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Scoping Review of Best Practice Guidelines for Care in the Labor and Birth Setting of Pregnant Women Who Use Methamphetamines

Open AccessPublished:December 13, 2021DOI:https://doi.org/10.1016/j.jogn.2021.10.008

      Abstract

      Objective

      To use a scoping review to explore the existing literature on best practice guidelines for safe, dignified, and compassionate care in the labor and birth setting for pregnant women who use methamphetamines.

      Data Sources

      We conducted a systematic search for articles and best practice guidelines from health-related databases (MEDLINE; CINAHL; and the Web of Science, including the Core Collection and Social Science Citation Index, PsycInfo, Women’s Studies International, and Sociological Abstracts) and gray literature. Search terms included substance use disorder, methamphetamine, childbirth, and labor and delivery.

      Study Selection

      We included English-language, peer-reviewed reports of primary research, systematic reviews, and practice guidelines from credible databases and organizations published between 1991 and 2020. We screened 1,297 resources and agreed to review 156 articles and 16 gray literature resources in the full-text analysis. Nine of the 156 articles and 16 gray literature resources met the inclusion criteria.

      Data Extraction

      We used the Joanna Briggs Institute review guidelines (2015) criteria for extraction of the following data: author(s); year of publication; type of study; objectives; country of origin; study population and sample size (if applicable); inclusion of best practice guidelines for the labor and birth setting; care approaches specific to safety, dignity, compassion; and the targeted substance(s) discussed (e.g., methamphetamine, opioids, etc.). We further documented the phenomena of interest to determine if articles or best practice guidelines included safe, dignified, and compassionate care approaches specific to pregnant women who use methamphetamine.

      Data Synthesis

      We summarized the best practice guidelines, which included universal screening, assessment, and management of analgesia during labor, as well as broad guidance regarding the inclusion of a multidisciplinary health care team. Safe, dignified, and compassionate care approaches were focused on communication, shared decision making, and the provision of nonjudgmental care. Although evidence about substance use during the childbearing years is increasing, stronger evidence for clinical care approaches in the labor and birth setting is needed, inclusive of all stakeholder perspectives.

      Conclusion

      The articles and best practice guidelines reviewed provided broad clinical recommendations that were applicable to pregnant women who use methamphetamine. However, we did not find a complete comprehensive best practice guideline for labor and birth that was specific, was solution focused, and delineated a safe, dignified, and compassionate care approach.

      Keywords

      Methamphetamine (MA) use in pregnancy is a major global public health concern that may be accompanied by grave consequences for the woman and developing fetus (Perez et al., 2021;
      World Health Organization
      Guidelines for identification and management of substance use and substance use disorders in pregnancy.
      ). The use of MA is growing (Nickel et al., 2020), and MA is one of the most common illicit drugs taken by women who are pregnant (Perez et al., 2021). Women with substance use disorders (SUDs) can experience extreme health inequities across a wide range of health conditions (
      • Haycraft A.L.
      Pregnancy and the opioid epidemic.
      ;
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ). Although SUDs can affect anyone irrespective of socioeconomic status, SUDs are overrepresented among those with histories of trauma and toxic stress (
      • Bushnik T.
      • Yang S.
      • Kaufman J.S.
      • Kramer M.S.
      • Wilkins R.
      Socioeconomic disparities in small-for-gestational-age birth and preterm birth.
      ). The experiences of past traumas predispose vulnerable women to use multiple substances and potentially be disengaged from the health care system (
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ). Women reported varying reasons for substance use, including weight control, exhaustion, pain, and attempts to self-medicate for mental health conditions (
      • Becker J.B.
      • McClellan M.L.
      • Reed B.G.
      Sex differences, gender and addiction.
      ;
      National Institute on Drug Abuse
      Substance use in women DrugFacts.
      ).
      Viewing an SUD as a chronic illness rather than a character weakness or moral failing is an important consideration for health care providers and policy makers when they allocate time and resources for treatment (
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ).
      • Faherty L.J.
      • Kranz A.M.
      • Russell-Fritch J.
      • Patrick S.W.
      • Cantor J.
      • Stein B.D.
      State policies related to substance use in pregnancy.
      provided evidence that policy makers are still adopting punitive processes, in direct conflict with professional societies and federal agencies that advocate for a nonpunitive approach. Incarceration during pregnancy for individuals with SUDs still exists in certain regions despite the movement toward harm reduction and decriminalization of drug use or possession offenses (
      Association of Women’s Health, Obstetric and Neonatal Nurses
      Optimizing outcomes for women with substance use disorders in pregnancy and the postpartum period [Position statement].
      ;
      • Sutter M.B.
      • Gopman S.
      • Leeman L.
      Patient-centered care to address barriers for pregnant women with opioid dependence.
      ). Health care providers want practical and actionable strategies when they care for pregnant women who use MA (
      • Graves L.E.
      • Green C.R.
      • Robert M.
      • Cook J.L.
      Methamphetamine use in pregnancy: A call for action.
      ) so that they can provide risk-reducing, safe, dignified, compassionate, and comprehensive care (Hill, 2013).
      Health care providers want best practice guidelines to help them provide safe, compassionate, and evidence-based care for pregnant women who use methamphetamine.

