Category Archive

Substance Use and Domestic Violence ECHO Training Series

Weave West Virginia – Innovative West Virginia Partnership Launches Project to Improve Outcomes for Individuals Experiencing Intimate Partner Violence and Substance Use Disorder

Research Further Proves Effectiveness of Count the Kicks

Contact

Amy Tolliver, Director
West Virginia Perinatal Partnership
(304) 558-0530 ext. 5
atolliver@wvperinatal.org

She Shed gives mothers private place to nurse at the State Fair

From WVNS:

“Nursing Mothers have a new tool on their side this year at the state fair.

This year the state fair announced the addition of the She Shed, a private barn for nursing mothers.

Moms can scan the QR code to learn how to gain access. Inside there is a changing station, breastfeeding supplies, comfy places to nurse, and helpful tools for new mothers. One young mother we spoke with says she would have loved to have a place like this when she was nursing her daughter.

…

“Being able to have the supplies like that especially somewhere like this would have been very helpful that way I wasn’t having to lug around 2 different kinds of bags and all this stuff,” Cochran added.

The She Shed is located by the Smokin’ Gun and Firehouse Diner.”

For more information, read the full article here.

World Doula Week – WSAZ Interview with WV RMOMS Project Director Shauna Lively

Substance Use and Domestic Violence ECHO Training Series

Weave West Virginia – Innovative West Virginia Partnership Launches Project to Improve Outcomes for Individuals Experiencing Intimate Partner Violence and Substance Use Disorder

Research Further Proves Effectiveness of Count the Kicks

Go to the COVID-19 in Newborn Care webinar

Contact

Amy Tolliver, Director
West Virginia Perinatal Partnership
(304) 558-0530 ext. 5
atolliver@wvperinatal.org

COVID-19 in Newborn Care: Initial Lessons from the Pandemic

Webinar, Thursday, May 28 at 3:00 p.m. (Eastern)

Please join us on Thursday, May 28th for an interactive webinar on the impact of COVID-19 from the perspectives of nurses, physicians, respiratory therapists, families, and other members of the newborn care team.

Our expert panel includes Karen Puopolo, MD, PhD, FAAP, a lead author of new AAP guidance and member of the AAP Committee on Fetus and Newborn (COFN) and Mark Hudak, MD, a co-author of the guidance and Chair of the AAP Section on Neonatal Perinatal Medicine.

We will discuss the new guidance, results from the VON SONPM COVID-19 Impact Audit, and case-based discussions to address your most pressing questions about COVID-19 in the care of infants and families.

See the cases to be discussed on our website. Questions for the expert panel can be asked live during the webinar or submitted in advance through the VON Community Forum.

This webinar and all other VON COVID-19 resources are free and open to all, regardless of VON membership.

Related Resources

World Doula Week – WSAZ Interview with WV RMOMS Project Director Shauna Lively

Substance Use and Domestic Violence ECHO Training Series

Weave West Virginia – Innovative West Virginia Partnership Launches Project to Improve Outcomes for Individuals Experiencing Intimate Partner Violence and Substance Use Disorder

Research Further Proves Effectiveness of Count the Kicks

Contact

Amy Tolliver, Director
West Virginia Perinatal Partnership
(304) 558-0530 ext. 5
atolliver@wvperinatal.org

Opioid Crisis In Medicaid: Saving Mothers And Babies

View Original Health Affairs Blog Post Here

Written by: Jennifer E. Moore , Brian T. Bateman , & Stephen W. Patrick

The nation’s opioid crisis is well documented; however, little attention has been paid to the epidemic’s effect on pregnant women and infants. In recent years, opioid use disorder during pregnancy has increased along with a concurrent increase in neonatal opioid withdrawal, also known as neonatal abstinence syndrome (NAS). Given that Medicaid covers roughly half of all births, and more than 80 percent of NAS births, additional efforts are needed to improve outcomes for pregnant and postpartum women as well as infants enrolled in the Medicaid program.

Women of reproductive age and pregnant women covered by the Medicaid program fill prescriptions for opioids more commonly than those not in the program. In the 2000s, 21.6 percent of pregnant women enrolled in Medicaid filled an opioid prescription, with rates ranging from 9.5 percent to 41.6 percent across states, which is significantly higher than the rates of opioid use during pregnancy observed in a commercially insured population. Medicaid is more likely to be the primary payer of substance use-related maternal hospital stays (75.0 percent compared to 13.7 percent in private insurance). Additionally, women enrolled in Medicaid are more likely to be offered and fill a prescription for opioids to address postpartum pain. In fact, more than 10 percent of Medicaid-enrolled women who deliver vaginally fill a prescription for opioids after delivery. For some women, use of prescription opioids during the postpartum period may be a trigger for persistent opioid use and subsequent opioid use disorder. Understanding root causes for these differences and ensuring that opioid prescribing is necessary and appropriate is vital.

Some have argued that Medicaid expansion has played a role in contributing to the opioid epidemic; however, there is little evidence to support these claims. In fact, Medicaid plays a critical role in providing coverage for individuals with opioid use disorder; including pregnant women and infants. In this post, we focus on how Medicaid could improve outcomes for pregnant women and infants affected by the opioid epidemic.

Barriers In Care Delivery

Efforts to address opioid use disorder amongst pregnant women and improve pregnancy outcomes include substance use counseling, medication-assisted treatment (MAT), and behavioral health evaluation and treatment. Use of MAT during pregnancy may increase the likelihood an infant will be born with NAS; however, there is strong evidence that these therapies reduce the risk of more severe outcomes for mom (for example, overdose) and baby (for example, preterm birth). However, the limited number of treatment facilities with programs specific to the needs of pregnant and postpartum women is a common barrier. Only 13 percent of outpatient-only substance use treatment, 13 percent of residential treatment facilities, and 7 percent of hospital inpatient treatment facilities offered programs tailored for pregnant and postpartum women. Despite evidence that MAT is effective among women of reproductive age admitted to a treatment facility, only 48.5 percent of those using heroin and 36.9 percent of women using other opioids received this evidence-based therapy.

