University of South Florida College of Public Health associate professor Dr. Jennifer Marshall, an expert in maternal-child health, is a co-principal investigator with USF OB-GYN Dr. Kimberly Fryer of a “secret shopper” survey to evaluate access to prenatal care for women in Florida with opioid use disorder (OUD).

The study was prompted by a similar secret shopper study conducted by researchers at Vanderbilt University who hired a company to conduct calls in 10 states to measure access to medication-assisted treatment (MAT) for pregnant women with OUD.

Colleagues of the COPH at the Florida Department of Health and the Department of Children and Families asked if a COPH team could replicate the study in Florida. Marshall and her colleagues also collaborated with Dr. Stephen Patrick’s Vanderbilt team to examine opioid addiction treatment for pregnant and nonpregnant women in Florida.

Callers, armed with a specially designed protocol, posed as pregnant women with Medicaid receiving methadone treatment and made 1,755 calls to over one thousand OB-GYNs throughout the state.

“It was surprising that in both the access to treatment and access to prenatal care studies, over 50 percent of providers were unreachable, even after five attempts were made.”— Dr. Jennifer Marshall

And the results were sobering.

“It was surprising that in both the access to treatment and access to prenatal care studies, over 50 percent of providers were unreachable, even after five attempts were made. It’s hard to know why it was so difficult for callers to reach providers or receive a callback,” Marshall said.

Opioid Use on the Rise

Opioid use in general—and among pregnant women in particular—is a serious and growing problem, in the nation and in Florida. 

From 1999 to 2014, OUD increased from 0.5 to 5.6 per 1,000 delivery hospitalizations in the state. In addition to a greater risk of having their babies born with neonatal abstinence syndrome (a group of serious conditions that can occur when a baby is exposed to opioids in the womb), pregnant women with OUD have a greater likelihood of giving birth to babies who have a low birth weight, are small for their gestational age and/or have cognitive, psychomotor and behavioral issues.

Appointments Hard to Get

 As for the findings, even when the shoppers could reach a provider, care was far from guaranteed.

“When a woman was seeking treatment to stop using opioids, regardless of pregnancy or insurance status, only 25 percent of over 1,000 buprenorphine prescribers … and 64 percent of all 139 opioid treatment programs … offered appointments. Over half of these treatment providers required cash payment and would not take Medicaid or private insurance.”—Dr. Jennifer Marshall

Only 20 percent of prenatal care providers were willing to see the caller for an appointment. And when they were denied care, only a third were referred somewhere else. 

Things weren’t much better for those looking for OUD treatment. 

“When a woman was seeking treatment to stop using opioids, regardless of pregnancy or insurance status, only 25 percent of over 1,000 buprenorphine prescribers [buprenorphine is the preferred drug to treat OUD because of its convenience, better adherence profile and reduced stigmatization] and 64 percent of all 139 opioid treatment programs [using methadone] offered appointments. Over half of these treatment providers required cash payment and would not take Medicaid or private insurance,” Marshall reported.

Callers were also often met with judgment and made to feel stigmatized, Marshall said, either because they were using methadone or had delayed prenatal care or both.

What Needs Improvement

According to Marshall and her team, training clinicians and their staff to be more responsive to patients is critical. So is working with insurance companies, including Medicaid, to increase the availability of providers.

“The reimbursement rates for Medicaid are much lower than for private insurance,” Marshall explained. “And many providers were not taking new patients or accepting new Medicaid patients; they cap the number of Medicaid insured patients that they accept.”

“Women who are seeking [treatment] or are in recovery should be applauded and supported, not stigmatized.”—Dr. Jennifer Marshall

But perhaps most important, Marshall said, is compiling a publicly available, comprehensive and accurate list of prenatal care and OUD treatment providers, including those who accept Medicaid. Making quality ratings available to the public would also be beneficial.

“We need to ensure that treatment is available the moment an individual is seeking recovery,” Marshall said, “and most certainly that prenatal care is available for every woman the moment she discovers she is pregnant. Women who are seeking [treatment] or are in recovery should be applauded and supported, not stigmatized.” 

To access more information about the project, visit the Florida Department of Health’s website.

Story by Donna Campisano, USF College of Public Health