are
forgoing care due to stigma and fear (McLafferty et al., 2016). Most women are more motivated
to quit substance use during pregnancy and attempt to quit or reduce use on their own (Havens et
al., 2008). From a woman's perspective, despite being more motivated, she is afraid to seek care
due to fear that she will be judged by providers, face having her child or children removed from
her care, and face criminal charges. She has multiple co-occurring issues that cannot be cared for
in siloed services delivery systems, and she has multiple barriers to accessing care, including
financial barriers and limited options for care.
Healthcare systems and medical providers have been hesitant to offer services specific to
this unique population due to several factors, including limited reimbursement, negative
opinions, and limited knowledge of addiction medicine and mental health care. Larger healthcare
systems have been slow to invest in outpatient clinics as they do not generate as much revenue as
in-patient areas. On average, a baby who is admitted to the Neonatal Intensive Care Unit and is
treated for NAS will cost $66,000 to treat (National Institute on Drug Abuse, 2015) and about
80% of that will be paid for by Medicaid (The Economist, 2015) which generates income for a
healthcare system. However, medical providers are now faced with the growing recognition that
STIGMA-FREE PREGNANCY 18
addiction treatment cannot be an afterthought and are being pressured to become more aware of
and competent in treatment in their practices (Jacewicz, 2016).
Community service agencies, such as shelters, free community health clinics, mental
health agencies, and substance abuse providers, generally come from an advocacy perspective
for marginalized populations. Because these agencies tend to focus on services for populations
with mental health diagnoses and SUDs, they have an increased understanding of their complex
needs and issues and may have staff trained to treat SUD and mental health. Barriers for
community agencies include limited collaboration with medical providers and healthcare systems
and inadequate funding opportunities for mental health and substance use treatment.
Politicians and taxpayers’ perspectives are mostly influenced by public rhetoric and laws
associated with substance use. Although historically laws have not favored women who use
drugs during pregnancy, recent laws such as The Protecting Our Infants Act of 2015 and the
Comprehensive Addiction and Recovery Act of 2016 have been passed with the recognition of
the growing opioid crisis. When the White House declared the opioid crisis a national public
health emergency in 2017 (The White House, nd), victims of the epidemic began to be met with
a higher level of empathy not historically bestowed to individuals with addictions. Although this
level of compassion is still not extended to pregnant women who use drugs due to societal
expectations, the opioid epidemic is finally seen as a public health issue and not solely an issue
of the criminal justice system.
Law enforcement agencies and the child welfare systems have been tasked with
responding to the problem of substance-exposed infants; however, they are both reactive to the
issue, so by the time they are involved, harm has already occurred. A study completed in 2016
revealed that eighteen states considered substance exposure in-utero to be child abuse. In some
STIGMA-FREE PREGNANCY 19
states, mothers may face criminal charges and lose custody of their children (Mclafferty et al.,
2016). Although some state’s child welfare systems are attempting to shift to a preventative
approach through large data such as preventive analytics and risk-terrain modeling, some ethical
concerns for racial and historical biases have accompanied that shift (The MITRE Corporation,
2017). Fear of child welfare involvement and criminal repercussions continue to be one of the
primary barriers for women seeking care.
Evidence and Current Context for Proposed Innovation
One of the leading causes of death for both pregnant women and new mothers is drug
overdoses, and national data suggest the rates of women using illicit drugs during pregnancy will
continue to rise. In some states, overdose death rates during pregnancy rose as much as 200%
between 2005 and 2014 (Galvin, 2019). Another national study showed that from 2008-2015, the
rate of amphetamine use doubled, and opioid use quadrupled among pregnant women (Newman,
2018). The majority of these women did not receive substance abuse or mental health treatment
(Galvin, 2019). This deficiency of treatment and care demonstrations missed opportunities by
healthcare professionals to provide potentially life-saving interventions and reinforces the best-
practice suggestion that there must be an interdisciplinary workforce in primary care settings
with knowledge on mental health and addiction.
Historically, addiction has been seen as a moral failing and character flaw. However, in
the 18
th
and 19
th
centuries, despite public rhetoric, doctors did provide addiction treatments.
Although some states had passed laws, it was not until 1906 that the Pure Food and Drug Act,
the first federal law of this nature, was passed targeting home remedies. In 1914 the Harrison
Narcotics Act was passed, from which the Drug Enforcement Agency continues to use the
schedule of drugs today. The Marijuana Tax Act of 1937 was met with opposition by The
STIGMA-FREE PREGNANCY 20
American Medical Association due to the taxation of physicians who prescribed marijuana
(Martin, 2019). Physicians were being prosecuted because of these laws, acts, and Supreme
Court decisions (Hilgers, 2018), and as a result, they moved away from treating addiction.
A report published by the National Center on Addiction and Substance Abuse in 2012
indicated that the medical school curriculum dedicates approximately twelve hours to addiction
medicine over four years of schooling. Since this study was published, deaths due to opioid
overdoses have surpassed 14,000 each year, and doctors are now pressured to treat addiction as
part of their standard practice. In 2016 The American Board of Medical Specialties finally
recognized that addiction medicine could not be an afterthought and acknowledged it as a
subspecialty (Jacewicz, 2016). Dr. Anna Lembke, Associate Professor and Medical Director of
Addiction Medicine at Stanford University School of Medicine, stated that “treatment for
addiction works on par with treatment for other chronic relapsing disorders. So, it's not really
that there's no road map. It's that the road map has not been recognized or embraced by the house
of medicine" (Hilgers, 2018). The responsibility for meeting the challenges of addiction and co-
occurring health and mental health issues needs to be taken on by healthcare systems and
medical schools, especially to meet the unique and complex needs of pregnant women.
It is imperative that pregnant women with SUD are assured that they have access to non-
judgmental and non-punitive care that meets their needs as well as the needs of their babies.
Despite existing best-practice recommendations and evidence-based guidelines for addiction
treatment, they are not typically applied in medical offices nor adopted by healthcare systems
(Hilgers, 2018). Patrick and Schiff (2017), with the American Academy of Pediatrics (AAP)
state: "a public health response, rather than a punitive approach to the opioid epidemic and
substance use during pregnancy is critical.” The AAP supports an approach to illicit drug use in
STIGMA-FREE PREGNANCY 21
pregnancy that emphasizes primary prevention, early and easy access to multiple treatment
options, and improved provider-patient relationships, instead of marginalization and punitive
threats in attempts to enhance health outcomes and access (Patrick & Schiff, 2017).
Although there has been progress made nationally in terms of comprehensive coverage
being offered to pregnant women, Idaho, where this program is to be piloted, has not advanced
as rapidly. Medicaid Expansion only recently took effect on January 1, 2020 (Idaho Health and
Welfare, 2019). Idaho has several outpatient clinics that provide Medication-Assisted Treatment
(MAT) programs, mostly in urban settings. There are fewer clinics that provide services specific
to pregnant women. St. Luke's Regional Medical Center has a Maternal-Fetal Medicine Clinic in
Boise that offers MAT and obstetric care. In 2018 they had two providers with the required
training to prescribe buprenorphine and plan to eventually expand to other clinics within the
healthcare system (Langrill, 2018). Despite progress in developing programs specific to pregnant
women, clinic hours are limited to three hours per week for this population, and the clinic does
not have a multidisciplinary workforce and includes mental health professionals. Idaho child
abuse reporting laws align with those of most states in the United States. The Idaho Department
of Health and Welfare (IDHW) does not consider the fetus a child, for reporting purposes, until
the time of delivery. If the baby tests positive for illicit substances at the time of birth, the
hospital staff, who are considered mandated reporters, must make a referral to IDHW within
twenty-four hours (Idaho Legislature, 2019).
In the United States, addiction has been seen as a character flaw and moral failing.
Although historically, physicians attempted to provide a level of care for addiction, laws began
to penalize doctors for doing so. The effects of these laws were that physicians stopped treating
those with substance abuse issues, and medical schools limited their curriculum around addiction
STIGMA-FREE PREGNANCY 22
medicine. Punitive laws not only influence provider opinions towards pregnant women with
SUD, but criminalizing women has proven to be counterproductive and serves to decrease
maternal and fetal health outcomes. Amidst the opioid epidemic, there is increased recognition
that addiction is not a result of flawed character, and leaders of the medical profession are
making a renewed effort to develop addiction medicine and practice evidence-based treatment
strategies for SUD. This issue will require collaborative efforts by larger healthcare systems,
primary care providers, obstetricians, community social service agencies, and communities in
order to close the healthcare gap for pregnant women who are using illicit substances.
Comparative Assessment of Other Opportunities for Innovation
The proposed “Stigma-Free Pregnancy” innovation supports existing opportunities for
innovation because pregnancy is an opportune point in the problem lifecycle of substance abuse
to attempt to break the cycle. Women are more motivated to seek care during this time, and early
intervention programs are ideal for harm reduction and improved maternal and fetal health
outcomes. Several studies have shown that even though some women continue to use drugs
during pregnancy, overall, women make efforts to reduce use. Pregnant women are considerably
less likely to use illicit substances during pregnancy than women who are not pregnant of the
same age group (Havens et al., 2008). Research demonstrates a positive correlation between
maternal and fetal outcomes when women develop non-judgmental relationships with their
providers. Best-practice approaches support trauma-informed care and the recognition of the
cycle of family violence by providers as a way to break the cycle of substance abuse (Latuskie et
al., 2018).
Several current innovative programs exist, including wrap-around service programs,
outreach programs, technology for resources and referrals, in-home case management programs,
STIGMA-FREE PREGNANCY 23
peer-to-peer recovery specialists, supplemental funding for recovery programs, mobile health
clinics, public campaigns, policies supporting recovery, residential treatment programs, and
collaboratives. Despite having options, they remain limited and poorly funded, particularly in
rural areas. Persisting challenges include insufficient collaboration between social service
agencies and medical providers, isolated services and initiatives, public and provider stigma,
limited insurance coverage or supplemental funding sources for treatment, and poor marketing of
current services and resources. There are opportunities through this proposed innovation to
improve collaboration between the healthcare system and community-based service providers, to
increase marketing for existing programs, and to improve access to information and services for
women who are using drugs during pregnancy while reducing feelings of stigma.
Innovation’s Proposed Logic Model and Theory of Change
The purpose of this program is to introduce a recruitment and retention strategy, managed
by healthcare systems, to engage pregnant women with SUD into comprehensive care and retain
them in care to improve maternal and fetal health outcomes and disrupt the cycle of family
violence. The social-ecological framework looks at the relationship between a person, others,
organizations, the community, and policies (Lumen Candela, 2020). In this program, pregnant
women with SUD, community agencies, and providers will gain knowledge about SUD and the
effects on maternal and fetal health. Providers will take responsibility to establish interpersonal
relationships with pregnant women with SUD using psychoeducation, outreach, motivational
interviewing, and a Trauma-Informed Care approach. The healthcare system will establish
community-based partners to reach more vulnerable people and show that they are taking
responsibility to impact population health positively. Data collected through the evaluation
process can be utilized to affect programming and policies.
STIGMA-FREE PREGNANCY 24
The logic behind the “Stigma-Free Pregnancy” program is that if healthcare systems
become more accountable for recruiting and enrolling pregnant women with SUD into trauma-
informed, collaborative care in community-based settings, these women will feel less stigmatized
and barriers such as fear will also be reduced. The long-term goal is for women with SUD to
engage in care early during pregnancy through this recruitment and retention strategy to improve
maternal and fetal health outcomes as well as health across the healthcare continuum, and for
providers to gain a better understanding of trauma-informed care, particularly with marginalized
populations. Through the evaluation of data, additional targeted prevention programs and best-
practice recommended wrap-around service delivery programs may also be justified.
Likelihood of Success
This proposed innovation is a low-cost and highly scalable program that has a high
likelihood of success. Healthcare systems hold a unique position in states because they are
present in many communities and have both in-patient and outpatient care settings. This puts
them in ideal positions to take the lead in coordinated community efforts for improved
population health across the healthcare continuum. Pregnancy is an opportune time to provide
access to early interventions programs, as there is the potential to provide exponential positive
health and financial outcomes, including better maternal and fetal outcomes, decreased short
term and long-term healthcare costs, improved patient and provider satisfaction, keeping families
together, and disrupting the cycle of family violence. The innovation will close the healthcare
gap for pregnant women who are using drugs, in particular for those who are forgoing care due
to stigma, fear, and other access issues. The innovation can be designed and implemented with
limited financial impact on the healthcare system and community partners. Data can be collected
and reviewed quickly and analyzed to determine outcomes and inform future decision-making
STIGMA-FREE PREGNANCY 25
and prevention programs. St. Luke’s Regional Medical Center is a healthcare system in Idaho
and a potential partner for implementation and evaluation. This innovation is in alignment with
the healthcare system's goals as they shift to a population health approach. The program manual
has been reviewed by multiple stakeholders at St. Luke’s healthcare system with positive
feedback. A meeting has also been held with the Regional Administrator for SAMHSA who is
supportive of the program and available to collaborate as the program is implemented and
evaluated. The next steps are to collaborate with the Community Health sector at St. Luke’s to
gain stakeholder support and apply for grants.
Project Structure and Methodology
Description of Capstone Deliverable/Artifact
A program manual has been prepared to guide healthcare systems, including hospitals
and medical facilities, through the program's preparation, implementation, and evaluation
process. See appendix D for the program manual. The program manual includes an overview of
the program, the goals, and objectives, needed tools, detailed phases of implementation, a
workflow for the recruitment and enrollment process, suggested training modules for providers
and psychoeducation for end-users, evaluation and outcome measures, a communications plan,
and potential implications. Supplemental materials are attached as appendices, including
additional resources for providers, suggested push surveys for women using the app, suggested
e-mail surveys for providers and community partners, qualitative interview questions for end-
users and providers, an example of a financial plan along with suggested funding sources, a logic
model, a GANNT chart for the phases of implementation, and relevant statutes, regulations, and
policies. The program manual aligns with the logic of normative change because it guides
STIGMA-FREE PREGNANCY 26
healthcare facilities to take responsibility for improving access to healthcare for pregnant women
with SUD.
Comparative Market Analysis
Although several programs exist to support pregnant women with SUD, most of these
programs continue to face recruitment issues, among other challenges. There are a few programs
that have had success with recruitment and retention, such as the Integrated Care for High-Risk
Pregnant Women Program developed by the Minnesota Health Care Administration, that have
utilized non-cash incentives to get women to participate in social service programs (National
Center on Substance Abuse and Child Welfare, 2018). The Wolters Kluwer Company (2012) has
also found that incentives, through contingency management, can help in treating addictions
during pregnancy. Some healthcare systems have used mobile clinics for outreach, such as
Project Mother Care in New Haven, Connecticut (Reguero & Crane, 1994), and Lucile Packard
Children’s Hospital Women’s Health Van (Edgerley et al., 2007) with mixed results.
The "Stigma-Free Pregnancy" Program is innovative because it addresses recruitment and
retention issues, which utilizes the logic of normative change to shift the onus of full compliance
to care from women with SUD to healthcare facilities. Through primary and secondary research,
there were no programs identified that are in direct competition with this proposed innovation.
Cassie Alleman, the Manager of Addiction Treatment Services for the Center for Addiction and
Pregnancy program at Johns Hopkins Medical Center, stated, "recruitment is a tricky concept
with the nature of these services. A lot of patients are referred to us through other programs in
the community… I think our incentivized treatment helps in some ways, although I'm not sure if
that's more effective with recruitment or retention" (C. Alleman, personal communication, May
27, 2020). Amy Conway, the Director of Regional Early Start for Kaiser Permanente, and an
STIGMA-FREE PREGNANCY 27
expert in managing wrap-around service programs, suggests that Healthcare systems should have
integrated behavioral healthcare models in clinics (A. Conway, personal communication,
February 7, 2019) (see appendix B). There are opportunities through this proposed innovation for
effectiveness through recruitment and retention strategies, but also to improve collaboration
between the healthcare system and community-based service providers, to increase marketing for
existing programs, and to improve access to information and services for women who are using
drugs during pregnancy while reducing feelings of stigma.
Project Implementation Methods
The RE-AIM framework was selected to evaluate the impact of innovation on public
health (Glasgow et al., 1999) and to understand and observe the success of the implementation
and dissemination of the innovation (Palinkas & Soydan, 2012). For this pilot program at St.
Luke’s healthcare system in Idaho, the RE-AIM model's reach component will require the
eventual participation of forty-six medical providers, Emergency Department and Social Work
staff at St. Luke's Regional Medical Center, and seventeen community based-agencies in Ada
County, Canyon County, and Twin Falls County. The reach also includes an estimated 517
pregnant women with SUD living in Ada, Canyon, and Twin Falls Counties. For the innovation
to be effective and have the desired outcome of increasing access to care for pregnant women
with SUD, the innovation must be distributed as intended. The adoption of this intervention will
require the identified providers and community-based agencies to incorporate the innovation into
their services and health-delivery programs. Implementation will require fidelity to the program's
various elements and phases, as well as consistency of delivery. The innovation will need to
become part of the standard of practice within an organization to be maintained, which is a long-
term goal (See appendix C).
STIGMA-FREE PREGNANCY 28