Infants also encounter barriers to effective treatment. Increasingly, research suggests that standardized protocols to care for opioid-exposed infants improve outcomes, including shortening the length of treatment and length of hospital stay. Traditional approaches to NAS treatment include treatment of the infant in a neonatal intensive care unit, often separating mother and infant. However, minimizing this separation of mother and baby by allowing mother and infant to room together appears to improve clinical outcomes. Despite the potential benefits of these low-tech approaches, there is evidence that many hospitals have not adopted these approaches.

For families, the time immediately after hospital discharge is particularly vulnerable. Data suggest that infants with NAS are twice as likely as uncomplicated term infants to be readmitted to the hospital within 30 days of discharge. As families leave the hospital, there are numerous needs by mother and baby, and providers need to work together to coordinate evidence-based care. For instance, postpartum mothers may have their obstetric and addiction treatment follow-up appointments in addition to caring for their infant, who has follow-up appointments and home nurse visits, early intervention services such as IDEA Part C, and the involvement of child welfare services. Due to the complexity of needs for both the mother and infant and the numerous care providers and entities potentially involved in the care of families, there can be challenges in the coordination of this care.

Policy Barriers

In the Medicaid program, substance use disorder benefits such as psychotherapy and drug treatment programs vary by state. While every state provides MAT coverage for prescription medications used to treat opioid use disorder, including single-entity buprenorphine product, despite the availability of federal funding, methadone is not covered by every state Medicaid program. Evidence-based clinical guidelines, including those published by the Substance Abuse and Mental Health Services Administration (SAMHSA), suggest that both methadone and buprenorphine be available to pregnant women to tailor treatment to each individual.

To prescribe and dispense single-entity buprenorphine products, physicians must complete a waiver application and training to become a Drug Addiction Treatment Act (DATA)-waived physician. In 2016, policies expanded the number of patients who could receive MAT from a single DATA-waived clinician and expanded the types of clinicians (that is, nurse practitioners and physician assistants) who could prescribe buprenorphine. Despite these efforts, there remains significant gaps in the number of total clinicians available to meet the needs of individuals across the US, making it difficult for pregnant women to access the care they need. Contributing to this gap is the exclusion of certified nurse-midwives, an important women’s health provider in the US, from the expanded list of clinicians.

Furthermore, states have adopted laws that criminalize drug use during pregnancy, creating additional barriers for women, including those enrolled in Medicaid, from accessing treatment that they need and further contributing to the stigma surrounding opioid use disorders. Forty-four states will prosecute women for prenatal illicit drug use, 24 states and the District of Columbia consider prenatal drug use as child abuse or neglect, and four states recognize substance use as grounds for civil commitment. Several national organizations, including the American Academy of Pediatrics, have cautioned against criminal justice approaches to addressing opioid use amongst pregnant women; instead, opting for policies focused on medical interventions including prevention and expansion of MAT treatment options.

Opportunities To Improve Outcomes For Pregnant Women And Infants Affected By Opioid Use In Medicaid

As the payer for approximately 50 percent of all births and more than 80 percent of infants with NAS nationwide, Medicaid has the potential to play a critical role in improving care and outcomes for pregnant women and opioid-exposed infants. As the nation continues to focus on the opioid epidemic, it is important to consider the specific needs of pregnant women enrolled in Medicaid. There are key research and policy opportunities to consider that build upon SAMHSA’s final strategy recommendations in its 2017 Report to Congress.

Research Opportunities

Medical Research To Evaluate Causes Of Opioid Use Focused On Pregnant And Postpartum Women

To diminish the stigma harbored by society and clinicians, further research is needed to understand the causes of opioid use disorder, especially for women covered by Medicaid. Expanding research efforts to include an understanding of causes from the perspective of clinicians, individuals, and families will enhance overall efforts to address this epidemic.

Evidence-Based Interventions Designed To Address Opioid Use Disorders Amongst Pregnant And Postpartum Women And Infants

As more state and federal efforts are launched to address the opioid epidemic, it is critical that interventions and programs be evaluated for their efficacy in expanding access to treatment and improving quality of treatment, among other factors. Understanding the unique needs of pregnant and postpartum women and infants enrolled in the Medicaid program should include challenges in addressing social determinants of health to optimize treatment. The findings from the evaluation of the interventions should be disseminated widely, including in peer-reviewed journals to continue to build the growing evidence base on this topic.

Policy Opportunities

Opioid Treatment Programs Should Be Considered As Replacements For Criminal Penalties, Prosecution, And Incarceration Of Pregnant And Postpartum Women

Current criminal penalties and state laws can pose a barrier for pregnant and postpartum women misusing opioids to access care and treatment. Destigmatizing substance use disorder for pregnant women and treating it as a chronic medical condition will better enable those who are suffering from opioid addiction to receive behavioral therapy and MAT.

Streamlined And Efficient Enrollment Processes For Pregnant Women

Ideally, eligible pregnant women should be enrolled in Medicaid as quickly as possible to facilitate expedited access to routine prenatal care. In doing so, pregnant women misusing opioid prescriptions and illicit opioids may gain access to MAT services earlier in pregnancy, improving birth outcomes.

Expansion Of Workforce Development To Increase The Number Of Clinicians Trained To Prescribe And Provide MAT, Including Nurse-Midwives

Currently, the demand for opioid treatment vastly outweighs the number of available clinicians. The gap of available clinicians makes it difficult for priority groups, such as pregnant and postpartum women, to receive the treatment they need. Expanding the types of clinicians who can prescribe as part of MAT to include certified nurse-midwives will be beneficial for pregnant and postpartum women.