      Background

      Methamphetamine is a very potent stimulant; its use is accompanied by acute, chronic, and life-limiting health issues such as complex infections, cardiomyopathy, pulmonary hypertension, and chronic psychosis in pregnancy (
      • Pierce S.L.
      • Zantow E.W.
      • Phillips S.D.
      • Williams M.
      Methamphetamine-associated cardiomyopathy in pregnancy: A case series.
      ). Physician researchers at the Mayo Clinic are currently studying the excess burden of MA-associated cardiomyopathy in pregnancy (
      • Pierce S.L.
      • Zantow E.W.
      • Phillips S.D.
      • Williams M.
      Methamphetamine-associated cardiomyopathy in pregnancy: A case series.
      ). Increased preterm birth, stillbirth (
      • Hoang T.
      • Czuzoj-Shulman N.
      • Abenhaim H.A.
      Pregnancy outcome among women with drug dependence: A population-based cohort study of 14 million births.
      ;
      • Kalaitzopoulos D.-R.
      • Chatzistergiou K.
      • Amylidi A.-L.
      • Kokkinidis D.G.
      • Goulis D.G.
      Effect of methamphetamine hydrochloride on pregnancy outcome: A systematic review and meta-analysis.
      ;
      • Miller C.B.
      • Wright T.
      Investigating mechanisms of stillbirth in the setting of prenatal substance use.
      ), rates of admission to the ICU, and psychiatric disorders (
      • Wright T.E.
      • Schuetter R.
      • Tellei J.
      • Sauvage L.
      Methamphetamines and pregnancy outcomes.
      ) also coincide with MA use. In their systematic review and meta-analysis of eight studies with 626 women,
      • Kalaitzopoulos D.-R.
      • Chatzistergiou K.
      • Amylidi A.-L.
      • Kokkinidis D.G.
      • Goulis D.G.
      Effect of methamphetamine hydrochloride on pregnancy outcome: A systematic review and meta-analysis.
      found that women who used MA gave birth to neonates who had younger gestational age at birth and lower birth weight, head circumference, and body length than women who did not use MA. Methamphetamine-associated psychosis can occur and is profoundly destabilizing; it often requires psychosocial and pharmacologic treatment (
      • Glasner-Edwards S.
      • Mooney L.J.
      Methamphetamine psychosis: Epidemiology and management.
      ), and no current data are available to offer guidance for management in the labor and birth setting (
      • Krans E.E.
      • Campopiano M.
      • Cleveland L.M.
      • Goodman D.
      • Kilday D.
      • Kendig S.
      • Terplan M.
      National partnership for maternal safety: Consensus bundle on obstetric care for women with opioid use disorder.
      ). Pregnant women who use substances have a significantly greater rate of exposure to violence, sexual exploitation, and blood-borne infections during pregnancy (
      • Hoang T.
      • Czuzoj-Shulman N.
      • Abenhaim H.A.
      Pregnancy outcome among women with drug dependence: A population-based cohort study of 14 million births.
      ). In the limited studies specific to amphetamine-type stimulants, researchers reported greater morbidity and mortality for those who use MA (
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ; Perez et al., 2021). The availability and purity of street MA have increased while cost has decreased, so there is correlated consumption in young, poorly resourced individuals (Nickel et al., 2020). Despite the growing prevalence of MA use by women of childbearing age (Nickel et al., 2020), there remains a paucity of research regarding prevalence rates during pregnancy and the effects of MA on pregnancy (
      • Graves L.E.
      • Green C.R.
      • Robert M.
      • Cook J.L.
      Methamphetamine use in pregnancy: A call for action.
      ; Perez et al., 2021).
      The has focused on ensuring that all women and their infants survive and thrive to reach their full potential for health and life. The widespread concerns with all types of substance use are compounded by stigma, systemic marginalization, structural racism, and fear of child apprehension for the childbearing and childrearing parents (
      Association of Women’s Health, Obstetric and Neonatal Nurses
      Optimizing outcomes for women with substance use disorders in pregnancy and the postpartum period [Position statement].
      ;
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ; Motavalli et al., 2020;
      • Ordean A.
      • Wong S.
      • Graves L.
      No. 349—Substance use in pregnancy.
      ; Shirley-Beaven et al., 2020). As a result, the fear of criminal consequences and social stigma drive many women away from the care that would most likely optimize pregnancy outcomes and reduce harms secondary to MA use (
      • Gabrhelik R.
      • Skurtveit S.
      • Nechanska B.
      • Handal M.
      • Mahic M.
      • Mravcik V.
      Prenatal methamphetamine exposure and adverse neonatal outcomes: A nationwide cohort study.
      ). All too often, the first health care interaction of a pregnant woman who uses MA occurs with the onset of active labor (Renberger et al., 2019;
      • Stone R.
      Pregnant women and substance use: Fear, stigma, and barriers to care.
      ). Labor and birth settings are often ill equipped to provide comprehensive care for these women, who arrive in active labor with limited prenatal care and backgrounds of trauma, poor relations with health care providers, and current stimulant use (
      ). The barriers that can impede women who use substances and their infants from thriving require updated best practice guidelines (BPGs) with actionable strategies based on research (Perez et al., 2020).
      • Wells C.
      • Loshak H.
      • Dulong C.
      Withdrawal management and treatment of crystal methamphetamine addiction in pregnancy: A review of clinical effectiveness and guidelines 2019. Canadian Agency for Drugs and Technologies in Health.
      examined the literature regarding interventions for the withdrawal management of individuals who are pregnant. Their search did not yield results for evidence-based guidelines. Compassionate, patient-centered, trauma-informed, wraparound approaches, along with a skilled multidisciplinary team holistically addressing patient needs, in Canadian community settings has fostered engagement with the health care system and improved outcomes for pregnant and early-parenting women who use substances (
      • Rutman D.
      • Hubberstey C.
      • Poole N.
      • Schmidt R.A.
      • Van Bibber M.
      Multi-service prevention programs for pregnant and parenting women with substance use and multiple vulnerabilities: Program structure and clients’ perspectives on wraparound programming.
      ). We were unable to identify a systematic or scoping review on BPGs for pregnant women who use MA and present to the labor and birth setting.
      An expert working group of health care providers was assembled in Winnipeg, Manitoba, Canada, to discuss ways to develop and implement BPGs for pregnant women who use substances, with a focus on MA. The goal was to improve maternal and neonatal outcomes and patient experiences. The working group included health care providers from social work, nursing, anesthesia, midwifery, obstetrics, psychiatry, and emergency medicine. The impetus for this work was an increase in complex presentations among pregnant women who had histories of active MA use and/or appeared to be intoxicated with MA at admission to the labor and birth setting. It was determined that a scoping review to map the existing BPGs in relation to caring for pregnant women who use MA in the labor and birth setting was the needed first step. Therefore, the aim of our scoping review was to explore the existing literature on BPGs for safe, dignified, and compassionate care in the labor and birth setting for pregnant women who use MA.

      Methods

       Development of Scoping Review Protocol

      We used a scoping review approach (
      • Arksey H.
      • O’Malley L.
      Scoping studies: Towards a methodological framework.
      ;
      Joanna Briggs Institute
      The Joanna Briggs Institute reviewers’ manual 2015.
      ) to gather and review the extant literature to accomplish the objective of our review. This approach is known to be an effective way to capture a range of literature on a topic that is useful to policy makers (
      • Peters M.D.
      • Godfrey C.M.
      • Khalil H.
      • McInerney P.
      • Parker D.
      • Baldini Soares C.
      Guidance for conducting systematic scoping reviews.
      ). The scoping review differs from systematic reviews in that the focus is not on the assessment of quality as defined in the biomedical research paradigm (O’Malley & Croucher, 2005). Rather, the scoping review approach enables the solicitation of a broader range of literature, including all types of studies, policies, and practice guidelines from organizations and hospital institutions. The study protocol was registered with Open Science Framework Registries (
      • Thiessen K.
      • Gulbransen K.
      • Pidutti J.
      • Watson-Burgess H.
      • Winkler J.
      A review of policies related to care during labour and delivery for persons using illicit substances: A study protocol for a scoping review.
      ).
      The framework of
      • Arksey H.
      • O’Malley L.
      Scoping studies: Towards a methodological framework.
      guided our process for the scoping review, along with the updated recommendations from
      • Levac D.
      • Colquhoun H.
      • O’Brien K.K.
      Scoping studies: Advancing the methodology.
      . The five-stage approach included developing the research questions; searching for relevant material; defining the article and document selection; charting the data; and finally collating, summarizing, and reporting the results. Following the methodologic framework of
      • Arksey H.
      • O’Malley L.
      Scoping studies: Towards a methodological framework.
      for scoping reviews enables replication and strengthens the rigor of the review (
      • Tricco A.C.
      • Lillie E.
      • Zarin W.
      • O’Brien K.
      • Colquhoun H.
      • Kastner M.
      • Straus S.E.
      A scoping review on the conduct and reporting of scoping reviews.
      ). We did not formally evaluate the literature in our scoping review; rather, our aim was to obtain all of the available literature, regardless of quality, and determine if inclusion criteria were met (
      • Arksey H.
      • O’Malley L.
      Scoping studies: Towards a methodological framework.
      ;
      Joanna Briggs Institute
      The Joanna Briggs Institute reviewers’ manual 2015.
      ).

