Implementing evidence-based treatment for pregnant people with opioid use disorder in jail: A qualitative analysis of jail administrator and clinician perspectives.

INTRODUCTION: Overdose is a leading cause of maternal mortality in the United States, and pregnant individuals with opioid use disorder (OUD) frequently interact with the criminal legal system. While the benefits of providing life-saving medications for opioid use disorder (MOUD) during pregnancy are well-established, access to MOUD in jail remains limited and inconsistent. Although existing literature identifies general barriers to MOUD implementation in incarcerated settings, the specific needs of pregnant individuals are often overlooked. Our study assessed the perspectives of jail custody and medical leaders to examine pregnancy-specific MOUD implementation barriers and facilitators.

METHODS: From September 2019 to September 2020, we conducted semi-structured qualitative interviews with jail administrators and clinicians across the United States. Interview questions were organized around domains of the Consolidated Framework of Implementation Research (CFIR) framework to explore contextual elements of jails' provision of care to pregnant patients with OUD. We performed a CFIR-informed, directed content analysis to identify key themes and determinants for pregnancy MOUD implementation in jails.

RESULTS: We interviewed 28 individuals from 23 jails, 18 of which offered either full or modified MOUD in pregnancy. Our pregnancy-focused, CFIR analysis identified three main themes: (1) pregnancy introduced unique challenges and opportunities for MOUD implementation in jails; (2) concerns about ensuring fetal wellbeing strongly and positively influenced jails' decisions and approaches to providing MOUD in pregnancy, and discontinuing MOUD postpartum; and (3) stigma, judgment, and limited understanding of substance use and MOUD during pregnancy were widespread and significantly negatively shaped implementation efforts.

CONCLUSION: Study findings highlight the nuances of implementing pregnancy-specific MOUD and the complex care needs of pregnant and postpartum individuals in custody. Both jail custody and medical leaders expressed varying levels of concern for this population, which influenced their treatment approaches. Leveraging their concern for fetal wellbeing could be a critical determinant in encouraging implementation of pregnancy and postpartum MOUD in jails. Successfully implementing and sustaining pregnancy MOUD in jails requires tailored strategies that improve education around maternal-fetal-newborn wellbeing, strengthen infrastructure, and reduce stigma. As jail-community partnerships work to expand MOUD in custody, they must tend to perinatal specific needs in order to optimize maternal and infant health.