Current policy-making efforts focused on addressing the opioid epidemic in the US through prevention and treatment are crucial; however, we must not overlook the unique needs of pregnant and postpartum women enrolled in the Medicaid program. The US Congress is currently considering several pieces of legislation and regulatory actions focused on the opioid epidemic; however, their efforts have largely not included pregnant women or infants. As they consider legislative action to stem the tide of the opioid epidemic, it is imperative to consider the needs of this vulnerable population; including plans of safe care for infants and care coordination for both the mother and infant. The national interest in this topic provides Congress with any opportunity to invest resources to improve outcomes for our nation’s future by targeting funds to pregnant women and infants.

Related Resources

World Doula Week – WSAZ Interview with WV RMOMS Project Director Shauna Lively

Substance Use and Domestic Violence ECHO Training Series

Weave West Virginia – Innovative West Virginia Partnership Launches Project to Improve Outcomes for Individuals Experiencing Intimate Partner Violence and Substance Use Disorder

Research Further Proves Effectiveness of Count the Kicks

Contact

Amy Tolliver, Director
West Virginia Perinatal Partnership
(304) 558-0530 ext. 5
atolliver@wvperinatal.org

Novel corona virus disease (COVID‐19) in pregnancy: What clinical recommendations to follow?

View Original ACOGS Journal article : Here

1. INTRODUCTION

Pregnancy is a state of partial immune suppression which makes pregnant women more vulnerable to viral infections, and the morbidity is higher even with seasonal influenza. Therefore, the COVID‐19 epidemic may have serious consequences for pregnant women. Although the vast majority of cases of COVID‐19 are currently in China, the risk of outward transmission appears to be significantly raising global concern. Human to human transmission of the virus is proven to occur,1, 2 perhaps even from asymptomatic patients,3, 4 and the mortality is substantial, especially among frail, elderly patients with comorbidities.5 Although there have been some criticisms surrounding suppression of early warnings, and slow initial response followed by heavy‐handed quarantine measures, as well as concerns expressed about the capacity to cope with the large number of patients, and shortage of protective equipment and in‐hospital infections leading to deaths among a substantial number of healthcare professionals,6, 7 China’s effort to contain the disease and slow down its spread in China and world‐wide has been commendable. A large number of cases requiring hospitalization and intensive care is a serious burden even for affluent countries with well‐developed healthcare systems. However, the Chinese government, its health professionals, and the public, have set a new standard for handling the epidemic, and they have certainly contributed to reducing the potential risk of outbreak in neighboring countries with weaker healthcare systems. Furthermore, Chinese researchers and health professionals have generously shared their data, knowledge, experience and expertise that has helped to develop diagnostic tools, clinical management algorithms, set up clinical trials, and accelerate vaccine development. Clinical course and outcome of a substantial number of COVID‐19 patients have been reported, and recommendations regarding the care of such patients have been issued by several national health authorities across the world. However, the practices seem to vary considerably.

Interim guidance has been issued by the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) on managing COVID‐19, which include some recommendations specific to pregnant women, mostly drawn on experience from previous coronavirus outbreaks.8, 9 Chinese expert recommendations for the care of pregnant women with suspected and confirmed COVID‐9 were developed and disseminated in China quite early following the outbreak in Wuhan.10 These recommendations have been dynamic, evolving as more knowledge about epidemiology, pathogenesis, disease progression and clinical course among infected pregnant patients has been gathered. Limited clinical experience in managing pregnant women with COVID‐19 and their neonates has been reported from China recently based on a case series of nine pregnancies with confirmed COVID‐19 treated in Zhongnan Hospital of Wuhan University and 10 neonates (nine pregnancies) delivered at five different hospitals,11, 12 although many more cases (>100) of suspected or confirmed COVID‐19 have been treated and delivered in several hospitals in China according to the news releases and media reports. So far, no maternal deaths have been reported.

There appears to be some risk of premature rupture of membranes, preterm delivery, fetal tachycardia and fetal distress when the infection occurs in the third trimester of pregnancy. However, there is no evidence suggesting transplacental transmission based on very limited data, as the analysis of amniotic fluid, cord blood, neonatal throat swab, and breast milk samples available from six of the nine patients were found to be negative for SARS‐COV‐2. Whether virus shedding occurs vaginally is also not known.

Whether COVID‐19 increases the risk of miscarriage and stillbirth is unknown. Concerns have been expressed by experts in the media about women undergoing termination of pregnancy for fear of congenital infection and teratogenicity. However, information on the effect of COVID‐19 on the course and outcome of pregnancy in the first and second trimesters is not available yet.

As COVID‐19 still appears to be spreading, more infections in pregnant women are likely to be encountered in different regions, countries, and continents. Therefore, it is important that pregnant women and their families, as well as the general public and healthcare providers, receive as accurate information as possible. Here is our attempt to summarize some important practical clinical aspects of managing COVID‐19 in pregnancy:

2. PREVENTION

Incubation period of COVID19 is about 2‐14 days, but infected persons can transmit the virus via close contact and respiratory droplets perhaps even before they become symptomatic. Physiological changes in the immune and respiratory system may make pregnant women more susceptible to COVID‐19 infection during the epidemic. No effective vaccine is available at present. Therefore, it is advisable that pregnant women refrain from unnecessary travel, avoid crowds, public transport, contact with sick people, and more importantly, practice and maintain good personal and social hygiene. Pregnant women with symptoms of fever, cough, fatigue, myalgia, sore throat or shortness of breath should seek timely medical consultation and help. Women with a travel history to endemic areas and those with a clinical suspicion of infection should be isolated and investigated. Some pregnant women may develop severe anxiety and depression requiring professional psychological support to prevent adverse outcomes.

3. DIAGNOSIS

The main clinical manifestations are fever, fatigue, myalgia, dry cough, and shortness of breath. Few patients may present with nasal congestion, runny nose, sore throat, hemoptysis, or diarrhea.