       Research Questions

      To guide the search strategy and ensure that a broad range of literature was reviewed, the research questions were as follows: “What are the existing BPGs related to caring for women with histories of MA use during pregnancy in the labor and birth setting?” and “What are the safe, dignified, and compassionate care approaches for women with histories of MA use in the labor and birth setting?”

       Search Strategy

      We developed a search strategy in MEDLINE (Ovid) and CINAHL (EBSCO) and then translated it into Web of Science, including the Core Collection and Social Science Citation Index, PsycInfo (Ovid), Women’s Studies International (EBSCO), and Sociological Abstracts (ProQuest), to locate relevant articles and BPGs. The search terms included substance use disorder, methamphetamine, childbirth, and labor and delivery, and we used a published filter to limit the results to BPGs (). Each concept included Medical Subject Headings and keywords and was combined with Boolean operators (AND, OR) to produce a systematic search (see Supplementary Table S1). Searches were developed by a medical librarian, peer reviewed using the Peer Review of Electronic Search Strategies checklist, and run and exported on June 29 and 30, 2020. The search produced 1,244 total results. After we removed duplicates, 1,013 results remained for screening by title and abstract. To meet the inclusion criteria, articles were published in English in 1991 or later and were practice guidelines or peer-reviewed articles that included women during pregnancy, labor, and/or birth.
      A Google advanced search was undertaken to identify gray literature, and the same inclusion and exclusion criteria were applied. We further searched the gray literature within obstetric organizations that the health care team members were affiliated with in North America (e.g., Society of Obstetricians and Gynecologists of Canada), the provincial health authorities (e.g., Alberta Health Services), and other well-known maternal–child global leaders and organizations (e.g., the WHO). The list of organizations and health authorities searched was developed by subject expert authors (K.T. and K.G.). We included the same search terms in the search engines of the sites for gray literature: substance use, substance abuse, drug use, and drug abuse. A total of 53 websites were searched for gray literature, yielding 16 gray literature resources for full-text review.

       Selection of Articles

      We used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowchart to guide the screening, along with the PRISMA extension for Scoping Reviews checklist (
      • Tricco A.C.
      • Lillie E.
      • Zarin W.
      • O’Brien K.K.
      • Colquhoun H.
      • Levac D.
      • Hempel S.
      PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation.
      ). The PRISMA diagram details the flow of information through the different phases of the scoping review (see Figure 1) and maps out the number of records identified, as well as those that were included and excluded and the reasons for their exclusion.
      We conducted the screening of articles in two phases: title and abstract and then full-text review. An iterative process took place to discuss and determine a consistent approach to answer the research questions (
      • Levac D.
      • Colquhoun H.
      • O’Brien K.K.
      Scoping studies: Advancing the methodology.
      ). Two authors (K.G. and K.T.) independently reviewed the abstracts from the databases. After the first 100 abstracts were reviewed, we met to further discuss the inclusion and exclusion criteria. There was 83% agreement on the first 100 abstracts reviewed; discrepancies were related to the inclusion of articles that broadly discussed substances versus being specific to MA. We decided that if the article contained relevant BPGs for substance use that could be applicable to MA, it would be included for full-text review.
      • Arksey H.
      • O’Malley L.
      Scoping studies: Towards a methodological framework.
      have suggested a wide approach at this stage to generate breadth of coverage. We met 93% agreement for final text review after reading the titles and abstracts of all literature resources. Any discrepancies were discussed, and we came to 100% agreement for full-text review of 156 articles. There was 100% agreement on the 16 gray literature resources that met the inclusion criteria for review in the full-text review stage. Any gray literature excluded was due to a lack of clinical BPGs and/or a lack of content for the pregnant population in the labor and birth setting.
      Full-text versions of the articles were obtained, and each article was independently reviewed by three authors (K.G., K.T., and J.P.). These authors represented midwifery, nursing, and obstetrics to ensure a multidisciplinary approach in our review. We developed the inclusion and exclusion criteria based on the research questions and scope of the research study.

       Data Abstraction

      The fourth stage of
      • Arksey H.
      • O’Malley L.
      Scoping studies: Towards a methodological framework.
      scoping review is to chart the full-text resources to determine the final selection of resources that met the inclusion criteria. The data charting process was based on the
      Joanna Briggs Institute
      The Joanna Briggs Institute reviewers’ manual 2015.
      scoping manual, which brings together the work of
      • Arksey H.
      • O’Malley L.
      Scoping studies: Towards a methodological framework.
      with updates from
      • Levac D.
      • Colquhoun H.
      • O’Brien K.K.
      Scoping studies: Advancing the methodology.
      .
      We documented the following extracted information: author(s); year of publication; type of study; objectives; country of origin; study population and sample size (if applicable); inclusion of BPGs for the labor and birth setting; care approaches specific to safety, dignity, and compassion; and the targeted substance(s) discussed (e.g., MA, opioids, etc.). To determine if the BPGs included safe, dignified, and compassionate care approaches, the following definitions were agreed on by the authors and operationalized. Patient safety was defined as the prevention of errors and adverse effects to patients associated with health care and to do no harm to patients (
      World Health Organization
      Conceptual framework for the International Classification for Patient Safety. Version 1.1.
      ). This definition of safety was meant to encompass harm reduction, trauma-informed care, and risk-reducing care approaches that enhance safety for pregnant women who use substances (
      • Rutman D.
      • Hubberstey C.
      • Poole N.
      • Schmidt R.A.
      • Van Bibber M.
      Multi-service prevention programs for pregnant and parenting women with substance use and multiple vulnerabilities: Program structure and clients’ perspectives on wraparound programming.
      ). The definition of dignity was described as being an informed decision maker in one’s birth experience, having choice, and receiving respectful treatment from all care providers (Hill, 2013). Compassion was defined as being sensitive, providing empathic responses, and a willingness to help and to promote the well-being of that person (Perez-Bret et al., 2016). The three reviewers (K.G., K.T., and J.P.) engaged in this descriptive analytic phase by charting their results independently and then discussing the results to determine how resources met inclusion or exclusion criteria.

      Results

      We screened 156 full-text articles and 16 gray literature resources for our scoping review. They were primarily from Canada, the United States, Australia, and the European Union. They included published qualitative and quantitative research articles, systematic reviews, clinical practice guidelines, committee opinions, position statements, review articles, special reports, and toolkits. Several of the full-text articles and gray literature sources were informative in providing background information around substance use in pregnancy but did not specifically offer guidance on care provision. We excluded articles because of a lack of actionable clinical interventions that could be incorporated into a BPG for pregnant women who use MA. Many of the full-text articles focused on stigmas; barriers to care; opioid-assisted medication options; and/or tobacco, alcohol, and cannabis screening tools versus BPGs or safe, dignified, and compassionate clinical care approaches, which were being sought to address the research questions. Exploration of the gray literature showed that most of the resources from organizations and health authorities did not include BPGs for women who are childbearing or childrearing and were limited to a list of resources and phone numbers for individuals experiencing mental health and addiction.
      Existing recommendations include screening, analgesia during labor, and multidisciplinary care inclusive of addiction and pain specialists.