Analysis of obstacles and alternative pathways. Several potential barriers to
participation exist in each phase of the RE-AIM implementation framework. One of the primary
barriers in the Reach phase is obtaining buy-in from leadership from the regional medical center
as collaboration across service lines will be involved, and at times there are competing goals and
priorities, including allocation of funds. Potential facilitators for obtaining buy-in include
utilizing low-cost training approaches, gathering data on participation and outcomes, and
emphasizing the potential for improved maternal and fetal health as well as cost-savings across
the health care continuum. Barriers to the effectiveness are if staff from community-based
agencies and providers do not deliver the "Stigma-Free Pregnancy" kit to the target population,
maintaining engagement from leadership within the healthcare system and community-based
agencies, including prioritizing funding and staff time for the innovation. Facilitators to
maintaining the fidelity of the implementation of the innovation will depend upon having
qualified and trained staff members in community-based agencies and provider clinics. Feedback
on performance and outcomes can be provided to hospital leadership, community providers, and
community-based agencies to maintain engagement. Potential barriers to adoption include
limited integration of the innovation into the subculture of each agency (Lopez-Patton, 2015),
changes in community resources and funding for delivery options, and political culture. Staff
turnover, changes in roles within agencies, leadership changes, and training and logistical costs
associated with staff and administrator turnover are additional barriers to adoption. Overcoming
the barriers to adoption as mentioned above will be facilitated by providing adequate training and
education to agency staff and providers, using multifaceted training approaches, and a "train-the-
trainer" model to embed the innovation within the culture of agencies. Threats to the fidelity of
the innovation and barriers to implementation are that the innovation will not be delivered as
STIGMA-FREE PREGNANCY 29
intended, lack of community-agency staff and provider buy-in to the intended process of
delivery, as well as limited staff time for training. Facilitators for overcoming these barriers to
implementation include utilizing the Hybrid Type 1 design, utilizing multifaceted training
approaches, budgeting additional resources for the start-up year, and utilizing data-driven
decision making. Maintenance can be challenged by shifting community resources, staff and
leadership turnover, and lack of buy-in from community-based agencies, providers, and hospital
leadership as changes arise. Sustainability of the innovation can be facilitated by maintaining the
infrastructure of the program, and through the use of data analysis, outcomes can be shared with
medical center leadership, community-based agencies, and providers to prove the effectiveness
and maintain buy-in. (See appendix F)
Leadership strategies. This program will be embedded within a larger healthcare
system. Although the healthcare system's leadership structure is hierarchical, this program will
use a transformational leadership strategy and invert the hierarchy (Tropman, n.d.) (See appendix
G). Qualities of adhocracy are seen in specific programs in the outpatient setting, mainly related
to community outreach and development of programs in the primary care settings, where
innovation and creativity are encouraged, which is what this program will be. Aspects of the
"century club" are important to manage this project, including staying close to the mission,
developing partnerships within the system and in the community, being creative in response to
the feedback loop, and maintaining a strong connection to the community (Tropman, nd).
The “Stigma-Free Pregnancy” program will bring change within, in, and of the system.
The aim is to improve preventative care and health across the healthcare continuum. It is new
and innovative, but it also aims to improve existing programs and provide more knowledge and
data for future data-driven decision making (Tropman, nd). There are already several compliance
STIGMA-FREE PREGNANCY 30
programs in place for the larger healthcare system. It is accredited through the Joint Commission
Accreditation Certification and Standards, has a legal department and clinical specialists working
on updating policies and procedures. This program will be implemented in collaboration with
service line specialists, including the Director for Patient Experience, who will be reviewing
educational materials and approving them before being included in the app.
Financial Plans and Staging
The budget for the Start-Up phase and First Full Year of Operation (FFYO) for the
“Stigma-Free Pregnancy” program is estimated to be $216,000, which will be funded through
diverse community and system grants. Expenses during the start-up year are $111,000, and for
the FFYO are $104,000. Revenue will be provided by various grants, such as the PacificSource
Charitable Foundation, St. Luke’s Community Health Improvement Fund, St. Luke’s
Community Health Operational Budget, and the Women’s and Children’s Service Line Budget.
Outputs and outcomes will be evaluated and measured to determine the effectiveness and
efficiency of the project and to determine future budgets and community needs. The program has
two primary phases: the start-up phase and the FFYO. Feedback from these two phases will help
inform annual budgets moving forward.
Project Impact Assessment Methods
This program will be a Hybrid Type 1, quasi-experimental, mixed-methods design. It will
be Hybrid Type 1 to test the intervention and to observe and gather information on the
implementation strategy (Browson, Coditz, & Proctor, 2018). Both qualitative and quantitative
data will be collected, and pre-post tests will be used with community providers and pregnant
women with SUD. Non-probability sampling will be used to survey end-users. Qualitative
STIGMA-FREE PREGNANCY 31
interviews will be completed with women in community-based settings to capture behavior
changes over time. Purposive sampling will be used to survey providers
Outcome measures will include data related to recruitment, enrollment, retention, and
resiliency. The goal is to increase the number of pregnant women with SUD accessing care
through the program. Other goals are to increase access to substance use and mental health
treatment and prenatal care, to increase retention rates in care, and to reduce the number of
referrals to child welfare due to positive drug tests at the time of delivery. Outcome measures for
community-based agency staff and providers are determining how many providers are
completing training, referring women to the program, and seeing women access care because of
the program.
Data sources will include resources distributed, surveys, qualitative interviews, and data
downloads and app traffic from the iBirth app. Data will also include the number of community-
based agencies and providers participating in the program and the number of agency staff and
providers completing training modules. For the first 15 months, push surveys will be sent via the
app to end-users accessing the information on substance use (see Appendix H). Qualitative
interviews (see Appendix I) will be completed with these women by community-based agency
staff at the time of enrollment in the program, and every three months after that. App traffic and
data downloads can be tracked daily. E-mail surveys will be completed with providers every
month (see Appendix J) for 15 months. Qualitative surveys will be completed with providers
every three months for 15 months (see Appendix K). The number of contingency management
materials and "stigma-free pregnancy" kits given out will be tracked monthly. See Appendix L
for evaluation.
Stakeholder Engagement Plan
STIGMA-FREE PREGNANCY 32
Key stakeholders involved in the “Stigma-Free Pregnancy” program include pregnant
women and their families, healthcare systems, including executive leadership, medical providers,
and community services agencies. A bundled strategy will be used for stakeholder engagement,
which will include: promoting adaptability, building a coalition, developing and distributing
educational materials, using a train-the-training strategy, facilitating relay of clinical data to
providers, and altering incentive structures (Brownson, Colditz, & Proctor, 2018) (see Appendix
M). Promoting adaptability will include reviewing data downloads and app traffic to determine
rates of use. Surveying and interviewing end-users and community-based agency staff and
providers will provide feedback regarding local needs, and if those needs are being met. Building
a coalition will include calling and e-mailing leaders from the community-based agencies and
clinics, and meeting with leaders in person for buy-in, implementation, and continuity.
Relationships should first be established with providers and leaders from community-based
agencies, then education and start-up materials will be delivered, and relationships should be
maintained over time. Distribution of educational materials will include providing training and
distributing materials in person and electronically to providers, community-based agencies, and
end-users. A train-the-training strategy will be used to designate clinicians to train others in the
innovation. Training materials will also be available on-line to facilitate ease of training.
Facilitating relay of clinical data to providers is defined as providing as "close to real-time data
as possible about key measures of process/outcomes using integrated modes/channels of
communication in a way that promotes the use of the targeted innovation" (Brownson, Colditz,
& Proctor, 2018, p. 250). This strategy will aid in the engagement of executive leadership and
community stakeholders, as they can see the outcome measures. Altering incentive structures
will be using contingency management to recruit and retain end-users in the program.
STIGMA-FREE PREGNANCY 33
Communications Strategies and Products
The communication plan for dissemination of findings is primarily electronic distribution
of results of qualitative and quantitative data. Designated staff, such as a social worker or
community outreach worker, will collaborate with the data analyst and be primarily responsible
for disseminating the data to community partners and executive leadership. Data will be shared
in a monthly report, beginning in the sixth month of the start-up year (as outlined in the GANNT
chart in Appendix N). Data can be utilized to make data-driven decisions regarding
implementation and adaptations. Results will be communicated to providers and community-
based agencies to determine if adaptations and additional training are required.
Other communication products to promote this innovation include electronic and print
sources, as well as a campaign plan. Some marketing tools that have already been developed
include an infographic (see Appendix O), the iBirth app (to be updated with relevant information
on SUD), and a program manual (see appendix E). Flyers for the app are already distributed in
obstetricians' offices. An accompanying website will be updated through the Healthcare system
to include relevant materials as well. Packaging will be developed for the "Stigma-Free
Pregnancy." See Appendix P for an outline of the campaign activities. Evaluation results will be
shared with stakeholders, and opportunities for publishing in academic journals and public
speaking at conferences will be pursued.
Ethical Considerations
Pregnant women with SUD are a vulnerable population. Women who use illicit
substances during pregnancy are more likely to have a trauma history (Wong, Ordean, & Kahan,
2011). They are also forgoing care due to stigma and fear of child welfare involvement and
criminalization, making them a more vulnerable population. Ethical considerations include
STIGMA-FREE PREGNANCY 34
protecting the safety and privacy of the women, and beneficence should be maintained.
Participation is voluntary and should not be coerced. Dual relationships should also be avoided,
so it is recommended that community-agency staff complete the qualitative interviews with the
women instead of hospital staff who may be working with the women at the time of delivery or
post-partum period. Racism should also be considered an ethical issue, as women of color are
more likely to be stigmatized by providers, are more likely to be drug tested, and there are higher
rates of reporting to child welfare (Krase, 2019). The Black Lives Matter movement has helped
raise awareness that Diversity and Inclusion training should be considered by healthcare centers
at large, with careful consideration of implicit bias and how racism has manifested itself within
healthcare systems and healthcare delivery.
Conclusions, Actions, and Implications
Summary of Project Plans, Next Steps, and Readiness to be Shared
Short-term project plans include meeting with key stakeholders within the healthcare
system to finalize plans for implementation and to establish funding. A virtual focus group was
completed with the Director of Patient Experience, the Social Work Clinical Educator, and the
Behavioral Health Service Line's Manager to review the program manual. Educational material
will need to be approved by the Director of Patient Experience. Once that is approved, it can be
built into the app and accompanying website, and the design for the packaging for the "stigma-
free pregnancy" kits will be finalized. The Director of Community Health can support
collaboration with established community partners for buy-in to the program and dissemination
of materials and education. Once all of the tools are in place and staging has been completed, the
project will move into the “Preparation” Phase (see appendix D), where community-based
agencies and providers will be prepared for implementation.
STIGMA-FREE PREGNANCY 35
Long-term project plans include analyzing data, utilizing the data to inform data-driven
decisions related to the "stigma-free pregnancy" program, and other prevention programs, and
disseminating information more widely via conferences and academic journals. Data can be used
to justify the need for best-practice informed wrap-around services if women can successfully be
recruited and retained in care and more targeted prevention interventions in geographic regions
based on data collection and evaluation. Data can also be used for advocacy for maternal health,
beginning at the State level.
Current Practice Context for Project Conclusions
The Center or Disease Control and Prevention (2018) reports that the opioid epidemic
began in the 1990s when doctors started prescribing opioids at a higher rate. The second wave of
the epidemic began in 2010 with the escalated use of heroin. The next wave of the epidemic
came just three years later in 2013 when synthetic opioids took over as the leading cause of death
by overdose. Over 64,000 people died because of addiction in 2016 (Hilgers, 2018), which is
more than the death tolls of Americans in the Vietnam, Afghanistan, and Iraq Wars combined
(Bajekal, 2018). Over 70,000 people died due to overdoses in 2017 in the United States, which is
worse than any given year during the AIDS epidemic (Stone, 2019). Even though addiction is
one of the most severe healthcare crises in America's history, it is primarily managed as a
separate issue and outside of healthcare systems. One of the leading causes of death for pregnant
women and new mothers is drug overdoses, and the majority of these women did not receive
substance abuse or mental health treatment (Galvin, 2019).
A recruitment and retention strategy is needed for healthcare systems to be leaders in
care, to take responsibility for the long-term health of their communities, and to reduce the
harmful impacts of substance use, particularly during pregnancy. It is clear that substance use,
STIGMA-FREE PREGNANCY 36
particularly opioid use, is on the rise, and it disproportionately affects vulnerable populations,
including people of color and those with trauma histories. Social workers can help bridge the gap
between vulnerable communities and healthcare systems by providing education and innovative
solutions, such as the "Stigma-Free Pregnancy" program, to fill these gaps and improve
population health, starting with the most marginalized. The "Stigma-Free Pregnancy" program
aims to fit one of these gaps in access to care.
Project Implications for Practice and Further Action
There are implications at the micro, mezzo, and macro level. At the micro-level, women
with SUD will be recruited into care, including prenatal care and substance use and mental health
treatment. The number of referrals to child welfare due to substance exposure at the time of
delivery will also be reduced. At the mezzo-level, more medical staff and community-based
agency staff will receive training on trauma-informed care, motivational interviewing, substance
use during pregnancy, and there will be more data collection. On the macro level, substance use
during pregnancy will be decreased, and the risk of child abuse and neglect will also be
mitigated, thus disrupting the cycle of family violence. This program has the potential to increase
healthcare cost savings and, therefore, savings to taxpayers. Data can also be used to inform
community health programs as well as child-welfare programs, public policy, and advocacy.
It can be anticipated that changes will need to be made to the program over time to meet
changing political and social climates, changing laws and child welfare policies, trends in
substance use, public health crisis, updates in and availability of technology, availability of
funding sources, and attitudes of physicians towards pregnant women with SUD and minority
populations. In order for the “Stigma-Free Pregnancy” program to be successful over time, the
Hybrid Type 1 design and RE-AIM framework were selected as constant feedback loops to test
STIGMA-FREE PREGNANCY 37
the intervention and observe and gather information on the implementation strategy and make
needed adjustments over time. The social-ecological framework was selected as change will be
needed on the individual, interpersonal, community, and policy levels. As the "Stigma-Free
Pregnancy" program scales up within Idaho and expands into other states, considerations will
need to be made for additional community partners, funding sources, state-specific laws and
policies related to child-abuse reporting (consider ethical issues to maintain beneficence) and
issues of external validity (for more detail, see Project Limitations).
Project Limitations
There are several limitations and risks related to the "Stigma-Free Pregnancy" program.
The program makes some assumptions that this population will have access to appropriate
technology and community-based settings. There are also issues of external validity that need to
be considered. For example, Idaho's racial and ethnic demographics also differ significantly from
other areas of the country (in 2010, Boise was 89% white only) (U.S. Census Bureau, 2010).
These differences should be considered because biases related to race, ethnicity, and socio-
economic status may manifest themselves differently in communities of other demographic
makeup. The issue of social desirability bias should also be considered a limitation, as this
population already feels judged, stigmatized, and afraid. They may be more likely to answer
survey and interview questions in a manner that they feel will be more favorable to interviewers
and under-report their use. Another limitation is that there are no existing measurement tools as
this is a new program, and the interviews and surveys were created to evaluate the data. COVID-
19 has been an unexpected limitation and can affect access to community-based agencies and
providers. It also directly affects more vulnerable populations, including racial minorities.
STIGMA-FREE PREGNANCY 38
Substance use has also increased during this pandemic (Erdman, 2020). COVID has also
impacted healthcare systems financially, which may also affect funding sources.
There are several recommendations for overcoming these limitations and risks.
Community-based agency staff will be available to assist women with accessing technology and
enroll them in services (for example, assisting them to call providers and schedule
appointments). Designated providers from the healthcare system will also be engaging with
women through outreach in community-based settings every week to establish trust and rapport
and eliminate barriers to accessing providers via technology. Strategies for overcoming external
validity issues may include adding diversity and inclusion training modules for providers and
community-based agencies and having materials available in multiple languages. Social
desirability bias can be minimized by allowing for anonymous responses, using technology for
surveys, establishing trust and rapport with providers and interviewers in community-based
settings, providing psychoeducation to end-users, and using open-ended questions in qualitative
interviews. Survey and interview questions can be reviewed and edited over time if issues are
identified. COVID-19 has reinforced the importance of the need for technology in care delivery,
and the need for community-based settings approaches and preventative care for vulnerable
populations. Virtual meetings and focus groups have been used as a way to overcome some of
the barriers to progress with this program within the healthcare system.

