(35) Breaking Barriers: Social Vulnerability and Retention among Pregnant Women with Opioid Use

Background & Introduction: Pregnant women represent an especially vulnerable and important patient population with a high-risk period for substance use in the perinatal period. Perinatal substance use is associated with adverse maternal and neonatal outcomes. The rate of babies born with Neonatal Opioid Withdrawal Syndrome (NOWS) is two times higher in Pennsylvania when compared to the national average. Individuals experiencing socioeconomic disadvantages are more likely to have babies affected by NOWS due to higher rates of maternal opioid use, which is often associated with poverty, lack of access to healthcare, and unstable housing. There is very little research regarding the relationship between social vulnerability and Opioid Use Disorder (OUD), particularly in the perinatal population. Social vulnerability reflects various susceptibilities at the community level, such as concentrations of marginalized or disadvantaged populations and substandard infrastructure including elements such as socioeconomic factors. Specifically, the Social Vulnerability Index (SVI) was developed by the Centers for Disease Control and Prevention (CDC), which utilizes U.S. Census tract data to assess the social vulnerability of communities across the United States by analyzing 16 sociodemographic variables grouped into four key themes: socioeconomic status, household characteristics, racial and ethnic minority status, and housing type & transportation. In 2016, the Allegheny Health Network (AHN) created the Perinatal Hope Program (PHP) which provides comprehensive and coordinated treatment and support for pregnant and postpartum women who are struggling with substance use disorders (SUD), including opioid use disorder. This study aimed to examine the association between social vulnerability index and treatment retention, gestational age at first PHP appointment, number of days on Medication for Opioid Use Disorder (MOUD), and NOWS score.

Methods: We conducted a retrospective chart review of PHP patients from January 1, 2016 through October 1, 2024 who had a diagnosed OUD. Other SUDs were excluded. Diagnosis of OUD was determined from the patients’ medical records showing OUD listed on their problem list, accompanied by the corresponding ICD diagnostic code used by the healthcare provider. This study was approved by the Institutional review board. We collected demographic data and assessed co-occurring mental health conditions for all patients. We examined the neonatal outcomes associated with OUD including NOWS at birth, preterm birth ( <37 weeks), and low birth weight ( < 2500 g). We evaluated the number of PHP visits attended by the patients during pregnancy and up to 2 years after pregnancy. Each patient’s zip code was used to identify their census tract and then linked to SVI scores released by the CDC and Agency for Toxic Substances and Disease Registry. Each census tract receives an overall SVI score, as well as a score for each of the four themes, that is between 0 and 1. The higher the SVI score, the higher the social vulnerability of the community. In our study, SVI was used as a continuous variable, meaning it can increase or decrease by any amount. We measured SVI in single-unit increases (e.g., from a score of 1 to 2). We then examined how changes in SVI impact the number of visits. All statistical analyses were conducted under alpha level 0.05 with SAS 9.4.

Results: A total of 234 patients with OUD patients met the criteria for study inclusion. Each pregnancy was associated with an intake day which is the date the patients joined PHP. Participants had an average age of 30 years, 13% were Black, and 87% White. 2% were Hispanic and 98% were non-Hispanic. 57% of patients had a mental health comorbidity while 43% did not. Retention in care was defined as number of appointments during pregnancy and within the first 2years after pregnancy. Comparing pregnancy visits to post-partum visits, women had approximately 8 PHP visits during pregnancy and 12 visits after delivery. 46% had babies with NOWS diagnosis and 22% had babies with low birth weight. SVI was a significant predictor for pregnancy visits after controlling the demographics, specifically, with higher SVI (indicating greater vulnerability), pregnancy visits increased by 9%, OR = 1.09 [1.06, 1.12], p < 0.0001. However, for post-pregnancy visits, higher SVI led to a 2% decrease, OR = 0.96 [0.94, 0.99], p = 0.0073. SVI did not impact gestational age at first PHP intake appointment, MOUD days (defined as total number of days on MOUD between intake and end of pregnancy) or NOWS score.

Conclusion & Discussion: Social vulnerability encompasses various social and structural factors, such as income, employment, education, health insurance, language proficiency, housing, and transportation, that influence health and contribute to inequities. The Social Vulnerability Index (SVI), initially designed to identify vulnerable areas during public health crises and natural disasters, is also used in public health research to measure vulnerability and disadvantage at the neighborhood and county levels. High SVI typically reflects poverty, limited healthcare access, poor nutrition, stress, and other factors contributing to pregnancy complications and these individuals often face healthcare access barriers leading to missed appointments, etc., despite potentially needing more frequent contact with the healthcare system. Programs like PHP at Allegheny Health Network aim to support expectant mothers with substance use disorders by improving access to care through a multidisciplinary care team that includes social workers and providing solution to barriers to care (for e.g. Providing transportation to each clinic appointment). Our study found a high SVI was associated with an increased number of pregnancy visits, likely due to multiple factors including the substantial multidisciplinary social support services offered by PHP. This obviated the potentially detrimental effects of a high SVI on outcomes including late gestational age at time of healthcare intake and NOWS scores. High SVI was significantly associated with reduced post-natal clinic visits, an important area for focused efforts at retention in care. Low attendance at postnatal visits can negatively impact maternal and infant health by delaying the detection and treatment of complications, missing breastfeeding support opportunities, risk of return to substance use, and reducing access to essential postpartum care.

References: 1. Centers for Disease Control and Prevention, Agency for Toxic Substances and Disease Registry. (n.d.). CDC Social Vulnerability Index (SVI). Retrieved from https://www.atsdr.cdc.gov/place-health/php/svi/index.html

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