       Synthesis of Resources

      The final stage of the scoping review is to collate, summarize, and report the results (
      • Arksey H.
      • O’Malley L.
      Scoping studies: Towards a methodological framework.
      ). This last step is intended to synthesize the identified resources and present them in meaningful ways so that the relevant data effectively addresses the research questions (
      • Levac D.
      • Colquhoun H.
      • O’Brien K.K.
      Scoping studies: Advancing the methodology.
      ). The results from our full-text review led to the selection of nine resources that met the inclusion criteria. We determined that the publications would be succinctly synthesized for discussion and presented in a table. Supplementary Table S2 summarizes the BPGs from each of the nine publications, along with how they incorporated safe, dignified, and compassionate care approaches.
      The reviewers reached 100% agreement on the inclusion of seven articles from the databases (
      • Arunogiri S.
      • Foo L.
      • Frei M.
      • Lubman D.I.
      Managing opioid dependence in pregnancy—A general practice perspective.
      ;
      • Blandthorn J.
      • James K.
      • Bowman E.
      • Bonomo Y.
      • Amir L.H.
      Two case studies illustrating a shared decision-making approach to illicit methamphetamine use and breastfeeding.
      ;
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Krans E.E.
      • Campopiano M.
      • Cleveland L.M.
      • Goodman D.
      • Kilday D.
      • Kendig S.
      • Terplan M.
      National partnership for maternal safety: Consensus bundle on obstetric care for women with opioid use disorder.
      ;
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ;
      • Sutter M.B.
      • Gopman S.
      • Leeman L.
      Patient-centered care to address barriers for pregnant women with opioid dependence.
      ;
      • Young J.L.
      • Martin P.R.
      Treatment of opioid dependence in the setting of pregnancy.
      ) and two gray literature resources (
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ;
      World Health Organization
      Guidelines for identification and management of substance use and substance use disorders in pregnancy.
      ) for the final summary of this scoping review. We included practice guidelines (n = 2), a special report (n = 1), a perspective article (n = 1), a case study article (n = 1), and review articles (n = 4). The final nine publications were selected because they provided BPGs and/or considerations for patient safety, dignity, and/or compassionate care approaches. Only two of the nine publications provided specific guidelines for MA. The other seven publications offered BPGs for all substances that were applicable to MA. These seven publications included relevant BPGs for various illicit substance use during labor and birth applicable to pregnant women who use MA.
      The BPGs offered in each of these publications are relevant to a range of health care disciplines whose members care for pregnant women who use substances. Overall, the BPGs were general, with broad recommendations for routine screening, assessment, the management of analgesia during labor, and rooming-in to keep the mother–infant dyad together during the fourth stage of labor. Care provided by a multidisciplinary team that is nonjudgmental and specialized in substance use and maternal–child care was highly endorsed (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Krans E.E.
      • Campopiano M.
      • Cleveland L.M.
      • Goodman D.
      • Kilday D.
      • Kendig S.
      • Terplan M.
      National partnership for maternal safety: Consensus bundle on obstetric care for women with opioid use disorder.
      ;
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ;
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ;
      World Health Organization
      Guidelines for identification and management of substance use and substance use disorders in pregnancy.
      ).

       Screening

      The authors of the publications consistently recommended universal or ongoing substance use screening for all women during pregnancy and in the labor and birth setting (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Krans E.E.
      • Campopiano M.
      • Cleveland L.M.
      • Goodman D.
      • Kilday D.
      • Kendig S.
      • Terplan M.
      National partnership for maternal safety: Consensus bundle on obstetric care for women with opioid use disorder.
      ;
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ;
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ;
      • Sutter M.B.
      • Gopman S.
      • Leeman L.
      Patient-centered care to address barriers for pregnant women with opioid dependence.
      ;
      World Health Organization
      Guidelines for identification and management of substance use and substance use disorders in pregnancy.
      ;
      • Young J.L.
      • Martin P.R.
      Treatment of opioid dependence in the setting of pregnancy.
      ). Young and Martin emphasized the importance of health care providers protecting patients and opposing coercive screening, testing, and treatments that lead to punitive consequences. Krans et al. offered the importance of nonbiased criteria for screening and transparency about hospital notifications to Child Protective Services. Consistent use of a validated screening tool to determine substance use was also endorsed by several of the authors (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ;
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ;
      • Ordean A.
      • Wong S.
      • Graves L.
      No. 349—Substance use in pregnancy.
      ; WHO, 2020). Ecker et al. described the six commonly used screening tools for substance use during pregnancy: Drug Abuse Screening Test, 4 P’s, Substance Use Risk Profile Pregnancy scale, CRAFFT screening tool, Wayne Indirect Drug Use Screener, and National Institute on Drug Abuse quick screen. A brief description and the reliability and validity of each of these tools are described in Table 1. Authors also recommended the use of an open-ended interview style to decrease women’s reluctance to admit to the use of substances (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Young J.L.
      • Martin P.R.
      Treatment of opioid dependence in the setting of pregnancy.
      ).
      Table 1Screening Tools for Substance Use in Pregnancy
      Screening ToolTool DescriptionReliability and Validity
      Drug Abuse Screening Test (DAST-10)Ten-item general substance use screening questionnaireSensitivity of 47%, specificity of 82%, positive predictive value of 43%, and negative predictive value of 84% (
      • Grekin E.R.
      • Svikis D.S.
      • Lam P.
      • Connors V.
      • LeBreton J.M.
      • Streiner D.L.
      • Ondersma S.J.
      Drug use during pregnancy: Validating the Drug Abuse Screening Test against physiological measures.
      )
      4 P’sFour questions about parents, peers, past, and pregnancy in relation to substance useSensitivity of 87%, specificity of 76%, positive predictive value of 36%, and negative predictive value of 97% (
      • Chasnoff I.
      • Wells A.
      • McGourty R.
      • Bailey L.K.
      Validation of the 4P’s Plus© screen for substance use in pregnancy validation of the 4P’s Plus.
      )
      Substance Use Profile PregnancyThree questions (one on marijuana use, one on alcohol use, and one on amount of drug use)Sensitivity of 48% and specificity of 85% with alcohol use; sensitivity of 85% and specificity of 68% with marijuana use (
      • Yonkers K.A.
      • Gotman N.
      • Kershaw T.
      • Forray A.
      • Howell H.B.
      • Rounsaville B.J.
      Screening for prenatal substance use: Development of the Substance Use Risk Profile-Pregnancy scale.
      )
      CRAFFT screening toolAdolescent substance abuse tool: six yes/no questions on alcohol and drug usePositive predictive value of 90% and negative predictive of 80% (
      • Knight J.R.
      • Sherritt L.
      • Shrier L.A.
      • Harris S.K.
      • Chang G.
      Validity of CRAFFT substance abuse screening test among adolescent clinic patients.
      )
      Wayne Indirect Drug Use ScreenerSix true/false items related to behavior and smokingSensitivity of 76% and specificity of 68% (
      • Ondersma S.J.
      • Svikis D.S.
      • LeBreton J.M.
      • Streiner D.L.
      • Grekin E.R.
      • Lam P.K.
      • Connors-Burge V.
      Development and preliminary validation of an indirect screener for drug use in the perinatal period.
      )
      National Institute on Drug Abuse Quick Screen (2012)Four direct questions about substance useHas not been validated for pregnancy