STIGMA-FREE PREGNANCY 39
Resources:

American Society of Addiction Medicine (n.d.). Medicaid Coverage of Medications for
Treatment of Opioid Use Disorder. Retrieved from: https://www.asam.org/docs/default-
source/advocacy/state-medicaid-reports/state-medicaid-reports_id.pdf?sfvrsn=6
Bajekal, N. (2018). Want to Win the War on Drugs? Portugal Might Have the Answer. Time.
Retrieved from: https://time.com/longform/portugal-drug-use-decriminalization/
Ben-Zeev, D. (2014). Technology-based interventions for psychiatric illnesses: improving care,
one patient at a time. Epidemiology and Psychiatric Science, 23, 317-321.
Best Beginnings (n.d.). Parents Who Use Drugs. Retrieved from:
https://www.bestbeginnings.org.uk/parents-who-use-drugs
Bortz, K. (2017). Combating neonatal abstinence syndrome amid opioid crisis. Infectious
Diseases in Children, 30(8), 1–12.
Brown, T., Gehlert, S., Andrews, C., Zebrack, B., Walther, V., Steketee, G., Maramaldi, P.,
Jones, B., Golden, R., Ewald, B., Bernstein, S., Begun, A., Allen, H., Guth, S., Ross, A.,
Moore, M., & Merighi, J. (2017). Strengthening Health Care Systems: Better Health
Across America [pdf]. Retrieved from: http://grandchallengesforsocialwork.org/wp-
content/uploads/2017/11/WP22.pdf
Brownson, R. C., Colditz, G. A., & Proctor, E. K., (Eds.), (2018). Dissemination and
Implementation Research in Health: Translating Science to Practice. 2
nd
Edition. New
York: Oxford University Press.
Center for Disease Control and Prevention (2018). Opioid Overdose. Retrieved from:
https://www.cdc.gov/drugoverdose/epidemic/index.html
STIGMA-FREE PREGNANCY 40
Chen, A. (2018). Q&A on Pregnant Women's Coverage Under the ACA. National Health Law
Program. Retrieved from: https://healthlaw.org/resource/qa-on-pregnant-womens-
coverage-under-medicaid-and-the-aca/
Cody, M. (nd). Source Characteristics. [Asynchronous lecture]. University of Southern
California.
Crescer (2017). The Association. Retrieved from: http://crescer.org/en/the-association/
Daley, D., Bachmann, M., Bachmann, B., Pedigo, C., Bui, M., & Coffman, J. (2016). Risk
terrain modeling predicts child maltreatment. Child Abuse & Neglect, 62, 29–38.
Edgerley, L. P., El-Sayed, Y., Druzin, M. L., Kiernan, M., & Daniels, K. I. (2007). Use of a
community mobile health van to increase early access to prenatal care. Maternal and
Child Health Journal, 11(3), 235-9.
Erdman, S. (2020). Opioid drug overdose deaths are down in US, study finds, but COVID-19
could change that. Retrieved from: https://www.cnn.com/2020/05/21/health/drug-
overdose-deaths-covid-19-trnd/index.html
Fong, R., Lubben, J., & Barth, R. (2018). Grand challenges for social work and society. New
York, NY: Oxford University Press.
Galbraith, J. (2014). Designing organizations : strategy, structure, and process at the business
unit and enterprise levels (Third edition.). San Francisco: Jossey-Bass, a Wiley brand.
Galvin, G. (2019, May 9). Drugs the Top Killer of Pregnant Women, New Moms in Utah. U.S.
News. Retrieved from: https://www.usnews.com/news/healthiest-
communities/articles/2019-05-09/drugs-the-top-killer-of-pregnant-women-new-moms-in-
utah
STIGMA-FREE PREGNANCY 41
Green, A., & Conway, A. (2018). Kaiser Permanente’s Early Start Program: A Successful
Perinatal Substance Abuse Intervention [PowerPoint slides]. Retrieved from:
http://www.nationalperinatal.org/resources/Documents/2018%20Conference/Thursday/C
onway%20-%20NPA%20Early%20Start%20presentation%20-3.15.2018-v2.pdf
Glasgow, R., Bogt, T. & Boles, S. (1999). Evaluating the public health impact of health