Peripheral white blood cells count is normal or decreased in early stages, and the lymphocyte count may be reduced. C‐reactive protein may be increased. Some patients may have mild thrombocytopenia, elevated levels of liver enzymes and creatine phosphokinase.

A computed tomography (CT) scan of the chest without contrast is the most useful investigation to confirm or rule out viral pneumonia, and should be performed in suspected cases as the risk of radiation exposure to the fetus is very small. In a recent report, sensitivity of chest CT in diagnosing COVID‐19 was shown to be greater than that of RT‐PCR (98% vs 71%).13 Radiological signs of viral pneumonia were present in an overwhelming majority of reported pregnancies with COVID‐19 infection.

SARS‐COV‐2 is the etiologic agent of COVID‐19, and its viral nucleic acid detection using real‐time polymerase chain reaction (RT‐PCR) is considered the reference standard for the diagnosis. Specimens should be obtained from saliva, upper respiratory tract (nasopharyngeal and oropharyngeal swabs), lower respiratory tract (sputum, endotracheal aspirate, or bronchoalveolar lavage), urine and stool if possible. Repeated testing may be required to confirm the diagnosis. If the SARS‐COV‐2 nucleic acid is not detected in respiratory tract samples taken on two consecutive occasions at least 24 hours apart, COVID‐19 can be ruled out. Serology as a diagnostic procedure should be used only if RT‐PCR is not available.

To screen for other respiratory infections, samples should also be tested for other viruses (such as influenza virus A and B, adenovirus, respiratory syncytial virus, rhinovirus, human metapneumovirus, SARS‐CoV), bacterial pneumonia, chlamydia and mycoplasma pneumoniae.

It is important to take blood cultures for bacteria that cause pneumonia and sepsis ideally before initiating antimicrobial therapy.

4. MANAGEMENT

Pregnant women suspected of COVID‐19 should be isolated and investigated. Those diagnosed with infection should be promptly admitted to a negative pressure isolation ward, preferably in a designated hospital with adequate facilities and multi‐disciplinary expertise to manage critically ill obstetric patients. They should be triaged and stratified into mild (symptomatic patient with stable vital signs), severe (respiration rate ≥30/min, resting SaO₂ ≤93%, arterial blood oxygen partial pressure (PaO₂)/ oxygen concentration (FiO₂) ≤300 mmHg) or critical (shock with organ failure, respiratory failure requiring mechanical ventilation or refractory hypoxemia requiring extra‐corporal membrane oxygenation) categories based on clinical evaluation, and managed by a multidisciplinary team of midwife, obstetrician, specialist in intensive care medicine, microbiologist, anesthetist and neonatologist. All medical staff caring for COVID‐19 patients should use personal protective equipment including gown, N95 masks, goggles, and gloves. Special consideration should be given to physiological adaptations in pregnancy when treating pregnant women with COVID‐19 infection.

4.1 Supportive therapy

Adequate rest, hydration, nutritional support, and water and electrolyte balance should be ensured. It is essential to monitor vital signs and oxygen saturation closely. Depending on the severity of the disease, supplemental oxygen inhalation (60%‐100% concentration at a rate of 40 L/min) should be given via high‐flow nasal cannula depending on the severity of hypoxemia. Intubation and mechanical ventilation or even extra‐corporal membrane oxygenation (ECMO) may be required to maintain oxygenation. Other complications may include septic shock, acute kidney injury, and virus‐induced cardiac injury. Therefore, it is important to check arterial blood gases, lactate, renal function, liver function and cardiac enzymes as indicated by the clinical situation.

4.2 Antiviral treatment

Antiviral treatment has been routinely used to treat COVID‐19 infection in China, and is also recommended for pregnant patients. Combination therapy with antiproteases Lopinavir/Ritonavir has been the preferred drug regimen as it is known to be relatively safe in pregnancy. The recommended dose is two capsules of Lopinavir/Ritonavir (200 mg/50 mg per capsule) orally together with nebulized α‐interferon inhalation (5 million IU in 2 mL of sterile water for injection) twice a day.

WHO advises caution and careful risk‐benefit analysis before using investigational therapeutic agents in pregnant women outside clinical trials. Remdesivir, a nucleotide analog, and chloroquine, an antimalarial drug, are promising drugs against COVID‐19 as they are known to inhibit SARS‐COV‐2 virus in vitro.14 Clinical trials have already started in China and are planned elsewhere.

4.3 Antibacterial treatment

The extensive lung damage by the virus substantially increases the risk of secondary bacterial pneumonia. Antibiotics are indicated only if there is evidence of secondary bacterial infection. However, antibiotics should be administered without delay if bacterial sepsis is suspected. Intravenous Ceftriaxone can be administered initially while awaiting culture and sensitivity results.

4.4 Corticosteroid therapy

In general, use of corticosteroids in the treatment of COVID‐19 pneumonia is not recommended as it may delay the virus clearance from the body. However, short‐term (3‐5 days) administration of methylprednisolone (1‐2 mg/Kg bodyweight per day) has been used frequently in China, especially when dyspnea and hypoxemia are severe, in an attempt to ameliorate lung inflammation and prevent acute respiratory distress syndrome. This regimen is also recommended for pregnant women with COVID‐19, although data on its effectiveness and safety need further evaluation. Administration of Betamethasone 12mg intramuscularly followed by another dose 24 hours later should be considered to promote fetal lung maturity when preterm delivery is anticipated.

5. TIMING AND MODE OF DELIVERY

Timing of delivery should be individualized based on disease severity, existing comorbidities such as preeclampsia, diabetes, cardiac disease etc, obstetric history, and gestational age and fetal condition. In mild and stable cases responding to treatment and in the absence of fetal compromise, pregnancy may be continued to term under close surveillance. Regular monitoring of maternal vital signs (temperature, heart rate, blood pressure, respiration rate and oxygen saturation by pulse‐oximetry). Dynamic assessment of electrolytes and fluid balance, arterial blood gases, and acid‐base status is required. Ultrasound examination of the fetus and fetal heart rate monitoring are recommended to assess fetal wellbeing.