       Pain assessment and management

      In most articles (n = 6), the authors discussed the importance of labor and birth pain assessment and management (
      • Arunogiri S.
      • Foo L.
      • Frei M.
      • Lubman D.I.
      Managing opioid dependence in pregnancy—A general practice perspective.
      ;
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ;
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ;
      • Sutter M.B.
      • Gopman S.
      • Leeman L.
      Patient-centered care to address barriers for pregnant women with opioid dependence.
      ;
      • Young J.L.
      • Martin P.R.
      Treatment of opioid dependence in the setting of pregnancy.
      ). Ongoing assessment of pain during labor is necessary because pain tolerance and management can change unexpectedly (
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ). Arunogiri et al. discussed the importance of adequate pain control during birth (vaginal, assisted, or cesarean), which can require ongoing coordination with the addiction medicine and pain team. Ecker et al. further acknowledged that if birth trauma has been experienced, a plan for longer-term pain management should be considered. Additionally, nonopioid pain management, such as ice, heat, and local anesthetic, after vaginal birth is recommended (
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ). Acetaminophen and ibuprofen are the routine pharmacologic preferences after normal vaginal birth. If more severe pain exists, consideration of epidural morphine, hydromorphone, or a short course of low-dose opioids can be offered (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ). Dosing for methadone or buprenorphine medications needs to continue in the labor and birth setting when women are taking these medications for opioid treatment (
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ;
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ).

       Multidisciplinary team approach

      In most of the publications (n = 5), optimal care from a multidisciplinary team specialized in substance use and maternal–child care to implement evidence-based strategies throughout pregnancy and during labor and birth was recommended (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Krans E.E.
      • Campopiano M.
      • Cleveland L.M.
      • Goodman D.
      • Kilday D.
      • Kendig S.
      • Terplan M.
      National partnership for maternal safety: Consensus bundle on obstetric care for women with opioid use disorder.
      ;
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ;
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ;
      World Health Organization
      Guidelines for identification and management of substance use and substance use disorders in pregnancy.
      ). Collaborative care among many care providers, such as obstetricians, midwives, anesthesiologists, and pain and addictions specialists, was identified as the ideal approach to provide appropriate services (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Sutter M.B.
      • Gopman S.
      • Leeman L.
      Patient-centered care to address barriers for pregnant women with opioid dependence.
      ). Members of the health care team may include an obstetrician, addiction specialist, midwife, nurse, maternal–fetal medicine specialist, behavioral health specialist, and social worker (
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ). Each of the care providers and specialists, including the addiction specialist, should be comfortable with and knowledgeable about substance use and pregnancy (
      • Sutter M.B.
      • Gopman S.
      • Leeman L.
      Patient-centered care to address barriers for pregnant women with opioid dependence.
      ).

       Safe, dignified, and compassionate care considerations

      Safe, dignified, and compassionate care actionable approaches were broadly focused on therapeutic communication (
      • Arunogiri S.
      • Foo L.
      • Frei M.
      • Lubman D.I.
      Managing opioid dependence in pregnancy—A general practice perspective.
      ;
      World Health Organization
      Guidelines for identification and management of substance use and substance use disorders in pregnancy.
      ), shared decision making (
      • Blandthorn J.
      • James K.
      • Bowman E.
      • Bonomo Y.
      • Amir L.H.
      Two case studies illustrating a shared decision-making approach to illicit methamphetamine use and breastfeeding.
      ;
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ;
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ;
      World Health Organization
      Guidelines for identification and management of substance use and substance use disorders in pregnancy.
      ), and nonjudgmental attitudes of health care providers (
      • Blandthorn J.
      • James K.
      • Bowman E.
      • Bonomo Y.
      • Amir L.H.
      Two case studies illustrating a shared decision-making approach to illicit methamphetamine use and breastfeeding.
      ;
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ;
      New South Wales Health
      Guidelines for the management of substance use during pregnancy, birth and postnatal period.
      ;
      • Sutter M.B.
      • Gopman S.
      • Leeman L.
      Patient-centered care to address barriers for pregnant women with opioid dependence.
      ;
      World Health Organization
      Guidelines for identification and management of substance use and substance use disorders in pregnancy.
      ;
      • Young J.L.
      • Martin P.R.
      Treatment of opioid dependence in the setting of pregnancy.
      ). Ecker et al. suggested that when pregnant women screen positive for substance use, the health care providers’ reactions should be similar to when women have high glucose levels. Suggestions for health care providers to provide a safe care approach that is nonjudgmental and based on harm reduction were offered in a few of the articles but with little nuance (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Krans E.E.
      • Campopiano M.
      • Cleveland L.M.
      • Goodman D.
      • Kilday D.
      • Kendig S.
      • Terplan M.
      National partnership for maternal safety: Consensus bundle on obstetric care for women with opioid use disorder.
      ; McLafferty et al., 2016). Krans et al. and NSW Health recommended the development of a safety plan; however, what to include in the safety plan was not addressed. Ecker et al. emphasized continuity of care and a collaborative care approach to decrease retraumatization for pregnant women who use substances. Overall, there was a general lack of nuanced approaches offered or elaboration on how to provide dignified care in the labor and birth setting for pregnant women who use MA.