promotion interventions: The RE-AIM framework. American Journal of Public Health,

89, 1322-1327.

Grol, R., Bosch, M., Hulscher, M., Eccles, M., & Wensing, M. (2007). Planning and Studying
Improvement in Patient Care: The Use of Theoretical Perspectives. Milbank
Quarterly, 85(1), 93–138.
Havens, J., Simmons, L., Shannon, L., & Hansen, W. (2008). Factors associated with substance
use during pregnancy: Results from a national sample. Drug and Alcohol
Dependence, 99(1-3), 89–95.
Hand, D., Ellis, J., Carr, M., Abatemarco, D., & Ledgerwood, D. (2017). Contingency
management interventions for tobacco and other SUDs in pregnancy. Psychology of
Addictive Behaviors : Journal of the Society of Psychologists in Addictive
Behaviors, 31(8), 907–921.
Hilgers, L. (2018, May 19). Treat Addiction Like Cancer. The New York Times. Retrieved from
https://www.nytimes.com/2018/05/19/opinion/sunday/addiction-cancer-treatment.html
Hutchinson, M., Chisolm, M., Tuten, M., Leoutsakos, J., & Jones, H. (2012). The efficacy of
escalating and fixed contingency management reinforcement on illicit drug use in opioid-
dependent pregnant women. Addictive Disorders & Their Treatment, 11(3), 150–153.
STIGMA-FREE PREGNANCY 42
Idaho Department of Health and Welfare (nd). Pregnant Women and Women with Dependent
Children. Retrieved from:
http://healthandwelfare.idaho.gov/Medical/SubstanceUseDisorders/FindTreatment/Pregn
antWomen/tabid/1001/Default.aspx
Idaho Health Plan (2016). Retrieved from:
https://healthandwelfare.idaho.gov/Portals/0/Medical/MedicaidCHIP/Idaho%20Health%2
0Plan%20English.pdf
Idaho Health and Welfare (2019). Medicaid Expansion Home Page. Retrieved from:
https://medicaidexpansion.idaho.gov/
Idaho Legislature (2019). Idaho Statutes Section 16-1605. Retrieved from:
https://legislature.idaho.gov/statutesrules/idstat/title16/t16ch16/sect16-1605/
Idaho Vital Statistics (2018). 2017 Idaho Natality. Retrieved from:
https://healthandwelfare.idaho.gov/Portals/0/Health/Statistics/2017-
Reports/2017_Births.pdf
Jacewicz, N. (2016, August 2). Teaching Future Doctors About Addiction. Kaiser Health News.
Retrieved from: https://khn.org/news/teaching-future-doctors-about-addiction/
Jackson, A., & Shannon, L. (2012). Barriers to Receiving Substance Abuse Treatment Among
Rural Pregnant Women in Kentucky. Maternal and Child Health Journal, 16(9), 1762–
70.
Johns Hopkins Medicine (2020). Center for Addiction and Pregnancy. Retrieved from:
https://www.hopkinsmedicine.org/psychiatry/patient_information/bayview/medical_servi
ces/substance_abuse/center_addiction_pregnancy.html
STIGMA-FREE PREGNANCY 43
Krase, K. (2019). Child Maltreatment Reporting by Educational Personnel: Implications for
Racial Disproportionality in the Child Welfare System. In Goodley, T, Williams, J,
Martell, T., & Gorin, S. (Eds.), Grand Challenges for Society (121-131). Washington
DC: NASW Press.
Langrill, C. (2018). St. Luke’s Joins with Patients and Their Unborn Children to Combat the
Ravages of the Opioid Crisis. Retrieved from: https://www.stlukesonline.org/blogs/st-
lukes/news-and-community/2018/aug/combat-opiates
Lopez-Patton, M., Weiss, S., Tobin, J., Jones, D., & Diaz-Gloster, M. (2015). Translating

evidence-based interventions from research to practice: challenges and lessons

learned. Translational Behavioral Medicine, 5(2), 233–241.

