FDOH-Citrus offered prenatal care to over 300 pregnant people annually as part of their services for the community. FDOH-Citrus is one of two obstetric clinics in the county. The other obstetric clinic refers all pregnant people with substance use disorder (SUD) to FDOH-Citrus for prenatal care as they are not able to provide care for that demographic. In 2017 the FDOH-Citrus OB provider attended a summit on Neonatal Abstinence Syndrome. There was also a Healthy Babies initiative that gained community engagement due to the ongoing and rising overdose and substance use issues in the county. Referrals of pregnant people with SUD started long before FDOH-Citrus was ever able to meet the needs for treatment of SUD.
In 2018, a retrospective study of 201 DOH-Citrus pregnant patients was conducted. All patients received a drug screen at their initial prenatal visit. Out of 201, 76 (38%) tested positive for controlled substances. Nicotine and alcohol were not included in the screenings. After the retrospective study was conducted the Citrus SEN Task Force was formed. The Citrus County Substance Exposed Newborn Taskforce (Citrus SEN) began in 2018 in alignment with the Circuit 5 SEN Taskforce with the purpose of addressing the unique needs of substance exposed newborns in Citrus County. The Citrus SEN Taskforce is a collaborative group comprised of agency representatives from those providing prevention and services to expectant families of newborns. In 2018, with an increase of community support, FDOH Citrus started looking into options for treatment within county. In the past clients that tested positive for substances were referred out of county. This was not a sustainable practice, as Citrus County is a rural county with limited resources for public transit. Most of these clients were also low-income, so leaving the county for medical services on a weekly basis was not an attainable outcome. This also often left them having to pick between getting to a prenatal appointment or an medicated assisted treatment (MAT) appointment.
At the time federal regulations expanded for Certified Nurse-Midwifes (CNM) to allow subscribing power for MAT. FDOH-Citrus CNM took training in 2019 to provide MAT for pregnant people receiving prenatal care and needing treatment for SUD. In 2019, mental health providers were engaged and educated on SUD and options for treatment. The Citrus-DOH OB provider obtained certification to treat SUD. Citrus-DOH works with Lifestream to coordinate care of behavioral health and peer support a key component to sustaining SUD recovery. The first patient for the program was seen in 2020.
This practice addresses health inequities in our jurisdiction by providing SUD treatment to prenatal clients, where services were not provided before. This addresses the health inequities by giving access to high-quality and affordable healthcare services.
The target population to be served is all women of childbearing age in the community, and the extended families faced with caring for a SEN newborn. Substance use during pregnancy is a complex public health problem often resulting in multiple consequences for a woman and her newborn. Nicotine, alcohol, cocaine, hallucinogens' including marijuana, prescription or nonprescription narcotic/opioids, and certain non-narcotic medications during pregnancy may result in adverse effects on the health and well-being of the newborn. Education of the providers in the Citrus County community will lead to accurate and consistent diagnoses of exposed births allowing for early intervention services for the newborn and mother. These services are critical in minimizing the acute and long-term effects of prenatal substance exposure.
FDOH-Citrus had to overcome several obstacles to like community and legal perceptions of services that were being offered. FDOH-Citrus actively worked to address stigma of SUD within the department and educate staff as to why non-biases treatment was needed. In addition, issues with billing and services provided had to be addressed.
In the process of developing this program Programmatic concerns had to be addressed, there were concerns about the connotation associated with DOH-Citrus becoming a clinic that provided various MAT services and how this could be perceived by the public. DOH-Citrus had to clarify what was within the practice guidelines regarding medication treatment for those receiving prenatal care within the department. To avoid confusion around what services DOH-Citrus offered, clear distinctions had to be made. DOH-Citrus relayed that they were not providers of MAT to anyone within the community, and that the program only incorporated MAT for pregnant clients struggling with SUD who also needed concurrent prenatal care. DOH-Citrus framed perinatal SUD as a health condition requiring a medical diagnosis, similar to how other physical conditions would be assessed. By approaching clients as obstetric patients requiring treatment for a medical condition, offering concurrent prenatal care and MAT became the prescribed standard of care for a pregnant person with SUD. Ensuring that MAT is included in the standard prenatal care has been critical for sustaining this program, as this program is funded solely by the patient's health insurance. This approach not only reduces barriers to care by providing lifesaving treatment and necessary prenatal care jointly, but it also helps to reduce stigma around perinatal substance use that often limits access to care.
Initially, this program was thought to reach approximately 5 pregnant people a year. In less than 3 years almost 30 pregnant people have worked with the program, some even coming from other counties as the same options were not available to them locally. Since the program's inception, the positive outcomes with the pregnant people we hope to encourage more to address SUD in their prenatal program. Along with published papers and education through national conferences, FDOH-Citrus is hopeful that this program will reach a much higher number and hopefully be implemented in many other local small prenatal clinics. Thus, reducing the stigma and barriers to healthier pregnancies, deliveries and babies.
This current practice is innovative as it is the only health department within the state of Florida to offer MAT treatment to prenatal clients. MAT treatment for prenatal clients is not new to the field of public health, however it is uncommon and pregnant people often deal with added barriers and stigma. There is little to no data on substance use during pregnancy, which makes it difficult to justify needs to new programs.
A focus group of FDOH-Citrus OB patients was conducted in partnership with Florida State University (FSU) providing further qualitative feedback. The Citrus County Prenatal Program Participant Focus Group is a feature of Strategy 5 within the Overdose Data to Action (OD2A) initiative which is funded by the Centers for Disease Control and Prevention (CDC) and administered by the Florida Department of Health (FDOH). The focus group was a way for FDOH-Citrus to learn more about the barriers to receiving prenatal care, They're just they're so coldhearted, (other area OB provider). It's just I don't know why they do not communicate with the health department, or they don't reassure women that there's help. Why is it stopping you from telling a person who is hooked on heroin or opiates or whatever that, ‘Hey, listen, there's this program and we're gonna help you.' What stops them from doing it? Why did that lady that day on the phone was telling me basically, ‘Hey, you're a piece of crap, and we can't take care of you.' And hang up on the phone. I mean, I just I don't get it. It really blows my mind how coldhearted someone could be, especially knowing a woman in the beginning of your pregnancy, your hormones are everywhere on top of going through an addiction.”