      Discussion

      General practice recommendations for the care of pregnant women who use MA exist; however, these guidance documents are broad and not comprehensive for the labor and birth setting.
      • Rutman D.
      • Hubberstey C.
      • Poole N.
      • Schmidt R.A.
      • Van Bibber M.
      Multi-service prevention programs for pregnant and parenting women with substance use and multiple vulnerabilities: Program structure and clients’ perspectives on wraparound programming.
      identified successful community programming for pregnant women who use substances with the key components of harm reduction, culturally safe, and trauma-informed care approaches to promote women’s successful engagement and improve outcomes. These key components from community settings for pregnant women who use MA were not explicitly discussed in relation to the labor and birth setting, despite the potential for them to be incorporated. The labor and birth period can present challenges when women who use MA are admitted in labor with little or no prenatal care, such as unknown gestational age and unknown frequency of MA use, last use, and which specific substances are used (
      • Schiff D.M.
      • Nielsen T.
      • Terplan M.
      • Hood M.
      • Bernson D.
      • Diop H.
      • Land T.
      Fatal and nonfatal overdose among pregnant and postpartum women in Massachusetts.
      ). Providing optimal care that is trauma informed, incorporates harm reduction, and is culturally safe requires relationship building with a woman who uses substances. This is particularly true when the woman did not receive prenatal care or unknown health care providers are present in the labor and birth setting (
      ).
      Further exploration of trauma-informed, harm reduction, and wraparound care approaches for the labor and birth setting is warranted.
      The labor and birth experiences represent a major transition in a woman’s life during which a trusting relationship with health care providers is essential (). Gaining trust and being empathic is vital to relationship development during all health care encounters with pregnant women who use substances (
      • Rutman D.
      • Hubberstey C.
      • Poole N.
      • Schmidt R.A.
      • Van Bibber M.
      Multi-service prevention programs for pregnant and parenting women with substance use and multiple vulnerabilities: Program structure and clients’ perspectives on wraparound programming.
      ). Many pregnant women’s greatest fear is child apprehension by authorities, which prevents them from sharing their substance use history (
      • Frazer Z.
      • McConnell K.
      • Jansson L.M.
      Treatment for substance use disorders in pregnant women: Motivators and barriers.
      ; Holt & French, 2020;
      • Mahoney K.
      • Reich W.
      • Urbanek S.
      Substance abuse disorder: Prenatal, intrapartum and postpartum care.
      ; O’Connor et al., 202; Renberger et al., 2020; Shirley-Beaven et al., 2020). This needs to be taken into consideration when caring for a woman in labor who has a history of MA use. Screening is not a straightforward process. It is complex because rapport must be established, emotional well-being considered, and the potential legal and social consequences of a positive screening result for substances disclosed (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ). Health care providers must examine the ethical issues inherent in identifying that a pregnant woman uses substances (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ). Future research to improve the approach to screening and comparing times and places of screening in a case–control research design would be useful for practitioners and the development of BPGs. It is unknown which screening tool and approach are optimal because there are few studies examining the reliability and validity and a complete lack of the patient perspectives that should inform the use of the different tools available (
      • Coleman-Cowger V.H.
      • Oga E.A.
      • Peters E.N.
      • Trocin K.E.
      • Koszowski B.
      • Mark K.
      Accuracy of three screening tools for prenatal substance use.
      ;
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ). Furthermore, the current screening recommendations fail to include ways to address the barriers to disclosure in the labor and birth setting. There are few next steps after screening offered in the literature.
      Harm reduction and integration of the pregnant woman’s support system are known to be paramount to the success of community programming and treatment (;
      • Rutman D.
      • Hubberstey C.
      • Poole N.
      • Schmidt R.A.
      • Van Bibber M.
      Multi-service prevention programs for pregnant and parenting women with substance use and multiple vulnerabilities: Program structure and clients’ perspectives on wraparound programming.
      ). A team that leads in shared decision making, provides continuity of care, integrates a wraparound approach, and strongly advocates for and intervenes on behalf of individuals with SUDs is critical to pave the way for the implementation of BPGs (
      • Rutman D.
      • Hubberstey C.
      • Poole N.
      • Schmidt R.A.
      • Van Bibber M.
      Multi-service prevention programs for pregnant and parenting women with substance use and multiple vulnerabilities: Program structure and clients’ perspectives on wraparound programming.
      ). Successful wraparound services include trauma/violence support, women’s health care, prenatal/postnatal care, child health care, parenting support through cultural programming, peer support, food/nutrition support, basic needs housing, and child welfare support. A safety plan for parents who use or have used substances in the past often includes the following elements: identification of a friend, family member, or supportive person who checks in regularly; attendance at support meetings for substance use; development of community resources and contact information; and development of a recovery plan, including coping strategies (
      Center for Addiction and Mental Health
      Safety plan worksheet for addiction.
      ). Developing and evaluating screening tools along with interventions such as safety planning are essential.
      Pharmacologic treatments do not exist for MA in comparison to treatment with methadone or buprenorphine for opioid use disorders (
      • Sutter M.B.
      • Gopman S.
      • Leeman L.
      Patient-centered care to address barriers for pregnant women with opioid dependence.
      ). Many women have mixed use disorders that may include opioids, and some patients may be on opioid-assisted therapy (
      World Health Organization
      Guidelines for identification and management of substance use and substance use disorders in pregnancy.
      ). One feature of medical treatment for opioid use disorders is the potential for longitudinal relationships and continuity of care with care providers (
      • Ecker J.
      • Abuhamad A.
      • Hill W.
      • Bailit J.
      • Bateman B.
      • Berghella V.
      • Yonkers K.
      Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
      ;
      • Young J.L.
      • Martin P.R.
      Treatment of opioid dependence in the setting of pregnancy.
      ). Unfortunately, no such opportunity is available for women who use MA. Education for all health care providers to recognize and understand addiction as a chronic neurobiological disease and the best care approaches available is a fundamental step in improving care (Healy et al., 2021; ).

       Gaps and Recommendations

      The findings from our review suggest that stakeholder perspectives, most importantly those of pregnant women who use MA, are missing in many of the practice guidelines offered. It is unknown what their perspectives are on priorities for a BPG. In their qualitative research of the lived experience of pregnant women who use MA,
      • Frazer Z.
      • McConnell K.
      • Jansson L.M.
      Treatment for substance use disorders in pregnant women: Motivators and barriers.
      found that the act of screening can provoke fear, shame, and even cravings while potentially invoking systemic discrimination when the woman is labelled a “user” or inequitably targeted for screening based on prejudiced profiling. Empathetic patient-centered strategies to overcome these harms in the acute labor and birth periods were not fully discussed in any of the literature that was summarized. How to implement care strategies into the labor and birth setting that have been successfully used in community programming for pregnant women warrants further exploration. There is room for the development of a comprehensive BPG that incorporates safe, dignified, and compassionate care approaches for women during labor through discharge from the birth setting.

       Limitations

      Although we used a well-established framework and strategy to retrieve articles and gray literature and used three reviewers with different training backgrounds, our narrow focus on BPGs for the labor and birth setting resulted in few articles and other resources to include in our review. Relevant studies may have been omitted that were published in other languages. The lack of articles specific to MA is a significant limitation but also a major finding. Based on the English language limiter, the data produced results mostly focused on North America, the European Union, and Australia. Although we excluded articles before 1991, MA was not a commonly used drug before this date.

      Conclusion

      We found that the BPGs identified in the literature offer recommendations for routine screening, management of pain and offering of analgesia during labor, and the need for a multidisciplinary care team. Although researchers identified stigma and shaming as barriers to care, little information was offered to guide a change in approach to incorporate into a BPG. Authors did not explicitly discuss how to be empathetic and acknowledge that substance use and health care interactions can affect an individual’s sense of dignity. Trauma-informed care was not a common term in any of the literature reviewed, despite the evidence that this is needed for women who use substances (
      ). Threading ways to enhance dignity and embed compassion in interactions with women who use MA would be useful for care providers in the labor and birth setting. We recommend that future work focus on establishing BPGs for women who use MA that incorporate actionable safe, dignified, and compassionate approaches to care. Such BPGs will need to be implemented and evaluated. The adoption of comprehensive BPGs has the potential to foster a safe, compassionate, nonjudgmental approach to health care delivery that will ultimately improve maternal and neonatal outcomes and patient experiences with health care providers and the health care system.

      Uncited Reference

      • Klaman S.I.
      • Isaacs K.
      • Leopold A.
      • Perpich J.
      • Hayashi S.
      • Vender J.
      • Jones H.E.
      Treating women who are pregnant and parenting for opioid use disorder and the concurrent care of their infants and children: Literature review to support national guidance.
      • Marwick C.
      NIDA seeking data on effect of fetal exposure to methamphetamine.
      .

