Implementation of a women's reproductive behavioral health telemedicine program: a qualitative study of barriers and facilitators in obstetric and pediatric clinics.

BACKGROUND: Perinatal Mood and Anxiety Disorders and Substance Use Disorders are common and result in significant morbidities and mortality. Despite evidence-based treatment availability, multiple barriers exist to care delivery. Because telemedicine offers opportunities to overcome these barriers, the objective of this study was to characterize barriers and facilitators to implementing a mental health and substance use disorder telemedicine program in community obstetric and pediatric clinics. METHODS: Interviews and site surveys were completed with practices engaged in a Women's Reproductive Behavioral Health Telemedicine program (N = 6 sites; 18 participants) at the Medical University of South Carolina and telemedicine providers involved in care delivery (N = 4). Using a structured interview guide based on implementation science principles, we assessed program implementation experiences and perceived barriers and facilitators to implementation. A template analysis approach was used to analyze qualitative data within and across groups. RESULTS: The primary program facilitator was service demand driven by the lack of available maternal mental health and substance use disorder services. Strong commitment to the importance of addressing these health concerns provided a foundation for successful program implementation yet practical challenges such as staffing, space, and technology support were notable barriers. Services were supported by establishing good teamwork within the clinic and with the telemedicine team. CONCLUSION: Capitalizing on clinics' commitment to care for women's needs and a high demand for mental health and substance use disorder services while also addressing resource and technology needs will facilitate telemedicine program success. Study results may have implications for potential marketing, onboarding and monitoring implementation strategies to support clinics engaging in telemedicine programs.

A Pilot Study Examining Access to and Satisfaction with Maternal Mental Health and Substance Use Disorder Treatment via Telemedicine.

Background: Mental health (MH) and substance use disorders (SUDs) are common during pregnancy and the postpartum year, and have a significant impact on maternal and child health. Most women do not receive treatment for these conditions due to barriers to care. Increasing access to these services via telemedicine is one potential solution to overcoming barriers, but it is unknown if this type of service is acceptable to women. The purpose of this study is to evaluate patient satisfaction with, and accessibility to, a maternal MH and SUD telemedicine service delivered to obstetric practices. Methods: The Telemedicine Satisfaction Questionnaire and the Questionnaire for Assessing Patient Satisfaction with Video Consultation were collected via online surveys. Responses were scored on a 5-point Likert scale, ranging from strongly disagree (1) to strongly agree (5). Paired t-tests were used to compare round trip travel time and distance between participants home and specialty clinic at an academic medical center versus their local obstetrics clinic where they received telemedicine services. Results: A total of 91.42% (32/35) of women agreed to take part in the study, and 43.75% (14/32) of women were living in a rural community. Patients reported high levels of satisfaction with the following: overall quality of care (mean [M] 4.66 [standard deviation, SD, 0.67]); similarity to face-to-face are (M 4.69 [SD 0.63]); and access to care (M 4.47 [SD 0.81]). Compared with in-person care at an academic medical center, women receiving care via telemedicine spent significantly less time (67.44 minutes vs. 256.31 minutes, p < 0.001) and distance (50.33 miles vs. 236.06 miles, p < 0.001) traveling round trip. Conclusions: Women receiving MH and SUD treatment via telemedicine within their obstetrician's office report high levels of satisfaction and increased access to care with this modality of treatment delivery. Telemedicine may provide one solution to removing barriers to care and mitigating the maternal and child risks associated with of untreated MH and SUDs.

A retrospective, observational study on medication for opioid use disorder during pregnancy and risk for neonatal abstinence syndrome.

OBJECTIVES: The prevalence of opioid use disorder (OUD) among pregnant women is increasing. Research consistently demonstrates the efficacy of medications for OUD (MOUD); however, researchers have called for additional studies evaluating the safety of MOUD during pregnancy, particularly the relative safety of two commonly used MOUD medications-methadone and buprenorphine. This study aimed to evaluate the consequences of MOUD exposure during pregnancy on risk for neonatal abstinence syndrome (NAS). METHODS: In a clinical sample of infants born to women with OUD, we evaluated the risk of NAS among those exposed to (i) methadone and (ii) buprenorphine compared with those unexposed to MOUD, as well as the risk of NAS among those exposed to (i) methadone compared with those exposed to (ii) buprenorphine. RESULTS: Compared with buprenorphine-exposed infants (n = 37), methadone-exposed infants (n = 27) were at increased risk for NAS (odds ratio [OR] = 4.67, 95% confidence interval [CI]: 1.03, 21.17). Compared with unexposed infants (n = 43), buprenorphine-exposed infants were at decreased risk for NAS (OR = 0.45, 95% CI: 0.14, 1.39) and methadone-exposed infants were at increased risk for NAS (OR = 2.64, 95% CI: 0.79, 8.76), though these associations were not statistically significant. CONCLUSIONS: Our study suggests that when methadone and buprenorphine are equally appropriate options for the treatment of OUD in pregnant women, buprenorphine may add the additional benefit of reduced risk of newborn NAS.

Medications for opioid use disorder (MOUD), such as buprenorphine and methadone, are effective in reducing the significant harms associated with untreated opioid use disorder (OUD) in nonpregnant and pregnant adults. While previous research clearly documents that the risks of MOUD in pregnancy are less than the risks of untreated OUD in pregnancy, researchers have called for additional studies evaluating the safety of MOUD during pregnancy, particularly the relative safety of methadone and buprenorphine. In a clinical sample of infants born to women with OUD, we showed that buprenorphine-exposed infants were at significantly reduced risk for neonatal abstinence syndrome compared with methadone-exposed infants. Our study adds to the growing body of evidence supporting the use of buprenorphine over methadone for the treatment of OUD among pregnant women.

Treatment of Opioid Use Disorder in Pregnant Women via Telemedicine: A Nonrandomized Controlled Trial.

Importance: There are high rates of maternal and newborn morbidity and mortality associated with opioid use disorder (OUD). Integrating OUD treatment in obstetric practices for pregnant and postpartum women via telemedicine can increase access to care and reduce the consequences of OUD. Evaluation of this care delivery model, however, is needed before widespread adoption. Objective: To compare maternal and newborn outcomes among pregnant women with OUD receiving care via telemedicine vs in person. Design, Setting, and Participants: A nonrandomized controlled trial including 98 women receiving perinatal OUD treatment in 4 outpatient obstetric practices by telemedicine or in person and followed up until 6 to 8 weeks post partum was conducted from September 4, 2017, to December 31, 2018. Logistic regression with propensity score adjustment was applied to reduce group selection bias and control for potentially confounding variables. Interventions: Participants were seen weekly for 4 weeks, every 2 weeks for 4 weeks, and monthly thereafter and provided relapse prevention therapy and buprenorphine. Main Outcomes and Measures: The outcomes were retention in treatment, defined as uninterrupted addiction treatment during pregnancy through 6 to 8 weeks post partum; urine drug screen results at delivery and 6 to 8 weeks post partum; and a neonatal abstinence syndrome (NAS) diagnosis collected via electronic health records. Results: The mean (SD) age of the 98 pregnant women was 30.23 (5.12) years. Of these, 41 of 44 women (93.2%) in the telemedicine group and 48 of 54 women (88.9%) in the in-person group chose to continue treatment in the program after an initial evaluation. After propensity score weighting and doubly robust estimation, no significant differences were found between groups in retention in treatment at 6 to 8 weeks post partum (telemedicine: 80.4% vs in person: 92.7%; treatment effect, -12.2%; 95% CI, -32.3% to -4.4%). Similarly, after propensity score weighting and doubly robust estimation, there were no significant group differences in rates of NAS (telemedicine: 45.4% vs in person: 63.2%; treatment effect, -17.8%; 95% CI, -41.0% to 8.9%). Conclusions and Relevance: In this nonrandomized controlled trial, virtually integrated OUD care in obstetric practices produced similar maternal and newborn outcomes compared with in-person care. These findings may have important public health implications for combatting the opioid crisis and its consequences on pregnant women and their families. Future large randomized clinical trials are needed. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT04049032.