Estimated read time: 8-9 minutes
Pregnancy can be a time of joy and anticipation for many expectant moms. For women experiencing substance use disorder, the emotional and physical challenges they face during pregnancy can isolate them from the care and compassion they need.
Old stigmas, trauma, lack of access, previous poor encounters with the medical system and fear of being unfairly judged create barriers to seeking prenatal care.
"Women were hiding, and that's because of punitive policies that eventually punished them for disclosure and a public policy of removing children from the custody of their parents without trying to address this issue or provide the support," says Marcela Smid, MD, a maternal-fetal medicine and addiction medicine physician at University of Utah Health.
In 2017, she teamed up with Jasmin Charles, MS, PA-C, a certified physician associate at U of U Health, to open the first Substance Use & Pregnancy—Recovery, Addiction, and Dependence (SUPeRAD) Clinic at the university. Smid serves as medical director of SUPeRAD, while Charles is clinical director.
"When Dr. Smid and I joined together, we knew we had a crisis on our hands," Charles says. "Much of society deems substance use disorder a fault of character, while it is a chronic illness. The clinic became a safe space for everyone to be treated as a human — to provide an unbiased, judgment-free zone and have an open door to meet people where they are at."
For years, substance use disorder has not been addressed as a medical issue. It has been addressed as a moral issue or somehow a failure to parent or make good choices.
–Marcela Smid, maternal-fetal medicine and addiction medicine physician.
Expanding access to care
The need for multi-disciplinary care and support is so great for pregnant and postpartum women that a third SUPeRAD clinic location is opening this March in Rose Park. That's largely thanks to receiving opioid settlement money from the state and Salt Lake County.
Other locations are located in South Jordan and at University of Utah Hospital. Expansion of the program is critical to meeting people where they are, reducing the barriers of transportation, time and access to care in an area they feel comfortable and know.
"For years, substance use disorder has not been addressed as a medical issue," Smid says. "It has been addressed as a moral issue or somehow a failure to parent or make good choices." Charles adds, "First and foremost, we have an adult patient who is pregnant with a chronic illness. And her chronic illness does not define her ability to parent or what kind of a parent she will be — should she choose to parent."
At the clinics, substance use disorder is treated like any other health condition. Since 2017, SUPeRAD team members have helped more than 75% of pregnant people with opioid use disorder transition to a medication for opioid use before they give birth. The program has also reduced the hospital stay for babies with neonatal opioid withdrawal syndrome from a national average of 14 days to 10.5 days.
Tapping into the clinics' services often begins with a word-of-mouth referral and a call or text to a care coordinator for the SUPeRAD program. The coordinators make the callers feel at ease before answering their questions, going over what to expect in clinic and what services they can receive before offering the opportunity to schedule an appointment. Then, it's up to the pregnant woman to take the next difficult step forward.
"The bravest thing that women do is walk through our doors because they have now declared when they come to see us that there is a substance use problem," Smid says. "And we must have the hard conversations about what does that mean, if there is ongoing substance use, and if they are ready to engage."
Providing a safe place for patients
The first visit to the clinic is different from almost any other interaction these patients will have with the medical community. Charles describes it this way: "A new patient will spend two to four hours with us. It's a marathon and an investment for the long haul. A chance for us to get to know you and you to get to know us. We try to introduce patients to all the services available while also gathering critical medical information and catching them up on necessary obstetric, chronic, and acute care. The goal is for the patient to leave knowing it is a safe space and that the team is invested. As a team, we are honored to be a part of their health care journey."
In addition to lab work and an ultrasound, trainees from all licensures of medicine will ask patients to share an extensive history that includes substance use, psychiatric, and social history along with their family's psychiatric history.
"Those histories help us better understand and follow along with their journey, to let us know where they've been, where we may be able to help them, and where their triggers and hurdles have been," Charles says. Over time, these histories also help Smid and Charles collect the data they will use to design the future of the SUPeRAD program and train those who will lead it.
The University of Utah recently received an NIH Maternal Center of Excellence grant, which established the ELEVATE Center. One of the aims of the ELEVATE Center is to reduce maternal morbidity and mortality from substance use disorder.
This kind of education was never offered in medical and physician assistant schools before the 2000s. Today, the team at SUPeRAD includes obstetricians, physician assistants and nurse midwives who are highly trained in treating substance use disorder. Several also specialize in maternal-fetal medicine.
Comprehensive postpartum care
A critical focus at the Rose Park clinic and throughout the SUPeRAD program going forward is on postpartum care. Smid serves as chair of the Utah Maternal Mortality Review Committee and she acknowledges that, nationwide, "Substance use disorder is the leading underlying cause of pregnancy-associated and related deaths within pregnancy and the year postpartum."
Statistical evidence shows that up to 80% of individuals with a substance use disorder will achieve sobriety on their own during pregnancy. And that is regardless of whether they have a team like the one at SUPeRAD helping them through their pregnancies. However, the unspoken and not clearly addressed issues arrive six to nine months postpartum.
Smid and Charles follow their patients for up to a year after they give birth. But it's difficult because, when the pregnancy ends, the noise returns. "The stress is back, the sleep deprivation, postpartum depression, anxiety, finances, etc." Smid says. "That's when people really start to circle the drain, return to use and some ultimately die."
'We show up so they can show up'
As of this year, the SUPeRAD team has seen more than 1,200 patients at their clinics. Unfortunately, losing patients is a reality when working with this chronic illness. Since the inception of the SUPeRAD program, seven of those patients have died. Smid describes that as an "extraordinarily high" number for a provider caring for pregnant and postpartum individuals.
The day-to-day work at the clinics can be disheartening, exhausting and demanding. It requires commitment and resilience, but Smid and Charles refuse to be discouraged. They believe in what they have built and continue to build, knowing it is a necessary service that makes an impact.
As the years progress, they see the outcomes — both the numbers and, more importantly, the lives. Patients return for stable health care and to avoid the unsafe and unhealthy spaces they know still exist. They watch families grow and patients succeed: building careers, finding housing, working in the recovery field and on the SUPeRAD team.
"What's our secret?" Charles says. "We show up so they can show up. We show up as a team—and as a nonjudgemental, non-stigmatizing, trauma-informed team. A former patient said it best: 'They loved me until I learned to love myself.'"
Smid agrees: "We get to celebrate a lot of joys," she says, summing up her feelings about SUPeRAD. "And perhaps even more meaningful is that people allow us to be part of the worst days of their lives as well. It is so hard, and yet it is also the glue that keeps us together as a team."
If you or a loved one are interested in services or resources available at SUPeRAD, please visit this website.
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