In critical cases, continuing pregnancy may endanger the safety of the mother and her fetus. In such situations, delivery may be indicated even if the baby is premature, and termination of pregnancy should be considered as an option before fetal viability is reached in order to save the pregnant woman’s life after careful consultation with the patient, her family and an ethical board.

Mode of delivery is mainly determined by obstetric indications. Careful consideration should be given in regards to choice of anesthesia when a delivery by cesarean section is required. In two published reports from China involving a total of 18 pregnant women with COVID‐19, all but two were delivered by cesarean section, and none of the neonates were infected by SARS‐COV‐2. As the of evidence for vaginal shedding of virus and vertical transmission is lacking, vaginal delivery may be considered in stable patients.

6. CARE OF THE NEWBORN

Limited data obtained from cases of pregnant women with COVID‐19 suggest that the transplacental transmission is unlikely in late pregnancy close to term, as the virus was not identified in the amniotic fluid, placenta, breast milk of these mothers or in the nasal secretions of their neonates. However, infection can occur in neonates via close contact. Two such cases of neonatal COVID‐19 infection have been confirmed so far at 36 hours and 17 days after birth, and both appear to have been infected postnatally.15

Therefore, early cord clamping and temporary separation of the newborn for at least 2 weeks is recommended to minimize the risk of viral transmission by avoiding longer, close contact with the infected mother. The neonate should be cared for in an isolation ward and carefully monitored for any signs of infection. During this period, direct breast feeding is not recommended. A possible option is for the mother to pump her breast milk, which can be fed to the baby by a healthy caregiver.9

7 . CONCLUSIONS

As the COVID‐19 epidemic continues to spread around the world, we need to plan and prepare ourselves proactively. Providing appropriate clinical management and support to patients while adequately protecting healthcare professionals should be our goal. A multi‐disciplinary team approach should be adopted in managing these patients as it allows to effectively share the expertise as well as responsibility, and treat our patients with dignity and compassion. However, there are many challenges to overcome, such as shortage of protective equipment, depleting supply of medicines and blood products (reduced blood donations), infected pregnant women showing up directly to delivery rooms in advanced labor, psychological pressure and panic, just to mention a few. In hospitals, the transmission of the virus and deaths among healthcare professionals are serious concerns. Improving healthcare governance, as well as supporting, educating and training healthcare personnel in infection control and self‐protection need to be prioritized. Clinical recommendations for managing COVID‐19 infection in pregnancy should be based on data from the current epidemic rather than drawing on limited experience from previous outbreaks of different types of corona viruses, as their epidemiology, clinical course and response to treatment may differ. Guidelines will evolve as more data become available and experience is gathered. Therefore, complete data on all pregnancies affected by COVID‐19 should be collected and made publicly available. Sharing data, knowledge and expertise, and helping countries with poor resources and weaker healthcare systems are important in this respect

Related Resources

World Doula Week – WSAZ Interview with WV RMOMS Project Director Shauna Lively

Substance Use and Domestic Violence ECHO Training Series

Weave West Virginia – Innovative West Virginia Partnership Launches Project to Improve Outcomes for Individuals Experiencing Intimate Partner Violence and Substance Use Disorder

Research Further Proves Effectiveness of Count the Kicks

Contact

Amy Tolliver, Director
West Virginia Perinatal Partnership
(304) 558-0530 ext. 5
atolliver@wvperinatal.org

DHHR Receives $3 Million to Expand Opioid Use Disorder Services for Pregnant and Postpartum Women

View original WV DHHR news release here

The West Virginia Department of Health and Human Resources (DHHR) has received a $3 million federal grant from the Centers for Medicare and Medicaid Services (CMS) Innovation Center to address opioid use disorder among pregnant and postpartum women. West Virginia is one of only 10 states to receive the funding.

The grant will support the Maternal Opioid Model (MOM) initiative, which focuses on improving health outcomes for mothers and babies by addressing fragmentation of care for pregnant and postpartum women receiving Medicaid benefits. The initiative builds upon the Drug Free Moms and Babies programs that provide services through 14 maternity care sites in West Virginia with funding from DHHR and the Claude Worthington Benedum Foundation.

Marshall Health/Marshall University Resource Corporation will lead the MOM project as the designated Care Delivery Partner for Medicaid. The West Virginia Perinatal Partnership will collaborate on the project to implement provider outreach education and support to program sites.

“We are grateful for the opportunity to take this successful and innovative project to the next level to ensure comprehensive services are available to all pregnant and postpartum women in West Virginia,” said Christina Mullins, Commissioner of DHHR’s Bureau for Behavioral Health.

The grant, which will fund the MOM initiative over a five-year period, provides the foundation for Medicaid to develop funding streams that support integration of maternity and behavioral health care.

“Under the MOM initiative, we will explore the development of a health home model for this vulnerable population. This would enable Medicaid to support services provided in care settings where behavioral health and care coordination historically have not been reimbursed,” said Cynthia Beane, Commissioner of DHHR’s Bureau for Medical Services.

Through the MOM initiative, women are screened for substance use disorder and then provided comprehensive care coordination to help ensure the best possible health outcomes.

“The programs are by design all located within delivery hospitals and obstetric offices, where women seek maternity care rather than solely within behavioral health clinics. It is the integration of behavioral health care into these environments that is innovative and as we have found, critically important,” said Janine Breyel, Director of Substance Use Programming for the WV Perinatal Partnership.