Lumen Candela (2020). Core Principles of the Ecological Model. Retrieved from:
https://courses.lumenlearning.com/suny-buffalo-environmentalhealth/chapter/core-
principles-of-the-ecological-model/
Macafee, L., Harfmann, R., Kolenic, G., & Dalton, V. (2017). Barriers to reproductive health
services for women with opioid use disorder in substance use treatment across
Michigan. Contraception, 96(4), 297–297.
Mclafferty, L., Becker, M., Dresner, N., Meltzer-Brody, S., Gopalan, P., Glance, J., Victor, G., et
al. (2016). Guidelines for the Management of Pregnant Women With Substance Use
Disorders. Psychosomatics, 57(2), 115–130.
National Center on Substance Abuse and Child Welfare (2018). Tapping Tribal Wisdom:
Providing Collaborative Care for Native Pregnant Women With SUDs and Their
Infants [pdf]. Retrieved from:
https://ncsacw.samhsa.gov/files/tapping_tribal_wisdom_508.pdf
STIGMA-FREE PREGNANCY 44
National Center on Substance Abuse and Child Welfare (2018). The Use of Peers and Recovery
Specialists in Child Welfare Settings [pdf]. Retrieved from:
https://ncsacw.samhsa.gov/files/peer19_brief.pdf
National Institute on Drug Abuse (2019). Idaho Opioid Summary. Retrieved from:
https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/idaho-
opioid-summary
National Institute on Drug Abuse (2015). Dramatic Increases in Maternal Opioid Use and
Neonatal Abstinence Syndrome. Retrieved from:
https://www.drugabuse.gov/related-topics/trends-statistics/ infographics/dramatic-
increases-in-maternal-opioid-use-neonatal- abstinence-syndrome
Newman, K. (2018, November 30). Study: More Expectant Moms Using Meth, Opioids. U.S.
News. Retrieved from: https://www.usnews.com/news/healthiest-
communities/articles/2018-11-30/meth-opioid-use-up-among-expectant-mothers-in-us-
study-suggests
O'Brien, M., & Phillips, S. (2011). Substance Exposed Newborns: Addressing Social Costs
Across the Lifespan [pdf]. Retrieved from:
https://masshealthpolicyforum.brandeis.edu/forums/Documents/FINAL-SEN-
IssueBrief_For-Print.pdf
O'Connell, E., Zhang, G., Leguen, F., & Prince, J. (2010). Impact of a mobile van on prenatal
care utilization and birth outcomes in Miami-Dade County. Maternal and Child Health
Journal, 14(4), 528–534.
Oei, J.L. (2018). Adult Consequences of Prenatal Drug Exposure. Internal Medicine
Journal, 48(1), 25–31.
STIGMA-FREE PREGNANCY 45
Palinkas, L., & Soydan, H. (2012). Translation and Implementation of Evidence Based
Practice. New York: Oxford University Press.
Paltrow, L., & Flavin, J. (2013). Arrests of and Forced Interventions on Pregnant Women in the
United States, 1973-2005: Implications for Women’s Legal Status and Public
Health. Journal of Health Politics, Policy and Law, 38(2), 299–343.
Pantalon, M., Ferro, G., Chawarski, M., LaPaglia, D., Pakes, J., & Schottenfeld, R. (2004).
Voucher Purchases in Contingency Management Interventions for Women with Cocaine
Dependence. Addictive Disorders & Their Treatment, 3(1), 27–35.
Parent-Child Assistance Program (2019). Retrieved from: https://depts.washington.edu/pcapuw/
Parolin, M., Simonelli, A., Mapelli, D., Sacco, M., & Cristofalo, P. (2016). Parental Substance
Abuse As an Early Traumatic Event. Preliminary Findings on Neuropsychological and
Personality Functioning in Young Drug Addicts Exposed to Drugs Early. Frontiers in
psychology, 7, 887.
Patrick, S., Faherty, L., Dick, A., Scott, T., Dudley, J., & Stein., B. (2019). Association Among
County-Level Economic Factors, Clinician Supply, Metropolitan or Rural Location, and
Neonatal Abstinence Syndrome. American Medical Association. JAMA. 2019;
321(4):385–393.
Patrick, S. & Schiff, D. (2017). A Public Health Response to Opioid Use in Pregnancy.
American Academy of Pediatrics. Retrieved from:
https://pediatrics.aappublications.org/content/early/2017/02/16/peds.2016-
4070?versioned=true
RE-AIM Framework Planning and Evaluation Questions for Initiatives Intended to Produce
Public Health Impact (2019) RE-AIM.org. Retrieved from: http://www.re-aim.org/wp-
STIGMA-FREE PREGNANCY 46
content/uploads/2018/02/Planning-and-Evaluation-Questions-for-Initiatives-Intended-to
-Produce-Public-Health-Impact-_Final.pdf
Reguero, W., & Crane, M. (1994). Project MotherCare: one hospital's response to the high
perinatal death rate in New Haven, CT. Public Health Reports (Washington, D.C. :
1974), 109(5), 647–652.
SAMHSA (2012). Idaho-Substate Estimates From the 2010-2012 NDUHS, SAMHSA, CBHQ
[Data file]. Retrieved from:
https://www.samhsa.gov/data/sites/default/files/substate2k12-StateTabs
NSDUHsubstateStateTabsID2012.htm
SAMHSA (2009). Substance-Exposed Infants: State Responses to the Problem [pdf]. Retrieved
from: https://ncsacw.samhsa.gov/files/Substance-Exposed-Infants.pdf
SAMHSA (2013). TIP 51 Substance Abuse Treatment Addressing the Specific Needs of
Women [pdf]. Retrieved from: https://store.samhsa.gov/system/files/sma15-4426.pdf
SAMHSA (nd). A Collaborative Approach to The Treatment of Pregnant Women with Opioid
Use Disorders [pdf]. Retrieved from:
https://ncsacw.samhsa.gov/files/Collaborative_Approach_508.pdf
Schottenfeld, R., Moore, B., & Pantalon, M. (2011). Contingency management with community
reinforcement approach or twelve-step facilitation drug counseling for cocaine dependent
pregnant women or women with young children. Drug and Alcohol Dependence, 118(1),
48–55.
Steiner, A. (2017). Women's Recovery Grants Support Programs That Help Mother's Overcome
Addiction. MinnPost. Retrieved from: https://www.minnpost.com/mental-health-
STIGMA-FREE PREGNANCY 47
addiction/2017/01/women-s-recovery-grants-support-programs-help-mothers-overcome-
addic/
Stone, B. (Interviewer) & Lembke, A., Peterson, L., & Tamar H. (Interviewee). (2019). Aspiring
Doctors Seek Advanced Training in Addiction Medicine [Interview transcript]. Retrieved
from NPR website:
https://www.npr.org/templates/transcript/transcript.php?storyId=695690652
Substance Abuse and Mental Health Services Administration; Office of the Surgeon General
(2016). Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs,
and Health [Internet]. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK424859/
Surgeon General (2016). Surgeon General’s Report on Alcohol, Drugs, and Health. Retrieved
from: https://addiction.surgeongeneral.gov/index.php/
The Economist (2015). Soothing mama, harming baby. Retrieved from
http://search.proquest.com/docview/1679729377/?pq-origsite=primo
The MITRE Corporation (2017). Predictive Analytics in Child Welfare: An Assessment of
Current Efforts, Challenges, and Opportunities [pdf]. Retrieved from:
https://aspe.hhs.gov/system/files/pdf/257841/PACWAnAssessmentCurrentEffortsChallen
gesOpportunities.pdf
The New York Times, (2018). Children of the Opioid Epidemic. Retrieved from:
https://www.nytimes.com/2018/05/09/magazine/children-of-the-opioid-epidemic.html
Terplan, M., Mcnamara, E., & Chisolm, M. (2012). Pregnant and non-pregnant women with
SUDs: The gap between treatment need and receipt. Journal of Addictive
Diseases, 31(4), 342–349.
Text4baby, (2017). Retrieved from: https://www.text4baby.org/learn/pregnancy/substanc-abuse
STIGMA-FREE PREGNANCY 48
Torres, C., Farley, C., & Cook, B. (2012). A Special Educator’s Guide to Successfully
Implementing Evidence-Based Practices.
Tropman, J. (nd). Long-lasting companies [Asynchronous lecture]. University of Southern
California.
Tropman, J. (nd). Organizational Culture [Asynchronous lecture]. University of Southern
California.
Tropman, J. (nd). Three Forms of Change [Asynchronous lecture]. University of Southern
California.
Tropman, J. (nd). Transformational Leadership [Asynchronous lecture]. University of Southern
California.
Tuten, M., Fitzsimons, H., Chisolm, M., Nuzzo, P., & Jones, H. (2012). Contingent incentives
reduce cigarette smoking among pregnant, methadone‐maintained women: results of an
initial feasibility and efficacy randomized clinical trial. Addiction, 107(10), 1868–1877.
Tuten, M., Svikis, D., Keyser-Marcus, L., O'Grady, K., & Jones, H. (2012). Lessons Learned
from a Randomized Trial of Fixed and Escalating Contingency Management Schedules
in Opioid-Dependent Pregnant Women. The American Journal of Drug and Alcohol
Abuse, 38(4), 286–292.
U.S. Census Bureau (2010). U.S. Census Bureau QuickFacts: Boise City, Idaho. Retrieved from:
https://www.census.gov/quickfacts/fact/table/boisecitycityidaho,fortworthcitytexas/POP0
60210
Walters, K., Spencer, M., Smukler, M., Allen, H., Andrews, C., Brown, T., Maramaldi, P.,
Wheeler, D., Zebrack, B., & Uehara, E. (2016). Health Equity: Eradicating Health
Inequalities for Future Generations [pdf]. Retrieved from:
STIGMA-FREE PREGNANCY 49
http://grandchallengesforsocialwork.org/wp-content/uploads/2016/01/WP19-with-
cover2.pdf
The White House (nd). Ending America’s Opioid Crisis. Retrieved from:
https://www.whitehouse.gov/opioids/
Wolters Kluwer Company (2012). Incentives help in treating addictions during pregnancy,
reports addictive disorders and their treatments. Retrieved from:
https://wolterskluwer.com/company/newsroom/news/health/2012/08/incentives-help-in-
treating-addictions-during-pregnancy-reports-addictive-disorders--their-treatment.html
Wong, S., Ordean, A., & Kahan, M. (2011). Substance use in pregnancy No. 256, April 2011.
International Journal Of Gynecology & Obstetrics, 114(2), 190–202.

STIGMA-FREE PREGNANCY 50

Appendix A: Logic Model
STIGMA-FREE PREGNANCY 51
Appendix B—Primary Research Template

Section 1: Interviews and Key Takeaways
Name Organization Title Expertise/
Reason
Key Takeaways

1 Jeffrey
Jenson, PhD
University of
Denver
Philip D. and
Eleanor G.
Winn
Professor for
Children and
Youth
Focused
research on
public health
approaches to
prevention of
child and
adolescent
problems
with health
and behavior
Declined to interview:
stated that he does not
feel like he is an expert
in this area.
2 Richard
Barth, PhD
University of
Maryland
Dean of
School of
Social Work
and
Professor
Expert on
child welfare
and effects of
parental
substance
abuse
• Some reasons that
the cycle of
violence persists
are patriarchal
beliefs and the
separation of
people who use
violence from the
people who
experience violence
with little support
or education for the
ones who use
violence.
• We need to use a
better screening
process for
violence—take
more time and have
people that are
trained to respond
to positive screens.
• Increase
community
outreach.
• Increase use and
access to
technology:
provide people
with phones;
provide free Wi-Fi
STIGMA-FREE PREGNANCY 52
(for example in
housing projects).
• Provide increased
opportunities for
development of
coping skills for
those that use
violence and/or
substances.
3 Emily
Putnam-
Hornstein,
PhD
University of
Southern
California
Associate
Professor of
Social Work,
Dept. of
Children,
Youth, and
Families
Expert on
child
maltreatment
• Healthcare data can
be used to identify
highest risk
population
• Look at ways to
incentivize
providers to serve
high risk/low
resourced
communities
• The missing piece
in the knowledge
base is how to
successfully engage
highest risk
individuals
• Look at ways to
engage
fathers/partners
• Improved long-
term case
management model
with highest risk
patients (could use
predictive risk
modeling for this)
4 Dr. Matthew
Cox
St. Luke’s
Regional
Medical Center
Medical
Director of
St. Luke’s
Children at
Risk
Evaluation
Services
Expert
witness on
child abuse
Attempted contact on:
1. 1/22/19
2. 1/30/19
3. 2/5/19
5 Dr. Stacy
Seyb
St. Luke’s
Regional
Medical Center
Medical
Director of
Maternal
Works with
pregnant
women with
SUD
• One of the biggest
problems is
creating trust to get
women in the door.
STIGMA-FREE PREGNANCY 53
Fetal
Medicine
Better staff training
on trauma informed
care to increase
compassionate care
and retain women
in care. Word of
mouth referrals will
increase.
• Make resources
available where
patients are. We
can’t expect
patients to go out
of their way.
• We need better
screening processes
as well as staff in
place who are
trained to respond
to positive screens.
• We need to better
utilize technology
(apps, tele-health,
etc.)
• Establish
partnership
between law
enforcement and
Health services for
direct referrals to
OB Clinics and
services.
6 Dr. Robert
Davis
St. Luke’s
Regional
Medical Center
MD at
Maternal
Fetal
Medicine
Works with
pregnant
women with
SUD
• We need better
screening and
people in place in
the clinics to
respond to positive
screening.
• Improve
compassionate care
and coordination
with the
community.
• We can use social
media to increase
access—women
STIGMA-FREE PREGNANCY 54
create communities
on social media.
• Improve and
establish
relationships with
law enforcement
and the criminal
justice system.
• Help remediate
those that use
violence.
• Current
interventions are
working on an
individual level but
substance use is
increasing across
populations.
7 Dr. Ashley
King
St. Luke’s
Regional
Medical Center
MD at the
Family
Justice
Center
Specializes in
caring for
victims of
domestic
violence
• Utilize early
interventions—
education in
schools on healthy
relationships.
• Improve and
increase screening.
Have training for
how to ask
questions and what
to do if there is a
positive answer.
• Trauma informed
care providers,
wrap around
services, and
community
education.
• Increase use of
technology and
follow-up via
technology to meet
immediacy of need.
8 Kristine
Schmidt,
MN, RN
St. Luke’s
Regional
Medical Center
Program
Manager
Helped
develop the
local center
of excellence
for managing
• Traditional western
medical
model/paternalistic
approach to
medicine
STIGMA-FREE PREGNANCY 55
substance use
during
pregnancy
contributes to the
cycle of family
violence
• We need more
consistent
screening processes
in primary care
clinics and better
resources and
trained staff to
respond to positive
screens.
• Improve education
among medical
providers and staff
related to mental
health and
substance abuse
• Increase
community based
interventions
• Increase
technology use and
availability to
access
professionals and
support in “real
time”
• There is a loss of
autonomy once a
woman becomes
pregnant, and
culturally
acceptable
substance use (eg.
alcohol) is now
associated with
negative stigma.
• Most SUD
diagnosis occurs
during child
bearing years. We
need this to be a
maternal health
initiative.
STIGMA-FREE PREGNANCY 56
9 Amy
Conway,
MPH
Kaiser
Permanente,
Early Start
Program
Early Start
Regional
Director
Expert in
managing
wrap around
services for
pregnant
women with
SUD
• Healthcare systems
should have
integrated
behavioral
healthcare models
in clinics
• Community based
peer-to-peer
services are helpful
for getting women
to access care.
• Pregnant women
are reflecting what
is happening in
society as a whole,
so its not that
programs for
pregnant women
are not working,
but substance use is
increasing.
Society’s view on
what is socially
acceptable is also
changing.
10 Karis
Coleman
Kaiser
Permanente,
Early Start
Program
Early Start,
Project
Manager
Expert in
managing
wrap around
services for
pregnant
women with
SUD
Deferred interview to Amy
Conway, Early Start
Program Manager
11 Dr. Nicole
Fox
St. Luke’s
Regional
Medical Center
Psychiatrist Psychiatrist,
works with
pregnant
women
• We need better
legislation for
physicians to be
able to prescribe
Suboxone,
including in
emergency
departments
• We could increase
access and sustain
care by increasing
appointment
reminders and
utilizing incentives
STIGMA-FREE PREGNANCY 57
• Technology could
be leveraged by
making public
phones/technology
available that
would connect
women to
community
supports
• Incentivize! Put
something in the
pregnancy test box
to incentivize or
redeem for
showing up in
clinic.
• Take care to
“them”: eg. By
setting up
residency clinic in
shelters one day per
week.
• Need to have
embedded social
workers in clinics.
12 Best
Beginning
Staff
Best Beginning App
development
Created an
app for
pregnant
women with
SUD in the
UK
Attempted contact on:
1. 1/12/19
2. 1/14/19
3. 2/2/19
13 Jerri
Woodworth
St. Luke’s
Regional
Medical Center
Clinic
Manager/RN
Clinic
Manager and
RN for OB
clinic
providing
services to
pregnant
women with
SUD
• Include partners in
the treatment
process
• Better system
education on non-
judgmental care
• Including text
messaging options
for patients and
providers
• Create options for
peer-to-peer
support
STIGMA-FREE PREGNANCY 58
• Create partnerships
with housing
programs
• Create engagement
activities in the
communities
14 Krista Kotz,
PhD, MPH
Kaiser
Permanente,
Family
Violence
Prevention
Program
Family
Violence
Prevention
Program,
Program
Director
Program
Director for
Kaiser
Permanente’s
Family
Violence
Prevention
Programs
• Intergenerational
trauma sustains the
cycle of family
violence as an issue
• Screening is key,
but you also need
to have trained staff
structure, support,
and resources
available
• To increase access
to care when
stigma and fear are
the barriers, women
need to know that
“something good”
will come of their
disclosures and
seeking care
• Some hotlines use a
chat option that are
safe and
anonymous
• Increase
partnerships with
OBGYNs
15 Likely User
1
Chemically
dependent
pregnant
woman/woman
who already
gave birth
Likely user Likely User In discussion with St.
Luke’s research team for
next steps
16 Likely User
2
Chemically
dependent
pregnant
woman/woman
who already
gave birth
Likely user Likely user In discussion with St.
Luke’s research team for
next steps
STIGMA-FREE PREGNANCY 59
17 Likely User
3
Chemically
dependent
pregnant
woman/woman
who already
gave birth
Likely user Likely user In discussion with St.
Luke’s research team for
next steps