      Acknowledgment

      The authors thank Carolyn Ziegler, information specialist at Unity Health Toronto, for conducting a PRESS and Dr. Brenda Query for her editorial support.

      Conflict of Interest

      The authors report no conflicts of interest or relevant financial relationships.

      Funding

      Funded by the Canadian Institutes of Health Research.

      Supplementary Material

      References

        • Arksey H.
        • O’Malley L.
        Scoping studies: Towards a methodological framework.
        International Journal of Social Research Methodology. 2005; 8: 19-32https://doi.org/10.1080/1364557032000119616
        • Arunogiri S.
        • Foo L.
        • Frei M.
        • Lubman D.I.
        Managing opioid dependence in pregnancy—A general practice perspective.
        Australian Family Physician. 2013; 42: 713-716
        • Association of Women’s Health, Obstetric and Neonatal Nurses
        Optimizing outcomes for women with substance use disorders in pregnancy and the postpartum period [Position statement].
        • Becker J.B.
        • McClellan M.L.
        • Reed B.G.
        Sex differences, gender and addiction.
        Journal of Neuroscience Research. 2017; 95: 136-147https://doi.org/10.1002/jnr.23963
        • Blandthorn J.
        • James K.
        • Bowman E.
        • Bonomo Y.
        • Amir L.H.
        Two case studies illustrating a shared decision-making approach to illicit methamphetamine use and breastfeeding.
        Breastfeeding Medicine. 2017; 12: 381-385https://doi.org/10.1089/bfm.2017.0010
        • Bushnik T.
        • Yang S.
        • Kaufman J.S.
        • Kramer M.S.
        • Wilkins R.
        Socioeconomic disparities in small-for-gestational-age birth and preterm birth.
        Health Repository. 2017; 28: 3-10
        • Canadian Agency for Drugs and Technologies in Health
        Strings attached: CADTH database search filters.
        • Center for Addiction and Mental Health
        Safety plan worksheet for addiction.
        • Chasnoff I.
        • Wells A.
        • McGourty R.
        • Bailey L.K.
        Validation of the 4P’s Plus© screen for substance use in pregnancy validation of the 4P’s Plus.
        Journal of Perinatology. 2007; 27: 744-748https://doi.org/10.1038/sj.jp.7211823
        • Coleman-Cowger V.H.
        • Oga E.A.
        • Peters E.N.
        • Trocin K.E.
        • Koszowski B.
        • Mark K.
        Accuracy of three screening tools for prenatal substance use.
        Obstetrics & Gynecology. 2019; 133: 952-961https://doi.org/10.1097/AOG.0000000000003230
        • Ecker J.
        • Abuhamad A.
        • Hill W.
        • Bailit J.
        • Bateman B.
        • Berghella V.
        • Yonkers K.
        Substance use disorders in pregnancy: Clinical, ethical, and research imperatives of the opioid epidemic: A report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine.
        American Journal of Obstetrics and Gynecology. 2019; 221: B5-B28https://doi.org/10.1016/j.ajog.2019.03.022
        • Faherty L.J.
        • Kranz A.M.
        • Russell-Fritch J.
        • Patrick S.W.
        • Cantor J.
        • Stein B.D.
        State policies related to substance use in pregnancy.
        RAND Corporation, 2020https://doi.org/10.7249/IG148
        • Frazer Z.
        • McConnell K.
        • Jansson L.M.
        Treatment for substance use disorders in pregnant women: Motivators and barriers.
        Drug and Alcohol Dependence. 2019; 205 (Article 107652)https://doi.org/10.1016/j.drugalcdep.2019.107652
        • Gabrhelik R.
        • Skurtveit S.
        • Nechanska B.
        • Handal M.
        • Mahic M.
        • Mravcik V.
        Prenatal methamphetamine exposure and adverse neonatal outcomes: A nationwide cohort study.
        European Addiction Research. 2021; 27: 97-106
        • Glasner-Edwards S.
        • Mooney L.J.
        Methamphetamine psychosis: Epidemiology and management.
        CNS Drugs. 2014; 28: 1115-1126https://doi.org/10.1007/s40263-014-0209-8
        • Government of Canada
        Chapter 4: Care during labour and birth.
        • Graves L.E.
        • Green C.R.
        • Robert M.
        • Cook J.L.
        Methamphetamine use in pregnancy: A call for action.
        Journal of Obstetrics and Gynaecology Canada. 2020; 43: 1001-1004https://doi.org/10.1016/j.jogc.2020.11.017
        • Grekin E.R.
        • Svikis D.S.
        • Lam P.
        • Connors V.
        • LeBreton J.M.
        • Streiner D.L.
        • Ondersma S.J.
        Drug use during pregnancy: Validating the Drug Abuse Screening Test against physiological measures.
        Psychology of Addictive Behaviors. 2010; 24: 719-723https://doi.org/10.1037/a0021741
        • Haycraft A.L.
        Pregnancy and the opioid epidemic.
        Journal of Psychosocial Nursing Mental Health Services. 2018; 56: 19-23https://doi.org/10.3928/02793695-20180219-03
        • Hoang T.
        • Czuzoj-Shulman N.
        • Abenhaim H.A.
        Pregnancy outcome among women with drug dependence: A population-based cohort study of 14 million births.
        Journal of Gynecology, Obstetrics, and Human Reproduction. 2020; 49 (Article 101741)https://doi.org/10.1016/j.jogoh.2020.101741
        • Joanna Briggs Institute
        The Joanna Briggs Institute reviewers’ manual 2015.
        • Kalaitzopoulos D.-R.
        • Chatzistergiou K.
        • Amylidi A.-L.
        • Kokkinidis D.G.
        • Goulis D.G.
        Effect of methamphetamine hydrochloride on pregnancy outcome: A systematic review and meta-analysis.
        Journal of Addiction Medicine. 2018; 12: 220-226https://doi.org/10.1097/ADM.0000000000000391
        • Klaman S.I.
        • Isaacs K.
        • Leopold A.
        • Perpich J.
        • Hayashi S.
        • Vender J.
        • Jones H.E.
        Treating women who are pregnant and parenting for opioid use disorder and the concurrent care of their infants and children: Literature review to support national guidance.
        Journal of Addiction Medicine. 2017; 11: 178-190https://doi.org/10.1097/adm.0000000000000308
        • Klinic Community Health Centre
        Trauma-informed: The trauma toolkit (2nd ed.).
        • Knight J.R.
        • Sherritt L.
        • Shrier L.A.
        • Harris S.K.
        • Chang G.
        Validity of CRAFFT substance abuse screening test among adolescent clinic patients.
        Archives of Pediatric & Adolescent Medicine. 2002; 156: 607-614https://doi.org/10.1001/archpedi.156.6.607
        • Krans E.E.
        • Campopiano M.
        • Cleveland L.M.
        • Goodman D.
        • Kilday D.
        • Kendig S.
        • Terplan M.
        National partnership for maternal safety: Consensus bundle on obstetric care for women with opioid use disorder.
        Obstetrics & Gynecology. 2019; 134: 365-375https://doi.org/10.1097/aog.0000000000003381
        • Levac D.
        • Colquhoun H.
        • O’Brien K.K.
        Scoping studies: Advancing the methodology.
        Implementation Science. 2010; 5 (Article 69)https://doi.org/10.1186/1748-5908-5-69
        • Mahoney K.
        • Reich W.
        • Urbanek S.
        Substance abuse disorder: Prenatal, intrapartum and postpartum care.
        MCN. The American Journal of Maternal/Child Nursing. 2019; 44: 284-285https://doi.org/10.1097/nmc.0000000000000551
        • Marwick C.
        NIDA seeking data on effect of fetal exposure to methamphetamine.
        JAMA. 2000; 283: 2225-2226
        • Miller C.B.
        • Wright T.
        Investigating mechanisms of stillbirth in the setting of prenatal substance use.
        Academic Forensic Pathology. 2018; 8: 865-873https://doi.org/10.1177/1925362118821471
        • National Institute on Drug Abuse
        Substance use in women DrugFacts.
        • New South Wales Health
        Guidelines for the management of substance use during pregnancy, birth and postnatal period.
        NSW Ministry of Health, 2014
        • Ondersma S.J.
        • Svikis D.S.
        • LeBreton J.M.
        • Streiner D.L.
        • Grekin E.R.
        • Lam P.K.
        • Connors-Burge V.
        Development and preliminary validation of an indirect screener for drug use in the perinatal period.
        Addiction. 2012; 107: 2099-2106https://doi.org/10.1111/j.1360-0443.2012.03982.x
        • Ordean A.
        • Wong S.
        • Graves L.
        No. 349—Substance use in pregnancy.
        Journal of Obstetrics and Gynaecology Canada. 2017; 39: 922-937https://doi.org/10.1016/j.jogc.2017.04.028
        • Peters M.D.
        • Godfrey C.M.
        • Khalil H.
        • McInerney P.
        • Parker D.
        • Baldini Soares C.
        Guidance for conducting systematic scoping reviews.
        International Journal of Evidence-Based Healthcare. 2015; 13: 141-146https://doi.org/10.1097/XEB.0000000000000050
        • Pierce S.L.
        • Zantow E.W.
        • Phillips S.D.
        • Williams M.
        Methamphetamine-associated cardiomyopathy in pregnancy: A case series.
        Mayo Clinic Proceedings. 2019; 94: 551-554https://doi.org/10.1016/j.mayocp.2018.12.008
        • Rutman D.
        • Hubberstey C.
        • Poole N.
        • Schmidt R.A.
        • Van Bibber M.
        Multi-service prevention programs for pregnant and parenting women with substance use and multiple vulnerabilities: Program structure and clients’ perspectives on wraparound programming.
        BMC Pregnancy and Childbirth. 2020; 20 (Article 441)https://doi.org/10.1186/s12884-020-03109-1
        • Schiff D.M.
        • Nielsen T.
        • Terplan M.
        • Hood M.
        • Bernson D.
        • Diop H.
        • Land T.
        Fatal and nonfatal overdose among pregnant and postpartum women in Massachusetts.
        Obstetrics and Gynecology. 2018; 132: 466-474https://doi.org/10.1097/AOG.0000000000002734
      1. Seng J. Taylor J. Trauma informed care in the perinatal period. Dunedin Academic Press, 2015
        • Stone R.
        Pregnant women and substance use: Fear, stigma, and barriers to care.
        Health & Justice. 2015; 3 (Article 2)https://doi.org/10.1186/s40352-015-0015-5
        • Sutter M.B.
        • Gopman S.
        • Leeman L.
        Patient-centered care to address barriers for pregnant women with opioid dependence.
        Obstetrics and Gynecology Clinics of North America. 2017; 44: 95-107https://doi.org/10.1016/j.ogc.2016.11.004
        • Thiessen K.
        • Gulbransen K.
        • Pidutti J.
        • Watson-Burgess H.
        • Winkler J.
        A review of policies related to care during labour and delivery for persons using illicit substances: A study protocol for a scoping review.
        Open Science Forum Registries, 2021, June 12https://doi.org/10.17605/OSF.IO/4XJ8T
        • Tricco A.C.
        • Lillie E.
        • Zarin W.
        • O’Brien K.
        • Colquhoun H.
        • Kastner M.
        • Straus S.E.
        A scoping review on the conduct and reporting of scoping reviews.
        BMC Medicine Research Methodology. 2016; 16 (Article 15)https://doi.org/10.1186/s12874-016-0116-4
        • Tricco A.C.
        • Lillie E.
        • Zarin W.
        • O’Brien K.K.
        • Colquhoun H.
        • Levac D.
        • Hempel S.
        PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation.
        Annals of Internal Medicine. 2018; 69: 467-473https://doi.org/10.7326/M18-0850
        • Wells C.
        • Loshak H.
        • Dulong C.
        Withdrawal management and treatment of crystal methamphetamine addiction in pregnancy: A review of clinical effectiveness and guidelines 2019. Canadian Agency for Drugs and Technologies in Health.
        • World Health Organization
        Conceptual framework for the International Classification for Patient Safety. Version 1.1.
        2009
        • World Health Organization
        Guidelines for identification and management of substance use and substance use disorders in pregnancy.
        2014
        • World Health Organization
        A comprehensive guideline to intrapartum care for a positive childbirth experience.
        2018
        • Wright T.E.
        • Schuetter R.
        • Tellei J.
        • Sauvage L.
        Methamphetamines and pregnancy outcomes.
        Journal of Addiction Medicine. 2015; 9: 111-117https://doi.org/10.1097/ADM.0000000000000101
        • Yonkers K.A.
        • Gotman N.
        • Kershaw T.
        • Forray A.
        • Howell H.B.
        • Rounsaville B.J.
        Screening for prenatal substance use: Development of the Substance Use Risk Profile-Pregnancy scale.
        Obstetrics and Gynecology. 2010; 16: 827-833https://doi.org/10.1097/AOG.0b013e3181ed8290
        • Young J.L.
        • Martin P.R.
        Treatment of opioid dependence in the setting of pregnancy.
        Psychiatric Clinics of North America. 2012; 35: 441-460https://doi.org/10.1016/j.psc.2012.03.008

      Biography

      Kristen Gulbransen, MN, RN, is a PhD candidate, University of Manitoba, College of Nursing, Winnipeg, Manitoba, Canada.
      Kellie Thiessen, PhD, RM, RN, is an associate professor, Bachelor of Midwifery Program Director, and Associate Dean, University of Manitoba, College of Nursing, Winnipeg, Manitoba, Canada.
      Joel Pidutti, MD, MPH, is an obstetrics and gynecology resident physician, University of Manitoba, Department of Obstetrics and Gynecology, Winnipeg, Manitoba, Canada.
      Heather Watson, MD, is an obstetrician, University of Manitoba, Department of Obstetrics and Gynecology, Winnipeg, Manitoba, Canada.
      Janice Winkler, MLIS, is a medical librarian, University of Manitoba, Rady School of Health Sciences, Winnipeg, Manitoba, Canada.