Beth Welsh, Associate Director of Operations for Addiction Sciences in Family Medicine at Marshall University added, “Pregnancy is a key time to interrupt the cycle of addiction as women want the best for their babies. Many communities have fragmented care or just no care options for pregnant women. We are eager to lead this project to help replicate these services to reach women in low-access areas of the state.”

Related Resources

World Doula Week – WSAZ Interview with WV RMOMS Project Director Shauna Lively

Substance Use and Domestic Violence ECHO Training Series

Weave West Virginia – Innovative West Virginia Partnership Launches Project to Improve Outcomes for Individuals Experiencing Intimate Partner Violence and Substance Use Disorder

Research Further Proves Effectiveness of Count the Kicks

Contact

Amy Tolliver, Director
West Virginia Perinatal Partnership
(304) 558-0530 ext. 5
atolliver@wvperinatal.org

Mothers, Babies Overlooked in the Drug Crisis

By Gaby Galvin, U.S. News & World Report Staff writer | December 30, 2019 | Read Original Story at U.S. News & World Report News

The U.S. drug epidemic is evolving – and physicians say mothers and babies may be left behind in its latest wave.

Pregnant women who are addicted to opioids often struggle to access treatment and services, and their challenges have received relatively little attention despite being a targeted group in the nation’s response to the opioid epidemic. Now, doctors say the emerging problem of polysubstance use – when people use more than one type of drug, such as opioids and methamphetamine – is being overlooked among pregnant women, with unknown long-term consequences for mothers and babies alike.

“We have put a lot of time and money and energy into opioids, which is awesome,” says Dr. Katrina Mark, an OB-GYN and medical director of the University of Maryland Medical Center’s women’s health clinic. “But we really need to have a wider view and realize that a lot of these women with opioid use disorder have polysubstance use (issues), and even the ones who aren’t using opioids are using other substances.”

West Virginia, for example, long considered an epicenter of the opioid crisis with one of the highest overdose death rates in the country, has been awarded $70.7 million in federal grants to combat the epidemic. Several hospitals have established separate neonatal intensive care units for babies suffering from opioid withdrawal, while in 2018, West Virginia became the first state approved to authorize centers that provide services for these babies and their families through Medicaid.

In 2016, the state made it easier for hospitals to track opioid exposure among newborns. The following year, 50.6 babies per 1,000 births were born with neonatal abstinence syndrome, which occurs when an infant suffers opioid withdrawal as a result of the mother’s use while pregnant, causing symptoms such as trembling, irritability and dehydration. Nationally, that rate was 7 per 1,000 in 2016, the most recent year for which data is available, according to the Healthcare Cost and Utilization Project.

But now a new trend is apparent. After surging in western states, meth-related overdose deaths have been climbing in states like West Virginia in recent years, and it’s unclear how mothers and babies have been affected.

“I think opioids are the past, or are going to be soon, because there are so many treatment programs for them that I think we’re trying to get a handle on it,” says Dr. Stefan Maxwell, pediatrics chief at Charleston Area Medical Center’s Women and Children’s Hospital in West Virginia. “Meth seems to be more of a problem, and I’m concerned because I don’t really know what that’s going to lead to.”

In addition to opioids, West Virginia recently began tracking other substances babies were exposed to in utero, Maxwell says, but it will be six months to a year before that data is meaningful. Few other states, if any, have similar tracking tools, he says.

Some data suggests the polysubstance abuse trend is occurring among mothers nationwide. Across the U.S. in 2018, 5.4% of pregnant women reported using any illegal drug in the last month, down from 8.5% in 2017, according to a federal health survey. That decrease – representing about 66,000 women – was driven in part by a 31.3% decline in the number of pregnant women who reported using opioids, from about 32,000 to 22,000. Yet pregnant women who said they had used meth doubled from 3,000 to 6,000.

A survey of nearly 16,000 people entering treatment for opioid use disorder between 2011 and 2018, meanwhile, showed an 85% uptick in the number of people who said they’d also used meth in the last month. More than 90% of people who used opioids had also used at least one other illegal drug.

Adding to the concern is the fact that meth today, mostly imported from Mexico, is far more potent than two decades ago, experts say. Studies indicate women who use meth during pregnancy are more likely to have infants who are small for their gestational age and are born with low birthweight, but the stimulant’s long-term developmental effects on babies are unclear. And when infants are born exposed to a mix of drugs, it’s harder for providers to know what their risks are – and how to address them.

“In the early newborn period, we can treat anything,” says Maxwell, former chairman of the West Virginia Perinatal Partnership. “But the problem is, what happens when they are 5, 7, 9 years of age and going into school, and they’ve been exposed to these complex amounts of drugs in utero – how did that affect their developing brain?”

Shifting drug use patterns are often first reflected in births, and pinning down the number of babies born exposed to specific substances could offer a fuller picture of the current status of the U.S. drug epidemic than the number of overdose deaths. That information gap means it’s challenging for policymakers to allocate funding and develop programs to support these newborns and their families.

“As we continually focus on the death side of (the drug epidemic), we don’t understand the living side,” says Dr. Daniel Ciccarone, a drug researcher and professor at the University of California-San Francisco School of Medicine. “The living side of it – no matter how deadly the drug is – naturally is much bigger. It’s the base of the pyramid.”

Policymakers are beginning to address the issue. The federal spending package finalized this month includes legislation that will allow states to use some of their billions in federal opioid funding to address the surge in meth and cocaine use, The New York Times reported.

The Food and Drug Administration, meanwhile, recently held a conference to discuss whether drugs could be developed to treat addiction to stimulants like cocaine and meth. Medication-assisted treatment – a combination of counseling and medication that blunts withdrawals – is the standard treatment for opioid addiction, and providers currently rely on behavioral therapies alone to treat other substance use disorders.

“With opioids, you have medication-assisted treatment, which is great, and it works really well,” Mark says. “It is effective, it is safe and we have good protocols for how to do that. But with a lot of the other drugs, like cocaine and methamphetamine, we don’t have that, and so we’re sort of lagging behind on exactly how to treat for those things.”

