Ongoing Care

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Ongoing MOUD Care in Pregnancy

Pregnant patients with OUD need regular prenatal care, MOUD dose assessments, and social needs evaluations to optimize their pregnancy and recovery outcomes. Care for pregnant patients with OUD should be trauma-responsive, non-judgmental, and patient-centered.  

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Ongoing MOUD Care in Pregnancy

HOW

  • Dose MOUD (also referred to as MAT) daily.
    • Because of metabolic changes in pregnancy, pregnant individuals taking methadone and buprenorphine will likely need more frequent dose adjustments.
    • Pregnant patients often need split dosing (dose MOUD twice a day).
    • Counsel patients on expectations of giving birth with OUD and breastfeeding while on MOUD. It is safe and recommended to breastfeed while on MOUD!
  • Refer all pregnant patients with OUD to counseling/behavioral health care, and support groups.
  • Provide access to routine prenatal care by a qualified health provider.
  • Train jail medical and custody staff to identify urgent maternal warning signs and symptoms of being unwell.
  • Provide access to high-risk pregnancy care specialists if needed.
  • Screen all pregnant patients for depression and other behavioral health conditions. If screen positive, refer to a mental health professional. A score of 9 or more suggests minor or major depression may be present. 
  • AVOID use of restraints in pregnancy, NEVER use restraints during labor and birth, and follow your state’s law.
  • NEVER put a pregnant patient in disciplinary/administrative segregation.
  • Prepare for reentry with special attention to pregnancy OUD-specific needs.


WHY

  • Ongoing treatment with MOUD during and after pregnancy prevents withdrawal symptoms, reduces or eliminates cravings, improves newborn outcomes, and reduces the risk of maternal death from overdose.

  • Treating just 20 pregnant people with buprenorphine prevents 1 serious complication. That’s a bigger impact than many treatments we routinely provide for other health conditions. 

  • Most incarcerated women have histories of trauma and mental health diagnoses, and need mental health care. Being incarcerated while pregnant adds additional layers of trauma for people.
  • Behavioral health counseling in conjunction with MOUD can help address the root causes of trauma and promote positive coping skills.


KEEP IN MIND

  • Be kind! Use a trauma-informed, non-judgmental approach. Be aware of the language you use, and convey support for their parenting and recovery goals.
  • Review the urgent maternal warning signs and educational materials on being pregnant/postpartum with OUD with patients. Educate your patients about these symptoms so they are aware while in jail and in the community. 
  • Addressing the social needs of pregnant patients is just as important as treatment to prevent return to use. Jail staff must prepare ahead of time for reentry. See MOMCARE Reentry Planning.
  • If they are nearing the end of their pregnancy (i.e. ~32 weeks), have a designated jail staff member help the patient figure out an infant care plan in case they deliver while in custody. See MOMCARE Guardianship and Infant Placement.

HOW

How can jail staff provide ongoing OUD care to pregnant patients in custody?

  • Provide their daily dose of methadone or buprenorphine, whether that is on-site at your jail or via off-site transport.
    • Pregnant patients on methadone or buprenorphine should see a specialist regularly (~weekly) to assess if they need a change in their dose. Encourage pregnant patients on MOUD to let the medical team know if cravings or withdrawal symptoms emerge since this can be a sign that their dose needs to be increased, or split and given twice a day.
  • Refer pregnant patients with OUD—including those who choose not to be on MOUD—to recovery support services: counseling/behavioral health care, and support groups.
    • Counseling and other supports are important for successful recovery. However, patients on MOUD should not be forced to be in counseling, and medication should not be withheld if they decline counseling. 
  • If your jail is not already set up to provide MOUD or behavioral health to pregnant patients with OUD, you can contact your local health department, and use these resources to find a provider in the community.


What ongoing pregnancy care do pregnant individuals in custody need?