Section 2: Interview Questions
Questions for experts:
1. What do you believe sustains they cycle of family violence (including substance abuse,
child maltreatment, and intimate partner violence) as an issue?
2. What do you think healthcare systems can do to address family violence and the cycle of
abuse (substance use, intimate partner violence, and child maltreatment) as a public health
issue?
3. How might we increase and sustain access to care and sustaining women in care
throughout their pregnancy?
4. How is technology being leveraged to increase access and decrease stigma?
5. What partnerships do you think would be valuable that have not yet been established that
could help address the problem of family violence?
6. What else can be done to prevent and disrupt the cycle of family violence?
7. Why do you think what is currently being done to stop substance use during pregnancy is
not working?
8. How can research limitations be circumvented or changed to increase opportunity for
pregnant women with SUDs to participate in research that could improve both maternal and
fetal outcomes during their pregnancy?

Questions for likely users:
9. What did you find as the biggest deterrent to seeking care, including mental health
treatment, substance abuse treatment, and prenatal care?
10. If there were/is one thing that you could change that would enable you to obtain care,
what would that be?
11. In terms of technology, can you envision anything that would increase your ability to
access needed care?
12. What do you picture your ideal prenatal care to include?
13. What do you believe is currently being done to support women who are trying to seek
care during pregnancy?
14. What isn’t currently being done that you need?

STIGMA-FREE PREGNANCY 60
Appendix C: RE-AIM Framework Planning and Evaluation Questions for Initiatives
Intended to Produce Public Health Impact
Dimension Core Questions Probes
Adoption What settings or organizational types
are you targeting?
-Community-based settings that provide
services to high-risk populations, such as
shelters and free community clinics
-OB clinics/providers
-Mental health and substance abuse
providers
How many of these settings and
organizations do you estimate will use
the initiative?
-In Ada County (7) these agencies
include: The Interfaith Sanctuary, City
Light Shelter, Allumbaugh House,
Planned Parenthood, Family Medicine
Residency of Idaho, Genesis World
Mission, Terry Reilly Health Services,
and the Central District Health
Department, and 30 medical providers
What are key characteristics
of the target setting?
-They provide services to
populations at higher risk for
using illicit substances.
-They are free or reduced cost.
-They are easily accessible to
community members (e.g., On
or near public transportation)
-Confidentiality is maintained
-Providers of substance abuse,
mental health, and/or prenatal
care
Who might be interested in
this initiative?
-Community mental health
providers
-Community substance use
providers
STIGMA-FREE PREGNANCY 61
-In Canyon County (7), this includes
Central District Health in Caldwell, Terry
Reilly Health Services (two locations),
Planned Parenthood, Hope’s Door, The
Salvation Army Community Family
Shelter, and Lighthouse Rescue Mission.
-In Twin Falls County (3) this includes
Central District Health in Twin Falls,
Valley House, and Victory Homes
shelters, and 16 medical providers
-All Emergency Department and Social
Work staff for SLRMC
Who will deliver the initiative and do
they have the skills and time:
-Social Work at St. Luke’s will develop
the content supplemented with
time/money from a PATHS grant
-Population Health/Social Work will
complete the community outreach
-Community-based agencies will provide
the pregnancy tests and marketing
material to end-users provided by the
-OB Clinics
-Department of Health and
Welfare- Child Protection
-Service Lines at St. Luke's,
Including Population Health,
Women's and Children's
Service Line, Behavioral
Health Service Line, and Acute
Care
How will settings hear about
this?
-Community Outreach
-Single Point Lessons
-In-person training
What are characteristics of
settings that did not
participate?
-Agencies that do not offer a
variety of treatment options to
pregnant women
-Agencies and providers
outside of counties where
SLRMC has a hospital facility
STIGMA-FREE PREGNANCY 62
Healthcare system via SW or population
health
How many of these staff do you
estimate will use the initiative?
-All staff can be trained at the agencies
-Primary staff providing the initiative or
referral to the initiative will be providers,
nurses, social workers, and case
managers.
What external or
environmental supports or
threats are there?
-Threats include political
culture and stigma, limited
public transportation options,
limitation on clinic hours,
child welfare and reporting
laws, community-agency
staffing, inter-organizational
collaboration/relationships and
alignment of goals,
client/patient advocacy,
information transmission
between agencies
-Potential supports include:
upcoming Medicaid expansion
in Idaho, community-agency
staffing, inter-organizational
collaboration/relationships and
alignment of goals,
client/patient advocacy
STIGMA-FREE PREGNANCY 63
How will you know if
organizations used the
initiative?
-Surveys, interviews,
contingency resource tracking,
data downloads/traffic on the
app, verbal/written reporting
Who can help gather
information about this?
IBirth app data analysts,
community agencies, surveys
on the app
What are the expertise or
characteristics of those you
are targeting to deliver the
intervention?
Community-based agency staff
(case managers and social
workers), mental health
providers, substance use
providers, OB providers, ED
providers, and staff—those
STIGMA-FREE PREGNANCY 64
interfacing with high-risk
populations
What characteristics may
differ from the targeted staff
and those who participate?
Area of specialization, biases
held towards the targeted
population (particularly ED
staff), resources available
geographically
Reach Who will benefit from the initiative?
-Pregnant women with SUD
-Children/families of the women
-Taxpayers
-Healthcare systems
How will you know if those who
participated are representative of the
target population?
-Surveys on the iBirth app
-Qualitative interviews with providers
and end-users
Whom do you plan to reach
in your initiative? Define the
target group
-Pregnant women with SUD
How will you advertise and
promote the initiative? Who
needs to approve these
methods?
-Stigma-Free Pregnancy Kits
distributed through
community-based settings
-Contingency management
STIGMA-FREE PREGNANCY 65
-Data tracking on child welfare referrals
due to positive drug testing at the time of
delivery (trends)
-Materials distributed/used in the
community
-This needs to be approved by
the Women’s and Children’s
Service line through SLRMC
(they manage the app) and
Acute Care SW Service Line.
The marketing team also needs
to approve staff time to update
marketing materials targeting
this population. Community
agencies need to be willing to
participate in the distribution
of materials and resource
referrals.
How will you know if the
initiative reached the
intended audience and who
participated?
-Surveys included on the app.
-Provider surveys
-Data downloads and traffic on
the sites
-Qualitative interviews
STIGMA-FREE PREGNANCY 66
What methods will you use
to focus on health inequities?
-Community-based settings
approach
-Community outreach
What information is
available to determine that
the sample is representative
of the target audience?
-Surveys on the iBirth app
-Qualitiatve interviews
-National data on rates of
substance use during
pregnancy
Implementation How will the initiative be delivered,
including adjustments and
adaptations?
-The initiative will be delivered via
outreach and technology (the iBirth app)
distributed at community-based settings
-Adjustments and adaptations will be
made based on need and distribution of
What are the key elements of
the initiative that must be
delivered to be successful?
-The information on substance
use during pregnancy to
pregnant women with SUD
-Rapport building with staff
-Contingency management
STIGMA-FREE PREGNANCY 67
materials, as well as based off of survey
results
To what extent will the key aspects of
the initiatives be delivered as intended?
-The key aspect of the initiative is to
increase access to care through
technology delivered in community-
based settings. This should be delivered
as intended.
What adaptations or modifications do
you think are necessary to help
implement the initiative in your chosen
settings?
-I do not anticipate any adaptations to the
implementation plan at this time.
However, data related to rates of
substance use during pregnancy are not
available in Idaho at this time, so I am
basing the number of needed materials
off of national averages. I may need to
change the number of materials, and
geographic needs may differ as well.
How will you measure this
data?
-Through data downloads from
the app, traffic on the web
sites, and surveys on the app
Describe the feasibility of
these methods.
-Data downloads and traffic
can be measured. Surveys will
depend on response rates,
which can be more difficult.
Participation in qualitative
interviews will be incentivized.
What are likely
implementation challenges
you will need to overcome?
-Feelings of fear/stigma from
women
-Buy-in from the staff at
SLRMC and/or community-
based agencies
-Collaboration across service
lines at SLRMC
STIGMA-FREE PREGNANCY 68
How will you know what adaptations
or modifications were made during the
initiative?
-Follow-up surveys, interviews, or focus
groups with providers in the community
What are some of the possible obstacles
to implementation?
-Community buy-in
-Lack of funding
-Service-line buy-in
What costs (including time and
burden, not just money) need to be
considered?
-Transportation for community out-reach
-Staff time at SLRMC as well as
community-based agencies
-Marketing materials
-Pregnancy tests
-Content design
-Maintenance of material on the iBirth
app
-Planning meetings
-Training on resource use
-Geographic barriers
Who can help you keep track
of modifications or
adjustments made?
-The data analyst
-Surveys from providers
-In-patient social workers (data
tracking of CPS referrals made
due to maternal substance use)
Are there competing projects
or programs to consider?
-Text4Baby app…however
they do not use the same
marketing and implementation
approaches
Are these costs and resources
available and reasonable to
ask for (high enough
priority)?
-Yes. This is a low-cost
program with the potential for
significant healthcare savings.
STIGMA-FREE PREGNANCY 69
-Staff time for completing
surveys/follow-up
There is also a need in the
community.
Effectiveness What are the most important outcomes
you expect to see?
-Increased access to care
-Decreased child welfare referrals
associated with in-utero substance
exposure
-Decreased feelings of stigma
-Improved patient and provider
satisfaction
-Improved health across the healthcare
continuum
-Decreased healthcare expenses in the
long-term
How likely is it that your initiative will
achieve its key outcomes?
-It is very likely to achieve outcomes as
this population is motivated to seek care
What unintended consequences or
outcomes might there be?
-Continued feelings of stigma
-Other access issues posing barriers
What is the targeted
individual-level change?
-Pregnant women with SUD
will access care during
pregnancy (harm reduction)
-Women will be able to
connect with providers who
can meet their unique needs
How will you measure these
changes?
-Surveys on the iBirth app
-Qualitative interviews
-Data downloads and traffic on
the app
Who will care about the
outcomes?
-Healthcare providers
-Women and families
-Department of Health and
Welfare
STIGMA-FREE PREGNANCY 70
How will you share these
outcomes?
-Report to services lines
What are the biggest threats
to seeing the outcomes you
want?
-Funding
-Lack of buy-in from women
-Not implemented/offered
correctly from community-
based agencies
What has gone wrong in
other similar initiatives?
-Poor marketing
-Limited options for providers
-Does not reach the target
population
-Continued fear/stigma
Maintenance What will happen over the long term?
-Resources in the community can change,
so will need to keep resources updated
-Research related to substance use during
pregnancy can change
What infrastructure will be
needed to sustain the
initiative?
-The iBirth app and
accompanying website
STIGMA-FREE PREGNANCY 71
-Funding/sources can change
-Leadership changes
Can organizations sustain the initiative
over time and are there plans to leave
trained staff in place?
-Yes
How likely is your initiative to produce
lasting effects for individual
participants?
-Very likely. This population of women
is more likely to be motivated to seek
care and sustain care once they enter it
How will you be able to follow your
initiative for an extended period of
time?
-Through the use of technology and
feedback from technology
-Through surveys and focus groups with
providers
-Data analysts from iBirth app team
How will you get the word out about
your product and lessons learned?
-Reports to leadership
-A network of community-
based agencies and providers
-Contingency management
plans
Is there an infrastructure
and funding that will
remain?
-Yes, for the iBirth
app/website
-Pregnancy tests will need to
be purchased annually. After
the first year, there will be a
better estimate for need in the
community. Future funding
sources will need to be
established to sustain the
initiative over time.
-Funding for contingency
managment
How will individuals be
delivered key program
components over time? Will
they stay in contact?
STIGMA-FREE PREGNANCY 72
-Reporting back to community-based
agencies and providers
What are likely modifications of
adaptations that will need to be made
to sustain the initiative over time?
-Focus prevention initiatives in areas
where more women are accessing the
materials
-Update information based on street drug
trends
-Update information based on new
research (effects of SUD during
pregnancy)
-Marketing approaches based on
effectiveness
-The network with
community-based agencies and
providers will stay in tact.
-End users will continue to
receive information in the
community.
How will you continue to
track its success and provide
on-going feedback?
-Data downloads and traffic
from websites
-Surveys and interviews with
end-users and community-
based agencies
-Number of CPS referrals
made due to maternal
substance use at the time of
delivery
-Review data semi-annually to
adjust material distribution and
input other feedback
What easy-to-understand
materials can you produce to
STIGMA-FREE PREGNANCY 73
tell others about your lessons
learned?
-Written updates on usage with
graphics
-Oral and written presentations
with Q&A
How can you track the major
changes made over time?
-Written documentation
-Graphs