Addiction treatment for mothers is lagging in general. Just 19 states have drug treatment programs specifically for pregnant women, according to the Guttmacher Institute, and it’s not always accessible. Across West Virginia, Kentucky, North Carolina and Tennessee in 2017, opioid addiction treatment providers were less likely to take a new patient if she was pregnant, according to a Vanderbilt University study.

Some opioid treatment programs, meanwhile, kick women out if they test positive for other substances, while stigma or fear of legal repercussions may also keep women from disclosing their drug use to providers. In 23 states, substance use during pregnancy is considered child abuse, according to Guttmacher.

“I understand why those policies exist, but it also becomes a really big problem in that people that have polysubstance use can’t find good treatment sometimes,” Mark says.

Screening women for drug use and helping them find accessible treatment early in – or before – pregnancy could help curb the number of babies born affected by substances like opioids or meth, Mark says. And Ciccarone notes that mothers and children should be one focus of a comprehensive plan to address the ever-shifting drug use patterns in the U.S.

“All of a sudden, there’s a small wave of affected babies, and, of course, that makes us concerned,” Ciccarone says. “But it’s part of the whole thing – that’s why we call it a crisis, because there’s a lot of moving parts and a lot of places to be concerned about.”

Related Resources

World Doula Week – WSAZ Interview with WV RMOMS Project Director Shauna Lively

Substance Use and Domestic Violence ECHO Training Series

Weave West Virginia – Innovative West Virginia Partnership Launches Project to Improve Outcomes for Individuals Experiencing Intimate Partner Violence and Substance Use Disorder

Research Further Proves Effectiveness of Count the Kicks

Contact

Amy Tolliver, Director
West Virginia Perinatal Partnership
(304) 558-0530 ext. 5
atolliver@wvperinatal.org

Study: 54 out of every 1,000 WV children are affected by opioid use, will need $4B in services

By Amelia Ferrell Knisely Staff writer | Nov 13, 2019 | Read Original Story at The Gazette Mail

West Virginia holds the nation’s largest share of children who will face devastating, lifelong consequences linked to the opioid crisis, new data shows.

The report, released Wednesday by a New York nonprofit, said 54 out of every 1,000 children in West Virginia were affected by opioid use in 2017.

The state’s figure is at least twice the rate of 17 other states, including those with much larger populations.

The children, most under the age of 12, are more likely to develop an alcohol or drug disorder, more likely to need special education and are 70 times more likely to be obese.

The opioid crisis will likely cost the state $4 billion in services for children affected by the epidemic, the study said.

Money will go toward hospitalization, depression counseling and the criminal justice system — all outcomes associated with children who have a parent with opioid use disorder.

United Hospital Fund, a nonprofit health system, and the Boston Consulting Group are behind the report, which paints an alarming picture of the devastating effects of the opioid crisis on children nationwide. The group studied Americans under age 18.

Researchers said that although the opioid crisis is the deadliest drug epidemic in the country’s history, its long-lasting effects on children have received little attention.

Their research found 2.8 percent of the 74 million children in 2017 were directly affected by parental opioid use or their own use.

“If current trends continue, the number of children affected nationwide by opioid use will rise to an estimated 4.3 million by 2030, and the cumulative lifetime cost will reach $400 billion in additional spending on health care, special education, child welfare and criminal justice,” a release about the report said.

For comparison, the data showed that 1.8 million children have been diagnosed with autism.

The data also shows that:

240,000 children in 2017 had a parent die from an opioid overdose;
1.4 million children have a parent living with opioid use disorder;
170,000 children have an opioid use disorder themselves or have accidentally ingested opioids.

Researchers also looked at the effect of opioid use on states’ foster care systems. The number of children in West Virginia’s foster care system — around 7,000 — has grown in correlation with the opioid epidemic. The state has the highest number per-capita of children in state custody.

A class-action federal lawsuit filed in October claims West Virginia has failed to protect children in its care, alleging rampant issues with overburdened case workers, out-of-state children’s facilities and failure to prepare foster children for adulthood.

The study noted that, despite signs the opioid epidemic had hit an inflection point, the crisis is far from over.

Research from the Centers for Disease Control and Prevention released earlier this year showed the national fatal overdose rate had dropped by 5 percent in 2018, the first dip since 1990. The CDC attributed the dip largely to decreases in heroin and prescription opioid overdoses.

UHF included solutions in its report, including creating protocols for emergency responders to connect with children on scene and reducing the stigma of opioid use among people interacting with pregnant women and parents.

“This report shines a light on a population affected by opioids that is often hidden from view,”Suzanne Brundage, director of UHF’s Children’s Health Initiative and study co-author, said. “But these estimates should not cause despair. Instead, they highlight the urgent need to take action now to help these children and their families.”

California has the largest number of children affected by the opioid epidemic, and the state is projected to face a cost of $36 billion for services and care for those children. However, the state’s rate of children affected — 20 per 1,000 children — is still lower than West Virginia’s rate.

Related Resources

World Doula Week – WSAZ Interview with WV RMOMS Project Director Shauna Lively

Substance Use and Domestic Violence ECHO Training Series

Weave West Virginia – Innovative West Virginia Partnership Launches Project to Improve Outcomes for Individuals Experiencing Intimate Partner Violence and Substance Use Disorder

Research Further Proves Effectiveness of Count the Kicks

Contact

Amy Tolliver, Director
West Virginia Perinatal Partnership
(304) 558-0530 ext. 5
atolliver@wvperinatal.org

West Virginia Bucks Rising United States Maternal Mortality Trend

By Kara Leigh Lofton, West Virginia Public Broadcasting
See the Original Article

The United States has some of the highest maternal mortality rates in the developed world — and unlike most other first-world countries, our rates are going in the wrong direction.