  • Provide access to routine prenatal care by a qualified clinician (Ob/Gyn, family physician, certified nurse midwife, or NP/PA who has received training in pregnancy care), per nationally established prenatal care guidelines, either on-site at your jail or off-site in the community.
    • While it is beyond the scope of this resource to enumerate all aspects of prenatal care, generally routine care consists of regular, frequent visits with a qualified clinician where blood pressure, weight, and fetal heart rate are also checked; laboratory tests; ultrasounds; counseling and access to screening for fetal genetic abnormalities; and access to abortion care when indicated.
  • Custody and clinical staff should be trained to know when a pregnant patient has urgent maternal warning signs and should be sent to the hospital. Some conditions in pregnancy can present with very subtle symptoms, like preterm labor, which may just involve light bleeding. When in doubt, consult with a qualified perinatal care provider or just send them to the hospital. Here are some warning signs/symptoms specific to pregnancy that require immediate evaluation (not an exhaustive list):
    • Vaginal bleeding at any point in pregnancy, no matter how light or heavy
    • Abdominal or pelvic pain/cramping
    • Contractions-
      • if preterm (<37 weeks), more than 5 contractions in 1 hour
      • if term (>37 weeks), contractions every 5-10 minutes
    • Leaking fluid- can be a sign that someone’s water broke
    • Blood Pressure of 140/90 or greater, severe headache (can be signs of pre-eclampsia)
    • Decreased fetal movement- if >24 weeks
    • Physical trauma/injuries, especially direct abdominal trauma
  • Provide access to high-risk pregnancy care, usually through referral to specialists off-site or through telehealth, for people with high-risk medical or obstetric conditions in pregnancy, such as diabetes, high blood pressure, and asthma, among others.
  • Counsel patients on the safety and benefits of breastfeeding, particularly for patients on MOUD; what to expect with birth, especially if they might deliver in custody; and that they can still get an epidural and continue their MOUD in labor. Recognize that they may have a lot of anxiety over what will happen to them and their baby during the birth hospitalization and after, both because they have OUD and because they may be in custody at the time of delivery.
  • Provide counseling on expectations of giving birth with OUD.
  • Be kind! Use a trauma-informed, non-judgmental approach. Be aware of the language you use, and convey support for their parenting and recovery goals.
  • Follow state laws and safest medical practice by not using restraints on pregnant individuals during labor and birth; when taking pregnant patients off-site for MOUD dosing, other clinic appointments, or court appearances; and during the postpartum period.
  • To avoid psychological harm and ensure timely access to urgent medical care, pregnant patients should NEVER be put in isolation or restrictive housing. Isolation and restrictive housing is unsafe and against national guidelines from the National Commission on Correctional Health Care.


What mental health care needs do pregnant and postpartum patients need?

  • Screen all patients for depression and other behavioral health conditions.
    • Use the validated screening tool, Edinburgh Perinatal Depression Scale. A score of 9 or more suggests minor or major depression may be present. 
    • Patients with psychiatric diagnoses or who screen positive should be referred to mental health providers. 
    • If they are on psychiatric medication, this should NOT be discontinued just because they are pregnant. Most psychiatric medications are safe in pregnancy. A qualified provider should assess if they are one of the few medications that is not recommended in pregnancy.
  • Allow patients to make free phone calls to the National Maternal Mental Health Hotline– 1-833-852-6262


WHY

Why should jail staff pay special attention to the ongoing care needs of pregnant patients with OUD?

  • Ongoing treatment with MOUD during and after pregnancy prevents withdrawal symptoms, reduces or eliminates cravings, and reduces the risk of maternal death from overdose.
  • When patients with OUD are engaged in prenatal care and recovery care, overdose risk is reduced, the likelihood of a stillbirth decreases, and health outcomes for the pregnant patient and baby are improved.
  • Pairing MOUD with psychosocial treatment (e.g. counseling) and addressing co-existing mental health conditions improves the chances of successful recovery.
  • Patients who decline MOUD and choose to “detox” in pregnancy need counseling, support, and prenatal care as well!
  • Mental health conditions, especially depression, are common among incarcerated women in general, and people with OUD. Treatment of mental health conditions, sometimes with medications, is essential for recovery and healthy pregnancy outcomes.

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