(re-aim.org, 2019)

STIGMA-FREE PREGNANCY 74
Appendix D: Phases of Implementation

Phase 1: Training

Objective(s) 1. Providers and community-based agency staff will be educated
on trauma-informed care.
2. Providers will be educated on evidence-based treatment
approaches for working with pregnant women with SUD.
Activities 1. All community partners will complete training module on
trauma informed care (see training Module 1)
2. All community partners will complete training on Motivational
Interviewing (see training Module 2)
3. Medical providers will complete training on substance use
during pregnancy (see training Module 3)

Phase 2: Preparation

Objective(s) 1. Community-based agencies will have the needed materials to
enroll women in the program
2. Community-based agency staff will be trained in the use of the
“Stigma-Free Pregnancy Kit”
3. Community-based agency staff will be prepared to complete
qualitative interviews with end-users

Activities 1. Provide “stigma-free pregnancy test kits” and incentives for
contingency management to community-based agencies and
providers who are participating in the enrollment process
2. Train agency staff and providers on enrollment, use of the app,
and the incentives program
3. Agency staff will be trained in completing qualitative
interviews with end users
4. Agency staff and providers will be taught about data collection
process, including tracking numbers of materials distributed,
women recruited to the program, and incentives provided to
the women to recruit and retain them
5. Participating agencies and providers will be provided with an
overview of follow-up e-mail surveys and qualitative
interviews that they will participate in for data collection and
program evaluation
6. Designated staff members (hospital or community partners)
who will be working directly with women during the
recruitment and enrollment phase to develop interpersonal
relationships will be provided with basic training and scripting
for establishing relationships and encouraging care
STIGMA-FREE PREGNANCY 75

Phase 3: Recruitment

Objective(s) 1) To recruit and enroll women with SUD into the “stigma-free
pregnancy” program
2) To establish rapport between women with SUD, community-
based agencies, and providers
Activities • Women a woman presents to a community-based agency or
provider with concerns for a pregnancy, she will receive a
“stigma-free pregnancy” kit
• Agency staff to utilize motivational interviewing techniques
and a trauma informed approach to establish rapport with the
woman
• Agency staff to provide brief psychoeducation on care,
resource options, and available technology
• A staff member to assist the women to download the app and
provide brief instruction on how to navigate the app.
o If a woman would like help connecting with care at that
time, agency staff is also able to assist.
• Agency staff member will complete an initial qualitative
interview with the woman.
• Following that they will validate the coupon.
• Invite the woman to a meeting at a designated community-
based agency to meet an outreach staff member from the
healthcare system, or partnering agency, at which she will
receive another incentive from the contingency management
program

Phase 4: Enrollment

Objective(s) 1) To maintain rapport between women with SUD, community-
based agencies, and providers
2) To enroll women in comprehensive care, including prenatal
care, mental health, and substance use treatment.
3) Connect women with other needed community resources to
support retention.
Activities • A trained and designated member of the healthcare system or
partnering agency will go into the community once per week at
a designated location and time (which will vary to increase
accessibility) to establish an interpersonal connection, build
rapport, and open dialogue with women interested in accessing
care.
o Women’s privacy should be ensured.
• Establish a schedule for community outreach and shared it
with community-based partners every month.
STIGMA-FREE PREGNANCY 76
• Upon completion of the group introduction, the woman will
receive the incentive from the contingency management
program, along with a follow-up coupon to redeem at a
subsequent appointment for a qualitative interview with a
trained agency staff member

Phase 5: Retention

Objective(s) 1) To retain women in comprehensive care to reduce harm and
improve maternal and fetal health outcomes.
2) To maintain established rapport between women and
community-based providers.
3) Increase resilience of pregnant women with SUD through
regular comprehensive care and social connection.
Activities • Women to be incentivized to return to follow-up appointments
for prenatal care, substance use treatment, and mental health
treatment
• Women to be incentivized through the contingency
management program to return to the community-based
agency every three months to do follow-up assessments to
determine if they are accessing care
• Providers to continue to use trauma-informed care and
evidence-based approaches to caring for pregnant women with
SUD

Phase 6: Evaluation

Objective(s) 1) To have qualitative and quantitative program outcomes to
make data-driven decisions for program improvements.
Activities • Complete qualitative surveys with women (at the three-month
intervals)
• Complete qualitative surveys with providers (three-month
intervals)
• Complete push surveys on the app (monthly)
• E-mail surveys to providers (monthly)
• App download and app traffic can be monitored daily
• Number of “Stigma-Free Pregnancy Test” kits distributed at
community-based agencies
• Evaluate data
• Present recommendations to leadership at the healthcare
system and participating agencies and providers.

STIGMA-FREE PREGNANCY 77
Appendix E: Program Manual

STIGMA-FREE PREGNANCY 78

STIGMA-FREE PREGNANCY 79

STIGMA-FREE PREGNANCY 80

STIGMA-FREE PREGNANCY 81

STIGMA-FREE PREGNANCY 82

STIGMA-FREE PREGNANCY 83

STIGMA-FREE PREGNANCY 84

STIGMA-FREE PREGNANCY 85

STIGMA-FREE PREGNANCY 86

STIGMA-FREE PREGNANCY 87

STIGMA-FREE PREGNANCY 88

STIGMA-FREE PREGNANCY 89

STIGMA-FREE PREGNANCY 90

STIGMA-FREE PREGNANCY 91

STIGMA-FREE PREGNANCY 92

STIGMA-FREE PREGNANCY 93

STIGMA-FREE PREGNANCY 94

STIGMA-FREE PREGNANCY 95

STIGMA-FREE PREGNANCY 96

STIGMA-FREE PREGNANCY 97

STIGMA-FREE PREGNANCY 98

STIGMA-FREE PREGNANCY 99

STIGMA-FREE PREGNANCY 100

STIGMA-FREE PREGNANCY 101

STIGMA-FREE PREGNANCY 102

STIGMA-FREE PREGNANCY 103

STIGMA-FREE PREGNANCY 104

STIGMA-FREE PREGNANCY 105

STIGMA-FREE PREGNANCY 106

STIGMA-FREE PREGNANCY 107

STIGMA-FREE PREGNANCY 108

STIGMA-FREE PREGNANCY 109

STIGMA-FREE PREGNANCY 110

STIGMA-FREE PREGNANCY 111
Appendix F: Table of Barriers and Facilitators (RE-AIM)
Dimension Barriers Facilitators
Reach -Buy-in from leadership from multiple
Service Lines at medical centers
-Selection and engagement of
community-based agencies and providers
-Obtaining financial support to sustain the
innovation
-Leadership from medical centers and
community-based agencies allowing and
funding additional time for staff training
-Allocating hospital staff time to
complete content design/build and staff
training
-Coordinating efforts across service lines
-Determining participation
-Emphasizing health and cost-
savings benefits of the innovation,
improved maternal/fetal health
outcomes, and improved patient
experience and satisfaction
-Highlighting the low-cost
innovation to both the healthcare
system and community-based
agencies and providers
-Utilize a multifaceted, low-cost
approach to staff training
-Offering short surveys through
the app and anonymous surveys to
determine participation
Effectiveness -Community-based agencies and
providers not utilizing the innovation as
intended or not educating the intended
population about it is availability
-Maintaining engagement from leadership
-Availability of qualified staff
-Identify qualified staff and
providers to participate and train
-Provide continued feedback to
leadership and agencies/providers
on outcomes and performance
STIGMA-FREE PREGNANCY 112
Adoption -Changes in community resources and
Medicaid coverage/regulations
-Changes in political culture
-Staff turnover and administrative
changes
-Training cost and logistics associated
with staff and administrator turnover
-Utilizing a train-the-trainer model
-Utilize multifaceted training
approaches
-Regularly updating content and
resources on the iBirth app
Implementation -The innovation will not be implemented
as intended
-Data related to rates of substance use
during pregnancy are not available, so the
estimated quantity of materials is based
on national averages
-Lack of community-agency or provider
buy-in
-Limited staff time for training
-Maintenance of material and resources
on the iBirth app
-Utilizing a train-the-trainer model
-Utilize written protocol for the
use of innovation
-Follow-up focus groups and
surveys to determine gaps and
needs
-Measure data downloads and
traffic on the app
-Data collection to make
modifications as needed