American women are three times more likely to die during or after birth than women in Great Britain and eight times more likely than women in Scandinavian countries.

But despite the prevalence of major risk factors such as low access to prenatal care, a high poverty rate and a largely rural population, West Virginia, is bucking the maternal mortality trend. Maternal deaths are not only low, they’re also stable.

Part of that may be due to statewide initiatives to improve outcomes.

Lauren Headley

When Lauren Headley was 35, she got pregnant. Her age categorizes her as high-risk, but she is a nonsmoker and was a Zumba teacher at a healthy weight at the time she conceived.

About six months into her pregnancy, though, Headley was diagnosed with gestational diabetes. Her obstetrician was concerned that, as a result, her baby would be born large and wouldn’t fit through her birth canal. So at around 39 weeks, doctors induced labor. The baby girl was born healthy and neither mother or infant had any complications.

Then on the 10th day after she gave birth, Headley woke up bleeding.

“But this was like gushing and red clots of Jell-O,” she said.

She called her doctor’s office and her doctor told her that some bleeding was normal but, if it continued, to go to the emergency department or to call back. So she got into the shower to see if that would calm things down.

“As I’m in the shower, the blood just pours out,” she said. “I mean cups of red Jell-O is what it looks like and it’s just pouring out. And I get really weak and I sit down in the shower and yell for my husband, and he comes in and he looks in there and he’s like ‘Oh dear God, you need to call your doctor back. There’s no way this is normal.’”

Headley was taken by ambulance to the emergency department at Thomas Health, where she was diagnosed with a severe postpartum hemorrhage — which is one of the leading complications that causes maternal mortality in the United States.

Postpartum hemorrhage 10 days after birth is admittedly pretty rare, but how well a hospital is prepared to deal with obstetric emergencies can mean the difference between life and death for someone like Headley.

Which may be part of why West Virginia’s rates are so low.

West Virginia’s rates are low — but why?

West Virginia actually ranks 5th in the country — tied with Hawaii — for least number of maternal mortality deaths in the nation — behind California, Massachusetts, Colorado and Nevada, according to data from the Centers for Disease Control and Prevention.

Maternal deaths in West Virginia related to pregnancy and childbirth have bounced between 1 to 4 deaths a year during the past 11 years. Even though West Virginia is a small state and has few births annually, this is a pretty low rate and surprising because West Virginia is poor, rural and has higher rates of comorbidities, which are all risk factors.

But when you try to dig into the numbers, “it’s hard to know exactly why our rates are lower,” said Amy Tolliver, director of the West Virginia Perinatal Partnership. She said over the last 10 years, they’ve been working closely with all of the hospitals in the state that deliver babies to improve the care they offer to moms.

“We have been implementing different training programs specifically around maternal hemorrhage — that is one of the bigger drivers that we see in regard to maternal morbidity and nationally in terms of maternal mortality,” Tolliver said.

Tolliver said every hospital in the state that delivers babies has a specific set of protocols they are supposed adhere to in the event of complications like uncontrolled postpartum bleeding.

“To have the crash carts available with all of the equipment necessary, to have trainings in place, and to continue doing those staff trainings — we think that’s one of the biggest factors in improving care is practicing for the high-risk patient.”

“I think we also do a good job in this state of accepting the fact that we have a lot of the risk factors that increase the risk for maternal mortality,” said Dr. Ally Roy, an obstetrician at Marshall Health.

Roy delivers babies at Cabell Huntington Hospital. When a patient is admitted there, she says there is a checklist the staff goes through with the patient. If they meet the criteria for moderate or high risk for a postpartum hemorrhage, they receive interventions at delivery time aimed at reducing their risk. Anecdotally, she said, the protocols have greatly improved outcomes for patients with postpartum hemorrhage.

“When you have an emergency, you want people to be able to react smoothly and seamlessly,” said Tolliver. “There should be no downtime in trying to figure out what they need to do next. It needs to be very quick, very regimented, getting the process in place.”

In an email exchange with Thomas Health, the hospital Headley was taken to, a representative said that Thomas has protocols in place for how to deal with hemorrhage that were developed in conjunction with the statewide initiatives.

But experts working in this field in West Virginia say there’s still work to be done.

In 2008, West Virginia established a maternal mortality review committee made up of experts from across the state that basically looks at all of the data around deaths linked to pregnancy and childbirth and sees what happened. They then make recommendations based on the findings. About half of U.S. states currently have such committees.

“One of the first things that we did find was that some of our women who were postpartum may have presented in an emergency room with a severe headache and other symptoms, but they weren’t caught quickly enough in regard to understanding that that was preeclampsia, for example, that they may have been experiencing,” said Tolliver. “So there were some efforts put together to do some education with our emergency room staffing.”

Preeclampsia is a pregnancy complication that is usually characterized by high blood pressure and, if untreated, can cause organ damage and even death.

Last year, the committee recommended a renewal of those education efforts, so the Perinatal Partnership is getting ready to go out around the state to do more trainings.

Tolliver said the objective is to have caregivers “be prepared to be looking at the patient just a little bit differently [and] to ask the question, ‘Has she given birth recently?’ Those answers to those questions may drive the care in a different direction and get to the bottom of what is going on with her much more quickly,” she said.

So is there anything women could do to protect themselves against dying in childbirth? First, say experts, understand that women can experience life-threatening complications during childbirth, thus they recommend that women listen to their bodies, advocate for themselves, and talk about risk with their care team.

Related Resources

World Doula Week – WSAZ Interview with WV RMOMS Project Director Shauna Lively

Substance Use and Domestic Violence ECHO Training Series

Weave West Virginia – Innovative West Virginia Partnership Launches Project to Improve Outcomes for Individuals Experiencing Intimate Partner Violence and Substance Use Disorder

Research Further Proves Effectiveness of Count the Kicks