Maintenance -Changing community resources
-Staff and leadership changes
-Continued buy-in from community-
based agencies, providers, and hospital
leadership
-Maintain infrastructure of the app
and web site
-Offer on-going/low-cost training
options
STIGMA-FREE PREGNANCY 113
-Track data over time and share
data/effectiveness and outcomes
with medical center leadership,
community-based agencies, and
providers

STIGMA-FREE PREGNANCY 114
Appendix G—Leadership Structure

Project
Manager/Coordinator
App Designer
Data Analysist
Product Marketing Service Providers Community Agencies
STIGMA-FREE PREGNANCY 115
Appendix H: Push Survey for End-Users

Survey for Women

1) Where did you find out about his app?
a. From a friend
b. From your doctor/counselor
c. At a community agency
d. Searching the internet
2) Did you receive a pregnancy test with flyer for the app?
a. Yes
b. No
3) Were you already receiving medical care for this pregnancy?
a. Yes
b. No
4) Did you make an appointment for prenatal care through this app?
a. Yes
b. No
5) Do you have a mental health diagnosis?
a. Yes
b. No
6) Did you make a counseling appointment through this app?
a. Yes
b. No
7) Do you use drugs or alcohol?
a. Yes
b. No
8) Did you make an appointment for substance use treatment through this app?
a. Yes
b. No
9) Did using this app provide you with the information that you need to decide whom to go
to for care?
a. Yes
b. No
10) What is your age?
a. 12-17
b. 18-26
c. 27-35
d. 36+

STIGMA-FREE PREGNANCY 116

Appendix I: Qualitative Interview Questions: Pregnant Women with SUD - Initial

1) What concerns do you have about going to the doctor for prenatal care?

2) What experiences have you had in the past with different treatment providers?

3) If you have tried to get into treatment in the past, what has been your experience?

4) What resources or education would make it easier for you to decide where to go for care
or treatment?

5) Is there anything else that would make it easier for you to go to the doctor?

6) If you could receive any kind of care or treatment, what would that look like to you?

7) Do you see any barriers to your ideal treatment?

8) What do you want providers to know about you that they don’t ask?

STIGMA-FREE PREGNANCY 117

Appendix J: Email surveys for Providers and Community-based Agencies

Survey for Providers/Stakeholders
1) What is your primary area of practice?
a. OBGYN
b. Another medical provider
i. Please specify
c. Substance Abuse Treatment provider
d. Mental Health provider
e. Other community service agency provider
i. Please specify
2) Have you referred chemically dependent pregnant women to the iBirth app as a resource
for prenatal care, including substance abuse and mental health treatment?
a. Yes
i. Within the past 7-14 days
ii. Within the past 15-30 days
iii. Over one month ago
b. No
3) How often are you referring women to the iBirth app for substance abuse resources?
a. Never
b. More than one time per week
c. One time per week
d. 1-3 times per month
e. Less than one time per month
4) Have women reported to you that they are seeking care with you because of the
information that they received via the iBirth app?
a. Yes
b. No
5) Have you noticed an increase in women seeking care or services with you?
a. Yes
b. No
6) How many women have you seen in your practice in the past 30 days who are pregnant
and have reported substance use?
a. Enter number
i. How many of those women have scheduled a follow-up visit?
1. Enter number
ii. How many of those women have completed a follow-up visit?
1. Enter number

STIGMA-FREE PREGNANCY 118

Appendix K: Qualitative Interview Questions: Community Providers- Initial

1) What is your area of practice?

2) What concerns do you think women with SUD have about receiving for treatment?

3) What experiences have you had in the past with caring for this population?

4) What resources or education would make it easier for you to provide care to this
population?

5) Is there anything else that you think would make it easier for pregnant women with SUD
receive treatment or care?

6) If you could do three things to improve the environment or care that you provide to this
population, what would that be?

7) Do you see any barriers to delivering best-practice treatment? And what do you think
needs to happen to overcome these barriers?

STIGMA-FREE PREGNANCY 119

Appendix L: Evaluation

STIGMA-FREE PREGNANCY 120
Appendix M: Implementation Strategy— RE-AIM

STIGMA-FREE PREGNANCY 121

Appendix N: GANNT Chart
STIGMA-FREE PREGNANCY 122

Appendix O: Infographic
STIGMA-FREE PREGNANCY 123
Appendix P: Lavidge and Steiner’s Hierarch of Effects and Campaign Activities
Stage of Lavidge & Steiner’s
Hierarchy of Effects

Campaign Activity
Phase 1: Target Audience: Providers
Awareness Distribute a short-form video (see link) via e-mail to designated
staff members.
Distribute infographic via e-mail and flyers to designated staff (see
appendix B).
Knowledge Distribute campaign flyers to medical offices and designated
hospital units. Electronic versions to be sent via e-mail. A link on
the e-mail and flyers will prompt staff and providers to a website
with information on the “Stigma-Free Pregnancy” program.
Liking Short video interview with women who overcame addiction during
pregnancy due to a positive patient-provider relationship and
written testaments to be distributed via e-mail to show positive
outcomes.
Statements from experts (ACOG, AAP, Board of Medicine) on the
need for addiction medicine, awareness, action, and best practice
recommendations.
Emphasis on the hypocritic oath to remind providers of the “softer
side” of medicine
Preference Short-From Video #2 with The Unique Selling Proposition
(providing help to this vulnerable population will improve maternal
STIGMA-FREE PREGNANCY 124
and fetal health outcomes, decrease healthcare cost, and disrupt the
cycle of family violence) distributed via e-mail.
Conviction Provide opportunities for continuing education and training
modules for participants related to trauma-informed care,
motivational interviewing, and substance use during pregnancy.
Conversational guides and prompts to be given to providers and
clinic staff.
“Stigma-Free Pregnancy” kits to be provided to offices in return for
participation.
Purchase Targeted e-mails with a “call to action” and “click here” button to
get information for becoming a partner and receiving “Stigma-Free
Pregnancy” kits and training materials
Phase II Target Audience: End-users
Awareness Flyers and posters distributed in community-agencies advertising
program.
Knowledge “Stigma-Free Pregnancy” kits distributed in community-based
agency settings with information and free code to managed app and
website
Liking Short video interview with women who overcame addiction during
pregnancy due to a positive patient-provider relationship and
written testaments to be distributed via e-mail to show positive
outcomes.
STIGMA-FREE PREGNANCY 125
Invitations by providers who participate in this program for women
to access care.
Purchase Call to action- “Click-here” buttons for scheduling appointments.
Contingency management.
Phase III Target Audience: General Public and Policy Makers
Awareness Billboards
Flyers in medical offices available to all patients
Knowledge Advertisement on healthcare system’s social media pages
(Facebook and Instagram) with links for accessing information on
the program website
Liking Brief statements and stories from local politicians supporting
maternal/fetal health issues and prominent community members
and doctors supporting the program (can be posted on healthcare
system social media pages and covered by local news channels)
(Cody, nd)

STIGMA-FREE PREGNANCY 126
Appendix Q: Flowchart for 10-Step EBP Implementation Process

Abstract (if available)

Abstract The Grand Challenge of Closing the Healthcare Gap encourages a population health approach, focusing on the most marginalized populations to improve health across the healthcare continuum. The proposed innovation, the “Stigma-Free Pregnancy Program, focuses on pregnant women with Substance Use Disorder (SUD), who face multiple barriers to care, including stigma, fear of child welfare involvement and criminalization, as well as other access issues such as transportation, child care, and geographical barriers. Increasing access to care for this vulnerable population will improve maternal and fetal health outcomes, reduce the risk for child maltreatment, neglect, and future risk for substance abuse, and decrease healthcare costs. ❧ The “Stigma-Free Pregnancy” program is a recruitment and retention strategy for healthcare systems to engage pregnant women with SUD in collaborative care. It utilizes a community-based settings approach, interpersonal relationships, contingency management, technology, and psychoeducation to increase access to care and early intervention and decrease feelings of stigma. The proposed innovation will incorporate evidence-based and research-based best practice approaches to preventative care and harm reduction strategies and connect women with services early in their pregnancies. The innovation utilizes the logic of normative change and will be embedded within a larger healthcare system, shifting the onus of compliance to care from the women with SUD to the healthcare system. This innovation is low-cost, highly scalable, and easily modifiable to adapt to different geographic regions.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

Integrative care strategies for older adults experiencing co-occurring substance use and mental health disorders (I-CARE)…

PDF

Implicit provider bias in cardiovascular disease care of Black women: the lives of Black women with heart disease matter

PDF

Interdisciplinary community collaborative to reduce adverse outcomes with teen pregnancies

PDF

Close the health gap: improving patient access to psychiatric treatment through primary care and telepsychiatry integration

PDF

The Linkage to Hope Project

PDF

Substance use disorder treatment clinician and director challenges working with collaborative justice court and child welfare systems: A multisite qualitative study

PDF

Exploring the social determinants of health in a population with similar access to healthcare: experiences from United States active-duty army wives

PDF

Assessment and analysis of direct care community worker training: addressing social determinants of health in the home care setting

PDF

Adoption of virtual healthcare, self-sufficient wages and paid neighbors concept will ensure optimal living for vulnerable people and their paid caregivers

PDF

Mental health advocacy and navigation partnerships: the case for a community collaborative approach

PDF

Empowering and building resilience with youth in congregate care

PDF

Empowering rural youth: a comprehensive approach to mental health services in rural America

PDF

Characterizing self-reported spatial and provider barriers to maternal health care utilization in Malawi

PDF

An intersectional approach to addressing the grand challenge to achieve equal opportunity and justice for neurodivergent individuals in mental health care

PDF

The Women and Girls Center for Maternal Health intergenerational approaches to address the Black maternal health crisis

PDF

Acculturation team-based clinical program: pilot program to address acculturative stress and mental health in the Latino community

PDF

Atender, live! Strategies to acknowledge and cope with cultural taboos in the Latinx community

PDF

Intimate partner violence in the Black community: empowering Black families through education and engagement to increase survivor safety via a strengthened social support network

PDF

Hire1ofUs: achieving equal opportunity and justice for minorities with disabilities who have been impacted by the criminal justice system

Asset Metadata

Creator Crow Cruz, Christina Nicole (author)

Core Title Stigma-free pregnancy: a recruitment and retention strategy for healthcare systems to engage pregnant women with substance use disorder in collaborative care

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 10/28/2020

Defense Date 07/24/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Closing the Healthcare Gap,collaborative care,community-based,harm reduction,health equity,OAI-PMH Harvest,population health,Pregnant women,preventative care,stigma,stopping family violence,substance use during pregnancy

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Manderscheid, Ron (committee chair), Bremond, Diandra (committee member), James, Jane (committee member)

Creator Email christinacrowcruz@yahoo.com,crowcruz@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-386533

Unique identifier UC11665844

Identifier etd-CrowCruzCh-9076.pdf (filename),usctheses-c89-386533 (legacy record id)

Legacy Identifier etd-CrowCruzCh-9076.pdf

Dmrecord 386533

Document Type Capstone project

Rights Crow Cruz, Christina Nicole

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA